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THE 


JOURNAL 

OF 

Nervous  and  Mental  Disease 


A  MONTHLY  PERIODICxVL 


CHAS.    HENRY   BROWN,   M.D., 

NEW  YORK. 
WITH   THE  ACTIVE  CO-OPERATION   OF 

L.  Fiske  Bryson,  M.D.,  Joseph  Collins,  M  D.,  C.  L.  Dana,  M.D.,  L.  C.  Gray, 
M.D.,  Gr^me  M.  Hammond,  M.D.,  Christian  A.  Herter.  M.D.,  Wm.   M. 
Leszynsky,  M.D.,  C.  F.  Macdonald,  M.D.,  W.  J.  Morton,  M.D  ,  Fred- 
erick Peterson,  M.D.,  New  York;  Wm.  A.  Hammond,  M.  D.,  Wash- 
ington, D.  C;    Morton  Prince,  M.D.,  Boston;   Wm.  C.  Krauss, 
M.D.,  Buffalo;    F.  R.  Fry,   M.D.,  St.  Louis,  Mo.;    C.  Eugenic 
RiGGS,  M.D.,  St.  Paul,  Minn.;    C.  K.  Mills,  M.D.,  Phila- 
delphia; Isaac  Ott,  M.D., Hasten,  Pa.;  H.  H.  Donald- 
son, Ph.D.,  University  of  Chicago;  Wm.  O.  Krohn, 
Ph.D.,  University  of  Illinois  ;  Frank  P.  Nor- 
bury,  M.D.,  Jacksonville,  111.,  and  others. 


VOLUME  XIII.     (New  Series),     isi 

[WHOLE  SERIES  VOL.  XV.] 


AMS   PRESS,  INC. 
NEW  YORK 


Reprinted  with  permission  of 
The  Jelliffe  Trust 


RC 


lit 

v.  I5~ 


Abrahams  Magazine  Service,  Inc. 

A  division  of 

AMS  Press,  Inc. 

New  York,  N.Y.  10003 

1968 


-r_-  L      FEB  11  1969       .11 


FEB  11  1969 


Manufactured  in  the  V.  S.  A. 


VOL.  XIII.  January,   1888.  No.   1. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


Original  ^rtid^is. 


COMPOSITE   PORTRAITS  OF  GENERAL   PARESIS 
AND   OF   MELANCHOLIA. 

By  WILLIAM  NO  YES,  M.  D., 

ASSISTANT   PHYSICIAN,    BLOOM1NGDALE   ASYLUM,  NEW    YORK. 

THE  accompanying  composite  photograph  of  general 
paresis  is  made  from  the  portraits  of  eight  patients, 
three  females  and  five  males.  The  composite  nega- 
tive was  made  by  THE  NOTMAX  PHOTOGRAPHIC  COM- 
PANY, of  Boston,  from  negatives  taken  by  the  writer.  The 
percentage  of  females  is  higher  than  in  the  natural  ratio  of 
the  two  sexes  in  the  disease.  The  cases  are  all  in  the 
second  stage  of  the  disease,  and  their  individual  portraits 
show  the  marked  characteristics  of  general  paresis.  One  of 
the  women  and  three  of  the  men  have  had  apoplectiform 
seizures.  The  average  duration  of  the  disease,  at  the  time 
of  photographing,  was,  in  the  women,  two  and  one-third 
years,  and  in  the  men  one  and  three-fourth  years.  With 
the  exception  of  one  woman,  all  were  in  good  general 
physical  condition,  and  able  to  go  out  walking  and  join  in 
the  usual  round  of  asylum  life  ;  the  one  woman  who  was 
the  exception  was  still  able  to  go  out  walking  on  pleasant 
days,  but  was  not  so  vigorous  as  the  others. 

The  composite  of  general  paresis  seems  fairly  to  repre- 
sent the  physiognomy  of  general  paresis  ;  the  eyes  have  the 
typical  inexpressive  and  staring  look  ;  and  the  facial  lines 
of  expression  have  been  gradually  obliterated  and  smoothed 


WILLIAM  A'OY£S. 

out,  giving  the  well-known  appearance  of  easy-going  com- 
placency. It  is  to  be  hoped  that  further  work  in  this  line 
may  give  a  more  just  conception  of  the  typical  expression 
in  the  different  forms  of  mental  disease  than  has  hitherto 
been  obtained  from  portraits  of  individual  cases. 

The   composite    portrait   of  melancholia   is   made   up   of 
eight  subjects. — all  men. 


General  Paresis. 


Melancholia. 


The  composite  of  melancholia  is  perhaps  somewhat  more 
clear  and  distinct  than  that  of  paresis.  A  comparison  of 
the  eyes  of  the  two  portraits  shows  much  more  expression 
in  the  portrait  of  melancholia,  and  the  facial  lines  in  this 
are  all  more  clearly  defined  than  in  the  other.  The  well- 
known  staring  look  of  paretics  is  entirely  absent  in  the  com- 
posite of  melancholia. 


PAIN    IN    THE    FEET. 

By   CHARLES   K.  MILLS,  M.D. 

PROFESSOR   OF   DISEASES   OF  THE   MIND   AND   NERVOIS   SYSTEM  IN    THE   PHILADELPHIA  POLYCLINIC  ; 
NEUROLIGIST    TO    THE    PHILADELPHIA    HOSPITAL,    ETC. 

A  Clinical  Lecture  delivered  at  the  Philadelphia  Hospital,  Nov.  12.  1887. 
Reported  by  William  H.  Morrison,  M.D. 

THE  first  patient  I  bring  before  you  this  morning  is 
suffering  not  from  an  affection  of  the  head,  with  which 
specialists  in  nervous  and  mental  diseases  arc  sup- 
posed to  be  more  particularly  interested,  but  from  a  disease 
of  the  feet.  It  is  my  purpose  to  show  you  this  and  some  other 
patients,  and  then  make  some  remarks  upon  the  subject  of 
pain  in  the  feet,  certainly  a  very  practical  topic,  and  one 
that  interests  us  as  neurologists,  as  surgeons,  and  as  general 
practitioners  of  medicine. 

I  will  first  give  a  partial  history  of  this  patient,  and  then 
examine  her  in  your  presence. 

A.  K.,  38  years  old,  born  in  Philadelphia,  white,  a  seam- 
stress, weighs  189  pounds  Both  father  and  mother  died  of 
phthisis  ;  one  brother  is  an  epileptic,  and  another  died  in 
the  insane  asylum.  She  has  been  a  drinking  woman,  and 
for  several  years  has  been  subject  to  epileptic  seizures. 

About  ten  months  ago,  during  the  winter,  she  began  to 
have  pain  in  the  left  foot,  chiefly  in  the  heel  and  along  the 
outer  border  of  the  foot.  This  pain  was  accompanied  by  a 
"pins  and  needles  "  sensation.  It  was  dull  and  aching  in 
character.  In  a  few  weeks  she  began  to  have  a  similar  but 
worse  pain  in  the  right  foot,  chiefly  also  on  its  outer  border 
and  in  the  heel.  Many  remedies  and  methods  of  treatment 
were  tried  without  affording   any  continuing  relief.     They 


CHARLES  K.  MILLS. 

4 

included  severe  counter-irritation,  temporary  rest,  galvan- 
ism ;  and  internally,  gaultheria,  salicylate  of  sodium,  iodide 
of  potassium,  colchicum,  etc.  June  1 1 ,  1887,  Dr.  J.  D.  Deaver, 
of  the  surgical  staff  of  the  Hospital,  stretched  the  posterior 
tibial  nerve,  making  an  oblique  incision  about  two  and  one- 
half  inches  long  between  the  internal  malleolus  and  the 
tuberosity  of  the  os  calcis. 

The  right  posterior  tibial  was  the  one  operated  upon,  for 
at  the  time  of  the  operation  the  pain  in  the  right  foot  was 
more  severe  than  in  the  left.  The  woman  was  kept  in 
bed  from  six  to  seven  weeks  after  the  operation.  Strange 
to  say,  the  left  foot  got  well,  while  the  right,  although  much 
improved,  is  not  yet  entirely  free  of  pain.  This  fact  led  some  of 
those  observing  the  case  to  think  that  possibly  it  was  a  hys- 
terical case,  for  you  may  have  a  hysterical  pain  in  the  feet, 
as  hysterical  pain  may  have  its  seat  anywhere.  I  think, 
however,  that  a  more  rational  explanation  is  to  be  given  of 
the  recovery  of  the  left  foot  :  the  woman  was  put  to  bed  and 
kept  absolutely  quiet  for  six  to  seven  weeks,  and  under  the 
influence  of  rest  the  trouble  subsided.  The  rest  instituted 
before  the  operation  was  neither  as  absolute  nor  as  complete 
as  that  after  the  nerve-stretching.  This  is  an  interesting 
therapeutic  observation,  and  shows  the  great  value  of  com- 
plete and  long-continued  rest  in  such  cases. 

Let  us  next  determine  the  condition  of  this  woman's  feet 
at  the  present  time.  The  proper  way  to  examine  a  foot 
which  is  the  seat  of  pain,  is  first  to  study  it  in  a  general  way, 
eliciting  the  statements  of  the  patient,  and  then  to  manipu- 
late it  by  certain  definite  methods.  First  manipulate  it  with 
reference  to  the  ankle  and  other  joints.  In  this  case  there 
never  was,  nor  is  there  now,  any  distinct  pain  in  the  ankle- 
joints.  The  metatarso-phalangeal  joints  should  be  exam- 
ined in  detail.  At  present  I  can  elicit  no  pain  in  the  left 
foot  either  by  pressure  or  handling.  The  foot  in  the  course 
of  the  examination  should  be  squeezed  laterally,  as  you  see 
me  do.  By  so  doing,  you  will  often  not  only  bring  out  a 
particular  sort  of  pain,  but  also  perhaps  the  exact  location 
of  the  lesion  that  causes  pain.  In  the  left  foot  this  compres- 
sion causes  no  pain.      Examining  now  the   right  foot,  I  find 


PAIN  IN  THE  FEET.  r 

no  pain  in  the  ankle-joint.  Squeezing  the  foot  in  the  line 
of  the  metatarso-phalangeal  articulations  causes  severe 
pain.  Pressing  each  metatarso-phalangeal  articulation  ver- 
tically, I  find  severe  pain  in  and  about  this  joint  of  the  fourth 
toe,  and  also  in  the  corresponding  joint  of  the  great  toe  ; 
there  is  very  little  in  the  joints  of  the  second  and  third  toe, 
and  none  in  the  joint  of  the  fifth  toe. 

As  I  have  already  said,  it  was  supposed  by  some  that 
this  was  possibly  what,  for  want  of  a  better  name,  we  call 
hysterical  pain.  Against  such  a  diagnosis  are  the  facts  that 
pain  is  present  in  different  locations,  and  that  it  is  increased 
by  special  manipulation  ;  that  the  pain  in  one  foot  gets  well 
under  a  certain  kind  of  treatment,  while  in  the  other  foot, 
although  abated,  it  continues.  This  woman  has  symptoms 
which  indicate  something  real,  and,  temporarily  at  least, 
organic.  Without  doubt  she  is  suffering  from  a  local  but 
somewhat  diffused  neuritis.  Her  weight,  and  the  more  or 
less  depraved  condition  of  her  blood,  have  probably  acted 
as  causative  factors. 

A  professional  friend,  a  man  weighing  between  two  and 
three  hundred  pounds,  consulted  me  informally  with  refer- 
ence to  a  severe  pain  in  his  heels.  The  pain  continued,  and 
to  a  certain  extent  spread  so  as  to  involve  a  portion  of  both 
feet,  although  it  was  most  severe  in  the  heels.  In  view  of  this 
lecture,  I  wrote  to  him  a  few  days  ago,  and  he  replied  that, 
after  trying  various  methods  of  treatment,  the  pain  had  dis- 
appeared since  he  had  adopted  shoes  of  a  certain  pattern. 
In  this  letter  he  states  that  he  has  had  several  patients  who 
have  complained  of  pains  in  the  heel  or  in  the  feet,  particu- 
larly across  the  instep  and  ball  of  the  foot,  and  that  these 
cases  occurred  especially  in  young  men,  who  either  wore 
shoes  that  were  too  tight  or  bad  fitting,  or  who  followed  oc^ 
cupations  which  required  them  to  be  on  their  feet  for  a  long 
time. 

Pain  in  the  feet  is  of  great  interest  not  only  from  the 
standpoint  of  a  particular  case  like  this,  with  a  local  cause 
and  seat,  but  also  because  frequently  it  is  the  evidence  of 
the  beginning  of  some  general  or  constitutional  trouble. 
Such  pain   may  be  due  to  a  number  of  conditions,  as  to  a 


(3  CHARLES  A".  MILLS. 

local  neuritis,  periostitis,  or  arthritis,  which  is  either  rheu- 
matic or  gouty,  and  this  is  the  conclusion  jumped  to  in  many 
cases  ;  sometimes  it  is  a  correct  conclusion,  even  cases  in 
which  acute  redness  or  swelling  are  not  present.  In  these 
cases,  treatment  will  help  decide  the  diagnosis. 

I  now  have  a  patient  under  my  care  who  has  suffered 
from  gout,  and  has  also  had  acute  rheumatism  within  a  few 
years.  A  few  months  ago,  he  was  taken  with  a  pain  at  the 
junction  of  the  tendo- Achilles  with  the  bone  on  each  side. 
Slight  evidences  of  thickening  were  also  present.  The  pain 
was  so  severe  as  to  seriously  interfere  with  his  walking. 
Under  the  use  of  lithium,  iodide  of  potassium,  and  arsenic, 
with  galvanism  and  massage,  the  case  is  getting  well  with 
moderate  rapidity. 

The  late  Prof.  S.  D.  Gross  paid  especial  attention  to  this 
subject  of  pains  in  the  feet,  and  as  far  back  as  1864  published 
a  paper  on  Pododynia,  describing  cases.  In  his  Surgery  a 
brief  allusion  to  this  subject  will  be  found.  He  speaks  of 
the  fact  that  a  large  number  of  his  cases  of  pains  in  the  feet 
occurred  in  tailors,  and  he  had  begun  to  think  that  it  was  a 
tailor's  disease  ;  but  further  experience  showed  him  that 
others  exposed  to  similar  causes  developed  the  same  trou- 
ble. Those  among  tailors  most  likely  to  be  affected  were 
cutters,  who  had  to  stand  at  their  work  for  hours.  His  view 
was  that  in  all  probability  it  was  due  to  periosteal  or  apon- 
eurotic inflammation.  "  The  soreness  in  pododynia,"  says 
Prof.  Gross,*  "  is  generally  most  severe  in  the  sole  of  the 
foot,  over  the  calcaneum  and  the  ball  of  the  great  toe,  or  in 
the  line  of  the  metatarsal-phalangeal  joints,  parts  which  are 
particularly  subject  to  pressure  during  the  erect  position. 
The  hollow  of  the  foot,  however,  occasionally  participates  in 
the  suffering.  The  pain  and  tenderness  are  deep-seated, 
and  are  always  aggravated  by  the  pressure  of  the  finger,  and 
by  walking  and  standing,  which  the  patient  is  often  obliged 
to  forego  in  consequence.  Instead  of  pain  there  is  often  a 
disagreeable  tingling  sensation  in  the  parts.  Little  swelling 
attends  the  disease,  and  there  is  seldom  any  marked  discol- 
oration of  the  skin,  except  in  the  more   severe   forms  of  the 

tern  of  Surgery. 


PAIN  IN  THE  FEET.  y 

affection,  when  the  surface  occasionally  exhibits  a  mottled  or 
purplish  appearance,  evidently  dependent  upon  a  congested 
condition  of  the  capillary  vessels.  A  sense  of  coldness  often 
pervades  the  entire  foot  ;  and  in  some  cases  the  disease  ex- 
tends to  a  considerable  distance  up  the  leg.  Both  feet  often 
suffer  simultaneously.  The  general  health  is  seldom  mate- 
rially, if  indeed  at  all,  affected. 

"  What  the  pathology  of  pododynia  is,  I  have  never  been 
able  to  determine,  as  no  opportunity  has  been  afforded  in 
dissecting  the  parts.  The  probability  is  that  it  is  a  form  of 
inflammation,  chiefly  of  the  periosteum  and  plantar  aponeu- 
rosis, attended  with  disordered  condition  of  the  vaso-motor 
nerves  and  an  inordinate  determination  of  blood.  In  the 
cases  which  have  fallen  under  my  observation,  it  has  not 
been  in  my  power  to  trace  any  connection  between  the  dis- 
ease and  gout,  or  between  it  and  rheumatism." 

Dr.  Sayre*  treats  at  length  of  a  certain  class  of  cases  of 
pain  and  weakness  of  the  foot  or  feet,  with  flattening  of  the 
arch,  of  which  I  have  seen  many  examples. 

"When  the  arch  of  the  foot,"  he  says,  "is  properly  sup- 
ported by  a  healthy  tibialis-anticus  muscle,  the  articulating 
facets  of  the  bones  composing  it  press  upon  each  other,  so 
as  to  sustain  the  weight  of  the  body  without  producing  pain. 
These  articular  cartilages  having  no  blood  vessels  or  nerves 
of  their  own,  are  insensible  to  pressure  ;  but,  when  the  arch 
of  the  foot  loses  its  proper  support  in  consequence  of  a  com- 
plete or  partial  paralysis  affecting  the  tibialis-anticus  mus- 
cle, these  articulating  facets  no  longer  press  upon  each  other 
equally,  but  are  made  to  tilt  a  little,  and  the  pressure  is 
brought  to  bear  upon  the  edges  of  the  articular  surfaces, 
where  the  supply  of  blood  vessels  and  nerves  is  most  abun- 
dant, which  gives  rise  to  indescribable  pain  and  suffering 
with  every  step  that  is  taken.  The  pathology  of  these  cases 
is,  first,  paralysis  of  the  anterior  tibial  muscle  ;  second,  set- 
tling of  the  arch  of  the  foot  ;  third,  abnormal  pressure  upon 
the  edges  of  the  cuneiform  and  scaphoid  bones.  The  pres- 
sure in  this  abnormal  position  produces  periosteal,  it  may  be 

*  Orthopaedic  Surgery  and  Diseases  of  the  Joints,  by  Lewis  A.  Sayre,  M.D. 


8 


CHARLES  A'.  MILLS. 


osteal,  or  synovial  inflammation,  and  then  it  is  that  the  case 
is  so  often  regarded  as  one  dependent  upon  constitutional 
disease." 

Dr.  Sayre's  treatment  is  the  division  of  tendons  in  some 
cases,  and  the  use  of  a  shoe  with  a  steel  sole,  which  is  a 
well-known  treatment  for  valgus.  My  own  experience  with 
some  cases  of  a  milder  type  is  that  it  is  not  always  necessary 
to  use  a  steel  sole,  and  that  the  trouble  can  be  remedied 
by  having  a  shoe  with  a  leather  sole  made  in  a  peculiar 
way.  The  heel  should  be  low  rather  than  high,  and  should 
run  from  half  an  inch  to  one  inch  further  under  the  foot  than 
is  usual.  In  order  to  take  away  from  the  clumsy  appear- 
ance of  such  a  shoe,  the  heel  can  be  cut  away  a  little  from 
behind.  A  thickness  of  stiff  leather  should  be  put  in  the 
position  of  the  hollow  of  the  foot,  and  another  should  extend 
up  the  inner  side  of  the  shoe. 

PAIN    IN    THE    FOOT    DUE    TO    LOCAL     NEURITIS    AM)    BONE 

PRESSURE — DR.  THOMAS   G.  MORIONS   OPERATION. 

NERVE-STRETCHING    AND   NERVE-SECTION. 

While  upon  this  subject,  I  wish  to  give  you  an  experience 
from  my  private  practice  which  illustrates  the  value  of  an- 
other method  of  treatment,  which  some  time  ago  I  was  in- 
clined to  try  in  the  present  case,  but  did  not  because  of  the 
diffuseness  of  the  pain.  You  will  occasionally  meet  with 
cases  in  which  for  months,  or  it  may  be  years,  pain  will  be 
localized  in  one  foot  and  perhaps  in  a  certain  spot.  Some- 
times the  pain  is  absolutely  excruciating.  On  a  winter's 
day  even,  the  patient  will  stop  in  the  street  and  will  remove 
his  shoe,  or  will  sit  down  anywhere  for  a  time,  in  order  to 
get  relief.  This  pain  is  present  more  or  less  all  the  time. 
I  have  certainly  had  from  five  to  ten  such  cases  during  a  few 
years.  If  they  are  examined  closely,  it  will  be  found  that 
in  some  of  them  the  pain  is  localized  to  some  one  part  of  the 
foot.  One  point  is  the  spot  which  in  our  first  patient  is  the 
most  painful — about  the  metatarso-phalangeal  articulation 
of  the  fourth  toe.  Dr.  Thomas  G.  Morton,  the  distinguished 
Philadelphia  surgeon,  has  paid  great  attention  to  the  sub- 
ject of  pain  in  the  feet  from  the  surgical  standpoint.     About 


PAIN  IN  THE  FEET.  g 

ten  years  ago  he  described  several  cases  of  this  kind,  and  he 
has  devised  an  operation  for  their  relief.  I  think  that  his 
view  as  to  the  causation  is  correct,  at  least  in  a  certain  num- 
ber of  cases.  As  I  have  already  pointed  out,  one  of  the 
spots  at  which  pain  is  most  likely  to  be  felt  is  about  the 
metatarso-phalangeal  articulation  of  the  fourth  toe.  Dr. 
Morton  gives  an  anatomical  reason  for  this  location  of  pain. 
So  important  is  the  matter  and  so  ingenious  the  explanation, 
that  I  think  it  is  best  to  quote  his  exact  words  : 

"  The  occurrence  of  the  neuralgia,"  says  Dr.  Morton,* 
"may  be  understood  by  a  reference  to  the  anatomy  of  the 
parts.  The  metatarso-phalangeal  joints  of  the  first,  second, 
and  third  toes  are  found  on  almost  a  direct  line  with  each 
other,  while  the  head  of  the  fourth  metatarsal  bone  is  from 
one-eighth  to  one-fourth  of  an  inch  behind  the  head  of  the 
third,  and  the  head  of  the  fifth  is  from  three-eighths  to  half 
an  inch  behind  the  head  of  the  fourth  ;  the  joint  of  the  third, 
therefore,  is  slightly  in  advance  of  the  joint  of  the  fourth,  and 
the  joint  of  the  fifth  is  considerably  behind  the  joint  of  the 
fourth. 

"  The  fifth  metatarsal  joint  is  so  much  posterior  to  the 
fourth  that  the  base  of  the  first  phalanx  of  the  little  toe  is 
brought  on  a  line  with  the  head  and  neck  of  the  fourth  meta- 
tarsal, the  head  of  the  fifth  metatarsal  being  opposed  to  the 
neck  of  the  fourth. 

"  On  account  of  the  character  of  the  peculiar  tarsal  artic- 
ulation, there  is  very  slight  lateral  motion  in  the  first  three 
metatarsal  bones.  The  fourth  has  greater  mobility,  and  the 
fifth  still  more  than  the  fourth,  and  in  this  respect  it  resem- 
bles the  fifth  metacarpal.  Lateral  pressure  brings  the  head  of 
the  fifth  metatarsal  and  the  phalanx  of  the  little  toe  into 
direct  contact  with  the  head  and  neck  of  the  fourth  metatar- 
sal, and  to  some  extent  the  extremity  of  the  fifth  metatarsal 
rolls  above  and  under  the  the  fourth  metatarsal. 

"  The  mechanism  of  the  affection  now  becomes  apparent 
when  we  consider  the  nerve  supply  of  the  parts.  The 
branches  of  the  external  plantar  nerve  are  fully  distributed 
to  the  little  toe  and  to  the  outer  side  of  the  fourth  ;    there 

*  Philadelphia  Medical  Times,  October  2,  1886. 


IO 


C/f axles  a:  mills. 


are  also  numerous  branches  of  this  nerve  deeply  lodged  in 
between  these  toes,  and  they  are  liable  not  only  to  be  un- 
duly compressed,  but  pinched  by  a  sudden  twist  of  the  an- 
terior part  of  the  foot.  Any  foot-movement  which  suddenly 
may  displace  the  toes,  when  confined  in  a  shoe,  may  induce 
an  attack  of  this  neuralgia.  In  some  cases  no  abnormality 
or  other  specific  cause  for  the  disease  has  been  detected." 

Dr.  Morton's  operation  consists  in  making  an  incision 
usually  about  two  inches  in  length  along  the  outer  edge  of 
the  tendon  of  the  toe  most  affected  ;  then  opening  the  artic- 
ulation and  removing  the  adjoining  portions  of  the  metatar- 
sal bone  and  phalanx.  Under  antiseptic  precautions  the 
operation  is  comparatively  trifling.  It  has  been  performed 
from  the  sole  of  the  foot,  but  the  operation  from  above  is 
preferable  as  the  bones  are  thus  more  easily  reached. 

Let  me  now  recur  to  the  illustration  from  my  private 
practice  of  a  case  successfully  treated  by  this  operation. 
The  patient  kindly  wrote  out  for  me  the  history  of  her  case, 
and  from  this  and  my  private  note-book  I  have  prepared 
the  following  account  : 

In  July,  1877.  m  jumping  from  one  stone  to  another  three 
or  four  feet  lower,  her  right  foot  slipped  and  she  came, 
with  all  her  weight  upon  her  left  foot,  upon  a  sharp  point  of 
rock,  twisting  the  ankle.  The  sole  of  the  shoe  was  cut 
through,  but  the  foot  was  not  bruised  at  all,  and  it  was  for 
only  about  a  week  that  she  could  not  walk  straight.  Dur- 
ing the  next  two  years,  at  intervals  of  from  two  to  eight 
weeks,  she  would  have  a  peculiar  pain  in  the  foot,  which 
would  only  last  about  two  or  three  days. 

In  1879  she  hurt  her  foot  again  in  the  same  way,  and 
then  pain  was  seldom  absent  longer  than  about  a  week,  and 
each  time  would  be  more  severe  than  the  last.  In  1881  the 
pain  became  constant,  never  being  absent  longer  than  an 
hour.  For  two  weeks  it  would  be  so  intense  that  she  would 
be  nearly  frantic,  then  for  about  a  week  or  ten  days  it  would 
be  less  severe. 

The  pain  was  a  dull,  heavy,  sickening  ache,  from  the  foot 
to  the  hip,  and  with  a  sharp,  hard  pain  through  the  foot. 
When  easier  the  ache  would  only  be  in  the  foot,  but  the 
sharp  pain  was  there  constantly. 


PAIN  IN  THE  FEET.  £  j 

Rising  in  the  morning,  the  patient  could  not  put  her 
weight  upon  her  foot,  until  she  had  taken  hold  of  the  foot 
suddenly  from  the  top  and  pressed  it  hard  together,  and 
held  it  in  both  hands  with  all  her  strength  for  several  min- 
utes. 

Many  plans  of  treatment  were  tried  in  this  case — gouty 
and  rheumatic  remedies  were  used,  and  many  forms  of  ex- 
ternal application,  without  success.  Painting  with  iodine, 
anodyne  ointments  and  liniments,  galvanism,  and  temporary 
rest,  were  alike  unsuccessful.  Persistent  blistering  gave  the 
most  relief.  The  patient  was  kept  in  a  sitting  or  recumbent 
position  for  several  weeks,  while  successive  blisters  were 
applied  to  the  sole  of  the  foot.  She  was  benefitted  by  this 
treatment  probably  as  much  from  the  rest  as  from  the  blister- 
ing, but  in  a  short  time  the  pain  returned  with  all  its  former 
severity. 

I  now  concluded  it  would  be  best  to  have  an  operation 
performed  for  the  relief  of  the  condition  which  was  scarcely 
endurable.  Dr.  D.  Hayes  Agnew  was  called  in  consulta- 
tion, and,  after  etherization,  excised  the  end  of  the  third 
metatarsal  bone  and  the  approximating  portion  of  the  phal- 
anx. The  patient  had  some  little  trouble  in  the  after  treat- 
ment of  the  wound,  but  in  about  three  months  everything 
was  completely  healed  and  the  pain  much  better.  About  a 
year  after  the  operation  the  foot  was  roughly  trodden  on  ; 
inflammation  ensued,  and  an  abscess  formed  and  discharged, 
but  healed  without  special  difficulty.  The  patient  writes  to 
me  this  week  that  she  has  not  had  the  slightest  trouble  for  a 
year  and  a  half,  and  has  walked  as  much  as  twelve  miles  at 
a  stretch  without  producing  any  trouble  in  the  foot. 

Another  private  patient,  a  lady  of  about  sixty  years  of 
age,  tells  me  that  forty-two  years  ago,  after  stepping  on  a 
stone,  she  was  suddenly  seized  with  a  pain  near  and  in  the 
line  of  the  fourth  toe.  The  pain  was  extreme,  and  was  ac- 
companied by  some  swelling  and  redness.  She  was  com- 
pelled to  keep  off  her  feet  from  three  to  four  weeks,  and 
suffered  considerably  for  some  weeks  afterwards.  Ever 
since,  at  times,  averaging  at  least  once  a  year,  she  is  seized 
suddenly    with    pain,    sometimes  very   severe  in  the    same 


12 


CHARLES  K.  MILLS. 


locality.     The  pain  usually  disappears  with  rest  and  care  in 
using  the  foot. 

Let  me  say  a  word  or  two  more  about  operative  proced- 
ure in  such  cases.  As  you  will  remember,  the  posterior 
tibial  nerve,  after  supplying  the  muscular,  osseous,  articular, 
and  cutaneous  tissues  of  the  back  of  the  leg  and  ankle,  di- 
vides upon  the  body  of  the  calcaneum  into  the  internal  and 
external  plantar  nerves,  which  supply  the  sole  of  the  foot 
and  adjoining  tissues.  The  internal  plantar  nerve  has  a  dis- 
tribution resembling  that  of  the  median  nerve  in  the  hand, 
the  external  that  of  the  ulnar  nerve  in  the  hand.  I  here 
show  a  diagram  illustrating  the  distribution  of  the  two  plan- 
tar nerves.  The  internal  planter  nerve  divides  into  two 
branches  called  the  internal  and  the  external.  The  internal 
branch  is  also  called  the  median  branch  and  first  digital 
nerve  ;  the  external,  also  called  the  lateral  branch,  divides 
on  about  a  line  with  the  tarso-metatarsal  joint  into  the  sec- 
ond, third,  and  fourth  digital  nerves.  The  first,  second, 
third,  and  fourth  digital  nerves  supply  the  first,  second,  and 
third  toes,  and  the  internal  aspect  of  the  fourth  toe.  The 
external  plantar  nerve  divides  into  internal  and  external 
branches,  which  supply  the  little  toe  and  outer  aspect  of  the 
fourth  toe.  This  is  simply,  in  general  terms,  the  distribu- 
tion of  these  nerves.  Numerous  small  branches  are  lodged 
in  various  positions. 

I  think  when  the  trouble  is  limited  to  the  branches  of 
the  external  plantar  nerve  going  to  the  fourth  and  fifth  toes, 
it  may  sometimes  not  be  necessary  to  perform  an  operation 
so  radical  as  the  excision  of  the  articulating  faces  of  the 
bones.  The  nerve  itself  might  be  resected  or  stretched. 
This  was  Dr.  Deaver's  idea  in  connection  with  our  first  case. 
The  posterior  tibial  nerve  was  stretched  in  the  hope  of 
avoiding  excision  of  the  joint.  For  some  reason,  however, 
this  operation  in  all  cases  does  not  succeed  so  well  as  ex- 
cision. Nerve  stretching  is  not  so  good  an  operation  for  the 
relief  of  pain  due  to  neuritis  as  for  true  neuralgia,  or  where 
certain  central  troubles  are  the  cause  of  pain.  I  think  that 
section  is  better  than  stretching  if  you  are  sure  that  you  can 
locate  the  particular  branch  of  the  particular  nerve  going  to 


PAIN  IN  THE  FEET.  j  - 

the  particular  spot  affected.  Of  course,  certain  objections 
to  the  operation  of  nerve  section  are  apparent.  It  may  pro- 
duce a  paralytic  condition  of  the  foot  which  may  interfere 
with  its  usefulness,  but  it  is  nevertheless  sometimes  a  desir- 
able procedure. 

In  1882,  a  young  lady  was  under  my  care  at  the  Univer- 
sity Hospital.  She  suffered  with  pain,  burning  and  tingling 
sensations,  marked  and  very  distressing,  chiefly  along  the 
outer  side  of  the  top  of  the  foot.  Many  measures  of  treat- 
ment were  tried  without  success,  including  counter-irrita- 
tion, galvanism,  rest,  and  rheumatic  and  gouty  remedies. 
Eventually,  two  operations  were  performed  by  Dr.  H.  R. 
Wharton.  Early  in  July,  he  cut  down  and  stretched  the 
musculo-cutaneous  and  external  saphenous  nerves,  an  oper- 
ation which  was  followed  by  a  slight  temporary  diminution 
of  pain.  August  18,  1882,  he  excised  one  and  a  half  inches 
of  the  external  saphenous  nerve,  and  peroneal  communi- 
cating nerve,  b^hind  the  external  maleolus.  This  operation 
was  followed  by  marked  diminution  of  pain,  and  after  a  long 
time  the  patient  recovered. 

PLANTER    NEURITIS    (OR    NEURALGIA). 

Dr.  C.  [H.  Hughes,  of  St.  Louis,  under  the  name  of 
plantar  neuritis,  or  neuralgia,  has  described  a  painful  affec- 
tion of  the  foot,  which  may  be  due  to  a  variety  of  causes. 
We  had  in  this  Hospital,  not  long  ago,  a  patient  with  caisson 
disease.  This  man,  while  working  in  a  caisson,  during  the 
building  of  a  bridge  across  the  Schuylkill  River,  was  taken 
down  with  symptoms  of  this  affection.  He  suffered  terrible 
pains  in  the  legs,  had  various  head  symptoms,  was  par- 
alyzed, and  went  through  the  whole  series  of  phenomena  of 
caisson  disease.  He  was  paralysed  for  months,  but  finally 
recovered  and  left  the  Hospital.  Among  other  symptoms, 
he  had  at  one  time  excruciating  pains  in  the  feet. 
Dr.  Hughes  speaks  as  follows  of  this  affection  : 
"  It  comes  on  as  a  sequel,  usually  of  a  low  form  of  blood 
depraving  fever,  like  typhoid  or  protracted  malarial,  with 
typhoid-like  depression,  or  in  the  latter  stages  of  phthisis  ; 
but  it  may  be  the  sequel  of  an  exhausting,  long-continued 


ji  CHARLES  K.MILLS. 

rheumatism,  or  possibly  of  a  badly  managed  or  neglected 
and  chronic  gonorhcea,  as  Ross  asserts,  though  I  have 
never  seen  this  as  a  result  of  that  disease.  It  appeared  as  a 
conjoint  symptom  in  some  cases  of  caisson  disease  at  the 
time  of  the  building  of  the  St.  Louis  bridge,  and  I  have  seen 
it  follow  upon  a  residence  in  the  high  altitudes  of  Colorado 
and  an  attack  of  the  so-called  mountain  fever  of  that  region. 
It  comes  upon  a  nervous  organization,  shattered  and  tremu- 
lous and  choreic,  and  the  painful  paroxysms  are  agonizing. 
The  patient  cries  out  with  pain,  and  often  cannot  rest  at 
night,  even  after  prolonged  wakefulness,  without  powerful 
anodynes.  The  slightest  touch,  such  as  the  application  of 
local  anodynes  with  the  hair  pencil,  to  the  painful  parts, 
often  cannot  comfortably  be  borne.  A  peculiar  burning 
sensation,  without  themometric  evidence,  accompanies  the 
pain.  The  pain  is  usually  localized  in  the  balls  and  the 
tips  of  the  three  toes  supplied  by  the  internal  plantar  nerve, 
and  in  the  heal  and  plantar  arch  of  the  foot,  but  sometimes 
implicates  also  the  two  smaller  toes,  which  are  supplied 
from  the  external  branch  of  the  plantar  nerve,  the  fifth  toe 
being  supplied  exclusively  by  the  external  plantar,  while  a 
filament  from  the  internal  joins  with  the  external  in  giving 
the  fourth  its  a_sthesiodic  supply."* 

The  following  case,  evidently  one  of  neuritis  occurring 
in  the  course  oi  typhoid  fever,  is  interesting  in  connection 
with  these  remarks  of  Dr.  Hughes  on  plantar  neuritis  as  a 
sequel  of  low  fevers.  Such  cases  indeed  are  not  rare,  but  are 
often  not  understood. 

The  patient,  a  young  man,  had  typhoid  fever  in  July, 
1884.  The  attack  was  a  severe  one,  confining  him  to 
the  bed  for  six  weeks  entirely,  and  partially  for  two  weeks 
longer.  His  convalescence  was  slow.  During  the  first 
two  weeks  of  the  fever  he  had  marked  brain  symptoms 
and  was  unconscious  of  his  surroundings.  On  coming 
to  himself  at  the  end  of  this  time,  he  began  to  suffer 
severely  with  burning,  tingling,  and  numbness  of  the  feet, 
which  were  also  hyperaesthetic,  so  that  he  could  scarcely 


*  Western    Medical    Reporter,    April,    1887,  and    Alienist   and    Neurologist, 
April,  1887. 


PAIN  IN  THE  FEET.  j  ,- 

bear  the  weight  of  the  bed  clothes  upon  them.  The 
condition  was  most  marked  across  the  toes  and  back  of  the 
feet  near  the  toes.  The  pain  and  uncomfortable  sensations 
were  temporarily  relieved  by  friction. 

On  getting  out  of  bed,  he  found  that  he  was  weak  in 
both  legs,  and  for  a  long  time  had  a  paretic  or  ataxic  gait. 
He  was  troubled  with  numbness  and  tingling  from  the 
upper  part  of  the  thighs  to  the  feet.  Both  feet  and  legs 
were  tender  to  pressure.  The  feet  showed  a  tendency  at 
times  to  swell,  and  on  exposure  became  white  and  mottled  ; 
they  also  showed  a  marked  tendency  to  sweating.  The 
soles  of  the  feet  were  exceedingly  tender. 

As  the  patient  grew  stronger,  the  condition  of  his  legs 
and  feet  gradually  improved,  but  for  many  months  he  suf- 
fered greatly.  The  pressure  of  the  feet  upon  the  floor  when 
standing  caused  him  intolerable  discomfort.  He  went  about, 
however,  suffering  more  or  less  all  the  time.  He  had  shoes 
of  half  a  dozen  different  patterns  made,  in  order,  if  possible, 
to  procure  some  relief.  Squeezing  the  foot,  either  vertically 
or  laterally,  caused  great  pain.  The  numbness  and  tingling 
disappeared  slowly  from  above  downwards,  a  marked  gird- 
ling or  encasing  sensation  being  ususlly  present  at  its  upper 
line.  Numerous  corns  formed  upon  his  feet,  he  not  having 
been  subject  to  them  before  his  sickness.  His  feet  felt  as  if 
they  were  cramping  or  contracting  downwards,  and  at  times 
assumed  a  condition  of  slight  plantar  flexion. 

Although  more  than  three  years  have  elapsed,  this  gen- 
tleman still  has  some  numbness  in  both  feet,  particularly 
across  the  dorsum  of  both  great  toes  and  the  adjoining 
sides  of  the  second  toes.  If  he  walks  much,  he  has  a  con- 
tracting sensation  in  the  balls  of  both  feet. 

Possibly  a  more  prompt  recovery  would  have  taken 
place  in  this  case  if  the  patient  had  been  taken  off  his  feet, 
and  had  had  gaultheria,  salicylate  of  sodium,  or  small  doses 
of  mercury  with  tonics,  internally,  with  counter-irritation 
and  galvanism  locally. 

ERVTHROMELAGIA. 

A  disease,  of  which  I  have  seen  five  or  six    cases,  is  in- 


j  5  CHARLES  K.  MILLS. 

eluded  by  Dr.  Hughes  under  the  head  of  plantar  neuritis, 
although  I  do  not  think  properly.  It  was  described  a  few 
years  ago  by  Dr.  S.  Weir  Mitchell,*  under  the  name  of  ery- 
thromelalgia,  which  term  indicates  pain  and  redness.  This 
is  a  most  remarkable  effection,  and  differs  somewhat  from 
those  already  described.  These  cases  begin  in  much  the 
same  way.  with  pain  in  the  heel,  or  in  the  sole,  or  in  a  toe, 
and  then  the  pain  will  increase  and  multiply.  It  augments 
both  in  extent  and  intensity.  Later,  another  phenomenon 
is  added,  that  is,  a  distinct  flushing,  or  even  a  reddish  or 
purplish  appearance  of  the  feet.  The  moment  the  feet  are 
allowed  to  assume  a  dependent  position,  a  horrible  pain  starts 
in  them,  and  almost  at  once  there  appears  a  slight  flushing, 
then  a  diffused  redness,  and  finally  a  mottled,  purplish 
appearance  spreads  over  the  feet.  One  of  the  patients 
described  in  Dr.  Mitchell's  paper  had  been  under  my  own 
observation.  This  man  was  perfectly  comfortable  so  long 
as  the  feet  were  kept  elevated.  I  remember  very  well  the 
first  time  that  I  saw  him.  He  was  lying  on  a  lounge,  with 
the  head  and  feet  about  in  the  same  place,  and  was  suffer- 
ing no  pain.  In  order  to  examine  his  feet,  the  leg  was 
allowed  to  hang  over  the  side  of  the  lounge.  In  a  moment 
it  begun  to  change  color,  and  instantly  the  patient  was  in 
agony.  As  long  as  the  horizontal  position  was  maintained 
he  was  free  from  pain  and  discomfort.  This  is  not  always 
the  case  in  neuritis.  Erythromelalgia,  in  some  cases  at 
least,  is,  I  believe,  disease  of  spinal  origin.  Sometimes  it 
may  be  due  to  a  neuritis,  or  even  possibly  to  some  disease 
of  the  veins.  In  the  following  case  of  multiple  neuritis,  or 
poliomyelitis,  it  was  present  as  a  symptom. 

S.  H.,  aged  40,  white,  born  in  Ireland,  is  a  dressmaker. 
She  has  had  syphilis,  and  drinks.  She  was  always  well 
until  about  five  years  ago,  when  she  had  an  attack,  which 
she  described  as  similar  to  the  present,  but  from  which  she 
recovered  in  a  few  months.  Six  years  before  this  she  had 
had  still  another  similar  attack. 

About  four  weeks  before  admission   to  the  Hospital,  she 

*  American  Journal  of  the  Medical  Sciences,  1878. 


PAIN  IN  THE  FEET.  t- 

began  to  have  pains,  of  a  sharp  shooting  character,  in  the 
feet  and  legs,  with  burning  and  flushing  ;  these  were  fol- 
lowed by  a  feeling  as  if  the  legs  were  asleep.  The  pains 
were  worse  at  night.  Just  before  admittance,  she  began  to 
have  contractures  in  both  legs,  and  both  were  atrophied. 

The  knee  and  muscle  jerk  are  abolished.  She  has 
always  had  control  over  the  bowels  and  bladder.  Sensation 
is  good,  and  she  has  no  hyperesthesia.  She  has  con- 
tractures of  the  fingers  of  the  left  hand.  Her  legs  feel 
numb,  and  she  has  severe  pain  in  them  occasionally.  She 
has  pain  on  pressure  along  the  trunks  of  the  posterior  and 
anterior  tibial  nerves  at  their  upper  parts.  They  are  some- 
what sensitive  towards  the  foot,  though  not  as  much  so  as 
nearer  their  origin. 

In  one  case  of  multiple  neuritis  or  general  poliomyelitis, 
a  woman  who  was  confined  to  her  bed  for  fourteen  months, 
when  gradually  recovering,  the  moment  she  attempted  to 
put  the  legs  in  a  hanging  position,  exactly  the  same  thing 
happened  as  we  see  in  erythromelalgia.  The  feet  would 
begin  to  pain,  turn  red,  and  then  purple.  This  tendency 
continued,  with  gradually  decreasing  severity,  for  two  or 
three  months,  when  it  entirely  disappeared. 

FEET     PAINS     IN     POSTERIOR    SPINAL    SCLEROSIS,    AND    IN 
SOME   OTHER    FORMS   OF   CHRONIC    SPINAL   DISEASE. 

It  is  well  known  that  one  of  the  very  earliest  symptoms 
of  posterior  spinal  sclerosis  is  the  occurrence  of  shooting, 
lancinating,  or  lightning-like  pains,  usually  in  the  lower 
extremities.  The  foot  is  not  the  commonest  seat  of  the 
initial  occurrence  of  these  pains,  but  it  is  by  no  means  an 
infrequent  locality.  Pain  in  the  heel  is  somewhat  common. 
Spitzka,  in  the  American  System  of  Practical  Medicine, 
speaks  of  one  patient,  who,  after  experiencing  initial  symp- 
toms for  over  a  year,  woke  up  at  night  with  a  fulminating 
pain  in  the  heels,  which  recurred  with  the  intensity  of  a  hot 
spear  thrust  and  with  the  rapidity  of  a  flash  every  seven 
minutes.  A  private  patient,  a  lady  46  years  old,  who  came 
to  me  ffrst  a  few  weeks  ago,  has  been  suffering,  off  and  on. 


x  g  CHA  KLES  K.  MILLS. 

for  four  years  with  cutting  pains  in  the  right  heel,  calf  and 
thigh,  and  sometimes  in  the  first  and  fourth  toes.  These 
pains  preceded  other  symptoms,  which  are  now  tolerably 
well  developed,  such  as  double  vision,  difficulty  in  holding 
her  urine,  diminished  knee  jerk,  and  slight  ataxia. 

For  the  sake  of  actual  illustration,  I  show  you  here  an 
ataxic  patient  from  the  Women's  Nervous  Wards.  She  is 
42  years  old.  About  five  years  ago,  she  was  kicked  in  the 
left  side,  as  the  result  of  which  she  was  confined  to  her  bed 
for  a  week.  Soon  after  she  had  a  severe  uterine  haemor- 
rhage. After  this  she  did  not  menstruate  for  two  years,  then 
she  menstruated  regularly  till  September,  1886,  then  her 
menses  ceased  entirely.  Soon  after  she  received  the  kick, 
she  commenced  to  have  sharp  pains  in  her  limbs  and  feet, 
and  later  in  the  trunk  and  fingers.  Gradually  she  devel- 
oped the  typical  symptoms  of  posterior  spinal  sclerosis — 
ataxia,  failing  sight,  Argyle-Robertson  pupils,  anaesthesia, 
and  paresthesia,  abolished  knee-jerk,  etc.  She  sometimes 
has  sharp  pains  in  her  feet ;  a  few  days  ago,  for  instance, 
she  had  a  severe  pain  in  the  outer  side  of  her  left  foot  just 
in  front  of  her  heel,  as  if  a  knife  had  been  suddenly  thrust 
into  the  spot  and  then  suddenly  withdrawn.  This  pain 
sometimes  runs  along  the  outer  side  of  her  foot  ending  in 
the  ball  of  the  fifth  toe. 

Of  course,  I  could  furnish  from  my  note-books  many 
similar  illustrations  of  pains  in  the  feet  in  ataxic  patients, 
but  it  would  be  a  tiresome  and  unnecessary  repetition.  My 
only  purpose  in  calling  attention  to  these  pains  in  this  lec- 
ture, is  to  emphasize  the  fact  that  such  heel  or  feet  pains  are 
sometimes  very  early,  and  even  initial,  symptoms  of  this 
affection,  and  therefore  the  physician  should  be  on  his 
guard  and  not  make  an  improper  diagnosis.  Such  pains 
are  often  supposed  to  be  rheumatic  or  gouty,  or  to  be 
evidences  simply  of  a  local  neuritis  from  an  unknown 
can 

Posterior  spinal  Xerosis  is  not  the  only  form  of  chronic 
spinal  disease  in  which  feet  aches  or  pains  are  among  the 
early  or  initial  symptoms,  but  in  disorders  other  than  loco- 
motor ataxia,  the  pains  are  usually  not  simple  in  character, 


PAIN  IN  THE  FEET.  jq 

but  are  associated  with  other  conditions,  as  of  spasm  or 
vaso-motor  and  trophic  conditions. 

About  three  years  ago  a  lady,  60  years  of  age,  consulted 
me  about  a  burning  pain  or  sensation  along  the  outer  border 
of  the  left  foot  from  the  toe  to  the  ankle.  This  was  accom- 
panied by  a  peculiar  jerking  upwards  of  the  left  great  toe, 
and  sometimes  of  the  second  toe.  Her  fingers  also,  some- 
times, felt  stiff,  and  she  was  nervous  and  apprehensive,  but 
had  no  other  positive  symptoms.  During  the  last  three 
years,  however,  the  case  has  become  one  of  well  marked 
disseminated  sclerosis. 

In  1884,  I  was  consulted  by  a  gentleman  from  Illinois, 
52  years  old.  Three  years  before  coming  under  observa- 
tion, a  slight  burning  sensation  was  felt  under  the  nail  of 
the  second  toe  of  the  right  foot.  This  sensation  increased, 
and  soon  became  very  painful.  One  by  one,  all  the  other 
toes  of  the  same  foot  were  affected  in  a  similar  way,  and  at 
the  time  he  came  to  see  me  the  painful  disease  had  ex- 
tended until  it  had  involved  the  second,  third,  and  fourth 
toes  of  the  left  foot.  The  affected  toes  were  of  a  bluish  red 
color,  and  the  feet  were  mottled  to  a  short  distance  above 
the  roots  of  the  toes.  So  great  was  his  suffering,  that  in 
hope  of  relief  he  had  the  first  toe  affected  amputated  in 
January,  1883.  The  patient  did  not  remain  under  my  care, 
but  I  was  satisfied  as  the  result  of  my  examination,  that  he 
was  the  victim  of  a  chronic  nervous  disease,  probably  of  the 
spinal  trophic  centres. 

REFLEX   OR   TRANSFERRED   PAINS   IN   THE   FEET. 

In  order  to  round  out  my  subject,  let  me  say,  in  con- 
clusion, that  occasional  pains  in  the  feet  are  reflex  or  trans- 
ferred. Of  these  Dana*  speaks  as  follows  :  "Studies  of  the 
cause  of  reflex  pains  in  the  feet  show  that  they  may  be 
referred  in  almost  all  cases  to  irritation  of  the  genito-urinary 
tract,  and  occur  more  often  in  the  male  ("Med.  Record," 
July  25,  1885).     The  pains  of  uterine  disorder  when  reflected 

°  New  York  Med.  Journal,  July  30,  1887. 


2Q  CHARLES  K.  MILLS. 

down,  appear  rarely  to  go  below  the  knee  ;  in  other  words, 
they  affect  the  lower  branches  of  the  lumbar  plexus,  and 
not  the  sacral  nerves.  It  has  been  stated  that  pain  in  the 
heels  may  be  caused  by  ovarian  abscess.  In  my  experience, 
such  pains  are  dueto  lithaemic  and  neurasthenic  conditions, 
and  will  be  relieved  by  remedies  addressed  to  such  states. 
It  may  be  said  in  general,  then,  that  pelvic  irritations  are 
felt  most  frequently  in  the  upper  and  short  branches  of  the 
lumbar  plexus,  next  perhaps  in  the  intercostal  nerves  and 
upper  cervical  nerves,  then  in  the  trigeminus,  and  last  in 
the  hands  and  feet." 


REPORT  OF  A  CASE  OF  ANENCEPHALY,  WITH 
A  MICROSCOPICAL  STUDY  BEARING  ON  ITS 
RELATION  TO  THE  SENSORY  AND  MOTOR 
TRACTS. 

By  CHARLES  L.  DANA,  A.  M.,  M.D.,  New  York 

PROFESSOR   OF   NERVOUS   AND    MENTAL   DISEASES,    NEW   YORK    POST-GRAD'JATE   MEDICAL   SCHOOL 

AND   HOSPITAL. 

CASES  in  which  infants  are  born  at  full  term  with  no 
fore-brain  are  rare.  Syme  describes  a  case,  Edinb. 
Med.  and  Surg.  Journal,  vol.  xxiv,  p.  295,  in  which 
the  infant  lived  six  months.  After  death  only  the  cerebel- 
lum, pons,  and  parts  below  were  found.  Panizza,  of  Paris, 
reports  a  similar  case  that  lived  eighteen  hours  (Gintrac, 
Maladies  de  l'appareil  nerv.,  Paris,  1867,  v.  i.,  p.  51).  Olli- 
vier  reports  one  that  lived  twenty  hours  (Maladies  de  la 
moelle  epiniere,  Paris,  1837,  v.  i.,  p.  179).  The  two  cases  of 
Rohon  and  of  Starr  have  been  reported  recently,  and  are 
familiar. 

This  form  of  monstrosity,  so  far  as  I  can  judge,  would  be 
called  by  Geoffry  St.  Hillaire  "  pseudo-encephaly." 

The  interest  in  such  cases  previous  to  the  discovery  of 
the  modern  methods  of  studying  nerve  anatomy  has  been 
purely  clinical  and  teratological. 

We  know  now,  however,  that  all  such  cases  of  congenital 
anomalies  of  the  nervous  system  constitute  natural  experi- 
ments in    the  atrophy  method,  and  that  one  of  the  chief 


2  2  CHARLES  L.   DANA. 

interests  in  monsters  lies  in  what  they  tell  us  post-mortem 
regarding  nerve  tracts  and  centres. 

Clinical  History. — The  case  is  that  of  a  male  infant 
born  at  full  term.  The  mother  was  unmarried,  but  was 
healthy,  denied  syphilis  or  anything  unusual  in  the  mode  of 
sexual  intercourse  or  incidents  of  pregnancy.  She  had  had 
no  other  child.     The  father,  she  said,  was  healthy. 

The  child  was  large  for  its  age,  must  have  weighed  eight 
or  nine  pounds,  was  very  plump  and  healthy-looking.  It 
showed  no  deformity  except  that  the  head  was  peculiarly 
shaped.  It  was  large  proportionately,  the  forehead  narrow, 
and  the  whole  head  very  narrow  and  long  in  the  occipital- 
frontal  diameter.  The  sutures  were  not  united,  and  the 
bones  were  freely  movable.  The  eyes  were  generally  closed, 
but  occasionally  opened.  The  child  nursed  a  little,  but 
had  difficulty  in  swallowing,  and  after  feeding  would  have 
attacks  of  cyanosis. 

It  was  noticed  that  it  cried  very  little,  and  only  in  a  fee- 
ble way.  It  had  natural  movements  of  the  bowels  and 
bladder.  It  had  had  no  convulsions  or  rigidity  or  paralysis. 
On  pinching  or  pushing  it,  the  infant  cried.  It  lived  two 
and  one-half  days. 

AUTOPSY. — On  puncturing  the  membrane  between  the 
cranial  sutures,  a  yellowish  liquid  spurted  out.  Cutting  a 
way  the  calvarium,  the  whole  cranial  cavity  above  the 
tentorium  was  found  perfectly  empty  and  smooth.  The 
anterior  and  middle  fossae  contained  nothing  but  the  fold- 
ings of  the  membranes.  In  the  posterior  fossa  the  ten- 
torium was  bare,  but  the  cerebellum  could  be  felt  beneath 
it. 

The  cerebellum  was  fully  developed  and  of  good  size, 
measuring  6%  ctm.  in  width  and  3J4  ctm.  anterio-posteriorly. 
The  roots  of  all  the  cranial  nerves  were  present  except  the 
first.  The  optic  nerves  were  small,  and  the  chiasm  scarcely 
to  be  made  out.  The  optic  tracts  showed  barely  a  trace. 
The  third  nerves  were  well  developed.  The  fifth  nerves 
were  all  well  developed,  and  both  motor  and  sensory  roots 
could  be  seen.  They  arose  far  out  on  the  lateral  surface  of 
the  pons  in  the  sulcus  between  it  and  the  cerebellum.     The 


A  CASE  OF  AXENCEPHALY.  2  ,, 

other  cranial  nerves  could  be  made  out  in  the  sulcus  exter- 
nal to  the  olives,  the  hypoglossal  apparently  arising  from 
the  lower  outer  border  of  the  olives. 

The  vertebral  arteries  joined  to  form  the  basilar,  which 
at  the  cephalic  end  of  the  pons  abruptly  terminated  in 
four  small  arteries.  The  two  anterior  of  these  passed  for- 
ward to  the  optic  thalami,  the  two  posterior  to  the  cere- 
bellum. 

The  pons  varolii  was  very  small.  The  medulla  appeared 
to  be  made  up  mostly  of  the  two  large  olivary  bodies, 
which  almost  met  in  the  median  line.  The  corpora  quadri- 
gemina  seemed  fairly  well  developed.  Anterior  and  exter- 
nal to  these  were  two  lobes,  evidently  parts  of  the  optic 
thalamus,  and  the  sole  representation  of  the  first  cerebral 
vesicle.  The  left  was  much  the  larger,  and  measured,  in  a 
direction  from  outside  and  posterior  up  and  in,  3  ctm.  The 
spinal  cord  appeared  normal,  but  small. 

The  specimen  was  hardened  in  Muller's  fluid  and  then 
in  alcohol.  Sections  were  made  at  the  level  of  the  third  to 
fourth  lumbar  nerves,  eighth  to  tenth  and  fourth  to  sixth 
dorsal,  fourth  to  sixth  and  first  cervical 

Sections  were  also  made,  at  different  levels,  through  the 
medulla  and  pons.  These  sections  were  stained  in  Wei- 
gert's  and  ordinary  haematoxyloii,  carmine,  and  aniline 
blue. 

The  most  interest  attaches  to  the  appearances  in  the 
pons  and  medulla,  and  these  will  be  described  first.  The 
cerebral  hemispheres  and  corpora  striata  being  entirely 
absent,  as  already  stated,  we  should  expect  to  find  absent 
all  those  uninterrupted  tracts  depending  for  their  nutrition 
upon  the  integrity  of  the  parts  mentioned.  The  afferent 
tracts  to  the  brain  should  be  present. 

Microscopical  Appearances. — Section  I.  Beginning 
from  below,  I  find,  in  sections  at  the  level  of  the  motor  de- 
cussation, absence  almost  entirely  of  this  decussion  and  of 
the  lateral  pyramidal  tracts.  In  place  of  this,  one  sees  only 
a  decussation  of  sensory  fibres  starting  from  the  nuclei  of  the 
post-median  and  post-external  columns.  The  fibres  cross 
over  at  the  bottom  of  the  anterior  median  fissure,  part  (1) 


24  CHARLES  L.  DANA. 

turn  up  directly,  and  part  (2)  pass  anteriorly  along  the 
median  surface  of  the  anterior  fissure  to  go  towards  the 
olivary  body.  The  first  set  (1)  form  the  ascending  fibres  of 
the  inter-olivary  tract. 

Posterior  to  the  sensory  decussation  is  a  decussation  of 
a  few  fibres  connecting  the  cells  of  the  anterior  horns. 


Antero- lateral 
ascend,  col.   *  -- 


Lat.  col. 


-  _  Subst.  Gelat. 


Nuc.  of  col.  of 
Burdach. 


Nucleus  of 
col.   of  Goll. 


The  post-median  and  post-external  nuclei  are  well  de- 
veloped, as  are  also  the  corresponding  columns  at  a  lower 
level. 

The  gray  matter  is  normal  in  arrangement  and  in  its 
cells,  though  the  anterior  horns  are  a  little  smaller  than 
normal.  The  place  of  the  crossed  pyramidal  tracts  is  occu- 
pied only  by  a  few  nerve  fibres. 

The  anterior  columns  are  abnormally  narrow.  The 
direct  cerebellar  tracts  are  well  and  distinctly  marked. 
There  is  apparently  only  a  partial  development  of  the  an- 
tero  lateral  ascending  column. 

The  anterior  and  posterior  nerve  roots  are  well  devel- 
oped. The  fibres  of  origin  of  the  ascending  root  of  the  fifth 
are  visible.  The  nuclei  and  fibres  of  origin  of  the  eleventh 
and  twelfth  nerves  can  be  seen.  Fibres  can  also  be  seen  to 
pass  from  the  posterior  columns  into  the  lateral  column  &nd 
lateral  part  of  intermediate  gray,  then  turning  up  to  enter 
at  a  higher  level,  the  formatio-reticularis. 


A  CASE  OF  ANENCEPHALY.  35 

Section  II. — In  the  next  series  of  sections,  at  the  level 
of  the  lower  part  of  the  olive,  the  pyramids  are  seen  to  be 
entirely  absent,  so  that  the  olives  form  the  ventral  edge  of 
the  section. 

The  interolivary  tract  is  present,  but  is  very  poorly  de- 
veloped. The  part  best  seen  is  the  ventral  portion  lying 
almost  at  the  bottom  of  the  fissure  between  the  olives.  This 
ventral  portion  of  the  interolivary  tract  is  seen  to  be  made 


Post.  Long.  Bund. 


Ascend,  root  of  ix. 

N.  Post.  Median  Col. 

Nuc.  Post.  Ext. 
Col. 


--    Corp.  Resti- 
form. 

—   Ascend,  root 
of  V. 


Ant.  Vagus  Nuc. 


Interoliv.  tract. 

up  from  internal  and  anterior  arcuati  fibres  from  the  post- 
median  and  post-external  column  nuclei.  Posteriorly,  the 
longitudinal  bundle  is  seen  normal  in  size.  The  nucleus  of 
Roller  is  present.  The  formatio-reticularis  is  of  nearly  nor- 
mal appearance,  but  not  quite  so  rich  in  fibres  as  it  should 
be  ;  the  internal  and  external  olives  are  present. 

The  respiratory  bundle  is  normal.  The  anterio-posterior 
fibres  of  the  raphe  are  numerous,  but  seem  to  end  abruptly 
at  the  bottom  of  the  anterior  median  fissure  between  the 
olives.  The  raphe  fibres  in  general  are  much  more  numer- 
ous in  the  interolivary  portion,  as  is  the  case  in  normal 
cords. 

The  lateral  column  fibres  and  nucleus  are  very  distinct. 
The  gray  matter  and  cranial  nuclei  on  the  floor  of  the  ven- 
tricle are  normal. 


26 


CHARLES  L.  DANA. 


Section  III. — The  next  section  is  made  at  the  upper 
border  of  the  olives  and  lower  edge  of  the  pons.  The  inter- 
olivary  tract  is  quite  distinct  in  the  ventral  portion  between 
the  olives.  Its  middle  and  dorsal  portions  are  fairly  repre- 
sented, while  the  posterior  longitudinal  bundle  is  very  dis- 
tinct.    The  anterior  arcuate  fibres   pass  in  a  distinct   strand 


Pos'.  Long.         Knee 
Bund.  ofvii. 


Int    Nuc  of  viii. 


Ant. or  accessory 

or  Post.I.at  nuc. 

ol  viii. 

viii  Ext.  root, 
rnal  root. 


Interolivary  tract. 

from  the  corpus  restiforme  to  the  ventral  part  of  the  raphe. 
Here  some  cross  and  some  enter  the  lemniscus.  The  fibres 
of  the  raphe  are  fully  developed  dorsally. 

The  nuclei  of  Roller,  which  is  supposed  by  Bechterew  to 
be  the  end  station  of  the  fibres  of  the  lateral  fundamental 
column,  are  here  very  distinct.  The  formatio-reticularis  is 
rather  poor  in  fibres.  What  corresponds  to  the  caudal  edge 
of  the  pons  is  an  an  irregular  mass  of  undifferentiated  tissue 
through  which  the  sixth  cranial  nerves  run,  and  in  which 
can  be  seen  a  few  fully  developed  transverse  nerve  fibres. 

The  dorso-ventral  or  linear  fibres  of  the  raphe  are 
moderately  developed,  and  are  most  numerous  ventrally. 
Here  they  come  via  the  anterior  arcuate  fibres  from  the  cor- 
pus restiforme  ;  they  pass  up,  and  having  crossed,  enter 
the  lemniscus. 

It  thus  appears  that  the  fibres  of  the  raphe  serve  to  con- 
nect the  cranial  nerve  nuclei  with  the  pyramids,  and  also 
with  the  lemniscus  or  corpus  restiforme. 


A  CASE  OF  ANENCEPHALY. 


27 


SECTION  IV. — At  a  higher  level  of  the  pons,  but  still 
below  the  middle  and  at  about  the  level  of  the  nucleus  of 
the  sixth,  the  lemniscus  is  seen  in  its  altered   position  lying 


Ascend,  root  of  V 


vi.  Nerve 


Corp.  Trapezoid. 
Lemniscus. 


horizontally  upon  the  fibres  of  the  corpus  trapezoid,  which 
are  here  very  well  marked.  It  is  here  small.  The  fibres 
of  the  raphe  are  very  few.  The  formatio-reticularis  is  but 
imperfectly  developed  here. 


iv.  Nerve  . 

Motor  Nuc.  of  V. 

Sup.  Cerebral  Ped 
,  n.Teg. 


Post,  tubercles. 


.  Descend,  root  of  V. 

..  iv.  Nerve. 

.   Post.  Long.  Bund. 

Lat.  Lemniscus. 


Section  V. — In  a  section  still  higher,  through  the  upper 
part  of  the  pons  and  the  posterior  tubercles  of  the  corpora 


28 


CHARLES  L.  DANA. 


quadrigemina,  there  is  a  very  distinct  development  of  the 
lateral  or  lower  lemniscus,  while  the  median  or  upper  lem- 
niscus is  small. 

SECTION  VI.— At  a  still  higher  level,  just  through  the 
red  nuclei  and  touching  the  cephalic  edge  of  the  pons,  one 
notes  the  entire  absence  of  cerebral  peduncles.  The  red 
nuclei  are  apparently  well  developed. 


Ant.  tubercles  of 
—  Corp.  Quad. 


Form.  Retic.  -. 


Lemniscus 


Subst.  Nigra 


-  Nuc.  of  iii. 


—J     Post.  Long. Bundle. 


Red  Nucleus. 


Cephalic  edge  of  Pons. 


The  median  lemniscus  is  now  plainly  visible,  also  the 
nuclei  and  fibres  of  the  third  nerve.  The  lateral  lemniscus 
has  ended  in  the  posterior  tubercles,  and  is  not  seen. 
Fibres  can  be  seen  coming  from  the  posterior  commissure 
and  passing  down  to  enter  the  posterior  longitudinal  bundle. 
There  is  no  lenticular  loop.  The  corpora  quadrigemina 
seem  small  and  almost  structureless,  save  for  the  fibres  of 
the  posterior  commissure  which  run  through  its  lower  part. 
There  is  still  some  evidence  of  the  formatio-reticularis. 
The  substantia  nigra  is  present,  but  imperfectly  developed. 

At  this  level,  the  dorsal  part  of  the  raphe  contains  no 
fibres,  the  lower  or  ventral  partis  very  distinct,     The  fibre 


A  CASE  OF  ANENCEPHALY.  2g 

bundle  from  the  inner  part  of  crusta  is  absent.  The  fibre 
bundle  from  the  posterior  commissure  is  absent.  The  off- 
shoot bundle  of  Wernicke  is  absent.  The  nucleus  reticularis- 
tegmenti-pontis  sends  down  fibres  through  the  raphe.  This 
nucleus,  according  to  Bechterew,  is  the  end  station  of  fibres 
of  anterior  fundamental  column. 

The  aqueduct  of  Sylvius  is  imperfect.  The  posterior 
longitudinal  bundle  is  well  marked,  as  are  also  the  fibres 
from  the  anterior  cerebellar  peduncle.  The  descending  root 
of  the  fifth  is  here  visible.    The  nuclei  of  the  pons  are  present. 

Sections  through  the  optic  thalami  showed  a  nearly 
structureless  mass  containing  but  a  few  nerve  fibres  and  cells. 

SUMMARY:  The  pyramidal  tracts  are  absent,  and  in  con- 
sequence the  shape  and  relations  of  the  parts  are  changed. 

The  formatio  reticularis  is  apparently  normal. 

The  cranial  nerves  and  nuclei,  the  respiratory  bundle, 
posterior  longitudinal  bundle,  olives  and  supplementary 
olives,  and  in  inner  and  outer  nuclei  of  Roller,  are  present 
and  normal. 

The  sensory  decussation  and  interolivary  tract  and  lemis- 
cus  are  present,  but  the  median  portion  is  about  half  the 
normal  size. 

In  the  lower  sections  the  ventral  portion  of  the  interolivary 
tract  alone  is  normal  in  size,  the  parts  dorsal  to  it  being  barely 
visible;  at  higher  levels  (upper  olive),  the  tract  in  question  lies 
as  it  should  in  the  fibres  of  the  corpus  trapezoid,  but  is  small. 

At  still  higher  levels  (crossing  of  the  anterior  cerebellum 
peduncles)  the  lateral  or  lower  lemniscus  is  very  clearly  de- 
fined, the  median  very  scanty  in  fibres.  At  the  level  of  the 
red  nuclei  the  median  part  is  quite  distinct. 

The  following ,  therefore,  is  the  condition  of  the  lem.uscal 
tracts  : 

The  innermost  biindle  to  the  crusta  is  not  present. 

The  median  lemnisais  is  about  half  the  normal  size,  but 
is  traceable  as  far  as  the  anterior  tubercles  of  the  corpora 
quadrigemina,  which  it  appears  to  enter.  This  (the  median) 
is  the  lemniscal  tract  which  goes  partly  to  the  anterior 
tubercles,  partly  to  the  optic  thalamus  or  Luys'  body,  partly 
to  the  lenticular  nucleus  and  parietal  cortex  {Hauptschleifey 
Bechterew,  Rindenschleife  of  Monakow,  etc.,  upper  lemniscus. 


-,0  CJiARLES  L.  DANA. 

In  experimental  atrophies  the  degeneration  has  usually 
been  downwards,  but  in  Meyer's  case  it  was  upwards  in  toto, 
and  it  evidently  consists,  in  large  part  at  least,  of  afferent 
fibres. 

The  lateral  lemniscus  (lower),  which  begins  chiefly  in 
the  upper  olive,  by  which  it  is  connected  with  the  posterior 
branch  of  the  acoustic  nerve  (Bechterew,  Flechsig,  Ober- 
steiner),  is  present,  and  apparently  ends  in  the  posterior 
tubercles.     This  tract  is  doubtless,  therefore,  afferent. 

The  tegmental  part  only  of  the  crura  cerebri  is  present: 
The  substantia  nigra  is  present,  but  is  structurally  but  little 
developed. 

The  gray  nuclei  of  the  pons  are  present. 

The  Spinal  Cord. — As  a  whole  the  cord  is  smaller 
than  normal. 

The  diminished  size  is  due  to  the  small  anterior  and 
lateral  columns.  In  comparison,  the  posterior  columns 
look  unusually  large. 

The  nerve  roots  are  normal.  The  anterior  columns  are 
much  narrower  than  they  should  be,  but  show  nothing  ab- 
normal otherwise. 

The  lateral  columns  reveal  a  tract  of  connective  or  un- 
differentiated tissue  extending  throughout  the  length  of  the 


cord.  The  position  of  this  undeveloped  tract  in  the  upper  cer- 
vical region  is  peculiar.  As  shown  in  the  cut,  it  appears  to 
extend  laterally  and  ventrally  to  the  surface,  occupying,  in 
a  measure,  the  region  of  the  anterior  ascending  tract.  A 
few  nerve   fibres  are   present   in   this  region  ;  on  transverse 


A  CASE  OF  ANENCRPHALY.  3  I 

sections  of  the  cord  they  are  cut  off  obliquely  and  appear 
as  if  running  forwards  and  inwards.  The  direct  cerebellar 
tract,  Lissauer's  bundle,  which  may  be  called  the  posterior 
root  column,  the  postero-external  and  postero-median  col- 
umns are  normal. 

The  longitudinal  sections  were  made  at  the  level  of  the 
fourth  to  sixth  dorsal  roots,  the  plane  of  the  sections  being 
directed  anteriorly,  the  appearance  of  the  anterior  commis- 
sure was  studied  and  compared  with  similar  sections  in  a 
normal  cord. 

In  the  ancncephalic  cord  the  commissure  was  poorer  in 
fibres,  and  these  crossed  diretly  from  one  side  to  the  other 
at  a  very  acute  angle.  In  the  normal  cord  some  fibres 
crossed  in  this  way,  but  others  ran  along  the  edge  of  the 
fissure  for  a  short  distance  and  then  cross  at  a  more  obtuse 
angle.  This  must  represent  the  mode  of  crossing  of  the 
direct  pyramidal  tract  fibres. 


The  posterior  roots  can  be  seen  to  enter  in  two  bundles 
of  fibres  ;  one  of  fine  fibres  lies  external,  appears  to  connect 
directly  with  the  posterior  nerve  and  Lissauer's  bundle. 
The  other  divides  into  fibres  which  pass  through  (?)  and 
around  inner  side  of  subs.  gel.  to  posterior  cornual  cells  and 
Clark's  cells.  These  fibres  can  be  traced  to  the  anterior 
cornu  of  same  side  and  through  the  anterior  commissure 
to  the  anterior  cornu  of  the  other  side. 


-,2  CHARLES  L.  DA XA. 

The  anterior  commissure  is  divided  into  two  parts,  one 
lying  anterior  to  the  other,  and  it  is  through  the  posterior 
one  that  the  posterior  cornual  fibres  pass. 


The   gray  matter   of  the  cord  and  its  cells  are  fairly  de- 
veloped. 


ON  OIL  OF  GAULTHERIA  AND  SALOL  IN  RHEU- 
MATISM OF  NERVES  AND  MUSCLES. 

By  F.  X.  DERCUM,  M.D. 

INSTRUCT un.    in    nEKVOUS   UISKASES,    UNIVERSITY   OF  PENNSYLVANIA. 

Read  before  the  Philadelphia  Neurological  Society. 

IT  will  hardly  be  necessary  to-night  to  speak  in  favor  of  a 
drug,  the  usefulness  of  which  has  become  so  well  estab- 
lished as  that  of  the  oil  of  gaultheria.     I  bring  it  before 
you  merely  to  provoke   discussion  on  such   points  as  the 
proper  indication  for  its  use,  its  dosage,  and  its  value  com- 
pared with  that  of  other  salicylates. 

It  appears  to  be  the  fate  of  all  new  drugs  to  De  ushered 
into  the  world  with  acclamations  and  applause,  and  the  oil 
of  gaultheria  has  been  no  exception  to  the  general  rule.  At 
the  same  time,  it  must  with  justice  be  maintained  that  no 
other  drug  has  suffered  less  from  the  ever-increasing  test  to 
which  it  has  and  is  being  subjected.  While  many  of  you 
will  not  accept,  without  modification  at  least,  the  conclusions 
of  Kinnicutt,*  one  of  the  earliest  writers  upon  the  subject,  I 
think  that  you  will  all  agree  that  the  drug  has  acquired  a 
fixed  and  definite  position  among  our  therapeutic  resources. 
I  myself  believe  that  Kinnicutt's  conclusions  are  in  the  main 
correct,  and  yet  it  is  very  evident  that  such  assertions  as 
that  the  administration  of  the  drug  is  unaccompanied  by 
occasional  toxic  effects,  and  is  unattended  by  frequent  gas- 
tric disturbance,  need  qualification.  Kinnicutt  speaks  es- 
pecially of  its  application  in  acute  forms  of  rheumatism.  He 
believes  it  to  be  at  least  equally  efficient  with  the  sodium 
salicylate  in  reducing  both  temperature  and  pain.     On  the 

-Francis  P.  Kinnicutt,  New  York  Medical  Record,  Vol.  xii.,  No.  19,  p.  505. 


-,,  F.  X.  DERCUM. 

j4 

other  hand,  Dr.  Squibb,*  in  a  recent  article,  claims  that  it 
does  not  relieve  pain  or  reduce  temperature  as  promptly  as 
sodium  salicylate  or  salicylic  acid,  and  that  it  disturbs  sight 
and  hearing -less  promptly  and  to  an  inferior  degree.  On 
the  whole,  he  concludes  that  it  is  best  adapted  to  the  milder 
cases  of  gouty  rheumatism  or  rheumatic  gout. 

My  own  experience  with  the  drug  is  limited  almost  en- 
tirely to  rheumatic  affections  of  the  nerves  and  muscles.  I 
have  tested  it  in  a  large  number  of  neuralgias  and  in  almost 
every  form  of  muscular  rheumatism.  In  trigeminal  neural- 
gias, in  neuralgias  of  the  nerves  of  the  extremities,  especially 
sciatica,  I  have  had  the  happiest  results.  The  failures  have 
been  the  exception,  and  indeed  they  have  been  so  few  that 
I  have  difficulty  in  calling  them  to  mind.  In  those  cases  in 
which  I  have  found  the  drug  to  act  most  promptly,  there 
was  almost  always,  I  should  state,  more  or  less  distinct  ten- 
derness of  the  nerve  trunk  or  tenderness  over  the  foramina 
of  exit. 

I  should  also  state  that  I  have  not  been  able  to  elicit  a 
history  or  other  evidence  of  rheumatism  in  every  case  of 
successful  application  of  the  drug,  and  it  is  perhaps  unfair  to 
conclude,  that  because  a  nerve  or  muscle  pain  is  benefitted 
by  a  salicylate,  that  it  is  necessarily  due  to  rheumatism.  In 
fact  it  is  not  only  possible,  but  extremely  probable,  that  the 
salicylates  are  beneficial  in  pains  other  than  rheumatic.  This 
suggestion  I  have  before  thrown  out,  and  I  may  be  perhaps 
pardoned  for  quoting  briefly  from  a  former  paper. t  "  That 
salicylic  acid  acts  directly  on  the  nervous  system  cannot,  I 
think,  be  doubted.  To  me  the  single  fact  of  the  ringing  in 
the  ears  is  an  evidence  of  such  action,  and  the  further  fact 
that  increased  doses  result  in  deafness,  a  confirmation  of  this 
idea.  Now,  if  salicylic  acid  produces  ringing  in  the  ears  and 
even  deafness,  it  is  probably  by  a  direct  action  of  the  drug 
in  what  we  may  call  the  acoustic  protoplasm  ;  that  is,  the 
acoustic  protoplasm  is  molccularly  impressed ;  it  has  the 
rates  and  directions  of  its  molecules  so  affected  as  to  give 

°Ed.  A.  Squibb,  Ephemiris,  October,  1887,  p.  $50. 

t  **  A  case  of  tic  douloureux  of  twelve  years  standing  treated  by  large  doses 
of  salicylates  with  marked  success."  l!y  F.  X.  Dercum,  Phila.  Med.  Times, 
Vol  xvii.,  p.  471. 


OIL  OF  GAULTHERIA  AND  SALOL.  *c 

rise  first  to  abnormal  sensations,  and  finally  it  has  the  mole- 
cules so  much  arrested  or  inhibited  as  to  give  rise  to  an  en- 
tire loss  of  function.  May  it  not  be  that  the  action  of  the 
salicylate  in  nerve  pains  is  sometimes  to  be  explained  by  its 
modifying  impress  on  the  abnormal  movements  going  on  in 
the  molecules  of  the  diseased  nerve,  and  is  it  not  possible 
that  it  deadens  hyperesthesia  and  annuls  pain  by  virtue  of 
the  same  quality  by  which  it  produces  deafness  ? 

It  is  hardly  necessary  to  refer  to  the  physical  properties 
of  the  oil  of  gaultheria  in  order  to  call  attention  to  the  prac- 
tical advantages  it  possesses  over  the  salicylate  of  sodium. 
In  the  vast  majority  of  cases  it  is  preferred  by  patients  to  the 
latter  drug.  It  is  free  from  the  soapy,  nauseating  taste  of 
the  latter.  In  therapeutic  doses,  it  is  well  born  by  the 
stomach,  provided  its  administration  be  not  too  long  con- 
tinued. However,  like  the  sodium  salt,  though  to  a  less  ex- 
tent, it  is  a  gastric  irritant.  If  it  be  exhibited  for  many  days 
in  succession,  disturbance  of  the  stomach,  though  not  marked 
at  first,  is  very  apt  to  follow,  besides  the  strong  and  pro- 
nounced flavor  of  the  drug  makes  its  continued  administra- 
tion in  some  cases  practically  inadmissible.  In  some 
instances,  however,  as  in  a  case  now  under  my  care,  it  is 
well  borne  for  a  period  of  many  months. 

Regarding  the  dose  of  the  drug,  I  have  been  in  the  habit 
of  prescribing  ten  or  twenty  minims  of  the  oil  to  be  taken  at 
intervals  of  three  or  four  hours.  This  has,  on  the  average, 
proved  sufficient  to  produce  marked  impression  within 
twenty-four  or  forty-eight  hours,  as  evidenced  by  the  subsi- 
dence of  pain  and  ringing  in  the  ears.  Occasionally  I  have 
given  it  in  larger  doses  and  at  shorter  intervals.  In  one  in- 
stance, a  case  of  muscular  rheumatism,  in  which  the  pain 
was  obdurate  and  excruciating,  I  gave  a  half  drachm  every 
two  hours,  with  the  result  of  a  rapid,  absolute,  and  perma- 
nent relief.  In  this  patient,  five  or  six  doses  of  the  drug 
Avere  taken  before  marked  symptoms  of  gastric  disturbance 
became  evident.  The  fifth  or  sixth  dose — I  do  not  remem- 
ber exactly  which — was  rejected  by  the  stomach.  The 
patient's  pulse  became  rapid,  the  tongue  coated,  and  his 
nausea  was  extreme,  and,  to  judge  by  the  description  given 


-,A  F.   X.  DERCUM. 

Ju 

by  himself,  "  cinchonism"  was  excessive.*  He  described  the 
ringing  in  the  ears  as  frightful.  However,  he  reacted  quickly, 
and  although  he  had  been  sickened  by  the  oil,  he  was  cured 
of  his  pain.  On  the  following  day,  in  fear  that  his  pain 
might  return,  he  of  his  own  accord  resumed  the  drug  in 
smaller  doses. 

Under  circumstances  in  which  the  patient  ceases  to  be 
tolerant  of  the  drug,  it  has  been  my  habit  of  late  to  fall 
back  on  salol. 

Salol,  the  salicylate  of  phenyl,  is  also  a  powerful  salicy- 
late. Like  so  many  other  new  drugs,  it  has  been  heralded 
to  the  world  in  a  most  extravagant  manner.  It  would  be 
difficult  indeed,  judging  from  the  paper  of  Herman  Sahli.t 
to  discover  the  therapeutic  virtues  that  the  drug  does  not 
possess.  It  is  good,  he  tells  us,  all  the  way  from  rheuma- 
tism and  typhoid  fever  to  gonorrhoea  and  the  initial  lesion  of 
syphilis,  and  a  great  deal  more  besides. 

In  my  own  experience,  salol  has  special  virtues  of  special 
application.  It  is  an  almost  tasteless,  fatty,  insoluble  pow- 
der, which  is  as  bland  and  unirritating  to  the  mucous  mem- 
brane of  the  stomach  as  so  much  powdered  parafine  would 
be.  It  is  apparently  not  acted  upon  by  the  gastric  juice,  but 
depends  for  its  digestion  upon  the  pancreas.  At  least  it  is 
decomposed  in  the  small  intestine  into  salicylic  and  carbolic 
acids.  This  change  likewise  takes  place  when  salol  is  mixed 
with  pancreatic  secretion  or  with  pancreatic  tissue  outside  of 
the  body. 

As  far  then  as  the  stomach  is  concerned,  it  is  innocuous 
and  inert,  and  it  frequently  proves  a  grateful  relief  to  that 
viscus,  especially  when  the  oil  of  gaultheria  or  the  salicylate 
of  sodium  have  been  given  for  some  time.  Judging  from  my 
own  experience,  it  is  slower  in  producing  its  physiological 
action  than  the  other  salicylates.  The  effect  is  not  as  pro- 
nounced and  much  less  prompt.  That  it  is,  however,  effi- 
cient in  the  same  class  of  cases  as  the  oil  of  gaultheria  there- 
can  be  no  doubt.      I    generally  prescribe   fifteen   or   twenty 

*  See  also  Wood  &  Hare,  Therapeutic  Gazette,  1886,  p.  73. 
f  Herman  Sahli,  Ueber  die  therapeutische   Anwcndung  des  Salols.     Corrc- 
pondenz-Blatt  fur  Schweizer  Aerztc,  1886,  xvi.,  p.  321  and  350. 


OIL  OF  GAULTHERIA  AND  SALOL.  „- 

O/ 

grains  to  be  taken  every  three  or  four  hours.  The  effect  is 
gradually  produced,  and  is  manifested  in  large  doses  by 
more  or  less  "  cinchonism."  Curiously  enough,  I  have  noticed 
that  the  ringing  in  the  ears  is  less,  but  the  deafness  more 
marked,  than  from  the  gaultheria.  Occasionally  patients 
will  mention  the  darkening  of  the  urine  due  to  the  presence 
of  carbolic  acid. 

Now  and  then  patients  object  to  the  drug  on  account  of 
its  greasy  feel  and  greasy  taste,  and  sometimes  of  their  own 
accord  ask  to  be  placed  back  on  the  gaultheria  Occasion- 
ally, of  course,  it  is  well  to  alternate  the  gaultheria,  instead 
of  with  salol,  with  the  sodium  salicylate. 

For  the  various  affections,  then,  which  we  as  neurolo- 
gists are  called  upon  to  prescribe  salicylic  acid  preparations, 
I  for  one  much  prefer  the  oil  of  gaultheria.  Secondly,  I  fall 
back  upon  salol  now  and  then  in  order  to  give  the  stomach 
a  rest  ;  and,  thirdly,  I  regard  salol  as  inferior  in  efficiency. 
Occasionally  I  use  the  sodium  salt,  but  only  when  the  patient 
objects  to  the  decided  flavor  of  the  oil. 


NOTE  OX  NITRO-GLYCERINE  IN  EPILEPSY. 

By  WILLIAM  OSLER,  M.D., 

PROFESSOR    OF     CLINICAL     MEDICINE   IN     THE   UNIVERSITY    OF   PENNSYLVANIA;     PHYSICIAN     TO     THE 
INFIRMARY    FOR   NERVOUS   DISEASES,    PHILADELPHIA. 

NATURALLY  enough,  when  the  remarkable  action  of 
the  nitrites  on  unstriped  muscle  was  discovered,  their 
use  was  suggested  in  epilepsy,  a  disease  believed  to 
be  due  to  arterial  spasm  in  the  hemispheres.  Nitrite  of 
amyl,  nitro-glycerine,  and  nitrite  of  sodium  have  been  care- 
fully tried  by  many  observers  with  very  varied  results.  Dr. 
Wier  Mitchell  and  Dr.  Hammond  were,  I  believe,  the  first 
to  employ  nitro-glycerine  in  this  disease,  and  they  have  re- 
ported beneficial  effects  in  suitable  cases.  I  was  induced  to 
try  it  by  the  very  favorable  results  reported  by  Dr.  F.  W. 
Campbell,  of  Montreal.  I  have  used  it  in  nineteen  cases.  It 
may  be  administered  in  solution,  one  per  cent.,  or  in  pilules  of 
i-ioo  of  a  grain  ;  and  I  find  the  latter,  as  prepared  by  reli- 
able chemists,  very  satisfactory.  I  begin  with  two,  three 
times  a  day.  As  individuals  appear  to  differ  in  their  suscep- 
tibility to  this  drug,  each  case  must  be  tested  before  the 
proper  dosage  can  be  determined.  I  doubt  if  any  good  fol- 
lows unless  the  physiological  effect  is  obtained.  Sensations 
of  flushing  of  the  face,  fullness  of  the  head,  and  a  pleasant 
glow  over  the  body,  indicate  that  the  proper  dose  has  been 
reached.  In  some  patients  these  symptoms  are  produced  by 
one  or  two  pilules,  but  in  others  not  until  six  or  eight  have 
been  taken.  Headache  and  dizziness  were  the  only  un- 
pleasant symptoms  complained  of,  and  on  this  account,  in 
two  instances,  the  medicine  had  to  be  stopped.  I  have  notes 
of  nineteen  cases  in  which  the  nitro-glycerine  was  tried  for 
periods  ranging  from  six  weeks  to  six  months.     In   thirteen 


NITRO-  GL  YCERINE  IN  EPILEPS  Y.  „  rt 

09 

of  these  cases  there  were  severe  epileptic  seizures,  six  were 
instances  of  petit  mat  with  occasional  convulsions.  Briefly 
stated,  in  nine  cases  there  was  improvement,  as  shown  in 
the  reduction  of  the  frequency  of  the  attacks.  Of  these,  six 
were  cases  of  major  epilepsy  ;  and  three,  instances  of  petit 
mal.  The  benefit  was  usually  manifested  within  a  week  or 
ten  days.  Thus  case  16,  a  man  aged  27,  had  had  fits  for  ten 
years,  and  when  seen,  April  5th,  had  as  many  as  two  or 
three  a  day.  He  had  taken  potassium  bromide  largely,  and 
at  one  time  with  great  benefit.  Antifebrin  was  given  in 
gr.  viii,  two  or  three  times  a  day,  but  seemed  to  be  without 
any  influence.  On  June  1st,  nitro-glycerine  was  given,  1TI  v 
of  the  one  per  cent,  solution,  three  times  a  day.  Within  a 
week  the  attacks  were  greatly  lessened,  and  in  the  second 
week  after  beginning  he  had  only  two  attacks.  He  con- 
tinued to  take  it  all  through  the  summer,  getting  up  to 
H|viii  doses,  t.  i.  d.  He  does  not  think  that  anything  he  has 
ever  taken  reduced  the  fits  so  much.  On  November  nth, 
he  stated  that  he  had  stopped  it  for  a  month  ;  the  attacks 
have  recurred  less  frequently,  and  he  had  been  able  to  be  at 
work. 

In  some  of  the  cases  in  which  the  betterment  was  most 
striking  at  first,  the  remedy  seemed  to  lose  its  influence,  and 
after  a  month  or  two  had  to  be  abandoned.  I  cannot  say 
that  in  any  one  of  the  nine  cases  the  improvement  has  been 
more  than  temporary.  In  two  of  the  cases  of  petit  mal  the 
attacks  were  greatly  reduced,  and  one  patient  remained  free 
for  two  months,  but  I  learn  by  letter  that  the  attacks  have 
returned.  Altogether,  my  experience  has  not  been  very 
encouraging.  We  may  say  that,  in  a  limited  number  of 
cases,  when  the  bromides  have  failed  or  are  beginning  to 
lose  efficacy,  nitro-glycerine  may  be  used  with  advantage. 
I  have  also  used  the  nitrite  of  sodium  in  a  few  cases  with 
indifferent  success. 


NOTE  ON  ANTIPYRIN  AS  AN  ANALGESIC. 

By  J.  C.  WILSON,  M.D. 

PHILADELPHIA. 

ANTIPYRIN— dimethyloxy  chinizin,  C„  HI2  N2  O— 
may  share  with  antifebrin,  thallin,  and  other  anti- 
pyretic drugs  the  property  of  reducing  fever.  All 
antipyretic  drugs  may,  in  view  of  the  dangers  which  attend 
their  use,  and  the  passing  duration  of  their  effects,  yield  to 
the  employment  of  external  antipyretics  in  the  treatment 
of  grave  febrile  states.  But  for  the  relief  of  certain  forms  ot 
pain,  antipyrin  seems  destined  to  occupy  a  place  in  thera- 
peutics second  only  to  that  of  the  derivatives  of  opium. 

The  prediction  of  Germain  See,  made  July,  1886,  that 
this  drug  would  largely  take  the  place  of  morphine,  has  al- 
ready been  realized.  While  its  employment  was  yet  restricted 
to  the  management  of  fever,  careful  observers  were  impressed 
with  its  calmative  action  upon  the  nervous  system,  an  effect 
often  manifested  when  the  doses  have  failed  to  bring  about 
any  considerable  fall  of  temperature.  It  is  evident  that  the 
therapeutic  activity  of  antipyrin  is  exerted  in  a  two-fold 
manner,  first,  against  fever  as  a  symptom  ;  second,  against 
pain.  These  effects  are  produced  independently  of  each 
other.  The  general  experience  of  the  profession  indicates 
pretty  clearly  that  the  antipyretic  action  of  the  drug  is 
without  influence  upon  the  pathological  conditions  underly- 
ing the  fever,  and  is  therefore  not  curative,  its  beneficial 
influence  being  limited  to  the  lowering  of  abnormally  high 
temperatures  and  the  prevention  of  the  secondary  damage 
which   intense   pyrexia  inflicts. 

It  appears  to  me  that  the  action  of  antipyrin   in    painful 


ANTIPYRIN  A  S  AN  ANAL  GESIC.  *  j 

affections,  and  especially  in  those  in  which  its  more  bene- 
ficial effects  are  shown,  namely,  painful  affections  of  the 
nervous  system,  in  contradistinction  to  those  due  to  lesions 
of  other  structures,  as  traumatism,  inflammations,  pressure, 
and  so  on,  is  somewhat  analogous  ;  that  is  to  say,  antipyrin 
relieves  pain  without  especially  influencing  the  pathological 
underlying  condition.  Where  pain  constitutes  the  chief  or 
only  symptom  of  the  malady,  as  in  neuralgia,  myalgia,  an- 
gina, and  the  like,  to  relieve  it  is  to  cure.  When  such  a  malady 
is  in  itself  transient,  to  anticipate  its  more  intense  manifes- 
tations, or  to  ckeck  them  in  the  beginning,  is  likewise  to 
cure.  A  study  of  antipyrin  from  this  point  of  view  may 
serve  to  indicate  at  once  its  sphere  of  usefulness,  and  to  ap- 
proximately fix  the  limitations  of  that  usefulness. 

At  a  time  time  when  the  journals  teem  with  observations 
in  regard  to  this  drug  I  would  hesitate  to  occupy  your  atten- 
tion with  the  results  of  my  own  experience  were  it  not  for 
the  hope  of  eliciting  useful  discussion. 

I  have  used  antyprin  in  a  great  variety  of  painful  affec- 
tions during  the  past  year,  both  in  private  and  in  hospital 
practice.  The  time  allotted  me  does  not  permit  any  detailed 
review  of  the  cases,  and  a  mere  statistical  enumeration  of 
them  would  serve  no  useful  purpose.  It  has  been  adminis- 
tered by  the  mouth,  by  the  rectum,  and  subcutaneously. 

With  regard  to  dosage,  my  experience  leads  me  to  be- 
lieve that,  as  a  very  general  rule,  full  analgesic  effects  may 
be  obtained  by  amounts  much  smaller  than  usually  advised. 
I  have  seen  the  best  results,  not  at  all  inferior  in  promptness 
and  degree  to  those  of  morphine  injections,  follow  ten-grain 
doses  by  the  mouth.  My  present  practice  is  to  order  five,  or 
seven  and  a  half,  or  ten  grain  powders,  according  to  circum- 
stances, and  to  direct  that  one,  two,  or  three  to  be  taken  in 
cold  water  at  intervals  of  an  hour.  So  soon  as  pain  ceases 
the  medicine  is  discontinued,  to  be  resumed  at  once  upon 
the  recurrence  of  pain.  In  many  instances,  one  or  two  doses 
only  have  been  required. 

The  dose  by  enema  is  about  double  that  by  the  mouth. 

Antipyrin  is  extremely  soluble,  and,  as  a  rule,  unirrita- 
ting      Its  use  by  subcutaneous  injection  is  convenient.     A 


,2  7-   C.    WILSOX. 

sense  of  tension  and  moderate  stinging  pain  are  experienced 
at  the  place  of  injection.  These  phenomena  rapidly  subside. 
The  dose  for  subcutaneous  injection  is  from  three  to  seven 
and  a  half  grains. 

The  administration  of  antipyrin  in  those  doses  to  patients 
free  from  fever,  is  not  followed  under  ordinary  circum- 
stances by  marked  manifestations  beyond  the  abatement  of 
pain  and  a  certain  transient  sense  of  bien  aise.  The  temper- 
ature does  not  fall  below  the  normal  ;  sweating  is  some- 
times copious,  oftener  only  of  moderate  degree,  still  more 
often  scanty  or  absent  altogether.  The  pulse  is  at  first 
slightly  accelerated,  but  soon  resumes  its  previous  traits.  In 
a  few  instances,  I  have  observed  transient  and  insignificant 
cardiac  depression  ;  once  only,  and  that  after  a  five-grain 
dose  by  the  mouth,  in  the  case  of  a  very  fat,  middle-aged 
woman  with  feeble  heart,  alarming  syncope  with  cyanosis 
and  urgent  dyspnoea. 

Patients  taking  antipyrin  for  the  relief  of  pain  are  not 
allowed  to  go  about,  but  are  in  all  cases  advised  to  keep  the 
recumbent  posture. 

In  two  or  three  instances  there  has  appeared  the  tran- 
sient scarlatinous  eruption  which  occasionally  follows  the  use 
of  the  drug.  The  nature  of  the  cases  in  which  antipyrin  has 
proved  of  service  has  been,  in  the  order  of  the  degree  of 
benefit  :  neuralgias — trigeminal,  occipital,  sciatic,  intercos- 
tal ;  gastralgia  and  enteralgia,  migraine,  and  the  nervous 
headache  of  fatigue  ;  myalgias — especially  wry  neck,  lum- 
bago, pleurodynia,  the  pains  of  neurasthenic  subjects,  and 
the  myalgia  of  the  abdominal  muscles  caused  by  persistent 
cough,  as  in  measles  ;  the  precordial  pain  pf  advanced  dis- 
ease of  the  heart,  both  fibroid  degeneration  and  the  dilatation 
of  late  valvular  diseases,  pseudo-angina  pectoris — I  have 
had  no  opportunity  to  test  it  in  true  angina  pectoris  nor  in 
tabes — and  finally  the  paroxysmal  pains  of  gout  and  rheu- 
matoid arthritis. 

I  have  found  antipyrin  much  inferior  to  the  salicylates, 
both  in  relieving  the  pains  and  in  hastening  the  termination 
of  rheumatic  fever,  and  no  longer  employ  it  in  the  treatment 
of  that  malady. 


ANTIPYRJN  AS  AN  ANALGESIC.  A  -> 

It  has  yielded  very  satisfactory  results  in  the  paroxysms 
of  asthma,  in  the  asthmatic  form  of  hay  fever,  in  whooping- 
cough,  and  in  certain  forms  of  dysmenorrhea.  It  has  failed 
me  in  cases  of  pleurisy,  internal  malignant  disease,  thoracic 
and  abdominal  aneurism,  and  in  painful  inflammatory  dis- 
eases generally. 

Germain  See  has  experimentally  established  the  follow- 
ing facts  : 

i.  "  A  very  noted  diminution  in  the  general  sensibility 
and  a  true  analgesia  in  the  members  which  receive  the  in- 
jection of  the  remedy  ;  sometimes  also  in  the  opposite 
limb. 

2.  "  The  electrical  excitation  in  the  sciatic  nerve,  in  the 
animal  under  antipyrin,  produces  only  a  feeble  reflex  con- 
traction, indicating  enfeeblement  of  the  sensory  perceptivity 
and  reflex  activity  of  the  spinal  cord."  {Therapeutic  Gazette, 
Oct.  15th,  1887.)  Its  physiological  antagonism  to  strych- 
nine has  been  shown  by  the  experiments  of  Chouffe — ibid. 

Antipyrin  is  a  true  analgesic,  acting  through  the  central 
nervous  system.  Its  role  in  therapeutics  is  the  relief  of  cer- 
tain kinds  of  pain.  To  this  end  it  should  be  used  as  we  have 
been  in  the  habit  of  using  morphine  for  the  same  purpose  ; 
that  is,  from  time  to  time  as  pain  recurs.  It  is  useless  to 
administer  it  to  patients  suffering  from  recurrent  neuralgias 
or  other  paroxysmal  affections  in  the  intervals  of  the  attack, 
in  the  hope  of  affecting  a  cure.  On  the  contrary,  the  very 
action  which  renders  it  useful  during  the  paroxysm  must, 
when  prolonged  in  certain  cases,  increase  the  underlying 
defect  in  the  nervous  system.  Furthermore,  the  danger  of 
establishing  such  a  degree  of  tolerance  as  would  render  or- 
dinary doses  inoperative,  is  to  be  borne  in  mind. 

Finally,  among  the  advantages  of  antipyrin  as  an  anal- 
gesic, must  be  included  these  :  that  it  is  in  ordinary  doses 
well  borne  by  the  stomach  ;  that  it  causes  neither  loss  of 
appetite  nor  constipation  ;  and  that,  so  far  as  is  yet  known, 
its  use  is  not,  as  with  morphine  and  chloral,  attended  by 
the  danger  of  the  formation  of  a  vicious  habit. 


THEINE    IN   PAIN. 

By  THOMAS  J.  MAYS,  M.D. 

THEIXE  is  the  active  principle  of  Chinese  tea.  It  is 
an  alkaloid,  and  was  first  found  by  Oudry  in  1827, 
and  subsequently  confirmed  by  Mulder  and  Jokt  in 
1838.  It  was  believed  to  be  identical  in  composition  and 
in  action  with  caffeine  and  guaranine.  Chemically,  it  is 
known  as  tremethylxanthine,  and  occurs  in  snow-white, 
needle-like  crystals,  is  almost  tasteless,  and  is  soluble  in 
fifty  parts  of  cold,  but  more  soluble  in  warm,  water. 

Our  first  experiments  were  made  with  this  agent  about 
two  years  ago ;  and  on  a  frog  we  found  that  its  action  is  as 
follows  : 

(1).  It  has  a  special  affinity  for  the  nerves  of  sensation. 
(2).  It  produces  anaesthesia  when  administered  subcuta- 
neously.  (3).  Its  anaesthetic  action  is  confined  below  the 
seat  of  injection.  On  man  its  physiological  action  may  be 
summed  up  as  follows  :  When  tasted,  it  produces  a  slight 
tingling  on  the  end  of  the  tongue,  which  is  immediately 
followed  by  local  anaesthesia.  Subcutaneously,  in  the  arm 
— dose  from  one-fifth  to  half  a  grain — numbness  of  arm  and 
hand  below  seat  of  injection,  a  feeling  of  coldness  and  a 
slight  disturbance  of  temperature,  and  a  reduction  in  the 
pulse  rate,  but  no  intoxication  of  the  brain. 

Since  theine  is  of  precisely  the  same  chemical  composi- 
tion as  caffeine,  it  was  supposed  that  these  two  substances 
must  be  identical  in  their  physiological  action,  although 
Leven,  as  far  back  as  1868,  demonstrated  that  theine  pro- 
duced convulsions  in  frogs  while  caffeine  did  not,  and  that 
caffeine  was    more    poisonons   than   theine.     The   principal 


THEINE  IN  PAIN.  a- 

reason  why  Leven  obtained  such  different  results  from  pre- 
vious investigators  was  that  he  used  the  genuine  alkaloids 
extracted  from  tea  and  coffee  separately,  which  does  not 
appear  to  have  been  the  case  with  the  other  experimentors. 
This  procedure  is  absolutely  necessary,  for  until  very  re- 
cently theine  and  caffeine  were  made  from  tea,  coffee, 
guarana,  kola  nut,  etc.,  from  whichever  source  it  was  least 
expensive,  and  both  alkaloids  were  dispensed  out  of  the 
same  bottle  and  labeled  to  suit  the  demands  of  the  pur- 
chaser. Hence  it  is  useless  to  employ  the  commercial 
theine  as  contained  in  the  market  at  the  present  time,  with 
the  exception  of  that  manufactured  by  Merch,  who  has 
informed  us  that,  since  our  second  series  of  experiments, 
he  manufactures  these  alkaloids  separately.  We  may  say 
that  we  have  examined  specimens  of  his  manufacture,  and 
that  they  gave  rise  to  the  characteristic  distinctive  test. 
Hence,  so  far  as  we  know,  only  that  which  comes  from 
Merch  and  is  labeled  theine  is  reliable,  and  can  be  expected 
to  give  the  reputed  clinical  results. 

When  the  action  of  theine  is  compared  with  that  of 
morphine,  we  find  that  there  is  quite  a  marked  difference  in 
their  action.  Morphine  produces  its  analgesia  by  primarily 
influencing  the  cerebral  centers,  although  there  can  be  no 
doubt  that  it  causes  a  certain  degree  of  local  anaesthesia  at 
the  seat  of  injection.  But,  specifically  speaking,  its  action 
is  central  and  not  local,  while  theine,  as  we  have  seen,  has 
a  local  action  independent  of  the  central  nervous  system. 
Its  action  is  confined  altogether  below  the  seat  of  its  injec- 
tion, and  never,  according  to  our  own  experience,  is  the 
brain  intoxicated.  This  localized  influence  demonstrates 
one  of  the  great  therapeutic  advantages  which  theine  pos- 
sesses over  morphine,  and  over  all  other  agents  of  this 
class.  By  acting  only  on  the  peripheral  portion  of  the 
trunk  of  a  nerve  and  of  its  ramifications,  it  leaves  the  higher 
nerve  centres  uninfluenced,  and  therefore  does  not  develop 
the  undesirable  central  intoxication  which  so  frequently 
follows  a  dose  of  morphine.  In  order  to  obtain  the  best 
practical  results  of  these  agents,  we  must  give  morphine 
when  the  pain  is  acute  and  when,  in  order  to  relieve  it,  it  is 


4 6  THOMAS  J.  MAYS. 

necessary  to  narcotize  the  central  seat  of  sensation,  while 
theine  is  most  beneficial  in  chronic  affections  of  the  sensory 
nerves. 

Administered  to  a  properly  adapted  case,  theine  is  sur- 
prisingly prompt  in  its  analgesic  action.  We  have  on 
numerous  occasions  observed  patients  with  lumbago,  who 
were  too  stiff  to  bend  their  bodies,  or  had  almost  too  much 
pain  in  their  backs  to  rise  from  a  chair  or  sit  down  after  they 
were  up.  comfortably  straighten  their  bodies  in  less  than 
five  minutes  after  its  introduction.  When  not  so  prompt,  it 
is  probably  due  to  the  small  size  of  the  dose,  and  where 
one-half  of  a  grain  does  not  produce  the  desired  results,  it 
should  be  increased  to  one,  or  even  two  grains. 

When  injected,  it  gives  rise  at  first  to  some  burning,  but 
it  does  not  produce  any  prolonged  irritation  or  inflamma- 
tion. The  burning  is  soon  replaced  by  an  area  of  anaesthe- 
sia. Since  its  solubility  in  water  is  very  low,  we  prepare  it 
with  benzoate  of  soda,  according  to  the  following  formula  : 

R     Theinae,  .... 

Sodae  benzoa,  -            -            -             -  aa  3  '• 

Sodae  chloridi,  -             -             -             -  gr.  viii. 

Aquae,   -  -             -             -  fl  g  i. 

M.     Sig. — For  hypodermatic  use.     Six  minims  equal  one-half 
grain  of  theine. 

We  have  used  theine  as  an  analgesic  for  more  than  a  year, 
but  we  will  not  inflict  on  you  a  relation  of  the  histories  of 
cases  which  we  have  treated,  and  will  simply  say  that  we 
have  had  very  good  results  from  it  in  myalgia,  intercostal 
neuralgia,  brachialgia,  etc.,  and  in  addition  to  these  will 
relate  a  few  cases  of  sciatica  in  which  it  was  employed.  It 
is  but  fair  to  state  that,  in  connection  with  the  theine,  we 
also  prescribed  iron,  quinine,  salicylate  of  soda,  iodide  of 
potassium,  etc. 

SCIATICA. 
Case  I. — Mrs.  A.,  aged  49  years,  came  under  my  care 
May  2d,  1885,  when  she  had  constant  pain  in  right  leg  from 
hip  to  foot  ever  since  the  preceding   Christmas.     The   pain 


ANTI PYRIN  AS  AN  ANALGESIC.  aj 

followed  the  course  of  the  nerves  of  the  leg,  and,  of  course, 
was  very  much  aggravated  by  walking.  The  leg  was  con- 
siderably atrophied,  and  was  weak  and  uncertain  in  its  gait. 
Her  appetite  was  poor  and  bowels  irregular,  and  she  passed 
whole  nights  without  sleep  on  account  of  pain.  She  was 
anaemic,  and  had  been  treated  with  iron,  quinine,  ammonia, 
salicylate  of  sodium,  iodide  of  potassium,  atropine,  mor- 
phine, poultices,  blister,  etc.,  without  avail,  until  the  follow- 
ing 1 8th  of  July,  when  I  injected  one-fifth  grain  of  theine 
into  the  calf  of  her  leg.  The  pain  ceased  in  less  than  five 
minutes,  and  never  returned  in  its  original  force.  In  half  an 
hour  her  heel  and  foot  began  to  feel  numb  and  insensible, 
which  lasted  for  about  twelve  hours  ;  but  her  mind  was  per- 
fectly free  from  its  influence.  She  experienced  no  headache 
or  drowsiness. 

July  20th. — Pain  in  whole  leg  better  since  last  injection, 
but  has  not  entirely  disappeared  from  the  thigh,  so  I  intro- 
duced one-fifth  grain  into  the  latter  region. 

July  28th. — Leg  altogether  free  from  pain,  but  still  com- 
plains of  some  in  foot  ;  otherwise  she  is  improving.  Injected 
one-fifth  grain  over  instep. 

September  6th, — Feels  better  ;  slight  pain  around  ankle- 
joint.  Injected  one-tenth  grain  at  this  point.  This  was  the 
last  injection  she  received,  and  she  made  an  uninterrupted 
recovery. 

Case  II. — B.,  aged  50,  carpenter,  was  first  seen  April  3d, 
1886,  when  he  complained  of  a  severe  pain  for  nearly  two 
years  in  lumbar  region  radiating  down  both  legs.  He  is 
stiff  in  both  legs  and  in  the  back,  and  rises  from  a  chair  with 
great  difficulty.  He  had  malaria,  but  gives  no  specific  or 
rheumatic  history.  Injected  half-grain  doses  of  theine  on 
each  side  of  the  sacrum,  and  two  doses  of  similar  strength 
between  the  trochanter  on  both  sides.  He  said  it  relieved 
the  pain  and  stiffness  at  once,  and  that  he  was  as  able  as 
ever  to  get  up  from  a  chair. 

April  6th. — Says  he  is  better,  but  still  has  some  pain. 
Repeated  the  injections,  and  internally  gave  him  the  quinia 
and  ammonia  mixture. 

April  10th. — Pain  nearly  all  out  of  back  ;   legs  feel  some- 


,5  THOMAS  J.  MAYS. 

what  stiff.  Two  injections  between  trochanters  on  both 
sides.  Same  internal  treatment.  This  patient  continued  to 
improve,  and  was  entirely  well  by  end  of  same  month. 

Case  III — L.  M.,  aged  60,  came  to  me  April  22d,  1886, 
complaining  of  severe  pain  in  sacral  region,  which  radiated 
down  both  extremities  as  far  as  the  knees.  Injected  half  a 
grain  on  each  side  of  sacrum,  and  she  expressed  herself 
much  relieved  immediately  after  the  injection.  Internally 
she  received  the  quinia  and  ammonia  mixture. 

April  24th. — Better  ;  pain  in  sacral  region  almost  gone, 
and  she  could  walk  better  than  before.  Injected  half  a  grain 
in  the  fleshy  part  of  each  leg. 

April  27th. — Xo  pain  in  back.  Did  a  heavy  day's  wash- 
ing without  producing  any  pain  in  back,  since  her  last  visit. 
This  she  had  not  been  able  to  do  for  a  long  time.  The  only 
pain  she  complains  of  now  is  in  her  left  leg  from  knee  to 
ankle-joint.  Injected  half  a  grain  above  the  knee.  The 
pain  disappeared  at  once.  With  the  same  internal  treat- 
ment and  an  occasional  injection,  she  continued  to  do  well. 

Case  IV. — E.,  aged  35,  came  under  observation  June 
20th,  1887,  when  he  gave  the  following  history  :  Pain  along 
both  sciatic  nerves  during  the  last  three  years.  The  attacks 
of  pain  come  on  simultaneously  in  both  nerves,  although  the 
left  leg  is  the  worst.  Some  loss  of  motor  power  in  left  leg. 
Has  had  malaria  and  rheumatism.  Some  burning  in  soles 
of  feet.  Injected  half  a  grain  of  theine  in  each  buttock  over 
the  course  of  the  sciatic  nerves.  Internally  gave  him  the 
quinia  and  ammonia  and  soda  salicylic  mixture  in  alterna- 
tion every  three  hours. 

June  2 1st. — Pain  better  last  night  than  it  has  been  for  a 
long  time.  Slept  well,  which  he  had  not  done  for  several 
nights.  Gave  him  two  more  injections  in  same  regions,  and 
continued  same  internal  treatment.  The  pain  at  no  time 
became  bad  again,  and  in  less  than  a  month  of  the  treat- 
ment outlined  above  he  was  entirely  free  from  pain,  could 
sleep  well,  had  regained  the  want  of  power  which  existed  in 
his  left  leg,  and  he  was  able  to  resume  his  vocation. 


REVIEWS. 


Insanity — Its  Classification,  Diagnosis,  and  Treat- 
ment. A  Manual  for  Students  and  Practitioners  of 
Medicine.  By  E.  C.  Spitzka,  M.D.  Second  edition. 
F.  B.  Treat,  publisher,  771  Broadway. 

The  rapid  exhaustion  of  the  first  edition  of  this  work  is  a  demon- 
stration of  the  profession's  recognition  of  the  ability  of  the  author  and 
its  desire  to  become  acquainted  with  his  view,  which,  it  had  every 
reason  to  suspect,  would  be  to  a  great  extent  original.  Nor  can  this 
expectation  be  said  to  be  not  realized  by  a  perusal  of  this  work,  since 
the  author's  personality  pervades  almost  every  page. 

In  reviewing  a  second  edition,  it  becomes  the  duty  of  the  critic 
to  compare  it  with  the  first.  By  such  a  comparison  we  cannot  say 
that  any  great  changes  present  themselves  in  this  manual,  excepting 
the  correction  of  a  few  typographical  errors ;  the  modification  of  the 
tone  of  the  foot-notes,  which  in  the  first  edition,  although  they  may 
have  expressed  the  author's  true  sentiments,  ought  to  have  been 
nevertheless  foreign  to  a  scientific  work  and  to  have  found  no  place 
therein.  Still  we  can  very  well  understand  the  position  of  the  author 
in  this  regard,  for  it  is  our  opinion  that  the  patience  of  Job  himself 
would  have  been  sorely  tried  to  have  men  who  claim  to  be  expert 
alienists,  denying  in  ioto  some  of  the  most  fundamental  truths  of 
psychiatrical  science.  Hence,  we  suppose,  the  author  seized  the 
only  opportunity  which  presented  itself  to  show  the  deficient  educa- 
tion of  such  men  and  thus  established  the  fact  that  no  weight  should 
be  attached  to  their  teachings.  That  the  author  saw  his  mistake  and 
corrected  it  is  a  matter  for  congratulation. 

Other  modifications  consist  in  the  adoption  of  the  term  "paranoia" 


-0  REVIEWS. 

for  monomania,  and    the  addition  of  an  appendix  which  is  com- 
posed of  a  series  of  additions  to  the  original  text. 

That  the  change  of  term  was  a  wise  one  will  be  accepted,  we 
think,  by  all,  excepting  a  few  controversialists  who  still  cling  to  the 
belief  that  "monomania"  and  "paranoia"  are  not  expressive  of  any 
definite  mental  aberration.  But  the  fact  that  Mendel,  of  Berlin, 
adopted  this  substitution  for  the  German  "  Verrucktheit"  has  led  the 
author,  as  he  says  in  the  preface,  to  make  the  same  adoption  and  for 
the  same  reasons. 

The  additions  comprising  the  appendix  either  supply  deficiencies 
in  the  original  text  or  further  elucidate  the  author's  statements  therein. 
The  strongest  and  best  timed  of  these  is  a  very  just  criticism  on 
oophorectomy  as  a  means  of  curative  procedure  in  mental  disorders. 
It  his  high  time,  we  think,  that  indiscriminate  oophorectomies  should 
cease  and  that  gynaecologists  should  view  the  fact  that,  though  they 
be  good  operators,  they  may  not  be  good  alienists  ;  and  should  hence 
hesitate  to  operate,  especially  where  such  a  great  difference  of  opinion 
exists  among  alienists  as  to  the  curative  effect  of  this  operation  on 
hysteria  and  insanity.  In  fact  the  great  weight  of  opinion  is  against 
operation,  for  in  the  largest  number  of  cases  operated  upon  for  these 
troubles  no  change  occurred  in  the  mental  condition.  The  author 
well  says  "certainly  those  forms  of  insanity  which,  like  primary 
paranoia  and  moral  imbecility,  are  due  to  a  neurotic  taint  and  de- 
fect, should  be  regarded  as  a  noli  me  langere  by  the  oophorectomist."' 

It  is  not  often  that  we  are  called  upon  to  pass  criticism  upon  the 
publisher's  portion  of  a  work.  In  fact,  works  of  small  scientific  value 
are  often  gotten  up  regardless  of  expense.  We  might  expect  that 
when  a  book  of  such  intrinsic  worth  as  the  one  under  consideration 
was  published,  that  the  publisher  would  prepare  and  issue  the  typo- 
graphical portion  in  uniformity  with  the  value  of  the  contents.  But 
here  our  expectation  was  not  realized.  Indeed,  not  only  the  general 
appearance  of  the  book  is  shabby,  but  the  paper  and  character  of 
the  type  seem  to  exhibit  a  most  parsimonious  and  impecunious  spirit 
on  the  part  of  the  publisher.  We  would  hence  suggest  to  the  author 
to  seek  another  publisher  when  he  issues  his  larger  work  on  insanity 
which  he  promises,  and  to  thus  prevent  a  physician's  library  being 
disgraced  by  such  binding  which  so  demeans  the  present  volume. 

X.  E.  B. 


REVIEWS. 


I 


Functional  Nervous  Diseases,  their  causes  and  their 
treatment.  Memoir  for  the  concourse  of  1881-1883. 
Academie  Royale  de  Medecine  de  Belgique.  With 
a  supplement  on  the  Anomalies  of  Refraction  and 
Accommodation  of  the  Eye  and  of  the  Ocular  Muscles. 
By  George  T.  Stevens,  M.D.,  Ph.D.,  Member  of  the 
American  Medical  Association,  etc..  etc.  New  York  : 
D.  Appleton  &  Co.,  1887,  pp.  217. 

The  work  before  us  is  the  memoir  which  received,  from  the 
Academie  Royale  de  Medicine  of  Belgium,  the  highest  honors 
awarded,  1881-1883.  The  author's  views  have  long  been  known  to 
neurologists  and  ophthalmologists,  and  have  been  considered  by 
them  as  heterodox,  especially  his  views  on  the  cure  of  chorea  and 
epilepsy  by  the  treatment  of  ocular  muscles.  The  first  eighty  pages 
treat  of  "  Functional  Nervous  Diseases,"  such  as  neuralgia,  migraine, 
etc.,  by  the  correction  of  errors  of  refraction,  especially  astigmatism. 
In  this  part  of  the  work  there  is  nothing  new,  as  all  have  known  that 
errors  of  refraction  are  a  common  cause  of  headache,  and  that  as 
soon  as  the  correction  was  given  the  pains  in  the  head  and  neck 
would  disappear.  On  the  other  hand,  the  treatment  of  muscular 
inco-ordination,  as  practiced  by  the  author,  is  new  and  of  his  own 
devising.  There  has  no  doubt  much  been  learned  during  the  past 
few  years  in  regard  to  muscular  asthenopia,  and  both  Landolt  and 
Stevens  have  done  much  to  this  end. 

The  nomenclature  suggested  and  used  by  the  author  for  the  dif- 
ferent ocular  insufficiencies  is  an  improvement  on  the  former  modes 
of  expression,  as  the  term  exophoria  is  much  more  convenient  than 
insufficiency  of  the  internal  rectus. 

As  to  accepting  the  belief  of  the  author,  that  ocular  muscles  out 
of  equilibrium  are  the  cause  of  epilepsy,  chorea,  and  such  affections, 
and  that  by  partially  dividing  them  relief  is  obtained,  the  reviewer  is 
not  in  accord.  In  fact  he  has  yet  to  see  any  case  of  chorea  or  epi- 
lepsy permanently  relieved  by  the  partial  or  even  thorough  division 
of  the  ocular  muscles.  That  cases  of  epilepsy  are  occasionally  for  a 
short  time  improved  by  an  operation  on  the  ocular  muscles,  is  doubt- 
less true,  and  it  is  as  equally  true  that  any  operation,  the  patient 
knowing  it,  no  matter  how  little  the  pain  inflicted,  will  have  the 
same  benefit,  owing  to  the  mental  effect  produced.  In  closing  this 
review,  we  cannot  advise  the  practice  of  its  teachings.  The  book  is 
well  written  and  well  published. 


^orifty  &rport$. 


NEW  YORK  XKUROLOGICAL  SOCIETY 

Meeting  held  December  6lh,  1887. 

The  President,    Dr.  C.   L  Dana,  in  the  Chair. 


Dr.  Waitzfelder  presented  a  case  of 

PROFESSIONAL    CRAMP. 

The  patient  was  a  man  38  years  of  age,  and  had  been  a 
cigarmaker  for  twenty  years,  lie  was  first  seen  by  the 
speaker  six  months  ago.  Six  months  before  this  he  had 
commenced  to  notice  a  stiffness  and  awkwardness  in  form- 
ing the  head  of  the  cigar.  This  required  a  rotary  motion  of 
the  thumb  and  index  finger.  At  first  he  was  able  to  sub- 
stitute his  middle  finger  in  the  manoeuvre,  but  later  the 
stiffness  extended  to  this  and  finally  to  the  little  finger. 
When  first  seen  there  was  some  anaesthesia  of  the  skin  and 
tonic  spasm  of  the  flexors  of  the  fingers.  These  contract- 
ures were  partially  relieved  by  rest,  although  they  never 
entirely  disappeared.  They  were  aggravated  by  any  effort 
tr.  work  at  his  trade,  and  by  changes  in  temperature  either 
to  heat  or  cold.  Exhibition  causes  relaxation  of  the  spasm, 
while  associated  movements  increase  it.  A  short  time  ago 
the  patient  had  tried  varnishing,  work  which  requires  only 
coarse  motions  of  the   hand,  but  was  obliged  to  give  it  up. 

The  patient  had  been  under  treatment  for  six  months  with 
galvanism,  faradism,  strychnine,  etc.,  without  improvement. 
Regarding  the  lesion  as  central,  the  speaker  suggested 
tching  the  radial  nerve,  with  the  object  of  inducing 
atrophy  in  the  central  cells,  which  might  be  considered  the 

ource  of  irritation.  As  Dr.  Seguin  had  seen  the  case,  his 
"pinion  was  requested. 


NEW  YORK  NEUROLOGICAL  SOCIETY.  -~ 

Dr.  Seguin  saw  nothing  which  would  distinguish  the  case  from 
one  of  aggravated  professional  spasm.  He  regarded  such  dyskineses 
of  central  origin,  and  would  favor  nerve  stretching.  His  experience 
had,  in  fact,  been  discouraging  in  any  treatment  ror  professional 
cramp.  A  case  of  waiter's  cramp  had  come  under  his  observation. 
He  mentioned  it  because  rare.  The  man  had  been  a  waiter  for  four- 
teen years,  carrying  plates  in  the  manner  of  his  class,  until  reaching 
a  stage  when  he  broke  dishes  and  spilled  their  contents  over  the 
guests. 

Dr.  E.  C.  Seguin  read  a  paper  upon 

THREE    CASES    OF    HEMIANOPSIA, 

of  peripheral  or  neural  origin,  with  a  study  of  the  symptom  hemi- 
opic  pupillary  inaction,  its  diagnostic  value,  etc. 

All  of  the  cases  were  supposed  to  have  a  neural  peripheral  lesion. 
All  presented  the  pupillary  reaction  hinted  at  by  Wm.  Graefe,  and 
described  by  Wernicke  as  the  hemiopic  pupillary  reaction,  a  symp- 
tom never  yet  observed  or  described  in  this  countrv. 

Case  I.  was  first  seen  October  26th,  1887,  referred  from 
the  Eye  Department  of  the  Manhattan  Hospital  by  Dr. 
Webster.  Six  years  previously  the  patient  had  commenced 
to  suffer  from  headache,  mostly  frontal,  also  nausea  and 
vomiting.  Two  years  previously  he  had  suffered  from  more 
or  less  constant  pain.  For  the  last  few  months  the  head- 
ache had  been  less,  but  he  had  lost  vision  in  the  left  eye. 
No  history  of  syphilis  was  obtained.  On  examination,  the 
right  visual  field  showed  temporal  hemianopsia  outside  the 
point  of  fixation.  The  visual  field  of  the  left  eye  was  com- 
pletely blind.  Vision  was  at  this  time,  R.  E.  $fo,  L.  E.  o. 
Light  thrown  into  the  left  eye  caused  no  reaction  in  either 
pupil.  If  thrown  into  the  right  eye  in  the  optical  axis,  good 
reaction  in  both  pupils  occurred.  If  the  light  was  moved 
nasalward,  reaction  was  obtained  in  both  pupils,  also  if 
moved  temporalward  within  an  angle  of  sixty  degrees.  If 
thrown  further  toward  the  temporal  or  blind  side,  no  re- 
action in  either  pupil  occurred.  The  centripetal  portion  of 
the  arc  controlling  pupillary  reaction  was  complete  only  in 
the  right  eye,  while  the  centrifugal  portions  were  perfect  in 
both  eyes. 


-4  SOCIETY  REPORTS. 

Nov.  2 1 st  the  same  reactions  were  obtained.  If  light 
were  thrown  at  an  angle  of  ninety  degrees,  from  the 
nasal  side  at  any  angle,  or  from  the  temporal  side  up  to  an 
angle  of  seventy  or  sixty  degrees,  reaction  occurred  in  both 
pupils;  but  if  the  light  entered  the  eye  from  the  temporal 
side  at  an  angle  of  sixty  to  forty  degrees  from  the  horizon- 
tal, no  reaction  was  obtained.  Vision  was  now  found  as 
follows  :  L.  E.  o,  R.  E.  j^-,  showing  progressive  loss  dur- 
ing the  month. 

The  lesion  in  this  case  is  probably  one  of  the  chiasm, 
destroying  both  fasciculi  in  the  left  eye,  and  the  fasciculus 
cruciatus  for  the  right  eye. 

Case  II.  was  one  of  typical  temporal  hemianopsia,  with 
darkness  also  of  the  lower  nasal  quadrant  upon  the  left  side. 
The  patient,  41  years  of  age,  was  referred  to  the  author  by 
Dr.  David  Webster. 

In  1886  the  patient  had  noticed  occasional  headaches, 
with  increasing  failure  of  the  left  eye.  There  was  diplopia 
at  that  time.  If  two  objects  were  present,  the  patient  saw 
three  ;  if  four,  five,  etc.  Light  attacks  of  vertigo  were  com- 
plained of.  There  was  no  history  of  syphilis  in  the  case. 
The  patient  was  first  seen  by  the  author,  Nov.  nth.  The 
right  eye  showed  the  vertical  line  of  separation  passing 
through  the  point  of  fixation.  This  was  the  first  case  in  the 
author's  experience  of  either  central  or  peripheral  origin  of 
which  this  had  been  true.  There  was  right  hemiopic  pupil- 
lary inaction.  If  light  were  thrown  from  the  temporal  side 
at  an  angle  more  oblique  than  sixty  degrees,  no  reaction 
occurred.  If  thrown  from  the  nasal  side  or  directly  into  the 
eye,  reaction  of  both  pupils  was  obtained.  In  the  left  eye, 
slight  reaction  occurred  only  to  central  illumination. 
Vision,  R.  E.  7^,  L.  E.  $#.  The  latter  was  an  interesting 
finding,  as  the  left  eye,  with  the  better  vision,  had  a  smaller 
field  than  the  right  eye,  showing  that  the  vision  is  not 
measured  by  the  geometrical  extent  of  the  field,  but  rather 
by  the  general  state  of  nutrition  of  the  optic  nerve. 

The  lesion  in  this  case  involved  both  fasciculi  cruciati 
and  the  ventral  or  inferior  half  of  the  fasciculus  lateralis  of 

left  eve.     A  test  made  Dec.  1 6th  showed  that  color  per- 


NEW  YORK  NEUROLOGICAL  SOCIETY.  cc 

ception  was  normal  in  the  preserved  half  and  quarter  fields 
of  vision. 

Case  III.  was  25  years  of  age,  also  referred  to  the  author 
by  Dr.  Webster  from  the  Manhattan  Eye  Department.  The 
case  was  first  seen  Oct.  10th,  1887.  The  patient  had  com- 
menced to  suffer  from  loss  of  vision  two  years  previously. 
At  the  date  of  examination  the  right  eye  was  completely 
blind.  There  was  general  loss  of  strength,  but  no  aetiology 
of  injury,  and  no  history  of  syphilis.  There  was  no  paraly- 
sis, no  loss  of  equilibrium.  The  dynamometer  showed 
twenty-three  degrees  in  the  right  hand,  twenty  in  the  left. 
At  a  subsequent  examination,  the  left  eye  showed  typical 
temporal  hemianopsia.  Left  vision  was  good  ;  can  read 
No.  1  Jaeger  at  seven  inches.  The  right  eye  gave  a  pecu- 
liar field,  viz.,  all  dark  except  two  sectors  in  upper  quad- 
rants, separated  by  a  dark  median  strip.  The  lesion  in  this 
case  involves  the  fasciculus  cruciatus  for  the  left  eye,  and, 
irregularly,  both  fasciculi  for  the  right  eye. 

The  author  then  referred  especially  to  the  symptom 
common  to  the  three  cases,  called  by  Wernicke  hemiopic 
pupillary  reaction,  but  which  he  would  designate  as  hemi- 
opic pupillary  inaction  ;  and  its  diagnostic  value  in  hemi- 
anopsia of  central  or  peripheral  origin.  The  optic  arc 
consists  of  the  retina,  especially  the  macula,  the  optic  nerves 
and  tracts  for  its  peripheral  portion,  the  anterior  group  of 
the  corpora  quadrigemina  with  the  nuclei  of  the  motor  oculi 
nerves  as  centers,  the  motor  oculi,  the  ciliary  nerves,  and 
the  iris  for  its  centrifugal  portion.  Contraction  of  the  whole 
iris  follows  stimulation,  because  the  termination  of  the  cili- 
ary nerves  is  plexiform  in  arrangement.  The  path  may  be 
broken  by  lesion  of  the  centripetal  portion,  by  lesion  of  the 
reflex  center  (or  optic  lobes),  or  by  lesion  of  the  centrifugal 
paths.  The  termination  of  this — the  iris — may  be  immobile 
from  iritis.  In  the  cases  reported,  the  symptom  was  ob- 
served with  temporal  hemianopsia.  If  a  pencil  of  light  were 
directed  in  the  optic  axis,  or  moved  nasalward  so  as  to  strike 
upon  the  temporal  or  normal  half  of  the  retina,  good  re- 
action was  obtained  ;  also  if  moved  temporalward  up  to  an 
obliquity  of  sixty  or  seventy  degrees  ;    but  if  it  entered  at 


-  5  SOCIE  TV  REPOR  TS. 

an  angle  of  forty  to  sixty  degrees  from  the  horizontal,  no 
reaction  was  obtained.  The  light  experiment  was  not  ex- 
act, because  it  is  impossible  to  focus  exactly  the  pencil  of 
light.  By  focusing  nearly  in  the  optical  axis,  crossing  of 
the  rays  and  diffusion  upon  the  temporal  or  sensitive  portion 
of  the  retina  occurs.  Without  this  diffusion,  inaction  of  the 
pupil  would  be  noted  as  soon  as  the  rays  of  light  struck  the 
nasal  side  of  the  field,  and  the  experiment  would  be  as  ex- 
act as  the  perimetric  test. 

In  making  the  examination,  the  patient  should  be  in  a 
dark  room,  with  the  gasjet  or  lamp  behind  him  in  the  usual 
position  for  ophthalmic  examination.  The  patient  should 
be  directed  to  look  toward  the  farther  side  of  the  room,  and 
a  faint  light  from  a  plane  or  large  concave  mirror  held  out 
of  focus  thrown  into  the  eye.  Relaxation  of  the  iris  is  thus 
obtained.  A  beam  focused  by  an  ophthalmological  mirror 
is  then  thrown  into  the  pupil  from  the  optic  center  and  from 
various  angles  nasalward  and  temporalward,  and  reactions 
noted.  It  is  especially  important  that  the  patient  should 
look  at  a  distant  object  ;  the  same  was  true  for  pupillary 
examination  in  tabes,  etc. 

The  author  then  added  a  number  of  rules  for  determining 
the  location  of  the  lesion  in  hemianopsia.* 

Dr.  Graeme  Hammond  then  presented 

A    CASK    OF    BITEMPORAL    HEMIANOPSIA 

for  Dr.  C.   H.   Brown. 

The  patient  was  a  woman,  37  years  of  age.  Aug.  10th, 
1887,  was  suddenly  seized  with  pain  in  the  right  eye,  the 
sight  of  which  was  lost.  The  pain  spread  to  the  left  eye, 
and  in  three  minutes  she  was  totally  blind.  The  pain  con- 
tinued spreading  over  the  head  to  the  base  of  the  skull.  The 
patient  was  in  bed  six  weeks.  Nov.  15th  she  commenced 
to  walk  a  little,  and  under  the  iodide  treatment,  vision  re- 
turned, so  that  she  could  see  an  object  if  within  two  feet  of 
the  eye.     She  can  m5w  read  newspaper   headings,  but  effort 

0  For  the  complete  paper  with  diagnosis,  vide.  Journal  ok  Nervous  and 
Mental  Diseases,  Dec.    188  . 


NE W  YORK  NE UROL OGICAL  SOCIE TV.  ry 

to  do  more  than  this  gives  pain.  Examination  showed  ob- 
scuration of  the  nasal  half  of  the  field  covering  the  point  of 
fixation  in  both  eyes. 

Dr.  Dana  had  seen  the  fields  drawn  by  Dr.  Francis  Valk,  and 
the  obscuration  was  very  marked. 

Dr.  Seguin  was  able  to  give  a  satisfactory  demonstration  of  hemi- 
opic  pupillary  inaction  in  this  patient. 

Dr.  Brill  proposed  three  divisions  for  cases  of  hemianopsia  ; 
namely,  into  those  of  prosencephalic,  mesencephalic  and  peripheral 
origin.  Where  the  pupillary  reaction  was  retained  the  two  latter 
would  be  thrown  out  and  the  lesion  would  pertain  to  the  cortex  or 
subcortical  expanse. 

Dr.  Starr  suggested  that  the  Society  owed  its  thanks  to  Dr. 
Seguin  for  a  series  of  three  papers  upon  so  interesting  a  subject.  To 
make  accurate  diagnosis  possible  by  the  working  out  of  a  single 
symptom  was  an  enviable  result.  The  symptom  had  been  known 
and  its  lesion  tabulated,  especially  by  Wernicke  in  his  Gehirnkrank- 
heiten,  but  not  before  in  the  English  tongue.  The  symptom  has  to 
be  searched  for  carefully.  Unless  the  physician  uses  the  correct 
method,  it  will  not  be  found.  In  many  published  cases  it  was  un- 
doubtedly present,  but  was  not  discovered.  The  speaker  referred  to 
the  fact  that  Ferrier,  in  Brain,  Vol.  VI.,  makes  the  escape  of  the 
macula  a  diagnostic  point,  stating  that  where  the  lesion  is  located  in 
the  chiasm  and  tract,  central  vision  is  impaired  ;  that  where  it  is 
located  in  the  cortex  or  between  the  thalamus  and  the  cortex  central 
vision  is  not  impaired.  He  had  formed  his  new  diagram  in  the  sec- 
ond edition  of  his  Functions  of  the  Brain  upon  this  theory,  accord- 
ing to  which  central  vision  should  have  been  impaired  in  all  of  the 
reported  cases. 

The  speaker  did  not  agree  with  Dr.  Brill  as  to  the  practicability 
of  classification  according  to  the  fetal  development  of  the  brain. 
The  optic  nerve  is  derived  from  the  thalamencephalon  and  the  retina 
from  the  mesencephalon  ;  thus  two  portions  of  the  neural  tube  are 
concerned  in  the  peripheral  apparatus. 

Dr.  Leszynsky  had  had  the  pleasure  of  examining  two  of  the 
cases  referred  to  in  Dr.  Seguin's  paper.  The  examination  was  not 
difficult,  though  it  required  care.  He  considered  the  head  mirror  of 
assistance  in  the  manoeuvre.  The  term  inaction  of  the  pupil  he 
thought  misleading. 

Dr.  Birdsall  thought  the  classification  of  Dr.  Seguin  practicable 
and  likely  to  be  of  service. 


^  g  SOCIE  TV  REPOR  TS. 

Dr.  Brill  referred  to  the  fact  that  von  Gudden  had  obtained  re- 
action of  the  pupil  by  the  use  of  intense  sunlight  after  division  of  the 
optic  nerve,  showing  ganglionic  elements  in  the  iris  itself,  which  are 
able  to  function  independently. 

Dr.  Seguin  closed  the  discussion.  He  found  clinical  records 
opposed  to  Ferrier's  classification,  as  the  dividing  line  hardly  ever 
passes  through  the  point  of  fixation  in  any  form  of  hemianopsia,  and 
he  failed  to  find  light  on  the  escape  of  the  macula  by  any  theory  of 
decussation.  He  was  rather  inclined  to  think  it  dependent  upon  the 
structure  of  the  macula  which  was  somewhat  ganglionic  in  char- 
acter and  markedly  different  from  that  of  the  remainder  of  the  retina. 
Before  von  Gudden,  Brown  Sequard  had  demonstrated  the  existence 
of  a  local  mechanism  for  iris  contraction  in  lower  animals,  but  there 
was  no  evidence  that  such  a  mechanism  was  active  in  the  human 
eye. 

Dr.  Noyes  then  presented  specimens  of 

COMPOSITE    PORTRAITURE    IN    THE    INSANE. 

A  composite,  taken  from  eight  general  paretics,  was  exhibited. 
This  showed  in  a  marked  degree  the  washing  out  of  the  lines  of  the 
face.  Incidentally,  Dr.  Xoyes  also  exhibited  the  college  composites 
recently  published. 

Dr.  Seguin  suggested  that  the  Vassar  composite  had  a  more 
womanly  character  than  that  of  the  Harvard  Annex. 

Dr.  Birdsall  agreed  in  this  opinion.  The  Harvard  composite 
figured  an  intellectual  rather  than  a  womanly  being. 

The  meeting  adjourned. 


>  ■  ^  ■  * 


THE  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

A  regular  meeting  of  the  Philadelphia  Neurological  Society  was 
held  November  28th,  1887,  Vice-President  Dr.  Charles  K.  Mills  in 
the  chair. 

Dr.  J.  C.  Wright  read  a  note  on 

antipyrin  as  an  analgesic  (see  p.  40). 

discussion. 

Dr.  William  Osler. — I  have  used  antipyrin  in  a  few  cases  at  the 
Infirmary  for  Nervous  Diseases,  and  I  regret  to  say  that,  on  the  whole, 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  rq 

my  experience  does  not  accord  with  that  of  the  reader  of  the  paper. 
Last  Wednesday,  four  cases  that  had  been  ordered  antipyrin  one  or 
two  weeks  previously,  returned,  and  the  uniform  statement  was  that 
no  benefit  had  been  obtained.  Two  were  cases  of  migraine  and  two 
were  cases  of  sciatica.  I  am  well  aware  that  in  some  cases  of  sciatica, 
antipyrin  is  of  undoubted  benefit,  but  other  cases  appear  to  resist  it. 
I  have  used  it  with  success  in  one  case  of  neuralgia,  and  in  two  cases 
of  rheumatism  it  has  had  no  influence  upon  the  pain.  In  one  case  of 
gastralgia  it  was  entirely  inert.  Altogether,  my  experience,  which  is 
however  quite  limited,  is  not  favorable  to  the  use  of  the  drug  in  pain- 
ful affections. 

Dr.  Wharton  Sinkler. — I  have  given  antipyrin  in  two  cases  of 
mgraine  during  the  paroxysm  with  marked  benefit.  I  have  also  met 
with  disappointment  in  its  use.  My  experience  is  however  not  ex- 
tensive. 

Dr.  Charles  K.  Mills. — I  have  used  antipyrin,  but  not  to  any 
great  extent.  I  have  tried  it  in  epilepsy,  and,  in  general  terms,  I  may 
say,  without  success.  I  have  used  the  drug  in  two  cases  of  sciatica. 
In  one  case  it  did  not  succeed,  but  in  that  case  all  other  remedies 
failed,  and  I  suspect  that  there  is  some  intra-pelvic  trouble.  In 
another  case,  the  patient  was  benefitted  by  its  use.  I  recall  one  case 
of  trigeminal  neuralgia  in  which  it  was  of  benefit.  I  used  the  drug  in 
one  case  of  recurring  headaches,  sometimes  taking  the  form  of  mi- 
graine, at  other  times  appearing  to  be  purely  neuralgic.  In  this  case, 
antipyrin  was  of  no  service.  It  seems  to  be  of  some  use  in  purely 
neuralgic  affections. 

Dr.  James  C.  Wilson. — I  believe  that  the  statement  which  I  have 
made  in  the  paper  is  perfectly  true,  that  is,  that  antipyrin  is  destined 
to  take  a  place  in  therapeutics  second  only  to  the  derivitives  of  opium, 
as  a  pure  analgesic.  I  have  carefully  studied  the  subject  clinically, 
but  the  time  has  not  permitted  the  naration  of  cases  in  detail.  I 
should,  however,  like  to  refer  to  one  illustration  of  the  effect  of  the 
drug.  Two  days  ago,  I  saw  a  case  of  migraine  in  a  child  eight  or 
nine  years  of  age.  He  had  been  living  in  the  South,  and  had  suffered 
with  severe  malarial  outbreaks  from  time  to  time.  The  spleen  was 
enlarged  and  the  general  health  was  considerably  undermined.  The 
child  was  suddenly  seized  with  well-marked  symptoms  of  migraine, 
and  these  had  continued  six  or  eight  hours  when  I  saw  him.  I 
ordered  four  grains  of  antipyrin,  to  be  repeated  in  an  hour  if  neces- 
sary. The  first  dose  caused  decided  relief,  and  the  second  was  fol- 
lowed by  complete  cessation  of  the  pain.     The  child  fell  asleep,  and 


6o 


SOC/E  T  Y  REPOR  TS. 


in  a  few  hours  awoke  in  his  usual  condition.  Other  eases  similar  to 
this  have  presented  themselves  to  my  attention. 

While  the  drug  relieves  the  paroxysm,  it  is  not  to  be  depended 
upon  to  cure  the  underlying  condition  to  which  the  pain  is  due. 
The  true  use  of  a  drug  of  this  kind  is  to  be  found  in  its  restricted  ap- 
plication. 

Dr.  Wm.  Osler  next  presented  a  note  on 

N1TRO-GLYCERINE  IN    EPILEPSY  (see  p.   38). 

A  paper  was  read  by  Dr.  F.  X.  Dercim  on 

OIL  OF  GAILTHERIA  AND  SALOL  IN   RHEIMATISM  OK  NERVES  AND    MUSCLES. 

(Seep.  S3.) 

Dr.  J.  H.  Misser. — While  not  bearing  directly  on  the  subject  of 
the  paper,  I  would  say  that  I  have  found  salol  of  extreme  benefit  in 
rheumatic  arthritis.  I  have  now  in  mind  a  case  which  has  been  un- 
der observation  for  several  months,  and  therefore  the  effect  of  diet, 
rest,  and  general  tonic  treatment  can  be  eliminated.  This  patient  has 
been  taking  salol  for  four  weeks,  and  has  been  greatly  benefited.  The 
pains  have  almost  entirely  disappeared,  and,  in  addition,  the  joints 
have  become  limbered  and  the  thickening  and  infiltration  has  dimin- 
ished. In  a  second  case  there  has  also  been  improvement,  although 
the  remedy  has  not  been  continued  so  long.  The  dose  in  the  first 
has  been  five  grains  every  three  hours.  This  has  caused  no  disturb- 
ance of  the  stomach  and  no  marked  physiological  effects.  In  the 
second  case  this  dose  produced  marked  symptoms,  and  had  to  be  re- 
duced to  five  grains  three  times  a  day. 

Dr.  Charles  K.  Mills. — I  have  used  the  oil  of  gaultheria  quite 
extensively  during  the  past  year  in  the  class  of  cases  referred  to  by  Dr. 
Dercum  ;  that  is,  where  the  affection  is  not  directly  neuralgic,  but 
rather  a  form  of  neuritis,  usually  rheumatic  neuritis.  I  have  also  used 
the  oil  of  gaultheria  in  combination  with  salicylate  of  sodium.  This 
has  been  usually  efficacious  in  these  cases.  My  experience  is  that  it 
is  not  so  useful  in  chronic  cases  as  in  the  acute  or  subacute.  I  have 
had  two  or  three  remarkable  successes  with  this  drug.  A  gentleman 
applied  to  me  with  a  severe  pain  in  the  neck,  which  had  continued 
ten  days,  with  also  slight  toticollis.  Ten  minims  of  oil  of  gaultheria, 
with  five  grains  of  salicylate  of  sodium,  dissipated  the  pain  entirely. 
He  took  a  few  more  doses,  and  has  had  no  return  of  the  trouble.  In 
another  case  where,  with  pain  over  the  brow,  undoubtedly  due  to 
supra-orbital  neuritis,  three  doses  entirely  relieved  the  trouble. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  £j 

Dr.  James  Hf.ndrie  Lloyd. — I  should  like  to  ask,  in  connection 
with  this  discussion  on  neuro  therapeutics,  if  any  of  the  members  have 
observed  benefit  follow  the  use  of  these  drugs — antipyrin,  oil  of  gaul- 
theria, and  salol  — in  cases  of  neuritis  of  traumatic  origin. 

Dr.  William  Osler. — With  reference  to  the  oil  of  gaultheria,  I 
have  been  more  and  more  impressed  with  its  efficacy  in  rheumatism 
the  more  I  have  used  it.  It  has  rarely  failed  me.  I  have  one  case 
under  treatment  at  the  present  time,  in  which  it  has  proved  inert.  In 
this  case,  salol  and  salicylate  of  sodium  have  also  failed.  The  only 
difficulty  is  in  its  administration.  Patients  turn  against  the  drug,  and 
it  is  only  with  great  difficulty  that  they  can  be  induced  to  continue  it 
more  than  a  week  or  ten  days. 

Dr.  James  C.  Wilson. — I  have  found  oil  of  gaultheria  of  decided 
benefit  in  the  sub-acute  and  lingering  forms  of  rheumatism,  much 
more  so  than  in  acute  attacks.  I  have,  however,  not  been  able  to 
administer  such  large  doses  as  Dr.  Dercum  has  mentioned.  This  has 
been  more  on  account  of  the  disagreeable  symptoms  produced  than 
on  the  account  of  the  disturbance  of  the  stomach.  I  have  given  the 
remedy  in  capsules  containing  five  minims  of  the  oil.  Of  these  I  have 
ordered  two  or  three,  three  times  a  day.  In  a  case  recently  under 
observation,  I  have  been  able  to  give  the  drug  only  twice  a  day.  This 
patient  takes  three  capsules  after  breakfast,  and  five  or  six  capsules 
just  before  retiring.  The  disagreeable  effects  of  the  drug  usually  sub- 
side before  morning. 

I  used  salol  last  winter  quite  extensively.  I  had  no  trouble  as 
regards  the  stomach,  but  the  doses  required  were  so  large  and  the 
cost  was  so  great,  that  patients  objected  to  it.  I  have  usually  em- 
ployed the  remedy  in  pill  form,  but  occasionally  have  used  emulsion. 
While  it  has  not  a  strong  and  penetrating  taste,  the  flavor  is  disagree- 
able. 

With  reference  to  Dr.  L'.ovd's  question,  I  would  say  that  in  a  case 
of  traumatic  neuritis,  I  tried  antipyrin  without  any  benefit  whatever. 

Dr.  Judson  Daland.— I  would  mention  the  fact  that  the  dis- 
agreeable taste  of  the  salicylate  of  sodium  can  be  greatly  lessened  by 
dissolving  it  in  the  compound  tincture  of  cinchona.  One  drachm  of 
the  latter  will  dissolve  ten  grains  of  the  former. 

Dr  H.  A.  Hare. — It  has  been  proven  by  recent  physiological 
experiments  that  the  effects  produced  upon  the  special  nerves,  such 
as  deafness  and  amaurosis,  the  salicylates  and  quinine  are  partially 
due  to  the  action  of  the  drugs  upon  the  peripheral  ends  of  the  nerves. 
It  has  not  been  proved  that  the  peripheral  ends  of  the  nerves  of  other 


5 2  SOCIETY  REPORTS. 

parts  of  the  body  are  similarly  affected.  But  such  an  action  might 
explain  the  results  which  have  been  reported. 

The  fact  that  salol  acts  so  much  more  slowly  than  the  other  drugs 
may  be  because  it  is  absorbed  by  the  small  intestine.  Ewald  has 
taken  advantage  of  this  in  studying  cases  of  so-called  motor  palsy 
of  the  stomach.  By  giving  salol  he  could  determine  the  exact  time 
at  which  the  food  left  the  stomach;  for  as  soon  as  the  drug  reached 
the  duodenum,  it  was  absorbed  and  appeared  in  the  urine. 

In  reply  to  Dr.  Dercum,  Dr.  Hare  stated  that  he  believed  salicylic 
acid  and  its  compounds  circulated  in  the  blood  in  the  form  of  salicy- 
lates, more  especially  of  soda,  and  a  very  large  part  of  it  was  elimi- 
nated as  salicyluric  acid.  In  some  experiment  performed  with  Dr. 
Wood,  it  was  found  that  where  oil  of  gaultheria  was  given,  even  in 
large  amounts,  no  unchanged  oil  escapes  from  the  kidneys. 

Dr.  Wm.  Osler  presented 

MICROSCOPICAL     SECTIONS     FROM     A     CASE     OF     GLIOMA    OF    THE    MEDULLA 

OBLONGATA. 

Dr.  J.  K.  Mills,  for  Dr.  F.  X.  Dercum,  presented  a  brain  con- 
taining a  hemorrhagic  cyst  limited  to  the  lenticular  nucleus  and  the 
adjoining  border  of  the  internal  capsule. 

Dr.  J.  H.  Musser  exhibited  sections  from  a  sarcoma  of  the  brain, 
which  had  produced  no  symptoms. 

Adjourned. 


Meeting  of  December  ip,  1887. 

VICE-PRESIDENT,    DR.   CHARLES    K.    MILLS,  IN    THE    CHAIR. 

Dr.  Thomas  J.  Mays  read  a  paper  on 

THEINE    IN    PAIN    (see  p.  44). 
DISCUSSION. 

Dr.  Charles  K.  Mills. — A  few  months  ago,  I  began  the  use  of 
theine,  ordering  it  in  almost  every  case  of  neuralgia,  superficial  neuri- 
tis or  lumbago  that  came  to  the  polyclinic  service,  and  also  using  it 
at  the  Philadelphia  hospital.  I  have  used  the  drug  probably  in  about 
fifteen  cases,  but  I  have  not  had  time  to  prepare  notes  of  them  for 
this  meeting.      I  recall  three  cases  of  sciatica,  two  of  which   were  of 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  £, 

long  standing.  These  cases  were  all  improved,  but  none  of  them 
were  cured  by  the  use  of  theine  alone.  It  was  applied  hypodermically 
according  to  the  formula  of  Dr.  Mays.  The  pain  was  usually  much 
relieved  by  the  use  of  the  theine,  but  it  would  return  after  a  shorter  or 
a  longer  time.  In  connection  with  the  theine,  I  used  galvanism  to 
the  nerve  and  muscles,  and  internally  Donovan's  solution,  or  iodide 
of  potassium.  Two  of  the  cases  of  sciatica  were  cured  under  this 
conjoint  treatment. 

In  a  case  of  facial  neuralgia  or  neuritis,  I  used  a  hypodermic  of 
theine  in  the  face.  Following  this  the  patient  became  pale,  sick  at 
the  stomach,  and  seemed  to  be  in  a  slightly  dazed  condition  for  a 
time.  Whether  this  was  due  to  the  drug  or  simply  to  the  slight 
operation  I  cannot  say.  The  injection  entirely  relieved  the  pain  for 
three  days.  The  patient  then  returned  and  another  injection  was 
given  without  bad  effect.  In  another  facial  case  the  patient  was  cer- 
tainly relieved  by  theine,  and  so  far  as  I  know  remained  well.  I  have 
used  it  in  the  back  with  great  benefit  in  so-called  myalgia,  including 
under  that  term  muscular  rheumatism,  and  possibly  true  lumbar 
neuralgia.  I  believe  that  theine  is  an  analgesic;  that  it  relieves  pain 
in  cases  of  recent  and  superficial  neuritis  or  neuralgia.  In  chronic, 
painful  nerve  troubles,  particularly  where  the  nerves  are  deeply  situ- 
ated, it  seems  to  be  simply  a  helping  remedy,  and  sometimes  fails. 

Dr.  Thomas  J.  Mays. — I  merely  wish  to  say  that  the  proper  prov- 
ince of  theine  is  the  relief  of  pain.  I  think  that  it  is  expecting  too 
much  of  it  to  look  to  it  to  cure  the  cause  or  diathesis  upon  which  the 
pain  depends  The  physiological  action  of  the  drug  is  to  deaden 
sensibility.  I  have  always  found  this  its  characteristic  action  when  I 
have  employed  it  clinically. 

A  paper  was  read  by  Dr.  A.  P.  Brubaker  on 

DENTAL    IRRITATION    AS    A    FACTOR    IN    THE    CAUSATION    OF    EPILEPSY. 

Remarks  were  made  on  severe  neuralgic  headache  as  the  initial 
system  of  typhoid  fever. 

Dr.  William  Osler. — I  should  like  to  make  a  brief  reference  to 
the  occurrence  of  severe  neuralgic  headache  in  the  initial  stage  of 
typhoid  fever.  In  some  cases,  typhoid  fever  comes  on  with  such 
severe  headache  that  at  first  the  true  nature  of  the  disease  may  not  be 
recognized.  I  have  had  three  instances  of  this  kind  come  under  my 
observation.  In  two  the  patients  were  women,  one  plethoric  and  full- 
blooded,  and  the  other  pale,  nervous,  and  somewhat  emaciated.     In 


5  a  SOCIE  T  Y  RE  FOR  TS. 

the  latter  case  the  disease  was  not  recognized  for  over  a  week.  The 
disease  was  considered  one  of  neuralgic  headache,  although  it  was 
thought  remarkable  that  the  temperature  should  so  persistently  remain 
above  normal. 

In  the  other  case  the  patient  suffered  more  severely  from  headache 
than  any  that  I  have  seen.  The  pain  resisted  all  remedies.  At  the 
end  of  four  or  five  days,  it  was  suspected  that  some  constitutional  dis- 
ease was  developing,  and  the  case  proved  to  be  one  of  well-marked 
typhoid  fever. 

A  few  weeks  ago  I  saw  a  gentleman  who  had  been  ill  for  ten  days, 
and  whose  most  marked  symptom  was  severe  headache,  chiefly  over 
the  brow,  but  extending  to  the  vertex.  The  whole  scalp  was  exquis- 
itely tender.  The  patient  was  heavy  and  dull,  and  typhoid  fever  was 
suspected.  The  pain  resisted  chloral,  the  bromides,  urethran,  and 
other  remedies.  He  was  then  ordered  eight  leeches,  and  that  night 
he  had  the  first  quiet  sleep  that  he  had  obtained  for  ten  days.  He 
subsequently  developed  well-marked  typhoid  fever. 

We  of  course  all  know  that  headache  is  an  early  symptom  of 
typhoid  fever,  but  the  occurrence  of  this  severe  form  of  headache  is 
not  as  well  known  as  it  should  be.  Indeed,  in  one  case  the  diagnosis 
was  not  made  until  fatal  perforation  occurred  early  in  the  disease. 

Dr.  Charles  K.  Mills. — It  might  be  interesting  to  know  whether 
or  not  these  patients  who  suffer  from  this  severe  headache  are  liable 
to  neuralgic  headaches  when  in  ordinary  health.  A  case  of  typhoid 
fever  occurred  in  my  own  practice,  and  I  had  myself  a  severe  attack 
of  the  disease  within  a  short  time  of  the  occurrence  of  this  case.  I 
did  not  suffer  particularly  with  headache,  whereas  the  other  patient 
suffered  severely  with  headache.  He  was,  however,  subject  to  severe 
headaches  when  in  ordinary  health. 

Dr.  William  Osler. — Two  of  the  cases  to  which  I  have  referred 
were  not  especially  subject  to  headache.  I  cannot  speak  so  positively 
in  regard  to  the  third  case. 

Dr.  Wharton  Sinkler. — About  one  year  ago,  I  saw  a  young 
man  aged  about  '3  years.  He  came  home  one  evening  with  a 
violent  headache.  This  continued  thirty-six  or  forty-eight  hours,  and 
marked  the  beginning  of  a  long  attack  of  typhoid  fever.  The  head- 
ache did  not  recur  during  the  course  of  the  disease. 


Reading  ^otireisi. 


CONGRESS   OF   AMERICAN   PHYSICIANS   AND   SURGEONS. 

Dr.  Gr^me  M.  Hammond, 

Secretary  of  the  A  merican  Neurological  Society, 

New  York  City. 
Dear  Doctor  : 

As  supplementing  the  information  given  in  the  circular  recently 
published  respecting  the  Congress  of  American  Physicians  and  Sur- 
geons to  be  held  in  Washington,  D.  C,  in  1888,  I  now  beg  to  com- 
municate the  following  arrangements,  viz. : 

The  sessions  of  the  Congress  will  occur  on  the  evenings  of 
Tuesday,  Wednesday,  and  Thursday,  September  18th,  19th,  and 
20th. 

On  Tuesday  evening,  the  subject  of  "Interstitial  Obstruction  in 
its  medical  and  surgical  relations  "  will  be  presented  and  discussed. 

On  Wednesday  evening,  the  subject  of  "Cerebral  Localization  in 
its  practical  relations"  will  be  presented  and  discussed. 

On  Thursday  evening,  the  Address  of  the  President  will  be  de- 
livered, and  afterwards  there  will  be  a  General  Reception  in  the 
Museum  Building. 

No  entertainment  will  be  provided  in  connection  with  the  Con- 
gress. 

No  invitations  will  be  extended  by  the  Congress  to  physicians 
from  abroad  ;  but  all  such  as  may  be  present  as  guests  of  any  of  the 
special  societies  participating  will  be  considered  members  of  the 
Congress,  and  shall  be  entitled  to  participate  in  the  proceedings. 

The  sessions  of  the  Congress  will  be  open  to  the  profession  at 
large. 

It  will  thus  be  seen  that  the  morning  and  afternoon  of  each  day 
are  left  free  for  the  sessions  of  special  societies  participating. 

It  would  seem  desirable  that  the  Secretary  (of  the  Council)  of 
each  participating  society  should  communicate  to  the  Secretary  of 
the  Congress,  as  soon  as  convenient,  any  information  about  the  ar- 
rangement of  sessions  and  the  programme  of  scientific  work.  All 
such  information  shall  be  promptly  communicated  to  the  officers  of 
the  other  participating  societies,  so  as  to  afford  opportunity  for  any 
adaptation  of  sessions  and  subjects  of  discussion  that  may  be  de- 
sired. 

It  is  understood  that  the  American  Association  of  Physicians 
proposes  to  have   morning  and   afternoon   sessions,    on   Tuesday, 


66 


READING  NOTICES. 


Wednesday,  and  Thursday,  and  that  the  American  Surgical  Asso- 
ciation will  probably  have  its  meetings  at  the  same  dates. 
Respectfully  yours, 

W.  H.  CARMALT, 

Secretary  of  the  Congress. 


January  30th,   1888. 
Dr.  GitEME  M.  Hammond, 

Secretary  of  the  American  Neurological  Association. 
Dear  Doctor  : 

I  beg  leave  to  forward  to  you  a  copy  of  the  preliminary  pro- 
gramme of  the  Association  of  American  Physicians  for  their  Third 
Annual  Meeting  to  be  held  in  Washington,  D.  C,  on  the  mornings 
and  afternoons  of  September  18th,  19th,  and  20th,  1888,  in  con- 
junction with  the  Congress  of  American  Physicians  and  Surgeons. 
Verv  respectfully  yours, 

W.  H   CARMALT. 

PAPERS. 

"Cardiac  Changes  in  Chronic  Bright's  Disease," 

Dr.  Alfred  L.  Loomis,  New  York. 
"  Relation  between  Chronic   Intestinal  Nephritis  and  Angina   Pec- 
toris," Dr.  Samuel  C.  Chew,  Baltimore. 
"Disturbance   of  the    Heart   Rythm,  with  reference  to  Causation 
and  their  Value  in  Diagnosis," 

Dr.  Gustavus  Baumgarten,  St.  Louis. 

"Fatty  Heart,"  Dr.  Fredrick  Forcheimer,  Cincinnati. 

"Cardiac  Lesions  producing  Presystolic  Murmur," 

Dr.  Frank  Donaldson,  Baltimore. 

"Treatment  of  Valvular  Affections  of  the  Heart," 

Dr.  Jacob  Da  Costa,  Philadelphia. 

"Clinical  Investigations  in  the  Treatment  of  Cardiac  Disease," 

Dr.  James  K.  Thacher,  New  Haven. 
"Causal  Therapeutics  in  the  Infectious  Diseases," 

Dr.  James  C.  Wilson,  Philadelphia. 

"  Management  of  the  Stage  of  Convalescence  in  Typhoid  Fever," 

Dr.  James  H.  Hutchinson,  Philadelphia. 

"The  Geographical  Diffuseness  in   Typhoid   Fever  in   the  United 

States,"  Dr.  W.  W.  Johnston,  Washington. 

"The  Pathology  of  the  Thymus  Gland," 

Dr.  Abraham  Jacobi,  New  York. 

"The  New  Caesarean  Section,"  Dr.  William  T  Lusk,  New  York. 

"Gastric  Neurasthenia,"  Dr.  George  M.  Garland,  Boston. 

"Neuritis,'  Dr.  Francis  S.  Miles,  Baltimore. 

Subject  not  announced,  Dr.  George  Ross,  Montreal. 

"                  "  Dr.  Samuel  C.  Busey,  Washington. 


READING  NOTICES. 


6/ 


DISCUSSION. 

"The  Relation  between  Trophic  Lesions  and  Diseases  of  the  Ner- 
vous System." 

Referee  :  Dr.  Edward  C.  Seguin,  New  York. 
Co-referee  :  Dr.  Wm.  S.  Councilman,  Baltimore. 

"The  Absolute  and  Relative  Value  of  the  Presence  of  Albumen  and 
Casts  and  of  Renal  Inadequacy  in  the  Diagnosis  and  Prognosis 
of  Diseases  of  the  Kidneys." 

Referee  :  Dr.  Robert  T.  Edes,  Washington. 
Co-referee  :  Dr.  Edward  G.  Janeway,  New  York. 

"Demonstrations  in  Pathological  Anatomy," 

Dr.  T.  Mitchell  Prudden,  New  York. 

PAPERS    TO    BE    READ    BY   TITLE 

"Creasote  as  a  Remedy  in  Pulmonary  Phthisis," 

Dr.  Beverly  Robinson,  New  York. 
"Malarial  Modifications  of  Typhoid  Fever." 

Dr.  Edward  Whittier,  Boston. 
"Therapeutics  of  Phthisis," 

Dr.  Edward  S.  Solley,  Colorado  Springs. 
"Antiseptic  Medication,"         Dr.  Fredrick  P.  Henry,  Philadelphia. 

Furnished  by 

Dr.  HENRY  HUN, 

Secretary  of  the  Association  of  American  Physicians, 
3$  Elk  Street, 

Albany,  New  York. 


Dr.  James  Hendrie   Lloyd  has  been  elected  Neurologist  to  the 
Philadelphia  Hospital  in  place  of  Dr.  Roberts  Bartholow,  resigned. 


The  Georgia  Medical  Society, 

Office  of  Corresponding  Secretary 

Savannah,  Ga.,  January,  1888. 
To  the  Editor  of  Journal  of  Nervous  and  Mental  Diseases  : 

Dear  Sir  : — At  the  annual  meeting  of  the  Georgia  Medical 
Society,  held  January  3d,  1888,  the  following  resolution  was  unani- 
mously carried  : 

Resolved,  That  the  Corresponding  Secretary  enter  into  correspon- 
dence with  the  medical  journals  of  the  country  in  order  to  enlist 
their  influence  in  support  of  the  movement  to  remove  the  import 
duties  from  all  medical  and  surgical  instruments  and  appliances,  in- 
cluding those  used  in  the  diagnosis  as  well  as  treatment  of  disease, 
so  that  they  may  be  furnished  to  those  needing  them  at  the  lowest 
possible  price. 

In  compliance  with  the  above  resolution,  I  wish  to  solicit  your 


68 


READING  NOTICES. 


earnest  attention  and  a  notice  in  your  publication,  which  will  claim 
the  attention  of  your  readers,  hoping  that  your  country  readers,  es- 
pecially, will  appreciate  the  truth  and  importance  of  our  proceed- 
ings. 

Perhaps  the  statement  of  a  few  facts  will  assist  the  reader  in 
realizing  the  extent  of  the  grievance  and  the  justice  of  the  plea  for 
which  we  ask  co-operation. 

i  st.  Physicians  are  at  the  mercy  of  instrument  makers  in  regard 
to  price,  make  and  quality  of  finish,  because  of  the  lack  of  sufficient 
competition. 

2d.  The  price  of  instruments  made  in  this  country  is  out  of  pro- 
portion to  that  paid  for  similar  instruments  on  the  Continent  of 
Europe. 

3d.  Surgical  instruments  and  appliances  are  so  costly  that  but 
few  doctors  entering  the  profession  can  provide  themselves  with  an 
outfit  adequate  to  carry  on  a  general  practice.  At  present  prices  it 
is  impossible  for  a  country  physician's  income  to  sustain  his  invest- 
ing in  costly  instruments,  and,  as  a  result,  many  simple  cases,  such 
as  retention  of  urine,  foreign  bodies  in  nose  and  throat,  deep-seated 
abscesses,  etc. ,  all  of  which  could  be  relieved  at  once  with  the  proper 
instruments,  must  either  die  from  the  immediate  cause  or  from  the 
effects  of  time  lost  in  seeking  skillful  manipulation,  or  else  they  are 
frequently  crippled  and  disfigured  because  the  most  intelligent  help, 
though  patiently  given,  is  itself  crippled  for  want  of  proper  instru- 
ments. 

4th.  The  cheaper  grades  of  instruments  are  either  antiquated  or 
so  poorly  made  that  they  may  prove  a  cause  of  failure  in  operations, 
sapping,  as  it  were,  the  natural  inclinations  to  surgery  in  its  incep- 
tion. 

5th.  European  instruments  are  from  25  to  75  per  cent,  cheaper 
than  ours,  and  their  introduction  into  the  market  will  enable  the 
mass  of  doctors  to  buy  those  of  prime  necessity,  will  bring  down  the 
price  of  home-made  appliances,  and  oblige  the  makers  to  use  good 
material  and  put  a  better  finish  to  their  work. 

6th.   The  removal  of  import  duties  on  surgical  and  other  instru- 
ments used  by  the  profession  and  on  medicines  in  general,  will  pro- 
duce rhe  same  results  as  we  all  know  it  did  on  the  article  of  quinine. 
Respectfully, 

J.  C.  LeHARDY, 
Cot  responding  Secretary  Georgia  Medical  Society, 
1 1 3  Congress  Street, 

Savannah,  Ga. 


PERISCOPE. 

By  Drs.  G.  W.  JACOBY,  N.  E.  BRILL,  and  LOUISE  EISKE-BRYSON. 


ANATOMY  OF  THE  NERVOUS  SYSTEM. 

The  Brain  Weight  in  the  Insane.  Dr.  Bartels,  of 
Hildesheim  (Algemeine  Zcitschrift  fur  PscJiiatrie,  etc). 
The  author,  after  giving  the  literature  on  the  subject, 
tabulates  the 'findings  of  the  brain  weights  of  males  and 
females  in  ten  different  psychoses.  Accepting  the  average 
normal  weight  of  a  healthy  brain  to  be  1,460  g.  in  males  and 
1,320  g.  in  females  (Henle  and  Krause),  the  following  devi- 
ations in  the  various  psychoses  present  themselves  : 


Males.       Fema!  es. 

Average  Weight 
in  Grammes. 

27 

32 

74 

95 
23 

15 
"5 

1      62 
276 

44 
5 

2 
70 

32 
27 

18 
181 

124 
12 

1        6 

1423 
1288 

1437 
1284 
1446 

1255 
I416 
I263 

!353 
1 185 

1385 
1325 
1421 
1231 

1335 
1 194 
1408 
1263 

1359 
1200 

2.  Melancholia 

3.  Periodical  Insanity 

4.  Paranoia 

5 .  General  Paresis 

6.  Acute  Delirium   

7.  Epileptic  Insanity 

8.  Idiocy  and  Imbecility 

9.  Secondary   Dementia 

jo.  Senile  Dementia 

Too  much  weight  ought  not  to  be  placed  on  these  devi- 
ations ;  for,  as  the  author  well  says,  in  certain  groups  the 
number  of  cases  is  not  sufficient  to  deduce  a  safe  estimate. 
In  paranoia  and  secondary  dementia,  which  affect  the  indi- 


jq  ANATOMY  OF  THE  NERVOUS  SYSTEM. 

vidual  in  a  large  proportion  of  cases  late  in  life,  in  which 
the  brain  itself  would  naturally  begin  to  diminish  in  weight 
and  in  which  the  disease  itself  may  have  been  of  long  stand- 
ing, no  reliable  estimate  could  be  attained.  He  concludes  as 
follows  : 

i.  All  psychoses  necessarily  diminish  the  weight  of  the 
brain. 

2.  This  diminution  depends  (a)  on  the  age  of  the  patient, 
(b)  on  the  duration  of  the  disease,  (c)  on  the  intensity  of  the 
disease. 

a. — The  diminution  in  weight  is  smallest  in  both  sexes 
between  twenty  and  thirty  years  of  age,  largest  in  males 
of  seventy  years  of  age,  and  in  women  of  sixty  years  of 
age. 

b. — The  shorter  the  average  duration  of  the  disease 
the  smaller  in  general  is  the  loss  in  brain  weight  and  vice 
versa. 

c. — The  deeper  the  disease  affects  the  mental  life  of 
the  individual,  and  in  the  one  who  shows  the  smallest 
ability  for  mental  work,  the  greater  is  the  loss  of  brain 
weight,  and  vice  versa. 

3.  The  diminution  in  females  is  larger  than  that  in  males 
by  from  \  to  1.6  per  cent. 

N.  E.  B. 

Contribution  to  the  Morphology  and  Morphogen- 
esis OF  THE  CRUS  Cerebri,  by  G.  Jelgersura  {Central- 
blatt  fur    Nervcnhcilkunde,   etc.,    September    fjt/i    and 
October  13  th.) 
This  embraces  a  short  resume  of  the  author's  investiga- 
tions of  the  brains  of  five  idiots,  in  which  the  cortex  was  very 
much  atrophied  as  the  result  of  various   pathological   pro- 
cesses.    Only  one  of  the  hemispheres  of  two  of  these  cases 
showed  atrophic  changes,  the  other  hemisphere  in  each  be- 
ing  almost   entirely    normal.      There    were    almost   equal 
changes  in  both  hemispheres  in  each  of  the  other  cases,  and 
almost  the  entire  cerebral  cortex  was  destroyed  by  enceph- 
alitis  or   by  meningitis.     The    latter   cases   were   extreme 
idiots,  the  former  two  only  half  idiots  with  the  somatic  signs 


ANATOMY  OF  THE  NERVOUS  SYSTEM.  -j 

of  cerebral  hemiatrophy,  and  one  of  which  was  epileptic. 
All  died  of  some  intercurrent  affection,  between  the  ages  of 
twenty  and  forty  years.  These  cases  hence  afforded  to  the 
author  a  good  opportunity  of  utilizing  a  pathological  imita- 
tion of  the  atrophy  method  of  anatomical  research. 

"The  pons  and  arciform  nuclei  were  changed  in  all 
cases  either  on  one  or  both  sides,  according  to  whether  the 
pathological  process  involved  one  or  both  hemispheres  and 
involved  the  cells  as  well  as  the  fibres.  The  connecting 
paths  between  the  ganglion  cells  of  the  pons  and  the  cortex 
cerebri  were  also  atrophied,  and  were  best  demonstrated  in 
sections  at  the  level  of  the  crus,  which  was  much  reduced 
in  volume  even  in  the  mesal  as  well  as  in  the  lateral  thirds. 
The  pyramid  tract  in  the  mesal  third  was  constantly  atro- 
phic. In  none  of  the  cases  did  the  atrophy  of  the  pyramids 
involve  any  of  the  nuclei  in  the  medulla  and  spinal  cord 
which  belong  to  the  reflex  systems.  All  motor  nuclei  pre- 
sented an  entirely  normal  appearance  ;  and,  in  the  cases  of 
cerebral  hemiatrophy,  no  difference  between  the  motor  nu- 
clei of  either  side  belonging  to  the  reflex  arcs  could  be 
demonstrated.  Only  the  nerve  fibres  were  involved  in  the 
atrophy." 

"  In  the  pons  those  transverse  fibres  were  atrophied 
which  go  through  the  raphe  and  pontis-brachium  to  the 
opposite  side  of  the  cerebellum."  In  fact  these  cases  cor- 
roberated  the  statements  made  by  other  authors  regarding 
the  course  of  the  fibres. 

The  nuclei  arciformes  with  their  connections  were 
changed  in  unison  with  the  pons,  and  the  author  regards 
them  as  distal  prolongations  of  the  ganglion  cell  group  of 
the  pons. 

The  author  corroborates  the  findings  of  Bechterew,  who 
described  a  group  of  cells  in  the  pons  under  the  name  of 
"  nucleus  reticularis  pontis,"  and  which  lay  in  the  raphe  and 
presented  two  large  wing-shaped  extensions  between  the 
lemniscus  fibres,  and  which  were  involved  in  the  atrophic 
process.  This  atrophy  was  traced  to  the  mesal  third  of  the 
pes  pedunculi,  and  corresponded  in  course  with  the  course 
of  Meynert's  "  bundle  from  the  pes  to  the  tegmentum." 


y2  ANATOMY  OF  THE  XERVOUS  SYSTEM. 

"  The  changes  in  the  olive  were  numerous.  In  two  cases 
the  ganglion  cells  were  atrophied,  on  both  sides  in  one  case, 
and  very  extensively,  so  that  very  little  of  the  olive  re- 
mained ;  in  another,  the  cells  of  the  olive  on  the  atrophic 
side  were  remarkably  smaller  than  on  the  sound  side.  In 
the  other  cases,  also  a  cell  atrophy  could  be  unequivocally 
demonstrated." 

In  four  cases  there  was  atrophy  of  the  tract,  which  the 
author  described,  although  ignorant  of  the  description  of 
Flechsig  and  Bechterew  of  the  same  tract  connecting  the 
large  olive  with  the  cerebrum  (nucleus  lentiformis),  and 
which  they  called  the  central  tegmental  tract  (centrale  Hau- 
benbahn). 

In  one  of  the  cases  the  connecting  tract  between  the 
olive  and  the  cerebellum,  by  way  of  the  raphe  and  the  resti- 
form  body  of  the  opposite  side,  was  atrophic. 

The  hemispheres  of  the  cerebellum  were  plainly  atrophic 
in  four  cases.  The  dentated  body  of  one  side  was  larger  than 
that  of  the  other.  In  all  five  cases  the  tegmenti-brachium 
was  atrophic,  as  well  as  the  red  nucleus  of  the  tegmentum. 

The  thalamus  was  also  involved,  and  there  was  also  a 
diminution  in  volume  of  the  body  of  Luys  and  the  body  of 
the  substantia  nigra. 

"  Although  the  cerebral  atrophy  existed  for  years  and  a 
secondary  atrophy  of  the  pyramid  tract  resulted  thereby, 
the  primary  nuclei  in  the  medulla  and  the  anterior  cornua 
of  the  spinal  cord  remained  intact." 

The  author  then  considers  the  question  whether  there  is 
not  an  anatomical  basis  to  account  for  the  fact  that  some  of 
these  tracts  follow  the  law  of  degeneration  of  Waller,  while 
other  tracts  do  not,  and  refers  to  the  well-known  investiga- 
tions of  Golgi  on  the  structure  of  the  nerve  cells  and  their 
connections  with  nerve  fibres,  and  to  the  similar  investiga- 
tions of  Forel,  as  an  explanation.  X.  E.  B. 

Nuclear    Origin    of    the    Ocular    Facial — Mendel, 
Berlin  Medical  Society,  Nov.  9th,  1887. 
Investigations  on  rabbits  and  guinea-pigs  resulted  in  the 
discovery  that  the  upper  facial  branch  takes  its  origin  in  the 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM  - -> 

posterior  oculi-motor  nucleus.  In  reference  to  this  relation 
in  man,  there  are  not  sufficient  anatomical  and  pathological 
data  to  establish  it. 

The  way  the  upper  branch  reaches  the  peripheral  facial 
from  the  oculi-motor  nucleus  is  through  the  posterior  longi- 
tudinal fasciculus  and  the  facial  genu.  Analagous  relations 
in  the  division  and  origin  of  nerves  exist  in  the  spinal  cord, 
and  the  orbicularis  palpebrarum  and  the  levator  palpebrae 
superior  are  functionally  combined.  N.  E.  B. 


PHYSIOLOGY   OF   THE   NERVOUS   SYSTEM. 

ANAESTHETICS   AS   A    FACTOR    IN    INSANITY. 

Any  cause  giving  rise  to  delirium  may  set  up  a  more 
chronic  form  of  mental  disorder  quite  apart  from  any  febrile 
disturbance,  {a)  The  most  common  form  in  such  cases  is 
of  the  type  of  acute  delirious  mania  ;  (b)  though  such  men- 
tal disorder  is  usually  temporary  in  character,  it  may  pass 
into  chronic  weak-mindedness,  or  into  (c)  progressive  de- 
mentia which  cannot  be  distinguished  from  general  paresis 
of  the  insane. 

Alcohol  is  the  most  common  example  of  a  cause  pro- 
ducing permanent  disorder  of  the  mind.  Symptoms  of 
mental  disorder  may  follow  delirium  tremens,  but  instead 
of  the  delirious  stage  disappearing,  it  becomes  established 
more  firmly.  A  young  man  of  poor  nerve  inheritance  took, 
within  a  few  days,  a  large  amount  of  spirit  to  tide  him  over 
some  business  worry.  The  symptoms  that  made  the  ill- 
ness appear  to  be  delirium  tremens  passed  off,  and  left  the 
maniacal  excitement  persistent.  Exhaustion  and  mental 
exhaustion  followed,  with  ultimate  recovery.  Delirium  ac- 
companying fevers  may  have  similar  results.  A  seventeen- 
year-old  girl,  of  neuropathic  antecedents,  bright,  intelligent, 
and  active,  became  very  delirious  during  the  early  stages  of 
scarlet  fever,  and,  after  several  days  of  sleepless  delirium, 
passed  into  a  condition  of  mania,  at  once  alarming  and 
revolting.      In   an   asylum   she   slowly   recovered     and  has 


-  ,  PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

/4 

remained  well  ever  since.  Another  of  similar  age  and  cir- 
cumstance developed  acute  delirious  mania  after  measles, 
and  died  in  a  few  days.  Pneumonia  has  also  given  rise  to 
such  states.  Belladonna  has  proved  efficient  in  starting  the 
insane  process,  as  when  taken  by  mistake  in  the  form  of 
liniment.  A  girl  of  neurotic  stock  took  belladonna  liniment 
instead  of  cough  mixture,  and  passed  through  a  sharp  attack 
of  mania,  though  the  bodily  illness  was  not  extreme,  and 
recovery  took  place.  All  the  usual  anaesthetics  are  known 
to  produce  like  mental  disorders.  A  young  officer  in  the 
British  army,  of  uncompromisingly  bad  heredity — neuro- 
pathic, rheumatic,  and  phthisical — had  violent  and  destruc- 
tive acute  mania  after  alcoholic  excesses.  It  was  difficult 
to  keep  him  clad,  or  out  of  harm's  way.  An  injury  to  his 
hand  seemed  to  clear  up  his  wits.  Chloroform  was  given 
for  a  better  surgical  examination,  when  the  old  maniacal 
ideas  at  once  returned,  the  same  delusions  and  antipathies. 
He  recovered,  but  with  a  mental  relapse  when  the  hand 
healed.  An  elderly  patient  was  operated  upon  for  cancer 
about  the  rectum.  Upon  regaining  consciousness,  it  was 
apparent  that  his  mind  was  affected.  Admitted  shortly 
after  to  Bethlem,  he  had  the  aspect  of  a  man  half-drunk  or 
half-awakened  from  some  anaesthetic.  He  was  restless, 
incoherent,  repeating  meaningless  expressions,  and  of  very 
defective  memory.  Discharged  later  as  a  harmless  dement, 
he  remained  some  weeks  at  home  in  the  same  condition, 
when  he  suddenly  recovered,  and  performed  his  clerical 
duties  with  all  his  past  zeal  and  intelligence.  A  young 
woman,  the  mother  of  a  child  ten  years  old,  at  whose  birth 
transfusion  and  large  quantities  of  stimulants  were  necessi- 
ties, had  occasional  hysterical  attacks,  afterwards  known  to 
be  due  to  alcohol.  She  never  had  delirium  tremens,  al- 
though a  chronic  drinker.  After  the  administration  of 
nitrous  oxide  for  the  purpose  of  having  teeth  extracted 
painlessly,  this  patient  had  an  attack  of  delirious  mania 
which  settled  into  dementia,  she  never  after  regaining  her 
st  nses  or  recognizing  her  friends,  but  remains  to-day  silly 
and  fat.  The  points  in  this  case  are  the  acquired  nervous 
irritability,  the  acute  delirious  mania,  with   its  consecutive 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  j$ 

dementia,  following  in  a  few  hours  the  use  of  nitrous  oxide. 
Insanity  has  followed  ovariotomy  and  parturition  when 
chloroform  has  been  given. 

Any  toxic  agent,  more  especially  those  which  directly 
affect  the  nutrition  of  the  nervous  system,  as  alcohol,  lead, 
belladonna,  etc.,  will  cause  temporary  disorder  of  intellect 
in  the  nervously  unstable,  and  this  temporary  disorder  may 
assume  the  form  of  true  insanity  ;  and  this  insanity  gener- 
ally, though  not  always,  is  acute  delirious  mania.  Shock 
also  may  produce  similar  mental  disorder,  and  must  be  con- 
sidered as  an  element  in  surgical  procedures.  In  the  cases 
recorded,  it  had  the  least  possible  force.  Should  neurotic 
inheritance  or  neurosis  in  the  individual  "give  us  pause"  in 
considering  the  expediency  of  operations  not  essential  to 
life  ?  This  is  a  practical  question  for  the  surgeon  and  the 
neurologist.  George  H.  Savage,  M.D.,  F.R.S.,  in  the  British 
Medical  Journal,  Dec.  3d,  1887.  L.  F.  B. 

A  Case  of  Lingual  Mono-Hemiplegia  with  Corti- 
cal Localization — Bernheim  (Nancy).  French  As- 
sociation for  Advancement  of  Science,  sixteenth  session, 
1887.  Gazette  dcs  Hopitaux,  p.  1,016,  1887. 
It  is  known,  through  the  experiments  upon  animals  by 
Ferrier,  and  from  clinical  observations  by  Charcot  and 
Pitre,  that  the  lower  third  of  the  precentral  convolution 
presides  over  the  movements  of  the  opposite  side  of  the  face 
and  tongue,  and  that  destruction  of  that  territory  produces 
facial  and  lingual  hemiplegia.  Therefore  this  center  corres- 
ponds to  the  lower  facial  and  hypoglossus.  It  has  how- 
ever not  been  possible  thus  far  to  dissociate  these  two 
centers.  In  all  cases  of  glossoplegia  due  to  cortical  lesion 
of  the  precentral  convolution,  facial  paralysis  has  coexisted. 
In  Bernheim's  case  we  have  an  isolated  lingual  hemiplegia. 
The  patient  was  a  girl  23  years  of  age,  affected  with  multi- 
ple sarcomatous  tumors,  the  first  of  which  having  been 
observed  in  1886.  Suddenly  (Jan.  8th,  1887),  a  decided  de- 
viation of  the  tongue  supervened,  the  tip  pointing  to  the 
right.  She  swallowed  easily,  articulated  fairly  well,  but 
could  not  whistle.     No  other  paralysis  was  present,  but  the 


-5  PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

pressure  shown  by  a  dynamometer  was  four  degrees  less 
with  the  right  hand  than  with  the  left  (fifteen  degrees  with 
the  left,  eleven  with  the  right);  three  weeks  later,  ten  with 
the  left,  seven  with  the  right.  The  patient  died  on  the  2d 
of  February,  lingual  paralysis  persisting.  The  autopsy  re- 
vealed, in  addition  to  the  generalized  sarcomata,  a  cortical 
lesion  consisting  of  an  excavation  of  h\e  to  six  mm.  in 
depth  and  in  diameter,  and  caused  by  a  sarcomatous  hem- 
orrhagic clot.  This  lesion  was  situated  at  the  lower  border 
of  the  inferior  end  of  the  precentral  convolution.  The  con- 
clusion from  this  case  therefore  is,  that  at  the  lowermost 
extremity  of  the  precentral  convolution  there  is  a  special 
center,  the  cortical  center  of  the  hypoglossus.       G.  W.  J. 

Urine  of  Tabetics. — At  the  same  session  of  the  above 
society,  Charles  Livon  and  Henry  Alezais  (Marseilles)  read 
a  paper  upon  the  Urine  of  Tabetics.  From  a  series  of  ex- 
periments they  arrive  at  the  following  conclusions  : 

i.  There  is  in  tabetics  a  tendency  to  a  diminution  in  the 
amount  of  urea  excreted  in  twenty-four  hours. 

2.  Diminution  of  the  total  amount  of  phosphoric  acid 
eliminated  with  a  proportional  increase  of  the  phosphates. 

3.  Considerable  variation  in  the  amount  of  chlorides 
eliminated,  with  a  tendency  to  an  increase. 

4.  Intravenous  injections  of  tabetic  urine  seem  to  be 
fairly  toxic,  twelve  to  forty-four  cubic  centimetres  for  each 
kilo,  of  animal,  were  required  to  produce  death  in  dogs  by 
this  means.  G.  W.  J. 

The  Disease  of  the  Tics  Convulsifs.  —  Burot  (de 
Rochefort;,  Gazette  des  Hdpitaux,  p.  1,042,  1887. 
At  the  sixteenth  session  of  the  French  Association  for 
Advancement  of  Science  held  at  Toulouse,  Burot  read  a 
paper  under  the  above  title,  which  had  first  been  em- 
ployed by  Charcot,  and  which  affection  Gilles  de  la  Tourette 
has  described  as  a  nervous  affection  characterized  by  motor 
inco-ordination,  with  cholalia  and  coprolalia,  the  American 
Jumpers,  the  Tatah  of  Malasia,  and  the  Majirachik  of  Siberia 
probably  belonging  to  the  same  class.      Hurot's  patient  was 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  -jj 

a  girl,  19  years  of  age,  very  intelligent,  and  belonging  to  a 
family  of  the  better  class. 

The  convulsive  twitchings  occur  in  the  face  and  upper 
extremities,  and  are  accompanied  by  the  sudden  emission 
of  inarticulate  cries  and  of  obscene  and  filthy  words.  At 
the  age  of  six  years,  choreiform  movements  commenced  in 
the  eyes,  face,  neck,  and  arms.  At  twelve  years,  indistinct 
gutteral  noises,  as  ouh,  ouah  !  were  emitted.  At  fourteen, 
obscene  and  sacriligious  words.  She  repeated  all  noises 
which  attracted  her  attention,  barking  when  she  hears  or 
even  speaks  of  a  dog.  Gestures  are  sometimes  imitated. 
She  has  various  caprices.  She  not  only  does  and  says  that 
which  she  does  not  want  to,  but  cannot  always  do  that 
which  she  does  want  to.  Wishing  to  carress  a  cat,  she 
calls  it,  but  an  impulse  forces  her  to  push  it  from  her.  There 
is  no  inco-ordination,  but  a  true  impulse.  In  this  affection 
the  reflexes  are  unduly  excitable,  whereas  the  voluntary 
nervous  system  is  weakened.  There  is  no  inhibition  of  vol- 
untary acts.     All  in  all,  it  is  an  impulsive  mania. 

The  author  believes  that  the  affection  is  curable,  and  his 
plan  of  treatment  is  to  lessen  the  reflex  excitement  and  to 
strengthen  the  will-power.  This  was  attempted  by  moral 
influence  (faith  cure  ?),  and  with  beneficial  result. 

In  the  discussion,  Dulony  (de  Rochefort)  cites  a  case 
which  shows  that  the  affection  may  occur  in  persons  of  very 
strong  will-power,  and  believes  that  it  is  closely  allied  to 
hysteria.     Bezy  (de  Toulouse)  also  cites  a  similar  case. 

G.  W.  J. 

The  Lesions  in  Morphinomania  and  the  Presence  of 
Morphine  in  the  Viscera. — Prof.  Ball,  Gazette  dc 
HdpitauXy  p.  1,053,  1887. 

At  the  meeting  of  the  French  Academy  of  Medicine  of 
October,  1887,  Prof.  Ball  read  a  communication,  as  above. 
Thus  far  all  investigations  of  morphinomania  have  been  made 
upon  the  living  organism,  to  the  neglect  of  anatomical 
investigations.  This  may  be  ascribed  to  the  rarity  of  au- 
topsies in  such  cases.  All  that  has  been  noticed  anatomi- 
cally is  fatty  degeneration  of  the  heart,  morphinic   phthisis, 


yg  PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

various  other  acute  or  chronic  pulmonary  lesions,  gangrene 
of  the  extremities,  deep  abscesses,  cerebral  cedema,  etc,  but 
no  one  has  until  now  noticed  the  presence  of  morphine  in 
the  viscera.  Ball  has  observed  this  feature  in  a  case  which 
occurred  at  the  Asile  St.  Anne  of  Paris  upon  an  hysterical 
morphinomaniac,  who  took  one  gramme  of  morphine  daily. 
An  attempt  was  made  at  sudden  suppression,  in  conse- 
quence of  which  severe  collapse  ensued.  A  hypodermic  of 
morphine,  however,  restored  her.  Then  gradual  suppression 
was  attempted  ;  but  as  soon  as  the  morphine  was  entirely 
discontinued,  severe  collapse  occurred  and  death  ensued. 
The  autopsy  showed  fatty  degeneration  of  the  heart.  Micro- 
scopical investigation  showed  no  changes  in  the  nervous 
system.  Kidneys  and  liver  normal.  Chemical  examina- 
tion revealed  the  presence  of  morphine  in  nearly  all  the 
organs,  in  the  nervous  centers,  in  the  spleen,  the  kidneys, 
and,  above  all,  in  the  liver.  Ball,  in  view  of  this  case, 
warns  emphatically  against  the  sudden  withdrawal  of  mor- 
phine. G.  W.  J. 

Two  Peculiar  Forms  of  Spasms.  Report  of  the  6oth 
Congress  of  German  naturalists  and  physicians  at  Wies- 
baden. Sept.  18th  to  24th,  1887. 

Benedict,  of  Vienna,  before  the  section  of  internal  medi- 
cine, read  a  paper  which  described  two  peculiar  forms  of 
convulsive  or  spastic  attacks.  The  first  relates  to  patients 
convalescing  from  myelitic  paraplegia,  who  can  walk  but 
are  unable  to  stand.  In  these  cases  there  is  a  propulsive 
and  retropulsive  convulsive  movement  on  standing.  As 
soon  as  these  patients  attempted  to  stand,  they  were  driven  a 
few  steps  forward  and  then  just  as  many  steps  backward  from 
their  original  position.  In  a  case  of  convalescence  from 
subacute  myelitis,  this  symptom  developed  ;  and  from  the 
fact  that  it  conformed  to  a  sort  of  static  spasm,  the  author 
desired  to  call  it  forward  "  pendulum  spasm.  '  The  patients 
oscillate  forwards  on  attempting  to  stand. 

The  second  form  developed  in  the  convalescence  from 
hemiplegia.  The  affected  foot  is  not  put  forward  in  regular 
tempo,  but  the   patient  makes  a  number  of  forcibly  inter- 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  -g 

rupted  attempts  ;  each  interruption  forwards  follows  a 
shorter  backward  one,  and  may  be  compared  to  some  forms 
of  tremor.  This  condition,  the  author  remarks,  belongs  to 
the  group  of  post-hemiplegic  chorea  and  athetosis.  Bene- 
dict calls  it  the  "trill  spasm."  ( Trillcr-Krampf—  Central- 
blatt  fur  Nervenheilkunde,  Psychiatrie,  etc.,  Oct.  15th,  1887, 
No.  20).  N.  E.  B. 

On  the  Relations  of  Body-Weight  in  the  Period- 
ical PSYCHOSES.  Dr.  W.  Stark,  of  Illman — Allgemeine 
Zeitschrift  fur  Psychiatric,  etc. 
The  author,  by  constructing  a  series  of  co-ordinates,  the 
space  between  whose  vertical  lines  represented  the  mouth, 
and  between  whose  horizontal  lines  the  weight  in  an  as- 
cending scale,  was  enabled  to  present  a  graphic  account  of 
the  changes  of  the  body  weight  resulting  in  the  various 
emotional  conditions  of  exaltation  and  depression,  and  in 
the  interval  occurring  in  twelve  cases  of  periodical  insanity, 
six  of  which  were  suffering  from  the  circular  form  of  alien- 
ation. These  patients,  all  females,  were  under  observation 
for  a  period  extending  between  three  and  five  years,  and 
varied  in  age  from  18  to  59  years,  in  height  from  1.54  to 
1.69  m.,  and  in  average  weight  from  51  to  89  k.  He  derives 
the  following  general  conclusions  therefrom,  a  few  of  which 
are  here  given  : 

1 .  The  more  severe  and  protracted  the  paroxysm,  whether 
maniacal  or  depressive,  the  quicker  and  deeper  was  the  de- 
scent of  the  curve. 

2.  The  longer  and  uncomplicated  the  interval,  the  higher 
and  quicker  the  curve  arose. 

3.  Descent  and  ascent  occurred  the  most  rapidly  in  the 
beginning  of  the  paroxysms  and  of  the  intervals. 

4.  When  two  paroxysms  of  different  characters  follow 
each  other,  the  negative  deviation  of  the  curve  remains 
more  or  less  unmoved. 

5.  Repeated  paroxysms  force  the  entire  curve  niveau 
sharply  downwards. 

6.  Short  attacks  and  small  intervals  do  not  materially 
influence  the  nerve  movements  of  the  curve  resulting  there- 
from. 


gQ  PHYSIOLOGY  OF  THE  XER VOL'S  SYSTEM. 

7.  Developmental  periods  of  the  individual,  as  puberty 
and  the  climactesic  are  represented  in  the  excursive  magni- 
tude of  the  curve.  N.  E.  B. 

EARLY    SIGNS   OF    LOCOMOTOR    ATAXIA. 

Observations  made  on  one  hundred  and  seventeen  cases 
of  locomotor  ataxia  by  Dr.  Max  Karger,  of  Berlin,  give  the 
following  results  concerning  the  early  symptoms  of  this  dis- 
ease, at  the  stage  when  treatment  may  be  rational  and  sat- 
isfactory. In  fifty-three  per  cent,  of  the  cases  there  was  a 
history  of  syphilis.  There  were  symptoms  affecting  sensa- 
tion, lacinating  pains,  numbness,  especially  of  the  lower 
extremities,  cord-like  sensations  about  the  waist,  retarda- 
tion of  the  rate  of  conduction  of  sensations,  and  Romberg's 
symptom,  which  the  observer  does  not  consider  due  to  the 
ataxia,  but  thinks  it  an  abnormal  condition  of  sensation. 
Dr.  Karger  finds  at  the  commencement  of  the  disease  dimi- 
nution in  the  acuteness  of  vision,  and  a  concentric  contrac- 
tion of  the  field,  amblyopia  and  amaurosis,  due  in  thirty-five 
per  cent,  of  the  cases  to  optic  nerve  atrophy.  Slight  and 
transitory  paralyses  of  eye-muscles  were  also  present. 
Insensibility  of  the  pupil  to  light  was  found  in  sixty-six  per 
cent,  of  the  cases,  due  sometimes  to  a  paralyzed  condition 
of  the  sphincter,  and  sometimes  to  disturbances  of  reflex 
action.  Patellae  reflex  was  present  in  eight  of  the  one  hun- 
dred and  seventeen  cases  examined.  Bladder  reflex  was 
often  diminished,  suggesting  tabes  as  the  cause  of  chronic 
vesical  disease  of  unknown  origin.  Impotence  was  more 
common  than  any  sexual  reflex  ;  and  gastric  and  cephalic 
"crises,"  and  joint  affections  rarely  noted.  L.  F.  B. 

THOUGHTS   ON    INSANITY. 

The  elements  of  continuance  and  decay  are  identical. 
Conditions  determine  evolution  or  dissolution,  integration 
or  disintegration,  development  or  degeneration.  Function 
is  the  essence  of  vital  existence.  But  function  works  de- 
struction of  its  organic  basis,  even  as  it  works  its  evolution. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM.  gj 

Structure  originates  function,  but  reaction  of  function  devel- 
ops or  destroys  structure.  Insanity,  as  function,  determines 
its  own  evolution  and  evolution  of  its  structural  basis  ;  but 
the  very  forces  of  insane  function  can  be  turned  to  work 
dissolution  and  destruction  of  insane  function  and  organic 
substrate.  Here  lies  the  therapeutic  power  of  metaphysical 
diversion.  Vital  existence  contains  in  itself  the  elements  of 
its  continuance.  Morbid  ideas  contain  in  themselves  poten- 
cies to  continue  their  nutrition.  Excitation  and  flushing  of 
cerebral  processes  with  blood  supplies  the  physical  nutri- 
tion ;  introspection  and  external  metaphysical  agencies  sup- 
ply the  spiritual  pabulum. 

Whether  there  is  a  special  set  of  idio-volitional  nerves, 
originating  in  the  brain,  and  distributed  to  the  periphery  of 
sense,  or  whether  perceptional  or  hallucinational  insanities 
have  a  central  origin  and  reference  to  spacial  distance  ;  or 
whether  it  is  through  local  vaso-motor  peripheral  excita- 
tion, we  can  hardly  determine.  Several  cases  that  have 
come  under  my  observation  would  lead  me  to  believe  that 
the  fault  was  peripheral.  An  excited  imagination,  directed 
to  the  morbid  sense,  is  the  cause  of  the  evolution  of  hallu- 
cinational insanities,  for  this  state  of  things  continues  nutri- 
tion of  the  perceptional  illusion.  Imagination  unlocks  the 
channels  of  vaso-motor  activity,  and  flushes  the  structural 
basis  with  blood  ;  but  the  metaphysical  function,  that  is,  the 
illusion,  shapes  the  substrate  to  functionate  the  illusion. — 
Frank  W.  Vance,  M.D.,  in  Medical  Bulletin. 

L.  F.  B. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

ANTITHERMICS   AS   SEDATIVES   OF   THE   NERVOUS    SYSTEM. 

A  certain  number  of  antithermics  act,  not  by  lowering 
febrile  combustions,  but  by  direct  and  special  influence  upon 
the  thermic  centres  of  the  spinal  cord. 

Salicylic  acid  has  taken  its  place  among  analgesics, 
having  been  successfully  employed  in  neuralgias  and  tabes 
dorsalis.  Acetanilide  (CgH9NO),  or  antifebrin,  is  almost 
the  peer  of  salicylic  acid  in  the  treatment  of  acute  rheuma- 
tism.    Acetanilide,  when   employed  as  a  medicine,  should 


g2  THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

be  perfectly  pure.  Whatever  impurities  the  aniline  of  com- 
merce may  contain  ought  especially  to  be  eliminated.  Only 
slightly  soluble  in  water,  it  may  be  given  in  wine  or  some 
preparation  of  alcohol.  The  following  are  the  characters 
(Yvon)  which  should  belong  to  medicinal  acetanilide  : 
i.  It  should  possess  no  odor. 

2.  It  should  be  perfectly  white. 

3.  Heated  on  a  platinum  foil,  it  should  give  a  colorless 
liquid. 

4.  When  thus  heated,  it  should  be  entirely  volatilized, 
leaving  no  residue. 

5.  It  ought  not  to  give  with  hypobromite  of  sodium  an 
orange-yellow  precipitate. 

Doses  may  vary  from  twenty-five  centigrammes  to  three 
grammes  in  twenty-four  hours.  Whatever  the  daily  quan- 
tity, it  must  not  be  given  in  one  full  dose,  but  in  several 
small  doses  of  fifty  centigrammes  or  more,  at  regular  inter- 
vals. Administration  of  the  entire  amount  at  one  dose 
makes  collapse  a  possibility. 

Experiments  seem  to  show  that  acetanilide  is  not  by 
itself  a  true  poison,  but  that  it  acts  toxically  by  robbing 
the  blood  little  by  little  of  certain  principles  indispensable 
to  calorification,  causing  thus  a  progressive  refrigeration 
incompatible  to  life.  Oxyhemoglobin  is  markedly  dimin- 
ished in  the  blood  and  methsemoglobin  appears.  Aceta- 
nilide is  not  eliminated  in  substance.  No  trace  of  it  is 
found  in  urine.  It  is  almost  devoid  of  antiseptic  properties. 
It  has  an  antithermic  value  of  moderate  energy,  depressing 
temperature  by  acting  on  the  nervous  system  and  the  re- 
spiratory power  of  the  blood.  The  antithermic  action  is 
unequal.  In  small  doses  it  produces  and  sometimes  fails  to 
produce  any  considerable  thermic  fall.  Acetanilide  fre- 
quently causes  cyanosis.  It  is  inferior  to  antipyrin  as  an 
antithermic  and  decidedly  resembles  phenic  acid  in  its 
physiological  action  ;  and  like  phenic  acid,  should  be  dis- 
carded as  an  antipyretic.  As  a  nervine  medicament  it  is  a 
precious  acquisition  to  therapeutics.  I  have  combatted  by 
acetanilide  three  orders  of  phenomena, — the  element  of 
pain  in  general,  the  special  pains  of  locomotor  ataxia,  and 
lastly  epilepsy. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM.  g -, 

In  facial  neuralgia,  this  remedy  is  inferior  to  aconite. 
Yet  when  the  pains  in  the  head  are  linked  to  nerve-altera- 
tions, as  in  certain  cases  of  neuritis  of  the  orbital  nerves, 
acetanilide  has  been  found  of  more  value  than  anything 
else.  In  rheumatic,  muscular,  neuralgic,  and  even  articular 
pains,  it  seems  superior  to  salicylic  acid ;  and  will  cure 
when  aconite,  bromide,  and  iodide  of  potassium  fail.  It 
also  has  marked  somniferous  qualities. 

In  the  lightning-like  pains  of  locomotor  ataxia,  aceta- 
nilide renders  us  special  service.  The  painful  crises  are 
completely  removed.  Sometimes  the  effect  is  lasting  ;  but 
in  most  cases  the  amelioration  is  but  transient.  After  a 
fortnight  or  so  the  remedy  may  fail  utterly  to  relieve. 
Doses  of  one-half  gramme  three  times  a  day  have  broken  up 
attacks  of  epilepsy,  though  here  acetanilide  is  also  uncertain. 

Antipyrin  is  of  value  in  migraine  and  in  angina  pectoris 
accompanying  certain  diseases  of  the  heart,  especially  those 
of  the  aorta  and  coronary  arteries.  These  thoracic  and 
cardiac  pains  may  disappear  like  magic  after  the  adminis- 
tration of  a  few  gramme  doses  of  antipyrin.  It  is  an  anal- 
gesic, whether  introduced  by  the  mouth  or  by  the  hypo- 
dermic syringe,  and  has  none  of  the  disadvantages  of  opium. 
Salo'  is  chemically  produced  by  the  combination  of  salicy- 
lic acid  and  phenic  acid.  Like  all  its  cogeners,  it  has  anti- 
thermic properties.  Experiments  fail  to  reveal  any  poison- 
ous qualities.  It  allays  nervous  irritability  in  acute  articular 
rheumatism,  and  renders  real  service  in  the  pains  of  tabes 
dorsalis,  thus  bringing  about  rest  and  sleep. — Dujardin-Bau- 
metz,  Paris,  France,  in  Therapeutic  Gazette.  L.   F.   B. 

HYPNOTISM  IN  THERAPEUTICS. 
In  the  discussion  at  the  Medical  Society  of  Berlin,  on 
Oct.  26th,  1887,  the  use  of  this  measure  was  severely 
critized  by  Mendel,  Moeli,  and  others.  The  tendency  of 
the  remarks  of  these  gentlemen  went  to  establish  its  em- 
ployment as  a  dangerous  remedy.  Mendel  considered  it 
not  only  not  advisable,  but  almost  useless  ;  for  his  experi- 
ence taught  that  it  produced  nervousness  in  the  healthy 
and  increased  the  disease  from  which  the  sick  were  suffer- 
ing. (Centralblatt  fur  Nervenheilkunde,  Psych.,  und  ge- 
richt.  Psychopath.,  Nov.  15th,  1887,  No.  22,  s.  681.) 

N.  E.  B. 


§4 


THE  RAPE  l' TICS  OE  THE  XER  VOL'S  SYSTEM. 


THERAPEUTICS    OF   THE    URIC    ACID   DIATHESIS. 

The  subject  was  introduced  for  discussion  in  an  address 
recently  delivered  by  Dr.  Burney  Yeo  before  the  Section  of 
Pharmacology  and  Therapeutics  at  the  Dublin  meeting  of 
the  British  Medical  Association.  The  pathology  of  the 
condition  in  which  uric  acid  is  present  in  excess  in  the  or- 
ganism is  still  doubtful.  Murchison  regards  the  liver  pri- 
marily at  fault,  and  with  this  view  Latham  is  disposed  to 
concur.  According  to  this  theory,  the  essential  condition 
present  is  the  non-metabolism  of  glycosin  into  urea.  Gar- 
rod  thinks  the  kidney  is  the  active  producer  of  uric  acid, 
while  Ebstein  places  its  production  in  the  muscles  and  mar- 
row of  bones.  Frerichs  holds  that  the  essential  point  is  the 
perverted  metabolism  of  albuminoid  substances  into  urea. 
Bouchard  denies  that  the  presence  of  uric  acid  in  excess  is 
the  chief  feature  of  the  morbid  condition  in  question.  One 
thing  appears  certain — the  uric  acid  diathesis  has  its  foun- 
dation in  the  imperfect  metabolism  of  food,  especially  albu- 
minoids. Dr.  Yeo  would  define  it  as  "mainly  a  disturbed 
retrograde  metamorphosis."  Three  things  must  be  taken 
into  account,  as  in  all  therapeutic  questions  :  I,  the  patho- 
genic factor  ;  2,  the  constitutional  factor  ;  3,  the  remedial 
factor.  Next  to  heredity,  errors  in  eating  and  drinking  are 
the  most  potent  causes  in  this  diathesis.  A  tendency  to 
obesity  has  been  regarded  a  potent  factor  in  the  production 
of  this  condition.  A  minimum  of  fats  has  been  advised,  and 
the  yolk  of  eggs  prohibited.  Malt  liquors  and  bad  wines 
are  to  be  carefully  avoided.  The  quality  rather  than  the 
kind  of  wine  is  really  the  important  point.  Wines  having  a 
diuretic  action  are  generally  the  best.  Exercise  in  moder- 
ation is  important  as  tending  to  improve  the  general  health. 
A  warm,  dry,  equable  climate  is  useful.  All  climatic  con- 
ditions that  interfere  with  the  action  of  the  skin  are  hurtful. 
The  regular  use  of  large  quantities  of  water,  preferably  hot, 
is  highly  beneficial.  Garrod,  Sir  Thomas  Watson,  and 
Graves  bear  witness  to  the  value  of  colchicum,  which  has 
its  chief  action  upon  the  liver  (Yeo),  and  is  also  sometimes 
a  diuretic  and  diaphoretic.  Benzoate  and  salicylate  of 
sodium,  guaicum,  and  iodide  of  potassium,  with  lithia,  mag- 
nesia, and  lime,  have  all  been  highly  praised  as  remedial 
agents  L.  F.  B. 


VOL.  XIII.  February.   1888.  No.  2. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


Original  ^rtfcUjSi. 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI 
AND  PONS  VAROLII. 

By  ISAAC  OTT,  M.D. 

IN  my  experiments  upon  rabbits  I  found  when  a  puncture 
was  made  just  in  front  of  the  ear  into  the  cortex  there 
ensued  a  fugitive  rise  of  temperature.  This  observation 
lead  me  to  try  in  cats  the  effects  of  removal  of  areas  of  the  cortex 
in  this  and  other  regions.  The  method  was  as  follows  :  the 
animal  was  etherized  in  a  bag,  the  skin  in  front  of  the  ear 
divided,  the  muscles  separated,  the  bone  bared,  and  the 
trephine  of  Pasteur  applied,  which  rapidly  makes  an  open- 
ing through  the  skull.  With  a  small  hook- shaped  knife 
the  dura  mater  was  divided,  and  the  cortex  cerebri  beneath 
broken  up  to  the  depth  of  a  sixteenth  of  an  inch.  The  wound 
was  then  washed  with  a  carbolized  solution  and  the  integu- 
ments brought  together  by  sutures.  The  weight  and  rec- 
tal temperature  were  taken  previous  to  the  operation  and  in 
some  cases  the  animal  was  placed  in  d,  Arsonval's  calori- 
meter, and  heat  production  and  heat  dissipation  noted  for  an 
hour.  After  the  operation  the  animal  was  placed  in  a  box 
of  straw  and  allowed  to  sleep  off  the  ether,  after  which  he 
was  set  in  the  calorimeter  at  similar  dates  for  several  days. 
All  observations  with  the  calorimeter  were  made  about  the 
same  time  each  day  for  a  student  of  mine,  Mr.  W.  S.  Carter, 
has  found  that  heat  production  and  dissipation  have  periods 
of  rise  and  fall,  being  lowest  from  6  to  9  A.  M.,   and  highest 


86 


fSAAC  OTT. 


from  12  to  2  P.  M.  They  were  fed,  but  partook  sparingly  of 
food.  A  point  at  the  juncture  of  the  supra  Sylvian  and  post- 
Sylvian  fissures  was  found  to  have  the  highest  thermic  value. 
S  in  Fig.  i  shows  the  position  of  this  centre  and  from  this 
area  it  extends  downward  to  the  fissura  postica.  In  my  de- 
scriptions I  shall  follow  the  nomenclature  of  the  fissures  as 
given  by  Prof.  Wilder.     Other  parts  of  the  brain,   with  the 


Fig.  i.     Twice  the  natural  M/e      Alter  Wilder. 


exception  of  the  cruciate  centres,  had  but  small  effect  upon 
the  temperature.  In  the  experiments  will  be  found  the  de- 
tails of  observations  upon  other  regions  of  the  brain.  The 
rise  of  temperature  after  injury  to  the  Sylvian  centres  is  from 
three  to  four  degrees,  and  continues  till  the  death  of  the  an- 
imal, which  is  usually  about  the  sixth  day.  The  calorime- 
tric  investigations  show  that  either  immediately  or  at  the 
end  of  twenty-four  hours,  the  heat  production  and  heat  dis- 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI.         %j 

sipation  are  increased,  after  that  they  usually  fall  below  nor- 
mal, although  the  temperature  remains  elevated,  with  a 
weight  decreasing  daily.  In  Fig.  2  are  given  the  curves  of 
an  experiment,  the  highest  line  is  that  of  weight  ;  the  second 


line,  the  temperature  curve  ;  the  dotted  line  that  of  heat- 
dissipation  ;  the  continuous  line  that  of  heat  production. 
The  numbers  at  the  bottom  of  the  figure  are  the  days  during 
which  the  observations  were  made.  That  this  increase  of 
heat-production  is  not  due  to  circulatory  changes  is  seen  in 
the  experiment  where  the  pulse  and  pressure  were  noted 
after  an  operation  on  the  Sylvian  centre.  They  both  rise  for 
a  short  period  and  then  fall  to  a  certain  extent  below  nor- 
mal, although  the  temperature  is  afterwards  rising.     No  data 


88 


ISAAC  OTT. 


that  I  know  of  would  justify  any  one  in  assuming  at  the  end 
of  twenty-four  hours,  an  increased  production  of  heat  is  due 
to  a  depressed  circulation.  It  is  true  that  after  section  of  a 
nerve  there  is  an  increased  temperature  in  the  parts,  but  it 
by  no  means  follows  that  there  is  an  increased  production  of 
heat  in  the  part  due  to  increase  of  blood,  for  the  section  it- 
self may  remove  the  inhibition  of  thermogenesis  in  the  parts 
supplied  by  the  divided  nerve, 

Prof.  R.  Meade  Smith,*  in  a  series  of  observations  on  the 
thermic  phenomena  of  muscles,  arrived  at  the  conclusion 
that  with  a  large  supply  of  blood  the  cool  skin,  even  though 
exposed  to  excessive  and  rapid  loss  of  heat,  will  become 
warmer,  while  on  the  other  hand,  the  warmer  muscle  will 
become  cooler.  Consequently  he  states  the  conception  must 
be  erroneous  which  is  generally  held  as  to  the  temperature 
changes  in  muscle  from  alterations  in  the  blood-supply  after 
section  of  the  nerves. 

That  the  increased  heat  production  does  not  continue 
beyond  the  first  twenty-four  or  forty-eight  hours  is  in  part 
due  to  diminished  ingestion  of  food.  I  have  observed  a 
similar  increase  for  the  first  twenty-four  hours  when  experi- 
menting upon  the  four  cerebral  heat-centres.  In  examining 
the  curve  of  temperature  in  Fig.  2,  it  will  be  found  to  be  sim- 
ilar to  that  seen  after  injuries  about  the  corpus  striatum,  and 
dissimilar  to  those  seen  after  the  lesions  of  the  thalamic  or 
extra-thalamic  centres.  It  was  found  that  usually  the  tem- 
perature of  the  trunk  and  the  extremities  was  elevated,  the 
extremities  opposite  the  side  of  lesion  being  slightly  warmer 
than  those  on  the  side  of  injury.  Whilst  exploring  the  cor- 
tex I  found  that  the  cruciate  centres  (C.  Fig.  1.)  of  Eulen- 
berg  and  Landoisf  exhibited  upon  injury  the  phenomena 
described  by  them. 

I  shall  denominate  their  centre  the  cruciate  to  distinguish 
it  from  the  Sylvian.  I  should  like  to  state  here  that  after 
injuries  to  the  Sylvian  I  saw  no  evidences  that  the  cruciate 
was  involved  by  an  meningo-encephalitis,  in  the  production 
of  the  phenomena  attributed  to  the  Sylvian. 

0 Archives  of  Medicine,  1884. 

fTherapeutic  Gazette,  Sept.,    1887.      Vircho  wArchiv.  H.d.  68,  1876. 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI.         gQ 

The  cruciate  is  bounded  anteriorly  by  the  cruciate  sulcus, 
and  embraces  entirely  a  part  of  the  fourth  primitive  convo- 
lution and  particularly  the  posterior  and  lateral  convolutions 
of  the  "  Hackenformigen  "  gyrus,  which  corresponds  in  man 
and  apes  to  the  antero-central  convolution,  and  appears  to 
be  the  post-frontal  gyrus  of  Owen.  Destruction  of  the  parts 
was  accomplished  in  dogs  by  means  of  the  cautery,  which 
caused  a  considerable  rise  of  temperature  in  the  opposite 
extremities.  The  increase  of  temperature  often  takes 
place  before  the  animal  recovers  from  the  chloroform.  The 
difference  between  the  temperature  of  the  extremities  is  from 
1. 50  C.  and  130  C.  They  also  used  chloride  of  sodium,  which 
after  a  stage  of  excitation  acted  like  the  cautery  on  the  cen- 
tres, destroying  them.  The  temperature  of  the  ear  on  the 
side  of  lesion  was  higher  ;  destruction  of  the  gyrus  praefront- 
alis,  the  super  sylvian  and  others  is  without  effect  on  the 
temperature.  They  seem  to  think  that  when  a  part  of  the 
brain  near  the  cruciate  is  destroyed,  that  the  lesion  in  a  few 
hours  or  a  day,  may  cause  a  meningitis  or  encephalitis,  in- 
vading the  cruciate  centres  and  thus  elevating  the  temper- 
atures. If  this  is  true,  areas  in  the  neighborhood  may  have 
thermic  value  falsely  attributed  to  them.  The  temperature 
after  injury  to  the  cruciate  centres,  gradually  increases  and 
remains  elevated  from  three  days  to  three  months.  Irritation 
of  these  centres  causes  a  cooling  of  the  opposite  extremi- 
ties. Prof.  Wood  has  also  noted  phenomena  similarly  to 
those  stated  above,  and  he  found  that  the  increase  of  tem- 
perature was  attended  with  an  augmented  production  of 
heat.  He  did  not  ascertain  how  long  this  increase  of  heat- 
production  continues.  I  have  made  experiments  upon  this 
point  and  determined  the  weight,  temperature,  heat-produc- 
tion and  heat  dissipation  for  several  days.  The  animals  used 
were  cats,  and  the  same  method  was  followed  as  in  experi- 
ments upon  the  Sylvian  centres.  It  will  be  noted  that  at  the 
end  of  twenty-four  hours  the  heat  production  is  elevated 
above  normal,  and  then  returns  to  its  original  level,  to  again 
rise  on  subsequent  days.  Heat  dissipation  closely  follows 
heat-production.  I  have  also  sought  to  determine  the  effect 
of  these  centres,  as  well  as  the  Sylvian  on  the  rectal  temper- 


g0  ISAAC  OTT. 

ature,  and  found  that  when  irritated  they  depressed  it. 
When  by  puncture  of  the  corpus  striatum  the  temperature 
is  elevated,  then  irritation  of  the  cortical  centre  by  the  far- 
adic  current  still  depresses  the  hyperthermic  condition  gen- 
erated by  lesion  of  the  heat-centres  about  the  corpus  striatum. 
Experiments  upon  the  circulation  when  the  cruciate  centres 
are  mechanically  destroyed,  produce  the  same  results  as 
after  Sylvian  destruction. 

Pons  Varolii  :  The  discovery  of  the  four  cerebral  heat 
centres  by  the  method  of  puncture  at  the  base  of  the  brain, 
lead  me  to  use  it  in  the  pons  varolii.  When  the  lateral  col- 
umns of  the  spinal  cord  are  divided,  and  the  temperature  of 
the  ambient  air  is  about  that  of  the  animal,  the  temperature 
of  the  animal  rises  because  there  is  increased  production  of 
heat.  If  the  pons  is  transversly  separated  from  the  medulla 
a  similar  increment  of  heat-production  ensues,  causing  an 
elevation  of  temperature.  In  the  experiments  upon  the  pons 
I  have  used  rabbits,  and  the  puncture  was  made  through  the 
occiptal  bone,  and  cerebellum  into  the  pons  varolii.  Not- 
withstanding a  large  number  of  punctures,  the  increase  of 
temperature  was  only  a  few  degrees  and  not  permanent. 
These  results  convinced  me  that  it  was  not  necessary  to 
make  any  calorimetric  investigations,  for  it  is  usually,  when 
the  temperature  is  excessive  and  transient  or  when  it  is 
moderate  and  continuous  for  some  days,  that  any  notable 
increment  of  heat-production  ensues.  The  rise  that  takes 
place  after  an  injury  to  the  pons  varolii  from  a  transverse 
section,  is  due  to  removal  of  an  inhibiting  influence  upon  it 
and  the  spinal  cord.  In  section  of  the  lateral  columns  of 
the  spinal  cord,  a  similar  cause  is  at  work.  The  idea  that  a 
dominant  heat  centre  exists  in  the  pons  varolii  is  not  sup- 
ported by  these  experiments  or  by  any  others  when  they 
are  held  up  to  the  light  of  recent  discoveries. 

The  query  now  arises  what  is  the  nature  of  these  six 
centres  in  the  brain  ?  I  have  already  referred  to  the  three 
divisions  of  the  phenomena  of  fever  by  Dr.  Donald  Mac- 
Alister  into  thermotaxic,  thermogenetic,  and  the  thermo- 
lvtic.  The  fact  of  the  cruciate  and  Sylvian  centres,  upon 
their  destruction,  causing   an   elevation   of  temperature  for 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI.         q  j 

days,  their  irritation  a  slight  refrigeration  of  the  body,  and, 
when  striate  hyperthermia  is  produced,  irritation  of  the 
cruciate  centre  still  reduces  it,  causes  me  to  believe  the 
Sylvian  and  cruciate  to  be  thermotaxic.  The  striate,  extra- 
striate  and  thalamic  centres,  with  the  one  about  SchrifT s 
crying  centre,  constituting  the  four  heat  centres  at  the  base 
of  the  brain,  may  be  regarded,  according  to  the  different 
kind  of  impulses  sent  into  them  by  different  irritants,  as 
either  thermotaxic  or  thermogenetic. 

In  another  paper*  I  have  spoken  of  the  reasons  which 
lead  me  to  so  regard  them.  The  effect  of  section  of  the 
lateral  columns  of  the  spinal  cord  and  of  the  great  spinal 
stimulant,  atropine, t  in  causing  increased  temperature,  in- 
duces me  to  hold  that  the  spinal  cord  is  the  main  seat  of 
the  thermogenetic  centres.  The  increase  of  heat  produc- 
tion after  injury  to  the  Sylvian  and  cruciate  centres,  the  fall 
to  normal,  and  the  subsequent  rise  in  some  cases  (Exp.  12), 
indicates  that  there  is  a  play  between  these  centres  and 
those  beneath  for  mastery,  a  state  of  things  seen  in  the  tem- 
perature of  fever  patients.  If  these  experiments  are  ex- 
amined, they  afford  excellent  ground  for  the  belief  that  in 
certain  feverish  states  the  normal  of  heat  production  and  heat 
dissipation  is  reset  at  a  higher  rate,  but  at  the  end  of 
twenty-four  hours  slides  down  below  normal,  partly  from 
want  of  food.  Experiments  upon  the  four  basal  heat  cen- 
tres also  show  a  similar  state  of  affairs  during  the  first 
twenty-four  hours,  heat  production  and  heat  dissipation  are 
increased,  but  afterwards  fall,  although  the  fever  continues. 
It  is  probable  that  after  injury  to  the  cortical  heat  centre, 
the  basal  and  spinal  thermogenetic  centres  are  temporarily 
permitted  to  obtain  the  upper  hand,  but  that  shortly  the 
other  cortical  heat  centres  bring  the  thermogenetic  centres 
into  subjection,  and  thus  reduce  heat  production.  In  the 
case  of  lesion  of  the  basal  and  spinal  thermogenetic  centres, 
they  primarily  overcome  the  cortical  centres  for  a  short 
period,  but  finally  succumb  to  the  domination  of  the  ther- 
motaxic centres  of  the  cortex.  In  other  words,  the  Sylvian 
and  cruciate  centres  constantly  antagonize   the  basal  and 

0  Therapeutic  Gazette,  1887.  f  Therapeutic  Gazette,  1887. 


QO  ISAAC  OTT. 

spinal  thermogenetic  centres.  It  is  also  probable  that 
under  certain  impulses  the  cortex  and  basal  centres  com- 
bine together  to  antagonize  the  spinal  thermogenetic  cen- 
tres. It  would  seem  that  any  injury  to  the  thermotaxic  or 
thermogenetic  apparatus  sets  up  a  fever  which  is  primarily 
accompanied  by  increased  production  and  dissipation  ;  but 
but  they  soon  fall  below  normal,  whilst  the  fever  continues 
till  the  lesion  is  repaired.  This  would  lead  to  the  belief 
that  in  continued  fever  the  generation  of  a  ptomaine  is  con- 
tinuously carried  on  for  some  time,  and  thus  keeps  up  the 
fever.  These  experiments  show  how  delicate  and  complex 
is  that  most  important  mechanism  of  the  body  temperature- 
regulation  ;  each  of  these  six  cerebral  heat  centres  has  its 
own  laws.  Some  are  slow,  others  are  rapid  in  their  eleva- 
tion of  temperature  ;  some  continue  their  activity  for  days, 
others  for  a  short  time  ;  some  affect  one  part  of  the  body 
more  than  another  ;  others  do  not. 

The  crossed  action  of  the  cruciate  and  Sylvian  centres, 
the  former  being  stronger  in  crossed  activity  than  the  lat- 
ter, is  another  fact  in  support  of  a  view  already  advanced* 
as  to  the  decussation  of  thermotaxic  fibres. 

The  mechanism  of  temperature  production  is  as  follows: 

rrr,         J     .    ( Cruciate  (Eulenberg  and  Landois) 
Thermotaxic)      and 

Centres:     }  Sylvian 

Thermotaxic     (      The  centre   about  Schiffs  crying  centre  and  the 
and  •}  extra-striate,  striate  (Sachs  and  Aronsohn),  and  the 

Thermogenetic  :  (  thalamic  centres. 


Thermogene.ic  (  _    •      , 

^    j6  -  Spinal  centres. 


Centres  :       { 

Appended  are  the  experiments  upon  which  the  preced- 
ing statements  are  mainly  based  : 

R.  T.  means  rectal  temperature. 

'  .  T.       "       calorimeter  " 

A.  T.       "       air 

\V.  is  weight  in  pounds. 

II.  D.  is  heat  dissipation. 

H.  P.  is  heat  production. 


0  Journal  of  Nervous  and  Mental  Diseases,  July,  1887. 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI.         g -, 
EXP.  I. — Cat;  weight,  3.36  lbs. 


A. 

T. 

C.    T. 

R.   1 

12, 

SO 

p. 

M. 

SO. 

79-95 

I02. 

5 

I, 

,50 

' 

' 

83- 

55 

80.7 

IOO. 

5 

+.75        — 2.0 
H.  D.=3i.29  H.  P.=25.42 

2.10  p.  m.,  Sylvian  centre  destroyed. 


Second  Day. 

A.   T.               C.   T. 

12.06    p.  m.         73.4           7J-45 
1.06     "             75.3           72.7 

R.    T. 

IO5.2 
IOO.4 

1.25 
H.  D.=52.i5            H.  P.= 

Third  Day. 

—4.8 
:49-57 

106.5 


Fourth  Day. 
1   p.  M 105.4 


EXP.  II— Cat;  weight,  7.6  lbs. 

A.    T. 

C.    T. 

R.    T. 

5.06     P.    M.              76.4 

7O.98 

IC2.4 

6.06        "                   73.O 

72.5 

IOO.3 

+  1.55  —2.1 

6.30  p.  m. — Sylvian  centre  destroyed  on  right  side. 

H.  D'=63.4i  H.  P.=5i.oo 

8. 1 5  P.  M 102.2 

Second  Day. 

8  a.  m io5-9 

Left  posterior  extremity.  . .  .  105.2 

Right       "  "  104.8 

Trunk 104. 8 

Left  anterior   extremity.  . . .  104.7 
Right       "  "       ' 104.3 

a.  t.  c.  t.  r.  t.    Weight,  7  lbs. 

6.57   p.  m.         76.4  76.3  io4-3 

7.57      "  76.7  75.2  IOI.I 


1.6  — 3.2 

H.  D.=66.75  H.  P.  =48. 16 


q  *  ISAAC  0T7. 

Third  Day. 

A.    T.  C.    T.  R.    T.         \Y.,    7.38  lbs 

10.50  a.  m.         72.  ?i-75         106. 1 

11.50     "  74.  73.6  101.9 

+  1.85        —4.2 
H.  D.=77.i8  H.  P.  =5  2. 18 

Fourth  Day. 

II.3O    A.    M 1 04.  3 

Fifth  Day. 

2    P.    M IO5.4 

EXP.  III.— Cat.  Ri  T 

7.45  A.    M IOI.4 

8.00  "  Left  cortex,  injury  between  the  median 
line  of  brain  and  f.  lateralis  at  the 
posterior  part. 

Second  Day. 

10. 30  a.  m 101.3 

12.50  p.m. 102.4 

1. 00  "  Right  cortex  injured  at  the  posterior  edge 
of  f.  ansata  towards  the  median  line. 

Third  Day. 

2.05     "    104.2 

This  injury  involved  the  area  of  the  cru- 
ciate centre. 

EXP.  IV.—  Cat;  weight,  2.64  lbs. 

A.    T.  C    T.  R.   T 

II. 51     A.    M.  62.  61.9  102.  I 

I2.5I      P.    M.  64.5  62.95  99.3 

+  1.05  2.8 

H.  D.=43.8o  H.  P.  =38. 50 

2.00   p.  m. — Sylvian  centre  destroyed  on  leftside. 

2-3°     "         97-3 

3.25     "         101.1 

5.00     " 102.5 

Second  Day. 

8.00   a.  m 1 01. 9 

12.00   m 103.  1 

2.15   p.  m. — Sylvian  centre  destroyed  on  right  side. 

a.  t.  c.  t.  r.  t.       Weight,  2.60  lbs. 

4.38    p.  m.         63.  62.75         103-8 

5.38     "  66.  63.95         100. 1 

+  1.20         — 3.7 
H.  D.=50.o6  H.  P.  =40. 97 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI.         g5 
Third  Daw 


A.   T. 

C. 

T. 

R.   T. 

w 

eight, 

2 

50 

lbs. 

I 

2 

I  2 

12 

P. 

M. 
t 

65.5 
63.8 

6l 
62 

OS 
O 

IO3.4 
I00.6 

+1.-05        — 2-8 
H.  D.=43-8o  H.  P.  =37. 99 

Fourth  Day. 
12.00    M 104.5. 

Fifth  Day. 

a.  t.  c.  t.  r.  t.      Weight,  2.34  lbs. 

I.46     P.    M.  65.5  63.2  I02.4 

2.46     "  65.0  64.0  100.3 


.8  —2.1 

H.  D.^3.37  H.  P.=25.59 

EXP.  V.— Cat. 

R.    T. 
7.55   A.    M IOO.9 

8.00     "   Right  side,  injury  of  cortex  at  anterior 

end  of  super-Sylvian  fissure 
2.30  p.  M 98. 3 

Second  Day. 
1 2.  50     "  Left  side,  injury  of  cortex  just  back  of  an- 
terio  end  of  supra-Sylvian  fissure  near 
f.  ansata. 


Third  Day. 


EXP.   VI.—  Cat;  weight,  2.98  lbs. 

A.    T.  C    T.  R.    T. 

11.26    A.    M.  6l.  60.75  IOI.7 

12.26        "  6l.8  61.95  I00.6 


96.3 


-j-1.  20  I.I 

H.  D.=5o.64  H.  P.  =47. 34 

12.30  p.  M. — Sylvian  centre  on  right  side  destroyed. 
2.15     "         103.1 

A.    T.  C    T.  R.    T. 

3.32     P.    M.  65.4  62.8  IO4.2 

4.32        "  64.8  63.9  I02.4 


+  I.I  —I. 

H.  D.=45-89  H.  P.  =4 1. 44 


96 


ISAAC  OTT. 
Second  Da\. 

8   .A.    M 1 04.  5 

a.  t.  c.  t.  r.  t.      Weight,  2. 76  lbs. 

12.12     P.    M.  64.2  6l.8  I03-9 

I.  12        "  64.6  63.38  IOO.3 

4-1.58      —3.6 

H.  D.=75.9i  H.  P.  =67. 67 

Third  Day. 

a.  t.  c.  t.  r.  t.       Weight,  2.78  lbs. 

11.54   a.  m.         60.  59-75  104.8 

12.54    p.  m.         66.4  61.05  101.6 

—  i. 30         — 3.2 
H.  D.=54.33  H-  P-=46.93 

Fourth  Day. 

12.00  m.  .  .  .Left  post,  extremity 104.9 

Right  "  "         109.0 

Trunk 104.  5 

Left  anterior  extremity.  .  ..  104.5 
Right  "         104.5 

Fifth  Day. 
a.  t.  c.  t.  r.  t.      Weight,  2.36  lbs. 

12.46    P.    M.  67.5  61.95  IO4.3 

1.46      "  67.6  63.20  IOO.I 

+  1.25        — 4.2 
H.  D.=52.i5  H.  P.  =43. 86 

EXP.  VII.— Cat 

2.3O    P.    M I OI.  5 

2.35      "     Sylvian  centre  broken  upon  leftside. 

4.49  "      102.3 

Second  Day. 

8. 00    a.  H 1 03. 6 

5.00    p.  m 104. 1 

EXP.   VIII— -Cat 

2.30    P.    M 1 00. 8 

2.35      "     Sylvian  centre  on  left  side  broken  up. 

4.50  "     100.9 

Set  ond  Day. 
8.00   a.  m 103.  2 

5.OO    P.    M IO4.4 

Left  posterior  extremity.  .  .    103.4 
Right     "  "  ...103.6 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI.         g-r 

Third  Day. 

8.00    a.  M    103. 1 

4.00    P.  M    104.3 

Fourth  Day. 
8.30  a.  M 102. 1 

EXP.  AY.— Cat. 

R.    T. 
2.I5    P.    H I02.  I 

2.22      "  Sylvian  centre  exposed  and  faradaised  for 
two  minutes,  Du  Bois  coil  at  8. 

2.25      " 101.5 

2.32      "    101.1 

2.42     " 101.1 

EXP.  X.—  Cat. 

PULSE.  PRESSURE. 

I  I.  29     A.    M 76  124 

11.30     "     Sylvian  centre  destroyed. 

1 1 .  30. 1 5  a.  m 83  1 40 

n.3°-45     "    7°  J44 

11.40.00      " 72  118 

1 2. 1 8. 00  p.  m 70  118 

EXP.  AY.— Cat. 

R.  S. 

3-5°  p-  m     99-7 

Excision  of  cortex  on  both  sides  of  brain 
just  back  of  the  sulci  cruciati — consid- 
able  haemorrhage. 

4.25     "    93-9 

6. 00     "   96. 9 

8.35     " • IOO-7 

9.22     " ...101.2 

Second  Dm: 

8. 00  a.  m 102. 2 

1 2. 1 5  p.  m    103. 8 

3-°°     " J04-3 

6.30     "   102.9 

Third  Day. 

8. 00  a.  M 102.9 

3-45  p.  m 103. 

EXP.  XII.—  Cat;  weight,  4.78  lbs. 

A.    T.  C   T.  R.    T. 

11.55  A-  M-         62-f5  62.55         101.9 

12.55    ?•  M-  63-4  63.7  99.7 

1. 15  2.2 


gg  ISAAC  OTT. 

i.  20  p.  m. — Left  post-cruciate  centre  ablated  under  ether. 
H.  D.=47.97  H.  P.=39-25 

a.  t.  c.  t.  r.  t.      Weight,  4. 78  lbs. 

4.43     P.  M.  71.9  65.6  IOI.O 

5.43     "  71.6  66.85  99-° 


1.25             2.0 
H.  D.=52. 15             H.  P.=44.22 
9-3°  p-m 102.5 

Second  Day. 

9. 00  a.  m 102. 5 

6.00  P.  M 102.3 

Third  Day. 

II.3O    A.    M     IO3.8 

Fourth  Day. 

II.3O    A.    M 1 04.  4 

Fifth  Day. 

II.3O    A.    M IO3.2 

Sixth  Day. 
Right  side,  posterior  extremity 103.0 


Left 


.102.6 


Seventh  Day. 
2.35   a.  M 104. 1 

Eighth  Day. 
a.  t.  c.  t.  r.  t.      Weight,  4.36  lbs. 

12.36    A.    M.  62.  61.45  I02.0 

1.36    "  65.4         62.7  99.5 


1.25         2.5 

H.  D.  =52.15  H.  P.=42.07 


Ninth  Day. 


11.55    A-  M 


100.9 


98.7 


Tenth  Day. 

1.20   P.  M 

1.35      "   Puncture  into  corpus  striatum. 

3-r5       '    103.2 

3-55       ' 103.2 

4.00     "   Irritation  for  fifteen  seconds;    Du   Bois' 

coil  at  10  of  post-cruciate  centre  of 

right  side. 
4- 02      '• 102. 1 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI. 


99 


EXP  XIII.— Cat;  weight,  4.98  lbs. 

A.    T.  C.   T. 

II.30    A.    M.  67.8  67.7 

12.30     "  68.6  68.45 


IOI.9 

101.6 


H.  D.  =3 1.29 


75 


H.  P.  =30. 06 


1.40  p.  m. — Etherized,  left  post-cruciate  centre  broken 
up  with  galvano-cautery. 


r.41 

2.00 
3-42 

5.00 
8.20 


I2.00    M. 
I.  OO    P.   M. 


98.7 
IOI  *2 
I02.  I 
I02.0 
IO2.7 


A.   T. 

68. 
69.5 


Second  Day, 
c.  T. 
67.5 
68.65 


H.  D.=47-97 


1.15 


R.   T. 
IO3.2 

IOO.6 


2.6 


Weight,  5  lbs. 


H.  P.=37.i8 


EXP.  XIV.— Cat;  weight,  4.80  lbs. 

A.    T. 
II.30     A.    M.  65.3 

I2.3O         "  65.4 

H.  D.=47-97 


C  T. 
62.45 
63-55 

I.  IO  

H.  P.  =4 1. 20 


R.  T. 
IO2.9 
IOI. 2 


12.50  p.  m.     Under  ether  has  left  post  cruciate  centre 
destroyed. 


1. 00 
1.20 
3-50 
5-5° 
9.00 


98.7 
101. 6 
102.7 
103.0 
102.9 


Second  Day.          Weight,  4.62  lbs. 
9.00   a.  m 101. 9 


A.   T. 
I2.O5    p-  M-               64 
I.05       "                   64 

C.    T.                 R.    T. 
63.6                IO3.9 
64.5                IO3.  I 

H.  D.=39.63 

+.9              —.8 
H.  P.  =3  7. 00 

IOO  ISAAC  OTT. 

Third  Day. 
A.    T.  C.    T.  R.    T.        Weight,    2.2  2   lbs. 

u.oo  a.  h.  66.  65.6  1039 

12.00  m.  66.8         66. 5  101.2 

•95  2.7 

H.  D.=39.63  H.  P.  =34. 66 

Fourth  Day. 

a.  t.  c.  t.  r.  t.     Weight,  2.22  lbs. 

2.  ic  p.  m.  66.0  65.2  105.2 

3.10     "  67.2  66.35         101.7 

I-l5  3-5 

H.  D.=47-97  H.  P.=4i.53 

Fifth  Day. 

9.  OO    A.    M 1 04.  9 

Fifth  Day. 

I  I .  OO    A.    M I  05.  I 

Right  posterior  extremity 104.6 

Left         "  "        102.6 

EXP.  XV.— Cat;  weight,  2.78  lbs. 

A.    T.  C.    T.  R.    T. 

3.43     P-    M.  64.2  61.45  IO2.5 

4.43        "  64.  62.18  I02.0 

73-  -5 

5.00  p.  m. — Left  Sylvian  centre  destroyed. 

H.  D.=3o.45  H.  P.=25.47 

6.45    P.    M I02.6 

A.    T.  C.    T.  R.   T. 

8.37     P.    M.  63.7  62.3  IO2.9 

9.37        "  63.6  63.28  I02.0 

.98  .9 

H.  D.=4o.88  H.  P.  =38. 8 1 

Second  Day. 

a.  t.  c.  t.  r.  t.      Weight,  2. 26  lbs. 

4-35     A.    M.  66.5  65.3  IO3.8 

5.35    "  67.0        65.95       io2-8 

.65  1.0 

H.  D.=27. 11  H.  P.=25.24 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI.       JOl 
EXP.  XVI.—  Cat;  weight,  3  lbs. 

A.   T.  C.   T.  R.   T. 

II.OO    A.    M.  62.55  62.55  I02.0 

I2.00    M.  66.O  63.9  I  OO.O 

I.25  2.0 

12.15  p.  m. — Left  post-cruciate  centre  destroyed. 
H.  D.=56.32  H.  P.  =5 1. 34 

A.   T.  C.   T.  R.    T. 

3.26     P.    M.  64.5  63.8  IO4.5 

4.26        "  66.O  65.3  IOO.9 

1.5  3.6 

H.  D.=62.58  H.  P.  =53. 62 

Second  Day. 
a.  t.  c.  T.  R.  T. 

I.28     P.    M.  66.5  66.35  I06.  I 

2.28     "  68.5  67.45        103.6 

1. 10  2.5 

H.  D.=45-89  H.  P.  =40. 29 

EXP.  XVII.— Cat. 

1. 00  p.  M. — A  puncture  was  made  into  the  left  corpus 
striatum. 

Secofid  Day. 

R.   T. 

11.50  A.   M IO3.5 

1 1. 5 1  "    Right   post-cruciate   centre  was  irritated 

with  Du  Bois'  coil  at  10  for  two  min- 
utes. 

11.55      "    102. 1 

12. co     "    101.5 

12.05   p-  M 101.S 

EXP.  XVIII.— €at 

PULSE.  PRESSURE . 

2.     I .     O    P.    M 70  74 

Destruction  of  the  right  cruciate 
centre. 

2.    1. 1 5      "   68  74 

1.  1.45      "   92  100 

2.  2.   o      c'   —  74 

2.52.  o      "   64  — 


,QO  ISAAC  OTT. 

EXP.  XIX.— Rabbit  r.  t. 

2.35  P.    M I02.6 

2.36  "  Puncture  in  median  line  at  the  junction  of 

the  pons  and  medulla  oblongata. 
2.45      "    101.7 

3-35     "      99-5 

4.00  "    98.9 

6.25     "    98.5 

Second  Day. 

9. 1  2  a.  m 89. 7 

EXP.jXX.— Rabbit 

R.    T. 
JBTK  12.20    P.    M I02.0 

12.21  "   First  puncture  into  right  side  of  pons  varolii. 

12.21      '•    102.3 

1 . 1 5      ' 1 00. 9 

7-31      '       I0I-3 

Second  Day. 

2.10  p.  m.    Puncture  into  right  side  of  pons. 

3.40     "    101.4 

6.30     "    103.0 

8-05      "    103.9 

9.40     " 103.6 

Third  Day. 
Puncture  into  right  testes. 

7.40  a.  m 1  o  1 . 9 

8.00     "    101.8 

11. 15      "    102.3 

I  2.  37    P.    M        IO3.  5 

EXP.  XXL—  Rabbit. 

R.    T. 

12.00  M IO2.7 

12.01  "     Puncture  into  median  part  of  pons  varolii. 
12.30    '"      • 102.0 

5-3°    "       IOO-5 

EXP.  XXII.—  Rabbit. 

R.    T. 

12.04  P-    M IO3.2 

12.05  "   Puncture  in  median  line  at  junction  of  me- 

dulla and  pons  varolii,  runs  forward  in 
violent  manner  at  times. 

12.30     "    103.3 

1.40     "    104.8 

2.05      "    103.6 


THE  HEAT  CENTRES  OF  THE  CORTEX  CEREBRI. 
EXP.  XXIII.—  Rabbit. 


103 


R.   T. 


I  2.  09    P.    M I02.  9 


12.  IO 

I2.30 

2.15 

3-25 

5-3° 


12.52 
2.22 

3-05 
6.30 


Puncture  into  right  side  of  pons  varolii. 


Second  Day. 
Puncture  into  right  testes. 


Third  Day. 


I.30    P.    M. 


102.7 
102.2 

103.3 
101.3 


104.0 

104.3 

io3-5 


99.8 


EXP.  XXIV.—  Rabbit. 

R.    T. 

2.24  P.    M IO3.O 

2.25  "  Puncture   about   the  middle  of  the  pons 

varolii. 

3J5     "    102.9 

4.05     "    103.3 

525     "    102.9 


EXP.  XXV.—  Rabbit. 


R.   T. 


12.06  P.    M I02.6 

12.07  "  Puncture  at  end  of  pons  varolii,  where  it 

joins  the  crura  cerebri. 

12.25     " 101.6 

2.10     "    IOI.I 

6.35     "    101.7 


EXP.  XXVI.  —Rabbit. 


R.   T. 
IOI,7 


2.54  P.    M     

2.55  "  [ Puncture  into  pons  varolii. 

3-3°     "    101.0 

6.15     "      102.3 

9-3°     "    102.5 

Second  Day. 
8. 15  a.  m 1 01. 3 


104 

EXP.  XXVII.— Rabbit 

3.28       P.    M 


ISAAC  OTT. 


PULSE. 

6b 

3. 28. 30  ' '  Puncture  into  upper  part  of  pons 
varolii. 


3-29 
3-29-45 
3-38 
3-41 

4.07 


64 

■52 
58 


EXP.  XXVI I  I.—  Rabbit. 


PRESSURE. 
64 


76 
76 
78 
78 

66 


R.    T. 
IO3.2 


2.  14    P-    M     

2. 15  "  Puncture  into  median  part  of  pons  varolii 

2.30  "  103.6 

3.10  "  102.9 

6.00  "  103.7 


EXP.  XXIX.—  Rabbit. 

R.    T. 

2.  1 4    P.    M     1 02.  9 

2. 15      "   Puncture  into  the  right  upper  end  of  pons 

varolii. 
2.30     "    102.9 

3.  20     "    ico.  2 

6. 00  p.  m 99.  2 


IS  ATROPHY  OF  THE  CONDUCTING  APPARA- 
TUS OF  THE  EAR  IDENTICAL  WITH  PRO- 
GRESSIVE  ARTHRITIS   DEFORMANS? 

By  S.  O.   RICHEY,  M.D., 

OF   WASHINGTON,  D.  C. 

Read  in  the  Section  of  Otology  of  the  Ninth  International  Medical  Con- 
gress, Washington,  D.  C,  September,  1887. 

THE  name  General  Atrophy  of  the  Conducting  Appara- 
tus may  not  be  better  than  the  numerous  other 
names  by  which  the  affection  is  designated,  but  it 
has  the  merit  of  describing  the  result  of  the  process  as  we 
see  it,  instead  of  indicating  it  by  some  particularity  of  its 
course.  Some  attempt  will  be  made  to  show  its  probable 
neurotic  origin  in  the  spinal  system  by  its  similarity  to  a 
more  general  affection,  which  has  been  supposed  to  find  its 
source  there. 

Atrophic  degeneration  of  the  conducting  apparatus  of 
the  ear  may  not  be,  to  any  great  extent,  inflammatory  in 
any  part  of  its  course,  "  is  not  pre-eminently  local  in  its 
character,"  is  influenced  by  constitutional  dyscrasia,  prob- 
ably begins  at  the  cervico-spinal  nervous  centres,  and  is 
propagated  through  the  sympathetic  nervous  system,  or 
the  sensory  spinal  nerves,  interfering  with  local  trophic 
action. 

Many  pathological  changes  have  been  observed  in  the 
cavity  of  the  middle  ear  at  its  examination  after  death,  but 
we  are  not  assured  thereby  that  any  given  structural  varia- 
tion has  been  a  result  of  this  affection  alone,  as  we  are 
denied  the  opportunity  of  observing  it  during  the  progress 
of  the  disease.     For  many  reasons,  we  must  think  it  has  a 


I0£  S.   O.  RICHEY. 

broader  pathogenesis  than  that  generally  accredited  to  it, 
in  the  exposition  of  which  we  may  be  aided  by  the  pro- 
cesses of  analogy  and  induction. 

Garrod  says  of  "Progressive  Arthritis  Deformans  :*  "It 
is  much  easier  to  prove  what  rheumatoid  arthritis  is  not, 
than  to  give  the  slightest  clue  to  what  it  is.  .  .  .  It 
appears  to  result  from  a  peculiar  form  of  malnutrition  of  the 
joint  textures,  an  inflammatory  action  with  defective  power. 

.  .  It  usually  occurs  in  weakened  subjects,  and  expo- 
sure to  cold  is,  in  many  cases,  the  exciting  cause  of  its 
development."     Weber, t  considers  it  of  neurotic  origin. 

In  its  entire  history,  except  in  the  functional  peculiari- 
ties of  the  locality  attacked,  it  is  almost  a  complete  ana- 
logue of  atrophy  of  the  middle  ear  :  in  causation,  symptoms, 
progress,  and  therapeutics.  It  will  be  an  advantage  to  be 
able  to  watch  the  process,  as  we  cannot  in  the  ear. 

Herewith  is  a  parallel  of  the  two  affections. 


Progressive  Arthritis  Deformans. 
(i).  It  is  seldom  fatal. 


Atrophy  of  the  Conducting  Apparatus. 

(II.  We   do  not  know  it  ever  to  be 
fatal. 


(2).  At  an  early  stage,  swelling  and  (2).  At  an  early  stage,  this  may  be 
the  appearances  of  ordinary  inflamma-  the  cause  of  the  symptoms  of  inflamma- 
tion are  prominent.  tion. 

(3).  When  the  effusion  into  the  joint        (3).  When  this  happens  it  would  be 
is   absorbed,    the  capsule  is   commonly    liable  to  cause  tinnitus  or  impaired  hear- 
found  thickened,  the  cartilages  are  some-    ing,  or  both  :  a  flapping  mt.  and  disar- 
times   absorbed,  and  the  ligaments   so    ticulation  of  the  ossicula  auditus 
much   lengthened  as  to   allow  unusual 
mobility  and  dislocation. 

(4).  At  the  commencement  of  the  pro-        (4).   The  result  of  this  change  has  been 
cess   slow  absorption  of  the   cartilages    seen  in  anchylosis  of  the  ossicles,  especi- 
takes  place,  often  followed  by  fatty  de-    ally  of  the  stapes:  retraction  of  the  mt., 
generation   and  the  formation    of  liga-    and  bands  of  adhesion  in  the  cavity. 
mentous  bands. 

(5).  Heredity  does  not  seem  to  influ- 
ence the  affection,  for  one  member  of  a 
family  may  be  affected  and  the  rest  be 
free. 

(6).  Is  frequent  among  women  and 
rare  among  men. 


(5).  Complete  correspondence. 


(6).  Is  more  frequent  among  women 
than  among  men. 


*  Reynold's  System  of  Medicine,  vol.  i.,  p.  555. 

t  Journal  of  Nervous  Mkmai.  Disease,  vol.  viii.,  p.  630. 


ATROPHY  OF  THE  EAR.  lQ- 

(7).  It  occurs  at  any  age,  and  indi-  j  (7).  The  symptoms  manifest  them- 
viduals  of  weak  frames  whose  extremi-  [  selves  at  middle  age  or  just  before,  and 
ties  are  cold  are  most  liable  to  the  dis-  at  any  later  period.  Cold  extremities 
ease.  are  common. 


(8).  Idem. 


(9).  No  tests  have  been  made,  so  far 
as  I  know. 


(11).  An  open  question. 
(12).  Idem. 


(8).  Everything  debilitating,  as  uter- 
ine haemorrhages,  prolonged  grief,  per- 
sistent mental  distress,  loss  of  rest  and 
dissipation,  damp  dwellings,  poor  food, 
and  all  rheumatic  influences  are  sup- 
posed active  causes. 

(9).  By  test,  no  uric  acid  or  urate  of 
soda,  thus   removing   rheumatism   and 
gout  from  consideration  as  causes.    Re-  j 
duction  of  phosphoric  acid  in  the  urine. 

(10).  The  disease  is  slowly  but  steadi-        (10).   There  are  long  intermissions  in 
ly  progressive.     It  may  be  stationary    progress,  judged  by  the  impairment  of 
for  a  time,  but  exacerbations  are  sure  to    function, 
follow  (Weber).     There  is  slight  remis- 
sion,  but   no   intermission   during   the 
rest  of  the  patient's  life  (Haygarth). 

(11).  It  usually  begins  as  a  subacute 
disease. 

(12).  It  is  very  intractable.  When 
the  disease  is  not  advanced,  Che  affected 
joints  few  in  number,  and  progress  slow, 
the  prospect  is  more  hopeful,  especi- 
ally if  there  is  no  disease  to  keep  up  the 
impairment  of  the  general  health. 

(13).  The  treatment  must  be  sustain-        (13).  This  general  line  of  treatment 
ing.   Local  treatment  by  blisters,  iodine    is  the  best  with  which  we  are  yet  ac- 
paint  and  croton  oil  in  the  beginning,    quainted. 
Later,  use  counter-irritation  ;  later  still, 
friction  and  slight  motion.     Living  in  a 
moderete  climate  in  the  winter,  nutri- 
tious food,  warm  clothing,  etc. 

(14).  There  is  generally  aching  in  the  (14).  Any  existing  impairment  of 
affected  joints,  prophetic  of  an  increase  hearing  or  tinnitus  is  increased  under 
of  pressure  in  the  atmosphere.  the  same  circumstances. 

(15).    Frequent     mental     depression        (15).  Idem. 
without  a  known  sufficient  cause. 

(16).   It  does  not  lead  to  suppuration,         (\b\   Idem 
but  to  atrophy  and  more  or  less  deform- 
ity (Weber). 

Progressive  arthritis  deformans  begins  in  the  smaller 
joints  of  the  body,  is  symmetrical  in  appearance  and  prog- 
ress, with  lesions  of  the  tissues  surrounding  the  joints,  atrophy 


ioS 


S.   O.  RICHEY. 


of  the  muscular  tissue,  and, \  in  old  cases,  a  state  of  fatty 
and  connective  tissue  degeneration  (Weber).  The  Lillipu- 
tian joints  of  the  ossicula  auditiis  are  peculiarly  exposed  to 
atmospheric  changes  by  their  location,  and  are  in  one  of  the 
extremities  of  the  body,  for  which  reasons  they  would  seem 
to  be  more  liable  to  an  attack  of  this  affection  than  even  the 
joints  of  the  hand  or  foot.  Rheumatoid  arthritis  beginning 
in  the  small  joints  of  the  extremities  advances  to  the  larger 
joints  of  the  body.  This  may  explain  the  pressure  and  pain 
about  the  head,  and  the  diminution  of  intellectual  appre- 
hension, so  common  in  cases  of  profound  deafness  in 
advanced  aural  atrophy.  It  may  furnish  a  better  demon- 
stration of  the  deafness  of  boiler-makers  and  that  of  loco- 
motive engineers. 

Taking  its  symmetrical  onset  and  advance  as  a  point  in 
evidence  of  its  neurotic  origin,  it  may  also  explain  the 
change  in  voice  so  commonly  met  with  among  the  pro- 
foundly deaf,  who  have  become  so  by  slow  and  progressive 
stages,  for  the  recurrent  laryngeal  nerve  makes  the  connec- 
tion between  the  cerebro-spinal  nerve  centres  and  the 
vocal  cords  very  intimate.  The  recurrent  laryngeal  is  sup- 
posed to  get  its  motor  power  from  the  pneumogastric,  and 
irritation  of  the  pneumogastric  in  the  upper  part  of  the  neck 
has  been  proven  by  experiment  to  cause  heat  and  tingling 
of  the  ear.  Jewell *"  looks  upon  articular  rheumatism,  as 
well  as  certain  painful  affections  of  the  joints  simulating 
rheumatism  as  produced  .  .  .  by  disease  of  the  nerve  trunks 
or  nerve  centres,  leading  to  decided  local  irritation  at  the  per- 
ipheral termination  of  certain  nerves  ;"  and  Brow  n-Sequard 
has  shown  that  nerve  fibres  going  to  the  blood  vessels  of 
the  various  parts  of  the  head  come  out  chiefly  from  the 
spinal  cord  by  the  roots  of  the  last  cervical  and  the  first 
dorsal  nerves. 

Leloir  and  Dejerine1"  observe  that,  in  a  case  of  chronic 
rheumatism  with  considerable  muscular  atrophy  and  rapid 
eschars,  they  found  the  cutaneous  nerves  adjacent  to  the 
eschars    affected    with    atrophic     parenchymatous    neuritis 

•  Joir.  Nkrv.  and  Mental  Dis.,  1874.  426. 

tProgrta  Mt'dicale,  April  2d.  1881. 


ATROPHY  OF  THE  EAR.  IQg 

which  seemed  to  have  been  existent  anterior  to  the  eschars. 
Acute  atrophy  of  the  muscles  has  occurred  without  lesion  of 
the  cord.  Those  suffering  with  arthritis  deformans  appear 
to  be  emaciated  and  neurasthenic  as  a  rule,  complaining  of 
pains  over  a  great  part  of  the  body,  associated  with 
periodical  failure  of  control  or  power  in  the  muscles  and 
tendons. 

The  pain  in  the  joints,  weakness  in  the  muscles  and  ten- 
dons, and  some  emaciation,  often  precedes  the  manifest 
changes  in  the  size  and  form  of  the  joints. 

Women,  according  to  Rosenthal,  are  more  subject  to 
prosopalgia  in  early  life  than  men  :  neuralgia  is  most  fre- 
quent between  the  thirtieth  and  fiftieth  years  of  life  ;  is 
sometimes  accompanied  by  inability  to  fix  the  mind  on  any 
subject  or  attend  to  business,  and  this  effect  is  not  due  to 
pain.  Arthritis  deformans  is  often  introduced  by  hemi- 
crania,  and  lean  persons  have  a  more  decided  predisposition 
than  the  stout,  as  in  neuralgia  of  the  fifth.  The  temporo- 
maxillary  and  the  upper  cervical  vertebrae  are  joints  par- 
ticularly likely  to  be  affected.  No  one  questions  the 
character  of  neuralgias,  and  arthritis  appears  to  have  a  simi- 
lar neuropathic  origin  and  similar  favoring  causes. 

Weber-Liel*  has  seen  thirteen  persons  affected  by  pro- 
gressive deafness  presenting  the  symptoms  of  spontaneous 
nervous  pain  over  the  tracts  of  the  cervical  and  brachial 
plexus,  associated  with  pain  in  the  ears  and  disagreeable 
tinnitus,  varying  from  that  habitual  to  the  case.  Otalgia  is 
often  met  with  in  the  later  stages  of  atrophy,  generally  un- 
complicated with  neuralgia  elsewhere,  but  among  individuals 
of  the  neurasthenic  type.  Arthritis  deformans,  nervous  ex- 
haustion, and  aural  atrophy  (progressive  deafness)  very 
greatly  resemble  each  other.  Each  follows  causes  exhaus- 
tive in  character  ;  does  not  terminate  fatally  ;  most  of  the 
symptoms  are  subjective  and  functional,  and  often  without 
apparent  structural  variation.  In  each  there  is  intermit- 
tent and  periodical  hopelessness  and  discouragement.  In 
nervous  exhaustion  and  the  ear  affection  there  is  diminished 
ability  to  fix   thought  on  any  subject   (lack  of  mental  con- 

*  Monats  f.  Ohrenheilk.,  August,  1874. 


I  IO 


5.   O.   R1CHEY. 


trol),  and   change  in  the  voice  ;  and  Garrod  claims  that  the 
irregular  form  of  arthritis   sometimes   attacks   the  internal 
middle?)  ear  and  the  larynx,  and   causes  hoarseness  and  a 
peculiar  dry  cough. 

Mr.  R.  W.  Parker  reports*  a  case  of  rheumatoid  arthritis  ; 
the  girl,  aged  15  years,  whose  father  died  of  phthisis  and 
whose  mother  died  of  chalky  rheumatism,  had,  in  six 
months,  become  almost  completely  deaf.  She  had  double 
keratitis  and  enlarged  joints.  Xo  examination  of  the  physi- 
cal condition  of  the  ears  appears  to  have  been  made, 
unfortunately  ;  only  the  reference  above  to  the  disturbed 
function. 

Burnett  +  mentions  a  woman,  aged  26,  well-nourished, 
who  six  years  before  had  an  attack  of  probable  rheumatic 
facial  paralysis.  Two  or  three  years  later  she  noticed  sing- 
ing in  her  ears  and  impaired  hearing.  Lustre  of  Mtt.  good  : 
ett.  pervious.  When  excited  or  fatigued  there  was  flush  of 
the  cheeks  and  neck  and  increased  tinnitus. 

In  boiler-maker's  deafness,  undisturbed  control  of  equi- 
librium and  the  absence  of  vertigo  argue  against  the  theory 
of  labyrinthine  trouble.  Buck:t  thinks  the  peculiarities  of 
these  cases  due  to  rigidity  of  the  ligament  at  the  base  of  the 
stapes,  or  to  some  change  in  the  membrana  secondaria, 
which  to  my  mind  is  the  most  natural  explanation.  The 
fact  that  individuals  who  have  had  acute  or  subacute 
catarrhal  inflammation  of  the  middle  ear  present  the  feature 
of  hearing  better  in  a  din  of  some  kind,  does  not  invalidate 
Buck's  theory,  as,  in  even  acute  suppuration,  the  mem- 
brana secondaria  may  undergochanges  calculated  to  produce 
this  effect:  persistent  thickening  calcareous  deposits,  adhe- 
sive secretions,  etc.,  for  which  reason  some  of  these  cases 
can  be  comparatively  promptly  improved.  "  Pathological 
alterations  take  place  in  the  stapedio-vestibular  articulation 
in  the  course  of  chronic  inflammation  of  the  middle  ear 
sometimes  also  with  a  perfectly  normal  state  of  the  lining 
membrane  i'  i 


*  Tran*.  [nternat  Med,  Congress,  1881 .  Vol.  I.,  p.  128 

+  A  Treatise  <>n  the  Kar,  i^t  Ed.,  p.  391. 

I  New  Vork  Med.  Rec,  July  5th,  1875. 

$  Pol  :  iIh-  Ear,  Am.  I  'I.  ]>.  S6. 


ATROPHY  OF  THE  EAR.  j  r  j 

Among  boilermakers  the  continuous  action  of  the  ossic- 
ula  auditus  renders  them  more  liable  to  arthritis  ;  and  the 
exposure  to  draughts,  lack  of  exercise  of  most  of  the  other 
joints  of  the  body,  irregularity  in  taking  food,  which  is  often 
less  assimilable  than  it  should  be,  furnish  other  sufficient 
factors  in  the  causation  of  this  affection.  These  same  influ- 
ences obtain  among  ship-caulkers  and  locomotive  engineers. 
That  the  affection  may  be  manifest  in  no  other  joint  is  no 
sufficient  reason  against  its  attacking  the  ossicula,  when 
they  are  most  used.  The  affection  may  extend  to  the 
sutures  of  the  cranial  bones,  and  cause  disturbance  in  their 
relations  to  each  other,  followed  by  a  feeling  of  pressure,  or 
"weight  on  the  head,"  or,  "as  if  there  was  an  iron  band 
around  the  head,"  or,  "as  if  there  was  an  iron  axle  between 
the  ears,"  resulting  from  even  slight  distortion.  It  may 
thus  so  derange  the  cranial  contents  as  to  interfere  with 
normal  mental  alacrity  and  the  memory,  of  which  some 
people  with  "progressive  deafness  "  are  so  acutely  conscious 
in  the  later  stages.  It  may  alter  the  shape  and  size  of  the 
cranial  foramen  to  such  an  extent  as  to  cause  pressure  upon 
the  nerve  thus  finding  exit,  and  so  produce  neuralgia  in 
the  region  supplied  by  the  nerve,  this  being  one  of  the  ways 
in  which  persistent  neuralgia  is  supposed  to  be  produced. 

Arthritis  deformans  may  occur  at  almost  any  age  ;  at 
first,  in  the  most  exercised  small  joints,  and  if  neglected  it 
will  progressively  attack  every  joint  in  the  body.  It  would 
rarely  be  recognized  in  the  ear  before  the  age  of  thirty, 
when  the  true  function  of  the  ear  begins  to  be  impaired  in 
the  late  stage  of  atrophy,  though  it  might  have  existed  from 
the  age  of  four  or  five  years,  at  which  time  it  would  have 
been  in  its  inflammatory  stage.  This  stage  would  be  marked 
by  sudden  onsets  of  pain,  of  spasmodic  or  neuralgic  char- 
acter, causing  at  short  intervals  sharp,  quick  cries,  followed 
by  a  period  of  ease  and  quiet.  Though  during  the  day 
there  is  entire  comfort,  the  attacks  are  disposed  to  recur 
at  night,  the  child  sometimes  waking  from  a  sound  sleep 
with  a  cry  of  distress,  and  falling  to  sleep  again  in  a  short 
time.  These  attacks  are  supposed  to  be  harmless,  because 
they  do   not   result  in   suppuration,  immediate  deafness,  or 


I  12 


i-.   O.  RICHEY. 


any  other  material  change  in  function  or  structure,  for  they 
pass  oft"  after  several  hours  of  intermitting  pain,  leaving 
some  tenderness  to  touch,  to  recur  perhaps  the  next  night  to 
follow  much  the  same  course.  The  m.  t.  may  be  hyperae- 
mic.  but  is  not  thickened  ;  the  e.  t.  is  as  patulous  as  usual, 
and  there  is  no  appreciable  increase  of  secretion  ;  it  may 
recur  ever)'  evening  of  several  days  with  entire  subsidence 
of  pain  for  the  greater  part  of  the  twenty-four  hours.  These 
attacks  differ  in  several  particulars  from  the  catarrhal  affec- 
tion resembling  it,  which  causes  almost  continuous  pain, 
thickening  of  the  lining  membrane,  diminution  or  closure  of 
the  e.  t.,  and  increase  of  secretion,  with  bulging  of  the  m.  t., 
on  this  account  ;  sometimes  suppuration  occurs,  if  the  case 
is  not  promptly  and  properly  handled  ;  nearly  always  there 
is  more  or  less  impairment  of  hearing  from  congestive  thick- 
ening of  the  tissues,  or  the  presence  of  fluid  in  the  cavity. 
After  one  catarrhal  attack,  there  may  never  be  another. 

The  same  cause  seems  immediately  productive  of  each, 
because  each  is  more  liable  to  happen  at  the  change  of  the 
seasons,  the  child  being  more  exposed  to  the  cold  and  the 
damp  air  at  these  times. 

Thus,  even  in  childhood  a  differential  diagnosis  may  be 
made  from  the  catarrhal  affection,  and  we  may  reason  that 
the  affection  at  the  foundation  of  the  atrophic  process  may 
begin  at  any  age,  although  the  atrophy  is  a  malum  senilis. 
V.  Trolsch  thought  the  disease  without  catarrhal  symptoms 
should  be  given  a  different  classification,  but  it  is  yet  gen- 
erally classed  as  a  catarrh  by  authorities,  though  Pomeroy,* 
in  a  cursory  way,  says,  "I  believe  that  the  rheumatic  diathe- 
sis in  many  instances  has  much  to  do  with  the  obstinate 
character  of  this  affection  ;  the  rheumatic  inflammation,  ac- 
cording to  its  well-known  predilection  for  fibrous  tissues,  find- 
ing a  lodgment  in  the  muco-periosteal  lining  of  the  drum." 

Whether  or  not  atrophy  of  the  middle  ear  is  of  the  same 
origin  as  arthritis  deformans,  it  has  a  more  extensive  path- 
ology than  that  generally  accorded  to  it. 

Treatment. — Arthritis  is  introduced  by  a  chill  (Bruce), 
followed  by  hemicrania,  indicating  depression  of  the  nervous 

•  I  >:-.  of  Ear,  [).  148. 


A  TROPHY  OF  THE  EAR. 

3 


I  I 


and  circulatory  systems.  This  action  may  be  induced  by 
cold,  emotional  disturbance,  or  physical  shock  ;  it  concen- 
trates at  the  cerebro-spinal  nervous  centres,  and  radiates 
therefrom  to  express  itself  in  the  organ  of  the  least  resist- 
ance in  an  individual,  in  the  form  of  pain  and  trophic 
changes. 

The  views  of  the  writer  in  regard  to  local  treatment  in 
"progressive  deafness"  may  be  found  in  the  Am.  Jour.  Med. 
Sci.,  April,  1887,  p.  413-423.  Iodine  vapor  is  our  sheet- 
anchor  for  topical  medication,  but  our  efforts  may  be  mate- 
rially aided  by  constitutional  and  hygienic  influences,  under 
which  head  come  climate,  clothing,  food,  and  other  items 
of  general  treatment. 

Climate  should  have  special  consideration  in  the  choice 
of  a  winter  residence.  This  should  be  moderate  in  temper- 
ature, and  as  dry  as  possible.  The  sudden  changes  of  tem- 
perature in  the  higher  latitudes  are  more  deleterious,  be- 
cause they  take  place  through  a  lower  thermometric  range, 
and  passing  from  the  inside  to  the  outside  of  the  house  may 
produce  violent  circulatory  disturbances  during  cold  weath- 
er unless  the  cold  is  moderate.  A  climate  distinguished 
by  a  decided  difference  in  temperature  between  day  and 
night  is  undesirable,  unless  this  variation  is  guarded  against 
by  fire  and  clothing,  which  means  thought  and  care  on  the 
part  of  the  individual  not  likely  to  be  taken. 

Clothing  is  very  important,  as  it  should  be  of  such  char- 
acter as  to  afford  protection  against  the  depression  of  cli- 
matic variation,  that  worn  next  the  body  requiring  most 
thought,  though  at  present  it  has  least  attention. 

Three  areas  of  the  body  are  especially  sensitive  to 
changes  of  temperature  and  seem,  to  a  great  degree,  to 
influence  the  comfort  of  the  whole  body.  Such  spaces  are 
the  cervical  region  of  the  spine,  the  posterior  aspect  of  the 
arm  just  above  the  elbow,  and  the  nates. 

The  ordinary  dress  of  men  protects  them  very  well,  the 
buttocks  being  most  exposed,  and  from  this  region  the 
body  may  be  chilled  or  warmed.  The  exposure  of  this 
part  of  a  chilled  body  to  the  grateful  influence  of  radiated 
heat   diffuses  more  general    composure  than    warming  the 


j  j  ,  5.   O.  RICHE  Y. 

extremities,  and  every  man  will  receive  this  suggestion  feel- 
ingly. This  effect  is  probably  due  to  the  superficial  loca- 
tion of  the  sciatic  nerve,  and  its  short  cutaneous  branches. 

Among  women  the  cervical  region  of  the  spine  and  the 
arms  are  least  covered,  especially  when  in  "  evening  dress." 
When  entering  a  cold  bath  the  body  may  be  more  quickly 
adjusted  to  the  lower  temperature  by  dipping  the  elbows 
and  the  nates  than  by  wetting  the  head  and  neck,  according 
to  the  usual  custom,  and  in  this  we  may  find  some  proof  of 
the  above  statement.  Women,  and  particularly  neurasthen- 
ics, often  complain,  at  the  menstrual  period,  of  cold  on  the 
posterior  face  of  the  arm  just  above  the  elbow.  When  an 
individual  has  his  arms  bared  he  may  be  seen  to  hold  his 
elbows  with  his  hands  unconsciously,  unless  he  is  at  work. 
This  habit  may  be  observed  among  workmen  and  washer- 
women, and  sometimes  among  fashionable  dames  in  bare 
arms.  This  part  is  supplied  with  cutaneous  branches  from 
the  brachial  plexus,  and  thus  has  more  than  local  influence  ; 
our  instinct  is  to  protect  it  from  the  cold.  Women  ordinarily 
have  one  thickness  of  dress  upon  the  arm  and  neck  ;  some- 
times two  on  the  arms,  and,  in  the  coldest  season,  often 
none  on  arms  or  neck.  The  dress  may  be  worn  high  and 
covered  with  wraps  during  the  warmest  part  of  the  twenty- 
four  hours,  to  be  exchanged,  frequently,  for  a  decollete 
habit  when  the  temperature  is  lowest  (slippers  are  not  for- 
gotten). May  we  not  find  in  these  facts  some  of  the  predis- 
posing causes  of  the  greater  frequency  of  this  aural  affection 
among  women  ?  Fashion  is  without  discretion,  and  is  a 
Moloch  to  which  health  is  unpityingly  sacrificed  (self-sacri- 
fice;. Intelligent  advice  may  be  given  in  regard  to  dress, 
but  fashion  scorns  it,  and  medication  must  be  to  little  pur- 
pose without  rational  precautions  on  the  part  of  the  patient. 

General  Medication. — Avoidance  of  shock,  mental  dis- 
tress, pregnancy,  damp,  cold,  and  whatever  else  greatly  dis- 
turbs the  balance  of  circulation,  is  to  be  advised.  Nutritious 
food  is  to  be  taken  regularly,  and  in  such  quantity  as  can  be 
digested  and  assimilated.  The  moderate  use  of  red  wine  is 
beneficial.  Arsenic  (Liq.  potass,  arsen.),  in  drop  doses, 
taken  for  some  months,  promotes  digestion  and  assimilation, 


A  TROPHY  OF  THE  EAR.  .  T  - 

in  addition  to  its  specific  action  upon  the  mucous  membrane. 
In  the  same  way  it  probably  is  useful  in  anaemia  and  certain 
forms  of  neuralgia.  Syr.  ferri  iodidi  is  serviceable  in  cases 
dependent  upon  impoverished  blood,  and  may  be  associated 
with  arsenic  in  the  same  prescription.  Any  gain  from  the 
administration  of  cod-liver  oil  has  not  been  apparent  to  me. 
Salicylic  acid  and  the  salicylates,  in  small  doses,  have  had 
manifest  influence  in  some  cases.  Due  attention  should  be 
given  to  the  proper  performance  of  its  functions  by  every 
organ  of  the  body,  and  particularly  to  the  action  of  the 
bowels.  A  habit  of  constipation  must  be  corrected  to  aid 
proper  nutrition. 

The  above  outline,  taken  with  the  local  manipulations 
heretofore  described,  are  of  most  certain  value  in  the  treat- 
ment of  cases  of  aural  atrophy. 

It  is  needless  to  say  that  a  certain  number  of  cases  exist 
in  which  the  structural  injury  is  of  such  character  and  so 
established,  that  nothing  short  of  re-creation  will  restore  to 
the  organ  the  conditions  necessary  to  its  intended  duties  ; 
as,  for  instance,  some  cases  of  osseous  anchylosis,  or  disar- 
ticulation of  the  ossicula. 


DENTAL    IRRITATION    AS   A    FACTOR    IN    THE 
CAUSATION  OF  EPILEPSY. 

Read  before  the  Philadelphia  Neurological  Society,  December  19,   1887. 
By  ALBERT  P.   BRUBAKER,  M.D., 

PHILADELPHIA,   PA. 

IN  all  the  wide  divergence  of  view  as  regards  the  nature 
of  epilepsy  there  is  a  general  consensus  of  opinion  that 
its  essential  feature  is  of  the  character  of  an  explosive 
discharge  from  the  higher  nerve-centres,  the  nerve-force 
thus  liberated  bearing  down  upon  the  centrifugal  distribu- 
tions of  the  motor  nerve-tracks  with  such  an  excess  of  en- 
ergy that  inco-ordination  of  movement  reaches  the  stage  of 
convulsion  and  spasm.  Owing  to  the  periodicity  of  the  con- 
vulsive seizures,  it  has  been  assumed  that  in  individuals  pre- 
disposed to  epileptic  attacks  the  higher  nerve-centres  are  in 
a  state  of  high  tension,  of  unstable  equilibrium,  and  that  it 
only  requires  a  stimulus  of  a  definite  quantity  or  intensity  to 
excite  the  explosive  discharge. 

Writers  have  generally  laid  it  down  as  an  established 
fact  that  the  majority  of  the  cases  of  epilepsy  are  idiopathic, 
without  definite  causation,  and  due  solely  to  heredity  ;  but 
it  can  scarcely  be  doubted  that  these  cases  are  properly  so 
classed  only  as  regards  the  pre-disposition,  and  that  in  them 
all  a  morbid  action,  even  though  slight  in  amount,  is  neces- 
sary to  call  forth  the  nervous  discharge.  The  morbid  pro- 
cess may  be  centrally  located  and  beyond  the  reach  of  in- 
vestigation, or  it  may  be  peripherically  located  and  exciting 
the  convulsion  in  a  purely  reflex  manner.  It  is  fully  con- 
ceded by  all  that  injuries  to  nerves,  diseases  of  the  ear, 
intestinal  worms,  phimosis,  uterine  troubles,  etc.,  are  all  not 
uncommon  peripheral  causes  resulting  in  epileptic  attacks. 


DENTAL  IRRITATION  IN  EPILEPSY. 


I  I 


The  question  has  been  raised,  however,  as  to  whether  a 
convulsive  attack  due  to  a  peripheral  irritation  can  be  re- 
garded as  a  true  epilepsy,  and  whether  it  is  not  to  be 
regarded  rather  as  of  an  hysterical  character.  Without  at- 
tempting to  pass  judgment  upon  this  subject,  it  will  suffice 
to  quote  the  recent  views  of  a  very  competent  authority 
upon  nervous  diseases,  Prof.  H.  C.  Wood.  In  commenting 
upon  the  convulsion  due  to  a  peripheral  irritation,  he  says, 
"  It  is  almost  invariably  epileptiform  in  its  general  symp- 
toms, and  ma)-  conform  exactly  to  the  typical  epileptic  at- 
tack ;"  and,  while  admitting  that  many  of  these  reflex  con- 
vulsions partake  largely  of  the  hysterical  character,  he 
further  says,  "  There  are,  on  the  other  hand,  convulsions 
which  conform  to  the  epileptic  type,  and  which  are  the  re- 
sult of  an  organic  peripheral  irritation."* 

A  remarkable  feature  of  the  epileptic  convulsion  is  its 
periodicity.  Now,  it  is  proved  beyond  question  that  the 
higher  nerve-centres  of  the  brain  act  not  only  as  inciting  but 
also  as  inhibitory  centres  to  those  of  a  lower  level.  They 
are  at  once  reservoirs  of  nerve-force  and  regulators  of  its 
dispensation.  If,  therefore,  a  morbid  process  at  the  periph- 
ery continuously  attack,  through  nervous  intermediation, 
these  higher  nerve-centres,  it  follows  that  these  in  time 
must  have  their  resisting  power  overcome  at  intervals  and 
at  successively  higher  levels,  until  a  final  one  is  reached, 
when  control  is  no  longer  possible.  The  unremitting  irrita- 
tion having  at  last  overcome  the  resisting  power  of  the 
highest  nerve-centres,  their  energy  is  suddenly  liberated 
and  the  organism  is  flooded  with  waves  of  uncontrollable 
centrifugal  energy,  until  exhaustion  brings  about  a  tempo- 
rary equilibrium. 

The  object  of  this  paper  is  to  direct  the  attention  of  phy- 
sicians to  a  cause  of  epilepsy  which  has  not  hitherto  been 
estimated  at  its  full  value,  inasmuch  as  in  none  of  the  stand- 
ard works  upon  neurology  is  the  subject  even  alluded  to, — 
viz.,  pathological  states  of  the  dental  structures.  That  den- 
tal inflammations  and  disorders  are  more  often  provocative 
of  epileptic  seizures  than  is  commonly  supposed  appears 
quite  certain  from  the  following  cases,  and  also  from  the 
8  «'Nervous  Diseases  and  their  Diagnosis." 


j  j  §  ALBERT  P.  BRUBAKER. 

character  of  the  cause  and  its  effect.  Many  reasons  might 
be  given  why  dental  disorders  are  peculiarly  adapted  to  call 
forth  this  periodical  discharge,  and  why  these  disorders  are 
habitually  overlooked  by  the  physician,  but  they  need  not 
be  detailed  here.  As  exemplifying  these  phenomena,  some 
interesting  and  instructive  cases  are  adduced. 

The  following  case  occurred  in  the  clinical  service  of  Dr. 
Wharton  Sinkler  at  the  Orthopaedic  Hospital  and  Infirmary 
for  Nervous  Diseases,  to  whose  kindness  I  am  indebted  for 
the  privilege  of  recording  it  : 

Case  I. — Mary  L.,  xt.  9,  was  brought  to  the  hospital  in 
October.  1886.  with  a  history  of  epilepsy  dating  from  May 
of  the  same  year.  The  convulsive  attacks  first  made  their 
appearance  on  the  afternoon  of  the  same  day  that  the  child 
had  had  three  teeth  extracted  on  account  of  repeated  attacks 
of  toothache.  One  decayed  tooth,  however,  was  left  re- 
maining in  the  lower  jaw.  Previous  to  coming  to  the  hos- 
pital the  epileptic  attacks  occurred  two  and  three  times  a 
week.  From  all  that  could  be  learned  from  the  mother,  the 
symptoms  were  those  of  a  typical  epilepsy.  There  was  no 
neurotic  history  in  the  family.  She  was  placed  upon  from  3 
to  5  drops  of  the  fluid  extract  of  cannabis  indica  for  two 
weeks,  during  which  period  she  had  twelve  attacks.  The 
bromide  of  sodium  was  then  given  for  two  weeks,  during 
which  period  she  had  twelve  attacks.  The  bromide  of 
sodium  was  then  given  for  two  weeks,  during  which  she 
had  sixteen  attacks.  From  November  1  to  March  1,  1887, 
she  continued  taking  the  bromides  alone,  in  combination, 
and.  finally,  in  conjunction  with  the  infusion  of  digitalis. 
During  the  four  months  of  steady  treatment  she  had  forty 
seizures.  About  the  1st  of  March  the  mother  made  the  re- 
mark that  the  child  was  always  extremely  restless  at  night 
that  she  would  lie  awake  for  hours  complaining  of  tooth- 
ache :  and  even  when  asleep  she  would  continually  grind 
her  lower  teeth  against  the  upper  teeth.  Examination  of 
the  mouth  revealed  a  carious  and  inflamed  condition  of  a 
molar  tooth  in  the  lower  jaw  on  the  left  side. 

From   the   history  of  the   case,  and   the   possibility  tha 
the  irritation  arising  from  the  diseased   tooth   might  be  the 


DENTAL  I R RITA  TION  IN  EPILEPSY.  j  j  Q 

exciting  cause  of  the  attack,  it  was  concluded  to  have  the 
tooth  removed..  This  was  done  under  the  influence  of 
nitrous  oxide  gas.  The  night  following  the  child  rested 
much  better,  and  from  that  time  forward  her  sleep  became 
natural,  her  appetite  improved,  and  her  general  health 
became  decidedly  better.  From  the  last  week  in  February 
until  the  present  time  (Decemer  19,  1887,)  she  has  not  had 
a  single  symptom  of  an  epileptic  attack. 

That  a  dental  irritation  should  be  capable  of  exciting  an 
epileptic  condition  does  not  appear  at  all  strange  when  it  is 
fully  comprehended  how  numerous  are  the  recorded  cases 
of  ocular,  aural,  visceral,  muscular,  and  nervous  disorders 
which  have  been  caused  by  the  irritation  arising  from  the 
pathological  conditions  of  the  teeth  and  associated  struct- 
ures. 

The  interest  aroused  by  the  result  of  the  pi  ceding  case 
led  to  an  examination  of  medical  literature  for  reports  of 
similar  cases.  I  find  that  no  less  than  sixteen  cases,  en- 
tirely and  immediately  cured  by  the  removal  of  an  irritating 
tooth,  have  been  recorded  by  different  observers,  and  which 
are  here  arranged  in  chronological  order.  It  is  not  sup- 
posed that  this  collection  embraces  all  the  recorded  cases, 
but  it  is  hoped  that  it  will  elicit  references  to  many  others, 
and,  what  is  more  important,  the  reporting  of  many  new 
cases. 

The  injurious  effects  of  diseased  teeth,  and  the  irritation 
arising  from  them,  in  the  production  of  many  general  dis- 
eases did  not  escape  the  acute  mind  of  Dr.  Rush.  In  a 
paper  published  in  his  collected  works,*  he  records  the  fol- 
lowing : 

Case  II. — "Some  time  in  the  year  1801  I  was  consulted 
by  the  father  of  a  young  gentleman  in  Baltimore  who  had 
been  afflicted  with  epilepsy.  1  inquired  into  the  state  of  his 
teeth,  and  was  informed  that  several  of  them  in  his  upper 
jaw  were  much  decayed.  I  directed  them  to  be  extracted, 
and  advised  him  afterwards  to  lose  a  few  ounces  of  blood 
at  any  time  when  he  felt  the  premonitory  symptoms  of  a 
recurrence  of  his  fits.     He   followed  my  advice,  in   conse- 

0  Enquiries  and  Observations,  vol.  i.  p,  199. 


120 


ALBERT  P.  BRUBAKER. 


quence  of  which  I  had  lately  the  pleasure  of  hearing  from 
his  brother  that  he  was  perfectly  cured." 

Dr.  Ashburner  published,"  in  [834,  a  number  of  remark- 
able cases  of  hysteria,  spasms,  convulsions,  etc.,  due  to 
diseased  conditions  of  the  teeth.  Among  others  was  the 
following  case  of  epilepsy  : 

CASE  III. — A  young  lady  of  highly  nervous  tempera- 
ment was  attacked  with  epilepsy  in  the  eighth  month  of  her 
first  pregnancy.  She  had  two  attacks  before  her  labor, 
which  was  a  very  favorable  one.  Seven  months  afterwards 
the  fits  reappeared,  and  occurred  two  and  three  times  a 
week.  Various  methods  of  treatment  were  resorted  to 
without  success.  For  a  while  the  intervals  between  the 
attacks  were  someu  hat  longer,  and  for  a  while  they  ap- 
peared twice  daily.  An  examination  of  the  mouth  revealed 
seven  carious  teeth,  which  were  at  once  removed.  Three 
wisdom  teeth  were  prevented  from  erupting  on  account  of 
a  cartilaginous  condition  of  the  gums.  These  obstacles 
were  removed.  The  epileptic  fits  at  once  ceased,  and  after 
several  years  they  had  not  returned. 

Case  IV. — Albrecht  relatest  the  case  of  a  boy,  xt  12 
years,  who  for  a  period  of  six  months  suffered  daily  with 
general  convulsive  attacks.  Just  preceding  the  attack  there 
was  severe  pain  in  the  temporal  region.  No  cause  could  be 
assigned  for  the  seizures.  Treatment  was  without  avail. 
Examination  of  the  mouth  revealed  an  overcrowded  con- 
dition of  the  teeth,  which  were  in  addition  unusually  large. 
After  removal  of  some  of  the  teeth  the  convulsions  sub- 
sided, and  in  a  short  time  entirely  disappeared. 

Cam:  V. — Dr.  Tomes  publishes*  the  following  :  "  A  lad, 
a  farm-laborer  from  Windsor,  was  admitted  into  the  hospi- 
tal for  epilepsy.  The  usual  remedies  were  tried  for  six 
weeks  without  effect.  His  mouth  was  then  examined,  and  the 
molar  teeth  of  the  lower  jaw  were  found  to  be  much  decayed, 
and  of  some  of  these  only  the  fangs  remained.  He  did  not 
complain  of  pain  in  the  diseased  teeth  or  in  the  jaw.  The 
decayed   teeth  were,  however,  removed,  and  the  fangs  of 

•  On  Dentition  and  some  Coincident  Disorders,  p.  98. 
fCasper's  Wochenschrift,  1837,  p.  125. 
.stem  of  Dental  Surgery. 


DENTAL  IRRITA  TION  IN  E  PILE  PS  V.  I2I 

each  were  found  to  be  enlarged  and  bulbous  from  exostosis. 
During  the  eighteen  months  that  succeeded  the  removal  of 
the  diseased  teeth  he  had  not  suffered  from  a  single  fit, 
though  for  many  weeks  previous  to  the  operation  he  had 
two  or  three  per  day." 

Case  VI. — Dr.  Baly  records*  the  history  of  a  case  of 
epilepsy  from  dental  irritation,  occurring  in  a  man,  aet.  45. 
The  patient  was  an  employe  in  the  Millbank  Penitentiary  ; 
was  of  good  physique  ;  in  good  health,  and  had  never  suf- 
fered from  vertigo,  headache,  or  any  form  of  nervous  trouble. 
In  the  latter  part  of  October,  1850,  he  began  to  suffer  from 
toothache.  On  November  4th  the  tooth  was  examined  by 
the  medical  officer,  but  on  account  of  its  carious  condition 
and  deficient  light  it  was  not  extracted.  Nitric  acid,  how- 
ever, was  applied,  which  gave  the  patient  relief.  On  the 
6th  the  muscles  of  the  right  side  of  the  face  began  to  twitch. 
The  muscular  spasms  lasted  four  or  five  minutes,  and  oc- 
curred three  or  four  times  a  day.  "At  these  times,  when 
the  twitchings  had  reached  a  certain  degree  of  intensity, 
the  jaw  became  locked,  and  he  lost  the  power  of  speech  ; 
but  he  had  no  pain  in  the  head,  giddiness,  or  sense  of  stu- 
por. The  paroxysm  of  spasm  in  the  muscles  of  the  right 
side  of  the  face  and  jaws  occurred  the  next  day,  and  on  the 
following  day,  the  fourth  after  the  examination  by  Mr.  Chat- 
field  (the  medical  officer),  the  twitchings  became  more 
violent,  and  his  jaw  locked.  He  had  the  sensation  of  all  his 
teeth  falling  out,  and  then  lost  consciousness.  A  strong 
convulsive  fit  ensued,  which  lasted  half  an  hour  ;  the  same 
night  he  had  a  second  fit."  These  attacks  were  described 
as  presenting  all  the  features  of  an  epilepsy.  A  third  attack 
occurred  before  morning.  The  next  day  the  tooth  was  ex- 
tracted, together  with  a  small  piece  of  bone  attached  to  the 
root. 

For  one  month  the  patient  was  perfectly  well,  but  on 
the  7th  of  December,  in  the  middle  of  the  day,  he  again  ex- 
perienced the  spasmodic  twitchings,  and  at  the  same  time 
became  conscious  of  the  existence  of  something  protruding 
from  his  jaw  ;  with  his   fingers  he  removed  a  piece  of  dead 

X  London  Med.  Gazette,  xlviii.,  pp.  534-540. 


j  22  ALBERT  P.   BRUBAKER. 

bone.  In  the  evening  of  the  same  day  the  spasmodic  con- 
tractions of  the  face  occurred  several  times.  On  the  night 
of  December  8th  he  awoke  with  a  spasm  in  the  cheek,  and 
upon  getting  out  of  bed  fell  upon  the  floor  unconscious  ;  a 
general  convulsive  fit  followed,  during  which  there  was 
foaming  from  the  nose  and  mouth.  At  6  A.  M.  a  second  fit 
followed  more  violent  than  the  first,  and  lasted  five  min- 
utes. In  the  intervals  of  these  attacks  there  was  con- 
siderable uneasiness  and  confusion  of  mind.  The  next 
night  he  suffered  a  return  of  the  fit.  Examination  of  the 
mouth  revealed  a  swollen  and  tumid  condition  of  the  gum, 
but  there  was  no  discernible  source  of  irritation.  The  pa- 
tient was  placed  on  calomel  to  prevent  further  mischief  to 
the  deeper-lying  structures  around  the  diseased  tooth- 
socket.  He  remained  well  until  February  22d,  when  he 
had,  for  the  space  of  ten  minutes,  the  same  premonitory 
twitchings  in  the  muscles  of  the  face,  but  no  real  fit.  A 
small  piece  of  dead  bone  was  extracted  from  the  gum,  after 
which  the  old  wound  healed,  and  the  patient  entirely  recov- 
ered. 

In  1857,  Dr.  Sieveking  read*  before  the  Royal  Medical 
and  Chirurgical  Society  a  paper  entitled  "An  Analysis  of 
Fifty-two  Cases  of  Epilepsy."  In  the  discussion  that  en- 
sued Sir  Charles  Locock  said  he  had  noticed  the  omission 
of  the  paper  of  a  very  common  cause  of  epilepsy,  viz.,  den- 
tition. He  could  not  agree  with  Dr.  Ashburner  that  all 
cases  of  the  disease  could  be  cured  by  the  removal  of  the 
teeth ;  but  he  had  certainly  seen  the  affection  cured  in 
more  than  one  instance  by  removing  overcrowded  teeth. 

Case  VII. — Dr.  Ramskill  publishest  the  following: 
"A  boy,  13  years  old,  has  had  frequent  attacks  of  epilepsy 
for  the  last  eighteen  months.  Latterly,  his  mother  noticed 
that  some  days  he  rubs  his  left  cheek,  complaining  of  face- 
ache,  after  which  the  fit  follows.  On  examining  the  mouth, 
there  is  to  be  seen  a  molar  tooth  considerably  decayed, 
with  a  swollen  gum  around  it  and  partly  growing  over  into 
the  cavity  :  it  is  not  very  tender  to  the  touch,  and  the  ex- 
amination does  not  give  rise  to  toothache.    On  questioning, 

*  Lancet,  June,  1857.         f  Med.  Times  and  Gazette,  1862,  vol.  ii.,  p.  216. 


DENTAL  IRRITATION  IN  EPILEPSY. 


12 


I  find  the  sensation  which  the  boy  experiences  before  the 
fit  does  not  seem  to  be  one  of  pain,  but  rather  of  indefinite 
uneasiness.  He  always  has  a  fit  the  night  this  comes  on. 
Has  never  felt  it  during  the  day ;  it  is  always  about  seven 
or  eight  o'clock.  I  desired  the  mother  to  have  the  tooth 
extracted,  and  ordered  a  simple  saline,  with  one-quarter 
grain  of  belladonna,  to  be  taken  twice  daily.  This  was  in 
June.  The  tooth  was  extracted  next  day.  I  saw  this  boy 
once  a  fortnight  from  that  time  for  four  months,  but  he  had 
no  recurrence  of  the  fits.  In  this  case  I  believe  an  unfelt 
aura  commenced  about  the  gum  surrounding  the  tooth,  and 
was  not  recognized  till  some  degree  of  inflammation  arose, 
and  thus  a  modification  of  pain  became  associated  with  the 
aura  and  directed  attention  to  it." 

Case  VIII. — Trousseau  relates*  the  case  of  a  patient,  a 
young  notary's  clerk,  under  the  care  of  Dr.  Foville,  who 
had  been  subject  to  monthly  attacks  of  epilepsy  for  several 
years.  Many  remedies  had  been  tried  in  vain.  Dr.  Foville 
suggested  the  extraction  of  some  carious  teeth  which  ached 
constantly.  The  suggestion  was  acted  upon,  and  from  that 
day  the  fits  disappeared. 

Case  IX. — Dr.  Garrett  related  the  following  case  before 
the  Suffolk  District  Medical  Society,  and  was  reported  by 
Dr.  Page  :t  "A  man,  aged  40  to  50  years,  had  suffered  with 
his  teeth  for  years  ;  these  had  been  extracted  and  artificial 
ones  substituted.  He  became  paralyzed  in  the  muscles  of 
his  face  and  tongue.  There  was  a  peculiar  drawing  of  the 
mouth,  from  which  the  aura  epileptica  came  just  previous 
to  the  fit ;  the  tongue  was  inclined  to  fall  back  within  the 
mouth  ;  he  was  fearful  of  swallowing  it.  In  investigating 
the  case,  Dr.  Garrett  removed  the  false  teeth,  and  found  the 
soldering  discolored  ;  he  went  back  to  his  dentist,  had  a 
rubber  plate  made,  and  had  no  further  attacks  of  epilepsy ; 
the  paralysis  gradually  subsided." 

Case  X. — W.  H.  Waite  reports:;  the  case  of  a  young 
woman,  aet.  18,  who  consulted  him  for  treatment  for  a  ca- 
rious condition  of  the  incisor  and  canine  teeth  of  the  upper 

*  Clinical  Medicine,  New  Sydenham  Soc,  vol.  i 

f  Boston  Med.  and  Surg.  Journal,  November  8,  i860. 

%  British  Journal  of  Dental  Science,  1863. 


j  2  a  ALBERT  P.  BR  I  BAKER. 

and  lower  jaws.  The  teeth  had  been  diseased  for  four 
years,  and  were  very  sensitive.  For  three  years  the  patient 
had  been  subject  to  epileptic  attacks,  which  were  at  first 
quite  slight,  but  had  gradually  increased  in  severity.  After 
removal  of  the  diseased  teeth  and  filling  of  others,  the  epi- 
leptic fits  entirely  ceased.  After  some  months  the  fits 
returned,  attended  with  sharp,  shooting  pains  in  the  alve- 
olus. Examination  showed  that  several  other  teeth  had 
become  decayed.  These  were  removed,  and  from  that 
time  on  there  was  no  recurrence  of  the  epilepsy,  and  the 
patient  increased  in  health  and  weight. 

Case  XI. — Dr.  Nathan  Field  reports-  the  case  of  a  boy, 
about  five  years  old,  who  was  suddenly  seized  with  an  epi- 
leptic fit.  In  two  weeks  he  had  a  second  attack,  which 
passed  away  after  a  few  minutes.  In  the  course  of  the  next 
ten  days  it  was  estimated  that  the  boy  had  a  thousand  con- 
vulsions, occurring  every  few  minutes.  No  cause  could  be 
assigned.  It  was  finally  observed  that  before  the  appear- 
ance of  the  convulsion  there  was  a  twitching  of  the  muscles 
of  the  left  side  of  the  face.  Finally,  after  a  severe  convul- 
sion, while  the  child  was  unconscious,  he  drew  up  his  upper 
lip,  when  it  was  observed  that  the  canine  tooth  had,  instead 
of  causing  absorption  of  the  deciduous  tooth,  pushed  it  out- 
ward through  the  alveolus,  the  gum,  and  into  the  lip.  The 
tooth  was  removed,  and  in  less  than  an  hour  the  convul- 
sions subsided  and  never  appeared  again. 

Case  XII. — Mr.  Canton  related*  the  history  of  the  fol- 
lowing case:  "A  strong,  health}-  boy,  aet.  19.  who  had 
become  the  subject  of  epileptic  fits,  applied  to  Mr.  Canton 
for  treatment.  As  the  cause  of  the  fits  could  not  be  ascer- 
tained, it  occurred  to  him  that  they  might  be  due  to  the 
eruption  of  a  wisdom  tooth.  The  gum  was  freely  incised, 
and  the  crown  of  the  tooth  laid  bare.  From  that  time  the 
fits  never  returned. 

CASE  XIII.-  Mr.  Henry  Moon  related^  the  following 
case  :  "The  patient,  a  girl,  aet.  21,  was  brought  as  an  out- 
patient to  I)r.  Fagge  at  Guy's  Hospital,  and  he.  finding  that 

•Western  Journal  of  Medicine,  1869. 

+  Proceedings  Odontological  Soc.  of  Great  Britain,  1880. 

J  Proceedings  Odontologicai  Soc.  of  Great  Britain,  1882, 


DENTAL  IRRITATION  IN  EPILEPSY. 

0 


12 


her  teeth  were  in  a  very  bad  state,  sent  her  to  Mr.  Moon. 
She  had  suffered  from  fits  since  she  was  fourteen,  and  lately 
they  had  become  so  frequent  as  to  reduce  her  almost  to  the 
condition  of  imbecility.  On  examining  her  mouth,  a  third 
molar  was  found  in  process  of  eruption  ;  this  he  lanced 
freely.  Some  carious  teeth  were  extracted  and  others  were 
filled.  Treatment  by  the  bromides  of  potassium  was  or- 
dered at  the  same  time.  The  result  was  that  the  fits  entirely 
ceased  from  the  day  of  her  first  visit  to  the  hospital.  The 
girl  recovered  her  intellect,  and  although  she  was  kept  under 
observation  for  several  months,  she  had  no  return  of  the  fits." 
Case  XIV. — Dr.  Schwartzkopf  reportedt  the  following 
case  in  the  Deutsche  MonatscJirift  fur  ZahnJieilkunde,  1866  : 
"  A  man,  aet.  27,  suffered  severe  pain  in  the  right  upper  cen- 
tral incisor,  which  was  carious,  and  consulted  a  dentist,  who 
filled  it.  Soon  after  this  a  swelling  appeared  in  the  hard 
palate,  where  an  opening  formed.  The  patient  was  now 
easy,  but  the  tooth  continued  loose  and  tender  when  touched. 
The  fistula  also  remained  patent  and  discharging.  Ten  days 
after  the  tooth  was  filled  the  patient  had  an  epileptic  attack, 
and  these  recurred  at  gradually  shorter  intervals  until,  at  the 
end  of  eighteen  months,  they  occurred  several  times  a  week. 
During  this  time  the  patient  was  treated  with  bromides,  atro- 
pine, etc.,  but  without  results.  The  tooth  was  then  extracted, 
the  fistula  healed,  and  the  fits  ceased,  and,  at  the  time  of  re- 
porting, the  patient  had  remained  free  from  them  for  four 
years." 

The  two  following  cases  are  reported*  by  Dr.  Liebert : 
Case  XV. — Emil  S.,  aet.  25,  in  good  health  and  no  neu- 
rotic tendency,  began  to  suffer  with  attacks  of  vertigo  in 
February,  1883.  These  attacks  lasted  several  minutes,  after 
which  the  patient  appeared  perfectly  well.  On  one  occa- 
sion, however,  the  vertigo  was  so  severe  that  he  was  com- 
pelled to  sit  down  to  keep  from  falling.  On  one  occasion 
he  lost  consciousness.  By  April  25th  the  attacks  had  greatly 
increased  in  severity.  On  this  day  he  had  had  such  a  severe 
epileptic  attack  that  Dr.  Liebert  was  called  in.  The  patient 
had  been  lying  upon  the  floor  for  fifteen  minutes  wholly  un- 
conscious and  most  of  the  muscles  of  the  body  in  a  state  of 

t  Journal  British  Dental  Assoc,  1886. 

*  Deutsche  Medizin.  Wochenschrift,  Sep.emb;r,  1885. 


j  26  ALBERT  P.  BRUBAKER. 

tonic  contraction  ;  the  pupils  were  of  medium  width  and  in- 
sensible to  light ;  there  was  also  a  fresh  wound  of  the  tongue. 
After  careful  inquiry,  it  was  learned  that  just  previous  to  the 
attacks  the  patient  experienced  a  peculiar  tickling  or  crawl- 
ing sensation  in  the  tongue,  an  inability  to  speak  words  dis- 
tinctly, and  some  involuntary  movements  of  the  tongue.  Im- 
mediately after  there  followed  the  giddiness,  the  fall,  uncon- 
sciousness, etc.  Despite  large  doses  of  the  bromides,  the  at- 
tacks increased  in  frequency  and  severity.  Finally,  in  June,  he 
began  to  suffer  with  toothache.  Examination  of  the  mouth  re- 
vealed several  carious  teeth,  one  of  which  was  very  sensitive 
to  percussion.  This  was  extracted,  and  from  that  moment  all 
peculiar  sensations  and  motions  of  the  tongue  ceased,  and 
there  has  not  been  in  the  past  two  years  a  single  epileptic  seiz- 
ure. This  patient  had  in  four  months  several  hundred  attacks 
of  vertigo  and  eighteen  or  twenty  typical  epileptic  convul- 
sions. 

Case  XVI. —  Young  man,  xt.  35,  cabinet-maker.  Began 
having  epileptic  attacks  on  February  3,  1862,  which  came 
on  almost  daily  with  increasing  severity.  On  March  5th  he 
had  twenty-three  seizures.  With  the  exception  of  a  tooth- 
ache he  had  never  been  sick.  Repeated  inquiries  elicited 
the  information  that  from  December,  1861,  the  use  of  his 
tongue  was  for  some  seconds,  or  even  minutes,  frequently 
rendered  difficult,  and  this  fact  was  coupled  with  a  certain 
feeling  of  illness  or  vertigo.  In  the  attack  of  February  3, 
1862,  these  symptoms  were  exceptionally  severe,  the 
tongue  being  drawn  to  the  right  side  and  executing  spas- 
modic movements.  Immediately  thereafter  he  became  un- 
conscious and  fell  to  the  floor  in  convulsions.  The  tongue 
symptoms  were  usually  premonitory  of  the  frequent  subse- 
quent attacks.  Owing  to  the  fact  that  the  aura  appeared  to 
be  connected  with  the  mouth,  it  was  determined  to  seek  for 
the  cause  in  that  locality.  As  he  had  had  toothache  occa- 
sionally, several  carious  teeth  were  removed.  The  patient 
at  once  declared  that  he  felt  an  unwonted  freedom  from  a 
former  oppressive  feeling,  and  that  he  believed  he  would 
have  no  more  of  the  seizures.  His  conjecture  was  correct, 
for  he  remained  free  from  them  from  that  time  forth.  This 
patient  had  epileptoid  vertigo  for  three  or  four  months  and 
severe  epileptic  attacks  for  thirty-eight  days. 


A   CLINICAL   LECTURE    UPON   CERTAIN   TYPES 
OF    HYSTERIA 

By   LANDON   CARTER   GRAY,  M.D., 

PROFESSOR   OF   NERVOUS    AND    MENTAL   DISEASES   IN   THE   NEW   YORK   POLYCLINIC. 

I  PROPOSE,  gentlemen,  to  read  you  the  histories  of  a 
mother  and  daughter,  which  will,  I  think,  be  of  con- 
siderable interest  : 
The  mother  is  51  years  of  age,  born  in  Scotland.  She 
came  to  this  country  a  number  of  years  ago,  and  shortly 
afterwards  had  some  trouble  with  her  husband,  who  refused 
to  support  her,  whereupon  she  became  greatly  excited  and 
threw  herself  from  a  ferry-boat,  and  would  have  been 
drowned,  but  for  the  assistance  of  the  boat  hands.  A 
considerable  period  of  time  following  this  event  is  an 
entire  blank  to  her,  but  it  appears  that  she  was  insane  and 
was  sent  to  the  Ward's  Island  Asylum.  At  the  present 
time,  when  speaking  of  this  terrible  time  of  her  life,  the 
woman  utterly  breaks  down,  and  sobs  and  cries  as  if  her 
heart  would  break.  She  seems  to  have  come  honestly  by 
her  defective  nervous  system,  for  a  maternal  aunt  has  been 
speechless  and  bed-ridden  for  several  years,  and  several 
other  members  of  her  family  in  bygone  generations  have 
been  afflicted  with  nervous  disorders,  of  which  I  can  obtain 
no  precise  details.  After  these  neurotic  phenomena  of  the 
mother's  life  occurred  the  birth  of  the  daughter,  Gracie, 
whom  you  see  here,  and  whose  history  I  propose  to  read  to 
you  in  a  moment.  You  will  therefore  perceive  that,  hon- 
estly as  the  mother  came  by  her  neurotic  tendencies,  the 
daughter  came  still  more  honestly  by  hers.  Last  June  the 
mother  and  the  daughter  took  a  great  dislike  to  one  another, 
for  no  visible  reason  except  that  which  may  be  found  in  a 


I28  LAXDOX  CARTER  GRAY. 

condition  of  the  nervous  centres  of  both  of  them.  Neither 
one  can  tell  me  why  they  took  this  dislike,  and  I  have  ex- 
cellent reason  to  believe,  from  having  observed  them  both 
carefully  for  some  period  of  time,  that  neither  is  withhold- 
ing anything  from  me.  Shortly  after  taking  the  dislike  to 
each  other  both  became  afflicted  with  a  peculiar  difficulty 
of  speech,  which  in  the  daughter  became  so  pronounced 
that  the  mother  took  her  to  a  hospital.  After  leaving  the 
child  there,  the  mother  cried  almost  continuously  for  a 
week  or  more,  and  went  absolutely  to  bed  for  three  days, 
and  for  about  two  weeks  was  totally  unable  to  speak.  The 
present  condition  of  the  mother  is  this,  as  you  see  : 

She  is  as  timid  as  a  hare,  trembles  at  a  sound,  and  fairly 
shakes  with  her  mental  reflexes  when  a  disagreeable  thought 
occurs  to  her.  As  you  perceive,  she  speaks  in  an  almost 
inaudible  whisper.  When,  however,  I  speak  to  her  sharply 
and  harshly  (much  more  so  in  fact  than  I  care  to  do),  I  can 
force  her  to  raise  her  voice,  into  what  may  be  described  as 
an  undulating  whine.  Further  persistence  in  speaking  to 
her  sharply  and  harshly  will  force  her  to  speak  with  con- 
siderable distinctness  and  without  the  whine.  She  tells  me 
that  she  has  had  slight  contracture  occasionally,  during 
several  years,  of  the  left  big  toe.  She  has  absolutely  no 
paralysis  of  motion  of  any  of  the  muscles,  whether  of  the 
head  and  face  and  buccal  cavities  or  of  the  trunk  and  ex- 
tremities ;  nor  has  she  any  objective  sensory  disturbances, 
in  the  way  of  impairment  of  tact,  muscular  sense,  pain,  tem- 
perature sense,  sense  of  locality  ;  nor  any  affection  of  her  spe- 
cial senses,  such  as  sight,  hearing,  taste,  smell.  Examined 
with  an  ophthalmoscope,  her  retinae  are  found  to  be  perfectly 
normal,  the  veins  only  being  somewhat  over-dilated,  a  con- 
dition observed  in  so  many  normal  individuals  as  to  be  of  no 
significance  whatever.  Further  than  an  occasional  slight 
headache,  such  as  nervous  women  are  especially  subject  to, 
there  is  no  history  whatsoever  of  cephalalgia.  Nor  does  the 
most  careful  examination  in  other  points,  into  which  it  is 
not  necessary  to  enter,  demonstrate  the  presence  of  any 
organic  disease  of  the  central  and  peripheral  nervous  sys- 
tem.    This  mother  is  extremely  emotional,  cries  in  talking, 


CERTAIN  TYPES  OF  HYSTERIA.  j  2Q 

—indeed,  seems  to  have  scarcely  any  self-control.  She  tells 
me  that  she  has  always  been  so,  and  has  had  hysterical  at- 
tacks all  her  life  at  the  menstrual  periods. 

So  much  for  the  history  of  the  mother.  Now  listen  to 
that  of  the  daughter.  Bear  in  mind,  however,  that,  as  I 
have  told  you,  this  daughter  was  born  after  the  mother 
broke  down  into  a  suicidal  attempt  and  insanity. 

The  daughter  Gracie,  aged  14,  tells  me  that  about  thir- 
teen months  ago  she  began  to  notice,  while  at  school, 
that  first  one  and  then  the  other  heel  would  stamp  involun- 
tarily, this  persisting  till  last  June,  i.  e.,  up  to  the  time  when 
the  daughter  and  her  mother  took  a  dislike  to  one  another, 
and  the  former  was  sent  to  the  hospital.  She  claims  that 
she  noticed,  in  October,  that  when  she  had  touched  the 
hands  to  anything  dirty  or  sticky,  and  then  endeavored  to 
wipe  them,  the  wiping  motion  would  involuntarily  persist 
for  some  little  time,  until,  as  the  child  explains,  "I  could  get 
something  to  keep  my  mind  off."  After  lasting  some  eight 
months,  this  phenomena  suddenly  ceased.  In  April  last,  pa- 
tient fainted  away  in  church,  but  thinks  she  had  no  convul- 
sion. During  the  few  days  immediately  ensuing  upon  this 
she  had  some  slight  tremor  and  convulsive  movements  of 
the  hands,  all  which  suddenly  ceased  upon  her  being  made 
to  go  out  of  the  house  and  take  exercise.  When  she  and  her 
mother  took  the  great  dislike  to  each  other,  her  speech 
became  affected  at  the  same  time  as  did  her  mother's,  and 
she  became  well-nigh  incapable  of  speaking ;  but  hospital 
treatment  for  a  few  weeks  relieved  this  aphonia  entirely. 
Patient  was  then  perfectly  well  for  three  months.  At  the 
end  of  this  time  there  was  some  fracas  in  the  house  where 
she  lived,  and  immediately  the  tremor  recommenced.  In 
about  six  weeks  after  this  the  difficulty  in  speech  began 
again.  At  the  present  time,  as  you  see,  the  patient  talks 
huskily,  indistinctly,  pronounces  individual  sounds  well 
enough  separately.  You  will  notice,  also,  that  the  left 
corner  of  the  mouth  is  slightly  drawn  up,  as  if  there  were  a 
few  fibrillary  contractures  there  in  the  levator  labii  superioris 
al<zq<z  nasi  muscles.  When  she  shows  her  gums,  you  will 
notice  that  this  left  side  is  distinctly  less  contracted  than 


j  -,0  LANDON  CARTER  GRAY. 

the  other,  demonstrating  a  slight  paresis  of  these  same 
muscular  fibres.  When  she  protrudes  the  tongue  it  points 
very  slightly  to  the  left,  but  distinctly.  Uvula  points 
slightly  to  the  right  and  the  left  arch  of  the  soft  palate  is 
evidently  paretic.  I  have  had  her  under  observation  for 
several  weeks  in  the  hospital,  and  the  nurse  tells  me  that 
she  staggers  occasionally  in  walking,  which,  however,  I  have 
never  been  able  to  perceive.  The  pupils  are  large,  some- 
what over-sized,  but  reacting  well  to  light  and  movements 
of  accommodation. 

Now,  gentlemen,  when  I  first  heard  the  histories  of  these 
two  unfortunate  human  beings,  I  said  to  myself  at  once  that 
they  were  cases  of  hysteria.  But  let  me  warn  you  never  to 
make  a  diagnosis  of  hysteria  with  a  flippant  mind.  Just  think 
of  the  many  hundreds,  perhaps  thousands  of  years,  during 
which  physicians  set  down  as  hysterical  the  lightning  and 
the  stabbing  pains  of  locomotor  ataxia.  Just  think  of  the 
periods  of  time  during  which  physicians  must  have  set  down 
as  hysterical  the  early  symptoms  of  general  paralysis  of  the 
insane.  Just  exercise  your  imagination  a  few  moments  and 
range  over  the  whole  wide  range  of  nervous  and  mental  dis- 
eases, and  pick  out  those  which  for  hundreds  of  years  were  set 
down  as  hysterical.  And  those  of  you  who  have  been  five 
or  ten  years  in  practice  yourselves,  just  recall  to  memory 
the  cases  that  you  must  have  seen  of  grave  organic  affec- 
tions that  had  been  set  down  by  somebody  as  hysterical. 
Scarcely  a  month  of  my  life  goes  by  that  I  do  not  meet  with 
some  case  of  acute  suffering  that  has  been  pronounced 
to  be  hysterical  by  some  member  of  the  profession  ;  and  I 
have  assisted  at  more  than  one  autopsy  where  an  aneurism, 
or  a  tumor,  or  a  caries  of  bone  has  been  found  to  be  the 
cause  of  so-called  hysterical  symptoms.  For  these  and 
similar  reasons  I  never  make  a  diagnosis  of  hysteria  hastily. 
But  this  case  has  many  elements  about  it  that  tempted  me 
in  that  direction,  and  these  elements  were  : 

1.  The  frank  history  of  hysteria  throughout  life,  given 
me   by  the  mother  ; 

2.  The  extremely  emotional  condition  of  both  mother  and 


CERTAIN  TYPES  OF  HYSTERIA.  r  «,  , 

daughter,  evidenced  by  the  mother's  weeping  and  crying  in 
conversation,  by  the  violent  and  unreasonable  dislike  that 
mother  and  daughter  had  conceived  for  one  another,  by  the 
causation  of  attacks  in  mother  and  daughter  by  emotion,  by 
the  fact  that  both  mother  and  daughter  could  be  made  to 
speak  distinctly  when  sharply  and  harshly  spoken  to  ; 

3.  By  the  characteristic  one-sided  curl  of  the  lip,  due  to 
a  fibrillary  contracture,  which  is  quite  characteristic  of  cer- 
tain cases  of  hysteria. 

But  I  was  not  satisfied  even  with  these  facts  ;  for  it  is 
possible,  as  you  will  admit  upon  the  mere  mention  of  the 
fact,  that  a  hysterical  patient  might  have  organic  disease. 
There  certainly  was  in  the  mother  a  downright  insanity,  of 
a  somewhat  violent  type  and  lasting  for  some  little  time  ; 
and  the  daughter  bore  a  slight  lingual  and  facial  paresis. 
Both  the  maternal  insanity  and  the  filial  paresis  were  quite 
consistent  with  the  diagnosis  of  hysteria,  it  is  true,  but  it  is 
also  true  that  they  were  quite  consistent  with  a  diagnosis  of 
organic  disease.  So  I  separated  the  mother  and  the  daughter 
at  once,  took  the  latter  into  the  hospital,  made  the  former 
live  alone  at  home,  and  did  not  permit  them  to  see  one  an- 
other for  several  weeks.  Then  I  set  a  nurse  to  work  to 
make  careful  observation  of  the  daughter.  So  I  come  to 
you  at  the  end  of  that  time,  able  to  say  that  the  daughter 
presents  no  other  symptoms  than  those  I  have  shown  you, 
and  that  these  can  be  made  to  disappear  by  the  discipline 
of  a  well-ordered  hospital  ward. 

These  two  cases  are  rather  extreme  types  of  hysteria, 
and  are  not  met  with  very  frequently  in  our  clinics,  although 
they  have  been  well  enough  described  by  the  books.  The 
treatment  of  them  is  very  often  a  very  puzzling  one,  and 
becomes  well-nigh  impossible  when  the  means  of  the  pa- 
tient are  moderate.  These  graver  types  of  hysteria  are 
closely  allied  to  those  of  many  of  the  bed-ridden  women 
throughout  the  country,  who  furnish  forth  so  many  para- 
graphs for  the  Sunday  newspapers  when  they  have  been 
made  to  get  up  from  bed  and  walk  by  clairvoyants,  mes- 
merists, faith  cure,  or  that  craziest  craze  of  them  all  which 
goes  by  the  name  of  "  Christian  Science  "  or  some  equally 


T  -,  -,  LAXDOX  CARTER  GRA  Y, 

biblical  and  meaningless  term.  To  treat  all  this  class  of 
patients  with  any  possibility  of  success,  it  is  absolutely 
necessary  to  have  them  taken  away  from  their  friends.  It 
is  impossible  to  make  a  sympathizing  layman  or  laywoman 
understand  what  hysteria  is  ;  indeed,  it  is  almost  impossible 
for  any  one  to  understand  it  until  they  have  seen  its  eccen- 
tric and  often  really  insane  manifestations.  It  is  therefore 
utterly  useless  to  expect  the  co-operation  of  friends  or  rela- 
tives in  any  treatment  that  calls  for  self-control  on  the  part 
of  the  patient.  But  if  they  are  taken  away  from  their  home 
and  put  under  the  charge  of  a  nurse  who  is  trained  to  obey 
orders  like  a  soldier,  then  we  can  enter  upon  the  therapeu- 
tic struggle  with  some  chances  of  success.  Do  not  flatter 
yourselves,  however,  that  you  will  gain  an  easy  victor)-. 
By  no  manner  of  means  !  On  the  contrary,  you  must  ex- 
pect to  have  your  temper,  your  ingenuity,  your  nerves  tested 
to  a  degree  that  cannot  be  surpassed  even  by  the  great  sur- 
gical operations.  I  maintain  that  the  man  who  has  the 
nerve  and  the  tact  to  conquer  one  of  these  grave  cases  of 
hysteria  has  the  nerve  and  the  tact  that  will  make  him 
equal  to  the  great  emergencies  of  life.  Your  patient  must 
be  taught,  day  by  day,  to  do  what  she  has  never  done  be- 
fore, .i.e,  to  make  her  cerebrum  act  upon  her  muscles  in  the 
way  that  it  is  perfectly  capable  of  acting,  if  she  will  only 
make  it  act.  In  other  words,  she  must  be  taught  to  exert 
her  will,  not  by  preaching  or  sermonizing,  but  by  steady, 
resolute,  iron -willed  determination  and  tact — that  combin- 
ation which  the  French  writers  somewhat  melodram- 
atically call  "the  iron  hand  beneath  the  velvet  glove." 
It  is  utterly  impossible  for  me  to  give  you  more  than 
general  directions  of  this  nature,  for  each  individual  case 
will  require  a  different  application  of  the  same  general  prin- 
ciples. You  must,  however,  disabuse  your  mind  of  the  pre- 
judice that  most  physicians  have  against  making  use  of  mental 
impressions  as  therapeutic  agents.  In  treating  this  class  of 
patients,  you  may  be  perfectly  positive  of  failure  unless  you 
have  moral  courage  enough  to  make  impressions  upon  the 
auditory  and  the  optic  nerves  as  well  as  upon  the  pneumo- 
gastric.    In  other  words,  if  you  will  cling  to  the  old  idea  that 


CERTAIN  TYPES  OF  HYSTERIA.  ,  ,  , 

the  body  must  not  be  treated  except  through  the  involun- 
tary system  of  nerves  ;  that  it  is  dishonest  to  put  medicines 
into  the  body  except  you  lodge  them  within  the  gastro- 
intestinal tract  or  beneath  the  skin  ;  that  the  great  palpita- 
ting nervous  mass  of  the  brain,  with  its  immense  optic  and 
auditory  antennae,  is  to  lie  useless, — then  you  may  throw  up 
the  case  at  once.  Your  whole  treatment  must  be  based 
upon  mental  impressions.  Drugs  will  be  of  no  use  what- 
ever, unless  your  patient  is  wasted  in  health  and  strength. 
Should  there  be  any  necessity  for  tonics  and  nourishment, 
then  you  should  make  some  application  of  the  treatment 
which  has  been  made  so  well  known  to  the  world  by  Dr. 
Weir  Mitchell,  under  the  name  of  "  Fat  and  Blood  Making," 
and  which  consists,  as  you  doubtless  know,  of  putting  the 
patient  absolutely  to  bed  for  six  or  twelve  weeks,  gradually 
increasing  their  food  from  two  or  three  ounces  of  milk  every 
two  or  three  hours  to  three  full  meals  in  the  day,  adding 
malt  extract  and  iron,  and  using  electricity  and  massage  to 
overcome  the  ill  effects  muscularly  of  this  enforced  rest. 


De  L'EPILEPSIE  JACKSONIENNE.  Memoire  couronne  par 
la  Societe  de  Medecine  et  de  Chirurgie  de  Bordeau.  Par 
le  Dr.  E.  Rolland,  Medecin  des  Asiles  "John  Bost "  de 
Laforce  (Dudogne). 

Jackson ian  Epilepsy.  By  Dr.  E.  Rolland,  Physician  to 
the  "John  Bost"  Asylum.  Published  by  the  Progres 
Medecal,  1888,  pp.  181,  with  preface  and  24  illustra- 
tions. 

Dr.  Rolland's  work  is  the  first  monograph  to  appear  on  the  sub- 
ject of  Jacksonian  epilepsy.  Since  Hughlings  Jackson,  in  1863, 
published  his  minute  and  interesting  observations  on  the  disease 
which  now  bears  his  name,  several  other  close  observers,  especially 
Fournier,  Franck  and  Pitres,  and  Luciani,  have  studied  the  subject 
from  anatomical  and  pathological  standpoints  ;  but  until  the  present 
work  appeared,  no  one  has  attempted  to  collect  the  results  obtained, 
to  classify  them,  and  to  formulate  the  conclusions  which  must 
necessarily  be  deduced  by  the  careful  study  of  the  large  number  of 
cases  Dr.  Rolland  has  collected. 

As  physician  to  the  "John  Bost  "Asylum,  where  many  epilep- 
tics are  confined,  Dr.  Rolland  has  had  exceptional  facilities  for 
studying  epilepsy  in  all  of  its  forms.  The  first  chapter  of  the  work 
is  devoted  to  a  brief  summary  of  the  anatomy  and  physiology  of  the 
cerebral  convolutions,  especially  the  so-called  motor  convolutions, 
and  is  accompanied  by  the  usual  illustrations  seen  in  all  text-books 
which  treat  of  this  subject.  It  is  but  a  slight  sketch,  and  is  simply 
introduced  to  show  that  the  well-known  experiments  on  cerebral 
localization  on  the  lower  animals  are  fully  in  accord  with  the  path- 
ological developments  which  produce  the  symptoms  classified  under 
the  title  of  Jacksonian  epilepsy. 

The  symptomatology  of  the  disease  is  clearly  and  concisely  set 
forth  in  a  number  of  minutely  described   cases,  several   of  which 


REVIEWS.  T„- 

came  under  the  author's  personal  observation.  The  description  of 
the  attacks  are  models  of  what  such  observations  should  be. 

Under  the  heading  of  Pathological  Anatomy  and  Physiology,  the 
author  has  tabulated  one  hundred  and  twelve  cases,  arranged  into 
five  groups  depending  upon  the  localization  of  the  spasm.  In  all  of 
these  cases  the  pathological  lesion  was  discovered.  A  study  of  these 
cases  goes  to  show  that,  while  in  a  large  majority  of  them  the  lesion 
was  located  in  the  cortex  on  one  or  both  sides  of  the  fissure  of 
Rolando,  in  a  small  number  the  lesion  was  found  either  in  the  cen- 
tral gray  nuclei  (two  cases)  or  else  in  the  white  substance  of  the 
occipital,  temporal,  and  tempero-sphenoidal  lobes  (five  cases).  The 
differential  features  between  the  usual  and  the  unusual  types  are 
made  apparent  in  the  tables. 

In  regard  to  the  treatment,  the  author  has  nothing  new  to  sug- 
gest. The  operative  measures  instituted  by  Horsley  are  commended 
as  affording  the  best  means  of  relief,  except  in  syphilitic  cases,  where, 
of  course,  specific  treatment  is  advocated. 

Though  the  volume,  as  a  whole,  presents  few  new  features,  yet 
Rolland's  work  is  to  be  commended  for  the  thorough  and  exhaustive 
manner  in  which  the  subject  is  treated. 


$ori*ty  iUpotts. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  held  February  8,  1888. 

The  President,  C.  L.  Dana,  in  the  Chair. 


Dr.  J.  B.  Emmerson  presented  a  pile  of 

rectangular  prisms  in  a  single  frame. 

The  pile  consisted  of  Nos.  2,  4,  6,  8,  10,  12,  14,  16,  which 
were  fixed,  and  two  additional  prisms,  Nos.  1  and  16  which 
were  movable.  By  subtracting,  Nos.  3,  5,  7,  etc.  were  ob- 
tained, and  by  adding,  Nos.  18,  20,  22,  etc.  The  apparatus 
was  used  in  the  same  way  as  ordinary  prisms,  the  advant- 
age claimed  being  increased  facility  in  rapidly  changing  one 
prism  for  another.  The  muscles  could  be  tested  in  one- 
fourth  the  usual  time. 

Dr.  Birdsall  asked  what  was  the  price  of  the  instrument. 

Dr.  Emmerson  replied  that  Meyrowitz  furnished  it  for  $16.  Dr. 
Norris'  rectangular  prisms  cost  $18  ;  the  ordinary,  set  $12. 

Dr.  Dana  asked  whether  the  instrument  would  test  fractions  of  a 
degree,  referring  to  the  fact  that  Dr.  Stevens  reports  errors  in  frac- 
tions. 

Dr.  Emmerson  replied  that  he  had  never  tried  to  test  errors  in 
fractions  but  that  the  subtraction  of  a  y2  or  %  prism  would  enable 
this  to  be  done. 

Dr.  Leszynsky  considered  the  arrangement  very  ingenious.  The 
principle  of  subtraction  and  addition  was  that  of  the  opthalmoscope. 
He  however  thought  tests  by  prisms  unreliable.  By  means  of  the 
prism  it  was  possible  to  c  reate  the  appearance  of  a  condition  which 
did  not  exist. 

Dr.    Ira    VanGieson    presented    specimens  stained    by    Golgi's 


NEW  YORK  NEUROLOGICAL  SOCIETY.  ,*>* 

method.  Blocks  i  to  2c.  c.  in  dimensions  were  subjected  to  the 
action  of  a  2  per  cent,  solution  of  bichromate  of  potash,  or  Muller's 
fluid.  The  time  for  hardening  varied  with  the  temperature.  A  con- 
stant temperature  of  20°c.  to  25°c.  was  preferred.  In  the  summer 
hardening  was  completed  in  from  15  or  20  to  40  or  50  days.  In 
winter  5  to  15  weeks  were  required.  In  changing  the  bichromate 
solution  its  concentration  was  increased  up  to  5  per  cent. 

After  hardening,  the  specimen  was  placed  in  a  solution  of  nitrate 
of  silver  at  an  average  of  ^  of  one  per  cent  in  strength.  Where  the 
hardening  was  incomplete  a  1  per  cent,  solution  might  be  required. 
Where  it  was  more  complete  a  y2  per  cent  might  be  sufficient.  A 
precipitate  of  chromate  of  silver  required  that  this  solution  should 
be  frequently  changed.  The  specimen  was  kept  in  this  solution  for 
from  24  to  30  hours.  It  was  then  washed  in  water,  embedded, 
washed  in  alcohol  and  cleared  with  creosote  and  turpentine.  The 
same  result  could  be  obtained  by  immersion  in  a  corrosive  subli- 
mate solution  of  1  per  cent,  strength,  but  months  were  required  by 
this  method.  The  speaker  also  thought  it  less  certain  than  the  one 
described.  Both  methods  had  been  modified  by  Pal  of  Vienna. 
The  modification  required  the  immersion  of  the  silver  or  sublimate 
sections  in  a  1  per  cent,  solution  of  sodium  sulphide,  which  pro- 
duced a  more  complete  precipitation  in  the  finer  processes. 

The  object  of  the  method  was  the  staining  of  ganglion  ceils 
and  processes,  the  matrix  being  left  clear.  There  was  sometimes  a 
tendency  for  the  silver  to  precipitate  in  the  pericellular  spaces  and 
in  the  channels  around  the  processes  so  as  to  make  them  appear 
larger  than  they  ought  to  be.  It  was  however  the  only  method 
which  had  stained  the  ganglion  cell.  The  speaker  had  been  suc- 
cessful in  specimens  taken  from  the  cortex.  In  those  from  the  cer- 
ebellum and  spinal  cord  he  had  been  less  successful.  It  was  essen- 
tial that  the  specimen  should  not  overharden.  It  was  necessary 
every  day  or  two  to  sacrifice  a  piece  and  try  it  in  the  silver  solution 
to  determine  whether  the  hardening  was  sufficient. 

Literature  in  connection  with  the  subject  was  cited   as  follows  : 

C.  Golgi,  "  Recherches  sur  l'histologie  des  centres  nerveux,  " 
Arch.  Italiennes  de  Biologie,  Vol.  I II. -IV,  1883. 

C.  Golgi,  "Sulla  fina  anatomia  degli  organi  central!  des  systema 
nervoso,  "  Milano,  1886. 

Prof.  Forel,  "  Einige  hirnanatomische  Betrachtungen  und  Er- 
gabnisse  "  Arch.  f.  Psychiatrie,  Bd.  XVIII,  No.   *. 

Bleuler,    Correspondenzblatt  f.   Schweitzer  Aertze,    March.   15, 

1886. 


j  ^g  XEW  YORK  NEUROLOGICAL  SOCIETY. 

J.  Pal,  "Ein  Betrag  zur  Nervenfarbentechnik,"  Med.  Jahrbuch- 
der  K.  K.  Gesellschaft,  '86,  No.  8. 

C.  Mondino,  "Recherche  macro  e  microscopische  dei  cerebri 
nervosi,"  Torino,  1886. 

Marchi,  Sulla  strutura  dei  corpi  striati  e  thalmi  ottici,''  (Memoir 
dal  instituto  Lombardo  di  scienzi  e  lettere,  1887. 

Tara  Tun,  "Sulla  A  Sull'Anatomia  della  retina."  InternaL  Mo- 
natschrift  f.  Anat.  u.  Phys.  Bd.  IV.,  H.  10. 

L.  Petrone,  "  Sur  la  structure  des  nerfs  cerebro  rachidiens. "'  In- 
ternaL Monatschrift,  f.  Anat.  u.  Phys.,  Bd.  V,  N.   1. 

Dr.  Dana  also  presented  specimens  stained  by  Golgi's  method. 
He  had  not  so  far  been  so  successful  as  Dr.  Van  Gieson,  but  in  a 
few  specimens  he  had  got  staining  which  showed  one  interesting  pe- 
culiarity of  the  method,  viz  :  that  it  at  times  stained  cells  of  one 
class  ;  at  others,  those  of  another.  In  his  sections  the  connective 
tissue  cells  only  were  stained,  but  these  were  shown  in  a  striking 
manner.  Obersteiner  had  stated  that  by  the  sublimate  method  only 
about  j1^  °  of  the  cells  were  stained.  The  speaker  thought  that 
Golgi's  method  was  a  truly  epoch-making  one,  comparable  to  that 
of  Wiegert  for  the  nerve  fibres  :  but  naturally  great  care  would  be 
required  in  drawing  conclusions  from  what  was  seen.  He  presented 
Marchi's  monograph  on  the  structure  of  the  optic  thalamus  and  cor- 
pus striatum  in  which  it  was  shown  that  the  cells  of  the  former  gan- 
glion were  of  the  motor  type  and  those  of  the  latter  of  the  sensory. 

Dr.  Sachs  asked  whether  any  facts  had  been  demonstrated  by 
Golgi's  method  which  had  not  been  shown  by  others. 

Dr.  Van  Gieson  replied  that  we  have  no  other  method  which  will 
stain  the  ganglion  cell.  Golgi's  method  showed  the  axis  cylinder  as 
a  branch  of  the  cell.  It  showed  also  that  the  protoplasmic  processes 
do  not  inosculate. 

Dr.  Birdsall  objected  to  this  inference.  We  had  no  means  of 
knowing  that  even  by  this  method  the  whole  of  the  process  was 
stained  by  Golgi's  method,  we  could  trace  the  process  further  than 
by  other  methods,  but  we  could  not  say  that  finer  subdivisions  which 
the  precipitate  failed  to  indicate  did  not  exist. 

Dr.  A.  D.  Rockwkll  read  a  paper  upon 

NKI   K  \S\  IIKM  A    AMI    I  I  I  HJEMIA. 

A  diagnosis  of  neurasthenia  was  often  made  where  the 
stomach  and  liver  was  chiefly  at  fault.    Neurasthenia  on  the 


NEW  YORK  NEUROLOGICAL  SOCIETY.  j  ^g 

other  hand  was  often  mistaken  for  lithaemia.  Mental  de- 
pression was  common  to  both  ;  but  irritability  was  peculiar 
to  lithaemia  ;  the  tongue  was  coated  and  the  pulse  slow 
rather  than  fast.  Neurasthenia  presented  many  symptoms, 
those  of  lithaemia  were  few  and  cases  were  much  alike. 

In  treatment  lithaemia  responded  to  mineral  waters  and 
restricted  diet  ;  while  in  neurasthenia  relief  from  work,  and 
anxiety  and  increased  feeding  were  required. 

Dr.  Birdsall  remarked  that  the  term  neurasthenia  was  used  to 
cover  a  variety  of  nervous  disorders  not  due  to  organic  disease.  The 
term  lithaemia  also  was  commonly  used  in  a  vague  and  incorrect 
manner.  He  thought  it  impossible  to  make  a  division  between  the 
clinical  features  of  the  two  conditions.  There  were  many  interme- 
diate cases  which  would  disprove  any  classification.  All  were  prob- 
ably but  parts  of  a  vast  group  of  nerve  disturbances  based  upon 
faulty  conditions  of  nutrition.  Absence  and  rest  had  a  direct  effect 
upon  digestion.  The  results  of  treatment  thus  presented  no  ground 
for  the  conclusions  named.      Heredity  was  a  marked  factor. 

Dr.  Sachs  stated  that  for  a  long  time  he  had  been  skeptical  of 
the  existence  of  a  true  set  of  lithaemic  symptoms,  but  that  he  had 
found  them  in  private  practice  and  had  followed  up  a  number  of 
cases.  He  agreed  with  the  previous  speaker  in  regarding  neuras- 
thenia but  a  nervous  disturbance  of  which  lithaemia  might  be  the 
aetiological  factor.  Lithaemia  had  in  his  experience  been  almost 
limited  to  women  of  the  wealthy  class,  suffering  from  an  inactive 
life.  Nervous  symptoms  were  proportioned  to  the  amount  of  uric 
acid  in  the  urine.  With  increased  exercise  or  prolonged  massage 
the  uric  acid  disappeared  and  the  patient  improved.  Referring  to 
the  question  of  heredity  he  considered  cases  with  hereditary  lithaemic 
tendencies  gouty,  and  when  neurasthenic  he  classed  them  as  cases 
of  neurasthenia  upon  a  gouty  basis. 

In  treatment  he  agreed  with  the  reader  of  the  paper.  For  lith- 
aemia he  used  cholagogue  cathartics,  physical  exercise  and  massage. 

Dr.  Birdsall  explained  that  he  had  referred  to  the  inheritance  of 
neurasthenia,  not  of  the  lithaemic  symptoms. 

Dr.  Leszynsky  had  met  with  cases  which  merited  the  name  lith- 
aemic neurasthenia.  He  recalled  a  case  in  which  nervous  symptoms 
had  alternated  with  gouty  manifestations.  He  had  watched  the  case 
for  two  months,  during  which  no  diagnosis  but  that  of  neurasthenia 
could  be  made.     At  the  end  of  that  time   a  true  gouty  attack  had 


I40  NEW  YORK  NEUROLOGICAL  SOCIETY. 

developed.  While  the  gout  lasted  the  nervous  symptoms  were  absent. 
but  these  returned  when  the  gout  disappeared.  But  little  satisfac- 
tion was  obtained  from  examining  the  urine  in  these  cases.  It  was 
impossible  to  separate  two  classes  by  its  indications.  Concentration 
was  common  in  neurasthenia  and  other  states. 

The  speaker  added  that  the  late  Dr.  McBride  had  been  accus- 
tomed to  say  that  all  neurasthenia  was  due  either  to  lithaemia  or 
muscular  anomalies. 

Dr.  Emmersox  had  seen  neurasthenia  cured  by  the  correction  of 
errors  of  refraction  and  muscular  anomalies. 

Dr.  Dana  favored  the  classification  of  neurasthenic  symptoms 
into  further  clinical  groups,  the  subdivisions  to  be  based  upon  the 
aetiology,  symtomatology  and  the  chief  seat  of  the  disorder. 

Aetiologically  :  there  were  the  hereditary  and  the  acquired  torms. 
Among  the  acquired  were  to  be  placed  the  lithaemic. 

Svmptomatologically :  there  were  the  irritative  and  depressed 
forms. 

Anatomically  :  there  were  the  cerebral,  gastric,  sexual  and  others. 

In  classification  here,  as  in  insanity,  the  various  factors  above 
indicated  would  have  to  be  used. 

Dr.  Rockwell  explained  that  he  had  not  represesented  neuras- 
thenia and  lithaemia  as  separate  types  of  disease.  He  had  not  said 
that  there  was  a  distinct  dividing  line  between  them.  He  agreed 
with  the  lithaemic  origin  of  neurasthenia  in  some  cases.  There  was 
also,  however,  a  distinct  difference  in  the  behavior  of  certain  cases 
toward  food.  In  the  purely  nervous  case  an  abundance  of  albumin- 
ous food  was  indicated  ;  while  in  lithaemia,  on  the  contrary,  the 
quantity  of  such  food  was  to  be  curtailed.  Notwithstanding  the  exist- 
enie  of  intermediate  cases  there  were  others  which  were  distinct  re- 
quiring distinctive  treatment. 

Dr.  Dana  asked  whether  Dr.  Rockwell  limited  albuminous  food 
in  lithaemia. 

Dr.  Rockwell  replied  that  he  did.  He  had  indeed  cured  him- 
self of  excessive  irritability  with  lithaemia  by  dispensing  with  meat 
and  living  mainly  on  a  farinaceous  diet. 

Dr.  Dana  referred  to  the  fact  that  Dr.  Draper  had  in  the  Practi- 
tioners' Society,  about  two  years  ago,  recommended  a  purely  nitro- 
geneous  diet  in  those  cases.  He  had  used  the  same  in  his  own  prac- 
tice but  latterly  with  some  doubt. 

Dr.  BiKDSALL  stated  that  he  too  had  followed  Dr.  Draper's  rule. 
In  defective  digestion,  sugars  and  starches  were  many  times  at  fault. 


NEW  YORK  NEUROLOGICAL  SOCIETY.  j.j 

Fats  too,  might  be  the  offending  agent.  It  was  not  even  known  that 
uric  acid  was  the  poison  in  these  cases. 

Dr.  Sachs  in  his  treatment  preferred  nitrogeneous  to  albuminous 
food. 

Dr.  Dana  himself  was  skeptical  of  the  value  of  albuminous  food 
in  lithaemia.  It  had  to  be  remembered,  however,  that  there  were 
cases  in  which  apparently  only  nitrogeneous  food  could  be  di- 
gested. 


$eadiug  &otire$. 

The  remarkable  restorative  powers  of  the  Buffalo  Lithia  Water 
make  it  a  remedy  of  great  value  in  the  treatment  of  many  nervous 
disorders.  In  mental  overwork,  in  nervous  dyspepsia,  and  in  im- 
potence and  sterility  the  benefits  derived  from  the  judicious  use  of 
this  water  have  been  most  marked.  Its  freedom  from  any  unpleas- 
ant taste  is  also  a  great  point  in  its  favor.  The  large  number  of  tes- 
timonials from  the  most  eminent  physicians  in  the  country  shows 
the  high  estimation  in  which  this  water  is  universally  held. 


Fail-child  Bros.  &  Foster  have  gained  an  enviable  reputation  in 
the  manufacture  of  their  Pure  Digestive  Ferments.  Their  Pepsin  in 
Scales,  Extractum  Pancreatis,  and  Essence  of  Pepsin  cannot  be  ap- 
proached in  purity  and  efficiency  by  any  other  preparation  we  know 
of.  A  long  experience  in  their  use  satisfies  us  that  they  accomplish 
all  that  is  claimed  for  them.  The  Essence  of  Pepsin  is  to  be  par- 
ticularly commended  on  account  of  its  agreeable  taste  and  rapidity 
of  action. 


Mr.  Lorenz  Reich,  who  is  noted  all  over  the  country  as  the 
largest  importer  of  the  highest  grades  of  Hungarian  wines,  occupies 
beautifully  furnished  offices  in  "The  Cambridge."  No.  334  Fifth 
Avenue.  "The  Cambridge"  was  built  by  Mr.  Reich,  and  is  a 
monument  to  his  enterprise  and  ability.  It  is  a  pleasure  to  review 
the  treasury  of  good  words  written  by  prominent  men  and  women 
from  all  over  the  world  indorsing  the  excellence  and  purity  of  his 
wines.  Mr.  Reich  possesses  a  book  containing  over  five  thousand 
autograph  letters  from  the  most  eminent  physicians  and  laymen, 
extolling  the  virtues  of  his  Tokayer  Ausbruch. 


The  Ruhinat  Co.  have  e\ cry  reason   to  congratulate  themselves 
on  the  great  success  of  this  comparatively  new  water.      Introduced 


AEADIAG  NOTICES.  T  „  a 

but  a  short  time  ago,  it  has  rapidly  taken  its  place  in  the  front  ranks 
of  cathartic  waters.  The  great  objections  to  waters  of  this  class  are 
their  unpleasant  taste  and  their  debilitating  effects  Dn  the  system. 
The  Rubinat  water  is  free  from  these  objections,  and  is  quick  and 
efficient  in  its  action. 


The  following  letter  speaks  for  itself.  It  was  entirely  unsolicited 
and  is  therefore  the  more  valuable  : 

Headquarters,   Department  of  Texas, 

Medical  Director's  Office, 
San  Antonio,  Texas,  February  13th,  1888. 
The  J.  P.  Bush  Mfg.  Co  : 

Gentlemen — I  feel  that  I  ought  to  inform  you,  for  your  own 
satisfaction  as  well  as  for  the  benefit  of  a  large  class  of  invalids  we 
have  in  the  United  States,  who  suffer  from  anaemia,  nervous  debil- 
ity (neurasthenia),  and  green  sickness  (chlorosis),  that  I  have  used 
your  Bovinine  in  these  diseases  with  unmistakable  advantage.  These 
cases  all  have  the  more  or  less  gastric  irritation,  dyspepsia,  nausea, 
and  distressing  sensations  of  fullness  and  weight  in  the  stomach  after 
eating,  and  all  these  symptoms  are  quite  promptly  relieved  or 
lessened  by  the  Bovinine,  taken  soon  after  eating.  But  the  most 
striking  benefit  I  have  noticed  from  its  use  is  in  cases  where  agon- 
izing pain  (gastralgia)  follows  soon  after  eating ;  in  these  cases  the 
relief  from  pain  is  sometimes  more  prompt  and  complete  than  when 
chloroform,  morphine,  and  other  anodynes  are  employed,  but  with- 
out the  disagreeable  after  effects  of  such  medicines.  I  was  greatly 
surprised  at  the  anodyne  effects  of  Bovinine  on  the  stomach  when  I 
first  noticed  it ;  but  the  explanation  of  this  action  would  seem  to  be 
that  the  Bovinine  contains  the  elements  that  the  stomach,  in  its  mo- 
ments of  distress,  needs. 

Yours  very  respectfully, 

ED.  P.  VOLLUM, 
Lt. -Colonel  and  Surgeon  U.  S.  Army, 
Medical  Director. 


The  number  of  remedies  whose  unpleasant  taste  can  be  effectu- 
ally concealed  when  combined  with  Maltine,  seems  limitless.  The 
Maltine  Co.,  of  182  Fulton  Street,  New  York,  advertise  a  number 
of  excellent  combinations  with  Maltine.  Of  these,  perhaps  the 
most  important  of  all,  is  the  combination  of  Maltine  with  cod-liver 
oil.     Although  this  preparation  contains  about  fifty  per  cent,  of  pure 


!4  I  READING  NOTICES. 

oil.  the  Maltine  thoroughly  disguises  it,  so  that  it  cannot  be  detected 
either  by  taste  or  by  smell.  This  renders  it  of  inestimable  value  for 
children  and  for  adults  whose  delicate  sensibilities  prevents  them 
from  taking  the  ordinary  preparation. 


Notice  of  Awards. — The  American  Institute  has  awarded  the 
Medal  of  Superiority  to  the  Jerome  Kidder  Manufacturing  Company, 
No.  820  Broadway,  New  York,  for  their  1887  exhibit  of  '"Electro- 
Medical  Apparatus  and  Appliances  and  Instruments."'  For  fifteen 
years  the  Jerome  Kidder  Machines  have  received  the  highest  awards 
from  the  American  Institute  over  all  competitors  and  wherever  ex- 
hibited in  competition. 

Their  large,  elaborately  finished  Cabinet  Battery,  unique  in  de- 
sign, attracted  much  attention. 

The  materials  and  workmanship  of  their  batteries  are  not  to  be 
excelled,  and  the  experience  of  physicians  is  decidedly  in  their 
favor.  The  "Tip  Battery,'"  a  specialty  of  the  firm,  is  so  constructed 
that  it  can  be  instantly  thrown  into  or  out  of  action,  and  there  is  no 
trouble  from  the  handling  of  the  elements,  or  the  dipping  and  incon- 
venience incident  to  the  ordinary  Faradic  apparatus. 


Among  the  new  remedies  that  have  met  with  marked  success  in 
the  last  two  years,  Salol  stands  pre-eminently  in  the  lead.  Its  action 
has  been  found  to  be  speedy  and  free  from  the  objectionable  effects 
of  the  salicylic  salts.  W.  H.  Schieffelin  &  Co. ,  the  agents  for  this 
drug  in  America,  have  recently  issued  a  treatise  on  Salol  which  can- 
not fail  to  interest  the  physicians  who  desire  to  keep  pace  with  the 
progress  of  the  day.  The  treatise  embraces  new  and  important  ex- 
periences of  eminent  practitioners  on  the  use  of  Salol.  This  treatise 
will  be  sent  to  any  physician  who  sends  his  name  and  address  to 
W.  H.  Schieffelin  &  Co. 


IMPERIAL    COLLEGE    OF    AGRICULTURE, 

Sapporo,   Japan,  March  9th,   1887. 
Messrs.   Reed  &  C'arnrick. 

Gentlemen  : — Will  you  kindly  send  me,  as  soon  as  possible,  by 
express  via  San  Francisco,  One  5  lb.  Tin  of  "Carnricks  Soluble 
Food."  Forward  to  the  care  of  Lohmann  &  Co.,  Yokohama,  Japan. 
Perhaps  a  word  of  explanation  for  this  order  from  far  away  Japan 
may  not  be  without  interest  to  you.  My  baby  boy  is  now  two 
months  old  and  extremely  >trong  and  healthy,  and  is  gaining  in 
weight  steadily  at  the  rate  of  half  a  pound  per  week.  Three  weeks 
ago,  however,  he  weighed  half  a  pound  less  than  at  birth. 


READING  NOTICES.  j  .  r 

Forty-eight  hours  after  birth,  having  received  no  nourishment 
he  was  allowed  a  few  drops  of  cow's  milk  and  all  the  tepid  water 
he  desired.  But  the  milk  did  not  agree  with  him,  producing  the 
only  symptoms  of  colic  he  has  ever  shown.  On  the  third  day, 
there  still  being  no  milk  from  the  natural  source,  he  was  given  two 
meals  of  "Carnrick's  Soluble  Food,"  from  a  :rial  package  in  my 
possession. 

This  nourishment  agreed  with  him  perfectly,  but  was  discon- 
tinued on  arrival  of  the  mother's  milk. 

When  he  was  about  four  weeks  old,  he  showed  signs  of  serious 
indigestion,  passing  material  from  the  bowels  closely  resembling 
hard  curds,  and  which  analysis  proved  to  be  almost  wholly  un- 
changed casein.  The  most  natural  course  was  to  attempt  to  remedy 
the  difficulty  by  changing  the  diet  of  the  mother,  but,  after  two 
weeks  of  unsuccessful  experiment,  recourse  was  again  had  to  the 
"Carnrick's  Food,"  followed  by  immediate  disappearance  of  all 
digestive  trouble.  However,  with  a  supply  of  only  four  ounces  of 
the  remedy  within  8,000  miles,  and  with  the  mother  burdened  with 
milk,  some  other  means,  as  a  permanent  course,  had  to  be  adopted. 
The  analysis  of  the  mother's  milk  furnished  the  clue  to  the  proper 
course. 

The  nutritive  ratio  (relation  of  albuminoid  to  carbo-hydrate 
constituents)  was  found  to  be  too  low  ;  the  amount  of  fat  and  milk 
sugar  present  was  not  sufficient  to  enable  the  infant  to  digest  the 
excess  of  nitrogenous  food  furnished.  By  supplying  this  deficiency 
by  feeding  soluble  carbo-hydrates,  the  proper  nutritive  ratio  was 
restored  ;  and  the  mother's  milk,  thus  supplemented,  is  to-day  accom- 
plishing all  that  could  be  desired,  and  all  that  was  gained  by  the 
use  of  the  "Carnrick's  Food"  alone. 

With  this  experience  to  judge  from,  I  am  convinced  that  the 
"Carnrick's  Food"  is  as  perfect  and  efficacious  in  practice  as  its 
composition  is  correct  in  theory.  It  appears  to  me  to  be  com- 
pounded on  thoroughly  scientific  principles,  and  in  this  respect 
differs  from  most  of  the  other  articles  placed  on  the  market  for  sim- 
ilar uses. 

Assured  of  the  superiority  of  your  product,  and  feeling  deeply 
grateful  for  the  results  of  its  use  by  my  own  child,  I  deem  it  only 
just  to  communicate  these  facts  to  you,  with  my  sincere  thanks  for 
the  benefits  derived  from  "Carnrick's  Soluble  Food." 
Believe  me,  very  truly  yours, 

H.  E.  STOCKBRIDGE,  Ph.  D., 

Prof,  of  Chemistry  and  Consulting  Chemist  to  the  Imperial  Japanese 
Government. 


PERISCOPE. 

By  Drs.  G.  W.  TACOBY,  N.  E.  BRILL,  and  LOUISE  FISKE-BRYSON. 


ANATOMY  OF  THE  NERVOUS  SYSTEM. 

Contribution  to  the  Study  of  Cerebral  Localisa- 
tion. By  Prof.  E.  Leyden.  Deutsche  Medicinische  Woch- 
enschrifty  Nov.  24,  1887. 

The  author  after  giving  an  historical  sketch  of  the  discov- 
eries of  Hitzig  and  Fritsch,  of  the  observations  of  Goll  and 
Spurzheim,  of  the  fundamental  observations  of  Broca  on 
the  subject  of  speech  localisation  (aphasia),  calls  atten- 
tion to  the  work  of  Munk,  Goetz,  Exner,  and  others. 

He  formulates  all  the  clinical  experiences  on  the  subject 
of  cortical  localisation  into  three  groups. 

1.  The  first  group  he  calls  the  aphasic  disturbances. 

2.  The  second  group  represents  the  localisation  of  sen- 
sory functions,  principally  of  sight. 

The  most  frequent  visual  disturbance  accompanying  cen- 
tral cortical  disease  is  homonymous  bilateral  hemianopsia. 
Total  blindness  results  if  the  lesion  involve  both  occipital 
lobes.  In  addition  to  hemianopsia,  there  is  also  described 
a  peculiar  visual  disturbance  which  has  been  called  "  soul- 
blindness  "  (seelenblindheit).  The  patient  may  be  able  to 
receive  a  sensory  impression  on  the  affected  retinal  field,  but 
is  unable  to  form  a  perception  therefrom  ;  "  he  sees,  but  he 
does  not  perceive."  The  lesion  is  considered  by  Nothnagel 
to  overlie  that  which  produces  hemianopsia. 

3.  The  third  group  comprises  the  motor  cortical  centres 
about  the  central  gyri. 

Under  this  head  the  author  calls  attention  to  the  subject 


ANATOMY  OF  THE  NERVOUS  SYSTEM.  j^y 

of  cortical  epilepsy,  and  reviews  Hitzig's  experiments  and 
Jackson's  observations. 

There  is  nothing  new  in  the  entire  article,  which  seems 
to  have  been  written  for  the  purpose  of  presenting  some 
of  the  author's  cases  which  fell  under  the  second  and  third 
groups.  N.  E.  B. 

An  Indian's  Brain. — The  College  of  Physicians  of  Vi- 
enna were  greatly  interested,  at  a  recent  session,  by  the  ex- 
amination of  the  brain  of  an  Indian.  They  found  the  cere- 
brum inferior  to  the  cerebellum  in  development,  and  in  the 
former  a  tendency  to  the  formation  of  a  convolution  in  the 
frontal  lobe,  which  is  characteristic  of  the  horse  and  the  ox. 
—{Medical* News.)  L.  F.  B. 

Heteropy  of  the  Gray  Substance  of  the  Spinal 
Cord. — Kronthal,  Centralblatt  f.  Nervenheilkunde,  Jan. 
15th,  1888. 

A  plumber,  22  years  of  age,  who  had  often  been  treated 
for  lead-poisoning,  and  who  died  with  cerebral  symptoms 
(hallucinations),  had  a  diseased  nervous  apparatus  which 
showed  the  following : 

Muscles  normal,  the  only  deviation  being  an  increase  in 
the  nuclei.  Radial  nerve  showed  degeneration  and  disso- 
lution of  the  axis  cylinder  and  the  medullary  sheaths;  ulnar 
and  median  nerves  normal.  The  spinal  cord  microscopic- 
ally presented  an  uncommon  appearance.  Two  parts  had 
a  fluid  consistency  ;  above  and  below  these  appeared  a 
swelling  of  the  cord,  which  gave  the  idea  that  two  tumors 
were  present.  The  microscopical  examination  showed  a 
very  peculiar  heteropy  of  the  gray  substance. 

Evidently  there  must  have  been  two  distinct  pathologi- 
cal processes.  The  signs  of  an  old  process  were  the  intense 
vascular  lesions,  increase  of  connective  tissue  ;  of  a  recent 
process,  foci  of  softening.  The  ganglion  cells  were  only  a 
little  more  opaque  than  usual.  At  different  places  the  cord 
presented  abnormal  clefts  and  cracks.  N.  E.  B. 


148 


ANATOMY  OF  THE  NERVOUS  SYSTEM. 


The   Origin  of   Nervous  Symptoms  in  Anatomical 
Alterations  of  the  Sexual  Organs. 

Dr.  Engelhardt  has  availed  himself  of  the  abundant 
material  that  the  Freiburg  University  provides  in  its  gynae- 
cological clinic,  to  prove  that  pathological  alterations  in 
the  female  sexual  organs  as  primary  cause  of  manifold  nerv- 
ous disturbances,  has  frequently  been  greatly  exaggerated. 
He  arranges  his  cases  into  four  groups.  I.  Those  cases  in 
which  no  nervous  symptoms  appear,  not  even  dysmenor- 
rhcea,  notwithstanding  important  pathological  conditions  in 
or  of,  the  sexual  organs.  To  this  class  especially  belong  a 
considerable  number  of  large  tumors.  2.  Those  cases,  by 
no  means  rare,  in  which  the  sexual  organs  ar,e  perfectly 
healthy  and  normal,  but  in  which  marked  signs  of  affec- 
tions of  the  lumbar  portion  of  the  cord  with  or  without 
other  concomitant  nervous  symptoms  are  manifest.  Such 
patients,  without  exception,  have  never  conceived.  In 
forty  per  cent,  the  nervous  symptoms  are  ascribed  to  hered- 
itary predisposition  of  the  gravest  kind.  In  eighty  per  cent, 
the  symptoms  began  in  the  earliest  infancy,  sometimes 
originating  in  nerves  arising  in  the  lumbar  portion  of  the 
cord  or  in  other  nerves.  In  many  of  these  cases  dysmenor- 
rhcea  not  due  to  local  disease  can  be  traced  to  various 
extraneous  nervous  influences,  as  early  and  severe  physical 
labor,  combined  with  inadequate  nourishment,  mental 
strain,  etc. 

3.  This  class  comprises  cases  in  which  besides  symp- 
toms of  affections  of  the  lumbar  cord,  pathological  altera- 
tions of  minor  degree  were  present,  such  as  cervical  catarrh, 
relaxation  of  entire  ligaments,  slight  displacements,  ante- 
flexion with  posterior  perimetritis,  retroversion,  etc.  In  all 
these  cases  the  local  alterations  were  not  the  cause,  and 
could  only  have  aggravated  the  nervous  disorders,  for  the 
patients  had  always  been  delicate  women,  the  majority 
scrofulous  from  infancy. 

4.  To  this  class  belong  those  patients  in  whom  symp- 
toms of  lumbar  cord  affections  were  coexistent  with  serious 
local   disease  of  the   internal   sexual   organs.     But  in  these 


ANATOMY  OF  THE  NERVOUS  SYSTEM.  I*g 

also,  though  not  quite  so  definitely  as  in  the  former  group, 
irritability  and  debility  of  the  nervous  system  could  be 
traced  to  early  infancy. 

These  numerous  investigations  and  direct  observations 
established  a  certainty  of  congenital  predisposition  to  nerv- 
ous troubles.  At  the  first  commencement  of  menstruation, 
dysmenorrhoea  occurred,  and  chlorosis  was  only  exception- 
ally absent.  The  most  frequent  complications  were  relax- 
ation of  the  uterine  ligaments,  softness  and  flabbiness  of  the 
uterus,  catarrh  of  the  several  apparatus,  in  consequence  of 
defective  nutrition.  In  some  cases  psychical  influences,  in 
others  masturbation,  imperfect  coitus,  etc.,  have  been  as- 
signed as  a  cause.  Occasionally  local  affections  of  the 
sexual  system  are  the  direct  cause  of  nervous  troubles,  as 
well  as  other  injurious  influences,  such  as  depraved  nutri- 
trition,  loss  of  blood,  etc.  Diseases  of  the  sexual  organs 
that  last  for  years  may  and  do  lead  to  grave  general  nerv- 
ous disturbances. — London  Medical  Record,  Nov.  15,  1887. 

L.  F.  B. 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

On  the  Conception  of  Hysteria.  (Weber  den  Begriff 
der  Hysteric)  By  P.  J.  Mobius  {Centralblatt  fiir  Ner- 
venheilkunde,  etc.,  February  1,  1888). 

Dr.  Mobius,  in  calling  attention  to  the  various  concep- 
tions of  this  affection  by  medical  men,  takes  exception  to 
the  name  as  misleading,  and  asserts  that  physicians  are 
beginning  to  form  a  more  unanimous  idea  of  the  character 
of  this  affection. 

The  first  step  towards  this  is  in  the  recognition  of  the 
fact  that  this  disease  is  a  psychosis,  or  rather  that  the  es- 
sential, the  primary  change  is  a  morbid  condition  of  the 
psyche.  But  inasmuch  as  some  cases  occur  (especially  in 
males)  in  which  no  demonstrable  disturbance  of  the 
psychical  functions  is  present,  the  essential  characteristic 
may  be  found  in  the  somatic  symptoms.  He  says  :  "All 
those  changes  of  the  body  are  hysterical   which  are  pro- 


,  -0  PHYSIOLOGY  OF  THE  NERVOUS  SYSTEAf. 

duced  by  the  imagination."  He  adds  that  every  child  knows 
that  the  imagination  may  cause  bodily  changes,  and  gives 
as  examples,  crying,  laughing,  blushing,  the  secretion  of 
saliva,  vomiting  from  disgust,  sweating  from  dread,  collapse 
from  fear,  paralysis  of  movement  from  fright,  etc.,  etc.  The 
hysterical  state  consists  equally  in  the  fact  that  just  as  these 
changes  may  be  produced  to  a  greater  or  less  degree  by 
this  cause,  so  may  the  fancy  call  forth  somatic  disturbances, 
which  are  not  noticed  in  the  healthy,  e.  g.,  hemianesthesia. 
In  many  cases  the  form  of  the  somatic  disturbance  has  no 
direct  relation  to  the  causative  fancy.  But  the  character  of 
the  latter  may  determine  the  former  to  that  extent  that  the 
attention  may  be  directed  to  definite  regions  of  the  body. 
Thus  a  slight  injury  to  the  shoulder  may  be  the  occasion  of 
awakening  a  severe  injury  to  the  arm — an  hysterical  paraly- 
sis of  the  arm  may  be  the  result.  Most  probably  such  a 
relationship  is  of  more  frequent  occurrence  than  would  appear 
on  first  thought." 

Experience  teaches  that  hysterical  phenomena  are  often 
produced  and  as  often  destroyed  by  conceptions,  and  es- 
pecially by  those  emotional  phases  connected  with  such 
conceptions.  The  experience  gained  from  hypnotism  in 
general,  and  especially  the  results  of  the  phenomena  of 
suggestion  by  means  of  which  nearly  all  hysterical  symp- 
toms may  be  called  forth  at  pleasure  are  on  that  account  of 
much  scientific  value,  because  they  throw  light  upon  the 
existence  of  hysteria. 

He  continues  to  state  that  one  might  think  that  the  defi- 
nition of  hysteria  did  not  sufficiently  limit  it  in  reference  to 
the  phenomena  of  a  healthy  individual.  But  such  a  limit  is 
not  necessary.  Hysteria  is  indeed  the  diseased  increase  of 
a  condition  which  is  present  in  everybody.  "Everybody  is, 
so  to  speak,  a  little  hysterical." 

Hence,  in  its  practical  aspect,  the  only  therapeutics 
which  can  be  applied  for  its  alleviation  must  be  psychical. 

N.  E.  B. 


physiology  of  the  nervous  system.  j  r  t 

Upon  a  Peculiar  Deformity  of  the  Body,  Caused 
BY  SCIATICA. — J.  Babinsky,  Archives  de  Neurologic, 
p.  I,  1888. 

In  this  article  five  cases  are  published,  with  illustrations, 
which  prove  that  in  certain  cases  of  sciatica  a  peculiar  de- 
formity of  the  body  occurs,  which  until  now  seems  to  have 
escaped  observation.  It  is  not  simply  a  coincidence,  but 
an  actual  relationship  of  cause  and  effect.  The  position  of 
these  patients  is  striking,  and  differs  decidedly  from  the 
deformities  caused  by  other  affections  (coxalgia),  and  there- 
fore may  even  serve  as  a  diagnostic  point. 

Case  I. — Male,  aet.  37  ;  since  two  years  left  sciatica.  A 
year  ago  commencement  of  the  deformity.  No  affection  of 
the  hip-joint.  When  standing,  the  following  position  is 
taken.  The  body  is  inclined  to  the  right,  the  side  opposite 
to  the  affected  limb,  so  that  the  weight  of  the  body  is  sup- 
ported almost  entirely  by  the  sound  leg ;  in  addition  to  the 
lateral  inclination,  a  slight  flexion  of  the  body  forward  and 
a  certain  degree  of  rotation  of  the  body  upon  its  vertical 
axis  are  observed,  so  that  the  right  shoulder  is  thrown  for- 
ward and  the  left  backward.  The  spinal  column  presents 
two  curvatures,  the  one  in  the  lumbar  region,  with  its  con- 
cavity to  the  right ;  the  other  in  the  dorsal  and  its  concav- 
ity to  the  left.  The  right  leg  is  slightly  flexed  upon  the 
thigh.  This  deformity  persists  in  the  horizontal  position, 
and  all  attempts  to  rectify  it  cause  great  pain.  The  author 
considers  the  possibility  of  a  coxitis,  but  after  mature  rea- 
soning discards  it.  The  other  cases  present  variations 
dependent  upon  the  location  of  the  sciatica,  whether  right 
or  left.  The  mode  of  production  is  analysed.  To  the  ques- 
tion whether  the  deformity  may  disappear  entirely,  the 
author  answers  affirmatively.  G.  W.  J. 

Paramyolonus  Multiplex  and  Spasmophilia.  (JNeber 
Myoclonic  Convulsibilitat),  by  Prof.  Seeligmuller, 
Deutsche  Medicinische  Woe  hens  chrift,  Dec.  29,  1887. 

The  author  adds  two  more  cases  to  the  relatively  rapid 
increasing  histories  of  this  affection,   making  in  all  three 


j52  physiology  of  the  nervous  system. 

which  have  come  under   his  observation.     The  history  of 
the  first  of  the  latter  case  is  briefly  as  follows  : 

Carl  Kohler,  aet.  41,  laborer,  dates  his  present  trouble 
from  a  fall  on  the  left  side  in  June.  1887.  In  addition  to 
symptoms  of  pain,  anaesthetic  zones,  paresthesias,  etc. 
which  must  be  ascribed  to  the  effects  of  the  fall,  other 
symptoms  made  their  appearance.  Some  time  after  the  fall 
movements  in  the  neighborhood  of  the  thumb,  involving  in 
succession  the  muscles  of  the  forearm,  and  the  shoulder  of 
the  right  upper  extremity  and  to  a  lesser  degree  those  of 
the  left  arm.  These  spasms  increased  in  intensity  until  they 
reached  the  present  stage.  A  few  days  later  (October)  dur- 
ing the  night  severe  convulsions  of  the  entire  body  and  con- 
vulsive pains  in  the  left  thigh  and  calf  supervened,  and  did 
not  recur.  During  these  spasms  the  arm  movements  are 
said  to  have  ceased. 

The  spasms  continue  without  special  pauses  during  the 
day  and  night,  only  when  the  patient  after  much  fatigue  and 
exhaustion  gets  to  bed  and  falls  asleep  do  his  limbs  involun- 
rily  extend  themselves.  He  is  often  awakened  by  severe 
starts,  and  has  very  little  rest.  It  is  stated  that  it  is 
during  quiet  repose  that  the  movements  are  most  severe, 
although  the  author  was  unable  to  obtain  the  increase  on 
having  the  patient  lie  down. 

His  previous  history  discloses  that  he  had  similar  attacks 
but  of  short  duration  in  1870  and  1877,  occurring  after  an 
over-indulgence  in  beer  and  sleeping  in  the  open  air. 

The  history  is  minutely  given  and  expresses  every  detail 
concerning  the  character  of  the  movements. 

The  author  takes  exception  to  the  view  of  the  French 
writers  who  regard  this  affection  as  a  general  convulsive  tic, 
even  though  in  his  first  case  the  facial  region  was  involved. 
In  his  other  cases  no  part  of  the  face  was  affected.  In  con- 
vulsive tic,  which  differs  according  to  Marie-Guinon's  obser- 
vations from  ordinary  tic,  psychic  phenomena  are  present 
and  assume  a  prominent  clinical  feature,  whereas  in  Seelig- 
muller's  cases  such  were  absent.  The  author  considers  the 
disorder  due  to  an  enormously  increased  irritability  of  the 
large  ganglion  cells  of  the  grey  anterior  cornua  of  the  spi- 
nal cord.  N     E     ft 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

Galvanism  in  the  Treatment  of  Insanity. — In  the 
Journal  of  Mental  Science,  Dr.  Joseph  Wigglesworth  has  an 
article  on  the  use  of  galvanism  in  certain  forms  of  insanity.' 
These  are  his  conclusions  : 

i.  That  while  the  use  of  galvanism  to  the  head  is  a  pro- 
ceeding which  is  certainly  not  going  to  revolutionize  the 
treatment  of  insanity,  this  agent  is,  nevertheless,  one  that  is 
capable  of  doing  much  good  in  certain  selected  cases,  and 
that  by  its  judicious  employment  we  may  every  now  and 
then  cure  cases  which  would  drift  into  hopeless  chronicity. 

2.  The  class  of  cases  which  offer  the  best  field  for  the  em- 
ployment of  this  agent  is  that  which  includes  examples  of 
mental  stupor  and  torpor — cases  which  are  grouped  under 
the  specific  designations  of  melancholia  attonita  and  so- 
called  acute  dementia.  L.  F.  B. 

Tasteless  Preparations  of  Cascara  Sagrada 
(RHAMNUS  PURSHIANA.) — Recent  investigation  of  the  con- 
stituents of  Cascara  sagrada  has  led  to  the  discovery  of  new 
principles  and  facts  of  great  importance  pharmaceutically 
and  therapeutically. 

The  chief  objection  to  Cascara  sagrada  heretofore  has 
been  its  inherent  bitterness.  In  the  light  of  recent  re- 
searches, tasteless  preparations  of  this  drug  highly  effica- 
cious medicinally  are  now  to  be  had. 

These  discoveries  mark  a  distinct  advance  in  pharma- 
ceutical attainment  and  in  the  therapeutics  of  chronic  con- 
stipation, since  this  remedy  can  now  be  much  more  gener- 
ally and  persistently  administered,  and  its  well-known  tonic 
laxative  action  obtained  without  the  drawbacks  which 
seemed  formerly  inseparable  from  its  employment. 

The  facts  disclosed  concerning  this  remedy  deserve  more 
than  a  passing  notice,  especially  since  they  indicate  the  ex- 
istence of  principles  and  modes  of  action  extending  far 
beyond  the  subject  indicated,  and  are  well  worth  the  close 
attention  of  the  thoughtful  and  scientific  physician.  A  val- 
uable contribution  to  the  knowledge  of  the  chemical  con- 


jr  *  THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

stitution  of  this  drug  appeared  in  the  American  Journal  of 
Pharmacy,  for  February,  1888,  which  makes  it  possible  not 
only  to  obtain  a  true  interpretation  of  the  various  clinical 
observations,  but  clears  up  apparent  anomalies. and  also  in- 
dicates the  reasons  for  observed  effects,  which  have  lately 
been  disputed,  but  now  admit  of  no  further  question  or  mis- 
understanding. 

Among  the  discoveries  referred  to  in  this  valuable  paper, 
of  especial  interest  to  the  physician,  is  the  influence  of  a 
class  of  vegetable  ferments  and  their  recognition  as  the 
causes  of  various  abnormal  conditions,  such  as  colic,  vom- 
iting, nausea,  diarrhoea  and  dysentery,  which  occasionally 
attend  the  administration  of  certain  drugs. 

It  appears  that  Frangula  bark  when  fresh,  contains  such 
a  ferment  in  excessive  quantities  and  is,  therefore,  unfit  for 
use  until  the  ferment  has  exhausted  itself — the  process  usu- 
ally occupying  several  years.  It  also  appears  that  Cascara 
contains  some  of  this  principle  and  this  fact  will  account 
for  the  occasional  untoward  effects  of  the  drug,  which  have 
been  observed  as  consequent  on  the  employment  of  a  num- 
ber of  its  preparations  heretofore  in  the  market.  These 
facts  are,  therefore,  not  due,  as  has  been  supposed,  to  any 
idiosyncrasy  on  the  part  of  the  patient,  or  to  the  laxative 
or  tonic  constituents  of  the  bark  itself,  but  to  a  distinct  ob- 
jectionable principle,  which  once  recognized  can  be  ren- 
dered inoperative  and  harmless. — Am.  Journal  Pharmacy, 
Feb.,  1888. 

Pseudo-Angina  Pectoris. — Prof.  Roberts  Bartholow 
lectured  upon  this  subject  recently  at  the  Jefferson  Medical 
College  Hospital,  Philadelphia.  The  patient,  not  yet  thirty, 
of  well-marked  neurotic  constitution,  without  history  of 
rheumatism,  syphilis,  or  diphtheria,  presented  but  one  ab- 
normal condition — paroxysms  of  sudden  pain  in  or  about 
the  pra;cordial  region,  shooting  in  all  directions  over  the 
chest,  especially  into  the  left  neck  and  shoulder,  sometimes 
downward  into  the  left  arm.  Respiration  is  gasping  and 
shallow,  cyanosis,  an  agonized  expression,  some  protrusion 
of  the   eyes,  and    a    cold,   clammy   sweat    quickly    appear. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM.  ,  rr 

First  there  is  inhibition  of  the  heart's  movements,  then  the 
action  becomes  rapid  and  feeble,  and  irregular  in  rhythm  ;  a 
deadly  faintness  supervenes,  and  loss  of  consciousness  for 
an  instant.  Of  late  there  have  been  muscular  twitchings, 
complete  unconsciousness,  and  the  seizures  are  preceded  by 
uneasy  sensations.  These  warnings  come  from  the  organs 
connected  with  the  solar  plexus.  May  they  be  called  an 
aura  ?  Trousseau  describes  such  cases  as  "  marked  epi- 
iepsy."  In  treatment  it  is  important  to  recognize  the  true 
nature  of  these  attacks.  The  best  results  are  had  from 
combining  remedies  addressed  to  the  true  seat  of  the  mal- 
ady and  to  the  organs  suffering  the  most  severe  functional 
disturbances.  Thirty  grains  of  bromide  of  sodium  three 
times  a  day,  and  a  one  per  cent,  solution  of  nitro-glycerine, 
dose  increasing  from  one  minim  until  the  characteristic 
action  of  the  drug  is  manifested,  are  the  remedies  Dr.  Bar- 
tholow  ordered,  and  strict  attention  to  diet  as  well,  a  small 
amount  of  fresh  meat  once  a  day,  one  egg  at  breakfast,  one 
vegetable  at  dinner,  some  fresh  fruit  at  supper,  and  the  only 
drink  a  moderate  cup  of  warm  skimmed  milk. — Medical 
News,  Dec.  ioth,  1887.  L.  F.  B. 

Electricity  and  Neurotherapy  in  the  Treatment 
of  Cancer. 

In  a  letter  to  the  editor  of  the  Medical  Register,  Dr.  C. 
H.  Hughes,  of  St.  Louis,  says  : 

"Were  the  Crown  Prince  my  patient,  I  would  give  him 
bromide  of  ammonium,  muriate  of  ammonium,  the  hypo- 
phosphite  and  arsenic,  and  local  and  general  static  electri- 
zation ;  and  I  would  use  the  static  current,  the  direct  static 
current,  to  the  part,  powerful  enough  to  arrest  the  morbid 
cell  activity,  and  remove  the  growth  by  electro-cautery,  if 
it  did  not  disappear.  Cancer  is  a  neurotrophic  disease,  and 
the  cancerous  diathesis  is  neuropathic." 

So  far  as  we  know,  Dr.  Hughes  is  the  first  and  only 
physician  who  has  ever  proposed  to  treat  cancer  with  elec- 
tricity and  a  scientific  neurotherapy.  Views  similar  to 
those  just  enunciated  as  regards  the  origin  and  cause  of  the 


j  r  5  THE  K  A  J  'E  I '  Tli  'S  OF  THE  A  E K I  'O I  S  S )  'S  TEA/. 

disease,  were  uttered  in  the  St.  Louis  Medical  Society  ten 
years  ago  ;  but  to  Dr.  Hughes  belongs  the  credit  of  having 
first  suggested  the  electric  treatment. 

Elsewhere  he  says : 

"Inquiry  and  observation  show  the  frequent  inter- 
changeability  of  cancer  with  grave  diseases  of  the  nervous 
system  in  families  in  which  the  neuropathic  diathesis  pre- 
vails. It  is  no  uncommon  history  for  one  branch  or  one 
member  of  a  family  to  show  insanity,  epilepsy,  or  organic 
paralysis,  and  another  to  reveal  the  neuropathic  taint  in 
cancer.  It  belongs  to  a  period  of  life  at  which  the  tonicity 
of  the  nervo  js  system  is  on  the  wane  in  many  organisms  ; 
when  the  trcphic,  nutritive  and  assimilative  functions  are 
more  liable  to  depression  than  in  more  vigorous  periods. 
It  is  often  quite  rapidly  developed  after  sudden  and  pro- 
found shocks  to  the  nervous  system.  Its  well-known  me- 
tastatic peculiarities,  especially  after  excision,  are  like 
those  in  certain  well-known  nerve  diathesis  with  devel- 
oped local  disease.  Lastly,  the  only  real  benefit  derivable 
from  treatment  aside  from  palliating  escharotic,  and  cleans- 
ing local  measures,  comes  from  plans  of  treatment  addressed 
to  the  restoration  of  general  nerve  tonicity  and  consequent 
resisting  power. 

"Even  where  excision  has  been  resorted  to,  the  after- 
care and  treatment  reveals  the  fact  that  successful  results 
have  been  due  to  this  rather  than  to  the  knife,  whose 
triumph  has  been  chiefly  due  to  the  removal  of  the  local 
strain  and  waste,  without  the  prolonged  irritation  of  the 
painful  caustic  processes  and  the  neuropsychical  rebound 
following  the  local  relief,  the  hope  revived,  and  the  suc- 
cessful neurotherapy  instituted. 

"Cancer  is  probably  as  amenable  to  treatment  as  any 
other  diathetic  condition,  if  we  recognize  it  as  such  .  .  . 
but  the  hope  of  conquering  it,  lies  in  recognizing  its  nero- 
pathic  relations,  and  in  an  early,  persistent,  vigorous,  and 
confident  effort  to  improve  them.  The  law  of  resistance  to 
cancerous  invasion  is  in  the  conservation  of  energy." 

L.  F.  B. 


VOL.  XIII.  March,  1888.  No.  3. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


©rigtoal  gtrtirteis. 


PARANOIA— SYSTEMATIZED     DELUSIONS     AND 
MENTAL    DEGENERATIONS: 

AN   HISTORICAL   AND    CRITICAL    REVIEW. 
By  J.  SfiGLAS, 

ASSISTANT    PHYSICIAN    OF    THE    HOSPITAL    OF    BICETRE,  PARIS. 

Translated  by  William   Noyes,  M.D., 

ASSISTANT    PHYSICIAN    OF    THE    BLOOMINGDALE    ASYLUM,    NEW    YORK. 

FOR  several  years  frequent  descriptions  have  been  given 
in  the  foreign  journals,  especially  German  and  Italian, 
of  the  forms  of  insanity  designated  by  the  names 
Paranoia,  Verriicktheit,  and  Wahnsinn.  Although  all  these 
forms  have  been  studied  in  France,  the  question  has  not 
been  viewed  from  the  same  point ;  then,  too,  there  have 
been  difficulties  in  the  way  of  fixing  the  value  of  certain  par- 
ticular terms  and  the  place  the  facts  they  serve  to  describe 
should  hold  in  psychiatry.  On  the  other  hand,  the  study  of 
mental  degenerations  being  everywhere  the  order  of  the  day, 
and  these  having  a  direct  connection  with  the  question  of 
paranoia,  it  seems  as  if  a  review  of  the  principal  works  pub- 
lished up  to  this  time  upon  this  subject  would  not  be  out  of 
season,  and  possibly  would  be  of  some  service. 

I. — To  give  at  once  a  definition  of  paranoia  would  be 
difficult,  not  to  say  impossible.  In  fact,  it  is  perhaps  the  one 
word  in  psychiatry  that  has  the  most  extensive,  but  most  ill- 
defined  acceptance.  Moreover,  the  term  by  itself  does  not 
have  a  very  precise  definition,  as  may  be   seen  from  its  ety- 


I5g  /.    SEGLAS. 

mology  (irapa,  near  to,  at  the  side,  near,  across  ;  and  voea>, 
to  think,  to  be  wise).  Different  authors,  too,  interpreting  it 
some  in  one  way,  some  in  another,  give  it  the  meaning  of 
deviation  of  intelligence  or  of  incomplete  intelligence.  This 
ambiguity  will  be  to  others  an  evidence  in  favor  of  the  ex- 
cellence of  the  term,  indicating,  on  the  whole,  a  qualitative 
and  quantitative  alteration  of  intelligence.  Let  us  simply 
say,  for  the  moment,  that  we  find  the  term  paranoia  em- 
ployed by  authors  synonymously  with  the  German  words 
Verriicktheit  and  Walinsinn  ;  the  first,  however,  approaching 
more  to  the  meaning  of  paranoia  in  the  sense  that  we  have 
given  it  (systematized  delusion  grafted  on  an  incompletely 
developed  intelligence),  while  the  word  wahnsinn  simply 
designates  the  qualitative  alteration  of  the  mind.  This  will 
be  made  clear  in  the  exposition  that  follows  ;  in  the  mean- 
while, let  us  simply  say  that  the  terms  may  be  rendered  by 
the  expression  systematized  insanity  or  systematized  delu- 
sion, which  includes  all  the  forms  of  paranoia  described  by 
the  authors.  A  feeble  mental  constitution  may  accompany 
the  delusion  or  not,  and  there  may  or  may  not  have  been  a 
previous  psycho-neurotic  state  (mania  or  melancholia). 

II. — The  term  paranoia  has  been  employed  in  psychiatry 
for  many  years.  In  fact,  if  we  may  credit  Bucknill  and 
Tuke,  Vogel  used  the  word  in  1764,  and  under  the  name 
paranoia  included  nine  classes  of  neuropathies,  among  them 
mania.  This  is  as  far  removed  as  possible  from  the  modern 
conception  of  paranoia. 

In  1 8 18  we  find  the  term  paranoia  again  employed  by 
Hcinroth,*  but  he  had  only  a  vague  and  indefinite  idea  of  it. 
Nevertheless,  under  the  name  of  extasis  paranoica,  he  has 
described  certain  secondary  states  of  mental  exaltation  with 
fixed  delusional  conceptions  and  an  exaggerated  sentiment 
of  personality. 

We  again  find  these  ideas  in  Esquirol.t  who  describes  the 
intellectual  monomanias,  and  reports  several  observations  in 
which  he  insists  especially  upon  the  ideas  of  grandeur. 

•  Heinroth,  Lehrbuch  der  Storungen  dcs  Scelenlebens,  1818. 
\  Esquirol,  Des  maladies  mentales,  t.  ii.,  1838. 


PARANOIA.  j  eg 

In  Germany,  Griesinger*  (1845)  describes  systematized 
insanity  (Die  Verriicktheit,  p.  382),  and  considers  it  as  a 
disease  always  secondary  to  melancholia  or  to  mania.  He 
describes,  also,  the  small  number  of  fixed  delusions  which 
the  patient  is  constantly  repeating. 

These  ideas,  which  always  relate  to  the  personality  of  the 
individual  and  to  his  relations  with  the  world,  may  be  active 
and  exalted  (ideas  of  grandeur),  or  passive  (ideas  of  persecu- 
tion). Two  forms  of  systematized  insanity  are  thus  distin- 
guished. 

Finally,  Griesinger  classes  this  form  of  insanity  among 
the  secondary  states  of  intellectual  enfeeblement,  thus  ex- 
plaining the  formation  and  permanence  of  the  delusion.  To- 
gether with  this  secondary  form  we  find  another  form,  wahn- 
sinn  (p.  357),  a  state  of  mental  exaltation  with  fixed  delu- 
sions of  an  ambitious  character.  We  see,  also,  that  this  ex- 
alted monomania  is  completely  confounded  with  the  prodro- 
mal period  of  general  paralysis  and  certain  states  of  mental 
exaltation. 

At  this  same  time  Ellinger  t  admits,  by  the  side  of  this  sec- 
ondary form,  a  form  of  primary  systematized  insanity,  but 
without  describing  it. 

Up  to  this  time,  then,  we  have  nothing  sufficiently  clear  on 
systematized  insanity  ;  and  although  the  idea  has  been  ad- 
vanced, it  has  not  been  described  accurately  and  particularly. 
Lasegue  now  fills  this  gap,  and  we  may  agree  with  Witkowski  \ 
in  saying  that  it  is  he  who  deserves  the  first  place  in  the  de- 
scription of  systematized  insanity  by  his  study  of  the  delusion 
of  persecution  §  (1852).  We  now  find  systematized  insanity 
in  the  works  of  Morel.  In  his  "  Etudes  cliniques  "  j|  (1852)  he 
gives  some  observations  on  the  transformation,  among  the 
hereditarily  insane,  of  hypochondriacal  ideas  into  ideas  of  per- 


*  Griesinger,  Traite  des  maladies  mentales.  Traduction  franchise  de  Doumic, 
1865.  (See,  in  English,  Robertson  and  Rutherford's  translation,  published  by 
the  New  Sydenham  Society,  1867,  p.  303.) 

f  Ellinger,  Allg.  Zeit.  f.  Psych.,  anno  II.,  1845. 

%  Witkowski,  Berliner  klinische  Wochensch.,  1876. 

§  Lasegue,  Arch,  de  med.,  1852. 

I  Morel,  Etudes  cliniques,  1852,  t.  i.,  pp.  163  to  166  and  363  to  367. 


!60  /•    SEGLAS. 

secution  and  afterward  of  grandeur.  In  his  "  Traite  des  mal- 
adies mentales  "  *  (i860)  he  adopts  the  words  "  systematized 
insanity  "  as  a  substitute  for  the  monomania  of  Esquirol  and 
separates  these  states  from  dementia,  the  reverse  of  Grie- 
singer.  His  first  two  classes  of  hereditary  insanity  comprise 
almost  the  entire  outline  of  that  which  has  since  been  de- 
scribed under  the  name  of  primary  systematized  delusions. 
He  describes  the  fixed  ideas,  the  eccentricities,  and  the  oddi- 
ties of  these  hereditary  subjects,  insists  on  the  very  great  fre- 
quency of  systematization  in  these  forms,  upon  the  rapidity  of 
the  appearance  and  disappearance  of  the  delusional  ideas  in 
certain  cases,  and  upon  the  slow  but  continuous  development 
in  others — all  this  developing  on  a  constitution  of  original 
weakness,  or  rather  on  one  of  unstable  mental  equilibrium. 
The  same  author  also  describes  the  fusion  of  the  two  forms, 
the  expansive  and  the  depressive,  in  certain  states  of  system- 
atized delusion,  comparable  to  the  hereditary  states,  the  pas- 
sage of  hypochondria  into  the  delusion  of  persecution  (trans- 
formed hypochondria),  and  from  that  to  the  delusion  of 
grandeur  ;  and  the  incurability  of  this  form  through  an  evo- 
lution that  is  sometimes  remitting  but  continuous,  and  which 
terminates  in  dementia.  In  short,  we  see  that  through  these 
two  masters  French  psychiatry  first  described  primary  sys- 
tematized insanity.  We  may  cite,  again,  in  further  confirma- 
tion of  this,  the  works  of  Lelut  and  of  Voisin  upon  sensorial  in- 
sanity, which  certain  authors  have  since  regarded  as  an  acute 
form  of  paranoia  (Westphal).  Since  that  time  but  small  ad- 
vance has  been  made  in  France  on  this  subject,  at  least  dur- 
ing recent  years  ;  and  if  we  say  that  the  theory  of  paranoia 
had  its  birth  in  France,  we  must  acknowledge  that  it  has  been 
developed  abroad,  and  especially  in  Germany. 

In  1863  Kahlbaum  t  remained  faithful  to  the  doctrine  of 
Griesinger  on  the  secondary  origin  of  systematized  insanity, 
although  admitting  the  possibility  of  a  primary  form. 


Snell.t  in  1865,  is  the  first  to  describe  clearly  a  fundamental 

•  Morel,  Traite  des  maladies  mentales,  i860. 

\  Kahlbaum,  Gruppirung  der  psychischen  Krankheiten,  Dantzig,   1863. 

\  Snell,  Ueber  Monomanie  als  primare  Forme  der  Seelenstorung  (Allg.  Zeit.  f. 

ch.,  1865,  B.  xxii.,  p.  368;. 


PARANOIA.  J6! 

form,  distinct  from  mania  and  from  melancholia,  and  charac- 
terized by  the  primary  appearance  of  a  series  of  particular 
delusional  ideas  of  a  mixed  nature  (persecution  and  grandeur) 
and  accompanied  by  hallucinations  (primary  or  true  wahn- 
sinn).  The  delusions  are  not,  as  in  the  other  forms,  an  echo 
of  the  whole  mental  life,  a  tendency  to  generalization.  The 
most  striking  symptom  is  a  delusion  of  persecution,  with  an 
exaggeration  of  the  sentiment  of  personality,  and  a  tendency 
to  activity  rather  than  to  passivity,  differing  in  this  from  mel- 
ancholia. There  are  also  delusions  of  grandeur  uniformly 
primary,  contemporary,  or  consecutive  to  the  delusion  of  per- 
secution, and  bringing  about  a  change  in  the  personality. 
The  development  of  these  forms  of  insanity  is  slow,  but  some- 
times they  develop  quickly  on  account  of  the  mental  excite- 
ment. The  prognosis  is  bad,  yet  in  these  cases  a  true  con- 
secutive dementia  is  never  observed. 

In  1867  Griesinger,*  retracting  the  opinion  that  he  had 
formerly  professed,  admitted,  with  Snell,  the  primary  origin 
of  the  mixed  states  (delusions  of  persecution  and  of  gran- 
deur), and  he  described  them  under  the  name  of  primare  ver- 
rucktheit.  He  described,  in  addition,  the  hypochondriacal 
and  erotic  forms. 

Sander, t  pursuing  the  subject  still  further,  studied  in 
1868  a  special  form  of  primare  verriicktheit  which  he  called 
originare.  He  showed  the  degenerative  characters  common 
also  to  the  other  primary  forms,  and  the  distinctive  feature 
consisting  in  the  congenital  origin.  The  patients  are  born 
with  hereditary  predispositions  which  they  manifest  from  in- 
fancy (anomalies  of  intelligence,  of  character,  of  sentiments, 
and  of  physical  conformation). 

Arrived  at  the  period  of  puberty  they  follow  two  routes  : 
Some,  too  poorly  equipped,  fall  in  the  struggle  for  existence  ; 
they  are  seized  with  hallucinations  and  delusions,  and  rapidly 
fall  into  dementia.  The  others  resist  for  a  long  time,  and 
live  in  society,  where  they  are  conspicuous  by  their  oddities 

*  Griesinger,  Vortrag  zum  Eroffnung  der  psychiatrischen  Klinik  zu  Berlin, 
Mai  2,  1867  (Arch.  f.  Psych.,  B.  i.,  S.  148,  1867). 

t  Sander,  Ueber  eine  specielle  Form  der  primaren  Verriicktheit  (Arch.  f. 
Psych.,  1S68-1869,  B.  i.,  S.  387). 


j  5  2  /.   S  EG  LAS. 

and  eccentricities.  They  are  emotional,  mistrustful,  misan- 
thropic, and  often  onanists.  In  these  cases  illusions  and  hal- 
lucinations develop  unexpectedly.  The  morbid  subjectivity 
to  which  these  subjects  are  the  prey,  connecting  everything 
with  themselves,  increases  ;  it  is  the  same  with  the  other 
parts  of  their  character,  which  appear  to  hypertrophy,  and 
then  they  develop  systematized  ideas  of  persecution,  of  poi- 
soning, etc.,  varying  in  color  according  to  the  education  of 
the  patient  and  the  surroundings  of  his  life.  Along  with  this 
slow  and  gradual  development  Sander  also  notes  the  fre- 
quency of  remissions  and  the  slight  tendency  to  dementia. 
As  regards  the  etiology  of  these  idiopathic  {originare)  delu- 
sions, we  must  look  for  it  most  frequently  in  heredity  and  in 
the  nervous  and  cerebral  diseases  of  childhood,  arresting  the 
normal  development  of  the  brain.  Pederasty  and  sexual  per- 
versions would  be  characteristic  of  the  originare  form  of  sys- 
tematized insanity. 

In  1873  Snell  described,  under  the  name  of  systematized 
insanity  (  Wahnsinri)  consecutive  to  melancholia,  to  mania, 
or  to  epilepsy,  a  secondary  or  improper  systematized  insan- 
ity, since  adopted  by  Hertz,*  Ripping,  and  Nasse. 

Samt,+  in  1874,  described  the  hallucinatory  variety  of  the 
originare  form  of  Sander,  dividing  it  into  two  subvarieties. 
The  first,  depressive  hallucinatory,  often  breaks  out  after  a 
very  long  period  of  incubation  at  the  menopause  in  women. 
Here  the  hallucinations  of  hearing  are  of  principal  impor- 
tance. The  ideas  of  persecution  that  accompany  them  are 
only  a  syndrome  and  are  not  characteristic,  being  found  in 
other  forms  of  insanity.  Samt  considers  that  the  fixed  ideas 
have  the  same  pathological  basis  as  the  hallucinations,  and 
are  not  an  attempt  at  explanation  on  the  part  of  the  patient. 
Hallucinations  of  other  senses  are  found,  but  only  rarely  of 
vision  ;  the  delusion,  in  which  there  are  no  signs  of  intellect- 
ual enfeeblement,  has  a  very  slow  course,  with  exacerbations 
and  remissions ;  it  is  only  exceptionally  that  there  is  delusion 
of  grandeur. 

•  Hertz,  Allg.  Zcitschr.  f.  Psych.,  B.  xxxiv. 

+  Samt,  Die  naturwissenschaftliche  Methode  in  der  Psychiatrie,  Berlin,  1874, 
S.  38,  42. 


PARAAOIA.  x6" 

The  second  subvariety,  exalted  hallucinatory,  is  distin- 
guished by  the  predominance  of  visual  hallucinations,  follow- 
ing generally  a  state  of  excitement.  Auditory  hallucinations 
are  also  observed,  but  are  very  vague.  The  delusion  has  an 
irregular  course  and  is  not  accompanied  by  signs  of  intellect- 
ual enfeeblement.  As  an  example,  we  have  the  religious 
delirium  and  the  true  delusion  of  grandeur. 

Westphal,*  in  1878,  first  described  the  acute  form,  and 
offered  a  classification  of  systematized  insanity  (  Verriicktheit), 
which  he  divided  into  four  groups  :  1.  The  hypochondriacal 
form,  already  described  by  Morel,  having  a  chronic  course 
with  typical  remissions.  The  troubles  of  general  sensibility 
form  the  substratum  of  the  delusion  of  persecution,  accom- 
panied by  illusions  and  hallucinations.  2.  The  chronic  form, 
having  a  slow  beginning  and  a  remitting  course.  The  hallu- 
cinations and  the  delusion  of  persecution  appear  first — some- 
times one,  sometimes  the  other — and  are  not  preceded  by 
an  hypochondriacal  stage.  At  the  end  of  a  certain  time  the 
ideas  of  grandeur  come  into  prominence.  3.  The  acute  form 
is  characterized  by  the  sudden  explosion  cf  hallucinations, 
especially  of  hearing,  accompanied  by  ideas  of  grandeur.  At 
the  height  of  the  disease  the  incoherence  is  such  that  it  sug- 
gests a  febrile  delirium.  In  certain  instances  there  are  im- 
pulses ;  in  others,  on  the  contrary,  there  is  complete  dejec- 
tion. Westphal  also  places  in  this  group  many  cases  of 
melancholia  with  stupor  and  the  katatonia  of  Kahlbaum.t 
These  deliriums  progress  rapidly  or  slowly  to  a  recovery.  4. 
The  last  form  is  simply  the  originare  form  of  Sander,  and  is 
the  only  one  in  which  Westphal  admits  a  basis  of  degenera- 
tion. 

While  certain  authors,  as  we  have  seen,  hold  to  the  ter- 
minology of  Snell,  others  adopt  that  of  Westphal  ;  these  are 
Leidesdorf,  Koch,  Jung,  Schuele,  and  Merklin.  Murh,|  in 
1876,  reported  the  autopsy  of  a  case  of  systematized  insanity, 

*  Westphal,  Ueber  die  Verriicktheit  (Allg.  Zeit.  f.  Psych.,  B.  xxxiv.,  S.  252, 
1878). 

f  Kahlbaum,  Die  Catatonie,  Berlin,  1874. 

\  Murh,  Anatomische  Befunde  bei  einem  Falle  von  Verriicktheit  (Arch.  f. 
Psych.,  1876,  B.  vi.,  S.  733). 


X64  J'    S  EG  LAS. 

not  originare,  in  which  he  found  atrophy  of  the  right  hemi- 
sphere of  the  brain.  Leidesdorf*  (1878)  returned  to  the 
theory  of  secondary  systematized  insanities  ;  but  he  went  to 
the  point  of  exaggeration  in  admitting  as  primary  states  not 
only  psycho-neurotic  states,  but  even  some  infantile  diseases 
and  traumatism,  which  are  only  causes.  Fristh  \  studies  the 
connections  of  delusions  with  the  emotional  state.  In  mania 
and  melancholia  the  idea  is  secondary,  and  precedes  the  emo- 
tional state  ;  this  would  be  the  inverse  in  systematized  insan- 
ity. 

Kahlbaum  I  (1878),  struck  by  the  differences  of  intensity 
that  distinguish  the  secondary  systematized  delusions  from  the 
primary,  proposed,  in  order  that  they  might  not  be  con- 
founded, to  keep  the  name  of  paranoia  for  the  primary  cases, 
and  to  give  to  the  others  the  old  name  of  verriicktheit. 

Schuele,§  in  1878,  described  verriicktheit  among  the  de- 
generative forms,  and  placed  wahnsinn  among  the  psycho- 
neuroses  between  mania  and  melancholia  on  one  side  and 
dementia  on  the  other.  We  shall  have  occasion  to  review 
more  in  detail  the  ideas  that  this  author  has  advanced  on  this 
subject  in  the  last  edition  of  his  book. 

Emminghaus    (1878)  shares  in  these  views. 

In  this  same  year  a  work  appeared  by  Feaux  H  upon  hallu- 
cinatory systematized  insanity,  corresponding  to  the  acute 
form  of  Westphal. 

Merklin  **  (1879;  and  Schaefer  tt  adopted  the  classification 
of  Westphal,  and  described  in  addition  an  hysterical  form  an- 

•  Leidesdorf,  Causistiche  Beitrage  zur   Frage  der  primaren  Verriicktheit,  In 
psych.  Studien,  Wien,  1877. 

•f-  Fristh,  Psych.  Centralbl.,  1878.      See,  also,  Fristh,  Zur  Frage  der  primaren 
Verriicktrnit  (Jahr.  f.  Psych.,  1879). 

%  Kahlbaum,  Sammlung  klinischer  Vortrage,  No.  126,  Leipsic,  1878. 

^  Schuele,  Handbuch  der  Geisterstorung,  1878. 

I  Emminghaus,  Allgem.  Psychopath.,  1878. 

iux,  Ueber  die  hallucinat.  Wahnsinn,  Inaugural  Dissertation,  Marburg, 
1878. 

**  Merklin,  Studien   ueber  die  primare  Verriicktheit,  Inaugural  Dissertation, 
Dorpat,  1879. 

\\  Schaefer,  Ueber  die  Formen  der  Wahnsinn,  etc.  (Allg.  Zeits.  f.  Psych.,  B. 
xxxviL,  S.  55). 


PARANOIA.  j^r 

alogous  in  its  course  to  hypochondria,  but  without  its  typical 
remissions  ;  in  these  cases  the  delusion  generally  has  an  erotic 
coloring. 

Krafft-Ebing,*  in  the  first  edition  of  his  "  Text-book  " 
(1879),  and  again  in  the  second  edition,  gives  a  description  of 
paranoia.  He  places  the  primary  form'among  the  mental  de- 
generations ;  to  his  mind  it  is  a  morbid  form  that  can  only  de- 
velop in  an  affected  brain,  heredity  being  the  most  frequent 
cause  ;  the  foundation  on  which  it  rests  is  formed  by  the  delu- 
sions, of  which  the  primary  origin  is  well  shown  by  the  absence 
of  all  emotional  basis  or  of  a  process  of  reflection  that  might 
give  place  to  delusions.  The  disease  has  a  uniform  character 
and  is  thoroughly  constitutional.  It  does  not  tend  to  de- 
mentia, but  most  frequently  leaves  the  logical  apparatus  and 
thought  intact.  Krafft-Ebing  studies  the  psychical  constitu- 
tion of  these  patients,  and  shows  that  in  fact  the  delusion  that 
breaks  out  later  is  only  the  exaggeration  of  their  character, 
so  that  often  the  gradual  development  prevents  assigning  a 
precise  date  for  the  beginning.  The  dominating  symptom  in 
this  disease  is  the  morbid  subjectivity  already  pointed  out  by 
Sander,  and  the  exaggeration  of  the  sentiment  of  person- 
ality. 

Krafft-Ebing  distinguishes  two  kinds  of  paranoia  :  First, 
that  with  delirium  of  persecution,  which  he  fully  describes, 
with  its  three  periods  of  hypochondria,  of  persecution,  and  of 
grandeur,  and  its  subvariety  the  "  quarrelling  insanity  "  {folie 
de  la  chicane),  where  not  only  the  life  of  the  patient,  but  his 
interests  are  in  jeopardy,  and  in  which  he  behaves  in  a  fixed 
manner,  becoming  the  persecutor  instead  of  the  persecuted. 
It  is  here  that  the  degenerative  taints  are  most  evident.  The 
second  form,  the  delusion  of  grandeur,  is  also  studied  in  its 
two  varieties,  the  religious  and  the  erotic  (erotomania).  The 
occasional  causes  are  oftenest  puberty,  the  menopause,  uter- 
ine and  intestinal  affections,  febrile  diseases,  and  onanism. 
In  studying  the  fusion  of  paranoia  with  hypochondria,  the 
author  describes,  as  a  subvariety  of  paranoia,  hypochondria 

*  Krafft-Ebing,  Lehrbuch  der  Psych.,  Stuttgart,  1879,  B.  ii.      See,  also,  Lehi- 
buch  der  gerichtliche  Psycho-Pathologie,  Stuttgart,  1881. 


l66  /.    SEGLAS. 

with  delusion  of  persecution  (secondary  form),  the  paranoia 
of  masturbators,  always  developing  on  a  neurasthenic  base, 
and  in  which  ideas  of  persecution  by  electro-magnetism  and 
hallucinations  of  smell  are  often  observed.*  As  for  the  sys- 
tematized delusions  that  are  often  found  among  hysterics, 
epileptics,  and,  especially,  alcoholics,  these  are  not  special 
characteristic  forms,  but  ought  to  be  attributed  to  the  pri- 
mary neurosis,  or  to  the  intoxication.  In  particular,  Krafft- 
Ebing  places  among  the  alcoholic  insanities  the  delusion  of 
persecution  of  insane  drinkers  described  by  Calmeil  and 
Thomeuf.t  and  by  Nasse4  The  fixed  ideas  are  separated 
from  the  primary  paranoia,  at  the  same  time  being  classed 
beside  them  in  the  mental  degenerations. 

As  for  secondary  paranoia,  the  author  simply  regards  it  as 
one  of  the  possible  terminations  of  the  psycho-neuroses  §  and 
as  a  secondary  state  of  psychical  enfeeblement  ;  the  delusion 
is  quiet,  monotonous,  and  unvarying,  differing  thus  from  that 
of  the  primary  forms  ;  the  secondary  insanities  would  be  es- 
pecially the  result  of  melancholic  states  rather  than  of  mania- 
cal states. 

Krafft-Ebing  entirely  denies  the  existence  of  the  acute 
form,  and  under  the  name  of  hallucinatory  wahnsinn  unites 
the  acute  primary  paranoia  of  Westphal,||  the  acute  halluci- 
natory form  of  sensorial  delirium  of  Meynert.H  the  hallucina- 
tory mania  of  Mendel,**  the  delusional  stupor  of  Newington, 
and  the  acute  and  subacute  general  dementia  of  Tilling. tt 
In  these  psycho-neurotic  forms  there  is  always,  according  to 
him,  a  clear  systemization  of  the  delirium,  which  cannot  be 


*  See,  also,  Krafft-Ebing,  Ueber  primare  Verriicktheit  auf  masturbatorischer 
Grundlage  bei  Mannern.     Irrenfreund  xx. 

f  Calmeil  and  Thomeuf,  Gazette  des  H&pitaux,  1856. 

*  N'asse,  Allg.  Zeitsch.  f.  Psych.,  B.  xxxiv.,  S.  167,  1878. 

§  We  have  seen  above  that  among  these  forms  is  classed  the  hypochondriacal 
paranoia  that   Krafft-Ebing  regards  as  one  of  the  possible  terminations  of  severe 
forms  of  hypochondria,  the  other  being  dementia. 
'    I  Westphal,  loc.  cit. 

"    Meynert,  Acute  Formen  des  Wahnsinns  (Jahrb.  f.  Psych.,  B.  ii.,  iS8i). 

*«  Mendel.  Die  Manie,  1882,  S.  55. 

+  +  Tilling,  Psych.  Centralb.,  1878,  Xos.  4  and  5. 


PARANOIA.  i6j 

as  lasting,  and  is  not  accompanied  by,  the  permanent  altera- 
tions of  personality  that  are  the  rule  in  paranoia.* 

Koch  +  follows  the  opinion  of  Krafft-Ebing  on  this  sub- 
ject. 

Scholz,*  in  the  same  year  (1880),  renews  the  distinction 
already  made  by  Samt,  and  distinguishes  two  principal  forms 
of  the  disease:  1,  The  originare  form  of  Sanderj  and,  2, 
the  hallucinatory  form.  His  theory  is  briefly  as  follows  :§  The 
systematized  delusions  cannot  be  explained  without  taking 
into  full  account  the  unconscious  psychical  life.  If,  under 
physiological  conditions,  the  sphere  of  the  unconscious  is  the 
foundation  on  which  the  elementary  psychical  processes  or- 
ganize themselves,  the  final  results  of  which  enter  afterward 
into  the  domain  of  consciousness,  then  in  these  diseases  the 
mental  representations  ought  to  be  the  definite  result  of  the 
unconscious   activity  of  the   brain,   but   with  this  difference, 

*  A  brief  summary  of  Krafft-Ebing's  classification   may  make  the  preceding 
considerations  more  clear.     The  principal  lines  of  his  classification  are  here  given; 

A. 
Mental  Affections  of  the  Well-developed  Brain. 


I.  Psycho-neuroses.  \ 


f       r,  •  1,      .   ..       (a.   Melancholia 

I  1.   Primary  curable  states.  -  ,      M     . 


(  b.   Mania. 


f        0  ,  , ,  (a.   Secondary  paranoia. 

2.   Secondary  incurable  states.  •<  ,      ,-.  f- 

fa.  Constitutional  affective  insanity  (folie  raisonnante). 
I  b.   Moral  insanity. 

it    t»      i_-     1  j  •.■         c.   Primary  paranoia. 

II.  Psychical  degenerative  ,d    Fixed  ££._ 

states-  I  Epilepsy. 

I  e.    Neurotic  insanities.  -j  Hysteria. 

(  Hypochondria. 
fa.  Dementia  paralytica. 

ftt     n     ■     j-  •*.!.        j  .ib.  Cerebral  syphilis. 

III.  Brain  diseases  with  predominating  mental'  fc  chronic  al^holism# 

symptoms.  j  d    Senile  dementia_ 

|^e.  Acute  delirium. 
B. 
Arrests  of  Development  of  Intelligence. 
Idiocy  and  cretinism. 

\  Koch,  Irrenfreund,  1880,  No.  8,  and   Beitrage  zur  Lehre  von  der  primare 
Verrucktheit  (Allg.  Zeitsch.  f.  Psych.,  xxxvi. ,  S.  543). 

X  Scholz,    Ueber   primare    Verrucktheit    (Berliner   klinisch.    Wochenschrift, 
i88o). 

§  See  Buccola,  Riv.  Sper.  di  Fren.,  1882,  S.  80. 


j  68  /.    SEGLAS. 

that  these  activities  come  from  molecular  anomalies  of  the 
nerve-cells.  The  psychical  apparatus  is  then  guided  by  false 
premises,  and  if  the  logical  apparatus  functions  regularly  it  is 
without  doubt  because  it  has  not  undergone  profound  ana- 
tomical modifications.  In  the  acute  form,  on  the  contrary, 
unconsciousness  has  no  direct  relation  ;  the  genesis  of  the 
disease  is  due  to  morbid  perceptions  which,  according  to 
Scholz,  do  not  develop  in  the  cortical  centres,  but  in  the 
peripheral  centres  or  conducting  tracts.  But  the  brain  must 
always  be  one  that  is  pathologically  disposed  to  transform 
the  first  excitation  into  false  perceptions. 

Then,  too,  the  hallucinatory  delusion  develops  more  fre- 
quently in  convalescence  from  febrile  affections.  The  delu- 
sion then  appears  as  a  sequel  to  the  hallucination. 

Meynert  *  (1881)  also  describes  the  acute  (hallucinatory) 
form  of  systematized  delusion  (wahnsinn). 

Max  Bucht  (1881)  reports  a  case  of  primary  systematized 
insanity  occurring  in  a  young  man  who  was  an  epileptic,  and 
presented  hereditary  antecedents. 

The  work  of  Kandinski  %  and  the  book  of  Weiss  §  (188 1) 
give  us  nothing  new  on  this  subject. 

Gnauck  |j  describes  a  form  of  epileptic  paranoia  which  he 
separates  from  epilepsy  by  overlooking  its  pathogenic  char- 
acter. 

Moeli  IT  (1881)  describes  some  cases  of  systematized  in- 
sanity developed  after  febrile  diseases,  the  puerperal  state, 
and  alcoholic  abuse. 


*  Meynert,  Die  acuten  (hallucinatorischen)  Formen  des  Wahnsinns  und  ihr 
Verlauf  (Jahr.  f.  Psych.,  B.  ii.,  1881). 

f  Max  Buch,  Ein  Fall  von  acuter  primarer  Verrucktheit  (Archiv  f.  Psych., 
1881,  B.  xi.,  S.  465).  In  addition,  this  case  was  characterized  by  ideas  of  perse- 
cution, doubling  of  personality,  hallucinations  of  sight  and  hearing,  especially  on 
the  left  side,  due  to  an  otitis  media  with  perforation  of  the  tympanum  dating  from 
infancy.  The  author  makes  this  otitis  responsible  for  everything,  having  observed 
an  amelioration  after  local  treatment. 

\  Kandinski,  Arch.  f.  Psych.,  B.  xi.,  1881. 

^  Weiss,  Compend.  der  Psych.,  Vienne,  1881,  Cap.  iv.  ;   Die  Verrucktheit. 

I  Gnauck,  Arch.  f.  Psych.,  B.  xii.,  1882,  S.  337. 

•  Moeli,  Falle  von  Verrucktheit,  in  Charitie's  Annalen,  vii.,  1882. 


PARANOIA.  jgg 

Jung*  (1882)  gives  the  differential  diagnosis  between 
systematized  delusions  and  primary  affective  forms  (mania 
and  melancholia),  reasserting  the  views  of  Fristh  (see  p.  6). 
He  claims  that  there  has  been  an  increase  of  paranoia  of  late 
years,  and  this  transformation  of  the  forms  of  insanity  is  due, 
in  his  mind,  to  the  somatic  and  psychical  degeneration  of  the 
human  race  that  is  going  on  from  day  to  day. 

Rauch  f  (1883)  does  not  advance  any  new  ideas  on  the 
subject. 

Tuczek,J  studying  hypochondria,  says  it  is  not  a  true  dis- 
ease, but  a  symptom  of  melancholia  or  of  systematized  in- 
sanity. He  differs  from  Krafft-Ebing  in  holding  that  the 
so-called  hypochondriacal  melancholia  does  not  change  into 
systematized  insanity  and  that  hypochondriacal  systematized 
insanity  does  not  tend  to  dementia. 

Sakaki  §  (1883)  describes  the  brain  of  a  case  of  chronic 
systematized  insanity  with  hallucinations. 

Kroepelin  j|  (1883)  distinguishes  primare  verriicktheit, 
without  a  condition  of  mental  debility  and  comprising  the 
delusion  of  persecution,  the  delusion  of  grandeur,  and  the 
erotic  and  religious  delusions  ;  then,  2,  secunddre  verriick- 
theit, grafted  on  a  basis  of  degeneration,  and  developing 
rather  after  states  of  depression  than  after  maniacal  states. 
Like  Koch,  Pelman,  and  Krafft-Ebing,  he  emphasizes  the 
monotonous  and  unvarying  character  of  the  secondary  form, 
at  the  same  time  admitting  some  cases  that  have  an  acute 
course,  recovering  in  some  weeks  or  months.  He  describes 
in  full  the  delusion  of  the  litigationists,  and  regards  this  as  a 


*  Jung,  Allg.  Zeitsch.  f.  Psych.,  B.  xxxviii.,  S.  361,  1882. 

f  Rauch,  Die  primord.  Verriick.,  Leipsic,  1883. 

JTuczek,  Allg.  Zeitsch.  f.  Psych.,  B.  xxxix.,  1883,  Annual  Congress  of  the 
Society  of  German  Alienists,  Session  at  Eisenach,  1882. 

§  Sakaki,  Gehirn  in  chronischen  Verriicktheit  (Allg.  Zeitsch.  f.  Psych.,  B. 
xl.,  1883).  The  author  found  in  this  case  an  alteration  of  the  pericellular  spaces 
of  the  cortex,  especially  on  the  superficies  of  the  convolutions  and  the  presence  of 
a  flocculent  yellowish  substance ;  analogous  to  that  already  described  by  Mendel 
in  general  paralytics ;  the  predominating  seat  of  these  lesions  being  the  point  of 
the  tempero-sphenoidal  lobule,  the  island  and  the  ascending  convolutions. 

I  Kroepelin,  Compend.  der  Psych.,  Leipsic,  1883. 


t  jq  J.    SEGLAS. 

manifestation  of  moral  insanity  due  to  a  lack  of  the  halluci- 
nations that  are  customary  in  systematized  delusions,  and 
due,  also,  to  the  absence  of  ideas  of  objective  right  and  of 
the  identification  of  personal  interests  with  the  general  good. 

Arndt  *  places  paranoia  among  the  atypical  psychoses  or 
states  of  mental  enfeeblement,  and  recognizes  two  forms  :  1st, 
one,  secondary,  classed  among  the  secondary  atypical  psy- 
choses ;  2d,  the  other,  primary,  classed  among  the  primary 
atypical  psychoses,  together  with  idiocy,  imbecility,  and  cre- 
tinism. This  last  form  (idiopathic  {priginelle)  primary  para- 
noia) comprises,  a,  moral  insanity  ;  /9,  partial  paranoia  (rudi- 
mentary, or  fixed  ideas,  which  he  first  describes,  and  the  de- 
lusion of  persecution) ;  7,  complete  paranoia,  which  is  the 
generalization  of  the  preceding. 

Mendel  f  (1883)  gives  a  complete  classification  of  para- 
noia, a  term  that  he  adopts  definitely.  He  insists,  especially, 
on  primary  paranoia,  which  he  divides  into  simple  and  hallu- 
cinatory, each  of  which  maybe  either  acute  or  chronic.  The 
acute  form  of  simple  primary  paranoia  generally  comes  on 
without  prodromes,  and  is  characterized  by  a  delusion  of 
vague  persecutions  without  persecutors.  The  chronic  form 
may  be  divided  into  three  periods.  The  beginning  of  the 
first  is  difficult  to  indicate  precisely,  and  often  reaches  back 
to  youth  ;  it  is  characterized  especially  by  hypochondriacal 
tendencies.  Then,  in  the  second  period,  a  delusion  of  per- 
secution appears,  developing  slowly,  with  a  sequel  of  delusion 


*  Arndt,  Lehrbuch  der  Psychiatrie,  etc.,  Vienna,    1883.     The  principal  feat- 
ures of  his  classification  are  as  follows  : 


I.  Typical.  pcri0dic 


(a.   Legitimate. 

!  b.    Circular. 

!  c.   Periodic. 

I  d.  Progressive  paralysis. 


[a.    Secondary  (  I.  Complete  or 
(to  the  typ-  X      dementia,  avoid. 
II.    Atypical.  |      ical  forms).    (  2.  Incomplete,  -rapavoia. 

or  states  of  !  \l.  Idiocy,  cretinism,  and  imbecility, 

mental    en-1  f«-    Moral  insanity, 

feeblement.      .    Pr-       ru       J  2.  Original   pri-       ,  $.    Partial  paranoia 

I  °-  ^rimary-       J      mary  para-  J      (rudimentary  and  deli- 

|       noia.  I       rium  of  persecution). 

[7.  Complete  paranoia. 

\  Mendel,  Lulenberg's  Encyclopaedia,  November,  1883. 


PARANOIA.  j -j 

of  grandeur ;  this  delusion  especially  characterizes  the  third 
stage,  which  may  terminate  in  dementia.  As  varieties  of 
this  form  Mendel  describes  idiopathic  (priginare)  paranoia, 
always  hereditary  and  degenerative,  and  the  delusion  of  the 
quarrelling  insanity,  a  weakened  form  of  the  delusion  of  per- 
secution, and  where  the  degenerative  basis  is  very  question- 
able. 

(To  be  continued.) 


GLIOMA    OF   THE   MEDULLA    OBLONGATA. 

By  WILLIAM  OSLER,   M.D., 

f ROFBSSOR  OF  CLINICAL  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA  ;  PHYSICIAN  TO  THE 
UNIVERSITY  HOSHTAL,  TO  THE  PHILADELPHIA  HOSPITAL,  AND  TO  THE  INFIRMARY  FOR  DIS- 
EASES  OF    THE    NERVOUS    SYSTEM. 

ROBERT  B ,  aged  32,  laborer,  colored,  was  admitted 
to  the  Philadelphia  Hospital  on  the  4th  of  March, 
1887.  He  was  a  well-nourished,  muscular  man,  and 
gave  a  very  good  account  of  his  condition  and  history.  He 
knew  little  or  nothing  of  his  family  ;  had  lost  his  mother  and 
all  his  brothers  and  sisters.  He  had  a  chancre  two  years 
ago,  with  secondary  symptoms.  With  the  exception  of  a 
very  severe  attack  of  headache  with  dizziness  in  1885  he  has 
been  well  until  six  or  eight  weeks  ago,  when  he  began  to 
have  fits,  for  which  he  was  admitted  to  the  Pennsylvania 
Hospital,  where  he  remained  a  week.  At  first  he  had  only 
one  or  two  attacks  a  week ;  now  they  recur  more  frequently, 
and  he  has  had  three  in  the  past  six  days  ;  he  begins  also  to 
feel  a  little  uncertain  on  his  feet. 

Condition  on  the  6th,  when  first  seen,  was  as  follows:  Is 
intelligent  and  answers  questions  promptly.  Complains  of 
headache,  unsteadiness  in  walking,  odd  sensations  over  his 
body,  and  fits.  There  is  no  wasting,  no  paralysis.  The 
grasp  of  the  hands  is  fairly  strong  ;  musculai  power  of  legs 
unimpaired.  He  complains  of  great  stiffness  and  pain  in  the 
muscles  of  the  back  of  the  neck,  and  on  getting  up  he  carries 
the  head  and  back  stiffly,  but  turns  the  head  easily  from  side 
to  side.  He  walks  without  assistance,  but  says  he  feels 
"  drunk,"  and  he  tends  to  sway.  He  paced  the  ward  alone, 
and  with  the  aid  of  an  assistant's  arm  went  to  the  ophthalmo- 
scope room,  fully  100  feet  off.     The  co-ordination  in  hands 


GLIOMA    OF  THE  MEDULLA    OBLONGATA.  T  n  -> 

is  impaired,  he  does  not  grasp  objects  quickly,  nor  can  he 
rapidly  touch  the  tip  of  his  nose.  He  gets  out  of,  and  re- 
turns to  bed  with  great  deliberation,  like  a  man  with  lum- 
bago. Sensation  is  everywhere  retained  ;  feels  a  pin-prick 
rapidly.  Complains  of  numbness,  tingling,  and  creeping 
feelings  in  the  hands  and  feet.  Says  his  legs  "  feel  as  if 
something  had  laid  upon  them  and  put  them  to  sleep."  Has 
also  sensations  of  cold  in  hands  and  feet,  and,  to  use  his  own 
words,  "  they  are  warm,  but  they  feel  so  cold."  This  was  a 
very  frequent  complaint.  Sensation  in  region  of  fifth  nerve 
normal.  Special  senses  unimpaired  ;  he  hears  the  watch  well 
at  either  ear  ;  no  affection  of  taste  or  smell.  Vision  good. 
The  eye-grounds  were  examined  twice  ;  no  neuritis;  veins 
looked  full,  but  there  were  no  special  changes.  The  head- 
ache was  not  constant,  was  chiefly  occipital,  and  he  did  not 
seem  clearly  to  be  able  to  separate  it  from  the  painful  feel- 
ings of  stiffness  in  the  nape  of  the  neck. 

Reflexes  are  present ;  patellar  somewhat  exaggerated.  In 
the  fits  the  movements  are  bilateral ;  he  froths  at  the  mouth  ; 
says  he  does  not  lose  consciousness.  This  is  probably  a  mis- 
take. He  fell  out  of  bed  last  night  in  one  and  knocked  his 
head.  They  last  from  five  to  fifteen  minutes,  and  he  comes 
out  of  them,  as  a  rule,  with  the  mind  clear. 

The  appetite  is  good  ;  he  vomits  sometimes  ;  bowels  reg- 
ular. There  is  a  loud  apex  systolic  murmur,  transmitted  to 
axilla,  and  the  pulmonary  second  sound  is  accentuated.  Pulse 
fair  in  volume,  90  per  minute.     Urine  clear ;  no  albumen. 

Taking  into  consideration  the  fact  that  he  had  had  a 
chancre  two  years  ago,  the  lesion  was  thought  to  be  syphi- 
litic, and  he  was  given  large  doses  of  potassium  iodide. 

On  the  7th  and  8th  he  was  better,  but  the  pain  in  the 
back  of  the  neck  was  severe.  On  the  9th  the  tingling  and 
numbness  of  hands  and  feet  were  not  so  distressing,  and  he 
had  less  headache.  Had  a  severe  convulsion  last  night. 
There  is  increasing  difficulty  in  getting  in  and  out  of  bed. 
Pupils  are  dilated  to-day.  He  talks  clearly  and  says  he  is 
improving. 

On  the  10th,  at  12  o'clock,  he  was  given  a  dose  of  the 
iodide  and  immediately  had  a  sort  of  fit,  but  he  did  not  move 


j-r^.  WILLIAM    OSLER. 

the  hands.  At  12.45  I  came  into  the  ward  and  found  him  in 
the  following  condition  :  Is  unconscious.  Respirations  very 
slow,  three,  four,  and  rive  in  the  minute.  Inspiration  is  pro- 
longed and  quiet ;  expiration  short  and  noisy.  Pulse,  IOO- 
108,  fair  in  volume.  At  12.55  the  respirations  had  fallen  to 
two  in  the  minute,  and  pulse  stopped  somewhat  suddenly. 
No  heart-beat  or  heart-sound  could  be  detected  after  12.55. 
Last  inspiration  at  I  o'clock. 

Autopsy. — Twenty-four  hours  post  mortem.  Old  scars 
on  forehead  and  arms.  Calvaria  normal,  perhaps  a  little  thick 
in  the  frontal  region.  Much  blood  escaped  on  removal  of 
brain.  Dura  is  adherent,  sinus  very  full — on  either  side  there 
is  a  line  of  fresh-looking  pachymeningitis.  Arachnoid  is 
clear  at  base.  Veins  of  pia  dilated  and  full.  Parts  at  base 
present  following  condition  :  Olfactory  and  optic  nerves  small, 
but  have  normal  color.  No  effusion  in  interpeduncular  space. 
Anterior  margin  of  pons  is  very  close  to  optic  commissure. 
Vessels  of  circle  of  Willis  contain  blood  ;  they  are  not  athe- 
romatous. The  third,  fourth,  and  fifth  nerves  look  normal, 
and  those  emerging  from  the  lateral  part  of  medulla  have  a 
natural  appearance.  The  crura  were  cut,  and  cerebrum 
removed  separately.  Vessels  on  the  cortex  very  full ;  gray 
matter  of  pink-red  color.  White  matter,  in  section,  looks 
moist  and  glistening  ;  no  foci  of  disease.  The  ventricles 
contain  a  slight  excess  of  fluid  ;  lining  membrane  normal. 
Crura  show  no  change.  Pons  normal.  The  fourth  ventricle 
is  dilated,  particularly  in  the  lateral  recesses.  The  Fallopian 
aqueduct  not  enlarged.  The  floor  of  the  ventricle  looks  nor- 
mal above  the  level  of  the  acoustic  stria;,  the  right  of  which 
are  not  so  distinct  as  the  left.  A  large  vein  curls  over  the 
left  margin  of  the  medulla  at  the  level  of  the  left  striae. 

The  lower  part  of  medulla  and  beginning  of  the  cord  are 
occupied  by  a  large  growth  extending  from  below  the  cala- 
mus, projecting  more  on  the  left  than  on  the  right  side.  It  is 
everywhere  covered  by  pia.  On  the  left  side  it  has  a  reddish- 
brown  vascular  appearance;  on  the  right  side  the  white  sub- 
stance of  the  medulla  is  apparent.  No  trace  to  be  seen  of 
restiform  bodies  or  of  posterior  pyramids.  The  olivary  bodies 
are  visible,  but  wider  apart  than  normal,  and  the  lower  parts 


GLIOMA    OF   THE   MEDULLA    OBLONGATA.  j^-c 

absorbed.     The  growth  reaches  to  within  7  or  8  millimetres  of 
the  fissure  separating  the  medulla  and  pons. 

The  cerebellum  is  a  little  compressed  just  above  the  tumor. 


Fig.  i.  —  Section  through  the  Tumor 
below  level  of  Calamus.  Natural 
size. 


Fig.  2.  — Section  through  the  Olivary 
Bodies  and  uppermost  portion  of 
the  Tumor. 


No  other  changes.  The  upper  part  of  cervical  cord  is  soft 
and  the  postero-lateral  columns  have  a  very  translucent  aspect. 
The  central  canal  is  somewhat  dilated.     A  cross-section  just 


f« 


y 


VssFfcjws 


.■^r--> 


*^» 


^v 


i3 


Fig.  3. — Section  at  the  edge  of  the  Growth,  showing  the  gliomatous  tissue  and  dis- 
tended Blood-vessels  Nos.  7  and  3. 

below  the  calamus  has  the  appearance  represented  in  Fig.  I 
(actual  size).  The  tumor  is  an  inch  in  breadth  by  three- 
fourths  of  an  inch  in  antero-posterior  diameter.  In  fully  one- 
half  of  the  circumference   it  is   in  contact  with  the  pia  mater 


j  75  WILLIAM   OSLER. 

of  the  left  side  ;  in  the  rest  of  the  extent,  with  the  compressed 
and  flattened  columns  of  the  cord.  In  the  medulla  it  does  not 
reach  above  the  middle  of  the  olivary  bodies  ;  Fig.  2  repre- 
sents the  section  at  this  level.  The  tumor  was  firm,  of  a  red- 
brown  color,  with  recent  hemorrhages  into  its  substance.  The 
large  lacunae  represented  in  Fig.  I  were  filled  with  clots. 
Histologically,  as  shown  in  Fig.  3,  the  tumor  is  composed  of  a 
stroma  of  nucleated  fibre-cells  supporting  blood-vessels  which 
in  places  are  so  closely  set  that  the  appearance  is  that  of  an 
angioma.  In  other  regions  the  gliomatous  tissue  is  more 
dense  and  the  blood-spaces  less  numerous. 

The  situation  of  the  tumor,  pushing  aside  and  compressing 
chiefly  the  posterior  columns,  explains  the  disturbances  of 
sensation  and  the  inco-ordination  which  were  the  prominent 
features  of  the  case.  It  is  probable  that  the  central  hemor- 
rhages, which  looked  recent,  caused  death  by  increasing  the 
pressure  and  disturbing  the  respiratory  and  cardiac  centres 
which  lay  just  above  the  growth. 

Gliomata  of  the  medulla  are  rare.  Sokoloff  has  recently 
described  a  case,*  and  has  collected  seven  instances  from  the 
literature. 


*  Deutsches  Archiv.  f.  klin.  Medicin,  B.  xli.,  H.  5,  1S87. 


HYGIENE   OF   REFLEX   ACTION.* 

By  HENRY  LING  TAYLOR,   M.D., 


NEW    YORK. 


MAN  is  the  only  creature  that  can  live  anywhere  in  the 
world.  He  can  make  shift  to  get  along  on  an 
island,  a  mountain,  or  a  tree-top  ;  in  a  cell,  a  desert, 
or  a  city.  He  will  live  an  average  lifetime  on  rice,  blubber, 
or  clay,  and  will  submit  to  the  most  diverse  conditions  im- 
posed by  nature  or  himself.  His  pre-eminence  in  this  respect 
is  due  to  the  differentiation  of  the  functions  of  his  nerve- 
centres,  and  the  capacity  they  have  acquired  for  storing  up 
energy,  which  can  be  drawn  upon  to  meet  the  vicissitudes  of 
his  changing  environment.  The  more  varied  and  thorough 
the  training  and  experience  of  his  nerve-centres,  the  better 
will  he  be  equipped.  In  every  community  we  see  a  natural 
elimination  going  on  of  individuals  who  imperfectly  adapt 
themselves  to  the  conditions  of  their  lives,  and  it  is  with 
those  subjects  who  imperfectly  react,  whether  temporarily  or 
habitually,  to  the  stimuli  which  reach  their  nerve-centres, 
that  the  physician  has  to  do. 

Without  stopping  to  describe  the  special  mechanisms  by 
which  these  adaptations  are  accomplished,  and  confining  this 
discussion  mainly  to  the  functions  of  those  cerebro-spinal 
centres  immediately  concerned  in  the  associated  reflex  move- 
ments of  the  trunk  and  limbs,  let  us  consider  in  a  general  way 
the  effect  upon  the  individual  of  their  various  states  and  re- 
actions, especially  as  observed  in  orthopaedic  practice. 

By  countless  filaments  connected  with  receptive  surfaces 


*  Read  at  the  meeting  of  the  Neurological  Section  of  the  New  York  Academy 
of  Medicine,  held  March  9,  1888. 


I78  HEXRY  LIXG    TAYLOR. 

and  spaces,  showers  of  impressions  are  constantly  pouring  in 
upon  the  centres,  some  leading  to  no  visible  effect,  yet  not 
without  effect,  others  going  to  set  up  changes  which  are  di- 
rectly reflected  to  the  muscles  and  glands  to  spur  them  to 
action,  or  passed  from  cell  to  cell,  and  all  ultimately  modify- 
ing in  some  degree  the  function  of  the  remotest  cell  in  the 
body.  By  far  the  larger  portion  of  these  in-streaming  stimuli 
are  never  consciously  perceived,  but  help  to  form  that  sub- 
stratum of  unconscious  life  upon  which  the  fabric  of  our  being 
rests. 

There  is,  therefore,  a  continuous,  unperceived  alimenta- 
tion and  training  of  the  nerve-cells  of  the  cerebro-spinal  axis, 
from  the  absorption  of  incoming  stimuli  and,  in  many  cases, 
their  reflection  along  various  paths  ;  but,  important  as  are  the 
impressions  received  through  the  special  sense-organs,  par- 
ticularly for  consciousness,  it  is  probable  that  the  innumerable 
afferent  impulses  from  skin,  membrane,  muscle,  gland,  and 
other  tissues,  responsive  to  changes  in  temperature  and  con- 
tact of  the  atmosphere  and  the  blood,  and  changes  in  tension 
and  position  of  the  muscles  and  members,  are  equally  funda- 
mental and  important. 

A  centre  may  have  its  activity  re-enforced  or  interfered 
with  by  impulses  from  connected  centres,  and  its  function  at 
any  moment  is  the  resultant  of  its  own  activity  and  all  the 
re-enforcing  and  checking  influences  which  reach  it.  Certain 
cells  become  specialized  by  inheritance  or  training,  so  that 
they  store  up  the  effect  of  impressions,  giving  out  their  im- 
pulses when  properly  stimulated.  There  is  thus  a  selection 
of  reflex  arcs  and  paths  in  the  evolution  of  the  organism,  so 
that,  starting  with  but  few  and  imperfect  ones,  many  new  ones 
are  added  according  to  its  experience  and  necessities. 

Reflex  actions,  as  we  observe  them,  are  the  products  of 
the  activity  of  many  end-organs,  fibres,  and  cells  ;  the  latter 
connected  with  neighboring  cells  of  similar  grade  and  distant 
cells  of  higher  function,  and  through  their  influence  reacting 
to  an  ever-changing  environment.  The  co-ordination  of  com- 
plicated movements,  to  a  small  degree  innate,  is  for  the  most 
part  painfully  wrought  out  by  innumerable  repetitions,  fail- 
ures, and  modifications,  until  our  reflexes  become  what  they 


HYGIENE    OF  REFLEX  ACTION.  j^q 

are.  A  lady  who  has  preserved  the  first  little  shoes  of  all  her 
children  tells  me  they  exhibit  evidence  of  the  most  varied 
use,  one  pair  being  worn  at  the  toes,  another  at  the  heels, 
and  others  at  the  sides. 

This  acquirement  of  definite  reflexes,  i.e.,  habits,  is  in  the 
interest  of  an  economy  of  force,  and,  once  the  needful  asso- 
ciations are  formed,  volition  is  left  free  to  initiate  or  control 
movements  instead  of  laboriously  executing  them.  "The 
digital  struggle  and  facial  contortion  "  of  the  youthful  pen- 
man indicate  the  large  number  of  nerve-cells  necessarily  in- 
volved in  such  an  operation  at  first.  Constant  repetition  and 
practice  enable  a  much  smaller  group  to  do  the  work  infi- 
nitely better,  and  at  a  fraction  of  the  cost  in  protoplasmic  wear. 
Talking,  singing,  playing  on  instruments,  the  use  of  tools, 
etc.,  and  most  of  our  oft-repeated  actions,  undergo  similar 
improvement,  to  the  economy  of  the  organism  and  especially 
of  the  master-cells  in  the  brain. 

The  reactions  of  the  cord-centres  will  thus  be  seen  to  de- 
pend upon  the  nature  and  intensity  of  the  stimuli  received, 
so  that  we  have  a  means  of  reaching  and  treating  the  nerve- 
centres  by  stimuli  properly  applied.  When  these  are  suf- 
ficiently varied,  without  being  too  numerous  or  too  violent, 
the  correlated  peripheral  and  central  areas  readily  act  and 
react,  each  arc  and  group  of  arcs  working  out  its  experience 
and  adjustment,  until,  in  the  same  manner  as  a  man's  face  re- 
flects his  character  and  experience,  his  hand  or  his  back  will 
acquire  a  form  and  expression  largely  dependent  upon  its 
neural  life-history.  Similarly,  his  carriage  and  attitude  and 
the  grace  and  dexterity  of  associate  movements  will  depend 
upon  previous  training  of  the  reflexes.  We  recognize  a  sail- 
or or  a  case  of  Pott's  disease  at  once  from  the  gait,  i.e.,  from 
reflexes  conditioned  by  special  experiences. 

The  neural,  and,  to  a  great  extent,  the  general  vigor  will 
depend  upon  the  tonic  action  of  large  numbers  of  adequate 
adjustments  and  reactions  well  distributed  over  the  different 
regions  of  the  body.  Unfortunately  the  environment  sup- 
plied by  our  modern  city  life  narrows  the  experiences  of  im- 
portant regions  of  the  body  while  it  unduly  quickens  many 
purely  cerebral  processes,  so  that  our  wits  are  taxed  more 


!g0  HEXRY  LIXG    TAYLOR. 

than  our  muscles.  Shoulders,  chest,  back,  and  loins,  and 
with  them  the  thoracic  and  abdominal  viscera,  suffer  particu- 
larly from  our  restricted  and  feeble  muscular  experiences, 
which  lowers  the  tone  of  the  centres,  as  in  Langley's  experi- 
ment on  the  frog,  where  "the  ordinary  reflex  action  pro- 
duced by  the  stimulation  of  one  sciatic  is  diminished  by  sec- 
tion of  the  other  sciatic"  (Foster,  p.  605).  Many  persons,  in 
being  shielded  from  the  necessity  of  any  sufficient  variety  or 
vigor  of  purposeful  and  useful  reflexes,  either  never  emerge 
from,  or  lapse  into,  a  state  of  spinal  torpor,  where  the  logical 
tendency  would  be  toward  a  purely  vegetative  existence  and 
the  shedding  of  the  appendages,  as  has  already  happened 
in  some  of  the  Crustacea.  Such  conditions  of  torpor  from 
"  starvation  "  of  the  spinal  nerve-centres  may  exist  with  con- 
siderable cerebral  activity  of  one  kind  or  another — overstim- 
ulation of  the  brain  is  apt  to  depress  the  tone  of  the  cord — 
which  leads  to  the  remark  that  in  practice  an  uneven  or 
vicious  distribution  of  stimuli  is  more  common  than  absolute 
excess  or  deficiency.  How  we  do  a  thing  is  not  less  impor- 
tant than  what  we  do  and  how  much.  One-sidedness  is  the 
disease  that  is  killing  us. 

In  general,  the  kind  of  education  which  the  spine  and 
brain  get  from  manual  proficiency  is  very  solid  and  very 
wholesome,  but  this  has  been  much  curtailed  in  the  artisan, 
professional,  and  leisure  classes  by  the  excessive  monotony  of 
impressions  from  the  sudden  development  of  the  extreme 
division  of  labor  and  use  of  machinery  which  characterize  our 
modern  civilization.  We  are  just  beginning  to  realize  that  the 
experiences  of  skin,  membrane,  and  muscle-regions  are  as 
important  and  more  fundamental  than  auditor}'  or  visual  im- 
pressions. One-sidedness  tends  to  overuse  of  the  active  re- 
gion, often  culminating  in  strain  and  exhaustion  of  the  cen- 
tres, which  produces  a  profound  detrimental  effect,  not  only 
upon  their  function  but  on  tissue-metabolism.  It  would  seem 
that  for  every  organism  there  is  a  certain  range  of  stimula- 
tion within  which  it  reacts  readily  and  makes  easy  adjust- 
ments and  assimilations.  When  the  stimuli  become  too  in- 
tense, too  constant,  or  too  disorderly,  symptoms  of  wear  and 
overwork,  a  sort  of  "  neural  dyspepsia,"  show  themselves  in 


HYG1EXE    OF  REFLEX  ACTION. 


181 


the  centres,  and  the  nutrition  of  the  body  soon  suffers,  which 
in  turn  increases  the  protoplasmic  distress  in  the  centres  and 
establishes  a  vicious  circle,  exceedingly  difficult  to  break  up. 
Disturbances  of  this  kind  beginning  at  one  pole  of  the  neural 
axis  react  upon  the  chain  of  connected  ganglia,  sweeping 
forward  as  a  disturbing  -wave  and  exploding  with  peculiar 
violence  at  the  terminal  links.  Thus  among  the  numberless 
symptoms  of  brain-tire,  debility  and  irritability  of  the  gen- 
ito-urinary  and  locomotor  apparatus  often  occur,  revealing 
the  perturbed  condition  of  the  corresponding  spinal  centres. 
On  the  other  hand,  besides  disturbed  locomotor  reflexes, 
states  of  profound  mental  depression,  with  a  tendency  to  mor- 
bid religious  notions,  fear  of  suicide,  and  fear  of  insanity,  at 
times  amounting  to  melancholia,  often  result  from  imperfect 
sexual  hygiene. 

Health  and  mental  vigor  will  be  best  secured  by  the  exer- 
cise and  co-ordination  of  large  numbers  of  reflex  arcs  in  widely 
separated  parts  of  the  body,  and  a  rational  distribution  of 
neural  reactions. 

This  view  will  present  competitive  athleticism,  one  form 
of  one-sided  use  of  the  neuro-muscular  apparatus,  in  a  less 
favorable  light  as  a  health-promoter  than  has  been  claimed 
for  it  by  some  of  its  muscular  advocates.  Dissipation  is  the 
habitual  excessive  stimulation  of  nerve-centres,  and  will  be 
detrimental  according  to  the  intensity,  frequency,  and  dura- 
tion of  the  molecular  catastrophe  and  the  grade  of  the  cells 
involved.  Thus  medicinal,  alcoholic,  narcotic,  alimentary, 
athletic,  sexual,  social,  emotional,  intellectual,  and  all  other 
forms  of  intemperance  are  included  from  this  point  of  view  in 
one  class  as  physiologically  related. 

The  recent  interesting  experiments  of  Lombard  show 
how  delicately  the  knee-jerk  reacts  to  the  general  condition 
of  the  body  and  the  state  of  the  centres.  While  they 
strengthen  the  view  that  the  knee-jerk  is  not  a  true  reflex 
act,  its  force  seems  to  depend  largely  upon  the  state  of  the 
spinal  centres,  and  one  cannot  help  regarding  its  incessant  va- 
riations as  in  some  degree  an  index  of  the  flushes  of  proto- 
plasmic activity  which  there  alternately  glow  and  fade.  These 
states  will  depend  not  only  upon  the  stimuli  directly  received 


l%2  HENRY  L/XG    TAYLOR. 

from  the  periphery,  but  also  upon  those  retarded  impressions 
received  from  the  brain. 

Stimuli  projected  against  a  background  in  the  centres  ap- 
propriate to  the  production  of  painful  sensations  referred  to  a 
particular  spot,  as  well  as  imperfect  mechanical  conditions, 
will  interfere  with  the  usual  and  normal  reflexes  of  a  part. 
Thus  unstable  footing  from  any  cause,  or  a  pain  referred  to  a 
limb,  will  modify  locomotor  reflexes. 

Practically,  nothing  is  more  certain  than  that  we  can  edu- 
cate the  spinal  reflexes.  Persons  who  have  been  prevented 
from  walking  for  many  months  on  account  of  joint-disease  or 
other  cause  have  their  cerebro-spinal  habits  very  much  mod- 
ified, and,  on  the  disappearance  of  the  general  or  local  trou- 
ble, it  is  found  that  locomotion  is  lost  or  imperfectly  accom- 
plished, and  largely  by  direct  exercise  of  the  will.  Analysis 
of  such  conditions,  with  recognition  of  the  cerebral  and  spinal 
elements,  is  often  necessary,  preparatory  to  establishing  a 
more  ready  and  perfect  reflex  response  to  locomotor  stimuli. 

When  the  functions  of  joints  or  muscles  have  been  inter- 
fered with  by  disease  or  design  for  considerable  periods  the 
habitual  reflex  arcs  become  rearranged  ;  we  say  a  patient  has 
a  trick  or  habit  of  walking.  Instinct  is  not  always  a  safe 
guide  in  such  cases.  There  are  many  cripples  and  invalids 
who  have  not  acquired  the  associated  movements  which 
would  enable  them  to  make  the  most  of  the  limited  motion 
in  a  damaged  joint  or  the  limited  power  in  weakened  muscles. 
These  considerations  will  apply  to  many  cases  among  the 
hemiplegics,  paraplegics,  and  paretics,  whether  from  cerebral 
or  spinal  lesions,  in  which  the  vitally  important  question  for 
the  patient  will  be  how  to  get  the  best  service  in  associated 
reflexes  out  of  his  imperfect  cerebro-spinal  apparatus.  The 
fact  that  the  muscles  are  not  sufficiently  used,  or  even  the 
circumstance  that  the  accustomed  neural  paths  are  not  kept 
worn  smooth,  is  not  the  whole  explanation  of  the  difficult}- ; 
the  lack  of  proper  afferent  impulses  from  sufficient  peripheral 
stimulation  is  in  all  probability  a  most  important  factor. 
Such  cord  and  brain  centres,  closely  related  to  the  member 
in  question,  as  may  still  be  intact,  suffer  from  the  lack  of  im- 
pinging stimuli  and  grow  lethargic. 


HYGIENE    OF  KEFLEX  ACTION.  jg^ 

By  a  careful  study  and  training  of  such  capacity  as  exists, 
the  physician  will  not  only  vastly  improve  the  condition  of 
these  patients  but  give  them  the  very  best  chance  for  increas- 
ing their  powers  by  proper  use.  There  are  few  cripples 
whose  condition  after  the  cessation  of  disease  may  not  still 
be  ameliorated  with  time  and  painstaking. 

In  the  neuro-muscular  degenerations  following  acute  an- 
terior polio-myelitis  it  is  especially  important  to  restore  to 
the  paretic  extremities,  so  far  as  possible,  the  stimuli  of  loco- 
motion and  other  normal  associated  movements  without  the 
inhibition  of  insecure  footing  and  strained  tissues.  This 
should  be  the  aim  of  mechanical  treatment  in  such  cases,  and 
it  is  for  the  specific  purpose  of  restoring  to  the  damaged  cord 
and  muscles  the  cutaneous,  muscular,  and  articular  stimuli  of 
locomotion  that  our  apparatus  are  constructed.  Even  in 
mild  cases  a  varus  foot  or  wobbly  ankle  may  produce  such  a 
sense  of  insecurity  that  the  gait  will  be  largely  cerebral,  con- 
sequently imperfect  and  exhausting,  instead  of  mainly  spinal 
and  unconsciously  performed  ;  as  in  trying  to  walk  on  a 
slippery  place  or  on  rollers  the  postural  reflexes  of  the  knee, 
hip,  and  trunk — in  fact,  of  the  entire  body — are  rearranged  by 
cerebral  interference,  and  the  joints  held  in  special  relations 
to  afford  a  fixed  point  for  the  unsteady  foot  or  to  favor  weak- 
ened muscles.  Normal  reflexes  of  locomotion  are  broken  up 
and  a  wasteful  and  cumbersome  set  installed  subject  to  con- 
stant cerebral  interference  in  the  efforts  at  balancing  and 
progression,  and  additionally  disturbed  by  the  strain  on 
weakened  muscular  and  joint  structures,  which  is  rendered 
inevitable  by  the  lack  of  balance  between  opposing  groups. 
Thus  the  foot  may  be  the  key  to  the  function  and  nutrition 
of  the  entire  limb,  and  even  to  the  health  and  carriage  of  the 
whole  body. 

Deformity  having  been  overcome  and  the  position  of 
election  given  to  the  foot  with  exactness  by  mechanical  sup- 
port, and  the  direction  and  amount  of  motion  precisely  lim- 
ited according  to  the  indications,  the  sole  is  placed  evenly 
upon  the  ground  and  the  ankle  held  from  lateral  insecurity, 
so  that  the  normal  stimuli  of  pressure  and  motion  are  sent  to 
the  cord  and  reflected  to  the  muscles,  as  well  as  the  central 


Tg,  HEXKY  L/.VG    TAYLOR. 

lesion  will  permit.  This  mechanical  protection  with  muscu- 
lar training  enables  the  patient  to  acquire  a  better  set  of  re- 
flexes and  promotes  the  nutrition  of  the  part.  The  special 
vascular  paresis  of  this  condition  is  most  successfully  cor- 
rected by  the  stimuli  of  very  hot  air  locally  applied,  by  means 
of  a  box  heated  by  alcohol  or  a  gas-jet. 

This  is  the  theory  of  treatment  of  infantile  paralysis.  If 
many  reflex  arcs  are  severed  this  stimulating  influence  can 
be  less  perfectly  produced,  and  its  effect  on  the  muscles  whose 
motor-centres  are  absolutely  and  permanently  destroyed  must 
be  largely  lost.  But  the  ultimate  fate  of  such  muscles  is  not 
doubtful,  and  the  stimulating  influence  of  correct  relations 
and  reactions  of  the  locomotor  apparatus  will  be  felt  in  the 
posterior  columns,  and  radiated  by  them  to  neighboring  motor 
areas  and  to  the  brain  ;  the  latter  effect  is  very  often  marked. 

I. — A  little  girl,  6  years  of  age,  brought  to  me  in  the 
fall  of  1886,  had  been  unable  to  stand  or  to  walk  since  an 
attack  of  infantile  paralysis  three  years  previous.  She  had  al- 
ways been  perfectly  content  to  sit  quietly  on  her  mother's  lap 
without  inclination  to  talk  or  to  join  in  the  activity  around 
her,  but  on  being  placed  upon  her  feet  and  enabled  to  walk, 
at  the  end  of  two  weeks,  she  apparently  experienced  an  en- 
tire change  of  disposition  ;  she  became  talkative,  lively,  and 
ambitious  to  join  in  the  plays  of  the  children,  and  her  mother 
had  difficulty  in  restraining  her. 

These  conditions  of  treatment  cannot  be  realized  without 
the  greatest  care  in  the  design  and  construction  of  apparatus 
and  perfect  exactness  and  precision  in  their  application,  with 
such  progressive  changes  as  may  be  necessitated  by  the  alter- 
ing indications.  If  a  paralyzed  knee  or  ankle  is  allowed  to 
yield  a  little  from  faulty  construction  or  application  of  the 
apparatus,  inhibitory  influences  are  at  once  excited  which  in- 
terfere with  that  symmetrical  development  of  associated  re- 
flexes which  has  been  mentioned.  While  it  is  not  claimed 
that  muscles  which  have  absolutely  disappeared  can  be  re- 
stored, the  plan  of  treatment  above  outlined  is  a  rational  at- 
tempt to  make  the  best  use  of  what  are  left,  and  it  is  astonish- 
ing how  helpless  many  patients  are,  whose  condition  is  really 
far  from  desperate,  for  lack  of  a  little  well-directed  assistance 


HYGIENE    OF  REFLEX  ACTIOX.  jgr 

and  training.  The  little  girl  just  mentioned  was  brought  to 
us  two  years  before,  and  would  then  have  come  under  treat- 
ment if  the  mother  had  not  lost  confidence  by  the  favorable 
prognosis  that  the  child  would  probably  walk  within  two 
months. 

II. — This  little  girl  was  severely  paralyzed,  but  a  boy  of  9 
years  who  came  in  March,  1886,  and  had  never  walked  since 
his  paralysis  in  November,  1885,  was  a  case  of  only  moderate 
severity.  He  had  fair  power  in  the  right  leg  and  could  stand 
on  it  for  a  short  time  ;  the  left  leg  was  practically  helpless  ; 
the  knee  was  flexed  35  degrees,  and  abducted  20  degrees, 
and  there  was  no  power  in  the  extensor  muscles.  There  was 
a  talipes  equinus  of  20  degrees  at  both  ankles,  as  well  as  a  ten- 
dency to  valgus.  These  contractions  were  stretched  by  means 
of  an  apparatus,  locked  at  the  knee  at  the  angle  of  choice  and 
extending  the  entire  length  of  the  left  leg,  and  an  ankle-brace 
applied  to  the  outside  of  the  right  foot  with  a  screw-stop 
for  progressively  increasing  ankle-flexion.  These  apparatus 
were  so  contrived  as  to  be  capable  of  progressive  modification 
as  the  boy  improved  and  to  serve  as  suppcrting  braces  after 
the  deformities  were  overcome. 

The  deformities  were  entirely  rectified  by  the  end  of  three 
weeks,  with  the  exception  of  the  knock-knee,  which  was  so 
much  diminished  as  to  be  no  longer  disabling.  This  patient 
has  been  walking  freely  ever  since  for  considerable  distances 
without  other  support  than  his  braces,  and  his  progress  has 
been  remarkable  in  other  respects.  The  left  (worst)  leg 
gained,  in  the  first  year,  1^  inch  at  the  top  of  the  thigh,  y2 
inch  each  at  the  knee  and  calf  in  circumference,  while  the 
right  leg  gained  I  y2  inch,  5/fa,  and  ^  inch  respectively,  the  legs 
remaining  equal  in  length.  He  was  then  able  to  walk  with  a 
free  knee-joint  and  the  lock  was  discarded,  although  there 
was  no  return  of  power  in  the  quadriceps  muscle.  He  could 
also  walk  very  fairly  without  his  braces,  and  it  is,  in  my  opin- 
ion, only  a  question  of  a  moderate  length  of  time  before  he 
will  be  able  to  discard  mechanical  support  altogether. 

The  spasmodic  condition  of  the  neighboring  muscles,  re- 
sulting from  the  stimuli  of  the  irritated  tissues  in  progres- 
sive joint  disease,  presents  a  condition  opposite  to  the  one  dis- 


j g5  HEXRY  LIXG    TAYLOR. 

cussed.  We  cut  off  locomotor  stimuli,  in  the  acutest  cases,  by 
putting  the  patient  to  bed  for  a  month  or  six  weeks,  and  elim- 
inate, so  far  as  possible,  by  counter-extension  the  specially 
irritating  and  damaging  stimuli  occasioned  by  the  rubbing 
and  pressing  of  the  inflamed  surfaces.  When  the  recession 
of  the  inflammatory  action  is  fully  inaugurated,  we  allow  lo- 
comotion, with  the  weight  borne  on  the  perineal  strap  of  the 
counter-extension  splint,  which  takes  the  pressure  from  the 
joint  and  does  not  permit  the  foot  to  touch  the  ground,  using 
crutches  also  if  necessary.  In  the  recovering  stages  it  is 
desirable  to  permit  a  certain  amount  of  stimulation,  in  order 
to  promote  nutrition,  before  the  joint  can  safely  bear  press- 
ure ;  we  therefore  give  the  joint  motion,  the  amount  of  which 
is  regulated  by  proper  stops  on  a  jointed  apparatus,  which 
still  suspends  the  leg  and  carries  the  weight  on  a  perineal 
strap.  In  this  way  the  amount  and  kind  of  reflex  stimulation 
which  the  leg  receives  is  carefully  regulated  according  to  the 
indications.  The  withdrawal  of  stimulation  causes  muscular 
weakness  and  wasting,  which  is  favorable  to  the  joint  in  the 
active  stages  of  disease,  but  the  muscles  improve  as  the  joint 
recovers  and  the  stimuli  are  readmitted.  It  is  thus  seen  that 
bracing  a  paralyzed  leg  and  a  diseased  one  have  entirely  dif- 
ferent objects  and  results. 

Variously  disturbed  and  faulty  reflexes  are  a  prominent 
and  sometimes  the  paramount  factor  in  many  cases  of  so- 
called  "  chronic  sprains,"  neuroses  of  the  joints,  neurasthenic 
hysteria,  sluggish  and  irritable  viscera,  imperfect  general  nutri- 
tion with  nervous  symptoms  and  backache,  often  distinguished 
by  the  bedridden  or  partly  bedridden  condition.  This  com- 
prises a  large  and  somewhat  heterogeneous  class  of  invalids, 
many  of  whom  are  exceedingly  helpless  and  very  great 
sufferers,  whose  condition  is  the  logical,  we  may  say  the  in- 
evitable, result  of  faulty  training  of  the  reflexes,  in  them- 
selves as  well  as  in  their  ancestors.  Their  nervous  system, 
and  perhaps  general  nutrition,  suffering  according  to  circum- 
stances and  temperament  from  the  strain  or  relaxation  of 
imperfect  adjustments,  affords  favorable  conditions  for  the 
formation  of  local  disturbances  of  reflex  action  from  causes 
sometimes  so  slight  as  to  escape  observation.     The  neuro- 


HYGIENE   OF  REFLEX  ACTION.  jgy 

muscular  machinery  is  vulnerable,  and,  given  the  proper  soil, 
the  abundant  and  varied  crop  of  neural  disorders  easily 
germinates.  Take  a  case  of  "  chronic  sprain."  The  patient 
presents  himself  to  the  physician  usually  with  pain  and  ten- 
derness in  the  affected  part,  often  with  wasting,  rarely  with 
heat  or  swelling,  though  a  subjective  sensation  of  burning  and 
the  puffiness  of  relaxed  tissues  are  not  uncommon.  Disa- 
bility of  the  most  varied  character  and  imperfect  co-ordination 
of  the  neighboring  muscular  reflexes  are  among  the  most 
common  symptoms,  and  the  most  characteristic  one  is  the 
visible  though  often  unconscious  accommodation  of  the  re- 
flexes of  the  entire  body  to  the  condition  of  the  disabled 
member.  This  is  equally  true  of  allied  neuroses,  and  it  is 
usually  more  distinct  and  more  widely  distributed  than  the 
secondary  reflex  adjustments  in  joint-disease,  and  somewhat 
different  in  character,  possibly  due  to  greater  prominence  of 
the  cerebral  element.  If  the  patient  have  a  lame  ankle  he  is, 
so  to  speak,  "  ankle  all  over ;  "  if  it  be  a  young  woman  with 
a  backache,  she  presents  every  evidence  in  her  conscious  and 
unconscious  life  of  the  paramount  influence  of  that  region  of 
the  body.  If  we  may  speak  of  "care  "as  referring  to  atti- 
tude and  movements  in  joint  diseases,  we  may  possibly 
characterize  as  "apprehension"  the  phenomena  referred  to 
in  these  functional  troubles.  The  "  care  "  of  a  diseased  joint 
is  most  distinctly  noticed  in  distant  reflexes  when  the  joint 
is  hurt  or  threatened  with  violence.  Pain,  especially  in  the 
earlier  stages  of  joint  disease,  is  rather  paroxysmal  in  char- 
acter and  often  absent ;  the  patient  frequently  forgets  his 
trouble  and  hurts  his  joint  by  too  spontaneous  movement. 
In  a  neurotic  joint  affection,  pain,  while  more  constant,  is  not 
invariably  a  prominent  feature,  but,  no  matter  what  the  dis- 
tractions of  the  patient,  the  remotest  muscular  reflexes  of  the 
body  are  in  a  would-be-protective  state  of  apprehension  in  a 
typical  case.  This  influence  can  often  be  distinctly  perceived 
in  the  expression  of  the  face  and  the  tone  of  the  voice  as  well 
as  in  the  peculiar  mental  attitude  of  the  patient ;  the  percep- 
tions, emotions,  and  intellect  will  frequently  revolve  around  a 
knee  or  a  back  for  a  centre  as  plainly  as  the  muscular  reflexes. 
So-called  "  chronic  sprains,"  as  I  have  seen  them,  usually  re- 


jgg  HENRY  LING   TAYLOR. 

solve  themselves  into  disturbances  of  the  associated  reflexes 
about  the  joint  in  question,  whose  starting-point  has  often 
been  a  real  sprain  or  strain,  but  which  had  long  before  re- 
covered, leaving  disordered  neuro-muscular  action  in  its 
wake  ;  these  in  turn  interfere  with  the  nutrition  of  the  part 
and  keep  up  the  pain,  which  originally  may  have  represented 
a  slight  organic  lesion. 

III. — A  gentleman,  aged  38,  came  in  May,  1883,  to  have 
a  brace  applied  to  his  right  ankle,  which  he  had  sprained 
three  months  previously.  There  was  pain  and  disability  from 
the  time  of  the  accident.  He  did  not  use  the  foot  for  four 
weeks,  and  after  that  walked  lame  and  only  for  short  dis- 
tances. The  examination  showed  pain  and  tenderness  about 
the  ankle,  especially  the  outside,  with  limited  motion  and  ir- 
regular, spasmodic  action  of  the  muscles.  Considerable  mo- 
tion at  the  ankle  was  brought  out  by  finessing,  much  to  the 
patient's  surprise,  as  he  could  scarcely  move  it  at  all  when 
told  to  do  so.  The  diagnosis  of  disturbed  reflexes  about  the 
ankle-joint  without  present  organic  lesion  was  made,  and  ed- 
ucation of  the  reflexes  by  passive  and  active  movements  ad- 
vised and  begun.  On  the  third  day  motion  was  nearly  nor- 
mal, with  scarcely  any  pain,  and  the  patient  stated  he  had 
not  felt  so  well  since  the  accident.  Three  days  later  the 
patient  was  discharged  cured,  with  normal  locomotion,  the 
movements  of  the  ankle  being  perfectly  natural  and  under 
control.  Eight  months  after  he  was  reported  as  continuing 
perfectly  well. 

IV. — A  lady,  about  50  years  old,  came  to  me  in  June, 
1884.  She  had  slipped  on  a  piece  of  orange  peel  and  turned 
the  left  ankle  two  years  previously.  This  accident  was  fol- 
lowed by  pain,  swelling,  and  disability.  She  walked  for  the 
first  time,  six  weeks  after  the  accident,  and  then  for  a  long 
time,  from  sickness  in  the  family,  she  was  obliged  to  be  con- 
stantly on  her  feet  and  suffered  from  overexertion,  anxiety, 
and  broken  rest.  She  asserted  that  pain,  heat,  swelling,  and 
lameness  had  continued  up  to  the  time  of  examination,  and 
had  been  worse  during  the  previous  six  or  eight  weeks.  The 
symptoms  had  been  so  severe  that  for  a  week  before  coming 
she  had  used  crutches.     The  patient  was  a  delicate  woman, 


HYGIENE    OF  REFLEX  ACTION.  jgg 

who  had  been  worn  out  by  mental  strain  and  overexertion. 
She  had  had  milk-leg  on  both  sides  several  times,  and  vari- 
cose veins  were  present.  The  examination  showed  no  swell- 
ing. She  was  able  to  relax  the  ankle  and  permit  it  to  move 
naturally  in  all  directions,  and  also  to  execute  these  move- 
ments voluntarily.  She  said  she  had  never  tried  to  move 
the  ankle  before,  and  did  not  know  that  she  could.  It  was 
explained  to  the  patient  that  the  ankle  was  suffering  from 
disuse  and  imperfect  hygiene.  The  crutches  were  at  once 
discarded,  and  physical,  educational,  and  developmental 
treatment  begun.  In  a  week  the  patient  stated  that  she  did 
not  know  she  had  an  ankle,  and  was  able  to  lie  on  the  left 
side,  which  she  had  not  done  before.  She  remained  for  sev- 
eral weeks  for  general  tonic  treatment,  and  has  since  been 
seen  socially  from  time  to  time,  and  reported  that  her  ankle 
had  remained  well  and  that  only  occasionally,  after  overexer- 
tion, was  she  reminded  of  the  accident. 

V. — While  passing  through  Fall  River  in  July,  1884,  I 
was  called  to  see  a  large,  athletic  young  man,  17  years  old, 
whose  left  knee  had  given  out  while  tramping  through  Swit- 
zerland six  months  previously.  He  afterward  limped  when 
he  tried  to  use  it,  and  thought  that  it  swelled.  He  had  been 
better  and  worse  by  turns,  but  the  knee  had  never  ceased  to 
trouble  him,  and  for  ten  weeks  he  had  walked  on  a  crutch 
and  a  cane,  bearing  very  little  weight  on  the  affected  limb. 
Naturally  energetic,  he  felt  his  condition  very  much,  and 
chafed  under  the  awkward  work  he  made  in  hobbling  around, 
and  was  exceedingly  anxious  to  be  relieved.  The  left  thigh 
measured  1  inch  less  at  the  top,  1^  inch  less  above  the  knee, 
f  of  an  inch  less  at  the  calf,  and  \  inch  less  over  the  knee, 
although  he  believed  it  to  be  swelled.  Mobility  was  good, 
and  it  was  perfectly  evident  that  the  limb  was  suffering  from 
nothing  except  disuse.  After  going  through  a  few  passive 
and  active  movements  of  the  leg  in  various  directions,  I  got 
him  to  stand  up  with  his  feet  flat  on  the  floor,  and  made  him 
bear  his  weight  on  both  limbs.  Inside  of  five  minutes  I  had 
him  walking  around  the  table  without  assistance,  and,  to  fol- 
low up  the  impression,  I  took  him  a  short  turn  in  the  street 
and  up  the  front  steps  of  the  house.     At  the  end  of  fifteen 


•jqq  HENRY  LING    TAYLOR. 

minutes  he  walked  without  a  limp,  and  I  took  my  leave  of 
the  bewildered  family.  This  young  man  never  had  any 
trouble  afterward,  and  played  on  the  Harvard  team  in  the 
intercollegiate  football  match  last  Thanksgiving. 

VI. — A  married  lady,  44  years  of  age,  came  in  May, 
1884.  She  had  suffered  a  great  deal  with  her  left  knee  for 
30  years.  While  at  boarding-school  at  the  age  of  14  her 
knee  began  to  hurt  her  at  times,  especially  on  stepping  up, 
but  she  did  not  remember  to  have  injured  it.  She  afterward 
met  with  a  number  of  rather  trivial  accidents  which  had  laid 
her  up  for  months  at  a  time  and  obliged  her  to  use  crutches  ; 
the  knee  also  troubled  her  sometimes  without  known  cause, 
so  that  it  was  often  treated  locally.  Two  years  before  com- 
ing she  fell  and  struck  her  knee,  and  since  then  had  used 
crutches  constantly  and  kept  the  knee  bandaged.  Aching 
had  been  frequent  and,  since  the  last  accident,  located  on 
the  inner  aspect  of  the  knee  below  the  patella.  The  patient 
held  her  knee  in  continuous  complete  extension,  as  had  been 
her  habit  when  it  troubled  her  (I  have  noticed  this  peculiar- 
ity, impossible  to  the  sufferer  from  synovitis,  in  several  cases). 
Her  right  knee  measured  1  ]/x  inch,  and  the  right  calf  1  ^  inch 
less  than  the  left.  She  was  of  nervous  temperament,  but  of 
fair  physique  and  general  health,  and  not  morbid.  Exam- 
ination showed  no  organic  change  in  the  joint,  except  that 
incident  to  prolonged  disuse.  The  knee-motion  was  of  con- 
siderable extent  and  good  quality,  but  voluntary  control  of 
the  muscles  moving  the  knee  was  deficient.  She  could  hold 
the  knee  out  when  sitting,  but  not  extend  it  from  the  flexed 
position.  The  diagnosis  was  atrophy  of  the  limb  and  prob- 
able dryness  of  the  knee-joint  from  disuse  and  disturbed  re- 
flexes. Graduated  passive  movements  at  the  knee  by  special 
apparatus  actuated  by  steam-power  were  given  for  half  an 
hour  daily,  and  gradually  increased  in  extent  and  duration. 
She  was  also  drilled  in  placing  the  foot  squarely  on  the  floor, 
in  bending  the  knee,  and  in  gradually  increasing  the  amount 
of  weight  borne  upon  the  limb  as  she  walked  with  the 
crutches.  This  was  followed  in  a  few  days  by  some  increase 
of  pain  and  considerable  puffiness  about  the  knee,  though 
the  exercises  themselves  were  not  painful.     Nine  days  after 


HYGIENE    OF  REFLEX  ACTION.  jgj 

beginning  the  treatment  she  was  able  to  extend  the  leg  from 
the  flexed  position  ;  three  days  later  she  laid  the  crutches 
aside,  walking  readily,  though  with  a  slight  limp.  In  a 
month  after  coming  she  was  able  to  bend  her  knee  and  to 
walk  considerable  distances  without  crutches,  and  the  pain 
had  greatly  diminished.  She  gained  markedly  in  flesh  and 
in  spirits,  and  lost  the  drawn  and  anxious  expression  she  had 
had.  In  five  weeks  from  coming  the  affected  knee  had 
gained  one  inch  in  circumference  and  the  calf  13^  inch,  and 
the  patient  returned  to  her  home.  She  has  since  been  fre- 
quently reported  by  members  of  her  family  as  enjoying  per- 
fect health  and  locomotion. 

VII. — A  bright,  active,  intense  woman,  27  years  of  age, 
came  in  May,  1885.  She  had  fallen,  striking  the  lower  part 
of  her  left  knee,  seven  months  before.  It  pained  her  only 
moderately,  and  she  went  on  teaching  as  usual,  not  walking 
much,  until  two  weeks  afterward  the  knee  became  red  and 
swollen,  and  there  was  a  pricking  pain.  She  was  put  to  bed 
and  kept  there  four  months,  blisters  and  iodine  being  applied 
to  the  knee.  During  this  time  the  knee  was  kept  stiffly  ex- 
tended, and  when  she  got  up  it  was  put  in  plaster  for  three 
weeks,  and  she  walked  on  crutches,  with  a  high  sole  on  the 
right  foot.  She  came  on  crutches,  and  had  not  borne  any 
weight  on  the  left  leg  since  she  went  to  bed.  She  had  had 
burning,  itching,  and  aching  sensations  in  the  knee,  aggra- 
vated by  motion,  but  no  sharp  pains.  The  patient's  health 
had  always  been  good,  and  she  had  had  no  previous  sickness. 
She  had  felt  the  effect  of  her  knee-trouble  severely,  but  did 
not  think  she  had  lost  much  flesh  ;  a  few  days  after  coming 
she  weighed  97f  pounds.  Examination  showed  that  the 
limb  was  held  in  complete  extension  by  contraction  of  the 
quadriceps.  There  was  about  10  degrees  of  voluntary  and 
restrained  passive  motion,  which  was  not  very  painful,  though 
the  patient  was  apprehensive  ;  when  her  attention  was  dis- 
tracted the  motion  was  somewhat  greater.  The  thigh  and 
leg  rotated  outward  when  the  patient  was  lying  on  her  back ; 
the  muscles  and  even  the  subcutaneous  tissues  were  very 
much  atrophied,  and  the  skin  very  thin,  having  the  appear- 
ance of  being  drawn  over  the  bones  like  parchment.     The 


jq2  HEXRY  UNG    TAYLOR. 

measurements  were  as  follows:  Above  the  knee,  right,  13!; 
inches;  left,  12  ;  knee,  right,  13^;  left,  12-t;  calf,  right,  12; 
left,  \o\  ;  there  was  no  evidence  of  any  inflammatory  trouble 
in  or  about  the  joint,  nor  of  any  organic  lesion  anywhere. 
Diagnosis  of  restraint  and  abnormal  reflexes  following  slight 
injury  was  made  and  the  condition  explained  to  the  patient, 
who  was  then  able,  with  a  little  preliminary  training,  to  walk 
alone  without  crutches  in  a  few  moments,  with  only  moderate 
discomfort  and  very  little  limping.  Systematic  passive  move- 
ments and  training  of  the  reflexes  were  begun  at  once. 
There  was  some  puffiness  and  muscular  soreness  during  the 
first  few  days,  but  at  the  end  of  two  weeks  there  was  very 
great  improvement  in  the  condition  and  nutrition  of  the  leg, 
which  had  already  gained  an  inch  in  the  calf  and  lower  thigh 
measurements.  Five  days  later  she  discarded  her  crutches 
entirely,  and  there  was  a  gain  of  \\  and  1^  inch  at  the  lower 
part  of  the  thigh  and  the  calf  respectively,  over  the  first 
measurements.  The  patient  left  in  about  six  weeks,  with 
perfect  motion  and  good  control  over  the  knee,  though  it  had 
not  yet  attained  the  strength  of  the  right  leg.  Her  general 
health  was  perfectly  restored,  and  she  had  gained,  in  five 
weeks,  7f  pounds. 

With  some  care  on  the  part  of  the  patient  the  knee  con- 
tinued to  improve  during  the  summer,  and  in  April,  1886, 
she  called  to  demonstrate  its  entire  restoration,  the  legs  be- 
ing then  equal  in  size  and  function. 

VIII. — A  little  girl,  9  years  old,  was  brought  in  the  fall  of 
1882,  walking  on  crutches,  which  she  had  used  for  a  year, 
during  which  time  she  had  suffered  from  pain  in  the  right 
hip  with  extreme  flexion  at  the  hip  and  knee.  All  efforts  to 
straighten  the  leg  caused  such  excruciating  pain  that  they  had 
to  be  abandoned.  The  muscles  relaxed  under  ether,  but  on 
recovering  from  the  anaesthetic  they  became  as  rigid  as  be- 
fore. Her  family  physician  had  recognized  the  neurotic  na- 
ture of  the  case,  but  all  of  his  efforts  at  procuring  relief  had 
been  completely  baffled.  She  was  an  excessively  intense, 
self-conscious  child  ;  her  general  health  was  fair,  and  she  was 
very  happy  in  running  around  on  her  crutches  and  joining  in 
the  plays  of  the   children.      Five    months   of  training,  which 


HYGIENE    OF  REFLEX  ACTION.  jg-, 

was  not  directed  to  the  hip,  as  she  was  already  hyper-con- 
scious of  that  part,  were  followed  by  a  complete  cure,  and 
she  went  home  without  pain  and  walking  perfectly.  This 
little  girl  had  pain  at  the  hip  at  long  intervals  for  a  consider- 
able time,  but  she  never  had  any  recurrence  of  the  functional 
trouble  in  that  location. 

She  was  brought  to  me  three  years  afterward  as  a  bed- 
ridden invalid  suffering  from  backache  and  extreme  mental 
depression.  After  a  long  and  varied  experience,  she  was 
taken  home  in  an  essentially  bedridden  condition  and  has 
never  walked  since.  There  is  no  question  of  any  organic 
disease,  she  is  simply  floored  by  her  chaotic  reflexes. 

IX. — A  lady  about  40  years  of  age,  the  wife  of  a  physi- 
cian, consulted  me  in  September,  1885,  about  her  left  shoul- 
der ;  she  had  wrenched  it  three  months  before  while  trying 
to  save  herself  from  falling  on  the  stairs.  She  did  fall,  and 
bruised  herself  in  several  places,  but  not  on  the  shoulder. 
Her  arm  was  afterward  stiff  and  painful,  and  she  found  it 
powerless  at  the  shoulder  and  elbow ;  she  carried  her  arm  in 
a  sling,  and  it  had  been  treated  electrically.  At  the  time  of 
the  examination  there  was  pain  in  the  elbow  when  she  raised 
the  arm  ;  she  could  not  raise  the  hand  to  the  face  nor  abduct 
the  arm  more  than  45  degrees  from  the  side.  When  passive 
movements  were  made  the  muscles  about  the  shoulder  re- 
sisted, and  motion  was  not  free.  Diagnosis — of  restraint  and 
disturbed  reflexes.  Training  of  the  reflexes  by  systematic 
movements  was  followed  by  marked  improvement  in  mobil- 
ity and  usefulness  of  the  arm,  but  after  being  treated  for  a 
week  the  patient  was  obliged  to  leave  and  went  home  with 
the  arm  still  very  much  disabled.  It  remained  in  about  the 
same  condition  until  the  death  of  her  husband,  which  occurred 
unexpectedly  a  few  weeks  later.  The  shock  was  so  great 
that  she  became  entirely  unconscious  of  her  arm,  and  from 
that  time  it  has  been  perfectly  normal  in  every  respect,  as  she 
was  able  to  prove  to  me  at  her  next  visit. 

Cases  similar  to  the  above  are  of  very  frequent  occurrence 
in  our  practice.  I  recently  saw  a  gentleman  who  had  walked 
with  the  toes  and  inner  border  of  the  foot  elevated  for  nine 
years,  without  organic  lesion.     Some  time  ago  a  lady  reported 


jg.  HENRY  UNG    TAYLOR. 

who  had  walked  many  years  with  her  toes  voluntarily  digging 
into  the  ground  at  every  step.  Only  a  few  weeks  ago  I  saw 
a  lady  in  whom  a  rather  severe  injury  to  one  finger  had  been 
followed  by  disturbed  reflexes  of  the  arm.  I  have  under  my 
observation  at  the  present  time  a  young  lady  in  whom  weak- 
ness of  the  knee  from  relaxed  ligaments  caused  such  severe 
pains  across  the  back  and  down  the  thighs,  and  so  much  dis- 
ability, that  there  seemed  to  be  hesitation  on  the  part  of  the 
patient  and  of  her  father,  who  was  a  physician,  in  accepting 
the  diagnosis  of  disturbed  neurility  from  knee-strain  alone. 
Avoidance  of  locomotion  for  a  few  weeks  caused  an  entire 
disappearance  of  pain  in  the  back.  Such  instances  might  be 
indefinitely  multiplied.  I  see  more  cases  of  functional  joint 
troubles  than  of  joint  diseases  ;  they  are  exceedingly  common 
in  this  country,  and  the  importance  of  carefully  differenti- 
ating between  the  two  conditions  can  hardly  be  exaggerated, 
as  many  of  these  functional  troubles  will  be  indefinitely  pro- 
longed, with  great  distress  and  harm  to  the  patient,  unless 
recognized  and  properly  treated. 

I  have  already  referred  to  the  fact  that  there  is  a  wide 
range  of  disturbance  even  in  those  cases  where  local  trouble 
predominates.  Not  a  few,  beginning  with  a  local  disorder, 
degenerate  into  a  condition  of  general  invalidism,  with  scarce- 
ly any  normally  adjusted  reflexes,  as  in  the  case  of  the  child 
bedridden  at  thirteen.  This  is  more  apt  to  happen  when 
the  main  disturbance  is  in  the  trunk,  back,  or  viscera — of 
course,  the  primary  and  essential  trouble  lies  in  imperfect  ad- 
justments of  the  higher  cerebral  centres  in  a  very  large  num- 
ber of  cases,  but  that  element  only  enters  incidentally  into 
this  discussion. 

X. — A  little  girl,  12  years  old,  an  only  child,  was  brought 
in  May,  1884;  she  had  always  been  delicate  and  the  object 
of  great  solicitude  on  the  part  of  her  parents.  She  had  suf- 
fered at  various  times  from  chills  and  sick  stomach  ;  the  last 
time  in  November,  1883,  when  these  symptoms,  with  pain  in 
the  back  and  jaundice,  followed  a  fall.  She  had  been  allowed 
to  walk  but  very  little  afterward,  and,  as  she  continued  to 
complain  of  her  back,  caries  of  the  spine  was  suspected  and 
an  apparatus  applied,  which  she  still  wore.    She  was  pale  and 


HYGIENE    OF  REFLEX  ACTION:  jgr 

thin,  with  an  expression  indicating  solicitude,  and  was  carried 
from  the  door  to  the  office  in  a  chair.  It  was  perfectly  evi- 
dent that  the  entire  family,  including  the  sufferer,  were  in- 
tently engaged  in  watching  for  the  development  of  expected 
symptoms.  Examination  of  the  spine  showed  it  to  be  quite 
normal,  with  the  exception  of  a  slight  bending  occasioned  by 
the  shortness  of  one  leg  from  asymmetrical  growth  of  the 
extremities.  Diagnosis  of  reflex  debility,  the  effect  of  "  too 
much  mother,"  was  confirmed  by  the  rapid  improvement 
which  followed  separation  from  the  parents.  Gentle  exercises 
calculated  to  give  tone  to  the  cord  and  develop  the  associated 
reflexes  of  the  trunk  and  limbs  were  given,  and,  the  burden 
of  constant  repression  and  restriction  being  removed,  it  was 
a  pleasure  to  see  the  pale,  sad  child  taking  her  first  taste  of 
natural  childhood.  On  the  ninth  day  she  walked  two  miles  ; 
on  the  tenth  she  walked  upstairs  for  the  first  time,  an  effort 
which  the  spinal  neurasthenic  instinctively  avoids.  In  three 
weeks  from  coming  she  was  riding  on  horseback,  and  at  the 
end  of  two  months  she  returned  home  in  perfect  health.  I 
am  confident  she  would  have  suffered  a  relapse  had  we  not 
undertaken  the  education  of  the  parents,  who  had  become 
completely  demoralized  by  the  abnormal  relation  to  an  only 
child,  and  who  were  trained  with  difficulty  not  to  watch  nor 
repress  her.  She  returned  for  inspection  in  five  months, 
natural  and  well  in  every  respect,  and  having  gained  consid- 
erably in  weight  and  height. 

XI. — In  May,  1886,  a  gentleman,  28  years  old,  who  had 
always  been  rather  delicate  and  had  broken  down  at  college 
five  years  before,  came  with  a  variety  of  complaints,  of  which 
backache  and  general  debility  were  very  prominent.  He  had 
not  been  able  to  do  any  work  since  leaving  college,  and  had 
been  growing  steadily  worse,  until  he  was  unable  to  sit  up 
for  his  meals,  and  even  talking  made  his  back  ache  unbear- 
ably. Pain  and  apprehension,  with  introspection  and  mental 
and  physical  demoralization,  made  him  a  helpless  wreck. 
The  attempt  was  made  to  tone  up  the  centres  and  restore  the 
equipoise  of  the  various  functions  by  properly  directed  exer- 
cises. He  proved  a  difficult  case,  but  the  attempt  was  so 
successful  that  he  was  able  to  leave  for  home  comparatively 


jg5  HEXRY  I./XG    TAYLOR. 

restored  at  the  end  of  two  months.  I  continued  to  advise 
him  by  letter  from  time  to  time  after  the  discontinuance  of 
the  treatment,  as  is  my  invariable  custom  in  such  cases.  The 
following  fall  he  took  a  position  as  civil  engineer  with  a  field- 
party,  which  he  has  held  creditably  ever  since,  and  when  I 
saw  him  a  few  months  ago  he  was  a  perfectly  healthy  young 
man. 

XII. — A  case  similar  as  to  the  general  condition,  ap- 
proaching the  bedridden  state,  with  excruciating  pain  in  the 
back,  great  prostration,  disinclination  to  exertion,  and  abnor- 
mal reflexes  of  the  back  muscles,  was  that  of  a  young  lady 
who  came  to  me  in  February,  1886.  The  pain  was  so  great — 
"as  if  her  back  would  break  in  two,"  she  expressed  it — that 
it  had  led  to  the  diagnosis  of  Pott's  disease,  and  the  applica- 
tion of  a  planter  jacket,  which  she  was  still  wearing.  In  spite 
of  the  protest  of  the  patient,  for  her  reflexes  had  accommo- 
dated themselves  to  the  rigid  casing,  the  jacket  was  at  once 
removed  and  the  usual  means  for  the  development  of  neuro- 
muscular tone  were  employed.  This  case  returned  home  at 
the  end  of  two  months  in  fair  health  and  much  relieved,  but 
I  have  recently  heard  that  she  has  relapsed. 

XIII. — The  next  case  was  that  of  a  lady,  aged  34,  who 
had  been  confined  to  the  bed  and  a  wheel-chair  for  seventeen 
years.  She  stated  soon  after  coming,  December,  1884,  that 
exactly  seventeen  years  before  she  had  gone  to  church  for 
the  last  time  and  attended  five  services.  Spinal  pain  and 
weakness  had  been  prominent  symptoms  throughout  the 
case,  and  had  resulted  in  a  readjustment  of  the  reflexes  to 
the  abnormally  restricted  condition.  That  this  patient  was 
walking  within  a  few  days  and  improved  steadily  in  all  re- 
spects was  largely  due  to  her  own  intelligent  and  hearty  co- 
operation, once  the  condition  was  explained  to  her.  For 
some  weeks  her  main  difficulty  was  in  accustoming  the  soles 
to  bear  the  pressure  of  use,  for  the  feet  had  lost  their  form 
and  character,  and  required  to  be  reshaped.  She  went  home 
at  the  end  of  four  months,  walking  freely  and  in  fair  health. 
A  month  after  she  reported  in  fine  condition,  having  gained 
twenty-five  pounds  in  four  months  and  a  half.  While  not 
robust  she  leads   a   tolerably  active    life,  visiting,   shopping, 


HYGIENE    OF  REFLEX  ACTION.  lgj 

and  attending  to  her  domesuc  and  social  duties  at  her  pleas- 
ure. 

It  is  not  necessary  to  prolong  this  enumeration  of  type- 
cases,  where,  from  causes  depending  upon  local  conditions  and 
upon  states  of  the  centres,  the  associated  reflexes  of  the  trunk 
and  limbs,  or  of  special  areas,  have  become  too  keen,  too 
sluggish,  or  too  disorderly.  The  object  of  these  outlines  is 
to  indicate  that  such  detrimental  conditions  do  exist  in  vari- 
ous localities,  either  alone  or  associated  with  organic  or  func- 
tional troubles,  and  that  they  are  susceptible  of  analysis  and 
rational  treatment.  Sometimes  the  consideration  of  faulty 
reflexes  will  not  be  important,  in  view  of  more  urgent  indica- 
tions, but  there  are  cases  of  serious  local  or  general  disturb- 
ance where  the  best  results  have  been  obtained  by  progres- 
sive, systematic  training  and  development  of  associated  mus- 
cular movements.  By  thus  feeding  in  appropriate  stimuli,  we 
can  fill  up  gaps  and  reclaim  barrens  in  the  centres,  balancing 
and  distributing  nerve-force  as  may  be  desired.  The  steps 
must  often  be  so  gradual  as  to  commit  the  centres  to  a  certain 
line  of  action,  stimulate  consciousness  of  power,  and  promote 
nutrition,  without  exciting  the  inhibition  of  undue  fatigue, 
pain,  apprehension,  or  resistance,  but  in  certain  cases  very 
much  may  be  accomplished  by  sudden  and  profound  impres- 
sions. The  training  will  often  be  directed  to  regions  remote 
from  the  part  affected ;  for  instance,  a  functional  spasm  in  the 
lower  extremity  may  be  favorably  affected  by  the  exercise  of 
the  trunk  and  arms  as  a  physiological  diversion.  The  effect 
of  local  treatment  in  exaggerating  the  attention  already  fixed 
upon  the  affected  part  should  be  carefully  considered. 

We  are  frequently  obliged  to  draw  up  a  physiological  bal- 
ance-sheet, and,  if  necessary,  place  the  system  in  the  hands  of 
a  receiver,  going  over  the  assets  and  liabilities,  finding  where 
the  former  can  be  increased  and  the  latter  diminished,  where 
idle  capital  can  be  made  to  yield  interest,  and  wasteful  extrav- 
agance checked.  These  patients  have  the  right  to  expect 
something  more  than  the  prescription  of  drugs,  diet,  braces,  or 
exercise.  Quantitative  analysis  of  the  various  activities  of 
the  organism  will  be  needed,  and  a  complete  system  of  physi- 
cal economies  adopted,  which  shall  recognize  and  regulate,  so 


igS,  HENRY  LING    TAYLOR. 

far  as  may  be  desirable,  all  the  functions  and  all  the  condi- 
tions of  life.  Change  of  moral  atmosphere,  separation  from 
the  family,  the  acquisition  of  definite  aims  and  purposes,  the 
control  of  emotional  excess,  the  introduction  of  order  and 
system  into  daily  habits,  are  examples  of  what  is  meant. 

Much  of  this  will  best  be  done  indirectly  by  the  modify- 
ing influence  of  neuro-muscular  training  on  the  organism  and 
its  higher  centres.  We  wish  to  practise  economy  in  the  or- 
ganism, not  that  we  may  spend  less,  but  more  in  the  long 
run.  Analysis  should  reveal  weak  points  in  order  to 
strengthen  them  and  make  the  organism  more  efficient. 

In  concluding,  I  will  mention  some  of  the  means  which  we 
have  found  useful  in  promoting  reflex  hygiene  :  Daily  rest, 
lying  down  at  a  stated  hour,  with  complete  relaxation  of  mind 
and  body. 

Systematic  heating  of  the  legs  from  above  the  knees  by 
the  hot-air  box,  kept  at  a  temperature  of  about  130-1400  F. 

Drill  in  the  "  standing  frame,"  with  knees  or  hips,  or  both, 
supported,  thus  training  the  centres  without  the  disturbing 
influence  of  balancing  the  body,  and  enabling  the  physician 
to  throw  more  or  fewer  muscle-groups  into  active  use  while 
giving  all  the  stimulus  of  standing. 

Drill  in  locomotion,  free  or  between  parallel  bars. 

Localized  active  and  passive  movements  by  hand  and  by 
means  of  special  apparatus,  susceptible  of  accurate  adjustment 
of  the  resistance  and  amount  of  motion,  among  the  most  use- 
ful of  which  for  the  purpose  considered  are  : 

Passive  alternate,  right  and  left  flexion  of  the  trunk  by 
means  of  steam-power  apparatus,  patient  lying  ;  46  complete 
movements  a  minute  ;  2,760  an  hour. 

Active  flexion  and  extension  of  trunk  through  lumbar 
region,  patient  lying  ;  the  upper  or  lower  half  of  the  body 
fixed  as  desired. 

Passive  (steam-poweri  flexion  and  extension  at  the  knees, 
patient  seated.  This  apparatus  gives  25  movements  of  flexion 
and  extension  a  minute  ;    1,500  an  hour. 

Passive  (steam-power)  flexion  and  extension  at  hips  and 
knees,  patient  partly  reclining  ;  23  complete  movements  a 
minute,  or  about  1,400  an  hour. 


HYGIENE    OF  REFLEX  ACTIOX.  jqq 

Active  extension  at  the  hips  and  knees,  patient  partly  re- 
clining ;  and  flexion  and  extension  at  ankle,  both  against  grad- 
uated resistance. 

Weight  and  pulley  for  arm-movements. 

Artificial  respiration  by  means  of  an  apparatus  known  as 
the  "  respirator  "  (steam-power),  which  produces  full  inspira- 
tion and  expiration,  by  drawing  the  arms  of  the  patient 
strongly  upward,  the  chest  being  at  the  same  time  arched 
back ;  the  patient  is  reclining  and  passive,  except  as  to 
grasping  the  handles  of  the  apparatus.  This  machine  has 
rendered  us  yeoman  service  in  regulating  reflexes  and  dis- 
tributing nerve-energy,  besides  which,  it  develops  the  chest, 
oxygenates  the  blood,  equalizes  the  circulation — warming  the 
extremities — and  acts  as  a  general  tonic  to  the  system.  We 
use  two  apparatus,  one  giving  13  and  the  other  16  respirations 
a  minute. 

The  exercise-room  is  provided  with  couches,  and  all  pa- 
tients are  required  to  rest  before  and  after  each  movement. 

What  I  wish  to  emphasize  as  the  central  idea  of  this  paper 
is  the  development  and  use  of  associated  reflexes  as  a  practi- 
cal means  of  modifying  nerve-centre  function.  The  spinal 
and  cerebral  factors  are  to  be  recognized  and  differentiated, 
in  order  to  send  re-enforcing  or  inhibiting  impressions  into 
appropriate  areas,  by  applying  or  removing  particular  stimuli, 
and  thus  to  effect  an  advantageous  redistribution  of  their 
energy. 


REVIEWS. 


Lemons  sur  les  Fonctions  motrices  du  Cerveau,  et 
SUR  L'EPILEPSIE  CEREBRALE.  Par  le  Dr.  Francois 
Frank.  Cours  du  College  de  France,  1884-85,  pp.  ix., 
570.  Paris  :  O.  Doin,  1887.  LECTURES  ON  THE  MOTOR 
Functions  of  the  Brain  and  on  Cerebral  Epi- 
lepsy.    By  Prof.  Francois  Frank. 

Prof.  Francois  Frank  has  made  a  number  of  important  contri- 
butions to  physiology,  some  of  which  are  more  original  than  the  pre- 
sent work  ;  but  none  have  been  more  thorough  and  careful  than 
those  recorded  in  this  volume.  In  it  he  gives  the  result  of  exten- 
sive experimental  researches  upon  the  motor  functions  of  the  brain, 
going  over  the  same  ground  which  has  been  covered  by  the  classical 
works  of  Fritsch  and  Hitzig,  Munk,  Ferrier,  and  Luciani,  and  com- 
ing to  conclusions  which  agree  very  fully  with  theirs.  His  experi- 
ments have  been  upon  the  cortex  of  the  brain  in  dogs  and  monkeys, 
and  he  has  irritated  the  various  areas  by  the  faradic  and  galvanic 
currents,  producing  irritative  manifestations.  He  reaffirms  what 
has  been  so  often  proven,  that  the  motor  area  is  about  the  transverse 
fissure  ;  that  its  upper  third  is  related  to  movements  of  the  leg ;  its 
middle  third  to  those  of  the  arm,  and  the  lower  third  to  those  of  the 
face,  of  the  opposite  side  ;  but  he  does  not  localize  the  movements 
any  more  exactly  than  this,  as  has  been  done  by  Ferrier.  He  finds 
that  the  motor  tract  is  not  as  excitable  as  the  cortex,  it  being  neces- 
sary to  use  a  stronger  current  upon  the  fibres  in  the  centrum  ovale 
or  internal  capsule  to  produce  the  same  movements.  Irritation  of 
the  basal  ganglia  does  not  cause  movements,  an  assertion  which  dif- 
fers from  that  of  other  observers.     A  number  of  electric  shocks  to 


REVIEWS.  20 1 

the  cortex,  any  one  of  which  is  insufficient  to  cause  a  motion,  will,  if 
repeated  at  very  short  intervals,  produce  one  ;  a  fact  to  which  he 
gives  the  name  of  the  cumulative  action  of  the  cortex.  And  a 
long-continued  excitement  reduces,  and  finally  suspends,  the  excit- 
ability. These  results  of  experiment  are  carefully  recorded  by  the 
graphic  method,  which  has  not  before  been  used  in  such  experiments  ; 
so  that  the  degrees  of  muscular  contraction,  and  the  time  elapsing 
between  irritation  and  result,  are  here  accurately  determined.  And 
the  results  reached  are  then  compared  with  the  phenomena  presented 
by  patients  suffering  from  cortical  epilepsy.  It  is  this  feature  of  the 
book  which  adds  greatly  to  its  value — the  comparison  of  clinical 
and  experimental  facts  being  fully  worked  out.  One  interesting  fact 
from  a  number  may  be  selected  as  an  example.  He  found  that 
moderate  irritation  of  the  motor  area  will  produce  an  epileptic 
fit  in  an  animal,  and  that,  after  this  fit  has  occurred,  the  animal  is 
thereby  rendered  susceptible  to  the  recurrence  of  such  fit  on  irrita- 
tion in  any  area  of  the  cortex  ;  whereas,  irritation  of  the  occipital 
lobe  in  an  animal  which  has  never  had  such  an  artificially  induced 
fit  will  not  produce  a  convulsion.  This  is  compared  to  the  well- 
known  clinical  fact  that  the  occurrence  of  a  single  epileptic  convul- 
sion predisposes  the  individual  to  a  subsequent  attack  under  suffi- 
cient physical  or  mental  excitement.  That  the  irritation  of  the  cortex 
in  order  to  produce  a  fit,  must  either  originate  in,  or  extend  to,  the 
motor  area  of  the  brain,  is  also  conclusively  proven  by  the  author* 
Cortical  epilepsy  begins  with  a  tonic  spasm,  followed  by  clonic 
spasms,  which  are  at  first  slight,  then  severe.  Reflex  epilepsy,  on 
the  other  hand,  begins  with  large  clonic  spasms,  and  if  a  tonic  spasm 
occurs  it  is  in  the  midst  of  the  fit,  as  an  evidence  of  cumulative 
excitement.  No  one  who  is  familiar  with  the  clinical  features  of 
Jacksonian  epilepsy  can  fail  to  be  exceedingly  interested  with  the 
experiments  and  conclusions  bearing  on  this  disease. 

The  effects  of  electrical  irritation  of  the  cortex  upon  the  respira- 
tion, vascular  tone,  heart  action,  pupillary  contraction,  secretion  of 
saliva  and  sweat,  and  excretion  of  urine,  are  very  carefully  investi- 
gated, and  in  the  lectures  upon  these  experiments  much  that  is  new 
is  to  be  found.  Frank  does  not  consider  it  justifiable  to  conclude, 
as  Ferrier  does,  that  because  irritation  of  a  part  of  the  brain  causes 
secretion  of  saliva,  that,  therefore,  that  part  contains  the  "  gustatory 
centre."  He  finds  that  the  influence  of  cortical  irritation  on  secre- 
tion is  wholly  indirect. 

The  results  of  the  destruction  of  motor  areas  are  considered 


202 


REVIEWS. 


much  more  briefly  than  those  of  irritation.  The  author  holds  that 
physiology  must  here  yield  the  palm  to  pathology,  since  conclusions 
regarding  loss  of  function  are  less  reliable  when  derived  from  the 
observation  of  animals,  than  when  based  on  the  statements  of  pa- 
tients. He  prefers,  therefore,  to  draw  practical  conclusions  from 
such  collections  of  cases  as  have  been  made  by  Charcot  and  Pitres, 
rather  than  to  record  the  results  of  experiment.  In  this  he  is  sup- 
ported hy  Charcot,  who  commends,  in  his  preface  to  the  work,  the 
willingness  of  the  physiologist  to  give  a  place  to  clinical  observation. 
The  book  should  be  studied  carefully  by  those  who  are  interested 
either  in  nervous  physiology  or  in  the  subject  of  Jacksonian  epi- 
lepsy. M.  A.  S. 


£oriehj  Imports. 


THE   PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

Stated  Meeting,  January  23,  i«88. 
The  Vice-President,  Charles  K.  Mills,  M.D.,  in  the  Chair. 


Dr.  F.  X.  Dercum  reported  a  case  of 
cholesteatoma,  with  remarks  on  the  origin  of  the  tumor. 

P.  J.,  aged  43,  unmarried,  an  Englishman  by  birth,  was 
admitted  to  the  nervous  wards  at  the  Philadelphia  Hospital 
on  August  3,  1887.  He  was  dull  and  stupid.  He  answered 
questions  slowly  and  imperfectly,  and  gave  a  very  poor  and 
disconnected  account  of  himself.  He  said  that  about  nine 
years  ago  he  had  had  a  wen  removed  from  his  scalp  at  the 
German  Hospital.     Otherwise  he  had  been  in  good  health. 

Careful  examination  of  the  scalp  failed  to  reveal  any  evi- 
dence of  a  former  operation,  and  an  exhaustive  search  among 
the  records  of  the  German  Hospital  failed  to  reveal  any  his- 
tory of  it. 

His  present  trouble  had  commenced  about  three  months 
ago,  with  trembling  of  the  hands,  and  more  or  less  mental 
confusion.  He  had  what  he  called  a  "  rigmarole  of  things  " 
in  his  head.  On  admission  he  complained  of  constant  and 
persistent  headache,  which  he  invariably  referred  to  the  base 
and  the  back  of  the  skull.  He  was,  in  addition,  quite  weak, 
but  in  no  sense  paretic.  Sensation  seemed  to  be  normal. 
The  knee-jerks  were  markedly  increased.  An  examination 
of  the  eyes  revealed  double  optic  neuritis.  The  pupils  at 
this  time  showed  no  decided  inequality. 


2Q4  SOCIETY  REPORTS. 

Brain-tumor  was  deemed  probable,  but,  owing  to  the 
absence  of  special  symptoms,  it  was  not  possible  to  locate  the 
lesion.  There  had  at  no  time  been  any  focalized  palsy,  any 
convulsion,  or,  in  fact,  any  symptom  referable  to  this  or  that 
part  of  the  cortex. 

The  patient  was  under  constant  observation  up  to  the 
31st  of  August,  when  he  died.  During  this  time  his  mental 
condition  gradually  grew  worse.  He  became  more  and  more 
stupid,  and  at  times  wandered.  On  the  day  of  his  death  he 
commenced  vomiting,  the  vomit  consisting  merely  of  mucus 
and  bile.  He  rapidly  became  less  and  less  conscious,  and 
finally  lay  perfectly  quiet,  with  the  exception  of  occasional 
movements  of  the  head  and  arms.  These  movements  were, 
however,  not  in  any  way  convulsive.  When  the  hands  or 
arms  were  pricked  with  the  aesthesiometer  he  would  draw 
them  away,  but  further  than  this  he  could  not  be  aroused. 
His  right  pupil  was  now  seen  to  be  widely  dilated,  while  the 
left  responded  but  sluggishly  to  light.  His  pulse  was  64,  soft 
and  compressible,  and  his  respiration  was  28.  His  general 
appearance  was  that  of  a  man  in  a  sound  sleep,  but  whose 
face  was  flushed.  Toward  evening  his  depression  deepened, 
and  at  7. 20  P.M.  he  died. 

At  the  autopsy  it  was  found  necessary  to  remove  the 
brain  entire  with  the  calvarium,  all  of  the  tissues,  the  brain, 
dura,  and  bone  being  very  much  adherent  to  one  another. 
An  examination  revealed  this  adhesion  to  exist  in  an  area 
some  two  or  three  inches  in  diameter  in  the  right  frontal 
region.  In  forcibly  separating  the  dura  from  the  bone  a 
rough  prominence  was  discovered  on  the  latter,  occupying 
the  middle  of  this  area.  The  prominence  measured  about 
two-thirds  of  an  inch  across,  and  about  one-sixteenth  to  one- 
eighth  of  an  inch  in  height.  The  outer  surface  of  the  cal- 
varium revealed  no  change  other  than  a  slight  deepening  of 
color — a  faint  purple  tinge — at  the  site  corresponding  to  the 
prominence  on  the  inner  side.  The  dura  mater,  on  the  other 
hand,  exhibited  a  depression,  a  shallow  pit,  the  counterpart 
of  the  bony  prominence.  Beneath  this  pit,  and  for  the  radius 
of  an  inch  or  more  around,  the  tissue  felt  much  firmer  than 
normal,  and   a   rounded   mass   was    readily   outlined   by  the 


THE    PHILADELPHIA    NEUROLOGICAL   SOCIETY.      20r 

finger.  On  attempting  to  raise  the  dura  it  was  found  to  be 
intimately  united  with  the  underlying  tissue,  not  only  over 
the  tumor,  but  also  over  the  entire  vertex.  The  pia,  in  turn, 
was  everywhere  intimately  adherent  to  the  cortex.  Its  meshes 
were  quite  cedematous,  as  was  also  the  brain  substance.  Some 
of  the  convolutions,  especially  at  the  base,  were  much  swollen. 
The  walls  of  the  ventricles  were  exceedingly  pale.  The  right 
lateral  ventricle  was  much  compressed.  The  choroid  plexuses 
were  cystic.  The  vessels  at  the  base  were  apparently  healthy. 
The  veins  of  the  pia  were  quite  full. 

The  tumor  was  found  to  be  situated  between  the  first  and 
second  frontal  convolutions,  on  the  one  hand,  and  the  anterior 
central,  on  the  other.  It  had  developed  downward,  and  gradu- 
ally separated  these  convolutions.  The  pia  was  intimately 
adherent  to  the  edge  of  the  growth,  and  did  not  separate  it 
from  the  brain  substance.  A  number  of  vessels  could  be  seen 
passing  from  the  former  directly  into  the  latter.  When  in- 
cised the  tumor  had  a  whitish  or  pinkish-white  color.  It  was 
quite  friable,  and  a  pinkish-white  juice  could  be  expressed 
from  it. 

The  microscopical  examination  reveals  its  general  struct- 
ure to  be  that  of  a  sarcoma,  while  scattered  through  it  in 
varied  profusion  we  find  typical  pearly  bodies. 


Dr.  Dercum  had  not  been  able  to  find  in  the  literature  of  endo- 
theliomata  or  cholesteatomata  an  exactly  similar  case.  The  forma- 
tion of  the  pearly  bodies  in  the  midst  of  a  sarcomatous  tissue  is  ex- 
ceedingly interesting,  especially  in  the  present  instance,  as  the  locality 
of  the  tumor  gives  abundant  opportunity  for  the  origin  of  the  endo- 
thelioid  formations.  As  seen  in  the  drawing,  they  closely  resemble 
the  pearly  bodies  of  the  epitheliomata,  so  much  so  that  some  writers 
still  believe  them  to  be  of  epiblastic  origin.  Their  occurrence,  as  in 
the  present  instance,  in  the  depth  of  a  sarcomatous  tissue,  is  cer- 
tainly another  argument  against  this  view. 

On  examining  them  closely  their  concentric,  onion  like  structure 
is  readily  seen.  Their  centre  appears  to  be  made  up  of  a  granular 
and  nuclear  material  which  is  probably  cell  detritus.  Toward  the 
periphery  individual  cells,  more  or  less  preserved,  are  still  to  be  dis- 
tinguished.    They  are  sharply  differentiated  from  the   surrounding 


206 


SOCIETY  REPORTS. 


tissue ;  though  the  vacant  space  seen  about  them  is  probably  the 
result  of  the  hardening  proces?. 


KlG.   I. 

Clinically  this  tumor  is  interesting  from  the  absence  of  symptoms 
enabling  us  to  localize  it.  Dr.  Dercum's  impression  was  that  it  was 
either  far  forward  in  the  frontal  region  or  back  somewhere  in  the 
occipito-temporal  region,  not  interfering  with  the  cuneus.  He  fa- 
vored the  latter  supposition  on  account  of  the  basal  and  occipital 
pain.  He  regretted  that  the  scalp  was  not  shaved,  in  order  that 
evidences  of  traumatism  could  have  been  better  sought  for. 

The  man  had  an  exostosis  on  the  inner  table  of  the  calvarium 
involving  the  upper  portion  of  the  frontal  bone  somewhat  in  advance 
of  its  junction  with  the  upper  portion  of  the  right  parietal.  There 
had  been  inflammation  of  the  dura  about  the  exostosis,  with  adhe- 
sion to  the  pia.  From  this  focus  of  irritation  the  tumor  appears  to 
have  developed. 

Dr.  William  Osler  said  that  a  short  time  ago  he  reported  a 
case  in  which  the  pearly  bodies  were  even  more  distinct  than  in  the 
specimen  shown,  and  in  which  the  origin  from  the  endothelium  of  the 
floor  of  the  third  ventricle  and  infundibulum  was  evident.  In  this 
tumor,  as  in  Dr.  Dercum's,  there  were  many  spindle-cell  elements. 
Cholesteatomata  are  more  common  at  the  base  than  on  the  cortex. 


THE  PHILADELPHIA    NEUROLOGICAL    SOCIETY.     2OJ 

Dr.  Charles  K.  Mills  said  that  Dr.  Dercum's  case  was  of  in- 
terest as  bearing  upon  the  localization  of  growths  in  the  second 
frontal  convolution.  In  the  case  on  which  Dr.  Keen  operated,  the 
tumor  was  in  much  the  same  position,  perhaps  a  little  lower.  In  a 
case  which  he  reported  to  the  Pathological  Society  the  tumor  was 
situated  in  much  the  same  locality.  In  all  these  cases  there  were 
eye  symptoms.  In  his  own  case  he  noted  a  certain  fixity  of  the  eyes 
with  dilatation  of  one  pupil.  These  cases  to  a  certain  extent  car- 
ried out  the  idea  of  Ferrier  and  others,  that  the  oculo-motor  centres 
are  located  in  the  second  frontal  convolution. 

Dr.  Dercum  said  that  his  patient  had  no  specific  symptoms  of 
the  locality  of  the  tumor.  He  did  not  place  the  same  interpreta- 
tion upon  the  eye  symptoms  as  did  Dr.  Mills.  This  tumor  did  not 
press  directly  upon  the  cortex,  nor  did  it  irritate  the  cortex.  The 
man  was  killed  by  oedema  of  the  brain,  and  not  directly  by  the  tumor 
itself.  The  mass  grew  downward  between  the  first  and  second 
frontal  convolutions  and  the  ascending  frontal,  and  it  separated 
these  so  gradually  that  no  irritation  was  produced.  The  eye  symp- 
toms were  of  late  occurrence.  The  tumor  became  so  large  that  the 
venous  return  was  interfered  with  and  the  brain  became  oedematous, 
and  was  so  found  at  the  post-mortem.  As  a  result  we  should  expect 
oculo-motor  symptoms  from  transmitted  pressure.  The  size  of  the 
tumor  was  probably  also  increased  by  cedema.  The  right  half  of  the 
brain  was  not  as  oedematous  as  the  left,  as  it  had  not  so  much  room 
to  swell.     The  left  base  was  much  swollen. 

Dr.  Osler  presented 

A    CASE    OF  LOCAL    SYNCOPE    AND    ASPHYXIA    OF    THE    FINGERS. 

The  patient  came  to  the  Infirmary  for  Nervous  Diseases 
a  few  days  ago,  with  her  hands  in  the  following  condition  : 
The  second,  third,  and  little  fingers  of  the  left  hand  were 
like  marble,  the  line  of  demarcation  being  at  the  second 
joint.  The  thumb  and  index  fingers,  with  those  of  the  right 
hand,  were  livid,  particularly  the  terminal  phalanges.  The 
condition  is  aggravated  by  exposure  to  cold.  The  local 
syncope  is  so  marked  that  he  thought  the  members  would 
be  interested  in  it.  The  condition  is  variable,  the  syncope 
in  a  short  time  is  followed  by  asphyxia.  This  is  the  mildest 
grade  of  Reynaud's  disease,  which  in  extreme  cases  may  re- 
sult in  gangrene  of  the  affected  finger-tips. 

He  thought  that  the  local   syncope  is  caused   by  vaso- 


2q8  SOCIETY   REPORTS. 

motor  spasm.  Following  this  there  is  relaxation  of  the  spasm 
with  extreme  engorgement.  Such  a  condition  produced  by 
the  local  action  of  cold  is  closely  related  to  chilblains.  Many 
of  these  cases  have  had  chilblains.  Last  winter  he  had  at  the 
University  Hospital  a  child,  aged  thirteen  or  fourteen,  who 
had  presented  for  many  years  this  condition  of  local  asphyxia 
of  the  terminal  phalanges  of  both  hands.  It  did  not  vary  in 
any  degree  while  under  observation. 

Dr.  Edward  N.  Brush  reported 

A    CASE    OF    PORENCEPHALIA,    WITH    SPECIMEN. 

J.  K.,  aged  57,  a  native  of  Pennsylvania,  married,  by 
occupation  a  laborer,  was  admitted  to  the  Pennsylvania  Hos- 
pital for  the  Insane,  June  16,  1885. 

The  following  is  an  abstract  of  the  history  of  the  case :  At 
birth  the  patient  was  observed  to  be  unsymmetrically  devel- 
oped. The  left  side  was  smaller  than  the  right,  the  limbs 
were  shorter  and  their  circumference  less.  No  history  of  in- 
fantile paralysis  could  be  obtained,  and  the  patient  is  said  to 
have  walked  at  about  the  usual  age,  though  with  a  limp 
which  continued  through  life,  owing  to  the  shortness  of  the 
left  leg. 

At  the  age  of  nine,  while  playing  in  a  barn,  he  fell  to  the 
floor  from  the  hay-loft,  a  distance  of  some  sixteen  feet,  strik- 
ing the  back  of  his  head.  For  some  weeks  following  this  fall 
he  complained  of  headache,  but  his  general  health  did  not 
seem  to  be  affected. 

As  a  young  man  he  was  intemperate  in  the  use  of  liquor, 
but  he  had  been,  for  some  years  prior  to  admission,  of  tem- 
perate habits. 

A  maternal  uncle  had  been  insane,  and  several  relatives 
are  said  to  have  died  of  "  dropsy  of  the  heart." 

About  nine  years  before  admission  to  the  hospital  he  had 
sunstroke,  and  was  from  that  time  frequently  troubled  with 
severe  headache,  especially  during  the  hot  weather. 

He  had  always  been  a  man  of  violent  temper  and  rough 
in  conversation,  and,  following  the  sunstroke,  is  said  to  have 
become  worse  in  these  respects.  By  some  he  was  regarded 
as  not  possessing  a  thoroughly  balanced  mind.      His  friends 


THE   PHILADELPHIA    NEUROLOGICAL    SOCIETY.      2Qg 

had  not  noticed  any  active  mental  disturbance  earlier  than  a 
week  prior'to  his  admission  to  the  hospital,  when  he  suddenly 
became  noisy  and  violent,  and  gave  expression  to  extrava- 
gant delusions.  His  condition,  however,  on  admission  pointed 
to  a  much  longer  period  of  mental  disturbance,  as  he  was  in 
advanced  general  paresis.  Upon  inquiry,  it  was  found  that 
as  early  as  December  he  had  been  talking  in  a  boastful  man- 
ner of  his  power  and  possessions,  and  particularly  of  the 
speed  of  his  horse.  It  was  also  found  that  he  had  not,  on 
account  of  his  imaginary  wealth,  made  any  charge  for  his 
services  as  a  carter  since  spring. 

On  admission  he  walked  with  a  slight  halt,  the  left  leg  was 
shorter  than  the  right — as  was  also  the  left  arm  ;  there  was 
some  asymmetry  of  the  skull,  particularly  in  the  occipitopa- 
rietal portions — the  left  arm  was  stiff  from  an  old  fracture. 
In  addition  to  the  limp,  his  gait  was  somewhat  ataxic.  He 
swayed  to  a  marked  degree  when  standing  with  his  eyes 
shut.  The  tendon  (patella)  reflexes  were  absent.  The  pu- 
pils were  unequal,  the  left  being  the  smaller.  They  responded 
to  light  very  slowly,  and  not  at  all  to  accommodative  changes. 
No  other  examination  of  the  eyes  was  made  at  the  time,  and 
the  patient  was  never  in  a  condition  subsequently  to  permit 
any.     There  was  commencing  cataract  in  each  eye. 

The  patient  gave  expression  to  very  extravagant  delu- 
sions of  wealth,  and  was  lavish  in  his  gifts  of  checks  to  all 
about  him. 

There  was  marked  tremor  of  the  lips  and  tongue,  and  of 
the  hands  and  fingers  as  well.  He  pronounced  his  words  in 
a  hesitating,  drawling  fashion,  and  frequently  stumbled  over 
words  of  many  syllables. 

The  case  progressed  without  incident  for  some  weeks. 
He  was  frequently  noisy,  shouting  and  singing.  His  gait 
grew  more  disturbed — he  manifested  a  tendency  to  fall  for- 
ward, and,  when  once  started,  would  almost  run  at  times  to 
keep  from  falling.  At  the  end  of  a  month  his  pupils  had  be- 
come almost  pin-points.  His  speech  was  more  hesitating 
and  his  delusions  more  extravagant.  He  said  that  he  had  a 
horse  which  could  trot  a  mile  in  a  minute  and  a  quarter  less 
than  no  time — and  another  that  could  go  around  the  earth  in 


2IO  SOCIETY  REPORTS. 

two  minutes  and  a  quarter.     He  had   hallucinations  of  sight 
and  hearing. 

For  a  time  the  patient  gained  in  flesh,  but  soon  lost,  and 
in  the  fall  was  quite  emaciated,  though  eating  heartily.  The 
tendency  to  fall  forward  continued,  and  it  became  necessary 
to  support  him  in  walking.  When  he  could  be  induced  to 
stand  still,  he  was  able  to  support  himself  fairly  well. 

To  omit  unnecessary  detail,  it  will  suffice  to  say  that  the 
patient  became  noisy,  untidy,  and  very  destructive  of  cloth- 
ing— at  the  same  time  failing  mentally  and  physically.  In 
November,  five  months  after  admission,  he  was  quite  de- 
mented, and  his  speech  was  hardly  intelligible. 

On  December  2,  1885,  the  ward  notes  state  that  his  morn- 
ing pulse  was  48;  temperature,  970  ;  P.M.:  pulse,  56;  tem- 
perature, 97j\°  ;  in  bed,  quite  feeble.  On  the  day  previous 
he  had  been  up  and  had  taken  some  exercise  in  the  ward  with 
the  assistance  of  an  attendant. 

December  3d,  A.M. :  pulse,  60  ;  temperature,  97TV°  ',  P.M.: 
pulse,  64;  temperature,  980  ;  heart  sounds  muffled;  respira- 
tion, 14. 

December  4th,  A.M. :  respiration  blowing,  10  to  12  ;  pulse, 
48;  face  pale  ;  body  generally  blanched.  Is  comatose.  At 
2.30  P.M.,  the  respirations  were  but  eight  per  minute  and 
wholly  diaphragmatic;  pulse,  54.      Died  at  8.15  P.M. 

Autopsy  sixteen  hours  after  death.  Examination  made 
of  brain  only.  On  removing  the  calvaria  the  dura  in  the 
right  occipito-parietal  region  protruded,  bulged  out  as  if 
from  internal  pressure.  Dissecting  the  dura  carefully  from 
the  brain,  to  which  it  was  strongly  adherent  over  the  vertex, 
this  protrusion  was  seen  to  be  due  to  a  large  accumulation  of 
serum  beneath  the  arachnoid.  In  removing  the  brain,  the 
arachnoid  was  accidentally  ruptured  and  the  fluid  escaped. 
About  six  fluid-ounces  were  collected,  and  found  to  differ  in 
no  respect  from  the  ordinary  cerebro-spinal  fluid. 

Enlarging  the  opening  in  the  arachnoid,  the  cavity  which 
is  shown  in  the  specimen  was  found.  It  will  be  observed 
that  it  communicates  with  the  lateral  ventricle,  the  posterior 
cornu  of  which  is  enlarged,  and  that  it  is  lined,  except  where 
it  communicates  with  the  ventricle,  with  the  pia  mater.    This 


THE   PHILADELPHIA    XEUROLOGICAL    SOCIETY.     2\\ 

cavity,  it  will  be  observed,  occupies  the  position  of  the  parietal 
lobe  and  encroaches  also  upon  the  occipital  and  temporal. 
The  ascending  parietal  convolution  is,  in  its  upper  por- 


tion, almost   wholly  absent,  a  small  amount  of  cortical  sub- 
stance held  in  the  meshes  of  the  membranes  alone  remaining. 
The  superior  parietal  lobule,  or   a  portion   of  it,   rather, 
forms  the  roof  of  the  cavity.     Nothing  of  this  lobule  remains 


Fig.  3. — A,  Pariefxxdpital  fissure;  B,  calcarine  fissure. 


but  a  mere  shell  of  cortical  substance  and  membrane  which 
overhangs  the  cavity. 

The  posterior  portion  of  the  superior  temporal  convolu- 
tion is  absent,  and  nothing  but  a  thin   membrane  exists  be- 


2  12 


SOCIETY  REPORTS. 


tween  the  cavity  and  the  fissure  of  Sylvius,  which  is  turned 
abruptly  upward.  The  inferior  occipital  convolution  appears 
intact,  but  of  the  superior  and  middle  convolutions  but  a 
small  portion  remains. 

On  the  inner  surface  of  the  hemisphere  the  cuneus  is 
simply  represented  by  a  shell  of  brain  substance,  and  of  the 
quadrate  lobule  nothing  remains  but  a  thin  stratum  of  brain 
substance  at  its  anterior  portion. 

If  the  right  hemisphere  is  compared  with  the  left,  the 
portion  not  encroached  upon  by  the  cavity  is  markedly 
smaller,  and  the  convolutions  are  not  as  well  developed.  The 
difference  in  weight  between  the  two  hemispheres  was,  when 
removed  and  thoroughly  freed  from  fluid,  nine  and  one- 
eighth  ounces. 


Right  half  of  cerebellum,  not  symmetrical   with  the  Id  tml   lobe,  Wt   liemi 

ere  :   C,  i  entral  fissure  (fissure  of  Rolando). 

The  cerebellum  has  developed  unsymmetrically,  the  right 
half  extending  upward  and  forward  considerably  in  advance 
of  its  fellow,  owing  to  the  absence  of  resistance  from  the  right 
cerebral  lobes.  It  is  to  be  regretted  that  the  maniacal  state 
present  at  the  admission  of  the  patient,  and  the  subsequent 
dementia  into  which  he  passed,  prevented  a  more  careful 
clinical  study  of  the  case,  and  especially  that  no  opportunity 
was  afforded  for  recording  the  eye  symptoms. 

Dr.   E.  T.   Brlen  also  presented  a  specimen  from  a 

CASK    OF    PORKNCEPHAl 

The  specimen  of  the  brain  which  was  presented  was  re- 
moved from  the  body  of  Mary  C,  aged   32,  who  died  in  the 


THE   PHILADELPHIA    AEUROLOGICAL    SOCLETY.      2\7. 

Philadelphia  Hospital  September  21,  1887.  On  removing 
the  dura  mater  four  cysts  were  found,  situated  upon  the  cor- 
tical portion  of  the  brain  near  the  occipital  lobes  of  both 
sides. 

There  were  two  cysts  on  each  side  of  the  median  fissure, 
those  on  the  right  side  were  irregular  in  shape,  and  some- 
what larger  in  size  than  a  walnut.  They  were  situated  mostly 
over  the  occipital  lobe,  but  the  outer  one  particularly  ex- 
tended over  a  portion  of  the  parietal  lobe.  In  the  left  cortex 
the  cysts  were  much  larger,  the  one  close  to  the  longitudinal 
fissure  extended  forward  three  inches,  and  was  an  inch  in 
diameter.  The  smaller  cyst  was  two  inches  long  by  three- 
quarters  of  an  inch  in  diameter.  The  inner  and  larger  cyst 
extended  over  the  occipital  and  parietal  lobes,  parallel  with 
the  longitudinal  fissure.  The  outer  and  smaller  cyst  occu- 
pied a  position  over  the  occipital  lobe,  but  extended  some- 
what over  the  parietal  lobe.  The  walls  of  the  cysts  were 
composed  of  thin  lamina  of  membrane,  and  contained  a  clear 
fluid.  Owing  to  the  pressure  occasioned  by  the  cysts,  ex- 
tensive atrophy  of  the  convolutions  of  both  occipital  lobes 
had  occurred,  but  upon  the  left  side  the  convolutions  of  the 
superior  portion  of  the  parietal  lobe  had  also  been  decidedly 
involved  in  the  atrophy  consequent  upon  the  pressure.  This 
process  was  so  marked  that  the  surface  of  the  left  cerebrum 
was  depressed  half  an  inch  below  that  of  the  right,  and  the 
entire  left  hemisphere  occupied  by  the  cysts  appeared  dis- 
tinctly smaller.  The  close  proximity  of  the  cysts  upon  the 
left  side  to  the  fissure  of  Rolando,  shows  that  the  motor  tract 
on  this  side  of  the  brain  must  have  been  subjected  to  irrita- 
tion by  pressure  during  the  development  of  the  cysts. 

Dr.  Osler  had  seen  several  specimens  of  cysts  in  the  brains  of 
adults  which  were  evidently,  from  the  history,  due  to  embolism  or 
thrombosis,  with  secondary  atrophy.  Such  defects  may  be  large, 
and  form  examples  of  true  porencephalus  ;  but  the  condition  which 
Heschel  first  accurately  described,  and  to  which  Kundrat  has  de- 
voted a  large  monograph,  more  often  originates  in  foetal  life,  either 
in  an  error  of  development  or  as  the  result  of  disease.  Encephalitis, 
obliteration   of  arteries,  traumatism  at  birth — any  condition,  in  fact, 


2  j  «  50 C/^E 7"  K  REPORTS. 

which  in  the  foetus  or  child  leads  to  destruction  of  brain  tissue — may 
produce  porencephalus.  Kundrat  states  that  in  the  congenital  cases 
the  arrangement  of  the  convolutions  about  the  defect  is  radial.  Bi- 
lateral lesion,  as  in  Dr.  Bruen's  specimen,  is  rare,  but  the  convex 
surface  in  the  neighborhood  of  the  motor  zone  is  the  most  common 
seat.  Intellectual  defects  and  spastic  paralysis  are  almost  invariable 
associations  when  the  condition  is  congenital  or  due  to  disease  dur- 
ing infancy. 


PBI^ISGOPB. 


By  Drs.   M.   A.   STARR,  G.   W.   JACOBY,   N.   E.   BRILL,  and  LOUISE 
FISKE-BRYSON. 


ANATOMY  OF  THE  NERVOUS  SYSTEM. 

Note  on  the  Ascending  Antero-lateral  Tract.  H.  H. 
Tooth,  M.D.  (Saint  Bartholomew's  Hospital  Reports,  vol.  xxiii., 
1887). 

In  this  paper  the  author  describes  a  small  tract  in  the  antero- 
lateral region  or  "  mixed  zone"  (Flechsig)  which  was  first  recognized 
by  Gowers,  but  which  other  observers  have  regarded  as  a  part  of  the 
cerebellar  tract.  Bechterew  and,  lately,  Sherrington  have  shown  that 
this  tract  is  composed  of  fibres  which  acquire  their  medullary  sheath 
at  a  definite  time  in  the  developing  foetus.  The  lesion  in  the  case 
consisted  of  a  rapidly  growing  sarcoma,  involving  the  membranes 
and  compressing  the  cord  from  about  the  mid-dorsal  to  the  mid- 
lumbar  regions.  That  part  of  the  cord  involved  in  the  tumor  was 
completely  disorganized  and  softened,  as  were  also  the  lumbar  and 
sacral  regions.  The  sections  were  cut  from  the  cervical  region, 
which  was  in  excellent  preservation.  The  cord,  after  being  cut  into 
segments,  was  hardened  in  potassium  bichromate,  and  was  then 
stained  in  the  mass,  in  Weigert's  haematoxylin  solution,  for  four  days. 
They  were  then  washed  and  kept  in  potassium  ferrocyanide  so- 
lution for  four  days.  After  careful  washing  they  were  dehydrated 
and  saturated  with  solid  paraffin.  Sections  made  in  this  way  showed 
the  degeneration  very  plainly.  All  of  the  sections  showed  degenera- 
tion of  the  posterior  median  columns  and  degeneration  in  the  an- 
tero-lateral tracts.  The  latter  degeneration  could  be  traced  up  to 
a  level  with  the  lowest  part  of  the  olive.  The  author  goes  on  to 
state  that  the  ultimate  fate  of  the  antero-lateral  tract  is  a  point  of 
considerable  interest,  more  especially  as  there  is  every  reason  to  be- 


2I6         physiology  of  the  nervous  system. 

lieve  that  its  fibres  are  concerned  in  the  conduction  of  pain  sensa- 
tions. "  One  thing  seems  certain,  viz.,  that  these  fibres  do  not  pass 
to  the  cerebellum  via  the  restiform  body.  What,  then,  becomes  of 
them  ?  There  are  two  possible  ways  in  which  they  may  terminate. 
They  may  have  passed  into  the  central  part  of  the  medulla,  and  thus 
become  lost  in  the  mass  of  fibres  forming  the  bulk  of  the  formatio 
reticularis,  or  they  may  have  become  connected,  fibre  by  fibre,  with 
the  numerous  ganglion-cells  lying  about  in  that  part  of  the  medulla, 
more  especially  with  that  group  of  them  known  as  the  nucleus  late- 
ralis. The  nucleus  lateralis  is  the  remnant  or  upper  termination  of 
the  lateral  horn  of  the  gray  matter  of  the  cord.  If  we  accept  as  pos- 
sible the  conclusion  that  this  tract  is  ultimately  connected  with  the 
cells  of  the  nucleus  lateralis  in  the  medulla,  there  is  no  reason  why 
its  fibres  should  not  be  received  from  time  to  time  in  its  upward 
course  into  the  cells  of  the  lateral  horn  of  the  cord  lower  down. 
Thus  we  have  some  sort  of  anatomical  evidence  that  the  gray  matter 
of  the  cord  is  concerned  in  the  conduction  of  pain  sensations." 


PHYSIOLOGY  OF   THE   NERVOUS  SYSTEM. 

Experiments  on  Special  Sense  Localizations  in  the  Cortex 
Cerebri  of  the  Monkey.  By  E.  A.  Schafer,  F.R.S.  {Brain, 
x.,  362,  January,  1888). 

It  is  well  known  that  experiments  upon  animals  regarding  the 
visual  area  of  the  brain  have  led  to  different  results  in  different 
hands.  Ferrier  was  the  first  to  localize  this  area,  and  he  found  it  in 
the  angular  gyrus.  Munk,  Luciani  and  Tamburini,  and  Schafer  and 
Horsley  all  agreed  in  localizing  the  visual  area  in  the  occipital  lobe, 
contending  that  the  angular  gyrus  had  nothing  to  do  with  vision. 
All  cases  of  cortical  blindness  in  man  support  the  last  view,  and  in- 
dicate that  in  monkeys  bilateral  hemiopia  rather  than  unilateral  blind- 
ness should  be  the  effect  of  occipital  lobe  lesion.  In  the  last  edition 
of 'his  work  on  "  Functions  of  the  Brain  "  Ferrier  admits  that  the  oc- 
cipital lobe  has  something  to  do  with  vision,  and  admits  that  its  lesion 
causes  hemiopia,  but  he  still  claims  for  the  angular  gyrus  an  impor- 
tant part.  It  was  in  order,  if  possible,  to  finally  settle  this  contro- 
versy that  the  present  series  of  experiments  was  undertaken  by 
Professor  Schafer  and  Dr.  Sanger  Brown.  They  seem  to  prove  con- 
clusively that  the  visual  area  lies  wholly  in  the  occipital  lobe,  each 


THERAPEUTJCS    OF   THE   NERVOUS   SYSTEM.  2ly 

hemisphere  being  related  to  both  eyes,  so  that  a  unilateral  destruc- 
tion produces  bilateral  hemiopia.  They  further  show  that  the  cortex 
of  the  angular  gyrus  has  nothing  to  do  with  vision,  but  that  beneath 
it  passes  the  visual  tract  leading  to  the  occipital  lobe,  injury  of  which 
tract  was  probably  responsible  for  the  effects  observed  by  Ferrier  (a 
probable  explanation  which  was  first  offered  by  the  reviewer,  in  1884, 
in  the  American  Journal  of  the  Medical  Sciences,  and  which  has  met 
with  approval  and  adoption  elsewhere  since).  These  experiments 
ought  to  put  an  end  to  the  controversy,  since  they  bring  clinical 
facts  and  experimental  results  into  complete  harmony. 

The  results  regarding  the  auditory  area  [are  entirely  negative. 
Ferrier  located  this  area  in  the  superior  temporal  gyrus,  but  Schafer 
and  Brown  have  destroyed  this  gyrus  in  six  monkeys  without  in  any 
way  affecting  hearing.  They  gently  condemn  any  conclusions  as  to 
sensory  areas  from  irritation  of  the  brain,  and  depend  on  the  re- 
sults of  destruction  in  their  conclusions.  It  may  be  stated  that  very 
little,  if  any,  reliable  clinical  evidence  can  be  cited  to  show  that  the 
auditory  area  in  man  lies  in  the  first  temporal  convolution  :  a  case 
of  L.  C.  Gray's,  recently  reported,  having  demonstrated  that  com- 
plete [softening  of  both  temporal  lobes  does  not  necessarily  pro- 
duce deafness.  On  the  other  hand,  word-deafness  is  undoubtedly 
caused  by  such  lesion  in  the  large  majority  of  cases  ;  and  recent 
anatomical  investigations  seem  to  indicate  that  the  intra-axial  course 
of  the  auditory  tract  ends  in  the  temporal  lobe. 

The  animals  in  which  the  entire  temporal  lobe  was  removed 
showed  no  evidence  of  loss  of  taste  or  smell. 

In  regard  to  these  results,  it  must  be  stated  that  they  do  not  har- 
monize with  those  of  all  the  other  observers,  who  unite  in  assigning 
these  functions  to  the  temporal  lobe.  In  regard  to  tactile  sensibility, 
Schafer  found  that  removal  of  the  gyrus  fornicatus  caused  hemian- 
esthesia of  the  opposite  side,  except  of  the  forearm  and  hand  in  one 
monkey.  This  persisted  for  seven  months  after  the  operation.  Any 
conclusion  from  a  single  experiment  is  not,  however,  warranted. 

M.  A.  S. 


THERAPEUTICS    OF   THE   NERVOUS   SYSTEM. 

On  the  Treatment  of  Hydrophobia  bv  Hyposulphites.     Dr. 
A.  H.  Newth  {Maryland  Medical  Journal,  March,  1888). 

Nearly  thirty  years  ago  Professor  Polli,  of  Milan,  suggested  the 
use'of  sulphurous  acid  in  cases  of  icorrhaemia.     He  proved  by  ex- 


2I8         THERAPEUTICS   OF   THE   NERVOUS   SYSTEM. 

periment  that  dogs  who  had  putrid  blood  injected  into  their  veins 
quickly  died.  But  if  hyposulphite  of  sodium  was  previously  mixed 
with  the  blood  they  were  not  affected.  Further,  if  the  hyposulphite 
was  administered  to  the  dogs  either  before  or  immediately  after  the 
injection  of  putrid  blood,  they  did  not  suffer. 

I  have  used  this  remedy  repeatedly  in  cases  of  blood-poisoning 
with  most  marked  success.  For  instance,  a  patient  has  received  a 
punctured  wound,  which  has  inflamed,  the  lymphatics  have  become 
swollen  and  reddened,  the  parts  are  extremely  painful,  and  there 
are  rigors.  Within  a  short  time  after  the  exhibition  of  the  hyposul- 
phites the  pain  has  decreased,  the  parts  are  less  inflamed,  and 
all  the  symptoms  of  poisoning  have  abated. 

I  find  even  children  take  hyposulphites  readily,  and  I  have 
never  met  with  the  slightest  unpleasant  symptoms  from  their  use. 
Probably  this  may  in  some  measure  be  due  to  the  fact  that  I  am 
in  the  habit  of  prescribing  the  hyposulphites  in  combination  with 
bicarbonate  of  soda  and  sulphate  of  magnesia  in  peppermint-water. 
For  children  I  simply  give  it  with  sirup  and  caraway-water.  I 
would  suggest  a  fair  trial  of  this  remedy,  not  only  when  hydropho- 
bia has  developed  itself,  but  as  a  prophylactic.  After  a  bite  by  a  mad 
dog  I  would  give  five  or  ten  grains  of  the  hyposulphite  of  sodium 
or  magnesium  (the  latter  is  richer  in  sulphurous  acid)  for  the  first 
three  or  four  days  every  four  hours  ;  then  three  times  a  day  for  a 
week  ;  then  twice  a  day  for  another  ^week  ;  then  .every  morning 
early  for  one  month  ;  recommending  a  Turkish  bath  twice  a  week. 
When  the  disease  has  developed  I  would  prescribe  the  hyposulphite 
every  hour  or  every  two  hours,  with  vapor  or  dry  hot-air  baths  or 
prolonged  warm-water  baths  containing  some  hyposulphite  in  solu- 
tion. The  hypodermic  injection  might  also  be  tried,  especially  if 
the  patient  is  unable  to  swallow. 

The  Treatment  of  Neuralgia  in  General  Practice.  Dr. 
Gustavus  Elliot,  A.M.,  M.D.  (in  a  paper  read  before  the  Ninth 
International  Medical  Congress,  September  8,  1887). 

Of  all  the  drugs  which  have  been  recommended  and  tried  in  the 
treatment  of  neuralgia,  three  are  invaluable.  They  are  morphine, 
quinine,  and  iron.  In  acute  attacks  of  marked  severity,  morphine 
is  almost  indispensable.  It  is  preferably  administered,  if  the  patient 
is  seen  while  severe  pain  continues,  by  hypodermatic  injection. 
Given  by  this  method,  in  doses  of  one-quarter  or  one-half  grain,  at 


THERAPEUTICS    OF   THE   NERVOUS   SYSTEM.  21Q 

the  onset,  or  during  the  persistence  of  a  paroxysm,  the  relief  which 
follows  is  prompt,  grateful,  and  often  complete.  Thus  used,  it  is 
always  palliative,  and  sometimes  curative,  a  seconc.  attack  never  oc- 
curring. 

It  is,  however,  rather  unusual  to  see  the  course  of  neuralgia  im- 
mediately arrested  by  this  treatment,  if  it  is  commenced  after  more 
than  one  paroxysm  has  occurred.  In  these  cases  it  is  desirable  to 
prescribe,  if  possible,  some  remedy  which  is  more  directly  curative. 
The  drug  which  acts  more  positively  in  this  direction  than  any  other, 
which  more  justly  than  any  other  might  be  called  a  specific,  is 
quinine.  It  should  be  given  in  large  doses,  and  is  of  value  in  all 
cases,  but  especially  in  those  which  are  markedly  paroxysmal,  and 
most  of  all  in  those  which  are  dependent  upon  malarial  poisoning. 

In  a  considerable  proportion  of  cases  anaemia  is  not  a  prominent 
feature.  The  patients  are  well-nourished  and  full-blooded  subjects. 
In  them,  neuralgia  is  an  expression  of  an  exhaustion  of  nervous 
force,  perhaps  due  to  cold  or  to  over-exertion  ;  or  of  a  toxaemia, 
perhaps  malarial ;  or  of  some  reflex  irritation.  In  the  latter  cases, 
the  removal  of  the  source  of  irritation  is,  of  course,  indicated.  In 
the  other  cases,  in  connection  with  proper  hygiene,  including,  as  of 
highest  importance,  rest  and  good  food,  a  combination  of  quinine 
and  morphine  is  of  the  greatest  value.  In  such  cases,  seeing  the 
patient  in  the  interval  between  the  paroxysms — when,  of  course,  the 
hypodermatic  use  of  morphine  is  not  indicated — it  is  often  conven- 
ient to  give  the  two  drugs  together.  One  drachm  of  sulphate  of 
quinine  and  one  grain  of  sulphate  of  morphine,  having  been  thor- 
oughly mixed,  may  be  divided  into  twelve  powders.  Of  these,  one 
may  be  given  two  or  three  hours  after  each  meal,  and  two  (or  more, 
if  necessary)  at  once,  one  or  two  hours  before  the  paroxysm  is 
expected. 

In  another  large  class  of  cases  anaemia  is  the  predominant  charac- 
teristic. These  cases  are  often  exceedingly  obstinate,  and  likely  to 
recur.  For  them,  no  drug  is  more  valuable  than  iron  When  given 
continuously,  as  the  quality  of  the  blood  improves,  the  neuralgic 
tendency  grows  weak. 

As  remedies  of  secondary  value  may  be  classed  gelsemium  and 
aconite.  They  certainly  deserve  to  be  ranked  as  valuable  adjuncts 
to  the  remedies  previously  named.  The  danger  of  producing  un- 
pleasant toxic  effects  with  either  drug  is,  however,  so  great  as  to 
render  it  inexpedient  to  rely  upon  either  as  a  single  remedy  in  ordi- 
nary cases.     The  uncertainty  in  regard  to  the  strength  of  the  vari- 


2  20         THERAPEUTICS    OF    THE   NERVOUS   SYSTEM. 

ous  preparations,  as  manufactured  by  different  pharmacists,  is  also 
so  great  as  to  constitute  a  serious  hinderance  to  the  general  use  of 
either  drug.  .Furthermore,  the  varying  susceptibility  of  different 
patients  introduces  another  element  of  uncertainty.  I  desire,  how- 
ever, to  bear  personal  testimony  to  the  utility  of  five-drop  doses  of 
the  fluid  extract  of  gelsemium,  repeated  every  four  hours,  and  given 
in  connection  with  quinine  and  morphine.  These  three  together 
will  often  give  most  favorable  results. 

As  remedies  of  the  third  class  may  be  mentioned  arsenic,  nux 
vomica,  belladonna,  phosphorus,  and  iodide  of  potassium.  These 
have  long  been  highly  commended.  I  name  them  rather  in  def- 
erence to  popular  opinion  than  because  I  consider  them  of  great 
value.  I  have  used  them  all,  but  have  failed  to  obtain  with  them 
results  which  warrant  me  in  commending  them.  Arsenic,  in  par- 
ticular, has  been  recommended  by  many  authors.  I  have  never 
seen  very  marked  improvement  follow  its  use.  On  the  contrary,  I 
have  seen  symptoms  of  considerable  severity  develop  in  spite  of  its 
administration  in  full  doses,  advised  with  the  hope  of  preventing  the 
attack.  As  an  adjuvant  of  iron  in  cases  of  anasmia,  it  is  unques- 
tionably of  value  in  curing  the  anaemia.  Thus,  indirectly,  it  may 
contribute  to  the  cure  of  neuralgia.  Similarly,  nux  vomica  and  its 
alkaloid,  strychnine,  are  of  use  as  stomachic  tonics,  when  the  gen- 
eral nutrition  is  impaired  by  indigestion. 

External  applications  are  of  considerable  utility  as  adjuvants  to 
internal  medication.  Counter-irritants  have  been  largely  used.  In 
obstinate  cases,  particularly  of  sciatica,  blisters  and  cauterisation 
sometimes  do  great  good.  In  cases  of  moderate  severity — as  in 
intercostal  neuralgia — sinapisms,  applied  either  over  the  seat  of  pain 
or  over  the  origin  of  the  affected  nerve,  often  afford  some  relief. 
Various  sedative  applications  have  some  value  as  palliatives.  I 
have  frequently  used  a  mixture  containing  one  part  of  oil  of  gaul- 
theria  and  two  parts  of  olive-oil,  or  a  combination  of  equal  parts  of 
oil  of  origanum,  tincture  of  opium,  spirit  of  ammonia^  and  olive-oil 
— known  as  Fahnestock's  liniment — warmed  and  thoroughly  rubbed 
along  the  course  of  the  affected  nerve  and  its  branches,  hot  flannel 
being  superposed,  and  have  found  that  either  will  produce  a  pal- 
liative effect  in'many  instances. 


VOL.  XIII.  April.   1888.  No.  4. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


(Original  ^Vrtirtrs. 


LOCOMOTOR  ATAXIA  CONFIXED  TO  THE  ARMS: 
REVERSAL  OF  ORDINARY  PROGRESS.* 

By  S.  WEIR   MITCHELL,  M.D., 

E.  C.  B.,  M.D.,  of  California,  aged  55.  (Private  Note 
Book;   Case  No.  1 167.) 

This  gentleman  was  in  active  practice  until  two  years 
ago.     He  has  no  constitutional  disease  of  any  description. 

The  patient,  by  his  own  description,  was  a  well  man  up 
to  July,  1887,  possessing  nearly  perfect  health.  Near  to 
that  time  he  observed  that,  in  writing  with  a  steel  pen,  his 
hand  began  to  change — becoming  unsteady.  There  was 
no  tremor,  certainly  none  manifested  in  his  hand  writing. 
He  only  discovered  that  there  was  slightly  increasing 
numbness  in  the  cushions  of  the  finger  ends  of  both  hands, 
extending  through  the  hand,  up  into  the  arm,  through  the 
chest  and  down  over  the  belly  and  back.  About  Septem- 
ber 20th,  this  was  slightly  present  in  the  toes,  but  more 
distinctly  afterwards.  There  seems  to  have  been  no  pre- 
ceding eye  or  bladder  symptoms,  nor,  indeed,  any  warning 
such  as  usually  attends  an  outbreak  of  locomotor  ataxia. 
The  character  of  the  case  has  not  greatly  changed  since 
the  first  attack ;  it  has  only  shown  more  decisively  its 
nature.  Perhaps  the  best  description  I  could  give  of  it 
would  be  that  which  I  take  from  my  note  book  of  January 
15th,  1888.  To  make  clear  what  follows,  I  will  state  that 
the  case  is  in  my  experience  exceptional.  I  have  seen 
none    which   I    could    place  along   side    of  it.      It  consists 

*  Read  before  the  Philadelphia  Neurological  Society,  March  26,  1888. 


222 


S.    WEIR  MITCHELL. 


of  an  attack  of  locomotor  ataxia  affecting  practically  the 
upper  extremities.  In  other  words,  the  legs  now  show 
the  same  condition  which  one  is  apt  to  see  in  ordinary 
cases  of  this  disease  in  the  arms  after  the  legs  are  pretty 
well  on  their  course  of  degenerative  change. 

Nutrition, — This  gentleman  weighs  138  pounds;  has  lost 
20  pounds  ;  his  height  is  5  feet  9  inches  ;  his  limbs  are  thin  ; 
throughout  the  body  the  muscles  are  more  or  less  flabby, 
notably  in  the  upper  extremities,  but  nothing  to  be  called 
atrophy  ;  the  legs  are  liable  to  swell  slightly  during  the 
day  ;  the  arms  are  more  liable  to  be  swollen  after  sleep. 

The  patient,  an  accomplished  physician,  declares  the 
swelling  not  to  be  at  any  time  oedematous.  It  offers  slight 
resistance  to  pressure,  and  but  a  part  of  the  swelling  is  due 
to  serum. 

There  is  an  appearance  of  yellow  pallor  about  him 
which  caused  me  to  request  Dr.  John  K.  Mitchell  to  make 
an  examination  of  the  blood.  The  result  surprised  me. 
The  corpuscles  amount  to  3,980,000  per  C.  C.  M.;  the  color- 
ing matter  is  75  per  cent,  of  the  normal,  by  Fleischl's  test. 
Certainly  the  appearance  of  the  skin  would  seem  to  indicate 
a  want  of  blood  not  shown  to  exist  by  accurate  test,  re- 
peated again  and  again.  This  condition  of  things  I  have 
several  times  seen  in  post,  sclerosis,  a  not  excessive  want 
of  color  or  corpuscles,  and  a  whiteness  of  skin  and  mucous 
surfaces,  which  once  we  would  have  accepted  as  sure  evi- 
dence of  anaemia. 

Sensation. — There  is  no  pain  of  the  character  of  neural- 
gia. He  says  that  since  his  boyhood  he  has  been  liable  to 
aches  in  the  great  trochanter  and  between  the  shoulders. 

Touch. — At  a  half  inch  the  compass  points  begin  to  be 
felt  as  two  in  the  finger  of  either  hand.  There  is  no  re- 
markable difference  between  the  two  hands.  The  sensation 
of  numbness  with  which  the  disease  began  are,  perhaps, 
more  pronounced  in  the  legs  now  than  at  first  ;  but  about  the 
clavicles  the  sensation  in  all  kinds  appears  to  be  normal; 
also  it  is  fair  for  heat  and  cold,  but  decisions  as  to  these  are 
ess  rapid  in  the  arms  than  in  the  legs.  The  pain  sense  is 
verywhere  preserved.     I  ought  to  add  that  when  the  left 


L  OCOMO  TOR  A  TAXI  A.  2  2  -. 

hand  is  chilled  it  is  apt  to  cause  pain  to  run  up  the  arm  on 
that  side.     The  special  senses  appear  to  be  normal. 

Dr.  G.  E.  de  Schweinitz  gives  the  following  statement 
of  the  eye  conditions  :  "Vision  in  each  eye  with  correcting 
glasses,  normal  ;  no  disturbances  of  accommodation  and 
his  reading  glasses  allow  comfortable  range  ;  3  degrees  of 
insufficiency  of  the  interni ;  no  other  muscular  anomalies, 
except  slight  drooping  of  the  right  upper  eyelid.  Pupils 
present  normal  reactions  for  light  and  accommodation ; 
ophthalmoscope  shows  fine  floating  vitreous  opacities  ;  dis- 
tinctly gray  optic  discs  with  hazy  edges  and  general  epithe- 
lial choroiditis.  Form  fields  are  normal  ;  there  is  concen- 
tric contraction  of  the  color  fields.  From  these  facts  I 
conclude  that  there  is  beginning  gray  degeneration  of  the 
optic  nerves,  as  well  as  the  disturbances  of  the  chroid  and 
vitreous  humor." 

Motion. — Motion  is  generally  weak  ;  when  he  walks  any 
distance  he  moves  slowly,  and  in  action  the  arms  tire 
more  easily  than  the  legs.  He  stands  well  with  his  eyes 
open  ;  but  with  his  eyes  shut  he  sways  one  inch  to  the  right 
and  an  inch  and  a  half  forward,  so  that  his  station  may  be 
stated  to  be  good  for  a  man  in  his  condition.  It  certainly 
shows  how  little  ataxic  trouble  there  is  in  the  lower  limbs. 
He  moves  the  legs  well,  and  the  common  actions  of  the  feet 
exhibit  little  inco-ordination  in  these  parts.  On  the  other 
hand,  the  upper  limbs  are  awkward  in  their  movements. 
There  is  a  great  lack  of  co-ordination  in  every  effort  to  make 
delicate  adjustments,  as  when  he  attempts  to  touch  his  nose 
or  ear  with  the  eyes  shut,  or  to  bring  the  forefinger  of  his 
right  hand  in  contact  with  the  tip  of  the  little  finger  of  the 
left  hand.  He  fails  also  in  the  test  of  weights  ;  he  is  un- 
able to  tell  the  difference  between  an  ounce  placed  in  his 
palm  and  a  half  ounce,  or  an  ounce  and  a  half.  I  took 
tracings  of  his  efforts  to  hold  a  pencil  steady.  They  showed 
no  tremor — less  than  is  common,  and  this  negative  symp- 
tom is  a  remarkable  one  in  ataxics.  The  effort  to  draw  a 
from  right  to  left  resulted  in  a  singular  illustration  of  dejec- 
tive  co-ordination. 

Electrical  Reactions. — There    are   no   unusual   peculiari- 
ties. 


„,  5.    WEIR  MITCHELL. 

224 

Muscular  Reaction. — All  the  muscles  of  the  arms  react 
to  a  direct  blow,  but  are  incapable  of  being  reinforced  by 
motion.  The  leg  muscles  have,  as  I  judge,  about  the  nor- 
mal amount  of  response  to  the  hammer  blow,  but  are  read- 
ily reinforced  by  hand  motions. 

It  is  interesting  to  contrast  these  conditions  of  the  leg 
and  arm  muscles.  Elbow  jerk  is  lost  on  both  sides,  and 
non-reinforcible  by  motion  or  sensation.  Knee  jerk  is  ex- 
cessive on  both  sides  and  is  easily  reinforced.  Ankle  jerk 
is  also  extreme,  and  when  powerfully  reinforced  a  slight 
clonus  exists.  Thus,  if  the  tip  of  the  foot  be  pushed  upward 
so  as  to  stretch  the  tendo  Achillis,  the  blow  on  it  results  in 
two  or  three  forward  movements  of  the  foot  at  the  same 
time,  the  patient  makes  a  powerful  motor  reinforcement.  I 
remark  in  this  case,  as  I  have  done  in  others,  that  a  blow  on 
the  left  patellar  tendon  gives  rise  to  motion  in  the  left  leg, 
also  to  what  seems  to  be  a  reflex  jerk  of  the  left  arm.  I 
suspect  that  this  phenomena  is  due  to  the  strong  reinforce- 
ments produced  by  emotion  ;  for,  while  it  is  frequently  seen 
in  the  first  interview  with  the  patient,  it  may  be  impossible 
to  evolve  it  at  another  sitting. 

Secretions. — Generally  normal  ;  occasional  diarrhcea  ; 
no  painful  gastric  crises.  There  is  no  trouble  with  the 
bladder  or  rectum.     Sexual  power  is  lost. 

Skin  irritations  of  the  soles  of  the  feet  appear  to  cause 
no  motion.  Testicle  reflexes  absent,  as  also  abdominal 
reflexes. 

Remarks. — This  case  stands  alone  in  my  experience.  It 
is  a  locomotor  ataxia  beginning  in  the  arms.  These  lose 
their  tendon  reactions,  but  show  excess  of  direct  mechan- 
ical excitability.  In  the  legs  we  find  excessive  knee  jerk 
and  normal  mechanical  responses.  The  conditions  seen  in 
common  cases  of  ataxia  are  here  reversed.  I  have  little 
doubt  that  in  the  earliest  stages  of  this  disease  the  tendon 
reactions  are  excessive. 


PARANOIA:    SYSTEMATIZED    DELUSIONS  AND 
MENTAL  DEGENERATIONS. 

AX    HISTORICAL   AND   CRITICAL    REVIEW, 
By  J.   SEGLAS, 

ASSISTANT   PHYSICIAN    TO   THE    HOSPITAL   OF    BICBTRE,    PARIS. 

Translated  by  William  Noyes,  M.D., 

ASSISTANT    PHYSICIAN   TO   THE    BLOOMINGDALE   ASYLUM,  NEW    YORK. 

[Continued  from  last  Number.} 

THE  acute  form  of  primary  hallucinatory  paranoia  begins 
with  a  prodromal  period  ot  insomnia,  irritability,  or 
depression ;  but  sensorial  troubles  (of  hearing  or 
smell)  develop  unexpectedly,  together  with  sudden  delusions 
of  grandeur  and  of  persecution,  either  combined  together  or 
alternating,  and  accompanied  by  excitement ;  a  period  of 
quiet  may  follow,  but  the  hallucinations  persist  with  ideas  of 
poisoning,  persecution,  etc.  This  acute  form  may  terminate 
in  recovery  or  may  pass  into  the  chronic  state.  It  may  fol- 
low acute  diseases,  such  as  the  puerperal  state,  hysterical  or 
epileptic  attacks,  or  the  abuse  of  alcohol  or  morphine. 

The  chronic  form  is  especially  characterized  by  the  per- 
sistence of  the  sensorial  troubles,  illusions,  and  hallucina- 
tions, with  a  fixed  delusion  of  persecution.  The  most 
important  variety  is  hypochondriacal  paranoia.  In  fact, 
Mendel  returns  to  the  acute  form,  upon  which  he  insists  ; 
and,  on  the  other  hand,  he  greatly  limits  the  degenerative 
element  in  the  systematized  delusions,  since  he  recognizes  as 
a  distinct  form  only  the  idiopathic  {originare)  variety  of  pri- 
mary paranoia.  Finally,  he  also  admits  secondary  paranoia 
in  his  classification,  but  at  the  same  time  entirely  transfers 
it  to  the  second  scheme. 


225  7-  SEGLAS. 

In  another  work*  he  had  already  insisted  on  its  rarity 
(five  cases  in  one  hundred  and  fifty).  Yet  he  reports  in  his 
memoir  three  observations  of  secondary  paranoia  developed 
secondary  to  primary  melancholic  syndromes,  and  to  all 
appearance  reaching  the  full  limit  of  their  evolution.  He 
describes  the  resemblance  that  exists  between  the  delu- 
sional conceptions  of  melancholiacs  and  those  of  the  system- 
atized insanities.  The  difference  is  that  the  one  class  find 
in  themselves  the  material  for  their  complaints  and  accusa- 
tions, while  the  others  draw  it  from  the  external  world. f 

Meyser+  (1885),  returning  to  the  study  of  the  hallucinatory 
delusion  (Wahnsinn)  of  Krafft-Ebing,  whose   ideas  he   fully 

0  Mendel,  Ueber  secondare  Paranoia  (Berliner  Gesellschaft  f.  Psych,  und 
Nerven.  Sitzung,  9  Avril,  1883. — Neurologisches  Centralblatt,  No.  5,  1883). 

f  At  the  conclusion  of  the  reading  of  this  paper  before  the  Society  of  Psychi- 
atre  and  Nervous  Diseases  of  Berlin  (April,  1883),  a  discussion  followed  at  the 
session  of  June,  1883,  which  we  think  it  will  be  interesting  to  resume,  Jastrowitz 
said  that  he  had  never  seen  true  melancholia  change  into  systematized  insanity; 
but  he  had  seen  some  patients  with  systematized  insanity  at  advanced  period  of 
their  disease  (dementia)  have  hypochondriacal  melancholy  symptoms. 

Westphal,  recognizing  fully  that  melancholiacs  generally  accuse  themselves, 
had  also  observed  it  in  systematized  insanity.  It  is  not  the  character  of  the  ideas 
but  their  genesis  that  is  of  greatest  importance.  As  in  Mendel's  cases,  a  certain 
interval  elapses  between  the  existence  of  the  melancholia  and  the  time  of  the  ap- 
pearance of  the  ultimate  systematized  insanity,  and  it  might  be  thought  that  the 
same  individual  had  been  successively  attacked  by  different  independent  psycho- 
ses. For  these  very  same  facts,  where  the  establishment  of  a  direct  connection 
appears  to  be  clearly  justifiable,  are  open  to  the  following  objections  :  where  the 
systematized  insanity  has  the  appearance  of  taking  its  origin  in  a  melancholia, 
hypochondriacal  ideas  are  always  prominent  at  the  same  time;  now,  these  last 
have  invariably  constituted  the  point  of  departure  of  ultimate  conceptions  of  the 
systematized  insanity.  Moeli  held  that  the  character  of  the  ideas  alone  sufficed 
for  the  diagnosis  between  melancholia  and  systematized  insanity.  Mendel  replied 
that  it  was  the  genesis  of  the  conceptions  that  he  insisted  on.  The  interval  that 
elapsed  between  the  melancholia  and  the  systematized  insanity  had  never 
been  in  his  patients  a  period  of  perfect  health,  and  the  new  psychical  complexus 
had  been  shown  from  the  first  week  after  the  melancholic  state.  It  is  extremely 
difficult  to  demonstrate  the  psychopathic  connection  for  each  particular  case,  but 
one  of  them  i*  clear  (a  female  melancholiac  began  all  at  once  to  accuse  her  parents 
and  to  have  later  ideas  of  grandeur  and  of  persecution);  without  doubt  two  of  the 
observations  gave  evidence  of  hypochondriacal  conceptions  which  dominated  the 
scene,  but  who  can  determine  tin-  line  of  demarkation  between  pure  melancholia 
and  hypochondriacal  melancholia?     (See  Arch,  de  Neur.,  1884,  No.  23.) 

\  Aleyser,  Wahntmn  hallucinatorischer  (All.  Zeitsch.  f.  Psych.,  Bd.  xlii,  1, 
1885):  This  would  be  a  general  delusion  of  the  asthenic  order,  similar  to  the  post- 
febrile psychoses  of  Kroeprlin,  sometimes  acute,  sometimes  chronic,  resembling 


PARANOIA.  2  2  ~ 

shares,  finds  however  that  the  expression  of  this  author  is 
not  happy  since  alienists  do  not  agree  whether  they  ought 
to  call  paranoia  Wahsinn  or  Verriicktlieit,  and,  on  the  other 
hand,  the  actual  language  identifies  Wahnsinn  with  Verriickt- 
heit,  while  hallucinatory  Wahnsinn  differs  completely  from 
paranoia.  It  is  therefore  necessary  to  find  a  special  title  for 
this  well  characterized  malady. 

In  this  scheme,  Meyser  makes  the  hallucinatory  mania 
■of  Mendel,  the  disorder  in  the  hallucinatory  ideas  of  Fristh, 
the  disorder  in  the  pseudo-aphasic  ideas  (Meynert,  Schlan- 
genhausen),  and  the  disorder  in  the  curable  hallucinatory  or 
acute  primary  ideas  (Meynert  and  Fristh),  identical  in  them- 
selves with  the  acute  Verriicktlieit  of  Westphal,  the  acute 
systematized  delusion  (Acuter  Wahnsinn)  of  Schaefer,  the 
first  group  of  acute  partial  insanity  of  Kretz,*  the  delusions 
of  exhaustion  of  Voigt,  and  the  case  of  primary  systematized 
insanity  of  M.  Buch. 

Witkowskif  (1885)  devotes  an  entire  treatise  to  the  nos- 
ography  of  Verriicktlieit  in  its  connections  with  melancholic 
depression.  The  fundamental  process  of  Verriicktlieit,  he 
says,  is  always  the  production  of  delusional  ideas  with  ten- 
dencies to  systematization.  But,  by  the  side  of  this  process, 
certain  phenomena  from  time  to  time  may  come  in  a  perma- 
nent manner  to  occupy  the  first  place,  and  of  such  a  nature 
that  it  is  necessary  to  reserve  for  them  a  separate  place  in 
the  terminology,  instead  of  inventing  such  terms  as  hypo- 
chondriacal hallucinatory,  stuforous,  and  melancholie  Ver- 
rucktheit,  which  are  all  forms  that  do  not  exclude  one  an- 
other, but  may  exist  concurrently  or  succeed  each  other. 

There   exists  also  an   illusionary  Verrucktheit,  in   which 

the  maniacal  form  of  agitation  with  disorder  in  the  ideas,  and  ideas  of  persecution, 
based  upon  multiple  hallucinations  and  slight  intellectual  weakness,  or  that  of 
periodic  insanity. 

*  Kretz,  XVe  Congress  des  Alienistes  de  FAilemagne  du  sud-oest.  Session  at 
Carlsrhue,  Uctober,  1882. 

This  group  is  characterized  by  the  primary  appearance  of  hallucinations  or 
illusions,  while  in  the  second  group  it  is  the  delusion  that  controls  the  scene,  the 
hallucinations  coming  afterwards  reinforce  this  and  sustain  it  as  in  the  chronic 
forms  of  primary  systematized  insanity. 

fWitkowski,  Congres  annuel  des  Medians  a/iemstes  Allemands.  Session  at 
iJaden,  1885.     (Allg.  Zeitsch.  f.  Psych.,  Bd.  xlii.,  6,  1886. 


22g  J.   S  EG  LAS. 

the  hallucinations  of  hearing  and  the  hypochondriacal  com- 
plaints lose  their  importance  in  comparison  with  the  forget- 
fulness  of  persons  and  things  ;  while,  at  the  same  time, 
transiently  or  permanently,  the  depression  may  play  a  fun- 
damental role.  There  exists,  in  addition,  a  form  intermediate 
to  true  melancholia  and  Verrucktheit.  These  are  the  people 
permanently  depressed  (those  who  are  constantly  making 
negatives,  the  sceptics,  the  damned,  and  the  ones  who  are 
rotting). 

But  in  the  majority  of  cases  it  is  the  Verrucktheit  which 
constitutes  in  them  the  basis,  which  gives  rise  to  the  ideas, 
systematizes  them,  and  brings  about  the  abnormal  concep- 
tions and  the  modifications  of  temperament  absolutely  inde- 
pendent of  the  melancholia.  The  Verrucktheit  brings  about 
a  condition  of  mental  debility. 

Such  are  these  cases  of  systematized  insanity,  which  are 
partial  and  stationary  (among  the  persecuted  whose  intelli- 
gence preserves  for  a  long  time  a  high  degree  of  vigor),  and 
by  the  side  of  these  cases  are  found  some  forms  of  progres- 
sive systematized  insanity,  generally  tending  to  dementia. 
Very  often  also,  among  the  congenitally  weak,  delusional 
ideas  are  found  more  or  less  distinct,  sometimes  reaching  a 
high  degree  of  systematization,  at  other  times  degenerating 
into  absurd  and  fanciful  creations.  The  author  concludes 
that,  in  fact,  Verrucktheit  is  an  insanity  with  concrete  per- 
manent delusional  ideas,  with  a  tendency  to  systematization 
that  is  more  or  less  clearly  marked  and  more  or  less  per- 
fect. We  may  note  here  the  work  of  Vejas*  (1886)  upon 
epilepsy  and  systematized  insanity,  and  that  of  Schmidtt 
upon  systematized  morphine  insanity,  analogous  to  alco- 
holic. We  have  already  seen  these  forms  described  by 
Gnauck,  Moeli,  and  those  distinguished  by  Krafft-Ebing. 

•Vejas,  Epilepsie  und  Verruckthtil  (Arch.  f.  Psych.,  Bd.  xviii,  i,  i886>. 
t  Schmidt  (Arch.  f.  Psych.,  Bd.  xvii,  1886). 

[To  /'C   Con /in  lot1. 


OCULAR     SYMPTOMS     IN     DISEASES     OF     THE 
SPINAL    CORD* 

By  WILLIAM  OLIVER  MOORE,  M.D. 

PROFESSOR   OF   THE  DISEASES   OF  THE  EYE   AND    BAR    IN   THE  NEW   YORK   POST-GRADUATB  MEDICAL 
SCHOOL  AND   HOSPITAL,  ETC.,  ETC. 

OF  Nature's  minute  wonders  the  human  eye  is  the 
paragon.  But  it  is  not  the  apparatus  which  the  delicate 
knife  of  the  anatomist  reveals,  the  retina  and  lenses, 
or  even  their  combined  arrangement,  that  most  strikingly 
indicates  the  subtile  workmanship  involved  in  the  little 
fleshy  globule  we  call  the  eye  ;  it  is  the  effects  they  pro- 
duce, the  purposes  they  subserve,  the  results  they  accom- 
plish. Far  greater  are  these  than  the  careless  crowd  dream 
of,  or  the  imaginative  fully  realize.  The  phenomena  of 
sight  is  indeed  sufficiently  extraordinary  ;  not  less  so  are 
the  minor  missions  which  the  visual  organ  fulfils.  The  eye 
speaks  with  an  eloquence  and  truthfulness  surpassing  speech. 
It  is  the  window  out  of  which  the  winged  thoughts  often  fly 
unwittingly.  It  is  the  tiny  magic  mirror  on  whose  crystal 
surface  the  moods  of  feeling  fitfully  play,  like  the  sunlight 
and  shadow  on  a  stream.  How  aptly  has  the  eye  been 
called  the  "window  of  the  soul"  ;  instinctively  it  is  raised 
in  devotion,  and  bent  downward  in  shame.  When  enthusi- 
asm lends  fire  to  the  soul  the  eye  flashes  ;  when  pleasure  stirs 
the  heart  the  eye  sparkles  :  when  deep  sorrow  darkens  the 
bosom  the  eye  dispels  hot  tears  ;  when  confidence  stays  the 
mind,  the  eye  looks  forth  proudly  ;  when  insanity  desolates 
the  brain,  the  eye  roves  wildly  ;  and 

"  O'er  the  eye  Death  most  exerts  his  might, 
And  hurls  the  spirit  from  its  throne  of  light. ' ' 

°  Read  before  the  Section  on  Neurology,  N.  Y.   Academy    of  Medicine, 
March  9,  1888. 


2  WILLIAM  OLIVER  MOORE. 

Eye  language  is  thus  a  part  of  our  study  in  medicine,  and 
should  be  more  generally  understood  than  it  is,  not  in  dis- 
eases of  the  brain  and  cord,  but  in  general  affections.  The 
unfortunate  know  a  friend  and  are  reassured  ;  the  timid 
recognize  a  master  spirit  and  are  strengthened  ;  the  guilty 
know  their  accuser,  and  quail.  Beware  of  the  man  whose 
eye  you  can  never  meet. 

That  the  eye  should  show  changes  in  the  diseases  affect- 
ing the  brain,  with  which  it  is  so  closely  connected,  is  clear, 
but  why,  in  those  situated  in  the  spinal  cord,  it  is  not  quite 
so  easy  to  comprehend.  Ever  since  the  diseases  of  the 
"golden  bowl"  have  been  the  subject  of  close  study,  ocular 
symptoms  have  been  noticed,  and  of  late  years  these  same 
symptoms,  associated  with  affections  of  the  "silver  cord," 
have  claimed  much  attention  and  enquiry. 

I  regret  that  I  am  unable  to  make  any  new  contribution  to 
our  knowledge  of  the  pathological  anatomy  of  these  dis- 
eases, but  hope  that  in  the  discussion  it  may  be  evoked. 

In  enteringthis  vast  and  interesting  field  one  must  be  very 
careful  to  make  minute  and  accurate  observations,  especially 
in  reference  to  pupillary  signs,  as  Iwano  has  found  that 
out  of  134  young  persons  examined,  131  had  assymetry  of 
the  face,  and  that  the  pupils  were  irregular  in  122  :  and  that 
the  largest  pupil  occurred  most  frequently  on  the  left  side, 
which  was  usually  the  smaller  side  of  the  face. 

We  shall  not  attempt  to  cover  the  above  field,  which  the 
title  of  the  paper  indicates,  but  only  take  up  certain  points 
that  have  always  interested  us. 

Your  attention  will  be  more  particularly  called  to  atrophy 
of  the  optic  nerve,  and  ophthalmoplegia  interna,  with  but 
only  a  passing  notice  to  ophthalmoplegia  externa,  and 
nystagmus. 

Atrophy  of  the  optic  nerve  comes  chiefly  under  the  notice 
of  the  ophthalmologist,  while  the  affections  of  the  iris  more 
commonly  under  the  observation  of  the  physician. 

The  ocular  symptoms  in  spinal  cord  disease  are  to  be 
looked  upon  as  associations  and  not  as  effects  ;  and  that 
they  are  also  always  the  result  of  degenerative  processes  in 
the  cord. 


DISEASES  OF  THE  SPINAL  CORD.  2 -,  T 

The  usually  slow  progress  of  the  spinal  symptoms  is  evi- 
dence of  this  fact. 

Among  the  many  degenerative  diseases  of  the  cord  it  is 
strange  that  most  of  the  eye  symptoms  should  be  with  one 
of  them  alone,  with  tabes  dorsalis.  The  fact  that  they  are 
associations  and  not  effects  is  clearly  stated  by  Gowers  in 
the  following  manner  : 

i.  "  That  disease  of  any  nature  may  exist  in  any  part  of 
the  spinal  cord  without  the  occurrence  of  ocular  symptoms, 
if  we  except  the  very  rare  paralysis  of  the  dilators  of  the 
pupil  in  disease  of  the  sympathetic  tract  in  the  cervical 
region. 

2.  "  The  ocular  symptoms  which  may  be  absent  when 
the  cord  disease  is  advanced  may  exist  in  extreme  degree 
when  such  disease  is  in  a  very  early  stage. 

3.  "With  the  single  exception  of  the  sympathetic  symp- 
toms just  mentioned,  we  know  of  no  anatomical  connection 
or  functional  mechanism  by  which  the  spinal  cord  disease 
can  produce  the  ocular  symptoms." 

INJURIES   TO   THE   SPINE. 

Experimentally  in  laboratories,  injuries  to  the  spinal 
cord  of  animals  have  shown  ocular  symptoms,  and  these 
naturally  lead  us  to  expect  similar  results  in  man,  where 
injuries  of  the  spinal  column  have  inflicted  pressure  on  the 
cord. 

Mr.  Erichsen,*  of  London,  has  done  much  to  bring  this 
to  notice,  and  all  but  considered  it  sufficiently  frequent  to 
establish  a  causal  relation  between  the  two  events. 

It  is  stated  on  authority,  that  Alexander  the  Great  was 
in  danger  of  losing  his  eyesight  from  the  blow  of  a  heavy 
stone  on  the  back  of  the  neck.  Thirty-six  per  cent,  of 
Erichsen's  cases  showed  undoubted  eye  symptoms. 

These  are  more  commonly  :  difficulty  of  seeing  in  poor 
light  to  read,  blurring  of  the  type,  floating  bodies  before  the 
eyes,  occasionally  diplopia,  with  photophobia.  The  oph- 
thalmoscopic appearances  are  usually  negative. 

Wharton   Jonest    considers  the   eye   symptoms   in   these 

*  Erichsen,  "Concussion  of  the  Spine,"  London,  1875. 

■J"  "  Failure  of  Sight  after  Railway  and  other  Injuries  of  the  Spine  and  Head," 
London,  1869. 


2  ,  2  WILLIAM  OLIVER  MOORE. 

cases  due  to  the  disturbance  in  the  cilio-spinal  centre,  and 
the  sympathetic  filaments  springing  from  the  dorsal  and 
cervical  cord. 

Other  authors  have  reported  severe  eye  symptoms  from 
comparatively  slight  injuries  of  the  spine. 

I  have  seen  but  two  cases  of  concussion  of  the  spine,  and 
in  each  of  these  eye  symptoms  were  present  in  the  shape  of 
asthenopia.  The  fundus  in  each  case  was  normal,  and  dis- 
tant vision  good,  yet  difficulty  was  experienced  on  reading  ; 
both  were  females,  and  each  had  loss  of  accommodation, 
that  is  to  say,  they  could  not  use  the  ciliary  muscle  long 
without  fatigue,  and  a  convex  glass  had  to  be  given  to 
rectify  this  difficult}-.  In  neither  case  was  muscular  dis- 
turbance of  the  extrinsic  muscles  of  the  eye  found. 

In  Caries  of  the  Vertebra,  when  of  traumatic  origin  we 
frequently  find  intra-ocular  symptoms,  and  the  ophthalmo- 
scope usually  shows  a  condition  of  engorgement  of  the 
vessels  of  the  optic  disc  and  surrounding  parts. 

Dr.  Chas.  S.  Bull  *  reports  the  histories  of  eleven  cases 
of  traumatic  caries  of  the  spine,  mostly  occurring  in  the 
cervical,  but  some  also  in  the  dorsal  and  lumbar  regions. 

Seven  had  engorgement  of  retinal  veins,  with  no  changes 
in  the  arteries  :  in  two  choked  disc  was  noticed,  and  in  two 
anaemia  seemed  to  be  present,  although  the  veins  were 
enlarged. 

I  have  examined  fifteen  cases  of  ocular  disturbance  in 
vertebral  caries  of  traumatic  origin,  and  found  the  following 
conditions:  In  two.  optic  neuiitis,  with  swelling:  three, 
hyperaemia  of  the  disc,  with  blurred  outline,  but  no  oedema  ; 
eight  had  enlarged  veins,  and  arteries  normal  in  size  or  only 
slightly  enlarged,  the  changes  were  symmetrical  in  each 
eye  ;  two  had  floating  bodies  in  the  vitreous,  with  enlarged 
retinal  veins  ;  these  changes  are  probably  due  to  the  sym- 
pathetic filaments  springing  from  the  dorsal  and  cervical 
cord. 

LOO  IMOTOR    A  l  AXIA. 

The  frequency  with  which  optic  nerve  atrophy  occurs  in 
tabes  is  differently  stated  ;   Leber  found  it  present  in  26  per 
0  Trans.  American  Ophthal.  Society,  vol.  ii. 


DISEASES  OF  THE  SPINAL  CORD.  2  ■,  , 

cent.,  Gowers,  in  20  per  cent.,  and  Nettleship,  in  50  per 
cent. 

During  the  past  ten  years  we  have  made  notes  of  80 
cases  of  atrophy  of  the  optic  nerve,  where  no  other  history 
could  be  obtained,  and  of  this  number  32  had  the  signs  of 
tabes  as  shown  by  the  absence  of  the  knee-jerk  ;  18  had 
ataxic  symptoms  when  first  seen.  In  examining  the  re- 
ports of  many  of  the  ophthalmic  hospitals  of  this  country, 
we  are  unable  to  tell  the  proportion  of  optic  nerve  diseases 
due  to  locomotor  ataxia,  owing  to  the  method  of  recording 
diagnoses.  Erb  found  only  12  y2  per  cent,  of  his  cases  to 
have  atrophy  of  the  optic  nerve  ;  so  that,  although  it  is  ad- 
mitted by  all  writers  as  a  frequent  association,  the  percentage 
is  at  great  variance.  It  has  been  said  that  the  percentage 
given  by  the  ophthalmologist  is  too  high  :  I  do  not  think 
so,  but  rather  that  it  is  due  to  the  fact  that  the  patient  seeks 
advice  for  failing  vision,  when  no  signs  of  ataxia  are  yet 
present,  and  that  the  observers  being  on  the  alert  for  a  cause 
of  the  optic  atrophy,  enter  into  an  examination  of  the  gen- 
eral condition  of  the  patient  and  discover  tabetic  symptoms. 
I  know  this  has  been  my  personal  experience  in  this  direc- 
tion. Atrophy  of  the  optic  nerve  belongs  to  the  more 
frequent  of  the  complications  of  tabes  ;  it  commonly  arises 
in  the  initial  stage,  and  may  be  the  first  manifestation  ;  the 
amblyopia  produced  by  it  may  last  for  as  many  as  ten  years, 
before  other  symptoms  of  tabes  appear,  as  in  the  case  re- 
ported by  Charcot.  Gowers  has  also  reported  similar  cases  ; 
in  one  the  optic  atrophy  preceded  the  locomotor  symptoms 
twenty  and  in  another  fifteen  years.  That  optic  atrophy 
ever  occurs  before  the  loss  of  the  knee  jerk,  I  am  not  satis- 
fied ;  in  all  the  cases  under  my  observation  it  was  absent — 
and  I  believe  it  is  well  recognized  that  the  loss  of  the 
knee  jerk  may  precede  for  a  long  time  other  locomotor 
symptoms. 

When  the  disease  was  supposed  to  be  situated  and  limited 
in  the  posterior  columns  of  the  cord,  the  association  with  it 
of  a  peripheral  degeneration  of  the  optic  nerve  was  an 
anomaly.  But  since  the  recent  pathological  researches  of 
Pierret,  who  has  shown  that  the  degeneration  of  the  optic 


.,  „,  WILLIAM  OLIVER  MOORE. 

nerve  is  not  the  only  peripheral  lesion,  and  that  that  in  the 
cord  is  not  the  only  central  change.  He  has  shown  that 
there  is  often  an  independent  degeneration  in  the  cutaneous 
nerves,  commencing  in  the  extremities,  and  that  the  optic 
nerve  change  is  strictly  analogous  ;  that  there  may  also 
exist  a  degeneration  at  the  central  termination  of  the  optic 
as  well  as  of  other  cranial  nerves,  similar  to  that  existing  in 
the  posterior  columns  of  the  cord.  From  his  standpoint 
tabes  is  considered  a  "wide  sensory  neurosis,"  in  the  course 
of  which  the  optic  nerve  atrophy  occurs.  Dejerine  and 
Westphal  have  also  enlarged  our  former  narrow  concep- 
tions of  the  tabetic  process.  During  the  period  when  there 
is  no  affection  of  the  patient's  gait,  and  only  the  loss  of  the 
patellar  reflex,  unsteadiness  on  standing  with  bare  feet  close 
together,  with  closed  eyes,  and  with  lightning  pains,  there 
is  no  doubt  that  optic  atrophy  often  commences  and  ad- 
vances to  a  considerable  degree,  and  according  to  Gowers, 
it  occurred  during  this  period  twice  as  frequently  in  this 
than  the  later  stages  of  the  affection.  In  my  cases,  14  out 
of  32  had  only  loss  of  knee  jerk  and  rheumatic  pains  in  the 
legs.  It  is  rare  for  it  to  occur  when  the  ataxia  is  so  great 
that  the  patient  cannot  walk. 

The  atrophy  usually  begins  in  one  eye  before  the  other, 
and  may  reach  a  considerable  degree  before  the  fellow-eye 
suffers.  The  immediate  cause  of  the  amblyopia  in  tabes  is 
the  gray  degeneration  of  the  optic  nerves — a  degeneration 
similar  in  all  respects  with  the  changes  in  the  spinal  cord. 
One  disease  begins  at  the  periphery  of  the  trunk  of  the  optic 
nerve,  and  gradually  attacks  the  central  fibres  ;  it  always 
begins  on  the  trunk  of  the  nerve  or  the  portion  nearest  the 
eye,  and  from  thence  toward  the  optic  tract.  The  narrow- 
ing of  the  visual  field  would  lead  us  to  this  conclusion,  had 
not  post-mortem  changes  already  shown  this  condition. 

The  disease  of  the  optic  nerve  manifests  itself  by  diminu- 
tion in  the  acuteness  of  vision  ;  the  field  which  is  at  first 
normal  becomes  gradually  narrower,  the  field  being  irregu- 
larly contracted.  The  color  field  is  usually  limited  before 
the  visual,  the  perception  of  green  being  lost  first,  then  red, 
and  then  yellow  and  blue.     Ophthalmoscopic  examination 


DISEASES  OF  THE  SPINAL  CORD.  2  ,  r 

shows  in  the  early  stages  a  dirty-looking  nerve,  which  is  in- 
dicative of  a  low  grade  of  neuritis,  and  this  continuing  pro- 
duces the  final  full  marked  appearances  of  white  atrophy 
of  the  optic  nerve,  with  narrow  arteries  and  other  parts  of 
the  fundus  appearing  normal. 

The  optic  nerve  atrophy  occurring  in  tabes  is  usually 
progressive,  and  leads  to  complete  blindness,  though  I  have 
seen  two  cases  where  vision  was  not  completely  destroyed. 
And  one  may  observe  no  ophthalmoscopic  change  in  the 
fundus,  and  yet  amblyopia  of  a  high  grade  present  ;  in  such 
cases  doubtless  degeneration  is  retro-bulbar. 

The  next  most  frequent  ocular  symptom  in  tabes  is  the 
pupillary  change.  Of  the  four  muscular  actions,  contraction 
of  the  pupil  on  stimulation  of  the  optic  nerve,  contraction 
of  the  sphincter,  in  association  with  that  of  the  ciliary  and 
internal  recti  muscles,  and  contraction  of  the  dilator  fibres 
of  the  iris  on  stimulation  of  the  skin,  and  contraction  of 
the  ciliary  muscle  on  accommodation,  some  or  all  may  be 
lost  in  association  with  spinal  disease.  These  changes  de- 
pend upon  or  leave  three  centres  capable  of  separate  action, 
all  of  which  probably  lie  in  the  tract  beneath  the  aqueduct 
of  Sylvius.  Experiments  made  by  Hensen  make  it  likely 
that  the  anterior  portion  of  the  tract  governs  accommoda- 
tion, and  the  centre  next  behind  it  the  reflex  contraction  of  the 
iris.  On  the  outer  side  of  the  latter  is  a  centre  on  which 
depends  the  reflex  sensory  dilatation  of  the  pupil.  The 
efferent  path  of  the  two  former  are  through  the  third  nerve. 
As  yet  we  know  little  as  to  the  centre  for  the  contraction  of 
the  iris  which  is  associated  with  accommodation,  not  know- 
ing whether  the  nucleus  for  the  ciliary  muscle  is  connected 
with  the  mechanism  for  contraction  of  the  pupil  at  the 
centre,  or  in  the  lenticular  ganglion,  or  in  the  ganglionic 
mechanism  within  the  eye.  It  is  more  probable  that  the 
connection  is  in  the  lenticular  ganglion. 

The  path  by  which  stimulation  of  the  skin  causes  reflex 
dilitation  of  the  iris  is  circuitous.  The  afferent  impulse 
reaches  the  centre  by  the  cervical  part  of  the  spinal  cord 
when  the  skin  of  the  neck  is  stimulated,  and  the  efferent 
impulse  descends  the  cervical  cord  thence  to  the  superior 


2-,  6  WILLIAM  OLIVER  MOORE. 

thoracic  ganglion  of  the  sympathetic,  and  then  ascends  the 
sympathetic  to  the  eye. 

These  pupillary  symptoms  are  as  common  in  tabes  as 
they  are  rare  in  other  spinal  diseases. 

The  most  common  being  the  loss  of  reflex  action  to 
light,  while  the  pupil  still  contracts  to  accommodation,  the 
"  Argyll-Robertson  "  pupil  or  reflex  iridoplegia. 

Associated  with  this  symptom  is  also  a  loss  of  the  dilita- 
tion  of  the  pupil  on  stimulation  of  the  skin.  Next  in 
frequency,  but  very  much  less  common,  is  paralysis  of  all 
the  intrinsic  muscles  of  the  eye,  the  ophthalmoplegia  interna 
of  Hutchinson. 

The  rarest  is  loss  of  accommodation,  cycloplegia,  with- 
out loss  of  reflex  action. 

If  we  embrace  all  of  the  pupillary  symptoms,  both  slight 
and  transitory,  and  the  more  profound,  we  will  find  them 
present,  according  to  Erb,  in  more  than  one-half  of  all 
tabetic  cases.  Gowers,  in  72  cases  of  primary  degenerative 
ataxia,  found  the  internal  muscles  of  the  eye  affected  in 
92  per  cent. 

The  percentage  of  his  cases  with  pupillary  signs  was  in 
the  first  stage  84,  in  the  second  93,  and  in  the  third  100. 

In  forty-one  of  our  own  cases  already  spoken  of,  the 
"  Argyll-Robertson  "  pupil  was  present. 

When  the  light  reflex  is  lost  the  pupils  are  often  small, 
but  not  necessarily  so. 

When  there  is  loss  of  accommodation  they  are  rarely 
very  small,  less  than  2^  mm.,  and  are  often  4  or  5  mm.  in 
diameter. 

The  reflex  dilatation  of  the  pupil  when  the  skin  is  stimu- 
lated is  a  phenomenon  closely  allied  to  the  contraction  of 
arteries,  which  may  be  produced  in  animals  by  the  stimulus 
of  pain.  The  dilatation  of  the  pupil  may  be  obtained  by 
irritating  the  skin  of  the  face  or  the  neck  ;  it  is  double,  that 
is,  the  stimulation  of  one  side  causes  dilatation  of  both 
pupils. 

The  skin  reflex  is  usually  absent  when  the  light  reflex  is 
lost  ;  the  skin  reflex  may  be  retained  when  cycloplegia  is 
present. 


DISEASES  OF  THE  SPINAL  CORD.  2\'7 

Dr.  Hughlings  Jackson  has  reported  a  case  where  vision 
was  absolutely  lost  by  optic  atrophy,  in  whom  the  "  Argyll- 
Robertson  "  pupil  existed,  and  when  the  patient  "made 
believe "  look  at  the  clouds  the  pupil  enlarged,  and  con- 
tracted when  he  made  the  effort  to  look  at  a  near  object. 

In  examining  the  reflex  dilatation  which  accompanies 
stimulation  of  the  skin,  precaution  as  follows  should  be  ob- 
served :  the  eye  should  be  shaded  from  a  glare  of  light, 
voluntary  movements  on  the  part  of  the  patient  should  be 
arrested  during  the  test,  as  any  movements  being  made  the 
pupils  being  shaded  will  cause  dilatation  of  the  pupils. 

Urthoff *  found  reflex  immobility  of  the  pupil,  combined 
with  preservation  of  reaction  on  convergence,  in  67  per  cent, 
of  all  tabetic  cases,  and  also  the  pupils  were  found  to  be  un- 
equal in  one-fourth  of  the  cases  ;  one-sided  cycloplegia  was 
found  in  only  five  out  of  166  cases.  Reflex  immobility  of 
the  pupil,  without  reaction  on  convergence,  was  found  in 
thirty  cases. 

We  must  not  omit  the  paralysis  of  the  externe  muscles 
of  the  eye,  that  are  so  commonly  seen  in  tabes,  usually 
either  the  abducens  or  the  motor  oculi,  and  rarely  the  fourth 
nerve,  which  give  rise  to  various  symptoms  of  dizziness, 
diplopia  and  strabismus.  Graefe  has  pointed  out  that  tabetic 
patients  show  little  disposition  to  fuse  the  images  in  binocu- 
lar vision,  and  this  is  taken  as  sign  of  the  central  origin  of 
the  affection.  These  muscular  paralyses  are  frequent  in  the 
early  stages  of  the  disease  ;  they  are  transient  often  in  char- 
acter, and  this  fact  has  not  been  very  readily  explained. 
Ptosis  is  also  present  when  no  other  branch  of  the  third 
nerve  is  involved. 

In  203  cases  of  tabes  collected  from  various  sources,  par- 
alysis of  ocular  muscles  occurred  in  52,  or  over  25  per  cent. 

GENERAL   PARESIS   OF   THE   INSANE. 

In  this  disease  ocular  symptoms  are  quite  prevalent  and  in 
great  variety.  Mr.  W.  B.  Lewis,  of  Wakefield,  England,  has 
collected  the  histories  of  sixty  patients,  with  the  following 
result :  Loss  of  reaction  of  the  pupil  to  light,  78  per  cent.; 

♦Berlin,  " Klinisch Wochenschr. "  1886,  No.  3. 


2^g  WILLIAM  OLIVER  MOORE. 

movements  on  accommodation,  associated  iridoplegia,  43 
per  cent.;  reflex  dilatation  to  cutaneous  stimulation  was  lost 
in  63  per  cent.;  complete  fixity  of  the  pupil,  without  impair- 
ment of  accommodation,  was  found  in  15  per  cent.;  in  7  per 
cent,  of  ophthalmoplegia  interna  occurred,  although  it  was 
rarely  complete  as  regards  the  ciliary  muscle. 
He  summarizes  as  follows  : 

1 .  A  loss  of  reflex  dilatation  to  sensory  stimulation  occurs 
in  a  very  large  proportion  of  cases. 

2.  Reflex  iridoplegia  (loss  of  action  to  light)  next  to  the 
preceding  is  the  most  frequent  accompaniment  of  the 
disease. 

3.  Complete  loss  of  movements  of  accommodation  oc- 
curred in  25  per  cent. 

4.  Cycloplegia  associated  with  the  latter  in  four  of  the 
60,  (more  or  less  complete)  and  was  found  only  in  the  ad- 
vanced stages  of  the  disease. 

And  he  concludes  that  the  sequence  of  morbid  phenomena 
occurring  in  the  iris,  is  as  follows  : 

Paralysis  of  reflex  dilitation  to  cutaneous  stimulation, 
reflex  iridoplegia  probably  shown  at  first  by  an  initial  con- 
traction, followed  by  dilitation  under  full  focal  light,  and 
passing  into  a  later  stage  of  immobility,  and  occasionally 
complete,  ophthalmoplegia  interna.  Optic  nerve  atrophy 
occurs,  and  in  22  cases  examined  by  Dr.  Lawford,  London, 
Eng.,  three  were  found  thus  affected. 

Nystagmus  is  associated  with  tabes,  but  is  a  rare  symptom 
in  this  affection,  and  is  usually  found  in  multiple-sclerosis  ; 
it  has  been  ably  set  forth  by  Friedreich,  who  states  that  it  is 
always  bi-lateral,  and  that  the  movements  of  the  eyes  are 
rotatory  and  irregular,  as  seen  in  the  case  presented  to  the 
Society  this  evening : 

Richard  Purcell,  aet.  42,  watchman.  Sent  to  me  by  Dr. 
A.  C.  Coombs,  of  Newtown,  N.  Y.,  Feb.  13,  with  the  follow- 
ing history  :  That  for  the  past  fourteen  months  he  has  no- 
ticed a  difficulty  with  his  eyes  ;  that  they  "jump  "  and  annoy 
him  very  much  by  causing  objects  to  move  rapidly  in  front 
of  him.  Has  no  pain.  In  1872  he  was  struck  on  the  left 
shoulder  by  a  falling  telegraph  pole  ;  this  knocked  him  over 


DISEASES  OF  THE  SPINAL  CORD.  2*g 

and  caused  a  severe  contusion  of  the  arm  and  shoulder,  so 
that  he  could  not  use  it  for  many  weeks,  and  he  never  has 
had  freedom  from  pain  in  it  since,  although  he  has  moderate 
use  of  the  member.  Has  not  used  tobacco  since  1886,  but 
has  used  alcohol  in  moderation. 

Present  condition,  Feb.  13,  1888,  well  nourished  and  all  the 
functions  good.  R.=  f|,  L.=  f§ — 2.5  D,Q — 2.75  D,  cy.  ax.  300. 
Abduction,  8°  ;  adduction,  150  ;  no  vertical  deviation  by 
the  prism  test,  nor  hyperphoria  at  20  feet.  With  the  cor- 
recting glasses  in  position  the  nystagmus  is  the  same  as 
without  them.  There  is  no  contraction  of  the  visual  or  color 
field  as  tested  by  the  perimeter. 

Both  eyes  show  a  marked  nystagmus  both  around  a  trans- 
verse as  well  as  an  antero-posterior  axis,  which  gives  the 
eye  a  peculiar,  swimming  appearance.  When  the  patient 
looks  downward  the  ocular  movements  cease,  as  they  also- 
do  when  he  fixes  the  eyes  on  a  given  object,  but  as  soon  as 
they  are  removed  the  oscillations  begin  with  marked  vigor. 

Pressure  on  the  nape  of  the  neck  by  the  fingers,  or  throw- 
ing the  head  back  so  that  the  neck  impinges  upon  the  collar, 
causes  the  motions  of  the  eye  to  cease.  When  lying-  in  bed 
the  patient  states  the  eyes  are  quiet. 

The  fundus  in  each  eye  shows  a  dirty-looking  optic  nerve, 
but  one  which  would  not  be  considered  abnormal  by  many ; 
yet  I  am  inclined  to  consider  the  nerve  in  a  state  of  neuritis 
of  a  low  grade  which  will  produce  atrophy  ;  the  ophthalmo- 
scopic examination  is  very  difficult,  owing  to  the  rapid 
movements.  The  pupil  responds  to  light  and  accommoda- 
tion. 

The  knee-jerk  is  present  so  far  as  my  testing  has  proved  ; 
the  patient  complains  of  swaying  while  walking,  and  that 
his  feet  do  not  have  the  proper  sensation  on  touching  the 
floor.  I  present  him  as  an  example  of  nystagmus  probably 
due  to  multiple  sclerosis,  from  the  injury  of  the  shoulder 
years  ago. 

It  does  not  occur  during  rest,  but  always  on  an  attempt 
to  fix  the  eye. 

Frederich  considers  it  due  to  a  form  of  ataxy  of  the  move- 
ments of  the  eye,  and  speaks  of  it  as  ataxic  nystagmus,  and  the 


2  «0  WILLIAM  OLIVER  MOORE. 

cause  to  be  due  to  a  disturbance  of  the  co-ordinatory  tracts, 
which  lead  from  the  centres  of  co-ordination  to  the  nuclei  of 
the  nerves  of  the  ocular  muscles  lying  on  the  floor  of  the 
fourth  ventricle,  and  that  it  does  not  occur  in  spinal  disease 
until  the  medulla  is  involved. 

Pierret  explains  these  movements  on  the  ground  of  the 
primary  disease  of  the  sensitive  root  tracts  of  the  trigeminus 
in  the  medulla. 

Nystagmus  is  a  very  common  symptom  of  multiple  scle- 
rosis, and  it  is  increased  by  any  effort  of  the  will  or  any 
violent  emotion  ;  according  to  Charcot  it  is  met  with  in  one- 
half  of  the  cases. 

In  multiple  sclerosis  of  the  cord,  we  have  temporarily  a 
permanent  diplopia  due  to  paralysis  of  the  various  ocular 
muscles  ;  amblyopia  is  also  observed,  but  it  rarely,  as  in 
tabes,  leads  to  positive  blindness,  with  optic  nerve  atrophy, 
although  in  rare  cases  it  does  ;  the  difficulty  is  probably  due 
to  nodules  of  sclerosis  in  the  optic  tracts  and  optic  nerve. 

The  paralyses  of  the  external  muscles  of  the  eye  due  to 
spinal  cord  disease,  we  will  reserve  mention  of  till  a  future 
occasion,  as  the  subject  of  ophthalmoplegia  externa  is  of 
much  scope  and  interest. 


ATAXIC  LATERAL  SCLEROSIS* 

By  J.  G.   PRESTON,   M.  D., 

PROFESSOR  OF  GENERAL  MEDICINE  IN  THE  BALTIMORE  POLYCLINIC. 

UNDER  the  names  Ataxic  Paraplegia,  Combined  Scle- 
rosis, Mixed  Sclerosis  &c,  have  been  described  a 
quite  definite  group  of  symptoms  for  which  I  would 
suggest  the  term  Ataxic  Lateral  Sclerosis.  Since  the  time 
(1875)  that  Erb,  and  soon  after  Charcot,  described  primary 
lateral  sclerosis,  cases  have  been  reported,  possessing 
most  of  the  characteristic  symptoms  of  this  disease,  with 
certain  additions.  Some  of  these  cases  fell  under  spastic 
paraplegia,  others  again  were  described  as  abnormal  cases  of 
posterior  sclerosis. 

No  account  of  this  disease  will  be  found  in  works  on 
general  medicine,  and  few  writers  on  nervous  diseases  (if  we 
except  to  R.  Gowers,  who  has  admirably  described  it)  have 
done  more  than  alude  to  it. 

The  disease  appears  to  be  more  common  in  men  than 
in  women,  and  begins  usually  about  the  thirtieth  year.  So  far 
as  has  been  observed  it  does  not  follow  any  neurotic  ten- 
dency, and  appears  to  be  entirely  unconnected  with  syphilis. 

Most  writers  suggest  over  exertion,  sudden  cooling  of 
the  body,  excesses,  &c,  as  probable  causes.  In  the  case 
which  I  will  relate,  over  exertion  was  the  only  assignable 
cause.  It  is  not  improbable,  as  has  been  suggested,  that 
some  cases  of  sclerosis  are  really  traumatic,  produced  by 
the  rupture  of  spinal  arteries,  with  secondary  degeneration. 

*Read  before  the  Clinical  Society  of  Maryland,  Mar.  16th,  1888. 


2  ,2  J.   G.  PRESTON. 

The  symptoms  of  the  disease  are  usually  easy  to  bring  out. 
There  is  a  history  of  a  tired,  weak  feeling,  beginning  in  the 
legs,  which  lasts  for  months.  The  patient  notices  that  he  is 
more  easily  fatigued,  and  that  his  legs  feel  stiff  on  rising. 
Often  there  is  a  good  deal  of  ataxia  present  at  this  stage, 
and  the  history  will  show  that  the  patient  complains  of 
staggering  when  he  attempts  to  walk  at  night,  and  has  to 
keep  his  eyes  on  the  ground. 

As  the  disease  progresses  spastic  gait  becomes  more  and 
more  marked.  Owing  to  the  over  action  of  the  gastroc- 
nemius the  heel  is  drawn  up  and  the  toe  thrown  forward. 
The  patient  is  thus  obliged  to  adopt  a  "  waddling"  gait,  to 
prevent  the  toe  dragging.  Going  up  and  down  stairs  is  very 
difficult,  and  rough  ground  makes  progress  very  tedious. 
Sometimes,  however,  this  spastic  gait  is  somewhat  modified 
by  the  ataxic  symptoms.  There  is  no  girdle  pain,  or  light- 
ening pains,  so  common  in  posterior  sclerosis,  though  there 
may  be  sensations  of  numbness,  and  slight  pains  in  the  legs. 
Sexual  power  and  control  over  the  sphincters  is  usually 
much  impaired.  The  reflexes,  superficial  and  deep,  are 
greatly  exaggerated.  The  knee  jerk  is  much  increased,  and 
ankle-clonus  is  readily  obtained.  Usually  the  pupils  react 
normally.  As  the  disease  advances  the  spastic  conditions 
become  more  marked,  until  the  slightest  attempt  at  motion 
causes  a  spasm  of  the  extensor  muscles.  Finally  paralysis 
more  or  less  complete  comes  on.  The  arms  are  rarely 
attacked,  but  may  show  to  a  less  degree  the  symptoms  so 
characteristic  in  the  lower  extremities.  As  illustrative  of 
this  disease  I  will  relate  the  following  case,  now  under  my 
care. 

R.  M.,  set.  33,  engaged  in  putting  up  stoves,  ranges,  &c. 
No  neurotic  history  ;  never  had  syphilis  or  rheumatism  ; 
has  always  been  health}-  ;  worked  hard  since  boyhood,  and 
in  the  course  of  his  business  had  much  heavy  lifting. 

About  two  years  ago  he  noticed  that  his  legs  were  get- 
ting weak — had  slight  pains  and  numbness.  Continued  to 
get  gradually  worse  ;  noticed  that  he  staggered  when  at- 
tempting to  walk  at  night.  Sexual  power  has  now  almost 
disappeared,  and  he  has  lost  perfect  control  over  bladder 


A  TAXIC  LA  TERAL  SCEROSIS.  2  .  - 

and  rectum  ;  often  has  cramps  in  his  legs  ;  no  pain  or  ten- 
derness over  spine  ;  no  girdle  sensation.  Sways  slightly 
when  standing  with  eyes  closed,  and  walks  with  difficulty. 
Muscles  are  well  nourished,  and  react  rather  more  than 
normal  to  Faradaic  current.  Gait  spastic  ;  drags  his  toes  ; 
says  he  always  wears  out  his  shoes  at  the  toe — right  leg 
rather  more  affected  than  left — no  impairment  of  sensibility; 
knee  jerk  much  exaggerated,  and  ankle-clonus  well  marked. 

In  this  case,  as  often  happens,  the  ataxic  symptoms, 
prominent  in  the  early  stages,  are  obscured  to  some  degree 
by  the  spastic  and  paralytic  phenomena. 

In  this  particular  case  the  ataxic  symptoms  are  in  the 
background,  while  the  spastic  phenomena  are  prominent. 
The  sensory  and  ataxic  disturbances,  and  the  loss  of  con- 
trol over  the  sphincters  would  tend  to  discredit  the  notion  of 
pure  lateral  sclerosis,  while  the  absence  of  girdle  pain,  or 
in  fact  any  localized  pain,  together  with  the  fact  that  the 
symptoms  appeared  simultaneously  on  both  sides  would 
make  against  the  diagnosis  of  chronic  myelitis. 

While  this  disease  is  hybrid,  so  to  speak,  and  should 
not  be  considered  as  a  perfectly  distinct  affection,  still  it  is 
convenient  for  diagnostic  purposes  to  separate  it  from  the 
two  forms  of  sclerosis,  posterior  and  lateral,  which  it  so 
much  resembles. 

The  diagnosis  is  to  be  made  between  the  affection  we 
have  been  considering  and  which  we  would  call  Ataxic 
Lateral  Sclerosis,  and  several  diseases  of  the  cord.  Chronic 
myelitis  and  slow  compression  often  present  symptoms  sim- 
ilar to  the  ones  here  described,  but  in  these  conditions 
we  have  nearly  always  localized  pain,  girdle  pain,  marked 
interference  with  sensation,  and  after  a  period  of  a  few 
months  tendency  to  recovery  or  marked  destructive  lesions. 
Posterior  sclerosis  presents,  at  least  during  the  greater  part 
of  its  course,  no  paresis  or  spasmodic  phenomena,  marked 
pupillary  reactions,  lightning  pains  with  trophic  changes 
and  other  marked  special  symptoms.  Simple,  primary  lat- 
eral sclerosis  shows  no  ataxia,  no  changes  in  sensory  con- 
duction, and  according  to  Erb,  Charcot,  Ross  and  others, 
no  interference  with  sexual  powers  and  no   loss   of  control 


244  J'  G'  PRESTOX- 

over  the  sphincters.  There  is  another  form  of  sclerosis, 
which  from  the  nature  of  the  lesion,  is  often  impossible  to 
distinguish  from  ataxic  lateral  sclerosis,  namely,  dissemina- 
ted, or  multiple  sclerosis.  The  sclerotic  patches  may  of 
course  occupy  any  position,  and  consequently  give  rise  to  a 
great  variety  of  symptoms.  One  of  Charcot's  cases,  diag- 
nosed ataxic  lateral  sclerosis,  proved  on  autopsy  to  be  a 
case  of  very  general  multiple  sclerosis. 

The  autopsies  on  patients  dying  from  this  form  of  scle- 
rosis have  not  been  numerous,  but  have  gone  far  to  bear 
out  the  clinical  picture.  Westphal,  in  a  very  typical  case, 
found  (Archiv.  f.  Psyc.  Bd.  XV.)  post-mortem,  sclerotic  de- 
generation in  the  lateral  columns  and  also  in  the  columns  of 
Goll.  Hamilton  (X.  Y.  Record,  XV,  1879),  Omerod  (Brain 
XII,  1885),  Dana  (Med.  News,  1887-1),  and  a  number  of 
others  have  reported  autopsies  of  cases  presenting  the 
symptoms  enumerated  above,  in  which  were  found  degener- 
tion  of  both  lateral  and  posterior  columns. 

The  degeneration  is  not  always  found  to  be  strictly  sys- 
temic, but  may  spread  over  adjacent  regions  to  a  certain 
extent.  Generally  the  most  marked  sclerosis  is  in  the  dor- 
sal region  in  the  pyramidal  tract,  and  in  the  columns  of 
Goll.  The  posterior  root  zones  are  rarely  much  affected. 
The  direct  cerebellar  tracts  may  or  may  not  be  included  in 
the  degeneration.  Of  course  there  may  exist  great  variey  in 
the  extent  and  intensity  of  the  process,  just  as  we  see  in 
most  other  forms  of  sclerosis,  and  secondary  degeneration 
may  follow  the  primal  lesion. 

The  prognosis  of  ataxic  lateral  sclerosis  is  very  favora- 
ble as  regards  life.  It  is  the  most  chronic  of  all  the  scler- 
oses, and  rarely  ever  of  itself  produces  death.  It  may  ap- 
parently be  arrested  in  its  course,  and  cases  have  been  re- 
ported in  which  improvement  and  even  recovery  have  taken 
place.  Generally  speaking,  however,  we  can  rarely  hope 
for  cure  in  this  more  than  in  other  forms  of  sclerosis. 

As  to  treatment,  rest,  warm  baths,  arsenic,  massage, 
calabar  bean,  bromides  and  general  tonics  are  to  be  recom- 
mended. 

The  bladder  must  be  carefully  watched,  and  the  general 


A  TAXIC  LA  TERAL  SCLEROSIS.  245 

health  of  the  patient  attended  to.  Often  a  sea  voyage 
proves  beneficial.  Electricity  is  probably  hurtful  and  if  used 
at  all  should  be  employed  cautiously. 

The  patient  whose  case  I  have  reported  has  certainly  im- 
proved on  arsenic,  warm  baths  and  massage. 

I  have  refrained  from  describing  minutely  the  symptoms 
or  pathology  of  this  disease,  since  they  are  both  well-known 
or  at  least  have  been  often  described  in  the  two  forms  of 
which  this  affection  is  the  hybrid.  I  wish  simply  to  call  at- 
tention to  this' interesting  variety  of  sclerosis. 


£ofiehi  §fport$. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

Stated  Meeting,  February  27 ,  1888. 

The  Vice-President,  Charles  K.  Mills,  M.  D.,  in  the 

Chair. 


Dr.  William  Osler  reported  the  following  case  of 

ENLARGEMENT    AND     CONGESTION     OF    THE     RIGHT     ARM 
FOLLOWING  EXERCISE  OF  ITS  MUSCLES. 

J.  B.,  aged  forty-eight,  white,  a  robust,  vigorous-looking 
man,  applied  at  the  University  Hospital  on  Novemebr  4, 
1887,  complaining  of  swelling  of  the  right  arm  when  he 
worked. 

His  family  history  was  good,  and  he  had  always  been 
healthy  with  the  exception  of  several  attacks  of  sciatica, 
which  he  had  suffered  with  lately.  He  was  married  and 
had  five  children,  all  healthy.  When  he  was  young  he  had 
had  the  smallpox.  He  entered  the  navy  in  1861  and  left  it 
in  1863,  and  has  been  a  storekeeper  ever  since.  He  had 
gonorrhoea  in  1858,  but  there  was  no  history  of  syphilis. 
About  two  days  before  he  applied  at  the  hospital  he  began 
to  work  as  a  carpenter,  but  had  to  give  it  up  in  two  or  three 
days  on  account  of  the  swelling  in  the  right  arm.  The  arm 
also  became  tender  and  blue,  but  on  raising  it  over  his  head 
the  swelling  and  dark  color  would  disappear.  There  was 
no  history  of  sprain  or  injury,  and  otherwise  he  appeared  to 
be  in  excellent  health. 

Before  exercise  the  measurements  were  as  follows : 
Right  arm,  11.4  inches;  forearm,  11  inches;  left  arm,  10.25 
inches  ;  forearm,  1 1  inches. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  2A7 

The  patient  was  a  well-developed,  well-nourished  man, 
with  chest  well  formed,  sternum  a  little  prominent  over 
manubrim,  subcutaneous  veins  somewhat  prominent,  those 
over  the  anterior  aspect  of  the  left  shoulder  more  than  the 
right.  His  pupils  were  equal.  The  heart  apex  beat  was  just 
visible  below  and  inside  the  nipple.  There  was  dulness  at 
the  lower  border  of  the  fourth  inside  nipple  line,  and  the 
right  border  of  the  sternum.  The  sounds  at  the  apex  were 
clear ;  at  the  base  somewhat  feeble  first  ;  second  distinct, 
not  specially  ringing  or  metallic  ;  and  not  more  distinct 
toward  the  right  than  the  left  clavicle  ;  no  pulsation  on  the 
vessels  of  the  neck  and  no  murmur.  Radials  were  equal; 
no  atheroma  ;  no  increased  tension,  and  no  stiffness  in  the 
vessel  wall  were  apparent.  The  right  arm  and  hand  looked 
larger  than  normal  ;  and  when  at  rest  the  skin  was  the  same 
color  in  both  ;  the  muscles  were  well  developed  ;  the  pan- 
niculus  was  the  same  on  both  sides.  There  was  no  disten- 
tion of  the  veins,  and  no  oedema.  The  brachial  artery  could 
be  easily  felt,  and  the  axillary  artery  was  not  very  deep  on 
either  side.  No  difference  in  the  pulsations  of  the  two  axil- 
lary arteries  could  be  detected,  and  no  murmur  could  be 
heard  in  either. 

After  exercise  the  measurements  were  as  follows :  In  a 
few  minutes  the  right  arm  measured  1 1  inches  ;  forearm, 
12%  inches.  It  became  livid  ;  there  was  capillary  injection, 
and  the  distended  veins  felt  like  cords.  The  radial  pulse 
was  only  just  perceptible.  Auscultation  of  the  axillary  gave 
a  distinct  murmur  not  audible  on  the  other  side.  When  the 
arm  was  held  up  the  congestion  would  disappear  in  a  few 
minutes.  There  was  a  feeling  of  fulness,  but  no  pain.  Deep 
percussion  in  the  upper  axillary  region  was  negative. 
There  was  no  enlargement  of  the  axillary  glands  ;  the  ex- 
pansion at  the  apices  was  equal.  No  pain  was  experienced 
on  deep  pressure  in  the  neck.  The  side  of  the  face  did  not 
flush  with  the  arm,  and  the  opposite  side  was  not  affected. 
Percussion  was  the  same  on  both  sides  behind. 

Dr.  Osier  wished  to  place  this  case  on  record,  as  it  pre- 
sented very  unusual  features.  He  thought  at  first  that  the 
condition  was  due  to  obstruction,  perhaps  from  pressure,  on 


248  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

the  subclavain  or  axillary  veins,  or  possibly  occlusion  with 
reestablishment  of  a  collateral  circulation  sufficient  for  the 
ordinary  blood  flood  which  occurs  during  active  use  of  the 
muscles.  There  was,  however,  no  evidence  whatever  of 
any  such  obstruction,  nor  were  the  veins  of  the  shoulder- 
girdle  distended.  The  glands  were  not  enlarged  ;  there 
was  no  subclavicular  dulness,  or  evidence  of  disease  at  the 
right  apex.  The  condition  had  remained  unchanged  during 
the  four  months  in  which  the  patient  had  been  under  obser- 
vation. He  was  now  more  inclined  to  believe  the  condition 
one  of  faulty  innervation  of  the  vessels  of  the  arm  during 
exercise,  a  defect  in  the  local  regulating  mechanism  con- 
trolling the  supply  and  outflow  of  the  blood,  the  circulation 
of  which  is,  as  we  know,  enormously  increased  by  contrac- 
tion of  the  muscles. 

Dr.  James  Hendrie  Lloyd  presented  the  following 

REPORT  OF    A    CASE    OF    RAPIDLY    FATAL    EXOPHTHALMIC 

GOITRE. 

On  August  1 2th  he  was  summoned  to  a  case  which  was 
described  as  cholera  morbus.  The  patient  was  a  single 
woman,  aged  thirty-nine,  who  had  been  suffering  for  some 
hours  with  diarrhoea  and  vomiting.  Pulv.  opii  and  plumbi 
acetat.  were  prescribed.  On  the  following  day  the  diarrhoea 
was  checked,  but  obstinate,  persistent  vomiting  continued. 
This  vomiting  was  quite  remarkable,  allowing  not  a  morsel 
of  food  or  even  a  small  quanity  of  water  to  remain  on  the 
stomach.  A  careful  physical  examination  failed  to  detect 
any  direct  cause  for  this.  There  was  a  slight  tenderness  in 
the  epigastrium,  but  no  hardness  or  evidence  of  any  growth  ; 
no  enlargement  of  the  liver  or  spleen  ;  no  evidence  of  her- 
nia ;  no  abdominal  pain,  or  any  tympanites.  A  very  mark- 
ed derangement  of  the  vascular  system  was,  however,  de- 
tected. The  whole  abdominal  aorta  to  its  bifurcation  was 
throbbing  intensly,  with  a  pulsation  somewhat  expansile. 
The  heart's  action  was  rapid,  but  there  was  no  intracardial 
murmurs.  It  was  now  observed  that  the  patient's  eyes 
were  very  prominent  and  staring,  which  symptom  had  es- 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  2z,g 

caped  observation  at  the  first  visit  on  the  preceding  evening 
(possibly  due  to  the  poor  light  in  the  room).  Further  ex- 
amination revealed  a  much  enlarged  and  rather  soft  thyroid 
gland. 

Careful  inquiries  were  now  made  of  the  parents  and  near 
relatives  about  the  patient's  previous  health.  They  had  re- 
garded her  as  a  perfectly  healthy  woman  up  to  this  attack. 
They  had,  to  be  sure,  noticed  the  altered  appearance  of 
her  eyes,  but  it  had  not  made  any  impression  upon  either 
them  or  her,  and  had  not  been  of  long  duration.  She  had 
had  a  spell  of  illness  about  six  months  previous,  the  exact 
nature  of  which  he  could  not  determine,  but  it  had  been  ac- 
companied with  some  irritability  of  the  stomach  and  pros- 
tration (as  she  recollected).  Since  then  she  had  been 
apparently  healthy,  bright  and  active  ;  had  not  complained 
of  dyspnoea  ;  and  had  been  out  on  the  day  of  the  onset  of  the 
so-called  "cholera  morbus,"  for  which  he  had  been  called 
to  her.  The  vomiting  continuing  as  the  most  distressing 
symptom,  a  carefully  regulated  diet  was  ordered,  and  tinct. 
ipecac,  gtt.  ij  was  ordered  every  hour.  The  pulse  was  beat- 
as  high  as  ioo  per  minute. 

The  patient  passed  a  restless  second  night.  In  the 
morning  the  vomiting  was  somewhat  relieved,  but  not  gone. 
The  prostration  was  growing  worse,  and  the  case  had 
assumed  a  threatening  aspect.  The  pulse  had  risen  to  170. 
Cyanosis  of  the  hands  and  feet  were  observed.  Consulta- 
tion was  now  held  with  Dr.  W.  G.  Porter,  who  concurred  in 
the  diagnosis.  Calomel  was  ordered  in  one-half  grain 
doses  every  hour;  ex.  opii,  gr.  l/2,  by  suppository  every  two 
hours  until  quieted  ;  digitalis,  which  had  not  been  given  be- 
cause of  the  extreme  gastric  irritability,  was  also  deter- 
mined upon  ;  brandy,  as  much  as  the  stomach  would  bear. 
At  the  evening  visit  the  pulse  was  found,  as  nearly  as  it 
could  be  counted,  70  to  the  third  of  the  minute,  210  per 
minute.  The  vomiting  had  ceased.  Ordered  one-half 
ounce  of  milk,  with  which  tr.  digitalis,  ffl  .  x,  was  to  be  put, 
every  half  hour,  the  digitalis  to  be  given  only  every  hour 
after  the  fourth  dose.  Collapse  was  imminent  ;  the  patient 
has    had    several  fainting  spells.      On  the  morning  of  the 


2-0  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

third  day  the  pulse  had  fallen  to  160,  apparently  under  the 
digitalis.  Dr.  Porter  again  saw  the  patient.  Ex.  bellad., 
gr.  }4,  was  added  to  the  suppositories.  Later  that  day 
the  patient's  pulse  again  failed.  At  the  last  visit  the  heart 
was  beating  in  a  very  tumultuous  way,  and  no  pulse  was  per- 
ceptible at  the  wrist.  The  mind  was  perfectly  clear.  She 
died  at  the  end  of  the  third  day  of  her  ilness. 

The  autopsy  in  this  case  was,  unfortunately,  not  con- 
plete,  owing  to  the  jealousy  of  the  family,  who  refused  to 
allow  the  skull-cap  to  be  removed.  He  therefore  reported 
it  more  for  its  clinical  interest  than  for  any  light  it  throws 
upon  the  pathology  of  this  interesting  but  obscure  disease. 
The  examination  was  made  by  Dr.  Dock,  in  the  presence 
of  Dr.  Porter,  Dr.  J.  H.  Musser,  and  himself.  The  heart 
was  a  little  dilated  in  the  left  ventricle,  and  slightly 
hypertrophied.  The  lungs,  kidneys,  and  suprarenal  cap- 
sules were  normal  ;  the  liver  was  not  abnormally  fat.  The 
stomach  was  slightly  congested,  due  probably  to  the  ex- 
cessive vomiting.  There  were  no  other  abnormal  appear- 
ances in  the  chest  or  abdomen,  which  were  alone  opened. 

It  may  be  noted  that  this  patient  had  had  urticaria,  a  fact 
recorded  by  Dr.  Bulkley*  in  two  cases  of  the  same  disease. 
The  special  interest  which  attaches  to  this  case,  however, 
is  its  very  acute  character  and  rapidly  fatal  termination  ; 
for  while  there  was  some  evidence  of  the  disease  having 
been  making  insidious  approaches  for  several  months,  it  had 
not  impressed  its  presence  upon  the  notice  of  either  the  pa- 
tient or  the  family  until  it  culminated  in  a  violent  crisis, 
which  quickly  deprived  the  woman  of  her  life. 

Dr.  Wm.  Osler  said  that  these  acute  cases  of  exoph- 
thalmic goitre  are  rare.  Were  any  mental  symptoms  pres- 
ent ?  Recently,  in  Dr.  Henry's  ward  in  the  Philadelphia 
Hospital,  was  a  case  of  this  disease,  in  which  acute  symp- 
toms suddenly  developed,  and  death  took  place  with  marked 
mental  trouble. 

Dr.  J.  H.  LLOYD  said  that  in  his  case  the  mind  was  per- 
fectly clear,  nor  was  there  the  slightest  hysterical  character 
about  the  symptoms.  The  patient  was  naturally  much  agi*- 
tated  over  her  condition. 

0  Hammond  :  Diseases  of  the  Nervous  System,  p.  812. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  2cI 

Dr.  W.  B.  Jameson  made  the  following  remarks  on  a 
case  of 

CARDIAC   ANEURISM   FROM   AN   INSANE   MAN. 

The  heart  which  he  exhibited  was  from  an  insane  man 
who  died  in  Dr.  Lloyd's  wards  in  the  Insane  Department  of 
the  Philadelphia  Hospital  ;  and  it  was  through  his  courtesy 
that  he  was  able  to  present  it.  The  man  was  fifty-six  years 
of  age  ;  a  native  of  Switzerland.  He  was  probably  a  priest, 
but  for  several  years  before  admission  to  the  hospital  was 
engaged  as  a  teacher.  He  had  no  friends  in  this  country, 
and  it  was  impossible  to  obtain  a  definite  history.  He  was 
arrested  on  the  streets  and  sent  to  the  hospital.  When  ad- 
mitted he  was  in  an  excited  state ;  had  evident  delusions  of 
persecution,  believed  that  his  food  was  being  poisoned,  and 
also  had  hallucinations  of  sight  and  hearing,  and  would  of- 
ten preach,  and  sometimes  chant.  His  physical  condition 
was  good.  No  physical  lesions  were  discovered  on  admis- 
sion. The  heart  sounds  were  clear,  distinct,  and  without 
murmur.  It  was  thought  that  there  was  possibly  a  pleural 
friction  sound,  but  this  was  not  definitely  determined. 

When  Dr.  Jameson  went  on  duty  in  the  Insane  Hospital 
six  months  ago,  the  man  was  apparently  in  perfect  health. 
He  was  quiet,  speaking  pleasantly  when  spoken  to,  but 
nothing  more.  He  was  well  advanced  in  dementia,  although 
perfectly  cleanly  in  his  habits.  One  day  while  Dr.  A.  A. 
Stevens  and  Dr.  Jameson  were  in  an  adjoining  ward,  they 
were  summoned  to  see  this  man  who  was  said  to  be  dead  or 
dying.  They  found  him  lying  on  the  floor  absolutely  pulse- 
less, face  white,  extremities  cyanotic  and  cold,  and  respira- 
tion gasping.  Brandy  was  given  and  ether  hypodermati- 
cally.  He  was  then  put  in  a  bath  with  the  temperature  rof 
the  water  at  about  1170.  He  shortly  improved,  became 
quite  rational,  and  talked  clearly.  He  complained  of  no 
pain  whatever.  He  was  kept  in  the  bath  three-quarters  of 
an  hour,  when  he  began  to  sink,  and  was  taken  out  and 
soon  died. 

Three  hours  after  death  the  autopsy  was  made.  The 
brain  showed  nothing  special.     There  was  nothing  of  inter- 


2s2 


PHILADELPHIA  XECROLOGICAL  SOCIETY. 


est  found  in  the  abdominal  cavity.  When  the  first  costal 
cartilage  was  cut,,  blood  gushed  out.  raising  a  distance  of  at 
least  two  inches.  The  whole  mediastinal  space  was  filled 
with  fluid  and  partially  coagulated  blood.  Extensive  pleu- 
ral adhesions,  more  particularly  on  the  right  side,  were 
found.  The  space  that  was  left  was  filled  with  blood.  The 
total  quantity  was  estimated  at  about  two  pints.  The  aorta 
was  examined  carefully  with  the  parts  in  place,  but  nothing 
abnormal  was  found.  The  pericardial  sac  was  found  to  be 
one-third  filled  with  fluid  blood.  An  aneurism  was  found 
at  the  apex  of  the  right  ventricle,  and  just  at  the  septum 
there  was  a  small  opening  where  a  rupture  took  place.  The 
opening  in  the  pericardium  was  not  positively  located. 

In  looking  over  the  literature,  Dr.  Jameson  found  but 
one  or  two  references  to  the  subject.  One  case  of  rupture 
of  the  left  ventricle  was  reported  in  the  American  Journal 
of  Insanity  for  January,  1885.  In  this  article  reference  is 
made  to  three  other  cases  which  had  been  reported  in  the 
Edinburg  Medical  Journal  {ox  February,  1884.  In  all  these 
cases  the  patients  were  about  seventy  years  of  age. 

In  this  case  there  was  no  atheroma  of  the  aorta.  There 
was  an  ulcerated  condition  along  the  lateral  border,  also 
on  a  spot  about  the  epicardial  surface,  three-fourths  of  an  inch 
broad  by  one  inch  long,  which  presented  the  same  appear- 
ance as  the  aneurism.  Whether  this  spot  was  connected 
with  the  ulcer  inside  he  could  not  say. 

Dr.  Wm.  Osler  said  that  it  was  very  unusual  to  find 
aneurism  of  the  right  ventricle  of  the  heart.  This  condition 
is  most  common  on  the  left  side.  The  majority  of  aneu- 
risms are  the  result  either  of  local  weakening,  due  to  peri- 
carditis, which  is  the  less  frequent  case,  or  to  a  fibroid  con- 
dition of  the  left  apex.  There  is  one  other  condition  which 
may  lead  to  the  rapid  production  of  aneurism  of  the  heart, 
viz.,  myomalacia  or  anaemic  softening,  due  to  arterial 
changes.  He  would  suggest  that  sections  made  from  this 
locality  might  throw  some  light  on  the  nature  of  the  con- 
dition. The  fact  that  we  have  in  the  immediate  vicinity  of 
the  aneurism  another  spot  of  disease,  would  seem  to  point 
in  this  direction. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  2-<, 

Dr.  J.  Madison  Taylor  exhibited  a 

NEW  FORM  OF  PERCUSSION  HAMMER 
devised  to  serve  as  nearly  as  possible  all  ends  for  which  a 
hammer  is  likely  to  be-called  into  use  by  clinicians.  This 
feature  at  least  would,  he  thought,  commend  it.  In  shape 
it  is  a  cone  flattened  on  the  opposite  side,  with  apex  and 
base  carefully  beveled  or  rounded,  of  about  the  thickness 
throughout  of  the  human  index  finger.  The  material  is 
moderately  soft  rubber.  It  is  held  by  an  encircling  band  of 
metal  midway  between  the  apex  and  base  transversely,  and 
from  it,  on  the  edge,  depends  the  straight  handle.  The 
handle  is  rigid  though  light,  it  being  Dr.  Taylor's  opinion 
that  this  had  better  be  under  the  full  control  of  the  wielder. 
If  elastic,  as  recommended  by  some,  an  element  of  uncer- 
tainty enters  in  the  degree  of  force  used  in  the  blow.  The 
special  feature  of  this  hammer  is  that  the  shape  of  the  strik- 
ing surface  is  like  the  outer  aspect  of  the  extended  hand, 
palm  downward,  which  is  most  often  used  in  obtaining  ten- 
don jerk.  The  rounded  apex  end  is  adopted  to  reach  the 
biceps  tendon  at  the  bend  of  the  arm.  The  last  has  become 
important  in  diagnosis.  In  fact,  in  the  light  of  recent  in- 
vestigations, the  study  of  tendon  jerks  of  knee,  biceps,  and 
Achillis  tendons,  of  the  jaw  jerk  as  discovered  by  Dr.  Mor- 
ris Lewis,  has  become  a  valuable  addition  to  our  means  of 
unravelling  the  causes  of  nerve  maladies.  The  matter  is 
even  now  engaging  the  attention  of  the  foremost  writers — 
Jendrassik,  Weir,  Mitchell,  Lewis,  Lombard,  and  others. 
Especially  is  this  true  now  that  the  field  is  immensely 
widened  by  the  corroborative   symptoms  of  reinforcement. 

This  little  tool  will  also  well  serve  to  elicit  chest  sounds, 
to  percuss  the  abdomen,  and  in  fact,  is  useful  whenever 
an  elastic  hammer  is  needed.  The  material  being  of  soft 
rubber,  the  blow  does  not  hurt  the  intercepting  fingers  as 
does  the  hammer  usually  employed  to  strike  the  tendons 
and  muscles.     It  is  made  by  Snowden,  of  Philadelphia. 

Dr.  Charles  A.  Oliver  made 
a  further  demonstration  of  wernicke's  hemiopic 
pupillary  reaction. 

It  was  his  intention    to    present    a   patient  with   well- 


2- a  PHILADELPHIA  XEL'ROL OCJICAL  SOCIE T Y. 

marked  left  homonymous  hemianopsia,  in  whom  the  hemi- 
opic  pupillary  inaction  of  Seguin  could  be  beautifully  seen, 
but  this  was  not  possible.  He  gave  a  rough  demonstration 
upon  the  blackboard  of  a  few  observations  worthy  of  notice. 
The  case  was  seen  a  few  weeks  ago  in  consultation  with 
Drs.  Mills  and  Turnbull.  The  fields,  which  were  carefully 
taken  for  form,  yellow,  blue,  red,  and  green,  showed  the 
distinctive  and  typical  limitation  of  hemianopsia,  in  which 
the  appearance  of  a  double  bow-like  curve — the  smaller  one 
sweeping  around  and  avoiding  the  point  of  macular  fixation, 
and  the  second  continuing  irregularly  both  above  and  be- 
low to  the  outside  in  the  left  field  and  to  the  inside  in  the 
right  field,  was  plainly  visible  ;  the  sequence  of  the  fields 
following  the  order  of  the  colors  just  noted.  Both  of  the 
remaining  fields  were  regularly  contracted,  without  inden- 
tations or  scotomata  ;  the  series  on  the  left  side  being  but 
one-half  the  size  of  those  on  the  right  side,  although  the  in- 
tensity and  brightness  of  the  colors  seen  in  and  around  the 
macular  fixation  of  the  left  side  were  more  vivid  and  pro- 
nounced. Vision  for  form  was  reduced  in  each  eye,  but 
slightly  more  so  in  the  right  ;  this  was  partially  accounted 
for  by  marked  astigmatism  with  a  low  degree  of  hyperme- 
tropia,  which,  upon  being  excluded  by  proper  lenses,  show- 
ed that  its  vision  almost  equalled  that  of  its  fellow.  With 
or  without  the  correcting  lenses,  the  pupil  of  the  right  eye 
did  not  respond  to  light  stimulus  so  freely  as  the  left  when 
equal  amounts  of  light  were  projected  into  the  interior  of 
the  organs  from  the  different  portions  of  the  existent  field 
areas.  The  pupillary  reactions,  which  were  pursued  in  the 
ordinary  method  of  concentration  of  narrow,  yet  strong 
beams  of  artificial  or  natural  light  from  various  directions 
upon  the  pupil,  whilst  the  organ  was  feebly  illuminated  to  a 
sufficient  degree  to  observe  the  actions  of  the  irides,  were 
not  only  typical  of  the  hemiopic  type,  but  were  peculiar  in 
the  fact  that  in  nearly  all  the  experiments  there  seemed  to 
be  an  absolute  ratio  established  between  the  amount  of 
pupillary  reaction  and  the  degree  of  color  saturation  seen  ; 
this  being  true  both  in  monocular  action  and  consensual  ; 
this  was  plainly  shown  by  the  amount  of  reaction  in  the  left 


PHILADELPHIA  XECROLOOICAL  SOCIETY.  2  .  r 

iris  being  at  least  one  and  a  half  millimetres  greater  upon 
exposure  of  its  own  arc,  than  when  its  fellow  arc — that  of 
the  right  eye — was  similarly  stimulated. 

Another  instance  which  beautifully  illustrates  the  same 
point,  was  seen  in  a  case  of  brain-tumor  which  he  examined 
in  consultation  with   Drs.   Keen  and   Mitchell,  in  June  of 

1887.  There  were  unequal  pupils  corresponding  in  direct 
ratio  with  unequal  amounts  of  hemianopsia,  in  which  the 
greater  percentage  of  lost  color  manifested  itself  in  the 
smaller  field  ;  there  was  at  least  one  and  a  half  to  two  milli- 
metres greater  response  in  one  or  both  irides  when  the  arc 
holding  the  better  conception  was  stimulated  ;  this  con- 
dition has  been  carefully  studied,  and  will  be  combined  in  a 
forthcoming  report  of  the  case. 

This  observation,  therefore,  is  of  value  in  adding  another 
partially  objective  factor  to  the  various  means  employed  in 
gaining  better  information  in  reference  to  the  now  all  im- 
portant question  of  cerebral  localization,  as  it  distinctly 
shows  which  arc  has  the  greater  amount  of  destructive  or 
irritative  lesion,  and  thus  becomes  an  additional  sign  of 
special  and  distinctive  usefulness. 

Dr.  J.  Lloyd  presented 

SPECIMENS  FROM  A  CASE   OF    PROBABLE    ALCOHOLIC    MUL- 
TIPLE NEURITIS,  WITH  BRAIN   ENVOLVEMENT. 

M.  L.  W.,  white,  thirty-seven  years  of  age,  a  dressmaker 
by  occupation,  was  brought  into  the  hospital  February  21, 

1888,  in  a  delirious  state.  When  first  seen  she  was  unable 
to  move  her  left  leg,  but  moved  the  right  one  with  some 
difficulty.  The  day  following  both  legs  were  rigidly  ex- 
tended, and  she  was  apparently  unable  to  move  either.  She 
complained  of  severe  pains  in  the  calves  upon  passive  mo- 
tion. The  muscles  of  the  face  kept  twitching  all  the  time. 
The  arms  were  constantly  thrown  about,  the  hands  flexed, 
and  the  thumbs  turned  inward.  On  the  night  of  the  22d, 
she  became  very  violent,  raving  constantly.  She  would 
catch  hold  of  the  attendants  and  beg  them  piteously  to  keep 
her  from  falling.     She  was  given,  during  the  night,  ninety 


2  -ft  PHILADELPHIA  XECROLOGICAL  SOCIETY. 

grains  of  potassium  bromide  and  twenty  grains  of  choral. 
The  next  morning  she  was  very  much  depressed.  She  had 
retention  of  urine  ;  about  one  pint  was  obtained  by  cathete- 
rization in  twenty-four  hours.  The  urine  was  dark  colored 
and  filled  with  urates,  but  no  albumen  or  sugar.  On  ac- 
count of  the  small  quantity  of  urine  passed,  one-fourth  of  a 
grain  of  pilocarpine  was  administered  hypodermatically. 
The  abdomen  was  much  distended  with  flatus.  After  the 
administration  of  pilocarpine  she  became  rather  weak,  and 
digitalis  and  whiskey  were  then  given.  The  pulse  rate  be- 
came better,  falling  from  135  to  90  per  minute.  Hyoscine 
was  then  administered  with  the  intention  of  securing  sleep  : 
Y^th  of  a  grain  was  given  at  9  P.  M.,  j^j-th  at  midnight.  At 
8  P.  M.  of  the  24th  ^th  of  a  grain  was  again  given.  On  the 
morning  of  the  24th  she  seemed  much  more  rational  and 
quiet,  the  hyoscine  having  had  the  desired  effect,  but  toward 
noon  the  pulse  rate  again  became  very  rapid — from  135  to 
160  per  minute.  The  lungs  quickly  became  cedematous, 
and  she  died  at  1:45  P.  M.  of  the  same  day.  The  left  pupil 
was  perceptibly  larger  than  the  right.  There  was  little 
rise  in  the  temperature,  the  highest  being  about  101.60  F. 
During  her  illness  she  retained  very  little  food  or  medicine, 
vomiting  it  as  soon  as  it  had  been  administered.  Her  bow- 
els were  constantly  moving  involuntarily.  The  heart 
sounds  were  normal  but  very  feeble.  Her  family  could 
give  no  account  of  her  at  all,  as  they  had  not  seen  her  for 
years  ;  they  surmised  that  she  had  been  leading  an  immoral 
life  for  a  long  time.  She  died  in  about  twenty-four  hours 
after  she  was  first  seen  by  Dr.  Lloyd. 

At  the  post-mortem  examination  very  few  gross  changes 
of  any  kind  were  found.  There  was  some  congestion  of  the 
pia  mater,  particularly  along  the  longitudinal  sinus.  In 
addition  there  was  marked  adhesions  of  the  dura  mater. 

The  peripheral  symptoms  simulated  those  of  multiple 
neuritis,  and  she  had,  in  addition,  a  maniacal  and  delirious 
condition.  She  had  cutaneous  hyperaesthenia  and  muscular 
tenderness.  She  had  paralysis  of  the  extensors,  which  is 
characteristic  of  multiple  neuritis.  Dr.  Lloyd's  opinion  was 
that  the  case  was   one   of  alcoholism  and   not  of  epidemic 


PHILADELPHIA  NETROLOGICAL  SOCIETY.  2-- 

cerebro-spinal  meningitis,  some  cases  of  which   latter  dis- 
ease have  recently  occurred  in  this  city. 

Dr.  Charles  K.  Mills  made  the  following  remarks  on 

THE    PROBABLE    OCCURRENCE    OF    MULTIPLE    NEURITIS    IN 
EPIDEMIC   CEREBRO-SPINAL  MENINGITIS. 

Recently  a  number  of  cases  of  cerebro-spinal  meningitis 
have  appeared  in  Philadelphia,  of  which  he  had  seen  several 
in  consultation,  three  quite  recently,  two  with  Dr.  Cahall, 
of  the  Falls  of  Schuykill,  and  one  with  Dr.  Dick.  They 
had  some  of  the  typical  symptoms  described  by  authors. 
The  particular  point  to  which  he  wished  to  call  attention 
was  that  in  two  of  these  cases  markedly,  and  in  the  third  to 
some  extent,  there  were  symptoms  which  seemed  to  point 
to  multiple  neuritis,  or,  at  least,  to  neuritis  involving  certain 
portions  of  the  body.  In  one  case  the  most  decided  com- 
plaint of  the  patient  was  pain  and  soreness  in  his  legs.  He 
found  soreness  over  the  nerve  trunks  ;  and  also,  in  addition, 
muscular  and  cutaneous  hyperaesthesia.  He  also  had  the 
appearance  of  the  legs  often  seen  in  multiple  neuritis,  the 
equino-varus  position  of  the  foot.  The  knee-jerk  was  di- 
minished. In  another  case,  outside  of  the  mental  condition, 
the  pain  and  tenderness  in  the  leg  were  the  most  distinct 
symptom.  The  conditions  were  exactly  those  which  are 
regarded  as  diagnostic  of  multiple  neuritis — that  is,  tender- 
ness over  the  nerve-trunks,  and  pain  in  the  muscles  with 
tenderness  on  pressure.  In  going  over  the  literature  of 
multiple  neuritis  lately,  Dr.  Mills  found  that  this  affection 
had  been  associated  with  or  caused  by  neary  all  the  infec- 
tious diseases,  but  no  cases  were  reported  in  connection 
with  so-called  cerebro-spinal  fever.  In  this  disease  we  have 
a  true  meningitis,  and  he  thought  we  might  have  a  perineu- 
ritis, or  a  neuritis.  In  some  cases  the  multiple  neuritis 
might  alone  be  present.  In  this  way  certain  irregular  cases 
might  be  accounted  for.  Stille  and  others  refer  to  a  neural- 
gic form  of  cerebro-spinal  meningitis.  The  point  which  he 
wished  to  make  was  that  true  diffused  neuritis,  either  alone 
or  in  connection  with  other  conditions,  probably  occurred 
as  a  result  of  the  infection. 


2  -  S  PHILA  DEL  Pill  A  XE I POLOGICAL  SOCIL  TV. 

Dr.  W.  Osler  had  recently  had  an  interesting  case  of 
cerebro-spinal  meningitis,  which  proved  fatal.  The  patient, 
a  young  girl,  when  admitted  to  the  hospital  was  thought  by 
the  resident  to  be  hysterical.  She  was  nervous  and  twitched 
on  attempting  the  slightest  movement.  He  thought  at  first 
that  it  was  a  case  of  subacute  rheumatism.  She  subsequent- 
ly developed  well-marked  symptoms  of  cerebro-spinal 
meningitis.  The  case  proved  fatal,  and  the  autopsy  showed 
the  characteristic  leisons  of  the  disease.  There  was  ex- 
tensive recent  exudation  down  the  whole  posterior  surface 
of  the  cord.  In  the  brain  it  was  limited  to  small  patches 
on  either  side  of  the  pons,  but  there  was  the  most  intense 
congestion  of  the  cortex.  It  is  remarkable  in  Dr.  Mills's 
cases,  if  they  be  instances  of  multiple  neuritis,  that,  unlike 
other  examples  of  this  complication  of  specific  fevers,  the 
symptoms  have  appeared  early  in  the  course  of  the  disease. 
In  other  affections,  as  typhoid  fever,  pythisis,  and  diphtheria, 
the  neuritis  appears  as  a  late  complication. 

He  would  like  to  make  one  remark  with  reference  to 
central  nerve  irritation  producing  symptoms  of  cerebro-spi- 
nal meningitis.  There  are  cases  of  typhoid  fever  with 
marked  meningeal  symptoms,  and  he  has  known  such  cases 
to  be  diagnosed  by  careless  observers  as  cerebro-spinal 
fever,  and  the  autopsy  has  shown  the  specific  lesion  of  the 
intestines,  and  only  congestion  of  the  spinal  and  cerebral 
meninges.  The  diagnosis  of  meningitis,  either  in  the  brain 
or  the  cord,  may  be  extremely  difficult.  Unless  the  nerves 
at  the  base  are  involved,  it  may  be  impossible  to  say  whether 
or  not  there  is  exudation.  This  is  well  illustrated  in  the 
meningitis  of  pneumonia,  which  may  produce  an  ever-deep- 
ening coma,  not  to  be  distinguished  from  that  which  accom- 
panies cases  with  intense  cerebral  congestion,  unless  pres- 
sure on  one  of  the  nerve-roots  give  the  clew  ;  and  this  led 
to  the  diagnosis  in  one  of  the  eight  cases  of  the  most  intense 
meningitis  in  this  disease,  which  were  observed  in  the  Mon- 
treal General  Hospital  between  1876  and  1884. 


AE  W  YORK  NE  UROL  O  GICA  L  SOCIETY.  2  5  Q 

NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  of  March  jt/i,  1888. 

The  President,  Dr.  C.  L.  Daxa.  in  the  Chair. 

THOMSEN'S   DISEASE. 

The  President  reported  a  case,  in  some  respects  atypical, 
and  showed  a  specimen  of  muscle.  The  patient  was  a 
man,  thirty-five  years  of  age,  single.  He  had  been  delicate 
as  a  child,  and  at  the  age  of  fifteen  or  sixteen  years  had 
masturbated,  but  not  to  excess.  At  the  age  of  fourteen 
years  he  had  been  affected  with  talipes  varus  in  the  left  leg, 
but  it  was  cured  by  tenotomy.  The  symptoms  of  the  dis- 
ease in  question  had  not  appeared  until  the  twentieth  year, 
when  the  patient  began  to  notice  stiffness  of  the  hands  and 
difficulty  in  opening  them  when  closed  ;  also  stiffness  of  the 
leg  and  of  the  muscles  of  mastication.  He  tired  easily,  es- 
pecially in  the  arms.  Until  recently  he  had  a  high-pitched 
child's  voice  and  a  child's  larynx.  Erections  were  incom- 
plete, and  there  was  mental  difficulty  in  concentrating  his 
thoughts.  The  muscular  development  was  good.  Meas- 
urement around  the  biceps  gave  ten  inches  in  each  arm. 
The  dynamometer  showed  400  in  the  right  hand  and  380  in 
the  left,  the  normal  measurement  by  the  president's  dy- 
namometer being  430  to  500.  There  were  tonic  contrac- 
tions of  the  calf  muscles  and  of  the  pillars  of  the  fauces. 
Striking  the  muscles  of  the  arm  or  forearm  caused  tonic  con- 
tractions in  those  muscles.  Striking  the  biceps  with  the 
percussion  hammer  would  cause  a  welt  and  a  myoid  tumor 
as  well.  There  was  no  increase  of  irritability  to  mechanical 
stimulation  in  the  nerves.  By  galvanism,  Erb's  reaction  was 
obtained.  There  was  increased  muscular  irritability,  also  a 
closure  tonic  contraction  which  persisted  as  long  as  the  cur- 
rent continued  to  be  passed.  There  was  closure  tetanus 
both  to  the  cathode  and  to  the  anode.  There  was  no  open- 
ing contraction  to  either  pole.  A  peculiarity  of  the  reaction 
to  faradaism  was  that  in  the  arm  the  contractions  persisted 
after  the  current  ceased  to  be  passed.     There  was  no  ankle 


260  NKW  YORK  XEUROLOGICAL  SOCIETY. 

clonus,  no  increase  of  the  reflexes,  and  no  spastic  condition. 
In  the  eve  the  fundus  was  normal,  but  there  was  a  fibrillary 
contraction  of  the  muscles  of  the  lid.  There  was  vaso- 
motor weakness  ;  the  hands  and  feet  were  red,  and  easily 
became  cold. 

A  piece  of  the  supinator  longus  had  been  removed  ;  also, 
for  comparison,  a  piece  of  the  same  muscle  from  the  presi- 
dent's own  arm.  These  specimens  had  been  placed  in  weak 
alcohol,  and  stained  with  picro-carmine  and  Bismark  brown. 
The  specimen  taken  from  the  patient  showed  an  increase  of 
the  nuclei  of  the  sarcolemma,  an  increased  number  of  fibres, 
and,  in  addition,  a  dichotomous  division  of  the  fibres  such  as 
were  found  in  muscle  of  the  heart.  This  was  characteristic  of 
Thomsen's  disease,  and  was  supposed  to  indicate  reversion  to 
an  earlier  type.  The  tonic  contractions  of  this  disease,  too, 
were  characteristic  of  unstriped  muscle  fibre. 

Dr.  GEORGE  W.  JACOBY  had  examined  the  specimens, 
and  compared  them  with  those  from  his  own  case.  He  did 
not  consider  this  the  typical  case  which  Erb's  monograph 
had  described.  Erb  had  excluded  all  the  published  cases 
but  eight.  Erb's  typical  case  showed  no  disease  of  the  cen- 
tral nervous  system.  In  the  president's  case  there  was  at 
least  a  suspicion  of  such  disease.  The  reactions  of  the  mus- 
cles, too,  were  incomplete,  or  failed  to  fulfill  the  require- 
ments given  by  Erb.  The  speaker  did  not,  however,  be- 
lieve in  Erb's  lines.  He  thought  they  were  too  close.  While 
this  case  did  not  come  under  the  heading  as  limited  by  Erb, 
it  did  not  come  under  the  name  as  understood  by  others. 
Erb's  theory  was  that  of  a  disorder  of  the  muscles  them- 
selve,  a  congenital  malformation  of  the  muscular  system. 
If  the  Assuring  of  the  muscles  and  the  increase  of  nuclei  in 
the  case  under  discussion  were  dependent  upon  a  central  af- 
fection, this  alone  was  an  interestiog  fact.  It  would  demon- 
strate that,  microscopically,  alone,  a  diagnosis  of  myotonia 
congenita  could  not  be  mode.  Our  knowledge  of  primary 
muscle  affections  was  not  yet  on  a  solid  basis.  It  was  possi- 
ble that  there  was  first  trouble  in  the  central  nervous  sys- 
tem, from  which  the  other  proceeded. 

DR.  C.  HEITZMAN  had  examined  the  specimens  with  a 


NEW  YORK  NEUROLOGICAL  SOCIETY.  2^{ 

low  power,  and  had  been  impressed  with  the  belief  that 
this  was  not  a  genuine  case  of  Thomsen's  disease.  In  a 
typical  case  the  nuclei  of  the  muscles  were  augmented.  The 
president  had  made  Erb's  mistake  when  he  spoke  of  the  nu- 
clei of  the  sarcolemma.  The  sarcolemma  was  a  structure- 
less membrane.  There  was  also  augmentation  of  the  sarco- 
plasts,  or  muscle-corpuscles.  There  was  too  much  muscle 
substance  from  the  earliest  period  ;  hence  the  name  myo- 
tonia congenita.  The  president's  case,  on  the  contrary, 
could  not  be  called  congenital,  as  the  disease  had  not  de- 
veloped until  the  twentieth  year.  Moreover,  the  muscle- 
fibres  were  not  distinctly  augmented  in  size  ;  compared  with 
those  in  Dr.  Jacoby's  case  the  difference  was  marked.  Be- 
sides, the  Assuring  was  not  prominent.  For  these  reasons 
he  was  loathe  to  accept  the  diagnosis.  He  was,  on  the 
other  hand,  unable  to  tell  what  else  the  condition  could   be. 

Dr.  J.  B.  Emerson  had  examined  the  patient's  eyes. 
There  was  no  insufficiency  of  the  muscles,  and  the  pupils 
had  reacted  normally. 

Dr.  M.  A.  Starr  realized  that  we  could  not  yet  lay  down 
any  positive  deductions  in  regard  to  electrical  reactions.  In 
degeneration  we  observed  the  pure  reaction  of  degeneration, 
an  intermediate  reaction  of  degeneration,  and  the  normal 
muscle  reaction.  Erb  had  given  the  reactions  for  three 
cases  only.  Other  cases  might  not  substantiate  those  re- 
sults. He  considered  the  president's  case  valuable  and  one 
to  be  put  on  record.  For  reliable  data  a  large  number  of 
cases  were  required.  Even  Dr.  Heitzman's  objection  of 
muscular  anomalies  was  not  fatal  to  the  theory  of  its  being 
a   case  of  Thomsen's  disease. 

The  President  explained  that  he  had  not  called  the 
case  one  of  myotonia  congenita,  but  an  atypical  case  of 
Thomsen's  disease.  It  remained  to  be  proved  whether  my- 
otonia was  always  congenital.  He  had  recently  seen  a  case 
which  commenced  at  the  eighth  or  tenth  year.  Since  the 
appearance  of  Erb's  book  four  additional  cases  had  been  re- 
ported besides  his.  He  agreed  with  Dr.  Heitzman  that  the 
enlargement  of  the  fibres  was  not  positive.  He  had  meas- 
ured the  fibres  with  a  stage  micrometer  in  the  specimen 


2£2  NElv  YORK  NEUROLOGICAL  SOCIETY. 

from  Dr.  Jacoby's  case,  in  that  from  the  case  under  discus- 
sion, and  in  that  from  his  own  arm.  He  had  found  the 
fibres  in  the  first  T^-(T  to  -^  of  an  inch  broad  ;  in  the  second, 
2^  to  1  ;  and  in  his  own,  ^^  of  an  inch.  Thus,  in  the  case 
under  discussion,  some  of  the  fibres  were  larger  and  some 
smaller  than  normal.  The  increase  of  the  nuclei,  however, 
was  shown  in  some  of  the  specimens  as  typically  as  in  Erb's 
plate.  He  acknowledged  that  the  Assuring  might  have  been 
produced  artificially  by  tearing.  Electrically,  there  was 
greatly  increased  irritability  of  the  muscles  both  to  galvan- 
ism and  to  faradism.  The  contractions  were  tonic  with 
closure  tetanus.  There  was  normal  excitability  of  the 
nerves.  Clinically,  the  patient  presented  the  phenomena 
of  Thomsen's  disease.  It  remained  to  be  proved  whether 
the  phenomena  of  Thomsen's  disease  could  be  produced 
by  disorders  in  which  the  central  nervous  system  was  in- 
volved. 

TUMOR  OF  THE  BRAIN. 

Dr.  Starr  presented  a  specimen.  The  patient  was  a 
woman,  fifty-six  years  of  age  at  the  time  of  her  death,  who 
for  two  years  had  presented  the  general  symptoms  of  tumor 
of  the  brain — vertigo,  projectile  vomiting,  dulness  of  the  men- 
tal faculties,  and  optic  neuritis.  During  the  last  five  months 
she  had  been  examined  carefully,  but  without  revealing  any 
evidence  as  to  the  locality  of  the  tumor,  except  on  one  oc- 
casion, when  during  an  attack  of  vertigo  she  fell  forward 
and  to  the  right.  This  was  not  a  prominent  symptom,  and 
it  was  the  only  evidence  pointing  to  cerebellar  disease.  The 
tumor  was  the  size  of  a  hen's  egg.  It  was  found  on  the 
lower  surface  of  the  tentorium,  simply  resting  upon,  and 
compressing  one  lobe  of  the  cerebellum.  There  was  no  ad- 
hesions and  it  was  unfortunate  that  no  symptoms  had  pointed 
to  its  location,  as  it  might  have  been  removed  easily.  In 
187*8,  Xothnagel  had  remarked  that  tumors  of  the  lateral 
lobes  of  the  cerebellum  did  not  give  rise  to  the  symptoms  of 
inco-ordination  common  to  other  cerebellar  tumors. 
BASEDOW'S   DISEASE. 

Dr.    J.   WEST  ROOSEVELI    presented    the    report    of  a 
case,    with    that   of  the    autopsy.        The   patient    had   been 


NEW  YORK  NEUROLOGICAL  SOCIETY.  26^ 

admitted  into  the  Roosevelt  Hospital  on  May  25,  1887. 
She  was  a  widow,  forty-seven  years  of  age,  a  housekeeper. 
Both  the  personal  and  family  history  were  good.  Two 
years  before,  she  had  begun  to  complain  of  palpitation, 
dyspncea  upon  exertion,  and  swelling  of  the  throat, 
which  was  largest  upon  the  right  side.  She  could  not  lie 
upon  that  side.  In  the  course  of  a  year  the  eyes  began  to 
protrude,  and  at  the  time  she  entered  the  hospital  she 
had  a  profuse  watery  diarrhoea.  The  pupils  were  found 
to  be  equal,  and  the  reaction  to  light  and  to  accom- 
modation were  good.  The  lids  did  not  follow  the 
eyeballs.  The  neck  measured  thirteen  inches  around  the 
lower  thyroid  region,  and  ten  inches  and  a  half  around  the 
upper  thyroid  region.  There  was  dysphagia  to  solid  food. 
The  pulse  was  from  100  to  120,  and  the  respiration  38.  The 
apex-beat  was  found  in  the  fifth  space,  in  the  nipple  line. 
There  was  epigastric  pulsation  and  the  area  of  dullness  was 
slightly  increased.  There  was  a  short  systolic  murmur  at 
the  apex.  There  was  a  systolic  thrill  over  the  jugulars,  also 
a  continuous  venous  hum.  The  pulmonary  resonance  was 
exaggerated.  The  veins  of  the  retina  pulsated,  but  the  ar- 
teries did  not.  There  was  no  tremor.  The  patient  lived 
until  May  31st.  She  suffered  from  watery  diarrhoea  and 
restlessness,  but  was  not  otherwise  sick.  In  walking  to  the 
bath-room  one  evening,  she  fell  dead  on  the  floor.  The 
autopsy  showed  the  thyroid  reduced  in  size,  but  still  moder- 
ately enlarged  and  of  a  pink  color.  The  kidneys  showed  a 
trace  of  fibrous  tissue,  but  otherwise  the  organs  were  nor- 
mal. There  was  apparently  nothing  abnormal  in  the  me- 
dulla nor  in  the  sympathetic  or  vagus  nerves.  Microscopic 
examination  of  these  parts  also  showed  nothing. 

Dr.  W.  O.  MOORE  had  seen  twelve  cases,  all  in  women 
of  the  average  age  of  forty  years,  the  youngest  being  thirty- 
one  and  the  oldest  forty-five.  Ophthalmoscopic  examina- 
tion had  simply  shown  enlargement  and  tortuosity  of  the 
blood-vessels.  Great  relaxation  of  the  bowels  had  been 
present  in  one  of  the  cases,  as  many  as  ten  evacuations  tak- 
ing place  in  the  day,  which  it  was  impossible  to  control. 
Electricitv  had   been  of  no   avail   in   these   cases.     All  had 


25i  NEW  YORK  NEUROLOGICAL  SOCIETY. 

presented  the  three  characteristic  symptoms,  exophthalmia, 
thyroid  enlargement,  and  rapid  action  of. the  heart.  All 
had  shown  the  symptom  to  which  Von  Graefe  had  first  called 
attention,  namely,  a  disturbance  of  the  usual  co-ordination 
of  the  movements  of  the  eyeball  and  the  upper  lid,  so  that 
when  the  patient  looked  downward  below  the  horizontal 
meridian  the  lid  no  longer  followed  the  eyeball  in  its  motion, 
but  halted  in  its  course.  This  fault  in  the  action  of  the  lid 
was  supposed  to  be  due  to  some  defect  in  the  orbicularis, 
and  was  not  present  in  patients  having  prominent  eyes  from 
other  causes.  Occasionally  the  prominence  was  so  great  as 
to  cause  the  eye  to  be  exposed  at  all  times,  whether  the 
patient  was  awake  or  asleep.  In  one  case  in  his  experience 
suppuration  had  occurred  and  the  eye  had  been  lost.  The 
patient,  aged  forty-five  years,  stated  that  when  a  child 
she  had  lost  the  sight  of  the  right  eye  by  an  accident,  and 
that  one  year  before  coming  under  observation,  she  had 
noticed  commencing  enlargement  of  the  neck,  dyspnoea 
upon  exertion,  and  prominence  of  the  left  eye.  Six  months 
later,  vision  for  near  objects  began  to  fail,  and  four  weeks 
before  coming  under  notice  the  left  eye  had  become  painful 
and  inflamed.  An  examination,  December  13,  1886,  showed 
in  the  right  eye  phthisis  of  the  bulb,  total  corneal  leucoma, 
and  exophthalmia  so  marked  that,  although  the  eyeball 
was  atrophied,  the  lids  were  as  full  as  in  the  usual  healthy 
state.  The  eyelids  on  this  side  covered  the  globe  fully 
when  shut.  In  the  left  eye  the  exophthalmia  was  so  great 
that  the  lids  were  retracted  to  their  full  extent  and  the  eye- 
ball was  dislocated  through  the  commissure  of  the  lids. 
The  ocular  conjunctiva  kwas  chemotic  and  the  cornea  was 
cloudy  through  its  whole  extent.  At  the  upper  border  of 
the  cornea  there  was  a  serpiginous  ulcer  ;  in  other  words, 
there  was  a  keratitis  from  loss  of  nutrition  and  exposure  to 
the  air.  The  pulse  was  irregular  at  1 10.  The  patient  was 
admitted  into  the  Post-Graduate  Hospital,  the  outer  canthus 
was  cut,  hot-water  applications  were  made,  and  the  parts 
were  protected  by  lanolin.  In  spite  of  treatment,  perfora- 
tion took  place,  with  escape  of  the  vitreous  and  lens.  The 
eye   began   to   recede   and   phthisis  bulbi  developed.     Had 


NEW  YORK  NEUROLOGICAL  SOCIETY;  2frr 

this  case  been  seen  earlier,  the  speaker  would  have  united 
the  upper  and  lower  lids,  thus  covering  the  eyeball.  At 
the  end  of  a  few  weeks  the  lids  would  have  been  reopened, 
when,  as  a  rule,  the  exophthalmia  would  be  found  improved 
and  the  corneal  trouble  removed.  For  constitutional  treat- 
ment the  patient  should  receive  digitalis,  ergot,  and  tonics. 
This  case  was  remarkable  from  the  facts  that  an  eye  was 
lost  by  suppuration  and  that  this  loss  was  associated  with 
phthisis  in  the  other  eye.  The  loss  of  an  eye  from  exposure 
was  so  rare  that  the  speaker  knew  of  but  ten  reported  cases 
in  this  country,  while  Wells  had  reported  only  one^case.j 

Dr.  Starr  said  that  the  fact  that  no  lesion  had  been 
found  in  the  sympathetic  in  Dr.  Roosevelt's  case  did  not,  of 
course,  prove  anything  conclusive.  Ross  had  reported 
eight  cases  in  which  such  lesion  had  been  found  out  of 
twelve  cases,  as  far  back  as  1882.  The  pathology,  how- 
ever, was  not  clear.  It  was  difficult  to  understand  how  any 
one  lesion  could  produce  all  the  phenomena  of  this  disease. 
The  hypothesis  accepted  by  Gowers  was  that  of  lesion  of 
the  vagus  nucleus  in  the  medulla.  The  rapid  pulse  would 
be  accounted  for  by  the  loss  of  the  inhibitory  power  of  the 
vagus.  It  was  known,  too,  that  vaso-motor  disturbances 
were  produced  by  irritation  of  the  medulla  in  this  region. 
The  speaker  had  some  time  since  collected  twenty-one 
cases  of  lesion  of  the  medulla,  in  eight  of  which  the  lesion 
was  in  its  upper  part,  in  the  region  of  the  nucleus  of  the 
tenth  nerve.  In  all  those  cases  there  were  subjective  flush- 
ings and  objective  increase  of  perspiration,  while  in  the 
thirteen  in  which  the  lesion  was  in  the  lower  part  of  the 
medulla  there  were  no  vaso-motor  symptoms  whatever, 
thus  substantiating  the  hypothesis  of  the  physiologists  that 
there  was  a  vaso-motor  centre  in  the  medulla  and  that  this 
centre  was  in  the  neighborhood  of  the  nucleus  of  the  tenth 
nerve. 

The  speaker  had  personally  observed  seven  cases,  five  in 
the  female  and  two  in  the  male.  In  all  but  one  palpitation 
of  the  heart  had  been  the  first  symptom.  This  disproved 
the  theory  that  the  goitre  was  primary,  and  that  the  other 
symptoms  were  due  to  the  pressure  of  the  tumor  upon  the 


,,^6  KEkV  YORK  XELROLOGICAL  SOCIETY. 

pneumogastric  nerve.  The  pulse  had  ranged  between  90 
and  [55.  In  all  but  one  the  eyes  had  been  prominent. 
In  six  there  had  been  nerve  symptoms,  in  four  tremors,  in 
four  Von  Graefs  symptom,  and  in  six  flushes.  Mental  dis- 
turbance had  been  present  in  one  case,  in  which  there  had 
been  delirium  every,  night  for  several  months,  and  subacute 
mania  for  several  weeks.  The  first  symptom  in  this  case 
had  been  insomnia,  which  resisted  treatment.  The  speaker 
supposed  it  to  have  had  its  origin  in  a  condition  of  the 
vessels  of  the  brain  similar  to  that  in  the  back  of  the  eye 
and  the  thyroid  gland.  Digitalis  had  done  no  good  in  his 
experience.  Ergot  and  bromide  had  quieted  the  tremor, 
but  no  drug  which  he  had  tried  had  reduced  the  action  of 
the  heart.  He  had  used  electricity  according  to  Benedict's 
recommendation,  but  without  result.  He  had  himself,  when 
in  Vienna,  watched  the  treatment  of  three  cases  in  which 
Benedict  had  given  a  good  prognosis,  but  had  failed  to  find 
any  reduction  of  the  pulse  while  the  galvanism  was  being 
used.  In  his  own  cases  he  had  tried  every  method  de- 
scribed as  galvanization  of  the  sympathetic  ;  he  had  placed 
the  poles  upon  either  side  in  front  of  the  sterno-cleido- 
mastoid,  behind  the  sterno-cleido-mastoid,  and  at  the  back 
of  the  neck  and  at  the  epigastrium,  carrying  the  current  as 
high  as  nine  milliamperes,  which  was  as  strong  as  could  be 
borne  with  a  small  electrode,  and  he  had  never  been  able 
to  produce  any  retardation  of  the  pulse.  Dr.  Janeway  had 
expressed  himself  as  having  had  the  same  experience. 

Dr.  A.  D.  ROCKWELL  had  met  with  about  thirty  cases  of 
this  disease,  and  in  nine  cases  he  had  observed  an  approxi- 
mate cure.  He  had  employed  diet,  galvanism,  and  very 
full  doses  of  digitalis,  bromide  of  zinc,  ergot,  and  iron.  He 
had  authentic  records  of  his  results.  He  believed  that  the 
cases  not  benefited  by  treatment  were  organic,  and  that 
those  benefited  were  functional  in  origin.  Those  having  all 
the  cardinal  symptoms  were  more  often  responsive  to  treat- 
ment than  those  in  which  the  symptoms  were  more  incom- 
plete. He  recalled  a  case  in  which  there  was  a  pulse  of  1 10 
reduced  to  80.  There  was  puffiness  of  the  eyelids  in  that 
case.    In  the  galvanic  applications  one  pole  had  been  placed 


NEW  YORK  NEUROLOGICAL  SOCIETY.  2ftj 

over  the  eyelid,  and  the  other  behind  the  sternocleido- 
mastoid muscle  at  its  upper  third.  In  another  case  the  pulse 
had  ranged  from  130  to  150  for  several  years.  There  was 
dilatation  of  both  pupils,  and  there  was  a  pulsating  swelling 
over  the  solar  plexus.  This  patient  was  placed  upon  the 
use  of  a  milk  diet  and  persistently  treated  for  many  months, 
when  the  pulse  fell  to  below  100,  and  the  swelling  of  the 
thyroid  and  the  exophthalmia  had  become  less. 

Dr.  Starr  asked  whether  Dr.  Rockwell  had  observed  a 
reduction  of  the  number  of  the  heart-beats  while  the  current 
was  being  used,  also  whether  he  had  ever  seen  paling  of  the 
face  and  dilatation  of  the  pupils — phenomena  which  followed 
galvanization  of  the  sympathetic  when  needles  are  used. 

Dr.  ROCKWELL  replied  that  he  had  not  made  his  obser- 
vations during  the  application,  but  that  subsequently  such 
slowing  had  been  demonstrated.  Lowering  of  the  pulse 
was  also  a  very  common  result  of  general  faradization. 

Dr.  Jacoby  considered  exophthalmic  goitre  a  rare  dis- 
ease. For  eight  or  nine  years  he  had  seen  in  his  dispensary 
from  six  to  seven  hundred  neurological  cases  a  year.  Not 
more  than  twelve  of  them  had  been  cases  ot  exophthalmic 
goitre.  The  patients  had  been  regular  in  attendance  and 
the  treatment  had  been  persistent,  but  he  had  tried  every 
means  heralded  without  result.  Subaural  galvanization  had 
been  without  effect  upon  the  color  or  the  pulse.  He  con- 
sidered the  disease  a  hopeless  condition.  Bodily  and  mental 
rest  constituted  about  all  that  could  be  done.  He  had  tried 
faradization  according  to  the  recommendation  of  Vigouroux, 
but  also  without  result.  He  thought  the  exophthalmia  the 
least  constant  symptom.  Where  goitre  was  present,  one 
side  of  the  neck  was  usually  larger  than  the  other.  Some 
said  that  the  right  was  always  the  larger.  This  he  could 
contradict,  as  in  a  case  which  he  had  recently  seen  with  Dr. 
Birdsall  the  enlargement  had  been  equal  upon  both  sides. 
Von  Graefe's  symptom  was  not  always  present.  Tremor 
was  often  the  first  symptom.  In  one  case  in  his  experience 
tremor  had  existed  for  a  year  before  the  development  of 
the  other  symptoms.  At  the  end  of  the  second  year  these 
had  become  well  developed,  and  bronzing  of  the  skin  also 


268 


NEW  YORK  NEUROLOGICAL  SOCIETY 


was  present.  Yigouroux  had  stated  that  the  electric  resist- 
ance was  diminished  in  all  cases,  and  even  in  the  com- 
mencement of  the  disease.  This,  if  true,  would  be  an 
important  diagnostic  point.  In  twenty  cases  Wolfenden 
had  also  found  this  lowered  electrial  resistance.  Histories 
of  two  of  these  cases  had  been  published  in  full.  In  one  of 
the  latter  the  resistance  was  only  300  ohms.  It  was  men- 
tioned that  there  was  profuse  sweating  in  this  case.  In  the 
second,  the  resistance  was  200  ohms.  Of  this  case  it  was 
said  that  there  were  clamminess  of  the  surface  and  sweat- 
ing. In  the  other  eighteen  cases  the  resistance  was  from 
500  to  1,300  ohms.  The  speaker  said  that  the  standard  of 
resistance,  however,  varied  according  to  the  method  used. 
It  had  been  given  as  300,000  to  400,000  ohms  by  Jolly ; 
Gartner  gave  it  as  30,000  to  40,000 ;  and  here  we  estimated 
it  at  a  third  or  a  quarter.  He  had  recently  tested  the  resist- 
ance in  three  cases,  his  method  having  been  to  place  the 
body  in  the  circuit,  the  electrodes  being  equal  in  size  and 
wet.  When  the  galvanometer  needle  ceased  to  be  deflected, 
the  body  was  taken  out  of  the  circuit  and  a  resistance  coil 
inserted  until  the  deflection  of  the  needle  was  again  brought 
to  the  same  point.  The  amount  required  equaled  the  re- 
sistance of  the  body.  Comparative  observations  were  at 
the  same  time  taken  upon  himself.  The  first  case  was  that 
of  a  woman,  twenty-eight  years  of  age,  with  exophthalmia, 
palpitation,  and  sweats.  The  resistances  obtained  were  as 
follows  : 

^,  ,    . ,  1  (  Patient,  6,000  ohms ; 

Through  the  palms.       -         -         -      j  ^        g^       „ 

T,  ,    .1  (  Patient,  1,200 

Through  the  goitre.       -  -      |  Sdf.        ^       „ 

Through    the    posterior  part  of  the   j  Patient,  1,400       " 
neck,  -          -          -          -          -      j  Self,         2,400        " 

The  second  case,  Dr.  Birdsall's,  presented  goitre  with 
palpitations  and  exophthalmia,  and  the  comparative  obser- 
vations were  taken  upon  Dr.  Birdsall  and  himself.  The 
resistances  obtained  were  as  follows : 

Patient,  through  the  hands,  5,000  ohms ;  through  the 
goitre,  800  ohms  ;  through   the   posterior   part  of  the   neck, 


NEW  YORK  NEUROLOGICAL  SOCLE TY.  25q 

1,000  ohms.  The  measurements  in  himself  were  respectively, 
5,500,  2,400,  and  2,000  ohms,  and  in  Dr.  Birdsall,  8,000, 
1,000,  and  1,000  ohms. 

In  the  third  case  the  resistances  were  : 

Patient.  To  control  subjects. 


Through  the  hands   5,000  ohms      u.ooo  and  10,000  ohms. 

Through  the  thyroid       i,oco  ohms.       4,000  and    3,000  ohms. 


Through  the  neck,  antero-posteriorly . .     1,500  ohms. 


3,000  and    3,oco  ohms. 


The  reduction  was  thus  scarcely  a  quarter,  certainly  not 
a  half,  and  not  more  than  would  be  accounted  for  by  the 
maceration  of  the  skin  due  to  the  abundant  perspiration  in 
these,  cases,  or,  as  in  the  goitre,  to  the  fluxion  of  blood. 
The  speaker  failed  to  see  how  any  importance  could  be 
attached  to  the  test  as  a  symptom. 

The  President  was  surprised  to  hear  that  there~was 
any  dispute  in  regard  to  the  possibility  of  lowering  the  pulse 
by  galvanism.  In  a  case  of  Basedow's  disease  in  Bellevue 
Hospital  a  pulse  of  140  was  found  lowered  fifteen  or  twenty 
beats  after  the  current  had  been  applied.  The  sedative 
effect  of  galvanism  was  generally  admitted,  though  we  could 
not  say  whether  it  was  produced  through  the  pneumogastric 
or  through  the  sympathetic  nerve.  Dr.  Starr's  theory  he 
thought  incorrect.  Lesion  of  the  nucleus  of  the  pneumo- 
gastric should  give  the  same  symptoms  as  division  of  its 
trunk,  and  this  never  gave  rise  to  the  phenomena  of  Base- 
dow's disease.  It  might  perhaps  be  said  that  this  disease 
was  due  to  lesion  of  the  nucleus  of  the  pneumogastric  and 
neighboring  parts.  He  thought  that  the  resistance  was 
diminished  in  these  cases — at  least  slightly,  perhaps  1,200 
ohms.  In  testing  he  placed  one  electrode  on  the  region  of 
the  seventh  vertebra  and  the  other  on  the  sternum. 

Dr.  Roosevelt  had  had  the  same  experience  as  Dr. 
Starr  and  Dr.  Jacoby.  He  had  used  both  strong  and  weak 
currents  without  any  influence  on  the  sympathetic  nerve. 
He  was  surprised  to  hear  digitalis  recommended.     He  be- 


2-0  NEW  YORK  XEUROLOGICAL  SOCIETY. 

lieved  that  digitalis  was  without  value  for  heart  failure 
except  from  organic  disease.  He  had  had  five  cases  of 
exophthalmic  goitre  under  observation.  Two  of  the  patients 
had  improved,  but  both  were  young  anaemic  girls.  The 
measurement  of  electrical  resistance  he  thought  a  difficult 
problem,  because  the  factors  varied. 


PERISCOPE. 

By  DRS.  G.  W.  JACOBY,  N.  E.  BRILL,  and  LOUISE  FISKE-BRYSON. 

PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

A  Certain  Kind  of  Insomnia.— The  two  most  reliable 
signs  of  perfect  health  are  the  absence  of  pain  and  the  abil- 
ity to  sleep  tranquilly  and  soundly.  One  kind  of  insomnia 
is  frequently  met  with  and  is  most  difficult  to  treat— the 
insomnia  caused  by  malaria.  First,  we  have  a  group  of 
patients  who  sleep  neither  day  nor  night.  They  count  each 
stroke  of  the  clock  all  night,  lie  awake  tortured  by  their 
own  thoughts,  rise  in  the  morning  all  tired  out,  and  unfit 
for  daily  duties.  In  another  form  of  this  complaint,  after  a 
rest  of  two  or  three  hours,  the  patients  waken  and  get  no 
more  sleep.  This  short  slumber  refreshes  them,  they  can 
attend  to  business,  giving  out,  however,  quite  frequently 
during  the  day,  their  limbs  seeming  to  give  way  under 
them.  To  a  third  class  belong  those  who  fall  asleep  and 
sleep  well  up  to  a  certain  hour  or  moment.  Their  short 
rest  seems  to  have  perfectly  refreshed  them,  but  they  are 
frequently  subject  to  slight  chills  and  fever  and  sweating, 
also  to  neuralgia  and  lumbago  and  exhaustion. 

It  seems  probable  to  me  that  the  microbes  of  malaria 
may  produce  a  similar  condition  to  that  of  certain  alkaloids 
—caffeine,  theine,  theobromine,  etc.,  that  cause  wakeful- 
ness. It  is  evident  that  these  malarial  microbes  are  con- 
tained in  great  quantities  in  the  veins,  and  also  in  the 
smaller  vessels  of  the  pia  mater  and  the  large  gangla  of 
the  brain.  Here  they  may  act  as  a  delicate  "reagent,"  by 
means  of  which  the  existence  of  malaria  may  be  proved, 
viz.,  by  their  effect  in  producing  the  insomnia  of  the  patient! 
Massage,    hydropathic    treatment,    and   quinine    combined 


072  PNy  BIOLOGY  OF  THE  XERVOL'S  SYSTEM. 

with  sodium  bicarbonate  or  dilute  phosphoric  acid  are  of 
great  service  in  such  insomnia.  Morphine,  chloral,  etc., 
are  dangerous  and  non-curative,  heightening  rather  than 
diminishing  the  disease,  and  producing  an  overwhelming 
sensation  of  excessive  fatigue  and  mental  depression,  ac- 
companied frequently  by  increased  sexual  desires  and  a 
morbid  anxiety  about  business  and  the  affairs  of  life. — 
F.  Eklund,  M.D.,  Stockholm,  Sweden,  in  Therapeutic  Gazette, 
Dec.  15,  1887.  L.  F.  B. 

PUERPERAL    INSANITY. 

The  term  puerperal  insanity  is  employed  in  a  compre- 
hensive sense,  embracing  (1)  the  insanity  of  gestation  ;  (2) 
post-parturient  insanity,  and  (3)  lactational  insanity,  or  cases 
caused  by  long  nursing.  It  is  the  most  favorable  form  of 
mental  derangement.  The  forms  that  it  may  assume  are 
melancholia,  mania,  delusional  insanity,  and  dementia.  Its 
causes  are  predisposing  and  exciting,  as  in  other  diseases. 
Heredity,  and  an  acquired  predisposition  from  former  attacks 
of  insanity,  play  the  most  important  part.  In  765  cases  col- 
lected by  Dr.  Ripping,  16.4  belonged  to  the  first  type  (in- 
sanity of  gestation),  50.6  to  puerperal  insanity,  and  33  per 
cent,  to  the  lactational  type.  The  first  form  usually  makes 
its  appearance  about  the  end  of  the  third  or  the  beginning 
of  the  fourth  month  of  pregnancy.  Griesinger  attaches  con- 
siderable importance  to  the  emotions  of  women  pregnant 
for  the  first  time.  He  also  says  (quoting  Marce's  "  Folie  des 
Femmes  Enceintes):  "Slight  mental  disorders,  hysterical 
humors,  irresistible  longings,  foolish  jealousy,  and  klepto- 
mania are  more  frequent  during  pregnancy  than  fully  de- 
veloped insanity."  Depression,  or  mild  melancholia  with 
anxious  delusions,  is  the  form  that  mental  derangement 
generally  assumes  at  this  period.  Puerperal  insanity  begins 
within  thirty  or  sixty  days  after  delivery,  occurring  more 
frequently  during  the  week  following  parturition  than  at  any 
other  time,  usually  on  the  third  or  fourth  day.  "  Mental  in- 
coherence during  natural  labor"  (Montgomery)  is  well 
known    to    every   accoucheur,  and    is    only  an    evanescent 


PH YS10L OGY  OF  THE  XER  VO US  S  YS TEA/.  2j~ 

state.  Melancholia,  delusional  insanity,  and  even  dementia 
may  occur,  although  mania  is  the  most  common  form  of  in- 
sanity following  parturition,  and  is  the  most  dangerous  to 
life.  Tense  cases  very  often  resemble  an  acute  phrenitis. 
The  suicidal  tendency  is  not  uncommon,  especially  in  melan- 
cholia. The  character  undergoes  a  complete  change.  The 
woman  may  evince  a  profound  aversion  to  her  nearest  and 
dearest,  talk  incessantly,  give  way  to  the  most  violent  anger, 
utter  the  most  awful  oaths  and  imprecations,  and  act  as 
though  possessed  by  demons.  Anxiety,  severe  and  tedious 
labors,  convulsions,  or  great  loss  of  blood,  are  among  the 
exciting  causes  of  this  unhappy  state.  Insanity  of  lactation 
occurs  in  delicate  women  who  have  borne  children  rapidly 
and  suckled  them  a  long  time.  The  patient's  thoughts  as- 
sume a  sad  and  sombre  hue,  and  soon  are  only  on  one  sub- 
ject— herself.  Delusions,  self-reproach  and  self-accusation 
of  the  "  unpardonable  sin  "  are  common.  The  majority  of 
such  cases  are  of  the  melancholic  type,  but  exceptional 
cases  of  mania  do  occur.  Whatever  the  form  of  insanity 
due  in  some  way  to  reproduction,  each  patient  should  be 
studied  as  a  unique  specimen,  and  the  case  treated  accord- 
ing to  the  symptoms  it  presents.  In  acute  maniacal  cases, 
the  first  and  most  important  indication  is  to  allay  the  ex- 
citement by  subduing  the  irritation  of  the  nervous  system. 
This  is  best  accomplished  by  free  catharsis,  followed  by 
sedatives  aud  anodynes.  Chloral,  the  bromides,  and  hyos- 
cyamus  are  more  to  be  depended  upon  than  opiates.  When 
the  febrile  excitement  has  been  subdued,  tonics — iron,  cin- 
chona, quinine,  and  simple  bitters,  with  good,  nourishing 
diet  and  wine — are  indicated.  Warm  bathing,  rest  and 
quiet,  together  with  moderate  systematized  exercise,  are 
also  in  order.  In  cases  of  profound  melancholia,  with  stupor 
and  apathy,  blisters  to  the  temple  and  nucha  are  frequently 
beneficial.  Lactational  insanity  requires  the  weaning  of  the 
child  first  and  tonic  treatment  next.  With  insanity  of  ges- 
tation there  is  usually  a  strong  hereditary  predisposition, 
and  recovery  is  doubtful  before  delivery.  Active  treatment 
is  contra-indicated.  Diet,  exercise,  and  hygienic  surround- 
ings are  the  only  safe  measures  to  be  adopted. — J.  E. 
Bowers,  M.D.,  in  Northwestern  Lancet,    Feb.  i,  1888. 

L.  F.  R. 


274 


PHYSIOLOGY  OF  THE  XERVOCS  SYSTEM. 


PARAPLEGIA    FOLLOWING    PNEUMONIA. 


In  an  article  published  in  the  Gazette  Hebdomadaire, 
Dr.  Carre  has  collected  the  various  cases  ofparaplegia  fol- 
lowing pnemonia  thus  far  published,  eight  in  all,  and  adds 
one  observed  by  himself.  From  a  comparison  of  these 
cases  it  seems  that  they  are  very  dissimilar.  Most  fre- 
quently a  general  weakness  is  noticed ;  the  paralysis  may, 
however,  be  complete,  particularly  in  the  lower  extremities. 
Sometimes  the  muscles  of  the  chest,  of  the  shoulders,  of  the 
larynx  and  of  the  pharynx  are  affected.  Paresthesia,  and 
even  anaesthesia,  has  been  noticed.  In  some  cases  the 
paralysis  began  in  the  lower  extremities  and  ascended  ;  in 
others  the  course  is  descending,  affecting  the  four  extremi- 
ties without  any  regular  sequence.  Occasionally  the  symp- 
toms are  purely  spinal,  at  other  times  the  intra-cranial 
nerves  are  also  affected.  In  all  the  cases  the  paralysis 
occurred  during  convalescence  from  the  pneumonia ;  in  one 
half  the  cases  the  termination  was  fatal.  Carre  believes  the 
cause  to  be  infectious,  and  considers  the  existence  of  mi- 
crobes in  the  nervous  centres  probable.  {Journal  de  Mede- 
cine,  March,  1888.)  G.  W.  J. 

PARALYSES   FOLLOWING    RAILROAD   ACCIDENTS. 

Onimus,  in  his  "Traite  delectricite  Medicare,"  devotes  a 
chapter  to  the  above  subject.  It  seems  that  particularly 
those  persons  are  subject  to  spinal  lesions  who  travel  seated 
with  their  back  to  the  engine.  Persons  sleeping  at  the 
time  of  the  accident  escape  to  a  great  extent.  The  causes 
of  both  these  facts  are  purely  physical  ones.  This  spinal 
concussion  is  of  importance,  because  it  dominates  all  other 
symptoms  following  the  accident  and  often  produces  paraly- 
sis after  days  or  even  weeks.  Also  characteristic  is  the  long 
duration  of  the  affection.  Onimus  cites  a  case,  noteworthy 
on  account  of  the  smallness  of  the  lesion,  which  consisted 
only  of  slight  atrophy  of  the  trapezius  and  contracture  of 
the  scaleni  and  which  during  years,  although  the  atrophy 
had  disappeared,  remained  in  a  state  of  contraction,  render- 
ing  all    movements  of  the   neck   difficult  and  painful.     The 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  27K 

principal  difficulty  in  diagnosis  consists  in  the  exclusion  of 
■simulators.  The  electric  current  serves  as  a  guide.  {Jour- 
nal de  Medecine,  March,  1888.)  G.  W.  J. 

RETROGRADE     AMNESIA     FOLLOWING      INTENSE      EXCITE- 
MENT. 

Under  the  name  of  retrograde  amnesia,  Azam  has  de- 
scribed the  following  facts  :  A  healthy  patient  receives  a 
severe  cranial  injury,  he  loses  consciousness,  and  when  this 
is  regained,  it  is  found  that  the  recollection  of  the  accident, 
as  also  the  memory  for  events  preceding  the  occurrence 
are  entirely  lost.  Two,  three  or  four  days  prior  to  the  acci- 
dent, and  the  circumstances  of  the  accident  itself  are  entirely 
obliterated  from  the  subject's  memory ;  in  every  other  re- 
spect his  memory  is  perfect.  Little  by  little  the  recollection 
of  occurrences  anteceding  the  accident  is  regained  until 
finally  there  is  only  a  hiatus  as  regards  the  occurrence  itself. 
Arnozan  has  described  an  analogous  condition  occurring  in 
a  patient  after  intense  emotion  due  to  the  receipt  of  bad 
news.  From  the  moment  of  the  mental  shock,  without  any 
nervous  symptoms  or  other  intellectual  disorder,  every  fact 
connected  with  the  subject  disappeared  from  his  mind,  and 
he  was  unable  to  comprehend  any  of  the  details  explained 
to  him  or  to  appreciate  the  consolations  offered  him.  When 
seen  by  Arnozan  he  presented  loss  of  memory  for  all  actions 
and  facts  which  had  taken  place  during  three  days.  In 
every  other  point  his  memory  was  normal.  The  disorder 
was  only  transitory,  for  in  twenty-four  hours  all  traces  of 
the  affection  had  disappeared.  {Journal de  Medecine,  March, 
1888.)  G.  W.  J. 

CEREBRAL   TUMOR   WITH    HEMORRHAGE. 

(E.  J.  Sidebotham,  M.B.,  in  Saint  Bartholomew's  Hospital 
Reports,  Vol.  xxiii.,  1887.) 

The  patient,  aet.  20,  apparently  in  perfect  health,  was 
suddenly  attacked  by  pain  in  the  head.  A  physician  who 
was  sent  for  found  him  comatose.  The  pupils  were  con- 
tracted to  a  pin-point,  and  there  was  divergent  squint.     He 


276  PHYSIOLOGY  OF  THE  SERVOUS  SYSTEM. 

soon  regained  consciousness,  and  the  pupils  became  natural. 
He  complained  of  pain  on  the  right  side  of  the  head,  the 
movements  of  the  left  arm  and  leg  were  feeble,  and  the 
knee-jerk  was  absent  on  the  left  side.  There  was  hiccough, 
retching  and  vomiting.  During  the  next  four  days  the  fol- 
lowing symptoms  were  observed  :  .  There  were  wide  hyste- 
roid  movements  of  the  right  limbs,  purposeless  as  a  rule  ; 
profuse  sweating  ;  pupils  equal ;  divergent  squint ;  paralysis 
of  the  left  arm  and  leg,  sometimes  rigidity  of  both  arm  and 
leg  ;  the  left  knee-jerk  was  absent,  the  right  normal ;  the 
temperature  varied  from  100.80  to  1040;  there  were  several 
attacks  of  opisthotonos  with  spasm  of  the  left  limbs,  also 
side-arching  of  the  body,  the  concavity  of  the  arch  being  to 
the  left  side  of  the  body,  but  in  one  attack  it  was  to  the 
right.  He  died  on  the  fifth  day.  The  evening  before  his 
death  the  hysteroid  movements  ceased.  The  whole  body 
was  periodically  thrown  into  tonic  spasm. 

At  the  post-mortem  examination,  a  large  irregular 
haemorrhage  was  discovered  in  the  right  hemisphere  of  the 
brain,  whose  origin  was  obviously  a  tumor,  which  was  situ- 
ated on  the  surface  of  the  angular  gyrus.  The  haemorrhage 
extended  from  the  surface  of  the  brain  to  the  posterior  part 
of  the  internal  capsule,  and  had  neither  burst  into  the  lateral 
ventricle  nor  externally.  The  tumor  was  an  inch  in  length 
by  three-quarters  of  an  inch  in  diameter.  It  consisted  of  a 
close  plexus  of  blood  vessels.  These  vessels  appeared  to 
be  derived  from  the  artery  upon  which  they  lay,  reinforced 
by  branches  from  neighboring  arteries.  The  tumor  must 
therefore  be  classed  as  an  angioma  or  nsevus. 

REFLEX    PSYCHOSIS   FROM   TRAUMATISM. 

At  a  meeting  of  the  Berliner  Gesellschaft  fur  Psychiatre 
und  Xervenkrankheiten,  held  on  January  9th,  1888,  Dr. 
Thomsen  presented  the  following  case  : 

W.,  an  invalid  soldier,  with  heredity  history,  but  himself 
always  healthy,  received  a  gun-shot  wound  in  the  right  up- 
per extremity,  in  1X70.  In  1884,  attacks  of  pain  appeared 
in  the  arm  ;  these  gradually  increased,  and  in  1885,  during 
every   attack   of  pain,  an   hallucinatory  mental    disturbance 


PHYSIOL OGY  OF  THE  NER VO US  S YS TEM.  2ni 

made  its  appearance;  of  short  duration  and  with  pure  inter- 
vals at  first,  but  later  more  intense  and  less  clearly  period- 
ical, the  intervals  being  filled  with  fearful  dreams,  emotional 
depression,  etc.  During  the  paroxysm  the  patient  sees 
forms  and  animals,  men  covered  with  blood,  dogs,  buffaloes, 
etc.,  which  threaten  him,  so  he  believes.  During  the  severe 
attacks  he  becomes  confused  and  very  much  excited  ;  dur- 
ing the  mild  ones,  merely  seized  by  fear  ;  during  the  inter- 
vals he  is  wholly  mentally  sound  and  has  full  knowledge  of 
his  condition. 

During  the  attack  there  is  right-sided  hemianaesthesia, 
involving  both  the  skin  and  the  organs  of  special  sense ; 
smell  and  taste  are  gone  on  the  same  side,  the  field  of  vision 
is  enormously  contracted  on  both  sides,  colors  are  distin- 
guished very  poorly  or  not  at  all  (excepting  red);  there  is 
deafness  in  left  ear. 

During  the  interval  all  disturbances  of  sensation  disap- 
appear. 

On  December  27th,  1887,  the  cicatrix  was  cut  out,  two 
days  after  which  there  was  a  return  of  hallucinatory  attack 
lasting  but  twenty-four  hours,  and  ever  since  then  a 
return  to  mental  health  and  normal  sensation.  The  patient 
never  had  epilepsy.  The  speaker  concluded,  therefore,  that 
the  patient  was  a  case  of  pure  peripheral  reflex  psychosis. 
(Centralblatt  fur  Nervenheilkunde,  etc.,  February  15th, 
1888.)  N.  E.  B. 

TABES   DORSALIS. 

Dr.  Martins  (Deutsche  Medicinische  Wochenschrift, 
March  1st,  1888).  The  following  case  presents  some  excep- 
tional points  of  interest: 

The  patient  was  perfectly  well  up  to  his  fifty-third  year, 
never  had  syphilis  ;  was  taken  ill  in  June,  1885,  with  typhoid 
fever,  which  confined  him  to  his  bed  for  six  weeks,  at  the 
end  of  which  time  the  first  symptoms  of  tabes  appeared. 
These  consisted  of  paresthesia,  exclusively  confined  at 
first  to  the  upper  extremities,  especially  to  the  hands  and 
finger  tips  (feeling  of  stiffness,  fur  sensation,  and  the  like). 
It  was  not  until  two  months  thereafter  that  the   lower  ex- 


2  -  g  PHYSIO  LOG  Y  OF  THE  AER  VO  US  S  YS  TEA/. 

tremities  became  involved.  Soon  thereafter  a  palpable  feel- 
ing of  weakness  in  the  lower  extremities  appeared,  and  it 
was  this  that  brought  him  to  the  hospital  (Charite). 

At  his  entrance  the  history  was  as  was  given,  paresthe- 
sias in  hands  and  feet,  weakness  in  knees.  Objectively,  the 
internal  organs  were  found  to  be.  healthy;  in  the  motor 
sphere,  no  signs  of  ataxia,  nor  was  the  walk  ataxic  :  pupils 
reacted  normally  to  light,  no  swaying  on  closing  eyes  ;  knee 
phenomena  present  on  both  sides  and  easily  worked.  The 
only  demonstrable  symptom  in  the  sensory  sphere  was  that, 
on  closing  the  eyes,  the  patient  could  not  distinguish  with 
his  hands  little  objects,  the  feeling  being  as  if  he  had  thick 
gloves  on  his  fingers.  There  was  a  disturbance  of  pressure 
sense,  less  of  temperature  sense. 

Tabes  was  thought  of,  but  the  diagnosis  could  not  be 
substantiated,  for  the  classified  symptoms,  viz.,  the  Rom- 
berg, Robertson,  and  Westphal  signs  were  all  absent.  It 
was  only  after  two  months  that  the  girdle  sensation  ap- 
peared. 

At  the  end  of  March,  the  patient  died  of  an  intercurrent 
pneumonia,  on  the  third  day  of  the  disease.  During  the 
pneumonia,  reflex  iridoplegia  appeared,  but  the  patellar  re- 
flex remained  until  death. 

The  spinal  column  appeared  microscopically  normal  ;  it 
was  only  after  it  had  been  hardened  in  Miiller's  fluid  that 
definite  fields  of  degeneration  in  the  spinal  cord  could  be 
distinguished.  The  fields  showed  a  different  area  than  is 
usual  in  tabes,  and  the  degeneration  was  most  extensive 
and  intense  in  the  cen>ical  region,  and  very  little,  if  any  at 
all,  in  the  lumbar  cord.  N.  E.  B. 

Nervous    Symptoms    of    Secondary    Syphilis. — Prof. 
Fournier,  Journal  de  Medecine ,  p.  15,  1888. 

Individual  conditions  have  a  great  influence  upon  the 
nature  of  the  disorders  produced  by  the  syphilitic  virus. 
Sex  also  plays  an  important  role  ;  women  being  more  prone 
to  general  nervous  disturbances  than  males,  also  more  often 
develop  general  neuroses  as  a  consequence  of  syphilis. 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  27Q 

These  occurrences  Fournier  has  divided  into  headache, 
disturbances  of  sleep,  neuralgias,  affections  of  sensation, 
general  neuroses,  neuroses  of  the  great  sympathetic,  and 
visceral  neuroses.  The  headaches  are  not  any  more  fre- 
quent in  females  than  in  males.  The  disturbance,  of  sleep 
occur  as  a  symptom  of  secondary  syphilis  very  frequently 
in  women,  and  are  independent  of  any  pain  or  headache : 
it  is  an  essential  insomnia  without  any  recognizable  cause. 
In  some  patients  all  symptoms  of  neurasthenia  occur,  and 
are  then  only  relieved  by  antiluetic  remedies.  Neuralgias 
are  more  frequent  in  females,  and  differ  from  ordinary  neu- 
ralgias in  the  pain  being  more  neuralgiform  than  neuralgic. 
They  appear  in  three  types — fascial,  very  frequent  ;  inter- 
costal and  sciatic,  less  frequent.  In  the  fascial  form  the 
infraorbital  branch  is  most  frequently  affected,  in  the  sciatic 
also,  only  a  single  branch  is  involved.  The  diagnosis  is  of 
importance,  but  not  always  easy.  The  disorders  of  sensa- 
tion which  occur  as  a  result  of  syphilis  are  not  generally 
known,  and  are  often  confounded  with  symptoms  of  hyste- 
ria. The  occurrence  of  analgesia,  anaesthesia,  and  loss  of 
temperature  sense  is  referred  to,  and  their  duration  said  to 
be  very  long,  from  several  to  fifteen  months.         G.  W.  J. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

TREATMENT   OF  NERVOUS   AND   MENTAL  DISEASES   BY  SYS- 
TEMATIZED  ACTIVE   EXERCISE. 

While  massage  and  electricity  have  received  a  large 
share  of  attention  from  neurologists,  these  have  neglected 
too  much  the  use  of  medical  gymnastics,  particularly  sys- 
tematized active  exercise.  In  a  large  number  of  nervous 
and  mental  cases,  the  improvement  of  general  nutrition  is 
the  one  thing  needed  to  bring  about  relief  or  cure.  To  this 
end  a  most  effective  aid  is  found  in  systematized  active  ex- 
ercise. The  movements  may  be  classed  as  passive,  dupli- 
cated active  (operator  and  patient  both  taking  part,)  and 
active  exercises.     Treatment  should  be  carefully  individu- 


2 So  THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

alized.  It  is  usually  necessary  to  combine  respiratory  with 
muscular  movements.  "  On  the  two  powers,  muscular  and 
respiratory,  depend  the  ability  to  perform  all  bodily  exer- 
cises" (Maclaren).  Inherent  nervous  power  has  also 
something  to  do  with  the  capacity  to  perform  bodily  exer- 
cise. Want  of  respiratory  power  is  certainly  either  at  the 
root  or  is  an  essential  constituent  of  many  morbid  nervous 
conditions.  Often  when  of  apparently  equal  muscular  abil- 
ity, there  will  exist  in  different  pessons  marked  difference, 
of  respiratory  power.  Inspiratory  exercises  insure  further 
muscular  development,  greater  aeration  of  the  blood,  and 
increased  control  over  nervous  and  muscular  effort. 

For  gout  and  lithaemia,  to  promote  excretion  and  nutri- 
tion ;  for  anaesnia  and  spanaemia,  to  assist  assimilation  and 
further  oxidation  ;  for  headache,  sleeplessness,  and  nervous 
irritability,  to  soothe  and  calm  the  nervous  system  ;  to  aid 
elimination  in  cases  of  lead,  arsenic,  mercurial,  and  other 
metalic  or  toxic  diseases  ;  for  diabetes,  to  favor  activity  of 
the  skin  and  increase  combustion,  systematized  active  ex- 
ercises have  a  value  which  cannot  be  too  highly  extolled. 
Also  in  curable  ataxias,  as  in  those  which  follow  diptheretic 
or  exanthematous  diseases  and  in  the  hysterical  varieties, 
systematized  active  movements,  the  patient  lying  down  at 
first,  then  sitting,  then  standing,  have  proved  of  great  ser- 
vice. The  advantage  of  any  treatment  that  involves  spe- 
cific direction  and  the  adroit  calling  out  of  the  volition  of  a 
patient  must  be  evident  to  any  one  who  has  had  experience 
with  hysteria  in  its  manifold  forms.  Whatever  view  may 
be  taken  of  the  much  mooted  question  of  neurasthenia, 
without  doubt  both  respiratory  and  muscular  power  are  of- 
ten deficient,  and  the  nerve  centres  themselves  can  be 
strengthened  by  exercising  these  two  powers.  Those  forms 
of  nervous  palpitation  which  are  dependent  upon  a  neuras- 
thenic condition,  associated  or  not  with  digestive  disorder, 
are  greatly  benefited  by  systematized  movements.  Special 
forms  of  gymnastics  have  been  employed  with  advantage 
for  the  treatment  of  chorea.  Napoleon  Laisne,*  a  French 
professor  of  gymnastics,  and  evidently  an   earnest  and  en- 

•Applications  de  la  Gymnastique  a  la  Guerison  de  quelques  Maladies.   Paris,  1865. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 


28l 


thusiastic  worker  in  his  chosen  field,  under  the  direction  of 
Dr.  Blache  and  other  physicians  of  Paris,  has  used  gym- 
nastics largely  both  for  chorea  and  other  convulsive  disor- 
ders. In  1865  he  published  a  book  in  which  his  methods 
are  set  forth.  Both  Schreiber  and  Dujardin-Beaumetz  refer 
to  his  labors  and  successes.  His  method  in  mild  cases,  as 
described  by  Schreiber,  is  to  place  the  child  before  him, 
steadying  it  between  his  knees,  and  then  take  its  hands  in 
his  and  perform  rhythmic  movements  with  each  arm,  keep- 
ing time  by  counting,  or,  better  still,  singing  out  loudly — 
"one,"  "two,"  "three,"  etc.  The  child,  at  the  same  time, 
is  also  urged  to  keep  time  with  the  movements,  and  not  to 
make  them  irregularly. 

"Care  must  be  taken  in  the  beginning  to  prevent,  as 
much  as  possible,  the  coincidence  of  involuntary  move- 
ments with  the  rhythmic  ones.  When  the  a:ms  have  been 
exercised,  similar  movements  are  undertaken  with  the  legs. 
From  time  to  time,  a  pause  for  rest  is  made,  during  which 
the  limb  must  be  held  firmly  enough  to  prevent  the  occur- 
rence of  involuntary  motions.  The  child  is  then  laid  on  its 
back  upon  an  inclined  ladder,  the  feet  being  held  by  an  as- 
sistant ;  then  grasping  a  rung  above  its  head,  it  holds  on  in 
that  position  as  long  as  it  is  able.  This  is  to  be  repeated 
several  times,  and  to  be  followed  by  a  short  rest.  After- 
ward, the  shoulders,  back,  and  legs  are  rubbed  and  gently 
kneaded." 

Lengthy  details  of  treatment  will  be  found  in  Schreiber's 
Manual  of  treatment  by  massage  and  methodical  muscle 
exercise  (translated  by  Walter  Mendelsohn,  of  New  York). 

In  patients  suffering  from  multiple  neuritis,  or  some  cur- 
able forms  of  myelitis,  advantage  should  be  taken  of  the  first 
signs  of  motor  improvement  to  begin  with  active  exercises, 
while  the  use  of  electricity  and  massage  is  continued.  The 
particular  point  upon  which  I  desire  to  insist,  is  that  the  at- 
tempt to  join  the  will  of  the  patient  to  the  long  unused 
muscles,  shall  not  be  deferred  a  moment  longer  than  is 
necessary. 

In  the  treatment  of  various  forms  of  paralysis,  that  sys- 
tematized active  movements  may  be  employed  with  advan- 


2g2  THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

tage  has  long  been  known.  Even  in  paralysis  from  organic 
brain  disease,  a  clear  method  of  using  gymnastic  treatment 
will  be  found  to  serve  an  excellent  purpose.  Such  paraly- 
sis is  usually  the  result  of  hemorrhage,  embolism,  thrombo- 
sis, tumor,  abscess,  or  depressed  fracture  ;  less  frequently 
of  meningitis  or  cerebritis,  of  atrophy  or  arrested  develop- 
ment, and  still  more  rarely  of  uraemia.  Sometimes  in  cases 
of  sudden  lesion,  as  hemorrhage  or  embolism,  the  assault 
upon  the  nervous  system  is  so  violent,  or  the  destruction  is 
so  great,  that  death  results  quickly,  or  the  patient  is  reduced 
to  a  state  of  helplessness,  for  which,  practically,  nothing 
can  be  done.  In  many  cases,  however,  soon  after  the  at- 
tack, or  even  at  a  later  period,  the  amount  of  palsy  is  dis- 
proportionate to  the  cerebral  lesion  by  which  it  has  been 
initiated.  Many  cases  of  monoplegia  and  hemiplegia  illus- 
trate this  truth.  Little  by  little  some  of  these  patients  re- 
gain muscular  power  to  such  an  extent  as  almost  to  induce 
the  belief  that  they  will  get  entirely  well  ;  indeed,  in  some 
cases  of  hemorrhage,  tumor,  traumatism,  syphilitic  menin- 
gitis, and  uraemia,  complete  or  almost  complete  recovery 
does  not  occur.  We  should,  therefore,  not  disregard  en- 
tirely the  treatment  of  such  patients. 

A  method  of  gymnastic  treatment  which  I  have  often 
employed  with  benefit  in  cases  of  monoplegia  and  hemiple- 
gia, is  to  cause  the  patient,  first,  to  make  a  movement  upon 
the  unaffected  side,  and  then  instantly  to  perform  the  same 
movement  with  the  paralyzed  member,  following  this 
quickly  with  an  attempt  to  do  the  same  thing  with  both 
limbs.  It  is  surprising  the  curious  results  that  will  some- 
times be  obtained  in  this  way,  if  the  leg  is  but  little  affected, 
and  the  patient  can  stand  while  these  movements  are  per- 
formed by  the  upper  extremities.  To  exercise  the  legs, 
the  patient,  of  course,  should  be  placed  in  an  easy  position, 
and  one  that  will  allow  the  movements  to  be  performed 
with  the  greatest  convenience.  Exercises  of  this  kind 
probably  have  some  effect  in  bringing  the  paralyzed  side  of 
the  body  under  control  of  the  uninjured  side  of  the  brain 
through  comissural  channels  in  the  spinal  cord. 

For  some  of  the  arthritic   neuroses,  and   for  rheumatic 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM.  2g^ 

neuritis,  or  muscular  rheumatism,  these  exercises  are  of  un- 
doubted value.  I  have  seen  three  cases  of  a  form  of  rheu- 
matic neuritis  affecting  the  deltoid  and  adjoining  muscles, 
in  which  the  progress  to  complete  recovery  was  much  as- 
sisted by  an  early  resort  to  dumb-bell  exercises  and  pulley- 
weights.  Cases  of  this  kind  are  best  treated  by  using  large 
doses  of  oil  of  gaultheria,  or  sodium  salicylate,  with  hypo- 
dermic injections  of  morphia  in  the  most  acute  stages  ;  a 
little  later  resorting  to  massage,  electricity,  or  both  ;  and 
then  to  exercise  with  light  dumb-bells  or  pulley-weights. 
Here,  again,  the  point  I  wish  to  impress  is,  that  such  active 
exercise  should  not  be  deferred  too  long. 

For  the  group  of  diseases  which  fall  to  the  lot  of  both 
the  neurologist  and  the  orthopaedist,  cases  of  curvature, 
deformity,  atrophy,  etc.,  systematized  active  exercises 
have  long  been  used  by  the  best  authorsties. 

In  the  treatment  of  ataxic  affections,  even  sometimes 
when  dependant  upon  organic  diseases  of  the  cerebrospi- 
nal axis,  the  use  of  what  may  be  called  balancing  or  acro- 
batic gymnastics  is  of  some  value.  Dr.  Mortimer  Granville, 
in  the  Practitioner  for  1881,  and  subsequent  to  his  mono- 
graph on  "  Nerve  Vibration  and  Excitation,"  discusses  a 
method  for  the  regeneration  of  the  nerve  elements  by  exer- 
cise on  the  basis  of  the  law  of  development  through  func- 
tion, holding  that  the  ataxic  subject  is  reduced  by  dissolu- 
tion to  the  postion  of  a  child  just  learning  to  stand  or  walk. 
His  plan  is  to  direct  the  patient  to  stand  with  his  eyes 
closed  in  his  bath,  after  pouring  a  small  can  of  water  down 
his  spine,  or  applying  a  mustard  poultice  over  the  full 
length  of  the  spine  for  ten  minutes  or  a  quarter  of  an  hour, 
and,  as  his  state  improves,  for  half  an  hour  every  morning. 
He  is  to  be  furnished  with  a  chair  or  rail  at  hand,  to  which 
he  can  cling  in  case  of  need,  but  is  instructed  to  avoid  using 
it  except  when  in  danger  of  falling  The  exercise  must  be 
continued  diligently  for  weeks  before  success  can  be  ob- 
tained. 

Dr.  Chas.  Fayette  Taylor,  who  published  as  early  as  1861, 
The  Theory  and  Practice  of  the  Movement  Cure,  thus  speaks 
of  the  combination  of  rest  and  exercise. 


2g  i  THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

"The  true  remedy,"  he  says  "is  rest  and  exercise.  Let 
the  rest  be  complete  relaxation  of  all  muscular  effort — not 
the  entertaining  of  company,  sitting  bolt  upright,  so  that 
the  spinal  muscles  must  be  constantly  acting,  or  reclining  in 
a  'graceful'  attitude  on  a  lounge,  with  a  book  in  hand,  but 
a  completely  sustained  position,  when  all  the  muscles  must 
cease  to  act.  Then  the  exersises  to  follow  should  be  short, 
varied,  and  taken  with  some  vigor." 

The  now  generally  accepted  views  with  reference  to 
cerebral  localization  throw  some  light  upon  the  manner  in 
which  systematized  active  exercises,  or  other  forms  of  gym- 
nastic treatment,  improve,  or  repair  the  nervous  system,  and 
especially  the  brain.  This  fact  has  not  been  overlooked  by 
authorities  in  neurology  and  gymnastics,  as  by  Emil  Du 
Bois-Reymond,  Schreiber,  Crichton-Brown,  and  others. 
In  the  brain  are  represented  both  a  differentiation  and  an 
integration  or  solidarity  of  function.  Centres  for  speech, 
for  vocalization,  for  particular  movements,  for  the  special 
senses,  for  the  muscular  sense,  for  organic  sensations,  for 
some  of  the  higher  faculties,  as  of  attention  and  inhibition, 
are  now,  with  reason,  claimed  to  have  been  isolated.  For 
the  localization  of  some  or  these,  as  of  speech,  motor,  and 
some  of  the  sensory  centres,  the  facts  and  arguments  are 
practically  incontrovertible.  In  the  plainest  of  terms,  if 
brain  centres  which  determine  certain  movements  exist, 
the  performance  of  these  movements  must  develop  and 
train  not  only  muscles  concerned  in  these  actions,  but 
the  cerebral  centres  with  which  they  are  connected, — 
CHARLES  K.  MILLS,  M.  D.,  in  the  Maryland  Medical  Jour- 
nal, Feb.  ii,  and  1 8,  1888. 

L.  F.  B. 


VOL.  XIII.  May,   1888.  No.  5. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


©riginal  gwriktas. 


PARANOIA:    SYSTEMATIZED    DELUSIONS  AND 
MENTAL  DEGENERATIONS. 

AN     HISTORICAL   AND   CRITICAL    REVIEW, 
By  J.  SEGLAS, 

ASSISTANT   PHYSICIAN   TO  THE    HOSPITAL   OF   BICBTRE,    PARIS. 

Translated  by  William  Noyes,  M.D., 

ASSISTANT   PHYSICIAN   TO   THE    BLOOMINGDALE  ASYLUM,  NEW   YORK. 

[Continued from  last  Number.'] 

SCHUELE*  (1886)  gives  a  very  detailed  description  of 
systematized  insanity.  He  distinguishes  in  the  most 
formal  manner  Wahnsinn  from  Verrucktheit,  as  will 
be  seen  from  the  place  he  assigns  this  in  his  classification. 
It  is,  in  fact,  in  the  second  class,  that  of  psychoses  based  on 
an  incomplete  development  or  on  hereditary  degeneration, 
that  he  places  Verrucktheit.  It  appears  there  between  the 
hereditary  neurosis  and  simple  hereditary  insanity  (insanity 
with  delusions  of  possession  by  evil  spirits,  folie  du  doute,  and 
quarreling  or  quibbling  insanity,  folie  de  la  chicane),  and 
moral  insanity  and  idiocy;  this  originare  Verrucktheit  is, 
according  to  this  author,  grafted  on  an  abnormal  hereditary 
constitution  characterized  by  original  psychical  anomalies; 
that  is  to  say,  it  manifests  itself  at  an  early  age;  it  would 
thus  be  only  the  hypertrophy  of  the  original  character.  On 
the  other  hand,  it  is  in  the  first  class  (psychoses  in  the  com- 
pletely  developed    individual),    but   in  the    second    group 

*  Schuele,  Klinische   Psyschiatrie — Specielle   Pathologie  und    Therapie  der 
Geisteskrankheittn  (Leipsic,  1886).     As  this  passage  may  seem  obscure,  we  have 


2g6  J.   SEGLAS. 

(cerebro-psychoses  or  diseases  of  the  invalid  brain)  that  we 
find  Wahnsinn.  This  word  is  only  a  generic  term  which 
denotes  the  existence  of  delusional  conceptions  more  or  less 
united,  systematized  and  associated  in  groups  more  or  less 
connected,  and  forming  a  more  or  less  crystalized  whole. 

Schuele  has  divided  the  chapters  relative  to  Wahnsinn, 
properly  so  called,  as  follows:  this  primary  Wahnsinn  may 
be,  first,  chronic;  second,  acute;  third,  stuporous.  The  au- 
thor describes  the  typical  chronic  form  by  saying  that  all 
the  chronic  cases  tend  to  systematization,  properly  so 
called;  a  special  chapter  is  devoted  to  chronic  depressive 
Wahnsinn,    comprising   two  sub-chapters:    (a,  delusion    of 

thought  best  to  give  a  tabular  view  of  his  classification  to  facilitate  comprehen- 
sion. 

I.  Psychoses  grafted  on  the  complete  organs— psychic  development. 
f  I.   Of  the  sourui  brain  (psycho-neuroses  properly  so  called) — 

'  x  '  >  with  their  secondary  states. 

b.  Melancholia,  ) 

.    Of  the  "  invalid"  brain  (cerebro-psychoses) — 
a.   Mania,  grave  (furor); 
5  b.    The  systematized  delusion  ( Wahnsinn) : 

•«  1  I.  Acute, 

2.  Chronic, 

3.  Stuporous. 

c.  Acute  primary  dementia;  hallucinatory  stupor. 

d.  Hysterical,  epileptic,  and  hypochondriacal  insanity;   the  periodic 
insanities,  circular  and  alternating. 

B.  Insanities  consecutive  to  extra-cerebral  somatic  diseases  (fever,  puerperal 
state,  and  intoxication). 
3.   States  of  pernicious  exhaustion  of  the  brain — 

a.  Acute,  dangerous  (acute  delirium). 

b.  Chronic,   with  destructive  degeneration  (progressive    general  par- 

alysis). 

c.  The    psychic    cerebropathies,    or   psychoses   consecutive  to   sub- 

acute  or   chronic   organic  cerebral  diseases,  diffused  or  local- 
ized. 

II.  Psychoses  grafted  on   an   incomplete  or  constitutional  organo- 

PSYCHIC     DEVELOPMENT,     WITH     HEREDITARY     OR     CONSTITUTIONAL 
PREDISPOSITION. 

a.  Hereditary  neurosis  with  transitory  insanities. 

b.  Simple  hereditary  insanity  (folie  du  doute  et  du  toucher;  folie  impulsive; 

delusion  of  persecution  (litigation  ists). 

c.  Idiopathic  systematized  insanity  (ori^inirc  Verriicktheit). 

d.  Degenerative  hereditary  insanity  (moral  insanity). 

e.  Idiocy. 


PARANOIA.  2  g  y. 

persecution ;  b,  expansive  form).  The  variety  of  acute 
Wahnsinn  comprises  four  sub-varieties.  The  first  is  acute: 
sensorial  Wahnsinn  (hallucinatory). 

Here  is  described:  a,  the  hyper-acute  and  acute  halluci- 
natory Wahnsinn  with  exaltation  (menstrual  diseases);  b, 
the  sub-acute  maniacal  delusion  of  grandeur;  c,  the  acute 
and  sub-acute  hallucinatory  delusion  of  persecution;  d,  the 
depressive  and  then  acute  expansive  Wahnsinn;  e,  the  acute 
and  at  the  same  time  depresso-expansive  Wahnsinn;  b,  the 
acute  hypochondriacal  Wahnsinn;  c,  acute  or  sub-acute- 
cerebro-spinal  Wahnsinn.  The  second  sub-variety  is  the 
acute  melancholic  Wahnsinn  (demonomania);  the  third 
sub-variety,  the  expansive  maniacal  Wahnsinn;  the  fourth, 
the  acute  stuporous  or  stuporo-hallucinatory  Wahnsinn. 
The  stuporous  form  of  Wahnsinn  (attonita  and  katatonia} 
comprises  three  sub-varieties :  a,  expansive  religious  insanity ; 
b,  depressive  religious  insanity;  c,  a  form  resting  on  a  basis 
of  constitutional  hysteria,  without  prepossession  from  that 
which  describes  in  the  chapter  on  hysteria.  Here,  in  fact,. 
Schuele  describes  an  hysterical  systematized  insanity  (Wahn- 
sinn or  Verriicktheit  indifferently),  which  may  consist  of  sev- 
eral types:  a,  a  type  approaching  the  idiopathic  hereditary 
systematized  insanity  {priginaria  hereditaria  Verriicktheit)',. 
b,  a  type  that  is  the  hypochondriacal  systematized  insanity 
{JiypochondriascJier  Wahnsinn) ;  c,  a  type  characterized  by 
fantastic  caprices;  d,  a  type  characterized  by  a  vague  delu- 
sion of  persecution  without  great  systematization,  and  the 
character  of  which  varies;  e,  a  type  described  as  a  condi- 
tion of  acute  abortive  systematized  insanity  (Wahnsinn)  y 
presenting  the  form  of  sudden  irresistible  thoughts;  f,  kata- 
tonic  systematized  insanity  ( Wahnsinn) ;  g,  chronic  incur- 
able hysteria  with  symptoms  of  degeneration. 

III. 

Such  are,  in  a  word,  the  ideas  expressed  in  the  principal, 
German*  works  upon  systematized  insanity  ;  other  countries 

*We  desire  here  to  thank  our  colleague  Dr.  Keraval,  physician  of  the  Colony 
ofVancluse.  for  the  hearty  manner  in  which  he  has  assisted  us;  his  profound, 
knowledge  of  the  German  language  has  been  of  the  greatest  assistance  in  our 
bibliographical  researches. 


2gg  J.   SEGLAS. 

have  followed  the  impulse.  Thus  in  Russia  we  find  the 
conception  of  systematized  insanity  in  the  works  of  Tiling 
{1878-1879),  Kadinski  (1881),  and  Max  Buch  (1881),  already 
•cited,  and  of  Rosenbach*  (1884),  who  is  of  the  opinion  that 
paranoia  can  only  develop  on  a  basis  of  mental  debility,  be- 
cause the  sensorial  troubles  can  be  interpreted  in  the  sense 
of  a  delusion  which  arises  spontaneously  elsewhere,  and 
the  elements  of  which  these  sensorial  troubles  do  not  fur- 
nish. Still  further,  the  ambitious  ideas  are  not  a  logical 
consequence  but  are  often  contemporary  to  the  ideas  of  per- 
secution which  already  indicate  an  exaggertion  of  the  per- 
sonality. 

Dr.  Greidenbergt  (1885),  studying  acute  hallucinatory 
systematized  insanity  {paranoia  hallucinatoria  acuta)  dis- 
tinguishes two  forms  of  this  ;  the  one  hereditary,  and  the 
other,  the  more  frequent,  asthenic,  producing  in  their  train 
sometimes  an  intellectual  enfeeblement,  and  sometimes  a 
true  dementia,  or  tending  to  recovery.  In  England,  Buck- 
nill  and  TukeJ  (1879),  reject  monomania  and  describe  de- 
lusional insanity,  the  word  delusion  of  the  English  alienists 
designating  the  primary  delusional  conceptions  {les  concep- 
tions delirantes  prhnatives),  the  original  lesions  of  ideation. 

Maudsley§  (1883),  when  he  describes  the  insane  temper- 
ament, especially  in  its  suspicious  variety,  only  describes  in 
full  the  character  of  patients  suffering  from  Paranoia  or  cer- 
tain weakened  forms.  In  America,  Spitzka II  (1880- 1883) 
adopts  the  conception  of  paranoia,  which  he  describes, 
although  he  adopts  the  word  monomania.^  He  admits 
that  this  form  of  primary  delusion  is  the  expression  of  a  true 
intellectual  enfeeblement;  he  also  classifies  it  in  the  group 
of  states  of  mental  enfeeblement,  which  are  almost  always 
hereditary  and  constitute  a  sort  of  chain  whose  extremities 

•Rosenbach, — Messager  russe,  1884. 

fGreidenberg. — Messager  russe,  1885. 

JBucknill  and  Tuke.     A  Manual  of  Psychological  Medicine,  1879. 

$Maudsley.—  The  Pathology  of  Mind,  1883. 

||  Spitzka.—  A  case  of  Orig.nal  Monomania  (Medical  Times  and  Gazette, 
February,  1881),  and  Manual of  Insanity,  New  York,  1883. 

r  [In  the  edition  of  his  Manual  of  Insanity  in  1887,  Spitzka  definitely  adopts 
the  term  Paranoic      W.  N.] 


PARANOIA.  2gg 

are  formed  on  the  one  side  by  idiocy  and  on  the  other  by 
insanity  with  primary  systematized  delusions.  Between 
these  he  classes  imbecility,  moral  insanity  and  epileptic  in- 
sanity.* In  another  work,  f  the  same  author  has  given 
us  a  classification  of  delusions  which  he  divides  into  system- 
atized and  non- systematized  delusions.  The  systematized 
delusions  are  of  two  forms  :  first,  the  expansive  systematized 
delusions  (megalomania),  subdivided  into  a,  systematized 
delusions  of  social  ambition;  b,  systematized  delusions  of 
an  expansive  erotic  character;  c,  systematized  delusions  of 
an  expansive  religious  character.  The  second  form  is  that 
of  systematized  depressive  delusions,  subdivided  into,  a, 
systematized  delusions  of  depressed  social  ambition;  b, 
systematized  delusions  of  a  depressive  erotic  character,  usu- 
ally of  persecution;  c,  systematized  delusions  of  a  depres- 
sive religious  character. 

Regarding  the  non-systematized  delusions  these  are  inco- 
herent delusions  resulting  from  the  destruction  of  the  power 
of  association,  and  the  emotional  delusions  dependent  on 
the  exaltation  of  the  mental  sphere  by  a  violent  emotional 
trouble. 

We  may  also  mention  in  America  the  works  of  Beard, % 
Fenn,§  and  Hammond. || 

IV. 

But,  after  the  Germans,  the  Italians  have  occupied  them- 
selves most  in  the  study  of  paranoia.  In  a  first  memoir, 
Buccola"!  (1882)  undertakes  the  study  of  primary  systema- 
tized delusions  and  seems  to  concur  with  the  opinion  of 
Krafft-Ebing. 

These  delusions  are  to  his  mind  the  expression  of  a  feeble 
mental  state  as  shown  by  their  etiology,  their  continuous  and 

•Spitzka. — St.  Louis  Clinical  Record,  1880,  VII. 

fSpitzka.—  Insane  Delusions ;  Their  Mechanism  and  their  Diagnostic  Bear- 
ing (Journal  of  Nervous  and  Mental  Disease,  1881). 

J  Beard.-  Monomania  and  Monohypochondria  (New  York  Medical  Record, 
March,  1882). 

§Fenn. — Original  Monomania,  (American  Medical  Weekly,    August,    1882). 

||Hammond. — A  Treatise  on  Insanity,  London,  1883. 

^[Buccola. — I  deliri  sistematizzati primitivi  (Riv.  Sper.  di  Fren.,  1882,  p. 80). 


yr\(~\  J-  S£GJLAS. 

remitting  course,  etc.  Moreover,  complete  physiological 
exercise  of  the  mental  functions  cannot  be  judged  solely  by 
the  persistence  of  the  logic,  but  by  the  nature,  the  quantity 
and  the  association  of  the  psychical  energies,  and  the  har- 
monious relations  that  should  exist  between  the  ideas,  the 
sentiments  and  the  acts. 

In  this  work  Buccola  studies  the  genesis  of  the  delusion, 
and  remains  undecided  on  the  subject,  questioning  whether 
the  hallucinations  are  primary  and  the  delusional  ideas  only 
the  interpretation  of  them  or  arise  from  unconsciousness. 
He  studies  the  course  of  the  systematization,  especially  in 
the  delusion  of  persecution,  of  which  he  reports  two  cases. 

Morselli  and  Buccola*  (1883)  show  the  special  develop- 
ment of  these  delusions,  their  chronic  course  without  de- 
mentia properly  so  called,  and  their  limited  curability.  Re- 
garding the  delusion,  two  forms  may  be  distinguished: 
first,  the  delusion  of  persecution,  of  a  variabie  nature  accord- 
ing to  the  age,  temperament,  and  education.  In  this  form 
would  come  the  quarreling  insanity,  a  true  delusion  of  active 
persecution.  The  second  form  would  be  the  delusion  of 
grandeur,  associated  at  first  or  existing  alone,  most  fre- 
quently with  an  trotic  or  religious  coloring.  The  fixed 
ideas  should  be  regarded  only  as  an  abortive  form  of  these 
delusions,  they  being  differentiated  by  the  fact  that  the  pa- 
tient has  a  consciousness  of  his  condition. 

Regarding  the  clinical  nature  of  these  delusions  Morselli 
and  Buccola  place  them  among  the  degenerative  psychoses, 
and  divide  them  into  two  classes  :  first,  primary  systema- 
tized delusions  with  anomalies  of  the  development  of  the 
psychic  individuality  (P.  originare  of  Sander);  second, 
systematized  delusions  showing  themselves  in  a  psychic  in- 
dividuality already  developed.  Then  intervene  some  occa- 
sional causes  (acute  diseases,  menopause,  and  traumatisms). 
Even  in  these  cases,  however,  hereditary  influence  exists  in 
the  majority  of  cases. 

The  forms  that  Morselli  and  Buccola  place  under  the 
head  of  acute  primary  insanity  are  the  following: 

*Monelli  et  Buccola. — La  pazzia  sittematizzata.  Giorm.  della  R.  Academ. 
di  Torino,  1882,  p.  210. 


PARANOIA.  2qI 

ist.  The  intellectual  monomania  of  Esquirol. 

2d.  Sensorial  insanity,  when  the  hallucinations  are  not 
brought  on  by  mania  or  melancholia  but  from  delusions, 
from  an  original  lesion  of  the  perceptive  centres. 

3d.  The  so-called  cases  of  lypomania  with  delusion  of 
persecution,  in  which  the  melancholic  state  is  secondary. 

4th.  The  hypochondriacal  insanities,  in  which  the  synes- 
thetic  hallucinations  are  the  pivot  of  the  delusions,  and 
where  a  delusion  of  persecution  is  often  concealed  under 
hypochondriacal  ideas. 

5th.  Certain  cases  of  hysterical  insanity  that  present  an 
erotic  delusion  without  remission  (Merklin  and  Schaefer). 

6th.  Certain  cases  of  claustrophilia  or  claustrophobia  that 
have  been  wrongly  interpreted,  and  concealing  a  delusion 
of  persecution.  A  certain  number  of  analogous  forms,  all 
characterized  by  the  predominance  of  a  given  group  of 
ideas  and  tendencies  constituting  the  abortive  forms  of  pri- 
mary systematized  insanity,  while  others  form  the  group  of 
fixed  ideas  where  consciousness  remains. 

7th.  The  forms  intermediate  between  sanity  and  insanity 
(the  insane  temperament),  the  graphomanias  with  con- 
cealed ideas  of  grandeur. 

8th.  Certain  cases  oifolie  lacide,  or  folie  raissonnante. 

9th.  The  eccentric  and  original  individuals. 

Amadei  and  Tonnini*  (1883)  give  us  a  very  complete 
description  of  paranoia,  showing  that  the  delusion  is  only  a 
phase  and  the  culminating  point  of  the  disease.  The  devel- 
opment, characteristics,  course,  transformations  or  associ- 
ations, and  the  termination  of  the  delusions  are  clearly 
studied.  But  the  most  original  point  of  the  memoir  is  the 
classification.  The  authors  admit  by  the  side  of  a  degener- 
ative form  a  psycho-neurotic  form,  and  they  bring  forward 
the  following  arguments: 

ist.  Absence  in  these  cases  of  a  constitutional  element 
from  which  the  disease  could  be  foreseen;  no  usual  symp- 
tom of  neuropathy. 

2d.  Frequent  existence  of  occasional  causes  or  of  tem- 
porary  predispositions    that    may    explain    the    paranoia, 

*  Amadei  and  Tonnini. — La  Paranoia  et  le  sue  forme  (Arch.  ital.  per  le 
malattie  nervost,  1883-1S84. 


292 


J.   SEGLAS. 


without  which  there  would  be  a  necessity  of  seeking  a  pre- 
disposition in  the  antecedents. 

3d.  Often  these  cases  recover,  sometimes  there  results  a 
certain  mental  enfeeblement. 

4th.  In  these  psycho-neurotic  forms  there  is  neither 
more  nor  less  heredity  than  in  mania  or  melancholia. 

5th.  The  duration  of  the  acute  forms  of  the  disease  and 
the  beginning  of  the  psycho-neurotic  forms  is  in  contradic- 
tion with  the  former  mental  life  of  the  patient,  while  this  is 
not  so  in  the  degenerative  forms. 

Here  is  the  classification  of  paranoia  that  they  propose: 


-; 


I.  Degenerative  Paranoia  : 
A.   Idiopathic  {originaire). 

\  a.   Simple:   delusions  of  persecution,  ambitious,  religious,  and 
I  erotic. 

I  b.  Hallucinatory:  delusions  of  persecution,  ambitious,  religious, 
erotic,  and  hypochondriacal. 

l£.   Late. 

(  a.   Simple :  delusions  of  persecution  and  of  quibbling,  ambitious, 
I  religious,  and  erotic. 

I  b.  Hallucinatory:  delusions  of  persecution,  ambitious,  religious, 
erotic,  and  hypochondriacal. 

II.  Psychoneurotic  Paranoia  : 

\  A.  Primary. 

f  A.  Acute  and  curable. 


\ 


[a.   Simple:   delusions  of  persecution,   ambitious,  reli 

gious,  and  erotic. 
I  b.  Hallucinatory:  delusions  of  persecution,  ambitious, 

religious,  and  erotic. 

.  B.   Incurable, 

I  a.   Simple:   delusions   of  persecution,   ambitious,  reli- 
gious, and  erotic. 


I  b.   Hallucinatory:  delusions  ot  persecution,  ambitious, 
religious,  erotic,  and  hypochondriacal. 


y  B.  Secondary. 

\  a.   Post-maniacal. 
I  b.    Post-melancholic. 

As  is  seen  by  this  table,  degenerative  paranoia  alone 
would  be  always  primary,  the  secondary  being  solely  the 
termination    of   a   psychoneurotic    state.      This   secondary 


PARANOIA.  2Q3 

form  is  considered  by  these  authors,  together  with  Krafft- 
Ebing,  as  a  state  of  mental  enfeeblement  consecutive  to 
some  of  the  primary  forms  of  psychoneuroses. 

Regarding"  the  degenerative  defect  in  paranoia  of  the 
first  category,  this  is  never  the  most  profound,  and  does  not 
reduce  the  patients  to  the  last  degree  of  the  scale  of  the 
degenerates.  Schuele  also,  with  good  reason,  separates 
these  forms  of  degeneration,  in  the  strict  sense  of  the  word, 
to  make,  as  we  shall  see,  the  neuroses  with  a  degenerative 
basis.  But  this  is  not  simply  a  question  of  degree,  and 
there  should  be  intermediate  forms  between  the  degener- 
ative forms  of  paranoia  and  certain  simple  delusional 
outbreaks  observed  in  imbeciles,  and  also  between  certain 
states  of  mental  debility  and  the  idiopathic  {originaire) 
paranoias  where  the  delusion  is  but  little  accentuated. 

In  conclusion,  Amadei  and  Tonnini  hold  that  the  sen- 
sorial delusion*  (Wahnsinn  of  Krafft-Ebing),  the  true  type 
of  non-systematized  delusions  may  pass  into  paranoia 
through  the  stage  of  fixed  ideas,  which  is  a  rudimentary 
or  prodromal  form  of  paranoia,  differing  from  this,  however, 
by  the  consciousness  of  the  subject. 

Finally,  we  may  distinguish  (as  Krafft-Ebing  has  done) 
true  paranoia  in  certain  more  or  less  systematized  delusions 
of  epilepsy,  hysteria,  alcoholism,  etc. 

Raggit  (1884)  considers  that  the  role  of  the  degener- 

*  [In  explanation  of  this  term  (delire  sensorial),  Folsom's  description  (Primary 
Delusional  Insanity,  in  Pepper's  American  System  of  Medicine)  may  be  of  ser- 
vice :  "  Transformed  delusions  (sensorielle  Verrucktheit)  arise  usually  in  some 
anomally  of  sensation,  which  probably  directs  the  delusions  already  forming  in  a 
mind  in  the  early  stage  of  disease  rather  than  causes  the  disease.  The  causes  lie 
in  a  deep-seated  exhaustion  of  the  nervous  system,  especially  in  the  neuropathic 
constitution  and  profound  hysteria.  Various  anomalous  sensations  give  rise  to  a 
belief  in  delusions  as  to  their  being  caused  by  individuals  for  a  purpose,  or  to  their 
being  an  indication  of  all  sorts  of  impossible  and  most  extraordinary  changes  in 
the  part :  the  chest  is  of  stone,  the  leg  of  brass,  the  head  on  fire,  the  hand  of  ice, 
and  so  on  indefinitely.  Hallucinations  and  a  cataleptiform  state  are  common. 
The  variety  of  delusions  which  may  arise  is  almost  endless,  and  they  may  have 
their  origin  in  the  unhealthy  action  of  any  organ  in  the  body  ;  one  of  the  most 
troublesome  forms,  called  ovarian  insanity  by  Skae,  causes  single  women  of 
severely  continent  lives  to  imagine  all  sorts  of  impossible  marital  relations  with 
men  whose  lives  are  equally  beyond  scandal  and  above  suspicion." — W.  N.] 

t  Raggi. — Dell'  element o  degeneratio  nella  genesi  dei  cosi  detti  delire  siste- 
matizzati primative  (Arch.  ital.  per  le  mal,  nerv.,  1884J. 


2Q4  J.   SEGLAS. 

ative  element  in  the  genesis  of  paranoia  is  far  from  being 
demonstrated  ;  he  denies  all  the  distinctive  characteristics 
drawn  from  the  etiology,  evolution,  symptomatic  corn- 
plexus,  and  the  course. 

To  his  mind  heredity  plays  no  larger  role  here  than 
elsewhere  ;  the  priority  of  the  idea  in  date  to  the  troubles 
of  sensation  is  not  in  the  least  demonstrated,  and,  on  the 
contrary,  the  slightest  amount  of  emotional  trouble  in  these 
patients  suffices  to  change  or  excite  their  delusions.  More- 
over, all  the  authors  do  not  agree  upon  the  symptoms,  some 
regarding  the  hallucinations  as  primary,  others  as  second- 
ary to  the  delusion,  which  is  one  of  persecution  with  some 
and  of  grandeur  with  others.  Regarding  the  course,  do 
not  some  authors  admit  that  the  delusions  have  an  acute 
course,  a  thing  that  is  incompatible  with  an  idea  of  degen- 
eration ? 

All  these  arguments  are  very  specious,  and  it  seems  to 
us  that  it  is  sufficient  to  cite  them  to  show  how  few  of  them 
should  be  takeninto  consideration. 

In  this  same  year  (1884),  Tanzi*  published  an  historical 
study  on  paranoia,  a  kind  of  introduction  to  a  monograph 
on  this  form  of  insanity  made  in  collaboration  with  Riva.t 

To  Tanzi  and  Riva  paranoia  is  a  functional  psychopathy 
founded  on  a  degenerative  basis,  characterized  by  a  par- 
ticular deviation  of  the  highest  intellectual  functions,  imply- 
ing neither  a  grave  decay  nor  a  general  disorder ;  it  is 
almost  always  accompanied  by  hallucinations  and  by 
permanent  delusions  more  or  less  systematized,  but  inde- 
pendent of  all  definite  occasional  cause  or  of  all  emotional 
morbid  condition,  which  pursues  a  course  neither  uniform 
nor  continuous,  but  nevertheless  essentially  chronic,  and 
generally  does  not  in  itself  tend  to  dementia. 

In  only  fourteen  cases  out  of  a  hundred,  according  to 
Tanzi  and  Riva,  heredity  was  unknown  but  not  excluded, 
and  in  eighty-six  other  cases  the  paranoia  had  a  degenera- 

*  Tanzi. — La  J'aranoia  (dclirio  sistematizzato)  e  ia  sua  evolutional  storica 
(Rev.  sperim.  di  freu.,  1884J. 

f  Tanzi  et  Riva. —La  Paranoia  cotUributo  alia  sloria  dtlle  degrnerazion  psi- 
chiche  (Kiv.  sperimen.  difren.,  1884,  /88j,  1886J. 


PARANOIA.  29S 

tive  basis  either  from  heredity  (77),  or  from  diseases  of 
infancy  implicating  the  development  of  the  individual  (9.5). 
From  this  it  is  not  unfair  to  conclude  that  paranoia  is  a  form 
of  mental  debility.  It  is,  as  already  shown  by  Amadei, 
Tonnini  and  others,  simply  a  degenerative  psychosis  due  to 
an  hereditary  or  constitutional  defect,  as  shown  by  its 
chronic  course  and  insidious  beginning  and  its  variable 
symptomalology. 

The  psychical  constitution  of  paranoiacs  can  be  put  in 
evidence  only  through  the  systematized  delusion  which 
rises  on  the  mental  constitution  and  is  the  exaggeration 
of  this ;  and  meanwhile  this  constitution  is  all  important, 
constituting  sometimes  in  itself  the  whole  disease  (indiffer- 
ent paranoid),  and  showing  forth  again  in  the  prodromes 
and  in  the  periods  of  remission. 

It  consists  especially  in  anomalies  of  the  intelligence 
(associations  of  odd  ideas  and  absurd  judgments)  or  of  the 
affective  sentiments  (egoism,  defiance,  romanticism,  irritabil- 
ity, emotionality,  sexual  perversions,  etc.). 

The  psychical  characteristics  of  this  constitution  develop 
with  the  years  until  they  reach  a  degenerative  maturity  at 
the  age  when  a  sane  man  is  at  the  height  of  his  intellectual 
power  (thirty-two  years  on  an  average).  It  is  then  that 
the  delusion  generally  develops,  but  sometimes  it  is  lacking 
(in  eccentric  and  original  individuals),  or  it  is  insufficient  to 
disturb  the  psychic  equilibrium  ;  the  patient  has  no  delusion 
properly  so  called,  but  he  reasons  falsely  aud  is  paradoxi- 
cal (fo/ie  raissonnante, — indifferent  type). 

In  fact  paranoia  is  a  morbid  constitutional  form,  and  the 
■delusion  is  only  a  symptom.  Moreover,  it  is  not  absolutely 
specific  and  it  may  be  found  in  other  psychopathic  forms 
without  distinct  psychological  characteristics,  but  in  these 
cases  it  is  independent  of  the  psychic  constitution  and  arises 
under  the  influence  of  an  incidental  somatic  cause;  circula- 
tory (mania  or  melancholia),  inflammatory  (general  parly- 
sis),  toxic  (alcoholism),  etc. 

As  regards  the  genesis  of  the  delusion  it  develops  unex- 
pectedly without  a  previous  emotional  morbid  state,  and  it 
is  accompanied  by  hallucinations  that  are  secondary,  affecting 


2r6  PARANOIA. 

most  frequently  the  sense  of  hearing,  afterwards  the  general 
sensibility, — visual  hallucinations  being  extremely  rare. 
The  delusion  may  undergo  transformations,  becoming  either 
multiple  or  indetermintae,  or  be  entirely  wanting. 

From  this  point  of  view  paranoia  may  be  divided  as  fol- 
lows : 

ist.  Paranoia  with  delusions  of  persecution.. 

2d.  Ambitious  paranoia. 

3d.  Religious  " 

4th.  Erotic  " 

5th.  Intermediate  "         (Quarrelling  insanity  ;  paranoia 

without  delusions). 

6th.  Mixed 

7th.  Rudimentary  "         (Fixed  ideas). 

From  the  point  of  view  of  the  onset  two  kinds  of  paranoia 
may  be  distinguished  (an  artificial  distinction  it  may  be,  the 
ground  remaining  always  the  same): 

ist.  Idiopathic*  paranoia  {priginarc  type  of  Sander). 

2d.  Late  paranoia  :  a,  post  puberal ;  b,  of  the  menopause 
(these  two  varieties  following  the  biological  evolution  of  the 
individual);  c,  simple  (independent  of  the  biological  evolu- 
tion). 

Regarding  the  course,  which  is  essentially  chronic,  it 
may  be  divided,  according  to  the  delusional  symptom,  into 
uniform  (same  type  of  delusion)  and  variable,  and  accord- 
ing to  the  mode  of  succession  of  the  symptoms  into  con- 
tinuous, remittant,  and  with  exacerbations.  All  these 
varieties  may  be  combined,  and  we  shall  have  these  a 
course  : 

(   Continuous  (delusions  of  persecution). 
Uniform       <  Remittant. 

'  With  exacerbations. 
Continuous  (transformations  of  the  delusion  of  persecution  into 

ambitious  delusion). 
Remittant. 
With  exacerbations. 

The  exacerbations  may  be  brought  about  by  psycho- 
neurotic attacks  (mania,  melancholia,  or  stupor). 


And  variable. 


°In  this  translation  the  word  idiopathic  has  been  used  to  designate  the  orig- 
tn&re  and  originaire  of  the  Germans  and  French,  thus  leaving  the  primary  for 
the  corresponding  primart  and  primative.     W.  N. 


PARANOIA.  2gy 

As  regards  the  terminations,  mental  enfeeblement  is 
little  frequent,  and  absolute  dementia  is  very  rare.^When 
it  exists  it  may  show  itself  under  three  aspects :  first,  pre- 
mature senility,  the  expression  of  the  rapid  failure  of  the 
degenerated  organism ;  second,  dementia  due  to  inter- 
current psychoneurotic  attacks  (mania  or  melancholia); 
third,  apparent  dementia  may  appear  in  two  forms  :  in  the 
first  the  patient,  seeing  the  uselessness  of  his  ideas,  remains 
calm,  loses  confidence,  and  becomes  indifferent ;  in  the 
second  he  concentrates  himself  more  and  more  in  his  delu- 
sion, becomes  exalted  and  extravagant,  and  gives  himself 
up  to  disordered  and  incoherent  actions. 

Regarding  the  place  paranoia  occupies  among  the  de- 
generations, Tanzi  and  Riva  place  it  in  the  purely  psychical 
forms  (that  is  to  say,  without  disturbances  of  motion  or 
sensibility),  called  by  Morsel li  paraphrenias,  and  in  this 
sub-group  may  be  distinguished,  first,  the  intellectual 
psychical  degenerations  with  or  without  delusions,  that  is  to 
say,  paranoia ;  and  second,  the  affective  psychical  degener- 
tions  (moral  insanity,  congenital  delinquency,  and  sexual 
perversions). 

Furthermore,  and  notwithstanding  the  opinion  of  Bon- 
vecchiato,*  who  finds  this  classification  too  systematized, 
Tanzi  and  Riva  willingly  admit  mixed  forms,  both  intel- 
lectual and  affective,  all  resting  on  the  same  degenerative 
basis. 

During  the  course  of  the  publication  of  this  long 
memoir,  other  works  on  this  same  subject  have  appeared 
in  Italy. 

Salemi-Paci  (1885)  distinguishes  two  kinds  of  paranoia  : 
one,  simple  paranoia,  independent  of  all  degenerative  ele- 
ment;  the  other,  degenerative  paranoia  ;  he  describes  also  a 
form  of  consecutive  or  secondary  paranoia,  but  he  does  not 
see  the  necessity  of  making  a  particular  form  of  it,  as  do 
the  other  two  authors. t 

*  Bonvecchiato. — La  pazzia  sistematizzata  ptimitiva.     Venice,  1875. 
f  Salemi  Pace.—  La  classijicazione  dela  frenopathie .     II  Pisani,  J885. 
This  distinction,  which  is  apparently  very  simple  at  first  sight,  is  much  less 


298 


J.   SEGLAS. 


One  may  well  have  doubts  of  the  existence  of  simple 
paranoia  when  he  sees  an  author  place  it  by  the  side  of 
moral,  impulsive  and  sensorial  insanity,  and  emotional  de- 
lusions. 

Angelo-Zuccarelli*  (1885)  reports  an  observation  on 
primary  paranoia  with  delusions  of  persecutions  of  a  chronic 
form,  that  he  held  to  be  of  a  non-degenerative  nature. 

Guiccardit  (1886)  agrees  with  the  ideas  ofTanzi  and 
Riva  regarding  the  interpretation  of  the  psychical  phenom- 
ena that  characterize  the  paranoiac  personality. 

B.  BattagliaJ  (1886)  cites  a  case  of  paranoia  with  ambi- 
tious delusions,  that  is  at  least  open  to  criticism.  We  shall 
content  ourselves  with  remarking  that  the  author  pretends 
not   to   have   found    hereditary   antecedents,   nor   signs   of 

so  when  the  following  resume  of  his  classification  is  considered  : 


Group  I. 
Cerebro-tieuroses. 


I  Nervous  insanity. 
[Hypochondria. 

</.       Simple  insanities. 


Group  II. 

Dynamic  csrebro- 

insanrttes. 


I  Melancholia. 

-   Mania. 

(  Circular  insanity. 


f  Sp« 


:ific. 


Diathetic  insanities. 


Impulsive  instinct- 
ive insanities. 


Z.  "J   Sensorial  insanity. 

■2       Moral  insanity. 

%       Intellectual  insanity 

su 


Neurotic. 


f  Pellagous  insanity. 

I    Puerperal  " 

•j    Syphilitic  " 

Alcoholic  ' ' 

[  Rheumatic  " 

(Epileptic  " 

Choreic  " 

Hysterical  " 

Erotic  " 


Kleptomania,  pyromania,  agor- 
aphobia, dipsomania,  suicidal 
and  homicidal  insanity,  etc. 

Metaphysical  insanity,  insanity 
of  doubt,  delusions,  of  touch, 
simple  paranoia. 


Group  III. 

States  of  cerebral 

defect. 


Imbecility,  idiocy,  cretinism. 


f  Paranoia — degenerative,  consecutive,  or  secondary. 
I    Primary  dementia. 
Group  IV.  ( lonsecutive  or  secondary  dementia. 

Senile  dementia. 

Paralytic  dementia. 

*  Angelo-Zuccharelli. —  Contribution  a  P  etude  medico-legate  de  la  Paranoia 

(II  mnnicomto,  /88<;J. 

-Mujiccardi. — P.xchologia  e psychatria  (Ri-.  sp, r.  Ji  fren.,  /88b,  p.  5Ji)- 
i  Bruno*  BattagliiL  —  Contribuzione    alia     casistica    del/a     Paranoia.        (La 

psychiati  e    1886,  fasc.  3  and  4,  p.  354. 


PARANOIA.  2qq 

degeneration.  Nevertheless,  he  tells  us  that  his  patient 
had  a  feeble  mind,  was  ill-balanced,  loved  the  marvellous, 
was  unstable,  and  was  disgusted  with  life  without  good 
reasons  ;  he  lacked,  he  says,  the  faculty  of  adaptation  to 
his  social  circle,  and  the  spirit  of  rational  criticism.  Now, 
are  there  not  here  sufficient  signs  of  a  state  of  mental 
degeneration  ? 

Morselli*  (1886)  reports  a  case  of  rudimentary  impulsive 
paranoia.  We  have  already  seen  that  Arndt  was  the  first 
to  describe  this  form  of  paranoia. 

This  rudimentary  paranoia  (or  rather  the  fixed  ideas) 
has  been  divided  by  Tamburini  t  into  three  classes:  first, 
the  simple  fixed  ideas  (ex  :  pure  folie  du  doute),  without  a 
tendency  to  transform  themselves  into  acts ;  second,  the 
emotional  ideas  with  simultaneous  actions  (ex  :  folie  du 
doute  avec  deHre  du  toucher);  that  is  to  say,  with  a  tendency 
to  the  exteriorization  of  their  motor  content ;  third,  the 
impulsive  ideas.  Morselli  admits  only  two  classes,  uniting 
into  one  the  last  two  of  Tamburini,  because  in  these  cases 
there  always  exists,  according  to  him,  the  tendency  of  an 
ideational  representation  to  transform  itself  into  an  act. 
Regarding  the  ground  on  which  these  ideas  develop,  there 
is  likewise  much  contest. 

Krafft-Ebing,i  Cantarano§  and  Andrianill  regard  these 
forms  as  being  always  manifestations  of  degeneration. 
Others,  with  Berger.^T  Kroepelin,**  Tamburini,  Amandeiand 
Tonnini,  and  Tanzi  and  Riva,  admit  that  they  may  develop 
on  a  neurasthenic  constitution,  but  are  not  always  here- 
ditary. Morselli  inclines  to  this  latter  opinion  and  classes 
them  in  the  Paraphrenias  of  the  second  group.     The  ideas 

*  Morselli. — Paranoia  rudimsntale  impuisiva  (Pi v.  sper.  difren.,  1 886,  f.  4, 
p.  495. 

"f"  Tamburini. — Sulla  pazzia  del  dobbio  (Riv.  sper.  difren.,  i8dj). 

%  Krafft-Ebing.     Lehrbuch  der  Psych,  1879. 

§Cantarano.  Con'ributo  alio  studio  delta psicosi  degenerative.  (La  psychi- 
atria,  1884) 

[|  Andriani.  Contributo  alia  conoscenza  delle  psicoside generative  (idee  fisse) 
La  pschiairia,  1885. 

^[Berger.  Grubelsacht  ein  psychopathische symptom.  —  Grubelsacht  und  Zwang- 
vorsellungen  (Arch.  f.  Psych.,  Bd.  vi.  and  viii.). 

**Kroepelin.      Comp.  der  Psych.     Leipsic,  1883. 


3QO  %   SEGLAS. 

of  this  author  will  be  made  clearer  by  an  explanation  of  the 
place  that  the  different  forms  of  paranoia  occupy  in  his  class- 
ification of  mental  disease.  Properly  speaking,  Morselli 
admits  only  two  typical  forms  of  paranoia  ;  first,  idiopathic 
{originaire)  degenerative  paranoia  with  its  three  varities  of 
persecution,  grandeur,  and  the  erotic  form  (erotomania); 
second,  rudimentary  paranoia  with  its  two  varieties,  idea- 
tional and  impulsive.  Both  are  classed  among  the  para- 
phrenias (anomalies  of  cerebral  evolution  with  abnormal 
formation  or  perversion  of  the  personality).  But  although 
idiopathic  {originaire)  degenerative  paranoia  is  a  part  of 
the  sub-group  of  Paraphrenias  formed  by  the  psychical  de- 
generations (paraphrenias  depending  on  a  psychopathic 
constitution  most  frequently  of  hereditary  origin),  rudimen- 
tary paranoia  is  classed  under  a  second  sub-group,  that  of 
constitutional  psychopathies  (Paraphrenias  depending  on  a 
psychopathic  constitution  most  frequently  congenital). 

Regarding  the  forms  of  acute  paranoia  and  secondary 
paranoia,  admitted  by  some  authors,  these  are  completely 
separated  from  the  preceding  and  classed  among  the  psy- 
choncuroscs,  a  sub-group  of  phrenopathies  (diseases  of  the 
completely  developed  brain  with  morbid  changes  and  alter- 
ation of  the  personality).  The  one,  paranoia,  called  acute 
or  hallucinatory  or  curable,  is  described  under  the  name  of 
acute  sensorial  insanity  and  placed  by  the  side  of  maniacal 
or  melancholic  states.  The  other,  secondary  systematized* 
insanity  (so  called  secondary  paranoia),  with  its  two  forms 
of  persecution  and  grandeur,  is  not  considered,  with  dementia, 
as  a  terminal  condition, — a  conditional  of  intellectual  en- 
feeblement.     (Synonym,  incomplete  dementia.) 

•It  should  be  noted  that  Morselli  designates  these  forms  under  the  names  of 
of  acute  sensorial  insanity  (Frenosi  sensoria  acuta)  and  secondary  systematized 
insanity  (Pazzia  sittematizzata  secundaria),  reserving  for  the  idiopathic  (otigin- 
aire)  and  rudimentary  lorms  the  term  paranoia,  which  seems  thus  ssociated  in 
the  author's  mind  with  the  idea  of  a  neuropathic  constitution,  which  may  be  con- 
genital or  hereditary. 

[To  be  Continued.} 


OPHTHALMOPLEGIA  EXTERNA  PARTIALIS. 

By  M.  ALLEN  STARR,  M.D.,  PhD., 

Clinical  Lecturer  on  Diseases  of  the  Mind  and  Nervous  System,  College  of  Physicians  and 
Surgeons.  New  York. 

Read  before  the  Neurological  Section  of  the  Academy  of  Medicine,  April  13,  1888. 

THE  condition  of  paralysis  of  all  the  muscles  moving 
the  eyeball,  ophthalmoplegia  externa  totalis,  is  well 
known  and  easily  recognized.  Its  lesion  consists  of 
a  general  destructive  process  of  a  subacute  inflammatory  or 
degenerative  nature  in  the  nuclei  of  origin  of  the  sixth, 
fourth,  and  third  nerves  upon  the  floor  of  the  fourth  ventri- 
cle and  aqueduct  of  Sylvius.  It  is  always  bilateral.  The 
destruction  of  the  sixth  nerve  nucleus  on  either  side  causes 
a  paralysis  of  conjugate  movement  of  both  eyes  toward 
the  side  of  the  lesion  ;  and  when  both  sixth  nerve  nuclei 
are  involved  together,  the  eyes  look  directly  inward  and 
cannot  be  turned  from  side  to  side.  The  destruction  of 
the  fourth  nerve  nuclei  produces  a  paralysis  of  the  act  of 
looking  upward  and  inward;  and  that  of  the  third  nerve  nu- 
clei deprives  the  patient  of  all  other  movements  of  the  eye- 
ball and  upper  lid,  so  that  in  the  terminal  stage  of  this 
disease  double  ptosis  and  immobility  of  both  eyeballs  are 
present.  The  motions  of  the  iris  are,  however,  unaffected 
in  this  disease,  and  the  nuclei  governing  the  movements  are 
not  involved  in  the  degenerative  process,  though  they  lie 
quite  near  to  and  just  in  front  of  those  governing  the  other 
-muscles  supplied  by  the  third  nerve.  Twenty-seven  cases 
•of  this  affection  have  been  collected  by  Mauthner  in  his  lec- 
tures, a  number  of  them  accompanied  by  autopsy ;  and 
other  cases  published  since  1885,  some  of  which  were  brought 
together  by  Mittendorf  in  1887,*  have  established  the  ex- 

0  Journal  Nervous  and  Mental  Disease,  1887,  p.  78. 


M.  ALLEX  STARR. 


^02 


istence  of  this  disease  and  the  invariable  character  of  its 
lesion. 

It  is  not  to  total  ophthalmoplegia  externa  that  I  desire 
to  call  attention  in  this  paper,  but  to  a  condition  of  paralysis 
of  but  one  or  two  of  the  muscles  moving  the  eyeball,  a  con- 
dition which  may  be  termed  ophthalmoplegia  externa  partialis 
to  distinguish  it  from  the  condition  already  described. 

It  is  of  course  well  known  that  a  paralysis  of  the  exter- 
nal rectus  muscle  of  one  or  of  both  eyes  is  a  common  occur- 
rence due  to  a  lesion  affecting  one  or  both  sixth  nerves  in 
their  long  course  upon  the  base  of  the  brain.  Upon  this 
form  of  partial  ophthalmoplegia  I  do  not  care  to  dwell,  as  it 
is  well  understood.  Nor  need  I  refer  to  paralysis  of  the 
patheticus  or  fourth  nerve  which  occasionally  occurs,  but  is 
extremely  rare.  It  is  especially  to  paralysis  of  one  or  two 
or  more  of  the  muscles  governed  by  the  third  nerve  that  I 
desire  to  call  attention.  For  there  are  several  points  of 
interest  which  arise  in  its  study,  and  which  have  not  been 
fully  discussed  either  in  neurological  or  ophthalmological 
literature. 

Paralysis  affecting  but  one  or  two  of  these  muscles  mov- 
ing the  eyeball  is  so  rare  as  to  warrant  a  report  of  every 
case  observed.  And  the  fact  that  six  such  cases  with 
autopsies  are  now  on  record  warrants  an  attempt  at  the 
localization  of  the  lesion  during  life. 

The  following  case  has  been  under  observation  for  a 
year,  and  has  been  in  a  stationary  condition  for  the  past 
nine  months.  It  offers  a  number  of  points  of  interest  for 
discussion. 

S.  D.,  a  Frenchman,  aged  56,  a  painter  by  occupation, 
and  a  resident  of  Providence,  R.  I.,  was  brought  to  my 
clinic  April  18th,  1887.  He  had  been  a  healthy  man  all  his 
life,  with  the  exception  of  occasional  attacks  of  rheumatism 
and  frequent  attacks  of  migraine.  He  had  never  contracted 
syphilis,  and  denied  all  symptoms  of  pulmonary,  cardiac, 
gastro-intestinal  and  renal  disease,  although  a  physical 
examination  revealed  the  existence  of  slight  aortic  obstruc- 
tion producing  a  systolic  murmur  heard  at  the  base  and 
associated  with  slight  ventricular  hypertrophy. 


OPHTHALMOPLEGIA  EXTERNA  PARTIALIS.  m** 

He  stated  that  about  the  first  of  April,  1887,  he  had  been 
seized  very  suddenly  with  double  vision  and  vertigo,  objects 
appearing  to  move  up  and  down  constantly,  so  that  he  was 
much  bewildered  and  unable  to  stand  or  to  walk  alone. 
He  managed  with  help  to  reach  his  home,  but  has  no  recol- 
lection of  what  occurred  during  the  three  following  days, 
during  which,  according  to  the  statement  of  his  family,  he 
lay  in  a  somnolent  condition,  but  not  comatose  or  para- 
lyzed. He  was  then  able  to  get  up,  but  felt  stupid,  dizzy,, 
and  walked  with  difficulty,  it  being  impossible  for  him  to- 
ft x  any  object  with  his  eyes  ;  all  objects  being  seen  double 
and  in  motion.  These  symptoms  have  improved  slightly, 
but  he  still  feels  weak,  has  vertigo  and  double  vision.  He 
has  never  had  headache,  nor  has  he  felt  any  sensation  of 
numbness  or  cold  or  pain  in  his  body,  and  he  has  had  no> 
paralysis,  tremor,  or  spasm. 

Examination  shows  a  well-nourished,  intelligent,  active 
man,  whose  facial  expression  is  rendered  peculiar  by  the 
position  of  his  eyes.  When  at  rest,  they  diverge  slightly,, 
and  the  right  eye  is  turned  upward,  and  the  right  pupil  is; 
slightly  larger  than  the  left.  When  the  eyes  are  moved  it 
becomes  apparent  that  the  motion  is  defective.  The  eyes 
can  be  turned  from  side  to  side  together  perfectly,  but  such 
motion  soon  produces  lateral  nystagmus  of  the  right  eye 
They  cannot  be  converged  to  an  object  nearer  than  two- 
feet,  because  of  slight  weakness  of  the  right  internal  rectus 
muscle.  They  cannot  be  turned  downward  below  the  hori- 
zontal line  either  together  or  when  tested  separately.  When 
asked  to  look  up,  the  right  eye  follows  the  object  above  the 
horizontal  line,  but  the  left  eye  does  not.  Both  eyes,  however, 
turn  up  and  in,  though  this  motion  produces  rotary  nystag- 
mus. The  reaction  of  the  pupils  to  light  and  in  accommo- 
dation is  prompt,  though  the  right  pupil  contracts  in  accom- 
modation more  slowly  and  less  completely  than  the  otherr 
and  remains  slightly  larger.  Tests  by  secondary  deviation 
and  double  images  confirm  the  conclusion  reached  by  this 
examination,  viz.,  that  in  the  right  eye  there  is  paralysis  of 
the  inferior  rectus  and  paresis  of  the  internal  rectus  ;  and 
that  in  the  left  eye  there  is  paralysis  of  the  inferior  rectus, 


-,Q  ,  M.  ALLEN  STARR. 

and  superior  rectus.  There  is  no  ptosis.  There  is  no 
paralysis  of  the  oblique  muscles  or  of  the  external  recti. 
One  week  later  the  paresis  of  the  right  internal  rectus,  the 
difficulty  in  convergence,  and  the  difference  in  the  size  of 
the  pupils  had  disappeared,  but  all  the  other  conditions 
remained,  and  they  have  persisted  until  the  present  time 
(April,  1888).  He  is  still  suffering  from  general  weakness, 
vertigo,  and  double  vision,  although  the  latter  symptom  no 
longer  troubles  him  excepting  when  he  attempts  to  draw 
lines  in  painting,  when  he  finds  that  he  does  not  draw  accu- 
rately, and  hence  has  had  to  give  up  his  work.  He  often 
staggers  in  walking,  but  this  is  due  to  vertigo  and  not  to 
ataxia,  and  it  is  not  constant.  He  walks  as  well  with  eyes 
closed  as  with  them  open.  Attempts  to  turn  the  eyes  up  or 
down,  or  upward  or  inward,  produce  nystagmus  of  a  rotary 
kind,  more  marked  in  the  right  eye,  and  this  always  makes 
him  dizzy.  He  has  developed  no  further  symptoms,  is  not 
paralyzed,  has  equal  and  normal  tendon  reflexes,  and  has 
no  loss  of  sensation,  vision  or  hearing.  The  diagnosis  made 
is  embolism,  from  the  aortic  valve,  in  the  small  arteries  en- 
tering the  posterior  perforated  space  between  the  crura 
cerebri,  and  resulting  in  one  or  more  small  foci  of  softening 
in  the  tegmentum  cruris. 

This  diagnosis  can  be  reached  by  exclusion  ;  for  it  is 
impossible  for  the  symptoms  to  have  been  caused  by  a 
tumor  or  a  meningitis  upon  the  base  of  the  brain  in  the 
course  of  the  third  nerves.  Such  a  lesion  would  not  have 
come  suddenly  or  have  remained  stationary,  and  would 
have  involved  the  nerve  as  a  whole,  impairing  all  its  func- 
tions and  not  affecting  merely  a  part.  Nor  have  we  here  a 
condition  of  acute  inflammation  with  haemorrhage  in  the 
floor  of  the  aqueduct  of  Sylvius,*  nor  such  a  condition  as 
occurs  in  a  true  ophthalmoplegia  externa  ;  for  there  is  no 
tendency  manifest  toward  an  extension  of  the  symptoms, 
or  to  complete  immobility  of  the  eyes. 

It  is  true  that  a  haemorrhage  in  the  same  region  is  with 
difficulty  distinguished  from  an  embolism,  but  in  haemor- 
rhage some  evidence  of  pressure  upon  the  adjacent  sensory 

*  Polio  encephalitis  of  Werni  Ice. 


OPHTHALMOPLEGIA  EXTERNA  PARTIALIS.  ^Q<- 

or  motor  tracts  is  usually  shown  by  unilateral  symptoms, 
which  have  been  wanting  here ;  and  here  there  is  a  rough- 
ened aortic  valve  to  give  rise  to  an  embolus.  The  nature 
of  the  lesion  is  therefore  easily  determined. 

The  chief  interest  in  this  case  lies  in  the  fact  that  it 
seems  to  aid  us  in  the  localization  of  the  oculo-motor  nerve 
nuclei  when  taken  in  connection  with  other  cases  recently 
published,  and  accompanied  with  autopsy. 

It  is  well  known  that  by  experimental  irritation  of  the 
floor  of  the  aqueduct  of  Sylvius  in  dogs,  Hensen  and  Volck- 
ers  claimed*  to  have  located  in  rabbits  the  nuclei  governing 
the  various  functions  of  the  third  nerve  in  the  following 
order  from  before  backward  : 

Ciliary  muscle,  accommodation. 

Sphincter  iridis,  light  reflex. 

Rectus  internus. 

Rectus  superior. 

Levator  palpebral. 

Rectus  inferior. 

Obliquus  inferior. 

If,  however,  the  cases  upon  record  of  paralysis  of  indi- 
vidual muscles  in  combination  be  considered,  it  is  evident 
at  once  that  this  order  of  the  nuclei  cannot  be  the  one 
which  obtains  in  man.  In  the  case  just  related,  for  example, 
the  rectus  internus  and  rectus  inferior  of  one  eye,  and  the 
rectus  superior  and  rectus  inferior  of  the  other  eye,  were 
paralyzed  together,  and  no  other  muscles  were  affected. 
A  single  lesion  would  not  explain  the  symptoms  in  either 
eye  were  this  scheme  true.  It  may  be  admitted,  however, 
that  the  centres  governing  the  movements  of  the  iris  do  lie 
anterior  to  all  the  others.  For  Westphal  has  recently  pub- 
lished a  case  in  which  all  the  nuclei  governing  the  motions 
of  the  eyeball  were  destroyed,  but  in  which  two  nuclei  lying 
in  the  floor  of  the  aqueduct  of  Sylvius  near  to  its  opening 
into  the  third  ventricle  were  found  intact.  And  to  these 
nuclei  he  assigns  the  function  of  governing  the  motions  of 

*  V.  Graefe's  Arch.  f.  Ophthal.,  1887,  vol.  xviii.,  p.  1.  They  admit  that  the 
evidence  is  not  wholly  satisfactory. 


3q6  M.  ALLEN  STARR. 

the  pupil  which  were  preserved  in  his  case.*  And  a  com- 
plementary case  has  recently  been  recorded  .by  Bernhardt, 
in  which  the  action  of  the  pupils  in  light  and  accommoda- 
tion was  permanently  lost,  with  only  temporary  affection  of 
the  other  ocular  muscles  on  one  side.t  And  Leube  has 
recorded  a  case,:}:  with  autopsy,  in  which  the  action  of  the 
right  pupil  was  suspended  and  the  right  levator  palpebral 
alone  of  all  the  ocular  muscles  was  paralyzed  ;  the  lesion 
lying  far  forward  beneath  the  corpora  quadrigemina  ante- 
rior. By  the  kindness  of  Dr.  Seguin,  I  am  allowed  to 
record  a  case  similar  to  these  two,  in  which  there  was  a 
paralysis  of  the  iris  for  three  weeks,  no  other  muscles  being 
at  all  affected. §  The  conclusion  from  these  cases  with  and 
without  autopsies  is  that  the  pupillary  action  is  controlled 
by  centres  lying  independent  of  and  farther  forward  than 
all  the  other  third  nerve  nuclei. 

The  independence  of  the  iris  centres  from  those  govern- 
ing the  ocular  muscles  had  been  reached  several  years  ago 
by  the  investigation  of  Hutchinsonll  upon  ophthalmoplegia 
externa,  in  which  it  was  shown  that  paralysis  of  the  ocular 
muscles  implied  a  progressive  destruction  of  the  various 
nuclei  concerned  in  motions  of  the  eyeball  from  the  sixth 
nerve  upward  through  the  third  nerve.  Hutchinson  sup- 
posed that  a  lesion  in  the  ciliary  ganglion  alone  produced 
pupillary  paralysis.  But  this  conclusion  was  soon  shown 
to  be  erroneous,  and  subsequent  investigations  proved  that 
when  the  entire  gray  matter  of  the  floor  of  the  aqueduct  was 
involved  the  iris  was  also  affected.  And  subsequent  cases, 
with  autopsies,  have  confirmed  this  statement.  The  inde- 
pendence of  the  centres  of  the  iris  from  those  of  the  eyeball 
does  not  therefore  imply  their  wide  separation. 

The  question   remaining  for  settlement  is  the  relative 

•  Westphal,  Arch.  f.  Psych.,  1888,  vol.  xix.,  p.  858.  It  is  true  that  the  light 
reflex  was  lost  in  this  case,  but  this  W.  explains  by  the  existence  of  posterior 
spinal  sclerosis. 

f  Bernhardt,  Berliner  Gesellsch.  f.  Neurologie ;  Arch.  f.  Psych.,  1888,  xix., 
505.     Case  1. 

\  I>eube,  Deut.  Arch.  f.  Klin.  Med.,  1887,  xl. 

§  See  thL  Journal,  this,  number,  page  317. 

||  Hutchinson,  Medico-Chirurg.  Trans.,  1879,  vol.  lxii.,  p.  307. 


OPHTHALMOPLEGIA  EXTERNA  PARTIALIS.  «Qj 

order  in  which  the  remaining  nuclei  of  the  third  nerve  are  ar- 
ranged. Whatare  the  facts?  Thereis,  first,  acaseof  Leube,(i) 
in  which  the  paralysis  of  the  pupil  was  accompanied  by  par- 
alysis of  the  levator  palpebral,  on  the  right  side  only.  There 
is,  secondly,  a  case  of  Bernhardt,  (2)  in  which  the  paraly- 
sis of  the  pupil  was  associated  with  paralysis  of  the  levator 
palpebral,  recti  superior,  inferior  and  internus,  the  latter  four 
muscles  all  recovering. 

There  is,  thirdly,  a  case  of  Thomsen,*  (3)  in  which  a  tem- 
porary paralysis  of  both  pupils  and  both  levator  palpebral 
was  accompanied  by  permanent  paralysis  of  both  superior 
recti. 

And,  lastly,  there  is  a  case  of  Steffen.f  (4)  in  which  double 
ptosis  was  associated  with  sluggish  action  of  the  pupils, 
both  ascribed  to  a  destruction  of  the  corp.  quadrigemina. 

These  cases  seem  to  prove  that  the  centre  governing  the 
levator  palpebral  lies  next  in  order  to  the  centres  for  the 
iris.  Let  us  see  what  muscle  is  most  frequently  affected  in 
conjunction  with  the  levator  palpebral. 

Bernhardt!  has  recently  reported  another  case,  in  which 
the  levator  palpebral  on  the  right  side,  (5)  and  the  levator 
palpebral  and  superior  rectus  on  the  left  side,  (6)  were  para- 
lyzed. 

Mauthner§  cites  a  case  of  v.  Grafe,  in  which  congenital 
abscess  of  the  iris  was  accompanied  by  partial  ptosis  and 
imperfect  elevation  of  the  eyeballs,  (7)  and  remarks  that  he 
has  seen  a  similar  condition  without  absence  of  the  iris  (8). 

A  year  ago  I  published  ||  the  history  of  a  patient  who  was 
suddenly  seized  with  paralysis  of  the  left  levator  palpebral 
and  superior  rectus,  (9)  and  with  slight  right  hemianesthesia, 
all  of  which  symptoms  remained  as  long  as  the  patient  was 
under  observation  (five  months). 

In  1881,  Kahler  and  Pick  published  a  case,!  with  autopsy, 
in  which  the    levator    palpebral  and    rectus    superior  and 

*Archiv.  f.  Psych.,  xix.,  185. 

f  Cited  by  Nothnagel  '-Topische  Diagnostic,"  p.  214. 

X  L.  c.     Case  2. 

§  Mauthner,  Vortrage  ii.,  4,  370. 

||  Journal  of  Mental  *nd  Nervous  Disease,  1887,  p.  115. 

f  Zeitschrift  £  Heilkunde,  1881. 


^Qg  »/.  ALLEN  STARR. 

obliquus  inferior  were  totally  paralyzed  on  the  left  side,  (10) 
and  the  rectus  inferior  and  rectus  internus  were  weak.  The 
lesion  in  this  case  was  a  haemorrhage  in  the  tegmentum, 
involving  the  left  red  nucleus  and  the  fibres  of  the  third 
nerve  which  pass  through  it,  especially  those  in  its  lateral 
part,  the  median  part  being  unaffected. 

To  this  case  they  added  another,  ( 1 1 )  in  which  a  temporary 
paresis  of  the  levator  palpebrae,  rectus  superior  and  inferior, 
was  accompanied  by  a  paralysis  of  the  rectus  internus,  which 
persisted  until  death.  The  obliquus  inferior  was  not  affected. 
The  autopsy  showed  a  small  haemorrhage  in  the  right  half 
of  the  tegmentum,  involving  the  red  nucleus  and  the  fibres 
of  third  nerve  passing  through  its  median  portion. 

In  the  case  of  Thomsen  already  cited,  the  temporary 
paralysis  of  the  pupils  and  levator  palpebrae  was  accom- 
panied by  a  permanent  paralysis  of  the  superior  rectus  on 
both  sides. 

From  these  cases  it  seems  evident  that  the  levator  pal- 
pebrae and  superior  rectus  are  so  often  associated  together 
in  paralysis  as  to  indicate  a  close  proximity  of  their  respect- 
ive nuclei. 

There  have  been  a  number  of  cases  observed,  in  which 
the  superior  and  inferior  recti  were  associated  together  in 
paralysis,  other  eye  muscles  escaping.  Thus  a  case  of 
Wernicke*  (12)  is  recorded,  in  which  after  a  left  hemiplegia 
there  was  a  disturbance  of  the  movement  of  both  the  eyes 
of  such  a  character,  that  looking  up  or  down  was  almost 
impossible,  while  lateral  motions  were  well  performed,  there 
being  at  rest  an  evident  paralysis  of  the  left  superior 
rectus  (13).  There  was  no  ptosis.  The  autopsy  showed 
an  old  contracted  cicatrix  in  the  right  corp.  quadrigemina 
and  optic  thalamus,  which  had  resulted  from  a  softening. 
It  will  be  remembered  that  in  the  second  case  of  Kahler 
and  Pick  (11)  there  was  a  paresis  of  the  levator  palpebrae 
rectus  superior  and  inferior,  as  well  as  a  paralysis  of  the 
rectus  internus.  In  the  case  here  presented  (14)  there  was 
a  paralysis  of  the  left  superior  and  inferior  recti,  no  other 
muscle  being  affected.      And  in  these  cases  the  obliquus 

■     -  ■    ■  .    ■         ■ ,   • 1 

0  Wernicke,  Berl.  Klin.  Wocb.,  1876,  No.  29,  and  Arch.  f.  Psych.,  viii. 


OPHTHALMOPLEGIA  EXTERNA  PARTIALIS. 


309 


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M.  ALLEN  STARR. 


inferior  was  not  involved  when  the  superior  rectus  was 
affected.  It  is  well  known  that  the  action  of  these  two 
last-named  muscles  is  homologous;  but  they  are  not,  there- 
fore, necessarily  affected  together,  and  cases  recorded  by 
Henoch,*  (15)  by  Gowers,t  (16)  and  the  case  of  Thomsen 
already  cited,  in  all  of  which  the  only  permanent  paralysis 
was  that  of  the  superior  rectus  in  one  or  both  eyes,  prove 
that  the  obliquus  inferior  may,  and  often  does,  escape  when 
the  superior  rectus  is  paralyzed. 


DIA  GRAM  II. —  To  Show  the  Associated  Paralysis  of  Rectus 
Superior  and  Inferior. 


Cases. 


Wernicke. 


Starr. 


Kahler  and  Pick.1 


Iilchthelm. 


Bernhardt 1 


Parinaud 8 


Kahler  and  Pick..  2        r. 


Rictus  Sup. 


Rectus  Inf. 


+ 


+ 
+ 


+ 


"  + 


From  these  cases  we  may  argue  that  the  centre  of  the 
inferior  rectus  lies  next  in  order  to  that  for  the  superior 
rectus.  But  since  in  some  cases  the  obliquus  inferior  has 
been  paralyzed  with  the  superior  rectus  and  without  an 
affection  of  the  inferior  rectus,  it  is  necessary  to  locate  its 
centre  equally  near  to  that  of  the  superior  rectus.     This  can 

*  Henock,  Berl.  Klin.  Woch.,  1864,  No.  13. 

f  Gower's  Dis.  of  Nerv.  Syst.,  1888,  vol.  ii.,  p.  174. 


OPHTHALMOPLEGIA  EXTERNA  PARTIALIS.  ,  j  j 

only  be  done  by  assuming  that  the  centres  for  the  superior 
rectus  and  inferior  rectus  lie  side  by  side,  while  that  of  the 
inferior  oblique  lies  next  to  but  behind  that  of  the  superior 
rectus. 

The  last  muscle  to  be  considered  is  the  rectus  internus. 

The  fact  that  the  recti  interni  are  concerned  in  the  act 
of  accommodation  has  led  to  the  supposition  that  its  centre 
lies  in  close  proximity  to  the  centres  for  the  pupil.  And 
this  view  has  prevailed  in  spite  of  the  fact  that  its  associated 
action  with  that  of  the  abducens  of  the  opposite  side  would 
lead  to  the  hypothesis  that  the  centres  of  the  rectus  internus 
and  rectus  externus  would  be  near  together.  Paralysis  of 
one  rectus  alone  has  not  yet  been  observed,  but  it  has  been 
noted  that  a  paralysis  of  the  act  of  convergence  may  occur 
when  the  action  of  the  muscles  in  other  movements  is  pre- 
served, and  in  six  cases  published  by  Parinaud,*  the  paral- 
ysis of  convergence  was  accompanied  by  defective  pupil- 
lary action.  These  cases  would  indicate  that  the  nucleus 
of  the  internal  rectus  is  near  to  that  of  the  iris.  A  few  cases 
have  been  recorded,  in  which  paralysis  of  the  internus  has 
occurred  with  that  of  other  muscles.  Thus  is  the  second 
case  of  Kahler  and  Pick  the  rectus  internus  was  permanently 
paralyzed  and  the  levator  palpebral,  superior  rectus  and 
inferior  rectus  were  paretic.  In  a  case  of  Lichtheim,t  (17)  the 
right  rectus  internus,  levator  palpebral  and  rectus  superior 
were  paralyzed,  and  the  rectus  inferior  and  obliquus  inferior 
were  paretic.  In  a  case  of  Graefe^:  the  right  rectus  internus, 
levator  palpebral  and  rectus  inferior  were  paralyzed,  (18)  and 
the  left  rectus  internus  was  weak,  while  the  left  levator  pal- 
pebral was  paralyzed.  (19)  In  my  case  here  published,  the 
right  rectus  internus  was  temporarily  paretic,  and  the  right 
rectus  inferior  was  permanently  paralyzed.  (20)  In  the  cases 
of  Kahler  and  Pick  (No.  1),  and  Bernhardt  (No.  i),the  rectus 
internus  was  paretic  as  were  also  the  rectus  inferior  and 
levator  palpebral,  and  rectus  superior. 

It  is  evident  from  these  cases  that  the  rectus  internus 
■centre  is  closely  related  to  several  other  centres,  viz.,  to 

*  Brain,  Oct,  1886. 

f  Lichtheim,  cited  by  Mauthner.     Case  17,  1.  c. 

\  Graefe,  cited  by  Mauthner.     Case  28,  1.  c. 


312 


M.  ALLEN  STARR. 


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2  2 


OPHTHALMOPLEGIA  EXTERNA  PARTIALIS.  3  {  3 

that  of  the  iris,  to  that  of  the  levator  palpebral,  to  that  of  the 
rectus  inferior,  and  to  its  fellow  on  the  opposite  side.  A 
central  position  with  these  muscles  on  its  four  sides  is  there- 
fore the  only  one  which  will  conform  to  the  facts. 

Can  any  diagram  be  made  out  which  will  explain  all 
these  cases.  In  1881,  an  arrangement  of  the  nuclei  of  the 
third  nerve  was  proposed  by  Kahler  and  Pick,  which  was 
based  entirely  upon  the  two  cases  with  autopsies  here  cited. 
And  it  must  be  confessed  that  when  those  autopsies  are 
studied  it  seems  as  if  the  conclusion  drawn  was  hardly  war- 
ranted by  the  premises  ;  for  the  lesions  in  each  case  involved 
the  nerve  roots  of  the  third  nerve  rather  than  their  nuclei ; 
and  this  has  been  the  case  in  most  of  the  cases  of  partial 
ophthalmoplegia  externa  hitherto  published.  But  the  ar- 
rangement proposed  by  these  authors  has  shown  itself  com- 
petent to  explain  the  various  cases  as  they  have  arisen  since 
1 88 1,  and  the  cases  here  brought  together  afford  a  brilliant 
confirmation  of  the  essential  part  of  the  diagram  of  Kahler 
and  Pick,  and  establish  it,  I  believe,  for  the  first  time,  upon 
a  sufficient  basis.  It  is  true  that  Mauthner,  in  his  lectures, 
has  approved  of  Kahler  and  Pick's  arrangement  in  prefer- 
ence to  that  of  Hensen  and  Volche'rs',  but  he  cites  but  five 
cases,  and  admits  that  the  evidence  is  scanty.  The  cases 
here  collected  are  twenty  in  number,  each  eye  being  counted 
as  one  case,  unless  both  eyes  were  affected  alike.  The  fol- 
lowing diagram  shows  the  relative  position  of  the  nuclei, 
and  the  extent  and  degree  of  the  paralysis  in  each  case 
cited,  the  numbers  corresponding  to  the  cases  numbered  in 
the  text,  and  being  underlined  when  the  paralysis  was  com- 
plete or  permanent.  For  convenience,  the  arrangement  on 
the  left  side  of  the  raphe  only  is  represented,  all  the  cases 
being  tabulated  as  if  on  the  left  side. 

The  relative  position  of  the  centres  for  the  sphincter 
iridis  and  ciliary  muscle  is  still  an  open  question.  The  ob- 
servation of  Westphal  is  sufficient  to  indicate  that  they  lie 
side  by  side.  Kahler  and  Pick  placed  the  centre  for  accom- 
modation in  front  of  that  for  the  light  reflex.  But  the 
observation  of  Parinaud  cited  would  indicate  that  the  centre 
for  accommodation  being  usually  affected  with  that  of  the 


3^4 


M.  ALLEN  STARR. 


DIAGRAM  IV.— The  Position  of  the   Third  Nerve  Nuclei 
on  the  Left  Side. 

Spkin.  Iridii.  Ciliary  MxucU. 


Lev.  Palp. 

1 

2 

3 

i 

5 

6 

— 

8 

9 

10 

11 

17 

18 

19 

Red.  Sup. 

2     3 

i 

7     8 

0 

10    11 

12 

13    H 

15 

16    17 

Red.  Int. 

2 

10 

11 

17 

18 

19 

20 

Red.  Inf. 


2 

10 

11 

12 

13 

n 

17 

18 

20 

061.  Inf. 


10  17 


OPHTHALMOPLEGIA  EXTERNA  PARTIALIS.  -j, 

rectus  internus  lies  nearer  to  it  than  does  the  centre  for  the 
iris.  The  number  of  fibres  passing  from  the  corpora  quad- 
rigemina  to  the  lateral  of  the  two  nuclei  described  by  West- 
phal  seems  greater  than  the  number  passing  to  the  median 
nucleus,  and  as  these  fibres  probably  complete  the  reflex  arc 
for  light  reflex  joining  the  optic  and  iris  centres,  I  have 
placed  the  sphincter  iridis  nucleus  outside  of  that  for  the 
ciliary  muscle.  It  will  be  noticed  that  this  arrangement 
brings  the  ciliary  muscle  centre  near  to  that  of  the  rectus 
internus  as  the  cases  of  Parinaud  require.  Another  fact 
which  can  be  deduced  from  the  diagram  is  the  relative  fre- 
quency of  affection  of  the  various  muscles,  it  being  evident 
that  the  superior  rectus  and  levator  palpebral  are  most  fre- 
quently paralyzed,  and  the  superior  oblique  is  rarely  in- 
volved. 

One  pathological  fact  of  importance  remains  to  be 
noticed.  In  all  the  cases  recently  examined  after  death,  in 
which  one  or  more  of  the  muscles  of  the  third  nerve  was 
paralyzed,  but  in  which  total  ophthalmoplegia  externa  was 
not  present,  the  lesion  found  did  not  involve  the  nuclei  of 
the  third  nerve  in  the  aqueduct  of  Sylvius,  but  the  roots  of 
the  nerve  on  their  way  from  those  nuclei  through  the  teg- 
mentum to  their  exit  from  the  crus.  These  roots  pass 
through  the  red  nuclei  of  the  tegmentum.  These  nuclei 
are  closely  connected  with  the  superior  peduncles  of  the 
cerebellum.  It  is  not  at  all  unlikely,  therefore,  that  the 
vertigo  which  so  frequently  occurs  in  such  cases  is  due  not 
so  much  to  the  disturbance  of  vision,  but  to  the  lesion  of 
these  nuclei,  and  is  comparable  to  the  vertigo  of  cerebellar 
disease.  In  my  own  cases  the  patients  complained  of  ver- 
tigo in  the  dark  and  when  the  eyes  were  closed,  as  well  as 
when  they  were  open.  It  seems  warrantable,  therefore,  to 
conclude  that  in  any  case  of  partial  ophthalmoplegia  externa 
associated  with  vertigo  the  diagnosis  of  a  lesion  in  the  teg- 
mentum cruris  affecting  the  red  nuclei  may  be  made,  pro- 
vided the  vertigo  is  not  ocular  in  origin.  While  in  cases  of 
total  ophthalmoplegia  externa  in  which  vertigo  is  not  a 
marked  symptom  the  diagnosis  of  a  lesion  in  the  gray  mat- 
ter of  the  aqueduct  of  Sylvius  above  the  tegmentum  is 
justifiable. 


.,  j  5  3/.  ALLEN  STARR. 

CONCLUSIONS. 

Therefore,  in  any  case  in  which  the  muscles  moving 
the  eyeball  are  involved,  it  may  be  possible  to  locate  the 
lesion.  If  the  iris  alone  is  affected,  the  lesion  is  small, 
and  lies  either  in  the  ciliary  ganglion  in  the  orbit,  or  just  at 
the  opening  of  the  aqueduct  of  Sylvius  into  the  third  ven- 
tricle. If  all  the  muscles  of  the  eyeball  are  affected  together, 
the  external  rectus  and  superior  obliquus,  as  well  as  those 
supplied  by  the  third  nerve,  excluding  the  iris,  the  case  is 
one  of  ophthalmoplegia  externa  totalis,  and  the  lesion  lies 
in  the  gray  matter  of  the  floor  of  the  fourth  ventricle  and  of 
the  aqueduct  of  Sylvius.  Both  eyes  are  then  involved.  If 
all  the  muscles  of  the  eyeball  supplied  by  the  third  nerve 
are  affected,  including  the  iris,  the  case  is  one  of  total 
peripheral  paralysis  of  the  third  nerve,  and  the  lesion  lies 
on  the  base  of  the  brain,  and  may  in  time  implicate  other 
cranial  nerves.     One  eye  is  usually  alone  affected. 

If  one  or  two  of  the  muscles  of  the  eyeball  supplied  by 
the  third  nerve  are  affected,  others  escaping,  the  lesion  lies 
in  the  tegmentum  of  the  crus  cerebri,  between  the  nuclei  of 
origin  and  the  point  of  exit  of  the  third  nerve.  One  eye  or 
both  may  be  affected,  but  both  eyes  are  rarely  affected  in 
the  same  manner. 

There  is  but  one  exception  to  the  last  conclusion,  and 
that  is  in  the  case  of  post  diphtheritic  ocular  paralysis,  in 
which  the  peripheral  branches  of  the  third  nerve  are  affected 
after  the  entrance  of  the  nerve  trunk  into  the  orbit.  And 
here  the  existence  of  a  diphtheria  preceding  the  paralysis 
will  establish  the  diagnosis. 


NOTES  OF  FIVE  CASES  OF  OPHTHALMOPLEGIA. 

By  E.  C.  SEGUIN,  M.D. 

THESE  notes  were  read  before  the  New  York  Neuro- 
logical Society  in  the  course  of  the  discussion  of  Dr. 
Starr's  valuable  paper  on  the  subject.  The  cases 
present  points  of  interest  which  perhaps  justifies  their  publi- 
cation. 

Two  cases  presented  areas  of  anaesthesia  in  the  distribu- 
tion of  the  trigeminus  ;  and  one  case  developed  during  my 
observation  paralysis  and  atrophy  of  the  muscles  of  masti- 
cation. This  coincidence  of  lesion  of  the  motor  and  sensory 
roots  of  the  trigeminus  is,  I  am  informed  by  Dr.  Starr  (who 
has  had  occasion  to  search  the  bibliography  of  the  subject 
thoroughly),  almost  if  not  quite  without  precedent. 

Case  V.  was  one  in  which  only  the  ciliary  apparatus  was 
affected,  and  is  especially  interesting  from  a  therapeutical 
standpoint. 

/.   Ophthalmoplegia  externa  et  interna  bilateralis. 

A  man,  aet.  31  years,  first  seen  at  the  Manhattan  Eye 
and  Ear  Hospital,  January  4th,  1884.  Nine  years  ago  had  a 
chancre,  followed  by  secondary  symptoms,  treated  by  two 
well-known  New  York  physicians.  After  working  in  a 
basement  and  committing  various  excesses,  one  morning, 
about  two  years  ago,  he  suddenly  discovered  double  and 
dim  vision,  and  external  strabismus  of  the  left  eye.  After- 
ward, along  with  symptoms  of  general  ill-health,  he  suffered 
from  pains,  dull  and  shooting,  mostly  in  the  legs,  occasion- 
ally in  the  arms  ;  without  paresis  or  numbness.  Hair  has 
come  out.  About  three  months  ago  suddenly  lost  con- 
sciousness, and  fell,  cutting  his  head.     About  five  months 


5  jg  E.  C.  SEGUZN. 

ago  the  left  testicle  became  enlarged  and  hard.  Has  re- 
cently returned  from  Hot  Springs,  Ark.,  where  he  took 
mercury  and  much  K  I. 

Present  condition.  Partial  double  ptosis,  needing  help 
of  frontalis  to  expose  the  pupils.  In  the  right  eye  all  the 
muscles  supplied  by  X.  III.  are  more  or  less  paralyzed  ;  the 
superior  and  inferior  recti  acting  feebly.  The  external  rec- 
tus (N.  VI.)  is  normal.  In  the  left  eye  (which  has  improved 
during  preceding  treatment)  all  muscles  supplied  by  N.  III. 
act,  though  feebly ;  the  external  rectus  is  normal.  The 
frontalis  is  constantly  and  automatically  active  to  secure 
vision.     The  pupils  are  of  medium  size,  the  left  larger  (left 


Engraved  from  a  photograph  of  Case  I.     Automatic  action  of  frontalis, 
ptosis,  and  divergence  of  eyes  shown. 


eye  first  affected);  they  are  completely  motionless  to  light 
and  to  accommodative  effort.  Examination  in  the  ophthal- 
mic classes  gives  the  following  results  :  Right  V.  -f-J  -f-  -rV  = 
f#.  Left  V.  §#  +  4V  —  \%.  Accommodation  right  h,  left 
rV.     No  lesion  of  optic  nerves  ;  fields  not  tested. 

Besides  the  ocular  symptoms  there  were  slight  signs  of 
crossed  paralysis.  The  left  cheek  seemed  a  little  inactive, 
the  tongue  deviated  slightly  to  the  right  and  the  grasp  was, 
lv.  420  and  440,  L.  450,  which  in  a  right-handed  man  meant 
paresis.    The  knee-jerk  is  exaggerated  on  both  sides.    Stands 


OPHTHALMOPLEGIA.  -  j  g 

well  with  eyes  closed  (claims  that  while  at  Hot  Springs  he 
staggered  when  standing  with  closed  eyes).  The  left  tes- 
ticle is  hardened,  and  slight  hydrocele  is  present.  Alopecia 
is  present,  though  less  than  a  few  months  ago.  Heart  and 
the  viscera  normal,  except  bladder.  It  was  subsequently 
noted  that  the  power  of  muscles  supplied  by  the  left  N.  III. 
was  somewhat  variable. 

As  regards  the  bladder,  the  patient  complains  of  both 
feeble  and  involuntary  micturition.  A  No.  12  (Engl.)  sound 
passes  into  the  bladder  without  the  least  resistance.  The 
act  of  rising  from  the  recumbent  posture  causes  escape  of 
urine. 

Treatment  with  increasing  doses  of  K  I,  and  galvanism 
to  eyes  and  lumbar  region. 

In  May,  1884,  it  is  noted  that  sharp  pains  recur  from 
time  to  time  in  the  legs,  and  in  the  right  hypothenar  emi- 
nence. Eyes  and  bladder  substantially  as  before  (temporary 
improvement  in  eyes  in  February).  Hoarseness  appeared 
about  this  time,  and  an  examination  in  the  throat  depart- 
ment revealed  a  scalloped  ulcer  on  the  right  vocal  cord, 
with  inaction  of  this  organ.  Under  local  treatment  and  pro- 
longed use  of  mercury  and  iodide  of  potassium  this  ulcer 
was  cured  by  the  end  of  September,  but  some  hoarseness 
remained.  Eyes  and  bladder  as  before.  In  November  it  is 
noted  that  he  has  had  severe  fulgurating  pains,  with  hyper- 
algesia spots  where  pains' occurred,  in  thighs.  In  Febru- 
ary, 1885,  the  bladder  continues  feeble.  Pupils  are  as  before. 
The  ptosis  is  nearly  total  on  the  left,  partial  on  the  right 
side.  On  the  other  hand,  the  ocular  muscles  on  the  left  side 
act  almost  normally,  while  those  on  the  right  are  as  before ; 
internus  completely  paralyzed,  superior  and  inferior  recti 
weak.  Occasional  fulgurating  pains  in  legs ;  knee-jerk 
good ;  no  numbness.  In  April  the  fundus  is  noted  as  nor- 
mal. The  patient  complains  that  "after  chewing  awhile, 
his  chin  becomes  powerless."  Examination  shows  distinct 
paresis  and  atrophy  of  the  temporal  and  masseter  muscles 
on  both  sides.  The  last  note  made  of  this  case  was  in  March, 
1886,  when  it  is  stated  that  eyes  are  as  before  (ptosis  per- 
haps greater);  the  bladder  is  still  paretic,  and  the  muscles 


«20  E.  C.  SEGUIN. 

<of  mastication  show  objective  as  well  as  subjective  paresis, 
•and  atrophy  ;  masseters  very  thin.  No  marked  facial  pare- 
sis ;  can  whistle  and  hold  water  or  air  in  mouth.  The 
tongue  is  flabby,  but  not  wrinkled  ;  is  still  a  little  hoarse. 
A  photograph  of  the  patient  taken  about  this  time  shows 
very  well  the  compensatory  automatic  constant  contraction 
•of  the  frontalis  to  secure  some  vision.    ( Vide  snpra.) 

This  case  shows  signs  of  extension  of  the  lesion  to  nu- 
clei of  the  motor  roots  of  the  trigeminus.  It  also  exhibits  a 
trace  of  crossed  paralysis  ;  face  on  left  side,  limbs  on  right. 

The  fulgurating  pains,  with  hyperalgesia,  and  the  fall  in 
■degree  of  knee-jerk,  during  two  years  of  observation,  would 
seem  to  justify  a  suspicion  of  incipient  posterior  spinal 
sclerosis. 

II.  OphtJialmoplegia  externa  et  interna  bilateralis. 

A  woman,  aet.  20  years,  sent  for  examination  to  my  class 
at  the  Manhattan  Eye  and  Ear  Hospital,  Nov.  4th,  1887. 
The  history  is  simply  that  of  progressive  paresis  of  both 
levatores  palpebrarum  ;  the  left  more  affected.  There  has 
been  occasional  diplopia.  The  right  pupil  is  active,  the  left 
sluggish.  No  other  nervous  symptoms.  Patellar  reflex 
fairly  good.  The  post-cervical  glands  are  slightly  en- 
larged, but  no  history  of  syphilitic  symptoms  can  be  ob- 
tained. 

Nov.  18th.  —  Has  had  KI.  in  doses  of  fifteen  grains 
three  times  a  day.  Pupils  much  better  ;  the  left  much  bet- 
ter (this  pupil  is  a  little  wider  at  rest  and  in  medium  light). 
Palpebral  as  before.     Patient  was  not  again  seen. 

III.  Ophthalmoplegia  externa  et  interna  bilateralis. 

A  man,  aet.  40  years,  was  referred  to  me,  July  27th,  1887, 
by  my  friend,  Dr.  J.  B.  Isham,  for  treatment  during  his  tem- 
porary absence.  In  the  last  five  or  six  years  has  been  trou- 
bled by  imperfect  vision.  Eighteen  months  ago  external 
strabismus  of  the  right  eye,  and  later  ptosis,  appeared. 
About  four  months  afterward  the  external  rectus  was  cut, 
and  a  month  later  a  piece  of  skin  excised  from  the  upper 
eyelid,  but  neither  operation  did  good.     Some  four  or  five 


OPHTHALMOPLEGIA.  -,2I 

months  later  still,  slight  improvement  occurred  in  the  eye- 
lid. Six  weeks  ago  ptosis  gradually  developed  on  the  left 
side,  progressing  to  complete  closure  of  the  eye,  but  in  the 
last  few  days  a  return  of  power  has  begun.  With  the  onset 
of  first  symptoms  had  diplopia.  No  marked  headache  until 
recently,  when  a  dull  pain  has  been  constant  in  the  left 
parietal  region  ;  not  distinctly  nocturnal.  Micturition  has 
become  slow  ;  the  legs  tire  easily  ;  he  is  perhaps  a  little  un- 
steady on  legs,  more  especially  in  putting  on  his  trousers. 
Denies  sharp  pains  and  numbness  in  limbs  ;  but  in  the  last 
two  months  there  have  been  slight  numbness  and  anaesthe- 
sia in  the  distribution  of  the  left  trigeminus.  No  injury  to 
head.  Twenty-two  years  ago  had  a  double  chancre,  but 
never  any  secondary  symptoms. 

Examination  :  Almost  complete  ptosis  on  left  side  ;  on 
right  the  pupil  is  just  visible,  and  there  is  some  voluntary 
power  in  the  levator.  Eyeballs  are  slightly  divergent.  In 
the  right  eye  all  muscles  suplied  by  N.  III.  are  quite  inert; 
the  external  rectus  is  normal.  In  the  left  eye  all  the  mus- 
cles are  paralyzed,  the  external  rectus  least,  the  superior 
obliques  on  both  sides  act.  The  pupils  are  equal  and  of 
medium  size,  but  react  neither  to  light  nor  to  accommoda- 
tion. Vision,  R.  ^-{j-,  L.  i-jj-.  Optic  nerves  appear  normal, 
but  vessels  are  small.  The  tongue  is  straight  but  tremu- 
lous ;  the  left  facial  muscles  act  less  well  than  the  right ;  no 
weakness  of  extremities.  Patellar  reflex  exaggerated. 
Sensibility  is  normal  except  in  distribution  of  the  left  tri- 
geminus (excepting  the  mental  branch);  the  left  half  of 
tongue  feels  numb.  Memory  good.  Has  had  inunctions  of 
mercury  to  soreness  of  gums. 

Ordered  saturated  solution  of  KI.  at  bed-time,  sixty 
drops,  increased  by  five  daily  ;  also  a  mixture,  each  dose  of 
which  contains  ^  grain  of  red  iodide  of  mercury  and  fifteen 
grains  of  iodide  of  potassium,  after  each  meal. 

Sept.  9th. — Has  reached  dose  of  one  hundred  and  twenty 
drops  of  KI.  after  breakfast  and  two  hundred  and  fifty 
at  bed-time  (mixture  omitted  some  time  ago),  and  has  had 
galvanism  to  eyes  and  cervical  region.  For  a  few  days 
in  August  there  was  some  return  of  power  (?)  in  left  eyelid. 


E.   C.  SEGL'IX. 
O'" 


■;2  2 


Xo  improvement  on  the  whole  ;  eyes  same,  anaesthesia  as 
above,  micturition  slow.  The  iodide  was  subsequently  in- 
creased to  four  hundred  and  fifty  drops  (equal  to  about  four 
hundred  and  fifty  grains)  a  day  ;  then  stopped  and  strych- 
nine ordered. 

There  was  in  this  case  extension  of  disease  to  the  sensory 
root  of  the  left  trigeminus,  or  possibly  to  the  trunk  of  the 
nerve. 

IV.   OpJithalmoplegia  externa  bilateralis. 

A  man,  aet.  42  years,  was  referred  to  my  class  at  the 
Manhattan  Eye  and  Ear  Hospital  by  Dr.  Carey,  Assistant 
Surgeon  in  the  Ophthalmic  Department,  on  November  14th, 
1884.  Has  been  a  sailor,  but  is  now  in  the  life-saving  ser- 
vice. Has  enjoyed  good  health  ;  denies  syphilis  ;  has 
healthy  children.  Xo  injury  to  head.  Last  March,  after 
much  exposure,  and  straining  eyes  in  reading  signals,  he 
noticed  some  dimness  of  vision  for  distant  objects.  In  May 
the  right  eyelid  drooped,  and  the  left  also  in  June.  Before 
this,  not  long  after  the  first  symptoms,  he  had  noticed 
numbness  of  the  skin  in  the  right  temple  near  the  angle  of 
the  eye,  and  since,  the  numbness  had  extended  to  other 
parts  of  the  right  face.  No  deafness  or  loss  of  taste ;  no 
dizziness  or  headache.     Xo  peripheral  pains  or.numbness. 

Examination  :  Presents  peculiar  physiognomy  of  paraly- 
sis of  levatores  palpebrarum,  with  automatically  acting 
frontalis,  and  half-shut  eyes.  No  facial  or  lingual  paresis. 
In  the  right  eye  all  muscles  supplied  by  X.  III.  (except 
inferior  rectus?)  are  paretic,  the  external  rectus  is  normal. 
In  the  left  eye  all  the  muscles  are  paretic,  especially  the 
external  rectus  (N.  VI.)  and  the  superior  rectus.  Has  a 
feeble  degree  of  conveyance.  The  pupils  are  equal,  of 
medium  size,  and  react  well  to  ordinary  daylight  and  to 
accommodative  effort.  According  to  Dr.  Carey's  report, 
vision  is  normal,  except  for  slight  presbyopia  ;  reads  Jaeger 
No.  2  at  12".  The  right  side  of  face,  temple  and  ear  present 
slight  anaesthesia  and  analgesia.  Knee-jerk  is  exaggerated, 
and  a  distinct  wrist-reflex  is  obtained. 

On  December  1st,  after  having  taken  strychnine  in  doses 


OPHTHALMOPLE  GIA.  -  2  - 

t^  and  igig-  grain,  three  times  a  day,  it  is  noted  that  there  is 
improvement  in  the  ocular  muscles  ;  the  frontalis  is  less 
active.  Patient  returned  to  his  post  on  the  Jersey  coast, 
and  has  not  reported. 

This  case  is  remarkable  as  showing  besides  paresis  of 
both  third  nerves,  a  slight  lesion  in  the  sensory  nuclei  (or 
in  the  trunk)  of  the  right  trigeminus,  and  a  marked  lesion 
of  the  nucleus  of  the  left  N.  VI.  The  filaments  of  the  third 
nerves  which  innervate  the  iris  and  ciliary  muscles  escaped. 

V.   Ophthalmoplegia  interna  bilateralis. 

A  married  woman,  aet.  35,  was  referred  to  me  by  my 
friend,  Prof.  C.  R.  Agnew,  on  January  16th,  1888,  for  an 
opinion  as  to  the  pathology  of  the  symptoms  she  presented, 
viz.,  double  mydriasis  and  paralysis  of  accommodation. 
R-  V.  2^,  L.  V.  ?2o°q  ;  no  improvement  by  glasses.  Reads 
Jaeger  No.  14  without  glasses,  No.  5  with  +  28  (Agnew). 
Dr.  Jas.  A.  Booth  examined  the  patient  first,  as  I  then  hap- 
pened to  be  confined  to  my  room  by  illness.  He  obtained 
the  following  history :  Cataract  has  occurred  in  her  moth- 
er's family.  When  nine  years  old,  after  a  coasting  accident, 
her  eyes  were  much  swollen  for  a  time,  and  they  have 
"  troubled  her  ever  since."  Eleven  years  ago  "  blisters  ap- 
peared on  the  eyelids,"  which  affection  was  cured  by  Dr. 
Williams,  of  Boston.  (Dr.  Agnew  thinks  that  this  may 
have  been  phlyctenular  keratitis.)  Fourteen  months  ago, 
suddenly  found  that  she  could  not  see  elearly — everything 
was  blurred  ;  and  she  noticed  that  her  pupils  were  dilated. 
This  condition  has  continued.  Denies  all  symptoms,  direct 
and  indirect,  of  syphilis.  No  injury  to  head  since  that, 
twenty-six  years  ago. 

Examination  ;  Pupils  extremely  dilated,  only  a  small 
rim  of  iris  being  visible  in  both  eyes.  They  do  not  respond 
to  light  or  to  accommodative  effort.  The  optic  nerves  ap- 
pear slightly  grayish,  or  at  least  not  normal.  Denies  having 
used  any  drops  in  eyes  or  belladonna  outside.  In  Dr.  Ag- 
new's  note  it  is  stated  "  that  the  fundus  scanned  with  the 
ophthalmoscope  has  a  queer  look — astigmatic,  and  yet  we 
cannot  improve  her  V.  with  any  glass."  The  ocular  mus- 
cles  act  well,   except  possibly  the  right  external    rectus. 


-2,  E.  C.  SEGL'/X. 

Stands  well  with  eyes  closed ;  patellar  reflex  high.  Xo 
other  symptoms.  Eserine  solution  to  be  dropped  in  the 
eyes  twice  a  day. 

January  23d.  Temporary  pupillary  contraction  and 
better  vision  for  near  objects  resulted  from  use  of  eserine. 
I  now  see  the  patient  for  first  time,  and  verify  the  correct- 
ness of  Dr.  Booth's  examination.  Xo  eserine  has  been 
used  this  morning,  and  the  pupils  are  both  extremely  dila- 
ted, much  more  than  in  cases  of  third  nerve  paralysis. 
They  are  about  equal,  measuring  about  seven  mm.  in  diam- 
eter, and  with  about  one  mm.  of  the  iris  visible.  I  am 
strongly  impressed  with  the  patient's  peculiar  muddy  quasi- 
cachetic  appearance,  so  suggestive  of  constitutional  syphilis, 
and  question  her  closely  about  evidences  of  this  disease. 
All  that  is  admitted  is,  that  three  years  ago  she  suffered 
from  pains  in  the  right  upper  arm,  worse  at  night,  for  three 
or  four  days.  Xo  miscarriages.  The  post-cervical  glands 
are,  however,  distinct.  I  direct  the  continuance  of  eserine 
drops  in  the  eyes  twice  a  day,  and  prescribe  a  solution, 
each  dose  of  which  contains  \  grain  of  red  iodide  of  mer- 
cury, and  fifteen  grains  of  iodide  of  potassium,  to  be  taken 
after  each  meal.  (Patient  states  that  the  right  pupil  was 
first  dilated.)  On  January  27th,  Dr.  Booth  ordered  the 
dose  of  mixture  to  be  doubled.  February  1st.  Has  had  no 
eserine  since  7  P.  M.  yesterday  (fifteen  hours).  The  left 
pupil  measures  four  mm.,  the  right  six  mm.  Both  pupils 
now  act  in  accommodative  effort,  but  not  to  light.  Ordered 
a  new  solution,  each  dose  of  which  contains  ^  grain  of  red 
iodide  of  mercury  and  sixty  grains  of  iodide  of  potassium 
after  each  meal.  February  4th.  Xo  eserine  since  last  note. 
Right  pupil  six  mm.,  left  four  mm.  in  repose.  Both  act 
fairly  well  in  accommodation.  February  10th.  Very  great 
improvement:  the  left  pupil  is  of  normal  size,  the  right  is  still 
larger;  both  act  well  in  accommodation,  and  the  left  shows 
a  distinct  reaction  to  light.  Patient  left  for  home  with  in- 
structions to  take  bichloride  of  mercury  3V  grain  after  each 
meal  for  two  weeks,  then  fifty  drops  of  saturated  solution 
of  iodide  of  potassium  after  each  meal  for  two  weeks,  and 
so  on  alternately.  On  same  day,  eyes  re-examined  by  Drs. 
Agnew  and  Webster.  R.  V.  *fj  in  each  eye  ;  no  improve- 
ment with  glasses. 


A  MANUAL  OF  DISEASES  OF  THE  NERVOUS  SYSTEM,  By 
W.  R.  Gowers,  M.  D.,  F.  R.  C.  P.  American  Edition, 
with  341  Illustrations.     P.  Blakiston,  Son  &  Co.,  il 


From  a  small  beginning  a  great  work  has  gradually  been  evolved. 
Less  than  ten  years  ago  Gowers  put  forth  a  very  modest  little  book  on 
the  Diagnosis  of  diseases  of  the  Spinal  Cord,  which  was  soon  followed 
by  an  equally  modest  treatise  on  Diseases  of  the  Brain.  Two  years 
ago  the  first  half  of  this  manual  appeared,  comprising  Diseases  of 
the  Spinal  Cord  and  Nerves,  and  now  this  manual  of  diseases  of  the 
entire  nervous  system  is  placed  before  us. 

The  present  volume  is  an  exceedingly  clumsy  one  of  1357  pages, 
so  voluminous  indeed,  that  it  is  almost  impossible  to  hold  it  in  the 
hand  for  even  a  few  minutes  with  any  degree  of  comfort.  Why 
the  American  publishers  should  have  insisted  on  putting  this  vast 
amount  of  matter  into  a  single  volme,  we  cannot  understand.  To 
make  matters  worse,  the  typographical  appearance  of  the  book  has 
suffered,  the  type  is  often  blurred  and  the  illustrations  unnecessarily 
indistinct.  Publishers  should  remember  that  students  of  a  book 
such  as  Gowers',  will  not  refrain  from  buying  a  work  because  it  hap- 
pens to  appear  in  two  volumes.  With  this  protest  we  can  pass  on  to> 
the  work  itself. 

The  most  conscientious  reviewer  cannot  be  expected  to  read  1357 
pages  of  a  manual  from  beginning  to  end,  but  he  can  put  the  book 
to  a  different  yet  satisfactory  test.  The  present  writer  has  had 
Gowers'  manual  at  his  elbow  for  the  last  six  weeks,  and  during  that 
time  has  made  it  his  chief  book  of  reference  on  matters  neurological.. 
During  this  time  a  very  wide  range  of  subjects  has  been  con- 
sulted ;  among  these  were  neuritis,  locomotor  ataxia,  myelitis,  acute 
infantile  paralysis,  cerebral  hemorrhage,  ataxic  paraplegia,  pseudo- 
hypertrophic paralysis,  brain  tumors,  tetanus  and  neuralgias,  and 
many  more.     The  work  has  not  been  found  wanting  in  any  respecL 


-25  REVIEWS. 

All  these  chapters  have  been  written  with  unusual  care.  The  author's 
wide  clinical  experience  enables  him  to  lend  the  charm  of  personal 
observation  to  the  discussion  of  the  most  abstruse  forms  of  nervous 
disease,  while  every  earnest  student  will  stand  aghast  at  the  author's 
wide  reading  of  neurological  literature.  He  has  liberally  consulted 
English,  German  and  American  articles,  a  little  to  the  neglect,  we 
think,  of  French  writings. 

Besides  being  a  thorough  clinician,  Gowers  is  an  admirable 
pathologist,  and  in  no  work  on  nervous  diseases  that  we  are 
acquainted  with  has  the  pathology  of  nervous  diseases  been  so 
thoroughly  discussed  as  here.  Not  quite  so  much  can  be  said  of 
Gowers'  therapeutic  suggestions  ;  they  are  meager  rather  than  other- 
wise. Yet  it  is  questionable  whether  the  author  has  not  after  all 
shown  sound  judgment  in  limiting  himself  to  therapeutic  measures 
of  known  value  instead  of  entering  upon  the  efficacy  of  this  or  that 
drug  in  this  or  that  special  little  disease. 

Gowers  has  followed  in  the  footsteps  of  Strumpell  and  others  in 
beginning  his  book  with  diseases  of  the  peripherial  nervous 
system,  preceded  by  a  general  introduction  on  symptomatology  ; 
next  in  order  come  diseases  of  the  spinal  cord  ;  then  diseases  of  the 
brain,  and  lastly  general  and  functional  diseases  of  the  entire  central 
nervous  system. 

By  way  of  introduction  to  diseases  of  the  spinal  cord  and  brain, 
Gowers  gives  excellent  chapters  on  the  anatomy  and  physiology  of 
the  cord  and  brain.  These  chapters  are  of  a  very  high  order  of  ex- 
cellence, and  as  far  as  the  brain  is  concerned  no  better  and  more 
concise  description  of  its  anatomy  has  been  given  in  any  English 
text-book.  For  the  purpose  of  the  student  or  clinician,  all  that  he 
needs  to  know  on  this  head,  he  will  find  lucidly  stated  in  this  chap- 
ter. 

We  are  a  little  surprised  that  even  Gowers  should  have  slighted  the 
anatomy  of  the  peripheral  nervous  system.  Every  teacher  of  neurology 
will  agree  with  the  experience  of  the  present  writer  that  the  average 
medical  man  knows  just  a  little  more  (to  be  sure  it  is  not  much  at 
that)  of  the  anatomy  of  the  spinal  cord  than  he  does,  say,  of  the 
"make-up"  of  the  brachial  plexus.  A  few  more  good  illustrations  and 
a  short  descriptive  account  of  the  peripheral  nerves  would  have  added 
to  the  value  of  the  first  section  of  this  book. 

The  discussion  of  the  special  diseases  of  each  of  the  three  large 
divisions  of  the  nervous  system  is  preceded  by  a  chapter  on  the 
symptomatology  of  that  division.     The  plan  is  a  good  one  and  well 


REVIEWS.  >,2j 

executed,  but  it  increases  the  number  of  cross-references.  Thus, 
to  get  a  complete  idea  of  excessive  knee-jerks,  the  student  must  seek 
this  information  in  part  in  the  chapter  on  symptomatology  of  dis- 
eases of  the  spinal  cord,  and  in  part  in  the  chapter  on  primary 
spastic  paraplegia.  For  the  differential  diagnosis  of  apoplexies,  he 
must  look  up  apoplexy  and  find  a  little  but  by  no  means  as  much  as 
he  had  a  right  to  expect  under  cerebral  hemorrhage. 

But  we  will  not  quibble  with  the  author  regarding  the  arrange- 
ment of  his  book.  There  is  room  for  a  difference  of  opinion  on  such 
points.  The  author  has  shown  unusual  discrimination  and  restraint 
in  giving  due  consideration  to  each  subject  according  to  its  merits  ;  and 
not  enlarging  unduly  upon  subjects  which  the  author  had  made  special 
subjects  of  study,  and  yet  his  special  studies  tell  in  the  admirable 
chapters  on  muscular  paralysis,  on  optic  nerve  symptoms,  and  on 
spinal  scleroses.  Functional  nervous  diseases  are  slighted  just  a 
little,  and  we  are  astounded  that  but  one  page  out  of  1357  should 
be  devoted  to  neurasthenia.  The  author  denies  the  justice  of  con- 
sidering neurasthenia  a  clinical  entity.  This  challenges  the  convic- 
tion of  those  of  us  who  are  thoroughly  familiar  with  this  morbus 
Americanus,  and  who  know  that  there  are  cases  of  neurasthenia  which 
are  not  merely  cases  of  "neuralgia,  headache,  cephalic  sensations, 
hysteria  or  hypochondriasis. "  It  is  surely  as  distinct  a  clinical  con- 
ception as  hysteria  is. 

Gowers'  Manual  is  herewith  recommended  to  the  general  and  to 
the  special  student.  It  is  not  too  detailed  for  the  former,  while  for 
the  specialist  it  is  explicit  enough  as  a  first  book  of  reference.  It 
is,  on  the  whole,  an  admirable  treatise. 

B.  S. 


£oriiht  Reports. 


PHILADELPHIA  NEUROLGICAL   SOCIETY. 

Stated  Meeting,  March  26,  1888. 
The  President,  S.  Weir  Mitchell,  M.D.,  in  the  Chair. 
Dr.  S.  Weir  Mitchell  read  a  paper  on 

LOCOMOTOR  ATAXIA  CONFINED  TO  THE  ARMS  :  REVERSAL 
OF  ORDINARY  PROGRESS. 

Drs.  Charles  K.  Mills  and  W.  C.  Cahall  reported 
six  cases  of  epidemic  cerebro-spinal  meningitis. 

Dr.  William  Osler  said  that  it  was  interesting  to  note 
that  in  this  city  cerebro-spinal  meningitis  had  been  endemic 
for  so  many  years.  Dr.  Stille  states  that  every  year  since 
1863-64,  deaths  from  this  affection  have  been  reported. 
Many  of  the  cases  were  not  cerebro-spinal  meningitis.  Mis- 
takes in  diagnosis  were  very  common  in  this  affection.  Three 
or  four  instances  of  this  had  come  under  his  observation. 
One  case  of  smallpox  was  diagnosticated  as  cerebro-spinal 
meningitis.  Cases  of  what  the  French  term  the  cerebro- 
spinal type  of  typhoid  fever,  were  frequently  diagnosticated 
as  cerebro-spinal  meningitis,  and  at  the  post-mortem  the 
brain  was  deeply  congested,  while  the  intestines  exhibited 
the  characteristic  enteric  lesions.  The  fifth  case  reported 
by  Drs.  Mills  and  Cahall  resembled  typhoid  fever  with  se- 
vere cerebro-spinal  manifestations.  In  certain  of  these  cases, 
he  did  not  think  that  it  was  possible  to  make  a  positive  diag- 
nosis, unless  the  base  of  the  brain  was  involved. 

Dr.  MILLS  said  that  the  fact  that  in  the  fifth  case  the  pa- 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  ^2Q 

tient  became  blind  was  a  strong  point  in  favor  of  cerebro- 
spinal meningitis. 

Dr.  H.  A.  HARE  spoke  with  reference  to  the  use  of  sali- 
cylic acid  and  quinine  in  cerebro-spinal  meningitis.  He  had 
always  understood  from  his  reading  and  teaching  and  had 
found  it  practically  correct,  that  these  drugs  are  contraindi- 
cated  in  inflammation  of  the  meninges  of  the  brain  and  of  the 
brain  itself  on  the  ground  that  they  produced  congestion  of 
these  parts.  Studies  have  shown  that  in  animals  killed  with 
quinine  intense  inflammation  of  the  meninges  of  the  brain 
was  the  typical  post-mortem  lesion. 

Dr.  William  W.  Welch  had  been  much  pleased  in 
listening  to  what  had  been  said.  It  was,  he  said,  shortly 
after  the  war  that  he  first  saw  in  this  city  cases  of  cerebro- 
spinal meningitis,  and  they  answered  to  the  description 
given  that  evening.  Since  then  he  had  only  occasionally 
met  with  a  case.  He  was  inclined  to  agree  with  Dr.  Osier 
that  not  untrequently  a  mistake  in  diagnosis  was  made  in 
regard  to  this  disease.  He  had  seen  more  than  one  case  of 
smallpox  mistaken  for  cerebro-spinal  meningitis.  About  a 
year  before,  a  young  Swedish  girl,  suffering  from  this  dis- 
ease, had  been  brought  to  the  Municipal  Hospital  from  a 
ship  arriving  at  this  port.  Of  course  he  did  not  see  her  early 
in  the  disease  nor  was  he  able  to  obtain  any  history,  but 
when  admitted  there  was  cephalalgia,  hyperesthesia,  and 
marked  stiffness  of  the  neck  and  along  the  spinal  column. 
She  was  totally  deaf  and  in  the  course  of  the  disease  a  pur- 
ulent discharge  came  from  the  ears.  For  a  time  she  seemed 
to  improve,  but  finally  lapsed  into  coma,  and  finally  died 
after  being  in  the  hospital  thirty-six  days.  No  post-mortem 
was  made.  There  had  been  under  treatment  in  the  hospital 
two  cases  which  came  from  the  locality  mentioned  by  Drs. 
Mills  and  Cahall.  These  cases  were  not  sent  to  the  hospi- 
tal until  they  had  been  sick  about  two  weeks.  He  learned, 
however,  that  in  both  cases  the  sickness  came  on  suddenly 
with  a  chill  followed  by  fever,  nausea,  headache,  intolerance 
of  light,  delirium,  and  stiffness  amounting  to  rigidity  of  the 
cervical  muscles.  On  admission  most  of  these  symptoms 
continued.     It  was  about  seven  weeks  since  the  attack  oc- 


-^0  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

curred  ;  in  one  case  there  was  apparent  improvement,  but 
the  condition  of  the  other  was  still  critical.  The  convales- 
cence from  this  disease  is  always  protracted.  Indeed,  he 
had  sometimes  questioned  whether  in  severe  cases  perfect 
recovery  ever  takes  place. 


Stated  Meeting,  March  26,  188S. 


The  President,  S.  Weir  Mitchell,  M.  D.  in  the  chair. 
In  opening  the  discussion  upon  the  subject  of  the 

FORCIBLE  FEEDING  OF  THE  INSANE, 

introduced  by  the  translation  of  Dr.  Rader's  paper,   and  by 
the  paper  of  Dr  John  B.  Chapin. 

Dr.  S.  Preston  Jones,  of  the  Stockton  Sanitarium,  Mer- 
chantville,  N.  J.,  said  he  had  never  seen  any  serious  results 
from  forcible  feeding.  He  found  it  necessary  in  about  one 
out  of  every  one  or  two  hundred  cases.  Some  patients  re- 
fused food  because  there  was  actually  no  appetite  and  a 
loathing  of  food.  These  patients  were  in  bad  health,  and  in 
such  cases  forcible  feeding  he  thought  did  harm  and  the 
patients  would  mostly  die  at  any  rate.  If  the  patient  was 
in  good  general  health  and  refused  food,  he  did  so  because 
he  thought  it  was  poisoned.  It  could  be  forcibly  adminis- 
tered, and  digestion  as  a  rule  was  good.  He  had  seen  such 
patients  steadily  improve  under  such  a  course  and  some- 
times get  well.  Patients  sometimes  had  queer  reasons  for 
refusing  to  take  food.  One  man  under  his  care  had  told  his 
wife  as  she  was  about  leaving  him,  that  he  would  never  eat 
a  mouthful  in  the  hospital.  We  let  him  go  for  a  week  or  ten 
days  and  then  began  to  use  the  stomach-pump.  He  soon 
began  to  improve  and  would  have  gladly  taken  food  had  it 
not  been  for  the  fact  that  he  had  made  a  vow  not  to  eat 
voluntarily.  At  the  end  of  three  months  he  left  the  institu- 
tion restored  to  health.  Another  of  our  old  patients  was 
very  fastidious  about  his  food  and  unless  he  got  just  what 
he  wanted  he  would  not  eat.  This  became  troublesome 
and  on  one  occasion  we  used  the  pump,  not  in  the  gentlest 
manner.     And  there  was  no  further  trouble. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  ^^ 

Formerly  the  stomach-pump  and  tube  were  used,  but  he 
now  employs  the  nasal-tube.  This  was  easily  done,  did 
not  injure  the  oesophagus  or  stomach,  and  the  food  passed 
into  the  stomach  much  more  slowly  than  with  the  pump. 
He  thought  that  possibly  some  damage  might  be  done  by 
pumping  a  large  quantity  of  fluid  rapidly  into  the  stomach. 
The  use  of  the  stomach-tube  was  sometimes  done  in  a  rough 
manner,  causing  much  discomfort.  The  mouth  had  to  be 
forcibly  opened,  and  sometimes  this  was  a  serious  matter. 

Dr.  Jones  had  never  before  heard  of  a  patient  being 
strangled  under  the  operation.  He  thought  that  formerly 
patients  were  often  forced  to  take  food  too  soon.  At  one 
time  it  was  taught  that  the  patient  should  not  be  permitted 
to  go  more  than  one  or  two  days  without  taking  food.  He 
now  had  a  patient  who  was  rapidly  recovering,  who  had 
been  fed  twice  a  day  for  six  months  He  had  not  the 
slightest  doubt  but  that  he  would  have  died  if  he  had  been 
left  alone. 

Dr.  E.  N.  Brush,  first  assistant  physician  in  the  Male 
Department  of  the  Pennsylvania  Hospital  for  the  Insane, 
said  that  it  had  been  his  habit  for  the  past  ten  years  in  the 
two  hospitals  with  which  he  had  been  connected  to  use  for- 
cible feeding.  He  had  employed  the  nasal-tube,  the  stomach- 
tube  and  injections.  He  had  never  regretted  feeding  a  pa- 
tient, but  had  sometimes  regretted  that  he  had  not  done  it. 
He  thought  that  sometimes  patients  were  not  fed  soon 
enough,  and  not  often  enough  when  we  do  feed  them.  In 
some  hospitals  the  routine  custom  was  to  feed  two  or  three 
times  a  day.  He  thought  that  in  some  cases  it  would  be 
better  to  give  smaller  quantities  six  or  eight  times  a  day.  It 
was  an  easy  thing  to  use  the  nasal-tube,  or  if  there  was 
some  deformity  of  the  nose,  or  other  reason  contra-indica- 
ting its  use,  the  mouth  could  be  readily  opened  if  we  went 
about  it  in  the  right  way.  It  had  been  said  that  if  the  pa- 
tient was  a  lady,  the  best  plan  was  to  get  her  to  talk.  In 
other  cases,  the  index  finger  could  be  passed  between  the 
cheek  and  the  teeth  and  inserted  behind  the  last  molar,  and 
the  jaws  could  then  be  separated. 

The  importance  of  this  matter  should  be  impressed  on  the 


-,-2  PHILADELPHIA  XEUROLOGICAL  SOCIETY. 

general  practitioner.  We  frequently  see  cases  reported  in 
newspapers  where  death  has  resulted  because  artificial  feed- 
ing had  not  been  employed.  Physicians  had  a  fear  of  this 
simple  and  ordinary  operation.  He  frequently  used  the  tube 
as  a  siphon,  the  tube  being  provided  with  a  bulb  by  which 
the  flow  might  be  started.  A  similar  arrangement  might  be 
used  for  washing  out  the  stomach  in  case  of  poisoning.  The 
bulb  was  without  valves,  these  being  extemporized  by  the 
operator's  fingers.  In  a  certain  proportion  of  cases  washing 
out  of  the  stomach  as  part  of  the  feeding  operation — the 
washing  being  done  some  time  before  the  introduction  of 
food — resulted  in  an  improved  condition  of  that  organ  and 
a  voluntary  resumption  of  eating. 

Almost  all  of  the  ordinary  articles  of  food  might  be  given 
through  the  tube.  Mashed  potatoes  could  be  given  if  mixed 
with  a  little  milk  and  some  preparation  of  malt.  The  same 
might  be  said  of  the  farinaceous  foods.  Powdered  beef 
and  other  preparations  of  meat  are  easily  administered. 

Dr.  Brush  on  more  than  one  occasion  fed  patients  by 
the  rectum.  When  the  stomach  rejects  food,  or  when  the 
injection  of  food  caused  pain,  this  method  deserved  a  trial. 
He  had  employed  various  articles  by  this  method.  Some 
years  ago  he  tried  defibrinated  blood.  It  acted  satisfac- 
torily, but  gave  rise  to  such  an  offensive  odor  that  it  was 
discontinued. 

Various  methods  have  been  suggested  for  the  feeding  of 
patients.  One  of  the  most  striking  was  that  proposed  by  an 
Italian  physician.  He  suggested  that  the  food  be  prepared 
in  the  form  of  a  bolus,  which  was  placed  in  the  back  of  the 
pharynx,  and  then  an  electric  current  was  passed  through 
the  neck,  causing  the  mass  to  be  swallowed.  He  claimed  to 
have  accomplished  this. 

The  length  of  time  that  a  patient  can  be  kept  in  good 
condition  by  forcible  feeding  probably  depended  upon  the 
other  conditions  present.  He  saw  a  patient  of  Dr.  Yellow- 
lees,  in  Scotland,  who  had  been  fed  daily  for  six  years,  and 
was  still  in  good  condition.  He  had  fed  a  patient  for  eigh- 
teen months.  The  patient  was  then  transferred  to  another 
hospital,  where  at  last  accounts  she  was  still  being  fed.    Dr. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  ,,.* 

Westphal  preferred  the  use  of  a  funnel  with  a  stomach-tube. 
So  do  some  of  the  other  German  authorities.  Some  of  the 
English  alienists  still  use  the  stomach-pump.  Dr.  Yellow- 
lees  used  a  bottle  with  the  tube  attached  to  its  side,  at 
the  bottom. 

In  the  matter  of  tubes,  Dr.  Brushe's  preference  was  for 
the  soft  rubber  ones.  For  nasal  feeding  he  used  a  soft  rub- 
ber catheter,  with  the  opening  in  the  end.  He  had  various 
sizes  of  stomach-tubes  of  the  same  material. 

Dr.  J.  C.  Hall,  Physician-in-Chief  of  the  Frankford  In- 
sane Asylum,  Philadelphia,  said  the  ground  seemed  to  be 
pretty  well  covered  by  those  who  had  taken  part  in  the  dis- 
cussion. He  must  say  that  he  did  not  agree  with  Dr.  Rader 
in  regard  to  the  advisability  of  notfeeding.  He  hadnever  seen 
any  bad  results  from  the  practice,  and  he  thought  that  a  mistake 
was  often  made  in  waiting  too  long  before  beginning  forcible 
feeding.  He  should  not  like  one  of  his  patients  to  go  more 
than  twenty-four  hours  without  taking  food  if  he  thought  his- 
condition  required  it. 

At  the  present  time,  they  had  an  epidemic  of  not  eating 
in  the  institution  with  which  he  was  connected.  About 
ten  per  cent,  of  the  cases  refused  to  take  food.  He  found 
that  one  with  a  good  deal  of  strategy  will  influence  others  to 
follow  his  example.  Some  he  thought  had  taken  up  the 
matter  by  imitation.  He  employed  the  nasal-  tube,  although 
he  preferred  the  stomach-tube  where  it  could  be  used  with- 
out too  much  annoyance,  on  account  of  its  greater  rapidity. 
He  used  with  this  a  funnel.  The  only  objection  that  he  had 
met  with  was  that  the  patient  would  occasionally  regurgi- 
tate the  food.  He  thought  that  the  main  thing  to  be  taken 
into  consideration  was  not  to  allow  the  patient  to  go  too 
long  without  food.  He  recalled  one  case  of  melancholia  in 
which  food  was  refused  under  the  delusion  that  it  was  poi- 
soned. This  patient  was  fed  three  or  four  times  a  day  for 
eight  or  ten  months,  and  finally  recovered,  left  the  hospital 
and  went  into  business.  He  has  seen  many  other  cases  in 
which  the  advantages  of  forcible  feeding  were  clearly  illus- 
trated. Dr.  Chapin  had  well  covered  the  ground,  and  he 
agreed  with  him  on  most  of  the  points  presented. 


,  -  ,  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

Dr.  J.  WiLLOL'GHBV  Phillips,  of  Burn  Brae,  Clifton 
Heights,  Pennsylvania,  said  that  during  the  past  ten  years 
he  had  had  about  fifteen  cases  in  which  forcible  feeding  was 
called  for.  He  had  never  seen  any  accident ;  the  only  un- 
toward occurrence  that  he  had  known  of  was  a  convulsion 
during  the  passage  of  the  stomach-tube.  He  had  used 
both  the  stomach  and  nasal-tube,  and  either  can  be  em- 
ployed with  ease  if  properly  managed.  He  used  the  tubes 
simply  with  a  funnel.  He  had  then  in  charge  a  lady  who 
had  not  taken  food  voluntarily  since  a  year  ago  last  Decem- 
ber. The  nasal-tube  was  used  twice  daily  during  the  entire 
period.  She  had  not  gained  in  weight,  neither  had  she  lost. 
During  the  operation  the  patients  should  be  so  thoroughly 
under  control  that  there  can  be  no  possible  chance  of  their 
injuring  themselves  or  interfering  with  the  operation.  This 
can  be  accomplished  by  having  plenty  of  assistance. 

Of  the  foods  used  in  such  cases,  milk  and  eggs  head  the 
list ;  with  these  may  be  combined  beef  tea.  mutton  broth, 
and  strong  comsomme,  vegetables  in  liquid  form,  and  oc- 
casionally extracts  of  malt  and  spirits,  according  to  the  re- 
quirements of  the  case.  When  patients  are  debilitated  and 
run  down,  prompt  and  liberal  feeding  is  clearly  indicated. 
His  practice  was  to  administer  nourishment  twice  daily, 
the  amount  being  at  least  a  pint  and  a  half  at  each  meal. 

Dr.  William  Osler  said  that  in  general  practice  he 
often  had  occasion  to  feed  patients  with  the  tube.  In  the 
course  of  some  years'  observation  in  the  post-mortem  room, 
he  had  seen  three  or  four  instances  of  deglutition  pneumo- 
nia, which  had  been  referred  to  in  the  paper.  He  saw  such 
a  case  not  long  ago.  A  girl  was  admitted  to  the  hospital  in 
a  comatose  condition,  and  it  was  necessary  to  feed  her  with 
the  nasal-tube.  At  the  autopsy  a  double  deglutition  pneu- 
monia was  found.  It  was  extremely  important  that  the  op- 
eration should  be  properly  performed.  The  tube  should  be 
entirely  emptied  before  it  is  withdrawn,  and  tsken  out  care- 
fully. In  the  insane,  accident  is  not  so  likely  to  result,  for 
tlvc  patient  generally  coughs  the  foreign  matter  from  the 
Larynx,  but  the  comatose  patient  dose  not  recognize  it,  and 
the  fluid  passes  into  the  bronchial  tubes. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  --e 

Dr.  E.  N.  Brush  said  that  the  danger  to  which  Dr. 
Osier  referred  should  always  be  borne  in  mind.  His  invari- 
able custom  was  to  pinch  the  tube  if  it  was  soft,  or  if  it  was 
stiff,  to  place  his  finger  over  the  opening  while  removing  it. 
Dr.  Hall  had  referred  to  the  fact  that  he  had  had  an  epi- 
demic of  refusal  of  food.  It  was  found  that  if  other  patients 
knew  that  there  was  a  patient  being  fed  with  a  tube  there 
would  soon  be  other  cases,  especially  among  those  of  a 
hysterical  tendency.  A  curious  fact  may  be  mentioned 
that  many  of  the  case  which  refused  to  eat,  would  eat  if  they 
had  a  chance  to  steal  sufficient  to  live  upon  ;  and  acting 
upon  that,  he  had  often  avoided  the  necessity  of  feeding,  by 
directing  the  nurse  to  leave  food  where  these  patients  could 
surreptitiously  gain  access  to  it. 

Dr.  CHARLES  K.  Mills  said  that  he  regarded  the  sub- 
ject of  the  forcible  feeding  of  the  insane  as  one  of  great 
practical  importance  to  general  practitioners  of  medicine, 
as  well  as  to  those  who  had  charge  of  the  insane  institu- 
tions. When  we  read  in  the  Medical  and  S?<rgical  Reporter 
the  favorable  editorial  comments  on  Dr.  Rader's  paper, 
advocating  non-interference  when  insane  patients  refused 
food,  he  felt  that  the  subject  would  be  an  excellent  one  to 
bring  before  an  association  like  the  Philadelphia  Neuro- 
logical Society,  which  counts  among  its  members  neurolo- 
gists, alienists  and  general  physicians.  He  did  not,  how- 
ever, feel  that  he  could  add  much  to  the  discussion  ;  but  he 
would  like  to  emphasize  the  importance  of  forcibly  feeding 
the  insane  who  are  treated  at  their  homes,  or  not  in  insti- 
tutions especially  intended  for  such  patients.  He  saw  many 
cases  of  insanity  in  consultation,  and  was  frequently  called 
upon  to  treat  such  patients  at  their  homes,  either  alone  or 
in  connection  with  other  physicians.  He  could  recall  a 
number  of  cases  of  acute  mania,  melancholia,  delusional 
monomania,  and  stuporous  dementia,  in  which  he  was 
confident  that  fatal  results,  or  absolute  failure  to  succeed  in 
treatment  at  home,  were  due  to  carelessness  or  tardiness 
or  indifference  as  regards  forcible  feeding.  Occasionally 
cases  of  hysterical  insanity  will  either  intentionally,  or  in 
spite  of  themselves  because  of  their  morbid  impulses,  carry 


^6  PHILADELPHIA  XEL'ROLOGICAL  SOCIETY. 

their  refusal  of  food  so  far  that  their  stomachs  will  not 
respond  properly  to  the  stimulus  of  food  when  given,  and 
serious  results  will  then  ensue.  He  had  had  under  his 
charge  for  several  years  an  intelligent  young  man,  but  the 
unfortunate  victim  of  a  form  of  paranoia,  chiefly  exhibiting 
itself  in  abulia,  inchoate  delusions,  and  imperative  concep- 
tions, nearly  all  circling  about  a  fundamental  delusive  idea 
with  reference  to  the  sinfulness  of  having  blood  entering  in 
any  way  into  his  food.  This  patient  was  fed  400  to  500 
times  forcibly  with  the  oesophageal  tube  in  the  course  of 
about  two  years.  Dr.  Mills  had  but  little  doubt  that  his  life 
was  saved  by  the  procedure  ;  and  not  only  so,  but,  as  the 
patient  himself  had  more  than  once  declared,  the  forcible 
feeding  had  probably  prevented  him  from  passing  into  a 
state  of  acute  mania,  great  excitement  having  frequently 
resulted  from  the  terrible  conflict  precipitated  by  the  struggle 
between  the  desire  to  take  food  owing  to  pressing  physical 
necessity,  and  the  resistance  to  the  inclination  by  which  he 
was  delusively  dominated. 

As  to  the  methods  of  feeding  by  force,  his  experience 
was  in  favor  of  the  nasal-tube.  As  this  discussion  was 
intended  in  publication  to  cover  the  subject  of  forcible  feed- 
ing, he  would  close  his  remarks  by  quoting  from  his  little 
book  on  the  "Nursing  and  Care  of  the  Nervous  and  the 
Insane,"  a  few  remarks  on  this  subject  of  nasal  feeding : 
"The  number  of  patients  who  cannot  be  fed  by  the  nose  is 
very  small  ;  occasionally,  however,  a  patient  is  found  whom 
it  seems  impossible  to  feed  in  this  way,  owing  to  the  chok- 
ing and  strangling  produced.  This  may  be  because  of 
some  peculiar  anatomical  conformation,  or  some  special 
idiosyncrasy  on  the  part  of  the  patient.  Such  a  patient 
will  choke  or  strangle  with  nasal  feeding  when  he  will  not 
when  the  stomach-tube  is  resorted  to.  If,  when  the  attempt 
is  made  to  pass  the  well-oiled  tube  through  the  nostril, 
resistance  is  encountered,  and  if,  after  a  few  trials,  the  tube 
cannot  be  made  to  pass,  great  force  should  not  be  employed 
by  the  operator,  but  the  tube  should  be  at  once  withdrawn 
and  the  effort  should  be  made  to  pass  it  through  the  other 
nostril.     In   nearly   all   cases  where  special    resistances    is 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  .5,7 

53/ 

offered  on  one  side,  the  tube  will  pass  with  ease  upon  the 
other,  and  this,  in  most  instances,  is  because,  if  hypertro- 
phies or  projections  exist  upon  one  side,  there  will  be  upon 
the  other  corresponding  or  compensating  depressions  and 
enlargements.  Sometimes,  but  rarely,  the  mucous  membrane 
is  exceedingly  irritable.  After  the  nasal-tube  has  passed 
through  the  nostrils,  it  seems  to  have  a  peculiar  tendency 
in  some  cases  to  drop  into  the  glottis,  the  patient  struggling 
and  attempting  to  scream  meanwhile.  Some  patients  will 
spit  or  force  the  tube  out  into  the  mouth  ;  and  attendants 
can  sometimes  through  the  mouth,  keep  the  tube,  which 
has  been  passed  through  the  nose,  in  position.  Occasion- 
ally the  nose  is  made  sore  by  the  use  of  the  tube,  but  this 
is  not  likely  to  occur  if  the  tube  is  always  perfectly  cleaned 
and  well  oiled.  If  it  is  of  the  proper  kind  ;  that  is,  a  soft 
tube,  there  will  be  no  danger  of  injuring  the  parts  by  break- 
ing or  perforating  the  mucous  membrane.  In  using  the 
nasal-tube,  great  care  should  be  always  exercised  to  see 
that  at  least  fifteen  to  sixteen  inches  of  the  tube  has  been 
passed  before  beginning  the  feeding.  This  will  make  it 
certain  that  the  entrance  to  the  windpipe  has  been  passed. 
Of  course  care  should  be  taken  to  observe  that  the  tube  has 
not  doubled  itself."  He  would  add  one  remark,  nan\ely : 
Great  care  should  be  taken  not  to  administer  the  food  too 
hot.     He  knew  of  one  accident  occurring  in  this  way. 

Dr.  S.  S.  Shultz,  Physician-in-Chief  of  the  State  Hos- 
pital for  the  Insane  at  Danville,  Pennsylvania,  sent  the 
following  letter  to  Dr.  Mills  as  his  contribution  to  the  dis- 
cussion : 

Danville,  Pa.,  March  23,  1888. 

My  dear  Doctor: — I  give  you  herewith,  as  requested  by 
you  in  your  favor  of  the  17th  inst.,  briefly  my  views  in  regard 
to  the  forcible  feeding  of  the  insane. 

1st.  Is  it  ever  absolutely  necessary  to  administer  food 
against  their  will  to  any  class  of  the  insane  ?  Is  life  pro- 
longed or  restoration  to  reason  promoted  by  such  a  course 
of  treatment  ?  It  must  be  admitted  that  this  question  does 
not  allow  a  mathematical  demonstration  either  way.  It  is 
easy  to  claim  when  bodily  health  is  restored  or  the  mind 


■238  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

improved  under  compulsory  feeding  that  this  would  have 
happened  without  such  treatment,  or  when  death  occurs,  or 
insanity  becomes  chronic,  under  the  expectant  plan  that 
such  results  were  inevitable.  In  medicine,  few  problems 
could  be  solved  by  such  a  method  of  reasoning.  The 
majority  of  patients  who  come  into  hospitals,  from  country 
districts  at  least,  suffer  from  impaired  nutrition.  Until  there 
is  improvement  in  the  pasty  tongue,  the  want  of  appetite, 
anaemia  and  emaciation,  it  is  in  vain  to  look  for  improve- 
ment in  the  symptoms  of  insanity.  Impoverishment  of  the 
blood  seems  to  be  the  condition  which  gives  many  of  the 
so-called  causes  of  insanity  their  importance.  These  may 
be  incurable,  as,  for  instance,  the  remains  of  injuries  to  the 
skull,  or  disease  of  the  heart,  and  yet  if  the  nutrition  can  be 
improved  and  the  blood  enriched,  the  mental  disorder  often 
for  a  time  disappears.  When  insanity  is  the  result  simply 
of  defective  nutrition,  progress  towards  permanent  restora- 
tion keeps  pace  with  the  improvement  of  the  blood  result- 
ing from  better  nutrition.  If  this  torpid  condition  of  the 
nutritive  functions  is  permitted  to  remain  a  long  time,  the 
irregular  mental  habits  become  chronic,  and  the  risk  of 
incurability  rapidly  increases. 

This  much  to  show  my  deep  convictions  that  poor  blood 
plays  an  important  part  in  the  causation  of  many  cases  of 
insanity,  and  that  the  prompt  correction  of  this  will  give  the 
best  chances  of  recovery.  A  german  writer  defending  the 
expectant  plan,  sees  no  danger  in  fasting  when  it  is  not 
prolonged  over  fourteen  days  without  taking  water,  not 
over  fifty  days  when  water  is  taken,  nor  so  long  as  60  per 
cent,  of  the  body  weight  remains.  The  practice  of  such  a 
rule  or  anything  approaching  its  extremes,  it  seems  to  me, 
must  lead  to  the  sacrifice,  not  only  of  the  chances  of  recov- 
ery, but  of  life  itself.  It  can  certainly  not  be  the  part  of 
wisdom  to  allow  the  boat  with  its  living  human  freight  to 
drif:  to  the  very  brink  of  the  cataract,  without  attempting 
to  arrest  it  at  the  beginning  of  the  rapids,  where  it  can  be 
done  with  so  little  risk. 

Insane  patients  having  organic  disease  of  the  digestive 
apparatus,  as  inflammation  of  the  pharynx  or  cancer  of  the 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  -,,,,-, 

stomach,  are  likely  to  refuse  food  earlier  and  more  persist- 
ently than  the  same  in  similar  conditions,  and  the  measures 
suitable  for  those  whose  fasting  is  the  result  of  delusion 
need  modification  for  these.  The  melancholic  who  fast 
from  religious  or  suicidal  motives,  or  the  delusion  that  there 
is  no  room  for  food,  or  that  the  passages  are  closed,  most 
often  carry  their  purpose  to  a  dangerous  extent,  and  thwart 
persuasion,  reasoning,  coaxing,  no  matter  how  skilfully  or 
persistently  plied.  Xo  rule  based  on  the  element  of  time  of 
fasting  is  applicable  ;  but  as  there  has  been  usually  for 
weeks  an  insufficient  amount  of  food  taken,  it  is  safe  to  be- 
gin the  feeding  as  soon  as  the  purpose  of  abstinence  has 
shown  itself  to  be  settled,  and  refusal  to  yield  to  other 
resources,  and  both  bodily  and  mental  symptoms  become 
worse.  The  more  the  character  of  the  patient  while  in 
health  was  marked  by  resolute  purpose  and  stubbornness  of 
will,  the  less  likely  is  delay  to  be  of  any  use. 

Of  course  food  introduced  into  the  stomach  in  this  me- 
chanical and  compulsory  manner  is  of  less  value  than  when 
taken  at  the  promptings  of  natural  hunger  ;  but  one  must 
choose  the  lesser  of  two  evils. 

Nutritive  enemata  may  answer  for  a  time  when  fasting 
instead  of  being  the  result  of  a  fixed  purpose  has  its  origin 
in  the  loss  of  the  feeling  of  hunger. 

Patients  suffering  from  melancholy  no  doubt  must  often 
require  artificial  feeding,  but  other  forms  of  insanity  may 
demand  the  same  treatment.  When  no  physical  condition 
can  be  detected  that  would  justify  abstinence,  the  forcible 
administration  of  food  should  not  be  delayed  to  the  point  of 
starvation  in  any  form  of  disease.  When  emaciation  has 
surely  set  in,  the  breath  has  become  characteristically  heavy 
and  foul,  and  the  strength  is  diminishing,  active  measures 
should  be  no  longer  postponed,  when  the  will  of  the  patient 
cannot  be  persuaded. 

With  reference  to  the  manner  of  carrying  out  the  indica- 
tion, little  need  be  said,  as  the  nasal  tube  is  now  universally 
preferred  to  that  by  the  oesophagus.  It  has  the  advantage 
of  making  resistance  less  possible;  and  injury  to  the  teeth 
and  soft  parts  cannot  occur. 


3J.O  NEW  YORK  XEUROLOGICAL  SOCIETY. 

It  is  possible  that  the  tube  may  enter  the  larynx  through 
an  awkward  position  or  movement  of  the  patient.  If  the 
tube  is  pervious  and  haste  is  avoided,  such  a  misadventure 
will  be  defeated  through  the  restlessness  of  the  patient  and 
the  escape  of  the  air  through  the  outer  end  of  the  tube. 
Very  truly  yours, 

S.  S.  SCHULTZ. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  held  Tuesday  Evening,  April  3d,  1S88. 
The   President,  C.  L.  Daxa,  M.  D.,  in   the    Chair. 


Dr.  A.  Rockwell  presented  two  cases  of 

BASEDOW'S    DISEASE, 

illustrating  results  which  could  not  infrequently  be  obtained 
by  treatment.  The  first  case  was  that  of  a  young  lady  who 
for  a  year  and  a  half  past  had  presented  the  three  symp- 
toms— protrusion  of  the  eyes,  swelling  of  the  neck,  and  in- 
creased frequency  of  the  pulse.  The  neck  had  measured 
fourteen  inches,  and  the  pulse  had  varied  between  140  and 
160,  or  above.  Respiration  had  been  35,  as  a  rule.  After 
four  months  of  treatment,  consisting  of  dietetic  regulation, 
internal  medication,  and  electricity  to  the  neck,  the  size  of 
the  goitre  had  been  reduced  one  inch,  the  exophthalmus 
had  diminished,  and  the  pulse  had  diminished  60  beats. 
The  patient's  whole  physical  condition  also  had  been 
changed,  so  that  she  could  engage  in  the  occupations  and 
the  enjoyments  of  life.  At  the  end  of  treatment  the  pulse 
was  75  or  80.  It  had  intermitted  from  the  first,  and  it  still 
retained  this  characteristic.  Five  years  had  elapsed  since 
the  discontinuance  of  treatment,  and  there  had  been  no  re- 
lapse. 

The  second  case  was   that  of  a  gentleman  still   under 
treatment.     Out  of  thirty  cases  in  the  speaker's  experience 


NEW  YORK  NEUROLOGICAL  SOCIETY.  ^.j 

this  was  but  the  second   in  which  he  had  encountered  the 
disease  in  the  male.     The  case  was  of  an  incomplete  type. 
Great  improvement  had  followed  treatment. 
Dr.  W.  M.  Leszynsky  presented  a  case  of 

ACUTE   IDIOPATHIC   NEURITIS   OF   THE   BRACHIAL  PLEXUS, 

and  read  a  paper  embracing  the  history  of  the  case,  with 
carefully  recorded  electrical  tests. 

The  patient  .was  a  man  who  had  had  an  attack;  several 
years  before,  causing  a  painful  and  wasting  paralysis  of  the 
right  shoulder.  This  was  followed  recently  by  a  second 
attack,  involving  the  left  shoulder.  The  areas  of  anaesthe- 
sia, local  tenderness,  and  electrical  reactions  showed  that 
nearly  all  the  branches  of  the  brachial  plexus  were  involved. 
Syphilis,  lead,  and  trauma  were  excluded. 

Dr.  Birdsall,  while  acknowledging  the  difficulty  of 
following  the  details  of  a  written  history,  had  the  impres- 
sion that  the  case  presented  was  one  of  periarthritis,  with 
neural  involvement  starting  from  the  joint  disease.  Dr. 
Jacoby  had  reported  a  number  of  similar  cases. 

Dr.  Jacoby  was  inclined  to  the  same  view  ;  yet  he  had 
understood  that  there  had  been  no  antecedent  joint  trouble 
either  in  the  shoulder  or  the  wrist. 

Dr.  Birdsall  added  that  in  some  cases  the  pain,  the 
joint  involvement,  and  the  paralysis  appeared  together. 
Especially  in  the  case  of  the  shoulder  there  was  often  no 
antecedent  history  of  joint  involvement. 

Dr.  Dana  referred  to  Dr.  Jacoby's  article  and  asked 
whether  the  degeneration  reaction  had  not  been  absent  in 
liis  cases  of  arthritic  paralysis. 

Dr.  Jacoby  replied  that  it  had. 

Dr.  Birdsall  added  that,  while  this  had  also  been  the 
-experience  of  Erb,  in  some  of  his  own  cases  the  degener- 
ation reaction  had  been  obtained. 

Dr.  Putnam  Jacobi  asked  how  the  electric  resistance 
had  been  measured. 

Dr.  Leszynsky  replied  that  one  electrode  had  been 
placed  upon  the  hand,  and  the  other  upon  the  back  of  the 


n  ,  ,  NEW  YORK  XECROLOGICAL  SOCIETY. 

neck.  In  reply  to  the  objections,  he  stated  that  there  had 
been  no  antecedent  history  of  joint  trouble.  At  the  tim'e  of 
the  paralysis  of  the  deltoid  the  patient  could  move  the  joint 
without  pain.  The  suffering  occurred  in  paroxysms,  and 
with  each  paroxysm  fresh  paralyses  developed.  The  cir- 
cumflex was  first  affected,  the  paralysis  of  the  deltoid  occur- 
ring on  the  twelfth  day,  the  supra-spinatus  and  infra-spinatus 
on  the  twenty-fourth  day,  and  the  triceps  on  the  twenty- 
sixth  day,  after  a  very  severe  attack  of  pain  which  required 
a  large  dose  of  morphia  and  chloral  for  its  relief.  Later, 
the  subscapularis  and  teres  major  had  been  affected,  and 
last  the  biceps,  upon  the  forty-fifth  day  of  the  disease. 
Repeated  examinations  of  the  condition  of  the  joints  had 
been  made,  and  the  possibility  of  joint-affection  had  been 
excluded. 

Dr.  GlBXEY  had  had  the  case  under  observation,  and 
had  been  unable  to  arrive  at  any  decision  in  regard  to  it. 

Dr.  M.  Allex  Starr  presented  a  paper  upon. 

SYRINGOMYELIA,  ITS  PATHOLOGY  AND  CLINICAL  FEAT- 
URES, WITH  EXHIBITION  OF  SPECIMENS,  A  STUDY  OF 
A   CASE,  AND   REMARKS   UPON   ITS   DIAGNOSIS.* 

Syringomyelia  is  a  condition  of  the  spinal  cord  in  which 
abnormal  cavities  are  present  within  the  organ.  The  cavi- 
ties are  of  two  kinds  :  First,  a  dilatation  of  the  central  canal 
— hydromyelia.  Of  this  two  specimens  were  shown,  in 
each  of  which  the  cavity  was  easily  seen  by  the  naked  eye 
and  the  complete  epithelial  lining  was  visible  under  the 
microscope.  The  tissue  around  the  dilated  canal  was  nor- 
mal. Secondly,  a  destruction  of  elements  of  the  spinal 
cord — syringomyelia.  The  first  stage  of  its  pathology  is 
the  infiltration  of  the  spinal  cord  near  the  central  canal  with 
round  cells,  connective-tissue  nuclei,  or  gliomatous  cells. 
A  specimen  showing  this  condition  was  exhibited.  The 
next  stage  is  the  production  of  a  felt-like  connective  tissue 
with  numerous  nuclei  through  the  spinal  cord,  but  especially 
near  the  central  gray  substance,  pushing  aside  or  destroy- 
ing the  spinal  elements.     This  gliomatous  mass  has  a  tend- 

°Puhlisherl  in  full  in  the  Atner,  Jour.  Med.  Science,   May,  1888. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 


343 


ency  to  break  down  in  its  centre,  leaving  a  fissure  or  cavity 
whose  walls  are  formed  by  the  felt-like  connective-tissue 
mass.  The  formation  of  such  a  cavity  is  the  third  stage  of 
the  pathological  process.  Specimens  were  shown  illus- 
trating these  three  stages,  the  specimens  being  from 
Schultze's  cases  and  obtained  partly  from  Schultze  and 
partly  from  his  pupil,  Dr.  Van  Giesen.  In  some  specimens 
the  cavity  was  wholly  independent  of  the  central  canal, 
which  was    pushed   forwar:..     In    another  the    new  cavity 


Diagram  to  show  the  extent  of  the  cavity  in  the  spinal  cord  in  forty-eight  cases.  When  the 
area  represented  by  a  square  was  invaded  by  disease,  the  number  of  the  case  is  recorded  in 
that  square. 

opened  into  the  central  canal,  which  appeared  to  have  been 
dilated.  In  still  others,  no  trace  of  the  central  canal  was 
to  be  seen.  The  gliomatous  infiltration  about  the  cavity  was 
evident  in  all  the  specimens.  The  size  of  the  cavity  varied 
greatly,  from  a  small  fissure  to  a  large  cavity  around  which 
only  a  thin  rim  of  spinal  tissue  remained.  The  cavity  in 
some  cases  extended  only  through  a  few  segments  of  the 
cord.  In  other  cases  it  reached  through  its  entire  length. 
The   above    diagram    was    shown    representing  its  extent 


•2  44  "NEW  YORK  NEUROLOGICAL  SOCIETY. 

in  a  horizontal  section  of  the  spinal  cord,  the  cord  being 
divided  into  squares,  and  forty-eight  cases -being  tabulated. 
The  number  of  each  case  being  placed  in  every  square 
affected  in  the  case,  the  greater  number  of  squares  num- 
bered about  the  central  area  of  the  cord  indicated  the  fre- 
quency with  which  this  area  was  involved.  The  lower 
cervical  and  upper  dorsal  regions  of  the  cord  were  the  parts 
most  frequently  affected.  The  contents  of  the  cavity  is 
usually  serous  fluid,  but  may  be  bloody  or  thick  and  hya- 
line. 

The  clinical  features  of  the  disease  were  presented  by 
means  of  a  collection  of  typical  cases  accompanied  by 
autopsies.  They  were  found  to  be,  first,  progressive  mus- 
cular atrophy  with  paralysis  affecting  some  or  all  of  the 
muscles  of  one  limb,  and  usually  extending  to  the  opposite 
limb  and  to  the  trunk,  sometimes  attended  by  reaction  of 
degeneration  in  the  paretic  muscles  ;  secondly,  vaso-motor 
and  trophic  disturbances  in  the  affected  limb,  consisting 
of  cyanosis,  coldness,  bullous  eruptions,  ulceration,  and 
abscess,  and  even  atrophy  and  fragility  of  the  bones  and  a 
diminution  in  the  excretion  of  sweat;  thirdly,  peculiar  sen- 
sory disturbances,  consisting  of  a  loss  of  the  sensations  of 
pain  and  temperature  in  the  atrophied  part,  while  the  senses 
of  touch,  pressure  and  location  were  preserved. 

The  distribution  of  these  symptoms  in  accordance  with 
the  situation  of  the  lesion  in  the  cord  was  then  fully  dis- 
cussed. In  half  the  cases  cited  the  anterior  horns  were 
involved  and  paralysis  with  atrophy  was  present.  In  two- 
thirds  of  the  cases  the  posterior  horns  were  involved,  and 
the  peculiar  sensory  disturbances  were  observed. 

A  case  was  then  related  in  which  the  characteristic 
symptoms  were  present  and  in  which  the  diagnosis  of  syrin- 
gomyelia had  been  reached  by  exclusion,  all  other  forms  of 
spinal  disease  having  been  shown  to  be  impossible.  The 
differential  diagnosis  from  amyotrophic  lateral  sclerosis, 
tabes,  anterior  polio-myelitis,  meningitis,  intraspinal  tumor, 
and  neuritis  was  considered  in  connection  with  this  case. 
The  paper  closed  with  a  reference  to  the  etiology  and  treat- 
ment of  the  affection,  regarding  which  little  seems  to  be 
known. 


NEiV  YORK  NEUROLOGICAL  SOCIETY.  n  .  - 

045 

Dr.  Shaw  said  that  about  five  weeks  previously  he  had 
been  consulted  by  a  man,  a  German  stevedore,  who  by  his 
occupation  was  much  exposed  to  the  cold.  The  patient's 
complaint  had  been  that  he  was  unable  to  feel  and  protect 
himself  from  anything  hot.  The  anaesthesia  was  especially 
marked  in  the  right  hand,  but  was  present  to  some  extent  in 
the  other  also.  As  in  Dr.  Starr's  case,  there  had  been  a 
burn  on  the  right  arm  near  the  wrist,  for  which  the  patient 
could  not  account.  There  was  no  ataxia,  no  atrophy. 
There  were  no  pupillary  symptoms,  and  the  optic  nerve 
was  normal.  It  seemed  to  him  that  this  might  have  been 
a  case  of  cavity  of  the  cord  similar  to  those  of  the  cases 
described.  He  inquired,  however,  whether  the  origin  of  the 
condition  was  invariable.  Might  we  not,  for  instance, 
have  a  cavity  in  the  cord  from  malacia  secondary  to  caries 
of  the  spine. 

Dr.  Sachs  had  been  interested  in  the  subject  for  several 
years.  He  had  looked  up  the  literature  in  connection  with 
that  of  tumors  of  the  cord,  and  he  had  also  seen  a  number 
of  living  cases  diagnosed  by  Schultze  in  Heidelberg.  The 
clinical  phenomena  in  Dr.  Starr's  case  resembled  those  in 
Schultze's  cases  without  doubt.  He  inquired,  however, 
whether  diagnosis  between  syringomyelia  and  intramedul- 
lary tumor  was  not  difficult,  especially  at  an  early  date. 
The  duration  of  the  condition  would  give  a  decisive  indica- 
tion at  a  later  stage,  as  intramedullary  tumors  seldom  lasted 
as  long  as  two  or  three  years.  The  difficulty  of  diagnosis 
was  further  increased  by  the  fact  that  the  symptoms  so 
much  resembled  those  of  progressive  muscular  atrophy  that 
the  sensory  manifestations  might  easily  be  neglected  in  favor 
of  this  diagnosis. 

Dr.  Birdsall  recalled  from  his  own  experience,  three 
cases  presenting  motor  symptoms  of  the  atrophic  type, 
vaso-motor  and  some  sensory  symptoms,  which  he  thought 
might  be  due  to  cavity  in  the  cervical  portion  of  the  cord  ; 
he  had  not  yet  arrived  at  an  exact  conclusion  in  the  matter. 
There  had  been  in  these  cases,  too,  cessations  in  the  ad- 
vancement of  the  disease.  More  careful  observations  would, 
he  thought,  lead  to  less  frequent  diagnoses  of  the  typical 


•,,£  NEW  YORK  .\ECROLOGICAL  SOCIETY. 

or  system  diseases.  There  would  be  found  many  combi- 
nations of  symptoms  which  did  not  correspond  to  these 
types.  The  system  diseases,  too,  probably  required  to  be 
divided  up. 

Dr.  Booth  recalled  a  case  of  marked  atrophy  of  the 
arm  and  hand  with  anaesthesis,  so  that  burns  were  not 
felt. 

Dr.  Putnam-Jacobi  referred  to  the  fact  that  in  the  cases 
cited  a  gliomatous  tumor  had  served  for  the  inception  of 
the  condition.  She  asked  whether  all  cases  of  syringo- 
myelia were  referred  to  this  origin.  She  also  referred  to 
the  existence  of  vacuoles  in  the  cord  in  pseudo-hypertro- 
phic  paralysis,  in  the  medulla  in  tetanus,  and  in  the  condi- 
tion of  porencephalia  in  the  brain.  In  five  cases  of  pseudo- 
muscular  hypertrophy  there  had  been  found  dilatation  of 
the  central  cavity  or  cavities  in  the  posterior  horns,  although 
the  correlation  of  the  lesion  with  the  paralysis  had  not  been 
established. 

Dr.  PETERSON  referred  to  a  case  at  the  Manhattan  Hos- 
pital where,  in  1878,  Dr.  Seguin  had  diagnosed  cavity  of  the 
cervical  enlargement  of  the  cord.  The  patient  had  pre- 
sented atrophy  of  the  left  hand  and  arm  with  anaesthesia  of 
the  left  arm,  thorax,  and  leg. 

Dr.  Dana  suggested  that  many  cases  diagnosed  cervi- 
cal pachymeningitis  should  probaly  have  been  classed  as 
cases  of  this  disease,  as  in  Wichman's  case.  Dr.  Starr  had 
assumed  that  all  cases  of  syringomyelia  were  gliomatous  in 
origin.  Might  we  have  cavity-building  from  some  other 
cause  :  He  showed  a  specimen  in  which  similar  cavities  had 
resulted  from  a  central  myelitis.  There  had  been  two  cavi- 
ties in  this  case,  ^ne  one  and  a  half  inch  long  and  the  other 
not  so  large. 

Dk.  Starr  closed  the  discussion.  The  stationary  con- 
dition in  his  case  could  be  explained  by  the  fact  of  the  gli- 
oma having  broken  down  and  advancement  having  ceased. 
The  process  had  been  arrested.  It  was  not  possible  to 
diagnose  between  intramedullary  tumors  and  syringomyelia 
except  as  had  been  suggested  by  the  duration  of  the  case. 
The  lesion  had  been  discovered  accidentally  in  some  of  the 


NEW  YORK  NEUROLOGICAL  SOCIETY.  o17 

cases  cited.  The  same  had  been  true  of  multiple  sclerosis 
in  its  first  recognition.  Then  it  had  been  diagnosed  by  ex- 
clusion, all  cases  not  presenting  typical  symptoms  being 
referred  to  it.  Now  syringomyelia  received  consideration 
also  in  the  diagnosis  of  the  anomalous  cases.  It  might  be 
of  assistance  to  bear  in  mind  that  24  out  of  the  56  cases  had 
presented  cavity  in  the  anterior,  and  32  out  of  56  cavity  in 
the  posterior  part  of  the  cord.  The  chances  were  therefore 
in  favor  of  the  symptoms  of  progressive  muscular  atrophy  or 
analgesic  areas  being  present.  In  the  examination  it  was 
necessary  to  distinguish  between  analgesia  with  loss  of  the 
temperature-sense  and  general  tactile  anaesthesia.  Inter- 
missions were  not  uncommon  in  other  conditions.  He  had 
seen  ataxia  disappear  and  return  after  several  months.  The 
reaction  of  degeneration  did  not  appear  to  be  an  important 
diagnostic  point.  The  majority  of  the  cases  had  been  diag- 
nosed as  progressive  muscular  atrophy,  a  condition  in  which 
this  reaction  was  not  found.  The  condition  of  porencephalia 
referred  to  was  a  condition  of  childhood  and  fcetal  life  ;  he 
did  not  think  that  it  was  ever  found  developing  in  the  adult. 
The  condition  found  in  pseudo-hypertrophic  paralysis  has 
been  a  congenital  deformity  of  the  cord  with  abnormal 
fissures,  but  without  gliomatous  infiltration,  and  hence  was 
entirely  different  from  that  here  described.  The  age 
of  the  patients  with  syringomyelia  had  been  twenty- 
five  to  forty  years.  In  all  of  the  cases  observed  the  previous 
state  had  been  that  of  infiltration  with  gliomatous  cells. 
Destruction  did  not  occur  during  this  stage  ;  the  elements 
of  the  cord  were  simply  displaced. 


ELECTRICITY  AND  VITAL  ENERGY. 

Dr.  T.  W.  Poole,  in  the  Medical  Register,  Dec.  3d,  1887, 
makes  comments  on  a  paper  by  Dr.  F.  E.  Stewart,  who  claims 
that  heat  and  electricity  are  directly  transmutable  into  vital 
energy,  in  accordance  with  the  law  of  conservation  of 
force;  and  also  "that  it  is  possible  to  change  electricity 
into  vital  energy  by  passing  the  electric  current  from  a  bat- 
tery through  the  living  bodies  of  both  animals  and  vegeta- 
bles." A  reason  assigned  in  support  of  this  conclusion  is 
that  plants  grow  under  the  influence  of  electric  light. 
Electric  light  is  not  electricity.  An  established  fact  in 
relation  to  the  conservation  of  energy  is  that  a  physical 
force  ceases  to  exist  when  transmuted  into  another  corre- 
lated force.  Whenever  work  is  done  by  heat,  heat  disap- 
pears (Tyndall).  In  accordance  with  the  principle  of 
conservation  of  force,  light  runs  into  heat,  heat  into  elec- 
tricity, electricity  into  magnetism,  magnetism  into  mechan- 
ical force,  mechanical  force  again  into  heat  and  light 
Tyndall  .  or  into  chemical  affinity,  it  is  equally  true  that 
not  one  of  these  can  possibly  be  converted  into  vital  energy 
unless  it  be  then  and  there  present,  as  embodied  in  living 
protoplasm,  "  under  the  guidance  of  which  the  transforma- 
tion of  matter  takes  place"  (Balfour).  Vital  force  or  energy 
can  only  be  increased  by  appropriate  food  and  nutritive 
processes.  Electricity  itself  cannot  be  utilized  as  food 
even  by  plants,  and  when  converted  into  chemical  energy 
it  becomes  lost  as  electricity,  just  as  it  does  when  converted 
into  light.  Electricity  may  be  made  to  promote  growth  and 
nutrition  of  the  animal  body  or  portions  of  it,  not  by  any 
vitalizing  quality  but  as  is  explained  in  "  Medical  and  Surgi- 
cal Electricity,"  p.  205,  300 — "  The  muscular  contractions 
that  are  produced  by  the  current  in  its  passage  through  the 
limbs  or  body  cause  increase  of  local  processes  of  waste  and 
repair,  and  accordingly  the  muscles  increase  in  size,  just  as 
they  naturally  do  under  the  influence  of  any  other  form  of 
active  or  passive  exercise."  L.  F.  B. 


VOL.  XIII.  .  June.   1888.  No.  6. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


(Original  SUtirteis-. 


ON  SOME  RESULTS  OBTAINED  BY  THE  ATROPHY 

METHOD. 

BY  E.  C.  SPITZKA  and  R.  MOLLENHAUER. 

IN  the  sequel  we  shall  have  occasion  to  relate  observa- 
tions made  by  various  methods  of  research  employed 
on  the  brain  axis  of  man  and  lower  animals.  But  as 
the  more  novel  and  striking  of  these  were  derived  from  a 
case  of  artificially  induced  brain  atrophy,  and  the  latter  con- 
stitutes as  it  were  the  text  of  this  article,  of  which  the  other 
results  collaterally  obtained  may  be  regarded  as  commen- 
taries, we  shall  proceed  to  describe  the  former  in  its  general 
features,  before  discussing  special  problems  in  cerebral  ana- 
tomy. 

The  animal  selected  for  operation  was  a  kitten,  one  of  a 
litter  of  six,  and  if  anything,  the  largest  and  healthiest  of 
these.  A  cataract  needle  was  rapidly  passed  through  the 
middle  altitude  of  the  lateral  aspect  of  the  skull,  behind 
the  left  mastoid  crest,  obliquely  inwards  and  downwards,  to 
the  floor  of  the  skull,  and  then  after  a  quick  lateral  motion, 
withdrawn.  The  time  occupied  by  the  operation,  was  at 
most  three  seconds,  and  but  a  drop  of  blood  was  lost.  At 
the  time  of  the  operation  the  animal  was  two  days  old  and 
the  eyes  were  closed.  It  immediately  showed  manege  move- 
ments, which  were  towards  the  right  side  ;  it  walked  round 
and  round  in  a  circle  with  its  head  and  tail  appoachingeach 
other  on  that  side.     This  circle  did  not  exceed  the  length 


,-0  SPITZKA   A. YD   R.    MOLLEXHAUER. 

of  its  body,  and  consequently,  though  continually  moving — 
as  it  did  at  all  times  it  was  observed — it  did  not  get  further 
than  a  few  inches  from  any  given  spot  in  which  it  might  be 
placed.  It  being  found  that  this  imperative  motion  invariably 
defeated  all  attempts  to  obtain  nourishment — for  it  circled 
past  the  mother's  tit, — it  was  fed  by  hand,  a  task  requiring 
considerable  patience,  and  which  was  accomplished  by  one 
of  the  female  members  of  the  household.  The  date  of  the 
operation  was  June  22d.  1884.  Four  days  later  the  eyes 
opened,  that  is  a  day  later  than  those  of  the  other  kittens 
of  the  same  litter.  It  was  already  then  evident  that  it  was 
not  developing  as  well.  The  manege  movements  continued 
in  undimenished  intensity  for  two  weeks  ;  then  it  was  noted, 
that  it  occasionally  made  attempts  to  walk  straight  and 
would  even  in  attempting  to  overcome  the  manege  to  the 
right,  show  a  brief  deviation  to  the  left.  At  the  age  of  one 
month  it  walked  straight,  as  a  rule  ;  the  occasional  devia- 
tions noted  were  to  the  left,  it  often  tumbled  over  on  this 
side.  In  judging  this  phenomenon,  the  defect  of  vision 
should  be  borne  in  mind.  It  at  this  age  began  to  play  with 
the  other  kittens,  but  did  not  possess  one-third  their  range 
of  motion,  nor  anything  like  the  same  degree  of  skill.  It 
still  had  to  be  fed,  the  food  being  pushed  into  its  mouth. 
The  animal  often  assisted  this  procedure  by  pushing  its 
mouth  against  the  feeding  receptacle  so  as  to  retain  its  hold 
on  it. 

When  the  eyes  opened,  they  both  were  noticed  to  be  ab- 
ducted ;  two  weeks  later  the  right  appeared  normal  indirec- 
tion, also  showed  normal  pupillary  reactions.  To  the  end, 
the  left  eye  remained  strongly  abducted  and  there  was  com- 
plete left  iridoplegia  and  mydriasis. 

Its  gait  was  particularly  deliberate  and  slow,  as  far  as 
both  hind  extremities  were  concerned,  and  it  wabbled  from 
side  to  side  as  if  paraparetic.  In  stepping  out,  it  stretched 
its  hind-legs  overmuch.  It  is  able  to  rest  on  its  left  fore- 
paw,  raising  the  right  in  play,  but  holds  its  head  in  a  peculiar 
position,  as  if  to  look  with  the  left  (abducted)  eye  on  the 
floor.  It  evidently  has  the  use  of  this  eye,  at  least  with  a 
part  of  its  visual  field. 


RESULTS  OBTAINED  BY  THE  ATROPHY  METHOD.     ,,-, 

Cutaneous  impressions  appeared  to  be  correctly  localized, 
as  far  as  reflex  acts  enabled  us  to  determine.  Except  in  so 
far  as  it  was  invalidated  by  defective  nutrition,  its  muscular 
clumsiness  and  defective  fields  ofvision.it  appeared  to  have 
no  defect  of  intelligence.  It  was  exceedingly  good-natured 
and  far  from  being  lethargic  at  this  time.  Some  of  the  in- 
cidents noted  in  its  subsequent  career,  are  herewith  de- 
tailed. 

August  29th.  Tried  to  get  on  the  cross-piece  of  a  chair 
in  vain  for  over  a  quarter  of  an  hour.  The  mother  then 
called  her  kittens  round  her  on  a  sofa.  The  others  jumped 
up  immediately — but  the  operated  one  after  repeated  fail- 
ures was  assisted  by  the  little  boy  who  had  it  in  charge. 
When  there  it  played  with  its  mother.  The  other  kittens 
evidently  recognized  its  helplessness,  and  refrained  from 
the  rougher  play  which  they  indulged  in  with  each  other. 
In  its  manoeuvres  the  defective  one  was  often  non-plussed, 
particularly  in  jumping  at  its  antagonist,  when,  it  either  fell 
short  or  struck  to  one  side,  but  it  repeated  the  attempt  again 
and  again,  evidently  enjoying  the  sport  as  much  as  the  un- 
injured ones. 

September  5th.  The  animal  has  become  more  dull.  It 
has  retained  the  hair  it  was  born  with,  not  changing  the  fur 
as  the  healthy  ones  have  done.  It  measures  not  fully  two- 
thirds  their  average  length,  and  does  not  equal  one  third  (!) 
their  average  weight.  Its  head  appears  of  the  normal  size, 
a  slight  narrowing  at  the  temporal  region  is  noted.  The 
boy  who  had  it  in  charge  alone  was  capable  of  provoking  it 
to  action,  when  I  exhibited  it  to  my  class.  This  he  accom- 
plished by  imitating  a  fighting  cat,  it  then  ran  towards  him, 
bounding  along  in  a  line  to  the  left,  and  "over-reaching" 
in  raising  the  hind-quarters  ;  being  further  provoked  by  the 
boy's  imitation  of  a  mewing  and  spitting  cat,  it  mewed  and 
spit  in  return. 

This  kitten  was  killed  exactly  ninety  days  after  the  oper- 
ation, having  become  gradually  more  and  more  indifferent 
and  passive.  On  examining  the  calvarium,  it  was  seen  that 
the  sagittal  suture,  corresponded  to  the  sulcus,  separating; 
the  ectal  gyrus  from  its  fellow  on  the  right  cerebral  hemis- 


^5-2  SPITZKA   AXD  MOLLENHAUER. 

phere.  In  other  words  the  right  cerebral  hemisphere  pro- 
truded across  the  median  line  with  a  considerable  portion  of 
its  mass.  *  On  opening  the  skull  cavity,  it  was  found,  that 
the  right  cerebral  hemisphere  occupied  nearly  the  whole  of 
it,  there  being  but  a  shrunken  membraneous  sac  to  represent 
its  fellow,  only  the  olfactory  lobe  as  well  as  the  adjoining 
region,  in  the  anterior  perforated  space,  exhibited  something 
by  which  the  normal  elements  could  be  identified. 

There  was  no  trace  of  any  active  morbid  process  any- 
where. There  was  a  glairy  rust-colored  material  in  the 
antero-inferior  part  of  the  cranial  cavity,  it  was  connected 
with  a  trabeculated  membrane,  which  evidently  represented 
the  residue  of  atrophied  cortex  fused  with  the  leptomeninges. 
Possibly  there  had  been  a  hemorrhage,  but  no  distinct  traces 
of  such  were  found.  Behind  the  larger  cyst  representing 
the  left  cerebral  hemisphere,  were  smaller  ones,  included  in 
a  common  investment  which  at  the  base  of  the  brain  merged 
with  the  shrunken  crus  of  that  side.  These  cysts  corres- 
ponded to  the  left  thalamus,  which,  as  far  as  its  nervous 
tissue  is  concerned  had  been  almost  entirely  eliminated. 
Nothing  beyond  a  ridge  like  thickening  of  the  cyst  wall  at 
the  region  of  the  habena  gave  the  slightest  indication  of 
the  normal  components  of  the  thalamencephalon.  The 
left  optic  lobe  t  was  shortened  in  the  cephalo-caudal  direc- 
tion to  one-half  and  in  the  transverse  direction.to  two-thirds 
of  its  fellow  ;  it  was  very  flat,  while  the  right  was  beauti- 
fully prominent,  and  encroached  to  the  extent  of  fully  one- 
third  of  its  own  diameter,  beyond  the  ideal  plane  of  the 
axis.  The  dividing  line  between  the  optic  lobes  corres- 
ponded to  the  mesal  margin  of  the  right  cerebral  hemis- 
phere. 

There  was  no  gross  asymmetry  of  the  cerebellum.  At 
first,  owing  the  distortion  of  the  cerebral  axis,  it  seemed  as 
if  the  right  lobe  were  slightly  less  voluminous  than  the  left. 
The  subsequent  study  by  sections  showed  that  this   asym- 

°  The  various  measurements,  made  and  recorded  are  omitted,  except  where 
they  are  of  intrinsic  interest 

f  Anterior  Pair  of  the  Corpora  Quadirgemina. 


RESCL  TS  OB  TAINED  B  Y  THE  A  TROPHY  ME  THOD.      -,c-i 

metry  was  apparent  and  not  real  in  regard  to  bulk.  What 
the  right  lobe  lacked  in  width,  it  preponderated  in,  in  regard 
to  depth  and  fulness. 

The  distortion  of  the  brain  axis  can  be  best  pictured  by 
a  glance  at  the  accompanying  plate,  (Figure  i).  Beginning 
at  the  ethmoidal  crest  it  ran  obliquely  caudad  and  to  the 
right,  in  a  rather  direct  line  to  the  posterior  border  of  the 
pons.  Here  it  changed  in  direction  sharply,  the  ventral 
furrow  of  the  oblongata  coinciding  in  direction  with  that  of 
the  cord.  This  asymmetry  corresponded  with  that  of  the 
skull,  the  right  half  of  which  in  front  of  the  clivus  greatly 
preponderated  over  the  left,  which  was  reduced  in  the  three 
dimensions. 

The  optic  nerves  were  both  smaller  than  normal,  the 
left  was  reduced  to  two-thirds  the  section-area  of  a  corres- 
ponding healthy  kitten,  the  right  to  about  one-half,  the  latter 
was  therefore  the  smaller.*  There  were  no  traces  of  the 
left  optic  tract  ;  the  right  appeared  normal.  The  hypo- 
physis was  symmetrical  and  normally  developed  in  all  its 
parts.  The  left  oculo-motor  nerve  was  entirely  absent,  the 
right  entirely  normal.  The  pons  was  as  a  whole  smaller 
than  in  kittens  of  a  corresponding  age,  but  as  subsequent 
examination  showed  equally  so  in  all  directions.  The  bulge 
in  the  right  side  of  the  basilar  furrow  was  marked,  in  the 
left  it  was  barely  indicated.  The  left  pyramid  was  entirely 
absent,  and  a  depression  marked  the  spot,  where  it  is  ordin- 
arily located,  the  left  olivary  eminence  consequently  become 
entirely  exposed,  whereas  the  right  was  concealed  in  its 
cephalomesal  part  by  the  developed  right  pyramid.  The 
distance  between  the  left  abducens  radicles  and  the  ventral- 
furrow  was  much  less  than  that  between  the  right  abducens 
radicles  and  that  furrow.  A  glance  at  the  two  figures  (2  and 
3)  representing  trans-sections  respectively  through  the  mid- 
dle of  the  pons,  and  the  trapezium  Shows  the  chief  results 
produced  by  the  elimination  of  the  left  thalamus  and  left 
cerebral  hemisphere.     The  corresponding  pyramid  tract  is 

°  The  Figure  does  not  show  this,  owing  to  the  different  direction  of  the 
dividing  sections.  The  measurements  were  made  near  the  entrance  of  the  nerves 
in  the  eye  ball. 


.,(.,  SPITZKA   AXD  MOLLEXHAUER. 

entirely  eliminated,  not  a  trace  of  it  can  be'  discovered.  The 
mesal  division  of  the  lemniscus  (cortex-lemniscus  of  von 
Monakew,  interolivary  layer  of  Flechsig)  is  represented  by 
atrophic  relics. 

The  same  is  to  be  said  of  that  intermediate  division 
which  is  located  between  the  mesal  and  lateral  divisions  : 
(Figure  2,  L'  on  the  right  side,  LJ  on  the  left  side).  The 
lateral  division  of  the  lemniscus  is  unaffected.  The  brach- 
ium  conjunctivum  (tegmenta-brachium,  processus  e  cerebelli 
ad  cerebrum)  as  well  as  the  pontis-brachium  also  appears  to 
be  unaffected,  or  at  least  symmetrically  developed.  The 
posterior  longitudinal  fasciculus  is  much  reduced  on  the  left, 
as  compared  with  the  right  side,  while  the  tegmentum  gener- 
ally appears  smaller  on  the  left.  A  remarkable  exception 
is  noted  in  the  field  of  large  fibres  situated  near  the  raphe. 
These  show  a  crossed  atroply,  and  our  curiosity  is  aroused, 
and  leads  us  to  search  for  a  relationship  between  them  and 
the  fibres  of  the  fountain  decussation  of  Meynert,  or  per- 
haps of  the  posterior  commissure.  The  further  caudad  we 
proceed,  the  less  markedly  do  these  various  asymmetries  in- 
fluence the  contour  of  the  trans-sections,  and  the  deeper 
topography  of  the  brain  axis. 

To  sum  up,  the  experiment  had  consisted  in  the  nicking 
of  the  left  lateral  aspect  of  the  mesencephalon,  dividing  the 
various  tracts  which  run  to  the  higher  centres,  in  a  direction 
ventro-mesad,  the  left  optic  tract,  and  the  left  oculo-motor 
nerve.  All  other  cranial  nerves,  as  well  as  the  larger  blood- 
vessels escaped.  There  then  resulted  a  passive  atrophy  of 
all  the  centres  and  tracts  directly  represented  in  the  de- 
stroyed area.  The  nuclei  of  the  left  oculo-motor  nerve,  the 
left  thalamus,  the  left  cerebral  hemisphere  and  all  tracts  di- 
rectly depending  on  the  latter  two,  were  eliminated  so  com- 
pletely, that  not  a  trace  of  their  nervous  elements  could  be 
discovered.  To  derive  useful  results  from  the  observation 
of  so  extensive  an  atrophy,  it  will  be  necessary  to  take  up 
tract  by  tract  as  influenced  by  the  operation,  and  compare 
it  with  its  condition  in  experiments  where  less  severe  muti- 
lation had  been  accomplished.  As  we  shall  find,  the  plus  of 
tract  atrophy  found  in  our  case,  as  compared  with  v.  Mona- 


RESULTS  OBTAINED  BY  THE  ATROPHY  METHOD.     355 

kow  and  Forel's  observations,  is  attributable  to  the  destruc- 
tion of  the  thalamus,  and  consequently  we  are  enabled  to 
determine  the  extent  and  course  of  certain  of  the  tegmental 

fibre-systems. 

(To  be  continued. ) 


Figure  i  Ventral  view  of  the  entire  brain.  Cleft  :  Median  longitudinal  fissure  separating 
the  two  ctrebral  hemispheres  ;  Olf,  Left  Olfactory  bult.  3.  Left  atrophic  cerebral  hemis- 
phere, the  pointer  is  on  one  of  the  obliterated  vessels  ;  Hyp  Pituitary  body  ;  Ch  Chiasm 
III.  Right  Oculo-motor  nerve,  the  leit  being  absent.  2.  Cyst  occupying  the  place  of  the 
left  Thalamus,  the  pointer  ends  at  the  spot  where  the  cyst  terminates  and  the  rudimentary 
crus  begins  ;  Pons  Pons  Varolii  V.  Lett  Trigemiaus,  as  the  nerve  is  frayed,  out,  it  appears 
smaller  than  its  fellow,  in  reality,  they  were  symmetrically  developed.  1.  Depression  cor- 
responding 10  the  eliminated  left  Pyramid  bordered  ectad  by  the  (VI)  Abducens  roots. 
Trap  1  rapezium  Pyr.    Right  Pyramid  ;  Ol  Lett  Olive  entirely  uncovered. 

Figure  2.  Trans-section  of  Pons.  Ph.  Brachium  Pontis  (medipedunculus)  I.  Right  inter- 
olivary  layer.  Id.  Leit  ditto,  atrophied  :  Pyr.  Right  Pyramid  tract.  L1  L2  various  divi- 
sions of  Right  and  normal  lemniscus.  L2d.  Left  atrophied  representation  of  the  middle 
division.  Tgb.  Tegmentabiachium  (Bindearm  or  prepedunculus) ;  5d.  Descending  radicle 
of  Fifth  Pair  ;  h  crossed  tegn  ental  field. 

Figure  3.  Trans-secti ->n  of  Trapezium  VIII.  Auditory  radicle.  L  part  of  Lemniscus,  accu- 
mulating ectad  ot  trapezial  iridus  (so-called  superior  olive)  ret  Reticular  Field,  r  Restiform 
column  ;  5  Ascending  Radicle  of  Fifth  Pair,  m  fibres,  which  in  more  cephalic  levels  become 
the  lateral  division  of  the  Lemniscus,  designated  L  1  in  Figure  2  ;  7  germ  facialis  ;  Pyr 
Pyramid  Tract  of  Right  Side  :  L.  Right  interolivary  field,  extent  indicated  by  pointers  Id 
atrophic  Left  interolivary  field. 


PARALYSIS   AGITAXS,  AND  A   CONSIDERATION 
OF  SOME  CASES  OF  THIS  DISEASE. 

By  LEONARD  WEBER,  M.D. 
Read  before  the  New  York  Neurological  Society,  May  ist,  1888. 

FOR  the  first  regular  description  of  paralysis  agitans  we 
are  indebted  to  Parkinson,  18 17.  Charcot  was  the 
first,  I  believe,  to  draw  the  line  of  distinction  between 
paralysis  agitans  and  disseminated  sclerosis,  showing  that 
in  the  former  the  tremor  is  present  while  the  muscles  are 
in  a  state  of  rest,  and  that  there  is  no  spastic  paralysis, 
although  the  progressive  motor  weakness  may  even  amount 
to  paresis  ;  while  in  the  latter  there  is  tremor,  only  con- 
secutive to  motions  which  the  patient  wants  to  execute, 
and  more  or  less  spastic  paralysis. 

Paralysis  agitans  is,  then,  a  complexity  of  symptoms,  in 
which  progressive  tremor  and  motor  weakness  are  most 
prominent.  It  is  a  neurosis  in  the  sense  that  we  cannot 
characterize  it  by  a  special  lesion  of  its  own  in  the  brain  or 
spine,  or  both,  and  it  belongs  to  the  second  period  of  life. 

General  Symptomatology. — The  tremor  is  at  first  limited 
to  a  single  limb,  gradually  spreading  to  others,  and  over- 
running the  entire  body,  always  respecting  the  head,  I  be- 
lieve. Sooner  or  later  we  notice  an  apparent  diminution  of 
muscular  force,  the  movements  are  slow  and  appear  enfee- 
bled, though  no  actual  diminution  of  force  may  be  demon- 
strated by  the  dynamometer.  This  motor  weakness  appears 
to  be  dependent  in  part  upon  a  certain  rigidity  of  the  mus- 
cles. Among  the  curious  symptoms,  and  sometimes  even 
in  the  early  stages  of  the  disease,  there  is  to  be  noted  a  loss 
of  the  faculty  of  maintaining  the  equilibrium  in  walking. 
When  the  patient  starts,  he  runs  ;   he   is    propelled  forward. 


PARALYSIS  AGITANS.  ,-7 

In  some  cases,  by  tugging  at  the  patient's  clothes  on  the 
back,  he  can  be  made  to  run  backward  with  a  rapidly  pro- 
pelling motion,  the  same  as  he  follows  on  attempting  to  go 
forward.  This  curious  way  of  propelling  himself,  as  if  he 
had  to  run  after  his  lost  centre  of  gravitation,  may  be  due 
to  certain  lesions  in  the  cerebrum,  but  certainly  also  to  the 
peculiar  forward  bent  position  which  the  patient  generally 
maintains.  This  half  bent  and  half  contracted  attitude  of 
the  body  and  limbs  is  peculiar  and  rather  characteristic, 
and  so  also  is  the  fixed  stare  and  the  immobility  of  the 
facial  expression  in  the  later  stages  of  the  disease. 

Paralysis  agitans  is  slowly  progressive,  of  long  duration, 
even  up  to  thirty  years.  One  of  my  own  patients  has  had 
it  for  twenty-four  years,  and  is  still  among  the  living.  Death 
may  be  brought  about  by  marasmus,  bed-sores,  and  other 
complications,  or  an  intercurrent  disease. 

Varieties. —  I.  In  a  great  majority  of  cases,  paralysis 
agitans  has  an  insidious  and  rather  benign  beginning,  the 
tremor  being  limited  to  one  foot  or  hand,  or  even  thumb; 
may  remain  so  for  a  long  time,  having  rather  an  innocent 
appearance.  The  oscillations  of  the  different  segments  of 
the  hand,  for  instance,  toward  each  other  are  almost  patho- 
gnomonic. The  fingers  move  and  rub  toward  the  thumb,  the 
wrist  toward  the  forearm,  and  that  toward  the  arm.  At 
this  period  the  tremor  may  be  going  and  coming,  some- 
times remaining  away  for  many  months.  The  usual  prog- 
ress of  the  tremor  is  from  the  upper  to  the  lower  extremity 
on  one  side,  then  the  same  way  on  the  other  side.  The 
cross  form,  according  to  Charcot,  is  rare,  and  the  above 
hemiplegic  form,  if  you  please,  much  more  common  than  the 
paraplegic  form.  The  muscles  of  the  head  do  not  participate 
even  in  the  most  intense  form  of  paralysis  agitans — an  import- 
ant differential  point  from  disseminated  sclerosis,  where  the 
contrary  is  observed.  There  is  an  observation  of  Charcot 
which  may  be  noted  right  here.  He  says  that  the  tremor  is 
not  always'  the  first  phenomenon  in  the  disease  ;  that  it  may 
be  preceded  by  a  period  of  intense  feeling  of  fatigue  and 
neuralgic  and  rheumatoid  pains  in  the  limb  which  will  be 
the  seat  of  the   tremor    later   on.     Charcot's   cases  of  this 


-,-£  LEOXARD  WEBER. 

kind,  as  well  as  one  of  Romberg,  have  been  of  traumatic 
origin. 

But  the  tremor  may  also  come  on  suddenly  after  severe 
moral  emotions  or  a  great  fright,  attacking  either  one  limb 
or  all  at  once.  After  some  days  or  weeks,  there  may  be 
temporary  or  even  permanent  cessation  of  the  trouble,  but 
more  often  the  disease  takes  a  definite  hold  after  a  series  of 
exacerbations  and  remissions. 

In  the  further  developed  stage  of  the  disease  the  tremor 
is  of  varying  intensity,  but  incessant;  the  convulsive  move- 
ments ceasing  however,  during  natural  sleep  or  that  pro- 
duced by  anaesthetics.  The  facial  muscles  are  almost 
immovable,  the  face  itself  wearing  an  expression  of  sadness 
or  dullness.  The  speech  is  rather  slow,  sometimes  even 
saccade.  The  patient  prefers  using  short  words  and  sen- 
tences, as  if  speech  was  too  great  an  exertion  for  him.  De- 
glutition and  respiration  are  not  interfered  with,  although 
some  complain  of  a  sense  of  oppression  about  the  chest. 
The  bladder  and  rectum  are  seldom  affected  ;  but  in  the 
case  of  Mrs.  T.  there  was  vesical  paresis  and  obstinate  con- 
stipation of  the  bowels  for  two  or  three  years  before  she 
died.  There  is  a  good  deal  of  muscular  rigidity,  particu- 
larly in  the  flexor  muscles  of  the  upper  and  lower  extremi- 
ties, also  in  the  muscles  of  the  neck.  The  cramps  and 
neuralgic  pains  are  frequent,  and  often  very  annoying  to 
the  patient ;  but  there  are  no  permanent  contractures.  The 
hands,  however,  often  show  an  attitude  quite  similar  to  the 
deformity  seen  in  the  various  stages  of  arthritis  deformans. 

As  to  the  urine  of  patients  suffering  from  this  disease, 
Topinard  has  seen  glycosuria  in  one  case,  and  so  have  I  in 
the  case  of  Mr.  O.  There  is  sluggishness  of  thought  and 
action.  The  patient  generally  rises  slowly,  and  hesitates  a 
few  seconds  before  he  propels  himself  forward,  and  vertigo 
often  attacks  him  in  the  attempt  at  doing  so.  (The  cases  of 
Mr.  M.  and  Mr.  O.  '-how  this  symptom  well  marked.) 

ides  the  neuralgic  pains,  there  is  a  feeling  of  tension 
and  of  traction  in  the  muscles,  and  of  great  fatigue  and 
prostration  ;  also  a  desire  to  frequently  change  position, 
particularly  after  the  patient  has  gone   to  bed.     This  latter 


PARALYSIS  AG1TANS.  -cq 

symptom  is  due  to  cutaneous  hyperesthesia  as  well  as  mus- 
cular pains,  and  also  to  a  disagreable  sensation  of  excessive 
heat  which  some  patients  complain  of,  Mrs.  T.  among  my 
patients.  But  this  feeling  of  heat  is  subjective  only,  for 
dynamic  convulsive  movements  do  not  affect  the  tempera- 
ture of  the  body.  The  transmission  of  cutaneous  sensations, 
likewise  the  sense  of  touch,  etc.,  is  generally  normal. 

In  some  cases  there  is  marked  melancholia,  hallucina- 
tions, and  even  maniacal  disturbances  have  been  noted.  I 
have  not  seen  any  such  symptoms. 

In  the  terminal  stage  of  the  disease  there  is  an  increased 
difficulty  of  motion,  fatty  degeneration  of  muscles,  defective 
general  nutrition,  decrease  of  intellect  and  loss  of  memory. 
Bed-sores  occur  frequently,  and  the  disease  terminates  by 
general  marasmus  or  through  some  intercurrent  affection, 
like  pneumonia. 

Visceral  lesions,  such  as  occur  in  tabes  or  sclerosis,  have 
not  been  demonstrated  in  any  cases  of  paralysis  agitans. 

Pathological  Anatomy. — The  true  pathological  anatomy 
of  paralysis  agitans  has  yet  to  be  found.  In  looking  over 
the  reports  of  autopsies  we  find  cases  in  which  none  or  very 
trifling  changes  were  present  in  the  central  nervous  system 
(such  are  the  cases  of  Ollivier,  T.  H.  Saloman,  Kiihne, 
Jeffroy-Charcot) ;  others  with  lesions  of  softening  or  lesions 
•of  sclerosis  in  the  spinal  cord  only  (cases  of  Lebert,  Cohn, 
and  Murchison),  or  the  brain  only  (cases  of  Marshall  Hall, 
Cohn,  Rosenthal,  Leyden,  and  Chvosteck),  and  still  others 
with  extensive  changes  in  the  brain  and  cord  (cases  of 
Parkinson,  Opolzer,  Skoda,  Meschede). 

With  such  contradictory  post-mortem  results  it  will 
require  the  utmost  caution  to  advance  a  theory  of  the 
pathology  of  this  disease  ;  nor  is  it  even  possible  yet  to 
determine  whether  it  is  of  cerebral  or  spinal,  or  of  combined 
origin.  To  be  sure,  the  pathognomonic  tremor  would  be 
apt  to  point  to  lesions  in  the  spinal  cord.  From  the  fact 
that  there  are  some  patients  afflicted  with  this  disease  who 
present  the  symptom  of  falling  forward  on  attempting  to 
rise  or  to  walk,  and  others  who  do  not,  Remak  was  led  to 
distinguish  a  cerebral  and  a  spinal  form  of  paralysis  agitans, 


->6o  LEONARD    WEBER. 

according  to  the  presence  or  absence  of  that  symptom. 
Such  differential  diagnosis  would  strike  one  as  somewhat 
arbitrary,  but  the  cases  of  Mr.  M.  and  Mrs.  T.  among  my 
own  would  show  a  preponderance  of  the  cerebral  symp- 
toms, while  the  conditions  of  Mr.  O.  and  Mr.  H.  are  such  as 
to  make  me  believe  that  the  spinal  cord  is  more  or  less 
exclusively  affected  in  them.  The  cases  of  Cohn  and 
Stoffele  in  which  senile  atrophy  of  the  brain  was  found 
must  be  excluded  from  consideration,  for  the  reason  that 
senile  atrophy  of  the  brain  occurs  also  without  any  symp- 
toms of  paralysis  agitans. 

The  focal  lesions  thus  far  described  have  been  variable : 
the  thalamus,  probably  the  most  important,  the  pons,  and 
the  medulla  oblongata  have  been  found  in  a  sclerotic  or 
softened  condition,  but  the  variability  of  the  seat  of  the 
lesions  bars  out  positive  conclusions. 

Topinard's  case  with  glycosuria  and  Mr.  O.'s  case  among 
my  own  might  add  some  value  to  the  supposition  that  the 
medulla  oblongata  is  frequently  the  seat  of  disease  in  paral- 
ysis agitans,  if  it  were  nbt  for  other  autopsies  in  the  same 
disease  where  the  medulla  oblongata  was  found  entirely 
normal.  There  is  finally  a  case  reported  by  Larcher  of 
isolated  sclerosis  of  the  pons  with  a  course  of  symptoms 
during  life  not  at  all  like  those  of  paralysis  agitans.  Not  a 
few  cases  in  which  sclerotic  conditions  in  the  brain  and 
cord,  or  both,  were  found  have  been  put  on  record  as  cases 
of  paralysis  agitans  by  older  writers,  but  were  without 
doubt  cases  of  disseminated  sclerosis. 

Etiology. — Men  are  more  liable  to  get  the  disease  than 
women,  and  it  occurs  also  more  among  the  lower  strata  of 
society.  It  is  by  no  means  a  frequent  disease.  It  belongs 
to  the  later  period  of  life,  although  Meschede  reports  one 
case  of  paralysis  agitans  in  a  boy  only  twelve  years  old, 
developing  soon  after  he  was  kicked  in  the  face  by  a  horse, 
and  Duchenne  that  of  a  young  man  of  twenty.  Sander  and 
other  writers  make  the  statement  that  it  is  more  frequent  in 
England  and  America  than  elsewhere,  but  I  do  not  know 
how  much  value  may  be  attached  to  this  assertion.  Among 
the  twelve  cases  that  I  have  observed  there  are  only  two 


PARALYSIS  AGITANS.  36  I 

Americans,  but  I  have  to  take  into  consideration  that  my 
clientel  is  largely  German  or  of  direct  German  descent 
(probably  three-fourths,  and  only  one-fourth  American). 

Powerful  emotional  and  moral  influences,  the  action  of 
prolonged  damp  cold,  irritation  and  injury  of  peripheral 
nerves  by  traumatism,  are  mentioned  among  the  chief 
causes  by  the  different  authors.  I  am  inclined  to  believe 
that  sexual  excess  may  be  considered  as  an  etiological 
factor  in  some  cases,  and  suspect  it  to  be  so  in  the  cases  of 
Mr.  S.  and  Mr.  H.  I  am  glad  to  say  that  I  have  not  read 
nor  observed  myself  that  syphilis  for  once  has  anything 
to  do  with  the  production  of  this  disease  as  it  does  in  so 
many  other  chronic  ailments.  The  hereditary  element  does 
not  seem  to  play  any  role  here,  although  I  must  not  forget 
to  mention  that  in  the  case  of  J.  S.,  his  father  and  two 
brothers  have  been  afflicted  with  the  disease,  and  in  that  of 
L.  H.  one  brother  is  also  affected. 

Treatment. — With  a  view  of  arresting  or  even  retarding 
the  progress  of  the  disease,  I  have  for  some  years  tried 
principally  arsenic,  ergot,  and  nitrate  of  silver,  and  given 
them  thoroughly  and  persistently,  but  the  results  having 
been  entirely  negative,  I  have  for  many  years  made  no 
further  attempts  in  the  direction  of  so-called  curative  drugs. 
I  have,  however,  always  refrained  from  giving  the  patient 
an  absolutely  unfavorable  prognosis  of  his  case,  for  though 
we  know  the  prognosis  in  fully  developed  cases  to  be 
always  fatal,  it  has  been  my  experience  that  putting 
forth  such  prognosis  as  a  matter  of  fact  to  the  afflicted 
almost  always  had  a  bad  influence  upon  the  progress  of  the 
disease.  To  be  sure,  nothing  can  be  done  to  save  the 
patient,  but  a  great  deal  has  to  be  done  to  alleviate  his  suf- 
ferings and  give  him  such  comlort  as  every  poor  sufferer  is 
entitled  to. 

In  some  of  my  cases  I  have  succeeded  with  Brown- 
Sequard's  mixture  of  the  bromides  (the  iodide  of  potassium 
being  left  out)  in  diminishing  the  tremor,  allaying  restless- 
ness, and  relieving  neuralgias  and  cramps.  The  opiates 
generally  act  badly,  and  ought  not  to  be  given.  Hyoscy- 
amin  is  now  being  used  by  most  observers,  I  believe  ;   but 


^6  2  LEONARD    WEBER. 

having  found  its  continued  use  somewhat  dangerous,  I  have 
not  operated  with  itmuch  in  this  disease.  In  the  caseof  Mr.O., 
antipyrin,  twenty  grains  given  at  bedtime,  helped  for  a  time 
to  procure  better  nights  for  him  ;  and  so  did  chloral  hydrate 
with  bromide  of  potash  in  his  case  and  that  of  Mrs.  T.;  but 
the  action  of  all  these  remedies  has  been  quite  transitory 
and  much  inferior  to  another  preparation  which  I  have 
tried  during  the  last  eighteen  months,  and  particularly  in 
the  cases  of  Mr.  O.  and  Mrs.  T.,  and  that  is  paraldehyde. 
I  have  used  Merck's  preparation  exclusively,  and  given  from 
fifteen  to  thirty  grains,  made  with  gum  acacia  and  ginger 
syrup  into  an  emulsion,  at  bedtime  for  many  days  in  suc- 
cession. It  is  an  excellent  hypnotic,  it  assuages  pain,  and 
has  done  more  to  relieve  the  paresthesias,  restlessness,  and 
distress  at  night  in  the  cases  of  Mr.  O.  and  Mrs.  T.  than  any 
other  remedy  given  before.  It  is  perfectly  safe,  it  does  not 
molest  the  stomach,  although  its  taste  is  not  agreeable  ;  it 
does  not  weaken  the  heart,  it  does  not  cause  any  collapse 
or  other  unpleasant  symptoms,  and  it  does  not  lose  in  its 
efficiency  when  continued  for  any  length  of  time. 

The  galvanic  current  applied  to  the  head  and  spine  I 
have  found  of  some  value  in  some  cases  as  to  relieving  the 
feeling  of  fatigue  and  prostration  to  some  extent,  also  alle- 
viating neuralgia  and  vertigo  ;  but,  on  the  whole,  it  has 
neither  curative  nor  great  palliative  effects.  The  tepid  half 
bath  with  cold  affusions  given  two  or  three  times  a  week  acts 
in  a  similar  way,  but  with  more  certainty  and  promptness  than 
the  galvanic  current.  In  the  early  stages  of  the  disease  a 
course  of  sea-bathing,  with  all  the  necessary  precautions,  to 
be  followed  every  year,  would  seem  to  be  a  reasonable  and 
promising  remedy. 

Whatever  remedy  may  be  selected  by  the  physician  to 
relieve  his  patient's  sufferings  with,  he  must  also  bear  in 
mind  that  paralysis  agitans  is  debilitating  and  mostly  con- 
cerns debilitated  persons,  and  that  nutritious  food,  stimu- 
lants and  tonics  are  essential  adjuvants  to  any  special  form 
of  treatment. 

About  a  dozen  cases  of  paralysis  agitans  have  come  un- 
der my  notice  in  private  practice  ;  five  of  them  I  have   had 


PARALYSIS  AGITANS.  ^» 

under  my  charge  long  enough  to  study  what  there  was  of 
interest  in  them  to  me,  and  I  have  referred  to  them  in  this 
paper  from  time  to  time. 

i.  C.  M ,  now  about  seventy  years  old,  Amer.  mech., 

began  with  the  usual  tremor  symptoms  of  upper  and  then 
lower  extremities  about  twenty-four  years  ago.  When  I 
saw  him  first,  about  fifteen  years  ago,  the  cerebral  symp- 
toms of  forward  falling,  associated  with  depression  of  spir- 
its, diminution  of  mental  powers,  etc.,  were  already  marked, 
and  his  sleep  badly  disturbed  by  sensation  of  heat  and 
cutaneous  hyperesthesia.  He  still  lives,  though  quite  un- 
able to  get  about  now,  even  with  support.  The  prolonged 
influence  of  damp  cold  in  his  office  was  the  only  element  of 
importance  which  I  could  find  in  the  etiology  of  the  case. 

2.  Mrs.  L.  T came  under  my  care  in  1884.     She  was 

then  about  seventy  years,  a  woman  of  fine  intellect  and  vast 
knowledge  of  men  and  things.  To  know  and  talk  to  her 
was  a  bit  of  education.  She  gave  a  very  clear  history  of 
the  origin  of  the  tremor  symptom,  which  came  on  in  'yS, 
very  soon  after  receiving  the  news  of  the  fatal  ilness  of  the 
daughter  she  loved  most.  The  disease  having  been  upon 
her  for  six  years,  all  the  limbs  were  affected,  her  facial  ex- 
pression of  marked  sadness,  and  immobility  of  features ; 
paresis  of  bladder,  constipation,  and  increasing  motory 
weakness,  particularly  of  lower  extremities,  well  marked, 
but  no  spastic  paralysis  and  no  contractures  were  present. 
While  she  suffered  but  little  from  neuralgias,  and  could  sit 
with  comfort  in  her  easy  chair  during  the  day,  her  sleep 
was  often  disturbed  by  the  peculiar  restlessness  common  to 
all  advanced  cases  ;  the  sensation  of  heat  and  the  frequent 
desire  to  have  her  position  changed  ;  vertigo  frequently 
present.  A  tropho-neurotic  symptom,  which  has  not  come 
under  my  observation  in  any  other  case,  was  present  during 
the  last  three  years  of  Mrs.  T.'s  life  ;  an  atrophy  of  the 
epiderma  of  both  hands  and  forearms  and  feet  and  legs  re- 
ducing it  to  the  thinness  of  tissue  paper  and  such  trans- 
parency that  the  apparently  hyperaemic  cutis  could  be 
readily  distinguished  as  a  bright  red  membrane.  The 
motor  weakness  of  lower  extremities  developed  to  para- 


-,£4  LEOXARD  WEBER. 

paresis  during  the  last  six  years  of  her  life,  and  death  oc- 
curred in  consequence  of  pneumonia,  in  September,  1887. 
Her  nightly  sufferings  were  much  relieved  by  paraldehyde. 

3.  Mr.   H.  O ,    aet.    fifty-three,    German,    inkeeper, 

has  been  much  addicted  to  drinking  and  smoking,  denies 
having  had  syphilis,  but  gives  an  uncertain  history  of  rheu- 
matism. He  has  the  well-marked  symptoms  of  the  disease 
for  seven  years,  is  now  in  the  fully  developed  stage  of  it, 
and  also  has  glycosuria  with  considerably  increased  diuresis. 
How  long  he  may  have  had  this,  I  do  not  know  ;  however, 
neither  by  it  nor  the  plague  of  paralysis  agitans  has  his 
original  weight  of  320  pounds  been  reduced  to  less  than  280 
pounds,  his  present  weight.  This  patient  suffers  more  from 
pains  in  the  cutaneous  branches  of  both  sciatic  and  other 
neuralgias  than  any  other  of  my  cases,  and  neither  by  chlo- 
ral, nor  the  bromides,  nor  hyoscyamin,  have  his  nights  been 
made  comfortable  in  any  way,  until  at  last  paraldehyde,  in 
3ss.  doses  at  bedtime,  appears  to  be  of  good  service.  Well- 
marked  in  his  case  are  muscular  rigidity  in  various  parts 
and  troublesome  oedema  of  legs.  He  has  been  seen  by 
various  specialists  of  this  city,  also  by  my  friend,  Dr. 
Dana. 

4.  Mr.  L.  H ,  set  sixty-three,  German,  market  dealer; 

a  brother  of  his  has  paralysis  agitans  also.  No  history  ex- 
cept the  rheumatic  influences  coincident  to  his  business,  and 
sexual  excess.  The  tremor  began  two  years  ago  in  right 
hand,  extending  in  the  course  of  a  year  to  arm  and  shoulder, 
and  has  affected  the  right  leg  during  the  last  six  months. 
Paresthesias,  but  no  neuralgias  present.  Vertigo  fre- 
quent.    Arsenic  seems  to  do  him  some  good. 

5.  Mr.  J.  S ,  xt.  seventy-two,  German,  butcher.     His 

father  and  two  brothers  have  the  disease.  Has  been  guilty 
of  sexual  excess  until  very  recently,  and  acquired  syphilis 
late  in  life.  His  trouble  began  three  years  ago  and  affects, 
up  to  the  present,  left  upper  and  lower  extremities  only.  He 
is,  by  the  way,  left-handed.  The  shaking  of  hand  and  arm 
becomes  exceedingly  violent  when  in  the  least  excited.  He 
has  also  had  terrible  headaches  and  vertigo,  which  may 
have  been  due  to  syphilis,  as  they  got  well  by  specific  treat- 
ment.    His  sleep  is  good  as  yet. 


PARA  L  YSIS  A  GITANS.  -,£,-- 

CONCLUSIONS. 

1.  In  the  pathology  of  paralysis  agitans  we  have  not 
come  much  further  than  at  the  time  when  Parkinson  first 
described  the  same. 

2.  The  progressive  tremor,  while  the  patient  is  awake 
and  the  muscles  are  passive,  and  the  progressive  motor 
weakness,  are  as  yet  the  pathognomic  symptoms,  while  the 
absence  of  both  the  intention-tremor  and  the  contractures 
of  spastic  paralysis  distinguishes  it  from  disseminated  scler- 
osis. 

3.  In  the  etiology  of  two  of  my  cases  an  hereditary  ele- 
ment can  be  proved  ;  but  emotional  influences  and  long  ex- 
posure to  damp  cold  appear  to  be  the  most  potent  excitors 
of  the  disease. 

4.  In  the  fully  developed  stage  of  paralysis  agitans 
the  patients  often  suffer  greatly  by  neuralgias  and  other- 
wise, and  need  our  help  as  much  as  those  who  may  be 
afflicted  with  more  malignant  disease.  Opiates  afford  no 
relief,  and  are  contra-indicated  according  to  common  ex- 
perience. Hyoscyamin  combined  with  tonics  is  praised 
highly  by  many  authors.  Antipyrin  in  15  to  20  gr.  doses, 
and  particularly  paraldehyde  in  3SS-  doses  at  bedtime,  have 
proved  quite  efficacious  in  my  hands  to  alleviate  part  of  the 
sufferings  of  these  invalids. 

25  West  46TH  St.,  N.  Y. 


PARANOIA:    SYSTEMATIZED    DELUSIONS  AND 
MENTAL  DEGENERATIONS. 

AX     HISTORICAL   AND   CRITICAL    REVIEW, 
By  J.  SEGLAS, 

ASSISTANT   PHYSICIAN   TO   THE    HOSPITAL   OF    BICETRE,    PARIS. 

Translated  by  William  Noyf.s,  M.D., 

ASSISTANT    PHYSICIAN    TO    THE    BLOOMINCDALE   ASYLUM,  NEW    YORK. 

[Continued  from  last  Number.] 

V. 

IN  France,  since  the  works  of  Morel,  we  meet  with  this 
subject  only  in  isolated  memoirs,  describing  the  forms  of 
insanity  which,  in  spite  of  their  different  names,  seem  to 
us  to  correspond  to  certain  varieties  of  paranoia  that  we 
have  passed  in  review. 

We  must  notice  principally  in  this  connection  the  work 
M.  Ach.  Foville  upon  insanity  with  a  predominance  of  the 
delusion  of  grandeur  (1871);  then  that  upon  the  delusion  of 
persecution  by  Legrand  du  Saulle  (1873),  an  amplification 
of  the  memoir  of  Lesegue  upon  the  same  subject.  This 
delusion,  as  we  have  seen,  is  a  type  of  paranoia. 

The  thesis  of  P.  Gamier*  (1877)  on  the  same  subject 
should  also  be  remembered. 

In  [876  M.  Taguett  described  the  insane  persecutors, 
which  he  separated  from  the  group  of  persecuted.  This 
form  of  insanity  also  enters  into  the  domain  of  paranoia,  for 
it  corresponds  to  the  quernlanten  Waltnsinn  of  the  Germans, 

*  1'.  E.  Garnier. — Des  idees  de  grandeur  dans  le  delirium  des  persecutions. 
(These  de  Paris,  1887.) 

t  Taguet. — Les  Alients  persecuteurs.     {Am.  mid.  psych.,  lSjb.) 


PARANOIA.  ^5y 

and  to  the  querclcnti  and  litiganti  of  the  Italians,*  and  Ve 
have  already  seen  that  the  most  of  the  time  it  has  been  con- 
sidered as  a  form  having  a  degenerative  basis. 

This  also  appears  to  be  the  opinion  of  J.  Falret,  who 
discussed  the  question  in  1878,  and  made  the  class  of  perse- 
cutors a  form  of  the  delusion  of  persecution  developing  in 
subjects  with  an  hereditary  taint.  On  several  occasions 
since  then  he  has  returned  to  this  subject  and  has  devel- 
oped his  ideas  in  his  clinical  lessons  and  in  the  discussions 
on  hereditary  insanity  before  the  Medico-psychological 
Society  (1885-86).  We  may  also  refer  to  the  ideas  brought 
forward  in  the  thesis  of  one  of  his  pupils,  Dr.  Pottierf. 

In  1882  Cotard*  described  under  the  name  of  the  delusion 
of  negation  a  psychopathic  form  that  he  distinguishes  from 
the  delusion  of  persecution  with  which  it  might  be  con- 
founded by  the  systematization  of  the  hypochondriacal  ideas, 
and  the  ideas  of  persecution  and  grandeur.  But,  in  spite  of 
the  particular  characteristics  that  may  distinguish  the  nature 
of  these  ideas,  it  should  be  said  that  the  systematized  delu- 
sion of  negation  is  always  secondary  to  melancholic  condi- 
tions, and  most  frequently  to  anxious  states,  instead  of  being 
primary  as  in  the  delusion  of  persecution.  It  would  be  an 
example  of  the  so-called  secondary  forms  of  paranoia.  We 
have  reported  an  example  that  we  consider  typical.  § 

But  we  can  best  see,  by  comparison,  to  what  nosological 
forms  paranoia  corresponds  when  we  turn  to  the  works  of 
Magnan.il  In  fact  we  find  it  there  complete  ;  for  although 
considering   the   facts   from   another  point  of  view  Magnan 

*  We  have  translated  these  words  by  quarrelling  insanity  ( iolie  de  la  chi- 
cane), although  they  express  more  the  idea  of  complaint.  On  this  subject  see 
also  Liebmann — Ucber  querulanten  Wahnsinn  (Allg.  Zeitsch.f.  Psych.,  Bd.  xxxv., 
p.  395)  ;  Brosius  —  Leber  querulanten  Wahnsinn  (Allg.  Zeitsch.  f.  Psych.,  Bd. 
xxxii.,  p.  770). 

j  Pottier. — Etude  sur  les  aliened persecuteurs  (Thesis,  Paris,  1886). 

JCotard. — Le  delire  des  negations  (Arch,  de  neurolog.,  1882). 

§  J.  Seglas. — .Vote  sur  un  cas  de  melancholie  anxieuse  (diiirt  des  negations). 
(Arch,  de  neurolog.,  7884). 

||  Magnan. — Lecons  sur  la  folie  hcreditaire,  1882-18X3;  Les  delirants 
chroniques  et  les  de'generes  (Gaz.  des  hop  it.,  April,  1884.  De  la  folie  heredilaire 
(Journ.  des  conn,  tried,  1885,  No.  48).  Attn,  Med. -psych.,  18S5-1886;  Tribune 
medicate,  1886,  No.  954. 


-,58  7-  SEGLAS. 

has»  described  none  the  less  perfectly  the  same  forms  that 
we  have  been  examining.  Resuming  the  views  of  Morel  on 
hereditary  insanity,  he  studies  this  in  its  different  manifesta- 
tions, which  he  seeks  to  classify.  In  his  opinion  the  hered- 
itary subjects,  or  rather  the  degenerate  hereditary  subjects, 
may  be  divided  into  four  degrees  according  to  their  mental 
condition  :  first,  idiocy  ;  second,  imbecility  ;  third,  mental 
debility  ;  fourth,  the  superior  degenerates.  Now  the  mental 
condition  of  this  last  class,  with  its  anomalies  of  character 
and  of  intelligence,  corresponds  absolutely  to  what  other 
authors  (Sander,  Maudsley,  Krafft-Ebing,  Tanzi  and  Riva) 
have  described  under  the  name  of  the  psychic  constitution 
of  paranoia;  some  of  the  cases  would  even  be  examples  of 
the  so-called  indifferent  or  indeterminate  paranoia,  or  para- 
noia without  delusion.  And  in  all  these  cases  there  is  the 
soil  favorable  for  the  development  of  primary  systematized 
insanity,  and  that  even  certain  authors,  admitting  only  the 
degenerative  forms,  regard  as  indispensable,  the  delusion 
being  only  the  exaggeration  of  the  particular  character  of 
these  patients. 

Among  the  superior  degenerates  Magnan  makes  the 
synthesis  of  a  certain  number  of  particular  states  that  he 
designates  under  the  name  of  episodical  syndromes.  These 
conditions,  characterized  by  obstinancy  and  impulses,  with 
mental  anguish  and  clearness  of  mind,  are  what  other 
alienists  have  designated  under  the  name  of  fixed  ideas, 
and  thus  represent  that  form  of  rudimentary  paranoia  that 
Arndt  first  described.  In  this  connection  we  may  mention 
that  Magnan  belongs  to  that  group  of  physicians  who  con- 
sider that  these  psychical  troubles  are  characteristic  of  a 
state  of  degeneration*  (psychic  stigmata). 

Moreover,  deliria  may  develop  in  these  syndromes,  and 
these  may  be  of  several  kinds.  Besides  the  deliria  of  the 
onset  already  noted  by   Morel,  systematized  deliria  with  a 

•  Magnan. — Lemons  sur  la  dipsomania  (Progres  medical),  1SS4.  De  P ono- 
matomania (in  collaboration  with  Charcot),  Arch.  nmr.t  1885. 

We  cannot  enter  here  into  Magnan's  doctrine  of  hereditary  insanity.  We 
refer,  for  the  details,  to  the  thesis  of  Legrain,  who  gives  in  a  very  complete  man- 
ner the  ideas  of  his  master  on  the  different  points  we  have  noticed. 


PARANOIA.  ^5q 

slow  development  may  be  met  with  ;  some  are  primary, 
that  is  to  say,  they  fix  themselves  little  by  little  without 
attracting  attention  ;  others  may  be  consecutive  to  a  deli- 
rium of  the  onset,  which  may  prolong  itself  indefinitely  ;  at 
other  times  again  they  may  be  seen  to  follow  the  simple 
delirious  tendencies  which  seem  to  be  the  prodromal  period, 
and  of  which  they  are  only  the  exaggeration.  Who  will 
not  recognize  in  this  brief  sketch  of  the  slowly  developed 
deliria  of  degenerates,  those  forms  of  delirious  paranoia 
engrafted  on  degeneracy,  as  generally  admitted,  and  of 
which   the   idiopathic  (originare)  paranoia  of  Sander  is  the 

type- 
But  in  Morel's  classification  there  is  still  another  group 
of  patients  that  seem  to  us  to  correspond  also  to  certain 
forms  of  paranoia.  These  are  the  victims  of  chronic  delirium 
(les  delirants  chroniqties).  From  the  symptomatological 
point  of  view  the  subject  of  chronic  delirium  is  only  the 
common  persecuted  patient  taken  in  the  different  halting 
places  of  his  delirium,  as  already  partly  seen  by  Morel, 
Snell,  and  others  (period  of  disquiet,  of  persecution,  of 
grandeur  and  of  dementia),  and  representing  the  synthesis 
of  certain  old  monomanias  (hypochondria,  demonomania, 
megalomania,  theomania,  etc.).  It  is  then  that  the  delirium 
presents  a  most  marked  systematization.  Now,  the  com- 
parison of  observations  on  chronic  delirium  with  those  on 
delirious  paranoia  shows  us  in  the  majority  of  cases  an 
identical  description  of  one  and  the  same  form  of  insanity. 
There  is  the  same  symptomatology,  the  same  course  (as 
shown  by  the  hallucinations,  especially  of  hearing,  the 
nature  and  evolution  of  deliria,  and  the  reactions  of  the 
patient),  just  as  other  examples  show  us  similar  symptoms, 
and  an  evolution  analagous  to  that  of  the  deliria  of  degen- 
erates of  slow  development  (peculiar  mental  condition, 
insidious  and  progressive  beginning  or  rapid  appearance, 
hallucinations  either  numerous  or  absent,  and  the  relations 
between  these  and  the  deliria). 

In  connection  with  this  subject  it  should  be  recalled  that 
with  reference  to  the  succession  of  the  delusional  ideas,  the 
different  alienists  who   have  written    on  paranoia  have  ob- 


-,-n  7.   SEGLAS. 

served  that  the  ideas  of  persecution  or  of  grandeur  may 
exist  in  the  isolated  state,  or  if  they  are  recognized  in  the 
same  individual  {mixed  paranoid)  they  are  seen  to  be  con- 
temporaneous or  to  succeed  each  other,  the  ambitious  ideas 
being  the  consequence  of  the  ideas  of  persecution.  Now, 
when  we  turn  to  Magnan*s  classification  we  shall  see  in  the 
last  case  a  succession  of  ideas  analogous  to  those  that  are 
found  in  chronic  delirium,  while  the  other  varieties  corre- 
spond to  the  deliria  of  the  degenerates. 

Finally,  as  regards  the  termination,  we  shall  find  again 
strong  analogies  between  the  forms  of  delusional  paranoia, 
and  the  deliria  of  degenerates  and  chronic  delirium.  Their 
course,  which  is  very  long,  rarely  ends  in  a  true  dementia, 
and  in  the  midst  of  the  dissociation  of  the  intellectual  facul- 
ties there  is  often  found  a  trace  of  the  old  systematized 
delusion.  This  period  of  dementia  is  rather  a  period  of 
mental  confusion. 

In  direct  opposition  to  the  authors  that  we  have  passed 
in  review,  and  who  nearly  all  unite  together  all  the  varieties 
of  paranoia  by  attributing  to  them  a  common  degenerative 
basis,  Magnan  makes  a  separate  class  of  his  subjects  of 
chronic  delirium,  and  while  admitting  that  they  are  often 
hereditary  subjects  refuses  to  make  them  degenerates. 

This  opinion  does  not  seem  to  be  held  by  Gerente,  who 
in  his  monograph  on  chronic  delirium,  says  that  this  form 
of  insanity  is  not  met  with  in  the  earlier  writers  ;  it  requires 
a  long  incubation,  two  or  three  generations  preparing  the 
ground,  and  predisposition  is  necessary.* 

The  author  even  went  further  when  he  said  with  rela- 
tion to  the  breaking  out  of  the  delirium,  that  if  he  meets 
with  some  accident  the  patient  succumbs,  "being  moreover 
from  his  birth  what  is  called  a  weakling  or  being  mentally 
enfeebled  in  the  course  of  his  life."  He  seems  to  us  again 
to  unite  the  chronic  deliria  with  certain  deliria  of  the  degen- 
erates of  Magnan,  when  he  says  that  of  these  insanities  (the 
chronic   deliria  .  those  which   have   been   most   affected    by 

°  Gerente. — Lc  a<'iire  cAronique,    son   evolution   [Thise  de   Paris,    188    |. 
■ue-s  consideration     ur  revolution  </<■  dilire  dans  la  vesanie  (Arch.  </<-  neuro- 
logy t.  vi.,  1883,  p.   i' 


PARANOIA.  .,  7  j 

direct  insane  hereditary  influence  will  show  themselves  in 
their  essentially  intermittent  delirium,  and  will  recover  or 
recover  more  easily.  There  are,  moreover,  among  the 
observations  that  he  reports  examples  of  mental  degenera- 
tion. 

Another  pupil  of  Magnan,  Legrain,*  distinctly  admits 
that  degenerates  may  be  affected  with  chronic  delirium. 
This  opinion,  which  we,  for  our  part,  shall  be  disposed  to 
share,  surprises  us  however  in  Legrain's  book,  for  in  our 
opinion  it  contradicts  the  classification  that  he  adopts,  and 
consequently  renders  useless  the  distinction  that  he  makes 
between  deliria  of  degenerates  and  chronic  delirium,  which 
would  be  only  a  form,  at  least  in  certain  cases.  In  fact, 
whatever  may  be  the  basis  on  which  it  is  admitted  that  the 
chronic  delirium  develops,  its  diagnosis  from  certain  deliria 
of  degenerates,  which  simulate  it,  even  to  being  mistaken 
for  it,  is  clinically  the   most  difficult,  not  to  say  impossible. 

Very  interesting  observations  upon  the  question  that  is 
occupying  us  are  found  in  the  work  of  Legrain,  who  studies 
all  the  forms  of  deliria  that  are  met  with  among  the  degen- 
erates, their  mental  state,  the  episodical  syndromes,  and 
the  deliria  of  the  onset  or  of  the  chronic  development.  We 
must  reproach  him,  however,  for  not  giving  us  an  historical 
review  of  the  question,  which,  if  it  has  not  been  considered 
under  this  aspect,  has  however  been  already  treated  in 
great  part. 

We  may  refer  to  an  earlier  work  of  Saury, t  who  has  also 
studied  the  mental  states  of  degenerates  and  the  episodical 
syndromes,  but  has  only  described  the  deliria  of  the  onset. 

It  remains  to  say  a  few  words  on  the  French  works  rela- 
ting to  paranoia,  and  we  will  close  this  review  by  citing  the 
work  of  Regis, %  where,  under  the  name  of  partial  insanity, 
he  reproduces  the  ideas  of  Magnan  on  chronic  delirium  ; 
and  a  lecture  of  Ball§  (1885)  upon  a  particular  form  of  dis- 
tinct ambitious  delusion,  with  ideas  of  the   same   nature  as 

0  Legrain. — Du  delire  chez  les  degeneres  (Thesis,  Faris,  188b). 
f  Saury. — Etude  clinique  sur  la  folie  hereditaire  (les  degeneres),  188  b. 
\  Regis. — Manuel practique  de  medicine  mentale.     Paris,  1885. 
§Ball. — Du  delire  ambitieux  (L'Encephale,  1885). 


„-r2  J.   SEGLAS. 

the  weak  subjects  {debiles),  those  suffering  from  circular  in- 
sanity, the  persecuted  and  the  general  paralytics,  and  which 
he  likens  to  Ach.  Foville's  insanity  with  predominance  of 
delusions  of  grandeur. 

We  have  seen,  in  fact,  that  paranoia  is  no  new  thing  in 
psychiatry,  and  we  can  recall  its  history  by  citing  the  nu- 
merous names  under  which  the  alienists  of  different  epochs 
and  different  countries  have  designated  it.  We  see,  too, 
that  born  in  France,  the  doctrine  of  primary  systematized 
delusions  has  been  especially  developed  in  Germany,  and 
since  then  in  other  countries  and  especially  in  Italy.  Per- 
haps this  study  has  even  been  pushed  to  the  point  of  ex- 
aggeration, each  one  wishing  to  add  his  particular  note,  and 
bringing  confusion  from  the  multiplication  of  forms. 

What  is  there  especially  to  emphasize  in  a  resume  of  the 
different  theories  that  we  have  sought  to  explain  ?  One 
fact  that  stands  out  prominently  from  this  historical  review 
is  that  all  authors  admit  a  form  of  primary  paranoia  en- 
grafted on  a  soil  of  degeneration,  and  the  existence  of  which 
moreover  is  indisputable  ;  but  some  admit  only  this  form 
with  its  varieties  ;  others  restrict  its  domain  more  or  less, 
and  do  not  consider  that  the  ground  of  mental  degeneration 
is  indispensable  to  the  production  of  paranoia. 

It  is,  then,  in  the  scheme  of  this  psychoneurotic  para- 
noia, that  we  meet  by  the  side  of  the  chronic  form  that 
form  of  paranoia  called  acute,  psychoneurotic,  hallucinatory, 
and  curable,  admitted  for  the  first  time  by  Westphal.  Here 
opinions  are  much  divided  ;  some  follow  the  ideas  of  West- 
phal, as,  for  example,  Meynert,  Fristh,  Mendel,  Tiling, 
Amadei  and  Tonnini,  etc.  Others  completely  deny  its 
existence,  or  at  least  do  not  describe  it  as  a  form  of  para- 
noia :  these  are  Krafft-Ebing,  Pelman,  Mayser,  Morselli, 
Tanzi  and  Riva,  etc.  For  ourselves,  we  are  fully  inclined 
to  adopt  this  latter  opinion.  The  study  of  the  observations 
on  acute  paranoia  that  we  have  met  with  in  the  course  of 
our  reading,  has  failed  to  show  a  single  pathognomonic 
symptom  which  could  in  any  way  show  a  relationship 
between  this  acute  paranoia  and  the  chronic  form,  whether 
degenerative  or  primary. 


PARANOIA.  T.7X 

On  the  contrary,  it  seems  to  us  that  this  variety  is  very 
comparable  sometimes  to  certain  melancholic  states  more 
or  less  accentuated,  often  with  stupor,  but  sometimes  with 
depression  or  anxiety,  and  sometimes  to  states  of  simple  or 
symptomatic  maniacal  excitement. 

There  is  still  much  discussion  on  the  subject  of  the  form 
of  insanity  called  rudimentary,  described  by  Arndt,  and  the 
type  of  which  is  represented  by  the  fixed  ideas.  The 
ground,  as  we  have  seen,  upon  which  these  ideas  may  de- 
velop is  much  contested  ;  and  bn  one  side  certain  authors 
approach  entirely  the  fixed  ideas  of  paranoia,  distinguishing 
them,  however,  because  of  the  preservation  of  conscious- 
ness. Others  admit  them  as  a  rudimentary  form,  others  as 
a  prodromal  period,  and  still  others  as  an  episode  in  the 
course  of  paranoia. 

Regarding  the  secondary  form,  its  existence  is  indispu- 
table ;  but  it  is  only  one  form  of  paranoia  properly  so  called, 
and  it  is  only  one  form  of  systematized  delusion  simply  sec- 
ondary to  some  maniacal  or  especially  melancholic  states, 
of  which  it  serves  as  the  termination  or  as  a  bond  of  union 
between  them  and  dementia.  There  remain  still, the  pre- 
tended forms  of  hysterical,  epileptic,  and  alcoholic  paranoia. 

For  ourselves,  we  should  wish  with  Krafft-Ebing  to  do 
justice  and  put  them  under  the  pathological  state  of  which 
they  form  a  part.  It  should  be  remembered,  however,  that 
certain  of  these  patients  are  possibly  true  examples  of  para- 
noia,  and  that  there  may  be  found  among  them  the  co-exist- 
ence of  two  delusions,  that  only  an  attentive  observation  is 
able  to  distinguish.* 

*  In  this  connection  see  also  Magnan,  Arch  Neur.,  No.  I  ;  Gamier,  Gaz. 
hebd.,  1880;  Dericq,  Thesis,  Paris,  1886;  Krafft-Ebing,  ioc.  cit.  Among  the 
works  on  the  subject  of  paranoia  that  have  come  to  our  knowledge  since  the  com- 
position of  this  memoir  we  may  cite:  Poggi,  Riv.  sp.  di  fren.,  anno  x.,  fasc.  4; 
Guillardi  and  Tanzi,  ibid;  L.  Bianchi,  La  Psychiatrica,  anno  iv.,  fasc.  3  and  4, 
p.  2  ;  G.  Zuno,  ibid.,  p.  220;  Zenner,  The  Medical  Record,  1887,  p.  124;  P. 
Gamier,  J.  Falret,  Dagonet,  Briand,  and  Cotard. — Discussion  on  chronic  delu- 
sion {Ann.  Med. -psych,  and  Archives  de  Neur.,  1887). 

(From  Archives  de  Neurologic,  January,  March,  and 
May,  1887.) 


INSANITY  FROM  BRIGHTS  DISEASE. 

By  DR.   I  .   BREMER. 


ST.    LCLIS,    MISSOLR 


(Read  before  the  Missouri  State  Med.  Association,  April  17th,  1888.) 

B RIGHT'S  DISEASE  as  a  factor  in  insanity  is  by  no 
means  a  novelty,  yet  the  literature  on  this  subject 
is,  on  the  whole,  rather  scanty.  Besides,  in  many  of 
the  cases  reported  the  connection  between  the  renal  and 
mental  phenomena  is  not  quite  clear,  and  in  others  it  seems 
hardly  justifiable  to  qualify  the  manifestations  of  perverted 
mentality  observed,  as  insanity. 

Generally  speaking  the  insanity  of  Bright's  disease  is 
that  of  ura-mia,  and  "  urarmic  insanity"  would  perhaps  be  a 
more  appropriate  term.  It  is,  indeed,  generally  observed 
only  in  the  graver  or  fatal  forms  of  nephritis,  acute  or  chronic, 
in  which  the  functions  of  the  kidneys  are  impaired  to  such 
a  degree  that  the  greater  part  of  the  excrementitious  sub- 
stances normally  eliminated  by  these  glands  is  retained. 
Instead  of  the  characteristic  symptoms  of  urajmia,  viz.: 
headache,  vomiting  and  coma,  a  psychosis,  either  single  or 
complicated,  with  one  or  the  other  uraemic  manifestations  is 
set  up. 

Whether  in  such  cases,  it  is  the  retained  urea  alone  that 
produces  the  morbid  mental  states,  or  whether  there  are 
an)*  of  the  non-excreted  leucomanies  which  are  normally 
formed  by  the  splitting  up  of  the  albuminoids,  responsible 
for  the  disordered  brain  functions  is,  at  present,  an  open 
question.  It  is  held  by  some  that  in  the  common  form  of 
unemia,   ammonia,   by  others,*  the   potash  salts  cause  the 

0  N.  Feltz  and  K.  Rttter  De  l'uremie  experimentale,  Paris,  1881. 


INSANITY  FROM  BRIGHT S  DISEASE.  ^^ 

grave  nerve  symptoms.  However  this  may  be,  it  is  in  the 
highest  degree  probable  that  in  uraemic  insanity  it  is  the 
urea  that  so  peculiarly  influences  and  morbidly  affects  the 
highest  brain  centres,  although  experimentally  it  has  been 
demonstrated  that  this  poison  when  injected  into  animal5 
whose  renal  arteries  have  been  ligated,  gives  rise  only  to 
convulsions  and  stupor. 

There  is  a  certain  similarity  of  chemical  composition  be- 
tween urea  and  those  poisonous  albuminoid  bodies,  the 
ptomaines,  which  according  to  the  present  state  of  know- 
ledge are  looked  upon  as  being  at  least  in  part  instrumental 
in  bringing  about  the  delirium  and  mental  aberations  of 
many  of  the  acute  infectious  diseases,  e.g.  typhoid  fever, 
pneumonia,  etc.  It  is  true  that  generally  the  brain  symp- 
toms in  those  diseases  keep  in  proportion  to  the  rise  and 
fall  of  the  temperature,  and  that  over-heating  is  the  princi- 
pal cause  of  disordered  brain  action,  but  there  are  cases  of 
febrile  disease  in  which  the  latter  is  entirely  disproportion- 
ate to  the  moderately  high  temperature.  Such  discrepancy 
is,  for  instance,  not  infrequently  seen  in  certain  cases  of 
typhoid  fever,  in  which  the  sensorium  is  more  deeply  affec- 
ted than  the  fever-curve  would  warrant. 

Such  cases  are  liable  to  be  mistaken  for  insanity,  the 
typhoid  element,  owing  to  the  irregular  or  insignificant  ele- 
vation of  temperature,  being  entirely  overlooked,  and  it 
may  happen  that  patients  of  this  class  are  sent  to  an  insane 
asylum.  I  know  of  one  instance  in  which  a  superintendent 
of  a  lunatic  asylum,  being  in  the  first  stage  of  typhoid,  with 
strong  predominance  of  cerebral  symptoms,  was  committed 
by  his  assistants  to  his  own  institution. 

In  these  cases  as  well  as  in  uraemic  insanity,  it  is  a  toxic 
akaloid  like  principle,  a  ptomaine  in  the  former,  and  proba- 
bly urea  in  the  latter,  that  determines  for  some  unknown 
reason  the  preponderance  of  the  mental  over  the  other 
usual  disturbances. 

So  far  only  one  case  has  come  under  my  observation  in 
which  a  causal  connection  between  an  exacerbation  of  renal 
disease,  i.e.  accumulation  of  urea  in  the  blood,  and  indubi- 
table insanity  could  be  clearly  proven. 


<,-£  L.  BREMER. 

Cask  i. — M.  C,  a  maiden  lady,  set.  38,  coming  of  healthy 
stock,  had  rheumatism  followed  by  chorea  at  14.  Since  this 
time  she  has  periodically  suffered  from  palpitation  of  the 
heart,  sleeplessness  and  general  nervousness.  Four  years 
ago  she  fell  into  ice-cold  water  and  claims  that  from  that 
time  on  her  kidneys  have  been  out  of  order,  that  she  had  to 
get  up  at  night  to  urinate  three  or  four  times,  and  that  the 
quantity  voided  has  been  very  irregular,  scanty  at  times, 
and  excessive  at  others.  Her  urine  had  been  examined  by 
several  physicians  and  a  more  or  less  considerable  amount  of 
albumen  had  been  found.  There  never  was  any  cedema. 
The  present  attack  came  on  after  exposure  to  cold  and 
dampness,  the  secretion  of  the  urine  became  exceedingly 
scanty  ;  after  a  few  days  she  grew  morose  and  fretful  ;  she 
did  not  sleep  for  several  nights,  her  irritability  and  restless- 
ness increasing  constantly  until  a  week  after  the  exposure 
she  had  a  maniacal  attack.  For  a  day  and  a  night  she 
shouted,  gesticulated  and  sang  religious  songs,  beating  for 
hours  the  time  with  hands  and  feet.  On  the  day  following 
she  began  using  obscene  language,  swore  at  the  members 
of  her  family  and  tore  her  clothes.  This  lasted  about  two 
days  when  a  period  of  depression  set  it,  during  which  she 
wept  a  great  deal,  accused  herself  of  base  and  mean  actions, 
of  having  caused  the  death  of  her  mother,  and  of  having 
brought  utter  disgrace  and  ruin  on  her  family  and  the  whole 
neighborhood.  During  this  melancholic  stage  there  were 
twitchings  of  the  muscles  of  the  face  and  extremities.  On 
the  ninth  day  of  her  disease  she  attempted  to  cut  her  tongue 
out  with  a  table  knife  ;  a  copious  hemorrhage  resulted, 
which  was  stopped  with  a  great  deal  of  difficulty  after  the 
patient  had  become  almost  exsanguinated.  She  then  slept 
for  nine  hours  uninterruptedly.  When  she  awoke  she  was 
in  a  dazed  condition,  but  took  nourishment  freely  and  gave 
rational  answers  to  simple  questions.  In  the  course  of  two 
days  her  mind  became  perfectly  clear  ;  she  remembered 
dimly  some  of  the  events  that  had  taken  place,  but  had 
absolutely  no  recollection  of  her  attempt  at  self  mutilation. 
She  made  a  rapid  recovery. 

From  the  third  day  of  her  sickness  until  sometime   after 


INSANITY  FROM  BRIGHT S  DISEA SE.  ^y- 

her  restoration  to  health  I  made  daily  examinations  of  her 
urine.  In  the  mean  its  specific  gravity  was  1015  ;  it  was 
strongly  acid,  containing  a  large  quantity  of  albumen,  hya- 
line and  epithelial  casts,  pus-cells  and  blood  corpuscles  in 
small  number.  The  daily  amount  of  urine  voided  could  not 
be  ascertained  during  the  first  nine  days  of  her  sickness, 
the  patient  passing  it  most  of  the  time  involuntarily,  but  it 
was  far  below  the  normal.  The  casts  and  the  albumen, 
though  diminished  in  amount,  could  be  demonstrated  for 
three  weeks  after  she  recovered  her  senses,  when  the  urine 
seemed  to  become  perfectly  normal.  During  the  maniacal 
excitement  there  had  been  a  slight  rise  of  temperature,  after 
this  it  had  been  normal  and  even  sub-normal.  Neither 
vomiting  nor  headache  had  been  complained  of.  Pilocarpine, 
elaterium,  and  later,  digitaline  had  been  administered  with- 
out any  apparent  benefit. 

I  am  strongly  inclined  to  believe  that  the  sudden  termi- 
nation of  the  attack  is  due  to  the  copious  hemorrhage. 
Some  practitioners  are  still  treating  uraemia,  especially  when 
appearing  under  the  form  of  puerperal  eclampsia,  with  the 
lancet,  and,  apparently,  with  good  results,  especially  in  per- 
sons of  full  habit,  and  I  am  of  the  opinion  that  in  some  cases 
of  insanity  due  to  uraemia,  bleeding  is  the  proper  remedy  in 
spite  of  the  fact  that  such  a  procedure  would  not  be  in  har- 
mony with  the  teachings  of  modern  psychiatry,  and  that 
very  likely  it  would  be  branded  as  a  return  to  antiquated 
medical  barbarism.  But  it  appears  to  me  rational  and  proper 
to  remove  as  quickly  as  possible  the  retained  products  of 
metabolism,  a  powerful  nerve  poison,  which  by  its  continued 
action  on  the  nerve  centres,  renders  all  remedies  worthless. 

Cases  of  real  insanity  of  uraemic  origin  are,  on  the  whole, 
of  rare  occurrence;  as  a  rule  the.  mental  disorder  consists 
of  elementary  deliria  accompanied  by  hallucinations.  The 
following  case  may  serve  as  an  example. 

Case  2. — C.  B.,  aet.  26,  a  plumber,  habitual,  hard  drinker, 
is  suddenly  taken  with  what  appears  to  be  inflammatory 
articular  rheumatism  ;  feet  and  ankles  are  swollen,  red  and 
painful  ;  at  the  same  time  there  is  severe  pain  in  the  back ; 
the  left  tonsil,  parotid  and  submaxillary  glands  are  swollen; 


^--3  L-  BREMER. 

the  gums  look  inflamed  and  are  extremely  turgid  ;  tempera- 
ture ioo°.  His  legs  frequently  twitch  ;  whenever  he  tries 
to  walk  there  is  a  convulsive  tremor  through  the  whole  body 
and  a  general  spastic  condition  of  all  the  muscles  ;  he  walks 
on  tip-toe,  grating  the  floor  with  the  ball  of  the  foot;  can 
not  bring  down  the  heel  ;  the  head  is  drawn  backwards,  the 
spine  in  a  lordotic  state.  Several  times  a  day  he  gets  "rigid 
spells,"  even  in  bed  ;  there  is  opisthotonus,  his  legs  and 
hands  are  stiff  and  extended,  and  he  becomes  temporarily 
aphasic.  The  superficial  reflexes  )plantar,  cremasteric,  and 
abdominal),  normal;  knee  jerk  absent;  hyperesthesia  of 
■epigastric  region  and  of  the  lower  third  of  thorax.  The  ex- 
amination of  the  urine  which  is  scanty  at  times  and  copious 
at  others,  reveals  an  enormous  amount  of  albumen,  of  hya- 
line and  blood  casts  and  renal  epithlia  in  a  state  of  fatty  de- 
generation, or  impregnated  with  blood-pigment ;  the  color 
of  the  urine  is  of  an  intense  reddish-brown  ;  it  emits  a  fetid 
odor  and  abounds,  even  when  freshly  voided,  in  bacteria, 
the  nature  of  which  was,  however,  not  determined.  His 
mind  wandered,  although  he  could  be  easily  roused  to 
temporary  consciousness,  he  was  traveling  constantly,  driv- 
ing horses,  etc.,  he  had  hallucinations  of  sight  and  hearing; 
talked  to  imaginary  persons  ;  could  be  kept  in  bed  with  the 
greatest  difficulty  ;  when  interfered  with  in  his  attempts  to 
leave  the  bed  he  became  violent.  Six  leeches  were  applied 
to  the  nape  of  the  neck,  and  shortly  afterwards  a  general 
oozing  hemorrhage  set  in  ;  he  bled  from  the  gums,  the  nose 
and  intestines  ;  the  leech  bites  oozed  for  several  days  in 
spite  of  the  efforts  to  stop  the  bleeding.  His  symptoms, 
however,  grew  better  from  day  to  day ;  his  mind  became 
clear,  the  tremors  and  spastic  states  of  the  muscles  disap- 
peared ;  the  urine  was  free  from  albumen  and  contained  only 
few  casts  and  he  made  several  successful  attempts  at  walk- 
ing. The  improvement  lasted  three  weeks  when  his  mind 
again  became  clouded.  Though  his  temperature  was  normal 
his  mind  was  wandering;  he  was  constantly  driving  horses, 
but  was  always  on  the  wrong  road.  At  times  he  would  be 
maniacal,  try  to  break  things,  run  off,  etc.  "The  urine  con- 
tained an  increased  amount  of  casts  and  a  greater  quantity 


INSANITY  FROM  BRIGHT 'S  DISEASE.  „  yr, 

0/9 
of  albumen  ;  he  died  in  coma  eight  weeks  after  the  incep- 
tion of  the  disease.  Within  the  last  four  weeks  the  tempera- 
ture had  been  normal  and  subnormal.  Diagnosis  ;  acute 
parenchymatous  nephritis.     No  post-mortem. 

The  clinical  picture  of  this  case  was  in  the  beginning, 
that  of  an  infectious  disease,  perhaps  rheumatic  in  origin, 
and  complicated  with  some  other  morbid  elements  of 
bacterian  nature,  thus  constituting  a  mixed  infection. 

I  have  reported  this  case  at  some  length  because  it  shows 
the  usual  type  of  mental  disorder  in  uremic  conditions  and  is 
of  pathogenous  interest  in  so  far  as  it  exemplifies  the  truth  of 
the  assertion  that  Bright's  disease  is  in  its  inception  frequent- 
ly a  general  vascular  lesion.  The  general  hemorrhage 
proved  it.  Had  this  patient  recovered  from  the  acute  attack, 
the  probability  is  that  the  remnant  of  the  disease  would 
have  been  localized  in  the  kidney  as  one  or  the  other  form 
of  Bright's  disease. 

The  most  insidious  of  all  forms  of  nephritis  and  one  that 
frequently  remains  unrecognized  as  a  cause  of  mental  dis- 
turbance, is  the  shrunken  kidney.  Being  usually  chronic  in 
nature  from  the  beginning,  the  symptoms  are  often  vague 
and  indistinct,  and  it  runs  its  fatally  progressive  course  under 
the  guise  of  neurasthenia,  neuralgia,  etc.,  until,  all  at  once, 
grave  disorder  of  the  mind  sets  in  and  the  patient  lands  in 
the  insane  asylum. 

Within  the  last  six  weeks  three  cases  of  this  kind  were 
received  at  the  St.  Vincent's  Institution  of  St.  Louis,  all  of 
which  were  declared  insane  by  the  attending  physicians  ; 
the  urine  had  not  been  examined.  I  believe  them  of  suffi- 
cient interest  and  importance  to  briefly  report  them  as  fol- 
lows : 

Case  3. — Mrs.  H.,  aet.  48,  widow  of  a  physician ;  of  robust 
build.  Early  in  life,  when  six  or  seven  years  old,  she  ran  a 
piece  of  shingle  into  the  right  temporal  bone,  the  wound 
healed  and  a  slight  tumor  formed  at  the  site  of  injury,  which, 
about  twenty  years  ago,  gave  rise  to  attacks  of  neuralgia. 
The  tumor  was  removed  about  fifteen  years  back  and  two 
splinters  were  taken  out.  Fourteen  years  ago  she  had  an 
attack  of  puerperal  mania  from  which  she  recovered  in  the 


,g0  L.  BREMER. 

course  of  several  weeks.  Six  years  latter  she  suffered  for 
weeks  from  rheumatism  and  intense  insomnia.  This  was  fol- 
lowed by  an  attack  of  outspoken  melancholia  lasting  several 
months.  Three  weeks  before  her  admission  to  the  institu- 
tion she  went  through  a  railroad  accident  with  all  of  its  ex- 
citement and  exposure.  For  weeks  she  had  been  under 
great  mental  strain,  owing  to  business  affairs.  Several  days 
after  the  accident  she  was  taken  with  a  tonsillitis  ;  great  pain 
in  the  limbs,  took  (as  is  alleged)  an  overdose  of  morphine 
and  chloral  and  became  delirious  without  fever.  She  imag- 
ined she  was  on  board  a  ship,  saw  fish  coming  towards  her 
and  talking  to  her,  had  visions  of  terrible  faces  and  mon- 
sters threatening  her  ;  voided  urine  involuntarily,  etc.  A 
few  days  after  admission  to  the  hospital  died  of  uremic  coma. 
The  urine  contained  a  moderate  amount  of  albumen  and 
great  masses  of  hyaline  and  epithelial  casts  and  a  few  pus 
corpuscles.  Diagonis  :  shrunken  kindey.  Bright's  disease 
had  been  "suspected  "  for  a  number  of  years  by  her  husband, 
who  was  a  physician.  The  probability  is  that  her  previous 
attacks  of  genuine  insanity  were  due  to  the  same  cause  as 
the  last  one,  namely,  to  uraemia,  and  it  may  not  be  amiss  to 
state  at  this  place  that  in  regard  to  puerperal  mania,  I  have 
been  twice  in  a  position  to  corroborate  and  verify  the  state- 
ment of  Scott  Doncin,  who  maintains  that  there  is  a  renal 
form  of  puerperal  insanity.  In  two  cases  that  came  under 
my  observation,  albumen  and  casts  could  be  demonstrated 
and  the  attack  diminished  in  severity  and  disappeared  to- 
gether with  the  renal  symptoms. 

Case  4  is  similiar  to  the  preceding  one. 

Mrs.  F.  S.,  set.  55.  No  heredity.  She  is  brought  in  a 
comatose  condition  to  the  institution.  It  is  learned  that  for 
the  last  ten  years  she  has  been  subject  to  spells  of  sciatica 
of  great  severity.  About  three  weeks  before  her  admission 
she  was  taken  with  an  exceptionally  severe  one;  strong 
doses  of  morphine  were  administered  hypodermically  and 
chloral  given  for  about  ten  days  to  insure  sleep,  when  her 
family  began  to  think  that  she  "talked  funny"  and  that  her 
mind  was  not  quite  right.  She  imagined  that  she  was  in  a 
strange  place,  wanted  to  go  home,  although  she  was  in  her 


INSANITY  FROM  BRIGHT S  DISEASE.  *  g  j 

own  room,  called  for  her  husband  although  he  was  con- 
stantly present,  and  gave  other  evidence  which  showed  that 
she  utterly  failed  to  recognize  her  surroundings.  Being  very 
restless  and  becoming  violent  she  was  put  on  the  train  under 
a  dose  of  chloral  and  shipped  to  St.  Louis.  She  died  in 
uraemic  coma  about  one  week  after  her  admission  to  the 
institution,  never  having  recovered  consciousness  although 
at  times  she  could  be  roused  and  recognized  her  friends.  On 
examination  the  urine  (specific  gravity  1030)  was  found  to 
contain  "mucous  casts"  (so-called),  granular  casts,  epithel- 
ial cells  in  a  stage  of  fatty  degeneration,  pus  corpuscles  and 
blood  casts. 

The  interest  in  this  case  centres  on  the  fact  that  the  pati- 
ent had  been  subject  to  sciatica.  This  is  frequently  one  of 
the  signs  of  shrunken  kidney,  and  so  prominent  is  it  that 
often  the  original  trouble,  i.e.  Bright's  disease,  is  entirely 
overlooked.  Among  other  similar  cases  I  remember  that  of 
a  St.  Louis  physician,  who  died  several  months  ago  with  the 
symptoms  of  uraemia.  He  had  for  number  of  years  been 
subject  to  occasional  attacks  of  lumbago  accompanied  by 
sciatica.  During  the  last  of  these  he  dosed  himself  with 
morphine  to  the  extent  of  almost  poisoning  himself.  From 
this  time  on  grave  cerebral  symptoms  developed,  whilst  the 
temperature  remained  most  of  the  time  normal.  He  became 
very  violent,  broke  his  bed,  imagined  to  be  on  an  ocean 
steamer,  etc. 

It  was  thought  by  the  attending  physician  that  there  was 
some  obscure  form  of  brain  and  spinal  disease.  He  lived  in 
this  deranged  mental  condition  about  eight  weeks  from  the 
beginning  of  the  sciatica.  After  death  his  brain  was  found 
to  be  slightly  odematous,  corresponding  to  the  usual  patho- 
logical condition  of  that  organ  in  uraemia.  Unfortunately 
the  kidneys  were  not  examined  in  this  case,  but  in  the  light 
of  my  recent  experience,  lam  morally  certain  that  the  urine 
as  well  as  the  kidneys  would  have  revealed  the  true  state  of 
affairs,  i.e.,  uraemic  poisoning. 

Case  5. — L.,  an  alcoholic  of  long  standing,  becomes 
suddenly  insane  after  the  opening  of  an  intra-muscular  ab- 
scess situated  about  one  and  a  half  inches  below  the  apex 


-g2  L.  BREMER. 

of  the  heart.  He  is  admitted  to  the  St.  Vincent's  on  a  certi- 
ficate of  insanity.  There  is  cirrhosis  of  the  liver,  ascites  and 
considerable  exudation  into  the  pleural  cavity.  His  urine  is 
loaded  with  albumen,  hyaline  and.  epithelial  casts,  renal  epi- 
thelia.  Few  pus  corpuscles.  He  has  ideas  of  persecution, 
believes  that  the  attendants  in  the  institution  are  after  his 
money  ;  that  robbers  are  in  the  house  and  he  continually  at- 
tempts to  bar  the  door  of  his  room  to  keep  them  out,  etc. 
At  the  hospital  whence  he  came,  he  had  become  unmanage- 
able.    No  fever.     Death  from  coma.     No  post-mortem. 

For  the  sake  of  completeness,  I  will  briefly  mention  two 
cases  which  I  had  of  late  an  opportunity  of  observing  at  the 
City  Hospital  of  this  city. 

CASE  6. — A  negro  about  35  years  of  age,  an  alcoholic 
and  epileptic,  had  been  time  and  again,  at  varying  intervals, 
in  the  hospital  for  treatment  of  his  epileptic  seizures.  It 
was  known  that  he  had  Bright's  disease.  'During  the  last 
six  months  he  had  had  no  epileptic  attack.  He  was  brought 
into  the  hospital  in  a  stuporous  condition,  from  which  he 
could  not  be  roused.  He  remained  in  this  state  for  several 
days  when,  suddenly,  one  night  he  became  unmanageable, 
tried  to  break  the  furniture,  made  speeches,  declaring  that 
he  was  a  free  born  American  citizen,  entitled  to  all  the  rights 
and  privileges  of  such,  that  he  could  whip  any  man  in  town, 
etc.,  in  short,  he  was  typical  maniac.  No  fever.  About  one 
week  after  admission  he  died  comatose.  Post-mortem  re- 
vealed as  a  principal  lesions  :  cirrhosis  of  liver  and  kidneys. 

Case  7. — S.,  a  colored  woman,  set.  50,  had  been  admitted 
to  the  City  Hospital  without  a  history  about  one  week  pre- 
vious to  my  examination  ;  she  was  aphasic,  could  not  pro- 
nounce a  word  nor  understand  the  meaning  of  one  ;  whether 
there  was  word-blindness  or  agraphia  could  not  be  made 
out,  since  the  patient  was  illiterate.  On  being  asked  her 
name  she  invariably  answered  Til-lil-lil-lil.  This  was  the 
only  verbal  expression  that  could  be  elicited  to  any  question 
proposed.  She  had  to  be  spoken  to  several  times  before  she 
would  try  to  answer.  She  was  silly  and  had  a  giggling 
laugh  without  motive.  Xo  paralysis  on  right  side.  Tem- 
perature 970.     Urine  specific  gravity  IOI 5.     Pupils  contrac- 


INSANITY  FROM  BRIGHT S  DISEASE.  *&$ 

ted  and  sluggish  of  reaction  ;  urine  and  feces  were  passed 
involuntarily,  slight  tremor  at  times  in  hands  and  feet ; 
casts,  hyaline  and  epithelial,  pus  corpuscles,  albumen,  hy- 
pertrophy of  left  heart.  A  few  days  later  she  became  more 
attentive,  could  pronounce  her  name  (Martha  Smith)  thought 
with  difficulty,  execute  simple  movements  with  her  hands; 
when  told  to  do  so,  and  gave  other  evidences  of  returning 
intelligence.  It  was  now  quite  clear  that  she  was  suffering 
with  motor  aphasia,  since  she  became  impatient  and  irritated 
or  laughed  at  herself  whenever  she  tried  to  pronounce  a 
word  without  success  ;  after  she  had  mastered  the  pronoun- 
ciation  of  a  word,  she  would  repeat  it  several  times;  under- 
stood questions  better.  A  few  days  later  a  hemiparesis  of 
the  right  side  supervened  which  did  not  last,  however,  very 
long.  Finally  she  got  well  enough  to  help  about  the  ward, 
which  she  did  willingly.  But  the  improvement  did  not  last 
very  long ;  she  became  destructive,  uttered  threats  and 
seemed  to  have  homicidal  tendencies  ;  everything  she  could 
get  a  hold  of  she  would  throw  into  the  water-closet,  etc. 
She  was  then  transferred  to  the  City  Insane  Asylum. 

REMARKS. 

There  is  no  doubt  as  to  the  existence  of  renal  affection 
in  all  the  cases  reported  above,  nor  can  there  be  any  ques- 
tion as  to  the  cause  of  the  mental  derangement  observed  in 
these  patients,  although  there  was  in  none  of  them  the 
usually  observed  symptom-grouping  of  uraemia,  etc.,  viz., 
headache,  vomiting,  and  convulsions.  The  absence  seems 
in  a  measure  to  be  characteristic  of  uraemic  insanity,  and 
reminds  one  of  the  physical  equivalent  of  the  epileptic  at- 
tack. 

It  might  be  questioned  whether  the  morbid  mental  mani- 
festations in  all  the  cases  detailed  above  can  be  legitimately 
classed  with  insanity.  There  is  in  a  majority  of  them  a 
close  resemblance  to  the  delirium  of  alcoholic  intoxication. 
With  the  exception  of  cases  I.  and  VII.,  this  delirium  is  of  an 
elementary  character,  and  only  in  case  V.,  barring  case  I., 
which  is  one  of  equivocal  insanity,  is  there  a  feeble  attempt 
at   systematization    of  ideas   begotten    by  delirium.     Most 


^g4  L.  BREMER. 

doubtful  is  case  VI.,  owing  to  the  complication  of  alcohol- 
ism and  possibly  idiopathic  epilepsy. 

But  although  nobody  would  classify  the  drunken  man  or 
him  that  has  an  attack  of  delirium  tremens  with  the  insane, 
we  know  that  etiologically,  though  not  ontologically,  there 
is  such  a  thing  as  alcoholic  insanity,  as  there  is  one  from 
the  continued  abuse  of  drugs,  morphine,  hashish,  and  co- 
caine, for  instance.  Urea  retained  for  a  longer  period  in 
the  blood  seems  to  act  in  a  manner  similar  to  these  sub- 
stances on  the  highest  brain-centres,  producing  perversion  of 
thought,  feeling,  and  action  ;  and  the  absence  of  fever  and 
a  degree  of  chronicity  of  the  mental  change  will  warrant  the 
application  of  the  term  insanity  to  such  cases. 

But  as  in  alcoholic  or  the  other  intoxication  insanities, 
so  in  the  ursemic  variety,  there  is  no  type  ;  it  may  give 
rise  to  all  kinds  of  mental  abnormalities,  from  the  most  ex- 
pansive forms  down  to  imbecility. 

That  there  must  be  a  predisposition  to  mental  disorder 
in  the  individual  affected  by  uraemia  would  seem  to  be  a 
postulate  of  common  logic  ;  and  it  might  be  justly  claimed 
that,  as  in  ordinary  cases  of  insanity,  there  must  be  in  the 
uraemic  kind,  in  addition  to  the  exciting  cause,  a  remote 
one  which  is  of  much  greater  pathogenic  importance,  name- 
ly, hereditary  or  acquired  predisposition.  With  the  excep- 
tion of  case  III.,  which  looks  suspicious  on  account  of  the 
injury  of  the  head,  and  case  I.  (chorea),  no  predisposition 
or  heredity  could  be  made  out.  (Owing  to  the  absence  of 
any  record  whatsoever,  the  cases  VI.  and  VII.  are  not 
counted.) 

Yet,  judging  from  common  experience  in  matters  of  in- 
sanity, and  taking  into  consideration  the,  on  the  whole, 
deficient  histories  that  were  given,  and  the  well-known  ten- 
dency on  the  part  of  the  relatives  to  deny  insanity  in  the 
family,  I  am  inclined  to  believe  that  my  patients,  if  their 
and  their  families'  histories  had  been  known,  would  have 
been  found  to  be  tainted  ;  at  all  events,  considering  the 
different  effect  on  different  individuals  of  the  same  poison, 
there  must  be  a  preponderance  of  the  insane  over  the 
convulsive    temperament.       Even    the    alcoholic    intoxica- 


INSANITY  FROM  BRIGHT S  DISEASE.  ^gr 

tion,  the  prototype  of  toxic  insanities,  demonstrates  clearly 
the  different  modes  in  which  different  persons  are  affected 
according  to  their  organizations  and  idiosyncracies.  One 
becomes  maniacal,  another  melancholic,  a  third  has  con- 
vulsions, and  a  fourth  one  is  at  once  rendered  stuporous  and 
even  unconscious. 

Besides  these  resemblances  to  the  alcoholic  delirium,  the 
uraemic  attacks  reminded  me  often  of  post-epileptic  insan- 
ity, even  in  those  cases  that  were  free  from  convulsions. 

As  regards  the  aphasia  and  transitory  hemiparesis  in 
case  VII.,  there  is  a  possibility  of  holding  the  uraemia  alone 
responsible  for  such  disturbance,  although  there  is  a  possi- 
bility that  it  was  produced  by  a  coarse  lesion,  viz.,  circum- 
scribed haemorrhage,  or  thrombosis,  the  result  of  general 
vascular  disease  such  as  is  common  in  Bright's  disease. 

Brieger  (Klin.  Beob.  Charite  Annalen,  1882,  p.  237), 
saw  a  case  of  uraemia  in  which  there  were  convulsions  fol- 
lowed by  a  psychosis  lasting  eighteen  hours.  Amnesic 
aphasia  terminated  the  attack.     The  patient  got  well. 

I  did  not  propose  to  write  an  exhaustive  treatise  on  in- 
sanity from  Bright's  disease,  and  consequently  refrain  from 
enumerating  and  reviewing  the  literature  on  the  subject. 
My  purpose  in  publishing  those  cases  that  came  under  my 
observation  was  to  urge  the  necessity  of  examining  the 
urine  of  such  patients  as  become  suddenly  insane,  especially 
when  the  insanity  partakes  of  a  delirious  nature  and  when 
alcoholism  is  to  be  excluded.  I  think  that  many  a  case  of 
uraemia  has  been  put  down  as  mania  without  the  correct 
diagnosis  as  to  the  cause  having  been  made. 

An  exclusively  chemical  test  is,  of  course,  not  sufficient; 
albuminuria  is  not  Bright's  disease.  With  the  microscope 
alone  rests  the  final  decision.  That  even  this  instrument 
fails  in  some  cases,  for  a  time,  to  reveal  the  true  state  of 
affairs,  notably  in  contracted  kidney,  is  too  well  known  to 
require  discussion. 

From  a  therapeutical  point  of  view  the  importance  of  an 
early  diagnosis  is  obvious.  A  timely  regulation  of  the  diet 
may  turn  the  scales  of  the  balance  in  favor  of  recovery,  at 
least  in  the  more  acute  forms  of  the  disease. 


^36  L-  BREMER. 

From  the  clinical  course  of  cases  I.  and  II.,  I  consider 
myself  justified  in  concluding  that  in  certain  cases  such  in- 
cisive measure  as  blood-letting  is  indicated.  That  here  the 
strictest  individualization  is  required  is  self-evident. 

Again,  in  case  of  death,  it  is  of  great  import  to  the  fam- 
ily to  know  of  what  form  of  insanity  their  relative  died.  As 
regards  the  social  and  business  status  and  record  of  such  a 
family  in  the  community,  it  makes  a  great  difference  whether 
the  death-certificate  reads,  "  Mania,"  or  whether  the  cause 
of  death  is  given  as  "Uraemia." 

Finally,  a  correct  diagnosis  will  sometimes  serve  to  keep 
a  patient  out  of  an  insane  asylum,  and  will  cause  him  to  be 
treated  at  home,  on  the  same  ground  as  a  delirious  typhoid 
fever  patient  receives  home  or  general  hospital,  but  not  an 
asylum  treatment.  This  remark  does  not  imply  that  all  pa- 
tients suffering  from  uraemic  insanity  ought  to  be  treated 
outside  an  asylum. 


SIX  CASES  OF  EPIDEMIC  CEREBRO-SPINAL  MEN- 
INGITIS.* 

BY  CHARLES  K.  MILLS,  M.D.,  AND  W.  C.  CAHALL,  M.D., 

TF   PHILADELPHIA. 

Of  the  six  cases  briefly  detailed  in  this  communication, 
five  were  observed  at  the  Falls  of  Schuylkill,  Philadelphia, 
and  one  in  the  southwestern  portion  of  Philadelphia.  At 
the  Falls  of  Schuylkill  several  other  cases  have  recently 
been  observed,  and  it  is  interesting  to  recall  that  it  was  in 
this  neighborhood,  during  1864  and  1865,  that  the  disease 
was  widely  prevalent  and  very  virulent.  In  the  first  case 
an  elaborate  autopsy  was  made,  which  gives  the  case  a  dis- 
tinct scientific  value ;  in  the  other  cases,  certain  special 
points  of  interest  make  them  worthy  of  being  recorded. 
They  are  reported  briefly  so  as  not  to  load  the  paper  with 
unnecessary  details.  The  first  four  cases  occurred  in  the 
practice  of  Dr.  Cahall,  and  two  of  them  were  seen  by  Dr. 
Mills  in  consultation  ;  the  fifth  was  a  patient  of  Dr.  J.  Y. 
Kelley,  of  Manayunk,  Philadelphia;  the  sixth  was  a  patient 
of  Dr.  J.  W.  Dick,  and  was  seen  several  times  by  Dr.  Mills 
in  consultation. 

Case  I. —  Mrs.  W.,  aged  thirty,  the  mother  of  three 
children,  had  had  bad  health  since  the  birth  of  her  last  child, 
now  two  years  old.  She  was  greatly  depressed  in  spirits 
and  imagined  she  had  all  sorts  of  diseases,  but  for  a  few 
months  she  had  regained,  to  a  considerable  degree,  her  for- 
mer health  and  spirits. 

February  21,  1888,  she  was  taken  with  chills  and  head- 
ache, and  on  the  morning  of  the  22d,  when  first  seen  by  Dr. 

cRead  before  the  Philadelphia  Neurological  Society,  March  26,  1888. 


^38  CHARLES  K.  MILLS  A.XD    If.   C.   CAHALL. 

Cahall,  she  complained  of  acute  pains  down  both  legs,  but 
more  intense  in  the  posterior  aspect  of  the  knee-joints,  any 
movements  of  the  limbs  causing  her  to  scream  with  pain. 
She  already  had  headaches,  contraction  of  the  muscles  of 
the  neck  ;  and  ten  to  fifteen  irregularly  shaped  spots  of  a 
color  from  pink  to  purple,  and  from  the  size  of  a  pea  to  a 
silver  dime,  were  scattered  over  the  legs  and  abdomen. 
Diarrhoea,  abdominal  distention,  and  tenderness  were  pres- 
ent from  the  first.  Delirium  came  on  by  the  morning  of  the 
23d,  with  lucid  intervals,  when  she  said  she  saw  everything 
double.     All  the  other  symptoms  were  intensified. 

On  the  24th  she  was  totally  blind  and  partially  deaf,  but 
when  aroused  could  give  sensible  answers  to  questions.  She 
still  complained  of  the  headache,  but  not  of  the  pain  in  the 
legs  unless  pressure  was  made  along  the  course  of  the 
nerves,  when  she  would  cry  out  as  though  suffering  great 
pain.  The  pulse  was  rapid,  but  the  temperature  was  never 
over  1030.     There  was  general  hyperesthesia. 

On  the  26th  she  sank  into  a  stupor,  from  which  it  was 
gradually  more  difficult  to  arouse  her.  She  died  upon  the 
morning  of  the  29th  on  the  eighth  day  of  her  sickness. 

Dr.  Mills  saw  her  in  consultation  the  day  before  her 
death. 

Autopsy. — Drs.  A.  H.  P.  Leuf  and  Judson  Daland  per- 
formed the  autopsy,  at  which  the  writers  were  present,  and 
examined  the  specimens.  The  following  are  the  results  of 
the  megascopic  examination. 

Brain  :  The  pericranium  was  very  vascular.  The  veins 
of  the  dura  mater  were  gorged  with  dark  venous  blood  on 
the  outside,  and  the  inner  side  of  the  membrane  showed 
marked  arterial  injection.  It  was  adherent  to  the  convexity 
of  the  right  hemisphere  at  the  upper  border  of  the  quadrate 
lobule.  In  front  of  this  on  both  sides,  were  Pacchionian 
adhesions  of  the  dura  to  the  brain.  The  anterior  lobes  of 
the  brain,  especially  on  their  convexity  near  the  great 
median  fissure,  were  cedematous,  with  a  few  slight  opacities 
of  the  pia.  At  the  base  was  seen  liquid  and  semi-liquid  pus 
about  the  optic  chiasm,  interpeduncular  space,  pons,  and 
oblongata.     The  auditory  and  facial  nerves  were  bathed   in 


EPIDEMIC  CEREBROSPINAL  MENINGITIS.  ^q 

pus,  as  were,  in  fact,  all  the  nerves  at  the  base  of  the  brain 
except  the  olfactories.  All  the  cranial  nerves  were  soft,  es- 
pecially the  olfactory  and  optic.  Softening  of  the  crura 
cerebri,  pons,  crura  cerebelli,  and  oblongata  was  also  de- 
cided. The  pia  covering  the  isthmus  was  intensely  injected, 
but  this  could  only  be  seen  by  the  removal  of  the  pus  that 
covered  it.  The  arachnoid  between  the  medulla  and  cere- 
bellum was  also  covered  by  a  thick  layer  of  pus. 

The  puncta  cruenta  were  well  marked,  numerous,  and 
dark.  The  basal  ganglia  were  normal,  except  some  venous 
puncta.  The  fornix  was  softened.  The  fissure  of  Sylvius 
presented  nothing  abnormal  on  either  side  when  opened  for 
inspection  ;  and  all  the  cerebral  vessels  appeared  normal. 

Spinal  cord :  On  opening  the  spinal  canal,  the  cord  lay 
flat  and  spread  out  in  its  membranes,  instead  of  being  nar- 
row for  the  canal,  and  bulging  with  well  marked  convexity. 
The  dural  vessels  were  well  injected  externally  and  inter- 
nally. On  section  of  the  dura  pus  exuded  freely.  The 
membranous  coverings  of  the  spinal  nerves  within  the  canals 
were  almost  ecchymotic.  This  was  most  noticeable  in 
those  given  off  opposite  the  lumbar  enlargement,  and  es- 
pecially on  the  left  side.  The  whole  cord  was  surrounded 
with  yellow  creamy  pus.  The  lower  half  of  the  back  of  the 
cord  was  covered  with  a  yellow  gelatiniform  pus  layer,  while 
the  same  covering  was  found  on  only  the  lower  two  inches 
in  front.  All  the  pus  was  situated  between  the  dura  and 
pia.  The  anterior  and  posterior  spinal  vessels  were  gorged 
with  blood,  and  there  was  a  fine  injection  of  the  arterioles 
of  pia  and  dura.  A  few  adhesions  between  the  pia  and  dura 
were  noticed  behind,  but  many  throughout  the  whole  length 
of  the  cord  in  front. 

Peripheral  nerves :  The  lower  end  of  the  left  sciatic  in 
its  two  divisions  (the  internal  and  external  popliteal)  were 
removed  ;  they  were  marked  externally  by  several  distend- 
ed blood-vessels.  On  the  right  side  this  was  not  so  noticea- 
ble as  on  the  left.  The  second,  third,  and  fourth  digital 
nerves  of  the  dorsum  of  the  right  foot  presented  nothing 
abnormal,  but  slight  pressure  at  the  end  with  forceps  caused 
some  blood  to  appear.  The  same  was  true  of  the  second 
and  third  digitals  of  the  dorsum  of  the  left  foot. 


39o  CHARLES  K.  MILLS  AND    W.   C.   CAHALL. 

Muscles  :  A  piece  of  muscle  was  excised  from  the  lower 
end  of  each  semi-membranosus.  To  the  eye  it  presented 
nothing  abnormal. 

Thoracic  and  abdominal  viscera :  Careful  examination 
showed  the  lungs  to  be  crepitant  throughout  and  apparently 
entirely  normal.  The  pleural  cavities  were  free  from  effus- 
ion. A  few  adhesions  were  present  on  the  right  side,  and 
numerous  adhesions  on  the  left,  many  of  which  were  evi- 
dently quite  old. 

So  far  as  could  be  determined  by  careful  naked-eye  ex- 
amination, the  heart  and  aorta,  intestines,  liver,  and  kidneys 
were  normal. 

The  stomach  was  normal  in  size,  but  here  and  there, 
under  the  mucous  membrane,  were  seen  small  extravasa- 
tions of  blood.  The  spleen  was  twice  its  normal  size,  but 
of  firm  consistence,  and  its  capsule  normal.  The  uterus  and 
its  appendages  were  normal  in  size,  shape,  and  position. 
The  endometrium  was  somewhat  thickened,  and  of  a  dark 
red  color  ;  there  were  considerable  submucous  extravasa- 
tions of  blood. 

Marked  evidence  of  recent  moderate,  adherent  perito- 
nitis were  found.  This  was  particularly  noticeable  on 
the  surface  and  between  the  coils  of  the  small  intestine.  At 
no  place  did  the  layer  of  lymph  exceed  the  thickness  of  a 
sheet  of  paper,  and  the  peritoneal  cavity  contained  no  liquid 
effusion. 

A  small  drop  of  purulent-looking  substance  from  the 
thick  exudation  covering  the  spinal  cord  was  examined 
microscopically  by  Dr.  Daland,  and  showed  numerous 
leucocytes  imbedded  in  a  gelatinous-like  substance,  proba- 
bly lymph,  apparently  there  was  not  so  much  pus  as  would 
be  expected  from  the  marked  yellow  color. 

Cask  II. — X.  \\\,  aged  eleven,  daughter  of  Mrs.  W. 
(Case  I.;,  was  of  a  nervous  disposition  inherited  from  her 
mother. 

Three  days  before  her  mother's  death  the  child  was  taken 
suddenly  ill  with  pain  in  her  left  leg  below  the  knee,  par- 
ticularly severe  around  the  ankle-joint.  Slight  redness  and 
swelling  were  perceived  about  this  joint. 


EPIDEMIC  CEREBROSPINAL  MENINGITIS.  oqj 

Tincture  of  opium  and  sodium  salicylate  were  prescribed, 
and  on  the  following  morning  the  leg  was  much  better,  but 
her  neck  was  painful  and  drawn  to  the  left  side,  from  con- 
traction of  the  sterno-cleido-mastoid  muscle.  There  was 
tenderness  along  the  spine  from  between  the  shoulders  to 
the  occiput.  She  did  not  suffer  with  headache  and  had  no 
delirium.  The  special  senses  remained  normal.  The  bowels 
were  constipated.  In  the  evening  a  slight  rise  of  tempera- 
ture was  noticed,  but  her  pulse  was  slower  than  normal. 

Under  ordinary  circumstances  the  case  7/ould  probably 
have  been  dismissed  as  an  ordinary  one  of  rheumatic  or 
neuralgic  torticollis,  but  the  patient's  mother  was  lying  up 
stairs  with  an  undoubted  attack  of  cerebro-spinal  menin- 
gitis, which  had  commenced  in  a  similar  though  more  vio- 
lent manner.  This  aroused  suspicion  as  to  a  similar  cause  for 
the  two  attacks.  An  eruption  was  looked  for,  but  did  not 
appear  until  the  fourth  day,  when  five  spots,  two  pink  and 
three  purple,  made  their  appearance  on  the  legs  and  lower 
part  of  the  abdomen. 

The  tincture  of  opium  and  sodium  salicylate  were  con- 
tinued in  moderately  large  doses.  Friction  and  counter- 
irritation  were  used  upon  the  neck,  but  the  contraction  and 
tenderness  on  pressure  remained  in  a  marked  degree  for 
several  days,  and  did  not  finally  disappear  for  several  days 
longer. 

Case  III. — M.  M.,  aged  twenty-four,  a  mill-girl,  had  a 
history  both  in  herself  and  in  the  female  portion  of  her  fam- 
ily, of  a  highly  nervous  temperament.  On  the  16th  of  Jan- 
uary, while  enjoying  her  usual  health,  she  had  gone  to  her 
work.  During  a  passionate  debate  among  the  employes  as 
to  the  avisability  of  a  strike,  which  she  opposed,  she  pro- 
ceeded, with  the  others,  to  the  sidewalk,  laboring  under 
great  mental  excitement.  The  day  was  very  cold,  and 
shortly  after  reaching  the  windy  street,  she  fell  to  the  pave- 
ment screaming  with  a  pain  in  her  neck.  She  was  taken  to 
the  house  of  a  neighboring  physician,  who  gave  her  two 
hypodermatic  injections  of  morphia,  after  which  she  was 
brought  home.  At  first  she  complained  of  nothing  except 
the  intense  pain  in  the  neck.     The  head  was  drawn  back- 


-,,-.<,  CHARLES  A'.  MILLS  A. YD  If.   C.   CAHALL. 

ward.  She  had  no  fever ;  pulse  60.  The  day  following 
her  neck  was  about  the  same,  while  an  intense  headache  of 
a  constricting  character  was  added.  The  mental  faculties 
were  clear  and  all  the  functions  of  the  body  were  well  per- 
formed.    Fever  was  still  absent,  and  pulse  60. 

After  the  use  for  two  or  three  days  of  morphia,  bromide, 
and  chloral,  without  the  slightest  imp'rovement,  hysteria 
was  suspected,  but  later  a  genuine  organic  disease  seemed 
manifest.  At  about  the  end  of  a  week  she  complained  of 
great  pain  in  both  legs,  and  especially  upon  pressure  over 
the  nerves.  Dr.  Mills  saw  her  at  this  time  in  consultation. 
While  the  pain  in  the  legs  continued  the  headache  and 
neckache  were  greatly  lessened.  Morphia,  sodium  salicy- 
late, and  oil  of  gaultheria  were  given,  under  which  the  pain 
in  the  legs  disappeared.  The  headache  never  returned  with 
its  first  intensity,  but  an  active  delirium  took  its  place.  Il- 
lusions and  delusions  kept  her  in  a  state  of  excitement  for 
days  with  scarcely  any  sleep,  in  spite  of  large  doses  of  ano- 
dynes. The  drawn  state  of  the  neck  was  persistent.  Fever 
come  on,  although  never  nigh.     The  pulse  continued   slow. 

The  patient  drifted  from  bad  to  worse.  The  active  de- 
lirium gave  place  to  a  heavy  stupor,  when  it  was  difficult  to 
administer  either  medicine  or  nourishment ;  but  as  nourish- 
ment was  considered  the  most  pressing  need,  it  was  regu- 
larly and  persistently  forced  upon  the  patient.  A  flea-bite 
eruption  appeared  on  the  arms,  face,  and  neck,  but  not  until 
after  the  second  week.  The  eruption  would  disappear  and 
reappear,  but  never  so  distinctly  as  at  first. 

For  three  weeks  longer,  or  to  the  fifth  week  of  the  sick- 
ness, the  patient's  mental  condition  remained  practically 
unchanged.  Iodide  of  potassium,  5  grains  and  bichloride 
of  mercury  ^J;th  grain  were  given  three  times  a  day.  In 
three  days  the  girl's  mind  was  perfectly  clear,  and  she  re- 
membered her  sickness  only  as  a  disagreeable  dream. 

Cask  IV. — R.  L.,  aged  nineteen,  a  mill  girl,  was  taken 
suddenly  ill  while  at  her  work  upon  the  1st  of  March.  An 
intense  headache  followed  by  chills  ushered  in  a  high  fever. 
Her  temperature  was  103.50  the  first  evening.  She  com- 
plained of  pain  in  the  limbs  and  neck,  but  there  was  no  con- 


EPIDEMIC  CEREBROSPINAL  MENINGITIS  ln-> 

traction  of  the  muscles  of  the  neck  until  March  3d.  Nausea 
and  vomiting  were  present  during  the  first  three  days,  and 
during  the  nights  of  the  same  days  the  patient  was  delirious. 

Pills  of  opium  and  quinine,  with  an  effervescing  fever 
mixture,  reduced  the  temperature  by  March  4th  to  ioo°  F., 
above  which  it  never  again  rose.  From  the  4th  to  the  9th 
the  case  remained  at  a  standstill.  The  headache  was  greatly 
better,  but  the  contraction  of  the  muscles  of  the  neck  was 
increased,  fixing  the  head  immovably  backward.  Hyper- 
aethesia  and  deep-seated  pain  upon  slight  pressure  were 
present  over  the  whole  posterior  region  of  the  neck.  The 
patient  complained  of  feebleness  and  exhaustion.  On  the 
6th,  the  opium  and  quinine  were  given  at  longer  intervals, 
and  iodide  of  potassium  5  grains,  and  bichloride  of  mercury 
^th  grain,  four  times  a  day. 

In  two  days  the  patient  was  sitting  up,  with  fever  gone, 
neck  greatly  relieved,  and  appetite  and  sleep  returned. 
Her  convalescence  was  from  this  date  forward  rapid  and 
complete.     No  spots  were  found  in  this  case. 

Case  V. — Notes  of  the  following  case  were  furnished  by 
Dr.  J.  V.  Kelley,  of  Manayunk,  Philadelphia  : 

The  patient,  a  young  man,  was  first  seen  February  18, 
1888.  He  was  in  good  health  until  the  preceding  day,  when 
in  the  evening  he  was  taken  with  a  chill,  vomited  twice,  and 
had  two  stools.  He  worked  during  the  forenoon  of  the  day 
he  was  taken  sick,  although  feeling  very  badly.  At  2  P.  M., 
when  first  seen  by  Dr.  Kelley,  he  was  in  bed  and  com- 
plained of  great  soreness.  He  complained  of  tenderness 
confined  to  the  abdomen,  so  much  so  that  the  case  was  at 
first  thought  to  be  one  of  enteritis.  He  was  very  cold  ; 
pulse  134,  and  he  seemed  much  prostrated.  He  was  placed 
on  brandy  and  tonics,  and  the  next  day  in  a  manner  re- 
vived. 

February  20th,  he  was  seen  by  Dr.  Bruen,  who  thought 
the  case  to  be  one  of  cerebro-spinal  fever.  Herpes  labialis 
was  beginning  to  show.  The  next  day  he  had  some  delir- 
ium ;  his  pulse  was  still  134. 

On  the  22d,  he  was  seen  by  Dr.  Pepper,  who  agreed  that 
the  case  was  one  of  cerebro-spinal  fever.     Herpes  labialis 


-.q  i  CHARLES  K.  MILLS  AXD   IV.  C.  CAM  ALL. 

was  now  profuse,  some  delirium  was  present,  and  hearing" 
and  sight  both  defective.  He  had  two  offensive  stools,  and 
complained  of  great  general  soreness,  but  had  no  character- 
istic spots,  although  there  was  a  vesicular  eruption  on  the 
chest.  He  had  no  retraction  of  the  head,  although  his  neck 
was  somewhat  stiff.  His  abdomen  was  tympanitic,  and 
this  persisted  until  death  occurred, .February  28th. 

About  the  fifth  day  of  his  seizure  the  patient  complained 
of  blindness.  On  one  occasion  he  bled  from  the  nose  and 
spat  some  blood.  No  heart  or  lung  symptoms  could  be 
demonstrated  by  examination,  and  the  man  died  from  pros- 
tration on  the  eleventh  day  of  the  disorder.  He  showed 
typhoid  signs,  but  the  case  was  certainly  not  typhoid  fever. 
The  treatment  was  by  stimulation  and  tonics,  with  full 
feeding.  Brandy,  quinine,  digitalis,  opium,  and  turpentine 
were  given. 

Case  VI. — The  following  interesting  case  occurred  in 
the  practice  of  Dr.  J.  W.  Dick,  and  was  seen  by  Dr.  Mills 
several  times  in  consultation.  The  patient,  R.  A.,  a  boy 
eight  years  old,  in  the  latter  part  of  October,  1887,  had  an 
attack  of  mild  scarlet  fever,  followed  by  slight  nephritis, 
which  kept  him  in  the  house  until  the  last  of  December. 
After  this  time  he  began  running  out  of  doors  in  all  sorts  of 
weather,  in  his  play  sometimes  lying  down  in  the  snow.  He 
seemed  to  be  in  the  best  of  health  until  February  2d,  when 
he  was  suddenly  taken  sick  at  school.  He  came  home  com- 
plaining of  violent  headache,  and  was  taken  down  also  with 
vomiting  and  high  fever,  with  marked  delirium.  The  de- 
lirium soon  subsided,  and  he  sank  into  a  semi-conscious 
condition.  He  would  not  answer,  as  a  rule,  any  question  or 
demand,  but  sometimes  asked  for  a  drink,  and  he  would 
give  notice  when  he  wished  to  evacuate  the  bowels  or  blad- 
der. On  the  fourth  day  an  eruption  appeared  over  the  en- 
tire body,  more  especially  marked  on  the  face,  neck,  and 
upper  extremities.  The  eruption  consisted  of  small  pin- 
point, fleabite-like  spots,  which  did  not  disappear  on  pres- 
sure.    It  faded  in  about  four  days  after  its  first  appearance. 

His  temperature  varied  at  first  from  1030  to  1050  F., 
sometimes  higher  in  the  morning  than  in  the  evening,  and 


Morning. 

Evening. 

IO4.40 

1040  F 

IO4.4 

103.8 

IO3.6 

103.6 

I02.6 

103.2 

IO2.4 

102.6 

IO2.4 

101.6 

I02 

102 

IOI 

IOI 

IOI 

IOI 

IOI 

IOI 

EPIDEMIC  CEREBROSPINAL  MENINGITIS.  ,gr 

sometimes  the  reverse.     The  following  is  the  temperature 
record  from  February  17th  to  26th  : 

February 
17th 

1 8th 
19th 
20th 

2lSt 
22d 

23d 
24th 
25th 
26th 

After  this  his  temperature  showed  a  tendency  to  fall, 
and  came  down  to  95. 50. 

His  pulse  was  weak,  but  regular,  varying  usually  from 
112  to  120.  His  respirations  ranged  from  about  30  to  40. 
The  vomiting  lasted  only  during  the  first  day,  after  which 
he  took  and  retained  both  food  and  medicine.  His  bowels 
were  usually  slightly  constipated,  but  responded  freely  to 
enemata.  After  February  22d  he  did  not  attempt  to  speak, 
but  lay  in  a  comatose  condition,  with  frequent  sudden  out- 
cries, as  if  in  pain.  His  abdomen  became  decidedly  scaph- 
oid. He  was  troubled  with  a  cough  throughout  his  entire 
sickness.  There  were  abundant  mucous  rales,  with  a  little 
dulness  on  percussion  on  the  right  side. 

In  the  beginning  of  his  sickness  the  slightest  movement 
gave  rise  to  intense  pain.  This  gradually  subsided  ;  but  he 
continued  throughout  to  have  great  tenderness  on  pressure 
in  the  region  of  the  neck  and  in  the  legs.  The  pain  in  his 
lower  extremities  was  a  very  marked  symptom  ;  handling 
them,  and  pressure  along  the  nerves  or  squeezing  of  the 
muscles,  caused  great  suffering.  No  swelling  of  the  joints 
was  present.  He  exhibited  some  pain  and  tenderness  in  the 
upper  extremities,  but  not  nearly  as  marked  as  in  the  lower; 
the  knee-jerks  were  retained.  He  could  move  the  legs  up 
and  down  freely,  but  the  feet  had  a  tendency  to  assume  the 


^Q5  CHARLES  K.  MILLS  AXD   If.   C.  CAHALL. 

equino-varus  position  ;  this  foot-drop  was  more  marked  on 
the  right  side.  Xo  paralysis  of  the  cranial  nerves  was  pres- 
ent. For  three  weeks  before  his  death  he  was  apparently 
both  blind  and  deaf;  for  a  short  time  he  had  a  slight  dis- 
charge from  the  left  ear.     He  died  on  the  thirty-sixth  day. 

REMARKS. — These  cases  are  of  considerable  interest 
from  various  points  of  view,  but  we  shall  only  be  able  to  call 
attention  to  a  few  of  the  most  important  features.  At  a  for- 
mer meeting  of  the  Society  it  had  been  suggested  by  Dr. 
Mills  that  neuritis  was  probably  present  as  a  complication 
or  coincidence  in  some  of  the  cases,  and  in  others  the  in- 
fectious agent  caused  a  multiple  neuritis  rather  than  a  cere- 
brospinal disease.  As  no  microscopical  examination  has 
yet  been  made  from  the  specimens  of  Case  I.,  we  are  not 
able  to  say  positively  that  neuritis  was  present,  but  the  gross 
examination  of  the  sciatic  and  other  nerves  led  to  the  sug- 
gestion that  either  congestion  of  the  nerves  or  neuritis  was 
present. 

A  few  words  might  be  said  with  reference  to  treatment. 
Bromide  of  potassium,  in  half-drachm  doses,  failed  to  re- 
lieve the  headache  or  produce  sleep  in  the  severe  cases  (the 
same  result  followed  chloral).  Nothing  definite  can  be  said 
as  to  the  effect  of  quinine.  Sodium  salicylate  and  oil  of 
gaultheria  gave  relief  to  the  neuritic  pains  in  the  legs,  but 
produced  no  appreciable  benefit  to  the  head  and  neck. 
Opium  and  morphia  did  positive  good  in  every  case,  but 
after  the  more  acute  symptoms  had  passed  the  good  effect 
seemed  to  be  lost.  In  the  two  cases  where  iodide  of  potas- 
sium and  bichloride  of  mercury  were  used  by  Dr.  Cahall, 
the  effect  was  surprising  to  patient  and  physician  alike. 
The  improvement  was  too  rapid  to  be  the  result  of  the  alter- 
ative properties  of  the  drugs,  but  more  like  the  action  of 
specific  remedies. 


A  CASE  OF  PARAMYOCLONUS  MULTIPLEX. 
Reported  by  Frank  R.  Fry,  A.  M.,  M.  D. 

Clinical  Lecturer  on  Diseases  of  the  Nervous  System,   St.  Louis  Medical  College,    Consulting 
Physician  to  the  St.  Louis  City  Hospital  on  Diseases  of  the  Nervous  System. 

Minnie  R.,  set.  30,  single,  sewing-machine  girl,  living  at 
2009  S.  12th  St.,  St.  Louis,  applied  to  the  Clinic  of  the  St. 
Louis  Medical  College,  January  9th,  1888,  stating  that  she 
was  troubled  with  a  shaking  and  jerking  of  the  extremities, 
especially  of  the  lower. 

As  she  sat  in  a  chair  the  heels  of  her  shoes  kept  up  a 
great  clatter  on  the  floor.  I  grasped  one  of  the  knees,  think- 
ing to  hold  the  foot  to  the  floor  and  thus  stop  the  shaking 
or  tremor.  I  was  surprised  to  find  that  all  the  force  I  could 
command  was  not  sufficient  to  do  so.  I  felt  of  the  lower 
extremities  under  the  clothing  and  found  the  muscles  of  the 
thighs  in  a  condition  of  marked  clonic  spasm.  With  inter- 
vals of  a  few  minutes,  this  peculiar  spasm  repeated  itself  a 
number  of  times  during  the  short  period  she  was  before  the 
class.  I  saw  her  again  the  same  day,  when  she  had  a  more 
severe  attack.  She  made  a  determined  effort,  at  my  re- 
quest, to  restrain  the  movements.  Not  only  was  she  unable 
to  do  so,  but  the  effort  caused  her  a  very  appreciable  general 
fatigue.  At  this  second  interview  there  was  an  involve- 
ment of  the  muscles  of  the  right  shoulder  and  arm,  consist- 
ing of  occasional  rapid  abduction  and  adduction  of  the  arm 
that  disappeared  after  several  jerks  of  some  of  the  shoulder 
group  of  muscles. 

Late  in  the  afternoon  of  the  following  day,  at  her  home, 
I  witnessed  her  have  an  attack,  of  which  the  following  is  a 
description :  The  first  intimation  of  it  were  several  deep, 
sighing   inspirations,    immediately   followed    by   a   violent 


-,gg  FRANK  R.  FRY. 

spasm  of  the  flexors  and  extensors  of  the  thighs,  causing 
them  to  be  thrown  rapidly  up  and  down,  so  that,  as  she  sat 
in  a  chair,  the  feet  tramped  the  floor  with  much  force.  Her 
mother  and  sister  at  once  assisted  her  to  a  large  reclining- 
chair,  and  placing  a  pillow  on  another  chair,  lifted  her  feet 
onto  it,  remarking  as  they  did  so  that  she  hurt  her  heels  in 
the  hard  attacks  unless  they  were  thus  protected.  She 
was  immediately  seized  with  another  violent  paroxysm. 
Her  lower  extremities  were  thrown  up  and  down  as  she  lay 
in  a  semi-reclining  position  so  that  the  heels  struck  the  pil- 
low with  much  force  and,  except  for  the  protection  that  it 
afforded,  would  certainly  have  been  much  bruised.  Her 
body  was  jostled  about  in  the  chair  by  violent  contrac- 
tions of  the  gluteal  and  other  muscles  of  the  pelvis  and  thighs, 
and  those  of  the  back.  With  all  the  strength  I  could  put 
forth,  I  was  unable  to  hold  either  one  or  both  of  the  extrem- 
ities down  on  the  chairs.  During  the  attack  I  rapidly  loos- 
ened and  removed  most  of  the  clothing  from  the  upper  part 
of  the  body,  and  passing  my  hand  over  the  muscles  of  the 
abdomen,  back  and  shoulders,  I  felt  them  at  different  times 
in  a  condition  of  clonic  spasm.  There  were,  every  few  mo- 
ments, violent  movements  of  the  respiratory  muscles,  caus- 
ing the  respiration  to  appear  distressed  ;  but  she  at  no  time 
complained  of  difficulty  in  getting  her  breath.  Occasionally 
the  spasm  of  the  arms,  especially  of  the  right,  was  quite  as 
rhythmic  and  almost  as  violent  as  that  of  the  thighs.  The 
seizure  lasted,  in  varying  severity,  for  about  ten  minutes, 
passing  away  gradually  with  occasional  jerks  of  some  of  the 
muscles  of  the  thighs  and  arms.  When  it  was  gone  she  was 
much  exhausted,  saying  that  if  we  would  let  her  alone  she 
could  drop  off  to  sleep. 

During  the  whole  attack,  I  saw  no  spasm  of  either  leg  or 
foot,  forearm  or  hand.  I  watched  this  point  very  carefully, 
having  refreshed  my  mind  on  the  characteristics  of  paramy- 
oclonus multiplex  by  reading  again,  before  I  witnessed  this 
attack,  the  article  of  Dr.  M.  Allen  Starr,  in  the  Journal  of 
Xervous  and  Mental  Disease,  July,  1887.  There  was  no 
distinct  spasm  of  the  muscles  of  the  neck  or  face  ;  but  to- 
ward the  end  of  the  attack  there  was  a  tremor  of  the  jaw 


A  CASE  OF  PARAMYOCLONUS  MULTIPLEX.  .™ 

which  I  attributed  to  her  exhausted  condition.  She  had 
had  during  the  day  five  or  six  such  attacks  as  the  one  just 
described. 

Dr.  Henry  W.  Hermann,  Professor  of  Diseases  of  the  Ner- 
vous System  in  the  St.  Louis  Post-Graduate  School  of  Med- 
icine, saw  the  case  several  times,  and  presented  it  to  his 
class.  I  have  asked  him  to  furnish  a  description  of  one  of 
the  attacks,  that  I  might  present  it  along  with  my  own. 
This  he  has  kindly  done  as  follows,  it  being  a  description  of 
an  attack  of  moderate  severity:  '■  While  sitting  in  a  chair 
the  patient  executed  a  tramping  movement  with  her  feet  of 
considerable  rapidity,  bringing  them  down  alternately,  and 
toward  the  close  of  the  attack,  simultaneously.  With  a 
few  slower  kicks,  then  with  a  few  jerks  in  the  right  arm  and 
a  few  deep  inspiratory  sighs  the  attack  ended,  lasting  a  few 
minutes,  to  begin  again  in  a  little  while.  She  evidently  had 
no  control  over  the  movements,  and  felt  very  much  exhaust- 
ed after  them.  There  were  no  symptoms  of  hysteria.  The 
muscles  implicated  were  those  of  the  hips  and  thighs,  those 
of  the  right  shoulder  and  arm  also  participating  slightly. 
Only  once  did  I  see  a  slight  flexion  in  the  hand.  The  left 
arm  was  quiet,  and  only  rarely  participated,  I  was  told. 
There  was  no  disturbance  of  sensibility.  No  paralysis  ex- 
cept slight  weakness  on  account  of  the  exhaustion.  The 
patellar  tendon  reflex  was  exaggerated.  Co-ordination 
good,  and  the  mind  clear." 

The  patient's  statement,  recorded  January  12th,  1888,  is 
as  follows :  Her  health  has  always  been  excellent.  She 
never  has  suffered  from  headache  or  any  other  form  of  ner- 
vous trouble.  Her  menstruation  has  always  been  normal 
and  regular.  The  family  history,  gained  from  the  patient 
and  her  mother,  is  unimportant.  She  has  been  continously 
engaged  in  running  a  sewing-machine  for  the  past  twelve 
years,  most  of  the  time  on  heavy  work,  much  of  the  time 
averaging  ten  and  often  twelve  hours  a  day.  Several  years 
ago  she  formed  a  habit,  which  she  has  continued,  of 
placing  the  left  foot  in  front  of  the  right  on  the  treadle.  On 
account  of  this  position  the  left  extremity  did  most  of  the 
vork.    (Until  recently  the  attacks  almost  invariably  began  in 


4QO  FRANK  R.  FRY. 

the  muscles  of  the  left  thigh).  About  October  1st,  1887, 
she  had  the  first  attack.  While  at  work  her  lower  extremi- 
ties were  suddenly  seized  with  a  jerking.  Then  followed 
an  attack  of  the  usual  description,  that  lasted  several  hours, 
leaving  her  much  fatigued.  She  arose  on  the  following 
morning  feeling  very  tired,  but  went  to  her  place  of  em- 
ployment and  worked  all  day.  She  had  no  more  attacks 
for  two  weeks,  when  she  again  had  a  hard  one.  From  this 
time  she  had  them  occasionally,  the  intervals  of  time  be- 
tween them  constantly  lessening.  She  continued  at  work, 
losing  an  occasional  day  or  two.  About  the  20th  of  De- 
cember she  had  the  most  violent  attack  she  has  ever  had. 
Since  then  she  has  not  been  able  to  work,  except  on  por- 
tions of  one  or  two  days.  The  attacks  have  continued  to 
come  every  day,  and  on  many  days  frequently.  Excepting 
a  general  lassitude  she  feels  perfectly  well  and  comfortable 
when  free  from  attacks.  On  Christmas  day  a  severe  attack 
seized  her  when  standing,  and  she  almost  fell  before  she 
could  grasp  a  support.  This  is  the  only  occasion  on  which 
she  has  come  so  near  falling.  She  always  feels  a  slightly 
distressing,  drawing  sensation  at  the  pit  of  the  stomach,  and 
a  general  weak,  slightly  faint  condition  that  prompts  her  to 
immediately  sit  down  before  the  jerking  begins.  She  says 
the  attacks  come  harder  if  she  is  excited,  annoyed,  or  hur- 
ried. After  them  she  feels  much  exhausted,  and  at  times  in 
this  condition,  cannot  resist  a  crying  spell.'  In  some  in- 
stances there  is  an  almost  irresistible  desire  to  sleep  follow- 
ing a  hard  attack. 

Present  condition,  April  6th,  1888.  The  severity  and 
number  of  attacks  have  very  gradually  but  almost  uninter- 
ruptedly diminished.  During  the  past  week  she  has  had 
three  seizures  of  considerable  severity,  the  only  ones  of  the 
kind  for  five  weeks.  Prior  to  this  she  had  gone  three  and 
four  days  without  any  attacks  at  all.  Her  general  health  is 
not  as  robust  as  before  the  attacks  began  ;  but  she  has  lost 
only  slightly  in  weight,  eats  and  sleeps  well,  and  when  free 
from  attacks  feels  perfectly  well. 

She  has  taken  hyoscyamine,  chloral,  bromides,  mor- 
phine and  anti pyrin,  separately  and  in  various  combinations. 


A  CASE  OF  PARAMYOCLONUS  MULTIPLEX.  *ol 

Chloral  seemed  more  effective  than  any  other  remedy 
used.  Hyoseyamine  evidently  had  some  effect  in  arresting 
the  attack  when  first  employed.  Antipyrin  seemed  to  have 
an  equal  effect,  that  continued  longer.  The  bromides 
seemed  useless  or  nearly  so.  Morphine  was  used  but  little, 
and  in  combination  with  some  of  the  other  remedies.  She 
has  also  received  several  courses  of  arsenic,  each  time  con- 
tinued until  decided  evidences  of  its  constitutional  effects 
were  present. 

The  patient  is  of  medium  height,  well  nourished,  with 
an  unusually  good  muscular  development,  especially  of  the 
lower  extremities.  There  is  no  evidence  of  organic  disease 
of  any  description.  There  is  an  increase  of  galvanic  and 
faradic  excitability  of  the  muscles  of  the  extremities,  espec- 
ially of  the  lower  ;  no  qualitative  changes.  There  is  an  ex- 
aggerated knee-jerk,  and  occasionally  a  decided  ankle- 
clonus.  There  are  no  disturbances  of  sensation,  or  co- 
ordination.    There  are  no  evidences  of  hysteria. 

The  patient  has  been  under  my  observation  since  Janu- 
ary 9th,  1888.  I  have  seen  her  have  many  attacks  varying 
in  severity  from  the  one  described  above  to  a  slight  tremor 
of  the  lower  extremities,  with  an  occasional  jerk  of  them 
and  of  the  shoulders.  Twice  only  I  have  seen  slight  spasm 
of  some  of  the  muscles  of  the  right  fore-arm.  Dr.  Hermann 
also  observed  this  in  one  of  the  attacks  that  he  saw.  Ac- 
cording to  her  own  statement  it  has  occurred  very  seldom. 
Until  the  present  week  I  had  never  seen  any  spasm  of  the 
leg,  when  I  found,  in  one  attack,  the  muscles  of  the  left  calf 
in  active  clonic  spasm.  She  called  my  attention  to  the  fact 
and  stated  that  it  had  happened  for  the  first  time  two  days 
before  ;  and  she  was  much  distressed  over  the  fact  of  the 
"jerking"  coming  in  a  new  place.  I  have  never  seen  any 
involvement  of  the  neck  or  face.  The  attack  always  began 
with  a  rapid,  rhythmic  movement  of  the  thighs.  I  have  al- 
ways been  able  to  induce  an  attack  by  a  sharp  blow  on  the 
thighs,  or  on  the  patellar  tendon,  or  often  by  several  quick 
dorsal  flexions  of  the  foot.  Twice  she  has  had  hard  attacks 
immediately  on  getting  into  a  cold  bed. 

Note,  May  12th. — More  than  three  weeks  ago  I  began  in 


A02  FRANK  R.  FRY. 

this  case  a  methodic  course  of  galvanism,  which  prior  to 
then  had  been  impracticable.  This  has  been  continued  to 
the  present  time.  It  has  consisted  of  a  seance  of  five  to 
fifteen  minutes  every  other  day,  with  the  anode  (a  9x10  cm., 
sponge-covered  electrode)  on  the  neck  and  the  mobile 
cathode  (4x4  cm.)  down  the  back  and  all  the  extremities, 
with  a  current  of  10  to  15  ma.  She  has  taken  no  medicine 
at  all  since  the  above  treatment  was  begun.  She  has  im- 
proved very  rapidly  during  the  last  two  weeks,  occasional 
fibrillary  contra  ctions  being,  now,  the  only  evidence  of  the 
presence  of  the  trouble. 


EDITORIAL  NOTES  AND  MISCELLANY. 


THE  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Preliminary  Programne  of  Papers  to  be  Read  at  the  Special 
Meeting  to  be  held  in  Washington,  D.  C,  September  i8th, 
10th,  and  20th,  1888. 

Dr.  Robert  T.  Edes,  of  Washington,  D.  C,  will  read  a 
paper  on  "  The  Relation  of  Renal  Diseases  to  Diseases  of 
the  Nervous  System."  This  subject  will  be  discussed  by 
Dr.  F.  X.  Dercum,  Dr.  Leonard  Weber,  Dr.  E.  C.  Seguin, 
and  Dr.  L.  C.  Gray. 

Dr.  B.  Sachs,  of  New  York,  will  read  a  paper  on  "  Mus- 
cular Dystrophies."  This  subject  will  be  discussed  by  Dr. 
P.  C.  Knapp,  Dr.  G.  W.  Jacoby,  Dr.  W.  R.  Birdsall,  Dr. 
L.  C.  Gray,  and  Dr.  C.  K.  Mills. 

Other  members  are  cordially  invited  to  participate  in 
these  discussions. 

The  Council  requests  that,  so  far  as  practical,  the  re- 
marks offered  in  these  discussions  shall  be  in  writing  and 
shall  not  occupy  more  than  ten  minutes  to  read. 

The  Secretary  will  furnish,  on  application,  a  brief  state- 
ment of  the  manner  in  which  the  readers  intend  to  treat 
their  subjects. 

The  following  papers  will  also  be  read : 

Post-hemiplegic  Disturbances  of  Motion  in  Children.  By 
Philip  C.  Knapp,  M.D.,  of  Boston. 

Heat  Centres  in  Man.     By  Isaac  Ott,  M.D.,  of  Easton. 

The  "Ape-Fissure,"  so  called,  in  Man.  By  Burt  G. 
Wilder,  M.D.,  of  Ithica. 

Clinical  Report  of  Cases  of  Epilepsy  following  Cerebral 
Hemiplegia.     By  E.  D.  Fisher,  M.D.,  of  New  York. 

The  Relation  of  Urinary  Changes  to  Functional  Ner- 
vous Diseases.     By  C.  L.  Dana,  M.D.,  of  New  York. 


<0a  EDITORIAL  NOTES  AND  MISCELLANY. 

The  Differential  Diagnosis  between  General  JParesis, 
certain  forms  of  Intra-cranial  Syphilis,  and  the  Cerebral 
Type  of  Disseminated  Sclerosis.  By  Landon  Carter  Gray, 
M.D.,  of  New  York. 

Report  of  a  Case  of  Primary  Lateral  Sclerosis  with  late 
Cerebral  Symptoms  due  to  Cyst  of  the  Floor  of  the  Lateral 
Ventricle,  with  Microscopic  Report.  By  Wharton  Sinkler, 
M.D.,  of  Philadelphia. 

A  Case  of  unusual  form  of  Myxcedema,  illustrated  by 
photographs  and  sections  of  excised  tissues.  By  F.  X.  Der- 
cum,  M.D.,  of  Philadelphia. 

A  Case  of  Alcoholic  Multiple  Neuritis,  with  Sections. 
By  James  Hendrie  Lloyd,  M.D.,  of  Philadelphia. 

Observations  and  Experiments  respecting  the  Pathology 
of  Neuritis.     By  James  J.  Putnam,  M.D.,  of  Boston. 

Dr.  C.  K.  Mills  and  others  will  demonstrate  specimens. 

Myositis  Subcuta  Progressiva.  By  Geo.W.  Jacoby,  M.D., 
of  New  York. 

The  Differential  Diagnosis  between  Peripheral  Neuritis 
and  those  Cerebral  Affections  with  which  it  is  most  likely 
to  be  confounded.     By  E.  C.  Spitzka,  M.D.,  of  New  York. 

Nervous  Affections  following  Injury.  By  Philip  C. 
Knapp,  M.D.,  of  Boston. 

Hereditary  Chorea.  By  Wharton  Sinkler,  M.  D.,  of 
Philadelphia. 

Aneurysm  of  an  Anomalous  Artery  causing  Antero- 
posterior Division  of  the  Optic  Chiasm  and  Bitemporal 
Hemianopsia.  By  S.  Weir  Mitchell,  M.D.,  of  Philadelphia. 
To  be  read  by  F.  X.  Dercum,  M.D.,  of  Philadelphia. 

A  Case  of  Focal  Epilepsy,  with  Observations  on  Tre- 
phining.    By  James  Hendrie  Lloyd,  M.D.,  of  Philadelphia. 

The  preliminary  report  of  the  Committee  on  Encephalic 
Nomenclature  will  be  read  by  Burt  G.  Wilder,  M.D.,  Chair- 
man, of  Ithica. 

GR/EME  M.  Hammond,  M.D.,  Secretary, 

58  West  45th  St.,  New  York. 
James  J.  Putnam,  M.D.,  President, 

106  Marlboro  St.,  Boston,  Mass. 


EDITORIAL  NOTES  AND  MISCELLANY.  aQc 

In  the  February  number  of  the  JOURNAL,  under  the 
heading  of  "Electricity  and  Neuropathy  in  the  Treatment 
of  Cancer,"  Dr.  Hughes  is  credited  with  being  the  first  and 
only  physician  who  has  ever  proposed  to  treat  cancer  with 
electricity.  The  subjoined  letter  from  Dr.  W.  W.  Wood, 
U.  S.  A.,  shows  that  we  were  in  error. 

Fort  Walla  Walla,  Wash.  Terr.,  June  3, 1888. 
My  Dear  Dr.  Hammond  : 

The  statements  on  pp.  155-6  in  No.  2,  Vol.  XIII.,  JOUR. 
Nerv.  and  Ment.  DlS.,  in  regard  to  Dr.  Hughes'  proposi- 
tion to  use  electricity  in  the  treatment  is  calculated  to  mis- 
lead those  who  do  not  know  the  inaccuracy  of  "to  Dr. 
Hughes  belo7igs  the  credit  of  Jiazmig  suggested  the  electric 
treatment."  So  far  as  I  am  aware  no  one  had,  of  record, 
-treated  a  case  of  uterine  cancer  by  electrolysis,  properly 
so-called,  when  on  Nov.  15,  1886,  in  a  case  reported  Dec. 
2j,  1886,  I  used  a  current  of  35  milliamperes  for  fifty  min- 
utes— current  furnished  by  a  Mcintosh  18-cell  battery,  and 
measured  by  an  Edelmann's  Einheits  galvanometre.  I  have 
since  that  time  used  electrolytic  galvanic  currents  in  can- 
cers more  than  225  times,  with  great  benefit  to  my  patients, 
in  doses  of  from  15  to  225  milliamperes,  with  variable  dura- 
tion of  seances. 

I  have  no  desire  to  detract  from  the  well-earned  reputa- 
"tion'of  Dr.  Hughes,  but  "render  unto  Caesar     *     *     *     *." 

I  trust  that  you  will  make  the  necessary  correction. 

Very  truly  yours, 

W.  W.  Wood, 
Capt.  and  A  sst.  Surgn  U.  S.  A  rmy. 
Dr.  Graeme  M.  Hammond. 


PERISCOPE. 

By  DRS.  G.  W.  JACOBV,  N.  E.  BRILL,  and  LOUISE  FISKE-BRYSON. 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

BINET    AND    FERE    ON    THE    PHYSIOLOGY    OF    MOVEMENTS 
AMONGST   HYSTERICAL   PERSONS. 

The  researches  in  this  paper  have  been  chiefly  carried 
out  on  three  points  ; — i.  Cataleptic  plasticity  of  the  waking- 
state;  2.  Involuntary  and  unconscious  movements  ;  3.  Vol- 
untary movements. 

1.  Cataleptic  Plasticity. — This  phenomenon  is  produced 
in  hysterical  subjects,  who  present  anaesthesia  of  the  skin 
and  muscular  sense.  The  eyes  are  bandaged,  the  anaesthe- 
tic member  is  raised,  the  subject,  who  has  lost  the  conscious- 
ness of  passive  movement,  being  unaware  of  it  ;  in  the  ma- 
jority of  cases  member  drops.  In  other  cases,  however,  it 
remains  in  the  position  in  which  it  has  been  placed.  The 
chief  characters  of  the  phenomenon  are  as  follows  : — 
(1)  The  duration  of  the  position  is  extremely  lengthy;  in 
one  instance  the  right  arm  was  horizontally  extended,  and 
the  fore-arm  slightly  flexed.  They  remained  in  this  posi- 
tion for  an  hour  and  twenty  minutes.  (2)  There  is  a  com- 
plete absence  of  trembling  in  the  member.  (3)  Fatigue  is 
absent.  (4)  The  plasticity  of  the  members  does  not  en- 
tirely suspend  voluntary  movements.  (5)  After  the  mem- 
ber has  dropped  there  is  no  evidence  of  paralysis  ;  in  fact, 
in  one  case,  the  dynamometer  gave  a  higher  figure  after 
than  before  the  experiment.  When  the  conditions  under 
which  these  phenomena  take  place  are  examined,  it  is  found 
that  they  are  always  accompanied  by  superficial  and  deep 


PHYSIOLOGY  OF  THE  HERVOUS  SYSTEM.  aq-. 

anaesthesia,  or  sometimes  only  by  the  superficial  form.  An- 
aesthesia to  fatigue  is  also  a  necessary  condition.  Closure  of 
the  eyes  is  not  essential.  It  is  interesting  to  remark  that 
subjects  of  this  kind  are  able  voluntarily  to  extend  the  anaes- 
thetic member  during  a  much  longer  period  than  the  nor- 
mal member.  Temporary  disappearance  of  the  anaesthetic 
suppresses  completely  in  that  part  of  the  body  the  power  of 
preserving  voluntarily  a  position  during  a  considerable 
time. 

2.  Unconscious  Movements. — These  movements  were  ob- 
served in  eight  out  of  sixteen  patients  who  were  experi- 
mented upon.  The  seat  of  the  movements  is  in  those  parts 
of  the  body  which  are  anaesthetic.  We  may  classify  the  re- 
sults obtained  under  various  headings. 

Repetition  of  a  Passive  Movement. — The  eyes  of  the  sub- 
ject are  bandaged,  and  the  anaesthetic  arm  is  caused  to  ex- 
ecute rapidly  or  gently  a  regular  movement.  In  the  midst 
of  its  course  the  limb  is  suddenly  abandoned,  when  the 
movement  is  seen  to  continue  during  a  certain  time,  which 
varies  in  different  individuals.  The  same  result  may  be 
produced  by  faradic  contraction,  and  also  as  the  sequence 
of  a  reflex  movement. 

Repetitio7i  of  a  Graphic  Movement. — In  this  case  a  pencil 
is  placed  in  the  hand  of  the  patient,  which  is  caused  by  the 
operator  to  execute  some  movement,  such  for  instance,  as 
one  of  a  circular  nature.  Whilst  this  is  being  done  the  hand 
of  the  patient  is  observed  not  to  be  completely  passive. 
The  passive  movement  having  been  communicated,  the 
hand  of  the  patient  is  released,  the  point  of  the  pencil  being 
left  on  the  paper.  In  one  group  of  cases  the  hand  at  once 
falls  to  the  side,  in  a  second  the  hand  still  holds  the  pencil 
as  if  about  to  write,  but  nothing  more  than  a  slight  trem- 
bling occurs.  In  a  third  group  of  cases,  however,  the  hand 
continues  to  execute  the  movement  which  has  been  com- 
municated to  it  for  a  period,  which  has  been  known  to  ex- 
tend to  a  quarter  of  an  hour.  Complicated  words,  composed 
of  five  or  six  letters,  are  sometimes  reproduced  with  exact- 
itude. 


40g  PHYSIOLOGY  OF. THE  NERVOUS  SYSTEM. 

Repetition  of  a  Voluntary  Movement. — This  occurs  nota- 
bly in  movements  of  writing.  The  patient,  having  volunta- 
rily written  with  opened  or  closed  eyes  the  same  letter  sev- 
eral times  in  succession,  is  told  to  stop.  He  believes  that 
he  has  stopped,  but  the  hand  continues  to  write  the  same 
letter.  A  facsimile  of  a  letter  written  by  a  patient  is  given, 
in  which  it  is  obvious  that  she  was  obliged,  in  spite  of  her- 
self, through  a  kind  of  stammering  of  the  hand,  to  write  sev- 
eral times  in  succession  the  same  letter. 

Association  of  Unconscious  Movements. — An  unconscious 
movement  determined  by  the  observer  may  produce  a  sec- 
ond unconscious  movement  with  which  it  has  been  generally 
associated  ;  thus,  for  instance,  when  a  perfectly  anaesthetic 
subject,  who  is  seated  with  closed  eyes,  is  taken  by  the  arm, 
he  may  be  caused  to  rise  by  .the  associated  movement  in  the 
lower  extremities. 

Unconscious  Movements  of  Adaptation. — These  may  also 
be  produced  in  hysteric  subjects. 

Unconscious  Rendering  of  a  State  of  Consciousness. — It 
often  happens  that  when  a  patient  whose  eyes  are  closed  is 
told  to  think  of  a  figure  or  a  word,  the  anaesthetic  hand 
which  holds  a  pencil  traces  unconsciously  the  figure  or  word 
which  is  in  the  mind. 

Spontaneity  of  Unconscious  Movements. — It  has  been  a 
question  as  to  whether  the  unconscious  movements  are  sim- 
ply the  manifestations  of  an  unconscious  memory,  or  if  other 
functions,  reason,  for  example,  may  intervene  sometimes  in 
the  operation.  The  experiment  was  made  of  causing  a 
patient  to  write  his  own  name  misspelt.  In  some  cases  the 
unconscious  repetition  corrects  the  error ;  in  others  it  is 
allowed  to  remain  incorrect.  The  most  striking  effect  in 
connection  with  all  these  manifestations  is  that  the  hysteri- 
cal anaesthesia  is  nothing  less  than  an  anaesthesia.  The  pa- 
tients on  whom  these  observations  were  made  have  all  lost 
the  consciousness  of  the  passive  movements,  but  only  the 
consciousness  ;  the  physiological  process  of  sensation  is 
preserved.  The  unconscious  sensation  is  registered  in  the 
nervous  centres  of  the  patient,  and  thus  the  same  movement 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  .qq 

is  unconsciously  reproduced.  Without  being  infalible  the 
unconscious  perception  of  the  hysterical  person  appears  to 
be  much  more  exact  than  the  conscious  perception  of  the 
normal  individual.  If  the  hand  of  the  subject  is  touched 
during  the  writing  it  will  be  perceived  to  be  extremely  rigid, 
and  any  attempt  to  stop  the  movement  meets  with  consid- 
erable resistance.  The  will  of  the  patient  has  also  no  effect 
on  the  movement.  Whilst  the  passive  movement  is  in 
progress  the  patient  may  be  permitted  to  open  his  eyes. 
He  is  then  much  surprised  at  seeing  his  members  in  move- 
ment, and  his  surprise  is  increased  when  he  observes  that  he 
is  incapable  of  stopping  the  movements  whose  cause  he  does 
not  understand.  When  the  patient,  in  the  course  of  a  pas- 
sive movement,  is  asked  to  write  a  second  word,  a  curious 
mixture  of  the  two  words  is  produced.  The  authors  offer 
the  following  interpretation  of  the  preceding  observations. 
They  seem  to  prove  that  there  exists  in  certain  hysterical 
persons  in  a  waking  state  a  doubling  of  the  personality, 
which  is  not  successive  but  simultaneous,  both  being  en 
rapport  with  the  operator,  but  in  different  ways.  The  prin- 
personality,  which  is  that  which  everybody  knows,  com- 
municates by  a  word  or  by  voluntary  movements  ;  the  sec- 
ond personality,  which  is  more  or  less  rudimentary,  com- 
munitates  with  the  experimenter  principally  by  movements 
of  the  anaesthetic  side. 

Amongst  certain  hemi-anaesthetic  or  completely  anaes- 
thetic subjects,  every  motor  phenomenon  provoked  in  one- 
half  of  the  body  produces  an  analogous  but  feeble  phenom- 
enon localized  in  the  corresponding  portion  of  the  opposite 
side.  In  the  case  of  a  contraction,  for  instance,  a  short  in- 
terval exists  between  the  movements  of  the  two  sides.  The 
indirect  contraction  is  generally  more  feeble,  is  sometimes 
incomplete,  and  occasionally  a  prolonged  excitation  of  the 
one  side  is  necessary  to  produce  an  action  in  the  opposite. 
Faradic  contractions,  reflex,  passive,  and  active  movements, 
may  also  become  unilateral.  Paralyses  are  an  exception  to 
the  rule  which  governs  all  these  bilateral  motor  phenomena. 
Instead  of  a  paralysis  suddenly  provoked  being  produced 


4IO  THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

■on  the  opposite  side,  an  accession  of  force  as  shown  by  the 
•dynamometer  is  the  result. 

3.  Voluntary  Movements. — The  majority  of  hysterical 
■subjects  who  have  lost  superficial  and  deep  sensibility  pre- 
serve the  faculty  of  coordinating  the  movements  writing 
with  their  eyes  closed.  Those  whose  insensibility  is  pro- 
found agreeing  in  saying  that  they  do  not  feel  themselves 
write.  They  almost  all  concur  in  stating  that  they  see 
themselves  writing.  Some  patients,  and  these  form  the 
majority,  are  incapable  of  writing  exactly  a  letter  any  given 
number  of  times  ;  they  either  write  it  too  often  or  too  seldom. 
Others,  on  the  contrary,  obtain  the  exact  number.  It  ap- 
pears that  both  these  classes  and  especially  the  former  write 
chiefly  under  the  guidance  of  their  visual  memory. — London 
Medical  Record.  L.  F.  B. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

CASCARA   SAGRADA   IN  RHEUMATISM. 

The  effect  of  cascara  sagrada  in  rheumatism  I  discovered 
by  accident.  About  three  months  ago  I  was  attacked  with 
severe  rheumatic  pains  in  my  shoulder,  the  slightest  motion 
causing  intense  pain.  The  third  day  of  the  attack  I  com- 
menced taking  as  a  laxative  ten  drops  of  the  cascara,  t.  i.  d. 
The  first  morning  after  taking  it  the  pains  were  so  much 
less  severe  that  I  could  move  my  arm  freely.  The  day 
following  I  was  entirely  free  of  all  discomfort. 

Although,  as  I  have  intimated,  I  had  not  taken  the 
cascara  with  any  idea  of  relieving  the  rheumatism,  it  occur- 
red to  me  a  few  days  later  that  possibly  the  sudden  sub- 
sidence of  pain  might  have  been  due  to  the  drug.  There 
being  a  few  cases  of  rheumatism  in  the  wards,  I  determined 
to  try  to  verify  my  suspicions.  Discontinuing  the  salicy- 
lates, iodides,  etc.,  which  these  patients  were  taking,  I 
substituted  ext.  cascarae  sagradae  fi\,  1  c.  c,  t.  i.  d.  The 
result  astonished  me.  Within  twenty-four  hours  there  was 
marked  improvement  in  every  case.  One  case  is  especially 
worthy  of  notice.     The  patient  was  a  Swedish  sailor  who 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM.  *{l 

had  been  admitted  three  months  previously.  He  suffered 
intensely,  and,  although  almost  everything  had  been  given 
from  which  relief  might  be  expected,  his  suffering  was  not 
allayed.  For  a  day  or  two  after  admission  hs  improved  on 
large  doses  of  salicylate  of  sodium,  but  subsequently  the 
pains  returned  as  badly  as  ever,  and  the  salicylate  had  no 
further  beneficial  effect.  Iodide  of  potassium  was  given 
several  different  times,  but,  owing  to  an  idiosyncrasy,  could 
be  continued  only  two  days  at  a  time,  a  profuse  rash  making 
its  appearance  over  the  patient's  entire  body,  the  pains 
remaining  as  acute  as  ever.  They  were  not  confined  to  any 
two  or  three  joints,  but  felt  in  all,  being  more  severe,  how- 
ever, in  the  wrists,  finger  joints,  and  ankles,  all  of  which 
sometimes  became  cedematous.  On  the  evening  of  Febru- 
ary 5th  I  commenced  the  exhibition  of  fifteen-drop  doses  of 
cascara  sagrada  three  times  daily.  The  following  morning 
he  was  about  the  same  ;  the  second  day  he  was  much  better  ; 
on  the  seventh  he  was  so  far  recovered  that  he  asked  and 
obtained  permission  to  walk  out.  From  this  on  he  con- 
tinued to  improve  steadily,  and  on  the  17th  of  February 
was  discharged  recovered. 

I  have  since  used  the  cascara  in  fully  thirty  cases,  some 
ten  of  which  were  in  out-patients,  and,  with  the  exception 
of  three  or  four  in  which  there  was  a  syphilitic  taint,  I  have 
obtained  the  most  satisfactory  results.  I  commenced  with 
1  c.  c,  t.  i.  d.,  and  have  so  far  never  had  to  increase  it  be- 
yond. 1.5  c.  c,  and  even  to  this  extent  in  but  two  cases.  I 
have  seldom  had  to  wait  beyond  twenty-four  hours  for 
beneficial  effects.  In  two  cases  I  had  to  stop  it  temporarily 
owing  to  its  opening  the  bowels  too  freely.  In  such  cases 
I  would  suggest  that  one  of  the  preparations  of  iron  be 
given  (separately)  at  the  same  time.  I  usually  combine  it 
with  syrup  or  glycerine  in  equal  parts,  and  instruct  the 
patient  to  take  from  thirty  to  forty  drops  in  water.  In  one 
case  in  which  neither  it  nor  the  salicylate  of  sodium  ap- 
peared to  give  much  benefit  I  combined  the  two  with  good 
effect.  It  is  but  seldom  the  bowels  are  opened  too  freely 
by  it,  the  cases  referred  to  being  the  only  ones  I  have  so 
far  observed. 


412  THERAPEUTICS   OF  THE  NERVOUS  SYSTEM. 

Among  the  out-patients  upon  whom  I  have  used  it  were 
two  intelligent  officers  of  vessels.  One  was  an  old  river 
pilot  who  had  periodically  suffered  intensely  for  years.  I 
gave  him  equal  parts  of  the  cascara  and  syrup,  of  which  I 
instructed  him  to  take  2  c.  c,  t.  i.  d.,  and  requested  him  to 
see  me  again  in  three  days.  He  returned  a  month  later, 
and  then  only  to  get  the  medicine  renewed.  He  reported 
that  he  had  never  before  had  anything  relieve  him  so 
quickly.  The  pains  began  to  abate  within  twenty-four  hours 
after  taking  the  first  dose,  and  in  three  days  after  left  him 
entirely.  He  had  had  no  return,  but,  for  fear  of  another 
attack,  had  come  to  ask  for  a  bottle  to  keep  with  him. 

The  second  case  was  that  of  Mr.  R.,  first  clerk  on  a 
large  river  steamer.  He  was  suffering  so  much  with  pain 
in  the  hip-joint  and  thigh  that  he  could  scarcely  get  to  the 
office.  I  put  him  on  large  doses  of  salicylate  of  sodium, 
with  colchicum  and  iodide  of  potassium,  and  instructed  him 
to  return  in  a  day  or  two.  In  a  week  he  sent  a  friend  to 
say  that  the  pain,  instead  of  lessening,  was  so  severe  that 
he  could  not  get  to  the  office.  The  salicylate,  etc.,  were 
stopped  and  he  was  given  cascara  syrup,  thirty-five  drops, 
t.  i.  d.  This  was  on  Friday  afternoon.  On  Sunday  he  came 
to  the  hospital  and  reported  that  he  had  commenced  taking 
the  second  prescription  Saturday  morning,  and  that  on 
Sunday  he  had  felt  decidedly  better.  He  was  ordered  to 
continue  the  drops,  and  report  on  Wednesday.  Tuesday 
he  sent  word  that  he  should  be  unable  to  report,  as  he  was 
sufficiently  recovered  to  resume  his  usual  place  on  the 
steamer. 

I  am  not  able  to  explain  the  action  of  the  drug  in  reliev- 
ing rheumatism  ;  I  leave  that  to  other  observers.  I  write 
this  in  the  hope  of  inducing  other  medical  men  to  use  the 
cascara,  report  their  experience,  and  indicate,  more  par- 
ticularly, in  what  class  of  cases  they  have  found  it  of  most 
benefit.  (H.  T.  Goodwin,  M.D.,  N.  Y.  Med.  Jour.,  June  9, 
1888.) 


VOL.  XIII.  July.  1888.  No.  7. 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


Original  %tt\tlt$. 


THE  OCULO-MOTOR  CENTRES  AND  THEIR 
CO-ORDINATORS. 

xJy  e.  c.  spitzka,  m.  d. 

Address  delivered  before  the  Philadelphia  Neurological  Society. 

1KNOW  of  no  subject  within  the  domain  of  neuro-anat- 
omy,  whose  consideration  is  at  the  present  moment  so 
well  timed,  being  replete  with  clinically  suggestive 
facts,  as  that  of  the  cell-nests  which  are  connected  with  the 
third,  fourth  and  sixth  cranial  nerves,  together  with  the 
inter-nidal  tracts  which  unite  them  in  automatic  co-ordina- 
tion. Recent  researches  have  brought  our  knowledge  up 
to  a  point  of  almost  ideal  exactitude.  Inasmuch  as  my  col- 
lection of  specimens  enables  me  to  illustrate  several  of 
these  points,  I  have  selected  this  subject  in  response  to  the 
kind  invitation  of  your  council. 

The  intrinsic  anatomy  of  the  cell  nests  of  the  fourth  and 
sixth  nerves  is  comparatively  simple,  and  I  shall  refer  to 
these  only  in  so  far  as  they  are  involved  in  the  binocular 
mechanism.  That  of  the  third  pair  is  more  complex. 
There  is  strictly  speaking  no  oculo-motor  nucleus,  in  the 
sense  in  which  Meynert  and  his  followers  use  the  term  ;  that 
is,  no  single  undifferentiated  cell  nest,  on  each  side  of  the 
median  line,  giving  origin  to  the  oculo-motor  nerve  of  the 
corresponding  side,  and  to  nothing  else.  The  first  blow 
dealt  this  view  was  given  by  v.  Gudden,1  who  found  on  des- 


1  Ueber  die  Kerne  des  Augenbewegungsnerven.     Tageblatt  der  54ten  Ver- 
sammlung  der  Aerzte  und  Naturforscher  in  Salzburg,  1881,  p.  186. 


i,,  E.    C.  SPITZKA. 

troying  one  third  pair,  that  the  ensuing  nucleur  elimination 
was  not  limited  to  one  side,  but  involved  both  sides.  He 
was  thus  able  to  distinguish  two  nidi  for  each  oculo-motor  ; 
one  of  these,  representing  a  decussated  origin,  is  situated 
meso-caudal  (in  the  rabbit)  the  other,  and  main  nest,  is 
found  lateral,  and  gives  origin  to  those  fibres  of  the  third 
pair  which  remain  on  the  same  side.  I  have  been  able  to 
confirm  this  result  with  some  slight  and  immaterial  modifi- 
cations in  the  cat.1  On  examining  more  minutely,  it  is  seen 
that  it  is  the  innermost  and  most  posterior  rootlets  of  the 
third  pair,  that  cross  the  median  line  and  have  a  decussated 
origin. 

Now,  pathological  observations  in  the  case  of  man2 
show  that  it  is  precisely  these  rootlets  which  carry  the  in- 
nervation of  the  rectus  internus.  The  division  of  the  third 
pair  supplying  that  muscle  must  be  therefore  regarded  as 
bearing  a  similar  relation  to  the  division  supplying  the  leva- 
tor palpebral,  rectus  superior,  inferior,  obliquus  inferior, 
sphincter  iridis,  and  musculus  ciliaris,  which  the  decussated 
portion  of  the  optic  nerve  bears  to  its  non-decussated  divi- 
sion. There  is,  however,  this  noteworthy  inverse  relation 
between  the  optic  and  oculo-motor  nerves.  The  lower 
forms  with  total  decussation  of  the  optic  nerves  (and  con- 
sequent non-identity  of  the  retinal  fields)  appear  to  have 
no  decussated  origin  for  the  nerve  fibres  supplying  the  rec- 
tus internus.3  Those  with  a  partial  decussation  of  the  optic 
nerves,  do  have  such  a  decussated  origin  for  the  nerve  fibres 

1  Neurologisches  Centralblatt,  1885,  p.  246.  Vorlaufige  Mittheilung  uber 
einige  durch  die  Atrophie  Methode  erzielte  Resultate. 

* Kahler-Pick .     Archiv.  f.  Psychiatrie,  X,  p.  334. 

Among  the  cases  not  generally  cited  which  support  this  view,  is  one  by  Mil- 
lingen,  where  a  focus  of  disease  situated  to  the  right  of  the  Aqueduct  pressed 
close  on  the  median  line  of  the  central  tubular  gray  of  that  region.  There  had 
been  during  life  spastic  (irritative?)  contracture  of  both  internal  recti.  They 
would  have  to  be  situated  near  together,  and  mutually  near  the  median  plane,  to 
account  for  this  observation. 

3  I  can  find  no  indications  thereof  in  the  sea  Or  fresh-water  turtles  (Thalla>o- 
chelys  midas  and  Natmemys  guttata).  The  partial  decussatian  of  the  chiasm, 
the  decussation  of  the  rectus  internus  fibres,  and  the  bilateral  reflex  reaction  of 
the  orbicularis  palpebrarum  go  hand  in  hand. 


OCULO-MOTOR  CENTRES.  a{c 

supplying  the  rectus  internus.     In  other  words,  there  is  a 
parallelism  in  development  between  the  decussated  division 


Figire  I. — Transsection  through  human  meso-cephalon,  the  clea    spaces  at  the  base  of  the- 
aqueduct-gray  represents  the  sub-nests  of  the  venlo-motor  nidus. 

of  the  third  pair  and  the  non-decussated  division  of  the 
second  pair,  which  is  in  harmony  with  physiological  re- 
quirements, and,  if  I  may  use  such  a  term,  anatomical  con- 
venience.1 

This  is  not  the  only  differentiacion  of  the  nuclear  masses 
connected  with  the  third  pair.  Further  cephalad  near  the 
median  line  there  is  in  man,  a  closely  crowded  cell  mass, 
with  a  dense  molecular  basis  which  is  in  most  levels  sharply 
demarcated,  and  in  others  (as  far  as  I  am  able  to  determine 
individual  differences  exist)  sends  out  a  lateral  process.2  In 
caudal  levels  it  is  a  vertical  column  parallel  to  the  raphe;  in 
cephalic  levels  the  lateral  extension  preponderates,  the 
vertical  column  shrinks  and  eventually  it  becomes  a  mere 
appendix  to  the  transverse  oval  mass  into  which  this  exten- 
sion becomes  as  it  were  inflated. 

1    The  philosophy  of  this  mechanism  will  be  considered  in  connection  with  the 
posterior  longitudinal  fasciculus  of  the  tegmentum. 

sWestphal,  who  is  the  first  to  accurately  describe  this  sub-nidus,  says  that  no 
indications  can  be  found  in  any  illustrations  extant,  of  its  prior  recognition.  In 
the  accompanying  wood -cut,  which  has  seen  service  in  two  of  the  author's 
papers  (Journal  of  Nervous  and  Mental  Disease,  1879-1880.  and  N.  Y. 
Medical  Record,  Oct.  25,  1884),  it  will,  however,  be  seen  that  the  dis- 
tinction had  been  recognized,  though  less  accurately,  and  without  any  physio- 
logical deduction,  or  reference  in  the  text.  See  Westphal,  "Archiv.  f.  Psychia- 
tric," loc.  cit. 


41I6  £■    C.    SPITZKA, 

Westphal,  who  first  sharply  demarcated  this  sub-nucleus, 
adduces  clinical  and  anatomical  facts  to  prove  that  it  is  con- 
nected with  the  innervation  of  the  inner  muscles  of  the  eye, 
that  is,  the  ciliary  or  the  iris  sphincter,  or  both.  Before 
proceeding  to  discuss  this  exceedingly  plausible  view,  per- 
mit me  to  describe  in  detail  the  cell-nests,  and  their  rela- 
tions to  root  and  other  fibres,  as  derived  from  a  study  of 
three  sets  of  trans-sections  of  the  human  isthmus,  one  of 
which  was  a  complete  one. 

In  order  to  simplify  matters  I  will  distinguish  four  trans- 
section  levels,  designating  them  respectively,  A,  B,  C  and 
D  in  the  cephalo-caudal  direction. 

(A)  The  general  contour  of  the  aqueduct-gray  is  drawn 
ventrad  into  a  very  sharp  apex.  In  its  dorsal  part  it  is 
materially  encroached  upon  by  the  post-commissura.  Pow- 
erful fibre  bundles  surround  its  margin,1  occasionally  break- 
ing into  its  lateral  contour,  but  mostly  accumulating  latero- 
ventrad  to  form  the  posterior  longitudinal  fasciculus,  which 
in  this  level  is  extremely  small  as  contrasted  with  the  di- 
mension it  has  in  field  D. 

Cells. — The  cells  of  this  level  are  of  intermediate  dimen- 
sions, they  are  mainly  accumulated  in  a  single  mass,  which 
follows  in  contour  the  latero-ventral  outline  of  the  central 
tubular  gray.  They  are  parallel  to  this  contour  with  their 
long  axes.  They  do  not  stain  as  deeply  in  carmine  as  those 
of  levels  B,  C  and  D.  As  we  progress  caudad  they  become 
more  closely  crowded,  they  appear  smaller,  but  more  dis- 
tinctly stained,  and  the  basis  substance  assumes  more  of 
the  transparent  gelatinous  consistency,  hence  staining  deep- 
ly in  carmine. 

Intra-nidal  Fibres.- — -The  medullated  fibres  are  limited  to 
the  lateral  angle  of  the  aqueduct-gray,  just  ventrad  of 
which  they  break  into  it.     They  appear  to  terminate  in  and 


1  It  i^  their  existence  which  induced  Darkschewitsch  (Pfluger's  Archiv. 
XXXVIII.  ami  Xeurol.  Centralblatt,  1885,  No.  5,  p.  100),  to  predicate  a  connex 
between  the  post-commissura  and  the  oculo-motor  nuclei,  particularly  regarding 
it  u^  a  path  lor  the  light-reflex,  a  view  which  is  opposed  by  the  excellent  develop- 
ment of  this  commissure  in  animals  with  rudimentary  eyeballs,  and  the  absence 
of  any  lesion  in  it,  in  cases  where  there  was  reflex  iridoplegia.  (Moeli,  Arch.  f. 
P>ych.,  XVIII.,  p.  31.) 


OCULO-MOTOR  CENTRES.  4^7 

around  the  dorso-lateral  extension  of  the  cell  mass  just 
described. 

Posterior  Longitudinal  Fasciculus. — This  important  bun- 
dle can  be  distinctly  seen  to  be  built  up  by  arched  fibres 
coming  from  dorsad,  circling  round  the  lateral  angle  of  the 
aqueduct-gray,  ventro-mesad.  They  have  the  same  deriva- 
tion, apparently,  as  the  intra-nidal  fibres  of  this  level. 

Oculo-motor  Rootlets. — These  are  as  yet  few,  and  in  the 
cephalic  sections  of  this  level  entirely  absent.  The  most 
cephalic  rootlet  of  the  third  pair,  discoverable  in  a  perfect 
series  of  sections  from  man  is  directly  derived  from  the  most 
mesal  bundle  of  the  posterior  longitudinal  fasciculus.  It 
is  the  most  cephalic  and  at  the  same  time  a  mesal  rootlet  of 
that  nerve,  which  has  this  origin.  It  is  in  caudal  levels 
joined  by  fibers  derived  apparently  from  the  nidus  of  cells 
above  spoken  of. 


Figure  II.-  Transaction  in  second  fifth  of  human  oculo-motor  nidus.  1.  Lateral  division  of 
main  nidus  ;  probable  center  of  levator  pa'.pebrae.  a.  Fibres  ectad  of  Westphal's  nidus.  3. 
Westphal's  nidus.  4.  Emerging  rootlets  of  III.  pair,  from  fibres  surrounding  and  entering  that 
nidus.  5.  Main  portion  of  main  nidus.  6.  Rootlets  of  III.  pair  thence  emerging.  7.  Sagattil 
nidus. 


4Jg  E.   C.  SPITZ  A' A. 

(B)  As  we  proceed  caudad,  the  beautiful  circular  dorsal 
contour  of  the  aqueduct-gray  becomes  established,  the  post- 
commissura  no  longer  intruding.  A  lateral  angle  becomes 
more  prominent,  and  the  transverse  diameter  of  the  area 
becomes  greater.  At  the  same  time  the  ventral  prolonga- 
tion becomes  shortened.  The  demarcation  is  more  dis- 
tinct, the  posterior  longitudinal  fasciculus  forming  its 
boundary  even  to  and  through  the  raphe. 

Cells. — Two  distinct  nests  can  be  recognized;  one  bor- 
dering directly  on  the  posterior  fascicle.  The  other,  as  yet 
the  larger,  corresponding  to  Westphal's  nidus,  is  more  mesal 
and  slightly  dorsal.  Its  cells  are  smaller,  closely  crowded, 
and  become  more  so  the  more  caudal  we  pass.  The  lateral 
mass  is  of  larger  cells.  It  grows  larger  as  we  pass  caudad. 
I  shall  designate  them  respectively  as  Westphal's  and  the 
main  nidus. 

(a)  Westphal's  nidus. — From  being  parallel  to  the  lat- 
eral contour  of  the  ventral  half  of  the  aqueduct-gray,  and 
separated  by  a  considerable  interval  from  its  fellow,  which 
it  approaches  only  with  its  ventro-mesal  extension,  it  be- 
comes shaped  like  an  inverted  letter  L,  the  two  together 
occupying  this  relation  11".  It  is  the  lateral  extension 
which  is  occasionaly  cut  off  from  the  main  mass  and  which 
Westphal  designates  as  a  separate  nidus,  (his  lateral  cell- 
group).  Histologically  it  is  exactly  the  same  as  the  re- 
mainder of  Westphal's  nidus. 

(b)  Main  nidus. — Closely  applied  to  the  contour  of  the 
posterior  fasciculus,  extending  into  the  peninsulas  of  gray 
matter  which  the  aqueduct-gray  detaches  betwixt  its  bun- 
dles, this  cell-nest  gradually  increases  caudad, as  Westphal's 
nest  decreases.  It  extends  nearer  and  nearer  to  the  median 
line,  but  never  quite  reaches  it,  at  least  not  as  a  compact 
cell-mass.  It  is  everywhere  demarcated  from  Westphal's 
nest,  and  all  other  cell-groups  by  the  powerful  fibre-arch  to 
be  described. 

Intra-nidal  Fibers. — The  large  intrusion  of  fibres  noted 
in  level  A  increases  and  arches  completely  round  the  main 
nidus.  It  sends  off  numerous  detachments  into  it.  On  the 
whole  it  may  be  compared  to  a  horse-shoe  joined  at  either 


OCULO-MOTOR  CENTRES.  *Xg 

end,  apparently,  to  the  most  ectal  and  mesal  rootlets  of  the 
third  pair,  its  arch  resting  on  the  main  nucleus,  its  fibres 
fielding  off  the  latter  into  various  irregular  columns  and 
groups,  resembling  the  sub-nests  of  the  hypoglossal,  the 
facial  and  other  motor  nerve  origins.  I  shall  henceforth 
designate  this  as  the  great  intra-nidal fibre  arch. 

In  and  bordering  on  the  middle  line  of  the  aqueduct-gray, 
are  straight  fibres  which  take  the  following  three  courses, 
dorsal:  i.  Parallel  to  the  middle  line,  coursing  along  the 
mesal  aspect  of  Westphal's  nest  and  arching  ectal  round 
its  dorsal  aspect.  2.  Parallel  to  the  middle  line,  ectal  of 
those  just  described,  and  directly  abutting  on  that  nest.  3. 
Starts  parallel  to  median  line,  then  arch  over  between  the 
ectal  aspect  of  Westphal's  nest  and  the  great  intra-nidal 
fibre-arch,  with  which  it  is  confounded,  to  arch  round  the 
ectal  prolongation  of  Westphal's  nest  or  even  to  break  into 
it,  so  as  to  cut  off  one,  sometimes  two,  islands. 

Posterior  longitudinal  fasciculus.  —  This  bundle  has 
nearly  attained  its  full  dimensions,  it  extends  to  the  middle 
line,  across  which,  but  for  interruption  by  connective  tissue 
septa,  it  is  continuous. 

Rootlets. — The  innermost  rootlets  of  the  third  pair  are 
in  part,  directly  continuous  with  the  fibers  abutting  on  and 
encircling  Westphal's  cell-nest.  The  middle  and  ectal 
radicles  are  not  necessarily  derived  from  those  divisions  of 
the  main  cell-nest  opposite  which  they  appear  to 
emerge,  for  individual  fibres  can  be  seen  to  meander  quite  a 
distance  amongst  and  over  the  sub-nests  before  becoming 
lost.  Some  fibres  appear — but  it  is  impossible  to  establish 
this  clearly — to  emerge  from  the  great  intra-nidal  fiber-arch. 
(C)  The  aqueduct  gray  continues  to  becomes  wider,  and 
lower,  the  meso-caudal  prolongation  shrinking  upwards  ; 
still  there  is  a  considerable  prolongation  between  the  two 
main  masses  of  the  posterior  fasciculus,  abutting  the  junc- 
tion piece  of  the  latter.  At  the  lateral  angle,  where  the 
"arched"  (dorsal)  and  angular  (ventral)  half  of  the  aque- 
duct joins,  fibres  appear  to   originate  in  a   lateral   mass  of 


420  E ■   C   SPITZKA. 

cells  shaped  like  those  of  the  oculo-motor  nidus,'  and  run- 
ning lateral  and  slightly  caudal,  after  a  direct  course,  be- 
come lost.  Of  their  significance  nothing  is  known,  and 
they  are  excluded  from  consideration  here. 

Cell  nests. — There  are  three,  the  main  nest,  attaining  its 
full  development,  a  sagittal  nest,  between  the  two  main 
nests,  and  the  last  residue  of  the  disappearing  nests  of 
Westphal. 

(a)  WestphaVs  nest  is  represented  by  an  oval  mass, 
whose  long  axis  is  parallel  to  its  fellow  from  which  it  is 
separated  by  a  considerable  interval. 

Main  nest — same  character  as  in  level  B,  the  peninsular 
extensions  into  the  posterior  fasciculus  are  in  some  individ- 
uals very  large. 

Sagittal  nest. — The  ventral  extension  of  the  gray  matter 
contains  cells  shaped  like  those  of  the  main  nest,  and  de- 
marcated from  it  by  fibres  passing  on  either  side  ventro- 
dorsal to  the  relics  of  Westphal's  nest. 

In  addition  to  these  cell  nests,  the  small  scattered  angu- 
lar nerve  cells  which  are  found  in  all  levels  in  the  caudal  or 
angular  half  of  the  aqueduct-gray,  become  larger,  and 
near  the  floor  of  the  aqueduct  present  an  accumulation 
which  is  quite  distinct,  and  exactly  in  the  median  line. 

Intra-nidal fibres. — (a)  The  great  intra-nidal  fibre  arch 
becomes  more  and  more  individualized  as  we  proceed  cau- 
dal, and  the  main  nucleus  becomes  distinctly  isolated  and 
often  driven  out  of  the  contour  of  the  central  tubular  gray 
by  it.  It  is  plexiform  in  arrangement,  its  connex  with  the 
great  rootlets  of  the  third  pair  is  very  distinct. 

b  WestphaVs  fibre  field  \s  represented  by  a  vertical  col- 
umn of  fibres,  to  whose  dorsal  end  Westphal's  nest  is  at- 
attached  like  a  stone  enclosed  in  a  sling.  It  is  very  com- 
pact, but  ventrad  becomes  less  so — probably  by  gradual 
passage  to  cephalic  levels.  The  symmetrical  columns  form 
the  lateral  boundary  of  the  sagittal  cell-nest. 

(e)    The  deeus  sated  fibre  field. — There  is  a  distinct  decus- 


'They  might  be  confounded  with  the  lateral  group  of  Westphal's  nidus,  but 
they  do  not  appear  in  the  same  level,  are  not  continuous  therewith,  and  are 
larger  and  less  crowded. 


OCULO-MOTOR  CENTRES.  a2  i 

sation  of  fibres  which  appear  to  originate  in  the  cells  of  the 
sagittal  nest.  This  decussation  is  not  symmetrical.  In  one 
level,  the  bundle  from  left  to  right,  in  the  next,  that  from 
right  to  left  preponderates.  They  extend  but  a  short  dis- 
tance across  the  median  line  with  their  cell  origins  ;  the 
crossed  part  becomes  lost  in  the  great  arched  intra-nidal 
field. 

(D)  The  angular  part  of  the  aqueduct  gray  has  contracted 
so  much  that  but  a  small  part  falls  below  a  line  connecting 
the  "angles."  The  ventral  apex  is  still  present,  but  the 
lateral  contour  has  become  gradually  tilted,  so  as  to  be 
nearly  horizontal. 


Figure  III. — Section  through  more  caudal  level  of  human  oculomotor  nidus.  7.  Rootlets 
from  the  subdivision  of  main  nidus,  probably  representing  levator  palpebra.  12.  Fountain-like 
decussation  of  tegmentum. 

1.  Molecular  mass  of  raphe.  6.  Cells  of  descending  trigeminal  origin.  3.  Scattered  cells. 
5.  Main  nidus.  9.  Posterior  longitudinal  fasciculus.  10.  Sagittal  nidus.  11.  Great  intra  nidal 
fibre  arch.  The  molecular  masses  near  either  angle  of  the  floor  of  the  aqueduct  may  represent 
the  interoptic  ganglia  of  the  reptilia. 

Cell  nests. — Aside  from  the   diffuse  small  cells,  there  is 
but  one,  and  that  is  the   main  nest.     It  has  become  almost 


422  E-   C-   SPJTZKA. 

isolated  from  the  aqueduct  gray  by  the  great  intra-nidal 
fibre  arch,  which  here  shows  a  diminution,  to  eventually 
disappear,  before  the  nucleus  does  so.  The  distinction 
between  the  main  nucleus  and  the  common  gray  of  the 
aqueduct  can  however,  easily  be  made.  It  is  less  gelatinous, 
and  its  basic  substance  stains  less  deeply  in  carmine.  Its 
cells  are  the  largest  in  the  oculo-motor  nidus.  It  is  intim- 
ately connected  with  the  septa  of  the  posterior  fasciculus, 
accessory  bundles  of  which  appear  in  the  cross-section  of  this 
nidus,  and  in  sagittal  sections  appear  to  proceed  directly  out 
of  it. 

Rootlets. — There  are  no  rootlets  in  these  levels,  although 
the  large  nuclear  mass  above  spoken  of  extends  a  consid- 
erable distance  caudad. 

Intra-nidal  fibre  fields. — The  great  arched  field  disap- 
pears at  the  cephalic  part  of  the  insulated  division  of  the 
main  nest  just  described.  There  are  numerous  fibres  ap- 
parently passing  from  one  main  nest  to  the  other. 

Summing  up  the  foregoing,  the  topography  of  the  cell 
nests  in  the  angular  division  of  the  aqueduct  gray  may  be 
stated  to  be  as  follows:  First,  a  diffuse  formation  of  small 
angular  cells,  loosely  scattered,  or  as  in  level  c,  showing  an 
accumulation  ventrad  of  the  aqueduct.  Second,  a  distinct 
cell  nest,  successively  laurel  leaf,  inverted  L,  and  oval 
shaped,  with  small  crowded  cells  imbedded  in  dense  mole- 
cular substance,  which  is  at  once  a  dorso-mesal  and  the  most 
cephalic.  This  is  the  one  discovered  by  YVestphal.  Third, 
a  large  complex  nucleus,  beginning  far  cephalad,  but  yet 
caudad  of  the  cephalic  end  of  Westphal's  nucleus,  closely 
applied  to  the  posterior  fasciculus, increasing  caudad,  finally 
almost  isolated  from  its  parent  gray,  and  ultimately  lost 
among  the  septa  of  the  posterior  fasciculus.  This  is  the 
main  or  proper  cell-nest.  Fourth,  a  sagittal  cell-nest,  not 
separable  into  symmetrical  halves,  which  begins  in  the  third 
fifth  and  ends  before  the  last  fifth  of  the  cephalo-caudal  ex- 
tent of  the  main  nest. 

The  main  part  of  the  oculo-motor,  namely,  all  except 
its  most  cephalo-mesal  and  caudo-mesal  fibres,  originates 
from  the  main  nidus.     Its  most  cephalo-mesal  fibres  origin- 


OCULO-MOTOR  CENTRES. 


423 


ate  from  the  nidus  of  Westphal.  As  to  its  caudo-mesal 
fibres  there  is  some  doubt,  though  the  probability  is  that 
they  originate  from  the  sagittal  nidus.  It  is  noteworthy 
that  no  oculo-motor  rootlets  originate  from  the  posterior 
(semi-isolated)  division  of  the  main  nest,  imbedded  in  the 
posterior  fasciculus.  I  believe  this  mass  can  be  identified 
with  those  cells  to  which  Mendel  traced  the  orbicularis 
oculi  fibers  of  the  facial  nerve,  and  will  in  the  sequel  advance 
reasons  for  this  view. 


Figure  IV. — Transsection  of  mesen-cephalon  of  fresh-water  turtle. 

COMPARATIVE    DEVELOPMENT   OF   THE    OCULO-MOTOR 
NUCLEI    AND   FIBRE   TRACTS. 
In  the  reptiles  generally,1  there  is  but  little,  if  any,  indi- 


1  The   sea-turtle,  fresh-water    turtles,  snakes   and  Sheltopazik  which  I  have 
examined. 


424  £-   C   SPITZKA. 

cation  of  a  differentiation  of  these  cell-nests  of  the  third 
pair.  The  ventral  part  of  the  aqueduct-gray,  which  in  these 
animals  is  drawn  out  in  a  long  attenuated  area  on  either 
side  of  the  mesoccelian  slit,  contains  a  number  of  scattered 
elements  shaped  like  typical  motor  cells,  and  from  which 
the  fibres  of  the  third  pair  can  be  traced  with  a  distinctness 
seldom  found  in  mammals.  Some  indication  of  individuali- 
zation is  found  in  a  group  lying  most  ventral,  where  the 
aqueduct-gray  often  shows  a  slight  swelling  on  it.  Dorsal 
the  cells  become  smaller  and  are  followed  by  the  ordinary 
minute  elements  characterizing  the  outer  part  of  the  aque- 
duct-gray of  these  animals.  In  some  Saurians  like  the 
Anolis  and  Iguana,  the  nuclei  are  better  developed,  and  it 
is  particularly  the  cell-nest  of  the  trochlearis  that  is  beau- 
tifully individualized.1 

In  birds  the  nucleus  of  the  third  pair  is  very  large.  In 
a  series  of  sections  (sagittal)  from  the  ostrich,  I  can  distin- 
guish two  superimposed  strata  of  cells,  which  are  probably 
the  expression  of  as  many  lateral  extensions  of  the  central 
tubular  gray;  one  of  these  is  interradicular  and  ventrad  of 
the  posterior  fasciculus.  In  all  the  sauropsida  the  posterior 
longitudinal  fasciculus  is  very  distinct,  and  in  some  (chely- 
dra)  an  uninterrupted  course  of  single  axis  cylinders  can  be 
traced  to  the  fundamental  anterior  column,  of  the  spinal 
cord.2  In  all,  its  connection  with  the  nucleus  of  the  third, 
fourth  and  fifth  pairs  is  obvious.  In  none  can  its  origin  be 
traced  much  further  forward  than  the  anterior  end  of  the 
oculo-motor  nucleus.  The  fibres  of  most  cephalic  extent 
appear  to  be  derived  from  the  deep  gray  of  the  optici '  (an- 
terior pair  of  the  corpora  quadrigmina);  succeeding  fibers 

1  The  cell- nests  in  the  chamaleon  would  prove  an  interesting  study.  It  is 
not  impossible  that  the  nest  connected  with  the  nictitating  membrane  may  be  dis- 
covered in  some  of  the  sauropsida. 

*  Osborn  has  shown  me  drawings  from  an  amphibian  brain  in  which  this 
bundle  is  represented  as  giving  off  from  its  caudal  extent  a  fibre  to  the  horseshoe 
shaped  root  of  the  facial  nerve,  a  noteworthy  observation  stated  to  be  based  on 
unmistakable  ap]>earances. 

'  Owing  to  the  peculiar  distortion  of  the  mesencephalon  in  birds  the  optici  are 
crowded  latero-ventral.  It  i^  probably  connected  with  this  fact  that  the  anterior 
end  of  the  posterior  fasciculus  undergoes  a  marked  curve  ventrad. 


OCULO-MOTOR  CENTRES.  *2c 

originate  or  terminate  in  the  nuclei  of  the  oculo-motor  sys- 
tem, and  the  remainder  run  into  the  spinal  cord,  as  the 
deepest  fibres  of  the  anterior  column.1  These  relations  ap- 
pear to  be  maintained  in  all  higher  vertebrates,  including 
man.  In  the  dog,  cat,  sea-lion  and  lion,  the  nuclei  are  dis- 
posed similarly  to  the  plan  which  will  be  detailed  when  dis- 
cussing my  atrophy  experiment.  In  a  beautiful  section  paral- 
lel with  the  base  of  the  brain  of  a  dog,  two  distinct  cell-nests 
can  be  readily  distinguished.  One  of  these  is  a  slender 
column  near  the  median  line,  and  nearly  fusing  across  it  ;  it 
extends  further  cephalad  and  ceases  first  caudad.  Its  pos- 
terior extremity  is  grasped,  as  it  were,  by  the  other  large 
celled  cell-nest.  In  other  words,  the  main  nidus  opens  out 
like  the  petals  of  a  flower  to  enclose  the  root  of  its  pistils, 
represented  by  the  former  small  celled,  or  Westphal's  cell- 
nest.2  In  the  sea-lion  the  sagittal  nuclei  described  by  my- 
self, is  well-developed.  In  the  dog  a  remarkable  small 
celled,  thickly  crowded  sagittal  cell  mass  bisects  the  central 
tubular  gray  in  the  level  of  the  posterior  pair  of  the  quadri- 
gemina,  and  extends  into  the  level  of  the  trochlearis  origin. 
I  cannot  establish  its  existence  in  man. 

In  the  crepuscular  bats  the  cell-nests  of  the  oculo-motor 
system  are  very  small,  and  the  posterior  fasciculus  is  atten- 
uated. In  the  mole  the  nuclei  are  almost  absent,  and  the 
fascicular  is  atrophic.3  In  the  anthropoid  apes  alone,  of 
all  animals  examined,  is  the  anatomy  of  the  oculo-motor 
cell-nests  and  their  intranidal  tracts  approximately  as  com- 
plex as  in  man.  This  fact  adds  another  to  the  numerous 
observations,  which  induced  the  writer,  years  ago,4  to  point 
out  the  erroneous  nature  of  the  view  held  by  many,  that  in 
higher  development  the  "intellectual"  centres  are  devel- 
oped at  the  expense  of  the  reflex  centres,  or  that  the  more 
perfect  reflex   mechanisms  are  to  be  sought  for  in  lower 

1  Those  nearest  the  gray  substance  of  the  base  of  the  anterior  horn,  included 
between  it,  the  anterior  spinal  commissura  and  the  ventral  fissure. 

2  The  reader  may  be  reminded  at  this  point  that  in  the  dog,  the  accommoda- 
tion pupil  reaction  is  the  reverse  of  the  human. 

3  Ford,  Archiv.  f.  Psychiatrie,  vii.,  p.  421. 

*  Architecture  and  Mechanism  of  the  Brain,  Journal  of  Nervous  and 
Mental  Disease,  1879-1880,  pp.  45  and  67  of  reprint. 


426 


E.   C.  SPITZKA. 


forms.  The  nuclear  anatomy  of  the  spinal  centres  of  the 
hypoglossal  and  facial  nerves,  and  even  if  so  blindly  auto- 
matic a  system  as  that  of  the  ocular-motor  mechanism, 
prove  at  every  step  that  man  is  at  the  head  of  the  verte- 
brata,  not  alone  in  regard  to  his  central  development,  but 
also  in  the  extent,  complexity  and  intricacy  of  the  reflex 
centres  and  their  uniting  fibre  tracts. 

The  atrophy  experiment  I  have  referred  to  has  been 
detailed  in  its  general  features  elsewhere.1  Suffice  it  to  say 
that  the  left  third  pair  was  divided  at  its  emergence  from 
the  crus,  and  that  all  the  other  oculo-motor  nerves  were 
normal.  The  left  optic  tract  had  been  also  divided.  In 
the  sequel  I  shall  attempt  to  homologize  the  atrophied 
developed  sub-nuclei  with  the  human  by  giving  the  same 
names  used  in  the  above  description  of  the  human  sub- 
nuclei. 

(a)  Main  nucleus. — Normally  developed  in  all  levels  on 
the  right  side.  Present  only  in  its  most  posterior  division 
on  the  left  side. 

(b)  Sagittal  nucleus. — On  the  left  side  it  is  normally 
present,  but  on  the  right  side  of  a  line  drawn  from  the 
ventral  apex  of  the  aqueduct  to  the  raphe,  few,  and  those 
very  small,  cells  are  found. 

(V)  WestphaVs  nucleus. — As  I  am  uncertain  about  the 
homologies  of  this  nucleus  in  the  cat,  though  well  devel- 
oped in  the  dog,  I  reserve  any  opinion  for  the  present. 

{d)  Nucleus  under  aqueduct  symmetrically  developed. 

(e)  Intranidal  fibres. — These  in  my  specimens  of  nor- 
mal carnivora,  as  well  as  the  experimental  kitten,  are  more 
interlaced  a  id  less  distinctly  grouped  in  bundles  than  in 
man.  In  the  level  where  the  left  sagittal  and  right  main 
nucleus  are  in  their  main  development,  they  are  seen  in 
large  numbers  extending  dorsad  and  mesad  of  the  right 
main,  and  across  the  median  line  into  the  left  sagittal 
nucleus.  Both  classes  of  fibres  enter  the  emerging  rootlets 
of  the  right  third  pair. 


'  Journal  01  Nervous  and  Mental  Disease,  June,  1888,  vol.  xiii.,  No. 
6.  P-  349- 


OCULO-MOTOR  CENTRES.  *2j 

(/)  Posterior  longitudinal  fasciculus. — In  all  higher  lev- 
els a  marked  asymmetry  is  observed.  In  the  upper  level 
of  the  main  nucleus  it  is  absent  on  the  operated  side.  With 
the  appearance  of  the  sagittal  nidus,  it  is  found  on  both  sides, 
about  half  as  large  on  the  operated  as  on  the  unoperated 
side.  At  the  lower  end  of  the  oculo-motor  nidus,  whose 
posterior  division  as  stated  is  present  on  both  sides,  it  is 
about  two-thirds  the  area  on  the  operated  side,  as  com- 
pared with  the  other.  It  thus  continues  to  the  level  of  the 
abducens  nidus  caudad,  of  which  a  marked  difference  is 
not  noticeable. 


Figure  V. — Transsection  through  ocuto-motor  nidus  of  cat,  whose  left  third  pair  had  been 
destroyed,  i.  Subendymal  cell  mass.  2.  Crossed  nidus  of  third  pair,  .sagittal  nidus  .  3.  Main 
or  uncrossed  nidus.  4.  Intact  right  root.  5.  Nidus  symmetrically  developed  notwithstanding 
the  unilateral  destruction  of  the  third  pair,  and  identical  with  the  nidal  centre,  eliminated  by 
Mendel  through  peripherel  destruction  of  the  orbicularis  palpebraerum.    6.  Raphe. 

In  addition  to  these  observations  in  normal  human  and 
comparative  anatomy,  as  well  as  those  derived  from  the 
atrophy  method,  I  had  the  specimens  of  a  case  of  organic 
central  ophthalmoplegia  partialis  externa  at  my  disposal,  a_ 


42  g  E.  C.  SPITZ  A' A. 

complete  series  of  sections  from  which  had  been  prepared 
jointly  with  Dr.  N.  E.  Brill.  My  conclusions  from  these 
observations  and  the  observations  of  others  are  subjoined 
under  appropriate  headings. 

THE   INTRA-OCULAR    INNERVATIONS. 

The  rootlets  for  the  pupillary  and  ciliary  muscles. — Path- 
ological observations  show  that  lesions  of  the  crus,  involv- 
ing those  rootlets  of  the  third  pair  which  traverse  the  crus, 
produce  paralysis  of  the  outer  eye  muscles,  but  leave  the 
inner  ones  intact.  It  is  to  be  assumed  from  this  that  those 
anterior-most  fibres  which  do  not  traverse  the  crus,  or  only 
reach  it  shortly  before  their  exit,  are  related  to  pupillary 
and  ciliary  projection.  Experimentally  the  complementary 
observation  has  been  established.  Dividing  the  anterior- 
most  fibres  of  one  third  pair,  eliminates  accommodative 
power  on  the  corresponding  eye,  leaving  that  of  the  other 
eye  intact.2 

The  cell-nests  from  which  rootlets  for  the  pupil  and  ciliary 
muscles  arise. — Pathological  destruction  of  the  central  tubu- 
lar gray  of  the  posterior  division  of  the  third  ventricle,3 
sclerotic  induration  with  contiguous  endymal  hypertrophy,4 
and  experimental  interference5  with  the  same  region  will 
destroy  the  light  reflex  of  the  pupil.  In  case  the  affection 
be  unilateral,  the  loss  of  the  light  reflex  is  homolateral. 
Inasmuch  as  the  retinal  fibres  mediating  the  light  reflex  do 
not  run  in  the  optic  tract,  but  leave  the  optic  nerve  at  the 
chiasm  to  plunge  into  the  ventricular  gray,6  it  appears  rea- 
sonable to  assume  that  the  sub-nest  of  the  oculo-motor 
nucleus,  related  to  the  pupillary  movements  must  be  situ- 
ated far  cephalad,  in  order  to  be  most  conveniently  situated 
for  the  reception  of  the  nidal  end  of  the  pupillary  reflex 
arch.     This  view  is  strengthened  by  the  observations  just 

*  Oyon,  cited  from  Gazette  Medical  de  Paris,  1870,  No.  47.  by  Wernicke. 
Gehunkrankheiten. 

*  Heuser-Volckers,  Archiv.  f.  Ophthalmologic,  xxiv.,  pp.  1-26. 
W.  Sander,  Archiv.  f.  Fsychiatrie  und  neuenkrankheiten,  p.  287. 

*  Our  obiervation,  unpublished. 

*  Bechtherew,  Pfluger's  Archiv.,  xxxi. ,  1883. 

<  Bechtherew,  Neurologisches  Centralblatt,  1883,  No.  12. 


OCULO-MOTOR  CENTRES.  *2q 

cited,  demonstrating  the  rootlets  related  to  the  intra-ocular 
movements  to  be  most  cephalic.  There  is  one  observation 
which  enables  us  to  limit  the  cephalic  extent  of  the  pupil- 
lary nidus  more  narrowly  by  exclusion.  It  is  not  situated 
much,  if  at  all,  in  front  of  the  trans-section  level  of  the 
post-commissura,  because  lesion  of  the  region  in  front  when 
unilateral  abolishes  the  light  reflex  of  the  corresponding 
eye,  but  it  does  not  abolish  consensual  reaction  on  that 
eye.1  We  are  also  able  to  say  that  the  pupillary  nidus  is 
homolatateral  for  each  eye,  as  the  lesions  of  the  central, 
tubular  gray,2  or  special  rootlets,  producing  limited  pupil- 
lary paresis,  when  unilateral  were  always  on  the  same  side 
as  the  symptom.  But-  the  strongest  evidence  in  favor  of 
the  location  of  the  sub-nest  for  the  intra-ocular  muscles  is 
furnished  by  two  cases,  one  in  which  there  was  practically 
total  external  ophthalmoplegia  with  preserved  accommo- 
dation,3 and  the  other  in  which  there  were  gross  distur- 
bances in  the  innervation  of  all  the  external  muscles  of  the 
eye  except  the  right  abducens  and  both  superior  obliques, 
also  with  preserved  accommodation,4  and  in  both  of  which 
the  only  unquestionably  healthy  cell-nests  were  Westphal's 
nidi,  one  on  either  side  of  the  median  line.  At  present  we 
are  only  able  to  affirm  with  confidence  that  it  is  the  nidal 
centre  of  accommodation.  Its  freedom  from  disease  with, 
preserved  accommodation  in  the  midst  of  ophthalmoplegia, 
its  cephalic  location,  in  topographical  harmony  with  the 
results  of  electrical  irritation,3  and  with  the  situation  of  the 
accommodative  nerve-rootlets,  all  strongly  support  this 
view.  We  are  unable  to  differentiate  between  such  parts 
of  this  cell-nest,  if  any,  which  may  be  separately  consigned 
to  the  ciliary  and  pupillary  muscles. 

THE   EXTRA-OCULAR   NIDAL   CENTRES. 
The   rootlets   related  to   the   innervation  of  the  internal 
rectus. — In  a  case  where  the  most  meso-caudal  rootlets  of 

1  Bechtherew,  Pfluger's  Arch.  loc.  cit 

2  Sander,  Arch.  L  Psych,  loc.  cit. 

3  The  case  of  Westphal  already  cited. 

4  The  unpublished  case  of  my  own,  elsewhere  referred  to. 

5  Hensen  and  Volckers,  Graefe's  Archiv.,  1874,  p.  1. 


4^0  E-  C-   SP1TZKA. 

the  third  pair  were  destroyed  in  man,  the  paralysis  was 
limited  to  the  internal  rectus  muscle.  The  pupils  were 
entirely  unaffected.1  This  proves  that  the  rootlets  for  the 
two  are  distinct.  Indirectly  it  suggests  that  the  respective 
nidi  must  be  distinct,  because  the  nest  for  pupillary  inner- 
vation is  homolateral,  and  that  for  the  internal  rectus  is 
contralateral. 

The  nidal  centre  for  the  internal  rectus. — The  atrophy 
experiment  of  von  Gudden  in  the  rabbit,  and  the  same  ex- 
periment repeated  in  the  case  of  the  cat  by  the  present 
writer,  conclusively  prove  that  there  is  a  decussated  origin 
for  a  part  of  the  oculo-motor  nerve.  By  exclusion,  and  by 
physiological  deduction,  we  can  prove  that  this  cannot  be 
the  nidus  of  any  other  muscle  than  the  internal  rectus. 

The  nidal  centre  for  the  levator  palpebrcB. — All  gross 
lesions  of  the  main  nidus  produce  ptosis.  There  is  one 
observation  of  a  limited  lesion,  a  hemorrhage  destroying 
the  most  lateral  part  of  one  main  nucleus,  with  homolateral 
ptosis.5  In  another  case  of  multiple  paresis  of  the  oculo- 
motor apparatus,  marked  left  ptosis  was  associated  with  a 
macroscopic  hemorrhagic  focus,3  destroying  the  most  ex- 
ternal sub-group  of  the  main  nest,  in  varying  extent  in  its 
upp?r  and  middle  levels.  We  may  therefore  assume  the 
levator  palpebral  to  be  represented  in  at  least  the  middle 
altitude  of  the  main  nest  in  its  most  external  division. 

The  nidal  centre  for  the  orbicularis  palpebrarum. — The 
eyelid  sphincter,  under  the  reflex  dominion  of  retinal  im- 
pressions as  it  is,  and  intimately  bound  in  associate  inner- 
vation with  certain  extra-ocular  muscles  of  the  oculo-motor 
system,'  is  not,  as  has  been  heretofore  thought,  under  the 
dominion  of  the  nidus  facialis.  Mendel,  by  destroying  the 
orbicular  muscle  in  the  new-born,  produced  atrophy  in  the 


Kahler-Pick,  Archiv.  f.  Psych,  in  Nokikhtn.,  x.,  p.  334.  Wallenbergh's 
case,  if  the  accompanying  drawings  be  correct,  is  opposed  to  the  deductions 
which   appear   to  follow  so  easily  from  Kahler-Pick's  (Archiv.  f.  Psych.,  xix.,  p. 

298,  et 

Leube,  Deut->ches  Archiv.  f.  Klinische  Medizin,  1887,  p.  219. 
My  own  unpublished  case,  herein  repeatedly  referred  to. 
*  As  evinced   in   the  associated  rolling  motion  of  the  eyeballs  accompanying 
eye-cloiure. 


OCULO-MOTOR  CENTRES.  ,  ,  T 

most  posterior  division  of  the  oculo-motor  cell-nest.  It 
is  precisely  this  cell-nest  which  remain.'  uninfluenced  by 
destruction  of  the  trunk  of  the  third  pair.  The  inference  is 
obvious.  There  must  be  contained  in  the  oculo-motor  cell- 
nests  one  sub-nest  whose  emerging  fibres  are  not  included 
in  the  third  pair.     We  know  from  other  facts  that  there  is 


Figure  VI. — Flatwise  section  of  human  isthmus.  7.  g.  Genu  facialis.  P.  If.  Posterior 
longitudinal  fasciculus.  On  the  lettered  side  the  transition  of  fibres  from  the  latter  to  the 
former  can  be  clearly  seen. 

one  muscle  represented  in  the  seventh  pair  which  is  not 
represented  in  the  nidus  facialis.1  The  conclusion  follows 
that  an  aberrant  fasciculus  from  the  oculo-motor  nidus  must 
join  the  emerging  facial  root.     There  is  such  a  bundle  from 


1  Detailed  by  Mendel,  Neurologisches  Centralblatt,  1887,  No.  23. 


E.   C.  SPITZKA. 


432 

the  posterior  longitudinal  fasciculus  to  the  genu  facialis. 

THE   POSTERIOR    LONGITUDINAL    FASCICULUS. 

This  bundle  contains  a  number  of  elements,  (a)  The 
bundle  connecting  the  abducens  nidus  with  the  nidus  of  the 
internal  rectus,  and  through  which  lateral  associated  move- 
ment of  both  eyeballs  is  effected.  It  was  formerly  thought 
necessary  to  assume  a  decussated  course  for  this  bundle.2 
But  since  it  is  now  known  that  the  nidus  of  the  right 
internal  rectus  is  on  the  same  side  as  the  nidus  of  the  left 
external  rectus,  such  a  decussated  course  is  no  longer 
plausible.3  The  decussation  is  in  the  root-fibres  of  the 
third  pair,  {b)  This  fasciculus  includes  that  part  of  the 
root  of  the  facial  nerve  which  represents  the  orbicularis 
palpebrarum,  (c)  It  contains  other  fibres,  which  from  their 
(probable)  origir  in  the  deep  gray  of  the  optic  lobes  and 
(almost  cerrain)  caudal  termination  in  the  nidal  centres  of 
the  cervical  muscles  (head  rotation,  etc.,)  may  be  regarded 
as  mediating  that  element  in  conjugated  deviation  of  the 
eyes  and  head  which  is  not  mediated  by  the  portion  de- 
scribed under  the  caption  a. 

The  oculo-motor  mechanism  is  thus  shown  to  have  as 
complex  an  anatomical  basis  as  the  physiological  study  of 
its  peripheral  reactions  would  lead  us  to  anticipate.  And 
we  are  approaching  a  degree  of  accurate  knowledge  regard- 
ing the  central  seat  of  these  reactions  which  approaches  in 
exactitude  and  certainty  the  physiological  observation  itself. 

1  The  value  of  this  observation  is  not  diminished  by  the  fact  that  the  drawing 
was  made  and  published  before  its  significance  was  appreciated.  It  is  simply  an 
unbiassed  record, 

2  Duval  and  Laborde. 

3  And  is  contradicted  by  the  observations  of  J.  Nussbaum,  Wiener  Medizin- 
ische  Yahrbucher,  1887. 


DEGENERATION  OF  THE  PERIPHERAL  NERVES 
IN  LOCOMOTOR  ATAXIA. 

By  Dr.  JOHN  C.  SHAW,  of  Brooklyn,  N.  Y. 

CLINICAL   PROFESSOR     OF    DISEASES     OF     THE     MIND     AND     NERVOUS    SYSTEM,    LONG     ISLAND 
COLLEGE   HOSPITAL. 

A  paper  read  before  the  N.  Y.  Neurological  Society,  June,  1888. 

THE  opportunity  having  been  given  me  to  examine 
some  of  the  peripheral  nerves  in  a  case  of  locomotor 
ataxia,  I  believe  a  presentation  of  the  specimens 
may  be  of  interest  to  the  society. 

It  appears  that  Tiirck  was  the  first  to  investigate  into 
the  condition  of  the  peripheral  nerves  in  locomotor  ataxia. 
In  1858  he  examined  the  nerves  of  the  skin  in  two  cases 
(Dejerine),  but  found  no  alterations.  This  may  have  been 
owing  to  the  then  imperfect  methods  of  examination.  In 
1863  Frederich  found  alterations  in  the  peripheral  nerves  in 
some  cases  in  which  he  examined  the  sciatic,  crural,  and 
radial  (Dejerine).  In  1868  Vulpian,  in  a  study  of  the  sensi- 
tive nerves,  the  spinal  ganglia,  and  the  sympathetic  in  scle- 
rosis of  the  posterior  columns,  found  no  change  in  the 
cutaneous  nerves. 

Westphal,  in  1878,  in  the  study  of  a  case  of  combined 
sclerosis  (posterior  and  lateral  columns),  in  which  the  sci- 
atic, tibial,  and  posterior  cutaneous  nerves  were  examined, 
found  atrophy  of  the  nerve  fibres,  increase  of  the  connective 
tissue,  and  it  is  especially  noted  that  in  the  specimens  the 
axis  cylinders  can  be  seen  devoid  of  myeline;  these  nerves 
were  examined  only  after  hardening,  staining  with  carmine, 
and  on  sections. 

In  1880  Pierret  (Thesis  of  Robin)  says  that,  in  cases  of 
locomotor  ataxia  in  which  there  are  lightning  pains,  anaes- 


A%a  JOHN  C.   SHAW 

thesia,  and  pemphigoid  eruptions,  if  the  terminal  expansions 
of  the  nerves  supplying  these  parts  be  examined,  a  neuritis 
will  be  discovered  comparable  to  that  of  optic  neuritis. 

In  1883  Dejerine  reported  two  cases  of  locomotor  ataxia  ; 
in  both  were  found  the  changes  in  the  posterior  columns  ; 
the  posterior  roots  were  atrophied.  Examination  of  the 
cutaneous  nerVes  in  both  cases  showed  alterations  which  he 
considers  to  be  like  those  found  after  section  of  nerves. 

In  1883  Pitres  and  Vaillard  report  a  case  of  locomotor 
ataxia  with  oedema  of  the  left  lower  extremity,  arthropathy 
of  the  left  knee.  Microscopic  examination  of  the  peripheral 
nerves  showed  the  right  sciatic  to  be  normal,  while  the  left 
sciatic  presented  evidences  of  alterations  similar  to  those 
found  in  the  Wallerian  degeneration. 

In  1884  Sakaky  reports  a  case  of  tabes  from  the  clinic  of 
Professor  Westphal,  in  which  some  of  the  peripheral  nerves 
were  examined  and  marked  atrophy  of  the  nerve  tubes 
found.     This  study  was  made  on  sections. 

In  1886  Pitres  and  Vaillard  report  five  new  cases,  in  all 
of  which  changes  were  found  in  the  peripheral  nerves.  The 
nerves  examined  were  the  sciatic,  anterior  and  posterior 
tibial,  etc. 

My  own  case,  in  which  the  spinal  cord  and  some  of  the 
peripheral  nerves  have  been  examined,  I  believe  is  the  first 
case  reported  in  this  country,  and,  although  the  clinical  his- 
tory is  imperfect,  the  interest  attaching  to  the  changes  in 
the  peripheral  nerves  justify  me  in  presenting  it  to  you. 

A  man,  forty-seven  years  old,  was  seen  by  me  six  years 
ago  ;  examination  showed  him  to  be  suffering  from  typical 
locomotor  ataxia.  The  notes  dictated  to  the  house  physi- 
cian of  the  hospital  at  that  time  have  been  mislaid.  In 
December,  1886,  I  saw  this  patient  for  the  second  time,  and 
made  a  rapid  examination  of  him.  His  ataxia  is  extreme, 
he  throws  his  legs  about  wildly  in  attempting  to  walk  ;  he 
cannot  stand  without  being  supported  on  each  side  ;  mus- 
cular power  is  good  ;  the  tendon  reflex  is  absent ;  the  pupils 
are  quite  small,  and  do  not  react  to  light  or  accommoda- 
tion ;  he  has  extravagant  ideas  ;  mentally  he  is  weak,  mem- 
ory very  poor. 


L  OCOMO  TOR  A  TAXI  A .  a^c 

A  history  is  obtained  from  his  sister  at  this  time.  He 
has  always  been  temperate ;  his  mother,  a  nephew,  a  ma- 
ternal cousin,  and  an  aunt  are  insane.  His  first  symptoms 
began  nine  years  ago  ;  he  had  sharp  pains  in  his  legs  and 
knees,  and  when  he  walked  his  legs  "locked  together;"  he 
Soon  began  to  have  pains  in  his  abdomen,  and  spells  of 
vomiting  (gastric  crisis);  he  became  very  irritable.  Six 
years  ago  he  went  to  the  hospital,  where  I  saw  him  the  first 
time;  the  ataxia  was  extreme  then.  In  October,  1885,  he 
had  a  number  of  convulsions.  In  April,  1886,  she  first 
noticed  that  his  mind  was  affected,  he  appeared  to  be 
absent-minded  ;  and  by  August  he  was  quite  childish.  In 
November  he  had  some  more  convulsions,  and  developed 
extravagant  ideas,  thought  he  had  plenty  of  money,  and 
was  about  to  marry  the  queen  of  England,  etc.  At  present 
is  demented,  memory  quite  poor ;  thinks  he  is  pregnant. 

He  becomes  gradually  more  demented,  and  noisy  at 
night.  Insists  upon  saying  he  is  pregnant.  Is  growing 
more  and  more  feeble. 

April  3,  1887. — During  the  night  he  had  an  attack  of 
haematuria,  passing  about  a  pint  of  blood  ;  he  becomes 
very  feeble  and  comatose.  A  large  discolored  patch  is 
observed  in  left  inguinal  region.  The  bleeding  from  penis 
ceases,  and  he  appeared  somewhat  improved  at  night ;  but 
on  the  morning  of  April  4th  he  had  two  epileptiform  seiz- 
ures, bec(Fmes  comatose,  and  dies  early  on  the  morning  of 
April  5th.  An  autopsy  was  made  on  the  afternoon  of  the 
same  day.  The  body  is  emaciated  ;  there  is  a  very  exten- 
sive ecchymosis  over  the  left  lower  half  of  the  abdomen  and 
some  slight  oozing  of  blood  from  the  penis.  Section  through 
the  abdominal  muscles  shows  that  under  the  discolored 
spot  they  are  infiltrated  with  blood  ;  all  the  muscles  bleed 
freely  when  cut  into  ;  there  is  no  evidence  of  injury.  The 
bladder  contains  a  large  quantity  of  bloody  fluid.  The  in- 
testines are  all  more  or  less  discolored,  of  a  darkish  brown. 
The  right  kidney  is  much  congested  ;  the  capsule  tears  off 
easily;  one  of  the  calicis  at  the  lower  part  of  the  kidney  has 
projecting  from  it  clots  of  blood,  while  the  others  present 
no  similar  condition  ;  the  pelvis  of  kidney  contains  a  small 


,-,£  JOHX  C.  SHAW. 

quantity  of  slightly  bloody  fluid  ;  sections  through  the 
organ  showed  extravazations  of  blood  in  several  places  in 
its  substance.  From  this  kidney  evidently  came  the  haemor- 
rhage which  had  occurred  a  day  or  two  before  and  con- 
tinued somewhat  ever  since.  The  left  kidney  was  only 
congested.  The  lungs  were  the  seat  of  hypostatic  conges- 
tion, otherwise  healthy.  The  heart  is  flabby  and  the  aorta 
contains  atheromatous  plates. 

Portions  of  the  peripheral  nerves  were  removed  from  the 
right  leg,  placed  in  osmic  acid,  and  other  pieces  in  bichro- 
mate potass,  solution.  The  cord  was  also  removed  and 
placed  in  solution  of  bicromate  potass. 

The  spinal  cord  shows  the  usual  gray  degeneration  of 
the  posterior  columns.  The  portions  of  nerve  examined  are 
taken  from  the  sciatic,  popliteal,  and  external  plantar.  Of 
those  pieces  placed  in  osmic  acid,  the  first  thing  observed 
was  that  they  were  stained  by  the  osmic  acid  with  great 
difficulty,  and  this  lead  to  their  being  kept  in  the  solution  a 
longer  time  than  is  usual  ;  even  then  it  was  found,  on  teas- 
ing them,  that  there  were  portions  of  the  nerve  which  had 
not  taken  the  black  color  usual  in  this  method  of  prepara- 
tion. The  changes  observed  can  be  found  in  the  sciatic, 
popliteal,  and  plantar  ;  it  is  more  extensive,  however,  in  the 
popliteal  and  plantar  ;  the  number  of  healthy  tubes  is  less 
great  than  in  the  sciatic 

The  preparations  are  stained  in  carmine  and  mounted  in 
glycerine.  In  every  preparation  made  very  few  normal 
tubes  are  to  be  seen  ;  the  degree  of  change  varies  very  much 
in  the  different  tubes  ;  many  tubes  can  be  found  in  each 
specimen  presenting  the  condition  of  myeline  which  is 
observed  after  section  of  nerves  ;  that  is,  the  breaking  up  of 
the  myeline  into  more  or  less  irregular  pieces,  scattered 
about  in  the  sheath,  and  in  various  stages  of  disintegration. 
Some  stained  very  black  with  the  osmic  acid,  and  present- 
ing a  dense,  compact  appearance  ;  other  pieces  only  stained 
lightly  brown,  and  presenting  a  granular  appearance.  In 
another  portion  of  the  tube  may  be  found  a  still  more  ad- 
vanced process,  where  the  myeline  is  completely  broken  up 
into  a  fine  granular  mabs,  hardly  stained  by  the  osmic  acid 


L  OCOMO  TOR  A  TAX/A.  „  <,  7 

and  the  tube  is  smaller.  A  still  further  process  may  be 
seen  in  the  complete  absorption  of  this  granular  myeline 
and  shrinking  of  the  sheath.  There  is  commonly  observed 
in  the  preparation  entire  nerve  tubes  presenting  this  light, 
granular  appearance,  and  which  has  hardly  been  stained,  if 
at  all,. by  the  osmic  acid;  not  a  complete  block  of  well- 
stained  myeline  is  to  be  seen  in  the  tube,  and  this  explains 
the  lack  of  black  staining  which  the  nerve  tubes  present  at 
various  places  ;  the  change  has  been  so  great  in  that  por- 
tion of  the  bundle  that  there  is  no  myeline  to-  stain.  In 
those  portions  of  the  nerve  where  the  myeline  has  under- 
gone this  extensive  change,  the  sheath  appears  to  have 
taken  up  the  carmine  a  little  more  freely  than  it  usually 
does  ;  and  when  a  large  number  of  fibres  together  has  un- 
dergone this  process,  they  present  the  deep  carmine  stain, 
which  is  in  marked  contrast  with  the  adjacent  portions  of 
the  fibre  which  are  stained  more  or  less  strongly  black  by 
the  osmic  acid. 

Very  frequently  portions  of  a  fibre  or  fibres  appear  to 
have  undergone  such  rapid  change  in  its  myeline  that  the 
sheath  appears  to  be  filled  with  a  granular-looking  mass 
which  must  have  been  more  or  less  liquid.  The  process  of 
liquefaction  was  too  rapid  for  absorption,  and  collapse  of  the 
sheath  to  occur,  so  that  the  tube  appears  to  have  nearly  its 
normal  dimensions.  The  interannular  nucleus,  with  its  pro- 
toplasm, appears  not  to  have  taken  any  active  part  in  this 
process  of  disintegration  of  the  myeline,  as  they  are  not 
enlarged,  in  this  differing  from  that  found  after  section  of 
nerves.  The  nucleus  is  sharply  stained  by  the  carmine.  In 
all  the  preparations  there  are  to  be  observed  numerous 
rolled-up,  collapsed  sheaths  of  Schwann.  With  a  high 
power  one  can  observe  the  vestige  of  myeline  drops  as  fine 
granules  in  some  of  these  shrunken  sheaths. 

In  many  of  the  tubes  this  change  in  the  myeline  can  be 
observed  beginning  at  each  end  of  an  interannular  constric- 
tion, near  the  constriction  of  Ranvier,  while  the  interme- 
diate portions  are  apparently  normal.  Numerous  tubes  can 
be  seen  in  which  these  changes  in  the  myeline  occupy  only 
a  portion  of  the  tube,  so  that  the  parts  above  and  below  it 
are  apparently  normal. 


43S  JOHNC   SHAW 

In  these  tubes  in  which  the  myeline  has  been  absorbed 
there  appears  to  be  an  increase  in  the  number  and  size  of 
the  nuclei  in  the  sheath  of  Schwann.  A  peculiarity  of  this 
process  is  the  persistence  of  the  axis-cylinder.  In  those 
fibres  in  which  the  myeline  is  broken  up  into  blocks,  I  have 
been  unable  to  discover  the  persistence  of  the  axis-cylinder, 
but  these  fibres  are  not  as  numerous  as  those  which  present 
the  granular  myeline  alone  ;  in  these  fibres  the  persistence 
of  the  axis-cylinder  is  shown  beautifully,  as  it  is  stained 
sharply  with  the  carmine,  and  can  be  clearly  seen,  especially 
in  those  fibres  which  have  undergone  that  process  which  I 
have  considered  as  a  rapid  liquefaction  of  the  myeline. 
Often  the  axis-cylinder  can  be  seen  pushed  to  one  side  by 
this  fluid,  so  that  it  rests  against  the  sheath.  I  have  not 
observed  any  change  in  the  axis-cylinder. 

Many  tubes  are  to  be  seen,  which,  I  suppose,  are  tubes 
in  process  of  regeneration,  at  least  they  have  been  so  de- 
scribed by  writers  on  this  subject ;  they  are  small  fibres 
with  a  narrow,  dark-stained  band  of  myeline.  I  have  not 
observed  any  axis-cylinder  in  them. 

If  sections  are  examined  after  hardening  in  bichromate 
potass.,  and  mounted  after  staining  with  carmine  in  Canada 
balsam,  a  great  many  nerve  tubes  are  found  atrophied  in 
each  bundle.  The  changes  are  not  made  out  as  clearly, 
however,  on  sections  as  they  are  in  preparations  stained 
with  osmic  acid,  carmine,  and  teased. 

The  condition  observed  in  these  nerves,  and  which  I 
have  described,  does  not  correspond  exactly  to  that  given 
by  most  writers  on  the  changes  in  the  peripheral  nerves  in 
locomotor  ataxia,  many  of  them  stating  that  it  is  like  the 
changes  observed  in  the  Wallerian  degeneration.  The 
changes  observed  in  these  nerves  which  I  present  to  you 
are,  it  appears  to  me,  a  different  process  from  that  observed 
in  the  Wallerian  degeneration.  The  absence  of  increase  in 
the  interannular  nucleus,  the  persistence  of  the  axis-cylin- 
der, the  appearance  of  changes  in  certain  portions  of  the 
nerve,  while  that  portion  above  and  below  remains  com- 
paratively healthy.  The  greater  number  of  tubes  in  which 
the  myeline  undergoes  evidently  a  rapid  granular  liquefac- 


LOCO  MO  TOR  A  TAXI  A.  .^ 

tion  rather  than  breaking  up  into  blocks,  are  all  points  of 
marked  difference  in  the  two  processes. 

There  can  be  seen  in  these  specimens,  nerve  tubes  of 
considerable  length,  in  which  the  changes  appear  exactly 
like  those  in  the  Wallerian  degeneration,  that  is,  as  far  as 
the  myeline  is  concerned.  The  interannular,  nucleus  how- 
ever, does  not  present  the  marked  increase  in  size  that  is  so 
common  after  section  of  nerves.  The  fibres  piesenting  this 
appearance  are,  however,  not  nearly  so  numerous  as  those 
with  the  very  fine  granular  myeline  and  the  persistent  axis- 
cylinder. 

The  condition  here  is  similar  to  that  which  has  been 
described  by  Gombault  in  1880,  in  an  article  on  Parenchy- 
matous Neuritis  or  Segmentary  Periaxillary  Neuritis.  The 
observations  were  made  on  the  sciatic  of  fowls  which  had 
been  slowly  poisoned  with  lead.  He  especially  calls  atten- 
tion to  the  persistence  of  the  axis-cylinder,  the  segmentary 
nature  of  the  neuritis,  and  the  difference  in  the  process  from 
that  found  in  the  Wallerian  degeneration. 

Since  that  time  Pitres  and  Vaillard,  in  1886,  in  an  article 
on  the  Alterations  of  Nerves  in  Diphtheritic  Paralysis,  have 
recognized  the  condition  described  by  Gombault.  Still 
they  do  not  agree  fully  with  his  description.  They  admit 
the  segmentary  nature  of  the  neuritis,  but  deny  the  persist- 
ence of  the  axis-cylinder.  This  peculiar  change  of  the 
myeline  in  segments  was  observed  by  Gombault  in  the 
peripheral  nerves  of  man  suffering  from  various  conditions, 
such  as  protopathic  muscular  atrophy,  lateral  amyotrophic 
sclerosis,  traumatic  neuritis,  and  diphtheritic  paralysis. 

In  1882  P.  Meyer  observed  the  same  condition  in  a  case 
of  diphtheritic  paralysis.  The  presence  of  these  two  kinds  of 
disease  fibres  in  the  specimens,  the  one  having  the  blocks 
of  myeline  scattered  through  it  and  the  other  with  only  a 
fine  granular,  liquid-looking  contents,  have  been  observed 
by  Gombault,  Meyer,  Pitres  and  Vaillard,  and  myself,  in  all 
the  specimens  examined.  The  beginning  of  the  change  in 
the  myeline  near  the  construction  of  Ranvier  has  also  been 
pointed  out  by  each  observer.  Gombault  lays  considerable 
stress  upon  this  ;  in  my  own  specimens  it  can  be  observed 
if  carefully  looked  for. 


i,0  JOHX  C.  SHAW. 

In  view  of  the  presence  of  these  apparently  different 
processes  in  the  same  nerve  bundle,  one  asks  is  this  a  pecu- 
liar form  of  neuritis  parenchymatous  in  origin,  or  is  it  a 
process  similar  to  that  found  in  nerves  after  section.  I 
would  not  venture  any  positive  statement  from*an  examina- 
tion of  one  case,  but  it  appears  to  me  that  the  process  is 
quite  a  different  one  from  that  observed  in  nerves  after  sec- 
tion. I  look  upon  it  as  a  parenchymatous  neuritis,  the 
expression  of  a  more  or  less  general  degenerative  change 
in  the  entire  nervous  system,  a  kind  of  slow  breaking  up  of 
the  organism. 

Gombault  and  Pitres  and  Vaillard  have  taken  opposite 
sides  on  this  question.  Gombault  looking  upon  it  as  a  special 
form  of  neuritis  quite  distinct  from  the  Wallerian  degenera- 
tion and  to  explain  the  presence  of  these  fibres  with  the 
large  blocks  of  myeline  in  them  which  are  so  characteristic 
of  the  Wallerian  degeneration,  he  assumes  that  at  some 
point  above  where  this  segmentary  neuritis  has  been  going 
on  the  nerve  fibre  has  been  entirely  cut  off  by  the  exten- 
siveness  of  the  process,  the  other  portion  of  the  fibre  then 
degenerates,  following  the  course  of  that  found  in  the  Wal- 
lerian change. 

Pitres  and  Vaillard  look  upon  the  changes  as  one  and 
the  same  thing,  and  the  difference  in  appearance  is  due  to 
the  various  stages  of  the  process. 

The  view  advanced  by  Gombault  is  ingenious,  and  ap- 
pears to  me  the  most  likely  to  be  correct. 

These  peculiar  changes  in  the  peripheral  nerves  which  I 
have  been  describing,  have  not,  as  far  as  I  know,  been 
observed  in  cases  of  locomotor  ataxia  by  any  one  but  my- 
self;  it  is  a  change  which  is  evidently  not  peculiar  to  cases 
of  posterior  spinal  sclerosis,  as  it  has  been  seen  by  others  in 
a  variety  of  conditions,  especially  in  the  cases  of  diphthe- 
ritic paralysis  and  the  experimental  production  of  it  by 
Gombault,  which  has  been  previously  alluded  to,  and  it  is 
very  probable  that  further  studies  may  show  it  to  be  pres- 
ent in  a  large  number  of  the  changes  occurring  in  peripheral 
nerves. 


LOCOMOTOR  A  TA  XIA.  ..  j 

BIBLIOGRAPHY. 
1858,  Tiirck. — Quoted  from  Dejerine. 
1863,  Friedreich. — Virchow's  Archiv.,  B.  26. 
1868,  Vulpian. 
1878,  Westphal. — Ueber  Combinirte   (primare)  Erkrankung 

der  Ruckenmarksstrang*  Archiv.  fur  Psych,  and  Nerven, 

1878. 
1880,  Pierret. — Thesis  of  Robin.  Des  troubles  oculairesdans 

les  maladies  de  l'encephale.     Paris,  1880. 
1883,   Dejerine. — Des  alterations  des  nerves  cutanes   ches 

les  ataxiques.     Archiv.  de   physiol.  Normale  et  path., 

1883. 

1883,  Pitres  and  Vaillard. — Contribution  a  l'etude  des  nev- 
rites  peripheriques  nonTraumatiquesArchiv.de  Neu- 
rolpgie,  1883,  No.  14. 

1884,  Sakaky. — Ueber  einen  Fall  von  Tabes  dorsales  mit 
Degeneration  der  peripherischen  Nerven.  Archiv.  fur 
Psych,  und  Nerven.     B.  xv.,  H.  2. 

1886,  Pitres  and  Vaillard. — Contribution  a  l'etude  des  Nev- 
rites  peripheriques  ches  les  Tabetiques.  Rev.  de  Medi- 
cine, 1886,  No.  7. 

Gombault. — Contribution  a  l'etude  ae  la  Nevrite  paren- 
chymateuse  subaigne  et  chronique  Nevrite  segmentaire 
Peri-axite.     Archiv.  de  Neurologie,  1880  and  1881. 


EXPLANATION   OF   PLATE. 

Fig.  1. — Nerve  fibre  which  has  undergone  rapid  granular  disintegration  with 
persistence  of  the  axis  cylinder  and  which  is  pushed  to  one  side. 

Fig.  2. — Tube  in  which  the  myeline  has  disappeared,  leaving  the  axis  cylinder 
sharply  stained  by  the  carmine. 

Fig.  3. — Nerve  tube,  showing  the  typical  changes  as  seen  in  the  Wallerian  degen- 
eration, the  myeline  broken  up  into  blocks  and  floating  about  in  the  more 
granular  myeline. 

Fig.  4. — Fibre,  showing  the  beginning  change  in  the  myeline  at  each  end  of  an 
interannular  segment  persistence  of  the  axis  cylinder. 

Fig.  5. — Tube  in  which  the  myeline  has  entirely  disappeared,  the  sheath  of 
Schwann  has  collapsed,  and  an  increase  in  the  nuclei  of  the  sheath. 

Fig.  6. — Showing  a  small  portion  of  a  bundle  of  fibres  with  nerve  tubes  in  various 
stages  of  degeneration. 


CASE  OF  POST  EPILEPTIC    HYSTERIA.     EFFECT 

OF      INHALATION      OF      COMPRESSED     AIR. 

PHENOMENON  OF  TRANSFER. 

BY  DR.  MARY  PUTNAM  JACOB1,  M.  D. 

MISS  R.  K.,  act.  35,  suffering  from  epilepsy  for  about 
twenty  years.  Violent  attacks  infrequent,  and  pati- 
ent often  enjoys  several  months  of  quite  good  health: 
at  other  times,  liable  to  frequent  epileptical  seizures,  ming- 
led with  hysteriform  attacks.  Both  are  usually  control- 
lable by  nitrite  of  amyl.  Patient  takes  habitually  60  grains 
of  bromide  a  day :  often  has  taken  three  and  four  drachms, 
and  with  no  marked  benefit. 

In  October,  Miss  K.  suffered  for  a  fortnight  from  a  severe 
attack  of  gastric  catarrh.  Towards  the  close  of  this  attack, 
which  had  been  treated  carefully,  and  without  suspending 
the  bromides,  the  patient  had  an  epileptic  fit  of  extreme 
violence,  such  as  she  was  said  not  to  have  experienced  in 
five  or  six  years.  After  this  fit,  she  suffered  from  marked 
nervous  exhaustion,  claimed  to  feel  extremly  "  queer  "  in  the 
head,  to  tremble  all  the  time,  to  have  sensation  of  numbness 
throughout  the  body,  slight  on  the  right,  but  very  pronoun- 
ced on  the  left  side.  There  was  no  objective  anaesthesia. 
The  symptoms  all  pointed  to  a  persistent  effect  in  the  cor- 
tical centres  of  the  shock  sustained  during  the  epileptic  fit. 
It  was  a  question,  whether,  on  account  of  this,  the  cortex 
had  not  yet  regained  its  normal  control  over  the  subcortical 
vaso  motor  centres,  and  hence  that  some  degree  of  spasm 
persisted  in  the  cortical  blood  vessels,  maintaining  the 
anaemia,  or  dyspnoea  of  the  cortical  nerve  tissue.  I  decided  to 
try  the  effect  of  the  inhalation  of  compressed  air  from  the 
Waldenburg  apparatus,  and  anticipated  from  this  a  double 
effect:    1st.  The  introduction  of  some  more  oxygen  into  the 


POST  EPILEPTIC  HYSTERIA.  ,  ,  ., 

44  o 

blood,  which  might  serve  to  feed  the  dyspnoeic  cortical 
centres  of  the  brain.  2d.  An  increased  force  of  the  heart, 
indirectly  determined  by  the  greater  amount  of  blood 
in  the  systemic  circulation,  when  blood  should  have  been 
expelled  from  the  lungs  by  the  increased  pressure  of  air 
within  the  air  cells. 


BEFORE    WALDENBURG- 
Pr.    5. 


The  accompanying  pulse  traces  show  the  condition  of 
the  radical  pulse  before  and  after  the  inhalation.  The  trace 
No.  I,  taken  before  inhalation,  is  remarkable  for  its  vertical 
and  high  percussion  stroke,  relatively  rapid  collapse,  absence 
of  dicrotism,  very  small  tidal  wave.  These  characters  indi- 
cate a  low  arterial  tension,  against  which  the  heart  works 
with  energy,  but  without  much  benefit. 


AFTER     WALDENBUR& 
30     LBS.         PR.  5. 


Condition  of  the  Heart. — Immediately  after  inhalation    of 
one  cylinder  of  air  under  pressure  of  30  lbs.   or  -^  th  of  an 


444 


■ 


atmosphere,  trace  Xo.  II  was  taken.  In  this' the  percussion 
strike  is  considerably  increased  in  height,  but  the  tidal  wave 
is  also  increased,  the  collapse  of  the  artery  is  prolonged, 
and  there  is  an  approach  to  a  dicrotic  notch.  The  respira- 
tory base  line  rises  to  about  the  same  extent  in  both  trac- 
ings. 

NTo.  Ill  was  taken  after  three  cylinders  had  been  inhaled. 
The  percussion  stroke  is  lower  than  in  the  second  trace, 
though  higher  than  in  the  first,  but  the  tidal  wave  is  still 
more  developed.  This  seems  to  indicate  that,  with  an  in- 
creased force  of  cardiac  contraction,  an  increased  resistance 
was  now  offered  in  the  capillaries  and  arterioles.  This 
might  be  owing  to  the  greater  amount  of  blood  retained  in 
them  in  a  unit}-  of  time  ;  or  else,  to  an  improved  tone  of 
the  vaso  motor  centre,  under  increased  respiratory  stimulus 
ami  oxygenation. 


After  3  cylinders 

WALDENBURG- 
PR.  5.  30  LBS. 


ncidently  with  these  modifications  of  the  pulse,  the 
patient  noticed  that  the  left  side  of  the  body  was  now  free 
from  numbness,  while  this  was  intensified  on  the  right  side, 
where,  hitherto  it  had  been  scarcely  perceptible.  For 
several  subsequent  hours,  the  patient  felt  a  greal  deal  better, 
and  continued  to  do  so  during  four  or  five  days  of  daily  in- 
halation. She  then  ceased  attendance,  but  in  forty-eijjht 
hour-  symptoms  returned  :  consisting  now  in  clutching  sen- 
sation at  epigastrium,  pains  .all  through  the  limbs,  ravenous 
hunger  and  profound  mental  depression  ;  menstruation  was 
then  over-due  five  days.      I  he  patient  was  then  ordered  wine 


POS  T  EPIL  EPTIC  HYS  TERIA.  ..  - 

of  cocoa,  to  each  dose  of  which  was  added  a  grain  of  cocaine. 
This  at  once  made  her  feel,  (to  use  her  own  expression), 
"  splendidly;"  menstruation  came  on,  and  the  nervous  symp- 
toms all  disappeared. 

The  condition  which  persisted  after  the  violent  epileptic 
attack  in  this  case  was  probably  the  hysteroid  state,  so  well 
described  by  Gowers,  and  which  that  author  interprets  as 
indicating  commencing  nutritive  degeneration  of  the  brain. 

The  point  of  interest  in  this  special  attack,  lies  I  think, 
in  the  phenomenon  of  transfer,  which  was  effected  by  the 
compressed  air  inhalation  as  promptly  as  it  is  some  times 
observed  after  the  use  of  the  metallic  disks. 

This  transfer  began  immediately,  and  when  the  tracing 
showed  no  sign  of  an  effect  on  the  vaso  motor  system,  but 
only  of  increased  energy  in  the  cardiac  contraction. 

If  the  numbness  be  attributed  to  temporary  impairment 
of  the  nutrition  of  the  cortical  sensory  centres,  and  of  their 
circulation,  two  conditions  may  be  implied.  The  chemical 
processes  of  synthesis  and  of  deoxidation,  resulting  respec- 
tively in  storage  and  in  circulation  of  nerve  force,  must  be 
slackened  or  nearly  arrested,  while  the  process  of  supplying 
nutritive  material,  and  of  eliminating  of  waste  products  must 
both  be  similarly  reduced.  The  increased  force  of  circu- 
lation determined  by  the  compressed  air  inhalation,  as  well 
as  the  presumable,  though  slight  increase  in  the  oxygen  car- 
ried by  the  blood,  should  both  act  in  the  same  way  upon 
the  dyspnoeic  nerve  tissues.  The  greater  supply  of  oxygen 
should  stimulate  the  slackened  chemical  processes  sustained 
in  them  ;  and  by  the  greater  rapidity  of  the  blood  stream, 
their  lymphatic  sheaths  should  be  swept  clear  of  accumulated 
waste  products.  In  this  way  may  be  explained  the  relief 
afforded  to  the  various  paresthesias  complained  of.  But  the 
transfer  of  the  numbness  from  the  left  to  the  right  side  of 
the  body  remains  unexplained.  We  may  ask  the  following 
question  :  When  in  one  portion  of  the  cortex,  depression  of 
function  is  relieved,  and  an  active  circulation  re-established, 
must  there  be  a  temporary  recession  of  blood  supply  and 
nervous  activity  from  other  portions,  until,  after  a  succession 
of  oscillations,  complete  equilibrium  shall  have  been  re- 
stored ? 


SKIN   PRODUCTS. 

By  WALLACE  WOOD,  M.D., 

Professor  in  the  University  of  the  City  of  New  York. 

IT  requires  little  more  than  simple  inspection  to  reveal 
the  fact  that  the  human  body,  like  that  of  bird  or 
quadruped,  consists  of  a  frame  covered  by  a  kind  of 
double  sack,  the  skin  and  the  intestines.  Take  a  rough 
example  :  When  a  butcher  dresses  a  sheep,  he  pulls  off  the 
one  and  pulls  out  the  other.  One  is  the  tegument  or  outer 
covering,  the  other  the  intestinal  or  inner  lining.  Stripped 
of  these  two  skin  tissues,  the  lining  and  the  covering,  there 
remain  the  flesh  and  blood  and  bone  constituting  the  ani- 
mal frame.  One  of  these  sacks  is  the  cutaneous  tissue  with 
its  epidermis,  the  other  the  mucous  membrane  with  its  epi- 
thelium. Apart  from  its  fibrous  base  the  double  sack, 
between  the  two  portions  of  which  the  organism  grows, 
consists  of  epidermis  without  and  epithelium  within,  called 
by  morphologists  the  skin  sensory  layer  and  the  intestinal 
glandular  layer  ;*  between  these  two  is  the  double  fibrous 
layer  of  flesh  and  blood. 

In  lowest  organisms  the  covering  and  lining,  ectoderm 
and  endoderm,  constitute  the  whole  being.  In  embryology 
the  covering  and  lining  are  called  epiblast  and  hypoblast. 
Between  the  sack  covering  and  the  sack  lining,  ectoderm 
and  endoderm,  lies  the  mesoderm,  which  is  the  gross  con- 
struction of  the  body,  the  skeleton  with  its  muscular  tissue 
about  it,  and  its  sanguiniferous  trunk  within.  It  is  plain  to 
be  seen  how  perfectly  the  vertebral  column  with  its  enclos- 
ing ribs  embraces  and  holds  that  "light  ramified  tree,"  the 
circulatory  system,  and  how  upon  its  exterior  its  bears  the 
powerful  muscular  masses  and  long  limbs. 

0  Haeckcl,  "Anthropogenic  " 


SKIN  PRODUCTS.  .,- 

As  the  organism  develops,  and  while  the  mesoderm  or 
gross  construction  is  differentiating  into  skeleton,  vascu- 
lar system  and  muscular  system,  what  progress  is  taking 
place  in  the  covering  and  lining  ?  Both  embryology  and 
comparative  anatomy*  show  that  cutaneous  tissue  and 
mucous  membrane,  ectoderm  and  endoderm,  are  the  seat 
of  extraordinary  operations ;  that  here  are  exhibited 
extremely  singular  processes,  such  processes  being  the 
various  forms  of  inversion  which  these  membranes  undergo. 
Over  the  surface  small  depressions  appear,  which,  sinking 
deeper,  become  pits,  crypts  or  follicles,  become  inversions; 
or  invaginations  or  pouches.  At  first  one  would  hardly 
think  of  identifying  ^them  with  glands,  much  less  with  gan- 
glions. 

A  kind  of  pouch-making  process  seems  to  prevail  alf 
over  the  body,  inside  and  out,  wherever  the  skin  covering" 
or  lining  with  its  extraordinary  epidermis  or  epithelium  is 
found.  We  know  that  in  vertebrates  the  lungs  and  the 
liver  and  the  urinary  bladder  are  such  pouches,  inversions 
of  the  mucous  membrane  (endoderm,  intestinal  glandular 
layer).  We  know  that  the  trachea  of  insects  are  inversions 
of  the  outer  skin  and  their  nitrogenous  excretory  organs 
are  inversions  of  the  intestine. t  We  know  that  in  man  the 
sweat  glands,  the  lacrymal  glands,  the  sebaceous  glands, 
the  cerumenous  glands,  and  the  mammae,  are  all  pouches 
or  inversions  of  the  outer  skin. 

Now  comes  the  curious  part  of  the  teacning.  That  the 
liver,  the  lungs,  or  even  the  ovarium,  should  prove  to  be 
intestinal  inversions  seems  not  surprising ;  but  when  we 
find  also  that  upon  the  outer  skin  appear  depressions  that 
are  called  eye  spots  and  retina  and  ear  vesicles  and  brain 
bladders,  and  that  these  are  simply  cutaneous  inversions, 
amazement  begins  ;  yet  such  is  the  fact.  The  single  urinary 
bladder  of  the  body  is  an  intestinal  inversion,  the  double 
air  bladders  or  pair  of  air  bladders  which  become  lungs  are 

o  Balfour,  Comparative  Embryology;  Wiedersheim,  Comparative  Anatomy  of 
Vertebrates — two  invaluable  works. 

f  Jeffry  Bell,  Comparative  Anatomy  and  Physiology.  Also  Balfour,  Comp. 
Embryol. 


448  WALLACE  WOOD. 

intestinal  inversions  lined  with  epithelium;  the  five  brain 
bladders  are  simply  cutaneous  inversions  lined  with  their 
epithelium.* 

This  then  is  the  truth  that  science  has  forced  upon  us;  that 
the  eye  and  the  ear  in  their  essential  parts  and  the  brain 
itself  are  pouch-like  inversions  of  the  ectoderm,  as  the  lungs, 
the  liver  and  the  ovarum,  etc.,  are  all  pouches  or  inversions 
of  the  endoderm.  The  kidneys  and  testes  are  of  precisely 
similar  origin,  dermal  inversions  or  pouches,  either  in  lining 
or  covering. t 

While  kidneys,  testes  and  ovaries  at  one  extremity  of 
the  organism  are  lined  or  made  up  of  secreting  and  germi- 
nating epithelium,  the  retina,  the  internal  ear,  and  the  fore 
brain  at  the  other  extremity  are  lined  with  sensory  and 
reflecting  epithelium.  The  skin  follicles,  the  organs  of 
sense  and  the  brain,  are  part  of  the  outer  skin  series  of 
inversions  ;  the  mucous  follicles,  the  great  glands  and  pos- 
sibly the  ovarum,  part  of  the  inner  skin  series. 

Epidermis  and  epithelium,  outer  covering  and  inner 
lining  are  united  in  one.  The  inner  skin  is  but  a  continua- 
tion of  the  outer,  subject  to  different  conditions,  darkness 
and  moisture  instead  of  light  and  the  shocks  of  the  envi- 
ronment. From  recent  anatomy  and  embryology  it  may 
be  laid  down  that  the  human  organism,  and  every  other 
consists  of  two  parts,  a  frame  and  a  skin.  Even  a  tree  or 
plant  consists  of  these  two  essential  parts,  the  wood  or 
trunk,  fibre,  and  the  outer  bark  or  parenchyme  ;  an  animal 
being  double,  tube  formed  instead  of  rod  formed,  has  its 
frame  or  gross  construction  compound,  and  its  bark  or  skin 
is  continued  down  into  the  tube,  forming  a  lining. 

In  both  organisms  is  seen  a  kind  of  unit  or  life  of  the 
frame,  a  gross  or  crude  life,  and  a  unit  or  life  of  the  skin — 
a  culminating  or  refined  life.  The  skin  of  a  small  plant,  if 
examined,  seems  to  culminate  in  leaves  and  flowers  ;  the 
skin  of  the  vegetative  or  internal   part  of  a  small  animal, 

°  Haeckel,  "Anthropogenic"     Balfour,  "Comparative  Embryology." 
t  The   kidneys  certainly  of  cutaneous  origin  ;  that  of  the   testes  disputed. 
Balfour  gives  bibliography.     In  the  vertebrate  embryo  testes  and  ovaries  seem  to 
be  connected  with  the  mesoderm.     The  germ  glands  cannot  be  called  inversions. 


SKIN  PROD  UC  TS.  AAri 

449 

i.  e.,  the  mucous  membrane,  seems  to  culminate  in  these 
inversions — lungs,  kidneys,  and  genitals,  glandular  inver- 
sions giving  rise  to  gaseous  and  liquid  products  and  pon- 
derable forms  or  germs ;  while  the  skin  of  animal  life  seems 
to  culminate  in  the  organs  of  special  sense  and  the  brain 
bladders,  ganglionic  inversions  producing  color  and  vibra- 
tion, light  and  shadow  and  phosphorescence,  imponderable 
forms  or  spectra. 

This  greater  skin,  cutaneous  and  mucous,  with  all  its 
involutions,  constitutes  a  vast  field  of  varied  and  wonderful 
products.  The  inner  tract  is  covered  with  thick-set  columnar 
epithelium,  living  and  moving  like  a  field  of  waving  grain. 
This  membrane  produces  first  a  protective  mucus  and  vari- 
ous juices — oesophageal  juice,  gastric  juice,  intestinal  juice  ; 
while  the  outer  tract  produces  sweat  and  oil,  its  epithelium 
perpetually  exuviating,  and  bringing  forth  no  longer  soft 
mucus  but  hardened  horn  and  hair.  Both  the  inner  and 
outer  field  invert  into  glands  producing  strange  substances 
— the  ferment  of  saliva,  the  brine  of  tears,  the  bitter  of  gall, 
the  nourishment  of  milk,  and  the  formed  eggs  and  semen, 
the  highest  inner  product  being  these  material  germs. 

On  the'outer  and  partly  the  inner  field  are  the  inversions 
of  the  taste  bulbs,  the  olfactory  epithelium  of  th*e  nasal 
membrane,  the  retinal  rod  and  cone  epithelium,  the  vibra- 
ting epithelium  of  the  ear,  and  the  pyramidal  epithelium  of 
the  cerebral  cortex*  where  etherial  or  phosphorescent  germs 
are  found,  shadows  or  spectra  gathering  in  clusters  and 
forming  not  ponderable  embryos  but  imponderable  spectra 
or  "ideals."  Cerebral  shadows  or  spectra  are  the  highest 
outer-skin  products,  as  the  material  germs  are  the  highest 
inner-skin  products.  The  embryo  created  on  the  interior 
is  semi-fluid  and  ponderable  like  the  organism  itself;  the 
ideal  or  spectra  created  on  the  exterior  is  flitting  and  im- 
ponderable, it  is,  as  it  were,  the  shadow  of  the  organism. 

Of  an  indifferent  sculptor  with  very  handsome  children, 
Michael  Angelo  said  that  he  made  better  work  by  night 

c  The  gray  matter  of  the  brain  is  the  original  epithelium  lining  the  cutaneous 
inversion.     See  paper  by  George  Jacoby  in  the  Medical  Journal,  May,  1888. 


,-0  WALLACE    WOOD. 

than  he  did  by  day.  The  inner-skin  products  were  better 
than  the  outer-skin  products. 

Man  consists  of  a  frame  and  a  skin.  The  frame  is  the 
skeleton  with  the  muscular  and  sanguiferous  systems  ;  the 
skin  is  the  highly  involuted  covering  and  lining  of  the 
frame.  The  function  of  the  frame  is  to  support  and  to  nour- 
ish ;  the  function  of  the  skin  throughout  is  production. 
Physicians  and  surgeons  in  ordinary  deal  with  the  human 
frame  ;  gynaecologists,  dermatologists,  alienists,  and  neu- 
rologists deal  with  the  human  skin  and  its  products.  In 
this  view,  everything  about  the  organism  that  is  not  muscle 
or  bone  or  blood  or  aliment  is  skin  or  skin  product,  and  it 
is  the  greater  skin,  the  whole  skin — cutaneous,  mucous,  and 
serous, — which  is  the  common  basis  upon  which  these  four 
specialists  may  be  said  to  stand. 

Skin  products  are  the  results  of  the  thousand  epithelial 
inversions  and  exuviations,  and  are  solid  or  liquid  or  gas- 
eous or  viscid,  are  vaporous  or  etherial,  are  formed  or  un- 
formed. Breath  and  the  cutaneous  exhalations  are  gaseous, 
or  gaseous  and  vaporous  ;  tears,  urine,  bile,  and  milk  are 
fluid  ;  mucus  saliva,  sebum,  cerumen,  are  viscid  or  semi- 
solid ;  hair  and  horn  are  solid  and  formed  products  ;  eggs 
and  ova  are  viscid  and  formed  ;  tastes  and  smells,  sounds 
and  spectra,  are  gaseous,  vaporous,  or  etherial,  and  tend 
to  be  formed  products. 

Important  products  of  the  skin  of  the  vegetative  life 
in  man  are  gaseous  or  viscid — the  breath  from  the  lungs, 
the  ova  and  sperm  from  the  genital  glands.  Important 
products  from  the  skin  of  animal  life  in  man  are  solid  or 
etherial — hair  and  horn  on  the  one  hand,  sensations  and 
reflections  from  the  sensory  and  ganglionic  inversions  on 
the  other.  The  products  of  the  skin  of  vegetative  life  are 
nearly  as  mysterious  as  those  from  the  skin  of  animal  life  ; 
an  ovum  or  a  spermatozoon  is  visible  and  tangible,  can  be 
measured  and  weighed  ;  a  breath  cannot  ordinarily  be  seen, 
but  may  be  smelt  and  felt,  can  with  difficulty  be  measured 
and  weighed,  and  is  the  theme  of  the  poet.  Of  the  products 
orthe  animal  life,  a  horn,  a  hair,  a  tooth,  or  a  nail  is  solidly 
visib'e  and  tangible,  measurable  and   ponderable  ;  a  sound, 


SKIN  PROD UC  TS.  *  r  j 

an  odor,  a  taste,  or  a  color  or  spectrum*  can]  hardly  be 
weighed,  but  may  be  measured. — These  are  only  one  kind, 
and  the  highest  kind,  of  skin  products. 

When,  a  hundred  years  ago,  it  was  announced  that  the 
brain  secreted  thought  as  the  liver  secreted  bile,  the  crude- 
ness  of  the  doctrine  produced  a  shock  ;  but  it  seems  proved 
by  the  comparative  anatomy  and  the  comparative  embry- 
ology of  to-day  that  the  skin,  by  its  ectodermal  inversions, 
produces,  with  its  ganglionic  epithelium  the  medullary- 
plate,  the  elements  of  thought,  vibrations,  and  spectra,  or 
sensations  and  reflections,  in  a  way  analagous  to  that  in 
which  the  more  superficial  horn-plate  brings  forth  hair, 
nails,  and  teeth,  and  in  which  the  glandular  inversions  of 
the  inner  skin  produce  mucus  and  exhalations,  and  in  which 
the  terminal  germ  tissue  brings  forth  germs. 

Concentrate  our  attention  for  a  moment  on  the  two  foci 
of  the  organism.  The  spermatic  and  ovarian  germs  are  the 
elements  of  a  new  organism,  that  new  and  mysterious,  but 
material  man,  the  embryo.  Sensations  are  the  elements  of 
the  image,  or  ideal,  the  cerebral  born  man.  The  optic 
spectrum  gives  this  shadow  man  a  form,  and  the  auricular 
vibration  gives  it  a  voice  ;  taste,  smell,  and  touch,  and 
voluptuousness  may  all  add  their  quota  to  make  the  sweet 
(or  terrible)  illusion,  the  shadow  man  or  homunculus  more 
real.  That  the  shadow  man  can  come  out  of  its  cerebral 
womb,  and  materialize  and  talk,  is  a  matter  of  every-day 
observation.  It  is  materialized  in  marble  or  paint ;  it  talks 
in  a  book  or  periodical.  Xo  greater  wonder  need  be  sought ; 
the  truly  wonderful  lies  in  nature.  Science  with  its  research 
will  show  still  greater  wonders  when  it  shall  prove,  as 
seems  now  likely,  that  sensations,  emotions,  and  reflections 
are  produced  by  the  inverted  epithelium — when  it  shows 
that  ideals  and  phantasms,  spectres  and  goblins  and  faries, 
spirits  of  good  and  spirits  of  evil,  angels  and  demons,  the 
godesses  and  the  gods,  are  like  teeth  and  hair,  like  breath 
and  saliva,  like  tears  and  like  sweat,  like  the  egg  and  like 
seed,  and  like  the  embryo,  pure,  simple,  and  natural  skin 
products. 

°  To  see  a  spectrum,  look  steadily  at  the  sun  an  instant,  then  close  the  eyes 
tightly. 


CLINIC   ON    NERVOUS   DISEASES. 

By  M.  A.  STARR,   M.D.,  Ph.D., 

Held  at  the  Vanderbilt  Clinic,  March  24,  1888. 

LEAD    PARALYSIS. 

GENTLEMEN  : — The  demonstration  of  a  thing  is 
worth  all  the  descriptions  in  the  world.  You  will 
remember  that  at  our  last  two  or  three  clinics  we 
were  talking  about  the  reaction  of  degeneration,  and  you 
will  further  remember  what  we  considered  that  reaction  to 
be.  I  have  here  a  man  regarding  whose  condition  I  will 
say  but  little,  as  his  complaint  is  one  with  which  you  are 
familiar,  but  I  will  proceed  at  once  to  demonstrate  it.  The 
patient  is  about  thirty  years  of  age,  and  states  that  he  has 
had  his  present  trouble  about  seven  weeks  ;  that  it  began 
with  weakness  in  the  shoulder  ;  that  he  was  unable  to  lift 
his  arm,  or  to  straighten  his  fingers.  He  says  he  has  had 
no  pain,  no  numbness,  no  tingling  in  the  affected  parts  ;  he 
complains  only  of  motor  weakness.  He  also  tells  us  that 
his  condition  is  better  than  it  was  seven  weeks  ago.  His 
occupation  is  chat  of  carriage-painter.  He  had  colic  pre- 
ceding the  paralysis.     His  bowels  are  now  free. 

Gentlemen  : — This  man,  as  you  hear,  gives  a  straight- 
forward history.  He  is  a  painter,  works  in  varnish,  and  is 
engaged  indoors.  You  know  that  painters  who  work  within 
buildings,  and  especially  those  who  work  in  close  rooms, 
are  more  liable  to  develop  lead  poisoning  than  others. 
When  you  look  at  this  man  I  think  you  will  see  at  once 
that  he  has  the  appearance  of  being  well-nourished,  but  is 
an.L-mic  and  pale.  He  has  no  apparent  atrophy  in  any  of 
the  muscles,  but  if  we  ask  him  to  go  through  certain  move- 
ments, you  will  see  he  has  deficiencies.     When  told  to  lift 


NER  VO  US  DISEA  SES.  „  c  , 

453 

the  right  arm  to  the  head,  he  is  unable  to  do  so.  There  is 
inability  to  abduct  the  arm.  On  the  left  side  he  succeeds 
in  abducting  the  arm  to  a  certain  extent,  but  it  is  limited. 
When  we  look  at  him  from  behind  and  ask  him  to  lift  the 
arms,  we  see  the  degree  of  abduction  made  by  the  right 
arm  is  due  to  rotation  of  the  scapula  by  the  serratus  magnus 
muscle.  We  know  that  complete  abduction  of  the  arm 
involves  a  complex  process.  It  is  performed  partly  by 
rotation  of  the  scapula  by  means  of  the  serratus  magnusr 
and  partly  by  the  action  of  the  deltoid.  This  man's  scapula 
rotates  normally,  therefore  the  trouble  with  abduction  is 
due  to  disturbance  in  the  deltoid  muscle.  Now,  besides  the 
trouble  in  his  shoulder  he  complains  also  of  trouble  in  his 
arms.  When  I  hold  up  his  arm  you  will  plainly  see  the 
condition  known  as  drop-wrist.  This  is  not  as  marked  on 
the  left  as  on  the  right  side  in  this  case.  You  will  also 
notice  very  marked  tremor  when  he  attempts  to  hold  the 
arms  out  by  his  own  efforts.  You  will  remember  that  at  a 
previous  clinic,  when  I  spoke  to  you  about  tremor,  I  said  it 
was  a  symptom  of  lead  poisoning. 

When  I  place  my  hand  in  his  and  ask  him  to  grasp  it, 
he  does  so  with  great  feebleness  ;  but  when  I  correct  the 
paralysis  of  the  extensor  muscles,  he  squeezes  my  hand  so 
tightly  as  to  cause  pain.  You  see,  therefore,  although  flex- 
ion is  apparently  impaired,  it  is  not  actually  impaired  in  this 
case.  The  condition  of  paralysis  is  less  marked  on  the  left 
side  than  it  is  on  the  right. 

No  examination  of  a  case  of  paralysis  is  complete  until 
the  electrical  reaction  has  been  tested.  We  will  now  pro- 
ceed to  test  the  electrical  reaction  with  the  Faradic  current. 
We  find  that  a  moderately  strong  current  causes  the  biceps 
to  contract.  The  same  strength  of  current  applied  over  the 
deltoid  produces  no  effect,  and  when  I  carry  the  strength  of 
the  current  up  to  quite  a  high  degree  there  is  still  no  con- 
traction. On  the  left  side,  on  the  contrary,  there  is  a  slight 
movement  in  the  deltoid  produced  by  the  strong  Faradic 
current. 

We  will  now  try  the  galvanic  current,  using  this  small 
portable  chloride  of  silver  battery.     The  normal  reaction  to 


454  M-  A-  STARR- 

galvanism  is  easily  elicited.  This  we  prove  by  first  apply- 
ing the  negative  pole  over  the  patient's  biceps,  in  which  it 
causes  at  once  perceptible  contraction  when  the  circuit  is 
closed.  That  then  gives  us  the  cathodal  closure  contrac- 
tion. Now  we  will  apply  the  positive  pole.  The  anodal 
closure  contraction  in  the  biceps  muscle  is  less  than  the 
cathodal  closure  contraction.  This  man's  biceps  is  not 
paralyzed,  and  we  have  in  it  the  normal  reaction  to  the 
electrical  currents.  Now  we  will  try  the  deltoid  which  is 
paralyzed.  Cathodal  closure,  as  you  see,  gives  but  very 
slight  contraction.  Anodal  closure  gives  very  much  greater 
contraction.  Thus  we  find  that  the  anodal  closure  contrac- 
tion in  the  deltoid  is  greater  than  the  cathodal  closure  con- 
traction, which,  as  I  have  told  you  before,  constitutes  a 
reaction  of  degeneration.  On  the  left  side  the  difference 
between  the  cathodal  and  the  anodal  closure  contraction  is 
scarcely  perceptible.  It  is  difficult  to  say  whether  the  one 
is  greater  than  the  other ;  at  any  rate  the  reaction  cannot 
be  normal  because  the  cathode  should  produce  distinctly 
greater  contraction  than  the  anode.  We  have  then  on  the 
left  side  a  condition  known  as  partial  reaction  of  degenera- 
tion, while  in  the  right  deltoid  we  have  the  condition  known 
as  total  reaction  of  degeneration.  This  you  see  is  the 
result  of  the  electrical  examination.  It  demonstrates  at 
once  that  the  condition  in  the  deltoids  is  entirely  different 
from  that  in  the  biceps. 

You  well  know  that  the  reaction  of  degeneration  is  due 
to  disturbance  either  in  the  gray  anterior  horns  of  the 
spinal  cord,  or  in  the  nerve  outward  from  the  cord  to  the 
muscle.  In  this  case,  which  is  distinctly  one  of  lead  palsy, 
we  know  that  the  lesion  lies  in  the  nerves  and  not  in  the 
cord.  From  the  electrical  reaction  of  the  muscles  we  could 
not  tell  whether  the  lesion  lay  in  the  spinal  cord  or  in  the 
nerve  ;  we  could  only  tell  by  such  a  test  that  it  did  not  lie 
in  the  brain  or  in  the  motor  tract  from  the  brain  to  the 
anterior  gray  horn  of  the  cord.  Through  the  demonstra- 
tions of  pathology  we  have  learned  that  the  lesion  in  lead 
palsy  is  a  neuritis  ;  a  neuritis  which  is  limited  to  certain 
nerves  going  to  the  extensors  of  the  arm  and  to  the  deltoid. 


XER  VO  US  DISEA  SES.  .  -  r 

Now,  what  is  the  prognosis  ?  The  man  has  stopped  his 
work,  he  has  been  ill  only  seven  weeks,  he  has  improved 
rapidly ;  therefore  I  think  we  may  safely  say  that  he  will 
be  completely  well  within  three  months  of  the  tiniie  when 
his  symptoms  first  manifested  themselves.  It  is  a  light 
case  of  lead  poisoning.  Severe  cases  sometimes  last  longer. 
I  have  known  them  to  be  under  treatment  two  years  and 
then  recover. 

What  is  the  treatment  ?  The  indications  are  first  to 
eliminate  the  lead  from  the  system  so  far  as  possible.  That 
can  be  done  by  means  of  cathartics,  especially  by  epsom 
salts,  and  by  diuretics,  especially  iodide  of  potassium.  Iodide 
of  potash  hastens  the  elimination  of  the  lead  through  the 
kidneys.  The  second  indication  in  treatment  is  to  increase, 
if  possible,  the  nutrition  of  the  nerves  which  are  degener- 
ated. That  can  be  accomplished  by  tonic  treatment  in 
general,  especially  by  the  use  of  strychnine  in  doses  of  one- 
sixtieth  to  one-forty-eighth  of  a  grain,  administered  three 
times  a  day,  or  of  fifteen  to  twenty  minims  of  the  tincture  of 
nux  vomica.  The  patient  is  taking  nux  vomica.  The  third 
indication  is  to  hasten  regeneration  of  the  affected  nerves 
by  means  of  electricity.  This  is  applied  in  the  form  of 
a  constant  galvanic  current  of  moderate  strength  passed 
through  the  nerve.  Now,  the  treatment  which  this  patient 
has  received  is  just  that  which  I  have  mentioned.  He  has 
received  the  galvanic  current  passed  from  the  neck  down 
over  the  muscles,  and  in  that  way  the  current  passes  the 
entire  length  of  the  nerves  affected  with  degeneration.  But 
there  is  still  another  indication.  You  not  only  want  to 
eliminate  the  lead  and  increase  the  regeneration  of  the 
nerve,  but  you  should  keep  the  muscles  in  good  condition. 
When  the  nerve  is  degenerated  the  muscle  to  which  it  goes 
atrophies.  If  we  do  not  do  anything  for  these  muscles  they 
will  go  on  atrophying,  and  then  when  the  man's  nerves  have 
been  regenerated  and  enable  him  to  move  the  affected  parts, 
he  will  find  the  muscles  so  weak  that  he  will  be  disinclined 
to  use  them.  Therefore  the  paralyzed  muscles  should  be 
exercised  by  the  aid  of  the  interrupted  galvanic  current 
(not  the  constant  galvanic  current).     You  will  see,  there- 


456  M.  A.   STARR. 

fore,  that  galvanism  is  used  in  this  case  in  two  different 
ways.  First,  the  constant  galvanic  current  is  used  to  re- 
generate the  nerve.  Secondly,  the  interrupted  galvanic 
current  is  applied  to  the  affected  muscles  in  order  to  give 
them  exercise.  Besides  this  we  tell  the  patient  to  rub  his 
muscles  thoroughly  with  alcohol,  salt  water,  or  liniment  of 
any  kind.  This  patient  has  been  usuing  salt  water.  The 
benefit  does  not  come  so  much  from  what  we  put  on  the 
limb  as  from  the  rubbing  which  the  muscles  receive.  There 
is  another  little  practical  point  in  the  treatment  of  cases  of 
lead  palsy  which  is  of  some  interest.  That  is,  that  the 
atrophy  of  the  muscles  seems  to  progress  more  rapidly 
when  the  paralyzed  muscles  are  put  on  the  stretch.  Now, 
when  a  man  has  lead  poisoning,  he  is  apt  to  go  around 
with  his  wrists  dropped,  and  you  see  at  once  that  the  para- 
lyzed extensor  muscles  are  those  put  on  the  stretch.  You 
should,  therefore,  instruct  such  patients  to  carry  their  hands 
up  against  the  chest  in  this  way,  so  that  the  hand  shall  be 
kept  in  the  position  of  extension. 

CONFINEMENT    PARALYLIS. 

As  there  are  two  other  cases  which  I  wish  to  show  you 
in  addition  to  the  one  now  present,  I  will  hasten  over  the 
history.  This  little  girl  is  eleven  months  old.  The  mother 
says  that  her  right  arm  has  been  practically  useless  since 
she  was  b^rn.  I  saw  the  child  two  weeks  after  its  birth, 
when  its  condition  was  the  same  as  to-day.  She  is  un- 
able to  move  the  right  arm  as  she  does  the  left.  The 
arm,  you  will  observe,  is  held  in  a  natural  position,  and 
when  I  take  hold  of  it  she  attempts  to  pull  it  away.  She 
moves  it  voluntarily.  The  right  arm.  on  the  contrary,  hangs 
extended  at  the  side,  and  apparently  is  not  moved  volun- 
tarily at  all.  When  I  lift  it  and  attempt  to  make  her  lift 
the  arm,  it  drops  heavily  at  her  side  when  released.  There 
is  at  least  no  voluntary  movement  at  the  shoulder.  \\  hen 
I  turn  the  hand  up,  supinate  it,  and  then  let  it  fall,  we  can 
see  that  it  returns  at  once  to  the  position  of  pronation.  You 
can  see  that  the  child  is  unable  to  move  the  arm  into  the 
position  of  flexion  at  the  elbow  or  into  the  position  of  supin- 


NER VO US  DISEA SES.  AC~ 

45/ 

ation.  There  is,  therefore,  not  only  paralysis  at  the  shoulder, 
but  also  paralysis  of  flexion  at  the  elbow  and  of  supination. 
But  when  I  hold  the  hand  out  you  can  see  that  the  fingers 
move  freely ;  when  I  place  my  finger  into  the  palm  of  the 
child's  hand  it  is  clasped.  There  is,  then,  no  trouble  in 
either  flexion  or  extension  of  the  fingers  and  wrist.  Now,  I 
have  made  a  careful  electrical  examination  of  the  muscles 
(which  I  will  not  now  repeat  for  want  of  time  and  because 
of  the  difficulty  of  such  an  examination  in  a  child),  and 
found  the  reaction  of  degeneration  in  the  deltoid,  biceps, 
coraco  brachialis,  brachialis  anticus,  and  in  the  supinator 
longus  muscles.  I  could  not  get  at  the  supinator  brevis  be- 
cause the  arm  was  too  fat.  We  have,  then,  paralysis  of  a 
peculiar  group  of  muscles  which  I  have  just  named.  Now, 
this  form  of  paralysis  is  known  as  Erb's  paralysis,  because 
Erb,  of  Heidelberg,  was  the  first  to  describe  it.  It  is,  as 
you  see,  a  paralysis  of  a  group  of  muscles,  while  the  other 
muscles  of  the  arm  escape. 

To  what  may  that  be  due  ?  To  one  or  two  causes.  It 
may  be  due  to  a  lesion  of  the  spinal  cord  at  the  level  of  the 
fifth  cervical  segment.  As  I  have  shown  you  by  certain 
diagrams,  that  locality  corresponds  to  the  centres  in  the 
spinal  cord  which  govern  the  group  of  muscles  paralyzed  in 
this  case.  The  lesion  at  that  point  might,  then,  have  caused 
this  trouble  ;  but  there  is  also  another  lesion  which  some- 
times produces  it,  namely,  pressure  exerted  upon  the  fifth 
and  sixth  cervical  nerve  roots  of  the  brachial  plexus.  How 
can  we  distinguish  between  the  two  ?  It  can  be  done  by 
the  test  of  sensibility.  If  the  lesion  is  in  the  anterior  horns 
of  the  spinal  cord  ;  that  is,  if  there  is  infantile  paralysis, 
there  will  be  no  disturbance  of  sensation.  If,  however,  the 
lesion  is  in  the  nerves  containing  sensory  fibres  there  will 
be  disturbance  of  sensation.  Now,  it  is  difficult  to  test  the 
sensation  of  a  child,  and  sometimes  it  can  be  done  accu- 
rately only  after  repeated  trials,  but  I  think  you  can  see  in 
this  case  that  when  I  scratch  the  right  shoulder  with  a 
sharp  instrument  the  child,  although  it  looks  around  at 
what  I  am  doing,  pays  but  little  attention,  yet  I  have 
caused  the  skin  to  become  quite  red.     When,  on  the  con- 


,  eg  M.  A.   STARR. 

trary,  I  scratch  the  left  shoulder,  its  attention  is  attracted 
at  once,  and  on  going  a  little  further  with  the  test  the 
patient  makes  a  face  as  if  about  to  cry.  I  think  we  can 
fairly  conclude  from  this  test  that  the  child  has  lost  sensa- 
tion on  the  outer  side  of  the  right  arm.  I  have  further 
proven  this  fact  at  former  sittings  by  the  use  of  electricity. 
The  child  will  stand  a  very  much  stronger  current  without 
crying  when  it  is  applied  to  the  outer  side  of  the  right  arm 
than  when  it  is  applied  to  the  left.  There  is  disturbance  of 
sensibility  in  the  right  arm.  The  trouble  is  not  in  the 
child's  spinal  cord,  but  it  is  in  the  fifth  and  sixth  cervical 
nerves. 

What  is  the  cause  of  such  paralysis?  Usually  the  cause 
is  a  forcible  delivery  in  the  breach  presentation.  Now,  this 
child  presented  by  the  breach  and  the  labor  went  on  until 
it  was  time  for  the  head  to  be  delivered.  The  midwife  who 
was  present  extracted  the  child  manually.  How  did  she 
do  it?  In  all  probability  just  as  you  would  have  done,  by 
introducing  two  fingers  of  the  left  hand  and  seizing  the 
child  on  either  side  of  the  nose  upon  the  superior  maxillary 
bones.  The  next  step  is  to  extend  the  fingers  of  the  right 
hand  over  the  back  of  the  child's  neck  and  to  make  traction 
downward  and  backward.  You  will  see  as  I  put  my  fingers 
here  on  the  side  of  the  child's  neck  in  this  manner,  as  it 
would  be  done  in  the  course  of  labor,  I  make  pressure 
inward  and  downward  above  the  clavicles,  especially  with 
the  tips  of  my  fingers  ;  the  pressure  coming  about  the  point 
of  exit  of  the  fifth  and  sixth  cervical  nerves.  It  is  an  inter- 
esting fact  that  in  all  the  cases  that  I  have  seen  of  this 
disease  (and  I  have  seen  quite  a  number)  the  paralysis  has 
been  on  the  right  side  ;  and  you  will  notice  that  in  this 
position  the  middle  finger  falls  upon  the  right  side  of  the 
patient's  neck,  and  the  index  finger  on  the  left  side.  That 
is,  the  longer  finger  is  upon  the  right  side,  and  is  more 
likely  to  make  downward  pressure  so  as  to  involve  these 
nerves.  I  think  this  may  be  the  true  explanation  of  the 
greater  frequency  of  the  accident  on  the  right  side  of  the 
body. 

This  form  of  paralysis  was   first  described  by  Duchenne 


NER  VO  US  DISEA  SES.  ,  .  q 

as  confinement  paralysis,  and  it  has  been  recognized  as 
such  by  all  writers  on  paralysis  of  the  nerves  since  that 
date.  It  is  a  paralysis  due  to  pressure  at  the  time  of  deliv- 
ery upon  the  fifth  and  sixth  cervical  nerves.  Those  of  you 
who  have  attended  the  surgical  clinics  will  remember  a. 
similar  condition  in  an  adult  at  the  Roosevelt  Hospital. 
He  had  paralysis  of  the  deltoid,  of  the  biceps,  of  the  coraco- 
brachial, of  the  brachialis  anticus  and  si  pinator  longus 
muscles.  The  other  muscles  of  the  arm  were  somewhat 
weak,  but  they  were  not  paralyzed.  The  muscles  I  have 
just  named  exhibited  the  reaction  of  degeneration,  and  from 
that  fact  and  the  further  history,  the  man  having  received  a 
stab-wound,  Drs.  Sands  and  Hartley  made  a  diagnosis  of 
division  of  the  fifth  and  sixth  cervical  nerves.  That  diag- 
nosis was  established  by  the  operation.  They  cut  down 
and  found  the  divided  nerves,  united  them,  and  the  man 
recovered.  That  case  is  worthy  of  association  in  your 
minds  with  this  one,  which  is  a  typical  case  of  confinement 
or  Erb's  paralysis. 

What  is  the  prognosis  in  this  case  ?  It  is  somewhat 
doubtful.  I  recall  three  cases  in  which  recovery  was  spon- 
taneous. I  have  seen  two  others  in  which  recovery  took 
place  under  electrical  treatment.  The  electrical  treatment 
has  been  carried  on  somewhat  irregularly  in  the  case  of 
this  child,  and  we  cannot  say  that  there  has  been  any 
change  for  the  better.  I  should  say,  therefore,  that  it  is. 
a  somewhat  unfavorable  case,  yet  there  is  one  thing  which 
is  favorable  about  it.  You  will  notice  in  comparing  one 
shoulder  with  the  other  that  there  is  not  a  great  amount  of 
difference  as  to  size  ;  in  other  words,  the  right  deltoid  is 
not  atrophied  to  any  extent.  This  is  a  favorable  point  in 
prognosis.  If  the  nerve  were  absolutely  degenerated  and 
severed,  the  deltoid  would  be  thoroughly  atrophied.  When 
the  nerve  is  injured  in  only  a  moderate  degree,  atrophy  is 
less  extreme.  I  suppose  the  atrophy  in  a  well-nourished 
child  like  this  one  would  be  somewhat  concealed  by  the 
amount  of  fat.  Nevertheless,  I  think  the  fact  that  these 
muscles  which  are  paralyzed  have  not  atrophied  wholly, 
but  have  grown  to  some  extent,  would  make  the  prognosis 


i6o  •'/•   A.   STARR. 

in  this  case  good.  It  may  be  two  years  before  the  child 
will  get  the  use  of  its  arm,  but  I  think  that  eventually  she 
will  get  it.  The  electrical  treatment  in  a  case  of  this  kind 
is  the  same  as  in  the  one  of  lead  palsy,  just  described. 
Give  the  constant  current  through  the  nerve  and  the  inter- 
rupted current  over  the  muscle  so  as  to  produce  contrac- 
tion. 

EPILEPTIC   INSANITY. 

I  spoke  tc  you,  in  my  lecture  on  Thursday,  of  mental 
conditions  arising  in  connection  with  epilepsy.  You  will 
have  observed  that  the  case,  the  history  of  which  we  have 
just  obtained,  illustrates  two  of  those  conditions  very  well. 
In  the  first  place,  it  illustrates  the  condition  of  post-epileptic 
insanity.  Post-epileptic  insanity  may  take  the  form  either 
of  mania,  or  of  melancholia,  or  of  simple  dementia,  for  they 
are  all  examples  of  psychical  neuroses.  In  this  man  it  evi- 
dently takes  the  form,  to  a  certain  extent,  of  melancholia. 
He  is  now  thirty-two  years  old  ;  he  says  he  has  been  sick  at 
least  twenty  years.  His  mother,  who  has  come  with  him, 
tells  us  that  he  has  convulsions,  which  we  at  once  recognize 
from  her  description  as  those  of  epilepsy,  and  that  he  has 
after  each  convulsion  a  short  period  of  melancholia,  is 
alarmed,  is  troubled,  and  makes  exclamations  at  the  times 
of  his  attacks  in  the  form  of  prayer,  and  often  cries,  but  is 
never  violent.  During  the  attacks  and  shortly  afterwards 
he  is  perfectly  unconscious,  and  later  has  no  recollection  of 
what  had  taken  place.  You  will  find  other  forms  of  psychi- 
cal disturbance  which  are  not  so  harmless,  forms  in  which 
the  individual  after  the  fit  passes  into  a  state  of  acute  mania, 
has  hallucinations  which  terrify  him,  which  make  him  fear 
.that  he  is  going  to  be  injured,  and  which  lead  him  to  try  to 
get  away  from  those  around  him.  If  he  is  opposed  in  his 
attempts  at  escape,  he  will  kill  those  in  his  way.  The  most 
violent  of  all  lunatics  are  those  who  have  temporary  attacks 
of  mania  after  epilepsy.  They  are  perfectly  ungovernable. 
That  is  a  form  of  insanity  in  which  restraint  is  absolutely 
neccessary  ;  you  cannot  get  along  without  it.  The  state  of 
jnania,  melancholia,  or  simple  dementia,  which  occurs  in 
these  cases,  lasts  for  a  variable  time.     In   this  man  it  lasts 


NER VO US  DISEA SES.  ,5  l 

ten  minutes,  in  other  cases  fifteen  or  twenty  minutes,  and  in 
still  other  cases  four  to  five  hours.  During  that  time  the 
individual  is  not  at  all  legally  responsible  for  what  he  does. 
He  may  go  through  an  apparently  well-planned  attempt  at 
murder,  or  a  well-planned  attempt  at  theft,  or  an  attempt  at 
any  crime,  and  yet  when  he  awakes  from  his  sleep  and 
comes  out  of  this  abnormal  mental  condition  he  has  no  rec- 
ollection of  anything  he  has  done  during  that  time.  Now, 
that  is  a  condition  of  post-epileptic  insanity. 

But  there  is  another  form  of  mental  disturbance  which 
develops  in  epilepsy.  It  is  a  gradual  development  of  chronic 
dementia,  which  this  man  also  shows.  You  can  see  from 
his  appearance  and  judge  from  his  mother's  statements  that 
this  man's  mind  is  not  right.  His  memory  is  very  poor.  He 
cannot  do  anything  in  the  way  of  work,  evidently  because 
no  one  will  employ  so  weak-minded  a  person.  This  condi- 
tion of  weak-mindedness  develops  at  a  variable  period  in 
the  course  of  epilepsy.  If  the  epilepsy  develops  in  early 
life,  the  child  does  not  acquire  knowledge  readily,  it  grows 
up  somewhat  stupid  ;  if  the  disease  develops  in  the  adult 
and  continues  for  a  long  period,  at  the  end  of  some  twenty 
years  you  will  find  mental  deterioration  which  goes  on  fre- 
quently to  actual  dementia. 

I  will  not  dwell  upon  the  epileptic  features  of  the  case. 
You  have  heard  the  history ;  that  the  man  has  two  kinds  of 
attacks — grand-mal  type,  in  which  he  has  severe  convul- 
sions with  biting  of  the  tongue  and  convulsive  movements 
all  over  the  body ;  and  the  petit-mal  type,  in  which  he  has 
simply  temporary  loss  of  consciousness,  and  does  not  go  on 
to  have  a  convulsion.  These  occur  several  times  a  week. 
The  case  is,  therefore,  a  typical  one  of  epilepsy.  The  aura 
which  he  has  before  the  fit  consists  of  dizziness,  and  is  a 
very  common  aura,  one  which  does  not  give  us  any  indica- 
tion as  to  the  cause  of  the  attack.  The  aura  is  a  very  im- 
portant thing  to  investigate,  for  it  is  really  an  hallucination, 
and  an  hallucination  is  always  produced  by  an  irritation  of 
the  brain  somewhere.  If  the  aura  is  a  constant  one,  we  have 
an  indication  that  irritation  in  the  brain  is  localized  at  a 
definite  point.     If  the  aura  consists  in  numbness  beginning 


,52  M-  A-  ST-4RX- 

in  the  thumb  and  gradually  going  up  the  arm,  and  after  the 
numbness  has  reached  the  body  or  head  the  patient  goes  into 
a  fit,  we  know  that  there  is  an  irritation  in  the  brain  which 
begins  in  the  sensory  area  related  to  the  arm.  If  the  man 
has  an  aura  of  an  epileptic  fit  consisting  of  a  ball  of  fire,  or 
of  blue  light,  or  of  the  appearance  of  certain  figures  moving 
around  from  one  side  of  him  until  they  reach  the  middle 
line,  you  may  be  sure  that  that  man  has  an  irritation  in  the 
posterior  lobe  in  the  visual  area  of  the  brain.  If  the  man 
has  an  aura  beginning  as  a  very  loud  sound  in  the  ear,  you 
may  be  sure  the  irritation  in  the  brain  begins  in  the  audi- 
tory area.  So  you  see  that  the  aura  of  an  epileptic  fit  gives 
us  information  of  the  seat  of  the  irritation,  and  it  is  an  inter- 
esting fact  that  most  of  these  auras  occur  in  cases  where 
organic  disease  of  the  cortex  of  the  brain  is  to  be  suspected. 
But  in  a  case  like  this  one,  in  which  the  aura  is  only  an  in- 
definite sense  of  vertigo,  which  may  occur  in  idiopathic 
epilepsy,  the  lesion  is  one  which  we  do  not  know  anything 
about.  The  treatment  of  such  a  case  as  this  is  similar  to 
that  of  any  case  of  epilepsy,  and  he  is  taking  a  mixture  of 
the  bromides  of  potassium,  sodium,  and  ammonium,  thirty 
grains  three  times  a  day.  Under  this  line  of  treatment  the 
number  of  attacks  is  being  reduced.  The  treatment  does 
not,  however,  appear  to  effect  any  change  in  the  occurrence 
or  duration  of  the  melancholia  period  following  the  fit. 
When  such  a  patient  has  maniacal  attacks  he  requires  con- 
stant watching. 

PARANOIA. 

I  have  still  another  case  which  illustrates  an  interesting 
mental  condition,  and  one  which  those  of  you  who  have 
attended  the  lectures  regularly  will  at  once  recognize  as 
the  history  is  called  out.  We  have  elicited  from  the  man 
himself  as  distinct  a  history  of  his  condition  as  we  could 
desire.  His  age  is  about  forty-five  years.  His  sister,  in 
reply  to  our  questions,  gives  us  no  history  of  hereditary 
trouble.  She  says  he  has  always  been  a  somewhat  simple- 
minded  man.  Simple  in  the  Irish  vocabulary  means  some- 
thing a  little  different  from  what  we  naturally  think  of  when 
that  term   is   used,  for   in  Ireland   an   imbecile   is   called  a 


NER VOUS  DISEASES.  ,£ - 

simple  man,  and  it  is  probable  that  by  the  term  simple  she 
meant  to  say  in  as  kind  a  word  as  possible  that  her  brother 
has  not  been  quite  as  strong  mentally  as  other  men.  In 
his  description  of  his  case  you  will  notice  that  he  seems  not 
to  have  the  strength  of  character  which  most  men  have.  It 
is  possible  that  he  has  always  been  somewhat  weak  men- 
tally, but  his  present  mental  trouble  has  come  on  recently, 
and  is  characterized  by  a  delusion  of  persecution,  a  delusion 
which  has  increased  rapidly  in  the  course  of  three  months, 
and  which  now,  as  you  see,  dominates  his  views  of  things, 
and  which  he  has  told  us  freely.  He  not  only  thinks  cer- 
tain men  with  whom  he  has  worked  have  talked  against 
him  in  his  shop,  but  he  thinks  they  have  spread  a  malicious 
report  around  the  city  that  he  has  seduced  a  young  girl, 
and  is  the  father  of  her  child.  He  not  only  thinks  that 
they  have  spread  the  report  around  the  city,  but  that  they 
have  put  it  in  the  papers.  He  cannot  find  it  in  the  English 
papers,  he  cannot  read  the  German  papers,  but  he  thinks  it 
is  in  the  papers  and  therefore  that  it  must  be  in  the  German 
papers,  where  he  cannot  detect  it.  It  leads  him  not  only 
to  believe  that  everybody  in  the  streets  know  of  it,  but  that 
they  single  him  out  and  look  at  him  as  he  goes  by.  It  is 
not  probable,  although  he  thinks  it  is  so,  that  a  lady  walk- 
ing along  the  street  with  her  husband,  would  say  anything 
about  his  "  first-born,"  addressing  him,  a  stranger,  in  that 
way.  Therefore,  it  is  not  unlikely  that  he  has  hallucina- 
tions of  sound.  I  could  not  get  a  history  of  hallucinations 
from  his  sister,  but  it  is  not  impossible  that  he  may  have 
such.  Hallucinations  of  sound  are  not  at  all  uncommon  in 
the  course  of  paranoia.  That  is  a  form  of  degenerative 
insanity  which  is  chronic  and  which  is  bad  in  its  prognosis. 
The  man  is  apparently  harmless  as  yet,  but  his  sister  admits 
that  he  gets  excited,  that  this  delusion  excites  him  at  times, 
and  on  one  occasion  she  had  to  lock  him  in.  The  only  thing 
to  do  for  a  condition  of  mind  of  that  kind  is  to  put  the  man 
into  a  well-regulated  asylum.  There  he  will  be  prevented 
from  doing  any  harm,  which  elsewhere  he  might  take  it 
into  his  head  to  do.  As  far  as  any  active  treatment  for  his 
condition  goes,  we  know  of  nothing  which  will  in  any  way 


464  M'  A-  STARR. 

alleviate  it.  We  have  to  deal  with  the  symptoms.  You 
have  heard  his  sister  say  that  since  he  has  been  taking 
medicine  the  insomnia  has  subsided.  Insomnia  is  a  symp- 
tom of  this  form  of  insanity.  We  gave  him  bromides,  but 
they  failed,  and  we  then  gave  him  a  mixture  of  bromides 
and  chloral,  which  enabled  him  to  sleep.  He  has  also 
some  slight  amount  of  gastric  catarrh.  He  has  chronic 
dyspepsia,  and  he  is  in  some  degree  constipated.  When  I 
examined  him  at  a  time  previous  to  this  he  volunteered  the 
information  that  the  trouble  in  his  stomach  was  due  to 
something  which  his  enemies  had  put  into  his  food.  You 
see,  therefore,  how  his  sensations  are  brought  into  relation 
with  his  dominant  idea.  He  has  symptoms  of  pain  in  the 
chest,  of  disturbance  in  the  stomach,  of  insomnia,  all  of 
which  he  ascribes  to  the  influence  of  outside  enemies.  His 
case  illustrates  what  I  told  you  in  the  course  of  lectures, 
that  in  the  examination  of  a  lunatic  it  is  better  to  get  at  his 
history  from  a  standpoint  of  a  physician  asking  him  medical 
questions,  which  will  not  direct  his  attention  particularly 
to  his  delusion  ;  it  may  be  his  desire  to  conceal  that ;  but 
through  his  physical  symptoms  you  can  often  get  at  his 
mental  smyptoms.  You  saw  that  fact  illustrated  in  this 
case.  My  first  question  was  with  regard  to  his  health,  and 
his  first  reply  was  with  regard  to  the  pain,  and  it  was 
accompanied  with  the  statement  that  "they"  gave  him  the 
pain.  That  simple  remark  gave  his  whole  story  away.  It 
is  an  interesting  fact  that  in  the  examination  of  a  lunatic 
you  can  often  get  at  his  delusion  much  better  indirectly 
than  directly.  The  characteristic  feature  of  this  case  is  the 
existence  of  a  systematized  delusion  of  persecution  which 
dominates,  but  does  impair  his  mental  processes  ;  and  this 
is  the  characteristic  of  paranoia. 


Hysteria  and  Brain-Tumor.    By  Mary  Putnam  Jacobi, 
M.D.     pp.  213.     G.  P.  Putnam's  Sons,  1888. 

In  this  volume  the  author  presents  seven  essays  which  have  pre- 
viously appeared  separately  in  numerous  publications  or  have  been 
read  at  society  meetings. 

These  essays  are  entitled :  Some  Considerations  of  Hysteria ; 
Tumors  of  the  Brain ;  Note  on  the  Special  Liability  to  Loss  of 
Nouns  in  Aphasia  ;  Case  of  Nocturnal  Rotary  Spasm  ;  The  Prophy- 
laxis of  Insanity ;  Antagonism  between  Medicines  and  between 
Remedies  and  Diseases ;  and  Hysterical  Locomotor  Ataxia. 

Of  these,  the  first  two  deserve  more  than  a  passing  notice.  The 
author's  depth  of  thought  and  closeness  of  observation  are  nowhere 
made  more  apparent  than  in  the  opening  essay  on  Hysteria.  Many 
original  and  plausible  theories  are  advanced  and  numerous  cases 
are  cited  to  bear  out  the  author's  views. 

After  a  few  remarks  on  the  conditions  fundamental  to  hysteria, 
the  writer  goes  on  to  discuss  the  origin  of  the  sensory  and  motor 
symptoms.  The  sensory  symptoms — anaesthesia  and  pain — are 
attributed  respectively  to  privation  of  the  blood  supply  of  the  sen- 
sory centres,  and  to  excessive  centripetal  irritations  which  are  dis- 
tributed throughout  all  the  receiving  stations  of  the  cerebro-spinal 
axis.  The  motor  symptoms — paralysis  and  convulsion — are  attrib- 
uted respectively  to  depression,  or  inhibition  of  the  function  of  the 
cortical  motor  centres  in  liberating  energy  in  motor  tracts  in  response 
to  intracerebral  stimulus,  and  to  a  diminished  control  over  the  sub- 
cortical motor  centres  by  the  cortical  centres  which  normally  inhibit 
them  in  part.  The  causes  which  lead  to  these  abnormal  conditions 
are  fully  discussed  and  explained,  and  the  various  forms  of  pain, 
paralysis  and  convulsions  are  entered  into  with  a  minuteness  char- 
acteristic of  the  author.  The  psychical  phenomena  of  hysteria  are 
carefully  studied,  and  the   difference  between  hysterical  neuroses 


466  REVIEWS. 

and  neuroses  originating  in  medullary  spinal  centres  is  made  appar- 
ent. The  latter  part  of  the  essay  is  devoted  to  the  diagnosis  and 
treatment  of  hysteria.  In  regard  to  the  latter,  ^electricity,  massage, 
gymnastics,  the  health  lift,  together  with  the  usual  medicinal  reme- 
dies, are  recommended.  The  removal  of  the  ovaries  for  intractable 
cases  of  hysteria  is  advised  in  two  classes  of  cases.  One,  where  the 
ovaries  are  diseased  ;  the  other,  where  the  ovaries  are  normal,  but 
in  which  normal  menstruation  causes  intolerable  irritation. 

It  cannot  be  denied  that  the  removal  of  diseased  ovaries  is  often 
beneficial  in  the  treatment  of  hysteria,  but  where  the  ovaries  are 
normal  even  our  most  ardent  ovariotomists  would  be  inclined  to 
respect  them.  The  author  admits  that  the  operation  is  not  often 
immediately  successful,  either  because  menstruation  persists,  or 
because  the  nervous  phenomena  persist,  and  claims  that  the  oper- 
ation can  only  be  considered  unsuccessful  after  the  lapse  of  two 
years. 

The  article  on  Brain  Tumor,  though  not  containing  as  much 
original  thought,  is  of  as  great,  if  not  of  greater,  importance  than 
the  preceding  essay.  It  is  almost  a  complete  analysis  of  the  subject. 
The  symptoms  are  exhaustively  considered  in  relation  to  the  loca- 
tion of  the  lesions,  and  the  results  are  carefully  tabulated,  so  that  a 
complete  understanding  of  the  subject  may  be  obtained  almost  at  a 
glance. 

The  remaining  essays  are  treated  with  that  careful  consideration 
characteristic  of  the  author. 

As  a  whole,  the  work  is  a  valuable  addition  to  neurological 
science. 


J&wirty  geprtis. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Stated  Meeting,  May  ist,  1888. 
The  President,  George  W.  Jacoby,  M.D.,  in  the  Chair. 
Dr.  Leonard  Weber  presented  a  paper  upon 

PARALYSIS   AGITANS,  WITH   CASES. 

The  disease  had  been  first  described  by  Parkinson  in 
1817.  Charcot  had  differentiated  it  from  disseminated  scle- 
rosis. Progressive  tremor  and  muscular  weakness  affecting 
first  one  limb  and  subsequently  spreading  to  other  limbs 
were  its  chief  symptoms.  According  to  Charcot,  the  head 
was  always  respected.  There  was  apparent  diminution  of 
muscular  force,  and  in  well-advanced  cases  movements 
were  slow  and  uncertain.  There  was  loss  of  faculty  of  equi- 
librium. In  trying  to  walk  the  patient  would  run,  appearing 
to  be  running  after  his  lost  centre  of  gravity.  There  was 
bending  of  the  body  to  a  stooping  posture  and  an  immobile 
facial  expression  with  a  fixed  stare.  Death  occurs  from 
marasmus  or  intercurrent  disease.  The  onset  was  insidious, 
a  hand,  a  foot,  or  even  a  thumb  had  been  first  affected.  The 
crossed  form  is  rare,  and  the  hemiplegic  form  was  more 
common  than  the  paraplegic.  Charcot  referred  to  cases  in 
which  pain  had  been  the  first  symptom,  tremor  following 
later  on.  Deglutition  was  not  interfered  with,  the  bladder 
and  rectum  but  seldom.  There  might  be  annoying  cramps, 
but  contractures  did  not  occur.  Deformity  might  be  pres- 
ent, giving  to  the  hands  the  aspect  of  arthritis  deformans. 
Glycosuria  had  been  noted.     This  complication  had  been 


,68  NEW  YORK  XEUROLOGICAL  SOCIETY. 

present  in  a  case  of  his  own.  In  an  advanced  stage  there 
was  disturbance  both  of  thought  and  action.  Neuralgias 
were  present  with  a  sense  of  fatigue  and  restlessness,  re- 
quiring frequent  change  in  position.  There  was  a  subjective 
feeling  of  heat. 

Marked  melancholia  or  general  hallucinations  may  be 
present  with  even  maniacal  attacks.  Remak  had  differen- 
tiated a  cerebral  and  spinal  form.  In  two  of  his  own  cases 
cerebral,  and  in  two  others  spinal  symptoms  had  predomi- 
nated. Nothing  definite  to  account  for  the  tremor  had  been 
found  in  either  the  brain  or  the  cord.  It  is  a  disease  which 
affects  the  lower  strata  of  society  particularly,  and  men 
rather  than  women.  It  is  a  disease  of  advanced  life,  though 
Meschede  had  reported  a  case  in  a  boy  of  twelve  years, 
where  it  had  developed  after  a  kick  in  the  face  by  a  horse  ; 
and  Duchenne  one  in  a  man  of  twenty.  It  is  said  to  be 
more  frequent  among  English  and  American  people  than 
among  those  of  other  nations.  Powerful  emotional  and 
moral  shocks  have  produced  it,  also  irritation  of  the  periph- 
eral nerves  by  traumatism.  Prolonged  damp  cold  is  a  cause; 
also,  in  the  readers  opinion,  sexual  excess.  The  reader 
had  not  observed  that  syphilis  had  anything  to  do  with  its 
production.  Heredity  is  said  not  to  be  a  factor,  but  in  one 
of  his  own  cases  the  patient's  father  and  two  brothers,  and 
in  another  one  brother,  had  been  affected. 

Arsenic,  ergot,  and  nitrate  of  silver  had  no  retarding 
action.  The  comfort  of  the  patient  may  be  increased  by 
using  Brown-Sequard's  bromide  mixture,  leaving  out  the 
iodide  of  potassium.  Hyoscyamine  had  not  been  of  any 
value  in  the  reader's  experience,  producing  head  symptoms 
and  even  maniacal  attacks.  He  had  used  the  amorphous 
preparation  in  one-tenth  grain  doses.  Antipyrin  in  fifteen 
to  twenty  grain  doses  gave  rest  at  night  in  some  cases  ; 
chloral,  too,  had  been  useful,  but  the  effect  of  both  had  been 
transitory.  He  had  found  paraldehyde  superior  to  either  as 
a  hypnotic  in  these  cases.  It  was  given  in  emulsion,  fifteen 
to  thirty  grains  to  a  dose.  It  did  not  affect  the  stomach, 
did  not  weaken  the  heart,  and  did  not  lose  its  efficiency  by 
use.     The  galvanic   current  relieves  the  feeling  of  fatigue. 


NEW  YORK  NEUROLOGICAL  SOCIETY.  w^g 

Tepid  half  baths,  with  cold  affusions  to  the  head  and  spine, 
are  even  more  effective  and  prompt.  The  reader  has  had 
twelve  cases,  five  of  whom  had  been  under  his  care  suffi- 
ciently long  for  study.     He  briefly  referred  to  these  cases. 

Case  I.  was  a  man  of  seventy  years,  in  whom  the  disease 
had  existed  for  twenty-four  years.  The  patient  is  still  able 
to  get  about.     The  disease  was  produced  by  cold. 

Case  II.  was  a  woman  of  seventy  years,  first  seen  by  the 
reader  in  1884.  This  patient  was  a  very  cultivated  lady, 
with  fine  intellect,  and  a  great  knowledge  of  men  and  affairs. 
The  disease  dated  from  1876,  and  an  occasion  upon  which 
she  had  received  news  of  the  illness  of  a  loved  daughter. 
The  expression  of  face  in  this  case  was  markedly  sad  and 
immobile.  There  was  little  neuralgia,  no  spastic  paralysis, 
and  no  contractures.  A  peculiar  feature  was  atrophy  of  the 
epidermis  of  the  hands,  forearm,  feet,  and  legs.  Death  oc- 
curred in  1887  from  pneumonia.  Nightly  suffering  had  been 
in  this  case  relieved  by  paraldehyde  during  six  months. 

Case  III.  was  a  man  of  fifty-three  years,  a  German,  ad- 
dicted to  drinking  and  smoking  in  excess.  The  disease  had 
existed  for  seven  years  and  glycosuria  was  present.  The 
weight,  which  had  been  three  hundred  and  twenty  pounds, 
had  been  reduced,  but  not  below  two  hundred  and  eighty 
pounds.  CEdema  of  the  legs  had  been  present  in  this  case 
for  six  months.  Paraldehyde  in  a  dose  of  thirty  grains  at 
bedtime  gave  a  good  night's  rest. 

Case  IV.,  a  German,  aged  sixty-three  years,  was  a  mar- 
ket dealer,  presenting  as  causes  for  his  illness  exposure  to 
rheumatic  influences  connected  with  his  business,  and  sex- 
ual excess.  The  right  hand  had  been  first  affected,  and  in 
the  course  of  the  following  year  the  arm  and  shoulder.  The 
right  leg  had  been  seized  during  the  last  six  months.  There 
was  paresthesia  but  no  neuralgia  in  this  case. 

Case  V.  was  a  German,  aged  seventy-two  years,  whose 
father  and  two  brothers  also  suffered  from  the  disease.  The 
left  upper  and  lower  extremities  only  were  affected,  thus 
differing  from  the  usual  hemiplegic  form,  which  affects  the 
right  side.  It  was  to  be  remarked,  however,  that  this 
patient  was  left-handed.     The  shaking  was  violent  in  this 


^yQ  NEiV  YORK  NEUROLOGICAL  SOCIETY. 

case.     The    patient  was    easily  excited,  and  suffered  with 
vertigo  and  headache. 

Dr.  C.  L.  Dana  felt  that  the  obscure  points  of  pathology 
and  treatment  should  receive  consideration.  We  do  not 
know  the  nature  of  the  disease  nor  how  to  cure  it.  It  was 
his  opinion  that  paralysis  agitans  is  a  degenerative  disorder 
of  the  voluntary  motor  system.  The  sensory  symptoms 
and  the  mental  inquietude  are  explained  by  the  close  rela- 
tions between  the  motor  and  sensory  centres.  The  speaker 
had  had  twenty  cases  under  his  own  observation,  and  had 
seen  thirteen  others  in  the  Bellevue  out-door  department,  2 
had  been  between  thirty  and  forty  years  of  age,  5  between 
forty  and  fifty,  13  between  fifty  and  sixty,  9  between  sixty 
and  seventy,  and  4  between  seventy  and  eighty.  Of  31,  20 
had  been  males  and  1 1  females.  Of  34  in  whom  the  race 
had  been  mentioned,  26  had  been  Irish,  6  German,  1  Rus- 
sian, and  1  born  in  the  United  States.  The  Celtic  element 
had  thus  greatly  preponderated,  a  fact  not  entirely  explained 
by  the  large  percentage  of  Irish  attendants  at  this  dispen- 
sary. The  disease  seemed  increasing  in  frequency.  From 
1876  to  1879  tne  Bellevue  dispensary  had  presented  but  7 
cases  of  paralysis  agitans  in  a  total  of  2,300  cases  ;  while 
from  1885  to  1888,  11  were  recorded  out  of  a  total  of  2,200. 

He  could  corroborate  the  statement  that  rheumatic  in- 
fluences are  active  in  its  production.  He  too  had  had  a 
case  complicated  with  diabetes,  and  he  had  .had  four  cases 
in  which  the  head  had  been  affected.  He  thought  this  not 
uncommon.  It  might  be  shown  in  the  muscles  of  the  angles 
of  the  mouth  and  tongue.  In  treatment,  hyoscyamine  had 
given  the  best  results.  He  had  used,  however,  not  the 
amorphous  but  the  crystalline  form  in  iJ0  to  e'0  grain  doses. 
Given  thus,  it  has  never  failed  to  exert  a  palliative  action. 

Dr.  M.  A.  Starr  called  attention  to  a  monograph  upon 
paralysis  agitans,  by  Anton  Heimann,  published  in  Berlin 
six  weeks  ago,  and  only  last  week  received  here,  in  which 
the  theory  of  cortical  origin  referred  to  by  Dr.  Dana  was 
supported  by  the  report  of  a  case.     In  this  case,  which  had 


NEW  YORK  NEUROLOGICAL  SOCIETY.  .ji 

developed  under  the  writer's  observation,  the  four  limbs  were 
affected.  The  lesion  could  be  located  as  hemorrhage  into 
the  internal  capsule.  Coincidently  the  paralysis  agitans 
had  ceased  upon  the  hemiplegic  side.  The  inference  was 
that  the  paralysis  agitans  was  due  to  impulses  from  the 
cortex  through  the  internal  capsule,  and  that  the  irritated 
cortical  centres  were  cut  off  from  the  muscles  by  the  injury. 
Gowers  had  demonstrated,  too,  that  the  rate  of  vibration  in 
paralysis  agitans  was  eight  per  second.  It  is  known  that 
irritation  of  the  cortex,  of  a  moderate  degree,  in  monkeys, 
produced  tremor  of  the  muscles  characterized  by  eight 
vibrations  per  second. 

In  regard  to  the  extension  of  the  tremor  to  the  head : 
while  Charcot  had  stated  that  the  head  never  was  affected, 
the  majority  of  German  observers  among  whom  were  See- 
ligmiiller,  Strumpell,  and  Heimann,  added  to  Gowers,  in 
his  new  book,  had  found  the  head  affected  in  a  considerable 
proportion  of  cases.  The  speaker  had  had  seven  cases  ot 
paralysis  agitans  under  his  care  during  the  last  two  years. 
The  tremor  had  affected  the  head  in  two  of  these  cases. 
He  could  join  Dr.  Dana  in  his  endorsement  of  hyoscyamine, 
given  in  the  crystalline  form  and  iho  grain  doses.  This 
remedy  had  had  a  good  effect  in  all  of  the  cases  which  he 
had  seen. 

Dr.  L.  C.  GRAY  considered  the  origin  of  the  tremor  very 
obscure.  He  recalled  a  case  presenting  the  typical  symp- 
toms of  disseminated  sclerosis.  The  patient  was  under 
observation  in  the  hospital  for  a  year  and  a  half,  and  the 
post-mortem  showed  nothing  but  a  cortical  meningitis,  no 
lesion  in  the  brain  or  cord.  The  speaker  did  not  agree 
with  Dr.  Weber  that  the  diagnosis  between  paralysis  agitans 
and  disseminated  sclerosis  was  in  all  cases  easy  to  make. 
Voluntary  tremor  might  be  present  in  both,  and  in  the 
earlier  stages  diagnosis  might  be  impossible.  One  of  the 
most  typical  cases  which  he  had  known  had  had  move- 
ments of  the  head.  This  case  was  that  of  a  woman  of 
seventy-five  years,  who  had  had  paralysis  agitans  for  thirty 
vears.     It  had  started  one  day,  when  on  a  ferry-boat,  upon 


AJ2  XEir  YORK  NEUROLOGICAL  SOCIETY. 

seeing  a  baby  fall  into  the  water,  and  buoyed  up  by  its  long 
clothes  float  down  the  stream.  Upon  getting  home  she  had 
found  her  upper  lip  quivering  like  that  of  a  rabbit.  This 
had  been  the  commencement  of  a  widespread  affection. 

Dr.  Gr.-EME  Hammond  had  seen  three  or  four  typical 
cases  of  face  tremor.  In  a  case  of  which  he  had  the  brain, 
the  paralysis  agitans  had  been  present  for  eight  years. 
There  had  been  no  change  in  the  voice,  but  during  the  last 
year  there  had  been  paralysis  of  the  tongue,  lips,  throat, 
and  heart,  which  finally  terminated  life.  Post-mortem  there 
was  absolutely  nothing  found  ;  no  softening  in  the  medulla 
and  no  change  in  the  cortex.  A  few  years  ago,  the  speaker 
had  collected  all  the  reports  of  autopsies  which  he  could 
find  of  cases  of  athetosis,  chorea,  ataxic  tremor,  and  paral- 
ysis agitans. 

Where  any  lesion  was  found  it  occupied  the  position  of 
the  gray  nerve  cells  of  the  optic  thalamus,  corpus  striatum 
or  cortex.  Where  spastic  spasm  was  present,  either  com- 
bined with  the  tremor,  or  alone,  the  white  fibres  of  the 
internal  capsule  were  affected  as  well.  Where  spastic 
spasm  was  not  present,  the  lesion  did  not  affect  these 
tracts. 

Dr.  ROCKWELL  had  had  two  or  three  cases  under  forty 
years.  He  thought  that  the  younger  cases  responded  best 
to  palliative  treatment.  He  recalled  a  case  from  Peru 
which  he  had  treated  with  hyoscyamine  1J0  grain  dose  and 
the  galvanic  current.  This  patient  had  returned  to  his 
home  apparently  cured.  The  symptoms  returned,  he  came 
back,  was  again  subjected  to  the  treatment,  was  again 
cured  and  had  remained  well  for  a  year. 

Dr.  SACHS  regarded  Dr.  Heiman's  argument  as  ingenious 
but  not  conclusive.  Hemorrhage  into  the  internal  capsule 
is  the  commonest  cause  of  hemiplegia  in  middle  life.  Hemi- 
plegia is  not  very  uncommon  in  the  course  of  paralysis 
agitans  and  it  does  not  interfere  with  the  tremor  in  the 
usual  case.     In  regard  to  the  involvement  of  the  head,  he  had 


NEW  YORK  NEUROLOGICAL  SOCIETY.  .~~ 

a  case  now  under  treatment  in  which  the  head  was  affected. 
He  used  hyoscyamine  in  the  crystalline  form,  and  had 
found  it  so  reliable  as  a  palliative  that  no  other  drug  was 
required  in  his  experience.  Even  in  severe  cases  the  tremor 
was  lessened  by  means  of  it. 

Dr.  Petersen  referred  to  the  fact  that  when  in  the 
Poughkeepsie  asylum,  while  administering  the  hydrobro- 
mate  of  hyoscyamus  for  headache,  he  had  incidentally  re- 
lieved the  tremor  of  paralysis  agitans. 

Dr.  Weber  thought  that  Charcot's  rule  for  the  involve- 
ment of  the  head  would  be  found  in  the  main  correct. 
General  shaking  would  move  the  head,  but  tremor  of  the 
intrinsic  muscles  he  thought  rare.  In  regard  to  Dr.  Rock- 
well's case,  he  would  hesitate  about  pronouncing  a  cure. 
Paralysis  not  infrequently  presented  intermissions  of  a  year 
or  two,  but  would  ultimately  return.  In  regard  to  the  hyos- 
cyamine, he  had  tried  it  some  years  ago  ;  possibly  the  qual- 
ity had  not  been  as  good  as  that  now  obtained.  He  would 
again  give  it  a  trial  in  the  crystalline  form. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 

Meeting  of  June  $th,  1888. 
The  President,  Dr.  George  W.  Jacoby,  in  the  Chair. 

NOTES   ON   THE   PRINCIPLES   OF   CRANIOMETRY. 

Dr.  Frederick  Petersen  read  a  paper  thus  entitled. 
After  a  review  of  craniometric  nomenclature,  the  reader 
stated  that,  while  individual  convolutions  exerted  no  specific 
nfluence  upon  the  bones  of  the  head,  the  shape  of  the  skull 
was  modified  in  correspondence  with  the  gross  divisions  of 
the  brain  beneath  it.  The  left  temporal  bone  was  said  to 
be  depressed  in  congenital  aphasia.  In  infantile  spastic 
hemiplegia  there  was  flattening  of  the  side  of  the  skull  oppo- 
the  paralyzed  part.     Cerebral   localization  had  been  con- 


,-,  XEIV  YORK  NEUROLOGICAL  SOCIETY. 

4/  4 

cerned  mainly  with  motor  and  sensory  functions.  Ideational 
localization  had  yet  to  be  developed.  In  his  own  opinion, 
the  tempero-sphenoidal  lobes,  and  perhaps  the  occipital, 
contained  cortical  centres  for  depressing  emotions.  Musical 
ideas  and  auditory  memories  had  their  origin  in  the  tempero- 
sphenoidal  lobes.  Benedikt  had  reduced  craniometry  to  a 
science,  showing  that  the  skull  was  built  upon  crystallo- 
graphic  principles.  The  measurements  taken  should  be 
sufficient  to  reconstruct  the  skull.  Triangulation  of  the 
skull  should  be  required  in  asylums  in  the  case  of  every 
patient,  and  in  prisons  in  the  case  of  every  criminal.  We 
were  behind  European  countries  in  this  matter.  Even  in 
Italy,  fourteen  measurements  were  required  lor  asylum 
records.  The  reader  thought  that  eleven  measurements  at 
least  should  be  made:  i.  The  circumference  of  the  skull. 
2.  The  naso-occipital  arc.  3.  The  naso-bregmatic  arc. 
4.  The  bregmatic-lambdoid.  5.  The  binauricuJar.  6.  The 
antero-posterior  diameter,  taken  from  the  glabella  to  the 
maximal  occipital  point.  7.  The  greatest  transverse  diam- 
eter. 8.  The  binauricular  diameter.  9.  The  two  auricular- 
bregmatic  radii.  10.  The  facial  length.  11.  The  greatest 
height  of  the  skull.  Only  a  pair  of  calipers,  a  tape-measure, 
and  a  strip  of  lead  two  feet  long  were  required.  For  more 
detailed  measurements  other  instruments  were  necessary. 
Benedikt's  calipers  were  recommended.  The  pathological 
and  forensic  importance  of  such  measurements  was  shown 
by  the  fact  that  minimal  and  maximal  dimensions  were 
more  common  among  the  insane  and  criminal  classes  than 
among  other  people.  The  bregmatic-lambdoid  arc  was 
said  to  be  shortened  in  epilepsy.  The  reader  referred  to  a 
hundred  cases  of  his  own  observed  at  Hudson  River  State 
Hospital,  at  Ponghkeepsie,  in  which  asymetry  had  been 
observed. 

PROGRESSIVE    MUSCULAR    ATROPHY    IN    AX.KSTHESIA. 

Dr.  J.  A.  BOOTH  reported  the  case  of  a  man,  forty-two 
years  of  age,  a  shoemaker  by  trade,  who  was  still  under 
observation.     There  was  no  family  history  of  nervous  dis- 


NEW  YORK  NEUROLOGICAL  SOCIETY.  .- r 

orders,  nor  any  history  of  alcoholism  or  syphilis  in  the 
case.  The  patient  had  been  married  eighteen  years,  and 
had  had  two  children  ;  one,  a  girl  of  five,  had  never 
walked. The  affection  had  commenced  in  October,  1878, 
with  general  weakness  and  weakness  in  the  arms  and 
hands.  In  January,  1879,  the  patient's  voice  had  com- 
menced to  be  husky.  Six  months  later  he  complained  of  a 
feeling  of  cold  and  numbness  in  the  left  shoulder  and  side 
of  the  neck,  with  subsequent  decrease  in  size.  The  atrophy, 
commencing  in  the  deltoid,  had  spread  to  other  muscles  of 
the  trunk  and  upper  extremities.  At  the  present  time  the 
patient  weighed  155  pounds.  There  was  marked  sinking  in 
of  both  shoulders,  also  weakness  of  the  upper  extremities, 
with  marked  atrophy  of  the  interossei.  There  were  scars 
and  abrasions  about  the  hands  and  a  scar  on  the  neck.  The 
patient  stated  that  he  did  not  know  where  these  injuries 
had  been  received,  that  he  had  not  felt  them.  There  was 
no  ataxia  of  the  gait  or  upon  standing.  The  voice  was 
harsh,  and  the  left  side  of  the  palate  was  paretic,  the  uvula 
being  drawn  to  the  right.  The  larynx  had  been  examined 
by  Dr.  A.  H.  Smith.  The  left  superior  constrictor,  the  left 
palato-pharyngeus,  and  the  adductors  of  the  left  vocal  band 
were  paralyzed.  There  was  slight  deviation  of  the  tongue 
to  the  right.  There  were  marked  fibrillary  contractions  in 
the  atrophied  muscles.  The  patellar  reflexes  were  exag- 
gerated. There  was  sluggishness  of  the  accommodation, 
but  no  change  in  the  visual  field  and  no  diplopia.  Taste, 
smell,  and  hearing  were  not  impaired.  It  was  apparently  a 
case  of  progressive  muscular  atrophy  with  bulbar  symptoms. 
The  reader  called  attention  to  the  sensory  impairment  as 
an  unusual  complication,  and  suggested,  to  account  for  the 
anaesthesia  and  analgesia,  a  lesion  in  the  peduncle  or  pons 
on  the  right  side. 

Dr.  Starr  remarked  that  the  anomaly  mentioned  had 
been  recorded  by  Ross  and  by  Gowers  in  their  text-books. 
In  cases  of  this  character,  post-mortem  examinations  had 
shown  abnormal  cavities  in  the  cord,  due  chiefly  to  the  de- 
generation of  gliomatous  tumors.  Schultze  had  described 
cases,  Baumler  also  in  her  article  upon  syringomyelia.    The 


«-£  NEW  YORK  XEUROLOGICAL  SOCIETY. 

case  reported  by  Dr.  Booth  was,  in  the  speaker's  opinion,  a 
case  of  this  kind.  The  fact  that  the  senses  of  touch,  pain, 
and  temperature  were  all  abolished  would  support  this  view. 
The  sense  of  touch  sometimes  escaped  in  syringomyelia,  but 
not  always.  The  three  tracts  were  found  in  the  formatio- 
reticularis  of  the  medulla  and  pons,  and  extended  through 
at  least  one-fourth  of  its  extent.  A  lesion  affecting  them 
all  would  involve  also  the  cranial  nerves  passing  through 
this  part.  The  symptoms  reported  could  be  more  satisfac- 
torily explained  by  a  lesion  in  the  cord  and  by  considering 
the  case  as  one  of  syringomyelia. 

DEGENERATION     OF   THE     PERIPHERAL     NERVES   IN    LOCO- 
MOTOR   ATAXIA* 

Dr.  J.  C.  Shaw  reported  the  case  of  a  man,  forty-seven 
years  old,  who  had  a  typical  locomotor  ataxia.  Following 
an  attack  of  haematuria,  he  had  two  epileptic  seizures,  and 
had  died  the  following  day.  At  the  post-mortem  examina- 
tion the  haemorrhage  was  found  to  have  come  from  the  right 
kidney.  Pieces  of  the  sciatic,  plantar,  and  popliteal  nerves 
had  been  removed  for  examination,  part  of  the  specimens 
being  stained  with  osmic  acid  and  part  with  bichromate  of 
potassium  solution.  Changes  were  found  which  the  reader 
considered  distinct  from  the  Wallerian  degeneration.  These 
changes  consisted  in  granular  degeneration,  liquefaction, 
and  even  absorption  of  the  myeline  sheath,  with  persistence 
of  the  axis-cylinder  and  in  some  places  a  collapsed  sheath 
of  Schwann. 

°  For  full  report  of  the  case  see  page  433. 


VOL.    XIIL  August,  1888.  No.  8 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


©riginal  &vtit\t$ 


A    CONTRIBUTION    TO    THE    PATHOLOGY    OF 

TROPHIC  DISORDERS  OF  THE  MUSCULAR 

SYSTEM.* 

By  DAVID  INGLIS,  M.D., 

PROFESSOR   OF   NERVOUS   AND   MENTAL   DISEASES   IN   THB   DETROIT  COLLEGE  OF   MEDICINE. 

THE  patients  whom  you  have  just  seen  present  the  fol- 
lowing history : 

Their  grandparents  lived  to  old  age  and,  as  far  as 
can  be  learned,  both  were  healthy  themselves,  and  had 
brothers  and  sisters  of  excellent  physique.  They  had  a 
family  consisting  of  one  son  and  four  daughters.  This  son, 
who  died  of  accidental  injury  at  the  age  of  45,  was  healthy 
and  left  a  family  of  thirteen  children,  all  healthy.  The  four 
daughters  are  themselves  in  good  health,  are  all  married 
and  have  families  of  boys  and  girls.  The  family  of  one 
daughter  has  as  yet  shown  none  of  the  hereditary  tenden- 
cies now  to  be  related.  Of  the  remaining  daughters,  one, 
Eliza,  now  living  in  England,  has  been  twice  married  and 
has  had  four  sons  and  ten  daughters ;  her  daughters  are 
healthy,  but  her  oldest  son  from  his  earliest  infancy  showed 
marked  muscular  atrophy ;  he  has  however  grown  up  and 
married,  but  is,  at  the  present  time,  an  entirely  helpless 
cripple  from  the  gradual  increase  of  the  disease.  A  younger 
son  by  her  second  husband  has  also  been  affected,  and  is 
now  helpless  ;  he  is  said  to  be  apparently  very  muscular. 

Of  Eliza's   daughters   several  are  married ;    the   eldest 
daughter  has  a  son  who  is  similarly  affected. 

c  Read  before  the  Detroit  Medical  and  Library  Association. 


.-g  DAVID  IN G LIS. 

The  next  sister  of  Eliza,  Mrs.  K.,  has  a  family  of  four 
sons  and  one  daughter,  the  latter  healthy  ;  of  the  sons,  Her- 
bert, the  oldest,  now  aged  20  years,  showed,  from  the  time 
he  began  to  walk,  the  first  evidences  of  his  disease.  The 
parents  noticed  that  the  muscles  of  his  arms  instead  of  in- 
creasing seemed  rather  to  grow  smaller.  When  he  had 
learned  to  walk,  the  attitude  was  with  the  shoulders  held 
well  back,  and  the  shoulder  blades  were  unusually  promi- 
nent. Close  questioning  reveals  no  history  either  in  this  or 
in  the  two  following  of  any  sudden  paralysis  or  other  evi- 
dence of  attacks  of  poliomyelitis  anterior.  The  lad  learned 
to  walk  at  about  the  usual  age,  grew  at  the  usual  rate,  and 
is  now  a  tall  young  fellow.  It  is  to  be  remarked  that  coin- 
cidently  with  the  fact  of  extensive  muscular  atrophy  there 
has  taken  place  a  certain  amount  of  natural  muscular  growth. 
There  is  no  defect  in  the  bony  development ;  and  the  mus- 
cles of  the  arms,  while  they  have  been  atrophied  since  in- 
fancy, have  yet  grown  both  in  length  and  size.  The  patient 
now  presents  the  characteristic  attitude  which  you  have 
seen  ;  his  shoulders  are  thrown  far  back  when  standing,  the 
spine  curved  with  the  convexity  forward,  the  feet  spread 
apart,  one  always  in  advance  of  the  other,  and  one  heel 
always  off  the  ground.  He  rises  from  the  sitting  position 
by  lifting  as  much  of  his  weight  as  possible  by  the  arms 
braced  upon  his  knees  ;  then,  with  feet  widely  extended 
and  an  extraordinary  curving  of  the  spine,  he  alternately 
braces  his  hands  further  and  further  up  his  thighs,  and  so 
climbs  up  his  thighs.  From  lying  on  the  floor,  the  process 
of  standing  is  attained  with  difficulty,  and  in  a  similar  man- 
ner. He  first  gets  on  his  feet,  legs  extended  on  the  thighs  ; 
then,  from  resting  on  feet  and  hands,  goes  through  the  same 
process  of  climbing. 

Physical  examination  shows  very  extensive  muscular 
atrophy,  symmetrical  in  its  distribution.  The  erector  mus- 
cles of  the  back  are  most  involved  ;  those  of  the  hand,  fore- 
arm, arm,  and  shoulder  are  all  involved  ;  in  grasping  firmly, 
the  pronators  act  to  excess.  The  muscles  of  the  buttocks 
and  thighs  are  perhaps  as  well  developed  as  could  be  ex- 
pected, and  the  calves  are  developed  out  of  all   proportion. 


DISORDERS  OF  THE  MUSCULAR  SYSTEM.  .y^ 

They  stand  out  rounded  and  hard,  but  the  appearance  of 
strength  is  fallacious  ;  the  muscles  are  nearly  as  hard  and 
firm  when  at  ease  as  when  in  contraction,  and  offer  but  fee- 
ble resistance. 


Owing  to  relative  shortening,  the  feet  are  habitually  in 
a  position  of  slight  talipes  equinus,  thus  preventing  his- 
standing  with  both  heels  touching  the  floor.  The  picture, then, 
is  complete  of  pseudohypertrophy  of  the  muscles  of  the  legs, 
with  general  muscular  atrophy  of  the  muscles  of  the  back 
and  upper  extremities.     Before  leaving  this  case,  I  should 


.g0  DAVID  IX G LIS. 

state  that  the  boy's  general  health  has  been  good  ;  he  has 
had  no  symptoms  indicating  any  disorders  of  sensation  or 
of  voluntary  motion  save  the  weakness  clearly  caused  by 
the  state  of  the  muscles  themselves ;  his  intelligence  is 
good.     Tendon  reflexes  absent. 

The  next  brother,  Fred,  now  aged  18,  presents,  as  you 
see,  as  nearly  as  possible,  the  same  appearance,  the  same 
gait  and  attitude,  the  same  distribution  of  atrophied  mus- 
cles, the  same  pseudohypertrophy  of  the  calves.  It  would 
be  impossible  to  more  closely  duplicate  the  entire  group  of 
symptoms,  both  as  regards  their  character  and  extent ;  yet 
the  history  of  the  case  presents  this  curious  feature  that  in 
the  case  of  Fred  the  atrophic  changes  have  all  taken  place 
since  the  age  of  twelve  years. 

I  am  inclined  to  believe  that  the  pseudohypertrophy 
was  going  on  for  a  long  period  before  that,  for  the  boy 
states  that  he  was  always  easily  knocked  down,  but  he  was 
considered  by  his  parents  perfectly  sound  up  to  the  age  of 
twelve.  He  was  vigorous  and  active  as  any  young  lad  and 
with  the  full  use  of  his  arms  and  hands.  Without  any  ap- 
parent illness,  there  gradually  came  on  a  weakness  and 
wasting  of  the  hands,  arms  and  back.  The  order  in  which 
the  muscles  were  affected,  as  far  as  can  be  learned,  was 
first  those  of  the  back,  then  the  forearm,  the  flexors  of  the 
arm,  and  last  the  shoulder  muscles.  It  would  be  possible 
to  claim  that,  in  the  elder  brother,  the  apparent  atrophy  is 
simply  the  result  of  lack  of  development,  but  in  this  case 
the  process  has  been  one  of  distinct  atrophy,  ending  in  an 
identical  condition  ;  here,  too,  the  tendon  reflexes  are 
absent. 

Turning  now  to  the  third  married  sister,  Mrs.  King,  we 
find  that  she  has  three  sons  and  four  daughters  ;  her  daugh- 
ters are  robust  and  healthy.  Of  her  sons,  George,  now 
aged  19  years,  is  here  present,  and  presents  an  appearance 
even  more  striking  than  the  other  two.  His  height  is  5  feet 
4-rV  inches  ;  his  weight  130  pounds  ;  but  the  first  impression 
of  him  is  that  of  an  extraordinarily  muscular  young  fellow. 
On  physical  examination  we  find  an  enormous  pseudo- 
hypertrophy of  the   calves,  buttocks,  arms  and  forearms — 


DISORDERS  OF  THE  MUSCULAR  SYSTEM.  .gj 

symmetrical ;  the  erectors  of  the  spine,  on  the  contrary,  are 
atrophied.  The  tendon  reflexes  and  electrical  reactions  are 
the  same  as  in  his  two  cousins.  Strikingly  different  as  is 
his  appearance  the  net  result  is  the  same.  The  same  gait 
and  attitude,  the  same  method  of  attaining  the  erect  posi- 
tion, the  same  muscular  weakness.    The  history  of  this  case 


GEORGE. 

also  dates  back  to  early  infancy.  A  fat  baby,  he  was  sup- 
posed to  be  slow  in  learning  to  walk  from  his  weight. 
When  he  did  walk  the  gait  was  peculiar  and  unsteady. 
Hypertrophy  of  the  calves  was  followed  by  that  of  the  but- 
tocks, then  the  triceps,  and  lastly  the  forearms. 

Some   ten   years   ago   this  lad  developed  a  bronchocele. 


a  8  2  DAl  VD  WGLIS. 

which  disappeared  under  treatment,  but  began  to  return 
two  years  ago  and  has  now  reached  a  large  size,  bilateral 
and  soft.  The  oldest  brother  of  George  I  also  present, 
showing  the  malformation  of  his  foot.  He  is  a  hard- 
working young  man,  aged  28,  with  no  history  of  pseudo- 
hypertrophy or  atrophy  save  that  the  deformity  is  the 
result  of  a  stroke  of  paralysis  occurring  when  he  was  about 
about  a  year  old.  His  mother  states  that  he  could  walk- 
well  at  the  early  age  of  ten  months,  but  shortly  after  was 
noticed  to  lie  wherever  he  was  put.  By  degrees  it  was 
noticed  that  he  had  lost  the  use  of.  his  right  leg  entirely, 
from  the  hip  down.  Later  the  control  returned,  and  at 
seventeen  months  he  began  to  walk  again.  Recognizing 
the  difficulty  of  making  a  positive  diagnosis  at  this  late 
date,  it  yet  seems  fair  to  believe  that  this  insidious  paralysis 
of  the  leg,  evidently  of  rapid  onset  followed  by  recovery  of 
control  in  the  main,  but  also  by  contracture  and  permanent 
deformity,  was  an  attack  of  poliomyelitis  anterior. 

In  none  of  the  cases  fibrillar)-  twitching  or  parsesthesias 
were  manifested. 

Having  thus  presented  the  patient  with  this  interesting 
family  history,  several  questions  present  themselves.  Nota- 
bly the  extraordinary  uniformity  of  hereditary  transmission 
through  the  female  line  to  the  male  children.  I  am  in  cor- 
respondence with  the  members  of  the  family  in  England, 
and  hope  soon  to  be  able  to  elicit  information  upon  other 
points,  e.  g.,  whether  the  married  cripple  has  children,  and 
if  so,  what  hereditary  peculiarities  may  have  occurred.  It 
is  interesting  to  note  the  fact  that  the  mother,  Eliza,  being 
twice  married,  has  children  by  both  husbands,  presenting 
the  same  inherited  tendencies.  The  disease  has  now  begun 
to  show  itself  in  the  children's  children,  and  the  mysterious 
question  awaits  solution  :  what  was  the  cause  of  the  fatal 
gift  of  the  mother  to  her  daughters,  and  wherein  lies  the 
cause  that  only  the  daughters  should  transmit  the  inherit- 
ance which  could  only  develop  itself  in  the  sons.  It  is 
evident  that  the  explanation  so  frequently  given  of  greater 
frequency  of  certain  diseases  in  males,  to  wit,  greater  expo- 
sure  to   hardships,    does   not   here   apply.      An    interesting 


DISORDERS  OF  THE  MUSCULAR  SYSTEM.  .g^ 

series  of  cases  of  hereditary  haemophilia,  showing  an  almost 
identical  order  of  transmission,  and  involving  five  genera- 
tions, is  reported  in  the  London  Lancet  of  November,  1886. 

Leaving  the  question  of  heredity,  the  problem  at  once 
presents  itself:  What  is  the  bond  of  union  between  these 
varied  cases — infantile  atrophy,  pseudohypertrophic  paraly- 
sis, progressive  muscular  atrophy  and  bronchocele  ?  The 
question  has  additional  interest  from  the  fact  that  there  is 
at  present  a  strong  tendency  to  separate  pseudohyper- 
trophy from  the  atrophies  of  spinal  origin,  and  to  regard  it 
as  a  purely  muscular  affection.  Such  a  series  of  cases  as 
that  now  presented  seems  to  me  to  possess  a  distinct  value 
in  the  elucidation  of  this  question,  which  is  one  of  vital 
importance  if  we  ever  hope  to  solve  the  problem  of  the  suc- 
cessful treatment  of  these  intractable  cases. 

The  group  embracing  infantile  atrophy,  progressive 
muscular  atrophy  and  pseudohypertrophic  paralysis  pos- 
sess one  common  factor.  Various  as  their  symptoms,  they 
are  all  affections  of  the  motor  apparatus,  involving  sooner 
or  later  the  atrophy  of  groups  of  muscles  with  consequent 
loss  of  function.  Before  entering  upon  the  bearing  of  this 
series  of  cases,  let  us  recall  the  facts  which  have  been  estab- 
lished concerning  the  pathological  changes  in  these  affec- 
tions. Beginning  with  inrantile  paralysis  :  The  frequency 
of  the  occurrence  of  poliomyelitis  anterior  has  enabled  us 
to  obtain  very  conclusive  proof  that  the  disease  is  distinctly 
an  acute  process  by  which  a  rapid  atrophy  of  the  multi- 
polar cells  of  the  anterior  cornua  is  induced,  which  is  ac- 
companied by  an  immediate  loss  of  function  and  followed 
by  atrophy  of  certain  groups  of  muscles.  The  acuteness  of 
onset,  the  sudden  comparatively  widespread  paralysis,  the 
fact  that  the  atrophy  does  not  involve  all  of  the  muscles 
first  paralyzed,  and  the  fact  that  the  atrophy  follows  the 
paralysis  at  a  comparatively  late  date,  proves  to  demon- 
stration that  the  atrophic  change  has  its  starting  point  in 
the  cord,  that  the  muscular  degeneration  is  secondary. 
While  the  atrophied  muscles  present  a  constant  patho- 
logical appearance,  the  gray  matter  of  the  cord  presents 
just  as  constant  evidences  of  morbid  process. 


4  g  a  DAI  'ID  IX  G  LIS. 

In  progressive  muscular  atrophy  the  pathology  is  not 
disposed  of  so  summarily.  The  course  of  the  disease  being 
slow  it  becomes  difficult  to  state  which  post-mortem  ap- 
pearances are  primary  and  which  secondary. 

All  authors  are  agreed  that  the  atrophied  muscles  give 
evidence  of  a  chronic  interstitial  change,  ordinarily  termed 
a  myositis.  It  is  indeed  questionable  whether  the  process 
deserves  to  be  thus  considered  as  in  any  way  inflammatory, 
being  rather  a  substitution  of  a  less  highly  organized  tissue, 
but  at  any  rate  the  process  ends  in  a  cirrhosis — muscle 
fibre  disappears,  connective  tissue  remains.  The  question 
hinges  upon  the  lesions  of  the  nerves  and  cord.  A  large 
number  of  observations  have  been  made  in  which  lesions  of 
the  sympathetic  and  of  the  spinal  roots,  as  well  as  of  the 
antero-lateral  columns,  have  occasionally  been  noted,  but 
the  preponderance  of  evidence  is  clearly  that  the  anterior 
cornua  are  in  the  greater  number  of  cases  the  seat  of  degen- 
erative changes.  Ross  believes  that  the  diseased  process 
begins  in  the  gray  matter  about  the  central  canal  and 
spreads  especially  toward  the  anterior  cornua  and  also  per- 
pendicularly, a  theory  which  plausibly  explains  the  erratic 
manner  in  which  groups  of  muscles  are  involved  as  well  as 
occasional  sensory  disturbances.  The  atrophy  of  the  cells 
of  the  anterior  cornua  in  greater  or  less  number  is  the  com- 
mon, but  it  is  to  be  borne  in  mind  that,  leaving  out  of 
account  observations  made  many  years  ago,  at  a  time 
when  methods  of  examination  were  imperfect,  there  still 
remain  cases  in  which  observers  of  recognized  ability  have 
found  the  cord  intact.  Such  cases  demand  consideration  in 
formulating  a  theory  of  the  disease. 

The  pathology  of  pseudohypertrophic  paralysis  pre- 
sents still  greater  difficulty.  The  remarkable  gross  appear- 
ance of  the  muscular  masses  very  naturally  attracts  attention. 
Frequent  examination  has  shown  that  the  process  is,  in  this 
case  as  in  the  last,  one  of  substitution.  The  normal  con- 
nective tissue  of  the  muscular  substance  is  enormously  in- 
creased, and  amid  the  mass  of  connective  tissue  the  muscular 
elements  waste  away  and  at  last  disappear.  In  the  newly 
formed  connective  tissue  occurs  a  more  or  less  marked  for- 


DISORDERS  OF  THE  MUSCULAR  SYSTEM.  .gr 

mation  of  fatty  tissue.  These  newer  and  more  lowly 
organized  tissues  give  the  bulk  to  the  muscle,  but  the  atro- 
phy of  the  true  muscular  substance  is  the  same  as  in  the 
progressive  muscular  atrophy.  At  a  later  period  the  adi- 
pose tissue,  and  even  a  considerable  part  of  the  connective 
tissue,  may  in  time  waste  away,  leaving  the  gross  appear- 
ance, as  well  as  the  microscopical,  indistinguishable  from 
that  resulting  from  progressive  muscular  atrophy.  The 
pathological  changes  in  the  nervous  apparatus  have  been 
examined  in  a  much  smaller  number  of  cases  than  those  of 
progressive  muscular  atrophy,  and  vary  widely.  In  the 
greater  number  of  cases  lesions  of  the  cord  have  been 
observed  ;  but  while  in  some  atrophy  of  the  anterior  cornua 
has  been  present,  in  several  the  lesion  has  consisted  in 
changes  in  the  form  and  place  of  the  central  canal,  while  in 
others  the  cord  has  seemed  intact. 

The  problem  to  be  solved  is,  What  is  the  relation  be- 
tween the  changes  in  the  muscle  and  those  in  the  cord  ? 
Are  we,  with  our  present  knowledge,  justified  in  believing 
that  progressive  muscular  atrophy  is  due  to  a  primary  lesion 
of  the  gray  matter  of  the  cord,  to  which  the  muscle  changes 
are  secondary  ?  and,  if  so,  on  what  ground  are  we  to  sepa- 
rate pseudohypertrophy  from  it,  and  consider  the  muscular 
change  primary,  those  in  the  cord  as  non-essential  ? 

I  hold  that,  at  whatever  conclusion  we  arrive,  the  two 
diseases  should  be  classed  together.  Clearly  pseudohyper- 
trophic paralysis  is  allied  in  the  most  intimate  manner  with 
lesions  undoubtedly  spinal ;  for,  in  cases  of  infantile  paraly- 
sis, instead  of  the  usual  process  of  simple  atrophy,  this  same 
pseudohypertrophy  at  times  occurs. 

It  is  evident,  then,  that  an  atrophic  lesion  in  the  cord 
can  cause  just  that  form  of  muscular  change  which  does 
occur  in  pseudohypertrophied  paralysis.  This  same  process 
of  lifomatosis  also  occurs  in  the  progressive  muscular  atro- 
phy of  adults. 

In  order  to  throw  some  further  light  upon  the  enigma 
thus  presented,  it  will  be  well  to  recall  the  pathological 
changes  which  occur  in  certain  atrophic  disorders  due  to 
toxic  agents.    In  the  case  of  alcoholic  paraplegia,  the  symp- 


4^6  DAVID  INCUS. 

toms  are  those  of  combined  ataxia  and  progressive  muscular 
atrophy,  both  of  which  groups  may  reach  an  extreme  grade, 
so  that  the  atrophy  may  be  as  complete  as  in  a  far  advanced 
case  of  progressive  muscular  atrophy.  When  we  seek  for 
the  seat  of  the  pathological  changes  thus  developed,  we  find 
the  brunt  of  the  affection  has  fallen  upon  the  conducting 
nerves  ;  while  the  muscle  shows  the  usual  atrophic  changes, 
the  nerves  show  evidences  of  widespread  neuritis  ;  but  the 
cord  in  this  case  also  seems  to  be  intact. 

In  lead  paralysis,  likewise,  the  pathological  changes 
seem  usually  to  prove  the  existence  of  a  neuritis  ;  the  atro- 
phic muscular  changes  are  present. 

We  have  before  us  the  enigma  of  atrophy  of  the  muscle 
(varied  in  some  cases  by  an  apparent  but  fictitious  hyper- 
trophy, which  does  not  alter  the  fact  of  a  real  atrophy). 
The  atrophy  is  constant,  and  the  connected  nervous  lesions 
have  an  inconstant  location.  Vet  inconstant  as  are  the 
lesions  they  still  have  this  in  common  ;  they  are  all  to  be 
found  either  in  the  cells  of  the  anterior  cornua,  in  the  course 
of  the  axis  cylinders  or  in  the  muscular  elements. 

We  speak  of  these  as  dissimilar  elements,  as  if  the  cell 
were  one  thing,  the  nerve  fibres  another,  and  the  muscle 
something  quite  different.  A  moment's  reflection  is  suf- 
ficient to  recall  that  from  the  ganglionic  cell  its  protoplasm 
is  continued  by  its  axis  cylinder  process  to  the  axis  cylinder, 
and  this,  always  unbroken,  to  the  motor  end  plate,  from 
which  there  seems  to  be  a  direct  communication  with  the 
nuclei  of  the  muscular  elements  ;  in  other  words,  gangli- 
onic cell,  axis  cylinder,  and  motor  end  plate  are  not  three 
things,  but  one  continuous  mass  of  protoplasm. 

Granting  that  excitory  impulses  travel  uniformly  over 
this  route  from  central  cell  to  muscular  fibre,  there  yet 
remains  the  fact  that  the  nutritive  condition  of  this  con-, 
tiuous  mass  of  protoplasm  tends  to  uniformity.  We  have 
undoubted  evidence  of  this  in  the  well-known  fact  of  de- 
scending degeneration.  Once  the  axis  cylinder  is  cut  off 
from  its  connection  with  the  motor  cell,  it  dies  ;  and  it  is 
the  disconnected  part  which  dies.  Evidently  the  central 
point   for  the  regulation  of  the   life   of  the  string   is  at  the 


DISORDERS  OF  THE  MUSCULAR  SYSTEM.  ^g^ 

gray  cell ;  but  the  problem  is  not  so  simple.  Granting  that 
the  cutting  of  the  communications  causes  the  death  of  the 
distal  fragment  by  no  means  proves  that  while  the  commu- 
nication remains  a  change  in  the  nutritive  condition  of  the 
distal  extremity  may  not  continuously  influence  the  condi- 
tion of  the  central  end.  If,  then,  the  lesion  in  infantile 
paralysis  be  such  as  to  immediately  destroy  the  gray  cells, 
we  can  conceive  of  the  entire  mass  of  protoplasm  dying 
downwards.  The  cell  being  destroyed,  the  process  is  rapid  ; 
the  disease  has  struck  at  the  nutritive  centre  of  the  proto- 
plasmic system.  In  multiple  neuritis  the  break  occurs  lower 
down,  but  the  degenerative  process  goes  on  to  exert  its 
influence  on  the  muscular  fibre.  In  progressive  muscular 
atrophy  it  is  still  questionable  whether  the  atrophy  of  the 
motor  cells  is  primary  or  secondary,  but  in  pseudohyper- 
trophic muscular  paralysis  there  would  seem  to  be  much 
reason  to  believe  that  the  process  makes  its  first  appear- 
in  the  muscular  substance.  I  submit  that  in  diseases  as 
slow  in  their  progress  as  pseudohypertrophy  and  pro- 
gressive muscular  atrophy,  it  is  reasonable  to  conceive  that 
a  process  of  degeneration  slowly  going  on  in  the  motor 
end  plates  might  well  influence  the  nutrition  of  the  long- 
drawn-out  strand  of  protoplasm  of  which  the  motor  end 
plate  is  merely  one  portion.  That  such  an  origin  for  the 
degenerative  process  explains  better  than  any  other  the 
anomaly  of  constant  atrophic  changes  occurring  in  con- 
nection with  nerve  lesions  of  such  varied  location.  We 
have  not  yet  touched  upon  another  question,  viz.,  the 
increase  of  connective  tissue  and  fatty  deposit.  To  enter 
upon  the  consideration  of  this  in  detail  would  lead  too  far 
for  our  limits.  Suffice  that  this  fibrosis  seems  to  be  the 
customary  endeavor  of  the  organism  to  repair  damages, 
that  the  irritative  processes  which  lead  to  the  atrophy  of 
the  muscular  and  nerve  structures  according  to  common 
experience  might  well  be  expected  to  cause  an  increase  of 
the  more  lowly  organized  connective  tissue. 

The  value  of  the  series  of  cases  presented  lies  in  this, 
that  they  give  evidence  that  the  same  inherited  defect  is 
shown  to  give  rise  in  one  case  to  an  attack  of  poliomyelitis 


i  SS  DAVID  INGLIS. 

anterior  in  several  others  of  the  family  to  either  extra- 
ordinary muscular  atrophy  or  extreme  pseudohypertrophy. 
I  have  endeavored  in  this  paper  to  show  that  the  three  dis- 
eases ought  to  be  grouped  together  ;  the  inherited  defect 
groups  them  together,  as  we  see  here  to-night.  The  com- 
mon inheritance  of  these  young  men  has  been  a  tendency 
to  degeneration  of  those  protoplasmic  strands  which  begin 
as  motor  cells  and  end  as  motor  end  plates  or  muscle 
nuclei. 

To  sum  up,  I  would  claim  that  muscular  dystrophies 
can  be  properly  divided  into  two  classes :  first,  those  in 
which  a  true  paralysis  occurs,  in  which  there  is  a  break  in 
the  motor  conduction,  under  which  are  to  be  included  acute 
and  chronic  myelitis  anterior,  amyotrophic  lateral  sclerosis, 
primary  or  secondary,  and  atrophies,  due  to  neuritis  or  sec- 
tion of  nerves  ;  and  a  second  class,  in  which  no  true  paral- 
ysis exists,  but  an  impairment  of  function  proportionate  to 
and  dependent  upon  the  muscular  atrophy — in  this  class  are 
progressive  muscular  atrophy  and  pseudohypertrophic  par- 
alysis. 

I  would  also  claim  that  there  is  a  distinction  to  be  made 
between  the  relation  of  the  central  and  distal  ends  of  a 
nerve  fibre  in  the  case  of  an  entire  severance  of  connection, 
and  in  the  other  case  of  maintenance  of  continuity  with 
slow  changes  of  the  nutritive  condition. 

I  would  claim  that  both  progressive  muscular  atrophy 
and  pseudohypertrophy  are  essentially  of  spinal  origin ; 
that  the  cases  in  which  the  post-mortem  examination  shows 
the  cord  visibly  intact  do  not  invalidate  this  idea,  but  that 
the  defect  in  the  distal  ends  of  the  motor  fibres,  while  not 
in  every  case  accompanied  by  atrophy  of  the  central  cells, 
is  yet  the  indication  of  an  impaired  activity  of  those  cells. 

The  not  unfrequent  occurrence,  in  connection  with 
pseudohypertrophy,  of  bronchocele,  and,  in  other  cases,  of 
forms  of  mental  disturbance,  cannot  be  explained  by  a  pri- 
mary muscular  disease,  but  admit  of  explanation  as  due  to 
lesions  of  the  sympathetic  ganglia  propagated  from  the 
cord. 


IS   BELIEF   IN   SPIRITUALISM   EVER   EVIDENCE 
OF  INSANITY  PER  SE  ? 

By  MATTHEW  D.  FIELD,  M.D. 
Read  at  the  June  Meeting  of  the  Medico-Legal  Society. 

MUCH  interest  has  been  recently  shown  by  the  public 
in  this  question.  The  developments  that  resulted 
in  placing  certain  persons  in  the  Tombs,  and  their 
indictment,  have  led  people  to  ask  what  is  the  mental  con- 
dition of  one  of  their  prominent  believers,  who  had  given  a 
large  amount  of  property  to  place  the  "  Science  "  on  a  sure 
foundation.  Is  this  gentleman  capable  of  filling  a  position 
of  trust,  requiring  skill  and  judgment  ?  Was  his  firm  belief 
in  the  reality  of  the  manifestations  that  he  saw  evidence,  in 
itself,  of  mental  degeneration,  of  defective  judgment  suffi- 
cient to  indicate  insanity  ? 

A  will  contest  is  now  going  on  in  an  adjoining  State, 
where  it  is  claimed  that  the  testator  was  influenced  by  spirits, 
and  acted  in  accordance  with  information  that  he  received 
from  the  unseen  world. 

Last  year  I  was  a  witness  in  a  case  where  the  the  testa- 
mentary capacity  of  a  gentleman,  who  died  leaving  a  large 
fortune,  was  attacked  before  the  Supreme  Court  in  this 
State.  Besides  other  evidences  of  insanity,  it  was  shown, 
during  the  course  of  the  trial,  that  this  gentleman  had  for 
some  years  previous  to  the  execution  of  the  will  been  in  the 
habit  of  receiving  communications  from  the  dead,  and  from 
the  living  whom  he  knew  to  be  many  miles  distant  at  the 
time  ;  that  he  conferred  and  advised  with  these  spirits  upon 
matters  of  business ;  and  also  that  his  actions  were  gov- 
erned, in  certain  instances,  by  these  spirit  communica- 
tions. It  was  also  shown  that  this  gentleman's  second  wife 
was  a  spiritualist,  and  had  written  quite  extensively  upon 
that   subject.     The  lawyers  for  the    defence  attempted   to 


.g0  MATTHEW  D.  FIELD. 

ignore  all  other  evidences  of  insanity  except  those  of  his 
conversing  with  the  spirits,  and,  of  course,  held  that  belief 
in  spiritualism  was  no  proof  of  insanity. 

Examinations  of  medical  literature  show  very  little  that 
has  a  direct  bearing  upon  this  question. 

In  this  case  I  held  that  it  was  necessary  to  divide  the 
question,  or,  rather,  to  classify  the  believers  in  spiritual- 
ism. 

Those  who  nave  an  abstract  belief  in  the  communion  of 
spirits  I  did  not  consider  at  all  ;  for  no  abstract  belief  is 
evidence  of  insanity  per  se,  no  matter  how  absurd  it  may  be. 
And  again,  as  most  religions  treat  of  a  future  life,  and  of  the 
participation  of  the  soul  or  of  the  spirit  in  the  enjoyments  or 
miseries  of  the  hereafter,  and  that  spirits  have  communion 
one  with  another,  it  is  but  a  step  to  believe  that  spirits  may 
return  to  this  earth.  As  is  related  in  the  Bible,  Elias  and 
Moses  appeared  unto  Christ  when  he  was  accompanied  by 
Peter  and  James  and  John.  It  is  only  when  the  individual 
himself  participates  that  insanity  may  be  suspected.  In 
insanity  the  ego  is  always  involved.  People  may  believe 
that  God  can  talk  to  us  ;  this  may  be,  to  some,  the  most 
reasonable  belief,  or,  to  others,  the  most  absurd.  The  be- 
lief that  He  can.  or  cannot,  speak  to  us  here  assembled  has 
naught  to  do  vvith  insanity  ;  but,  if  an  individual  states  to 
you,  in  sober  earnest,  that  he  hears  God  speaking  to  him, 
and  his  actions  show  beyond  peradventure  that  he  does  be- 
lieve this,  then  we  question  his  sanity.  For,  even  though 
we  believe  God  may  talk  to  us,  and  that  He  did  talk  to 
Moses  and  many  others  in  the  Bible  times,  yet  this  intro- 
duction of  the  ego  convinces  us  of  mental  alienation.  We 
may  believe  that  the  ass  spoke  to  Balaam,  and  assume  that 
it  is  so  simple  because  the  Bible  says  so,  and  accept  the 
Bible  as  sufficient  authority  for  our  belief,  and  we  may  be- 
lieve that  God  can  make  any  beast  speak  ;  but,  at  the  pres- 
ent time,  if  a  person  says,  and  evidently  believes,  that  a 
beast  was  talking  to  him,  we  think  he  is  insane,  and  we 
think  this  because  the  ego  participates.  Therefore,  leaving 
the  belief  in  spiritualism  in  the  abstract  out  of  the  question, 
we  come  to  the  consideration  of  the  so-called  spiritualist, 
and  of  these  I  make  three  classes: 


SPIRITUALISM  AND  INSANITY.  ,  g  j 

First,  those  who  make  it  a  business  to  delude  and  mys- 
tify, i.  e.,  the  so-called  mediums. 

Second,  those  who  attend  seances,  and  are  deluded  and 
mystified ;  being  caused  to  see  curious  things,  as  hands  and 
faces  ot  the  dead ;  or  faces  produced  on  virgin  canvas,  ap- 
parently by  unseen  agencies  ;  or  hear  rappings  and  voices, 
and  receive  written  communications  in  the  same  inexplica- 
ble manner ;  and  things  are  told  them  that  they  supposed 
nobody  else  knew  but  themselves.  By  these  things  are  they 
so  astonished,  and  so  incapable  of  understanding  how  they 
could  be  accomplished  except  by  supernatural  agency, 
they  believe  ;  but  this  class  never  receive  these  manifesta- 
tions, nor  see  the  dead,  except  through  the  instrumentality 
of  members  of  the  first  class. 

This  class  embraces  a  large  number  who  are,  undoubt- 
edly, of  weak  mind  ;  those  who  are  superstitious,  and  of 
an  unstable  and  neurotic  organization  ;  and  those  who  re- 
quire but  a  slight  cause  to  render  them  insane.  Yet  many 
persons  of  fine  intelligence  and  of  brilliant  mind  are  found 
in  this  class.  There  would  not  be  sufficient  in  this  belief 
alone  upon  which  to  base  an  opinion  of  mental  incapacity. 

In  the  third  class  I  would  place  those  who  actually  be- 
lieve that  they  see  the  dead,  and  those  at  a  distance,  face  to 
face  in  the  material  form,  and  that  they  communicate  with 
them,  hearing  their  voices  distinctly  and  clearly.  All  of 
this  class  I  believe  to  be  insane  ;  at  least,  of  the  large  num- 
ber that  have  come  under  my  observation,  I  never  saw  one 
who  did  not  demonstrate  his  insanity  in  other  directions  as 
well. 

It  may  be  a  very  difficult  matter,  in  some  instances,  to 
distinguish  between  the  first  and  third  classes  ;  but  I  think 
the  rule  would  hold  good  in  every  case.  The  difficulty 
would  be  to  determine  what  individuals  actually  believed, 
and  what  ones  only  assumed  and  claimed  to  believe  for  the 
purpose  of  deception,  gain,  and  self-glorification. 

To  distinguish  between  these  two  groups  is  very  impor- 
tant, for  one  set  is  deserving  of  pity  and  kind  care,  and  the 
other  of  reproach  and  punishment.  This  distinction  once 
made,  it  is  an  easy  matter  to  determine  the  treatment  each 
class  deserves. 


.,,-  MATTHEW  D.   FIELD. 

492 

In  the  middle  class,  or  those  who,  after  attending  seances 
and  being  mystified,  believe,  many  will  be  found  who  are 
insane,  and  those  who  are  of  an  unstable  and  neurotic  or- 
ganization. Yet  I  am  sure  no  one  would  consider  that 
belief,  under  such  circumstances,  would  be  evidence  of 
insanity- per  se.  The  communications,  materializations,  and 
other  manifestations,  are  always  received  through  the  instru- 
mentality of  members  of  our  first  class.  The  perceptions, 
under  such  circumstances,  are  real ;  there  is  an  actual  ex- 
ternal object  produced  in  some  manner  by  the  so-called 
medium.  The  belief  in  supernatural  production,  and  that 
the  communications  received  are  actually  from  the  dead  or 
those  at  a  distance,  is  delusion,  beyond  doubt ;  yet  this  false 
belief  cannot  be  justly  considered  an  insane  delusion.  How- 
ever,such  belief,  taking  strong  possession  of  an  individual  of 
mature  years,  of  acknowledged  good  judgment,  whose  in- 
telligence and  will  had  always  dominated  his  emotions, 
would  arouse  strong  suspicion  of  mental  deterioration. 
Whenever  we  discover  alteration  in  an  individual's  mode  of 
thought,  actions,  and  emotions,  we  are  sure  of  some  mental 
change  as  well ;  yet  it  may  be  only  the  beginning,  and 
proper  care  and  treatment  may  arrest  insanity ;  still,  such 
alteration  is  always  a  grave  symptom. 

This  belief,  held  by  persons  who  we  know  have  always 
been  emotional,  superstitious,  and  fanatical,  would  be  of 
slight  significance,  as  it  would  be  in  harmony  with  the  usual 
mode  of  thought  of  such  a  one.  We  have  already  men- 
tioned that  among  the  middle  class  are  found  many  unstable 
and  neurotic  organizations ;  these  individuals  are  more 
easily  upset,  and  become  insane  from  causes  that  would  not 
affect  those  with  strong  and  healthy  nervous  systems. 
These  people  are  always  drawn  to  everything  mysterious 
and  all  that  appeals  to  the  emotional  side  of  their  nature  ; 
many  minds  of  this  class  are  unbalanced  and  destroyed  by 
every  public  excitement,  where  the  feelings  and  emotions 
are  thoroughly  aroused. 

What  could  more  strongly  excite  the  emotions,  at  the 
expense  of  the  intellect  and  will,  than  a  spiritualistic  seance, 
with    its  dim   and  ghastly  light,  the  expectation   of  super- 


SPIRITUALISM  AND  INSANITY.  ,  _  „ 

natural  communication,  being  often  startled  and  astonished 
by  what  is  seen  and  heard  ?  Much  insanity  is  unquestion- 
ably caused  by  this  means  ;  and,  I  believe,  great  misery  and 
distress  results  from  every  outbreak  that  brings  this  subject 
prominently  before  the  public. 

I  must,  in  justice,  say  that  the  delusions  of  many  insane 
take  the  direction  of  spiritualism,  where  spiritualism  itself 
had  really  nothing  to  do  with  the  production  of  insanity 
An  insane  person  may  believe  that  the  spirit  of  Abraham 
told  him  to  sacrifice  his  child,  and  he  acts  in  accordance 
with  this  command.  Another  is  told  by  the  spirit  of  his 
dead  child  to  reward  people  in  this  world  for  kindness  done 
him  while  living,  and  he  does  as  requested.  A  third  hears 
the  voice  of  God,  proclaiming  him  to  be  the  second  Christ. 

The  insanity,  in  each  of  these  causes,  may  have  come 
from  the  same  cause  ;  and  that  cause  may  have  been  mas- 
turbation. The  false  belief  following,  and  being  dependent 
upon,  false  perceptions  ;  that  is,  an  individual  of  diseased 
brain  has  an  hallucination  ;  by  this  I  mean  a  sensory  hallu- 
cination ;  an  involuntary  preception,  without  corresponding 
external  object.  If  the  false  perception  be,  as  in  the  cases 
cited,  that  of  hearing,  the  insane  individual  does,  as  a  sane 
person  would  do,  tries  to  explain  how  this  voice  reaches 
him.  He  fails  to  do  one  thing  that  a  sane  man  would  do, 
namely,  correct  the  false  perception  by  the  other  senses, 
and  by  his  intelligence.  But,  notwithstanding  that  he  fails 
to  correct  the  false  perception,  he  nevertheless  tries  to  ex- 
plain, and  does  explain  to  his  own  satisfaction.  He  does 
not  see  the  individual  who  is  speaking,  and  he  looks  to 
some  mysterious  agency.  One  satisfies  himself  that  it  is 
the  spirit  of  Abraham  ;  the  second,  that  it  is  the  spirit  of  his 
dead  child  ;  and  the  third,  that  it  is  the  voice  of  God.  A 
fourth  might  believe  the  voice  was  that  of  a  witch ;  and  a 
fifth,  that  it  was  a  telephone.  Had  there  been  no  spirit, 
God,  witch  or  telephone  known  to  the  world,  these  people 
would  all  have  become  insane,  had  hallucinations  of  hear- 
ing, but  would  have  explained  them  in  some  different  way, 
and  have  built  up  some  other  delusion,  in  accordance  with 
the  other  explanation.     It  is  quite  probable  that  the  larger 


,g,  MATTHEW  D.  FIELD. 

number  ot  persons,  who  I  place  in  my  third  group,  and  who 
I  would  consider  insane,  may  never  have  been  believers  in 
spiritualism,  and  never  have  attended  a  seance  in  their 
lives.  They  first  become  victims  of  hallucinations  of  the 
senses,  and  these  false  preceptions  become  fixed  beliefs, 
and  the  delusions  were  founded  upon  these  ;  the  spiritual- 
ism being  only  the  means  of  explanation  to  their  own 
minds.  After  they  have  once  turned  their  thoughts  to  the 
subject,  they  dwell  thereon,  and  their  disordered  brains 
build  up  new  and  more  elaborate  delusions  in  that  direc- 
tion. Whatever  subject  there  may  be  most  prominent  in 
the  community  at  a  given  time,  which  has  about  it  the 
greatest  element  of  mystery,  will  most  likely  shape  the 
direction  of  insane  delusions  at  that  particular  time.  A  few 
years  ago,  and  very  often  now,  the  telegraph,  telephone, 
and  electricity  played  a  large  part  in  the  delusions  of  the 
insane,  and  spiritualism  has  been  correspondingly  less 
prominent,  and  witchcraft  insignificant.  To  illustrate  how 
easily  delusions  may  be  built  up  from  sensory  hallucina- 
tions, I  can  state  that  I  have  seen  at  least  a  score  of  insane 
people  who  believed  that  Mr.  Jay  Gould  was  persecuting 
them  ;  the  steps  in  the  foundation  of  this  delusion  in  these 
cases  were  as  follows  :  First,  the  hallucination  of  hearing  ; 
second,  explanation  must  come  by  telephone  ;  third,  Mr. 
Gould  controls  all  the  telegraphs  and  telephones,  and  it 
must  be  he  who  is  persecuting  them. 

The  eminent  editor  of  the  Alienist  and  Neurologist,  in 
the  latest  number  of  that  periodical,  after  quoting  freely 
from  a  recent  sermon  of  the  Rev.  Dr.  Talmadge  on  "Spirit- 
ualism and  Insanity,"  observes  :  "The  superintendents  of 
American  and  foreign  asylumns  for  the  Insane  will  bear 
out  this  theologian's  statements  that  spiritualism  makes 
many    lunatics,    and    the    counter-statement    that    lunacy 

makes  spiritualists All  alienists  must  concede 

from  observation  that  spiritualism  has  destroyed  some  of 
the  brightest  intellects." 

It  hardly  seems  necessary  to  devote  much  time  to  the 
consideration  of  my  reasons  for  considering  all  of  those  in- 
sane who  would  come   under  my  third  class.     I   restricted 


SPIRITUALISM  AND  INSANITY.  ,  ~  - 

this  class  to  those  who  actually  believe  that  they  see  the 
dead,  and  those  at  a  distance,  face  to  face,  in  the  material 
form  ;  and  that  they  communicate  with  them,  hearing  their 
voices  distinctly  and  clearly.  Here  I  would  emphasize  the 
actual  belief  in  the  reality,  and  the  fact  that  this  class  see 
and  hear  by  themselves  when  not  aided  by  any  medium  or 
second  person.  These  individuals  are  the  victims  of  well- 
defined  sensory  hallucinations  ;  and  that,  as  they  actually 
believe  in  their  reality,  it  is  evident  that  they  do  not  correct 
their  false  perceptions  by  other  senses,  or  by  their  intelli- 
gence, but  rather  build  up  a  distinct  false  belief.  I  can 
imagine  that  my  legal  friends  are  running  over  in  their 
minds  many  questions  that  they  would  like  to  ask  on  cross- 
examination  of  one  expressing  these  views  upon  the  witness 
stand,  as  they  have  in  their  minds  so  many  examples  of 
hallucinations  occurring  in  the  illustrious  men  of  great  intel- 
lect— as  Martin  Luther,  when  he  threw  the  ink-stand  at  the 
devil ;  Goethe,  when  he  saw  his  own  shadow  walking  be- 
fore him  ;  Sam  Johnson,  when  he  heard  his  mother's  voice 
calling  him  "  Sam,"  when  she  was  miles  away.  These 
examples  might  be  greatly  multiplied  ;  but  we  have  only 
to  reply  to  this  that,  while  certain  illustrious  men  have  be- 
come insane  with  sensory  hallucinations  as  among  the  most 
marked  manifestations  of  their  insanity,  others  being  sub- 
ject to  hallucinations  have  been  able  to  correct  these  false 
perceptions,  in  the  reality  of  which  they  never  had  a  fixed 
or  permanent  belief. 


A  CLINICAL  LECTURE  OX  THE  DIFFERENTIAL 
DIAGNOSIS  OF  AXTERO-LATERAL  SCLERO- 
SIS  AND    POSTERIOR   SCLEROSIS   OF 
THE  SPIXAL  CORD.* 

BY  PROFESSOR   WILLIAM  A.   HAMMOND. 

THERE  are  two  patients  present  to-day  who  exhibit 
very  opposite  manifestations  of  spinal  disease,  and 
yet  they  are  very  frequently  confounded  one  with 
the  other.  I  think,  however,  that  when  we  come  to  exam- 
ine them,  we  shall  find  that  the  symptoms  are  almost  ac 
different  as  those  of  any  other  two  diseases  with  which  the 
human  body  can  become  afflicted. 

Before  proceeding  to  examine  those  patients,  I  shall  say 
a  few  words  regarding  the  spinal  cord,  as  the  basis  of  the 
remarks  I  shall  have  to  make.  The  spinal  cord  is  not  a 
simple  organ.  On  the  contrary,  it  is  a  compound  organ, 
anatomically  and  physiologically.  It  has  distinct  anatom- 
ical features,  and  these,  as  a  matter  of  course,  have  distinct 
physiological  manifestations.  As  a  consequence,  we  find 
that  in  spinal  disease  the  symptoms  exhibited  bear  an  exact 
relation  with  the  physiology  of  the  part  of  the  cord  affected. 

As  you  will  see  by  the  diagram,  the  spinal  cord  consists 
essentially  of  two  masses  of  tissue.  All  that  portion  on  the 
periphery  is  called  the  white  substance,  while  that  located 
centrally  is  called  the  gray  substance. 

The  external  portion  is  divided  into  various  sections  ; 
but  not  to  enter  into  details  of  the  divisions,  it  will  serve 
our  purpose  this  afternoon  to  speak  of  this  external  portion 
as  the  antero-lateral  and  posterior  columns. 

The  antero-lateral  columns  include  all  that  part  of  the 
white  matter  on  each  side  lying  between  the  posterior  horns 
of  gray  matter  and  the  anterior  median  fissure.  The  pos- 
tered at  the  New  York  I'ost-Graduate  Medical  School,  March  23,  1888. 


SCLEROSIS  OF  THE  SPINAL  CORD.  ,~- 

49/ 

terior  columns  embrace  that  portion  of  each  side  lying  be- 
tween the  posterior  horns  of  gray  matter  and  the  posterior 
median  fissure.  This  latter  is  divided  into  two  parts,  that 
lying  nearer  the  median  fissure  being  called  the  column  of 
Goll,  and  that  contiguous  to  the  posterior  horn  of  gray  mat- 
ter being  called  the  column  of  Burdach.  It  is  with  this 
latter  of  the  two  portions  of  the  spinal  cord  that  we  have  to 
deal  with  in  one  of  these  cases,  while  the  other,  as  I  think 
I  shall  be  able  to  show  you,  is  affected  with  a  disease  of  the 
antero-lateral  column. 

The  posterior  columns  of  the  spinal  cord  have  certain 
distinct  functions  ;  they  relate  to  sensibility  and  co-ordina- 
tion. 

The  column  of  Goll  is  primarily  so  seldom  the  seat  of  di- 
sease, and  a  post-mortem  examination  has  been  made  on  so 
few  of  the  patients  in  whom  it  has  been  affected,  that  the 
diseased  manifestations  to  which  it  gives  rise  are  not  definite- 
ly known.  It  has  been  pretty  reasonably  established,  how- 
ever, that  the  column  of  Goll  is  concerned,  like  the  column 
of  Burdach,  with  sensibility  and  to  a  certain  extent  with 
co-ordination.  This  column  of  Burdach,  with  which  we  are 
particularly  concerned  to-day,  is  sometimes  called  the  pos- 
terior root  zone,  because  the  radicals  which  come  from  the 
posterior  horns  of  gray  matter  seem  to  start  from  them.  It 
is  owing  to  pressure  upon  the  radicals,  due  to  the  abnormal 
process  characteristic  to  locomotor  ataxia,  that  we  have  the 
sharp,  shooting,  lightning  like  pains  which  are  almost  in- 
variably met  with  in  cases  of  that  disease. 

It  used  to  be  supposed  that  the  co-ordinating  faculty 
resided  in  the  cerebellum.  Probably  it  does  to  some  ex- 
tent. The  cerebellum  certainly  has  something  to  do  in 
maintaining  the  equilibrium  of  the  body,  and  so  have  the 
semicircular  canals  of  the  auditory  apparatus.  But  that 
function  seems  to  be  a  little  different  from  co-ordination.  A 
person  suffering  from  a  disease  of  the  cerebellum  cannot,  it 
is  true,  walk  well,  but  his  difficulty  in  walking  is  not  due  to 
his  inability  to  co-ordinate  well,  but  to  vertigo. 

You  probably,  in  the  course  of  your  attendance  upon 
physiological  lectures,  witnessed  the   removal  of  the   cere- 


.  g3  WILLIAM  A.  HAMMOXD. 

bellum  from  pigeons  ;  you  have  then  noticed  that  the  bird 
lodged  upon  the  table  unable  to  stand,  and  every  attitude, 
every  expression,  seems  to  show  that  it  suffers  from 
vertigo  ;  its  eyes  roll,  and  its  head  partakes  of  the  same 
motion.  When  thrown  into  the  air,  it  flies  in  a  way  which 
shows  that  it  is  subject  to  a  peculiar  sensation  that  causes 
it  to  act  in  a  manner  similar  to  that  of  a  child  that  has 
turned  around  many  times  ;  it  staggers  in  fact  in  the  air,  at 
the  same  time  it  does  not  appear  to  be  deprived  of  the  abil- 
ity to  co-ordinate  its  limbs  when  it  desires  to  move  them. 
That  is,  if  you  disturb  its  limbs  individually,  it  will  move 
them  in  a  perfectly  co-ordinate  manner.  I  judge  from  these 
phenomena,  and  from  the  symptoms  of  patients  suffering 
from  cerebellar  diseases,  such  as  an  abscess,  a  tumor,  or  an 
injur}-,  that  the  difficulty  in  locomotion  exhibited  by  them 
is  due  to  vertigo.  At  any  rate,  in  post-mortem  examina- 
tions of  persons  who  have  suffered  from  locomotor  ataxia 
the  cerebellum  is  usually  found  in  a  state  of  health,  while 
the  column  of  Burdach  in  the  spinal  cord  is  found  dis- 
eased. 

The  antero-lateral  column  has  nothing  whatever  to  do 
with  sensibility,  and  of  course  a  patient  suffering  from  dis- 
ease of  this  portion  of  the  cord  would  exhibit  no  aberration 
whatever  of  sensibility,  neither  in  paresthesia  nor  anaesthe- 
sia, so  long  as  the  disease  remained  in  that  portion  of  the 
cord.  Sometimes,  however,  the  membranes  of  the  cord 
become  involved,  and  then  there  are  some  painful  sensa- 
tions. Again,  the  disease  may  spread  to  the  posterior 
column,  as  it  sometimes  does,  and  then  there  is  derange- 
ment of  sensibility.  But  so  long  as  the  disease  is  confined 
to  the  antero-lateral  column  there  is  nothing  whatever  but 
derangement  of  motility,  because  there  is  nothing  in  that 
portion  of  the  cord  but  motor  fibres.  That  being  the  case, 
when  you  have  patients  affected  with  disease  of  the  antero- 
lateral column  you  expect  to  find  derangement  of  motion 
and  nothing  else.  We  will  now  see  how  these  statements 
accord  with  the  histories  in  these  two  cases.  First,  how- 
ever, let  us  turn  to  one  other  point. 

In  sclerosis  of  the  antero-lateral  column  and  of  the  pos- 


SCLEROSIS  OF  THE  SPINAL  CORD.  ,gg 

terior  column  the  disease  is  always  symmetrical.  There 
are  some  diseases  of  the  spinal  cord  which  are  not  sym- 
metrical. But  in  these  two  both  sides  are  affected,  and 
usually  to  the  same  extent.  Not  always  exactly  to  the 
same  extent,  because  it  does  not  always  affect  both  sides  at 
the  same  time,  and  the  disease  gets  ahead  on  one  side 
faster  than  on  the  other.  But  af^er  a  year  or  two  you  will 
find  the  manifestations  of  the  disease  are  about  the  same  on 
one  side  as  on  the  other. 

With  that  basis  for  an  examination  of  these  patients  we 
will  take  up  their  cases  one  at  a  time  and  see  how  they 
correspond  with  the  facts  just  gone  over. 

The  first  patient  tells  us  he  is  eighteen  years  of  age ; 
that  he  has  been  sick  about  four  years.  It  dates  from  a  fall 
on  the  back  of  the  head.  About  four  months  afterward 
people  began  to  notice  that  in  his  walk  he  kept  next  to  the 
curbstone,  or  by  the  houses.  After  his  attention  had  been 
called  to  this  peculiarity  in  his  walk,  he  found  that  unless 
he  gave  attention  to  where  he  stepped  he  would  have  a 
tendency  to   fall. 

He  says  he  did  have  pains  in  the  legs,  but  they  have 
disappeared.  The  pains  were  short  and  shooting.  When 
asked  whether  he  felt  distinctly  with  the  bottom  of  his  feet 
he  replies  no,  and  when  asked  whether  he  seemed  to  be 
walking  on  cushions  he  replies  that  the  bottom  of  his  feet 
seemed  to  come  to  a  point  as  if  he  were  walking  on  skates, 
and  they  wabbled.  He  says  he  passes  a  great  deal  of 
water,  but  he  is  able  to  pass  it  when  he  desires.  He  can- 
not restrain  it  long  after  the  desire  comes.  He  has  had 
feelings  as  if  a  rope  were  tied  around  the  waist  at  about  the 
crest  of  the  ilium.  He  sometimes  sees  double,  and  things 
look  blurred.  He  sometimes  has  pains  in  the  head.  He 
has  had  trouble  with  speech  for  sometime.  There  is  no 
trouble  with  the  arms ;  no  numbness,  he  tells  us ;  but  on 
inquiry,  we  find  that  he  is  unable  to  pick  up  a  pin  until  after 
several  trials.  He  has  trouble  with  his  fingers  ;  they  do  not 
feel  natural. 

The  tongue  is  not  tremulous.  He  says  his  food  seems 
to  stop  when  being  swallowed.     He  complains  of  difficulty 


-00  WILLIAM  A.   IIAMMOXD. 

in  the  pronunciation  of  words,  and  when  asked  to  repeat 
the  words  "truly  rural"  and  "national  intelligencer,-'  he 
does  it  with  difficulty.  He  can  repeat  the  sentence,  "Peter 
Piper  picked  a  peck  of  pickled  peppers,"  but  he  does  it  Very 
slowly  and  only  by  placing  his  whole  attention  upon  it.  I 
have  given  him  these  words  to  test  his  labials  and  Unguals, 
— the  power  to  use  his  lips  and  his  tongue.  Ordinarily  we 
do  not  have  to  give  our  attention  to  speech  which  has 
become  automatic  ;  this  young  man,  however,  cannot  pro- 
nounce Unguals  and  labials  without  thought. 

This  patient  has  not  the  Argyle  Robertson  symptom  of 
locomotor  ataxia.  In  a  patient  having  that  symptom  the 
pupil  does  not  contract  for  light,  but  it  does  contract  for 
accommodation.  In  this  patient  the  pupil  contracts  for  light 
and  also  for  accommodation.  His  pupils  are  larger  than  usual 
in  patients  who  have  locomotor  ataxia ;  in  fact  the  pupils 
are  usually  much  contracted  in  this  disease,  and  are  likely 
to  be  equal.  This  man's  pupils  are  about  equal ;  the  right 
may  be  a  little  larger  than  the  left,  but  they  are  both  larger 
than  we  commonly  observe  in  this  disease. 

None  of  the  symptoms,  as  far  as  we  have  gone,  are  ex- 
actly characteristic  of  locomotor  ataxia.  A  man  might 
have  all  of  his  symptoms  as  far  as  we  have  discovered  them, 
and  yet  have  some  other  disease  than  locomotor  ataxia. 
Now  we  will  inquire  with  regard  to  some  pathognomonic 
symptoms. 

When  asked  to  stand  with  his  eyes  closed*,  he  separates 
his  feet,  widens  his  base  ;  and  when  asked  to  walk  with  his 
eyes  closed,  he  goes  but  a  short  distance  when  he  begins  to 
stagger  and  fall.  He  has  lost  his  ability  to  bring  his  mus- 
cles into  such  harmonious  action  as  will  result  in  exact 
movement.  He  cannot  place  his  feet  where  he  wants  to 
except  by  concentrating  his  whole  attention  upon  his  move- 
ments. If  he  were  to  try  to  mount  a  horse,  he  could  not 
place  his  foot  in  the  stirrup.  If  he  were  to  try  to  get  into  a 
carriage,  he  would  probably  miss  the  step.  He  has  lost  to 
some  extent  the  power  of  co-ordination,  which  is  one  of  the 
symptoms  of  locomotor  ataxia,  and  without  which  locomo- 
tor ataxia  never  exists. 


SCLEROSIS  OF  THE  SPIXAL  CORD.  -OI 

But  there  are  other  diseases  in  which  there  is  want  of 
power  of  co-ordination  besides  locomotor  ataxia.  We  see 
the  same  thing  in  multiple  neuritis.  That  symptom  is  not, 
then,  sufficient  in  itself  to  establish  the  existence  of  loco- 
motor ataxia,  although  there  cannot  be  locomotor  ataxia 
without  it. 

We  now  proceed  to  test  his  patellar  tendon  reflex,  and 
we  find  that  it  is  present  in  nearly  a  normal  degree. 
That  settles  the  point  beyond  a  doubt  that  this  is  not  a  case 
of  locomotor  ataxia  pure  and  simple,  for  when  that  disease 
exists  alone,  there  is  always  abolition  of  the  knee-jerk  ;  that 
is,  when  the  legs  are  crossed  and  you  strike  just  below  the 
patellar,  there  is  no  rebound  of  the  foot.  I  have  never  seen 
a  case  of  pure  locomotor  ataxia  in  which  there  was  exag- 
geration of  the  patellar  tendon  reflex.  Not  that  the  aboli- 
tion of  the  tendon  reflex  is  itself  pathognomonic  of  the 
disease,  for  it  is  not.  There  are  some  people  who  never 
have  had  the  tendon  reflex,  who  have  been  born  without  it, 
who  are  not  suffering  with  locomotor  ataxia.  But  if  you 
put  those  two  symptoms  together,  the  diminution  or  aboli- 
tion of  the  patellar  tendon  reflex  and  co-ordination,  such  as 
is  seen  in  this  patient,  they  are  sure  indications  that  the  per- 
son is  suffering  from  locomotor  ataxia,  or  sclerosis  of  the 
column  of  Burdock — the  external  part  of  the  posterior  por- 
tion of  the  spinal  cord. 

When  I  began  the  examination  of  this  patient,  I  was  as 
much  surprised  as  any  of  you  to  find  that  the  patellar  ten- 
don reflex  had  not  been  abolished,  for  I  had  been  prepared 
to  look  for  the  further  symptoms  of  locomotor  ataxia  which 
up  to  that  point  in  the  examination  were  present.  But  the 
case  is  proving  all  the  more  interesting,  as  it  will  probably 
enable  me  to  demonstrate  a  combination  of  the  two  affec- 
tions, the  general  anatomical  features  of  which  I  have  just 
described. 

This  patient  speaks  of  a  sensation  of  constriction  around 
the  waist.  That  line  is  supposed  to  mark  the  upper  limit  of 
the  morbid  process  in  the  cord.  But  in  many  cases  which 
have  come  under  my  observation  I  am  perfectly  satisfied 
that  there  has  been  disease  above  that  line.     Therefore  I 


^02  WILLIAM  A.   HAMMOND. 

am  unable  to  explain  satisfactorily  what  that  sense  of  con- 
striction is  due  to.  I  do  not  even  know  what  the  condition 
in  the  muscles  or  nerves  is  which  gives  rise  to  it.  It  may 
be  a  sort  of  contraction  of  the  muscles,  or  it  may  be  some 
trouble  with  the  nerves  themselves. 

This  patient  states  that  his  legs  have  not  felt  stiff,  they 
do  not  shake,  but  they  sometimes  suddenly  spring  forward 
after  a  sleepy  attack.  He  has  not  ankle  clonus.  The  only 
regular  symptom  of  locomotor  ataxia  which  is  absent  in  his 
case  is  the  patella  tendon  reflex.  This  is  not,  I  think,  ex- 
aggerated, but  it  is  not  abolished.  The  only  way  in  which 
we  can  account  for  that  is  the  existence  of  a  condition  called 
spastic  ataxia,  which  consists  of  a  combination  of  locomotor 
ataxia  and  antero-lateral  sclerosis. 

It  is  characterized  by  the  symptoms  of  both  diseases  to 
a  certain  extent.  Suppose  this  man's  symptoms  began,  as 
they  probably  did,  in  the  posterior  columns  of  the  spinal 
cord,  and  that  in  the  first  place  there  was  diminution  or 
abolition  of  the  tendon  reflex.  Suppose  the  morbid  process 
extended  until  it  involved  the  antero-lateral  columns.  The 
tendency  of  disease  of  the  antero-lateral  columns  is  to  pro- 
duce exaggerated  tendon  reflex.  Consequently,  as  the  dis- 
ease advanced  in  this  case,  the  loss  of  the  tendon  reflex 
would  be  replaced  by  its  return  or  by  an  exaggeration  of  it. 
We  cannot  determine  whether  the  disease  began  as  an 
antero-lateral  sclerosis  or  as  a  postero-lateral  sclerosis  until 
we  shall  have  examined  further.  As  long  as  the  disease  is 
confined  to  the  posterior  columns  of  the  cord,  there  is  no 
loss  of  power  of  motion.  Let  the  patient  straighten  the  leg, 
and  you  will  find  yourself  unable  to  bend  it  at  the  knee.  I 
have  seen  patients  who  could  not  stand  with  their  eyes 
closed,  nor  walk  with  the  eyes  shut,  nor  feel  the  ground 
with  the  soles  of  their  feet,  yet  they  were  as  strong  as  you 
or  I,  and  it  was  impossible  to  flex  their  legs  against  their 
will. 

If  this  man  has  a  combination  of  the  two  diseases  under 
consideration,  he  has  lost  power  in  the  legs.  If  he  is  as 
strong  in  the  legs  as  he  ever  was,  he  has  a  disease  which  I 
have  never  seen.     If  he  has  the  combination  of  locomotor 


SCLEROSIS  OF  THE  SPINAL  CORD.  cn-, 

ataxia  and  antero-lateral  sclerosis,  he  must  necessarily  have 
lost  some  strength  in  the  legs,  for  in  antero-lateral  sclerosis 
there  is  loss  of  power. 

For  the  purpose  of  comparison,  we  will  now  obtain  the 
history  of  the  second  patient,  who  is  supposed  to  have 
antero-lateral  sclerosis.  His  age  is  forty-six.  He  says  he 
has  always  been  quite  weak.  By  weakness  he  means  his 
toes  have  always  dragged  on  the  ground  ;  that  is  to  say,  he 
could  not  raise  his  foot.  This  is  the  manner  in  which 
antero-lateral  sclerosis  begins.  He  had  a  tendency  to  fall 
down.  His  legs  got  a  little  stiffer  every  year  ;  they  would 
jump  at  night,  and  they  twitch  occasionally  yet.  As  you 
see,  in  his  walk  the  toes  drag  on  the  ground.  When  asked 
to  cross  the  legs  while  sitting,  he  is  compelled  to  lift  one 
leg  over  the  other  with  the  hands.  When  asked  to  lift  the 
heel  while  the  toes  rest  on  the  floor,  he  does  so,  and  says 
that  sometimes  the  foot  begins  to  shake,  but  it  rests  quietly 
now  because  it  is  too  stiff.  When  it  starts  going,  he  has  no 
power  whatever  to  stop  it  except  by  putting  the  heel  down. 
He  has,  then,  three  symptoms  which  are  characteristic  of 
antero-lateral  sclerosis,  viz.,  rigidity,  paralysis,  and  exag- 
gerated tendon  reflex. 

If  this  patient  should  come  back  again  in  three  or  four 
years,  we  should  find  that  he  had  no  exaggerated  tendon 
reflex  as  he  now  has,  he  would  have  lost  that  ankle  clonus, 
but  he  would  preserve  his  other  symptoms  and,  in  addition, 
he  would  have  loss  of  co-ordinating  power.  The  rigidity  of 
the  muscles  is  sometimes  so  great  that  when  such  patients 
in  walking  have  contraction  of  the  muscles  on  the  anterior 
face  of  the  thigh  and  legs,  the  one  leg  becomes  locked  over 
the  other,  and  they  are  unable  to  proceed.  This  patient 
says  he  has  not  been  troubled  in  that  way. 

When  asked  whether  he  has  any  pains,  he  replies  that 
he  has  not,  that  he  only  feels  stiff.  Whatever  pains  he  may 
have  are  due  to  stiffness  in  the  muscles  and  to  outside 
disturbances,  not  to  disturbance  in  the  cord. 

When  asked  to  stand  with  his  feet  close  together  and  the 
eyes  shut,  he  is  able  to  do  it  without  any  unsteadiness  what- 
ever.    The   other  patient,  you  will   see,  is  quite   unsteady. 


^04  WILLIAM  A.   HAMMOXD. 

The  second  patient  is  also  able  to  walk  as  well  with  the 
eyes  closed  as  with  them  open.  The  first  patient  says  that 
in  the  beginning  of  his  symptoms  his  legs  felt  too  heavy, 
and  that  when  sitting  in  a  chair  or  lying  on  the  sofa  he 
imagined  he  was  going  to  fall.  That  is  not  a  characteristic 
symptom  of  locomotor  ataxia.  His  legs,  he  says,  never  felt 
stiff,  nor  does  he  think  they  are  weak.  He  imagines  his 
legs  would  be  all  right  if  he  could  place  his  feet  where  he 
liked.  On  testing  the  strength  of  his  legs,  we  find  they  can 
be  bent  at  the  knee  very  easily,  while  on  one  of  the  healthy 
men  present  we  are  unable  to  overcome  the  power  of 
the  extensors  of  the  leg.  That  shows  this  patient  must 
have  some  other  affection  than  merely  locomotor  ataxia,  for 
the  strength  of  the  muscles  is  not  affected  in  the  last-named 
disease.  The  explanation  of  this  symptom  would  also  ac- 
count for  the  absence  of  the  Argyle  Robertson  pupil,  which 
is  almost  always  seen. 

There  ought  also  to  be  something  else,  to  which  I  have 
not  yet  alluded,  which  is  a  complicating  feature.  It  is  trou- 
ble with  speech  and  swallowing.  The  patient  says  he  some- 
times chokes,  that  he  has  trouble  in  moving  his  tongue  and 
in  bringing  his  lips  together.  When  saying  "  Peter  Piper," 
etc.,  he  did  not  bring  his  lips  closely  together.  That  is  evi- 
dence that  he  has  some  bulbar  disease  in  addition  to  antero- 
lateral and  postero-lateral  sclerosis  ;  that  is  to  say,  he  has 
indications  of  beginning  glosso-labio-laryngeal  paralysis. 
If  he  comes  here  within  a  year  or  two  you  will  find 
that  he  cannot  swallow,  that  the  saliva  dribbles  from  his 
mouth,  that  he  has  lost  ability  to  articulate,  and  the  lower 
part  of  his  face  is  almost,  if  not  quite,  paralyzed.  All  this, 
he  says,  came  from  the  blow  on  the  back  of  his  head.  That 
would  account  for  the  bulbar  disease,  but  it  would  not  in 
itself  account  for  the  other  symptoms — those  depending  on 
disease  of  the  spinal  cord.  Put  it  might  all  be  accounted 
for  by  the  commencement  of  the  disease  lower  down  in  the 
cord,  and  ascending,  involving  the  other  parts.  He  now 
says  that  his  eyesight  is  blurred.  All  the  symptoms  go  to 
show  advancing  disease,  having  already  reached  the  gan- 
glia at  the  base  of  the  brain,  affecting  the  third  pair  of 
nerves  and  the  optic  nerves. 


SCLEROSIS  OF  THE  SPINAL  CORD.  co- 

5°5 

When  we  began  to  examine  this  patient  we  expected  to 
find  locomotor  ataxia.  While  I  am  disappointed,  I  am  glad 
that  it  turned  out  not  to  be  a  simple  case  of  that  disease. 
Besides  the  interest  in  the  case  itself,  it  illustrates  very  well 
the  importance  of  not  stopping  and  making  a  diagnosis  after 
elucidating  what  appear  to  be  one  or  two  characteristic 
symptoms  of  any  affection  which  you  think  the  patient  may 
have.  I  was  astonished  to  see  his  leg  fly  out  when  testing 
the  patellar  tendon  reflex.  It  was  something  which  I  had 
not  at  all  expected,  for  the  other  symptoms  pointed  to  un- 
complicated locomotor  ataxia.  But  that  occurrence  dis- 
abused me  of  my  first  impression  of  the  nature  of  his  disease. 
And  so  you  will  often  find  that  as  you  proceed  with  the 
examination  of  a  case  you  may  change  your  mind  several 
times  as  to  its  real  nature.     All  that  is  instructive. 

The  third  patient  before  you  is  a  woman,  past  her 
thirtieth  year,  who,  when  questioned  regarding  the  symp- 
toms we  have  discovered  in  these  other  patients,  seems 
to  think  that  she  too  has  some  of  them.  She  makes  believe 
that  there  is  ankle  clonis  at  both  ankles,  and  so  with  some 
other  symptoms.  Instead  of  having  antero-lateral  sclerosis, 
she  is  simply  hysterical,  and  has  no  affection  of  the  cord  at 
all.  There  is  no  real  disease  about  her,  at  least  none  such 
as  we  are  looking  for.  All  that  is  simply  simulation  of  dis- 
ease. Her  walk  shows  that  she  has  no  paralysis,  no  loco- 
motor ataxia  ;  the  manner  in  which  she  stands  shows  that 
she  co-ordinates  well.  The  symptoms  which  she  has  are 
only  those  which  she  has  seen  us  experimenting  with  and 
which  she  has  imitated,  although  but  poorly.  She  is  hys- 
terical ;  she  has  a  disease,  a  disorder,  but  it  is  not  such  as 
these  other  patients  have.  I  had  her  come  in  simply  to 
show  one  of  the  manifestations  of  hysteria — how  it  may 
simulate  anything  at  all.  I  had  a  woman  patient  four  or 
five  years  ago  who  was  strongly  hysterical,  and  who  of  all 
persons  whom  I  have  seen  was  most  under  the  influence  of 
the  principle  of  suggestion.  I  could  make  her  believe  any- 
thing at  all.  I  suppose  we  can  generally  do  that  with 
women,  but  at  the  same  time  we  cannot  always  impose  on 
them  in  the  way  I  could  impose  on  that  one.     I  would  take 


-0<5  WILLIAM  A.  HAMMOND, 

up  a  book,  for  instance,  ask  "What  is  that?"  She  would 
reply,  "It  is  a  book."  I  would  say,  "It  is  not  a  book,  it  is 
a  watch."  She  would  say,  "No,  it  does  not  look  like  a 
watch."  I  would  say,  "Look  at  it  again,  and  see  if  it  does 
not  look  like  a  watch."  She  would  then  say,  "It  does  look 
like  a  watch."  "  Have  you  the  hardihood  to  tell  me  it  is 
not  a  watch?"  "I  beg  your  pardon,  doctor  ;  it  is  a  watch." 
"What  sort  of  a  watch  ?"  "  I  hardly  know."  "Is  it  a  silver 
watch?"  "Yes."  "Now  look  at  it  again,  and  you  will  see 
it  is  not  silver  ;   it  is  gold."     "Oh,  yes,  doctor  ;  it  is  gold." 

With  such  persons  you  could  do  anything,  make  them 
believe  anything,  for  they  lose  the  power  of  voluntarily 
directing  their  thought.  The  patient  before  us  is  one  of 
that  kind,  except  that  she  has  more  volition  remaining  than 
had  the  one  to  whom  I  have  referred. 

Let  us  return  for  a  few  minutes  to  the  first  two  cases. 

In  the  one,  we  have  found  that  he  has  an  affection  of 
two  portions  of  the  cord  ;  that  he  has  locomocor  ataxia 
and  also  antero-lateral  sclerosis.  Consequently  his  gait  is 
not  purely  that  of  locomotor  ataxia,  it  is  a  mixture  of  the 
gait  peculiar  to  these  two  affections.  The  gait  of  locomotor 
ataxia  is  perfectly  characteristic,  and  I  am  enabled  by  it  to 
tell  while  patients  are  walking  through  a  passage  way  of 
some  thirty  feet  to  enter  my  office  that  they  have  locomotor 
ataxia,  although  I  may  never  have  seen  them.  Such  patients 
make  two  distinct  movements  with  the  foot  and  two  distinct 
sounds.  This  patient  does  sometimes,  but  not  always.  If 
he  had  pure  locomotor  ataxia  he  would  do  it  always.  The 
heel  strikes  first,  making  a  distinct  sound,  and  then  the  sole 
strikes,  making  a  second  sound. 

This  patient  has  not  very  well  defined  symptoms  in  the 
sole  of  his  feet,  such  as  patients  suffering  from  locomotor 
ataxia  usually  have.  They  usually  consist  of  sensations  as 
if  the  patient  were  walking  on  a  cushion,  on  sand,  or  velvet, 
or  as  if  the  feet  were  too  large  for  the  boots,  or  as  if  some- 
thing were  crowding  the  toes.  At  the  same  time  this  patient 
has  some  change  in  sensation  in  the  sole  of  the  feet.  He 
describes  it  as  if  walking  on  skates,  and  as  if  his  feet  were 
inclined  to  roll.    He  probably  exhibits  in  a  very  mild  degree, 


SCLEROSIS  OF  THE  SPINAL  CORD.  -0- 

if  at  all,  the  retardation  of  sensibility  which  is  one  of  the 
characteristic  symptoms  of  locomotor  ataxia.  By  that  I 
mean  that  the  impression  made  on  the  cutaneous  surface  of 
the  feet,  for  instance,  is  not  appreciated  by  the  brain  for  a 
space  of  time  considerably  longer  than  would  be  necessary 
in  a  person  normally  constituted.  Sometimes  that  interval 
is  so  long  that  it  is  noticed  by  every  person  who  may  be  in 
the  room.  1  had  a  patient  once  at  my  clinic  at  the  Bellevue 
Hospital  Medical  College  suffering  from  locomotor  ataxia 
in  whom,  as  he  walked  about,  I  stuck  two  pins,  one  into  the 
calf  of  each  leg,  up  to  the  head.  Some  persons  present  took 
out  their  watches,  and  it  was  found  that  two  minutes  and  a 
half  elapsed  before  he  felt  the  pins,  and  he  then  jerked  up 
the  feet  as  if  something  hurt  him.  As  he  said,  you  might 
pour  boiling  water  on  his  legs  and  he  would  not  know  it 
until  the  flesh  had  fallen  off. 

I  do  not  believe  this  patient  is  affected  in  that  way.  I 
do  not  suppose  it  will  take  more  than  a  fraction  of  a  second 
in  his  case  for  the  sensation  produced  by  the  stick  of  a  pin 
into  the  feet  to  travel  to  the  brain.  You  see  he  complains 
apparently  immediately  after  he  is  pricked,  and  there  seems 
to  be  no  diminution  of  sensibility.  It  is  about  the  same  on 
both  sides. 

Sensibility  travels  along  the  nerves  at  about  the  rate  of 
eighty-one  feet  a  second.  Call  it  over  four  feet  to  his  brain, 
he  ought  to  feel  the  sensation  in  about  one-twentieth  of  a 
second,  and  that  probably  is  about  the  time  in  which  he 
does  feel  it.  You  can  appreciate,  then,  how  great  the 
retardation  must  have  been  in  the  patient  at  Bellevue  Col- 
lege. 

In  the  second  patient,  who  has  antero-lateral  sclerosis, 
we  do  not  expect  any  retardation  of  sensation,  for  he  has 
no  trouble  with  the  posterior  columns  of  the  cord ;  and  he 
has  no  retardation  of  sensation  as  is  shown  by  experiment. 

Another  word  with  regard  to  the  reason  why  the  first 
patient  is  unable  to  stand  with  the  eyes  closed.  He  can 
stand  much  better  with  the  eyes  open,  and  he  can  walk 
pretty  well  when  he  has  use  of  his  sight.  We  know  that 
when  walking  in  the  street  we  do  not  have  to  look  where 


-Q£  WILLIAM  A.   HAMMOXD. 

we  are  placing  our  feet,  or  just  the  place  where  we  are 
going.  We  look  and  get  a  general  idea  of  the  direction, 
but  we  do  not  watch  our  feet,  nor  do  we  have  any  guide- 
post  before  us.  But  these  patients  cannot  walk  in  that 
way.  They  must  have  a  guiding  spot  somewhere.  As  long 
as  a  patient  suffering  from  locomotor  ataxia  keeps  his  eyes 
on  the  guiding  spot  he  walks  pretty  well.  As  the  disease 
advances  he  shortens  that  spot,  brings  it  nearer,  until  finally 
he  has  to  keep  his  eyes  directed  to  the  floor  and  see  where 
he  is  next  to  place  his  feet.  The  moment  he  finds  his  eyes 
off  of  his  feet  he  begins  to  fall.  That  shows  that  there  is 
something  in  us  when  well,  aside  from  the  eyesight,  which 
enables  us  to  walk.  That  is  called  by  some  persons  the 
muscular  sense.  We  know,  in  a  way  which  we  do  not 
understand,  the  exact  state  of  contraction  that  our  muscles 
are  undergoing.  If  you  take  off  all  your  clothing  and  bend 
your  arm,  you  will  know  just  the  degree  to  which  you  are 
bending  it  without  looking  at  it.  How  do  you  know  that 
your  arm  is  bending,  or  how  much  it  is  bent  ?  I  do  not 
know.  But  it  is  attributed  to  the  muscular  sense.  These 
patients  do  not  know  what  use  they  are  making  of  their 
muscles  by  that  sense.  They  have  lost  the  muscular  sense, 
and  cannot  tell  what  their  muscles  have  done  unless  assisted 
by  sight.  They  have  to  see  what  they  are  doing.  Whether 
that  muscular  sense  can  be  called  a  sense  or  not,  there  is 
no  doubt  that  it  is  a  perception  of  some  kind  which  conveys 
the  impression  to  the  brain  and  gives  cognizance  of  what  is 
going  on.  This  patient  has  lost  that  perception  not  only 
in  the  legs,  but  also  to  some  extent  in  the  arms.  When  he 
is  asked  to  close  his  eyes  and  bring  the  index  finger  of  the 
outstretched  hand  to  the  tip  of  the  nose  or  to  the  middle  of 
the  eyebrow,  he  misses  the  mark  by  half  an  inch,  and  he 
does  not  fully  correct  the  mistake  after  several  trials.  Those 
of  us  who  are  in  normal  health  make  very  slight,  if  any, 
error,  even  at  the  first  trial,  and  when  we  miss  the  mark  at 
the  first  trial,  we  correct  it  at  the  second. 

One  reason  why  I  brought  these  two  cases  before  you 
to-day  was  to  sharply  define  the  difference  between  the 
symptoms  of  locomotor  ataxia  and   antero-lateral  sclerosis 


SCLEROSIS  OF  THE  SPINAL  COED.  cqq 

of  the  cord.  The  case  illustrating  the  former  disease  turned 
out  to  be  not  a  simple,  but  a  complicated  case,  and  there- 
fore somewhat  confusing.  Almost  every  case  of  antero- 
lateral sclerosis  which  is  sent  to  me  by  physicians  who 
have  not  made  more  or  less  a  specialty  of  diseases  of  the 
nervous  system  is  sent  as  one  of  locomotor  ataxia.  You 
now  see  how  essentially  distinct  are  the  two  affections. 
The  distinction  is  not  only  a  matter  of  scientific  import,  it 
is  also  one  which  directly  concerns  the  patient,  as  the  treat- 
ment is  different  in  the  two  classes  of  cases.  Antero-lateral 
sclerosis  is  much  more  amenable  to  treatment  than  is  loco- 
motor ataxia.  Of  all  the  organic  affections  of  the  spinal 
cord,  locomotor  ataxia  is  the  most  common,  while  it  is  the 
least  frequently  cured.  We  shall  have  to  postpone  the 
consideration  of  the  treatment  until  a  future  date. 


Socirty  Reports. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Meeting  of  April  jt/i,  1888. 

The  President,  Dr.  A.  JACOBI,  in  the  Chair. 

A  CONTRIBUTION    TO  THE   DIAGNOSIS   AND   SURGERY   OF 
CEREBRAL   TUMORS 

was  presented  by  Dr.  E.  C.  Seguin  and  Dr.  R.  F.  Weir, 
in  the  first  part  of  which  they  related  a  case.  The 
patient  was  a  German,  a  resident  of  Bridgeport,  under  the 
care  of  his  family  physician,  Dr.  Godfrey,  who  first  brought 
him  to  Dr.  Seguin's  on  August  12th,  1887.  In  Dr.  Seguin's 
absence  an  examination  was  made  by  Dr.  Booth.  The  pa- 
tient was  a  strong,  healthy-looking  man,  with  no  history  of 
syphilis,  and  no  history  of  epilepsy  in  childhood.  The 
family  history  was  supposed  to  be  good,  but  it  had  after- 
ward been  learned  that  the  mother  had  died  of  cancer, 
probably  scirrhus,  of  the  liver.  The  patient  had  been 
healthy  until  1882,  when  he  had  malarial  fever.  During 
this  illness  he  had  a  good  deal  of  pain  in  the  head,  and  one 
day,  when  feeling  strangely,  he  got  up  to  go  to  the  window, 
when  his  wife  observed  spasm  of  the  right  cheek  and  neck. 
Consciousness  was  not  lost.  One  or  two  similar  attacks 
occurred  before  1885.  These  spasms  in  the  face  and  neck 
on  the  right  side  were  the  only  symptoms  of  cerebral  dis- 
ease for  three  years.  In  1885  the  symptoms  became  more 
marked.  One  day  during  that  year  he  fell  unconscious  and 
bit  his  tongue.  He  had  similar  attacks  at  long  intervals 
afterward.  These  epileptic  attacks  were  preceded  by  an 
aura,  which  was  followed  by  twitching  and  jerking  in  the 
right  hand  and  arm  and  the  right  side  of  the  face,  and  loss 


NEW  YORK  ACADEMY  OF  MEDICINE.  -  T  T 

of  consciousness.  No  exciting  cause  had  been  observed. 
The  memory  was  not  so  good  as  formerly ;  the  speech  had 
become  thick.  Dr.  Seguin  saw  the  patient  for  the  first  time 
on  August  26th  ;  he  had  had  no  purely  motor  attack  in  the 
hand  alone  ;  it  had  always  been  affected  after  the  right 
cheek.  There  was  no  history  of  injury  to  the  head.  The 
patient  was  awkward  with  the  right  hand  ;  the  arm  and 
hand  were  the  seat  of  a  numb,  heavy  sensation.  The  left 
side  and  lower  extremities  were  not  affected.  At  this  time 
the  tongue  did  not  deviate,  but  at  a  later  examination  it 
deviated  a  trifle  to  the  right.  The  patieut  was  seen  and 
examined  on  September  21st  and  October  19th,  when  his 
symytoms  were  found  to  be  rapidly  progressing,  and  an 
operation  was  advised.  The  diagnosis  was  that  of  a  tumor 
in  the  left  motor  zone,  in  the  facial  centre.  There  was 
slight  diminution  of  the  tactile  sense  in  the  right  cheek  and 
arm.  There  was  slight  impairment  of  the  muscular  sense 
in  the  right  hand.  There  was  constant  loss  of  saliva  from 
the  right  buccal  angle.  The  strength  of  the  right  hand  and 
arm  was  about  two-thirds  that  of  the  left.  Subsequently 
tenderness  developed  over  the  motor  zone  of  the  left  hem- 
isphere. The  temperature  test  over  the  scalp  was  negative. 
Whether  the  tumor  was  cortical  or  subcortical  was  not 
determined.  Treatment  by  iodide  of  potassium  had  no 
effect.  Dr.  R.  F.  Weir  performed  the  operation  in  the  New 
York  Hospital,  November  17,  1887.  The  head  was  shaved 
the  previous  day,  and  great  pains  were  taken  to  make  the 
operation  perfectly  antiseptic.  The  spray  was  not  used. 
A  minute  perforation  was  made  through  the  scalp  and  the 
point  marked  with  a  lead-pencil  which  was  to  be  the  centre 
for  the  trephine.  Two  pieces  were  then  removed  with  the 
trephine,  and  the  openings  being  joined,  left  one  large 
opening  two  by  three  inches.  The  dura  mater  bulged  only 
a  little,  and  appeared  normal.  When  it  was  cut  the  brain 
bulged  somewhat  into  the  opening,  but  its  surface  was 
normal.  The  finger  recognized  no  tumor  until  firm  pressure 
was  made,  when  deep  resistance  was  felt  in  a  mass  of  small 
size  under  the  suspected  convolution.  It  was  of  the  shape 
and  of  about  the  size  of  the  end  of  the  forefinger,  or  of  an 


-  ,  ^  NI.  IV  YORK  ACADEMY  OF  MEDICINE 

5  '  - 

almond.  It  was  readily  lifted  out  by  a  Volkmann  s  spoon, 
blunted  for  this  purpose.  A  little  portion  of  brain,  of  about 
the  size  of  a  pea,  was  removed  with  it.  The  finger  passed 
in  an  inch  and  a  half  to  the  bottom  of  the  wound.  There 
was  no  haemorrhage  from  the  brain  itself.  A  rubber  drain- 
age tube  was  carried  to  the  bottom  of  the  cavity  and  out 
through  the  posterior  margin  of  the  wound  ;  the  dura  mater 
was  stitched  together  except  where  the  tube  emerged. 
After  the  final  dressing  the  wound  was  washed  with  cor- 
rosive-sublimate solution  (i  to  5,000).  The  discs  of  bone 
were  replaced.  At  the  close  of  the  operation  the  pulse  was 
12;,  and  the  general  condition  was  good.  Dr.  Peabody 
pronounced  the  tumor  an  infiltrating  sarcoma. 

Commenting  on  the  operation,  Dr.  Weir  said  he  thought 
there  had  been  more  haemorrhage  from  the  vessels  of  the 
scalp  than  he  would  allow  at  a  future  operation.  The  patient 
had  gone  to  his  home  a  month  after  the  operation. 

Dr.  SEGUIN  gave  the  history  of  the  case  from  the  time 
of  the  operation  until  about  the  1st  of  April.  There  was 
almost  complete  hemiplegia  with  aphasia  just  after  the 
operation,  but  these  subsided,  leaving  the  man  in  about  his 
previous  condition.  He  had  no  convulsion  until  the  18th  of 
December.  Driveling  had  ceased.  After  his  return  to 
Bridgeport  he  again  contracted  a  form  of  intermittent  fever, 
and  the  symptoms  due  to  the  cerebral  lesion  were  most 
pronounced  when  he  had  the  fever.  There  was  jaundice 
with  the  malarial  symptoms.  The  wife  had  observed  no 
twitching  in  the  muscles  of  the  face  since  his  return  home 
after  the  operation.  He  stated  that  he  knew  the  word  he 
wished  to  use,  but  could  not  utter  it.  The  right  hand  no 
longer  felt  numb.  The  muscular  sense  was  practically  per- 
fect, and  sensation  seemed  normal  in  the  right  hand.  Dr. 
Seguin  thought  life  had  been  prolonged  by  the  operation. 
The  paresis  seemed  to  be  somewhat  greater,  but  he  attrib- 
uted this  to  the  patient's  general  health.  The  sensibility  of 
the  face,  hands,  and  fingers  was  improved.  The  aphasia 
was  about  the  same  as  before  the  operation.  There  was  no 
indication  of  increased  intracranial  pressure  and  no  evidence 
of  a  relapse  of  the  disease.     The  speaker  was  not  positive 


NEW  YORK  ACADEMY  OE  MEDICINE.  -  T  -, 

that  the  tumor  had  been  entirely  subcortical.  It  might 
have  involved  to  some  extent  a  deep  gyrus  located  in  its 
neighborhood.  The  case  was  particularly  interesting  when 
considered  with  reference  to  recent  advances  in  the  physi- 
ology of  the  brain  and  the  application  of  such  knowledge  to 
surgical  interference  in  a  general  way  as  well  as  with  regard 
to  tumors.  The  diagnosis  of  tumor  of  the  brain  for  the 
guidance  of  the  surgeon  was,  as  a  rule,  reached  gradually. 
Then  the  locality  of  the  tumor  would  be  determined  by 
empirically  acquired  knowledge  due  to  the  studies  of  Broca 
and  others,  and  the  laws  of  cerebral  action  as  elicited  by 
Hitzig  and  others.  The  speaker  here  considered  the  signs 
of  a  tumor  in  the  motor  and  sensory  zones,  the  symptoms 
due  to  irritation  or  excitation  of  the  part  as  distinguished 
from  those  due  to  its  destruction,  etc.  Speaking  of  the  sig- 
nificance of  limited  spasm  or  paresis,  he  had  long  looked 
upon  the  early  spasm  as  a  guide  to  correct  localization  of 
the  disease.  It  was  of  so  great  importance  that  it  should 
always  be  traced  if  possible.  He  would  call  it  the  signal 
symptom  of  cerebral  tumor.  The  diagnosis  of  a  tumor  situ- 
ated in  the  sensory  zone  for  sight,  he  thought,  could  be 
made  just  as  positively  as  if  it  were  located  in  the  motor 
centre  for  the  hand,  face  or  leg.  It  was  of  importance  to 
determine  not  alone  the  region  in  which  the  tumor  was 
located,  but  also,  if  possible,  whether  it  was  cortical  or  sub- 
cortical. He  thought  that  at  present  we  were  unable  to 
distinguish  a  cortical  from  a  subcortical  tumor  by  the  symp- 
toms. Regarding  the  significance  of  headache,  his  conclu- 
sion had  been  negative.  Indeed,  headache  was  an  unreliable 
symptom  of  tumor  of  the  brain  independent  of  location.  His 
conclusion  with  regard  to  the  significance  of  scalp  tem- 
perature had  also  been  negative.  The  surgeon  would  be 
influenced  as  to  whether  he  should  or  should  not  operate 
by  the  question  of  the  probability  of  the  tumor  being  mul- 
tiple. The  presence  of  tuberculosis  or  of  cancer  in  other 
parts  of  the  body  would  contra-indicate  an  operation.  Com- 
bined symptoms  of  tumor  in  the  motor  and  sensory  zones, 
whether  sensory  or  motor,  would  point  to  multiple  tumor. 
Where  more   than   one   growth  existed  in  a  limited  area  of 


-  T  ,  .YE  IT  YORK  ACADEMY  OF  MEDICI XE. 

the  brain,  it  could   not  be  determined  during  life  ;  the  sur- 
geon might  remove  one  and  overlook  the  other. 

Dr.  We  if  then  considered  the  surgery  of  cerebral  tu- 
mors, and  read  a  portion  of  his  paper,  giving  a  synopsis  of 
the  operations  performed  by  Bennet,  Godlee,  Victor  Hors- 
ley,  and  others.  From  the  facts  presented  it  would  seem 
that  an  exploratory  operation  would  be  justified  when 
symptoms  pointed  to  progressive  brain  pressure,  whether 
from  tumor,  abscess,  or  an  intracerebral  blood-clot,  or  to 
continuous  irritation. 

Dr.  Keen,  of  Philadelphia,  related  briefly  the  history  of 
a  case  which  he  would  at  a  future  time  publish  in  detail — 
that  of  a  patient,  aged  twenty  years,  who  had  sustained  a 
fall  when  three  years  of  age,  which  had  left  a  scar  over  the 
left  motor  region.  It  was  not  until  some  months  before  the 
speaker  saw  him  that  he  had  begun  to  have  epilepsy  and 
paralysis  of  the  right  leg,  the  right  arm,  and  the  face,  and 
had  aphasia.  He  removed  a  large  tumor  from  the  left 
motor  zone,  symptoms  of  pressure  developed  afterward, 
and  he  had  to  change  the  dressing  and  remove  a  large 
blood-clot.  Hernia-cerebri  then  developed  and  gave  con- 
siderable trouble,  but  the  patient  recovered.  In  this  case 
the  blood-vessels  were  very  brittle,  and  he  had  had  much 
difficulty  in  controlling  haemorrhage.  He  employed  for 
this  purpose  hot  water,  ligatures,  and  pressure.  He  thought 
the  entire  scalp  should  be  shaved,  to  reveal  any  possible 
scars  to  which  attention  had  not  been  drawn. 


PERISCOPE. 


By    DRS.  G.  W.  JACOBY,  N.  E.  BRILL,    LOUISE  FISKE-BRYSON   AND 
GRACE  PECKHAM. 


ANATOMY  OF  THE  NERVOUS  SYSTEM. 

On  the  Minute  Structure  of  the  Corpora  Stria- 
ta and  the  Optic  Thalami.  Dr.  Vittorio  Marchi, 
(Rivista  Sperimentale  di  Frenatra  e  di  Medicina  Legale. 

In  an  elaborate  and  exceedingly  interesting  paper  on 
this  subject,  illustrated  with  some  very  fine  plates,  the  writer 
reaches  the  following  conclusions. 

I.  Two  types  of  cells  are  found  in  the  corpora  striata, 
large  and  medium,  which  are  furnished  with  numerous  pro- 
cesses, one  alone  of  which  is  distinguished  by  special  char- 
acteristics and  is  the  nervous  process,  the  others  correspond 
to  protoplasmic  processes. 

II.  The  nervous  processes  comport  themselves  in  two 
ways,  one  after  a  short  distance  from  their  origin,  divides 
completely  into  a  fine  rete  nervosa  the  other  constitutes  the 
axis  cylinder  of  a  fibre,  not  however,  without  first  giving 
off  a  few  delicate  branches. 

III.  In  the  nucleus  of  the  corpus  striatum  cells  of  both 
types  are  found  ;  this  predominance,  however,  is  less  pro- 
nounced in  the  lenticular  nucleus. 

IV.  In  the  optic  thalamus,  isolated  groups  of  cells  are 
not  found,  but  they  are  scattered  irregularly  through  the 
whole  mass  of  the  gray  substance.  The  larger  size  prevail 
and  are  very  similar  to  those  of  the  anterior  horns  of  the 
spinal  cord.  These,  as  in  the  corpora  striata,  show  the 
single  nervous  process  and  the  numerous  protoplasmic  pro- 
cesses. 

V.  Differing  from  the  corpora  striata,  the  first  type  of 
cell  prevails  in  the  optic  thalami. 


-  j  6  ANATOMY  OF  THE  NERVOUS  SYSTEM. 

VI.  Corresponding  to  the  double  manner  of  the  dispo- 
sition of  the  nervous  processes,  the  fibres  join  themselves 
with  the  cells  of  the  corpora  striata  and  the  optic  thalami, 
either  directly  uniting  with  the  nerve  process  of  the  cells 
of  the  first  type,  or  indirectly  losing  themselves  in  the  fine 
network  formed  from  the  nerve  processes  of  the  cells  of 
the  second  type,  together  with  the  lateral  branches  eman- 
ating from  the  same  prolongations  from  cells  of  the  first 
type. 

VII.  The  internal  capsule  contains  fibres  which  directly 
unite  the  peduncles  of  the  brain  to  the  corona  radiata. 
Others  which  leave  the  peduncles  stop  at  the  basal  ganglia; 
others  go  from  there  to  the  corona  radiata,  others  arising 
from  the  cells  contained  in  the  substance  of  the  same  cap- 
sule take  ascending  or  descending  direction. 

VIII.  With  reference  to  the  protoplasmic  processes, 
setting  aside  those  which  form  the  rete  nervosa,  observation 
leads  him  to  think  that  the  finer  ramifications  stand  in  rela- 
tion to  the  cells  of  the  neuroglia  and  to  the  vessels. 

IX.  The  neuroglia  is  essentially  represented  in  cells 
having  numerous  long,  fine  processes  which  ramify  many 
times,  and  by  means  of  various  expansions  insert  them- 
selves in  the  walls  of  the  vessels. 

X.  Finally,  the  ependima  which  covers  the  corpora 
striata  and  the  internal  surface  of  the  optic  thalami  is  com- 
posed of  cylindrical  conical  cells,  the  thinner  portion  of 
which  continues  with  a  process  which,  after  considerable 
ramification  in   most  instances,  is  inserted  into  the  vessels. 

The  writer  deduces  the  following  conclusions  in  regard 
to  what  he  styles  the  much  debated  question  of  the  func- 
tions of  the  basal  ganglia.  From  the  fact  that  the  two 
types  of  cells  prevail  in  both  the  corpora  striata  and  the 
optic  thalami,  he  argues  that  they  have  mixed  functions  of 
motion  and  of  sensation  ;  but  as  in  the  corpora  striata  the 
cells  with  numerous  processes  corresponding  to  the  multi- 
polar cells  of  the  posterior  horns  of  the  spinal  cord,  there- 
fore the  corpora  striata  pertains  mostly  to  sensation  ;  while 
in  the  optic  thalami  the  cells  corresponding  to  those  found 
in  the  anterior  horn  prevail.    He  finds  in  these  experiments 


ANATOMY  OF  THE  NERVOUS  SYSTEM.  r  j  - 

a  corroboration  of  the  law  formulated  by  Golgi,  that  in  all 
parts  of  the  central  nervous  system,  the  specific  function, 
whatever  may  be  its  nature,  ought  to  be  effected  not  by  the 
isolated  or  individual  action  of  its  single  ganglionic  ele- 
ments, but  by  the  conjoined  action  of  extensive  groups  of 
cells. 

It  may  be  well  to  add  the  method  of  preparation  which 
was  employed  to  obtain  the  fine  results  in  staining 
shown  in  the  plates.  The  specimen  is  best  taken 
from  young  animals,  must  be  carefully  and  well-hardened. 
Before  taking  out  the  brain,  he  makes  repeated  injections 
of  a  two  per  cent,  solution  of  bichromate  of  potassium  into 
the  carotid  artery.  This  makes  the  hardening  more  even. 
After  this  he  cuts  the  brain  into  pieces  and  leaves  them  in 
Miiller's  fluid  for  twenty-four  hours,  after  which  he  makes 
sections  with  a  razor  into  smaller  pieces  of  a  cubic  centi- 
meter. These  he  puts  again  into  Miiller's  fluid,  leaving 
them  at  an  ordinary  temperature  for  eight  or  ten  days  ;  if 
it  is  cold  it  is  necessary  to  leave  them  for  a  longer  time. 
He  then  places  them  in  a  solution  of  about  eight  parts  of 
Miiller's  fluid  and  two  parts  of  a  solution  of  one  per  cent,  of 
osmic  acid.  This  mixture  accelerates  the  hardening.  The 
fluid  should  be  abundant  and  clear,  and  contain  only  a  few 
pieces.  After  twenty-four  hours  they  should  be  placed 
directly  into  a  solution  of  sixty  per  cent,  nitrate  of  silver, 
which  should  be  changed  after  about  half-an-hour,  because 
of  the  precipitate  which  it  forms.  In  this  last  solution  it  is 
necessary  that  the  pieces  remain  at  least  twenty-four  or 
forty-eight  hours,  longer  will  not  cause  any  alteration. 
The  sections  should  then  be  made,  after  which  they  are 
washed  in  common  alcohol,  then  passed  directly  into  creo- 
sote and  left  until  they  have  acquired  an  evident  transpar- 
ency. Then  wash  them  a  number  of  times  in  turpentine, 
leaving  them  for  twenty  minutes,  after  which  mount  in 
Canada  balsam  without  covering. 

PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 
Traumatic   Cortical    Hemiepilepsy.      Dr.   E.   Houze 
(Bulletin  de  la  Societe  de  Medicine  Mentale,  1884,  p.  48). 
Patient,   male,   aet.   22,   entered    hospital   February   5th, 


5  i  8  PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

1886.  Three  years  previously  had  received  a  severe  blow 
with  an  iron  plate  on  the  top  of  the  head.  Deep  wound. 
No  loss  of  consciousness.  After  a  few  days,  convulsive 
movements  in  the  right  leg,  and  on  the  fifteenth  day  a  con- 
vulsive attack-  of  the  entire  right  side  with  loss  of  conscious- 
ness. Frequent  repetition  of  the  attacks,  after  which  walking 
became  difficult.  Severe  headaches.  After  several  months, 
convulsive  seizures  in  right  hand  and  arm  ;  since  six  months, 
of  face  also.     At  this  time  signs  of  amnesic  aphasia. 

Examination  shows  occasional  contractions  in  territory 
of  right  facial.  Speech  hesitating,  tongue  affected  with 
spasmodic  movements.  Speech  scanning;  amnesia;  lin- 
gual ataxia.  Agraphia  due  to  convulsive  movements  of 
arm.  From  these  symptoms  a  lesion  at  the  foot  of  the 
lower  frontal  convolution  was  assumed.  The  fingers  of  the 
right  hand  are  alternately  flexed  and  extended.  When  the 
foot  is  placed  upon  the  ground,  rapid  movements  of  the 
flexion  and  extension  also  occur.  Walk,  dragging,  hemi- 
paretic.  The  convulsive  attacks  occur  ten  to  fifteen  times 
daily.  These  are  usually  confined  to  the  right  side,  but  are 
sometimes  generalized. 

In  addition  to  these  symptoms  of  motor  irritation,  hy- 
peralgesia of  the  right  foot  and  hand  is  observed.  Muscu- 
lar sense  is  also  reduced ;  no  ataxia.  Tendon  reflexes 
normal.  Cephalometric  measurements  were  employed  for 
the  determination  of  the  precise  location  of  the  bone  cica- 
trix. These  showed  the  scar  to  be  situated  near  the  central 
fissure  and  bordered  by  the  central  convolutions. 

After  a  long  period  of  medicinal  treatment  the  patient 
improved  until  only  convulsive  movements  in  the  right  leg 
and  occasional  epileptic  attacks  upon  that  side  were  pres- 
sent.  After  five  months  of  slow  improvement,  trepanation 
was  performed.  A  small  spicula  of  bone  was  found  at  the 
superior  extremity  of  the  central  convolution  (the  symptoms 
of  irritation  of  the  arm  and  face  centres  are  considered  sec- 
ondary, due  to  indirect  pressure),  and  removed. 

When  discharged  from  the  hospital  he  had  no  attack 
for  two  months,  and  the  twitchings  in  the  foot  were  rare 
and  not  severe.  G.  W.  J. 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  cig 

Nervous  Disorders  and  Secondary  Syphilis;  Hys- 
teria ;  Epilepsy  ;  Neuroses  of  the  Sympathetic. 
Prof.  Fournier  (Journal  de  Med.,  p.  202,  1888). 

Secondary  syphilis  incontestibly  has  a  modifying  or  pro- 
ductive influence  upon  various  neuroses. 

Hysteria  which  for  a  long  time  has  been  dormant  is 
is  often  reproduced  by  the  syphilitic  virus. 

Epileptic  attacks  also  become  more  frequent  under  its 
influence. 

Can  secondary  syphilis  primarily  produce  these  disor- 
ders ?  As  far  as  hysteria  is  concerned,  this  is  certain. 
Hysteria  is  often  seen  to  occur  for  the  first  time  simultane- 
ously with  syphilis,  occasionally  in  persons  hitherto  normal, 
generally  in  those  of  a  neuropathic  constitution.  These 
disorders  are  usually  hysteroid,  and  not  true  hysterics,  and 
disappear  with  the  cure  of  the  syphilis.  There  are  excep- 
tional cases,  in  which  the  secondary  syphilitic  stage  is  char- 
acterized by  the  occurrence  of  epileptic  phenomena. 

Cases  are  also  mentioned  which  show  the  occurrence  of 
true  epileptic  attacks  coincident  with  the  occurrence  of  the 
secondary  symptoms,  and  which  disappeared  with  the  cure 
of  the  syphilis.  Under  these  conditions  only  "grand-mal" 
occurs,  never  "petit-mal,"  and  mental  symptoms  are  never 
observed.  The  prognosis  is  good,  and  the  treatment  that 
of  the  primary  disorder. 

The  sympathetic  system  may  be  influenced  in  various 
ways  by  secondary  syphilis.  Caloric  disorders  occur  either 
as  localized  or  general  coldness.  Coldness  of  the  extremi- 
ties, of  one  arm  or  leg,  may  prove  sufficiently  annoying  to 
prevent  the  patient  from  working.  Continuous  chilly  feel- 
ing without  increase  of  temperature  is  frequent.  These 
disorders  are  generally  tenacious,  and  last  from  five  to  six 
weeks  or  even  several  months. 

The  viscera  may  also  be  affected,  and  visceral  neuroses 
produced.  Dyspnoea,  occurring  in  attacks  and  lasting  sev- 
eral minutes,  is  rare.  Palpitation  of  the  heart  with  precor- 
dial oppression  occurs  more  frequently.  Irregularity  of  the 
heart's  action  is  also  encountered.  Disorders  of  the  diges- 
tive system  are  much  more  frequent,  particularly  in  women. 


-  2 0  Ph  YSIOLOG  Y  OF  THE  XER I 'OTS  S  YS TEM. 

The  gastralgic  and  dyspeptic  occurrences  show  nothing  of 
particular  interest.  In  certain  cases  the  syphilis  produces 
vomiting  analagous  to  the  vomiting  of  pregnancy.  This  may 
becoincidentwiththegastralgia.or  there  is  gastric  intolerance 
without  pain  in  which  everything  is  rejected  by  the  stomach. 
Comple  anorexia,  similar  to  hysterical  anorexia,  also  occurs. 
In  such  cases  inunctions  must  be  employed.  In  contra- 
distinction to  anorexia,  bulimia  occurs  in  the  early  part  of 
the  secondary  stage.  The  duration  of  the  latter  disorder 
varies  from  a  few  weeks  to  several  months,  and  is  generally 
the  sign  of  a  severe  form  of  secondary  syphilis.  The  spe- 
cific treatment  must  be  energetically  pushed.  Hydrother- 
apy is  also  of  value.  G.  W.  J. 

Etiology  of  Basedow's  Disease.  Societe  Medicale  des 
Hopitaux,  meeting  of  May  14th,  1888  (Gazette  des  Hop- 
itaux,  p.  519,  1888). 
Rendu  relates  the  history  of  a  patient  who  has  been 
under  observation  for  ten  years.  A  young  woman,  pet.  28, 
always  well  until  her  eighteenth  year,  when  she  became 
chlorotic,  with  severe  cardiac  palpitations,  vertigo,  and 
symptoms  of  cerebral  anaemia.  Under  treatment  she  im- 
proved, then  married  and  had  two  children.  Severe  aomes- 
tic  troubles.  In  the  spring  of  1877,  shortness  of  breath  in 
ascending  stairs,  pain  in  walking,  and  severe  pains  in  the 
shoulder  ;  angina  pectoris  ;  frequent  attacks  during  five  to 
six  days.  Rendu  prescribed  iodide  of  potassium,  two 
grammes  daily.  She  improved  greatly,  but  presented 
symptoms  of  iodism  ;  became  loquacious;  complained  con- 
tinually of  feeling  too  warm,  and  showed  generalized  symp- 
toms of  arterial  excitement.  Soon  all  the  symptoms  of 
Basedow's  disease  appeared,  minus  the  goitre.  Rendu  be- 
lieves that  in  this  case  there  is  a  relation  between  the 
administration  of  the  iodide  and  the  appearance  of  Base- 
dow's disease.  G.  W.  J. 

Hypnotism    at    the    Nancy    School.      Dr.   Bernheim 
(Gazette  des  Hopitaux,  p.  337,  1888). 
The  Nancy  doctrine  of  the  phenomena  of  hypnotism  has 
so  frequently  been   misrepresented  that  B.  here  gives  the 


PHYSIOLOGY  OF  THE  KERVOUS  SYSTEM.  r2I 

features  observed  at  Nancy  in  so  far  as  they  differ  from 
those  seen  at  the  Salpetriere. 

i.  The  three  phases — lethargy,  catalepsy,  somnambu- 
lism— are  never  observed.  In  all  subjects  cataleptic  and 
somnambulistic  phenomena  may  be  produced  by  simple 
suggestion.  Neither  opening  of  the  eyes  nor  friction  of  the 
vertex  in  any  manner  modifies  the  phenomena,  if  suggestion 
be  excluded. 

Transferred  through  magnets, muscular  hyperexcitability 
symptoms  of  cerebral  localization  (by  touching  certain 
parts  of  the  cranium),  are  never  observed  unless  suggestion 
is  employed.  All  these  phenomena  can  be  produced,  if  the 
patient  believes  that  they  are  to  occur.  The  three  so-called 
phases  of  the  hypnotic  state  are  due  entirely  to  suggestion. 

2.  In  hysterical  patients  the  hypnosis  does  not  differ 
from  that  in  other  subjects.     It  is  always  due  to  suggestion. 

3.  Hysteria  is  not  a  good  soil  for  the  study  of  hypnot- 
ism. Auto-suggestion  serves  to  obscure  the  clear  picture 
and  to  confuse  the  inexperienced  operator. 

4.  The  hypnotic  state  is  not  a  neurosis  ;  the  phenomena 
are  natural  and  psychological,  and  may  be  obtained  in  many 
subjects  during  natural  sleep. 

5.  The  hypnotic  state  is  not  peculiar  to  or  more  easily 
obtained  in  neurotic  individuals  than  in  others. 

6.  It  is  not  asserted  that  all  somnambulists  are  pure 
automatons,  but  that  among  this  class  there  are  some  in 
whom  the  power  of  resistance  is  so  greatly  reduced  that 
they  are  at  the  mercy  of  the  operator. 

7.  All  procedures  for  hypnotizing  may  be  summed  up 
under  the  word  "suggestion..'  No  procedure  will  succeed 
if  the  subject  does  not  know  that  he  is  expected  to  sleep. 

8.  Suggestion  is  the  key  to  all  hypnotic  phenomena. 
Every  physician  who,  in  his  hospital  ward,  does  not  succeed 
in  hypnotizing  eighty  per  cent,  of  his  patients  must  acknowl- 
edge to  lack  of  experience  and  refrain  from  expressing  an 
opinion  upon  the  subject.  G.  W.  J. 

A  Case  of  Pseudo-Tabes.    A.  Pitres  (Archiv  de  Neu- 
rologic p.  337,  1888). 
Certain  cases  are  known  which  during  life  presented  all 


r22  PHYSIOLOGY  OF  THE  XER  VOL'S  SYSTEM. 

the  symptoms  of  tabes  dorsalis,  but  at  the  autopsy  the  cen- 
tral nervous  system  was  found  to  be  almost  normal.  Such 
cases  led  Trousseau  to  look  upon  the  disease  as  a  neurosis. 
Others  reserved  their  interpretation  of  them  until  science 
should  have  advanced  our  knowledge.  It  soon  became 
possible  to  explain  those  cases  which  upon  autopsy  showed 
degeneration  of  the  posterior  columns,  but  intra-vitam  had 
not  shown  any  of  the  usual  symptoms  of  tabes  (sclerosis  of 
the  columns  of  Goll).  Then  also  it  became  possible  to  ex- 
plain a  certain  class  presenting  tabetic  symptoms  intra- 
vitam,  but  showing  no  lesion  of  the  cord  on  autopsy  (multiple 
neuritis).  Thus  the  term  pseudo-tabes  must  be  restricted 
to  cases  presenting  the  symptoms  of  tabes,  but  upon  autopsy 
showing  the  intactness  of  the  central  nervous  system,  the 
spinal  roots,  and  the  peripheral  nerves.  Such  a  case  is  here 
described. 

CASE. — Male,  aet.  45,  no  heredity,  no  syphilis  or  alco- 
holism ;  venereal  excesses.  In  1877,  at  a£e  OI"  36,  attacks 
of  sharp,  lancinating  pains,  beginning  in  the  right  hip  and 
extending  later  to  the  left.  Polyuria.  In  1880,  belt  pain  ; 
unsteady  gait ;  sensation  of  swelling  of  feet  ;  Romberg's 
symptom.  From  1881-86,  disorders  of  micturition,  rectal 
tenesmus,  gastric  crisis. 

Typical  fulgurating  pains.  Continuation  of  motor  inco- 
ordination. No  disorders  of  sight,  or  trophic  disturbances. 
Patellrar  tendon-reflexes  preserved.  Death  due  to  tuber- 
culous pleurisy. 

Autopsy:  No  sclerosis  of  the  cord.  No  atrophy  of  pos- 
terior roots.     Integrity  of  peripheral  nerves.         G.  W.  J. 

On  the  Disease  Phenomena  after  Concussion  of 
the  Spinal  Cord  in  Railway  Accidents  (Trans- 
actions of  the  Berlin  Society  of  Internal  Medicine. 
Meeting  of  January,  1888). 

Dr.  Oppenheim  in  discussing  this  subject  stated  that  the 
symptomatology  of  this  class  of  affections  had  not  been 
materially  changed  since  first  described  by  Erichsen.,  Only 
certain  symptoms  which  had  been  neglected  as  subordinate 
by  him   in   his  description   have  an   increased   importance, 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  -2, 

owing  to  newer  and  more  accurate  methods  of  investiga- 
tion. It  was  then  presumed  that  the  injury  was  confined  to 
the  spinal  cord,  and  all  symptoms  were  referred  to  that 
organ,  hence  the  term  railway-spine.  Certain  known  cere- 
bral symptoms  were  disregarded,  whereas  now  more  and 
more  attention  is  paid  to  the  latter,  so  that  the  terms  "rail- 
way-spine" has  become  converted  into  "railway-brain," 
and  traumatic  meningo-myelitis  into  traumatic  hysteria. 

The  symptomatology  is  varied  and  motley,  so  that  one 
cannot  speak  in  this  relation  of  a  definite  set  of  symptoms 
excepting  of  certain  nuclear  symptoms  which  appear  in 
every  case.  The  most  prominent  change  occurs  in  the 
psyche,  especially  in  the  affective  sphere.  Emotional  de- 
pression and  abnormal  irritability  represent  the  psychical 
disturbance.  The  patients  are  moody,  busy  themselves 
with  painful  delusions,  love  to  be  alone.  Two  conditions 
serve  to  differentiate  this  psychical  change  from  that  of 
melancholia  : 

i.  Abnormal  irritability. 

2.  Hypochondrical  nature  of  the  psychical  change. 

Sometimes  it  becomes  necessary  to  treat  those  cases, 
which  show  the  condition  of  fear,  in  asylums. 

Disturbances  of  sensation  and  of  the  functions  of  the 
organs  of  special  sense  occur  frequently.  Seldom  is  the 
typical  girdle  sensation  experienced. 

Motor  disturbances  show  themselves  by  the  energetic 
character  of  muscular  movements,  by  the  position  of  the 
body  in  walking,  etc.  Some  patients  can  walk  backwards 
better  than  forwards.     Tremor  is  most  frequent. 

Speech  disturbances  are  also  present  and  are  anomalous 
in  character.  Certain  phenomena  in  the  circulatory  appa- 
ratus, which  have  heretofore  been  undiscovered,  are  quite 
characteristic.  Very  frequently  there  are  attacks  of  cardiac 
palpitation  with  increased  pulse  rate  and  accompanied  by  a 
feeling  of  fear  and  unequally  dilated  pupils  ;  during  these 
attacks  the  pulse  may  record  160  beats  per  minute.  The 
least  emotional  disturbance  or  mental  impression  increases 
an  already  increased  pulse  beat,  the  entire  body  becomes 
flushed  and  perspiration  freely  flows  from  the  surface  of  the 


-  -,  ,  PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

body.  The  area  of  cardiac  pulsation  is  increased.  In  one 
case  hypertrophy  and  dilatation  of  both  ventricles  devel- 
oped. 

It  is  thus  seen  that  this  disease  is  essentially  a  combined 
psychosis  and  neurosis.  At  any  rate  almost  all  the  disease 
manifestations  point  to  a  cerebral  basis,  and  hence  the  term 
"railway-spine"  should  be  abolished.  Nor  should  trau- 
matic hysteria,  or  Page's  traumatic  neurasthenia  be  sub- 
stituted. Under  the  conception  of  traumatic  neurosis  and 
traumatic  psychosis  the  greatest  majority  of  the  cases  may 
be  included.  One  limitation  should  be  made  for  those  cases 
which,  few  in  number,  show  bladder  disturbance,  irido- 
plegia,  and  optic  nerve  atrophy  ;  cases  which  show  material 
changes  in  the  central  nervous  axis  concerning  which  we 
have  not  yet  been  enlightened.  X.  E.  B. 

Primary  Actinomycosis  of  the  Human  Brain  (Mun- 
chner  Med.  Wochenschrift,  1887,  No.  41). 

The  patient,  a  female  of  sixteen  years,  complained  one 
year  before  death  of  severe  headache,  to  which  there  was 
added  a  paresis  of  the  left  abducens.  Six  months  after  this 
she  was  delivered  of  a  healthy  boy.  The  headache  pro- 
gressively increased  in  severity,  and  attacks  of  unconscious- 
ness, short  in  duration,  supervened.  Later  there  were 
vomiting,  coma,  death.  The  diagnosis  was  a  cerebral 
tumor. 

The  autopsy  showed  a  tumor  the  size  of  a  hazel  nut  in 
the  third  ventricle,  chronic  internal  hydrocephalus,  with 
marked  distension  of  all  the  cerebral  ventricles.  The  tumor 
contained  an  albuminous  mass,  containing  mucin  and  large 
granulation  cells  and  innumerable  characteristic  colonies  of 
actinomyces.  N.  E  .B. 

The  Diagnosis  of  Premature  Cranial  Synostoses. 

At  a  meeting  of  the  Imperial  Society  of  Physicians  in 
Vienna,  Meynert  presented  two  cases  of  premature  closure 
of  the  cranial  sutures.  The  one  a  boy  of  9%  years,  who 
was  also  hydrocephalic,  and  whose  cranium,  as  a  result  of 
synostosis  of  the  entire   sagittal   sutures,  was    remarkably 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  c2Z 

long,  very  much  arched  from  behind  forwards,  and'  pre- 
sented the  appearance  of  a  boat  whose  keel  is  directed 
upwards  (scapho-cephalic).  In  addition  the  eyes  were  very 
deeply  set,  which  was  explained  by  the  fact  that  the  antero- 
posterior diameter  being  so  remarkably  long  the  orbits 
developed  in  a  similar  manner  and  thus  became  very  deep, 
and  since  the  bulbi  were  not  long  enough  to  fill  the  orbits, 
they  appear  to  lie  deeply  therein. 

The  second  case  was  one  of  a  man  35  year  old,  who  had 
had  epilepsy  since  his  12th  year,  and  whose  head  was  dome 
shaped.  This  was  explained  by  Meynert  to  be  due  to  a 
premature  synostosis  of  the  lateral  parts  of  the  coronal 
sutures,  whereby  a  shortening  of  the  anterior  part  of  the 
cranial  cavity  occurred  and  similarly  involving  the  orbit  so 
that  the  individual  appeared  to  be  flat-eyed  (oxy-cephalic). 
Meynert  attempts  to  elucidate  with  these  two  cases  a 
diagnosis  in  vivo  of  premature  cranial  synostosis.  Synos- 
tosis of  the  middle  portion  of  the  coronal  suture  produces  a 
bulging  in  the  occipital  region,  and  a  diminution  in  size  of 
the  frontal  and  parietal  regions,  the  brain  being  crowded 
backwards.  Synostosis  of  the  lateral  parts  of  the  coronal 
suture  the  growth  of  the  frontal  and  parietal  regions  is  hin- 
dered and  a  shortening  of  the  orbit  (flat-eye)  results. 
Ossification  of  the  posterior  part  of  the  sagittal  suture,  the 
breadth  of  the  cranium,  is  diminished,  and  the  cranium 
becomes  posteriorly  very  small. 

The  following  points  are  characteristic  in  defining  a 
synostotic  (oxy-cephalic)  cranium  : 

1.  Subnormal  horizontal  circumference  (Nanna-ceph- 
alus). 

2.  Vertical  diameter  larger  than  the  horizontal. 

3.  The  vertical  diameter,  however,  must  possess  this 
character :  the  vertical  index  must  be  brachycephalic. 

4.  The  flat  eye.  N    E.  B. 

Typical  Diphtheritic  Paralysis. 

This  affection  comes  on  some  little  time  after  the  acute 
illness  has  subsided.  The  paralysis  (which  involves  sen- 
sory and  motor  nerves  alike)  tends  to  be  of  symmetrical 


-25  PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM. 

distribution,  to  creep  from  part  to  part,  and  to  subside  in 
one  region  as  it  invades  another.  Sensory  disturbances  are 
not  limited  to  the  extremities,  but  are  apt  to  involve  dis- 
tricts situated  in  the  middle  line  of  the  body,  including  the 
tongue  and  mouth  and  the  senses  of  taste  and  smell.  Par- 
alysis of  diphtheritic  origin  is  liable  not  only  to  affect  the 
arms,  legs,  respiratory  muscles,  muscles  of  the  trunk  and 
accommodation,  and  of  swallowing,  but  also  the  vocal 
cords  and  even  single  nerves.  Knee-jerks  are  first  exag- 
gerated, then  abolished,  and  the  affected  muscles  acquire  the 
characteristic  reactions  of  degeneration.  Many  of  the  phe- 
nomena are  such  as  would  seem  to  be  best  explained  on  the 
assumption  that  they  are  due  to  spreading  neuritis.  Others 
(such  as  sensory  affections  along  the  middle  line,  the  early 
undue  briskness  of  knee-jerk,  and  nystagmus)  seem  rather 
to  be  due  to  some  spreading  central  lesion.  I  am  inclined 
to  believe  that,  in  diphtheritic  paralysis,  a  wave,  so  to 
speak,  of  slight  inflammatory  mischief  spreads  not  only 
through  the  medulla  oblongata  and  cord,  but  along  the 
nerve  trunk  also. — J.  S.  Bristowe,  in  British  Medical  Jour- 
nal. Feb.  14,  1888.  L.  F.  B. 

Dentition  among  Idiotic  and  Backward  Children. 

Dr.  Alice  Sollier  (Ancienne  Externe  des  Hopitaux  de 
Paris  et  de  l'Hopital  des  Enfants-Malades)  finds  that 
idiocy,  with  or  without  epilepsy,  predisposes  ninety-one 
per  cent,  of  the  victims  to  dental  deformity  and  disease. 
The  record  includes  one  hundred  clinical  cases.  Congeni- 
tal idiocy  has  no  more  special  influence  in  this  respect  than 
idiocy  developed  during  the  first  dentition.  Deformities 
and  lesions  are  almost  exclusively  associated  with  the  sec- 
ond dentition.  The  appearance  and  shedding  of  the  milk 
teeth  are  usually  delayed  In  fourteen  per  cent,  there  were 
dwarfed  teeth  ;  in  eleven  per  cent.,  giant  teeth.  Other  ab- 
normalities were  found  in  fifty-three  per  cent,  and  absence 
of  teeth  in  eleven  per  cent.  Giant  teeth  were  often  found 
where  others  had  not  developed,  or  else  they  represented 
anchylosis  of  two  adjacent  teeth.  In  only  two  per  cent. 
were  supernumerary  teeth   discovered.     Anomalies  of  im- 


PHYSIOLOGY  OF  THE  NERVOUS  SYSTEM.  c2y 

plantation  were  common  (thirty-four  per  cent.),  but  anoma- 
lies of  position  in  relation  toother  teeth  rare.  Crookedness, 
obliqueness,  etc.,  were  the  most  frequent  of  all  malforma- 
tions, and  chiefly  affected  the  canines  and  incisors.  Erosion 
(loss  of  substance  of  the  enamel  over  a  greater  or  less  area 
of  the  surface  of  a  tooth)  was  often  associated  with  convul- 
sions, but  was  most  frequent  in  cases  where  there  were  no 
convulsions  ;  thus  Dr.  Sollier  concludes  that  idiocy,  with  or 
without  epilepsy,  can  by  itself  cause  erosion.  In  forty-one 
per  cent,  of  the  whole  series  there  was  longitudinal  groov- 
ing of  the  enamel  ;  in  fifty-eight  per  cent,  the  edges  of  some 
of  the  teeth  were  notched.  Both  these  peculiarities,  espe- 
cially the  notches,  more  often  coincided  with  convulsions 
than  did  erosions.  The  articulation  of  the  upper  and  lower 
dental  arches  was  defective  in  forty-three  per  cent.  In 
thirty-eight  per  cent,  each  arch  showed  deformity.  Madame 
Sollier  calls  attention  to  an  undescribed  anomaly  of  this 
class,  where  the  level  of  the  two  halves  of  the  arch  is  un- 
symmetrical.  In  forty-five  per  cent,  of  the  cases  the  palat- 
ine vault  was  deformed.  In  nine  cases  of  idiocy,  and  imbecility 
with  epilepsy,  none  of  the  above  characteristic  lesions  could 
be  discovered. — British  Medical  Journal,  Feb.  28,  1888. 

L.  F.  B. 

Sleeping  with  the  Head  North. 

The  superstition  that  human  beings  should  sleep  with 
their  heads  to  the  north  is  believed  by  the  French  to  have 
for  its  foundation  a  scientific  fact.  They  affirm  that  each 
human  system  is  in  itself  an  electric  battery,  the  head  being 
one  of  the  electrodes,  the  feet  the  other.  Their  proof  was 
discovered  from  experiments  which  the  Academy  of  Sciences 
was  allowed  to  make  on  the  body  of  a  man  who  was  guillo- 
tined. This  was  taken  the  instant  it  fell  and  placed  upon  a 
pivot  free  to  move  as  it  might.  The  head  part,  after  a  little 
vacillation,  turned  to  the  north,  and  the  body  then  remained 
stationary.  It  was  turned  half-way  around  by  one  of  the 
professors,  and  again  the  head  end  of  the  trunk  moved  slowly 
to  the  cardinal  point  due  north,  the  same  results  being  re- 
peated until  the  final  cessation  of  organic  movement. — 
Pacific  Record.  L.  F.  B 


-  2  g  PHYSIOL OGY  OF  THE  XE RVOi  rS  S  i  'S TEM. 

Inebriety  a  Mental  Disease. 

The  following  questions  proposed  by  the  English  exam- 
iners in  psychological  medicine  to  the  candidates  for  cer- 
tificates, show  that  inebriety  is  recognized  among  the 
mental  diseases  of  the  old  world. 

"What  forms  of  mental  disorder  may  be  classed  under 
alcoholic  insanity  ? 

"Trace  the  relationship  of  alcohol  and  syphilis  to  gen- 
eral paralysis. 

"Describe  the  condition  commonly  known  as  chronic 
alcoholism  ;  give  the  prognosis  and  treatment." — Quarterly 
Journal  of  Inebriety.  L.  F.  B. 

Melancholia  and  other  Depressive  Mental  Affec- 
tions in  Otopiesic  Disorders  of  the  Ear.  Bouch- 
eron,  Gazette  des  Hopitaux,  p.  1,184,  1887. 

That  affections  of  the  ear  may  produce  various  nervous 
symptoms,  such  as  vertigo,  convulsions,  mental  depression, 
and  even  mania,  is  acknowledged.  These  symptoms  have 
however,  in  cases  thus  far  published,  always  been  the  result 
of  gross  lesions  of  the  ear,  and  the  relation  between  cause 
and  effect  has  been  easily  recognizable. 

B.  here  refers  to  a  class  of  irradiated  nervous  affections 
caused  particularly  by  obstruction  of  the  Eustachian  tube, 
which  the  atmospheric  pressure  not  being  counterbal- 
anced (on  account  of  the  vacuum  in  the  tympanic  cavity) 
produces  an  excitation  of  the  labyrinth  and  of  the  acoustic 
nerve,  by  compression — -otopiesis. 

In  such  a  condition  the  excitation  may  be  transmitted  to 
the  nervous  centres,  and  various  symptoms,  according  to 
the  predisposition  of  the  patient,  may  be  produced.  If 
transmitted  to  the  medulla  oblongata  or  to  the  cord,  this 
excitation  causes  epilepsy,  pseudo-meningitis,  or  various 
forms  of  convulsions  ;  if  to  the  cerebellum,  disorders  of 
equilibration,  vertigo,  rotary  movements,  etc.;  if  to  the  cere- 
brum and  cortex,  light  or  severe  mental  symptoms,  with 
the  predominant  character  of  depression.  The  less  severe 
symptoms  are  :  loss  or  diminution  of  memory,  of  power  of 
reflexion,  and  of  quickness  of  conception,  diminution  of  affec- 


THFRAPEUTICS  OF  THE  NERVOUS  SYSTEM.  ~2Q 

tion  for  relatives,  ideas  of  suspicion,  defiance,  persecution, 
and  hypochondriasis.  The  severe  symptoms  may  be  those 
of  acute  melancholia,  insanity  with  delirium,  hallucinations, 
and  illusions  of  hearing,  loss  of  consciousness,  e  c. 

The  treatment  of  these  symptoms  is  self-evident.    Insuf- 
flations of  air  into  the  Eustachian  tube.  G.  W.  J. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

Treatment  of  Disease  by  Nerve-Pressure. 

Dr.  Anders  Wide  (Nordiskt  Medicinskt  Arkiv.,  Nov. 
10,  1887  )  reports  three  cases  treated  by  nerve-pressure,  a 
method  originated  by  Ling.  The  first,  a  woman  twenty 
years  old,  suffered  from  tremblings  of  the  promotor  and 
supinator  muscles  of  the  arm,  causing  oscillations  in  the 
arm  and  hand  at  the  rate  of  two  hundred  a  minute.  Pressure 
was  made  upon  the  radial  and  median  nerves  about  the 
middle  of  the  humerus,  first  with  the  fingers,  then  with  a 
tourniquet,  in  the  beginning  from  two  to  four  hours,  then 
eight  to  ten  later.  After  eleven  days  of  treatment,  during 
which  the  tourniquet  was  applied  seven  times,  the  trem- 
blings ceased.  This  was  a  case  in  which  electricity  and 
other  remedial  measures  had  proved  of  no  avail.  A  spasm 
of  the  spinal  accessory  of  the  right  side,  drawing  the  head 
backward  and  to  the  left  with  such  force  that  the  patient 
was  often  obliged  to  hold  it  with  both  hands  to  prevent 
suffocation,  was  greatly  relieved  by  nerve-pressure.  Strong 
and  continued  pressure  with  the  fingers  was  made  on  the 
nerve  at  its  entry  into  the  trapezius  muscle.  Afterwards  a 
strap  in  the  form  of  a  figure  of  eight  bandage  round  the 
shoulders  to  exercise  a  sustained  pressure  upon  the  nerve. 
This  insured  freedom  of  breathing.  The  third  case — paresis 
and  atrophy  of  the  right  forearm  in  a  girl  of  eleven — was 
rapidly  benefited  by  pressure  upon  the  radial  nerve.  Elec- 
tricity, massage,  and  medical  gymnastics  had  been  tried  in 
vain.  The  power  of  contraction  returned  to  the  affected 
muscles,  and  the  nutrition  of  the  arm  gradually  improved. 
The  author  claims  to  have  brought  about  some  beneficial 


-  ,~  THERAPEUTICS  OF  THE  XERVOCS  SYSTEM. 

DJ° 

change  in  locomotor  ataxia  by  this  method.  Pressure  may  be 
applied  to  most  of  the  nerves  of  the  head,  trunk,  and  extremi- 
ties, and  also  to  the  sympathetic.  Affections  of  the  stomach 
have  been  relieved  by  pressure  applied  to  the  coeliac  plexus. 
— London  Medical  Recorder,  Feb.  20,  1888.  L.  F.  P. 

One  View  of  Neuralgia. 

Many  conditions  are  classed  under  the  head  of  neuralgia. 
There  is  the  pure  form  without  apparent  and  definite  cause 
during  life  and  with  no  discoverable  lesion  after  death. 
The  reflex  form  may  be,  and  frequently  is,  due  to  dental 
caries  and  other  remote  causes,  the  removal  of  which  gives 
speedy  relief  to  the  symptoms.  Another  form  is  due  to 
actual  inflammation  of  the  nerve — a  true  neuritis  and  not 
neuralgia  at  all ;  others  due  to  poisons  circulating  in  the 
blood,  as  lead,  syphilis,  gout,  and  malaria  ;  and  some  to 
pressure  upon  the  trunk  of  the  affected  nerve  or  to  some 
irritation  still  higher  in  its  course.  The  treatment  of  neural- 
gia may  be  considered  as  :  1,  external  ;  2,  external  remote  ; 
3,  internal. 

1.  Of  the  local  methods  of  treatment,  such  operations 
as  incision  and  division  of  the  nerve  explain  themselves. 
Stretching  the  nerve  and  acupuncture  seem  to  aid  in  the 
same  way,  probably  by  causing  a  solution  of  continuity  in 
the  sheath,  and  thus  relieving  tension  and  diminishing  the 
swelling  of  the  nerve.  Callender  considers  it  probable 
that  "stretching  is  of  use  by  numbing  the  nerve  for  a  short 
time."  If  this  be  really  true,  the  natural  explanation  would 
be  that  the  sensory  irritation  resulting  from  the  hyperemia 
would  for  a  time  cease,  and  on  its  cessation  the  reflex  dila- 
tation of  the  blood  vessels  would  also  be  brought  to  an  end. 
Electricity,  again,  in  common  with  belladonna  and  heat  or 
locally  applied,  would  contract  blood  vessels.  Belladonna, 
volatile  oils,  and  their  stearoptenes  (solid  crystalline  com- 
pounds separable  from  volatile  oils  by  cold),  such  as  thymol 
and  menthol,  also  chloroform,  not  only  contract  the  blood 
vessels,  but  also  diminish  the  sensibility  of  the  part,  while 
aconite  locally  applied  acts  purely  as  an  anodyne. 


THERAPEUTICS  OF  THE  NERVOUS  SYSTEM.  ctj 

2.  Counter-irritation  over  the  upper  part  of  the  dorsal 
spine,  which  apparently  does  good  in  some  cases  in  a  way 
not  easy  of  explanation,  is  one  method  of  external  and  re- 
mote treatment.  Ligature  of  the  carotids  is  eminently  suc- 
cessful. This  heroic  measure  has  been  tried  with  gratifying 
results  by  Dr.  Patruban  in  many  cases  of  severe  neuralgia. 
The  idea  of  the  operation  originated  from  a  knowledge  of 
the  relief  obtained  in  some  cases  by  simple  pressure  on  the 
carotid. 

3.  For  the  internal  treatment  of  neuralgia,  the  substances 
naturally  fall  into  four  groups  : 

(1.)  Those  which  contract  blood  vessels,  as  strychnia, 
atropia  and  its  allies,  bromide  of  camphor,  digitalis,  ergot, 
volatile  oils  such  as  turpentine,  etc.,  chloride  of  ammonium, 
and  quinine.  Several  of  these  drugs  have  also  a  specific 
action  on  sensory  nerves. 

(2.)  This  group  consists  of  bodies  which  act  as  general 
tonics,  such  as  quinine,  iron,  strychnia,  phosphorus,  and 
arsenic.  Arsenic  and  phosphorus  seem  to  have  some  more 
direct  action  than  that  of  simple  tonics. 

(3.)  A  third  division  consists  of  simple  anodynes  or  sed- 
atives, such  as  bromide  of  potassium.  This,  however,  like 
chloral,  diminishes  the  pulse  tension  and,  in  addition,  dimin- 
ishes reflex  excitability  by  depression  of  the  peripheral 
sensory  filaments.  Other  drugs,  such  as  cannabis  indica 
and  morphia,  seem  to  act  as  similar  anodynes. 

(4.)  The  fourth  group  consists  of  the  usual  tell-tale 
drugs,  which  are  always  appearing,  and  of  the  action  of 
which  no  very  apparent  explanation  can  be  given.  Among 
these  gelsemium  is  a  prominent  member,  and  probably  also 
arsenic  and  phosphorus. 

There  are  symptomatic,  pathological,  etiological,  and 
therapeutic  reasons  for  believing  that  the  blood  vessels  are 
at  fault  in  cases  of  neuralgia,  and  therefore  it  seems  neces- 
sary to  consider  true  neuralgia  as  a  sympathetic  neurosis, 


-  j  2  THERAPEUTICS  OF  THE  NERVOUS  SYSTEM. 

affecting  certain  tracts  of  cerebro-spinal  nerves,  resulting  in 
simple  dilatation  of  the  vessels  of  these  nerves,  brought 
about  by  unknown  causes,  or  by  reflex  irritation,  or  possibly 
by  the  specific  action  of  certain  poisons  in  the  blood. — James 
R.  Whitehall,  Edinburgh  Medical  Journal,  Dec,  1887. 

L.  F.  B. 

Neuralgia,  Chloroform,  and  the  Constant 
Current. 

Marvellous  results  are  claimed  by  Prof.  Adam  Kiewicz 
(Progres  Medical)  from  the  combined  action  of  chloroform 
and  the  constant  current  in  facial  and  other  forms  of  neu- 
ralgia. The  electrode  is  made  of  hollow  charcoal  into 
which  the  chloroform  is  introduced,  and  from  which  the 
current  sends  it  into  the  tissues.  That  this  power  of  pene- 
tration may  be  thus  obtained  is  thought  to  be  shown  in  the 
fact  that  when  chloroform  is  colored  with  gentian  violet 
and  applied  in  the  manner  described  to  the  ear  of  a  rabbit, 
the  tissue  becomes  dyed.  In  experiments  with  the  human 
subject,  the  writer  notes  at  the  commencement  the  triple 
action  of  the  constant  current,  the  chloroform,  and  a  con- 
dition of  cataphoresis  followed  by  a  burning  sensation  and 
finally  anaesthesia.  Several  remarkable  cases  of  cure  are 
cited.  Anaesthesia  is  not  obtained  when  the  nerves  are 
deep-seated,  nor  in  sciatica. — Medical  and  Surgical  Re- 
porter, Feb.  18,  1888.  L.  F.  B. 


VOL.  XIII.  September,  1888.  No.  9 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


Original  ^rtirUs. 


THE    RELATION    BETWEEN    TROPHIC   LESIONS 
AND  DISEASES  OF  THE  NERVOUS   SYSTEM.1 

By  E.  C.  SEGUIN,  M.D., 

PRESIDENT   OF   THE   AMERICAN   NEUROLOGICAL   ASSOCIATION,  ETC. 

THE  question  chosen  by  the  council  of  the  Association 
for  discussion  to-day,  viz.:  "  The  relation  between 
trophic  lesions  and  diseases  of  the  nervous  system,  ex- 
cluding changes  within  the  central  nervous  system  itself"  is 
one  which  brings  the  critic  face  to  face  with  an  enormous 
accumulation  of  more  or  less  well-observed,  widely  diverse, 
and  not  necessarily  correlated  clinical  and  experimental 
facts  or  data. 

The  very  terms  of  the  question  involve  to  my  mind  a 
petitio  principii :  for  the  essential  query  in  any  review  of 
the  data  is  whether  the  lesions  referred  to  are  really  trophic, 
in  nervous  causal  relation. 

Your  referee  has  been  informed  that  "permanent  vaso- 
motor changes,  in  so  far  as  they  can  be  shown  to  influence 
nutrition,"  may  or  should  be  included  in  the  discussion. 
This  I  consider  a  wholly  different  field  of  physio-pathology 
and  one  whose  introduction  into  the  discussion  would  only 
tend  to  obscure,  complicate  and  indefinitely  extend  the 
search  after  the  true  relation  between  trophic  lesions  and 
nervous  diseases ;  and  I  shall  consequently  omit  it  from 
my  remarks. 

1  Referee's  paper  read  before  a  joint  meeting  of  the  Association  of  Amer- 
ican Physicians  and  the  American  Physiological  Association  during  the  Congress 
of  American  Physicians  and  Surgeons  at  Washington,  D.  C,  Sept.  20,  1888. 


534  E-  c-  seguin. 

We  must  also  insist  upon  a  strict  definition  of  the  word 
lesion,  as  meaning  a  positive  histological  alteration  in  tissue, 
thus  excluding  retarded  or  imperfect  development,  simple 
quantitative  reduction  of  tissues,  and  alterations  in  local 
circulation  and  calorification  (as  observed  in  cerebral  and 
spinal  paralyses  occurring  before  the  full  growth  of  the  body, 
and  occasionally  after  it). 

Thus  simplified  the  question  may  be  re-stated  in  the 
following  terms : 

What  are  the  lesions  which  may  be  supposed  to  be  directly 
produced  by  disease  of  the  nervous  system  {brain,  spinal  cord, 
and  nerves}  ;  and  what  is  the  essential  causal  relation  between 
the  two  factors  ? 

To  attempt  to  enumerate  separately  in  a  systematic 
manner  all  the  lesions  of  the  non-nervous  tissues  which 
have  been  observed  clinically  and  experimentally,  and 
ascribed  to  a  direct  morbid  nervous  influence  (positive  or 
negative),  would  be  an  extensive  work,  far  beyond  the 
time  limits  of  this  discussion. 

Such  "trophic  lesions"  have  been  described  as  occurring 
in  almost  all  the  non-nervous  organs  and  tissues,  internal 
and  external.  We  find  medical  literature  filled  with  ex- 
amples of  such  lesions  in  the  cutaneous  tissue  and  append- 
ages, in  the  muscular  tissue,  in  bones  and  articulations,  in 
vascular  walls,  in  parenchymatous  organs,  and  in  internal 
epithelial  structures.  In  other  words,  wherever  nerve  fibres 
terminate,  and  even  where  none  can  be  demonstrated  (as  in 
cartilage)  such  lesions  have  been  described. 

Some  simple  mode  of  classification  of  these  data  must 
be  chosen  to  facilitate  discussion,  and  looking  at  the  subject 
from  the  standpoint  of  the  pathologist  and  practical  physi- 
cian I  would  suggest  the  following: 

FIRST  Class. — "Trophic  lesions"  occurring  in  parts 
whose  sensibility  is  more  or  less  reduced  by  the  nervous 
disease,  and  which  are  exposed  to  the  action  of  traumatic 
and  infectious  influences. 

This  class  includes  by  far  the  largest  number  of  the  data, 
such  as  cutaneous  ulcerations,  fall  of  nails  and  hair,  altered 
appearance  of  skin   and  nails,  articular  changes  (arthropa- 


DISEASES  OF  THE  NERVOUS  SYSTEM.  535 

thies),  fractures  of  bones,  deep  eschars,  necrosis  of  digits, 
and  most  of  the  lesions  observed  in  the  hollow  viscera 
lined  by  epithelia.  To  put  it  in  another  way,  this  class 
includes  the  various  lesions  observed  in  the  course  of  pos- 
terior spinal  sclerosis,  injuries  of  the  spinal  cord,  forms  of 
"myelitis"  so-called,  and  injuries  to  nerve-trunks.  Speak- 
ing before  this  audience  it  is  useless  to  further  specify  the 
"trophic  lesions"  referred  to. 

Second  Class. — Trophic  lesions  occurring  in  deeper 
parts,  not  exposed  to  bacterial  infection,  and  upon  which 
traumatic  influences  cannot  be  demonstrated  to  act :  in 
other  words,  the  apparently  spontaneous  trophic  lesions. 
This  class  is  made  up  of  the  muscular  atrophies  occurring 
in  the  course  of  nervous  diseases,  and  of  a  limited  number 
of  cutaneous  lesions.  Possibly  some  alterations  in  glandu- 
lar function,  due  to  nerve  lesion,  may  belong  to  this  class. 
Clinically  these  lesions  are  met  with  after  nerve  section, 
in  the  course  of  neuritis,  and  of  disease  affecting  prima- 
rily or  at  least  chiefly  the  ventral  cornua  of  the  spinal  cord 
and  their  homologues  in  the  cephalic  prolongation  of  the 
spinal  axis. 

With  respect  to  the  first  class  of  so-called  trophic  lesions, 
a  careful  study  of  the  conditions  under  which  they  arise, 
and  a  comparison  of  them  with  the  similar  peripheral  lesions 
which  present  as  complications  at  the  close  of  some  non- 
nervous  diseases  with  tendencies  to  asthenia  and  inanition, 
make  it  somewhat  doubtful  whether  they  can  rightly  be 
considered  as  direct  results  of  suppressed  or  perverted  ner- 
vous action.  Even  the  strongest  partisan  of  the  truly  dys- 
trophic nature  of  these  lesions  admits  that  extraneous  influ- 
ences (as  trauma  and  bacterial  infection)  play  a  certain 
though  wholly  secondary  part  in  their  genesis.  But  other 
observers  hold  an  opposite  extreme  view,  and  claim  that 
the  real  or  efficient  causes  of  the  lesions  are  trauma  and 
infection  acting  upon  parts  which  have  lost  their  automatic 
defence  through  anaesthesia,  and  whose  circulation  and 
general  nutrition  are  lowered,  but  not  specifically  altered, 
by  disease  and  inertia. 

This  second  view  is,  I  must   say,  supported  by  negative 


536  e.  c.  seguin: 

evidence,  experimental    and    clinical,  of  such    importance 
that  it  needs  to  be  stated. 

(a.)  Ulceration  of  the  cornea  and  even  panophthalmitis 
are  results  of  experimental  and  pathological  injury  to  the 
trigeminus  nerve,  more  especially  of  its  ophthalmic  branch 
and  of  the  Gasserian  ganglion.  These  ocular  lesions  are 
fully  described  in  text-books,  and  are  generally  looked 
upon  as  typical  trophic  changes  due  to  the  nerve  disease. 
Yet  thirty  years  ago  H.  Snellen1  and  M.  SchifP  separately 
demonstrated  by  the  simple  experiment  of  sealing  the  eye 
by  sewing  the  edges  of  the  lids  or  by  fastening  one  of  the 
animal's  ears  over  it,  that  ulceration  of  the  cornea  could  be 
prevented  after  section  of  the  trigeminus.  At  some  time 
prior  to  1872  von  Gudden8  proved  the  same  thing  by  a 
beautiful  experiment.  He  took  newly-born  rabbits  and 
produced  perfect  closure  of  the  eyelids  by  an  operation 
(artificial  ankyloblepharon).  When  the  wounds  were 
healed,  and  the  eyes  absolutely  sealed,  he  cut  the  trigemi- 
nus nerve  by  the  usual  intra-cranial  method.  Upon  open- 
ing the  eyelids  from  eight  to  fifteen  days  after  the  nerve- 
section  he  invariably  found  the  cornea  normal.  These 
experiments  make  it  clear  that  the  nerve  lesion  is  not  the 
real  or  efficient  cause  of  the  corneal  changes  in  the  usual 
experiments,  and  probably  not  in  human  cases  of  disease  of 
the  fifth  nerve. 

(6.)  Section  and  other  injuries  of  nerve-trunks  have  long 
been  known  to  be  followed  by  so-called  trophic  lesions  in 
the  distal  parts  supplied  by  the  injured  nerve.  Changes  in 
the  skin  and  hairs,  falling  of  the  nails,  ulceration,  and  even 
extensive  necrosis  or  gangrene  have  been  elaborately  de- 
scribed in  animals  and  in  man.  Yet  it  is  nearly  forty  years 
since  Brown-Sequard4  showed  that  (in  animals)  if  the  parts 

1  H.  Snellen,  De  invloed  der  zennwen,  op.  de  onsteking.  Dissert  Utrecht, 
r857-  Also  in  Archiv.  f.  d.  Hollandische  Beitrage  zur  Narur.  Heilkunde,  Bd.  L 
3,  p   206(1857) 

*  M.  Schiff,  in  Canstatt's  Jahresbericht,  I.,  p,  121,  1857. 

1  Von  Gudden,  cited  by  Kondracki  in  his  thesis,  Ueber  die  Durchschneidung 
des  Nervus  Trigeminus,  Zurich,  1872. 

«  Brown-Srquard,  Gazette  Medicale,  1849,  p.  880. 


DISEA  SES  OF  THE  NER  VO  US  S  YS  TEM.  537 

supplied  by  the  injured  nerve  be  kept  perfectly  clean  and 
protected  from  traumatic  influences,  ulcerations,  etc.,  did 
not  ensue.  He  also  demonstrated  that  wounds  made  in 
parts  supplied  by  an  injured  nerve-trunk  healed  as  well  as 
wounds  made  elsewhere.  These  experiments  (confirmed 
by  numerous  observers)  show  that  the  nerve  injury  in  such 
experiments  or  cases  is  not  the  true  efficient  cause  of  the 
ulcerations,  etc.,  and  also  (what  is  fully  as  important)  that 
the  nutritive  functions  which  go  to  repair  wounds  are  fully 
active  in  anaesthetic  and  paralyzed  parts.  In  the  practice 
of  medicine  we  have  frequent  occasion  to  apply  these  data, 
in  the  prevention  and  treatment  of  ulceration,  bed-sores, 
etc.,  by  mechanical  and  antiseptic  measures,  after  injuries 
to  nerves  or  to  the  spinal  cord,  as  well  as  in  cases  of  para- 
plegia. In  human  cases  of  section  of  sensory  nerves,  while 
certain  quantitative  changes  in  the  anaesthetic  area  are 
apparently  inevitable,  actual  histological  lesions  can,  I 
believe,  be  indefinitely  prevented  by  guarding  against  trau- 
matic influences.1  As  regards  bed-sores  in  paraplegia  you 
have  probaby  all  seen  them  show  healthy  reparative  action 
while  the  spinal  disease  was  growing  worse. 

(c.)  It  is  a  remarkable  fact  that  such  lesions  as  per- 
forating ulcer,  arthropathies,  fractures,  etc.,  which  occur  in 
the  course  of  posterior  spinal  sclerosis  and  other  nervous 
affections,  are  extremely  rare  in  patients  whose  circum- 
stances enable  them  to  avoid  over-exertion  in  the  later 
stages  of  the  disease,  and  to  receive  every  needed  care. 
This  certainly  would  point  to  traumatism  as  a  potent 
factor  in  the  production  of  the  so-called  trophic  lesions  of 
tabes. 

(d.)  Cystitis  was  until  a  comparatively  recent  time  con- 
sidered one  of  the  symptoms  of  myelitis  and  of  injury  to  the 
spinal  cord  ;  though  I  suppose  most  of  us  to-day  would 
speak  of  it  as  a  complication  preventable  by  the  use  of 
aseptic  catheters  introduced  with  the  greatest  care. 

The  negative  demonstrations  and  arguments  to  the  effect 

1  Except  some  lesions  of  the  second  class  which  are  unpreventable,  though  it 
would  seem  not  invariable  results  of  nerve  injuries. 


538  E.  C.  SEGUIN. 

that  the  greatest  number  of  the  most  formidable  of  the  so- 
called  trophic  lesions  of  the  first  class  are  preventable  and 
curable,  appear  to  my  mind  almost  overwhelming  proof 
that  the  efficient  cause  of  these  lesions  is  not  a  suppression 
or  perversion  of  nervous  action  or  influence. 

Consequently  I  would  refuse  the  name  of  trophic  lesions 
to  the  phenomena  embraced  in  the  first  class  of  data. 

We  are  now  brought  to  the  study  of  the  second  class  of 
"trophic  lesions,"  those  in  which  extraneous  or  traumatic 
causes  cannot  be  shown  to  act.  It  is  perhaps  in  the  study 
of  these  that  the  problem  of  the  relation  between  the  ner- 
vous disease  and  the  lesion  can  be  best  approached. 

The  most  typical  lesions  of  the  second  class  are  muscu- 
lar atrophy  with  degeneration,  and  the  cutaneous  affection 
known  as  herpes  or  zona.  Probably  other  so-called  skin 
diseases  belong  to  this  group,  but  full  demonstration  of 
their  nervous  origin  is  wanting. 

(a.)  The  natural  history  of  neuro-muscular  atrophic 
degeneration  is  well  known  to  all  of  you.  Within  a  few 
days  after  section  of  a  nerve-trunk,  or  after  destruction  of 
the  ventral  ganglion  cells  with  which  a  nerve-trunk  is  asso- 
ciated in  the  spinal  axis  (clinically,  in  cases  of  nerve  injury, 
neuritis,  poliomyelitis,  chronic  degeneration  of  ventral  gan- 
glion cells,  etc.),  the  nerve  fibres  distal  of  the  point  of  injury 
or  disease,  and  all  the  muscles  innervated  by  the  fibres  lose 
certain  properties  known  as  conductibility  and  irritability, 
react  abnormally  to  electrical  stimulation,  and  if  examined 
with  the  microscope  show  distinct  and  invariable  altera- 
tions. Later,  the  affected  muscles  undergo  a  marked  reduc- 
tion of  volume. 

In  adult  animals,  after  certain  lesions,  an  extreme  degree 
of  atrophy  is  established  and  persists.  In  young  animals, 
after  certain  lesions  (simple  nerve  injuries  and  neuritis  more 
especially),  a  process  of  regeneration  sets  in  which  in  a  few 
months  leads  to  return  of  a  normal  anatomical  state  of  the 
nerves  and  muscles,  and  to  renewed  functional  activity.  In 
some  cases  there  are  also  more  diffused  changes  produced, 
arrest  of  development  of  parts,  quantitative  modifications 
which  should  not  be  confounded  with  actual  lesions.    What 


DISEASES  OF  THE  NERVOUS  SYSTEM.  539 

I  wish  to  emphasize  is  that  we  have  here  to  deal  with  qual- 
itative or  histological  changes  in  nerves  and  muscles,  which 
occur  with  fatal  necessity  when  the  cause  has  acted,  and 
which  are  demonstrable  by  microscopic  examination  and 
by  electrical  tests  (reaction  of  degeneration).  Further, 
that  these  lesions  are  unpreventable,  and  in  one  sense 
incurable  ;  no  traumatic  or  infectious  influence  can  be  traced 
in  their  genesis,  and  no  amount  of  care  or  any  form  of  treat- 
ment will  prevent  the  appearance  or  thwart  the  evolution 
of  the  changes. 

(6.)  The  so-called  herpetic  lesions  of  the  skin.  The 
vesiculo-pustular  affection  appears  all  at  once  or  in  succes- 
sive crops  upon  areas  of  skin  supplied  by  one  or  more  of  the 
cerebro-spinal  nerves  ;  the  distribution  of  the  primary  erup- 
tion and  of  the  subsequent  scars  corresponding  exactly  with 
nerve  territories.  Hence  the  names  for  varieties  of  herpes, 
such  as  H.  frontalis,  H.  corneae,  H.  progenitalis,  H.  inter- 
costalis,  etc.,  etc.  Along  with  the  eruption  there  are  not 
rarely  subjective  symptoms  of  nerve  irritation,  such  as 
burning,  prickling,  pain,  or  numbness.  In  some  cases  pain 
(neuralgia)  persists  long  after  the  eruption  has  subsided. 
Usually,  scars  remain,  and  they  may  be  extremely  deep. 
Autopsies  have  shown,  beyond  room  for  doubt,  that  in  such 
cases  the  nerve  trunk  supplying  the  affected  cutaneous 
area,  and  especially  the  ganglion  upon  its  dorsal  root,  are 
the  seat  of  inflammatory  and  degenerative  processes.  Un- 
fortunately, with  the  means  at  our  command  the  lesion  has 
not  yet  been  traced  into  the  terminal  filaments  and  end- 
organs  of  the  affected  nerve  in  the  cutis  and  epidermis. 
The  demonstration  is,  however,  almost  complete  that  we 
are  here  in  presence  of  a  neuro-cutaneous  and  continuous 
lesion,  corresponding  to  the  continuous  lesion  observed  in 
(a.)  the  neuro-muscular  apparatus.  Here  again  we  have  to 
deal  with  an  evidently  non-traumatic  and  non-infectious 
lesion  (the  skin  lesion),  revealed  by  regular  and  constant 
symptoms,  unpreventable  by  mechanical  means  and  incur- 
able in  a  strict  sense  of  the  word. 

Similar  herpetic  cutaneous  lesions  are  observed  after 
injuries,  more  especially  such  as  give  rise  to  irritative  and 


540  E.   C.   SEGUIN. 

inflammatory  conditions  of  the  nerves.  Simple  section 
is  more  apt  to  be  followed  only  by  cutaneous  alterations  of 
the  first  class.  It  is,  furthermore,  possible  that  traumatic 
neuritis  may  produce  other  true  lesions  of  the  skin  besides 
herpes,  but  this  is  not  yet  proven. 

To  these  two  varieties  of  lesions,  embraced  in  the  sec- 
ond of  the  classes  which  I  propose,  I  am  ready  and  willing 
to  apply  the  term  trophic  lesions  in  the  true  sense  of  the 
word  ;  i.  e.,  they  are  histological  alterations  set  up  directly 
and  fatally  by  the  nerve  disease,  without  the  intervention  of 
accidental  or  extraneous  causes.  The  relation  of  cause  and 
effect  seems  indisputable,  and  we  may  therefore  say  that 
the  efficient  cause  of  the  trophic  lesion  is  disease  of  a  part 
of  the  nervous  system. 

And,  now,  as  to  the  mechanism  or  physiology  of  these 
trophic  lesions.  We  cannot  go  far  in  this  direction  without 
entering  the  domain  of  pure  speculation.  It  is  only  a  few 
weeks  since  I  heard  my  illustrious  master  and  friend,  Pro- 
fessor Charcot,  state  in  a  clinical  lecture  that  we  know 
absolutely  nothing  of  trophic  nerves  and  their  mode  of 
action.  In  this  negation  I  most  fully  concur,  especially  if 
it  be  applied  to  the  confused  or  unclassified  mass  of  so- 
called  trophic  lesions  about  which  so  much  has  been  writ- 
ten. The  existence  of  trophic  nerves  as  such  is  unanimously 
denied  by  physiologists,  and  much  of  the  speculations  of 
physicians  have  been  made  without  scientific  basis  in 
anatomy  and  physiology. 

The  attempt  to  simplify  the  problem  which  I  herewith 
submit  to  the  Association  may  not  advance  our  actual 
knowledge,  but  it  may  possibly  serve  as  a  step  toward  a 
more  exact  study  of  the  subject,  and  may  give  rise  to  a 
beneficial  discussion.  Allow  me  in  closing  to  "attempt  to 
show  in  what  way  this  analysis  may  be  a  slight  step  in 
advance. 

I  have,  in  the  first  place,  rejected  from  the  category  of 
trophic  lesions  all  vaso-motor,  calorific,  and  metabolic 
phenomena,  as  well  as  all  mere  quantitative  reductions  in 
tissues  and  organs  ;  reserving  the  name  for  such  alterations 
as  are  characterized  by  demonstrable  histological  changes. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  54 1 

This  will  doubtless  be  objected  to,  as  in  a  certain  sense  the 
excluded  phenomena  have  much  to  do  with  nutrition,  and 
the  word  "trophic  "  leads  the  mind  inevitably  to  think  of 
changes  in  nutrition,  which  for  me  is  far  too  vague  and  gen- 
eral a  conception  to  prove  of  help  in  the  study  of  our  sub- 
ject. Besides,  since  Claude  Bernard's,  Brown-Sequard's 
and  Ludgwig's  discoveries  a  sort  of  antagonism  has  been 
revealed  between  mere  vaso-motor  variations  and  the  activ- 
ity of  the  cellular  life  (salivary  secretions,  etc.). 

In  the  second  place,  I  have  attempted  to  show  that  his- 
tological lesions  apparently  due  to  nervous  disease  may 
be  divided  into  two  classes  ;  one  in  which  the  morbid  ner- 
vous influence  is  of  doubtful  or  at  least  of  secondary  causal 
value,  while  the  active  or  efficient  causes  of  the  lesions  are 
extraneous  and  accidental  (traumatism  and  infection); 
whereas  in  the  second  class  (by  far  the  smaller  at  present) 
extraneous  causes  are  unimportant  or  even  wholly  wanting, 
while,  as  far  as  our  present  means  of  observation  go,  the 
efficient  cause  of  the  lesions  is  a  morbid  state  of  the  nervous 
system. 

The  phenomena  which  make  up  the  first  class  I  hold  to 
be  mere  complications  having  a  complex  etiology,  while 
those  of  the  second  class  are  really  trophic  lesions  due  to 
disease  of  the  nervous  system. 

I  would  not  be  understood  as  claiming  that  the  classifi- 
cation here  proposed  is  final  or  absolutely  exact  in  all  its 
details.  For  example,  lesions  of  the  second  class  may 
co-exist  with  others  of  the  first  class  in  paralyzed  parts : 
e.  g.,  atrophic  or  herpetiform  lesions  in  paraplegia  of  the 
traumatic  form  especially.  Again,  a  reasonable  doubt  may 
be  entertained  as  to  whether  arthropathies  always  belong 
to  the  first  class  of  lesions.  It  would  be  necessary  to  make 
a  new  analytical  study  of  all  varieties  of  so-called  trophic 
lesions,  and  classify  them  according  to  their  histology,  eti- 
ology, in  the  light  of  the  subdivision  here  proposed. 

Third. — While  not  pretending  to  be  able  to  throw  any 
new  light  on  the  intimate  nature  of  real  trophic  lesions,  I 
desire  to  point  out  that  possibly  (and  I  say  this  with  all  due 
reserve)  the  mechanism  of  these  alterations,  or  as  the  ques- 


542  E.   C.  SEGUIN. 

tion  puts  it,  the  relation  between  the  trophic  lesions  and 
disease  of  the  nervous  system,  lies  or  is  embraced  in  a  law 
of  inter-dependent  life  in  continuous  tissues.  As  regards 
the  neuro-muscular  changes  of  our  second  class,  the 
operation  of  such  a  law  seems  highly  probable.  Anatom- 
ically and  physiologically  the  neuro-muscular  apparatus 
from  the  ganglion  cells  of  the  ventral  cornua  of  the  spinal 
cord  to  the  striated  muscular  substance  is  a  unity  or  becomes 
one  before  the  completion  of  foetal  life.  Whether  the  ulti- 
mate nerve  fibrillae  and  other  prolongations  of  neural  sub- 
stance which  lie  under  the  sarcolemma  actually  blend  with 
the  sarcous  substance,  is,  I  know,  an  unsettled  point ;  but 
their  coaptation  and  physiological  continuity  are  estab- 
lished. Besides,  in  lower  animal  forms  true  neuro-muscular 
structures  do  exist. 

With  reference  to  the  neuro-cutaneous  apparatus,  we 
need  still  more  delicate  and  reliable  histological  researches 
to  show  what  is  the  true  relation  between  ultimate  nerve 
fibrillae  and  the  peripheral  neural  substance  with  the  cells 
of  the  cutis  and  epidermis.  While  some  observers  claim 
actual  blending  of  the  two  substances,  by  penetration  of 
nerve  fibrillae  into  epithelia  and  by  the  interposition  of  cell- 
like nervous  expansions  in  among  the  cells  of  the  skin, 
others  are  in  doubt  as  to  the  arrangement.  Still,  at  the 
present  time,  the  weight  of  evidence  is  in  favor  of  the  exist- 
ence of  continuity  between  sensory  nerves  and  some  of  the 
elements  of  the  skin.  The  same  statement  may  be  made 
with  reference  to  the  relation  existing  between  the  termina- 
tion of  glandular  nerves  and  the  epithelia  of  gland. 

I  therefore  venture  to  suggest  that  disease  of  the  nervous 
system  produces  true  trophic  lesions  when  it  interferes  with 
the  associated  or  inter-dc pendent  life  of  continuous  tissues. 


TRANSACTIONS    OF     THE    AMERICAN    NEURO- 
LOGICAL   ASSOCIATION. 

FOURTEENTH   ANNUAL   REPORT. 

Tuesday  {First  Day),  Morning  Session. 

The  American  Neurological  Association  convened  at 
Willard's  Hotel,  Washington,  D.  C,  September  18th,  1888, 
and  was  called  to  order  by  the  President,  Dr.  James  J. 
Putnam,  of  Boston.  The  President  then  delivered  the  an- 
nual address. 

ADDRESS   OF   THE    PRESIDENT,  DR.  JAMES   J.  PUTNAM. 
Gentlemen  of  the  Neurological  A  ssociation  : 

It  is  my  pleasant  duty  to  bid  you  all  welcome  to  Wash- 
ington, in  the  name  of  yourselves  ;  and  to  declare  our 
meeting  to  be  formally  opened. 

The  Council  has  done,  and  will  do,  everything  in  its 
power  to  reduce  to  a  minimum  the  routine  business,  and  to 
leave  you  free  to  attend  to  the  scientific  communications 
which  we  have  come  to  hear. 

The  programme  is  a  full  one,  and  I  shall  detain  you 
only  a  few  moments  from  attacking  it. 

I  wish  to  ask  your  attention,  during  the  space  that  your 
courtesies  allow  to  the  presiding  officer,  to  the  consideration 
of  the  question,  whether  the  time  has  not  come  when  this 
Association  might  increase  its  efficiency  by  adopting  some 
plan  of  co-operative  work,  to  supplement  and  assist  the 
individual  work  of  its  members. 

I  purposely  avoid  for  the  moment  the  term  "collective 
investigation,"  because  I  do  not  mean  to  propose  that  we 
should  necessarily  adopt  the  exact  method  indicated  by 
that  name,  but  only  to  express  my  belief  that,  in  a  general 
way,  we   have   reached   such  a  point  in  our  development, 


5 44  AMERICAN  NEUROL OGICAL  ASSOCIA  TIOX. 

that  we  can  count  on  each  other  enough,  personally  and 
scientifically,  to  be  able  to  look  to  each  other  for  support 
during  the  progress  of  our  undertakings,  instead  of  only  for 
criticism  at  their  close. 

The  possible  advantages  to  be  expected  from  co-opera- 
tion in  some  portions  of  our  work  are,  I  think,  incontestible  ; 
the  difficulty  lies  in  realizing  them. 

That  which  usually  gives  to  a  scientific  enterprise  its 
pith  and  point,  is  the  genius,  faith,  energy,  or  personal 
ambition  of  a  single  man,  and  I  do  not  propose  that  we 
should  lose  sight  of  this  fact.  Nevertheless,  I  think  we 
may  make  a  step  forward  by  attempting  systematically 
what  we  now  do  in  a  desultory  manner,  in  the  way  of 
mutual  assistance. 

No  one  of  us,  not  even  the  most  talented  and  industrious, 
is  able  to  utilize  for  the  purposes  of  original  investigation 
more  than  a  small  proportion  of  the  vast  array  of  facts  that 
crowd  in  upon  him  on  his  daily  rounds  ;  but  we  should  be 
ready  to  devote  ourselves  with  increased  zeal  to  studying 
and  classifying  those  that  remained,  if  we  were  sure  that 
our  observations  were  being  made  in  such  a  way  that  each 
one  would  lend  its  testimony  to  the  proving  or  disproving 
of  some  particular  hypothesis  of  pathology  or  physiology 
or  therapeutics.  For  this  purpose,  however,  uniform  meth- 
ods of  examination  and  tabulation  would  be  necessary,  and 
the  knowledge  that  some  one  stands  ready  to  collaborate 
the  material  that  has  been  accumulated,  so  that  our  time 
and  labor  should  not  have  been  thrown  away. 

Again,  there  are  many  subjects  of  the  very  highest  prac- 
tical importance,  those  namely,  where  the  problems  at  stake 
are  of  a  statistical  character,  which  can  only  be  dealt  with 
satisfactorily  through  some  species  of  co-operative  inquiry. 
And  co-operation,  directed  to  this  end,  means  simply  an 
attempt  to  avoid  the  annoying  differences  and  errors  as 
regards  method  of  examination  and  point  of  view,  that 
come  in  to  vitiate  the  statistics  of  observers  working  at  dif- 
ferent times  and   places  and  without  mutual  understanding. 

I  am  speaking  as  if  co-operative  investigation  were  a 
new  thing,  whereas,  as  we   all    know,  it   has   been   tried,  in 


AMERICAN  NEUROLOGICAL  ASSOCIATION. 


545 


various  forms,  a  hundred  times,  sometimes  successfully, 
sometimes  unsuccessfully,  more  often,  no  doubt,  with  par- 
tial and  temporary  success,  then  to  be  given  up  or  changed 
for  something  better.  Such  temporary  success  even  is  often 
justification  enough  for  the  experiment.  One  does  not  look 
for  institutions  of  millennial  permanence,  but  for  ever  new- 
steps  in  advance. 

Let  us  glance  at  the  history  of  one  or  two  of  the  prom 
inent  co-operative  efforts  of  recent  times. 

The  first  Collective  Investigating  Committee  of  the 
British  Medical  Association  was  appointed  in  1881,  with 
Dr.  Mahomed  as  paid  Secretary.  Two  volumes  of  records 
have  been  publishd,  besides  reports  in  the  British  Medical 
Journal,  on  various  subjects. 

At  the  Industrial  Congress  at  Copcmiagen  in  1884,  an 
address  was  made  by  Sir  William  Gull,  favoring  the  appoint- 
ment of  an  International  Committee  for  a  similar  purpose, 
and  the  motion  was  warmly  seconded  and  the  committee 
appointed.  The  Verein  fur  innere  Medicin,  in  Berlin,  had 
already  given  its  sanction  to  this  method  of  research,  and 
had  formed  a  committee  with  Leyden  as  chairman. 

It  could  not  be  claimed,  perhaps,  that  the  work  of  these 
committees  has  always  been  of  the  first  quality.  The 
information  was  collected  through  circulars  sent  about 
rather  broadcast,  and  the  answers  must  have  been  of  vary- 
ing degrees  of  merit.  There  can  be  no  doubt,  however, 
that  something  substantial  has  been  gained,  not  only  of  the 
nature  of  harvest,  but  also  of  seed-grain,  since  those  who 
took  part  in  the  inquiry  must  have  been  trained  and  stimu- 
lated, so  that  another  time  they  would  both  observe  and 
report  to  better  advantage. 

An  Association  like  ours  would  have  a  better  chance  of 
success  in  carrying  out  a  plan  of  investigation  of  this  kind 
than  where  the  profession  at  large  was  called  upon  to  give 
its  co-operation  ;  since  most  of  our  members  are  familiar 
with  the  methods  of  accurate  research,  and  would  under- 
stand the  bearings  of  the  investigation  that  we  should 
make. 


-  ,5  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

To  speak  of  institutions  nearer  home,  some  of  the  New- 
York  physicians  formed,  a  number  of  years  ago,  a  society 
for  collective  investigation  in  therapeutics.  It  lasted,  I 
believe,  but  for  a  few  years,  but  during  that  time  published 
papers  of  real  value. 

If  care  were  taken  to  select  questions  for  inquiry  which 
were  of  fundamental  and  practical  importance  to  every 
observer,  such  a  scheme  would  have  a  greater  prospect  of 
permanence. 

It  is  not,  however,  at  the  history  of  committees  for  col- 
lective investigation  that  I  look  with  so  much  interest,  as 
affording  examples  for  our  instruction,  as  to  the  work  of 
individuals  whose  influence  and  energy  have  created  schools 
and  inspired  followers  ;  men  like  Prof.  Charcot,  to  name 
but  a  single  instance. 

I  have  also  in  mind  the  results  that  have  been  gained, 
especially  in  the  department  of  physiology,  by  dividing  up 
an  important  inquiry  into  a  number  of  related  parts,  which 
are  assigned  to  different  persons  acting  temporarily  as  assist- 
ants to  one  person,  by  whom  the  investigation  is  mainly 
undertaken. 

Charcots  are  not  to  be  had  for  the  asking  ;  but  we  have 
our  share  of  workers  with  ability,  energy,  and  zeal  enough 
to  be  good  workers  in  given  directions,  and  worthy  of  sup- 
port. My  own  feeling  is  that  there  is  more  vitality  in  a 
scheme  for  which  one  or  two  persons  make  themselves  re- 
sponsible, especially  if  they  are  already  identified  with  it, 
than  in  the  work  of  a  committee,  where  the  interest  is  less 
personal  and  the  responsibility  more  divided  ;  and  that  the 
efforts  of  our  Association  should  be  directed  to  furthering 
the  plans  of  such  persons,  by  moral  and  scientific  support 
and  by  furnishing  funds  for  printing  circulars  if  necessary, 
and  so  forth. 

I  can  see  no  better  way  of  accomplishing  this  than  that 
the  proposer  of  any  investigation  should  appeal,  either  per- 
sonally or  through  the  Secretary,  and,  if  necessary,  at  the 
expense  of  the  Association,  to  the  members,  stating  his 
plan  and  asking  for  support.  If  his  scheme  recommended 
itself  to  others  so  far  that  he  should  be  able  to  form  a  suffi- 


AMERICAN  NEUROLOGICAL  ASSOCIATION  547 

ciently  large  working  committee,  he  should  confer  again 
with  them  and  submit  details.  The  rest  of  the  committee 
should  have  the  right  of  criticism,  and  of  withdrawal  if  not 
satisfied,  and  the  publication  of  the  results  should  be  made 
in  the  name  of  the  committee  with  the  originator  as  chair- 
man ;  or,  if  it  was  agreed  that  the  originator  should  do  the 
greater  part  of  the  work,  and  make  himself  responsible  for 
the  conclusions,  he  might  publish  the  results  in  his  own 
name  with  those  of  the  rest  as  collaborators  ;  and  the  ques- 
tion as  to  whether  the  Association  should  vote  an  appro- 
priation for  his  assistance,  if  any  was  required,  and  the 
amount  of  the  appropriation,  should  be  decided  in  any  way 
that  the  members  of  the  council  might  determine. 

It  is  not  my  purpose  to  discuss  in  detail  what  subjects 
would  be  best  suited  for  investigation  in  this  manner,  and  I 
will  refer  only  to  one  or  two  by  way  of  illustration. 

In  the  first  place,  there  are  those  such  as  were  proposed 
for  the  British  Medical  Society,  including  the  vast  subject 
of  heredity  ;  the  laws  of  degeneration  and  (as  being  of  quite 
equal  importance)  of  regeneration  in  families  and  races  ; 
and  the  strange  transmutation  or  evolution  of  diseases  from 
one  form  to  another,  which  seems  to  be  entirely  distinct 
and  different. 

To  come  nearer  home,  there  are  various  questions  in 
therapeutics,  such  as  the  action  of  iodide  of  potash  on 
non-syphilitic  brain  tumors,  as  one  member  suggested  to 
me. 

Again,  we  all  know  that  Dr.  Dana  has  been  studying 
the  racial  relations  of  the  neuroses,  a  subject  which  Clifford 
Allbutt  also  has  recently  touched  upon  in  his  suggestive 
address,  and  for  the  investigation  of  which  no  country  could 
be  better  suited  than  ours.  It  would  be  an  easy  matter  for 
us  to  collect  large  numbers  of  facts  under  his  guidance  upon 
these  points,  and  the  comparison  of  the  experience  of  the 
different  cities  would  be  particularly  instructive. 

The  subject  of  cranial  measurements,  for  which  large 
masses  of  facts  are  also  needed,  is  another  fit  matter  for 
such  methods  of  research,  and  I  am  glad  to  be  able  to  say 
that  a  valuable  introduction  to  investigation  of  this  kind  is 
among  the  candidates'  papers  for  this  year. 


548  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

I  have  myself  been  interested  for  a  number  of  years  in  an 
inquiry  which  I  think  could  soon  be  brought  to  a  fairly 
definite  conclusion  in  this  manner,  namely,  the  effect  of  very 
small  doses  of  lead  as  predisposing  to  disease.  I  published, 
last  year,  the  report  of  the  analysis  for  lead  of  the  urine  of 
eighty-six  persons  with  various  symptoms  of  nervous  dis- 
ease, functional  and  organic,  but  not  presenting  unequivocal 
symptoms  of  lead  poisoning.  In  forty-eight  cases,  or  more 
than  fifty  per  cent,  of  the  whole  number,  lead  was  found, 
and  for  certain  groups  of  cases  the  proportion  ran  up  to  a 
much  higher  figure.  Out  of  a  group  of  eleven  cases,  on  the 
other  hand,  made  up  of  persons  who  were  practically  in 
good  health,  lead  was  found  in  only  two  cases. 

These  facts  seemed  to  me  of  importance  ;  but  it  was  also 
evident  that  their  clinical  significance  would  be  diminished 
if  it  should  appear,  on  further  investigation,  that  the  urine 
of  most  or  of  many  healthy  persons  also  contained  lead, 
showing  that  its  presence  need  not  be  injurious.  I  therefore 
made  arrangements  to  have  the  urine  of  a  large  number  of 
medical  students  analyzed,  and  up  to  the  present  time  I 
have  reports  on  twenty-three  cases.  In  only  three  of  these, 
or  thirteen  per  cent.,  lead  was  found,  and  then  in  very  small 
amounts. 

Even  these  few  affirmative  cases,  together  with  others 
of  a  similar  kind  which  I  have  collected  but  which  do  not 
belong  to  this  particular  set,  show  that  the  mere  finding  of 
lead  in  the  urine  is  not  an  indication  of  active  poisoning  ; 
but,  on  the  other  hand,  it  remains  to  be  proved  that  the 
majority  of  persons  can  carry  lead  about  with  them  all  their 
lives  and  still  keep  their  tissues  as  healthy  and  as  resistant 
as  if  it  were  absent ;  and  it  is  still  an  important  and 
open  question,  and  one  that  only  the  testimony  of  large 
numbers  of  facts  can  answer,  whether  the  first  signs  of 
poisoning  are  always  the  classical  symptoms  with  which 
we  have  long  been  familiar,  or  whether  lead,  like  syphilis, 
may  predispose  the  central  nervous  system  to  degenerative 
changes  of  an  entirely  different  order  from  those  seen  in 
typical  cases  of  poisoning. 

Such  an  investigation  is  too  expensive,  and  requires  too 


AMERICAN  NE URGLOGICAL  A SSOCIA TION.  549 

much  material,  for  a  single  person  to  deal  with  satisfactor- 
ily ;  but  if  a  large  number  were  to  take  part,  reasonable 
conclusions  could  soon  be  reached  ;  and  it  is  certainly  im- 
portant for  us  to  understand  accurately  the  effect  of  influ- 
ences to  which  the  whole  community  is  more  or  less 
exposed. 

But  I  do  not  think  it  is  by  collective  investigation  alone 
that  the  members  of  the  Association  can  be  useful  to  each 
other,  and  to  the  profession,  through  co-operative  work. 

In  the  first  place,  I  hope  that  another  year  we  may  do 
still  more  than  we  have  done  this  year  in  the  way  of  notify- 
ing members  of  the  contents  of  papers  to  be  read.  The 
Surgical  Association  has,  I  think,  set  us  a  good  example  in 
printing  quite  a  summary  of  the  points  to  be  raised  in  their 
discussions,  and  I  feel  sure  that  others  besides  the  principal 
speakers  will  be  stimulated  thereby  to  take  an  active  part. 

Another  piece  of  joint  work  which  has  occurred  to  me  is 
the  formation,  either  actually  or  on  paper,  of  a  collection  of 
microscopic  or  other  specimens,  to  be  kept  by  the  secretary 
or  by  an  officer  appointed  for  that  purpose,  or  deposited  in 
the  Army  Xat.  Museum.  If  the  collection  should  consist  of 
actual  specimens,  they  would  naturally  be  duplicates  ;  if  it 
should  consist  of  a  list  only,  this  might  contain  a  statement 
of  the  preparations  which  members  were  willing  to  lend, 
under  suitable  conditions,  and  of  those  which  they  would 
only  allow  to  be  consulted  in  their  own  laboratories. 

Perhaps  this  scheme  is  chimerical  and  would  lead  to 
nothing.  If  the  specimens  were  likely  to  be  largely  con- 
sulted, I  admit  that  their  owners  might  be  put  to  inconve- 
nience. As  a  matter  of  fact,  however,  I  presume  they  would 
be  consulted  but  little,  but  I  think  that  occasionally  this 
would  be  done,  and  with  the  greatest  possible  benefit. 

If  this  plan  should  lead  to  the  formation  of  a  central 
museum  of  such  specimens  as  crania  and  brains  which  had 
been  described,  and  would  otherwise  lie  idle  on  a  top  shelf, 
or  of  photographs,  drawings  and  casts  of  such  specimens, 
the  plan  would,  I  think,  be  justified.  Possibly  we  might 
some  day  publish  sets  of  illustrations  on  the  plan  of  the  new 
Iconographie  of  the  Salpetriere. 


550  AMERICAN  NEUROLOGICAL  ASSOCIATION 

[The  National  Army  Museum,  as  Dr.  Billings  assured 
us  in  his  address,  is  ready  to  take  charge  of  microscopic 
and  other  collections,  and  what  could  be  a  more  pleasant 
and  fitting  memorial  of  our  Association  than  to  have  its 
name  linked  with  such  a  collection,  and  to  have  been  the 
first  to  set  an  example  which  would  be  sure  to  find  follow- 
ers.] 

I  have  intended,  in  these  remarks,  only  to  ask  you  to 
reflect  whether  some  way  cannot  be  found  through  which, 
by  combining,  we  can  reach  certain  ends  either  of  the 
nature  of  actual  discovery,  or  of  critical  suggestion,  which 
could  not  be  reached  by  one  person  alone  ;  and  I  have  tried 
to  indicate  certain  methods  by  which  we  should  be  the 
most  likely  to  arrive  at  the  best,  though  perhaps  not  the 
most  conspicuous  results,  with  the  least  danger  of  failing 
through  overreaching  ourselves. 

If  the  general  suggestion  pleases  you,  I  dare  say  better 
means  than  mine  can  be  suggested  for  carrying  it  out.  The 
time  and  place  seem  to  me  appropriate  for  initiating  such 
an  enterprise.  This  is  the  first  meeting  of  the  Congress  of 
all  the  principal  Associations  of  the  country  for  their  mutual 
stimulation  and  support,  and  our  first  meeting  in  the  capital 
of  the  country. 

What  is,  however,  of  more  importance,  we  have,  I  think, 
reached  a  period  in  our  development,  when  such  a  step  is 
justifiable. 

We  have  learned  to  know  each  other  better  personally, 
and  we  have  all  of  us  learned  to  do  at  least  fairly  good 
work,  and  some  of  us  work  of  the  highest  quality,  and  all  of 
us  have  learned  to  appreciate  in  what  really  good  work 
consists. 

A  remark  made  to  me  ten  years  ago  by  one  of  the  most 
prominent  neurologists  of  Germany,  that  he  could  not 
make  much  use  of  American  cases,  they  were  so  inade- 
quately reported,  would  now  not  be  in  place. 

We  need  now  to  bring  our  best  workers  more  and  more 
prominently  to  the  front,  and  give  them  a  chance  to  exert 
all  the  influence  of  which  they  are  capable  ;  to  show  that 
we   appreciate   that   our   specialty  is   bound  to   be  of  more 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  5  5  I 

vital  importance  than  almost  any  other,  and  that  it  is,  above 
all,  the  specialty  of  research. 

And  it  should  be  remembered,  also,  that  we  are  not  a 
local,  but  a  national  Association,  with  natural  functions  of 
the  nature  of  encouraging  broad  and  liberal  enterprises  of 
education  and  investigation,  and  not  merely  a  collection  of 
workers,  bent  only  on  prosecuting  our  individual  aims,  and 
with  no  bond  of  union  but  our  yearly  meetings. 

REPORT   OF   THE   TREASURER. 

Dr.  Graeme  M.  Hammond,  of  New  York,  Secretary  and 
Treasurer,  presented  the  Annual  Report,  which,  on  motion, 
was  accepted.  There  was  a  balance  in  the  treasury  of 
$217.60. 

SCIENTIFIC    COMMUNICATIONS. 

Dr.  Philip  C.  Knapp,  of  Boston,  read  a  paper  on  Nervous 
Affections    following    Brain    Injury     ("Concussion    of  the 
Spine,"  "Railway  Spine,"  and  "Railway  Brain"). 
(For  paper  see  October  number. 

Dr.  ISAAC  Ott  read  a  paper  entitled 

HEAT   CENTRES   IN   MAN. 

In  this  abstract  I  will  give  only  the  principal  points  of 
my  paper  on  this  subject. 

There  have  been  localized  in  the  lower  animals  six 
centres  whose  injury  causes  increased  temperature.  The 
cruciate  about  the  Rolandic  fissure,  the  sylvian  at  the  junc- 
tion of  the  supra,  and  post-sylvian  fissure;  the  caudate 
nucleus,  the  tissues  about  the  corpus  striatum,  a  point 
between  the  optic  thalamus  near  the  median  line  ;  and  the 
antero  inner  end  of  the  optic  thalamus.  These  centres 
have  their  own  laws,  which  serve  to  distinguish  one  from 
the  other.  Dr.  W.  Hale  White1  has  published  a  paper  con- 
taining a  number  of  collected  cases  bearing  on  this  subject, 
and  I  have  mainly  used  them  to  support  the  theory  of  local- 
ized heat-centres  in  man.  He  has  ruled  out  all  cases  where 
the  cause  is  not  purely  nervous. 

In  support  of  a  heat-centre  about  the    Rolandic  fissure, 

1  Guy's  Hospital  Reports,  1884. 


q  q  2  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

there  are  two  cases  of  injury  in  this  region,  which  were  fol- 
lowed by  a  temperature  of  1040  F.  There  is  also  a  case  of 
softening  of  the  brain  in  the  neighborhood  of  the  Rolandic 
fissure,  with  a  temperature  of  1050  F.  reported. 

Corpus  Striatum. — There  are  recorded  two  cases,  one 
of  degeneration  of  the  corpus  striatum,  another  of  echino- 
coccus — cysts  in  it  which  caused  an  elevation  of  tempera- 
ture. These  cases  are  very  clear,  and  undoubtedly  seem 
to  show  the  corpus  striatum  to  be  a  thermic  centre. 

Thalamus  Opticus. — The  cases  bearing  on  this  point  are 
not  very  definite. 

Subnormal  Temperatures. — There  has  been  recorded, 
one  by  Dr.  Farnham  of  Cambridge,  a  case  of  typhoid  whose 
preceding  high  temperature  was  succeeded  by  a  fall  to 
95. 4C  F.  In  my  experiments  upon  the  heat  centres  it  was 
found  that  the  elevated  temperature  was  succeeded  by  a 
fall  below  normal,  and  heat  production  also  corresponded 
to  it.  Dr.  Williams  also  found  the  temperature  in  phthisis 
characterized  by  an  afternoon  pyrexia  and  a  subnormal 
temperature  (940  F.)  in  the  morning. 

In  the  convulsive  affections  I  have  shown  that  tetanus 
mainly  causes  heat  through  the  stimulation  of  thermic 
centres,  and  not  by  muscular  movement.  In  chorea  Prof. 
Osier,  from  an  analysis  of  410  cases,  arrived  at  the  conclu- 
sion that  fever  takes  place  when  rheumatism  sets  in,  when 
endocarditis  becomes  severe,  and  in  some  cases  of  chorea 
insaniens.  There  may  be  the  most  intense  and  violent 
movements  without  any  rise  of  temperature,  and  in  a  great 
majority  of  cases  remain  afebrile  throughout. 

In  epilepsy,  according  to  Lemoine,  in  nearly  two  hun- 
dred observations  of  isolated  attacks,  the    average  rise  was 

1.2°   F. 

Tumors  and  lesions  of  the  spinal  cord,  oblong  medulla, 
and  pons  varolii  are  usually  followed  by  a  high  temperature 
due  to  a  removal  of  the  influence  of  the  thermotaxic  cen- 
tre, permitting  the  spinal  thermogenesis  to  become  exag- 
gerated. 

Low  temperatures  are  due  to  the  excitation  of  the  ther- 
motaxic centres,  or  their  fibres,  or  to  affection  of  the  ther- 
molytic  apparatus. 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  5^3 

High  temperatures  have  been  reported  ranging  as  high 
as  1250  F.  to  1280  F.  These  cases,  if  true,  and  I  am  in- 
clined to  believe  them  possible,  are  paralelled  by  Allenberg 
and  Landois'  experiments  upon  the  Rolandic  centres  in 
dogs,  where  they  found  a  difference  of  230  F.  between  the 
extremities.  The  rapid  and  high  elevation  of  temperature 
often  seen  in  malarial  paroxysms  indicates,  to  my  mind,  an 
action  on  the  thalmic  heat-centre.  This  is  the  only  centre 
whose  rise  and  fall  of  temperature  corresponds  in  time  and 
degree  to  that  seen  in  these  conditions. 

Cases  of  temperature  of  1  io°  in  children  have  been  re- 
ported which  lasted  for  about  an  hour  and  then  fell  to  nor- 
mal, the  patients  recovering.  In  the  several  hundred  of 
temperature  experiments  upon  animals,  in  only  one  case 
have  I  seen  the  preceeding  cases  paralelled.  Thus,  after  a 
grain  and  a  half  of  atropin  per  jugular, the  temperature  sank 
to  970  F.,  but  on  applying  sciatic  irritation  the  temperature 
rose  rapidly  to  1020  F.,  a  gain  of  five  degrees  in  sixteen 
minutes.  It  is  well  known  that  a  dose  of  atropin  of  this 
size  would  prevent  the  sensory  irritation  from  having  much 
effect  upon  the  vaso-motor  apparatus  in  producing  contrac- 
tion of  the  vessels.  Atropin  in  large  doses  paralyzes  the 
main  vaso-motor  centre. 

Diagnostic  Value. — If  the  symptoms  point  to  a  lesion  of 
the  pons  certainly  high  temperature  will  be  an  important  aid. 
If  the  symptoms  indicate  a  lesion  about  the  corpus  striatum 
then  high  temperature  with  general  muscular  wasting  will 
be  strong  corroboration  of  the  diagnosis. 

These  points  will  be  either  confirmed  or  refuted  by 
lesions  in  man,  and  I  hope  this  paper  will  stimulate  neuro- 
logists to  make  more  frequent  observations  upon  tempera- 
ture. 

DISCUSSION   ON   DR.    OTT'S   PAPER. 

Dr.  Dercum  introduced  Dr.  Hare,  who  referred  to  the 
experiments  of  Dr.  Ott.  The  fact  that  destruction  of  a  cen- 
tre caused  elevation  of  temperature  could  not  be  said  to 
prove  that  the  centre  in  question  was  a  heat  centre,  but 
rather  that  it  was  an  inhibitory  heat  centre;  its  function  was 


554  AMERICAS7  NEUROLOGICAL  ASSOCIA  TIOX. 

to  inhibit  rather  than  to  stimulate  heat  production.  There 
was  an  apparent  fallacy,  too,  in  the  statement  in  regard  to 
atropin.  Atropin  does  not  paralyze  the  vaso-motor  cen- 
tres. The  chief  action  of  atropine  is  upon  the  motor  rather 
than  upon  the  sensory  system. 

Dr.  Gray  referred  to  a  case  of  leptomeningitis  above  the 
fissure  of  Sylvius,  in  which  the  temperature  was  at  no  time 
above  the  normal. 

Dr.  Lloyd  referred  to  a  case  of  subnormal  temperature 
after  injury  of  the  cortical  motor  region. 

Dr.  Ott  explained  that  he  had  stated  simply  that  de- 
structive excision  of  the  centres  caused  a  rise  of  temper- 
ature ;  he  had  not  stated  whether  those  centres  were 
inhibitory  or  not.  In  regard  to  atropin,  he  had  stated 
that  atropin  inhibited  the  vaso-motor  reflexes.  The  sub- 
normal temperature  in  Dr.  Lloyd's  case  would  be  explained 
by  irritation  of  that  region  of  the  cortex,  by  the  removal  of 
which  temperature  was  increased.  It  was  not  usual  to 
observe  the  temperature  of  patients  suffering  with  nervous 
disease,  and  variations  might  be  overlooked.  The  fact  that 
lesions  about  the  fissure  of  Rolando  were  not  always  fol- 
lowed by  an  elevation  of  temperature  proved  nothing  one 
way  or  the  other.     Paralysis  also  did  not  always  result. 

Dr.  E.  D.  Fisher,  of  New  York,  then  read  a  paper  en- 
titled: 

CLINICAL    REPORT   OF   CASES   OF   EPILEPSY    FOLLOWING 
CEREBRAL   HEMIPLEGIA. 

Of  late  much  has  been  written  in  regard  to  cerebral 
hemiplegia  in  children,  or  cerebrale  kinderlahmung, 
both  in  this  country,  in  England,  and  on  the  conti- 
nent. In  recording  the  following  cases  I  would,  however, 
lay  particular  stress  on  the  epileptic  seizures  associated 
with  the  disease.  The  picture  of  these  cases  has  been  so 
often  drawn  that  it  has  become  a  familiar  one.  The  hemi- 
plegia unilateral  and  bilateral,  as  it  is  sometimes  termed, 
coming  on  at  birth,  or  in  the  first  few  years  of  life,  is  similar 
in  most  respects  to  that  of  adult  hemiplegia,  with  the  addi- 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  555 

tional  symptoms  of  more  or  less  interference  with  the 
growth  of  the  parts  and  a  more  marked  condition  of  con- 
tracture. These  cases  are  to  be  found  in  every  almshouse 
or  home  for  the  feeble-minded.  There  is  usually  marked 
contracture  of  the  upper  extremity,  the  fingers  closed  in  the 
palm  and  resisting  in  many  cases  all  efforts  to  draw  them 
out.  The  lower  extremity  is  also  contractured,  the  gastroc- 
nemius being  involved,  causing  the  patient  to  walk  on  the 
ball  of  the  foot  with  the  heel  drawn  up  ;  the  face  is  but 
slightly  affected,  at  least  in  the  latest  stages  of  the  disease. 
There  is  some  interference  with  the  growth  of  the  parts, 
and  while  this  was  present  in  all  of  the  following  cases,  in 
only  one  was  it  marked,  affording  at  once  a  differential 
diagnosis  from  infantile  spinal  paralysis.  In  reference  to 
this  point  I  would  refer  to  three  cases  reported  by  H.  Quinke 
in  the  Deutches  Archiv.  f.  Klin.  Med.,  bd  xlii.,  h.  5,  of 
Glioma  involving  the  central  convolutions,  in  which,  along 
with  the  paralysis,  marked  and  rapid  wasting  was  present, 
leading  the  author  to  believe  that  a  trophic  centre  must 
exist  in  close  proximity  to  the  motor  centres.  The  author 
does  not  consider  it  possible  that  the  wasting  could  be  due 
to  inactivity,  as  is  the  case  usually,  or  as  the  result  of  des- 
cending degeneration  of  the  lateral  columns,  as  it  occurred 
so  soon  after  the  paralysis,  and  microscopical  examination 
revealed  no  changes  in  the  anterior  cornua. 

We  have  also  present  in  these  cases,  imbecility  or  idiocy, 
and  epilepsy,  conditions  not  existing  in  the  spinal  lesion. 
All  these  symptoms,  with  the  exception  of  the  last  two, 
may  exist  wherever  the  motor  tract  is  interrupted  in  its 
course,  whether  in  the  cortex,  sub-cortical  region,  basal 
ganglia,  capsule,  crura,  pons,  medulla,  or  cord.  It  rarely 
occurs  in  other  than  the  cortical  and  sub-cortical  regions, 
and  if  accompanied  by  imbecility  and  epilepsy,  can  only 
be  referred  to  the  cortex. 

Wallenberg,  in  Westphal's  Archiv.  f.  Psychiatrie,  bd. 
xix.,  h.  2,  reports  a  typical  case  of  spastic  cerebral  hemi- 
plegia of  childhood,  in  which  the  lesion  involved  the 
cornua  with  descending  degeneration  and  as  was  to  be  ex- 
pected   there    were  no  mental    symptoms  or  epileptic  seiz- 


556  AMERICAN  XEUROLOGICAL  ASSOCIA  TIOX. 

ures.  In  regard  to  the  epileptic  seizures,  there  is  no  rule 
as  to  their  commencement  on  the  paralyzed  or  on  the  non- 
affected  side,  indeed  they  more  often  resembled  in  their 
onset  idiopathic  epilepsy,  and  if  a  warning  were  present, 
consisted  in  an  epigastric  aura,  vertigo,  &c.  As  Jacksonian 
epilepsy  may  resemble  idiopathic  epilepsy  in  its  onset  and 
course,  so  may  the  idiopathic  form  simulate  in  every  parti- 
cular the  Jacksonian. 

When  the  hemiplegia  is  congenital,  the  cause  is  proba- 
bly in  the  majority  of  cases,  meningeal  hemorrhage,  in- 
duced either  through  injury  in  utero  or  at  time  of  birth. 
Porencephalus  is  also  a  factor  in  these  cases.  We  find  evi- 
dence of  the  hemorrhage  in  the  form  of  cysts  or  adhesions, 
between  the  dura  and  the  pia  mater,  with  sclerosis  and 
atrophy  of  the  convolution,  accompanied  by  secondary 
degeneration  extending  into  the  cord.  Both  hemispheres 
may  be  involved,  and  very  commonly  over  the  convex  sur- 
face. This  would  sustain  Gowers'  statement  that  in  con- 
genital cases  the  hemiplegia  is  more  often  of  the  double 
form  than  in  the  acquired  cases. 

In  these  latter  cases,  occurring  usually  at  the  age  of  two 
or  three  years,  Gowers  believes  that  thrombosis  of  the  lon- 
gitudinal sinus  is  a  very  frequent  cause,  with  thrombosis  of 
the  veins  entering  the  sinus  resulting  in  capillary  hemor- 
rhages, atrophy  and  sclerosis  of  the  convolution  with 
secondary  degeneration.  Embolism  is  more  likely  to  occur 
in  cases  of  more  advanced  years,  or  to  follow  the  exanthe- 
mata rheumatism,  &c. 

Poli-encephalitis  and  intra-cerebral  hemorrhage  are 
probably  not  as  frequent  causes  as  those  previously  men- 
tioned. 

In  an  interesting  paper  read  before  this  Association  in 
July  of  last  year,  Dr.  P,  C.  Knapp  enters  very  fully  into  its 
etiology,  and  also  gives  a  complete  bibliography  of  the  sub- 
ject. I  would  also  refer  to  Dr.  Osier's  lectures  on  the  sub- 
ject in  the  Phi  la.  Medical  News.  I  would  differ  with  Dr. 
Knapp  in  reference  to  the  interference  with  the  growth  of 
the  members  affected,  agreeing  with  Prof.  Henoch  that  as 
compared  with  infantile  spinal  paralysis  it  is  comparatively 


AMERICAN  NE  UROL  OGICAL  A SSOCIA  TION.  557 

small,  the  wasting  of  the  muscles  being  almost  exclusively- 
one  of  disuse,  as  seen  in  those  cases  with  permanent  con- 
traction; whereas,  when  athetoid  or  choreiform  movement? 
were  present,  the  muscles  were  often  well  developed. 

In  three  cases  affected  with  congenital  choreiform 
movements  either  constantly  present  or  increased  by  vol- 
untary action,  I  found  the  muscles  well  developed,  and 
although  muscular  power  seemed  somewhat  decreased,  it 
appeared  to  be  more  awkwardness  in  movement  than  actual 
loss  of  power.  These  cases  represent,  to  my  mind,  congen- 
ital injury  to  the  brain  substance  with  a  multiple  sclerosis, 
not  entirely  destroying  the  cortex  or  involving  all  the  motor 
fibres  and  leading  thus  to  irregular  motor  impulses.  These 
cases  are  similar  to  those  of  the  congenital  type  of  spastic 
hemiplegia,  the  lesion,  however,  being  more  diffuse  in  dis- 
tribution and  not  so  destructive  in  character.  I  would  re- 
fer here  to  an  article  on  intention  tremor  by  Dr.  Stephan  in 
the  Archiv.  fur  Psychiatrie  und  Nerven  Krankheiten  bd. 
xviii.,  h.  2. 

My  cases  are  mostly  congenital,  or  occurring  between 
the  ages  of  one  and  three.  In  one  case,  however,  resembling 
in  every  particular  the  spastic  hemiplegia  of  childhood,  with 
marked  contractions,  equino  varus,  exaggerated  reflexes 
and  epileptic  seizures,  the  paralysis  occurred  at  23  years 
of  age, followed  one  month  later  by  epileptic  attacks,  always 
commencing  on  the  paralyzed  side. 

In  regard  to  longevity,  in  most  instances  tne  average 
of  20  years,  as  given  by  Henoch,  was  far  exceeded.  The 
presence  in  greater  or  less  degree  of  mental  weakness  is 
always  marked  ;  this  is  accounted  for  by  the  occurrence  of 
the  disease  in  the  early  stage  of  cerebral  development  ; 
epilepsy  did  not  occur  in  many  of  these  cases  for  some  time 
following  the  paralysis. 

The  contractures  decreased  in  some  cases  in  the  course 
of  years,  so  that  in  one  instance  the  hand  became  a  fairly 
useful  member.  Relaxation  during  sleep  of  the  spastic 
condition  was  not  observed.  The  extreme  spasticity  caused 
in  voluntary  acts  was  illustrated  in  cases  I  and  18.  In 
the    latter   the  whole  of  the   affected    side,   including   the 


558  AMERICAN  NEUROLOGICAL  ASSOCIA TION 

muscles  of  the  face  were  thrown  in  violent  spasm  on  the 
slightest  attempt  to  rise  or  even  extend  a  limb  ;  in  the 
former,  flexion  of  the  arm  caused  flexion  at  the  wrist,  while 
extension  produced  excessively  violent  extension  of  the 
wrist,  this  was  beyond  the  control  of  the  patient  and  was 
only  overcome  by  great  force. 

As  remarked  in  the  beginning  of  this  paper  my  special 
interest  in  these  cases  was  the  associated  epilepsy,  and  it  has 
been  my  study  to  inquire  into  the  nature  of  the  attacks, 
their  onset  and  course,  in  order  if  possible  to  see  whether 
any  difference  existed  between  them  and  those  of  idiopathic 
epilepsy,  inferring  if  none  can  be  found,  or  at  least  if  no 
well-founded  and  persistently  acting  difference  exist,  that 
in  all  probability,  the  seat  of  the  disease  in  idiopathic 
epilepsy  must  be  in  the  same  region  and  probably  of  like 
nature  as  in  spastic  hemiplegia,  although  not  so  marked 
in  its  changes.  Perhaps  the  most  distinctive  characteristic 
of  epilepsy  is  the  loss  of  consciousness,  coming  on  suddenly. 
In  Jacksonian  epilepsy  the  consciousness  is  often  involved, 
but  here  we  have  a  case  of  convulsions  due  to  mechanical 
irritation  corresponding  to  the  physiological  experiments 
of  the  laboratory.  The  intelligence  of  the  patient  is  also 
much  less  apt  to  be  affected  than  in  petit  mal,  even  when 
the  latter  is  not  associated  with  grand  mal." 

In  cases  of  epileptic  seizures  from  tumors  of  the  brain, 
the  convulsions  may  be  due  to  a  general  pressure  or  dis- 
turbance of  cerebal  circulation  and  its  attacks  are  not 
localized  but  commence  bilaterally,  and  are  preceded  by  loss 
of  consciousness. 

A  statement  of  Luciani,  sustained  by  many  autopsies, 
may  be  of  interest  here,  that  while  a  paralysis  may  be 
strictly  localized  as  to  the  cerebral  lesion,  it  is  not  possible 
to  make  more  than  an  approximate  localization  in  epileptic 
seizures.  This  would  the  more  readily  occur  where  the 
tumor  was  of  large  size  or  of  such  nature,  or  so  situated  as 
to  produce  a  general  disturbance  of  the  circulation.  Such 
cases  are  found  in  the  epilepsy  of  spastic  hemiplegia,  and 
although  the  lesion  is  unilateral  I  find  that  the  attacks 
are  more  often  of  this  character  than  that  of  the 
Jacksonian    type. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  559 

This  then,  approaches  the  form  of  idiopathic  epilepsy 
where  the  marked  feature  is  the  disturbance  of  conscious- 
ness which  precedes  the  convulsion,  and  is  indeed  the  most 
serious  phase  of  the  case,  as  here  the  higher  centres,  the 
latest  evolved,  and  rerepresenting  all  the  lower  centres,  ac- 
cording to  Hughling  Jackson,  are  affected,  and  we  have  the 
resulting  dementia,  or  at  least  feeble  mindedness  so  often 
present.  When,  however,  the  lesion  can  be  localized  as 
due  to  a  circumscribed  pachymeningitis  following  insolation 
for  instance,  the  attack  commencing  with  a  localized  tremor 
or  tingling  preceding  the  loss  of  consciousness,  although 
the  convulsion  may  become  universal  and  of  great  severity, 
still  such  patients  may  live  on  for  years  with  but  slight  if 
any  mental  impairment. 

My  cases  as  I  have  said,  resemble  the  idiopathic  epilepsy 
rather  than  the  Jacksonian  form, contrary  to  the  expectation 
from  the  localization  of  the  lesion  ;  the  explanation  prob- 
ably lies  however  in  the  consideration  that  the  disease  in 
question  is  one  of  early  life,  during  the  most  active  period 
of  cerebral  development,  and  is  always  accompanied  by 
interference  with  this  development  and  the  growth  of  the 
cells  of  the  cortex. 

We  are  justified  by  analogy  to  infer  that  in  idiopathic 
epilepsy  the  seat  of  the  disease  lies  in  the  cortex  cells,  and 
consists  in  a  primary  change  in  their  nutrition.  That  it  is 
primary  and  not  induced  by  any  disturbance  of  circulation 
following  the  convulsions  would  seem  to  be  clinically 
proven  by  the  fact  that  in  many  cases  of  petit  mal,  when 
convulsion  can  be  excluded  the  mental  disturbances  are 
the  most  marked. 

In  looking  over  my  cases  of  idiopathic  epilepsy  I  find 
mental  weakness  almost  invariably  present.  As  Luciani 
has  well  stated,  "the  central  organ  for  epilepsy  upon 
which  its  pathology  substantially  rests  is  always  the  com- 
plex of  the  motor  centres  of  the  cortex,  whether  the  irrita- 
tion arises  directly  or  reflexly."  Thus,  any  internal  organ 
or  any  portion  of  the  periphery  may  become  a  epilepto- 
genous  zone  for  the  origin  of  an  epileptic  seizure,  but  this 
does    not   result    unless    the    cortex    is    in    a    condition    to 


560  AMERICAN-NEUROLOGICAL  ASSOC/AT/OX. 

respond  to  the  irritation,  in  other  words,  unless  we  have  a 
morbid  condition,  in  which  case  the  equilibrium  or  stability 
of  the  cells  is  easily  disturbed. 

Thus  it  is  that  heredity  becomes  as  important  a  factor 
in  prognosis  as  in  other  mental  disorders.  In  conclusion, 
it  is  noticeable  in  these  cases  that  the  great  majority  are 
of  the  hemiplegic  type,  only  one  side  being  involved,  and 
in  several  instances  the  paralysis  was  but  slightly  marked, 
so  that  only  a  careful  examination  revealed  the  fact,  that 
there  was  some  slight  interference  with  the  growth  of  one 
side,  with  exaggerated  patellar  reflex  of  that  side. 

This  would  lead  us  to  a  more  careful  examination  of  all 
cases  of  epilepsy  occuring  in  early  life,  and  probably  many 
now  referred  to  hereditary  or  unknown  causes  can  be  more 
properly  classed  as  due  to  cerebral  injury  in  utero,  at  birth, 
or  during  the  first  few  years  of  life.  These  facts  ascertained 
however, do  not  improve  the  prognosis,  as  we  may  see  from 
the  review  of  the  cases  detailed.  In  regard  to  treatment 
I  have  but  little  to  say.  Trephining  after  changes  have 
occurred  in  the  cerebral  and  spinal  structure  would  seem 
useless,  The  removal  of  some  portion  of  the  cortex  where 
the  epileptic  seizures  are  excessive  and  unilateral  in  char- 
acter, at  least  in  the  beginning,  has  proved  in  some  cases 
beneficial.  The  bromides  appear  to  act  as  beneficially  as 
in  ordinary  epilepsy. 

Case  I. — Geo.  T.,  aet.  25,  had  severe  fall  of  two  stories 
when  a  child.  Paralyzed  in  right  arm;  lower  extremity 
unaffected;  arm  and  hand  held  in  position  of  flexion,  but 
can  be  voluntarily  extended.  Seizures  occur  about  once  a 
month.  Patient  very  unintelligent  ;  reflexes  somewhat  in- 
creased, especially  of  right  side.  Warning  of  present  tremor 
commencing  in  right  side. 

Case  II. — Henry  H.,  aet.  17,  paralyzed  at  age  of  two 
years  on  right  side  ;  patellar  reflex  exaggerated  in  affected 
side  ;  marked  contractures  ;  gait  spastic  ;  right  limbs 
smaller  than  left  ;  speech  slow,  patient  unintelligent  ;  left 
internal  rectus  weak.  Attacks  occur  every  three  or  four 
days,  commencing  on  paralyzed  side. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  5 6  I 

Case  III. — James  J.,  aet.  56,  paralyzed  on  right  side  at 
six  years  of  age  ;  one  year  after  had  epileptic  seizures.  At- 
tacks occur  every  four  months  ;  increased  by  drinking  ;  no 
warning.  Patient  presents  usual  spastic  condition  of 
these  cases. 

Case  IV. — Henry  D.,  43;  hemiplegia  at  13  years  of  age; 
no  history  of  rheumatism,  no  cardiac  lesion.  Four  years 
later  first  attack.  Patient  has  been  under  observation  for 
the  past  ten  years  at  the  almshouse.  Attacks  come  on 
without  warning  ;  generally  falls  suddenly  backwards  ;  at- 
tacks vary  from  eight  or  ten  a  month  to  five  in  one  night  ; 
any  excitement,  joy  or  sorrow,  will  bring  one  on  ;  speech 
unintelligible  and  general  intelligence  growing  less. 

Case  V. — Geo.  Y.,  aet.  25,  spastic  hemiplegia  from  3 
years  of  age.  Attacks  about  once  a  week  ;  no  warning  ; 
not  limited  to  or  beginning  on  paralyzed  side  ,  dementia. 

CASE  VI. — James  L.,  55,  right  leg  amputated  six  years 
ago,  following  injury.  Three  months  later  epileptic  seiz- 
ures; now  about  three  in  a  month.     Memory  good. 

Case  VII. — Arthur  C,  50,  paralyzed  on  right  side  when 
seven  years  old.  Attacks  very  frequently  ;  not  beginning 
or  limited  to  one  side  ;  no  warning  ;  speech  unintelligible  ; 
dementia. 

CASE  VIII. — John  K.,  19,  right  hemiplegia  following 
fall  at  two  years  of  age.  Attacks  nine  to  fourteen  a  month; 
generally  no  warning  ;  dementia.  Reflexes  exaggerated 
on  both  sides,  most  marked  on  the  right. 

Case  IX. — Wm.  L.,  26,  hemiplegia  resulting  from  a  fall 
at  age  of  three.  Attacks  five  to  nine  a  month  ;  generally 
warning  of  dizziness  ;  reflexes  but  slightly  exaggerated  ; 
dementia. 

Case  X. — John  H.,  24,  congenital  paralysis  of  right  side. 
First  seizure  at  age  of  thirteen;  no  warning;  generally  about 
one  a  month  ;  feeble-minded. 

CASE  XI. — Martin  K.,  28,  congenital  left  hemiplegia 
with   epilepsy.     Attacks  six  to  nine  a  month  ;  warning  of 


562  AMERICAN  NEUROLOGICAL  ASSOCIATION 

dizziness.     Attacks  not  limited  to  or  commencing   unilate- 
ally  ;  weak-minded. 

Case  XII. — Wm.  H.,  aet.  26,  hemiplegia  of  right  side 
following  blow  on  left  side  of  head.  Arm  and  leg  much 
contracted.  Equino  varus  ;  seizures  two  or  three  a  month; 
warning  dizziness  ;  attacks  general  ;  speech  slow,  scarcely 
intelligible  ;  partial  dementia. 

Case  XIII. — Patrick  C,  aet.  49,  family  history  negative. 
Patient  gives  history  of  syphilis  and  alcoholism,  no  cardiac 
lesion.  Ten  years  ago  had  attack  of  vertigo  and  nausea;  un- 
conscious for  two  months,  and  gradual  loss  of  power  on  left 
side.  One  year  later  had  first  epileptic  seizure,  which  now 
occur  about  every  three  months  ;  no  warning,  never  bites 
the  tongue.  Attacks  general,  heretofore  commencing  on 
the  paralyzed   side. 

Case  XIV. — Frank  R.,  aet.  22,  perfectly  well  up  to  nine 
years  of  age,  when  he  fell,  breaking  bridge  of  nose.  Left 
leg  dragged  slightly  in  walking  ;  both  patellar  reflexes 
somewhat  exaggerated.  Patient  says  that  the  attacks  be- 
gin by  twitching  in  the  left  leg  which  passes  to  the  right  leg, 
and  then  he  loses  consciousness.  At  outset  cries  out, 
"  No  !  no!"  as  if  in  fear.  This  can  be  checked.  About 
one  year  ago,  while  attacks  were  very  frequent  for  ten 
weeks  had  spasmodic  attacks  in  one  arm  (?)  in  which  ham- 
mer-like strokes  were  kept  up  by  the  hour.  The  patient  semi- 
conscious and  moaning  as  from  fear.  Attacks  of  late  under 
large  doses  of  bromide  much  reduced  ;  patient  is  unable  to 
read  well,  is  slow  of  speech,  feeble  minded,  but  possesses 
considerable  talent  in  drawing. 

Case  XV. — John  H.,  aet.  32.  Hemiplegia  following 
scarlet  fever  at  age  of  three.  No  history  of  otitis  ;  hearing 
good  ;  spastic  condition  excessive  ;  marked  tremor  on  vol- 
untary action  ;  athetoid  movements  of  fingers  ;  equino 
varus.  First  fit  at  fourteen  years  of  age;  generally  preced- 
ed by  dizziness.     Patient  fairly  intelligent. 

Case  XVI. — Henry  Z.,  aet.  30.  Congenital  right  hem- 
iplegia ;  marked  flexion   elbow  and   wrist  ;  gait  markedly 


AMERICAN  NEUROLOGICAL  ASS0C1A  TION  563 

spastic;  reflexes  exaggerated.  Attacks  begin  on  right  side 
and  always  more  severe  on  that  side  ;  no  warning  ;  imbe- 
cility ;  athetoid  movements  of  fingers  of  right  hand. 

Case  XVII. — John  H.,  aet.  19.  Right  spastic  hemiple- 
gia from  a  fall  at  two  years  of  age.  Spastic  condition 
marked  ;  constant  tremor  of  right  eyelid  ;  patellar  reflex 
not  exaggerated.  Attacks  usually  at  5  A.M.;  no  warning 
and  generally  occurring  about  once  a  week.  Patient  unable 
to  read  or  write. 

Case  XVIII. — James  B.,  aet.  48.  Left  hemiplegia  at 
one  year  of  age,  with  convulsions.  Left  leg  smaller  and 
shorter  than  right  ;  left  hand  tightly  flexed  until  age  of  fif- 
teen years.  Can  now  open  it  ;  arm  well  developed,  show- 
ing but  slight  shortening.  Excessive  tremor  or  spasm  of 
left  side  of  face  on  talking.  Patellar  reflexes  greatly  ex- 
aggerated on  both  sides  ;  gait  that  of  spastic  paraplegia  ; 
no  epileptic  seizures  since  childhood  ;  intelligence  fair  ;  can 
read  and  write. 

Case  XIX. — John  V..  aet.  35.  Patient  has  had  epileptic 
seizures  since  two  years  of  age.  Attack  commences  with 
feeling  of  numbness  on  left  side.  On  examination  slight 
paresis,  with  exaggerated  patellar  reflex  on  that  side. 
Patient  able  to  read  and  write  a  little. 

Case  XX. — Mary  B.,  aet.  47.  Specific  history,  left  hem- 
iplegia three  years  ago  ;  reflexes  exaggerated  ;  has  had 
two  seizures  since  in  hospital  ;  denies  any  previous  attacks; 
no  warning,  feels  suddenly  both  sides  equally  affected. 
Paralysis  more  marked  for  several  days  following  attack. 
Intelligence  impaired. 

Case  XXI. — Mary  T.,  aet.  29.  Right  hemiplegia  with 
convulsions  following  small  pox  ;  intention  tremor  ;  reflexes 
exaggerated  ;  seizures  very  frequent,  beginning  with  chok- 
ing sensation  ;  uncertain  whether  they  begin  on  paralyzed 
side  ;  patient  imbecile. 

Case  XXII. — Maria  M.,  aet.  32.  Right  hemiplegia  with 
convulsions,  between  two  and  three  years  of  age.  Walk 
markedly  spastic;  attacks  about  once  a  month,  generally  no 
warning.     Imbecile. 


5 64  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

Case  XXIII. — Ida  C,  aet.  32.  Left  spastic  hemiplegia 
with  convulsions  at  six  years  of  age.  Attacks  about  once 
a  month  ;  petit  mal  daily  ;  feeling  of  dizzines  precedes 
attack.     Patient  unable  to  read  intelligently. 

Case  XXIV. — Ada  C,  aet.  34,  left  spastic  hemiplegia, 
with  epilepsy  since  childhood  ;  attacks  about  once  a  month 
at  time  of  menstruation,  warning  in  nature  of  peculiar 
feeling  ;  does  not  commence  unilaterally  ;  feeble  minded. 

CASE  XXV. — Mary  C,  aet.  19,  congenital  right  hemi- 
plegia; arm  flexed  at  elbow  and  fingers  in  hand;  impossible 
to  overcome  contracture  by  force  ;  leg  flexed  at  knee 
and  foot  in  position  of  equino  varus  ;  patellar  reflex  exag- 
gerated on  both  sides,  especially  on  right  side  ;  right  side 
much  shorter  than  left  and  muscles  atrophied  ;  seizures 
mild  but  very  frequent  and  always  commencing  on  para- 
lyzed side  ;  speech  scarcely  intelligible  ;  dementia. 

Case  XXVI. — Louise  W,  32,  congenital  left  hemiplegia; 
contractures  very  marked;  muscles  atrophic  and  considerable 
shortening  of  upper  and  lower  extremities  ;  head  unsym- 
metrical.  Attacks  first  came  on  at  two  years  of  age ; 
warning,  as  of  sensation  of  choking  ;  commences  usually 
on  left  side.  Xo  attacks  for  past  three  years  ;  speech 
intelligible,  but  patient  very  stupid,  unable  to  read  or  count. 

Case  XXVII. — Michael  S.,  aet.  31,  attacks  followed 
measles  at  age  of  two ;  did  not  return  until  twenty-seven 
years  of  age  ;  patient  says,  was  never  paralyzed,  but  on 
examination  find  paresis  of  right  side,  flatness  of  right  side 
of  face  ;  reflexes  exaggerated  ;  patient  says  that  he  has 
always  used  left  hand  more  than  right.  Although  he  went 
to  school  until  fourteen  years  of  age,  can  scarcely  read  ; 
patient  ascribes  this  to  defective  eyesight.  Attacks  of  late 
becoming  more  frequent,  about  one  a  month  ;  no  warning 
and  commence  bilaterally. 

CASE  XXVIII. — A.C.,  aet.  2^, (the  mother,  a  primipara  at 
42  years  of  age,  pregnancy  not  being  suspected, had  by  advice 
of  physicians,  bandaged  herself  rather  tightly  and  taken 
rather  violent   exercise  to  remove  the  supposed  flatulence  ; 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  565 

delivery  however,  natural  and  easy.  The  child  made  no  at- 
tempt to  walk  or  talk  till  two  years  of  age).  About  one  year 
ago  had  epileptic  seizure,  commencing  on  right  side  and  be- 
coming general  ;  remained  more  marked  on  that  side.  Has 
had  two  similar  attacks  since.  On  examination,  child  large 
and  well-developed  ;  gait  spastic,  pushing  one  foot  before 
the  other  and  walking  on  the  ball  of  the  foot  ;  reflexes 
exaggerated,  especially  on  the  right  side  ;  child  able  to  say 
a  few  words  and  beginning  to  show  desire  for  certain 
things  ;  expression  of  face,  idiotic. 

DISCUSSION   ON    DR.   FISHER*S    PAPER. 

Dr.  Knapp.  suggested  the  existence  of  trophic  cell  cen- 
tres in  the  cortex.  He  had  seen  cases  of  infantile  hemi- 
plegia in  which  the  atrophy  was  as  great  as  that  in  many 
cases  of  spinal  paralysis. 

Dr.  G.  E.  Walton  described  a  local  epileptic  attack. 
The  patient  had  been  healthy  to  within  a  few  weeks  when 
the  attacks  had  commenced.  The  convulsion  involved 
the  left  side  of  the  face  ;  there  was  slight  dilatation  of  the 
pupils,  and  the  head  was  turned  over  the  left  shoulder.  The 
hands  were  not  affected,  and  there  was  no  loss  of  conscious- 
ness, but  the  patient  talked  thick  after  the  attack.  This 
seemed  to  be  due  to  difficult  pronation  rather  than  to  apha- 
sia. The  speaker  referred  to  the  question  of  operation.  In 
monkeys  the  centre  for  turning  the  head  was  located  in  the 
first  and  second  frontal  convolution  near  the  ascending 
frontal.  The  centre  for  the  face  and  mouth  would  be  lower 
down. 

Dr.  FlSHER  did  not  find  the  wasting  infantile  hemiple- 
gia so  marked  as  that  in  Dr.  Knapp's  cases.  There  was 
always  some  wasting,  but  he  thought  not  more  than  would 
be  explained  by  disuse.  Another  proof  that  the  epilepsy 
of  this  condition  was  not  of  the  Jacksonian  type  and  de- 
pendent upon  local  lesion  was  the  fact  that  there  was  no 
aura  or  only  an  epigastric  aura  in  these  cases.  According 
to  Luciani  epileptic  seizures  had  but  little  value  for  locali- 
zation compared  with  paralysis. 


^66  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Afternoon  Session. 

Dr.  Robert  T.  Edes,  of  Washington,  D.  C,  read  the  fol- 
lowing paper,  entitled 

THE    RELATION    OF   RENAL   DISEASES   TO   DISEASES   OF 
THE   NERVOUS   SYSTEM. 

The  connection  between  renal  and  nervous  diseases  is  two- 
fold. First,  the  influence  of  renal  disease  in  the  production 
of  diseases  on  the  part  of  the  nervous  system  ;  and,  second, 
the  influence  of  nervous  diseases  in  producing  renal  symp- 
toms. It  is  only  the  first  of  these  to  which  I  shall  do  more 
than  allude. 

A  great  deal  of  observation  and  experiment,  to  say 
nothing  of  much  theorizing,  has  been  lavished  on  the  first 
part  of  the  question,  to  determine  the  precise  nature  of  the 
relationship;  the  fact  of  such  a  close  relationship  being  one 
of  the  earliest  observed  and  most  important  facts  in  the 
pathology  of  Bright's  disease. 

This  connection  is  usually  expressed  by  the  word 
"uremia,"  and  as  it  is  my  belief  that  a  considerable  confu- 
sion not  only  of  words,  but  of  ideas,  has  arisen  from  the 
general  and  undefined  use  of  this  term,  and  that  it  is  easier 
to  get  rid  of  the  errors  connected  with  it  by  simply  drop- 
ping the  whole  thing  together,  than  by  endeavoring  to 
establish  a  correct  definition,  I  shall  use  "uremic"  only  in 
the  old  sense  to  denote  phenomena  connected  with  the 
nervous  system  occurring  in  the  course  of  renal  disease, 
and  not  as  carrying  with  it  any  theory  whatsoever  ;  and 
adopt  for  purposes  of  classification  certain  others  which  do 
express,  as  I  consider,  more  accurately  the  true  pathology. 

The  word  "uro-toxic"  speaks  for  itself,  and  means — per- 
taining to  poisoning  by  the  retention  of  substances  con- 
tained in  the  urine.  Another  class  of  symptoms  might  be 
called  "uro-septic,"  but  with  these  we  have  less  to  do  than 
the  surgeons,  to  whom  it  is  of  great  interest  in  connection 
with  lesions  and  operations  in  the  lower  urinary  passages. 

For  the  symptoms  dependent  upon  affections  of  the 
vessels,  which    are    recognized    as  playing  so  important  a 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION 


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J 6S  AMERICA X  XECROL  OGICAL  ASSOCIA  TIOX. 

part  in  the  pathology  of  renal  disease,  the  word  "angio- 
pathic  "may  be  used, with  the  subdivisions  "angio-neurotic" 
already  in  use,  and  "angio-notheutic,"  a  word  which  I  owe  to 
the  kindness  and  learning  of  my  friend  Dr.  Fletcher,  and 
which  refers  to  symptoms  or  lesions  dependent  on  organic 
disease  or  degeneration  of  the  vessels  (ayyhox,  a  vessel, 
vopevdiz,  degeneration). 

We  find  as  symptoms  accompanying  acute  and  chronic 
diffuse  nephritis  in  their  various  forms  often  enough  to  be 
legitimately  recognized  as  having  an  intimate  relationship 
therewith,  and  not  being  present  merely  as  coincidences; 
convulsions,  coma,  delirium  sometimes  becoming  insanity, 
headache,  dyspnoea,  failure  of  vision  and  hearing,  paralyses, 
neuralgia,  itching,  sometimes  cutaneous  eruptions,  "  dead 
fingers,"  rarely  symmetrical  gangrene.  These  with  vomit- 
ing, which  is  sometimes  at  least  a  nervous  symptom,  make 
the  group  known  as  uremic. 

It  is  the  object  of  this  paper  to  insist  upon  the  fact  that 
they  are  not  all  urotoxic  and  to  suggest  the  nature  of  the 
pathogenic  connection. 

The  most  obvious  assumption,  that  which  holds  its  own 
to  the  present  day  in  some  form  and  which  does  actually 
cover  a  part  of  the  ground  is,  as  the  name  suggests,  that 
uremic  symptoms  are  due  to  a  retention  in  the  blood  of 
some  excrementitious  substance,  whether  water,  urea,  or 
some  product  of  its  decomposition,  extractive,  potash  salts, 
or  the  totality  of  the  urinary  solids.  Perhaps  we  may  add 
to  this  list  an  alternative  which  seems  to  me  to  have  a  con- 
siderable degree  of  probability  in  its  favor,  but  as  yet  little 
evidence,  that  new  toxic  agents  perhaps  in  the  nature  of  a 
ptomaines  may  be  present  in  some  cases.  This  might  ac- 
count for  the  difference  between  the  great  toleration  of 
anuria  from  the  arrest  of  the  healthy  secretion  by  mechan- 
ical means,  and  the  rapid  supervention  of  symptoms  from  a 
much  less  serious  retention  in  chronic  cases.  This,  how- 
ever, is  for  the  chemistry  of  the  future  to  decide. 

Such  an  accumulation  of  urinary  solids  is  assumed  to 
take  place  when  the  secretion  becomes  deficient  in  quan- 
tity,  and    it   has    been    demonstrated    by    actual    chemical 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  569 

analysis  in  a  certain  number  of  cases,  though  as  a  matter  of 
fact  in  much  fewer  than  might  be  supposed  from  the  fre- 
quency of  the  allusions,  the  water  and  the  urea  as  being 
the  larger  part  of  the  constituents  are  naturally  those  which 
have  been  most  frequently  examined.  Data  in  regard  to 
the  others  are  too  scanty  to  have  great  value 

It  is  not  at  all  certain  that  urinary  constituents  are 
accumulating  in  all  cases  in  which  renal  disease,  even 
advanced,  exists,  and  there  can  hardly  be  a  oetter  instance 
of  the  inconsistencies  of  medical  reasoning  than  the  indiffer- 
ence with  which  the  removal  of  one  kidney  is  spoken  of  in 
trust  that  the  other  will  carry  on  the  work  of  excretion 
thoroughly,  and  the  promptness  with  which  any  symptoms 
that  may  arise  in  any  stage  of  Bright's  disease  are  attributed 
to  a  so-called  uremia.  A  sort  of  reasoning  in  a  circle  takes 
place  by  which  the  pathological  theory  of  uremia  depend- 
ing on  an  accumulation  of  urea  is  proved  by  the  coincidence 
of  these  symptoms  with  known  renal  disease,  and  on  the 
other  hand,  the  diagnosis  of  renal  disease  is  confirmed  by 
the  occurrence  of  symptoms  supposed  to  depend  upon  the 
presence  of  urea  in  the  blood. 

A  deficient  secretion  of  urea  or  a  secretion  considerably 
less  than  that  stated  as  a  physiological  average  may  un- 
doubtedly take  place  in  nephritis,  even  in  the  earlier  stages  ; 
but  it  must  be  remembered  that  the  thirty  grammes  per 
diem,  which  are  often  taken  as  the  standard  and  which,  as 
I  have  elsewhere1  tried  to  show,  are  much  too  large  an  esti- 
mate for  a  considerable  number  of  healthy  persons,  are  not 
applicable  to  all  persons,  and  certainly  not  to  those  whose 
digestion  is  imperfect,  whose  blood  is  deficient  in  red  cor- 
puscles, and  who  are  undoubtedly  making  a  much  less  than 
the  proper  amount  of  nitrogenous  excreta.  The  quantity  of 
urea  varies  from  day  to  day  both  in  health  and  disease,  and  a 
single  observation  cannot  be  properly  regarded  as  conclusive 
of  a  diminished  secretion.  Unfortunately  quantitative  obser- 
vations extending  over  several  days  are  not  so  numerous  as 
is  desirable.     Twenty  grammes  is  probably  a  better  aver- 

1  Read  before  Association  of  Physicians,  1888. 


5  JO  AM  ERIC  AX  XE I  'ROL  OGICAL  A  SSOCIA  TIOX. 

age  for  many  persons,  and  low  feeding  and  old  age  as  well 
as  many  diseases  which  have  nothing  to  do  with  the  kid- 
neys, may  bring  it  much  below. 

The  most  convenient  question  with  which  to  approach 
this  inquiry  is  not  :  What  are  the  nervous  symptoms  of 
Bright's  disease?  for  this  may  refer  either  to  the  early 
stages,  when  the  exact  amount  of  secreting  tissue  thrown 
out  of  action  is  not  known,  but  which  may,  in  a  great  many 
cases.be  fairly  assumed  to  be  much  less  than  that  removed  by 
the  ablation  of  one  health}-  kidney  out  of  the  pair,  a  loss 
which  we  know  is  perfectly  well  borne;  or  it  may,  and  more 
frequently  does,  refer  to  the  culmination  of  a  long  series  of 
changes  involving  not  only  the  kidneys,  but  heart,  arteries, 
stomach,  and  blood,  and  perhaps  organic  changes  in  the 
nervous  system  itself. 

A  much  simpler  one,  and  one  there  is  an  abundance  of 
clinical  material  to  answer,  is  this,  What  are  the  symptoms 
of  a  total  loss  of  function  of  both  kidney^  ? 

This  is  easy  to  answer.  Cases  of  suppression  of  urine 
occurring  in  persons  free  from  chronic  diffuse  nephritis,  or 
where  such  a  nephritis  as  bearing  on  only  one  kidney,  has 
been  unconnected  with  constitutional  disease,  have  been 
recorded  in  considerable  number,  and  in  fact  they  present 
to  us  a  series  of  pictures  of  as  much  uniformity  as  can  be 
expected  in  clinical  observation.  It  is  interesting  to  notice, 
by  the  way,  how  strong  is  the  influence  of  preconceived 
ideas,  in  the  frequency  with  which  authors  introduce  into 
their  comments  and  into  their  titles  remarks  on  the  absence 
of  the  "usual"  symptoms  of  uremia. 

Dr.  Roberts  says  :  "  When  even  the  suppression  is  abso- 
lute, seven  or  eight  days  elapse  before  the  special  symp- 
toms of  uremic  poisoning  make  their  appearance  ;  but  when 
these  do  appear  the  end  approaches  rapidly,  and  death  is 
not  delayed  beyond  two  or  three  days.  Up  to  the  rise  of 
the  proper  uremic  symptoms  the  condition  of  the  patient  is 
as  a  rule  wonderfully  calm  and  free  from  distress  ;  the  func- 
tions generally  proceed  tranquilly  and  the  intelligence  is 
undisturbed.  The  most  distinctive  and  invariable  of  the 
special    uremic    signs   are    muscular   twitchings.     I    believe 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  5  7  I 

that  these  are  never  wanting.  Contraction  of  the  pupils  is 
also  a  constant  sign,  but  later  in  development  than  the 
muscular  twitchings." 

An  examination  of  the  cases  collected  by  Dr.  Fowler  ' 
and  a  number  of  later  ones,  although  confirming  the  gen- 
eral accuracy  of  this  description  would  lead  to  somewhat 
different  conclusions  in  details. 

The  muscular  twitchings,  although  occasionally  men- 
tioned, are  not  invariably  so.  They  might,  however,  more 
easily  escape  observation  than  some  other  symptoms.  The 
pupils  are  in  some  cases  distinctly  mentioned  as  dilated. 
Somnolence  with  restlessness,  and,  on  the  other  hand,  in- 
somnia are  very  common.  Convulsions  are  occasionally  noted 
but  they  are  by  no  means  so  common  as  one  might  expect 
from  a  comparison  of  these  cases  to  Bright's  disease,  or  in 
fact  as  the  authors  themselves  seem  to  have  expected.  In 
the  fatal  cases  death  has  come  in  two  quite  different  ways. 
In  one  set  the  patient  dies  very  quietly  in  the  full  posses- 
sion of  his  faculties,  and  often  a  few  hours  or  minutes  after 
having  been  up,  or  engaged  in  conversation,  i.  c,  without 
any  of  the  "usual"  uremic  symptoms.  In  the  other,  the 
end  comes  more  in  the  usual  way  after  an  interval  of  the 
more  classical  sopor  and  coma. 

Among  the  symptoms  which  have  a  special  interest  for 
our  present  inquiry,  headache  is  sometimes,  but  not  invari- 
ably, noted,  not  often  spoken  of  as  severe,  and  sometimes  a 
sense  of  pressure  in  the  head.  Dyspnoea  is  noted  in  a  certain 
but  not  large  number. 

We  may  describe  these  cases  in  general  by  saying  that 
the  poison  of  the  urine  is  a  slow  one  which  produces  but 
little  disturbance  for  a  number  of  days,  i.e.,  in  small  dose;  and 
that  a  patient  may  recover  after  days  of  anuria,  having 
hardly  had  an  inconvenient  symptom,  or  at  a  later  period 
after  those  which  are  distinctly  urotoxic. 

When  the  blood  has  been  thoroughly  impregnated 
with  the  poison  an  effect  upon  the  nervous  centres  is  per- 
ceptible, which  may  go  on  to  what  is  generally  considered 
uremia,  but  which  may  produce  death   by  an  action   on  the 

1  Suppression  of  Urine,  New  York,  1881. 


g  -  2  AMERICAN  XEUROLOGICAL  ASSOCIA  TIOX. 

heart  (and  muscles  of  respiration  ?)  before  this  condition 
has  become  at  all  prominent. 

We  may  reckon  as  purely  urotoxic  symptoms  :  insom- 
nia, restlessness,  somnolence,  mild  delirium,  sopor,  and 
coma  ;  muscular  twitching,  muscular  weakness,  rarely  con- 
vulsions, sudden  paralysis  (of  heart  and  respiratory  mus- 
cles ?) ;  sometimes  headache,  sometimes  dyspnoea, sometimes 
hiccough,  frequently  vomiting. 

It  is  not  necessary  to  our  present  inquiry  to  determine 
what  is  the  special  agent  in  the  urine  the  accumulation  which 
gives  rise  to  these  symptoms.  Many  theories,  which  I  will 
not  take  up  your  time  in  detailing,  have  been  framed  and 
put  to  the  test  of  experiment  and  clinical  observation.  The 
objections  to  assigning  this  place  to  urea  were  seen  at  an 
early  day,  and  led  to  the  making  of  the  well-known  ammo- 
nia theory  of  Frerichs  with  its  supplements  and  modifica- 
tions. Recent  experiments  have  shown  that  large  amounts 
of  urea  injected  into  the  blood  of  animals  deprived  of  the 
power  of  re-eliminating,  produces  symptoms  comparable  to 
uremia,  and  a  proportion  of  urea  somewhat  approaching 
that  which  remains  in  the  blood  of  these  animals  has  been 
found  in  a  few  cases  of  uremia  in  man.  It  is  possible  that 
urea  is  the  chief  poison  in  these  cases  of  suppression,  but  it 
is  probable  that  it  is  at  least  assisted  by  the  other  normal 
constituents. 

M'>re  recent  observations  attach  importance  to  other 
constituents  like  extractive,  and  potash  salts,  but  the  most 
hopeful  line  of  investigation  at  present  lies  in  the  investiga- 
tion of  self-formed  poisons  of  greater  subtlety  and  power.' 

How  far  are  these  facts  applicable  to  the  symptoma- 
tology of  chronic  Bright's  disease  in  any  of  its  forms3 

We  meet  with  these  phenomena,  complicated  with  ex- 
treme anemia  and  debility,  with  (edema,  not  only  of  the 
subcutaneous  tissue  but  of  internal  organs  and  with  cardiac 


•he  time  this  paper  was  read  the  author  had  not  seen  the  suggestive  but 

not  quite  conclusive  work  of  Ch.  Bouchard,    "Sar  les  Auto-intoxications,"  Paris, 

Thi-    author    assigns    to   urea    little    or  n.j  part  in  the  total  toxicity  of  the 

urine,  much  more  to  the  potash  salts,  but  concludes  that  there  are  several  poisons 

in  the  urine  nol  yet  to  be  chemically  defined.     They  are  probably  not  alkalosis. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TJON.  5  73 

weakness,  in  the  later  course  and  at  the  end  of  chronic 
nephritis,  and  then  there  is  no  reason  to  find  fault  with  their 
usual  explanation  as  depending  on  a  failure  of  the  kidneys 
to  do  their  work.  They  are  then  not  only  uremic  in  the 
ordinary  sense,  but  truly  urotoxic,  and  we  see  saturation  of 
an  enfeebled  organism  by  a  slowly  administered  poison,  of 
which  the  last  few,  perhaps  larger,  doses  bring  the  symp- 
toms rapidly  on. 

There  are  cases,  however,  where  these  and  other  ner- 
vous symptoms  are  met  with  in  the  earlier  periods  of 
nephritis  of  either  form  before  the  renal  disorganization  has 
reached  an  extreme  grade.  In  some  the  progress  is  un- 
doubtedly toward  atrophy  with  resulting  uremia  ;  in  others 
the  renal  symptoms,  though  undoubtedly  present  and  per- 
haps giving  the  name  to  the  disease,  are  subordinated  to 
the  vascular  and  nervous  ones. 

So  great  may  be  the  disproportion  that  Mahomed,  whose 
early  death  was  so  great  a  loss  to  this  department  of  path- 
ology, used  to  speak  of  cases  of  "  Bright's  disease  without 
nephritis,"  an  error  in  nomenclature  as  it  seems  to  me,  since 
Bright's  disease  ought  to  be  what  Bright  wrote  about,  which 
was  undoubtedly  the  disease  of  the  kidney,  but  yet  indicat- 
ing a  view  to  which  sufficient  attention  is  not  always  paid. 

In  these  the  word  "uremic"  loses  its  usual  or  etymolog- 
ical signification,  and  is  no  longer  synonymous  with  uro- 
toxic. It  is  more  by  analogy  than  by  actual  demonstration 
that  these  symptoms  are  supposed  to  depend  upon  the  same 
accumulation  as  takes  place  in  the  suppression  we  have 
been  considering. 

It  is  found  in  some  of  these  that  there  is  at  the  time  of 
the  outbreak  a  diminution  in  the  amount  of  urine  and  of 
urea,  but  in  many  others  more  or  less  decided  symptoms 
occur  while  the  usual  flow  is  going  on  or,  at  most,  only 
some  hours  after  it  has  become  diminished. 

This  outbreak  of  symptoms  very  soon  after  the  flow  of  urine 
has  become  diminished  as  regards  the  water, but  where  an  in- 
creased specific  gravity  indicates  that  a  considerable  quan- 
tity of  solid  matter  is  still  being  carried  off,  is  called  uremic  ; 
and  yet  if  the   kidneys,  which  are  still   doing  some  work, 


5  74  AMERICAN  NEUROLOGICAL  ASSOCIA  TIOX. 

were  removed  entirely,  as  happened  in  the  case  of  Dr.  Polk 
X.  Y.  Med.  Journal,  Feb.  17,  1883),  or  were  entirely  thrown 
out  of  action  by  any  of  the  numerous  accidents  which  may 
happen  to  the  lower  urinary  passages,  it  would  require 
eight  or  ten  days  for  sufficient  of  the  poison  to  accumulate 
to  produce  the  symptoms. 

It  may  be  said  that  in  such  cases  there  has  been,  not- 
withstanding an  abundant  secretion  of  water,  a  retention  of 
the  solid  elements  of  the  secretion  until  they  have  accumu- 
lated to  just  on  the  brink  of  a  poisonous  dose  which  the 
temporary  anuria  causes  them  to  exceed.  Such  a  kind  of 
retention  seems  possible  when  we  consider  the  separate 
functions  of  the  Malpighian  bodies  and  the  epithelium  of 
the  tubes,  and,  as  regards  any  one  constituent,  it  is  difficult 
to  disprove;  but  if  we  consider  the  water,  the  urea,  and  the 
total  solids,  we  find  that  they  may  be  excreted  up  to  or 
even  during  the  day  of  such  an  attack  in  a  quantity  which 
is  not,  to  be  sure,  equal  to  the  physiological  average,  but  is 
not  below  what  may  be  a  fair  quantity  for  persons  with 
a  much  diminished  tissue  metabolism. 

It  may  be  remarked,  as  bearing  on  the  probability  of 
this  form  of  retention  usually  taking  place,  that  most  of  the 
substances  found  in  the  urine  of  which  we  have  definite 
knowledge  are  diffusible,  some  of  them  highly  so,  and  that  in 
many  cases  of  destruction  of  the  kidneys  by  any  of  the  vari- 
ous lesions  of  the  lower  urinary  passages  it  is  often  remarked 
how  small  a  quantity  of  renal  tissue  suffices  to  produce  a 
large  amount  of  water,  and  that  in  these  cases  uremic 
symptoms  are  deferred  long  after  this  destruction  has  been 
going  on. 

It  is  to  be  noticed  also  that  the  form  of  Bright's  disease 
in  which  we  hear  most  about  its  latency,  where  an  outbreak 
of  uremia  occurs  in  the  midst  of  apparent  health,  is  not  that 
in  which  the  epithelium  is  the  first  to  undergo  degeneration, 
but  the  interstitial,  where  the  vascular  element  is  the  pre- 
dominant one. 

In  looking  over  a  somewhat  voluminous  literature  to 
find  how  close  a  correspondence  exists  between  a  dimin- 
ished diuresis  and  an  attack   of  well-marked    uremia,  it   is 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  575 

quite  clear  that  in  a  large  majority  of  cases  either  a  gradual 
diminution  in  the  amount  of  concentrated  urine  passed,  or  a 
somewhat  slighter  diminution  with  a  low  specific  gravity, 
takes  place  when  uremic  symptoms  are  about  to  occur,  and 
that  the  amount  of  water  and  solids  not  infrequently  in- 
creases coincidently  with  the  remission  of  the  symptoms  ; 
but  there  are  cases  enough  of  an  exceptional  character  to 
show  that  while  we  must  regard  the  ordinary  theory  of  the 
pathogenesis  of  the  severer  and  more  general  symptoms  of 
uremia,  and,  in  particular,  convulsions  and  coma  without 
hemiplegia,  as  the  correct  one,  yet  there  are  cases  to  which 
it  does  not  apply,  and  where  we  must  seek,  if  not  for  an  en- 
tirely different  explanation,  at  least  for  another  factor  of 
great  or  controlling  influence.  In  these  cases  are  found 
chiefly  headache,  dyspnoea  with  Cheyne-Stokes  respiration, 
coma  with  hemiplegia  and  unilateral  convulsions,  but  also 
coma  without  hemiplegia,  and  general  convulsions. 

Bouvat  (These  de  Lyon,  1883,)  reports  the  case  of  a 
man  of  twenty-two  with  an  acute  nephritis,  probably  of 
scarlatinal  origin,  who  had  headache  and  eclampsia.  The 
urine  contained  no  albumen,  but  numerous  granulo-fatty 
casts  and  much  urate  of  sodium.  During  the  time  at  which 
the  attacks  of  eclampsia  were  taking  place,  there  was  no 
mention  of  the  quantity  of  urine,  but  it  was  examined  on 
every  day  and  was  not  said  to  be  scanty ;  two  days  after 
the  last  eclamptic  attack,  and  while  the  patient  was  still 
somnolent,  there  were  seventeen  grammes  of  urea  in  two 
litres  of  water  passed  in  the  twenty-four  hours.  While  the 
patient  was  still  eclamptic  there  were  found  in  the  blood 
seventeen  and  nineteen  centigrammes  of  urea  per  litre,  an 
amount  which  the  author  thinks  sufficient  to  prove  the 
uremic  character  of  the  attacks,  but  which  is  so  little  in 
excess  of  the  normal  amount  (ten  centigrammes  to  the 
litre)  and  so  insignificant  in  comparison  with  the  amount 
which  it  is  necessary  to  inject  in  order  to  produce  decided 
symptoms  in  animals,1  and  which  was  found  in  some  patients 
by  Grehant  and  Quniquaud,2  that  the   case  seems  to  prove 

1  Six  per  cent,  found  in  blood. 

2  Two  to  four  per  cent,  found  in  blood.  Comptes  Rendus  de  l'Academie  des 
Sciences,  1884,  p.  383. 


576  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

the  contrary  theory.  It  is  interesting  to  note  that  delirium 
lasted  for  a  week  after  the  free  discharge  recorded  had  been 
going  on. 

Eiselt  (Aertz.  Ber.  der  K.  K.  Krankenhaus.  Prag.,  1884,) 
reports  the  case  of  a  man  who  had  well-marked  nephritis 
and  at  one  time  maniacal  attacks,  supposed  to  be  uremic, 
with  other  more  usual  symptoms.  At  a  later  period,  after 
passing  1,200,  1,500  grammes  of  urine  of  sp.  gr.  1,008  on 
two  successive  days,  he  had  an  epileptiform  attack  on  the 
day  on  which  the  quantity  rose  to  2,840.  On  the  next  day 
it  was  2,640,  and  he  felt  very  well.  On  three  days,  at  a 
subsequent  period  when  passing  1,300  to  2,600,  with  sp.  gr. 
of  1,006  to  1,016,  he  had  vomiting  and  headache.  Later 
the  urine  diminished  in  quantity,  and  he  had  eclampsia  and 
somnolence  under  the  usual  circumstances,  and  the  autopsy 
showed  granular  kidneys.  Thomayer  in  commenting  on 
this  case  speaks  of  other  cases  reported  by  B.  Strieker  and 
by  Budde,  in  which  uremic  symptoms  occurred  with  a  daily 
amount  of  urine  from  one  to  two  litres.  The  original  re- 
ports of  these  I  could  not  find. 

The  frequent  occurrence  of  headaches,  which  are  often 
so  characteristic  of  interstitial  nephritis  for  years  before 
renal  atrophy  has  advanced  far  enough  to  interfere  with  the 
secretion  of  a  sufficient  amount  of  urea,  is  well  known. 

The  following  cases  show  some  of  the  relations  of  head- 
ache to  urinary  excretion. 

C.  H.  W.,  aet.  40,  commercial  traveller.  Headaches  for 
a  long  time,  growing  worse  and  more  frequent  lately. 
Urine  copious,  with  albumen  and  casts.  Albuminuric  reti- 
nitis, high  arterial  tension,  severe  headache  and  vomiting, 
relieved  by  morphia.  Then  left  hemiplegia  with  relief  of 
headache.  From  time  to  time  until  death,  delirium,  con- 
stant polyuria. 

Solids  in  the  urine  as  calculated  from  the  total  quantity 
and  the  specific  gr.,  (which  of  course  only  gives  a  rough 
approximation), Sept.  21 — 87  grammes;  Oct.  2 — yy  ;  Oct.  13 
—51  ;  Oct.  17 — 18;  Nov.  1  — 100.  At  the  time  of  the  marked 
diminution  of  the  middle  of  October  it  was  noted  that  on 
October  10th  he  had  morphia  with   relief  of   headache   and 


AMERICAN  XE UROLOGICAL  A SSOCIA  TIOX.  577 

was  more  intelligent.  The  scantiness  of  urine  lasted  for 
about  a  week,  during  which  he  had  no  more  severe  head- 
aches, but  was  slightly  delirious,  and  the  next  mention  of 
headache  and  restlessness  occurs  on  October  30th,  several 
days  after  the  urine  had  again  become  abundant,  and  the 
day  before  one  on  which  the  calculation  gives  100  grammes 
of  solids.  Does  not  this  sequence  seem  much  more  like  a 
fall  and  rise  of  tension  than  an  accumulation  of  urinary 
solids  ? 

The  tracing  of  October  19th,  during  oliguria,  but  after 
the  headache  was  relieved,  shows  a  pulse  of  less  than  his 
usual  tension,  though  no  tracing  was  taken  during  the  sub- 
sequent period  of  polyuria. 

The  patient  died  on  December  13th,  and  the  autopsy 
showed  hypertrophy  of  the  left  ventricle  with  tracts  of 
thickening  here  and  there  in  the  aorta.  The  kidneys  were 
firm,  granular,  cystic  and  atrophied.  The  brain  was  un- 
usually firm  on  section,  with  several  small  cyst-like  cavities 
in  the  white  and  gray  substance  and  spots  of  reddish-brown 
in  various  parts  of  the  cortex  and  corpora  striata.  The 
arteries   at   the   base   had   yellowish   patches. 

The  diagnosis  between  Bright's  with  headache  on  the 
one  hand,  and  cerebral  disease  with  polyuria,  no  uncommon 
combination,  on  the  other,  is  not  always  easy.  Albumen 
and  casts  may  be  present  in  either.  Localization  of  the 
headache,  localization  of  any  paralytic  or  spastic  symptoms 
that  may  be  present,  study  of  the  eye  ground  and  of  the 
heart  and  more  than  a  single  careful  urinary  examination 
may  for  a  considerable  time  be  all  that  can  be  depended 
on  to  make  the  distinction. 

Headaches  and  polyuria  are  among  the  angio-neurotic 
phenomena  which  may  belong  to  more  than  one  disease, 
and  it  may  be  that  they  are  not  only  not  uremic,  but,  even 
when  albumen  and  casts  are  present,  not  intimately  con- 
nected with  the  local  renal  disease. 

While  recognizing  the  presence  and  importance  of  the 
uro-toxic  origin  of  headache,  I  cannot  believe  this  to  be  its 
usual  one,  considering  the  absence  or  rarity  of  headache  in 
complete  suppression  of  the   urine,  where  it  ought  to  be 


5  78  AMERICAN  NEUROLOGICAL  ASSOCIA  TIOX. 

present  and  to  increase  in  intensity  pari  passu  with  the 
duration  ;  and  also  considering  its  coming  and  going  in 
ordinary  cases  in  a  way  and  under  therapeutic  influences 
more  consistent  with  a  neurosis  than  with  any  form  of 
poisoning.  If  it  be  said  that  the  relief  which  is  afforded  in 
some  cases  to  the  headaches  of  renal  disease  by  the  hot  air 
bath  is  due  to  the  elimination  of  the  accumulated  urinary 
products  it  may  be  answered  that  the  bath  relaxes  the  arte- 
rioles as  well  as  carries  off  urea,  and  that  the  relief  is  often 
of  too  long  duration  to  be  explained  simply  by  the  removal 
of  a  certain  excess  of  poison  which  must  constantly  be  in 
process  of  renewal. 

P.  W.,  aet.  43,  syphilitic  ?  headaches  for  two  years.  Queer 
feeling  in  head,  left  arm  and  leg.  Convulsion  and  delirium. 
Urine;  low  sp.  gr.,  albumen  and  casts,  no  retinitis.  Fits 
repeated  several  times.  Urine  improved  in  character. 
Headache.  Physical  signs  of  consolidation  and  catarrh  at 
apex  of  right  lung.  Gain  in  weight.  Deep  sleep,  delirium 
and  death. 

Scalp  thick,  calvaria  dense,  thickening  of  dura,  thicken- 
ing of  arteries  at  base,  two  tumors  beneath  the  posterior 
part  of  the  first  temporal  convolution  on  the  right  side. 
Left  kidney  small,  but  normal  in  structure  to  the  naked  eye. 
Right  normal  in  size  with  slight  depressions  and  adhesion 
of  the  capsule  (chronic  interstitial  nephritis  in  incipient 
stages?)  cavity  in  apex  of  right  lung  with  cheesy  contents 
(quiescent). 

Miss  J.  P.,  very  severe  sick  headaches  with  vomiting. 
Intervals  of  freedom.  Albumen  and  casts  in  abundant 
urine,  during  intervals  as  well  as  during  attacks.  Mind 
clear  till  last  day  of  life. 

D.  A.,  at.  34.  Headache,  albuminuric  retinitis,  renal 
hemorrhage,  albumen  ;  granular,  fatty,  and  blood  casts  ; 
abundant  urine,  slight  hypertrophy  of  heart  ;  pain  in  back, 
copious  renal  hemorrhage  soon  followed  by  very  severe 
headache,  coma,  and  death.  Probable  cerebral  hemor- 
rhage. 

Kpilepsy  may  exist  side  by  side  with  chronic  nephritis, 
and  a  short  observation  would   lead   to  either  one  of  two 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  5  79 

opinions,  either  of  them  erroneous,  that  the  epilepsy  pro- 
duced sufficient  congestion  of  the  kidneys  to  cause  casts 
and  albumen,  or  that  the  fit  was  of  a  uremic  character. 

Thos.  Fl.,  hospital  repeater,  aet.  40,  epileptic  as  a  child 
but  not  of  late  years  until  the  present  attack  began,  when 
he  used  to  have  one  or  two  fits  after  drinking.  He  generally 
remained  in  the  hospital  a  few  days  and  was  discharged 
"  relieved  "  or  "  well."  The  urine  always  contained  albu- 
men casts,  which  became  worse  in  character,  and  he  died 
with  chronic  meningitis,  hypertrophied  heart,  and  intersti- 
tial nephritis. 

The  mental  disturbances  occurring  in  connection  with 
renal  disease  have  been  discussed  at  some  length,  and 
spoken  of  as  if  some  special  relation  existed  between  the 
two  conditions.  An  attempt  has  even  been  made  to  give 
such  a  connection  a  medico-legal  importance. 

If  we  go  back  to  our  typical  cases  of  retention,  where  we 
have  the  purest  type  of  urinary  poisoning,  we  find  that 
many  of  them  are  distinguished  by  almost  absolute  men- 
tal clearness  up  to  a  very  late  period,  and  that  in  others  a 
very  mild  delirium  toward  the  last,  and  especially  at  night, 
is  the  utmost  that  can  be  observed  in  this  direction. 

It  may  be  said  with  much  confidence  that  insanity  and 
delirium  are  not  early,  or  distinctive,  or  common  urotoxic 
symptoms. 

At  the  termination  of  chronic  Bright's  disease,  delirium 
is  more  common  and  more  marked  ;  but  here  we  are  deal- 
ing not  only  with  retained  secretion  but  with  anemia,  mal- 
nutrition, cardiac  weakness,  and  other  conditions  which 
produce  delirium  in  many  other  diseases. 

An  association  with  the  peculiar  nervous  restlessness 
of  interstitial  nephritis  is  quite   common. 

In  examining  those  cases,  of  which  there  is  no  in- 
considerable number,  where  insanity  in  various  forms, 
mania  with  excitement,  lypemania  with  fixed  delusions 
are  present  together  with  renal  disease,  it  may  be 
remarked,  in  the  first  place,  that  some  of  them  do 
not  bear  a  rigid  scrutiny  as  cases  of  nephritis.  In 
those  where  both  affections  are  undoubtedly  present,  it  is 


g SO  AMERICAN  NEUROLOGICAL  ASSOC IA  TIOX. 

true  that  in  the  later  stages  of  the  renal  disease  the  urinary 
poisoning  is  one  factor,  but  in  others  the  insanity  is  too 
early  a  symptom  to  be  attributed  to  urine  poisoning.  In 
one  case  given  by  Dieulafoy  (Gaz.  Hebd.,  1845),  where  a 
man  had  attacks  of  hysterical  violence,  terrific  hallucina- 
tions, lypemania,  delirium  of  persecution,  the  urine  was 
scanty  but  contained  39.9  per  litre  of  urea.  The  patient 
recovered  so  far  as  his  mental  symptoms  were  concerned, 
and  died  two  years  later  in  coma  without  delirium. 

A  case  reported  by  Raymond  (Arch.  Gen.  de  Med., 
1882,)  is  of  much  interest  as  showing  the  relations  of  deli- 
rium to  the  excretion  of  urea. 

A  woman,  aet.  66,  had  severe  dyspnoea,  with  Cheyne- 
Stokes  respiration,  and  entered  the  hospital  on  July  20th. 
On  this  day  she  passed  1,450  gr.  of  urine  with  18.7  of  urea 
in  the  twenty-four  hours. 

She  continued  to  pass  from  12  to  18  grammes  every  day 
until  the  27th,  when  she  began  to  be  delirious. 

There  was  then  a  period  of  three  days  in  which  no  urine 
was  passed  (or  none  reported),  and  after  this  a  much  dimin- 
ished secretion.  It  was  not  until  nearly  a  month  after  the  first 
diminution  of  urine  that  the  patient  became  comatose. 

As  the  patient  was  on  an  exclusive  milk  diet  it  is  hardly 
to  be  supposed  that  with  this  amount  of  excretion  there  could 
have  been  Jane  accumulation  of  urea  at  the  time  when  the 
delirium  began,  though  afterwards  the  increasing  somno- 
lence was  probably  due  to  gradual  accumulation  of  the 
urinary  poison. 

The'autopsy  confirmed  the  diagnosis  of  chronic  nephritis. 

The  connection  is  that  of  insanity  with  any  severe  de- 
pressing disease  with  a  brain  which  may  be  disturbed  by  any 
one  of  several  causes. 

It  may.be  perfectly  proper  to  speak  of  the  insanity  of 
Bright's  disease,  or  of  "  Folie  Brightique,"  as  a  concise 
method  of  indicating  the  exciting  cause,  but  not  as  denot- 
ing a  special  form  of  insanity. 

Much  interest  has  been  recently  awakened  in  a  class,  or 
two  classes,  of  cases  highly  important  in  themselves  and 
calculated   to   throw  light  on    the   pathology  of  so-called 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  5  8  I 

uremia.  I  refer  to  those  where  symptoms  that  would  nat- 
urally lead  to  a  diagnosis  of  a  localized  cerebral  lesion, 
such  as  hemorrhage  or  embolism,  are  shown,  either  by  the 
rapidity  with  which  they  disappear  or  by  an  autopsy,  not  to 
be  so  caused  ;  or  where  the  suddenness  and  severity  of  an 
apoplectiform  attack,  especially  but  not  exclusively  in  old 
people,  lead  to  a  similar  diagnosis  with  a  similar  result. 
These  are  the  "serous  apoplexies"  of  a  former  generation 
and  the  uremia  of  latent  Bright's  disease  of  the  present. 

They  are  not,  however,  necessarily  uremic  even  in  the 
widest  sense  of  the  word,  although  it  is  true  that  a  great 
many  of  them  are.  Still  less  are  they  urotoxic.  From  the 
character  of  the  lesion  they  may  occur  in  any  disease  with 
a  feeble  circulation  and  that  condition  of  the  vessels  and 
blood  which  permits  an  easy  and  rapid  escape  of  serum  into 
the  surrounding  tissues  ;  and  as  these  conditions  are  fre- 
quently met  with  in  advanced  Bright's  disease,  it  is  not 
strange  that  the  combination  should  be  a  common  one. 

In  many  of  the  cases  reported  the  urine  at  the  time  of 
the  accident  has  been  found  to  be  scanty,  but  it  is  by  no 
means  invariably  the  case  that  there  is  any  evidence  of  a 
long  accumulation,  nor  is  the  urine  always  extremely  scant}-, 
and  as  most  of  these  cases  occur  in  old  persons  where  the 
normal  amount  of  urea  is  considerably  reduced  (say  to 
eight  or  ten  grammes  per  diem),  it  is  not  at  all  certain  that 
the  full  amount  formed  may  not  be  secreted. 

The  great  frequency  of  cerebral  hemorrhage  in  intersti- 
tial nephritis,  referrible  to  disease  of  the  arterioles  and  to 
high  vascular  tension,  is  well  known.  A  certain  proportion 
of  unilateral  symptoms,  and  some  general  ones  like  coma, 
and  perhaps  rarely  convulsions,  are  thus  caused  ;  and  the 
headaches  which  precede  them,  as  in  a  case  already  re- 
ported, are  probably  connected  with  the  organic  changes 
in  the  vessels,  or  with  their  condition  of  fullness  rather  than 
with  any  assumable  excess  of  urea.  To  these  cases,  how- 
ever, having  an  actual  and  well-defined  lesion,  it  is  very 
properly  not  usual  to  apply  the  word  uremic  even  if  they  do 
accompany  renal  disease.  It  is  understood  that  it  is  the 
vessel  and  not  the  blood  which  is  at  fault. 


5  8  2  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

It  is  certainly  repugnant  to  our  notions  that  a  poison 
gradually  diffusing  itself  throughout  the  system  should  be 
supposed  to  affect  only  one  side  of  the  brain,  and  where  we 
fail  to  find  hemorrhage  or  closure  of  the  vessels  we  natur- 
ally look  for  some  other  factor  to  determine  the  localiza- 
tion. In  most  of  these  cases  a  state  of  things  is  found  to 
exist  in  the  brain  which  has  before  been  invoked  to  explain 
the  general  symptoms  of  uremia  when  the  chemical  theories 
have  been  deemed  insufficient  ;  but  having  been  found  not 
to  exist  in  all  cases,  and  thus  being  inadequate  for  a  general 
theory,  has  been  overlooked  or  regarded  as  of  little  impor- 
tance. It  is  not  so  obvious  as  hemorrhage  or  softening,  and 
may  easily  escape  attention,  especially  when  the  tendency 
is  to  regard  it  as  a  common  condition  and  not  distinctive  of 
anything  in  particular.  This  is  oedema  of  the  cerebral  tis- 
sue with  or  without  an  increase  of  fluid  in  the  ventricles. 
Such  a  condition  may  give  rise  either  to  no  symptom  at  all 
or  to  the  most  serious  ones,  according  to  its  degree,  and  the 
symptoms,  when  present,  may  be  either  generalized  or 
local  according  as  the  lesion  involves  a  large  part  of  the 
cerebral  centres  or  a  limited  area  in  the  motor  region. 

(  me  obvious  objection  to  accepting  this  lesion  as  an  effi- 
cient one,  beside  the  fact  that  it  is  often  present  without 
symptoms,  is  that  in  the  great  majority  of  cases  where  hemi- 
plegia has  been  present  there  has  been  no  discernible  differ- 
ence in  the  two  sides  of  the  brain. 

A  slight  difference  in  the  degree  of  cedema  between  the 
two  sides,  or  even  more  narrowly  limited,  would  be  very 
difficult  to  demonstrate,  but  might  yet  be  sufficient  to  make 
the  distinction  between  the  paralysis  of  one  side  and  the 
freedom  of  the  other.  It  is  certainly  much  easier  to  imagine 
this  than  a  restriction  of  the  action  of  a  poison  circulating 
in  the  blood  to  one  side  of  the  brain.  CEdemas  limited  to  a 
small  area  have  been  noted  in  other  parts  of  the  body.  In 
a  case  of  Dewevre  (Lyon  Med.,  1886,  p.  133),  a  patient  who 
had  "uremic  "  hemiplegia,  had  a  few  days  previous  a  transi- 
tory, circumscribed  cedema  on  the  back  of  one  hand. 

In  a  few  cases,  however,  a  difference  in  the  degree  of 
ma  on  the  two  sides  has   been  noted,  or  a  limited   area 


D*3 

of  well-marked  anemia,  or  a  difference  of  dilatation  of  the 
lateral  ventricles.  What  should  give  rise  to  a  greater  de- 
gree of  oedema  upon  one  side  than  the  other,  it  is  impossi- 
ble to  say  with  certainty  ;  but  one  who  has  watched  the 
rapidity  with  which,  especially  in  debilitated,  emaciated, 
and  flabby  patients,  the  fluids  of  anasarca  will  seek  the  de- 
pendent parts,  will  have  no  difficulty  in  admitting  the 
possibility  that  even  so  slight  a  circumstance  as  a  person 
sleeping  upon  one  side  rather  than  the  other  might  be 
enough  to  make  the  difference. 

To  illustrate  the  difference  in  symptoms  which  may  come 
from  a  moderate  inequality  of  pressure  on  one  side  when  both 
sides  are  affected  by  the  same  lesion,  I  may  mention  the  case 
of  a  man  picked  up  unconscious,  where  coma  and  a  well- 
marked  hemiplegia  led  to  a  diagnosis  of  hemorrhage  or 
softening,  but  where  an  autopsy  showed  that  an  acute  men- 
ingitis of  the  convexity  was  the  real  lesion,  the  prominence 
of  the  paralytic  symptoms  on  one  side  being  accounted  for 
by  the  greater  thickness  of  the  purulent  layer  upon  the 
opposite  surface  of  the  cerebrum. 

So  it  is  not  taking  a  long  step  in  the  dark  to  infer  that 
the  symptoms  which,  according  to  all  physiological  laws, 
ought  to,  and  in  the  great  majority  of  cases  do,  point  to  a 
focal  lesion  of  some  sort,  do  so  in  these  cases  as  well,  and 
that,  as  no  other  lesion  is  found,  oedema  is  sufficient. 

If  we  wish  to  ascertain,  by  an  examination  of  the  excre- 
tion, whether  there  is  a  more  or  less  remote  connection 
between  urinary  retention  and  the  appearance  of  the 
symptoms,  that  is,  whether,  even  if  we  cannot  look  upon 
them  as  directly  urotoxic,  they  may  not  be  indirectly 
so,  we  have  by  no  means  so  many  facts  to  guide  us 
as  might  appear  from  the  literature  of  the  subject,  al- 
ready becoming  voluminous  in  comparison  with  the  length 
of  time  which  has  elapsed  since  it  was  considered  that  the 
presence  of  a  distinct  paralysis  settled  the  diagnosis  as 
against  uremia.  Most  of  the  reports  of  these  cases  content 
themselves  with  a  statement  as  to  the  presence  or  absence 
of  albumen  or  sugar,  which  of  course  only  implies  that  there 
was  not  absolute  anuria.    Even  when  a  little  more  than  this 


5 84  AMERICAN  XE L 'R0L0G1CAL  A SSOCIA  TIO.\ . 

tated,  it  is  curious  to  see  how  few  physicians  remember 
that  to  get  a  product  you  must  have  a  multiplicand  and  a 
multiplier  both.  "Urea  diminished"  usually  means  per- 
centage diminished,  a  statement  of  very  little  value  alone. 

Neither  is  the  fact  that  at  the  moment  of  a  paralytic  or 
convulsive  seizure  the  urine  is  scanty,  any  proof  of  an  ac- 
cumulation. As  we  have  repeatedly  had  occasion  to  recall, 
it  requires  a  week  or  more  to  fully  develop  purely  urotoxic 
symptoms.  Any  severe  shock  or  nervous  affection  may 
check  for  a  time  the  flow  of  urine,  and  a  few  hours'  sup- 
pression is  much  more  likely  to  be  the  result  than  the  cause 
of  an  apoplectic  attack.  In  fact  we  know  that  alone  it  can- 
not be  the  cause  in  so  short  a  time. 

In  the  cases  given  by  Raymond  (Revue  de  Med.,  1885), 
in  not  one  have  we  the  means  of  judging  even  approxi- 
mately of  the  amount  of  urinary  solids  discharged.  We  can 
only  say  that  there  was  not  actual  suppression,  or  near 
enough  to  it  to  excite  remark.  The  cases  of  Chantemesse 
and  Tenneson  give  no  available  data  except  that  the  urine 
is  not  expressly  stated  to  be  scanty,  and  in  one  case  it  had 
the  specific  gravity  of  1017. 

Florand  and  Canniot  (Gaz.  Med.  de  Paris,  1886,  p.  532) 
report  two  cases,  in  the  first  of  which  the  urine  was  dark 
and  scanty ;  and  in  the  other,  where  a  hemiplegia  lasted 
from  the  4th  to  the  12th  of  October,  with  severe  headache 
but  no  loss  of  consciousness,  the  urine  was  clear,  not  albu- 
minous, and  passed  frequently  in  small  quantities.  In  their 
remarks  they  use  the  expression  "  normal  condition  of 
urine."  In  this  case  there  was  no  obvious  focal  lesion,  but 
oedema  of  the  brain  and  granular  kidneys. 

Buckling  (Brit.  Med.  Jour.,  1886,  II.  1076)  reports  the 
case  of  a  woman  of  62  with  hemiplegia  of  this  kind,  which 
recovered,  and  who  passed  an  average  of  forty  ounces  a  day 
with  one  per  cent,  of  urea.  This  would  give  about  twelve 
grammes  of  urea,  a  quantity  below  the  assumed  physiologi- 
cal average,  but  perhaps  not  below  what  we  have  a  right  to 
expect  from  a  patient  of  that  sex,  age,  and  condition  ;  nor 
approaching  the  condition  of  anuria,  which,  we  must  con- 
stantly repeat,  takes  a  week  at  least  to  produce  decisive 
results. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  585 

It  is  certainly  a  most  unfounded  assumption,  in  the  face 
of  the  statements  of  the  diminution  of  urea  in  old  age,  to 
suppose  that  all  nervous  symptoms  in  old  persons  not  ac- 
counted for  by  some  other  obvious  lesion  are  due  to  the  senile 
kidney  and  consequent  uremia.  As  is  elsewhere  remarked, 
there  is  no  reason  to  suppose  that  the  atrophy  of  the  kidney 
is  out  of  proportion  to  the  diminished  vital  metamor- 
phosis. 

Hemiplegias  without  hemorrhage  or  softening  are  not 
confined  to  renal  cases.  An  elderly  colored  woman,  who 
had  had  for  months  swelling  of  the  face,  legs,  and  abdomen, 
with  headache,  dyspnoea,  and  palpitation,  entered  the  Bos- 
ton City  Hospital  with  general  anasarca  of  a  passive  kind 
affecting  the  hands  and  the  dependent  portions  of  the  body. 
There  was  nothing  decisive  about  the  heart.  The  urine 
contained  considerable  albumen  and  casts,  not  of  blood  or 
waxy.  The  urea  was  noted  as  forty-one  grammes  per  litre. 
A  few  days  after  she  had  a  sudden  hemiplegia  without  loss 
of  consciousness. 

The  autopsy,  made  by  an  exceedingly  careful  patholo- 
gist, disclosed  no  plugging  of  the  arteries  or  hemorrhage  in 
the  brain. 

There  was  some  dilatation  of  the  heart,  though  the  mus- 
cular substance  was  firm.  The  kidneys,  though  slightly 
reduced  in  size,  showed  no  signs  of  nephritis,  the  diagnosis 
of  the  pathologist  being  "chronic  cyanotic  induration." 

In  some  other  cases  reported  it  is  very  possible  that  the 
renal  element  may  not  be  the  controlling  one,  but  rather  a 
condition  of  cardiac  failure  and  more  or  less  localized  vaso- 
motor paralysis. 

Level  (These  de  Paris,  1888),  who  rejects  the  oedema 
theory,  reports  cases  of  this  kind  where  nothing  was  found 
in  the  brain — one  of  these  which  seems  to  be  of  the  kind 
where  the  exception  proves  the  rule.  A  woman,  aet  70,  was 
brought  into  the  hospital  with  complete  resolution  of  the 
four  limbs,  conjugate  deviation  of  the  eyes  to  the  right,  and 
deviation  of  the  labial  commissure  in  the  same  direction. 
There  was  absolute  insensibility  of  the  left  side. 

Two  days  afterwards  the  paralysis  had  disappeared  ex- 


586  AMER/CAX  XEi'ROLOGICAL  ASSOCIATION. 

cept  the  deviation  of  the  eyes,  but  the  coma  continued,  and 
she  soon  died.  There  was  atrophy  of  the  kidneys  depend- 
ing on  cancer  of  the  uterus,  and  the  consequent  stoppage  of 
the  ureters.  The  heart  was  hypertrophied,  but  the  brain 
was  absolutely  healthy,  with  very  little  atheroma  of  the 
arteries  at  the  base.  Such  a  case  as  this  is  open  to  any 
theory,  but  cedema,  which  may  be  local  and  transitory, 
can  certainly  be  made  applicable  quite  as  easily  as  uremia 
which  certainly  is  never  local. 

Certain  experiments  of  Raymond,  which  show  that  a 
unilateral  lesion,  the  obvious  effects  of  which  have  disap- 
peared, is  sufficient  to  give  a  unilateral  form  to  accidents 
due  to  urinary  poisoning  at  a  subsequent  period  are  very 
interesting. 

This  hypothesis  of  a  lesion  which  does  not  destroy  the 
nervous  elements,  but  is  in  fact  compatible  with  a  complete 
and  rapid  restoration  of  their  function,  or  which  may  on  the 
other  hand  so  completely  throw  a  large  portion  of  the  brain 
out  of  action  as  to  cause  rapid  death,  is  not  a  new  one  in 
pathology.  Besides  its  having  always  held  a  sort  of  reserve 
position  in  the  present  connection  we  are  familiar  enough 
with  something  like  it  in  the  so-called  "congestive  attacks" 
of  coma  or  hemiplegia  or  excitement  in  the  course  of  gen- 
eral paresis,  or  in  the  partial  and  often  more  or  less  transi- 
tory paralyses  of  cerebral  syphilis  attributable  to  a  spas- 
modic action  of  arteries  already  narrowed  by  a  specific 
endarteritis. 

CEdema  is  well  known  to  depend,  it  not  always,  at  least 
often,  upon  a  certain  vaso-motor  condition,  a  condition 
which  may  be  present  in  the  brain  as  well  as  in  the  subcu- 
taneous cellular  tissue,  and  it  seems  probable  that  we  have 
in  many  of  these  nervous  symptoms  connected  with  renal 
disease  the  results  of  various  vascular  changes,  rang- 
ing from  spasm  to  paralysis  acting  as  exciting  causes  upon 
a  substratum  of  anemia,  hydra.*mia,  and  cardiac  debility, 
and  perhaps  often  of  contamination  of  the  blood  by  retained 
urinary  elements. 

There  are  many  other  nervous  symptoms  which  there  is 
not    time    to    treat    in    detail,  especially  as  my  object  has 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  587 

been  not  so  much  to  describe  them  all  as  to  comment  on 
the  erroneous  pathology  which  groups  them  altogether  as 
uremic.  The  "dead  fingers"  are  so  obviously  a  vaso-motor 
phenomenon  that  they  speak  of  themselves  against  so  com- 
prehensive a  classification.  Amaurosis  and  some  at  least 
of  the  troubles  of  audition  are  probably  referrible  to  the 
same  causes  as  eclampsia.  A  very  important  nervous 
symptom,  and  one  which  is  certainly  at  times  a  urotoxic 
phenomenon,  is  dyspnoea.  This  may  arise  in  the  course  of 
Bright's  disease  from  several  causes,  as  oedema  of  the  glot- 
tis or  of  the  lungs.  The  one  which  concerns  us  is  where 
none  of  these  conditions  is  present.  It  is  then  very  likely 
to  be  associated  with  Cheyne-Stokes  respiration.  Cuffer 
(These  de  Paris,  1878,)  refers  its  causation  to  anemia  and 
the  diminished  capacity  of  the  tissues  for  oxygen. 

In  many  cases  of  dyspnoea  we  find  that  the  urine  is 
diminished,  but  often  it  occurs  when  the  Uiine  is  copious, 
very  early  in  the  disease,  or  at  least  early  in  the  known 
course  of  the  disease. 

Uribe  (These  de  Paris,  1886),  gives  a  case  from  Rosenstein, 
where  attacks  of  dyspnoea  are  noted  at  intervals,  while  the 
patient  is  passing  an  abundance  of  urine,  as  5,000  of  1,008 
sp.  gr.  and  afterwards  from  2,300  to  2,600  of  sp.  gr.  1,009  to 
1,012.  When  intense  dyspnoea  was  noted  the  amount  was 
500  grammes  of  sp.  gr.  1,018.  Still  later  when  there  was 
"extreme  and  continuous  oppression"  there  was  1,500  of 
sp.  gr.  1,015. 

There  was  a  certain  amount  of  actual  pulmonary  lesion 
in  this  case,  but  the  dyspnoea  is  evidently  not  attributed 
entirely  to  this  by  the  reporter.  There  was  hypertrophy- of 
the  heart  and  granular  kidneys. 

In  a  case  of  Hervier  (These  de  Paris)  the  urine  had  al- 
ways been  normal  in  quantity,  the  mind  was  clear,  and 
there  was  no  oedema. 

Fifteen  days  after  beginning  of  the  dyspnoea  there  was 
a  sudden  loss  of  consciousness  with  complete  left  hemi- 
plegia. In  some  other  of  his  cases  the  urine  was  diminished 
in  quantity  and  deficient  in  ureci. 

Waldenburg    reports    the    case  of  a    man   with    uremic 


588  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

asthma,  headache  and  advanced  renal  disease.  He  im- 
proved under  treatment,  and  did  very  well  until  he  had  a 
fit  of  passion,  when  the  headache  reappeared  with  vomiting" 
and  diminution  of  urine  and  tenderness  on  pressure  in  the 
region  of  the  kidneys.  There  was  relief  from  dry  cups  on 
the  loins,  but  he  began  again  to  have  dyspnoea,  the  urine 
being  diminished  one  half.  Digitalis  gave  relief,  but  did 
not  much  increase  the  diuresis,  but  the  reporter  states  that, 
although  the  urine  was  much  less  than  it  had  been,  it  was 
about  equal  to  that  of  a  man  in  health. 

In  a  case  of  my  own  the  patient's  wife  informed  me  that 
her  husband,  at  a  time  when  he  was  still  going  into  town 
to  attend  to  his  business,  used  to  hold  his  breath  so  long 
when  asleep  at  night  that  she  was  frightened.  I  supposed 
this  to  be  Cheyne-Stokes,  which  he  afterwards  manifested 
most  distinctly.  When  he  was  dying  in  coma,  and  his  face 
was  encrusted  with  crystals  of  urea,  the  Cheyne-Stokes  dis- 
appeared and  the  breathing  was  of  the  usual  stertorous 
character.  A  brother  of  this  patient,  with  interstitial  ne- 
phritis, had  the  same  symptom  in  the  most  typical  form, 
but  in  his  case  it  was  among  the  terminal  symptoms. 

The  case  of  Raymond,  already  quoted  in  connection 
with  delirium,  shows  the  coincidence  of  extreme  dyspnoea 
with  an  amount  of  urea  excretion  fully  equal  to  the  forma- 
tion. 

The  causation  of  the  various  nervous  symptoms  of  renal 
disease  (and  the  same  may  be  said  of  many  others  which 
are  beyond  the  limits  of  this  discussion),  is  a  complicated 
interaction  of  several  causes,  in  one  instance  one  condition 
and  in  another,  another  assuming  the  predominace. 

For  the  sake  of  simplicity,  we  may  speak  of  four  princi- 
pal factors  : 

i.  Degeneration  of  the  blood  (anemia,  hydremia,  and 
perhaps  other  less  understood  conditions). 

2.  Poisoning  of  the  blood  (urea,  potash  salts,  extractives, 
ptomaine  ?). 

3.  Disordered  vaso-motor  action  (spasm,  paralysis). 

4.  Vascular  degeneration  (endarteritis,  endophlebitis, 
fatty  degeneration,  miliary  aneurisms). 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  589 

Some  of  the  earlier  symptoms  may  be  of  a  purely  neu- 
rotic character. 

In  some  cases  mechanical  obstruction  or  sudden  paralytic 
or  congestive  anuria  may  bring  the  blood-poisoning  to  the 
front  at  once  and  without  complication,  but,  with  this  ex- 
ception, we  are  seldom  in  presence  of  so  simple  a  state  of 
things. 

In  chronic  Bright's  disease  we  are  likely  to  find  oper- 
ative in  the  earlier  stages  those  causes  which  have  the  least 
to  do  with  marked  organic  changes.  Angio-neurotic  phe- 
nomena, and  perhaps  anemia,  are  in  the  foreground — the 
dead  fingers,  the  headaches,  the  polyuria,  and  the  asthma. 
As  degeneration  of  the  vessels  progresses,  we  have  hyper- 
trophy of  the  heart,  albuminuric  retinitis,  cerebral  hemor- 
rhage, and  cerebral  oedema  ;  and  when  the  kidneys  fail  to 
provide  for  the  necessary  excretion,  the  vomiting,  convul- 
sions, and  coma,  with  a  continuance  of  many  of  the  former 
symptoms. 

The  action  of  certain  drugs  and  therapeutic  measures  is 
very  suggestive  as  to  some  of  these  points  of  pathology,  as 
well  as  practically. 

Ball  and  Jennings  (L'Encephale,  1887,  p.  295),  in  exam- 
ining the  state  of  the  arterial  tension  in  a  case  of  chronic 
morphinism,  find  that  during  the  period  at  which  the  effect 
of  the  dose  has  passed  off  and  the  demand  for  a  new  one  is 
imperative,  ["etat  de  besoin"]  the  sphygmograh  gives  the 
tracing  of  high  tension  which  resembles,  as  is  evident  to 
any  one  familiar  with  this  feature,  the  'condition  found  in 
many  cases  of  Bright's  disease,  and  in  fact  considered  by 
some  persons  as  characteristic  as  the  state  of  the  urine. 
The  comparison  is  expressly  made  by  these  authors. 
This  indescribable  condition  of  distress  of  the  mor- 
phinist, which  probably  brings  as  much  suffering  bodily 
and  mentally  as  anything  short  of  severe  and  constant  pain, 
is  by  no  means  dissimilar  to  the  nervous  restlessness  often 
noticed  in  the  patient  with  chronic  interstitial  nephritis, 
which  probably  has  relations  on  the  one  hand  with  convul- 
sions, and  on  the  other  with  insanity. 

Ball  and  Jennings  find,  as  might  be  expected,  that  the 


590  AMERICAN  NEUROLOGICAL  ASSOCIATIOX. 

dose  of  morphine  which  brings  the  well-known  comfort,  re- 
duces also  the  arterial  tension  to  the  normal  point,  but  not 
only  this,  that  some  other  drugs  which  stimulate  the  heart 
without  raising  or  while  reducing  the  tension  also  bring 
relief.  These  are  sparteine  and  nitroglycerine.  Is  it  not 
more  probable  that  the  great  relief  from  many  uremic  symp- 
toms by  both  well-known  agents,  morphine  and  nitrogly- 
cerine, should  be  much  more  closely  connected  with  their 
action  on  the  vascular  tension  than  on  any  power  which 
they  might  be  supposed  to  have  of  assisting  elimination,  a 
power  which  there  is  not  the  slightest  independent  reason 
to  attribute  to  them  ?  So  far  as  opium  is  concerned  the 
effect  is  undoubtedly  in  the  opposite  direction. 

These  facts  suggest  a  query  which  I  propose  to  this  so- 
ciety with  a  due  sense  of  responsibility  involved  in  an  affirm- 
ative reply,  and  which  I  should  hesitate  much  in  putting  be- 
fore a  less  judicious  body,  namely,  whether  a  physician 
would  be  justified  not  only  in  using  morphine,  as  we  all  do, 
for  the  relief  of  nervous  symptoms  in  the  advanced  stage  of 
Bright's  disease,  but  in  instituting  a  treatment  by  small 
doses  as  soon  as  a  diagnosis  of  chronic  interstitial  nephritis 
with  high  tension  is  established,  using,  of  course,  all  meas- 
ures to  diminish  as  much  as  possible  the  injurious  effects,  in 
the  way  of  diet,  exercise  and  cathartics  ;  or  in  other  words 
making  his  patient  a  careful  morphinist  ?  We  might  go 
further  and  suggest  the  contrast  between  the  calm  of  the 
satisfied  opium  eater  and  the  restless  worry  and  drive 
which  I  believe  to  be  more  than  a  coincidence  in  the  middle 
aged  business  man  who  so  frequently  finds  himself  unex- 
pectedly with  Bright's  disease  in  full  force. 

Copious  diaphoresis  by  the  hot  air  bath,  or  more  re- 
cently under  the  influence  of  pilocartinc  is  well  known  to  be 
among  the  most  efficient  means  of  relief  in  uremic  attacks, 
and  the  explanation  usually  given  is  that  the  urea  or  other 
urinary  poison  is  carried  off  by  the  skin.  It  is  true  that  a 
good  deal  of  water  is  thus  got  rid  of  and  a  certain  amount  of 
urea  and  other  solids  accompany  it;  but  no  analysis  has  yet 
shown  that  all  such  supplementary  outlets  together  cover 
the  normal  amount  for  the  day,  to  say  nothing   of  an   accu- 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  5 9 1 

mulation  for  a  long  time,  such  as  is  demanded  by  the  re- 
tention theory.  The  same  is  true,  so  far  as  the  solids  are 
concerned,  of  the  vomiting  which  carries  off  some  solids  ; 
and  probably  of  the  fecal  discharges  also.  All  these 
emunctories  undoubtedly  afford  some  relief,  but  the  mere 
eliminative  action  cannot  account  for  the  more  continued 
good  effects  which  sometimes  follow. 

Such  measures  have,  however,  this  in  common  with  the 
drugs  we  have  considered,  that  they  relax  a  more  or  less 
extensive  territory  of  arterioles,  and  diminish  the  general 
tension.  Dry  cups  on  the  loins  which  carry  off  nothing  are 
often  useful  in  re-establishing  diuresis.  Bleeding,  which 
can  remove  but  a  small  fraction  of  the  total  urea  in  the 
body  and  which  certainly  cannot  diminish  the  percentage 
in  the  blood,  is  of  undoubted  value  in  some  cases  of  convul- 
sions and  has  also  been  followed  by  prompt  recovery  in 
cases  of  cerebral  oedema. 

DISCUSSION"    OX    DR.  EDES'   PAPER. 

Dr.  F.  X.  DERCUM  agreed  in  a  general  way  with  the 
reader  of  the  paper,  but  thought  that  one  should  be  careful 
about  making  deductions  which  assume  that  urea  is  not 
injurious  to  the  organism,  even  in  the  highest  degree.  It 
does  not  produce  nerve  symptoms  under  the  conditions 
quoted  only  because  the  other  emunctories  act  vicariously. 
The  animal  ultimately  dies  when  these  become  insufficient. 
We  know  too  little  about  the  subject  to  be  able  to  state 
whether  the  phenomena  of  uremia  are  due  to  the  retention 
or  the  perversion  of  this  product. 

Dr.  SEGUIN  added  that  nerve  symptoms  which  might 
be  attributed  to  uremia  were  the  nerve  symptoms  of  the 
prealbuminuric  stage  of  Bright's  disease.  These  were  of 
frequent  occurrence,  consisting  of  a  succession  of  headaches 
and  paresthesias  about  the  head  coexisting  with  high  arte- 
rial tension  and  a  negative  condition  as  regards  symptoms 
of  cerebral  disease.  A  previously  typical  migrane  would 
be  changed  in  character  and  become  more  frequent.  A 
characteristic    headache    of    the    prealbuminuric    stage    of 


592  AM  ERIC  AX  XE I  'ROLOGICAL  A  SSOCIA  TIOX. 

Bright's  disease  was,  however,  of  the  occipital  form,  bilat- 
eral pain  extending  often  into  the  cervical  region.  Occa- 
sionally there  was  increased  action  of  the  heart,  and  usually 
hyaline  casts  were  found  in  the  urine,  but  albumen  rarely 
at  this  stage.  Symptoms  of  indigestion,  too,  were  found  in 
the  formative  stage  of  interstitial  nephritis.  The  paresthe- 
sias about  the  head  are  probably  due  to  increased  arterial 
tension.  The  pressure,  confusion,  and  often  vertigo  are 
generally  wrongly  referred  to  hyperemia  of  the  brain.  The 
speaker  was  not  opposed  to  the  trial  of  the  morphia  treat- 
ment if  the  nerve  symptoms  were  prominent  and  persistent, 
and  if  proper  precautions  could  be  insured  to  prevent  abuse 
of  the  drug.  Still,  advising  such  a  treatment  must  always 
entail  a  heavy  responsibility,  partly  justified  by  the  fatal 
nature  of  the  disease. 

The  speaker  suggested  that  dementia  paralytica  might 
give  rise  to  a  confusion  in  diagnosis.  There  was  a  high 
arterial  tension  in  this  condition  ;  we  might  find  other  signs 
of  a  coexisting  interstitial  nephritis,  so  that  in  some  cases 
the  apoplectiform  and  epileptiform  attacks  may  in  reality  be 
due  to  "  uremia." 

Still,  referring  to  the  difficulty  of  diagnosis,  the  speaker 
related  the  history  of  the  case  of  a  little  girl  suffering  from 
the  ordinary  parenchymatous  form  of  Bright's  disease,  hav- 
ing also  hemiplegic  symptoms  with  localized  spasms  in  one 
hand.  There  were  atrophic  changes  in  the  optic  nerve  and 
retina.  The  question  was  whether  we  had  here  a  condition 
of  uremia  affecting  one  hemisphere  with  albuminuric  retin- 
itis, or  whether  we  had  a  coincidence  of  diseases,  a  tumor 
of  the  motor  region  of  one  side  explaining  the  convulsions 
in  the  hand  and  the  hemiparesis.  The  change  in  the  fun- 
dus oculi  consisted  in  hemorrhages  and  whitish  patches  of 
degeneration  of  evidently  nephritic  origin. 

Dr.  L.  C.  GRAV  referred  to  cases  in  which  the  differen- 
tial diagnosis  was  observed.  A  young  gentleman  of  28 
years,  of  immaculate  habits,  came  home  one  night  with  a 
slight  headache.  At  an  early  hour  the  sister  heard  a 
noise  in  his  vroom,  and  going  in  found  him  dancing  a  jig. 
Afterwards  he    lay  down   and   went  to    sleep.     When    the 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  593 

speaker  saw  him  he  was  apparently  oblivious  to  his  sur- 
roundings, yet  would  respond  to  requests,  but  with  the 
jerky  action  of  a  jumping-jack.  This  patient  finally  had 
convulsions  and  died.  There  was  found  chronic  interstitial 
nephritis,  and,  curiously  enough,  there  was  in  each  middle 
cerebral  artery  a  little  slit  through  which  the  blood  exuded, 
lifting  the  pia.  The  pia  was  not  opaque.  The  hemorrhage 
had  not  affected  the  integrity  of  either  the  pia  or  the  cortex. 
The  arteries  were  not  examined  through  accident. 

Another  case  was  that  of  a  gentleman  for  whom  he  had 
been  consulted  in  regard  to  commitment  to  a  lunatic  asy- 
lum. The  speaker  had  made  it  a  rule  in  all  doubtful  cases 
to  examine  the  kidneys.  There  was  found  well-marked 
pyeluria,  which  was  treated  with  dietetics,  laxatives,  qui- 
nine, and  rest  in  bed.  With  the  disappearance  of  the 
pyeluria,  the  mental  symptoms  improved.  After  some 
indiscretion,  the  pyeluria  returned  and  with  it  the  mental 
symptoms. 

In  another  case  of  Bright's  disease  with  convulsions  and 
death,  there  was  found  a  plug  of  the  basilar  artery,  and,  in 
another,  extensor  paralysis,  symmetrical  and  resembling 
that  of  lead  poisoning,  supervened  a  few  days  before  death. 
The  occipital  headaches  of  nephritis  often  had  a  quasi 
periodicty,  with  marked  relief  for  many  days  from  a  good 
dose  of  quinine. 

The  speaker  also  referred  to  a  curious  case  of  hematurea 
with  granular  casts,  during  which  condition  the  patient 
passed  into  coma  vigil,  when  pulsation  of  the  superficial 
veins  of  the  thorax  appeared. 

On  several  occasions  the  speaker  had  verified  the  test 
proposed  by  Dr.  McBride  for  differentiating  coma  of  Bright's 
disease  from  an  attack  of  hemiplegia.  A  man  woke  up  to 
find  himself  on  the  floor,  and  it  became  uncertain  whether 
he  had  fallen  under  the  influence  of  apoplexy  or  the  coma 
of  Bright's  disease.  The  cutaneous  and  tendon  reflexes 
presented  the  differential  test. 

In  treating  cases  of  nephritis  the  speaker  thought  it 
most  necessary  to  avoid  strain  upon  the  cutaneous  capilla- 
ries.    He  carefully  confined  such  patients  to  the  room  or 


594  AMERICAN  XEUROLOGICAL  ASSOCIA  TIOX. 

bed,  thus  shielding  them  from  the  variations  of  temperature. 
Neglect  of  this  precaution  has  been  followed  by  dangerous 
attacks  ;  while  with  it  cases  will  get  along  without  any 
active  medication. 

Dr.  DERCL'M  stated  that  it  was  his  custom  to  treat  all 
doubtful  cases  as  though  cases  of  Bright's  disease.  A  man 
68  years,  without  any  previous  seizure,  had  twenty-six  con- 
vulsions within  a  short  time,  limited  to  the  right  side  of  the 
body  and  face  ;  he  had  also  one  general  convulsion.  This 
man  was  sweated,  and  recovered  consciousness,  and  was 
now  apparently  well.  There  had  been  evidently  no  hemor- 
rhage. In  a  suitable  case  the  speaker  would  try  the  mor- 
phine treatment  recommended  by  Dr.  Edes. 

Dr.  Zenxer  suggested  localized  cedemas  as  the  origin 
of  the  symptoms  in  such  a  case  or  possibly  a  plug  which 
had  been  subsequently  washed  away. 

Dr.  Edes  stated  that  it  had  been  pretty  well  settled  that 
urea  was  not  a  highly  dangerous  product.  The  relief 
afforded  by  diaphoretics  was  very  slight  compared  to  the 
kidney  elimination.  Morphine  if  used  at  all  in  these  cases 
should  be  used  with  the  greatest  caution  in  the  smallest 
doses  which  would  produce  the  stimulant  effect.  The 
speaker  hoped  that  no  one  present  would  regard  him  as 
having  recommended  the  procedure  promiscuously,  and 
that  if  any  one  did  use  it,  he  would  do  so  upon  his  own 
responsibility,  and  with  regard  to  the  special  case  in  hand. 

The  speaker  thought  it  questionable  whether  Dr.  Seguin's 
instances  of  prealbuminuric  headache  had  preceded  the  kid- 
ney lesion.  The  outbreak  of  these  symptoms  did  not  mark 
the  beginning  of  the  lesion,  which  has  usually  existed  for  a 
long  time. 

In  regard  to  Dr.  Gray's  case  of  coincident  renal  and 
mental  disease  he  could  not  admit  its  oppositeness.  The 
case  was  described  as  one  of  "  pyeluria ;"  the  secreting 
structure  of  the  kidneys  might  not  have  been  invaded  at  all. 


Applied  Anatomy  of  the  Nervous  System,  by  A.  L. 
Ranney,  A.M.,  M.D.  2d  Ed.  D.  Appletcn  &  Co.  1888. 
Dr.  Ranney's  book  on  the  Anatomy  of  the  Neivous  System  is 
well  known  to  most  American  neurologists,  and  dees  not  call  for 
extensive  notice  in  this  journal.  The  criticisms  passed  upon  the 
first  edition  were  so  decided  in  their  tone  that  we  i  aturally  looked 
for  many  changes  in  this  second  edition,  which  the  author  has  "re- 
written, enlarged  and  profusely  illustrated."  That  it  is  rewritten  and 
enlarged  is  very  evident;  that  it  is  profusely  illustrated  falls  a  little 
short  of  the  truth.  The  illustrations  are  so  numerous  that  the 
printed  matter  appears  to  be  a  mere  accompaniment  to  the  text, 
and  we  are  bound  to  add  that  the  illustrations  are  not  always  hap- 
pily chosen.  They  are  culled  from  all  possible  sources,  and  many 
of  them  from  works  that  are  decidedly  antiquated.  The  author 
claims  "  originality  of  treatment  *  *  *,  because  diagrammatic 
illustration  forms  an  important  feature  in  the  author's  system  of 
teaching."  Ingenious  diagrams  are,  to  be  sure,  a  great  aid  in 
teaching,  but  it  is  not  sufficient  merely  to  alter  diagrams  of  other 
authors,  it  is  of  greater  importance  still  to  present  the  subject  in  a 
novel,  or  at  least  an  interesting  fashion.  This,  Dr.  Ranney  has  not 
done  ;  he  presents  an  immense  number  of  theories  and  controver- 
sial facts  on  every  point  that  is  at  all  in  doubt,  and  never  ventures 
to  express  a  decisive  opinion.  The  book  shows  too  plainly  that 
the  author's  own  researches  and  studies  do  not  entitle  him  to  speak 
with  any  sort  of  authority  on  any  subject  treated  in  this  book.  The 
author's  reading  too,  seems  to  be  of  a  peculiar  sort ;  "home  pro- 
ducts "  seem  to  make  a  deep  impression  upon  his  mind,  altogether 
out  of  proportion  to  their  true  worth,  entire  pages  are  quoted  from 
"  home  "  articles,  the  conclusions  are  taken  up  in  the  main  body 
of  the  work,  and  then  a  little  foot-note  is  added  to  say  that  there 
may  still  be  some  doubt  on  this  or  that  point.  This  is  supposed  to 
be  a  text-book  from  which  the  student  is  to  gather  accurate  infor- 
mation, and  Dr.  Ranney  should  have  resisted  the  temptation  of 
placing  all  this  recondite  lore  before  the  student  who  would  rise 
from  a  perusal  of  these  pages  with  the  idea  that  almost  anything 
and  everything  can  be  maintained  with  regard  to  cerebral  anatomy, 
provided  you  can  produce  a  few  neat  looking  diagrams  to  prove  the 
case. 


596  LETTERS  TO  THE  EDITOR. 

We  have  spoken  in  general  terms,  but  it  would  be  impossible  to 
criticise  in  detail.  The  author's  judgment  is  sufficiently  character- 
ized by  the  fact  that  he  reproduces  Luys'  absurd  theories  regarding 
the  thalamus  wnich  every  one  else  has  abandoned  ;  his  account  of 
the  lemniscus  is  a  mixture  of  the  views  of  Flechsig,  Meynert, 
Spitzka  and  others,  and  we  challenge  any  student  to  form  any  sort 
of  idea  of  what  the  lemniscus  is  and  what  it  is  not.  In  reporting 
Goltz's  views  the  author  refers  to  a  method  of  experimentation  which 
Goltz  abandoned  fully  six  years  ago.  Ecker's  well-known  diagram 
of  the  convolutions  is  said  to  be  after  Ferrier  ;  Flechsig"s  diagrams 
are  taken  at  second  and  third  hand,  and  after  they  have  passed 
through  this  piocess  are  slightly  altered  by  the  author. 

Such  criticisms  would  be  unjust,  if  the  author  did  not  point  to 
the  illustrations  as  the  important  feature  of  his  book. 

If  the  author  wishes  to  see  in  what  way  diagrams  can  be  made 
to  subserve  a  useful  purpose,  let  him  consult  Edinger's  little  book — 
a  book,  by  the  way,  which  he  might  have  consulted  with  great  ad- 
vantage to  himself.  If  the  public  calls  for  a  third  edition  of  the 
"Applied  Anatomy,"  we  hope  the  author  will  start  afresh,  that  he 
will  avoid  all  controversial  facts,  and  will  give  the  student  a  more 
concise  account  of  the  anatomy  of  the  central  nervous  system,  and 
fewer  "  pictures." 


betters  ta  the  Editor. 


To  the  Editor  ^/The  Jour,  of  Nervous  and  Mental  Disease. 

Sir: — The  admirable  abstract  of  Marchi's  paper  in 
your  journal  for  August,  1888,  pp.  515-517  contains  the 
terms  optic  thalami  six  times,  and  the  term  corpora  striata 
nine  times  in  addition  to  the  title.  If  I  am  right  in  holding 
that  no  misconception  could  possibly  arise  from  the  employ- 
ment of  the  mononyms  striata  and  thalamic  then  one- 
fiftieth  of  the  entire  abstract,  representing  two  whole  lines 
of  your  valuable  page,  has  been  needlessly  occupied  by 
really  irksome  repetitions,  involving  an  appreciable  loss  of 
time  and  energy  in  writing,  printing  and  reading. 

Burt  G.  Wilder. 


VOL.  XIII.  October,  1888.  tfa.  10 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


(Original  gtrtirUis. 


THE   ANTIPYRETICS— ACETPHENETIDIN    AND 
ANTITHERMIN. 

By  ISAAC  OTT,  M.D. 

ONE  of  my  pupils,  Dr.  Peter  J.  Martin,  in  his  prize 
essay1  has  shown  that  kairin,  hydrochinon,  anti- 
pyrin  and  thallin  reduce  the  heat  production  and 
heat  dissipation  of  animals  thrown  into  an  experimental 
fever  by  puncture  of  the  four  basal  heat  centres.  Drs. 
Wood,  Reichert  and  Hare  previously  had  utilized  the  dis- 
covery of  Drs.  E.  V.  Bergmann  and  O.  Angerer,2  that  pep- 
sin would  produce  fever.  They  studied  the  effect  of  anti- 
pyrin  on  this  fever  and  found  H.  P.  reduced  more  than 
H.  D.  Dr.  Girard3  has  recently  studied  the  effect  of  anti- 
pyrin  in  the  same  manner  as  Dr.  Martin,  by  puncture  of 
the  corpus  striatum.  He  concluded  that  antipyrin  in  physi- 
ological conditions  lowers  the  temperature  of  the  rabbit, 
that  this  agent  efficaciously  combats  the  hyperthermia 
caused  by  irritation  of  a  thermic  centre,  that  in  antipyrinized 
animals  the  puncture  of  the  caudate  nucleus  produced  its 
usual  result.  Sawadowski4  has  also  shown  that  antipyrin 
acts  upon  heat  phenomena  through  the  caudate  nucleus, 
for  when  the  copora  striata  were  removed  this  antithermic 
had  no  effect. 

1  University  of  Penna.,  1887.     Published  in  Therapeutic  Gazette,  1887. 

2  Festschrift  zur  dritten  Saecularfeier  der  Alma  Maximiliana,  gewidmet  von 
der  Medicinischen.     Facultat  Wurzburg,  Band  I,  1882. 

3  Revue  medicale  de  la  Suisse  Romande,  No.  11,  1887. 
'  *  Centralblatt  f.  med.  Wissenschaft,  1888. 


598  ISAAC  OTT. 

In  my  laboratory  Dr.  E.  W.  Evans1  has  exhaustively 
studied  the  effects  of  antifebrin  upon  the  heat  production 
and  heat  dissipation  of  the  normal  and  fevered  animal.  The 
fever  was  produced  by  deutero-albumose. 

Antifebrin  was  found  to  reduce  the  heat  production  of 
animals  normally  and  in  a  state  of  experimental  fever.     Dr 
Hobart  A.  Hare   has   confirmed    these   researches    of  Dr 
Evans. 

These  researches  inclined  me  to  study  the  latest  anti- 
pyretics. In  my  experiments  rabbits  and  cats  were  used, 
the  drug  being  given  by  the  stomach  either  by  catheter  or 
capsule.  The  insolubility  of  these  drugs  caused  me  to 
select  the  stomach  as  the  medium  for  exhibition  of  the 
drug.  Heat  production  and  heat  dissipation  were  measured 
by  means  of  d'Arsonval's  calorimeter.  To  produce  an  ex- 
perimental fever,  cats  were  used.  In  them  the  cruciate 
heat  centres  of  Eulenberg  and  Landois  were  removed, 
which  permitted  the  temperature  to  rise  and  to  remain  so 
till  the  death  of  the  animal,  The  operation  was  performed 
a  day  or  two  before  the  exhibition  of  the  antipyretics.  No 
food  was  given  to  them  for  three  days  previous  to  the  ex- 
periment. 

The  cruciate  centre  was  preferred  to  the  Sylvian  for 
injury,  as  Sylvian  lesions  on  both  sides  of  the  brain  would 
soon  cause  death.  How  these  centres  act  in  the  production 
of  fever  I  have  fully  detailed  in  a  previous  number  of  this 
Journal  (Feb.,  1888).  To  remove  the  cruciate  centres  the 
skull  was  perforated  near  the  median  line  on  both  sides 
with  Pasteur's  trephine.  The  dura  mater  was  divided,  and 
the  cortex  broken  up  with  a  blunt  probe,  care  being  taken 
to  avoid  injuring  the  longitudinal  sinus.  The  effects  of  the 
drugs  upon  heat  production  and  heat  dissipation  was  not 
tested  till  an  hour  after  their  administration. 
ACETPHENETIDIN. 

This  body  is  a  grayish  powder  whose  formula  is 

C  H  NO    nrfH    '  C^Hj 
^10nlsi\u2,  or  ^gri4  -  NH  (CjHj0). 

being  in  fact  benzol  C6H4  in  which   two  atoms  of  hydrogen 

1  Therapeutic  Gazette,  1887. 


THE  ANTIPYRETICS.  599 

are  replaced  by  compound  radicals.  It  has  neither  taste 
nor  smell,  almost  insoluble  in  water.  It  dissolves  in  alco- 
hol in  the  proportion  of  one  in  twenty.  It  arrests  the  alco- 
holic fermentation  of  grape  sugar.  In  order  to  test  the  action 
of  the*  drug  on  the  healthy  body,  Dr.  Georgieoski  took 
thirty  grains  a  day  in  three  doses  of  ten  grains  each,  sepa- 
rated by  intervals  of  an  hour.  The  only  sensation  produced 
was  a  slight  feeling  comparable  to  the  beginning  of  alcoholic 
intoxication.  No  reduction  of  temperature  was  produced 
though  the  drug  was  taken  for  some  days.  The  color  of 
the  urine  was  unchanged,  but  when  a  few  drops  of  solution 
of  chloride  of  iron  were  added  to  it,  it  gave  a  reddish-brown 
or  black  color  ;  sulphate  of  copper  gave  a  similar  reaction. 
The  urine  was  affected  in  half  an  hour  after  taking  the  dose. 
Observations  were  also  made  by  Dr.  Georgieoski  upon  thirty 
febrile  patients,  including  cases  of  phthisis,  typhoid,  pneu- 
monia, erysipelas  of  the  face,  acute  rheumatism,  quinsy, 
diptheria  and  pleurisy.  A  single  dose  of  three  to  five  grains 
was  sufficient  to  lower  the  temperature,  usually  in  half  an 
hour  it  had  gone  down  nearly  i°  F.  This  reduction  con- 
tinued, the  lowest  point  being  reached  in  three  to  four  hours 
after  the  dose  had  been  taken.  The  subsequent  rise  which 
then  began  was  very  gradual,  the  original  height  not  being 
reached  for  five  to  six  hours  more.  As  a  rule,  a  three-grain 
dose  reduced  the  temperature  1.8°,  and  a  five-grain  3.60. 
The  nature  of  the  disease  seemed  to  have  a  decided  influ- 
ence upon  the  effect  of  the  medicine  ;  thus  in  typhoid,  where 
the  temperature  curve  generally  shows  great  variations 
the  drug  produces  a  greater  and  more  prolonged  reduction 
than  in  the  diseases  like  pneumonia,  where  it  is  less  vari- 
able. This  drug  is  also  an  analgesic.  Acetphenetidin  has 
a  composition  analogous  to  antifebrin. 

In  the  following  table  the  results  upon  acetphenetidin 
are  arranged.  H.  P.  is  heat  production  ;  H.  D.,  heat  dissi- 
pation. 


6oc 

D 

ISAAC   OTT. 

Be/ore  drug. 

After  drug. 

EXP 

H.    D.               H.    P. 

R.  T. 

H.   D. 

H.    P. 

R.   T. 

I 

29.20         26.51 

103 

20.86 

23.21 

102.5 

2 

36.71         31.10 

102.6 

20.86 

20.30 

IOI.9 

3 

20.86         20.86 

102.2 

20.86 

18.95 

102.4 

4 

33-76         34.76 

IO4.8 

37-54 

33-25 

IOI.5 

5 

43.80          43-47 

102.  I 

36.29 

34.63 

IOI.9 

6 

10.43         I2-J5 

IO4.8 

14.60 

11. 15 

I02.2 

Increrse  or  decrease 

of 

Increase  or  decrease 

of 

H.  D.  after  drug. 

H.  P.  after  drug. 

—  8.34 

—  3-3o 

-5.85 

—  10.80 

.0 

—  1.91 

+  3-78 

—  1. 51 

—  7-51 

—  8.84 

+  4.17 

—  1.0 

By  an  examination  of  the  above  tables  and  Fig.  1  it 
is  seen  that  with  one  exception  the  temperature  is  reduced 
by  acetphenetidin.  Heat  dissipation  is  reduced  in  all  ex- 
periments except  two,  whilst  heat  production  is  diminished 
in    all    except   one. 

This  is  due  to  an  action  on  the  thermal  centres,  for 
when  blood  pressure  experiments  were  made  there  was  but 
little  change  in  cardiac  frequency.  The  slight  fall  of  pres- 
sure in  the  arteries  would  not  suffice  to  diminish  heat  pro- 
duction as  much  as  has  been  shown.  There  was  no  im- 
portant change  in  the  movements  of  the  respiratory 
apparatus. 

ANTITHERMIN. 

Its  formula  is 

CH,C(OH.N-NH)  CH,-CH2COOH. 

This  body  has  a  chemical  relationship  to  antipyrin  and 
is  composed  of  phenyl-hydrasin  with  levulinic  acid.  It  is 
one  of  the  intermediate  products  in  the  chemical  production 
of  antipyrin.  It  is  composed  of  colorless  crystals,  of  a 
slightly  bitter  taste,  which    causes  an    unpleasant  grating 


l^HE  ANTIPYRETICS. 


60 1 


Fig.  I. 


602  ISAAC    OTT. 

when  ground  between  the  teeth.    It  is   insoluble  in  water 
and  but  sparingly  soluble  in  alcohol. 

After  drug. 


Before  drug. 

EXP. 

H.    D. 

H.  P. 

R.    T. 

I 

35-46 

34.27 

101.6 

2 

33-37 

32.04 

104.4 

3 

3I-2Q 

29.90 

102.5 

4 

4:.92 

43-74 

103.1 

5 

46.72 

4.3-44 

102.8 

6 

16.68 

lb.  12 

102.7 

Increase  or  decrease  of 
H.  D.  after  drug 


2. 

09 

—  6. 

26 

—   2. 

.09 

2. 

,02 

—   II. 

36 

+  6 

.26 

H.    D. 

H.    P. 

R.    T. 

3  3-37 

33-37 

IOI.6 

27.  I  I 

24.25 

IOI.2 

29.2O 

29.20 

I02.6 

45.90 

35-96 

99-8 

35-46 

29.99 

100. 1 

22.94 

21.25 

101.5 

Increas 

e  or  decrease 

of 

H.  P.  after  drug. 

—    .90 

—  7-79 

—  0.50 

—  7.78 

-  13-45 

+  5.13 

In  the  experiments  upon  antithermin,  the  temperature 
fell  in  all  except  one,  and  heat  production  and  heat  dissi- 
pation also  were  diminished  in  all  cases  save  one,  see  Fig.  2. 
The  cardiac  frequency  was  not  perceptibly  altered  by  anti- 
thermin. The  arterial  tension  was  not  greatly  diminished. 
Its  diminution  would  not  account  for  the  lessening  of  the 
heat  production.  Xo  marked  change  was  noticed  in  the 
respiration.  These  experiments  lead  to  the  conclusion 
that  acetphenetidin  and  antithermin  diminish  temperature, 
heat  production  and  heat  dissipation  as  a  rule. 

As  antipyrin  acts  upon  the  thermal  centre  of  the  corpus 
striatum  to  reduce  temperature,  it  is  highly  probable  that 
these  antipyretics  act  in  a  similar  way. 

Appended  are  some  of  the  experiments  upon  which  the 
preceding  statements  are  based. 

A.  T.  is  air  temperature. 

E.  T.,  temperature  of  exit-tube. 

R.  T.,  rectal  temperature. 


THE  ANTIPYRETICS. 


603 


Fig.  2. 


604  ISAAC  OTT. 

EXP.  /—White  rabbit;  wt  4.06  lbs. 

P.  M.        A.  T.        C.  T.        E.  T.        R.  T. 

1.30     70       73       22.1      10.30 

2.3O        78  73.7        24.O        I02.2 


+  •7 


.8 


METER. 
22,424 
22,674 


H.  D.  =  29.20.     H.  P.  =  26.51. 
2.40     Five  grains  of  acetphenetidin  by  the  stomach. 
3.40  75.3  73.65  24.2  101.8 

4.40  75.0  74.15  23.8  102.5 


+  .50                 +.7 

H.  D.  =20.86.  H.  P.  =23.21. 

EXP.  //.—Rabbit,  wt.  3.40. 

P.  M. 

A.  T.        C.  T.        E.  T.        R.  T. 

12.  10 

67.8     66.8     19.5     102.65 

I.  IO 

69.O        67.68       20.4        IOI.OO 

+  88  —1.65 

H.  D.  =  36.71.      H.  P.  =31.10. 
1.28     Ten  grains  of  acetphenetidin  by  stomach. 
2.28  69.5  67.6  20.5  102. 1 

69.8  68.1  20.4  101.9 


22,674 
22,904 


M. 

77,980 
78,336 


78,336 
78,652 


H.  D.  =  20.86.      H.  P.  =  20.30. 


P.   M. 
12.7 

i-7 


1.25 
2.52 
3-52 


EXP.  ///.—Rabbit,  wt.  3. 

A.    T.  C.    T.  E.   T. 

66.O  64.6  19.  I 


65.2 


l8.4 


R.  T. 

METER. 

102.2 

78,652 

I02.2 

79»°34 

.0 

H.  D.  =  20.86.     H.  P.  =  20.86. 
Ten  grains  of  acetphenetidin  by  the  stomach. 


68.2 
67.0 


6^.6 


19. 1 

19.2 


103.0 
102.4 


79>°34 
29,284 


H.  D.  =  20.86.  H.  P. 


18.95. 


THE  ANTIPYRETICS. 


EXP.  IV—  Rabbit,  wt.  3.36. 


605 


P.  M. 

A.   T.                  C.   T. 

E.   T.                  R.   T. 

METER. 

12.32 

62                      61.35 

16.8            104  8 

79,284 

1.32 

64                      62.15 

18.3                  IO5.3 

80,975 

H.  D.  =33-76. 

H.  P.  =34.76. 

1-34 

Ten  grains  of  acetphenetidin  by  stomach. 

2.40 

68.8             62.4 

19.0            103. 1 

80;  975 

3-40 

68.8            63.3 
+  .9 

18.5             101.5 

8l,I26 

—  1.6 

H.  D.  =37-54. 

H.  P.  =33.25. 

EXP.   V.- 

—Rabbit. 

A.  M. 

A.   T.                   C.   T. 

E.  T.                  R.  T. 

METER. 

9.58 

66.8            64.3 

19.  I                   I02.  I 

8l,I26 

IO.58 

66.5        65.35 

l8.8                   I02.0 

82,290 

+  1.05  —  .1 

H.  D.  =43-80.      H.  P.  =43.47. 
11.00     Ten  grains  of  acetphenetidin  by  the  stomach. 
12.8  66.5  65.28  18.8  102.4 

1.8  69.0  66.15  J9'6  101.9 

H.  D.  =36.29.      H.  P.  =34.63. 


82,290 
83,028 


P.  M. 

4.20 

5.20 


EXP.   VI — Cat  (cruciate  fever),  wt  2.6. 

A.  T. 
83.2 
83.4 


+ 


C  T. 

E.   T. 

R.   T. 

METER. 

82.45 

28.5 

104.8 

45,H4 

82.7 

28.4 

IO5.6 

45.474 

+  .25 

H.  D.  =  10.43.     H-  p-  =12.15. 
5.30     Five  grains  of  acetphenetidin  by  the  stomach. 
6.05  83.8  82.7  29.2  103.8 

7.05  83.4  83.05  28.6  102.2 

H.  D.  =  14.60.      H.  P.  =11.15. 


45,474 
45,960 


EXP.   VII 

P.  M. 

A.  T.                   C  T. 

2.10 

82.6                   76.3 

3.IO 

8l.7                   77.15 

Rabbit,  wt.  4.78. 

E.  T.  R.   T.  METER. 

27.2  101.6  20,789 

26.O  IOI.3  2I,o8o 

H.  D.  =35-47-     H.  P.  =34.27. 


6o6 


ISAAC  OTT. 


3.  20     Five  grains  of  antithermin  by  stomach. 
4.13  81.8  77.3  29.1  101.6 

5. 13  81.2  78  1  26.2  101.6 


p.  M. 
3.10 
4. 10 

4.30 
5.20 
6.20 


.0  .0 

H.  D.  =33-37.      H.  P.  =  33-37- 

EXP.   VIII. — Cat  (cruciate  fever),  wt  5.36. 

A.  T.  C.  T.  E.  T.  R.   T. 

91. I  85.6  3I.7  I04.4 

87.4  86'4  3O.4  IO3.  I 

H.  D.  =  33-37-      H.  P.  =32.04. 
Fifteen  grains  of  antithermin  by  the  stomach. 
87.3  86.45  Z^-l  IOI-8 

87.7  87.1  30.9  101.2 

H.  D.  =  27.11.      H.  P.  =  24.25. 

EXP.  IX.— Rabbit,  wt.  3.84. 

E.  T. 
27.7 
26.8 


+  •75  — -5 

H.  D.  =  31.29.      H.  P.  =  29.70. 
2.40     Five  grains  of  antithermin  by  stomach. 
3.35  83.9  79.35  28.4  102.6 

4.35  82.5  80.05  27-°  102.6 


P.   M. 

A.  T. 

C  T. 

I.30 

81.9 

78.4 

2.3O 

83.6 

79.2 

+.70                                                    .O 

H. 

D.  =  29.20.      H.  P.  =  29.20. 
EXP.  X.—  Rabbit,  wt.  5.10. 

P.   M. 

A.  T. 

C  T.                   E.  T.                   R.  T. 

2.29 

69.2 

66.1             20.0            103. 1 

3-29 

69.5 

67.25           20.0             102. 1 

+  1. 15  —  1.0 

H.  D.  =  47-92-     H.  P.  =43-74- 
3.30     Ten  grains  of  antithermin  by  capsule. 
4.30  70.6  67.2  20.9  101.3 

5.30  71.2  68.1  20.9  99.8 


•    -9 

H.  D.  =  45.90. 


—  i-5 
H.  P.  =35-96- 


2I,oSo 

21, 336 


METER. 
49,969 

20,272 


50,272 
50,535 


R.   T. 

METER. 

IO2.5 

21,843 

I02.0 

22,  11  I 

22,  III 
22,422 


METER. 
83,028 
83,832 


83,832 
84,7IO 


A.  M. 
8.32 

9-32 


THE  ANTIPYRETICS. 
EXP.  XI—  Rabbit,  wt.  4.40. 

A.  T.  C.  T.  E.  T.  R.   T. 

68.5  68.28  20,4  I02.8 

72.5  69.4  21.8  101.9 


+    I. 12  .9 

H.  D.  =  46.72.      H.  P.  =  43.44. 
9.40     Ten  grains  of  antithermin  by  capsule. 
10.33  7°-8  69.4  21.5  101.6 

11.33  71.7  7°-25  2I-8  100. 1 

H.  D.  =  35  46.      H.  P.  =  29.99. 

EXP.  XII.—  Rabbit,  wt.  3.41. 


607 


METER. 
84,710 

24,889 


84,889 
85,756 


A.  M. 

A.  T.       C.  T. 

E.  T. 

R.  T. 

METER. 

11.40 

71.7       70.3 

21.8 

102.7 

85,756 

I2.40 

72.7       70.7 

22.  I 

IO2.5 

87,348 

H.  D.  =  16.68. 

H.  P. 

=  l6.  12. 

1.42 

73.8     70.7 

23.I 

I02.  I 

87,348 

2.42 

73.0     71.25 

22.5 

[OI.5 

87,979 

+  •55  --6 

H.  D.  =  22.94.     H.  P.  =  22.25. 

EXP.  XIII—  Rabbit 

P.  M.  PULSE.  ARTERIAL   PRESSURE. 

3.15  63  I20 

3. 25  Five  grains  acetphenetidin  by  the  stomach. 

4.46  64                                  no 

4.48  60                                 126 

5.10  58                                 112 


EXP.  XIV.—  Rabbit. 

A.   M.  PULSE.                         ARTERIAL   PRESSURE. 

II. 15  60                                                 108 

11.25  Five  grains  of  antithermin  by  stomach. 
p.  M. 

12.25  62                                  108 

12.42  63                                   90 


PHILADELPHIA   NEUROLOGICAL   SOCIETY. 

Stated  Meeting,  October  22d,  1888. 

The  Vice-President,  Charles  K.  Mills,  M.D.,  in 
the  Chair. 

Dr.  WlLLiAM  Osler  presented  a 

NOTE   ON   PACHYMENINGITIS   HEMORRHAGICA. 

There  are  several  points  of  interest  in  this  condition  : 
First.  Is   it  in   any  sense  of  the  term  an  inflammatory 

process  ?     Practically,   we  see   one  of  three  conditions  in 

these  cases  : 

a.  Subdural  vascular  membranes,  often  of  extreme  deli- 
cacy. 

b.  Simple  subdural  hemorrhage. 

c.  Combination  of  the  two — vascular  membrane  and 
blood-clot. 

In  two  specimens  which  I  showed  last  year  at  the  Path- 
ological Society,  I  remarked  on  the  absence  of  any  of  the 
features  to  which  we  could  apply  the  term  inflammatory. 

Dr.  Joseph  Wiglesworth,  in  the  January  number  of  the 
Journal  of  Mental  Science  for  this  year,  takes  the  same 
ground.  Apart  from  injuries,  dura-arachnitis  is  rare.  I 
have  seen  two  instances  in  the  specific  fevers.  In  both 
there  was  delicate  fibrinous  exudate  between  the  dura  and 
the  arachnoid. 

Second  :  Which  is  antecedent,  vascular  membrane  or 
hemorrhage  ? 

It  is  usually  stated  that  the  hemorrhage  occurs  first, 
and  from  the  blood-clot,  when  organized,  the  vascular 
sheet  arises.  This  may  be  the  case,  and  the  fact  that  sub- 
dural hemorrhage  is  often  found  alone — in  fifteen  out  of 
forty-two  cases  in  Wiglesworth's  series — lends  weight  to  this 
view.  On  the  other  hand,  the  vascular  membrane  may 
exist  without  a  trace  of  past  hemorrhage  ;  neither  staining 
nor  melanin  grains,  simply  a  fibrous  sheet,  varying  in  thick- 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  609 

ness  and  permeated  with  large  vessels.  The  specimen 
here  shown  illustrates  this  condition :  It  was  removed  from 
a  man,  aged  fifty-six,  who  died  of  aneurism.  The  skull 
cap  was  unusually  thick  and  dense  and  extremely  vascular. 
The  meningeal  arteries  ran  in  deep  grooves  through  the 
bone.  There  were  many  points  of  vascular  union  between 
the  inner  table  of  the  skull  and  the  dura.  In  spite  of  this, 
the  calvaria  was  removed  without  much  difficulty.  The 
inner  surface  of  the  dura  was  everywhere  covered  with  a 
fibrous,  highly  vascular  membrane.  Toward  the  vault  it  was 
from  half  a  line  to  a  line  and  one-half  in  thickness.  Toward 
the  base  it  was  extremely  thin.  It  was  chiefly  made  up  of 
large  veins  forming  in  places  beautiful  arborescent  tufts. 
On  section,  where  the  membrane  was  thickest,  the  veins 
bled  freely,  but  there  was  no  trace  of  clot.  Microscopically, 
the  membrane  was  composed  of  bundles  of  connective 
tissue  forming  a  supporting  framework  for  the  numerous 
vessels.  At  one  small  area  alone,  in  the  middle  fossa  on 
the  left  side,  there  was  a  brownish-red  staining  on  the  sur- 
face of  the  vascular  membrane. 

In  the  two  specimens  which  I  studied  last  winter  the 
identical  condition  existed,  though  in  neither  was  the  blood 
supply  abundant,  nor  the  vascular  membrane  thickened. 

Third.  Whence  the  hemorrhage,  dural  or  pial  ? 

I  have  always  thought  the  former,  but  I  see  that  Wigles- 
worth,  in  referring  to  the  atrophy  of  the  convolutions  as  a 
possible  cause  for  hemorrhage,  speaks  thus:  "The  pia 
mater  over  a  variable  area  may  be  so  intensely  congested 
as  actually  to  resemble  an  ecchymosis.  ...  It  is  manifest 
that  the  conditions  may  be  highly  favorable  to  actual  rup- 
ture, and  I  doubt  not  that  this  frequently  occurs." 

Certainly  in  the  instances  I  have  seen  the  subdural 
membranes  were  intimately  associated  with  the  dural  ves- 
sels, and  it  seems  more  probable  (and  is,  I  believe,  gener- 
ally acknowledged)  that  from  these  the  hemorrhage  always 
proceeds. 

Fourth.  The  explanation  of  the  occurrence  of  this  sin- 
gular structure  is  by  no  means  clear.  The  cases  are  com- 
monly met  with  in   asylums.     In  general   hospitals  years 


6  I O  PHIL  A  DELPHI  A  NE  UROL  OGICAL  SOCIE  TY. 

may  pass  without  seeing-  an  instance.  During  eight  years 
in  the  post-mortem  room  of  the  General  Hospital  of  Mon- 
treal, no  instance  occurred.  The  first  specimen  which  I 
saw,  after  having  been  for  fourteen  years  interested  in  mor- 
bid anatomy,  was  demonstrated  by  Virchow,  in  1884,  at 
the  Pathological  Institute.  At  the  Philadelphia  Hospital 
cases  are  by  no  means  uncommon.  Within  the  past  two 
or  three  months  there  have  been  four  specimens  found, 
usually  in  the  bodies  of  persons  from  the  insane  department, 
but  in  the  three  instances  to  which  I  have  referred,  the 
patients  came  from  the  medical  wards,  and  had  not  shown 
any  mental  symptoms. 

One  reason  urged  why  the  subdural  hemorrhage  is  much 
more  common  in  the  insane,  is  the  atrophy  of  the  convolu- 
tions so  constantly  associated  with  this  condition.  But 
there  must  be  something  more  than  this,  for  if  atrophy 
alone  is  the  chief  factor,  we  certainly  would  meet  with  it  in 
phthisis  and  in  other  cachectic  conditions  in  which  the 
cerebral  wasting  is  quite  as  common  as  in  general  paresis. 

The  frequency  of  this  condition  in  asylum  work  may  be 
gathered  from  the  fact  that  Wiglesworth's  paper  is  based 
upon  forty-two  specimens  which  occurred  in  a  series  of 
four  hundred  unselected  post-mortem  examinations  in  which 
the  persons  died  of  various  forms  of  insanity.  Wigles- 
worth's contribution  is  one  of  the  most  interestingand  valu- 
able that  has  been  made  upon  the  subject. 

Dr.  F.  X.  DERCUM  asked  if  Dr.  Osier  accepted  the  view 
of  Wiglesworth  that  this  condition  of  the  dura  is  really  due 
to  hemorrhage  from  the  pia.  He  could  not  understand 
how  a  hemorrhage  from  the  pia  could  become  so  intimately 
connected  with  the  dura.  He  had  always  regarded  the 
formation  as  dural. 

He  asked  Dr.  Osier  if  he  had  any  explanation  to  offer 
for  the  formation  of  the  curious  cysts  in  old  cases  of  pachy- 
meningitis. 

Dr.  James  Hendrie  Lloyd  said  that  Dr.  Osier  had 
stated  that  in  the  case  reported  there  was  aneurism  of  the 
aorta.  He  would  ask  if  there  was  any  connection  between 
the    two    conditions.     Were    there    any   brain    symptoms  ? 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  6 1  I 

The  idea  had  prevailed  heretofore  that  we  mostly  find  this 
condition  in  connection  with  brain  troubles  such  as  general 
paresis,  trauma,  and  chronic  alcoholism. 

Dr.  Charles  K.  Mills  said  that  the  paper  was  inter- 
esting in  connection  with  a  case  of  a  child  nearly  three 
years  of  age,  with  spasms  of  a  peculiar  type,  for  which  he 
advised  trephining  and  the  operation  was  done  by  Dr.  John 
B.  Roberts  at  the  Philadelphia  Polyclinic.  After  the  re- 
moval of  the  skull  and  dura  mater,  a  membrane  was  found 
which  was  easily  separated  from  the  pia  arachnoid.  It  was 
a  vascular  membrane,  between  the  dura  mater  and  the  pia 
arachnoid.  GEdema  and  great  vascularity  of  the  pia  mater 
were  also  present.  After  the  escape  of  some  serous  fluid, 
the  brain  apparently  receded.  The  history  was  that  a 
clock  had  fallen  upon  the  child's  head,  and  the  question 
was  whether  or  not  a  slight  hemorrhage  beneath  the  dura 
had  not  taken  place,  or  whether  there  might  not  have  been 
the  formation  of  a  membrane  without  the  presence  of  a 
clot.  It  may  be  that  this  is  the  explanation  of  some  of  the 
cases  of  infantile  spasm  of  peculiar  type.  This  child  often 
had  from  eight  to  ten  attacks  a  day.  The  day  after  the 
operation  it  had  two  slight  attacks,  but  since  then  none. 
He  had  seen  a  considerable  number  of  cases  of  pachymen- 
ingitis hemorrhagica  at  the  Philadelphia  Hospital,  some  of 
which  he  had  reported. 

Dr.  Osler  did  not  see  how  the  hemorrhage  could  be 
connected  with  the  pia  as  Dr.  Wiglesworth  thought.  The 
cases  he  had  seen  had  been  in  medical  wards,  and  had  pre- 
sented no  indications  of  cerebral  trouble.  Atrophy  of  the 
convolutions  does  not  always  coexist.  If  atrophy  were  one 
of  the  prime  factors  in  the  causation  of  this  condition,  we 
would  expect  to  see  it  more  frequently  in  phthisis  and  the 
chronic  cachexias,  in  which  the  cerebral  wasting  is  often 
quite  as  marked  as  in  general  paresis.  There  is  often  as 
much  thickening  of  the  pia  arachnoid  and  gelatinous  oedema 
between  the  convolutions  in  phthisis  as  in  general  paresis, 
yet,  so  far  as  he  knows,  subdural  hemorrhage  has  not  been 
described  in  connection  with  phthisis  except  in  the  inmates 
of  lunatic  asylums.     The  condition  is  rarely  met  with  in 


6l2  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

general  practice.  He  had  himself  twelve  years'  experience 
in  general  autopsical  work  before  he  saw  a  case  of  pachy- 
meningitis hemorrhagica.  The  first  case  that  he  saw  was 
demonstrated  by  Virchow  in  1884,  in  the- Pathological  In- 
stitute in  Berlin.  At  the  Philadelphia  Hospital  the  condi- 
tion is  met  with  two  or  three  times  a  month,  usually  in 
patients  from  the  Department  for  the  Insane. 

Dr.  OSLER  then  presented  a  communication  entitled 

INJURY  TO  THE  CAUDA  EQUINA  AND  SYPHILOMA  OF  THE 
CORD  AND  CAUDA  EQUINA. 

Dr.  F.  X.  DERCUM  reported 

THREE   CASES   OF   SPINAL   ACCESSORY    SPASM    UNSUCCESS- 
FULLY  TREATED'  BY   EXCISION   OF   THE   NERVE. 

The  following  cases  were  placed  on  record,  not  only  to 
confirm  the  inutility  of  the  treatment  by  excision  of  the 
nerve,  but  also  to  provoke  discussion  on  this  most  distress- 
ing affection. 

Case  I. — J.  F.,  aged  forty  years,  married,  and  a  gas-fitter 
by  trade,  presented  himself  at  the  Nervous  Dispensary  of 
the  University  Hospital,  with  the  following  history :  He 
had  had  rheumatism  at  various  times,  one  attack  of  which 
had  kept  him  in  bed  nine  weeks.  Eight  months  after  this 
last  attack  he  had  rheumatism  of  the  muscles  of  the  shoul- 
ders, and  then  began  to  have  turning  of  the  head  to  one 
side,  which,  up  to  the  time  of  his  first  examination,  had 
lasted  a  year.  The  movements  were  at  first  slight  and 
painless,  as  they  still  are,  but  about  one  month  after  their 
first  appearance  the  movements  became  excessively  violent, 
coming  on  in  paroxysms,  and  interfering  with  sleep.  His 
wife  described  these  attacks  as  irritable  convulsions.  How- 
ever, they  were  limited  to  the  neck,  and  were  unattended 
by  loss  of  consciousness.  These  excessively  severe  parox- 
ysms were,  later  on,  merely  occasional.  Short,  sharp,  jerky 
movements  were,  however,  never,  absent.  The  sterno- 
cleido-mastoid  of  the  right  side  felt  hard  and  contracted, 
and  was  evidently  the  principal  muscle  at  fault.  Indeed,  in 
the   movement  observed   by  us  it  appeared  to  be  the  only 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  613 

one  involved,  though  in  the  severe  paroxysms  described  by 
the  patient  the  other  neck  muscles,  doubtless,  played  a 
part. 

Some  years  ago,  Dr.  H.  C.  Wood  successfully  treated 
one  of  these  cases  by  severely  cauterizing  the  back  of  the 
neck  with  the  hot  iron ;  and  acting  upon  this  hint,  the 
Paquelin  cautery  and  antimonial  ointment  were  freely  used 
in  the  present  case,  but  without  any  relief  of  the  spasm. 

Finally,  the  patient  was  admitted  to  the  hospital  under 
the  care  of  Dr.  Agnew,  who  excised  a  portion  of  the  right 
spinal  accessory  nerve.  The  immediate  effect  of  the  oper- 
ation was  a  disappearance  of  the  spasm,  but  as  this  man 
had  left  the  hospital,  in  which  he  remained  twenty-five 
days,  the  small,  jerking,  rotary  movement  of  the  head  had 
again  appeared,  and  he  could  discover  little,  if  any,  differ- 
ence in  the  character  of  the  movement.  Whether  any  of 
the  more  severe  paroxysms  recurred  he  was  unable  to  say, 
as  the  patient  has  not  since  been  under  observation. 

Case  II — E.  L.,  aged  fifty-eight  years,  married,  a  watch- 
case-maker,  likewise  presented  himself  at  the  University 
clinic  two  years  ago.  When  apparently  in  good  health,  he 
commenced  to  have  slight  twitching  in  the  neck.  This 
twitching  had  gradually  become  marked,  and,  at  the  time 
of  making  the  note,  was  present  in  the  form  of  a  severe 
clonic  spasm.  There  was  no  history  of  rheumatism  or 
syphilis. 

Examination  showed  that  the  left  sterno-cleido-mastoid 
and  trapezius  muscles  were  affected.  The  spasm  was  slow 
and  irregularly  recurring,  and  was  accompanied  by  pain  in 
the  mastoid  and  occipital  regions.  It  interfered  greatly 
with  sleep,  the  patient  being  kept  awake  two  or  three  hours 
after  lying  down.  Phonation  also  seemed  to  be  occasion- 
ally interfered  with. 

The  patient  refusing  to  be  cauterized,  various  internal 
remedies  were  prescribed,  all  without  avail.  Finally,  he 
was  admitted  to  the  surgical  wards,  and  likewise  operated 
on  by  Dr.  Agnew,  who  again  removed  a  portion  of  the 
nerve.  However,  within  a  few  hours  after  recovering  from 
the  effects  of  the  ether,  we  might  say  almost  immediately, 


6  14  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

the  spasm  recurred,  and  it  persisted  during  the  entire  stay 
of  the  patient  in  the  hospital,  some  three  weeks.  I  should 
remark,  however,  that  the  spasm  appeared  to  be  less  severe. 
Certainly,  the  movements  were  of  less  extent. 

It  is  exceedingly  probable  that  in  this  and  the  preced- 
ing case,  other  muscles  than  those  supplied  by  the  spinal 
accessory  nerve  were  involved,  and  to  this,  in  part  at  least, 
the  failure  is  to  be  ascribed.  However,  I  determined  to 
give  the  method  another  trial  in  the  following  case,  which 
seemed  more  favorable. 

Case  III. — M.  K.,  female,  aged  fifty-five,  a  housekeeper, 
presented  herself  at  the  clinic  with  constantly  recurring 
slow  spasm  of  the  right  sterno-cleido-mastoid.  This,  she 
said,  had  existed  for  two  years.  At  its  commencement  she 
had  been  in  her  usual  good  health.  Examination  showed 
the  right  sterno-mastoid  to  be  markedly  hypertrophied, 
further,  that  the  right  trapezius  also  participated,  but  to  a 
slight  extent.  It  could  not  be  determined  that  any  other 
muscle  was,  or  had  at  any  time  been  involved.  The  patient 
complained  also  of  occipital  pain,  and  pain  along  the  dorsal 
spine. 

After  a  rather  prolonged  trial  of  the  cautery,  galvanism, 
and  various  drugs,  the  knife  was  again  appealed  to,  Dr. 
Ashhurst  this  time  being  the  operator.  Owing  to  the  appar- 
ently limited  character  of  the  spasm,  he  was  hopeful  of  a 
good  result.  Dr.  Ashhurst  performed  an  extremely  thor- 
ough excision,  removing  over  four  inches  of  the  nerve- 
trunk,  including  not  only  the  supply  to  the  sterno-mastoid, 
but  also  that  to  the  trapezius.  Previous  to  making  the  ex- 
cision, the  nerve  was  thoroughly  stretched,  very  marked 
force  being  used.  After  the  operation,  anJ  during  the 
entire  stay  of  the  patient  in  the  hospital,  some  twenty-one 
days,  no  spasm  whatever  was  observed.  However,  that  an 
inference  as  regards  cure  would  have  been  altogether  pre- 
mature, was  proved  subsequently.  The  operation  was 
performed  on  the  2d  of  June,  and  in  the  early  part  of  the 
following  August  he  received  a  letter  from  the  patient,  bit- 
terly complaining  that  the  spasm  had  returned,  saying  that 
it  was  "very  bad  again."  Of  the  extent  of  the  recurrence 
he  could  not  speak  with  certainty. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  615 

Whether  in  these  three  cases  the  recurrence  of  the 
spasm  was  due  to  the  spreading  of  the  affection  to  other 
muscles,  or  to  the  vicarious  nerve-supply  of  the  sterno- 
mastoid  and  trapezius,  is,  he  thinks,  a  matter  of  minor  im- 
portance. The  belief  that  these  spasms  are  centric  in 
origin,  certainly  gathers  additional  force,  and  the  problem 
that  presents  itself  is,  whether  the  centres  affected  are 
spinal  or  cerebral,  and  how  this  differentiation  shall  be 
made.  Secondly,  whether  a  more  radical  surgical  treat- 
ment should  be  invoked.  These  were  the  points  to  which 
he  invited  discussion. 

He  purposely  refrained  from  speaking  of  the  morphia 
treatment  of  these  cases,  inasmuch  as  its  application  to  dis- 
pensary patients,  who  can  be  so  loosely  controlled,  would 
be  of  more  than  doubtful  propriety. 

Dr.  C.  K.  Mills  added  another  to  the  list  of  unsuccess- 
ful cases  treated  by  this  operation.  On  the  6th  of  this 
month  Dr.  Roberts  operated  on  a  case  whieh  had  been  sent 
to  Dr.  Mills  by  Dr.  Tomlinson,  of  Wilmington.  Dr.  Roberts 
cut  down  on  the  spinal  accessory  nerve  of  the  affected  side, 
and,  after  identifying  the  nerve  by  the  faradic  current,  ex- 
cised one  and  a-half  to  two  inches.  Two  weeks  after  the 
operation  the  patient  left  the  hospital,  the  spasm  somewhat 
improved,  but  certainly  not  cured.  Dr.  Mills  had  had  a 
number  of  these  cases,  and  some  years  ago  wrote  a  paper 
on  the  subject.  Two  of  the  cases  reported  recovered  large- 
ly under  the  use  of  the  actual  cautery. 

One  of  the  questions  which  arises  in  a  consideration  of 
these  cases  is  whether  some  of  them  are  cortical  in  origin, 
due  to  lesion  of  the  centres  for  conjugate  deviation  of  the 
head.  He  believed  that  such  a  view  should  be  entertained, 
but  probably  not  for  such  a  case  as  he  had  referred  to,  or 
for  such  as  Dr.  Dercum  had  reported.  The  persistence  of 
the  spasm  and  its  tonic  character  in  most  cases  are  against 
the  supposition  of  cortical  lesion. 

Dr.  Dercum  said  that  the  point  is,  How  are  we  to  dif- 
ferentiate between  the  spinal  and  cerebral  cases?  If  conju- 
gate deviation  of  the  eyes  occurred  with  the  movements, 
there  would  be  reason  for  supposing  that  there  was  a  corti- 


6l6  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

cal  lesion.  It  is,  however,  rare  to  have  this  association.  It 
was  not  present  in  his  case. 

As  an  indication  of  the  utter  hopelessness  of  operations 
on  the  muscles  and  nerves,  it  would  be  well  to  bear  in  mind 
that  the  movement  is  one  in  which  a  large  number  of  mus- 
cles are  involved.  There  are  nine  muscles,  in  addition  to 
the  sterno-mastoid  and  trapezius,  which  are  called  into 
play  in  the  act  of  turning  the  head  and  neck,  besides  two 
others  which  act  as  rotators  at  times. 

Dr.  J.  H.  Lloyd  reported  the  following 

CASE    OF    ALCOHOLIC    MULTIPLE    NEURITIS, 

which  presented  such  a  characteristic  clinical  picture  of  a 
disease  which  is  not  common,  that  he  was  led  to  report  it 
in  spite  of  the  fact  that  the  pathological  study  was  incom- 
plete. 

Margaret  M.,  aged  about  thirty-five  years,  was  admitted 
into  the  nervous  ward  of  the  Philadelphia  Hospital  in  May, 
1888.  She  had  a  family  history  of  phthisis  on  the  father's 
side.  The  patient  had  never  been  very  strong,  but  had  had 
no  sickness  except  the  ordinary  diseases  of  childhood.  She 
was  married  at  seventeen  and  had  had  four  children,  the 
last  labor  occurring  five  years  before  admission.  She  de- 
nied syphilis,  and  presented  no  lesions  of  it.  She  also  de- 
nied excessive  drinking,  but  an  inquiry  of  her  friends  re- 
vealed the  habitual  use  of  alcoholics,  sometimes  in  excess, 
from  her  childhood.  Four  weeks  before  admission  she 
awoke  one  morning  to  find  both  feet  paretic.  For  one  week 
preceding  this  she  had  had  severe  pains  in  both  legs. 

On  examination  the  following  facts  were  noticed:  The 
patient  was  anaemic,  very  despondent  in  expression,  and 
rather  emaciated.  She  presented  double  wrist-drop,  with 
wasting  of  the  arm  muscles,  also  more  marked  on  the  left 
side.  There  was  paralysis,  quite  complete,  of  the  anterior 
leg  muscles  on  both  sides,  with  consequent  foot-drop  and 
wasting.  The  extensor  muscles  of  the  left  forearm  con- 
tracted sluggishly  to  the  faradic  and  galvanic  currents, 
and  showed  the  serial  reactions  of  degeneration:  A.C.C>C. 
C.C.     The  extensor  of  the  feet    muscles  especially  supplied 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  617 

by  the  anterior  tibial  nerves)  also  reacted  sluggishly  and 
showed  reactions  of  degeneration  to  galvanism.  The  pat- 
ellar reflexes  were  abolished.  There  were  small  areas  of 
anaesthesia  over  the  legs  and  feet.  She  would  believe 
that  a  pin  was  touching  the  foot  when  it  was  touching 
the  leg,  and  confused  the  legs.  The  sensory  symptoms 
were  very  significant.  She  suffered  from  severe  burning 
pain  on  the  soles  of  the  feet,  and  later  in  the  palms  of  the 
hands,  causing  her  to  complain.  The  nerve  trunks  were 
acutely  sensitive.  Pressure  over  the  popliteal  and  peroneal 
nerves  of  the  main  trunks  of  the  arm  was  productive  of 
most  severe  pain.  The  peroneal  nerves  especially  were 
sore.  The  muscles  of  the  leg  were  extremely  sensitive  to 
touch,  and  those  of  the  calves  especially  were  very  tender. 

The  lungs  were  normal.  The  heart  presented  a  faint 
systolic  murmur  at  the  apex  ;  not  always  heard,  and  possi- 
bly anaemic(?).  The  pulse  was  small  in  volume,  very 
rapid,  constantly  ranging  from  122  to  140,  and  easily  com- 
pressible. Her  temperature  was  constantly  afebrile,  except 
on  two  days,  when  it  rose  to  ioii°.  For  more  than  half  the 
time  she  was  under  observation  (about  four  weeks)  the 
temperature  was  rather  subnormal,  falling  as  low  once  as 
96f0.  It  was  taken  in  the  axilla.  The  loss  of  appetite  was 
complete,  and  the  tongue  was  furred.  She  slept  poorly 
and  her  mind  wandered.  At  times  she  was  in  a  well-marked 
delusional  condition,  and  was  restless  always  and  com- 
plaining. 

The  patient,  as  she  lay  in  bed,  with  the  wrist-drop  and 
foot-drop,  bore  a  striking  resemblance  to  the  picture  which 
Gowers,  has  in  his  recent  work,  of  a  patient  with  this 
disease. 

The  indications  for  treatment  were  especially  to  relieve 
pain  and  sustain  the  power  of  a  failing  heart.  It  was  soon 
evident  that  the  patient  would  not  respond  to  treatment. 
The  heart,  in  particular,  never  improved  in  its  action.  Di- 
gitalis was  given  in  the  form  of  tincture,  infusion,  powder, 
and  poultices  of  the  leaves,  but  the  pulse  remained  rapid 
and  feeble.  A  full  liquid  diet  was  administerred  in  oft- 
repeated  quantities,  but  alcohol  was  not  given  until  toward 


6  iS  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

the  last,  and  then  in  small  doses.  It  is  not  necessary  to 
detail  all  the  treatment.  Partial  relief  was  obtained  from 
the  burning  pains  in  the  soles  of  the  feet  by  lotions  of  car- 
bolized  water ;  and  small  cantharidal  blisters  were  used 
with  some  benefit  over  some  of  the  most  painful  nerves,  as 
the  peroneal.  The  patient  gradually  sank  from  a  weak 
heart  and  died  rather  suddenly  about  the  end  of  the  fourth 
week  of  her  sojourn  in  the  hospital. 

He  regretted  to  say  that  the  specimens  from  this  case 
became  decomposed,  in  some  unaccountable  way,  and  were 
unfit  for  microscopic  study.  The  brain,  cord,  and  affected 
nerves,  clear  to  their  ramifications  in  the  muscles,  were 
removed,  and  did  not  exhibit  any  marked  change  on  gross 
examination.  It  was  thought  that  some  parts  of  the  pos- 
terior columns  were  sclerosed  ;  an  observation  which,  he 
believed,  has  been  made  before  in  some  of  these  cases. 
The  history  and  observation  of  the  case  do  not  point  to  an 
original  posterior  sclerosis,  and  it  may  be  a  question  whe- 
ther such  a  change  in  the  cord  in  a  case  like  the  one  de- 
scribed could  not  be  secondary  to  the  original  nerve  lesions. 
It  is  also  a  question  whether  the  obstinately  feeble  action 
of  the  heart  in  these  cases  may  not  be  due  to  changes  in  the 
pneumogastric  similar  to  those  which  occur  in  the  other 
nerves.  The  heart  was  small  and  the  valves  normal.  The 
liver  was  fatty  and  the  kidneys  slightly  congested  and 
enlarged. 

Dr.  \V.  T.  Sharpless  reported  a  case  of 

EMBOLISM     OF     THE     MIDDLE    CEREBRAL    ARTERY. — LEFT 
HEMIPLEGIA,  ULCERATIVE    ENDOCARDITIS,    AND  LATE 
GENERAL   CONVULSIONS,    AND   SKIN    INFARCTS. 
M.   D.,   aged   thirty-one    years,  married   (service  of  Dr. 
C.  K.    Mills,  at   the    Philadelphia    Hospital),    had    nothing 
special  in  family  history.     He  had   been  very  intemperate 
for  several   years,  and  there  was  a  probable    history  of  sy- 
philis although  he  denied  it.     He  had  acute  articular  rheu- 
matism last  winter  which  was  his   only  attack.     In  March 
last  he  was  suddenly  paralyzed  on  the  left  side  and  entered 
the  hospital  on   April    18th.     His  condition  Aug.  ist,  when 


PHILADELPHIA   NEUROLOGICAL    SOCIETY.  619 

he  came  under  Dr.  Mills's  care,  was  as  follows  :  Left  he- 
miplegia ;  paralysis  marked  on  the  arm,  less  so  in  the  leg, 
and  not  at  all  in  the  face  ;  oedema  of  feet  and  legs,  extend- 
ing to  the  knees.  He  had  a  very  loud  double  aortic  mur- 
mur that  could  be  heard  as  far  down  the  back  as  the  sa- 
crum. Area  of  cardiac  dullness  was  very  much  enlarged, 
as  was  also  that  of  the  liver  and  spleen.  The  urine  con- 
tained albumen  in  considerable  quantity,  and  later  hyaline, 
granular,  and  a  few  epithelial  casts  were  found.  In  testing 
his  sensations  it  was  found  that  he  could  not  perceive  a 
light  touch  as  well  on  the  paralyzed  side  as  on  the  other  ; 
but  the  sense  of  pain  was  preserved.  Paralyzed  muscles 
responded  to  the  faradic  current  and  showed  no  reactions 
of  degeneration.  His  temperature  rose  to  1010  to  1020 
every  evening  and  regularly  fell  to  normal  in  the  morning. 

On  Sept.  6th  he  had  two  general  epileptiform  convul- 
sions, and  later  he  had  another  of  a  similar  character. 

On  Sept.  15th  petechial  spots  were  noticed  on  his  legs 
and  ankles,  which  increased  in  size  and  depth  until  his 
death,  which  occurred  Oct.  15th.  These  spots  varied  in  size 
from  that  of  a  pin's  head  to  a  dime  and  showed  no  disposi- 
tion to  heal.     They  were  probably  skin  infarcts. 

Autopsy,  October  15th  :  Right  middle  cerebral  artery 
close  to,  but  just  beyond  its  orgin  in  the  internal  carotid, 
was  closed  by  an  evidently  old  embolus.  All  branches 
of  the  middle  cerebral  beyond  this  were  thready  and  cord- 
like, and  could  be  distinctly  seen  lying  in  a  bed  of  yellow- 
ish softening,  which  extended  over  the  island  of  Reil  and 
the  internal  surface  of  all  convolutions  which  cover  in  the 
Sylvian  fissure.  The  cortex  of  the  motor  zone,  except  as 
just  stated,  was  not  softened.  A  cut  through  about  the 
middle  of  the  lenticular  body  revealed  softening  of  the 
entire  breadth  of  the  internal  capsule  and  adjoining  lenticu- 
lar and  caudate  bodies.  This  softening  was  in  the  middle 
part  of  the  capsule  and  did  not  extend  into  the  anterior  and 
posterior  third.  Evidently  some  collateral  circulation  had 
been  established  between  cortical  branches  of  the  middle 
and  the  anterior  and  posterior  cerebral  arteries.  This  was 
plain  in  several  places  where  the  narrowed  and  atrophic 
vessels  beyond  the  embolus  again  took  up  their  calibre. 


620  PHILADELPHIA  XEUROLOGICAL    SOCIETY. 

The  heart  was  enormously  hypertrophied.  On  the  tri- 
cuspid and  aortic  valves  were  the  vegetations  of  recent  ul- 
cerative endocarditis,  with  a  perforation  on  the  septum 
leading  from  the  left  to  the  right  ventricle,  just  below  the 
aortic  ring. 

Probably  the  sequence  of  events  in  this  case  was  as  fol- 
lows :  First,  the  abuse  of  alcohol,  and  the  syhilitic  infec- 
tion ;  then  disease  of  the  aortic  valves  resulting  in  their 
thickening  and  contraction  ;  next,  in  March  last,  the  em- 
bolus lodging  in  the  middle  cerebral  artery  and  producing 
the  hemiplegia,  and  recently  the  ulcerative  process  en- 
grafted on  the  sclerotic  valves. 

Dr.  William  Osler  said  that  we  are  apt  to  think 
that  the  cortical  cerebral  arteries  have  not  special  anasto- 
moses, but  an  examination  of  many  of  these  cases  of  total 
occlusion,  particularly  of  the  middle  cerebral  artery,  shows 
that  a  collateral  circulation  can  be  established,  usually,  as 
in  this  case,  by  the  enlargement  of  the  anterior  cerebral, 
so  that  the  nutrition  is  maintained  in  the  central  gyri. 


TRANSACTIONS  AMERICAN  NEUROLOGICAL 
ASSOCIATION. 

FOURTEENTH    ANNUAL    REPORT. 

Continued  from  September  Number. 

The  following  paper  was  read  : 

NERVOUS  AFFECTIONS  FOLLOWING  INJURY, 
"CONCUSSION    OF    THE    SPINE,"  "RAIL- 
WAY  SPINE"  AND  "RAILWAY  BRAIN." 

By  PHILIP  COOMBS  KNAPP,  M.  D. 

It  is  rather  singular  that  the  two  most  elaborate  works 
on  those  affections  of  the  nervous  system  which  are  sup- 
posed to  follow  injury  should  have  been  written  by  sur- 
geons, and  should  have  been  based  on  the  evidence  of 
railway  cases.  One  of  these  works,  the  influence  of  which 
is  not  yet  dead,  is  based  upon  the  ideas  in  regard  to  the 
pathology  of  the  nervous  system  which  obtained  twenty 
years  ago,  and  treats  of  all  forms  of  injury  of  the  central 
nervous  system  under  the  most  misleading  heading  of  "con- 
cussion of  the  spine  ;"  the  other,  which  reads  like  the  work 
of  a  special  pleader  for  the  railway  companies,  discusses 
case  after  case  of  obscure  nervous  disease  without  mention 
of  the  condition  of  the  reflexes.  Fortunately,  however,  the 
attention  of  neurologists  has  of  late  been  directed  to  the 
subject,  and  since  the  appearance  of  Page's  first  treatise  in 
1881,  many  valuable  contributions  to  our  knowledge  have 
been  made  in  this  country  and  in  Europe,  and  the  work 
done  in  German}-,  especially,  has  brought  the  matter  more 
fulh'  to  our  attention. 

Erichsen's  composite  of  "concussion  of  the  spine"  has 
been  found  to  be  compounded  of  too  many  distinct  condi- 
tions to  be  trustworthy,  and,  from  the  vagueness  of  his 
classification,  his  ideas  on  prognosis  proved  misleading  ; 
yet  his  work  has  had  such  an  influence  that  the  English 
railway  companies  are  said  to  have  paid  eleven  million 
dollars  in  damages  in  five  years,  and  I  have  no  question 
that  it  has  also  had  an  influence  upon  the  great  sums  that 


62  2  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

have  been  paid  in  this  country.  The  reaction,  of  course,  fol- 
lowed, and  it  was  aided  by  the  cynicism  that  naturally 
arises  when  we  see  a  man,  who  has  claimed  to  be  perma- 
nently injured,  walk  off  as  well  as  ever  when  the  "dam- 
ages" have  been  paid.  It  has  seemed  to  me,  however,  that 
this  reaction  has  gone  too  far,  and  therefore  I  have  thought 
it  worth  while  to  go  over  the  subject  once  more,  and  to 
review  some  of  the  recent  work  that  has  been  done  upon  it. 
Before  discussing  controverted  points,  however,  I  will  men- 
tion briefly  certain  definite  lesions  of  the  nervous  system 
which  may  unquestionably  follow  injury. 

Among  the  commoner  results  of  injury  are  the  affections 
of  the  peripheral  nerves.  The  obstinate  pain  and  persistent 
weakness  of  the  shoulder  which  so  often  follow  an  injury 
are  probably  due  to  an  implication  of  certain  nerve  fibres 
in  the  periarthritic  process.  Beside  that,  we  often  see 
various  local  paralyses,  due  to  all  sorts  of  lesions  of  the 
nerves,  from  simple  pressure  to  severe  crushing, — paralyses 
of  all  forms  of  intensity,  from  the  transitory  forms  with 
normal  electrical  reactions  to  the  severe  atrophic  forms 
with  reaction  of  degeneration.  The  prognosis,  of  course, 
varies  with  the  degree  of  injury,  and  is  governed  by  the 
ordinary  rules. 

Trauma  may  produce  certain  definite  lesions  of  the 
spinal  cord  and  its  coverings,  beside  the  vague  and  ques- 
tionable results  of  pure  "concussion."  It  may,  in  the  first 
place,  cause  fracture  or  dislocation  of  the  vertebra;,  and, 
secondarily,  affect  the  cord  itself.  In  these  cases  it  not 
infrequently  happens  that  the  patient  exhibits  the  symp- 
toms of  injury  to  the  cord,  while  the  injury  to  the  vertebrae 
is  noted  only  at  the  autopsy.  With  or  without  injur}-  of  the 
vertebrae,  however,  we  may  find  serious  injury  to  the  cord, 
— haemorrhage  into  the  meninges  or  into  the  cord  itself, 
rupture  of  the  pia  with  hernia  of  the  cord,  or  acute  myelitis.1 

In  addition  to  the  cases  of  what  may  be  called  "acute 
injury  to  the  cord,"  where  the  symptoms  develop  immedi- 
ately   after    the    accident,    it    is    a    well-attested    fact    that 

1  E.  Leyden.     Klinik  der  Kiickenmarkskrankheiten,  i.  371,  ii.  61,  92,  139. 


AMERICAN  NE UROL OGICAL  A SS0C1A  TION.  623 

chronic  degenerative  processes  may  be  due  to  injury ;  and 
here,  of  course,  the  symptoms  are  very  insidious  in  their 
onset.  Spitzka2  and  Gowers3  cite  cases  of  tabes  dorsalis 
due  to  injury,  and  Hoffmann4  has  just  reported  a  very  inter- 
esting case  of  tabes  from  Erb's  clinique  at  Heidelberg  due 
to  a  prolonged  daily  concussion  of  the  whole  body,  especi- 
ally the  abdomen.  Dana,5  too,  has  cited  a  case  where 
tabetic  symptoms  followed  a  railway  injury  to  a  syphilitic 
subject,  where  he  thinks  the  accident  determined  the  locali- 
zation of  the  morbid  process.  Besides  tabes,  injury  may 
produce  lateral  sclerosis,  progressive  muscular  atrophy,6 
diffuse  sclerosis,"  and  disseminated  sclerosis,8 — the  last  two 
affections  especially  being  extremely  difficult  to  diagnosti- 
cate in  their  early  stages. 

There  is,  or  rather  was,  another  lesion  of  the  cord  which 
was  once  deemed  of  great  importance  and  was  regarded  by 
Erichsen9  as  the  chief  source  of  the  symptoms  of  his  "con- 
cussion of  the  spine," — namely,  spinal  lepto-meningitis. 
We  used  to  hear  of  it,  but  lately  the  cases  have  become 
rare,  and,  in  fact,  few  now  disagree  with  Striimpell's  dic- 
tum,10— "A  case  of  primary  chronic  lepto-meningitis,  which 
can  be  surely  and  convincingly  proven  clinically  and  ana- 
tomically, does  not  exist." 

Finally,  in  the  brain  and  its  coverings  injury  may  pro- 
duce various  lesions, — fracture  of  the  skull,  meningeal  and 
intra-cerebral  haemorrhage,  pachymeningitis  interna,  haem- 
orrhagica,  meningitis,  softening,  abscess,  tumor,  and  vari- 
ous functional  disorders,  such  as  epilepsy,  paralysis  agitans, 

2  E.  C.  Spitzka.  The  Chronic  Inflammatory  and  Degenerative  Affections  of 
the  Spinal  Cord.     Pepper's  System  of  Medicine,  v.  855. 

3  W.  R.  Gowers.     Diseases  of  the  Nervous  System,  i.  289. 

4  J.  Hoffmann.  Beitrag  zur  .<Etiologie,  Symptomatologie  und  Therapie  der 
Tabes  dorsalis.     Archiv  f.  Psychiatrie  u.  Nervenkrankheiten,  xix.  438,  1888. 

5  L.  Dana.  Nervous  Syphilis  following  a  Railroad  Injury.  The  Post- 
Graduate,  April,  1888. 

6W.  R.  Gowers.  Op.  cit.,  i.  450. 

'  W.  R.  Gowers.  Op.  cit.,  i.  238. 

8  E.  C.  Spitzka.  Op.  cit.,  p.  884. 

9  J.  E.  Erichsen.  On  Concussion  of  the  Spine,  p.  85. 

10  A.  Striimpell.  Lehrbuch  der  speciellen  Pathologie  und  Therapie  der 
inneren  Krankheiten,  ii.  1,  450,  4te  Aufl 


624  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

and  chorea.11  Furthermore,  injury  may  give  rise  to  various 
psychoses u  and  chronic  degenerative  processes,  especially 
paretic  dementia.13  and  of  some  of  these,  and  of  certain 
functional  nervous  affections,  I  will  speak  later. 

Thus  far  all  is  clear  and  well  denned.  It  would  require 
an  exhaustive  treatise  to  speak  fully  of  all  these  conditions 
and  to  dwell  on  their  diagnosis  and  prognosis.  They  are 
met  with  more  or  less  often,  and  usually  they  can  be  readily 
recognized.  Besides  these  affections,  however,  there  are 
other  cases  of  a  more  obscure  character,  where  our  diag- 
nosis is  often  doubtful  and  our  prognosis  sadly  at  fault. 

Whether  there  is  a  true  "concussion  of  the  spinal  cord" 
is  still  a  matter  of  doubt.  By  this  term  I  mean  a  paraplegia 
following  injury,  where  the  cord  has  sustained  no  coarse 
mechanical  lesion,  where  "molecular  changes  in  the  finer 
nerve-elements  have  occurred,  giving  rise  to  an  immediate 
and  complete  functional  paralysis,"14 — a  condition  analogous 
to  the  commoner  concussion  of  the  brain.  Page15  questions 
the  possibility  of  such  an  affection,  but  cases  have  been 
reported  which  clinically  answer  the  requirements.16  The 
anatomical  relations  of  the  cord  naturally  render  it  difficult 
for  true  concussion  to  occur  ;  and,  moreover,  in  simple  con- 
cussion there  is  apt  to  be  recovery,  so  that  post-mortem 
evidence  is  lacking.  Cases  have  been  reported,17  however, 
where  paraplegia  came  on  suddenly  after  injury  and  termi- 
nated fatally,  although  no  lesion  could  be  found  after  death. 
Some  of  these  cases  are,  of  course,  untrustworthy,  as  they 
were  observed  at  a  time  when  the  methods  of  examining 
the  cord  were  less  exact,  so  that  it  is  hard  to  exclude  the 
existence  of  contusion  or  punctate   haemorrhages   into  the 

11  Ch.  Bataille.     Traumatisme  et  Nevropathie. 

,s  Hartmann.  Ueber  Geistesstorungen  nach  Kopfverletzungen.  Archiv  f. 
Psychiatrie  u.  Xervenkrankheiten,  xv.  98,  1884. 

13  R.  v.  Krafft-Ebing.     Lehrbuch  der  Psychiatrie.  i.  166. 
M  W.  H.  Erb.     Diseases  of  the  Spinal  Cord.     Ziemssen's  Cyclopaedia,    xiii. 
347- 

1 1.  W.  Page.     Injuries  of  the  Spine  and  Spinal  Cord,  p.  33. j 

m.  Hunt.     Concussion  of  the  Brain  and  Spinal  Cord.     Pepper's  System 
>f  Medicine,  v.  913. 

17  E.  Leyden.     Op.  cit.t  n.  93. 


625  AMERICAN  NE  UROL  OGICAL  A SSOCIA  TION. 

cord.  Dumenil  and  Petel,18  however,  still  hold  to  a  belief 
in  commotion  of  the  cord,  which  may  be  the  origin  of  con- 
secutive inflammatory  lesions  or  sclerosis,  and  Dana19  ad- 
mits the  existence,  rarely,  of  true  concussion.  Some 
writers,  Obersteiner20  among  them,  hint  at  the  existence  of 
chronic  concussion  in  men  who  are  constantly  exposed  to 
jarring,  as  railway  employes,  but  such  cases  are  more  likely 
to  be  classed  among  the  degenerations  of  the  cord,  as  in 
Hoffmann's  case  already  cited. 

Beside  the  true  concussion  there  are  a  host  of  obscure 
affections  which  have  been  classed  by  Erichsen  under  the 
general  head  of  "  spinal  concussion,"  and  about  which  there 
has  been  much  controversy.  Dr.  R.  M.  Hodges,21  in  a  paper 
read  before  the  Boston  Society  for  Medical  Improvement 
eight  years  ago,  was  one  of  the  early  dissenters  from  the 
views  of  Erichsen.  He  showed  that  a  strain  of  the  muscles 
or  ligaments  of  the  spine  was  capable  of  explaining  many 
of  the  symptoms,  and  he  believed  that  many  of  the  cases 
were  cases  of  functional  nervous  disease.  Soon  after  Page22 
advocated  the  same  views  with  somewhat  more  detail,  as- 
scribing  the  symptoms  in  cases  of  "railway  spine "  to  a 
traumatic  lumbago  (that  is,  a  strain)  and  a  traumatic 
neurasthenia  caused  by  the  shock  and  terror  of  the  acci- 
dent. 

Two  years  later  Walton23  found  that  in  a  number  of  cases 
of  injury  there  was  anaesthesia  or  hemianaesthesia,  often  in- 
volving the  special  senses,  and,  calling  our  attention24  anew 

1S  Dumenil  and  Petel.  Commotion  de  la  moelle  epiniere.  Archives  de  Neu- 
rologie,  Jan.,  Mar.,  May,  1885. 

19  C.  L.  Dana.  Concussion  of  the  Spine  and  its  Relation  to  Neurasthenia 
and  Hysteria.     Medical  Record,  6th  Dec,  1884. 

20  H.  Obersteiner  Ueber  Erschiitterung  des  Riickenmarks.  Med  Jahr- 
biicher,  p.  531,  1879. 

21  R.  M.  Hodges.  So-called  Concussion  of  the  Spinal  Cord.  Boston  Medi- 
cal and  Surgical  Journal,  21st,  28th  April,  1881. 

22  H.  W.  Page.  Op.  cit.,  p.  1 16  et.  seq.  Also  Boylston  Prize  Disertation 
for  1881. 

23  G.  L.  Walton.  Two  Cases  of  Hysteria.  Archives  of  Medicine,  Aug., 
1883. 

24  G.  L.  Walton.  Possible  Cerebral  Origin  of  the  Symptoms  usually  classed 
under  "Railway  Spine."  Boston  Medical  and  Surgical  Journal,  nth  Oct., 
1883. 


626  AMERICAN  XE UROL  OGICAL  A SSOCIA  T/OA. 

to  the  fact  that  many  of  the  symptoms  were  cerebral,  he 
suggested  the  term  "railway  brain,"  as  more  suitable  than 
"  railway  spine.''  About  the  same  time  Putnam25  reported 
similar  cases,  and  they  both  suggested  the  relation  between 
hemianaesthesia  and  hysteria.  This  theory  has  been  further 
elaborated  by  Charcot,26  who  states  that  "  these  grave  and 
obstinate  nervous  states,  which  are  presented  as  the  result 
of  railway  collisions,  rendering  their  victims  unable  to  re- 
turn to  their  work  or  resume  their  ordinary  occupations  for 
periods  of  several  months  or  even  years,  are  often  only 
hysteria,  nothing  but  hysteria."  Much  of  Charcot's  last 
volume  is  devoted  to  the  description  of  cases  of  traumatic 
hysteria,  and  a  number  of  his  pupils  have  published  further 
studies  upon  the  subject. 

Before  all  this,  in  1880,  Westphal27  had  reported  three 
cases  of  "  railway  spine,"  and  had  advanced  the  theory  that 
the  symptoms  were  due  to  small  foci  of  myelitis  or  enceph- 
alitis caused  by  trauma,  and  that  they  were  analagous  in 
their  symptoms  to  multiple  sclerosis.  Since  then  West- 
phal's  assistants,  Thomsen  and  Oppenheim,  have  made2"  an 
elaborate  study  of  sensory  disturbances  in  all  forms  of  ner- 
vous disease,  including  railway  spine,  and  have  shown  that 
hemianaesthesia  is  not  pathognomic  of  hysteria  ;  and  Oppen- 
heim,2' in  a  later  paper,  has  carefully  studied  a  second 
series  of  cases  of  "  railway  spine,"  with  the  result  of  sub- 
stantiating Westphal's  views. 

-  J.  J.  Putnam.  Recent  Investigations  into  the  Pathology  of  so-called  Con- 
cussion of  the  Spine,  etc.  Boston  Medical  and  Surgical  Journal,  6th  Sept  ,  1883. 
The  Medico-legal  Significance  of  Hemianaesthesia  after  Concussion  Accidents. 
American  Journal  of  Neurology  and  Psychiatry.  Nov.,  1884. 

MJ.  M.  Charcot.     Le<;ons  sur  les  maladies  du  systeme  nerveux,  iii.  251. 

27  C.  Westphal.  Einige  Falle  von  Erkrankung  des  Nervensysiems  nach  Ver- 
letzung  auf  Eisenbahnen.     Charite-Annalen,  v.  379,  1878. 

"  K.  Thomsen  und  H.  Oppenheim.  Ueber  das  Vorkommen  und  die  Bedeu- 
tung  der  sensorischen  An'asthesie  bei  Erkrankungen  des  centralen  Nervensys- 
tems.     Archiv  f.  Psychiatrie  u.  Nervenkrankheiten,  xv.  559,  633.      1884. 

49  H.  Oppenheim.  Wtitere  Mittheilungen  iiber  die  sich  am  Kopfverletzungen 
und  Erschiitterungen  (in  specie :  Eisenbahnunfalle)  anschliessenden  Erkran- 
kungen des  Nervensystems.  Archiv  f.  Psychiatrie  u.  Nervenkrankheiten,  xvi. 
743.     1885. 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  627 

Before  discussing  these  various  theories  I  will  cite,  as 
briefly  as  possible,  some  cases  of  nervous  affections  follow- 
ing injury  that  I  have  seen  in  the  last  three  years.  I  have 
not  selected  these  cases  in  support  of  any  theory,  but  I 
have  picked  out  cases  of  different  types,  representing  as 
fairly  as  possible  the  whole  number  of  cases  that  I  have 
seen.  In  only  three  cases  was  there  any  question  of  dam- 
ages. One  of  these  was  a  child,  and  another  was  seen  after 
the  award  had  been  made,  although  a  question  of  appeal 
was  pending.  Thus  we  can  eliminate  at  the  start  two  fac- 
tors which  have  tended  to  obscure  the  subject  and  to  bias 
opinion — the  idea  of  simulation  and  the  excitement  that 
naturally  attends  litigation  and  is  often  a  hindrance  to 
recovery.  This  gives  a  more  satisfactory  basis  to  reason 
from,  for,  as  the  late  Dr.  Curtis  said30  in  the  discussion  of 
Dr.  Hodges'  paper,  "treatises  based,  like  Erichsen's  work" 
— and  the  same  may  be  said  of  Page  and  Rigler — "  upon 
the  evidence  of  railway  cases  are  certainly  the  last  sources 
of  information  from  which  one  may  learn  to  make  a  correct 
diagnosis  and  prognosis,  and  to  escape  being  deceived  by 
the  voluntary  or  involuntary  exaggeration  and  simulation 
so  commonly  observed  in  plaintiffs  seeking  damages."  The 
sub-heading  of  "railway"  spine  and  brain  is  hardly  appro- 
priate, for  railway  accidents  were  not  the  cause  of  the 
trouble  in  the  majority  of  cases,  and  none  of  them  were 
victims  of  a  great  railway  accident,  like  that  at  Roslindale. 
Of  course  a  railway  accident  has  no  specific  effect,  except 
that  in  it  are  brought  to  play  the  most  tremendous  forces 
that  we  employ  in  our  daily  lives,  and  the  terror  and  horror, 
of  any  great  railway  catastrophy  has  a  vastly  greater  psy- 
chical effect. 

I  give  the  cases  as  briefly  as  possible,  omitting  unessen- 
tial symptoms.  I  regret  that  in  some  of  them  my  investi- 
gations in  the  domain  of  the  special  senses  have  not  been 
as  thorough  as  I  could  have  wished. 

I.  Jeremiah  C,  37,  m.,  railway  employee,  consulted  me 
in  March,  1887.     A  year  and  a  half  before  he  was  knocked 

30  Boston  Medical  and  Surgical  Journal,  5th  Feb.,  1880. 


6  2  S  AM  ERIC  AX  A  EUROL  OGICAL  A  SSOCIA  TIOX. 

off  a  cable  car,  striking  his  back,  and  losing  consciousness. 
On  return  of  consciousness  he  went  back  to  work,  and  kept 
at  it  for  an  hour  or  two,  but  afterwards  he  was  laid  up  for 
seven  weeks.  Now  he  has  pain  in  the  back,  especially  on 
motion,  with  rigidity  of  the  spine,  and  lumbar  tenderness. 
His  arms  feel  helpless  ;  he  has  numbness  and  tingling  in 
the  hands  ard  at  times  in  the  legs;  the  legs  are  not  as 
strong,  and  he  has  had  cramps  in  them.  Occasional  vertigo, 
and  rush  of  blood  to  the  head.  Nervous,  fretful,  low- 
spirited,  and  poor  memory.  Some  vesical  tenesmus,  and 
loss  of  sexual  power,  Some  exaggeration  of  knee-jerks. 
Some  improvement  under  faradism  and  the  actual  cautery. 

II.  John  D.,  30,  m.,  organ  finisher,  consulted  me  in 
February,  1888.  Fell  down  stairs  a  month  ago,  striking 
small  of  back  and  buttocks.  Great  pain  in  the  back.  Di- 
minished power  in  left  leg.  He  cannot  bend  his  spine,  and 
has  great  tenderness  in  the  lumbar  region.  He  has  a  desire 
to  empty  his  bladder  most  of  the  time,  and,  when  he  passes 
water,  he  thinks  he  is  through  before  he  really  is,  occasion- 
ally wetting  himself.  No  sexual  power  since  the  accident. 
Quite  nervous  and  rather  alarmed  as  to  his  condition.  Knee- 
jerks  rather  quickened,  a  tap  setting  up  a  general  shrinking, 
as  if  from  pain. 

III.  Martin  H.,  46,  m.,  draw-tender.  Referred  to  me  at 
the  Boston  Dispensary,  in  August,  1886.  Two  years  ago 
fell  from  a  mast,  thirty-six  feet,  striking  back.  Since  then 
has  had  sharp  pains  in  the  back  and  abdomen,  shooting 
down  the  legs.  The  legs  are  easily  fatigued,  feel  numb 
and  prickly,  and  as  if  a  pad  were  between  them  and  the 
floor.  "  Drawing"  girdle  sensation.  Twisting  or  bending 
the  spine,  or  riding  in  the  cars,  is  painful.  Faint  spells  and 
vertigo  ;  severe  headache  at  times.  Nervous,  low-spirited, 
and  a  poor  sleeper.  Short  breath,  palpitation,  and  a 
"drawing"  feeling  in  the  stomach.  Poor  appetite  and 
digestion.  Arms  feel  numb  and  fingers  feel  as  if  asleep. 
Diminished  sensation  in  arms  and  legs,  and  some  tender- 
ness of  nerve-trunks  in  legs.  Lumbar  spine  flat,  slight 
lateral  curvature  to  the  right,  tender  below  tenth  dorsal 
vertebra,  the   tenderness  being  greater  by  the  sides  of  the 


AMERICAN  NE UROL  OGICAL  A SSOCIA  TION.  629 

spinous  processes.     Reflexes  and  electrical  reactions  nor- 
mal.    No  ataxia. 

IV.  Bateman  C,  59,  m.,  electrician.  January,  1886. 
Some  months  before  he  fell  from  a  ladder,  striking  on  his 
buttocks.  No  loss  of  consciousness.  Nausea  and  vomiting 
till  two  months  ago.  Costive.  Since  accident  loss  of  power 
and  prickly  throbbing  in  legs,  worse  in  the  right  leg,  which 
has  wasted.  Legs  at  times  feel  hot  or  cold,  both  subject- 
ively and  objectively.  No  distinct  pain  in  legs.  Water 
had  to  be  drawn  for  a  week  after  his  fall.  A  month  ago 
fell,  rupturing  a  vessel  in  his  knee,  and  the  knee  had  to  be 
aspirated.  Right  leg  two  inches  smaller,  marked  diminu- 
tion of  sensibility.  Muscles  of  thigh  do  not  react  to  either 
current  on  right,  and  very  feebly  to  strong  galvanic  current 
on  left.  Much  fibrillary  contraction  of  right  quadriceps. 
Distinct  gain  under  galvanism.  With  improvement  in 
strength  and  sensation  in  legs  has  decided  pain  in  them. 

V.  Jeremiah  O'D.,  50,  m.,  carpenter.  Consulted  me  in 
August,  1885,  being  anxious  to  get  a  pension  on  account  of 
his  disability.  Was  stabbed  in  the  abdomen  in  1865,  and 
had  peritonitis  after  it.  In  1870  the  pension  board  rejected 
his  application,  thinking  his  hemiparesis  was  the  result 
of  apoplexy,  but  he  denies  any  history  of  apoplexy.  On 
recovery  from  the  peritonitis,  the  left  leg  began  to  be  weak, 
and  he  had  pain  and  stiffness  in  the  left  hip.  He  could  not 
walk  without  staggering  and  getting  exhausted.  Hard  to 
lift  left  leg  up  stairs.  Severe  pain  in  left  side  and  abdomen, 
and  left  side  of  head.  Depressed,  poor  memory,  slight 
mental  impairment,  vertigo,  and  diplopia ;  some  tinnitus. 
Numbness  gradually  developed  over  his  entire  left  side,  less 
marked  in  the  hands  and  feet,  but  amounting  in  some  places 
to  absolute  anaesthesia  and  analgesia.  Tingling  and  prick- 
ling on  left  side.  Smell  impaired ;  poor  vision  in  left  eye 
from  cataract,  field  not  contracted ;  taste  poor  on  left ; 
hearing  worse  on  left.  Diminished  tactile  sensibility  over 
entire  left  side  ;  left  arm  a  little  smaller  and  weaker.  Can- 
not put  left  leg  into  a  chair  without  great  effort.  Sways 
with  eyes  shut.  Knee-jerk  and  cremaster  reflex  most 
marked  on  right ;    knee-jerk   weak.     Speech  rather  indis- 


63O  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

tinct.  Slight  tenderness  over  left  posterior  tibial.  March, 
1888:  Question  of  pension  still  pending.  Has  not  improved 
since  1885.  Symptoms  much  the  same.  Still  has  anaes- 
thesia, which  is  most  marked  on  the  left,  although  tactile 
sensibility  is  blunted  on  the  right.  Considerable  difficulty 
in  walking,  drags  left  foot.  Trouble  in  locomotion  increased 
on  trying  to  make  any  quick  movement. 

VI.  Susan  \\\,  46,  m.  December,  1886.  Neurotic  taint. 
Fell  on  ice  last  winter,  striking  left  hip  and  elbow,  and 
causing  hernia.  Now  the  slightest  effort  causes  pain  across 
the  chest  and  in  the  back.  Lifting  causes  a  "  hot  water  " 
feeling  in  the  hernia.  Very  severe  headache,  impaired  vis- 
ion, and  increase  of  deafness  in  left  ear.  Tinnitus.  Short 
breath  and  pleuritic  stitch.  Weak  stomach  ;  very  costive  ; 
frequent  micturition.  Considerable  pain  in  the  arms,  numb 
feeling  on  left  side  ;  the  left  hand  and  foot  get  cold  readily. 
Staggers  on  walking,  and  the  left  leg  gives  out.  Cramps  in 
the  legs  ;  numbness,  prickling,  and  pain  in  the  left  leg. 
Great  spinal  tenderness  ;  tender  over  stomach  and  lower 
ribs  on  each  side.  Tender  over  left  ulnar,  sciatic,  and  pos- 
terior tibial  nerves.  Diminished  sensibility  in  left  ulnar 
region,  over  left  chest,  and  on  outer  side  of  left  leg.  Elec- 
trical reactions  normal.  Knee-jerks  exaggerated,  front-tap 
contraction.  Eyes  and  ears  not  examined.  March,  1888: 
Worse  since  last  seen.  Pain  in  left  side  and  back  ;  prickly 
feeling  all  over  body.  Much  vertigo.  Pain  in  right  foot. 
Poor  vision.  Very  nervous.  At  times  has  much  trouble  in 
passing  water.  Troubled  greatly  with  leucorrhoea  and 
piles.  Field  of  vision  good,  rou  20-50.  Fundus  normal 
Cannot  hear  watch  with  either  ear,  or  through  bone.  Marked 
opacity  of  membrana  tympani.  Cannot  stand  with  eyes 
shut.     Slight  tremor  of  hands.     Extreme  spinal  tenderness. 

VII.  Annie  S.,  45,  m.  Seen  in  consultation  February, 
1886,  with  Dr.  E.  S.  Boland,  who  has  reported  the  case  in 
full."  Not  neurotic.  Two  years  before  she  was  thrown 
down  an  embankment  by  the  sudden  starting  of  a  train,  and 
had  recovered  damages,  although  the  case  was  still   in  dis- 

Sl  E.  S.  Boland.  Symptoms  following  Injury  to  the  Head  and  Back.  Bos- 
ton Med    and  Surg.  Joarnal,  loth  Nov.,  1887. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  63  I 

pute.  Much  pain  in  head  and  lumbar  region,  and  consid- 
erable vertigo.  Sleeps  poorly  and  has  a  poor  memory. 
Poor  appetite ;  very  costive  ;  has  had  jaundice  since  the 
accident.  At  one  time  had  xanthopsia,  and  another  melan- 
opsia.  Menses  irregular  and  painful.  Urine  scanty.  Wets 
and  soils  herself  at  times.  Very  marked  anaesthesia  over 
whole  body,  with  analgesia.  Some  sensation  in  tip  of  nose, 
left  ulnar  region,  and  right  cheek.  All  muscular  efforts 
slow  and  weak.  Cannot  stand  without  support.  Muscles 
do  not  react  well  to  faradism  ;  knee-jerks  weak.  Field  of 
vision  contracted,  especially  in  right  eye  ;  vod,  can  count 
fingers  ;  vo s,  2-20.  Monocular  diplopia,  od.  Pupils  react 
sluggishly  to  light.  Loss  of  smell  and  taste.  Hearing  to 
watch,  contact  ad,  four  inches,  as.  Gained  under  treatment 
for  three  months.  Later  right  ankle  became  weak.  When 
last  heard  from,  December,  1887,  she  was  still  far  from  well, 
being  quite  lame,  and  having  much  pain  in  her  back. 

VIII.  Chas.  L.,  14,  s.,  school-boy.  Referred  to  me  by 
Dr.  Cutter,  of  Leominster,  in  May,  1886.  Nervous  heredity- 
Posthumous  child,  always  nervous  and  irritable,  had  con- 
vulsions in  infancy.  Six  years  ago  fell  from  a  bridge, 
striking  forehead.  Signs  of  shock  after  it.  "  Shoulders 
drew  up  and  spine  got  crooked."  Delirious  after  fall,  and 
very  nervous  since.  Said  to  have  lateral  curvature,  but  it 
was  not  detected.  Three  years  ago  eyes  began  to  trouble 
him,  with  dim  vision  and  pain.  Much  headache,  irritable, 
surly,  and  heedless.  Poor  appetite,  chronic  diarrhoea.  Pal- 
pitation. Passes  much  urine.  Rheumatic  fever  a  year  ago. 
Muscles  weak,  pain  in  legs  with  numbness  and  prickling  in 
hands  and  arms.  Fell  again  last  fall,  striking  head.  Worse 
since  then,  and  has  had  two  attacks :  in  one  unconscious, 
rigid,  trembled  and  screamed  ;  sleepy  after  it.  Two  attacks 
of  aphonia.  Left  leg  said  to  be  drawn  up  at  times.  Very 
fat.  Field  of  vision  normal,  vod  20-20,  vos  20-100,  astig- 
matism of  4  D,  os.  Quite  tender  over  spine,  and  more  or 
less  tender  all  over.  Smell,  taste,  and  hearing  normal. 
Slight  diminution  of  electrical  sensibility  on  left.  Knee- 
jerks  only  on  re-enforcement.  In  June,  1888,  reported  to 
have  had  chorea,  and  after  that  to  have  had  an  increase  of 
all  his  symptoms,  with  one  or  two  more  attacks. 


63  2  AMERICAN  XEUROLOGICAL  ASSOCIA  TIOX. 

IX.  Chas.  D.,  12,  s.,  school-boy.  Mother  consulted  me 
in  September,  1886,  for  an  opinion  in  relation  to  a  suit  for 
damages.  Xot  neurotic.  Two  years  ago  he  fell  down  a 
coal-hole,  striking  head.  Unconscious  for  a  time,  and  de- 
lirious for  several  days.  Scalp-wound,  and  question  of 
depressed  fracture.  Headache  and  vertigo  since ;  could 
not  go  up  or  down  stairs  safely,  owing  to  vertigo.  Violent 
headaches  induced  by  any  effort  or  excitement.  Very  for- 
getful, peevish,  fretful,  and  sleeps  poorly.  Has  had  attacks 
of  severe  headache,  with  nausea,  and  "  raving  attacks," 
when  he  would  call  out  various  phrases  referring  to  his  acci- 
dent, and  twisted  about,  his  limbs  working.  Exhausted  after 
these.  Sudden  attacks  of  pallor  and  vertigo.  Some  diplo- 
pia and  tinnitus.  Capricious  appetite  ;  has  not  grown 
much  or  gained  in  flesh  since  accident.  Slight  furrow  over 
right  parietal,  and  cicatrix  over  occiput.  Some  spinal  ten- 
derness in  upper  dorsal  region  ;  jarring  causes  vertigo. 
Field  of  vision  and  tactile  sensibility  normal.  Special  senses 
unimpaired.  Xo  knee-jerks.  Gradual  improvement,  but  in 
December,  1887,  was  still  subject  to  severe  headache  and 
vertigo  on  any  exertion  or  excitement.  Xo  attacks  since 
May.  1886. 

X.  Charles  C,  61,  w.,  machinist.  June,  1887.  X*o 
special  taint.  Eighteen  months  ago  he  was  thrown  from  a 
wagon,  and  was  unconscious  for  six'  and  a-half  hours  after 
it.  Xo  external  injury  or  fracture.  Hot  water  bottles  were 
put  to  his  feet,  burning  them  so  badly  that  he  was  kept  in 
bed  for  four  months.  On  getting  about,  his  shoulders  and 
right  leg  began  to  feel  heavy  and  his  arms  ached.  His 
head  felt  sore,  and  he  has  had  sharp  pains  in  it.  Discour- 
aged, low-spirited,  and  irritable,  but  mental  power  is  not 
impaired.  Short  breath,  poor  appetite,  constipation.  Prickly 
aching  and  burning  in  the  arms,  which  feci  weak  and 
heavy.  Right  leg  feels  numb  and  prickly,  and  both  legs 
ache.  He  has  pain  and  a  hollow  feeling  in  the  back,  which 
hinder  his  walking.  Says  he  is  growing  worse.  Marked 
myopic  astigmatism,  field  of  vision  normal.  Fibrillary 
tremor  of  tongue.  It  hurts  him  in  the  lower  dorsal  region  to 
bend  his  spine,  but  it  is  not  tender.      Some  inco-ordination 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  63  3 

of  the  left  arm,  and  a  little  tremor  of  the  hands.  Speech  is 
a  little  thick.  Epigastric  reflex  present  only  on  left.  Tri- 
ceps, radial,  ulnar,  and  patellar  reflexes  exaggerated. 
Slight  patellar  clonus  ;  front-tap  contraction.  March,  1888: 
Condition  not  improved.  Complains  greatly  of  his  back, 
and  of  inability  to  use  his  arms  well.  Numbness  of  both 
legs.  No  inco-ordination  of  hand.  Reflexes  exaggerated. 
No  consciousness  of  events  immediately  preceding  acci- 
dent. Was  thrown  from  a  carriage  fifteen  years  ago,  and 
after  that  had  some  stiffness  of  left  arm,  which  recovered. 
A  year  before  his  last  accident,  however,  this  arm  had  been 
rather  weak. 

XI.  Dennis  B.,  37,  m.,  printer.  Referred  to  me  by  Dr. 
Post,  in  August,  1885.  In  January,  1885,  was  struck  by 
shafting,  the  right  side  being  most  injured.  Right  instep 
and  right  little  finger  broken  ;  right  thigh  and  leg  much 
bruised.  Laid  up  until  May.  Two  weeks  ago  tried  to  go 
to  work  on  a  hot  day,  worked  an  hour  and  a-half,  and  had 
to  go  to  bed.  Memory  began  to  fail  after  injury,  and  he  has 
had  constant  severe  headache  ever  since.  Has  vertigo  so 
badly  that  his  wife  is  afraid  to  let  him  go  out  alone.  For- 
getful since  his  injury.  Very  restless  at  night.  Much  more 
irritable  and  excitable.  Considerable  diplopia.  Slight 
palpitation  and  shortness  of  breath.  Poor  appetite,  some 
vomiting.  At  times  has  to  wait  before  he  can  pass  water, 
and  at  times  the  stream  stops.  Cannot  close  right  hand  as 
well.  Frequent  and  severe  pain  in  the  right  leg  after  using 
it,  and  constant  numbness  and  prickling.  Right  leg  weaker, 
somewhat  wasted,  and  is  easily  fatigued.  After  his  attempt 
to  go  to  work,  was  in  bed  for  a  week;  headache  and  vertigo 
much  worse,  felt  dazed,  and  has  been  more  or  less  confused; 
had  constant  nausea  and  vomiting  for  a  week.  Field  of 
vision  good,  vod  20-20,  vos  20-30,  left  disk  paler.  Some 
weakness  of  external  recti,  with  nystagmus  on  excursion 
outwards.  Other  senses  and  tactile  sensibility  unimpaired. 
Arms  strong,  no  inco-ordination,  some  tremor  of  hands. 
Right  leg  smaller  than  left,  vastus  internus  does  not  react 
to  faradism,  lower  leg  muscles  require  a  stronger  current 
than    on    left.      Nerve-trunks    in    risrht    leg    rather   tender. 


634  AMERICAS'  XECROLOGICAL  ASSOCIAT/OX. 

Reflexes  normal.  His  symptoms  gradually  increased  ;  he 
grew  steadily  weaker,  the  mental  deterioration  became  more 
marked,  and  about  a  year  later  he  died.     Xo  autopsy. 

XII.  Wm.  M.,  49,  m.,  engineer.  Consulted  me  in 
March,  1887.  Gonorrhoea.  Considerable  tobacco,  little  al- 
cohol. Struck  by  a  stone  from  a  blast  twenty  years  ago, 
breaking  right  forearm  and  thigh,  and  cutting  radial  (?) 
nerve  in  upper  arm.  Anchylosis  of  right  elbow  joint.  Arm 
has  been  partly  paralyzed  since.  Ever  since  accident  has 
been  nervous,  "shattered."  Sleep  is  very  restless  ;  feels 
unstrung.  Any  excitement  or  any  considerable  exertion 
uses  him  up,  and  makes  him  put  out  of  breath.  Some 
"rheumatic"  pain  in  legs.  Cannot  move  right  arm  at 
shoulder  much,  or  at  elbow  at  all  ;  can  flex  and  spread 
wrists  and  fingers,  but  cannot  extend  them;  supinates  a  lit- 
tle, pronates  well.  Arm  two  or  three  inches  smaller  round; 
muscles  wasted,  do  not  react  to  faradism.  Diminished  sen- 
sibility in  distribution  of  radial  nerve.  Sensation,  motion, 
and  reflexes  elsewhere  normal.  March,  1888:  Condition 
much  the  same.  The  pain  in  the  legs  is  of  rather  recent 
date,  and  is  of  a  rheumatic  character.  He  is  able  to  work, 
but  since  his  injury  he  has  been  of  a  nervous,  unstable 
disposition.  Before  it  he  could  stand  anything  ;  since, 
everything  excites  him  very  much,  and  makes  him  very 
nervous. 

These  last  two  cases  are  of  further  interest  from  the 
fact  that  ErichsenM  claims  that  when  injury  produces  frac- 
duces  fracture  of  any  bone,  the  nervous  system  is  apt  to 
escape  from  the  effects  of  concussion,  the  violence  of  the 
shock  expending  itself  in  producing  the  fracture.  These 
cases,  as  well  as  a  good  many  others  that  have  been  re- 
ported, show  at  least  that  Erichsen's  rule  is  not  without 
exceptions. 

These  cases  certainly  present  divers  groups  of  symptoms 
which  demand  a  little  consideration.  The  commonest 
among  them  point  to  some  cerebral  disturbance.  Eight 
ha  1  headache  or  pain  in  the  head,  and  eight  had  vertigo  ; 
ten    had    some   psychical   disturbance,   nervousness,  restle- 

I.  E.  Erich  it.,  p.  73. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  635 

ness,  irritability,  inability  to  make  prolonged  effort,  depres- 
sion, anxiety,  loss  of  memory,  and,  in  at  least  one  case 
(XL),  distinct  mental  impairment ;  two  (VIII.  and  IX.) 
had  some  sort  of  convulsive  seizure;  one  only  (IX.)  seemed 
to  have  been  affected  by  any  terror,  and  in  him  the  effect 
was  slight. 

Motor  disturbances  were  not  uncommon.  Seven  patients 
had  muscular  weakness,  which  sometimes  amounted  to  ac- 
tual paralysis,  although  chiefly  when  there  was  neuritis. 
Several  had  tremor  ;  two  (V.  and  VI.)  Romberg's  symp- 
tom ;  and  one  (X.)  inco-ordination.  Several  had  muscular 
wasting,  and  four  diminished  electrical  excitability,  chiefly 
from  neuritis.  The  knee-jerks  were  increased  in  three 
cases,  diminished  in  three,  and  absent  in  one. 

Sensory  disturbances  were  less  common.  In  only  four 
cases  was  there  poor  vision,  due  generally  to  definite  causes 
independent  of  the  injury.  In  three  cases  the  other  special 
senses  were  impaired,  generally  on  one  side.  Three  pa- 
tients had  diplopia,  and  one  (XI,)  nystagmus.  One  (VII.) 
had  monocular  diplopia,  sluggish  pupils,  and  xanthopsia  ; 
the  last  symptom  was  noted  in  one  of  Oppenheim's  cases. 
Contracture  of  the  field  of  vision  was  found  but  once,  but  in 
a  few  instances  the  fields  were  not  examined.  Anaesthesia 
in  varying  degrees  was  noted  in  seven  cases,  due,  in  two  at 
least,  to  neuritis.  In  four  of  these  seven  cases,  and  in  two 
others,  there  was  paresthesia.  In  no  case,  unless  possibly 
in  Case  VIII.  was  the  anaesthesia  strictly  unilateral — hemi- 
anaesthesia. 

Digestive  disturbances  were  occasionally  seen,  and  in 
five  cases  there  were  vesical  symptoms — signs  of  paresis  of 
the  bladder.     Two  men  reported  impotence. 

Pain  in  the  back  was  found  in  seven  cases,  and  several 
others  had  pain  in  the  side,  limbs,  or  abdomen.  The  pain 
in  the  back  was  usually  associated  with  tenderness  over  the 
spinal  muscles  and  was  increased  on  motion.  In  a  few 
instances  it  was  associated  with  tenderness  over  the  spinous 
processes. 

What  is  the  cause  of  such  an  array  of  symptoms  ?  Is 
there    "only    hysteria,    nothing    but    hysteria?"       Is    there 


636  AMERICAS'  NEUROLOGICAL  ASSOCIATION. 

merely  a  strain  of  the  muscles  of  the  back,  with  neurasthe- 
nia added  to  it?  Is  there  merely  a  functional  derangement, 
or  is  there  some  structural  change  in  the  nervous  system  ? 
Of  course  it  is  not  possible  to  find  any  one  diagnosis  to  fit 
so  many  different  cases,  but  these  cases  and  their  attendant 
symptoms  may  furnish  us  with  some  data  to  aid  in  consid- 
ering the  whole  subject  of  so-called  "concussion  of  the 
spine." 

Before  discussing  the  question  further  it  is  essential  to 
give  some  sort  of  a  definition  of  what  is  meant  by  the  two 
vague  terms  hysteria  and  neurasthenia.  Neither  of  them 
can  rightly  be  regarded  as  a  disease.  They  are  both  con- 
ditions of  the  individual,  the  latter  being  well  defined  as  "a 
bodily  condition  which  is  frequently  associated  with  various 
chronic  disorders,  and  not  rarely  coexisting  with  perverted 
functional  activity  of  the  nervous  centres."  33  These  states 
are  often  erroneously  spoken  of  as  if  they  were  distinct  dis- 
eases, and  the  names  are  often  used  as  convenient  "  dumps  " 
for  cases  where  we  can  make  no  diagnosis.  Hysteria  is  the 
state  in  which  ideas  can  control  the  body  and  produce 
morbid  changes  in  its  functions,3'  while  neurasthenia  is  a 
state  of  exhaustion  from  over-strain.  The  two  states  may  be 
combined,  or  may  complicate  other  affections.  There  is  a 
hysterical  symptom-complex  that  is  so  definite  that  it  may 
fairly  well  be  spoken  of  as  a  disease,  and  that  is  the  group 
of  symptoms  that  make  up  the  grande  hysteric  of  Charcot. 
To  that  alone  I  will  apply  the  term  hysteria  ;  other  con- 
ditions I  will  speak  of  as  the  hysterical  or  neurasthenic 
states. 

That  psychical  disturbance  can  produce  functional  par- 
ralyses  has  been  known  for  many  years,  and  these  paralyses 
have  been  discussed  under  many  different  names,  such  as 
"emotional  paralysis,"  3'  "  paralysis  dependent  upon  idea,"  36 

M  H    C.  Wood.     Nervous  Diseases  and  their  Diagnosis,  p.  18. 

31  P.  J.  Mobius.  Unter  den  Begriff  der  Hysteric  Centralblafl  f.  Nerven- 
heilkundr,   1st.  Feb.,  1888. 

KB.  Todd.     Clinical  Lectures  on  Paralysis. 

38  J.  Russell  Reynolds.  Remarks  on  Paralysis  and  other  Disorders  of  Motion 
and  Sensation  dependent  on  Idea.     Briti>h  Medical  Journal,  6th  Nov.,  1869. 


AMERICAN  NE URO LOGICAL  A SSOCIA  TION.  637 

or  the  "Schrecklahmung"  of  the  Germans.37  It  was  reserved 
for  Charcot,3"  however,  to  give  us  the  explanation  of  their 
origin.  He  has  found  that  in  certain  hysterical  patients  at 
La  Salpetriere,  who  were  easily  hypnotizable,  he  could  pro- 
duce, by  suggestion  when  hypnotized,  paralyses  precisely  si- 
milar to  those  seen  in  other  patients  as  the  result  of  an  injury. 
He  therefore  suggests  that  the  mental  state  occasioned 
by  the  nervous  shock  of  the  accident  is  similar  to  the 
sommambulistic  stage  of  hypnotism — there  is  an  "obnu- 
bilation of  the  ego!'  The  idea  of  injury'  occurring  in  this 
state  of  nervous  shock  or  obnubilation,  acts  as  a  traumatic 
suggestion,  producing  the  same  results  as  ordinary  sugges- 
tion in  a  hypnotized  patient.  The  patient  develops  his 
own  idea  and  suggests  it. 

Charcot's  brilliant  reasoning  proves  beyond  question 
the  existence  of  a  traumatic  hysteria  in  his  cases,  but,  after 
a  careful  study  of  these  cases,  and  of  others  collected  by 
Rendu,39  Poupon,40,  Lyon,41  and  Berbez,42  I  am  unable  to 
trace  any  resemblance  between  them  and  the  cases  cited 
above,  or  the  cases  reported  by  German  observers.  Char- 
cots patients  present  either  typical  grand  hysteria,  with 
hemianaesthesia  of  the  skin  and  organs  of  special  sense,  and 
with  hystero-epileptic  attacks  with  grand  movements, 
passionate  attitudes,  and  the  arc  de  cercle  ;  hysterical  mon- 
oplegia ;  or  hysterical  articular  neurosis.  The  characteris- 
tics of  hysterical  monoplegia  are  paralysis,  with  or  without 
contracture  ;  anaesthesia  of  the  paralyzed  limb,  not  follow- 
ing any  nerve  tracts  but  having  a  sharp  line  of  demarcation 
and  encircling  the  limb  like  a  bracelet  ;  little  or  no  atrophy, 
and  normal  electrical  reactions.  The  joint  affection  is 
that  first   described   by  Brodie,  simulating  severe   organic 

37  E.  Leyden.     Op.  cit.,  i.  173. 

3SJ.  M.  Charcot.      Op.  cit.,  iii.  355,  392  et  seq. 

39  H.  Rendu.  Contribution  a  l'histoire  des  monoplegies  partielles  du  mem- 
bre  superieur,  d'origine  hystero-traumatique.  Archives  de  Neurologie,  Sept., 
1887. 

40  H.  Poupon.     Paralysies  hystero-traumatiques.     L'Encephale,  Jan.,  1886. 

41  G.  Lyon.  Note  sur  l'hysterie  consecutive  aux  traumatismes  graves.  L'En- 
cephale, Jan.,  1888. 

42  P.  Berbez.     Hysterie  et  Traumatisme.     Paris,  1887. 


638  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

disease,  and  attended  with  great  pain,  cutaneous  hyperes- 
thesia, and  tenderness  and  stiffness  of  the  joint,  the  stiffness 
disappearing  under  ether.  The  diagnosis  of  these  conditions 
is  not  difficult,  and  in  the  cases  reported  above  they  were 
not  present.  I  have  seen  all  three  of  the  conditions. — 
grand  hysteria,  hysterical  monoplegia,  and  articular  neuro- 
sis ;  but  I  have  not  yet  seen  these  conditions  appearing  as 
the  result  of  injury. 

The  researches  of  Thomsen  and  Oppenheim  have  shown 
conclusively  that  hemianesthesia  is  not  pathognomonic  of 
hysteria.  Charcot  formerly  held  **  that  general  anaesthesia 
was  rare  in  hysteria,  that  the  anesthesia  was  usually  un- 
ilateral, the  median  line  forming  the  limit.  This  claim  has 
been  abandoned,  for  many  of  his  cases  show  anesthesia  of 
only  one  limb,  and  Berbez  has  found  hemianesthesia  in 
only  thirty-eight  out  of  ninety-three  cases.  The  common- 
est sympton  in  sensory  anesthesia — a  point  in  which  both 
French  and  Germans  observers  agree — is  the  peripheral 
limitation  of  the  field  of  vision.  Thomsen  and  Oppenheim 
have  found  sensory  anesthesia,  which  in  many  cases  was 
unilateral,  in  epilepsy,  hysteria,  neurasthenia,  nervousness, 
chorea,  "railway-spine,"  multiple  sclerosis,  Westphal's 
pseudo-sclerosis,  organic  cerebral  disease,  certain  psycho- 
ses, and  other  conditions  ;  peripheral  limitation  of  the 
visual  field  being  the  most  constant  symptom.  Further- 
more, the  investigation  of  the  committee  of  the  Societe  de 
Biologie,  consisting  of  Charcot,  Luys,  and  Dumontpallier, 
have  shown  "  that  in  hemianesthesia  due  to  undoubted  or- 
ganic disease  of  the  brain  the  phenomena  of  transfer  can 
sometimes  be  excited  by  the  application  of  metals.  Thus 
it  seems  that  not  only  is  hemianesthesia  not  pathognomo- 
nic of  hysteria,  but  also  that  transfer  phenomena  in  hemi- 
anesthesia are  not  pathognomonic  of  hysteria. 

Thomsen  and  Oppenheim  oppose  the  hypothesis  of  hys- 
teria as  an  explanation  ot  their  cases  on  other  grounds. 
To   their    argument    that    the    anesthesia  is  fixed  and  un- 

*3  J.  M.  Charcot.     Le<;ons  sur  le^  l<x  aKsations,  etc,  p.  115. 
**  Premier  Rapport   fait  k  la  Societe  de  Biologie  sur  la  metallo-scopie  et  la 
m6talloth6rapi£  <lu  Dr.  Burq.     Gazette  Medicale,  28th  April,  1877. 


AMERICAN  NEUROLOGICAL  ASSOCIATION  639 

varying,  and  that  the  disposition  is  not  that  of  the  hyster- 
ical, Charcot  has  replied  by  citing  cases  where  the  anaes- 
thesia in  hysterical  patients  has  not  varied  for  years.  Op- 
penheim's  further  objections,  however,  seems  to  be  more 
conclusive.  He  finds  that  the  patients  are  anxious,  hypo- 
chondriacal, and  depressed  ;  complaining  of  headache, 
vertigo,  faintness,  and  occasionally  of  epileptiform  attacks. 
They  have  pain  in  the  back,  anaesthesia,  and  peripheral 
limitation  of  the  field  of  vision  ;  their  movements  are  slow 
and  feeble  ;  and  they  try  to  guard  their  spines  from  jarring; 
there  is  often  tremor  ;  the  vesical  functions  may  be  dis- 
turbed ;  the  pulse  is  often  rapid  ;  in  one  case  Oppenheim 
found  unequal  pupils  which  did  not  react  to  light,  in  another 
optic  atrophy.  This  latter  symptom  is  not  very  rare;  it  has 
been  noted,  for  example,  in  cases  reported  by  Rigler,45 
Walton,46  and  Wharton  Jones.4:  Not  only  are  these  symp- 
tom not  hysterical,  but  they  are  not  even  functional  ;  and 
Oppenheim  justly  argues  that  if  they  be  ranked  as  hysterical 
the  firmest  pillars  of  our  knowledge  are  overturned. 
Westphal,48  too,  asserts  that  these  cases  cannot  be  brought 
under  the  rubic  of  hysteria, 

Within  a  few  months  Oppenheim  has  reviewed  the  sub- 
ject again,  49  and  concludes  that  the  cases  with  signs  of  un- 
doubted organic  disease,  immobile  pupils,  optic  atrophy, 
and  vesical  symptoms  are  in  the  minority,  and  that  most 
cases  represent,  not  a  typical  neurosis  like  hysteria  or 
neurasthenia,  but  a  more  general  and  complex  psycho- 
neurosis,  from  which  the  patient  never  recovers. 

In  the  cases  reported  above  the  leading  symptoms  were 
certainly  not  those  of  hysteria.     The    psychical    conditions 

45  J-  Kigler.  Ueber  die  Folgen  der  Verletzungen  auf  Eisenbahnen,  insbe- 
sondere  des  Verletzungen  des  Riickenmarks.     Berlin,  1879. 

46  G.  L.  Walton.  Art.  cit..  Boston  Medical  and  Surgical  Journal,  nth  Oct., 
1883. 

41  Quoted  by  Eichhorst  Handbook  of  Practical  Medicine.  Am.  Trans.,  iii. 
144. 

48  Archiv  f.  Psychiatrie  u.  Nervenkrankheiten,  xvii.  282.      1886. 

49  H.  Oppenheim.  Wie  sind  die  Erkrankungen  des  Nervensystems  aufzu- 
fassen,  welche  sich  nach  Erschutterung  des  Riickenmarkes,  insbesondere  Eisen- 
bahnunfallen,  entwickeln?  Berliner  klinische  Wochenschnft,  No.  9.  27th  Feb., 
1888. 


64O  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

noted — depression,  anxiety,  loss  of  memory,  mental  im- 
pairment ;  the  tremor  ;  the  exaggerated  reflexes,  and  the 
swaying  with  closed  eyes  ;  the  pronounced  paresthesia  ; 
the  vertigo  and  headache  (persistent  headache  being  con- 
fessedly not  a  symptom  of  hysteria);50  nystagmus  ;  vesical 
paresis — all  these  point  to  something  beside  hysteria  or  the 
hysterical  state.  Moreover,  incontinence  of  urine,  nys- 
tagmus, and  exaggerated  reflexes  are  symptoms  which  we 
should  expect  to  find  in  organic  rather  than  in  functional 
disease.  Case  XL,  especially,  is  strongly  suggestive  of  dis- 
seminated sclerosis,  and  the  fatal  termination  renders  the 
diagnosis  of  organic  disease  assured. 

It  seems  to  me  that  the  theory  of  an  organic  lesion, 
possibly  the  lesions  suggested  by  Westphal,  is  the  one 
which  is  the  most  satisfactory  in  many  of  these  cases. 
Bramwell,  5I  who  is  certainly  sceptical  as  to  the  frequency 
of  organic  change,  suggests  that  there  may  be  multiple  ca- 
pillary haemorrhages  in  the  brain  and  cord,  which  give  rise 
to  inflammatory  processes,  and  finally  to  sclerosis.  These 
haemorrhages  are  so  small  as  easily  to  escape  notice,  and 
later,  if  there  be  sclerosis,  the  recent  methods  of  staining 
would  be  necessary  to  detect  it.  An  interesting  corrobora- 
tion of  this  theory  is  afforded  by  the  general  lesions  found 
in  the  bodies  of  some  of  those  killed  at  the  great  railway 
accident  at  Charenton  in  1881.  In  several  cases  Vibert" 
states  that  there  were  found  very  abundant  punctuate  hae- 
morrhages in  the  upper  part  of  the  body,  and  suggests  that 
they  arose  from  lesion  of  the  nervous  centres.  Willigk  5i 
found  in  one  case  dilatation  of  the  finest  vessels,  with  infil- 
tration into  the  perivascular  spaces,  and  degeneration  of  the 
coats  of  the  vessels.  Page,54  however,  asserts  that  in  these 
railway  cases  "  Mors  silet  ;  "  which  is  as  correct  as  many  of 
his  statements.  Autopsies  and  experimental  pathology  fur- 
nish us  with  various  facts  which    prove  an  organic  change- 

40  J.  M.  Charcot     Lecons  sur  les  maladies  du  systeme  nerveux,  iii.  268. 
51  B.  Bramwell.     Diseases  of  the  Spinal  Cord,  2d  ed.,  p.  312. 

41  Ch.  Vibert.  Etude  medico  legale  sur  les  blessures  produites  par  les  acci- 
dents de  chemin  de  fer.     Paris,  1888. 

M  A.  Willigk.     Anatomischer  Befund  nach  Himerschtitterung.     Vierteljahr- 
schrift  f.  die  prakt  Heilkunde,  cxxviii.  19,  1875. 
"H.  W.Page.      Op.  at.,  p.  82. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  64 1 

In  regard  to  experiment,  Mendel,55  believing  that  hyper- 
emia was  an  important  feature  of  the  early  changes  in 
general  paralysis,  sought  to  excite  an  intense  chronic  hy- 
peraemia  in  dogs.  For  this  purpose  he  fastened  the  animals 
on  a  revolving  table,  with  their  heads  toward  the  periphery. 
Rapid  revolution,  125  to  130  a  minute,  continued  for  half 
an  hour,  produced  punctate  haemorrhages.  Slower  revo- 
lutions (no)  for  six  minutes  a  day,  produced,  after  some 
weeks,  symptoms  of  general  paralysis,  and,  on  killing  the 
animals,  he  found  adhesions  between  the  skull,  the  menin- 
ges, and  the  brain,  an  increase  in  the  nuclei  and  cells  of 
the  glia,  an  increase  in  the  number  of  vessels,  and  changes 
in  the  ganglion  cells.  This  condition  finds  a  clinical  repre- 
sentation in  a  case  recently  reported  by  Bernhardt,56  where 
symptoms  of  general  paralysis  developed  gradually 
after  a  railway  injury.  Fiirstner  5T  has  repeated  Mendel's 
experiments,  with  fewer  revolutions  (60  to  80)  for  a  shorter 
time  (1  to  2  minutes)  and  continued  for  months.  He  found 
double  primary  degeneration  of  the  lateral  columns  and  of 
a  particular  part  of  the  posterior  columns,  changes  in  the 
optic  nerves  and  changes  in  the  brain  similar  to  those  found 
by  Mendel.  Similar  changes  in  the  lateral  columns  have 
been  found  after  death,  in  patients  who  had  suffered  from 
"  concussion,"  by  Dumenil  and  Petel,  and  also  by  Edes,5' 
who  has  called  attention  to  the  occurrence  of  symptoms  of 
spastic  paralysis  in  certain  cases. 

In  undoubted  organic  disease,  however,  no  matter  what 
the  case  may  be,  there  are  often  symptoms  which  are  due 
to  a  superinduced  hysterical  or  neurasthenic  state,  and 
these  symptoms  may  so  overlay  the  symptoms  due  to  the 
structural   changes    as    to    render  the  diagnosis  extremely 

53  E  Mendel.  Ueber  paralytischen  Blodsinn  bei  Hunden.  Ref.  in  Neurolog. 
Centralblatt,  15th  May,  1884. 

56  M.  Bernhardt.  Beitrag  zur  Frage  von  der  Beurtheilung  der  nach  heftigen 
Korpererschiitterungen,  in  specie  Eisenbahnunfallen,  auftretenden  nervosen 
Storungen.     Deutsche  medicinische  Wochenschrift,  29th  March,  1888. 

57  Quoted  by  Hoffman,  art.  cit. 

58  R.  T.  Eddes.  The  somewhat  frequent  occurrence  of  Degeneration  of  the 
Posterior-lateral  Columns  of  the  Spinal  Cord  in  so-called  Spinal  Concussion. 
Boston  Medical  and  Surgical  Journal,  21st  Sept,  1882. 


642  AMERICAN  NEUROLOGICAL  ASSOCIATIOX. 

difficult.  I  did  not  rehearse  these  symptoms  ;  they  were 
present  in  several  cases  where  I  believe  there  was  also  or- 
ganic disease,  and  I  have  seen  organic  disease  not  due  to 
injury  so  masked  by  hysterical  or  neurasthenic  symptoms 
as  to  make  the  case  a  puzzle.59  One  symptom  of  the  neu- 
rasthenic state  is  not  very  rare,  and  that  is  the  hyperes- 
thesia over  the  spinous  processes  of  the  vertebrae. 

Apart  from  this  mixture  of  functional  and  organic  symp- 
toms we  must,  however,  recognize  the  fact  that  there  are 
two  great  classes  of  cases  which  are  the  result  of  railway 
accidents  and  other  injuries,60  one  where  the  symptoms  are 
due,  as  I  have  endeavored  to  prove,  to  organic  changes  in 
the  central  nervous  system  ;  the  other  where  the  symptoms 
are  due  to  functional  disturbance. 

As  a  subdivision  of  this  latter  class  may  be  mentioned 
the  more  purely  psychical  disturbances,  which  are  not  rare. 
Naturally  these  are  seen  more  markedly  after  railway  acci- 
dents than  after  the  accidents  of  ordinary  life,  such  as  falls. 
The  horror  of  a  scene  like  that  at  Roslindale  is  not  soon 
forgotten  by  the  ordinary  spectator,  and  to  one  who  has 
been  an  active  participant,  with  the  terror  of  sudden  death 
or  some  fearful  injury  imminent,  the  effect  must  be  still 
greater.  Immediately  after  the  accident  at  Charenton 
Vibert S1  noted  a  pronouced  psychical  change  in  almost  all 
of  the  survivors,  characterized  by  nervous  excitability,  in- 
somnia, frightful  dreams  when  sleep  did  come,  tremor, 
headache,  and  a  sort  of  semi-consciousness  or  cerebral  au- 
tomatism. This  condition,  he  states,  disappeared  after  a 
short  time, — a  few  days  or  weeks, — but  I  believe  that  such 
disturbances  are  often  of  much  longer  duration  ;  at  any 
rate  I  have  known  the  psychical  shock  of  a  railway  accident 
to  be  apparent  for  a  good  many  months  afterwards.  Moeli  " 
has   noted  some    of  the  more  permanent  psychical  condi- 

*»  For  a  fuller  discussion  of  this  point  see  E.  C.  Seguin's  article  on  Hysterical 
symptoms  in  Organic  Nervous  Affections,  in  his  Opera  Minora,  p.  180. 

"  I  .  Kalliefe.  Ueber  Ruckenmarkserschiitterung  nach  Fisenbahnunfallen 
(Railway-spine),  p.  27. 

«' C.  Vibert     Op.  a'..,  pp.  11,  35. 

Moeli.      Ueber  psychi->he  StSrungen   nach  Eisenbahnunf  alien.     Ber- 
liner klinische  Wochenschrift.  7th  Feb.,  1881. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  643 

tions.  The  patient  becomes  sensitive  to  sensory  impressions, 
and  they  are  irritable,  anxious,  and  depressed.  They  are 
easily  fatigued,  weak,  nervous,  tearful  and  tremulous  ;  they 
are  unstable  and  incapable  of  mental  application,  and  all 
thought  becomes  difficult.  They  generally  have  headache, 
which  is  increased  by  mental  effort  or  by  slight  amounts  of 
alcohol.  Moreover  they  are  dominated  by  the  thought  of 
the  accident,  which  is  a  constant  source  of  oppression  to 
them  and  haunts  them  night  and  day.  Thomsen 63  has 
lately  described  a  case  under  the  name  of '"  acute  railway 
brain,"  where  there  was  a  slightly  different  symptom-com- 
plex. Immediately  after  the  accident  there  were  maniaca 
symptoms,  with  absolute  and  complete  anaesthesia,  confu- 
sion, and  delusions  of  persecution.  Latter  the  maniacal 
symptoms  disappeared,  the  anaesthesia  was  less  complete, 
but  the  man  became  lachrymose,  hypochondriacal,  de- 
pressed, irritable  and  unable  to  work  on  account  of  head- 
ache and  weakness. 

Beside  these  psychical  disorders  there  are  other  mani- 
festions  of  functional  nervous  disease.  I  believe  that  hys- 
teria (the  "grand  hysteria"  of  Charcot)  is  only  rarely  the 
result  of  injury,  but  there  are  a  large  class  of  cases  which, 
after  injury,  suffer  from  symptoms  which  are  a  part  of  the 
neurasthenic  state.  After  severe  concussion,  or  the  psychi- 
cal trauma  of  injury,  the  victim  is  thrown  into  a  pronounced 
neurasthenic  state,  which  may  last  for  years.  His  nervous 
system  is  utterly  shattered,  or,  to  use  the  phrase  of  the 
day,  he  is  "  all  broken  up."  He  is  nervous,  emotional,  irrit- 
able, perhaps  hysterical  ;  he  is  overcome  by  trifles  ;  he  is 
exhausted  by  the  slightest  effort.  He  may  present  no  objec- 
tive symptoms,  but  he  remains  an  utter  wreck.  There  is  a 
general  weakening,  and  a  decline  from  the  normal  standard 
in  the  functions  of  the  central  nervous  system,  especially  in 
the  domain  of  the  thought,  the  will,  and  the  emotions.64 
The  symptoms  may  be   milder,  as  in    Case  XII.     Here,  the 

63  R.  Thomsen.  Vorstellung  eines  Falles  von  acutem  schweren  Railway 
Brain.  Verhandl.  der  Gesellschaft  der  Charite-Aerzte  in  Berlin.  Berliner  klin- 
ische  Wochenschrirt,  18th  Aug.,  1887. 

«M.  Bernhardt.     Art.  cit. 


644  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

patient  finds  himself  changed  :  instead  of  being  capable  of 
continued  exertion  or  strain,  he  is  easily  upset,  trifles  annoy 
him,  he  is  irritable  and  quick  tempered,  he  has  lost  the 
power  of  rebounding  after  pressure,  of  maintaing  the  calm, 
good  tempered  spirit  which  perhaps  he  had  before  ;  his 
sleep  is  not  sound,  he  starts  when  a  door  slams,  his  children 
annoy  him,  he  is  fretful  and  fault-finding.  It  may  be  that 
such  a  man  is  able  to  work  as  well  as  before,  and  to  earn  as 
much  money,  but,  if  he  be  in  some  responsible  position, 
perhaps  his  judgment  is  less  sure,  or  his  bearing  toward  his 
associates  less  agreeable  ;  he  is  no  longer  a  "good  fellow," 
but  nervous  and  disagreeable.  These  things,  of  course,  are 
trifles,  for  which  no  jury  would  award  damages  ;  but  they 
are  trifles  which  mark  an  enfeebled  nervous  system, and  it  is 
these  very  trifles  which  are  like  sand  in  the  bearings  of  the 
carriage  :  they  decide  whether  life  is  agreeable  or  disagree- 
able, and  they  are  trifles  which  may  continue  for  years  ;  in 
fact,  the  man  may  never  recover  his  old  buoyancy,  his 
consideration  for  others,  and  his  good  nature. 

I  have  not  spoken  as  yet  of  the  subject  of  strain  of  the 
muscles  of  the  back,  upon  which  so  much  stress  has  been 
laid  by  Page.  It  is,  I  believe,  the  chief  source  of  the 
marked  rigidity  of  the  spine  so  often  seen,  and  by  it  or  by 
"  spinal  irritation  "  is  to  be  explained  the  spinal  tenderness 
so  often  met  with,  for  spinal  tenderness  has  as  little  to  do 
with  disease  of  the  cord  as  pain  in  the  back  has  to  do  with 
renal  disease.  Although,  however,  it  is  often  present,  I 
believe  that  it  usually  exists  as  a  complication  and  not  as 
the  sole  cause  of  the  symptoms.  The  first  two  cases  re- 
ported are  good  examples  of  muscular  strain,  but  in  neither 
of  them  was  that  the  only  trouble.  The  first  man  had  par- 
amnesia in  the  arms,  vertigo,  psychical  disturbances,  and 
vesical  symptoms,  and  the  second  had  vesical  disturbance 
and  impotence.  Page"  seeks  to  ascribe  incontinence  and 
impotence  to  the  strain  alone,  but  I  am  unwilling  to  accept 
his  conclusions.  With  strain  of  the  muscles  of  the  back 
there  may  be  a  little  difficulty  in  emptying  the  bladder, 
but,  when  there  is  pain  only  on  motion,  I  cannot  see  how 

H.  \V.  Page.     Op.  at.,  p.  18?. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  645 

the  strain  should  paralyze  the  sphincters.  In  severe  twists 
of  the  spine  the  nerves  may  be  implicated,  and  it  is  possible 
that  some  of  the  nerves  of  the  vesical  plexus  may  be  among 
them,  yet  that  is  by  no  means  clear.  Impotence  is  so  com- 
mon in  all  conditions  of  pain  or  weakness  as  to  be  of  no 
significance.  Strain  of  the  muscles  may  often  present  such 
prominent  symptoms  as  to  mask  the  symptoms  of  nervous 
disturbance  that  lie  beneath,  yet  I  believe  that  careful  in- 
quiry will,  in  most  cases  of  "  concussion,"  reveal  symptoms 
referable  to  the  nervous  system.  As  to  Page's  claim66  that 
these  cases  do  not  recover  owing  to  excessive  doses  of 
bromide  of  potassium,  it  is  too  much  the  argument  of  the 
railway  attorney  to  merit  consideration. 

Of  differential  diagnosis  I  will  say  but  little,  because 
there  is  so  much  to  say  that  it  might  easily  fill  a  book ; 
nor  will  I  dwell  upon  the  possibility  of  simulation,  which 
has  been  so  prominent  in  the  minds  of  some  writers  as 
almost  to  conceal  the  fact  that  there  was  a  real  affection  to 
be  simulated.  It  is  perhaps  needless  to  add  that  all  objec- 
tive symptoms  which  indicate  structural  disease  should  be 
noted  with  care  :  the  pupils  and  the  optic  nerve,  the  elec- 
trical reactions,  the  condition  of  the  reflexes,  the  presence 
of  tremor,  especially  fibrillary  tremor  of  the  face  and  tongue, 
ataxia,  and  Romberg's  symptom.  It  should  also  be  borne 
in  mind  that  peripheral  limitation  of  the  field  of  vision,  which 
is  regarded  by  Thomsen  and  Oppenheim  as  one  of  the  most 
constant  attendants  upon  anaesthesia,  and  is  considered  by 
Charcot  one  of  the  chief  stigmata  of  hysteria,  may  be  the 
earliest  recognizable  manifestation  of  atrophy  of  the  optic 
nerve. 

In  spite  of  the  most  rigid  examination,  however,  there 
are  many  cases  which  furnish  us  no  objective  signs,  notably 
the  cases  of  purely  psychical  disturbance,  and  the  condi- 
tions of  neurasthenia,  the  purely  "functional"  affections. 
Here  we  can  say  only  this,  that  if  the  patient's  statements 
be  true,  he  has  suffered  severe  and  perhaps  incurable  injury. 
If,  in  such  cases,  we  had  the  opportunity  of  long-continued 

66  H.  W.  Page.  On  the  Abuse  of  Bromide  of  Potassium  in  the  Treatment  of 
Traumatic  Neurasthenia.     Medical  Times  and  Gazette,  4th  April,  1885. 


646  AMERICAN  XECROLOGICAL  ASSOCIATION. 

and  constant  observation,  we  would  be  in  a  better  position 
to  judge  of  the  patient's  veracity  ;  but  it  may  be  as  difficult 
to  decide,  and  may  require  as  long-continued  study  as  it 
does  in  certain  cases  of  insanity. 

The  prognosis  in  these  cases  varies,  of  course,  with   the 
character   of  the  affection.     Although   meningeal   ha-mor- 
rhage  may  be  absorbed,  other  distinct  structural  affections 
of  the  brain  or  cord,  of  course,  seldom   recover.     A  note- 
worthy instance  of  recovery  after   paralysis   of  four  years* 
duration  is  the  case  reported  a  number  of  years  ago  by  Dr. 
Webber/'7     The  prognosis  of  neuritis,  which  was  present  as 
a  complication  in  several  of  the  cases  I  have  reported,  de- 
pends, of  course,  upon  the  amount  of  injury  to  the  nerve  as 
shown  by  the  electrical  reactions.     Strain  of  the  muscles  of 
the  back,  by  itself,  is  an  affair  of  long  duration,  and,  as  a 
complication,  I   have  found  it  very  persistent,  lasting  sev- 
eral years.     Never  having  seen  grand  hysteria  as  a  result 
of  trauma,  I  am  unable,  from   my  own  experience,  to  judge 
of  the  prognosis  ;    but  I  see  no  reason  why,  when   a  per- 
son is   once  thrown  into  that  state,  from  injury,  he  should 
recover,  in  the  sense  of  getting  out  of  the  state,  any  quicker 
than  one  who  gets  into  it  from  other  causes,  except  that 
the  absence  of  a  hereditary  nervous  taint  is  in  his  favor.     I 
suspect,  however,  that  comparatively  few  cases  of  hysteria 
are  induced  from  injury  in  persons  who  have  not  the  taint. 
Charcot's  cases  are  chiefly  "  hereditaires,"  but  Berbez   and 
Lyon  are  in  doubt  as  to  the   preponderance   of  hereditary 
taint  in  the  cases  reported.     Their  conclusions  are  less  de- 
cisive, however,  as  many  persons,  without  heredity,  may  be 
of  a  neuropathic   type.     I   find   my  own  opinion   supported 
by  the   recent  testimony  of  Bataille  :    "  It  is  apparent  that 
predisposition  is  alone  capable  of  making   us   comprehend 
the  development  of  these  attacks  of  hysteria."     Of  course, 
in   hysterical  cases  the   individual   symptoms — ana.-sthesia, 
paralysis,  contracture — may  disappear,  but  the  underlying 
state  remains,  capable  of  reproducing  all   the  symptoms   at 
short  notice. 

<j.  Webber.      Recovery  alter  tour  years'   paralysis  following  railroad 
injury.     Boston  Medical  and  Surgical  Journal,  18th  July,  1872. 


AMERICAN  NE UROLOGICA L  A SSOCIA  TION.  647 

What  has  been  said  of  the  hysterical  state  holds  true  in 
a  measure  of  the  neurasthenic  state.  Where  the  symptoms 
are  mild,  and  there  is  no  neurotic  taint,  the  patient's  chances 
of  recovery  are  of  course  better.  Even  in  severer  forms  of 
neurasthenia  the  prognosis  is  not  utterly  bad,  although,  un- 
fortunately, there  are  many  cases  that  never  recover, 
whether  the  neurasthenia  be  of  traumatic  origin  or  not. 
Nevertheless,  in  many  cases,  even  though  there  is  so  great 
improvement  that  the  patient  can  return  to  work  and  do  as 
much  as  before,  there  are  still  the  subtler  changes  of  which 
I  have  spoken  which  show  that  the  recovery  is  not  abso- 
lute. 

The  prognosis  of  purely  psychical  disturbances  is  also 
grave.  Hartmann  has  also  called  attention  to  the  fact  that 
psychoses  may  develop  a  long  time  after  an  injury,  espe- 
cially if  it  has  caused  headache,  vertigo,  irritability,  and  a 
loss  of  power  of  intellectual  application,  as  was  seen  in  Case 
IX.  Krafft-Ebing6S  also  shows  that  injury  may  make  the 
brain  the  place  of  least  resistance  ;  there  is  increased  irrita- 
bility, intolerance  of  heat  or  alcohol,  and  disturbance  of 
vaso-motor  innervation,  which  favors  the  devolopment  of 
psychoses.  Thomsen  also  regards  the  prognosis  of  his 
"  acute  railway  brain  "  as  grave. 

In  the  majority  of  cases  the  symptom-complex  is  some- 
thing like  this  :  the  patient  has  headache  and  vertigo  ;  he  is 
depressed,  irritable,  and  hypochondriacal,  with  a  diminished 
power  of  application  ;  he  may  have  some  visual  disturbance, 
he  often  has  a  contracted  field  of  vision  and  occasionally 
optic  atrophy  ;  there  is  some  tremor  and  perhaps  inco-ordi- 
nation  ;  he  has  some  anaesthesia,  usually  not  limited  to  one 
half  of  the  body,  and  with  it  numbness  and  pricking  ;  his 
movements  are  slow  and  weak ;  his  tendon  reflexes  are  ex- 
aggerated ;  there  is  often  some  lack  of  control  over  his 
bladder ;  and  he  may  have  pain  and  stiffness  in  the  back 
from  muscular  strain.  Here  I  believe  the  condition  is  due 
to  a  disseminated  miliary  sclerosis,  or,  in  the  early  stages, 
to  a  haemorrhage  or  inflammatory  process.  The  prognosis 
is  like  that  of  multiple  sclerosis.     With  rest,  freedom   from 

«*R.  v.  Krafft-Ebing.     Op.  cit.,  i.  166. 


64S  AMERICA  X  XE  C  ROLOGJCAL  ASSOC  I  A  T/OX. 

excitement, — such  as  comes  when  litigation  is  over  and  the 
anxiety  about  money  matters  is  settled, — and  judicious 
treatment,  the  patient  may  improve.  .The  same  holds  true 
of  tabes  dorsalis.  The  ultimate  prognosis  is  bad.  Oppen- 
heim  has  never  met  with  a  recovery  ;  Gowers"  has  found  a 
good  many  cases  where  "  damages  "  have  not  brought  about 
a  cure,  and  considers  that  where  there  has  been  a  late  or 
gradual  onset  of  symptoms  there  is  far  less  tendency  to 
arrest  or  subsidence  than  with  earlier  lesions  ;  and  Strum- 
pell,70  in  his  latest  edition,  warns  us  against  regarding  these 
conditions  as  mild  or  insignificent.  "The  patients  actually 
suffer  greatly  from  them,  and  the  suspicion  of  exaggeration 
and  simulation  is  certainly  much  more  rarely  justified  than 
it  is  pronounced." 

The  following  conclusions  seem  justifiable  : 

(1)  Concussion  of  the  spine,  in  the  strict  sense  of  the 
term,  although  probable,  is  still  a  matter  of  doubt. 

(2)  Muscular  strain,  spinal  irritation,  and  peripheral 
neuritis  are  not  uncommon  complications. 

(3)  Injury  may  give  rise,  not  only  to  gross  mechanical 
lesions  of  the  central  nervous  system,  with  symptoms  com- 
ing on  soon  after  the  accident,  but  also  to  typical  chronic 
degenerative  processes  of  insidious  onset. 

(4)  Injury-  may  also  give  rise  to  various  functional  affec- 
tions of  the  nervous  system,  including  psychoses,  hysteria, 
and  neurasthenia. 

(5)  Hemian.esthesia  is  not  pathognomic  of  hysteria, 
but  is  found  in  other  conditions. 

(6)  Psychical  disturbances  —  anxiety,  hypochondriasis, 
depression,  emotional  disturbance,  and  lack  of  power  of 
application — may  exist  alone  or  in  conjunction  with  other 
affections. 

(7)  The  neurasthenic  state  is  often  produced  by  injury, 
but  true  hysteria  is  rare. 

(8)  Both  the  hysterical  and  the  neurasthenic  states  may- 
be superimposed  upon  organic  disease,  obscuring  the  diag- 
nosis. 

»\V.  R.  Cowers.     Op.  cit.,  i.  453. 
Striimpell.      Op.  cit.,  li.  1,  164. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  649 

(9)  There  is  a  fairly  typical  symptom-complex,  with 
psychical  disturbances,  paresthesia,  anaesthesia,  slow  and 
feeble  movements,  exaggerated  reflexes,  etc.,  which  is  not 
uncommon,  and  is  probably  due  to  organic  disease. 

(10)  The  prognosis  of  these  conditions  is  grave.  Im- 
provement is  not  uncommon,  but  complete  recovery  is 
rare. 

DISCUSSION    OX   DR.  KNAPP'S   PAPER. 

Dr.  SEGUIX  referred  to  the  difficulty  of  diagnosis.  As 
elements  of  error  he  mentioned  uncertainty  or  unconscious 
deception  by  the  patient  who  ascribed  to  his  injury  symp- 
toms which  had  commenced  before  the  accident.  To  these 
were  to  be  added  intentional  deception  and  auto-sugges- 
tion. The  more  enlightened  school  of  hypnotism  has 
demonstrated  the  production  of  various  symptoms  of  nerve 
disease  in  the  healthy  person.  Bernheim  and  his  pupils 
have  shown  that  these  symptoms  might  be  produced  not 
only  by  the  suggestion  of  the  operator,  but  by  the  sugges- 
tion of  the  patient  himself,  in  whom  a  firm  beliel  and  a 
constant  thinking  may  result  as  in  the  hypnotic  state  in  an 
apparent  loss  of  power,  anaesthesia,  spasm,  etc. 

In  regard  to  the  hysterical  element,  he  referred  to  n 
paper  written  in  1875,  in  which  he  had  shown  the  frequent 
coexistance  of  hysterical  symptoms  with  organic  disease  of 
the  brain  and  cord.  This  combination  was  not  peculiar  to 
traumatism,  but  was  found  also  in  morphinism  and  after 
moral  shock. 

Dr.  L.  C.  Gray  also  alluded  to  the  influence  of  sugges- 
tion. The  psychical  lesion  was  so  large  as  to  make  the 
majority  of  cases  undiagnosible.  So  soon  as  a  person  was 
injured  he  was  besieged  by  runners  for  legal  firms.  By 
means  of  these  runners  and  the  lawyers  he  was  impressed 
with  the  danger  to  which  he  had  been  subjected.  The  suit 
then  followed,  running  on  for  two  or  three  years,  during 
which  time  the  patient  could  not  afford  to  get  well,  as  he 
would  thus  become  liable  to  a  suit  for  conspiracy.  Finally, 
after  having  kept  up  the  disease  for  the  two  or  three  or  four 
years  during  the  long  trial,  habit  would  prolong  it  for  at 
least  three  or  four  years  after. 


6  SO  AMERICAN  S'ECROLOGICAL  ASSOC  I  A  TIOX. 

In  several  cases  he  had  advised  the  counsel  to  settle  the 
case,  and  recovery  had  occurred  in  a  few  months. 

It  was  a  curious  fact  that  patients  suffering  from  organic 
injury  usually  did  not  have  neurasthenia.  The  exaggerated 
manner  of  the  neurasthenic  contrasted  curiously  with  the 
calmness  of  the  man  with  serious  organic  injur}-. 

The  psychical  results  of  injury  would  entitle  the  sufferer 
to  some  recompense,  but  of  course  not  to  so  much  as  mili- 
ary hemorrhages  or  other  wide-spread  disease. 

Dr.  ZENNER  referred  to  the  fact  of  hysterical  symptoms 
conjoined  with  organic  disease,  referring  to  a  case  of  lead 
poisoning  associated  with  tremor,  which  disappeared  under 
hypnotism  and  after  two  or  three  applications  was  cured. 
Deception  on  the  part  of  the  patient  should  not,  on  the 
other  hand,  lead  the  exclusion  of  other  serious  disease. 
Pure  malignering  was  a  very  rare  occurrence.  Deception 
n  itself  presupposed  disease. 

Dr.  KNAPP  recognized  the  tendency  to  auto-suggestion 
and  the  exaggeration  of  symptoms  produced  by  these 
medico-legal  trials,  but  neither  sources  of  error  were  pres- 
ent in  his  cases,  as  suits  for  damages  were  not  in  progress, 
and  all  had  been  anxious  to  get  well. 

The  following  paper  was  read  : 

THE    CORTICAL    LOCALIZATION    OF    THE 
CUTANEOUS    SENSATIONS. 

By  CHARLES  L.    DANA,   A.M.,  M.D.,  New  York. 

I  desire  to  present  the  evidence,  so  far  as  it  is  now  at- 
tainable, regarding  the  question  of  the  cortical  localization 
of  the  cutaneous  senses,  viz.,  tactile,  thermic  and  pathic. 

It  is  well  known  there  are  now  two  very  antagonistic 
views  with  regard  to  this  subject.  Ferrier  contends  that 
these  centres  are  in  the  hippocampal  gyrus  and  gyrus  for- 
nicatus.  He  bases  this  view  upon  experiments  upon  eleven 
monkeys,  certain  anatomical  considerations,  and  the  clini- 
cal fact  that  very  often  lesions  of  the  convex  motor  cortex 
of  the  brain  do  not  cause  any  sensory  symptoms.     His  ex- 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  65  I 

periments  are  confirmed  by  those  of  Horsley  and  Schafer. 
No  positive  pathological  evidence  is  brought  forward  to 
support  this  view. 

The  other  view  is  that  the  cutaneous  sensory  centres  are 
more  or  less  identified  with  the  motor  centres,  being  situa- 
ated  perhaps  a  little  more  posteriorly.  Munk,  Tripier,  and 
Luciani  and  Sepilli,  in  particular,  contradict  the  state- 
ments and  experimental  evidence  of  Ferrier.  Luciani  and 
Sepilli  record  experimental  observations  made  upon  ten 
dogs  and  four  monkeys,  besides  pathological  observations 
in  forty-seven  cases. 

There  is  still  a  third  view,  viz.,  that  both  the  motor  cor- 
tex and  the  limbic  lobe  are  concerned  in  the  representation 
of  cutaneous  sensations. 

Thus,  in  brief,  the  matter  stands  at  present. 

In  pursuing  an  investigation  of  this  kind,  we  make  use 
of  several  kinds  of  evidence  : 

1.  That  obtained  by  clinical  and  pathological  observa- 
tion on  man. 

2.  That  obtained  by  experiment  upon  the  lower  ani- 
mals. 

3.  That  obtained  by  studying  the  development  of  special 
tracts  in  the  embryo. 

4.  That  obtained  by  the  study  of  brains  genetically  im- 
perfect. 

5.  That  obtained  by  studies  in  comparative  anatomy 
and  physiology. 

The  atrophy  method  of  Gudden  cannot  be  directly  ap- 
plied to  this  question.  Of  the  foregoing,  it  is  the  first  class 
of  evidence  which  is  by  far  the  most  important  and  decisive, 
outweighing  all  the  others.  Perhaps  the  next  most  impor- 
tant is  the  experimental  evidence  obtained  by  observations 
on  monkeys.  At  least  it  seems  to  be  shown  that  the  repre- 
sentations of  motor  areas  in  the  brain  of  the  macacus  is  close- 
ly identical  with  that  in  the  brain  of  man. 

My  paper  deals  chiefly  with  pathological  and  clinical 
data,  and  these  I  shall  present  first. 

I.  A  few  cases  of  lesions  of  the  brain  cortex  with  sensibility 
disturbances  were  collected  by  Nothnagel  in  his  work  pub- 


652  AMERICAN  NEUROLOGICAL  ASSOCIATIOX. 

lished  in  1879.  They  were  insufficient  for  him  to  form  a 
conclusion  as  to  localization.  Exner  in  1880  collected 
twenty-two  cases,  Starr  in  1884  collected  forty-one  cases, 
Luciani  and  Sepilli  in  1885  forty-seven  cases,  illustrating 
sensory  localization,  these  latter  including  some  of  Starr*s 
and  Exner's.  I  have  consulted  the  originals  in  Starr's  list, 
and  eliminated  some  in  which  the  reports  did  not  seem 
satisfactorily  complete.  Adding  the  remainder  to  Luciani 
and  Sepilli,  I  found  that  I  had  eighty  cases.  Searching 
through  the  literature  of  the  last  four  years,  I  have  been 
able  to  find  fifty-eight  cases.  To  these  I  add  four  cases  of 
my  own,  making  a  total  of  one  hundred  and  forth-two. 

These  are  all  cases  in  which  symptoms  were  observed 
during  life, and  autopsies  were  made,  except  in  nine  instances. 
In  these  latter  there  was  injury  of  the  skull  and  rupture  of 
the  middle  meningeal  artery.  Trephining  proved  the  nature 
of  the  lesion.  Beside  this,  in  the  way  of  negative  evidence, 
I  have  collected  twenty  cases  of  lesions  of  the  gyrus  forni- 
catus  or  hippocampus. 

The  cases  have  been  tabulated  in  such  a  way  as  to  show 
the  location  and  nature  of  the  lesion,  the  leading  symptoms 
aside  from  the  anaesthesia,  and  the  kind  and  degree  of  the 
disturbance. 

The  numbers  of  the  cases  have  then  been  marked  upon 
charts  of  the  brain  cortex  somewhat  after  the  manner  of 
Exner  and  Xaunym  ;  only,  instead  of  dividing  the  brain 
surface  into  small  squares,  as  was  done  by  the  observers 
mentioned,  I  have  divided  the  chief  convolutions  into  thirds 
and  halves.  In  reading  descriptions  of  post-mortem  appear- 
ances, it  seems  to  have  become  a  custom  to  describe  lesions 
as  occupying  certain  thirds,  as,  for  example,  of  the  front  il, 
central,  and  temporal  convolutions.  Descriptions  are  rarely 
more  minute  than  this.  In  reading  over  some  of  Exner's 
cases,  one  is  a  little  astonished  at  the  confidence  with  which 
he  marks  down  a  lesion  in  a  minute  square  from  the  vaguest 
possible  description.  A  good  deal  of  scientific  imagination 
must  be  used  in  dealing  with  the  squares.  The  divisions  I 
have  made  therefore  are,  I  venture  to  think,  more  natural, 
less  arbitrary,  and  better   fit  into  ordinary  descriptions  of 


AMERICAN  NEUROLOGICAL  ASSOCIATION  653 

post-mortem   findings.     The  results  of  my  tabulation  upon 
the  brain  charts  are  shown  here.     Figs.  1  and  2. 

These  charts,  however,  do  not  give  a  perfectly  just  idea  of 
the  sensory  areas,  for  I  have  also  marked  down  the  areas  in- 
volved in  extensive  or  multiple  lesions,  for  example,  lesions 
involving  both  central  and  occipital  convolutions.  In  these 
cases  the  lesion  in  the  extra  motor  zones  caused  other 
symptoms,  or,  as  shown  by  other  cases,  had  nothing  to  do 
with  the  cutaneous  sensory  disturbances.  It  will  be  found 
that  no  lesion  in  the  occipital,  temporal,  or  anterior  part  of 
the  frontal  lobes  caused  cutaneous  sensory  troubles  unless 
there  was  also  some  involvement  of  the  motor  areas.  Even 
in  the  inferior  parietal  lobule  there  are  but  four  lesions 
causing  cutaneous  sensory  disturbances,  and  not  extending 
into  the  motor  regions. 

The  clinical  and  pathological  evidence  tlins  collected  shows 
that  the  motor  areas  of  the  cortex  contain  also  the  representa- 
tion of  cutaneous  sensations. 

A  study  of  the  cases  shows  that  the  sensory  centres  for 
special  parts  of  the  body,  i.  e.,  face,  arm,  or  leg,  are  in  gen- 
eral identical  with  the  motor  centres  for  those  parts,  but 
are  larger  and  more  diffuse.  It  takes  an  extensive  and,  as 
it  seems  to  me,  a  deep  lesion  to  cause  marked  anaesthesia. 
For  example,  in  the  cases  in  which  there  was  distinct 
and  very  marked  anaesthesia,  the  pathological  condition 
was  : 

Abscess,  _--___-2 
Softening  (from  thrombosis  or  encephalitis),  27 
Tumors,  ■>--..--.--  7 
Meningitis,    -------3 

In  very  few  cases  does  one  find  a  record  of  haemorrhage  ; 
hence,  the  sudden  appearance  of  anaesthesia  with  hemi- 
plegia is  rather  a  sign  of  necrotic  or  inflammatory  softening 
than  of  rupture  of  vessels.  Surface  clots,  however,  do 
sometimes  cause  incomplete  hemianaesthesia  along  with 
the  paralysis.1 

1  Thus  Wiesmann,  in  a  collection  of  over  two  hundred  cases  of  fracture  of 
the  skull  with  rupture  of  the  middle  meningeal,  found  incomplete  hemianaesthesia 
in  seven  cases.  I  have  noted  two  other  cases,  one  of  my  own  and  one  of  Wilkes's. 


654 


AMERICAN  NEUROLOGICAL  ASSOCIATION. 


AMERiCAN  NEUROLOGICAL  ASSOCIATION. 


655 


656  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

In  the  cases  of  paresthesia  alone,  the  lesions  were  : 

Tumors  -------       j6 

Softening,      -------7 

Meningoencephalitis,  -----         5 

Meningitis,    -------  1 

Clot,      --------         3 

Thus  it  seems  that  the  slowly  developing  lesions  oftener 
produce  only  paresthesia. 

An  analysis  of  the  cases  with  reference  to  localization  in 
the  right  or  left  hemisphere  shows  a  preponderance  oi 
nearly  two  to  one  in  favor  of  the  left  hemisphere,  especially 
in  the  central  convolutions,  e.  g.: 

Frontal  lobes,  except  paracentral  lobule — 

Right  hemisphere,         .         _         _         _         _  14 

Left             "                     -----  27 

Not  stated,    -------  1 

Ascending  central — 

Right.  -         -  -----       45 

Left,      --------       85 

Not  stated,    -------4 

Superior  parietal — 

Right,  --------  17 

Left,      -         -         -         -         -         -         -         -  12 

Not  stated,    -                   -----  4 

Inferior  parietal — 

Right,   - 17 

Left,      --------  25 

Not  stated,    -------  3 

Paracentral  — 

Right,  -          -                    4 

Left,      --------  6 

Not  stated,    -------  2 

Island  of  Reil — 

Right,  -          -                    -----  [2 

Left.      -                                      -                             -  5 

Not  stated     -                          -        -                 -  2 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  657 

In  the  island  of  Reil  the  lesions  are  much  oftener  on 
the  right  side. 

The  preponderance  indicated  may  be  due  to  a  greater 
frequency  of  recorded  lesions  in  the  left  hemisphere.  The 
paresthesias  alone  were  caused  by  lesions  about  equally 
distributed  in  each  hemisphere — r.  13,  1.  12.  The  severer 
cases  of  anaesthesia  were  also  due  to  lesions  about  equally 
distributed — r.  17,  1.  14. 

It  may  be  stated  here  that  the  cases  collected,  so  far  as 
they  go,  confirm  the  view  that  the  seat  of  muscular  memo- 
ries is  in  the  inferior  parietal  lobule. 

An  analysis  of  the  different  cases  of  paresthesia  alone, 
of  analgesia,  and  of  tactile,  thermic,  and  pathic  anaesthesia, 
two  or  all  forms  being  present  in  the  cases,  is  shown  on  the 
accompanying  charts. 


Fig.  A. 


Diagram  showing  localization  and  number  of  lesions  in  cases  in  which  there 
was  analgesia. 


658  AMERICAN  NEUROLOGICAL  ASSOCIATIOX. 


Figs.  B,  B>. 


Diagrams  showing  localization  and  number  of  lesions  in  which  there  was 
parses  thesia. 


AMERICAN  NEUROLOGICAL  ASS0C1A  7  JON. 
Figs.  C,  C. 


659 


A.    ? 


Diagrams  showing  number  and  localization  of  lesions  : 
•  =  tactile  anaesthesia. 
+  =  tactile  and  thermic  anaesthesia. 
O  =  combined  tactile,  thermic,  and  pathic  anaesthesia, 
or  tactile  and  pathic  anaesthesia  alone. 


66o  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Figs.  D,  D>. 


Cortical  areas  for  cutaneous  sensations. 


The  tables  and  cuts  do  not  show  any  especial  difference 
in'the  localization  of  the  three  different  sensations.  If  any- 
thing, tactile  sensation  seems  to  be  more  strictly  confined  to 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  66  I 

the  motor  areas.  On  the  whole, the  pathological  histories  show 
that  tumors  and  slowly  growing  lesions  in  the  motor  areas, 
either  in  or  just  below  the  gray  matter,  produce  paresthesia 
and  slighter  degrees  of  anaesthesia.  Softening,  thrombotic  or 
inflammatory,  of  the  same  areas  coming  on  suddenly  pro- 
duces localized  anaesthesia  if  it  is  extensive,  and  completely 
destroys  the  parts.  Pressure  clots  from  meningeal  hemor- 
rhage, if  extensive  and  severe,  will  cause  partial  anaesthesia 
of  the  opposite  side,  as  well  as  profound  hemiplegia. 

There  is  no  known  region  of  the  cortex,  lesion  of  which 
will  cause  anaesthesia  without  accompanying  hemiplegia. 
The  nearest  approach  to  this  is  in  lesions  of  the  supramar- 
ginal  lobule,  where  a  slight  degree  of  tactile  anaesthesia 
without  paralysis  has  been  occasionally  noted. 

It  is  not  possible  for  a  cortical  lesion  to  cause  total  uni- 
lateral anaesthesia  without  the  lesion  being  so  extensive  as 
to  be  rapidly  fatal.  That  there  is  a  total  crossing  of  the 
cutaneous  sensory  nerves,  however,  seems  probable  from  the 
fact  that  the  crossing  is  practically  total  in  the  cord,  medulla, 
pons,  and  capsule. 

Besides,  lesions  of  the  lower  part  of  the  central  gyri 
have  produced  almost  absolute  anaesthesia  as  in  Case  I.  of 
my  own  and  Case  III.  of  Petrina.  It  seems  like  an  "abso- 
lute" cortical  area  for  sensation. 

From  the  foregoing  we  deduce  further  general  laws, 
that  cutaneous  anesthesia  of  organic  cortical  origin  is  always 
limited  to  or  more  pronounced  in  certain  parts,  e.  g.,  the  face, 
or  arm,  or  lower  limb  of  the  body,  and  it  is  generally  incom- 
plete. 

Total  hemianesthesia  is  either  of  functional  or  subcor- 
tical origin. 

Cortical  anesthesia  is  akvays  accompanied  with  some  de- 
gree of  paralysis. 

II.  The  experimental  argument. — It  must  be  admitted 
that  at  present  many  facts  obtained  by  experiments  upon 
monkeys  favor  the  idea  that  the  limbic  lobe  is  the  seat  of 
cutaneous  sensations.  We  must  remember,  however,  that 
Ferrier  is  alone  in  denying  that  anaesthesia  is  caused  by 


662  AMERICAN  XECROLOGICAL  ASSOCIA  TIOX. 

removal  of  parts  of  the  motor  areas.  Schiff,  Luciani,1 
Tripier.  Munk,  all  have  noted  sensibility  disturbances  after 
these  lesions.  The  positive  experiments  made  upon  the 
limbic  lobe  are  as  yet  few  in  number,  and  the  operation  is 
confessedly  a  very  difficult  one. 

III.  The  cmbryological  evidence. — The  study  of  the  devel- 
opment of  sensory  tracts  in  the  embryo  has  so  far  failed  to 
show  that  any  but  a  very  small  part  of  the  sensory  tract 
turns  in  toward  the  limbic  lobe.  Most  of  the  fibres  pass  up 
in  the  direction  of  the  parietal  lobe  (including  the  postcen- 
tral convolution).  Von  Monakow  has  shown,  by  the  atro- 
phy method,  a  connection  between  the  parietal  cortex  and 
a  part  of  the  sensory  tract. 

IV.  The  evidence  from  teratology. — Zuckerkandl '  has  col- 
lected two  cases  in  which  infants  were  born  with  absence 
of  the  olfactory  lobe  on  one  or  both  sides.  In  these 
cases  there  was  decided  lack  of  development  of  the  cornu 
Ammonis  ;  the  middle  and  posterior  horn  of  the  lateral 
ventricle  in  one  case  was  absent,  and  the  hippocampus  and 
gyrus  fornicatus  in  both  cases  were  small. 

He  refers  to  two  other  cases  shown  him  by  Kundrat,  but 
I  cannot. find  any  details.3 

V.  The  anatomical  and  comparative  anatomical  evidence. 
— Mr.  Victor  Horsley  finds  in  the  anatomy  of  the  cortex 
an  evidence  of  sensory  function.  At  the  discussion  on  cere- 
bral localization  before  the  Congress  of  American  Physi- 
cians and  Surgeons,  September  19th,  1888,  he  said  that,  as 


•Luciani  and  Sepilli.  in  ten  dogs  and  four  monkeys,  found  that  extirpation 
of  motor  region  caused  an.  and  atax.  Tactile  sense  much  affected, muscular 
sense  even  more,  pain  and  thermic  sense  less. 

*Ueber  das  Riechencentre. 

1  Tiedman  reported  the  case  of  a  child  born  without  olfactory  nerves,  Am- 
nion's hom  and  fornix  not  developed  perfectly;  cited  by  Zuckerkandl,  p.  107, 
op.  cit. 

Rudolphi,  1814,  cited  by  Zuckerkandl,  p.  107,  op.  cit.,  described  the  brain  of 
child  with  aWnce  on  right  side  of  I.,  II.,  III.,  IV.,  VI.,  cranial  nerves.  The 
corpus  callosum  was  shorter  on  right  side,  the  right  lateral  ventricle  smaller,  an- 
terior horn  short,  defending  and  posterior  absent,  Ammon's  horn  very  small, 
ditto   fornix  and  corpora  albicantia. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  663 

the  large  pyramidal  cells  were  undoubtedly  motor,  the 
smaller  cells  were  probably  sensory,  and  he  showed  the 
following  diagram  : 


Slight  tacKlescTise  2I 

^icrA 

Diagram  A. 


Muscular  sense,  as  I  understand  him,  he  takes  to  be 
compounded  of  (a)  a  sense  of  present  movement  or  inner- 
vation, (b)  a  memory  of  past  movement.  It  can  only  be  the 
first,  as  it  seems  to  me,  which  is  in  the  motor  areas. 

The  muscular  memories,  by  which  co-ordinated  pur- 
posive movements  result,  seems  to  be,  so  far  as  is  shown 
by  the  evidence  of  human  pathology,  in  the  inferior  parietal 
lobule. 

Finally,  the  evidence  of  comparative  anatomy  is  quite 
against  the  view  that  the  limbic  lobe  is  the  centre  for  tac- 
tile or  pathic  sensations. 

The  elaborate  comparative  anatomical  studies  of  Broca 
some  years  ago  and  of  Zuckerkandl  (Ueber  das  Riechencen- 
trum,  F.Enke, Stuttgart,  1887)  show  that  in  anosmic  animals 
like  the  dolphin  this  lobe  is  rudimentary.  In  animals  with 
a  highly  developed  olfactory  nerve  like  the  dog,  this  lobe 
is  very  large.  Zuckerkandl  gives  the  following  table  show- 
ing the  relative  development  of  the  gyrus  fornicatus  : 

GYRUS  FORNICATUS. 

ABSENT.  RUDIMENTARY.  PRESENT. 

Monotemes.  Cetacea.  Ungulates. 

Marsupials.  Primalis.  Carnivora. 

Some  families  of  Some  prosimians.  Insectivora. 

chiroptera.  Man. 


664  AMERICAS  XEUROLOGICAL  ASSOCIATIOX. 

And  Zuckerkandl  concludes  that  the  limbic  lobe  is  the 
seat  of  olfactory  sensation. 

Objections. — In  answer  to  the  facts  which  I  have  brought 
forward,  two  objections  will  be  raised  :  first,  the  large  number 
of  negative  cases  in  which  no  sensory  disturbance  occurred 
despite  extensive  destruction  of  the  motor  tract ;  second, 
the  positive  experiments  of  Ferrier  and  of  Horsley  and 
Schafer  upon  the  limbic  lobe  in  monkeys.  To  the  first  of 
these  objections  one  cannot  yet  offer  a  perfectly  satisfactory 
answer.  To  be  sure,  it  is  not  true,  as  Ferrier  states,  that 
one  negative  case  upsets  the  whole  argument.  This  is  not 
logic,  or,  if  it  is,  it  is  a  logic  which  works  both  ways.  We 
would  have  to  give  up  our  cortical  motor  centres  ;  for  there 
still  occur  every  now  and  then  cases  in  which  there  is  pro- 
found and  extensive  destruction  of  the  motor  areas  without 
paralysis,  as  witness  the  cases  recently  reported  by  Byrom, 
Bramwell  {Intracranial  Tumors),  and  Gaskill  {Brit.  Med. 
Jour.,  vol.  I.,  1888).  On  the  other  hand,  in  late  years,  with 
more  careful  observation,  the  cases  of  serious  lesions  of  the 
motor  areas  without  sensory  disturbance  are  becoming  more 
and  more  rare.  Incomplete  observation,  late  observation 
when  compensation  has  occurred,  small  lesions,  slowly  de- 
veloping lesions,  are  the  factors  which  may  explain  the 
frequent  absence  of  sensory  disturbances. 

As  to  the  second  point,  a  word  may  be  said  first  regard- 
ing Ferrier's  anatomical  argument,  viz.  (loc.  cit.,  p.  326), 
that  there  is  a  bundle  of  fibres  in  the  outer  third  of  the  foot 
of  the  crus  which  does  not  degenerate  downwards,  which  is 
connected  probably  with  the  sensory  tract,  and  which  bends 
round  towards  the  hippocampus. 

This  statement  has  been  disproved  by  the  observations 
of  Bechterew,  who  shows  that  this  bundle  does  degenerate 
downward,  and  that  it  connects  the  frontal  lobes  with  the 
pons  nuclei  fibres,  passing  thence  to  the  contralateral  cere- 
bellum {Archiv  f.  Psych.,  1888).  The  experimental  facts 
adduced  by  Ferrier  are,  however,  most  weighty.  I  am  not 
prepared  to  deny  that  it  is  beyond  possibility  for  the  limbic 
lobe  to  be  shown  to  be  a  centre  for  cutaneous  sensations 
in  man  ;    but  the  facts  of  human   pathology  so  far  do  not 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  665 

give  it  the  slightest  support.  The  few  cases  of  lesion  of  the 
gyrus  fornicatus  collected  by  Exner  showed  it  to  be  a  latent 
region.  I  have  been  able  to  find  other  cases  making  in 
all  twenty,  in  Which  the  gyrus  fornicatus  or  hippocampus 
was  more  or  less  involved.  In  none  of  these  was  any 
anaesthesia  that  could  be  fairly  attributed  to  the  lesion  in 
the  gyr.  fornicatus  observed. 

LESIONS    OF    GYRUS    FORNICATUS    AND    HIPPOCAMPUS. 

i.  Von  Monakow,  Arch.  f.  Psych.,  xi.     Sarcoma  of  falx  pressing 
on  gyr.  forn.     No  symptoms. 

2.  Von  Monakow,   Arch.  f.   Psysh.,   xiv.,  Hft.   3,  1883.     Quoted 

by  Luciani  and  Sepilli.  Softening  of  lingual  lobe  and 
posterior  part  of  hippocampus,  1st  and  2d  temp,  cuneus. 
Blindness,  hemiplegia,  dementia. 

3.  A.  McL.   Hamilton,   N.  Y.    Med.   Jour.,  1882,  p.  575.     Unci- 

nate slightly,  also  hippocampus  ;  sensory  epilepsy. 

4.  Wildebrandt,  Arch.  f.  Ophthal. ,  31,  p.  119.     Cuneus  involving 

hippocampus  and  lingual  (5th  T. )  slightly.  Hemianopsia, 
slight  hemianaesthesia. 

5.  J.  A.  Vorthnis,  Brain,  July,  1886.     Upper  3d,  central  convol. 

Paracentral  lobule  extending  into  g.  fornicatus.  Hemi- 
plegia and,  later,  hemianaesthesia  in  foot. 

6.  Mills,  Phila.   Med.   Times,   Jan.    18th,  1879.     Tumor  of  right 

posterior  y2,  1st  of  and  2d  frontal,  small  segment  of 
anterior  gyrus  forn.  and  corp.  callosum.  Spasm  and  men- 
tal disturbance. 

7.  Seguin.     Tumor  and   cyst  of  paracentral   lobule,  part  of  first 

frontal,  and  involving  part  of  gyrus  fornicatus.  No  marked 
anaesthesia  at  any  time.     Jacksonian  epilepsy. 

8.  Bristow,   Brain,  1884,   Oct.,   Case  2.       Tumor  corp.  callosum 

involving  1st  and  2  frontal  postcentral  and  anterior  y2 
corp.  callosum.     No  anaesthesia. 

9.  Reinhard,    Arch.    f.  Psych.,   xviii.,  Case   13.      Softening,    fusi- 

form, cuneus,  convex  occip.  con.,  sup.  parietal  convolu- 
tions, ang.  gyr.,  2d  temp.  con.  Blindness,  motor  aphasia, 
dementia. 
10.  Seguin,  Arch,  de  Neurolog.,  1886,  No.  32,  Case  45.  Softening 
of  right  cuneus,  5th  temporal,  part  of  4th,  extending  for- 
ward into  part  of  hippocampus.  Hemianopsia,  slight 
ataxia. 


666  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

n.  Haab,  1882,  quoted  by  Seguin,  loc.  cit.,  Case  28.  Softening 
lower  y2  cuneus,  part  of  hippocampus  and  5th  temp,  conv., 
extending  into  ventricle.  Hemianopsia,  temporary  hemi- 
plegia, no  hemianaesthesia. 

12.  Huguenin,    quoted  by  Seguin,  Case   29,    loc.   cit.     Tumor  of 

right  cuneus,  extending  forward  and  involving  slightly  the 
hippocampus.      Hemianopsia. 

13.  Cassy,  quoted  by  Luciani  and  Sepilli,    op.    cit.,  p.  324.    Com- 

plete atrophy  of  cornu  Ammonis  and  hippocampal  gyrus. 
No  anaesthesia.  See  also  cases  of  atrophy  of  this  region  in 
epilepsy  cited  by  Meynert,  Snell,  Hencks,  Pfleger,  Tam- 
burini,  etc. 

14.  Only  general   convulsive  attacks.     Involvement  of  first  frontal 

praecent.,  and  anterior  y2  of  gyr.  forn.  Charcot  and 
Pitres  (Rev.  Mensuelle,  1878,  p.  810,  obs.  xix). 

1 5.  No  motor  or  sensory  disturbance.  Involvement  of  occipital  con- 

vexity, cuneus,    praecuneus.    and    posterior   of  gyr.    forn. 

Boyer  (Les.  Cortic,  p.  58,  obs.  31). 

16.  General   paralysis;    no   anaesthesia  or  paralysis.       Lesion  of 

frontal  lobes  and  anterior  3d  of  gyr.  forn.  Baraduc 
(Bull,   de   la  Soc.   Anat.,   Marz,    1876,   p.    277). 

17.  Tumor  involving  inferior  and  anterior  surface  of  temp. -sphen. 

lobe  and  extending  into  hippocampus.  Only  slight 
visual  disturbance;  right  hemiplegia.  Boyer  (Les.  Cortic, 
p.  48,  obs.  ix). 

18.  Claus,  Derlrrenfreund,  1883,  No.  6.  L. — Softening  (1)  posterior 

y2  fusiform  lobe  or  T. ;  (2)  spot  of  softening  3^  ctm.  long 
in  frontal  lobe,  5  ctm.  behind  anterior  end  gyrus  fornica- 
tus,  in  its  white  substance  close  under  the  cortex.  Mental 
disturbances,  aphasia,  no  paralysis  or  anaesthesia. 

19.  Bannister.     This   was  a  case  reported   to  me  verbally  by  Dr. 

Bannister.  The  patient  was  a  lunatic  who  died  with  gen- 
eral cerebral  symptoms,  but  without  any  general  anasthe- 
sia.  A  very  finely  limited,  cyst-like  cavity  was  found 
occupying  the  lower  part  of  the  paracentral  lobule  and 
the  adjacent  part  of  the  gyrus  fornicatus.  It  was  about  1% 
inches  in  diameter. 

20.  M.  Jastrowitz.      Localization  un   Gehirn,    Leipsig  and  Berlin, 

188S,  p.  49,  Case  VI.  Tumor  of  right  upper  central 
convolutions,  and  lower  anterior  part  of  praecuneus  and 
adjacent  gyrus  fornicatus.  Hemiplegia  of  leg  and  arm 
with  some  loss  of  cutaneous  sensation  which,  however, 
followed  the  gradual  development  of  the  paralysis. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  667 

Again,  anaesthesia  is  not  a  symptom  of  tumors  of  the 
corpus  callosum. 

As  to  the  theory  that  cutaneous  sensations  may  be  re- 
presented in  both  the  motor  areas  and  the  limbic  lobe,  the 
case  cited  above  by  Jastrowitz  (Case  XX.)  is  instructive. 
Here  there  was  a  tumor  with  softening  in  the  central  convo- 
lutions and  another  tumor  destroying  part  of  the  gyrus 
fornicatus.  Yet  the  anaesthesia  was  not  marked  and  it 
progressed  with  the  paralysis.  There  was.  however,  de- 
cided muscular  anaesthesia. 

It  is  hard  to  conceive  of  a  sensory  mechanism  so  com- 
plicated and  clumsy  as  that  required  by  a  hypothesis  of 
compound  sensory  centres,  one  in  the  limbic  lobe  and  one 
in  the  motor  cortex;  and  no  one  has,  I  think,  ventured  to 
explain  how  much  an  anatomical  arrangement  could  be 
put  in  harmony  with  the  psychology  of  sensation.  The 
mean  reaction-time  for  tactile  sensation  is  a  little  longer 
than  that  for  sound,  a  little  shorter  than  that  for  sight, 
(Wundt),  e.  g. 

Sound,   0.167  sec-   or  about  1-6  sec. 
Touch,  o.  213   "  "       1-5   " 

Sighi,      0.222    "  "       1-5   " 

The  mean  figures  given  by  Hirsch,  Hankel,  Exner, 
Auerbach  and  Kries  give  the  same  relations.  If  the  tactile 
senses  were  a  compound  mechanism  involving  the  interac- 
tion of  two  centres,  a  longer  reaction-time  might  be  ex- 
pected. As  it  is,  since  tactile  sensations  have  a  longer  dis- 
tance to  travel  on  the  peripheral  nerves  it  may  be  fairly  in- 
ferred that  the  actual  cerebral  portion  of  the  tactile  sensa- 
tion reaction  is  shorter  than  that  of  sound  or  sight-sensation. 

The  objection  which  may  be  raised  against  a  number  of 
the  cases  quoted,  that  the  lesion  was  not  a  purely  cortical 
one,  and  that  by  pressure  or  extension,  or  involvement  of 
the  posterior  capsular  fibres  anaesthesia  was  produced  will 
not  hold  for  a  very  large  number  of  cases. 

Owing  to  the  immense  typographical  difficulties  of 
printing  an  elaborate  tabulated  analysis  of  134  cases  I  have 
omitted  publishing  it.  I  am  certain,  however,  that  no 
amount  of  scrutiny  can  explain  aii'ay  the  numerous  cases   in 


668  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

which  superficial  cortical  lesions  have  caused  monoplegias  and 
monoancesthesias .  I  would  refer  as  good  examples  of  cases 
that  illustrate  anaesthesia  from  purely  cortical  lesions  to 
Cases  III.  and  VI.  of  Petrina,  Ztsckr.  f.  Heilk,  1S81,  Case  I. 
of  Luciani  and  Sepilli,  Loc.  cit.  p.  302;  case  of  Leyden, 
Beitrag.  zur  Lehre  von  der  Loc.  im  Gehirn,  1888,  p.  13. 
Some  of  Reinhardt's  cases  (loc.  cit.)  also  furnish  exam- 
ples of  superficial  lesions  causing  anaesthesia  and  paralysis. 

Finally,  it  has  been  plentifully  shown  that  the  an- 
terior part  of  the  frontal  lobes,  the  occipital  and  the  tem- 
pero-sphenoidal  lobes,  are  latent  regions  so  far  as  cutaneous 
sensory  disturbances  are  concerned. 

If  now  we  can  exclude  the  gyrus  fornicatus  and  hippo- 
campus, as  I  believe  we  can,  nothing  is  left  as  centres  for 
these  sensations  but  the  central  and  the  parietal  lobes.  My 
cases  certainly  appear  to  show  that  it  is  not  in  the  parietal, 
lobes,  if  we  except  the  upper  lobule  and  post-central  gyrus 
which  are  motor  areas.  By  exclusion,  then,  as  well  as  by 
positive  evidence,  we  must  conclude  that  the  sensory 
and    the  motor  areas  are  identical. 

Conlcusions. — The  cortical  areas  for  touch,  pain,  and 
probably  temperature,  are  identical  with  the  motor  areas. 

The  representations  for  the  different  parts  of  the  cutane- 
ous surface  are,  in  the  main,  identical  with  the  correspond- 
ing motor  segments. 

The  areas  for  the  different  segments  overlap  and  diffuse 
into  each  other. 

The  brain  cortex  of  the  left  hemisphere,  except  the 
island  of  Reil,  shows  lesions  causing  sensibility  disturb- 
ances twice  as  often  as  the  right. 

The  anaesthesia  produced  by  lesions  in  these  areas  is 
partial,  as  a  rule  ;  it  may  be  total  for  a  limited  area,  but 
never  total  for  the  entire  half  of  the  body.  The  anaesthesia 
from  cortical  lesion  is  limited  to  or  more  pronounced  in 
certain  parts  of  the  opposite  side,  such  as  the  face,  arm,  or 
leg- 

Slowly  developing  lesions  like  tumors  are  especially  apt 
to  cause  paraesthesia  or  sensory  aurae  if  there  is  epilepsy. 
Sudden  or  extensive  softening  causes  the  most  marked  and 


AMERICAN  NEUROLOGICAL  ASSOCIATION  669 

profound   forms  of  anaesthesia.     This    softening  need  not 
necessarily  be  deep  but  is  often  so. 

Pressure  lesions  like  superficial  clots  can  cause  some 
anaesthesia,  but  always  with  pronounced  hemiplegia.  Super- 
ficial syphilitic  and  tubercular  lesions  may  cause  partial 
anaesthesia. 

No  case  of  pure  lesion  of  the  limbic  lobe  has  yet  been 
observed  (and  reported)  in  which  anaesthesia  was  produced. 
This  lobe,  or  a  part  of  it,  is  probably  the  seat  of  olfactory 
sensation. 

The  comparatively  slight  involvement  of  sensibility  in 
lesions  of  the  motor  cortex  has  yet  to  be  satisfactorily  ex- 
plained. It  may  be  that  each  body  segment  has  a  larger 
area  of  representation  on  the  cortex  for  sensation  than  for 
motion  ;  or  it  may  be  that  each  segment  is  represented  to 
some  extent  in  both  hemispheres,  and  hence  compen- 
sation easily  occurs.  It  is  just  possible  that  there  is  some 
sensory  function  in  the  limbic  lobe. 

The  occurrence  of  slight  sensibility  disturbances  with 
spasms  and  paralysis,  points  to  lesions  high  up  near  or  in 
the  cortex. 

Profound  hemianaesthesia,  with  or  without  motor  symp- 
toms, points  to  a  lesion  lower  down  in  the  internal  capsule 
or  still  nearer  the  cord. 

Hemianaesthesia  is  always  accompanied  with  some  spas- 
modic or  paralytic  symptoms. 

APPENDIX. 
The  following  is  a  record  of  my  own  cases : 
CASE  /. — Sudden   right  hemiplegia,  motor  aphasia,  dyspha- 
gia, right  hemianesthesia  very  marked  in  face,  intelligence 
dulled  but  present,  early  rigidity,  hyperesthesia  o?i  right 
side.      Progressive  weakness,   bed-sores.     Death  in  two 
months.     Autopsy.      Yellow  softening;  deep  involvement 
of  2d  and  3d  left  frontal  and  part  of  lower  half  of  pre- 
central  convolutions ,  including  cortex. 
A.  G.,  female,  age  70,   native   of  Ireland,  widow.     No 
family  or  personal  history  obtained,  except  that  the  patient 
was  quite  well  up  to  April  21st.     On  the  morning  of  that 
day  she  suddenly  became  unconscious,  and  fell  to  the  floor. 


6  JO  AMERICAN  NEUROLOGICAL  ASSOC 'IA  TION. 

She  was  found  to  be  paralyzed  on  the  right  side.  She  could 
not  swallow.  Her  condition  remained  unchanged  until 
admission  next  day. 

On  admission  she  was  still  but  partially  conscious.  The 
right  side  of  the  face  and  right  arm  were  partially  paral- 
yzed. There  was  some  paralysis  also  in  the  leg.  There 
was  marked  rigidity  in  the  arm  and  leg.  Sensation,  motion, 
and  reflexes  were  normal  on  the  left  side.  Sensation, 
tactile  and  pat  hie,  was  nearly  or  quite  abolished  on  the  right 
side  of  the  face.  The  mouth  was  drawn  to  the  left  side, 
and  the  right  corner  of  the  mouth  was  lower  than  the  left. 
The  right  cheek  was  more  flaccid  than  the  left,  and  the 
right  eye  was  not  so  closely  shut  as  the  other  ;  it  was  suf- 
fused and  congested. 

Patient  does  not  speak,  but  comprehends  some  remarks 
addressed  to  her.  Her  intellectual  power  is,  however, 
notably  impaired.  She  grasps  anything  with  her  left  hand 
when  told  to  do  so,  and,  when  asked  to  put  out  her  tongue, 
attempts  to  pull  it  out  with  that  hand.  She  continually  puts 
her  hand  to  the  left  side  of  her  head,  as  if  in  pain.  She  can- 
not swallow,  and  grows  very  red  in  the  face  on  making  the 
attempt.     Her  eyes  are  turned  to  the  left. 

Patient  frequently  yawned.  Left  axilla  more  moist  than 
the  right. 

Pulse  slow,  resp.  normal,  temp.  ioo. 

Urine  clear,  normal  in  appearance,  s.  g.  1030,  and  con- 
tained no  albumen. 

Patient  is  a  large  and  muscular  woman.  Her  nutrition 
is  good  ;  her  liver  and  spleen  are  normal.  The  signs  of 
general  bronchitis  are  present. 

Ordered  ol.  tiglei  gtt.  ij.  in  the  afternoon.  During  even- 
ing she  had  two  passages. 

Of  milk  and  whiskey  §ij.  were  introduced  into  patient's 
stomach  by  means  of  the  stomach  pump.  Three  nutritive 
enemata  were  given  at  intervals  of  four  hours.  The  first  one 
was  not  retained.  Half  hour  before  the  second  enema  a 
suppository  of  tannic  acid  was  given,  and  the  remaining  two 
were  retained. 

April  22d,  7.30  P.M. — Temp.,  right  axilla,  100.  Temp., 
left  axilla,  97$. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  6  J I 

9.30  p.m. — Temp.,  right  axilla,  100.     Temp.,  left  axilla, 

95- 

April  23d. — Patient  about  the  same;  recognized  friends 
who  called.  Bowels  constipated  ;  retention  cf  urine.  Pulse 
80,  resp.  22. 

Fed  by  enemata  and  stomach  pump. 
April  24th. — No  change.     Patient  conscious. 
"       25th. — Patient  perspires  on  right  side  of  face  alone, 
and  right  arm.     Conjugate  deviation  of  eyes  to  left.    Rigid- 
ity still  present  in  right  leg,  but  not  in  arm. 
April  26th. — Pulse  75,  resp.  24. 
"       27th. — Patient  smiles  at  remarks  made,  and  some- 
times cries.     Still  has  aphemia  ;  vomits  occasionally. 
April  28th. — No  change. 
"      29th. — Can  move  right  leg  a  little. 
"       30th. — Patient  shows   more   intelligence,   tries  to 
speak.     Swallows  a  little  for  first  time. 

May  1st. — Continues  to  swallow  very  well.  Bowels 
opened  with  ox-gall  enemas.     Is  more  intelligent. 


RIGHT    AXILLA. 

LEFT    AXILLA. 

,d,  8  A.M.- 

—Temp.  99 

Temp.  99 

7.30  P.M. 

"      98^ 

'«      98 

4th,  A.M. 

"      99 

"      99 

P.M. 

"      99^ 

"      98 

5th,  A.M. 

"      99^ 

«      96 

P.M. 

"      99 

"      98^ 

6th,  A.M. 

"      99^ 

"     9SlA 

P.M. 

"      99^ 

"      97 

7th,  A.M. 

"      99 

"      98 

P.M. 

'■'    100 

"      99 

Pulse  80,  resp.  18.     Patient  has   pain  in  the   right  arm 
and  leg,  which  she  tries  to  move  with  her  left  hand. 


RIGHT 

AXILLA. 

LEFT   AXILLA. 

7th,  12  P.M 

— Temp.  100 

Temp.  98^ 

8th,  A.M. 

99 

"      96 

P.M. 

99 

"      96^ 

12  P.M. 

99*2 

»      96 

9th,  A.M. 

99 

"      98 

P.M. 

99 

11      98^ 

672  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Patient  still  complains,  by  means  of  signs,  of  pain  in  her 
right  arm  and  leg.  She  usually  retains  her  food  well,  but 
vomited  once. 

May  10th. — Patient  shows  signs  of  more  intelligence. 
She  moves  her  right  leg  rather  freely  and  her  right  arm  a 
little.     She  has  not  yet  spoken. 


RIGHT   AXILLA. 

LEFT   AXILLA. 

IOth,  A.M.- 

—Temp.  98 

Temp.  98^ 

P.M. 

"      99^ 

"       98 

Ilth,  A.M. 

"      98 

"       98^ 

P.M. 

" 

1 1 

I2th,  A.M. 

"      98 

'•       98^ 

P.M. 

"      99^ 

«'       99 

13th,  A.M. 

"      97 

P.M. 

"      99# 

14th,  A.M. 

"      98 

P.M. 

"      99 

15th, 

"    100 

1 6th, 

"      99 

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Patient  keeps  her  right  leg  flexed  all  the  time,  unless  it 
be  extended  by  force.  She  moves  it  much  more  freely  than 
her  right  arm.  The  leg  is  carefully  but  fully  extended 
morning  and  evening.  Patient  eats  with  evident  relish,  and 
retains  eggs,  corn-starch,  milk,  beef-tea,  etc.  Bowels  reg- 
ular.    Urine  passed  naturally. 

May  17th. — Reflex  less.  The  contracted  muscles  do 
not  relax  in  sleep. 

May  -22d — Extension  apparatus  with  4^  lb.  weight 
attached  to  contracted  right  leg. 

May  24th. — Vomited  three  times. 

May  31st. — Temperature  no  longer  taken.  Extension 
still  used.     Xo  vomiting.     Bowels  regular. 

During  June  patient  gradually  became  weaker.  Sensa- 
tion continued  absolutely  abolished  in  the  right  half  of  the  face 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  673 

and  imperfect  in  the  arm  and  leg.  The  left  lower  extremity 
continues  to  show  rigidity,  Vomiting  occurs  daily.  Bed-sores 
developed  on  nates  and  sacrum. 

On  June  16th   she    died. 

Autopsy  held  twelve  hours  after  death.  Body  some- 
what emaciated. 


Case  I. — Thrombosis  of  branch  of  left  middle  cerebral. 

Brain  very  oedematous,  its  tissue  not  firm.  Over  the  2d 
and  3d  left  frontal  convolutions  was  seen  a  light  brownish 
discoloration,  somewhat  depressed  and  soft.  The  left  occip- 
ital convolution  seemed  softer  to  the  touch  than  the  middle. 
The  arteries  at  the  base  were  very  atheromatous  and  patent. 
The  cerebral  arteries  were  followed  up  and  no  occlusion 
found.  In  the  3d  left  frontal  convolution,  extending  into 
2d  and  slightly  into  precentral,  and  into  the  island  of  Reil, 
was  a  yellow  softening.  The  tissue  was  yellowish,  of  nearly 
the  consistence  of  pus,  which  it  resembled  in  gross  appear- 
ance, but  under  the  microscope  showed  only  granular  and 
fatty  matter  with  many  compound  granular  corpuscles.  The 
softened  space  was  of  the  size  of  a  pigeon's  egg,  and  was 


674  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

just  in  front  and  outside  of  the  caudate  nucleus,  the  outer 
portion  of  which  was  slightly  involved.  The  cortex 
over  the  affected  part  was  profoundly  affected.  Nearly  the 
whole  of  left  occipital  lobe  and  part  of  the  parietal  were 
white  and  soft,  but  not  broken  at  all,  evidently  a  recent 
change.  There  was  no  evidence  of  a  haemorrhage  there. 
Most  of  the  parietal  lobe,  the  basal  ganglia,  and  the  right 
side  of  the  brain  were  normal  ;  also  the  cerebellum,  pons, 
and  medulla.     Ventricles  normal. 

Heart. — Mitral  valves  very  slightly  thickened,  and  two 
to  three  patches  of  atheroma  on  endocardium. 

Other  organs  normal. 

Probable  blocking  of  the  1st  (and  2d)  branches  of  the 
middle  cerebral. 

The  points  of  interest  here  are  the  unilateral  fever  and 
hyperidrosis,  dysphagia,  motor  aphasia,  early  rigidity  with- 
out involvement  of  the  ventricles,  total  anaesthesia  of  the 
face. 

The  occipital  lesion  was  evidently  a  late  one,  and  could 
not  have  had  any  relation  with  the  anaesthesia  which  was 
present  from  the  onset. 

CASE  II. — A.  D.,  female,  age  60. 

The  history  of  this  case  is  very  imperfect,  as  the  patient 
when  seen  was  entirely  aphasic.  I  depend  on  the  state- 
ment of  friends,  who  assured  me  that  five  years  before  she 
had  had  a  total  left-sided  paralysis,  and  that  for  some  time 
she  had  no  feeling  in  the  right  leg.  From  the  positive 
statements  made,  and  the  fact  that  the  symptom  was  remem- 
bered so  long,  it  must  be  concluded  that  the  sensory  dis- 
turbance was  very  great. 

She  was  brought  to  the  hospital,  February  22d,  with 
right-sided  hemiplegia  and  complete  motor  aphasia ;  no 
anaesthesia  noted,  intelligence  being  preserved.  She  died 
next  day. 

Autopsy  :  The  brain  showed  a  recent  haemorrhage  in 
the  left  hemisphere  and  an  extensive  convolutional  atrophy 
in  the  right  hemisphere  due  to  a  lesion  which  must  have 
involved  the  supramarginal  gyrus,  part  of  superior  parietal, 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  6  75 

and  part  of  middle  third  of  posterior  central,  and  part  oi 
first  temporal. 

There  was  a  blocking  up  probably  of  the  third  branch  of 
the  Sylvian  artery. 


Case  II. — Right  hemisphere. 

CASE  III. — The  specimens  in  this  case  were  shown,  and 
the  case  reported  briefly  at  a  meeting  of  the  N.  Y.  Neu- 
rological   Society   {Medical  Record,   March  ^  5th,    1887, 
p.   280). 
Pachymeningitis    hemorrhagica,    with    large    meningeal 
hemorrhage  pressing    chiefly  on  leg-centre — right  hemiple- 
gia, total  paralysis  in  leg,  aphasia,  hemianesthesia,  convul- 
sions limited  to  arm  and  face. 

The  patient  was  a  woman  about  68  years  old,  and  came 
into  the  hospital  with  complete  motor  aphasia,  and  unable 
to  give  any  previous  history.  She  had  no  paralysis  at  first, 
but  three  days  after  admission  she  had  a  general  convul- 
sion, followed  by  right  hemiplegia — total  in  the  leg,  and 
some  right-sided  analgesia.     On  the  second  and  third  days 


676  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

she  had  a  series  of  brief  localized  convulsions,  involving  the 
face  bilaterally  and  the  right  arm.  The  movements  were 
clonic,  beginning  in  the  muscles  of  the  lower  jaw.  The 
other  peculiarities  were  these  : 

i.  The  pupils  remained  small  during  the  convulsions. 

2.  The  conjugate  deviation  of  the  eyes  was  at  first,  and 
very  temporarily,  toward  the  side  of  the  lesion,  and  away 
from  the  paralyzed  side.  The  head  also  was  turned  toward 
this  side.     When   this  occurs  it  is  ordinarily  spoken  of  as  a 


Case  III. — The  darkened  area  indicates  where  the  severe  compression 
was  found. 

paralytic  deviation.  This  does  not  explain  it  here,  since 
almost  immediately  the  head  and  eyes  were  turned  strongly 
to  the  opposite  and  paralyzed  side. 

3.  The  temperature  on  the  paralyzed  side  was  one  de- 
gree higher  than  normal,  and  higher  by  a  degree  than  that 
of  the  other  side.  In  meningeal  haemorrhages  the  temper- 
ature is  often  below  normal,  according  to  Minot. 

4.  The  presence  of  hemianesthesia. 

The  patient  died  on  the  third  day.  Post-mortem  showed 
chronic  pachymeningitis  over  both  convexities,  but  more 
on  the  left  side.  On  the  left  convexity  there  was  a  very 
extensive,  fresh  meningeal  clot,  pressing  upon   and   flatten- 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  677 

ing  especially  the   upper   half  of  the   central   convolutions 
and  the  superior  parietal  lobule.     Brain  substance  normal. 


CASE  IV. — This  case,  taken  from  the  Bellevue  Hospital 
records,  though  imperfectly  recorded,  seems  to  be  of 
some  value. 

A  woman,  aged  58,  was  admitted  to  the  hospital  with  a 
history  of  having  had  a  sudden  attack  of  right  hemiplegia. 
On  admission  she  was  entirely  aphasic,  but  conscious.  The 
face  was  but  little  paralyzed,  but  there  was  a  total  loss  of 
motion  and  sensation  in  the  right  arm  and  leg. 


Case  IV. 

Autopsy  showed  a  thrombosis  of  a  branch  of  the  left 
middle  cerebral,  involving  the  middle  and  part  of  the  lower 
third  of  both  central  convolutions,  and  the  white  substance 
beneath,  and  the  anterior  part  of  the  corpus  striatum(caudate 
nucleus).     The  internal  capsule  was  normal. 

There  was  a  probable  blocking  of  the  second  branch  of 
the  Sylvian  artery  and  perhaps  of  anterior  central  artery. 


678  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

BIBLIOGRAPHY. 

The  cases  are  arranged  as  numbered  in  the  table.  The  first 
forty-seven  cases  are  taken  from  Luciani  and  Sepelli's  work,  and 
are  numbered  in  the  order  as  given  by  those  authors.  These  cases 
are  given  in  abstract,  and  I  have  not  gone  over  the  original  reports 
myself.     They  yre  analyzed  in  my  tables,  however. 

Thirty-three  cases  are  taken  from  the  table  prepared  by  Starr 
{Jour.  Nerv.  and  Men.  Disease,  July,  1884,  p.  401).  All  of  these, 
as  well  as  the  other  cases  reported  by  that  writer,  I  have  verified. 
The  remaining  sixty-four  cases  are  those  collected  by  myself,  includ- 
ing the  three  original  cases  reported  by  myself. 

Case  48.  Sands,  Med.  News,  April,  1883. 

49.  Dreschfeld,  Practitioner,  May,  1875. 

50.  Edinger,  Arch.  f.  Psychiat.,  x. ,  p.  93. 

51.  Bender,  Deut.  Med.  Woch.,  No.  50,  1882. 

52.  Bramwell,  Edin.  Med.  Jour.,  xxiv.,  145. 

53.  Carter,  Med.  Times  and  Gazette,  ii.,  399,  1880. 

54.  Wood,  Phila.  Med.  Times,  v.,  470. 

55.  Cock,  Amer.  Jour.  Med.  Sc,  Oct.,  1852. 

56.  Mills,  Arch,  of  Medicine,  Aug.,  1881. 

57.  Mills,  Arch,  of  Medicine,  Aug.,  1882. 

58.  Mills,  Phila.  Med.  Times,  ix.,  246. 

59.  Mills,  Arch.  Med.,  Aug.,  :88i. 

60.  Ivor,  loc.  cit. 

61.  Peabody,  Arch.  Med.,  April,  1882. 

62.  Noyes,  Amer.  Jour.  Med.  Sc  ,  July,  1882. 

63.  Liddell,  Amer.  Jour.  Med.  Sc,  July,  1883. 

64.  Franz  Moller,  Trans.  Nat.  Med.  Cong.,  1881,  p.  15. 

65.  Wood,  Amer.  Jour.  Med  Sc. ,  April,  1864. 

66.  Carson,  Practitioner,  xv. ,  217. 

67.  Mills,  Arch.  Medicine,  Aug.,  1881. 

68.  Smith,  Jour.  Nerv.  and  Men.  Dis.,  July,  1880. 

69.  Seguin,  Trans.  Neur.  Soc  ,  1877. 

70.  Morton,  Chicago  Med.  Jour.,  Ex.  xlvi.,  21. 

71.  Page,  Med.  and  Surg.  Reporter,  xxi.,  29. 

72.  Seaman,  Phila.  Med.  News,  Jan.,  1883. 
7$.  Seguin,  Case  1,  Arch,  de  Neurologic 

74.  Seguin,  Case  6,  loc.  cit. 

75.  Hosp.  Gazette,  vi.,  552. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  679 

Case    76.  Richardson,  Richm.  Med.  Jour.,  iii.,  426. 

77.  Starr,  Amer.  Jour.  Med.  Sc.,  July,  1884. 

78.  Chessman,  Arch.  of.  Med.,  Aug.,  1881. 

79.  Janeway,  Med.  Record,  ix.,  651. 

80.  Ball,  Archives  of  Medicine. 

81.  JofFroy,  Arch,  de  Phys.,  3,  s.  ix.,  2,  p.  168,  1887. 

82.  Nearonon,  Centralbl    f.  Nervheilk,  ix.,  4,  1886. 

83.  Janeway,  Jour.  Nerv.  and  Men.  Dis.,  1886,  p.  224. 

84.  Reinhard,  Arch.  f.  Psych.,  xvii.,  p.  726,  Case  III. 

85.  Ibid.,  Case  4. 

86.  "  "     10. 

87.  "  "     11. 

88.  "  "     12. 

89.  "  "     16. 

90.  J.  A.  Voorthnis,  Brain,  July,  1886. 

91.  Lyon  Medicale,  1886,  t.  xli. ,  Perret. 

92.  Koenig,  Arch.  f.  Psych.,  xviii.  Heft,  Case  1. 

93.  Ibid.,  Case  2. 

94.  J.  Black,   Brit.  Med.  Jour.,  March  5th,  1887,  p.  511. 

95.  M.  Brink,  Deut.  Arch.  f.  Klin.  Med.,  xxxviii,  3,  1886. 

96.  H.  Hun,  Am.  Jour.  Med.  Sc. ,  Jan.,  1887,  Case  3. 

97.  Ibid.,  Case 

98.  Blanc,  Lyon  Medicale,  No.  22.  1886  (or  1881). 

99.  Frankel,  Charite-Annalen,  xi.,  p.  190,  1886. 

100.  L.  Hirt,  Berlin  Klin.  Woch.,  xxiv.,  27,  1887. 

1 01.  Tomaschewskv,  Petersberg  Med.  Wochensch.,  No.   12, 
1887. 

102.  Leyden,  Deut.  Med.  Wochensch.,  xiii.,  47,  1887. 

103.  Mannkopf,  Zeitsch.  f.  Klin.  Med. 

104.  Wildebrandt,   Arch.    f.   Ophthalm.,    xxxi.,    3,    p.    119, 
1886. 

105.  Fere,  Arch,  de  Neurol.,  1885,  Case  3. 

106.  Horsley,  Brit.  Med.  Jour.,  1887,  p.  863,  Case  6. 

107.  Ferrier,  Brit.  Med.  Jour.,  1887,  p.  11 56. 

108.  H.    Jackson,    Med.    Times    and    Gazette,    June,    1875 
(quoted  from  Exner). 

109.  Ibid.,  Medical  Mirror,  Sept.,  1869  (Exner). 
no.  Prevost  and  Cotard,  Gaz.  Med.  de  Paris,   1806,  p.  253, 

(Exner). 

in.  Rosenthal,  Wien.  Med.  Presse,  1878,  p.  789,  Case  4. 
(Exner). 


680  AMERICAN  NEUROLOGICAL  ASSOCIATIOX. 

Case  112.      Haddon,  Brain,  1878,  vol.  i.,  p.  250  (Exner). 

"    113.     Broadbent,  Lancet,  March  2d.  1878  (Exner). 

"    114.      Med.  Jahrbuch,  1886  (Felix  Kanders). 

"  115.  Chr.  Leegard,  Norsk  Mag.  f.  Lagevid,  1885,  3,  R.  xv. 
— Neur.  Centralbl.,  1886,  p.  400. 

"116.     Le  Dentu.  Neurolog.  Centralbl.,  1886,  p.  45. 
'217.      E.  C.  Seguin  and  Weir,  Amer.   Jour.    Med.    Sc   Julv, 
1888. 

"    118.      Dana,  Case  1. 

"    119.     Ibid.,       '•     2. 

"    120.  •  "     3. 

''    121.      MacEwen,  Lancet,  May  23d,  1885. 

"    122.      Ibid.,  Lancet,  May  16th,  1885. 

"    123.     Granger  Stewart,  Brit.  Med.  Jour.,  vol.  i.,  '87,  p.  877. 

"    124.     Cornil,  Gaz.  Medicale,  1864,  p.  534. 

"    125.     E.    Rolland,    L'Epilepsie    Jacksonienne,    Paris,    1888, 
p.  64. 

"  126.  Wilkes,  Dis.  Nerv.  System,  p.  t,j.  Man,  age  30. 
Fracture  left  par.  bone,  rupture  middle  men. 
artery.     Right  hemiplegia  and  anaesthesia. 

'  127.  Banchet.  Fract.  r.  par.  bone  and  rupt.  mid.  men. 
art.  Paralysis  r.  arm  and  leg,  and  anaesthesia  r. 
arm.  Surface  clot.  Cited  by  Wiesman  (Deut. 
Zeitsch.  f.  Chirurg. ,  Bd.  21,  p.  44). 

'  128.  Marchant.  Fract.  left  parietal  bone  and  rupt.  mid. 
men.  R.  hemiplegia  and  partial  r.  hemianaes- 
thesia.  (Des  Epanchements  Sanguin.,  iii., 
obs.  1,  p.  142.) 

'    129.     Liegeois.      Fract.     and    rupt.     mid.    men.,    left    side. 
Right  hemiplegia  and  partial  anaesthesia.      (Bul- 
letin Soc.  Anat.  de  Paris,   1854,  p.  314.) 
"    130.     Binns.      Fract.   and  rupt.  r.  m.  m.      LeYt  hemip.    and 

hemian.     Cited  by  Wiesman,  loc.  cit. ,  p.  286. 
"    131.        Roncoroni.         Fract.     and      rupt.    of    r.    par.     bone 
and  m.  m.    Paralysis  left  arm,  and   anaes.    (Jour, 
des   Med.  Chir.,  Mars,  1848.)      Cited  by    Marc- 
hart  and  Wiesman,  loc.  cit.,  p.  503. 
"    132.      Kolb.      Fract.  r.  par.  bone.      Left    hemiplegia  and   r. 
paraesthesia.     Cited  by  Wiesman,  p.  305. 
133.      Wiesman.      Fract.    right    par.    bone,  rupt.  in.  in.      Left 
partial  hemip.  anaesthesia.     Loc.  cit.,  case  36. 


Case 

134. 

i  < 

135- 

< .' 

136. 

<  i 

137- 

<> 

138. 

i  ( 

l39- 

(  i 

140. 

i  i 

141. 

i  i 

142. 

AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  68  I 

Perret,  Lyon  Medicale,  1886,  p.  181,  Case  2. 

Batiman,  p.  73. 

Dana,  Case  4. 

A.   Chaufferd,   Rev.    de  Medicine,    1881,   p.   942.      L. 

softening ;    inf.  par.    lobule ;    aphasia,  analgesia, 

no  paralysis 
P.  Zenner,  Jour.  Nerv.  and  Ment.  Dis. ,  Oct.,  1885. 
Leyden  Beitrage  zur  Lehre  von    der   Locali    Zalini    un 

Gehion,  Leipsig,  1888,  p.  13. 
Jastrowitz,  ibid,  Case  VI. 

Ballet,  These,  quoted  by  Hamaide, These  de  Paris,  1888 
Ballet  These,  ibid. 

DISCUSSION  ON  DR.  DANA'S  PAPER. 

Dr.  C.  K.  Mills  considered  the  paper  interesting  and 
valuable,  yet  its  inferences  were  not,  he  thought,  sustained. 
He  had  himself  recently  gone  over  a  large  number  of  cases 
with  the  same  object  as  Dr.  Dana.  It  was  probable  that 
the  cases  gone  over  by  both  were  at  least  in  part  the  same. 
He  had  concluded  that  in  the  limbic  lobe,  the  precuneus, 
and  the  postero-parietal  region  were  probably  situated  the 
cortical  areas  for  cutaneous  sensation.  In  more  than  thirty 
out  of  the  forty-one  cases  collected  by  Dr.  Starr,  the  lesions 
involved  the  superior  or  inferior  parietal  lobule  in  addition 
to  the  central  convolutions.  Dr.  Starr  had  quoted  four  of 
his  own  cases.  In  all  of  these  he  thought  the  lesion  suffi- 
ciently deep  to  have  involved  the  tracts  going  to  or  coming 
from  the  gyrus  fornicatus,  the  procuneus,  or  the  postero- 
parietal  region.  Lesions  of  association  fibres  between  re- 
lated sensory  and  motor  areas  would,  he  thought,  account 
for  some  of  the  sensori-motor  phenomena.  The  speaker 
referred  to  a  case  in  which  the  fibroma,  starting 
from  the  first  and  second  frontal  convolution,  invaded  the 
gyrus  fornicatus  and  the  corpus  callosum.  It  did  not  in- 
volve the  optic  or  trigeminal  nerves,  yet  conjuntival  anaes- 
thesia and  ulcerative  keratitis  were  present.  In  a  case  of 
Loffler,  referred  to  by  Hitzig,  where  the  skull  was  driven 
in  about  median  line  in  the  leg  region,  both  legs  were  hy- 
persesthetic,  probably  from  actual  or  inflammatory  invasion 


682  AMERICAN  NEUROLOGICAL  ASSOC IATIO.\. 

of  the  gyrus  fornicatus;  Dr.  Mills  spoke  of  several  cases  of 
his  own.  To  say  the  least,  the  question  was  still  an  open 
one  ;  for  himself  he  believed  that  cortical  sensory  centres 
were  distinct  from  cortical  motor  centres. 

Dr.  M.  A.  Starr  considered  Dr.  Dana's  paper  one  of  great 
value.  All  admitted  that  the  location  of  the  cortical  sen- 
sory centers  was  an  open  question,  hence  very  addition  to 
to  the  facts  was  of  exceeding  value.  Dr.  Mills,  in  his  re- 
mark that  it  was  impossible  to  tell  whether  fibres  were  sen- 
sory or  motor,  did  not  recognize  the  fact  that  the  most  of 
the  work  done  in  tracing  fibres  was  now  done  upon  the 
brains  of  foetuses  where  the  distinction  between  the  sensory 
and  motor  tracts  could  be  readily  made  out  by  the  time  and 
direction  of  their  developement.  In  the  posterior  part  of 
the  internal  capsule,  behind  the  pyramidal  tract  there  was 
a  tract  known  to  be  sensory,  going  to  the  parietal  and  the 
post  central  convolutions.  The  direction  of  this  bundle  of 
fibres  was  outward,  not  into  the  gyrus  fornicatus  or  to  the 
limbic  lobe.  These  facts  aided  the  view  advanced  by  Dr. 
Dana,  and  not  the  view  of  Ferrier  advanced  by  Dr.  Mills. 

In  comparative  anatomy,  Zuckerkandl  had  on  the  con- 
tary  connected  the  sense  of  smell  with  the  gyrus  fornicatus, 
which  was  small  in  animal,  having  but  a  slight  sense  of 
smell,  though  they  might  have  a  large  general  sensory 
surface  ;  and  conversely  large,  where  the  sense  of  smell  was 
pronounced.  While  many  of  the  cases  in  his  own  collec- 
tion had  been  unsatisfactory,  there  had  been  none  among 
them  which  would  support  the  theory  of  Ferrier,  that  the 
centre  or  general  sensation  is  in  the  gyrus  fornicatus.  As 
to  the  case  which  Dr.  Mills  described  as  a  lesion  invading 
the  hippocampus,  the  crus  cerebri  was  so  near  that  the  in- 
vasion of  the  hippocampus  without  the  involvement  of  the 
crus  would  be  most  difficult  of  determination.  We  have 
undoubtedly  a  sensory  tract  in  the  crus,  presumably  in  the 
lemniscus.  Ferrier  in  his  last  edition  could  mention  only 
one  instance  in  which  in  experiment  upon  the  hippocampus 
the  crus  was  not  injured.  All  of  these  first  experiments 
were  performed  too,  before  the  adoption  of  antisepsis  and 
for  that  reason  are  unreliable.     As    to  the    other   instance 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  683 

mentioned  by  Dr.  Mills,  it  was  difficult  to  think  that  the  tri- 
geminal nerve  was  not  involved,  and  the  probability 
seemed  in  favor  of  a  basilar  affection  involving  it. 

The  signal  symptoms  of  cortical  epilepsy,  numbness 
and  tingling,  showed  that  there  must  be  a  connection  be- 
tween the  cortical  motor  regions  and  those  of  sensation, 
and  the  fact  that  the  sensory  disturbance  usually  preceded 
the  motor,  contraindicated  the  view  that  the  sensory  areas 
were  distant  from  the  motor. 

Another  fact  had  to  be  taken  into  consideration  in  in- 
terpreting lesions  of  the  cortex.  Each  half  of  the  body 
was  represented  in  both  sides  of  the  brain  so  that  lesion  of 
one  side  of  the  brain  would  cause  only  partial  anaesthesia 
with  compensation  by  the  other  half  for  the  action  lost. 

Dr.  SEGUIN  stated  that  the  results  of  extirpation  of  the 
motor  zone  would  support  Schiffs  theory  of  a  sensori  mo- 
tor function.  The  peculiar  attitude  of  the  fore  paw  in 
Schiffs  dogs  which  was  dragged  without  actual  paralysis 
was  explainable  only  by  a  degree  of  anesthesia  of  the  foot. 
The  aura  of  localized  epilepsy  (which  is  often  a  sensory 
signal  symptom)  in  brain  tumor  was  another  evidence  in  its 
favor.  The  speaker  referred  to  a  case  of  non-syphilitic, 
brain  tumor  cured  by  large  doses  of  the  potassium  iodide. 
In  this  case  the  convulsion  commenced  in  the  hand  of  the 
left  side  and  extended  to  the  forearm,  arm,  face  and  leg  ; 
then,  extended  to  the  other  side  when  consciousness  was 
lost.  These  attacks  always  commenced  with  the  sensation 
of  wires  "  working  "  in  forearm  and  hand.  The  attacks 
came  at  longer  and  longer  intervals  and  were  more  re- 
stricted until  only  the  arm  was  affected,  and  finally  the  at- 
tacks ceased.  Long  after  the  patient  denied  any  visible 
attack,  however,  the  sensation  of  wires  boring  into  the 
hand  would  recur  at  long  intervals. 

Another  argument  was  furnished  by  the  results  o 
operation.  The  speaker's  case  upon  which  Dr.  Weir  had 
operated  supported  the  conclusions  of  Dr.  Dana.  Before 
the  operation  the  man  had  had  some  anesthesia  of  the  right 
hand  and  cheek.  Since  the  operation  this  had  been  in- 
creased.    It  was   not  complete  but   was   still  very  marked. 


684  AMERICA*!  NEUROLOGICAL  ASSOCIATION. 

It  was  most  marked  for  tactile  sensation  ;  analgesia  was 
slight,  and  the  muscular  sense  normal.  The  anesthesia  af- 
fected the  right  hand,  cheek,  the  right  half  of  the  tongue 
and  the  inside  of  the  mouth.  The  tumor  removed  was 
deeply  situated  and  involving  the  caudal  extremity  of  the 
second  frontal  and  the  edge  of  the  precentral  convolution. 
A  space  about  the  size  of  a  silver  dollar  was  excised. 
There  was  no  lesion  of  the  fundus,  no  petit  mal.  In  ad- 
dition to  the  anesthesia  there  was  paresis  of  the  arm  and 
cheek.' 

Dr.  Dana  acknowledged  that  with  a  special  sense  such 
as  the  tactile  sense,  it  seemed  more  rational  that  there 
should  be  a  special  centre.  He  had  started  in  his  study 
of  the  subject  strongly  prejudiced  in  favor  of  the  gyrus  for- 
nicatus.  The  facts  of  pathology  were  however  opposed  to 
the  existence  of  a  sensory  centre  in  the  limbic  lobe.  The 
speaker  referred  to  the  case  of  Exner  in  which  the  anterior 
halt  of  the  limbic  lobe  was  softened  without  sensory  symp- 
toms. On  the  other  hand  the  lesions  of  the  cortex  which 
gave  rise  to  anaesthesia  were  not  always  deep.  Luciani  and 
Sepelli  had  reported  several  cases  of  simple  superficial 
softening  of  the  cortex  in  which  anesthesia  was  present. 

In  regard  to  Dr.  Starr's  suggestion,  he  thought  that  it 
could  not  be  borne  out.  The  sensory  fibres  crossed  in  the 
cord,  and  almost  complete  anesthesia  was  produced  by 
section  on  the  internal  capsule,  medulla,  or  cord. 

'Cf.   American  Journal  of  the  Medical  Sciences,  July,  Aug.  and  Sept  1888. 


VOL.  XIII.  November,  1888.  No.   11 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


(Original  ^rtirlc.si. 


OX  GOLD  AS  A  STAINING  AGENT  FOR  NERVE 

TISSUES. 


T 


By  Dr.  HENRY  S.  UPSON, 

OF  CLEVELAND,    OHIO. 

WO  methods  of  gold  staining  are  in  use  for  hardened 
tissues.  One  consists  in  bringing  the  section  to  be 
stained  into  a  dilute  solution  of  palladium  chloride, 
where  it  remains  for  five  minutes  ;  then  into  an  acid  solu- 
tion of  chloride  of  gold,  where  it  remains  for  twenty-four 
hours.  The  myeline  sheaths  of  the  coarser  fibres  are 
stained  violet. 

The  other  method,  introduced  by  Freud  of  Vienna,  is 
used  with  tissues  hardened  in  Muller's  fluid.  It  consists  in 
bringing  the  section  to  be  stained  into  a  one  per  cent,  solu- 
tion of  chloride  of  gold,  where  it  remains  for  from  four  to 
six  hours,  then  successively  into  a  twenty  per  cent,  solution 
of  caustic  soda,  and  a  ten  per  cent,  solution  of  potassium 
iodide.  In  this  last  solution  the  section  takes,  in  five  or  ten 
minutes,  a  reddish  or  violet  color.  In  a  successful  specimen 
ganglion  cells  and  axis  cylinders  are  sharply  stained,  as 
are  often  also  the  myeline  sheaths.  According  to  some 
authorities  the  result  is  sometimes  an  axis  cylinder,  some- 
times a  myeline  sheath  stain.  The  stain  results  from  a 
reduction  of  the  gold  salt  to  the  form  of  an  oxide,  or  to 
metallic  gold.  The  defect  of  the  method  is  its  extreme 
unreliability,  which  renders  it  worthless  for  staining  sections 
in  series. 


686  HENRY  S.    L'PSOX. 

But  reduction  of  gold  chloride  may  be  effected  with 
great  certainty  by  a  number  of  reagents.  They  must,  how- 
ever, be  employed  with  some  care,  in  order  to  determine 
the  formation  of  the  purple  or  red  oxide  chiefly  or  entirely 
in  the  nervous  elements  of  the  tissues. 

The  following  method,  if  faithfully  carried  out,  will  give 
sufficiently  uniform  results. 

The  piece  of  tissue  from  which  sections  are  to  be  cut,  is 
hardened  in  Miiller's  fluid  for  from  two  to  five  months  ;  it 
is  then  washed  for  a  few  minutes  in  water,  is  brought  for  a 
day  or  two  into  fifty  per  cent.,  then  into  ninety-five  per 
cent,  alcohol,  where  it  should  remain  for  two  months  or 
longer,  until  it  has  taken  a  greenish  tinge.  It  is  then  im- 
bedded in  celloidin  and  the  sections  cut.  The  sections 
should  remain  in  eighty  per  cent,  alcohol  for  a  time  varying 
from  a  few  days  to  several  weeks,  before  staining. 

The  section. to  be  stained  is  brought  from  water  into  a 
one  per  cent,  aqueous  solution  of  gold  chloride,  where  it 
remains  for  from  ten  to  thirty  minutes.  It  is  then  washed 
superficially  in  water,  brought  for  half  a  minute  into  a  ten 
per  cent,  solution  of  sodium  hydrate,  washed  again,  and 
brought  into  the  following  solution,  which  is  called  the 
reducing  fluid,  where  in  a  few  moments  it  takes  a  vivid  red 
color. 

Sulphurous  acid,  5  c.c. 

Tincture  of  iodine  5  per  cent.,        -  -  gtt.  v-x. 

Solution  of  ferric  chloride  $j  per  cent,  (officinal),  gtt.  i. 

The  section  is  then  washed  in  water,  and  mounted  in 
Canada  balsam  by  the  usual  manipulation. 

Sections,  until  they  are  brought  into  the  reducing  fluid, 
should  be  handled  with  platinum  or  some  non-metallic  sub- 
stance, as  an  iron  needle  streaks  the  specimen. 

The  reducing  fluid  should  always  be  made  fresh  just 
before  using. 

The  stain  which  is  taken  by  a  specimen  handled  as 
above,  varies  with  the  time  which  has  elapsed  since  the 
cutting  of  the   section.     If  the  section   is   stained  at  once, 


GOLD  AS  A  STAINING  AGENT  FOR  NERVE  TISSUES.     68  J 

there  is  a  more  or  less  diffuse  stain,  which,  if  the  tissues  are 
not  too  thoroughly  impregnated  with  the  bichromate,  differ- 
entiates in  the  course  of  a  week  or  more  after  the  specimen 
has  been  mounted  on  a  slide.  This  probably  takes  place 
better  in  the  dark.  The  axis  cylinders,  and  ganglion  cells 
and  their  processes,  are  sharply  stained,  and  the  myeline 
sheaths  are  somewhat  stained.  At  the  same  time  there  is 
a  good  deal  of  color  in  the  other  structures,  notably  the 
connective  tissue  nuclei.  After  a  day  or  two  in  the  dilute 
alcohol,  sections  take  a  stain  which  is  lighter,  and  almost 
entirely  confined  to  ganglion  cells,  axis  cylinders  and  mye- 
line sheaths.  Still  later  ganglion  cells  stain  little  or  not  at 
all  ;  after  this  the  larger  axis  cylinders  remain  unstained, 
and  a  specimen  is  obtained  in  which  only  myeline  sheaths, 
and  the  fine  axis  cylinders  of  the  gray  matter  are  stained  ; 
sections  of  this  kind  closely  resemble  those  stained  by  the 
Weigert  method  ;  at  last  only  myeline  sheaths  are  capable 
of  taking  the  coloring  matter. 

The  sequence  of  events  in  the  preceding  method  is  as 
follows  :  The  potassium  bichromate  of  the  Miiller's  fluid  is 
reduced  in  the  tissue  to  brown  chromium  dioxide,  or  to 
green  chromic  oxide,  partly  by  the  reducing  action  of  the 
fresh  tissue  itself,  partly  by  the  alcohol  into  which  it  after- 
wards comes.  This  process  is  completed  by  the  action  of 
alcohol  and  light  on  the  cut  section.  The  oxides  of  chro- 
mium are  displaced  by  the  gold  salt,  which  is  then  con- 
verted into  the  trihydroxide  by  the  sodium  hydrate,  and 
into  the  red  oxide  by  the  reducing  fluid. 

Dilute  alcohol  acts  on  chrome  salts  not  only  as  a  reduc- 
ing agent,  but  as  a  solvent  ;  to  this  fact  is  due  the  compar- 
atively rapid  change  in  the  manner  of  reaction  of  the  sec- 
tions to  the  gold  salt,  when  they  are  kept  in  eighty  per 
cent,  alcohol.  To  prevent  this  change,  and  at  the  same 
time  obtain  a  better  differentiation  of  the  nerve  elements, 
the  following  method  should  be  employed  : 

The  sections,  hardened  as  above,  are  brought  immedi- 
ately after  cutting  into  a  mixture  of  absolute  alcohol  four 
parts  and  glycerine  one  part.  In  this  solution  in  the  dark 
the  change  described  above  takes  place  little  more  slowly. 


688  HENRY  S.   UPSOX. 

They  may  then, if  necessary,  be  washed  out  for  a  day  or  two 
in  water  before  staining.  They  are  then  brought  for  a  day 
or  two  into  a  one  per  cent,  solution  of  nitric  acid  in  ninety 
five  per  cent,  alcohol ;  then  from  water  into  a  one  per  cent, 
chloride  of  gold  solution,  to  which  has  been  added  one 
per  cent,  of  nitric  acid  ;  after  remaining  in  this  last  for  an 
hour  or  two,  they  are  brought  successively  into  the  soda 
solution  and  the  reducing  fluid  as  before. 

The  stain  attained  is  of  a  bright  red  color,  axis  cylin- 
ders and  ganglion  cells  and  their  processes  being  very  dis- 
tinct, myeline  sheaths  and  connective  tissue  nuclei  lightly 
tinged.  The  color  may  turn  to  blue  or  purple  on  keeping. 
This  is  especially  apt  to  be  the  case  if  the  section  is  brought 
into  an  alkaline  solution  just  before  treatment  with  the  gold 
salt. 

The  success  of  the  above  method  depends  almost  wholly 
on  the  hardening  of  the  tissue.  Too  long  a  stay  in  Miiller's 
fluid  makes  necessary  a  more  thorough  removal  of  the 
bichromate  by  a  long  stay  in  alcohol  ;  the  time  allowed 
varies  somewhat  with  the  temperature,  which  last  should 
be  rather  under  eighty  degrees  F.  than  over  that  point  ; 
the  tissue  should  be  moderately  firm,  and  of  a  decided 
brown  color,  not  blackish,  when  removed  from  the  Miiller's 
fluid  ;  when  this  is  the  case,  a  clear  nerve  fibre  stain  may 
be  obtained  by  the  use  of  the  nitric  acid  solution,  even  after 
a  minimum  stay  in  alcohol. 

In  hardening  the  tissue,  the  bichromate  may  be  reduced 
more  rapidly  and  completely  by  other  means  than  by  alco- 
hol. Harden  the  tissue  in  Miiller's  fluid  for  two  or  three 
months,  then  bring  for  a  few  hours  into  sulphurous  acid. 
The  tissue  soon  takes  a  light  green  color  ;  it  should  then 
come  into  fifty  per  cent.,  then  into  ninety-five  per  cent, 
alcohol,  and  should  remain  for  a  few  weeks  in  the  latter  ; 
it  may  then  be  imbedded,  and  sections  cut  and  stained  as 
above.  Although  more  rapid,  this  manipulation  will  prob- 
ably not  be  found  as  advantageous  as  the  other  one. 

Sections  stained  by  chloride  of  gold  show  the  great  pre- 
ponderance in  the  gray  matter  of  the  spinal  cord,  especi- 
ally  in   the   cervical   and   lumbar   enlargements,   of  naked 


GOLD  AS  A  STAINING  AGENT  FOR  NERVE  TISSUES.     689 

over  medullated  nerve  fibres.  The  larger  axis  cylinders  are 
surrounded  by  rings  of  color,  the  most  distinct  one  gener- 
ally corresponding  to  the  outer  limit  of  the  myeline  sheath. 
The  color  in  the  axis  cylinders  and  ganglion  cells  has  the 
appearance  of  being  due  to  a  deposition  of  the  metal  in  the 
tissue  itself,  as  the  cells  are  readily  seen  to  be  lying  in  their 
lymph  spaces,  and  the  nuclei  and  nucleoli  are  differentiated. 

The  black  reaction  in  the  Golgi  stain,  as  shown  by  Ross- 
bach  and  Sehrwald  (Centralblatt  f.  die  med.  Wissenschaft, 
Juni,  1888),  is  due  to  the  formation  of  bichromate  of  silver 
in  the  lymph  spaces  around  the  ganglion  cells  and  axis 
cylinders,  and  gives  the  rounded  outline  of  these  spaces, 
not  that  of  the  cells. 

In  sections  stained  by  the  Weigert  method  there  are 
often  seen  rings  of  color  similar  to  those  of  the  gold  stain, 
which  correspond  to  the  clefts  and  outer  surface  of  the  mye- 
line sheaths.  This  suggests  the  probability  that  the  numer- 
ous smaller  fibres  in  the  gray  matter,  which  are  stained  by 
the  Weigert  method,  are  naked  axis  cylinders,  the  color 
being  due  to  a  deposition  of  the  mordant  (chrome  salt) 
around  the  fibre. 

It  might  be  interesting  to  note  in  connection  with  the 
mechanical  theory  of  mordants,  how  much  of  the  color  in 
tissue  staining  is  due  to  mordanting  or  coloring  matter 
deposited  in  spaces  left  by  nature,  or  by  unequal  contrac- 
tion in  hardening.  Undoubted  examples  of  space  staining 
are  seen  in  the  demonstration  of  endothelial  cells  and  of 
Ranvier's  crosses  by  means  of  nitrate  of  silver,  and  of  the 
corneal  cells  by  chloride  of  gold.  All  of  the  myeline 
sheath  stains,  except  perhaps  Weigert's  acid  fuchsine  stain, 
are  open  to  this  interpretation. 

I  have  seen  sections  of  spinal  cord  stained  by  the  Wei- 
gert method,  and  imperfectly  decolorized,  in  which  the 
whole  thickness  of  the  peripheral  horn-spongy  tissue  was 
occupied  by  a  black  network.  This  was  evidently  caused 
by  coloring  matter  deposited  in  interstices  due  to  the  hard- 
ening process.  The  black  network  in  liver  stained  by  the 
Weigert  method,  seen  by  some  observers,  may  be  explained 
in  the  same  way. 


MUSCLE     CONTROL 

By  SARAH  E.  POST,  M.D., 


NEW    YORK. 


MRS.  WARD'S  novel,  'Robert  Elsmere,"  touches  upon 
man>-  interesting  psychological  problems.  Among 
these  is  that  of  muscle  control  by  a  foreign  mind.  I 
reter  to  the  incident  in  which  the  heroine,  blindfolded,  takes 
her  lover's  hand  and,  without  previous  instruction,  advances 
and  kisses  a  statuette  under  the  influence  of  his  will.  The 
problem  here  presented  is  startling  from  its  suggestions  of  a 
spiritual  entity  or  an  unrecognized  medium  of  force.  The  first 
impulse  of  the  reader  is  to  doubt  the  phenomenon.  1  would 
myself  doubt  it  had  I  not  personal  knowledge  of  a  similar 
incident.  As  a  tribute  to  the  veracity  of  the  author  of 
"Robert  Klsmere,"  I  venture  to  detail  this  incident,  which 
occurred  to  me  in  the  summer  of  l88l,  while  passing 
a  fe\\'  weeks  in  a  boarding-house  devoted  to  women.  I 
was  at  the  time  convalescing  from  an  illness  which  had 
been  accompanied  by  great  pain,  and  I  was  still  very  sensi- 
tive to  light,  sound,  and,  indeed,  to  all  forms  of  irritation. 
Upon  the  evening  in  question  there  were  twenty  or  thirty 
of  us  together  in  the  parlor;  and  in  the  dearth  of  interest 
common  to  such  occasions,  one  of  the  ladies  had  suggested 
a  game  in  which,  the  subject  being  blindfolded,  she  was 
made  to  do  something  previously  agreed  upon  by  the  com- 
pany, the  medium  of  communication  being  the  operator's 
hands  upon  her  shoulders.  The  proposition  interested  me 
from  its  assumption  of  power  to  communicate  ideas  by  a 
method  outside  of  my  experience  ;  and  others  failing  to  do 
so.  I  offered  myself  as  the  subject.  I  expressed  myself  as 
willing  to  do  whatever  would  be  required  of  me.  thus 
narrowing  the  problem  down  to  the  simple  communication 
of  the  requirement  to  my  mind.  I  said,  "If  you  can  in  any 
way  make  me  know  what  I  am  to  do,  I  will  do  it." 


MUSCLE   CONTROL.  69 1 

The  game  is  not  a  new  one,  and  is  probably  familiar  to 
all. 

Under  the  guidance  of  the  hands  on  my  back,  I  searched 
for  lost  articles,  passed  from  one  room  to  another,  and  per- 
formed a  number  of  other  feats. 

So  far  as  I  had  expected  anything,  I  had  expected  a 
picture  or  presentment  of  what  I  was  to  do  in  such  shape  as 
to  allow  me  to  exercise  my  will  and  marshal  my  lorces  for 
its  accomplishment,  and  I  was  prepared  for  considerable 
mental  effort  in  grasping  the  idea  which  was  to  be  projected 
into  my  mind.  Nothing  of  the  kind,  however,  happened. 
I  was  given  no  idea.  While  perfectly  conscious,  I  proceeded 
blindly.  I  advanced  very  slowly,  each  step  being  taken  in 
response  to  a  simple  loss  of  equilibrium.  Apparently  I 
first  inclined  in  the  direction,  and  then  took  the  step  to 
save  myself  from  falling  down.  I  sat,  I  knelt,  I  reached 
out  my  hand  in  response  to  similar  impulses.  With  my 
mind  fully  awake  but  willingly  passive,  I  was  :m  autom- 
aton. 

I  am  aware  that  similar  exhibitions  have  been  explained 
by  conscious  or  unconscious  suggestion  conveyed  through 
the  hands  of  the  operator,  the  weight  of  her  body  being  the 
propelling  power,  and  I  would  accept  this  explanation  for 
my  own  case  were  it  not  for  what  followed.  Finding  me  so 
docile,  I  suppose,  it  was  determined  to  give  me  something 
more  difficult  to  do.  With  the  operator's  hands  upon  my 
shoulders,  I  again  successively  felt  the  loss  of  equilibrium, 
and  advanced  as  before  for  a  number  of  steps,  when  I  stood 
upright  and  then  bent  my  head  without  any  further  forward 
impulse.  While  wondering  a  little  at  this  loss  of  the  feeling  of 
instability,  I  commenced  to  experience  a  contraction  in  the 
muscle  around  my  mouth.  In  a  few  seconds  the  puckering 
of  the  lips  became  very  marked,  so  much  so  as  to  suggest 
kissing.  Upon  this  I  immediately  said  to  myself,  "  If  they 
require  me  to  kiss  any  one,  it  will  make  a  mistake,  because 
that  is  something  which  I  will  not  do."  Instantly,  however, 
I  reproved  myself  for  allowing  my  thoughts  to  wander,  and 
said  to  myself,  "  I  must  forget  this  kissing,  or  I  will  not  be 
able  to  receive  the  impulse  and  do  what  is  required  of  me." 


692  SARAH  E.    POST. 

I  did  then  succeed  in  putting  the  idea  out  of  my  mind,  and 
resumed  my  previously  passive,  receptive  condition,  but  no 
further  inclination  came  to  me.  Although  the  operator's 
hands  were  still  upon  my  shonlders,  I  had  no  further  loss 
of  equilibrium  nor  of  impulse  in  any  direction,  and  the  ex- 
periment was  then  declared  to  have  failed.  It  was  then 
told  to  me  that  I  had  been  required  to  kiss  one  of  the  young 
ladies.  I  had  advanced  to  her  side,  but  had  made  no  fur- 
ther response. 

It  will  be  seen  that  my  experiment  resembled  essen- 
tially that  of  our  author. 

In  my  experiment,  as  in  hers,  the  mind  of  the  subject 
had  nothing  to  do  with  the  result.  The  contraction  of  the 
orbicularis  oris  preceded  the  idea  of  kissing,  and  was  the 
cause  of  its  suggestion.  The  contraction  of  the  orbicularis 
oris  occurred  while  my  mind  was  a  blank.  My  experience, 
however,  goes  a  step  further  than  Mrs.  Ward's.  I  was  not 
led  by  the  hand,  and  it  was  not  a  case  of  "  Two  minds  with 
but  a  single  thought,  two  hearts  that  beat  as  one."  The 
operator  was  not  a  stranger  to  me,  but  neither  was  she  a 
personal  friend.  There  was  also  no  direct  contact  between 
the  operator  and  myself,  as  would  have  been  the  case  in  a 
clasping  of  hands.  Quite  a  number  of  thicknesses  of  cloth- 
ing intervened  between  us. 

Further,  Mrs.  Ward  represents  her  subject  as  in  an  un- 
conscious or  somnambulistic  state  during  the  experiment. 
When  it  is  over,  she  sighs,  passes  her  hand  over  her  eyes, 
and  seems  not  to  know  where  she  is.  My  experiment  was, 
on  the  contrary,  performed  with  the  subject  fully  conscious, 
proving  that  hypnotism  is  not  essential  to  the  result. 

Truth  is  again  stranger  than  fiction.  The  control  of  a 
circular  muscle  like  the  orbicularis  is  analogous  to  the  con- 
trol of  the  heart,  said  to  be  possible  in  some  cases.  Both 
would  appear  to  be  in  the  line  of  proof  that,  under  certain 
conditions,  the  muscles  of  one  body  may  be  controlled  by 
the  mind  belonging  to  another  body,  its  own  mind  being 
passive  in  the  matter.  I  should  not  be  surprised,  too,  to 
learn  that  such  substitution  is  not  rare.  It  seems  to  me 
that  the  mind  of  the  well   substitutes  the   mind  of  the  sick 


MUSCLE    CONTROL.  693 

again  and  again  in  the  practice  of  nurses  and  physicians.  I 
can  recall  two  cases  in  Bellevue  Hospital — cases  of  other- 
wise incoercible  vomiting  which  were  apparently  controlled 
by  such  substitution.  One  of  these  was  a  case  of  pneu- 
monia with  a  very  high  temperature  during  several  succes- 
sive days,  and  absolute  rejection  of  stimulants,  medicine, 
and  food.  Her  condition  was  desperate.  I  remained  with 
her  for  a  night,  and  the  tendency  to  vomit  seemed  to  be 
inhibited  by  my  keeping  myself  very  much  alert  to  the 
necessities  of  the  case.  Personal  contact  seemed  to  assist 
in  the  result.  If  I  left  her  bedside  for  five  minutes  the  vom- 
iting recommenced,  while  holding  her  hand  appeared  to 
strengthen  my  influence.  In  this  treatment  I  had  at  that 
time  no  theory  as  my  guide,  but  simply  followed  an  instinct 
in  the  matter.  The  patient  was  too  much  reduced  for  self- 
control.  I  did  not  address  myself  to  her  at  all,  but  simply 
tried  with  all  my  might  to  do  for  her  that  which  she  was 
unable  to  do  for  herself. 

In  another  case  of  incoercible  vomiting,  I  recall  the  same 
attitude  of  mind.  The  forlorn  patient  was  not  appealed  to, 
but  as  I  left  for  the  night  I  said  to  the  nurse,  "  If  that  woman 
vomits,  your  reputation  will  be  nothing  with  me."  I  was 
the  head  nurse  of  the  ward  at  the  time  and  had  some  dicta- 
torial power.  The  woman  did  not  vomit  and  made  a  good 
recovery.  Both  of  these  cases  had  been  declared  hopeless 
by  the  physicians — visiting  and  house  ;  and  the  nurse  had 
been  left  entirely  without  directions. 

It  will  be  seen  that  the  experiments  with  hypnotism 
which  excite  so  much  remark  belong  to  a  somewhat  differ- 
ent order  from  these  which  I  have  in  mind.  The  hypno- 
tized subject  acts  under  the  influence  of  suggestions.  Mr. 
Croffut,  a  celebrated  operator  in  hypnotism,  in  a  recent 
number  of  the  North  American  Review,  remarks  that  he  has 
never  obtained  compliance  without  suggestion,  that  is, 
without  the  spoken  word,  having  the  subject  face  to  face,  or 
in  some  other  way  presenting  the  matter  before  him.  The 
subject  is  instigated  to  rob  a  house.  The  plan  is  first  un- 
folded to  him,  and  then  he  proceeds  with  intention.  The 
operator  cuts  off  certain  faculties,  but  employs  others.     To 


694  SARAH  E.  POST. 

cut  off  the  whole  brain,  or  rather  the  whole  intelligence,  as 
in  my  case,  simplifies  the  experiment.  My  blundering  in- 
terference with  complete  success,  is  but  an  additional  evi- 
dence of  the  divorcing  in  the  experiment  of  the  mind  from 
the  body — of  that  which  controls  from  that  which  is  con- 
trolled. In  the  preceding  experiments  my  mind  had  had 
no  knowledge  of  the  meaning  of  my  motions  until  they  were 
completed.  I  found  things  without  knowing  that  they  were 
lost.  The  motions  were,  however,  simple.  The  last  ex- 
periment was  more  complex,  involving  in  its  consummation 
the  bending  of  the  head,  the  puckering  of  the  lips,  and  the 
actual  facial  contact.  Before  consummation,  it  revealed 
its  object.  I  found  myself  performing  an  action  which  was 
repugnant  to  me.  The  line  of  reasoning  taken  by  mind  is 
rather  interesting.  It  at  first  occurred  to  me  that  kissing 
was  a  part  of  the  experiment  ;  but  not  having  any  idea  in 
my  previous  performances,  the  fact  of  having  an  idea  made 
the  suggestion  irrational,  and  by  an  effort  of  the  will  I  ban- 
ished it.  I  then  reasoned  that  my  mind  had  wandered,  and 
that  I  had  created  the  thought  which  I  must  get  rid  of  as 
quickly  as  possible  in  order  to  assure  passivity  and  success. 
1  did  get  rid  of  it,  but  in  so  doing  frustrated  the  operator's 
control. 

Had  I  been  hypnotized,  so  as  to  have  eliminated  the 
objecting  faculty,  the  experiment  would  probably  have 
been  carried  through  ;  although  Mr.  Croffut  relates  the  cir- 
cumstance of  a  girl  who  could  not  be  induced  to  play  cards 
even  when  hypnotized  on  account  of  the  strength  of  her 
moral  objections. 

My  own  experiment  never  has  been  repeated.  The  cir- 
cumstances were  written  out  shortly  after,  and  later,  until 
revived  by  recent  discussions,  it  faded  from  my  mind. 


TRANSACTIONS  AMERICAN  NEUROLOGICAL 
ASSOCIATION. 

FOURTEENTH    ANNUAL   REPORT. 

SECOND   DAY. 

Wednesday,  Sept.  iotJi — Morning  Session. 

Continued  from  October  Xumber. 

ON   A   SUBCUTANEOUS   CONNECTIVE   TISSUE 
DYSTROPHY    OF  THE   ARMS   AND   BACK, 
ASSOCIATED    WITH    SYMPTOMS     RE- 
SEMBLING  MYXCEDEMA. 

Dr.  F.  X.  Dercum,  of  Philadelphia,  presented  the  case  of  a 
woman,  aged  51  years,  who  suffered  from  a  curious  enlarge- 
ment of  the  arms  and  back.  This  enlargement  had  existed  some 
two  and  a  half  years  and  had  been  very  gradual.  It  was 
stated  that  the  increase  in  size  was  due  to  a  dystrophy  of 
the  sub-cutaneous  connective  tissue,  and  that  neither  the 
muscles  nor  skin  contributes  to  it.  Sections  of  excised 
pieces  of  tissue  were  shown  and  revealed  mainly  mucous  or 
embryonal  connective  tissue.  In  some  fragments  fat  cells 
were  demonstrated  by  means  of  osmic  acid,  in  others  no  fat 
whatever  could  be  detected.  Some  of  the  preparations  ex- 
hibited, in  addition,  vessels  with  thickened  and  infiltrated 
walls  besides  non-medulated  nerves  in  which  inflammatory 
changes  had  taken  place.  Associated  with  this  condition 
were  the  following  symptoms.  Pain  increases,  confined 
almost  exclusively  to  the  right  arm,  and  while  marked 
along  the  nerve  trunks  also  diffused  throughout  the  tissue. 
A  peculiar  "  cakeing"  of  the  swelling  was  noted  at  the  time 
of  the  exises  as  well  as  a  "  bundle-of-worms-like"  feel  on 
the  inner  aspect  of  the  arm.  In  addition  to  the  pain  in  the 
right  arm,  various  patches  of  anaesthesia  were  noted — all 


696  AMERICAX  XEUROLOGICAL  ASSOCIATIOX. 

more  marked,  if  not  confined  to  the  right  side  of  trunk  and 
right  limbs.  The  special  nerves  also  showed  decided  im- 
pairment, the  visual  fields  being  markedly  contracted,  and 
hearing,  taste  and  smell  more  or  less  obtruded.  Sweating 
had  been  scanty,  especially  in  the  early  history  of  the  case. 
Occasional  bleeding  from  mucous  surfaces  was  noted.  Oc- 
casionally it  came  from  the  mucous  membrane  of  the  mouth 
or  throat,  sometimes  a  bloody  bronchial  sputum  was  noted, 
and  occasionally  hematomesis.  The  thyroid  gland  could 
not  be  felt.  The  urine  was  normal,  no  diminution  of 
urea  being  detected.  Counting  the  blood  corpuscles  yielded 
a  negative  result. 

Dr.  Dercum,  while  claiming  that  the  case  was  one  re- 
sembling myxcedema,  pointed  out  the  difference  between 
it  and  typical  instances  of  the  latter  affection.  In  the  first 
place  the  skin  itself  was  not  involved — secondly,  while 
slight  slowing  of  movement  existed  it  was  not  marked. 
Speech  disturbance  was  present  for  only  a  few  days,  and 
was  probably  due  to  the  swelling  of  the  tongue  and  oral 
tissues  accompanying  a  crisis  of  pain.  The  mind  was  clear 
but  the  patient  was  excessively  irritable.  Xo  depression  of 
temperature  was  observed  except  at  one  time,  when  970  was 
noted.  Subjective  chilly  feelings,  however,  were  frequently 
complained  of. 

DISCUSSION    OF    DR.    DERCL'M'S   PAPER. 

Dr.  MILLS  referred  to  the  case  of  a  woman  who  suffered 
from  what  appeared  to  be  myxcedema  of  the  face. 

Dr.  Wm.  A.  Hammond  was  struck  with  the  analogies 
between  the  author's  case  and  myxcedema;  yet  he  was  not 
sure  that  it  should  be  called  a  case  of  that  disease.  It 
lacked  certain  essential  features.  There  was  no  mental 
aberration.  Of  the  two  cases  reported  by  himself,  one  was 
dead,  the  other  was  alive.  This  patient  showed  the  charac- 
teristic scanning  speech.  If  asked  a  simple  question  a  half 
minute  was  required  in  getting  a  reply.  Clubbing  of  the 
fingers  was  marked  in  both  of  these  cases.  Dr.  Dercum's 
case  had  no  involvement  of  the  thvroid  which  would  also 


AMERICAN  NE UROL  OGICAL  A SSOCIA  TION.  697 

seem  to  be  essential  to  the  disease.  In  his  own  cases  re- 
ferred to,  the  thyroid  had  been  enlarged.  This  was  un- 
doubtedly a  remarkable  case,  analogous  to  those  of  the 
enlargement  of  lateral  half  of  the  body.  Of  this  he  had 
seen  two  cases.  If  these  cases  were  mycedematous  we  must 
revise  our  notions  of  that  affection. 

Dr.  Putnam  considered  that  transition  cases  were 
always  especially  valuable.  Pathologically,  the  affection 
described  would  appear  to  be  related  to  myxcedema,  but 
clinically  the  relation  did  not  appear  distinct. 

Dr.  Dercum  stated  that  the  fluid  which  exuded  in  his 
case  resembled  lymph  rather  than  the  denser  fluid  of  myx- 
cedema. He  thought  that  the  case  was  allied  to  the  type 
without  being  a  true  myxcedema.  He  referred  to  the  fact, 
however,  that  in  quite  a  number  of  cases  of  myxce- 
dema, mental  symptoms  had  been  marked.  In  some  cases 
too,  the  thyroid  had  not  been  enlarged  but  wanting.  He 
thought  it  difficult  to  determine  minor  degrees  of  enlarge- 
ment of  thyroid  through  the  skin. 

The  following  paper  was  then  read  : 

SUBACUTE   PROGRESSIVE   POLYMYOSITIS. 

By  GEO.  W.  JACOBY,  M.D. 

OF  NEW  YORK. 

The  increase  in  our  knowledge  of  the  various  affections 
of  the  muscles  has,  as  is  well  known,  during  the 
last  ten  years  assumed  proportions  which  could 
hardly  have  been  foreseen.  That  certain  muscular  affec- 
tions are  due  to  disease  of  the  anterior  columns  of  the 
spinal  cord,  that  others  are  due  to  disease  of  the  peripheral 
nerves,  and  that  still  others  are  entirely  independent  of 
such  affections,  but  are  primarily  localized  in  the  muscles 
themselves,  are  facts  which  have  assumed  the  character  of 
axioms.  All  the  attention  necessary  for  the  attainment  of 
these  results  has,  however,  been  given  to  the  chronic  forms 
of  muscular  disorders,  the  forms  generally  described  under 
the  designation  of  degenerative  atrophy,  and  the  acute  and 
subacute    disorders,    particularly    the    inflammatory    ones, 


69S  AMERICAN  NEUROLOGICAL  ASSOCIATION 

those  showing  the  characteristics  of  inflammation  as  seen 
in  other  organs,  have  been  markedly  neglected.  It  is 
therefore  our  purpose  by  means  of  this  paper  to  call  to 
your  attention  the  little  that  has  been  done  in  this  direc- 
tion, and  by  the  report  of  a  remarkable  case,  one  present- 
ing intra  vitam  all  the  typical  signs  of  inflammation, invading 
successively  nearly  all  the  muscles  of  the  body,  ending 
fatally,  and  showing  microscopically  not  only  the  char- 
acteristics of  acute  and  subacute  inflammation,  but  also 
many  of  those  found  in  the  chronic  forms  of  primary  dystro- 
phies, to  endeavor  to  trace  a  relationship,  perhaps  a  con- 
nection between  the  acute  and  chronic  primary  muscular 
affections.     The  case  is  as  follows  : 

Patient,  F.  H.,  male,  aet.  35.  Family  history  is  unim- 
portant. Married  ;  three  children,  one  dead.  His  wife  has 
had  no  miscarriages.  Neither  he  nor  his  wife  have  had 
syphilis,  nor  do  they  show  any  suspicious  marks.  Habits 
as  regards  alcohol  and  tobacco  good.  The  patient  was 
always  always  perfectly  healthy  until  about  four  years  ago. 
At  that  time  he  had  an  attack  of  intermittent  fever,  for 
which  and  during  subsequent  illnesses  he  was  treated  by 
Dr.  H.  J.  Boldt,  of  this  city,  by  whom  the  patient  was 
kindly  referred  to  us.  Four  or  five  months  later  he  had  an 
attack  of  pleurisy,  and  subsequently  he  was  prostrated  with 
a  severe  attack  of  typhoid  fever  which  incapacitated  him 
for  about  three  months.  The  recovery  from  the  typhoid 
was  complete,  and  he  remained  perfectly  well  for  more 
than  a  year.  During  this  time  he  attended  to  his  work, 
that  of  a  machinist,  without  the  loss  of  a  single  day,  and 
felt  as  well  as  in  his  healthiest  days,  weighing  more  than 
he  did  prior  to  his  illness.  After  the  lapse  of  this  year  (two 
and  a  half  years  ago),  having  been  in  good  health  the  day 
previously,  he  complained  of  a  feeling  of  tension  in  the 
right  calf.  The  gastrocnemius  muscle  "seemed  to  be 
severely  inflamed."  The  skin  was  red  and  shining  and 
there  existed  pain  to  superficial  as  well  as  to  deep  pressure. 
Slight  oedema  was  also  present.  The  diagnosis  of  a  cellu- 
litis was  made  and  a  deep  incision  effected  under  antiseptic 
precautions.     No  pus  was   present.     The  wound   healed  by 


AMERICAX  XEURO LOGICAL  ASSOCIATION.  699 

first  intention,  and  the  patient  seemed  improved.  After  a 
few  weeks  a  similar  condition  occurred  in  the  left  calf,  and 
the  right  one  also  returned  to  the  state  which  existed  prior 
to  the  incision.  The  tension  increased  in  both  legs  and 
was  particularly  noticeable  in  the  morning.  Finally,  on 
account  of  this  tension  and  swelling  of  the  muscles,  he 
found  difficulty  in  bending  the  legs  at  the  knees.  The 
condition  varied  from  day  to  day,  but  if  one  leg  seemed 
somewhat  better,  the  other  one  was  worse.  Then  the  thigh 
of  the  right  side  became  similarly  affected,  and  this  was 
followed  by  the  same  condition  in  the  left  thigh.  Then  the 
flexor  surfaces  of  both  forearms  became  involved,  and 
finally  the  biceps  of  both  arms. 

I  saw  the  patient  for  the  first  time  on  May  11,  1888, 
when  he  presented  the  following  status  :  He  is  a  tall,  thin 
cachetic-looking  individual.  The  facial  muscles  are  nor- 
mal. Eyes  and  pupils,  tongue  and  speech  normal.  The 
deltoid  and  trapezius  on  the  left  side  were  enlarged  and 
painful  to  pressure.  So  also  the  biceps  of  the  left  arm  and 
all  the  muscles  on  the  flexor  surface  of  the  forearm.  The 
right  arm  is  similarly  affected  but  to  a  slight  degree.  The 
entire  left  arm  feels  harder  than  the  right.  The  skin  over 
both  forearms  on  the  flexor  surface  shows  a  slight  erythe- 
matous blush,  which  is  also  more  marked  upon  the  left 
than  upon  the  right  side.  On  the  hands  the  balls  of  both 
thumbs  seem  somewhat  tender  to  pressure,  but  not  swollen. 

The  lower  extremities  are  both  equally  affected.  The 
quadriceps  cruris  and  the  adductors  are  very  much  en- 
larged and  painful  to  pressure,  as  are  also  the  gastrocnemii. 
The  muscles  of  the  feet  are  not  affected.  The  motions  of 
the  patient  are  impeded  in  accordance  with  the  muscles 
involved.  He  can  execute  all  movements,  but  those  requir- 
ing action  of  the  affected  muscles  show  a  certain  effort 
which  at  once  attracts  attention.  The  affected  muscles 
have  a  peculiar  feeling,  recalling  very  much,  as  do  also  all 
movements  of  the  lower  extremities,  cases  of  pseudo- 
hypertrophic paralysis.  They  however  feel  more  elastic. 
The  tendons  of  all  the  involved  muscles  can  be  plainly  felt 
as  tense  cords.     Slight  oedema  of  the  skin,  which  however 


-OO  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

does  not  take  the  impression  of  the  finger  is  noticeable  over 
all  the  affected  muscles.  The  pain  on  pressure  is  confined 
entirely  to  the  body  of  the  muscle.  Pressure  over  the  nerve 
trunks  does  not  cause  any  pain. 

Electrical  examinations  showed  the  excitability  of  the 
affected  muscles  to  be  greatly  reduced  to  both  currents. 
A  current  of  15  m.  a.  was  requisite  for  the  production  of 
cathodic  closure  contraction.  No  reaction  of  degeneration 
in  any  of  the  muscles.  Slight  patellar  tendon  reflexes 
obtainable  with  great  difficulty.  Sensation  normal.  No 
bladder  affection.  The  mechanical  excitability  of  the  af- 
fected muscles  was  not  increased,  perhaps  reduced.  Fibril- 
lary twitchings  were  not  present.  There  was  no  atrophy 
discernable  in  any  parts  of  the  body.  Heart,  lungs  and 
abdominal  organs  normal.  Measurements  of  the  legs  and 
thighs  gave  the  following  results: 

Thigh,  left,  upper  part,     -  -  58  cm. 

"     middle,  -  -  53     " 

"     lowers,  -  -  43     " 

Leg  left,  below  the  knee,  -  35     " 

"     middle  of  calf,    -  -  41     " 

The  right  leg  and  thigh  gave  slightly  smaller  figures. 

On  the  16th  of  May,  Dr.  Kammerer,  of  this  city,  kindly 
excised  for  me  two  pieces  of  muscle,  one  piece  from  the 
gastrocnemius  of  the  right  leg  and  the  other  pfece  from  the 
supinator  longus  of  the  left  forearm.  Both  wounds  healed 
by  first  intention. 

During  the  following  fortnight  there  was  no  particular 
change  in  his  condition.  One  day  he  would  be  able  to 
walk  around,  and  another  day  he  would  be  confined  to  his 
bed.  Then  his  condition  grew  decidedly  worse,  the  swell- 
ing of  the  extremities  increased,  the  muscles  became  ex- 
quisitely painful  to  the  touch,  but  the  joints  remained  freely 
moveable  and  free  from  exudation. 

On  July  3d,  Dr.  Boldt,  requesting  me  to  see  the  patient 
again,  writes  : 

"He  has  acute  cirrhosis  of  the  liver.  The  stage  of  en- 
largement has  passed  and  the  organ  for  the  past  ten  days 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  70! 

is  getting  smaller  again.  The  connective  tissue  seems  to 
be  rapidly  shrinking.  Examinations  of  the  urine  only 
show  decrease  of  urinary  salts." 

July  j-th. — I  found  the  condition  as  follows  : 
Abdomen  tense  with  ascitic  fluid.  The  face  and  body 
very  much  emaciated.  Sweats  profusely.  The  affected 
muscles  in  consequence  of  the  general  emaciation  appear 
much  more  swollen  than  actual  measurements  prove  them 
to  be.  The  figures  obtained  by  measurement  are  essentially 
the  same  as  those  above  given,  with  the  exception  of  the 
lower  parts  of  the  thigh.  There  is  very  great  pain  upon 
motion  and  to  pressure.  The  attachment  ends  of  the  mus- 
cles are  approximated  and  the  tendons  stand  out  hard  and 
unyielding.  The  skin  has  a  deep  erysipelatous  appearance 
over  all  the  implicated  muscles.  Minute  capillary  haemor- 
rhages are  also  seen  along  the  borders  of  these  discolored 
territories.  In  addition  to  the  muscles  previously  men- 
tioned as  being  affected,  the  glutei,  the  muscles  of  the  back, 
the  intercostals  and  the  external  obliques  of  the  abdomen 
are  also  more  or  less  involved.  That,  however,  which  at 
once  attracts  attention  on  account  of  the  contrast  produced 
is  the  atrophy  which  has  invaded  certain  muscles  and 
which  is  assuredly  not  due  to  the  general  emaciation.  Upon 
both  thighs  it  is  seen  that  the  lower  part  of  the  quadriceps, 
particularly  the  vasti  are  very  much  wasted.  This  is  par- 
ticularly marked  upon  the  left  side,  which  was  previously 
the  larger  of  the  two.  The  contrast  caused  by  the  wasting 
of  the  vasti  and  the  great  hypertrophy  of  the  rectus,  abduc- 
tors and  glutei  was  very  marked.  A  similar  contrast  was 
also  observable  in  the  arms  where  the  biceps  and  triceps 
were  very  much  enlarged  while  the  deltoid  and  anterior 
part  of  the  trapezius,  which  had  also  been  affected  were, 
particularly  upon  the  left  side,  almost  entirely  atrophied. 
The  shoulder  joints  were  movable.  The  dorsal  interossei 
of  both  hands  and  the  thenar  muscles  also  atrophied,  to- 
gether with  the  ball  of  the  thumb  of  the  left  hand,  that  of 
the  right  hand  being  swollen  and  painful. 

July  18th. — Condition  the  same.     Consolidation  of  apex 
of  left  lung.     No  other  muscles  involved  by  the  atrophy. 


•J02  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

July  2fjth. — General  condition  much  worse.  Has  diffi- 
culty in  swallowing.  Tongue  painful  and  swollen.  Cannot 
protrude  it  beyond  the  edge  of  the  teeth. 

Aug.  2d. — Pain  in  swallowing  so  great  that  only  by  the 
greatest  efforts  can  he  be  induced  to  take  a  little  milk.  His 
condition  is  a  truly  deplorable  one.  Active  movements  of 
any  kind  are  impossible.  The  head  cannot  be  lifted  from 
the  pillow  and  even  a  slight  rotation  of  the  head  causes 
great  distress.  The  forearms  are  flexed  almost  at  right 
angles  to  the  arms.  Pressure-force  of  hands  nil.  The  legs 
flexed  upon  the  thighs  and  cannot  be  straightened.  The 
feet  themselves  are  freely  movable.  Extended  passive 
movements  cannot  be  made  on  account  of  the  resistance  of 
the  tense  tendons.  Face  and  eyes  not  affected.  Sensation 
not  affected.  Pupils,  sight,  smell  and  hearing  normal. 
Sensorium  perfectly  clear. 

Aug.  12th. — Death  due  to  general  marasmus,  and  dis- 
orders of  respiration. 

Owing  to  my  absence  from  town  at  the  time  of  death,  a 

post-mortem  was  unfortunately  not  obtained. 

The  pieces  of  muscle  exsected  from  the  leg  and  arm 
were  immediately  placed  in  a  half  per  cent,  solution  of  chro- 
mic acid.  When  sufficiently  hardened  they  were  embed- 
ded in  celloidin  and  cross  and  longitudinal  sections  made. 
These  sections  were  then  stained  with  an  ammoniacal  car- 
mine solution  and  mounted  in  glycerine.  The  histological 
changes  found  will  now  be  described. 

In  transverse  sections  of  the  piece  of  muscle  exsected 
from  the  leg  (Fig.  I.),  the  small  size  of  the  single  muscle 
fibres,  without  any  noticable  decrease  in  their  number  in 
each  individual  bundle,  is  marked.  I  do  not,  however,  at- 
tribute this  feature  to  the  morbid  process  itself,  since  with 
the  exception  of  a  moderate  increase  of  the  perimysium 
internum,  the  fibres  have  retained  their  mutual  flattening, 
and  even  the  sarcolemma  sheath  appears  to  be  preserved, 
except  in  a  few  muscle  fibres  which  are  highly  altered.  In 
addition  we  also,  with  low  powers,  at  once  notice  a  distinct 
broadening  of  the  perimysium  externum  as  also  of  the  peri- 
mysium internum,  the  latter  not  being  so  conspicuous  and 
not  so  uniformly  observable  as  the  former. 


AMERICAN  NEUROLOGICAL  ASSOCIATION 


/03 


The  newly  formed  connective  tissue  which  goes  to 
make  up  the  augmented  perimysium  externum,  is  either 
myxomatous  or  fibrous  in  structure.  The  latter  again  is 
either  loose  and  delicate  or  dense  and  fibrous,  being  then 
made  up  of  comparatively  coarse  bundles.  In  both  varie- 
ties of  the  perimysium  externum  we  frequently  meet  with 
the  following  two  features. 


Fig.  I. — Transverse  Section  x  200. 
M.  M.  Muscle  fibres  of  average  size  in  partly  transverse,  partly  slightly  oblique  sections. 
P.  E    P.  E.   Perimysium  externum  with  numerous  capillaries. 
N.  N.   Nuclei,  some  in  centre,  some  at  periphery  of  muscle. 
W.  Muscle  fibre  in  waxy  degeneration,  holding  three  protoplasmic  bodies. 
M.  W.  Cluster  of  medullary  corpuscles  in  waxy  degeneration. 
F.  F.   Muscle  fibre  in  waxy,  possibly  combined  with  tatty  degeneration. 

Firstly,  fat  globules  in  a  more  or  less  regular  arrange- 
ment ;  and,  secondly,  waxy  degeneration  of  the  bundles  of 


704  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

fibrous  connective  tissue,  in  some  places  very  pronounced. 
The  perimysium  internum,  although  as  already  mentioned, 
augmented,  is  made  up  entirely  of  a  delicate  fibrous  con- 
nective tissue,  carrying  numerous  blood-vessels,  but  no- 
where exhibiting  fat  globules  or  waxy  degeneration. 

The  muscle  fibres  themselves  apart,  from  their  small 
size,  show  peculiar  changes,  which  never  invade  all  the 
fibres  of  a  single  bundle,  but  only  a  limited  number,  which 
varies  from  one  to  eight. 

These  affected  fibres  are  either  transformed  into  an  ap- 
parently homogeneous  mass,  with  traces  of  nuclei  in  it  and 
still  surrounded  by  an  unchanged  sarcolemma  sheath,  or 
the  muscle  is  transformed  into  a  highly  refracting  so-called 
waxy  mass  which  shows  distinct  nuclei,  or  is  entirely  homo- 
geneous, or  homogeneous  only  at  the  periphery  and  gran- 
ular in  the  centre.  It  is  not  uncommon  to  see  muscle 
fibres  which  are  partly  normal  in  appearance  and  partly 
waxy  or  homogeneous.  Many  of  the  fibres  contain  nuclei 
in  their  interior,  which,  when  fallen  out,  leave  open  spaces 
or  vacuoles.  The  number  of  such  nuclei  and  vacuoles 
varies  from  one  to  half  a  dozen  or  more  in  a  single  fibre. 
Other  fibres  again  are  in  part  or  entirely  broken  up  into 
smaller  lumps  with  or  without  nuclei  (Fig.  II.).  The  stain- 
ing of  the  specimens  with  the  ammoniacal  carmine  solution 
also  yielded  peculiar  results,  inasmuch  as  many  of  the  fibres 
appear  deeply  stained  in  one  part  and  unstained  or  yellow 
(owing  to  the  chromic  acid  solution)  in  another.  Such 
variations  in  color  occur  even  in  distinctly  waxy  fibres, 
some  of  which  are  deeply  carminized,  others  again  appear- 
ing unstained.  Since  haemorrhage  had  taken  place  at  the 
moment  of  excision  of  the  muscle  and  a  subsequent  satura- 
tion with  the  blood  plasma  must  have  occurred,  the  differ- 
ences in  the  reaction  to  this  staining  reagent  would,  it 
appears  to  us,  in  our  case  be  deserving  of  but  little  atten- 
tion. 

From  the  appearances  thus  far  described,  as  seen  with 
low  powers,  it  follows  that  a  plastic  or  formative  inflamma- 
tion has  invaded  the  muscle,  being  most  conspicuous 
through  the  augmentation  of  the  interstitial  connective  tis- 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  705 

sue,  more  especially  of  that  of  the  perimysium  externum. 
This  process  is  known  under  the  term  of  hyperplastic  peri- 
myostitis,  a  process  very  prominent  in  our  case  of  pseudo- 
hypertrophy from  which  microscopical  studies  were  presented 
to  this  Association  last  year. 


FlG.  II. — Transverse  Section  x  800. 

F.i.   Muscle  fibre  with  central  nuclei. 

F  2.  Muscle  fibre  with  augmented  peripheral  nucle;,  showing  indication  of  breaking  up  into 
muscle  plates. 

F,3.  Muscle  fibre,  holding  five  central  nuclei,  each  one  corresponding  to  a  muscle  plate, 
the  whole  resembling  a  myeloplax.     The  sarcous  elements  enlarged  and  crowded. 

F.4.  Muscle  fibre  transformed  to  a  great  extent  into  partly  nucleated,  partly  non-nucleated 
protoplasm. 

PI.    Perimysium  internum  almost  unchanged. 

At  the  same  time  marked  changes  must  have  occurred 
in  the  muscle  fibres  themselves,  leading  to  a  breaking  up  of 
the  individual   fibres,  their  contractile  matter  into  lumps, 


~o6  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

and  terminating  in  waxy  degeneration — a  process  which  is 
recognized  as  a  parenchymatous  one  since  Virchow,  and 
meriting  the  name  of  "  myositis." 

The  question  now  arises,  What  relation  in  our  case  does 
the  myositis  bear  to  the  perimyositis  ?  In  other  words, 
how  much  of  the  process  is  interstitial  and  how  much  par- 
enchymatous ? 

This  question  can  easily  be  settled  by  resorting  to  higher 
powers  (500  diameters).  The  first  feature  which  impresses 
the  observer  is  the  augmentation  of  the  nuclei.  In  the  nor- 
mal muscle,  nuclei  are  seen  at  the  periphery  of  the  muscle 
fibre  close  beneath  the  sarcolemma,  but  not  in  large  num- 
bers. In  our  case,  muscle  fibres  are  seen  holding  sharply 
defined  nuclei  scattered  throughout  the  body  of  the  fibre 
without  regularity,  and  surrounded  by  a  light  rim,  possibly 
due  to  shrinkage  ;  whereas  the  contractile  matter  is  appar- 
ently little  changed  and  still  exhibits  the  granulation  pro- 
duced by  the  sarcous  elements. 

As  central  nuclei,  in  the  fully  developed  fibre,  are 
known  to  occur  in  human  beings  only  in  the  muscle  of  the 
heart,  the  presence  of  a  larger  number  of  nuclei  within  the 
fibre,  as  such,  would  indicate  a  pathological  process.  When 
the  nuclei  are  much  increased  in  number,  the  transverse 
section  of  the  muscle  fibre  may  assume  the  aspect  of  a  so- 
called  giant  cell,  whereby  the  regular  arrangement  of  the 
sarcous  elements  is  lost  and  the  granulation  has  become 
irregular.  In  this  case  the  sarcolemma  sheath  is  still  pres- 
ent and  still  allows  the  boundary  of  each  single  muscle  fibre 
to  be  easily  defined.  In  the  next  stage  the  muscle  fibre 
breaks  up  into  a  number  of  indifferent  or  medullary  corpus- 
cles, many  of  which  still  contain  nuclei,  either  singly  or  in 
groups.  The  boundary  of  a  muscle  fibre  has  in  this  stage 
to  a  great  extent  lost  its  sharpness  ;  and  since  the  adjacent 
perimysium  is  largely  composed  of  similar  bodies  not  mark- 
edly nucleated,  no  strict  boundary  line  can  be  drawn  be- 
tween the  muscle  and  the  perimysium.  The  inference, 
however,  almost  forces  itself  upon  us,  that  the  original 
muscle  tissue,  after  having  split  up  into  medullary  corpus- 
cles, loses  its   specific   structure  and   becomes  transformed 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  JO  J 

into  fibrous  connective  tissue,  adding,  as  it  -were,  a  cer- 
tain amount  to  the  hyperplastic  perimysium  itself.  This 
inference  impresses  itself  upon  us  all  the  more  strongly 
when  we  see  fields  of  fibrous  perimysium  with  traces  of 
previous  muscle  fibres  composed  of  indifferent  corpuscles, 
and  finally  fields  of  considerable  extent  between  slightly 
changed  muscle  fibres,  embracing  fibres  in  waxy  degenera- 
tion. 

Still  more  instructive  are  for  our  purpose  muscle  fibres 
which  in  part  are  unchanged,  in  part,  on  the  contrary,  are 
transformed  into  a  coarsely  granular  mass,  which  has  en- 
tirely lost  the  regular  arrangement  of  the  sarcous  elements, 
and  is  provided  with  a  varying  number  of  nuclei.  The 
presence  of  the  sarcolemma  is  a  positive  proof  that  the 
morbid  changes  have  taken  place  in  a  portion  of  the  con- 
tractile substance  of  a  single  muscle  fibre  only.  Such  a 
partial  transformation  is  by  no  means  a  rare  occurrence. 

The  appearance  of  a  number  of  nuclei  within  the  muscle 
fibre  is  not  the  only  way  in  which  the  morbid  changes  are 
inaugurated.  Sometimes  a  muscle  fibre  breaks  up  partly 
or  in  toto  into  clusters  and  lumps,  apparently  due  to  an  in- 
crease of  the  contractile  matter  and  its  grouping  into  homo- 
genous masses.  Such  lumps  may  likewise  grow  up  to  the 
size  of  nucleated  medullary  corpuscles,  indicative  perhaps 
of  a  more  acute  course  of  the  process.  This  process  we 
must  define  as  a  myositis,  a  process  leading  first  to  a  reduc- 
tion of  the  muscle  fibre  into  its  embryonal  constituents,  the 
so-called  muscle  plates  or  sarcoplasts.  One  of  the  termin- 
ations of  myositis  has  already  been  described,  namely, 
transformation  of  the  contractile  matter  into  fibrous  con- 
nective tissue,  or  perimysium.  In  addition  to  this  termin- 
ation we  find  two  others  present  in  our  case,  namely,  fatty 
and  waxy  degeneration  of  the  muscle  fibres. 

Here  and  there  transverse  sections  of  muscle  fibres  are 
met  with,  which  contain  vacuoles  in  their  centres,  varying 
from  one  to  five  in  number,  and  enclosed  by  a  sharply  de- 
fined capsule.  Such  vacuoles  differ  in  appearance  from 
empty  spaces  by  dropped-out  nuclei.  Although  the  fat  is 
mostly  extracted  from  the  specimen,  owing  to  the  use  of 


708  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

alcohol  and  ether  for  the  purpose  of  embedding,  the  com- 
parison with  analogous  formations  in  the  perimysium  admits 
the  diagnosis  of  the  formation  of  fat  in  the  middle  of  the 
muscle  fibre.  It  is  also  this  treatment  with  ether  and  alco- 
hol which  renders  it  impossible  to  say  whether  or  not  fibres 
lacking  the  carmine  stain,  being  yellow,  highly  refractive, 
and  split  up  into  clusters  by  irregular  crevices,  are  in  fatty 
degeneration.  We  know,  however,  that  the  sarcous  ele- 
ments may  be  directly  transformed  into  fat  granules,  by  the 
coalescence  of  which,  appearances  are  produced  identical 
with  those  seen  in  these  specimens. 

The  second  and  more  common  termination  of  the  myo- 
sitis process  is  waxy  degeneration.  In  almost  every  bundle 
we  find  one  or  more  muscle  fibres  transformed  into  a  highly 
refractive  mass,  known  under  the  name  of  "waxy"  or 
"amylaceous."  The  manner  in  which  this  metamorphosis 
is  produced  can  easily  be  traced.  At  first  we  notice  a 
breaking  up  of  the  muscle  fibre  into  a  number  of  medullary 
corpuscles,  whereby  the  sarcolemma  sheath  remains  unal- 
tered. Such  corpuscles  are  saturated  with  or  infiltrated  by 
a  peculiarly  changed  blood  serum,  which  renders  them  re- 
fractive, glossy,  and  homogeneous.  Often  a  number  of  med- 
ullary corpuscles  coalesce  into  a  lumpy,  homogeneous  mass, 
in  which  faint  traces  of  the  boundaries  of  the  previous 
medullary  corpuscles  are  discernible.  In,  the  highest  degree 
of  waxy  degeneration  we  see  the  homogeneous  mass  almost 
continuous,  holding  in  its  interior  star-shaped  or  oblong 
protoplasmic  bodies  not  in  waxy  degeneration,  so  that  the 
appearance  of  cartilaginous  tissue  is  brought  forth.  If  the 
number  of  protoplasmic  bodies  prevails  over  the  waxy  basis 
substance,  the  latter  may  produce  a  framework  similar  to  a 
honeycomb,  the  sarcolemma  under  these  conditions  being 
entirely  lost. 

Longitudinal  sections  of  the  muscle  of  the  leg  show  all 
the  changes  described  above  as  present  in  transverse  sec- 
tions (Figs.  III.  and  IV.).  Especially  conspicuous  is  the 
small  size  of  all  fibres,  these  at  the  same  time  being  split 
up  lengthwise  into  minute  fibril l;e,  and  only  exceptionally 
exhibiting  a  distinct  transverse  striation.     The   size   of  the 


AMERICAN  NEUROLOGICAL  ASSOCIATION. 


/09 


sarcous  elements  is  strikingly  small.  The  augmentation  of 
the  number  of  the  nuclei  is  obviously  less  noticeable  in  the 
longitudinal  than  in  the  transverse  sections,  but  here  and 
there  chains  or  rows  of  nuclei  are  seen. 


Fig.  III. — Longitudinal  Section  x  200. 

Pe.  Perimysium  externum,  considerably  augmented  ;  composed  of  coarse  bundles  of  fibrous 
connective  tissue. 

V.   Vein,  engorged  with  blood. 

F.  P.    Fat  globules  in  external  perimysium. 

P.  I.    Perimysium  internum,  slightly  augmented. 

R.  N.    Rows  of  nuclei. 

F.   Row  of  nuclei. 

F.   Row  of  fat  globules   ''.    in  centre  of  muscle  fibre. 

W.  M.  Clusters  of  medullary  corpuscles  in  waxy  degeneration  In  the  vicinity  of  this 
cluster,  the  gradual  transformation  of  the  muscle  tissue  into  inflammatory  corpuscles  and  the 
destruction  consequent  destruction  of  the  muscle  tissue  is  marked. 

W.   Peripheral  portion  of  the  muscle  fibre  in  marked  waxy  degeneration. 


-J  I O  AMERICAS  A  El  K0L0G1CAL  ASSOCJA  TIOX. 


WJt 


FlG.  IV. — Longitudinal  Section  x  800. 

".  E.  Perimysium  externum,  broadened,  composed  of  coarse  bundles  of  fibrous  connective 
tissue  freely  vascularized. 

P.  I.    Perimysium  internum,  transformed  into  inflammatory  or  medullary  corpuscles. 

I.  I.   Groups  of  inflammatory  corpuscles,  obviously  arisen  from  previous  contractile  tissue 

N.    Nucleated  inflammatory  corpuscles  imbedded  in  muscle  tissue. 

C.I.  Clusters  of  inflammatory  corpuscles  in  bay  like  excavations  ot  the  contractile  tissue, 
in  part  spindle  shaped,  in  transition  to  fibrous  connective  tissue.  The  medullary  tissue  trans- 
versed  by  a  large,  probably  newly  formed  capillary  blood-vessel. 


Both  the  perimysium  internum  and  externum  have  in- 
creased in  size,  especially  the  externum.  That  this  increase 
is  not  a  mere  augmentation  of  the  fibrous  connective  tissue, 
but  is  the  result  of  an  active  participation  of  the  contractile 
tissue,  can  plainly  be  demonstrated  in  longitudinal  sections. 
Here  we  not  infrequently  encounter  muscle  fibres  whose 
body  terminates  almost  abruptly,  the  fibrillar  structure  be- 
ing lost  and  replaced  by  medullary  tissue.  It  also  happens 
that   only  a  limited    portion    of  the    muscle    fibre    appears 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  J I  I 

transformed  into  rows  of  medullary  corpuscles,  blending 
with  the  contractile  substance  proper.  This  contractile 
substance  first  shows  a  breaking  up  into  the  muscle  plates, 
and  subsequently  into  rows  or  clusters  of  medullary  cor- 
puscles. Such  clusters  are  seen  to  appear  in  the  middle  of 
a  muscle  fibre,  being  then  bordered  by  an  almost  unchanged 
muscle  tissue.  The  medullary  tissue  assists  in  the  new 
formation  of  both  external  and  internal  perimysium,  where- 
by the  bulk  of  the  muscle  fibre  is  diminished  and  that  of 
the  fibrous  connective  tissue  augmented. 

Waxy  degeneration  is  a  marked  feature  both  in  the  peri- 
mysium and  in  the  muscle  fibres.  In  the  former,  even  the 
middle  and  adventitial  coats  of  the  arteries  and  the  adven- 
titial coats  of  the  veins  are  subject  to  waxy  degeneration. 
In  no  place  of  the  muscle  tissue  itself  has  this  degeneration 
attacked  the  muscle  fibre  in  toto.  Lumps  showing  the 
characteristic  high  refraction,  as  a  rule  are  seen  only  in  the 
axes  of  muscle  fibres,  as  though  representing  prolongations 
of  them.  This  fact,  more  particularly  however  the  appear- 
ances seen  in  transverse  section  of  the  muscle,  forces  upon 
us  the  conviction  that  it  is  the  contractile  tissue  itself  which 
has  become  waxy,  after  having  first  been  broken  up  into 
medullary  tissue. 

Numerous  medullated  nerve  fibres  are  visible  in  longi- 
tudinal as  well  as  in  transverse  sections.  These  are  seen 
singly  as  also  in  bundles.  Many  of  these  nerves  appear  to 
be  unchanged,  whereas  in  others  an  increase  of  the  nuclei 
of  Schwann's  sheath  can  be  seen,  and  in  still  others  the 
perineurium  internum  appears  to  be  more  or  less  crowded 
with  medullary  or  inflammatory  corpuscles,  features  which 
we  are  accustomed  to  see  in  neuritis  and  perineuritis. 

How  many  medullated  nerve  fibres  have  been  destroyed 
by  being  transformed  into  fibrous  connective  tissue,  we  are 
unable  to  say.  The  large  number  of  unchanged  nerve 
fibres,  however,  strongly  points  towards  the  view  that  the 
process  of  neuritis  and  perineuritis  is  not  the  primary  one, 
but  altogether  secondary  to  the  myositis  and  perimyositis. 
In  the  same  manner  as  a  certain  amount  of  contractile  tissue 
is  transformed  into  fibrous  connective  tissue,  with  the  inter- 


7  I  2  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

vening  stage  of  inflammatory  or  medullary  tissue,  so  also 
the  nerves  are  at  least  in  part  changed,  first  to  medullary, 
and  finally  to  fibrous  connective  tissue. 

The  muscle  of  the  arm  shows  changes  identical  with 
those  observed  in  that  of  the  leg,  the  only  difference  be- 
tween the  two  being  that  the  process  is  less  extensive  and 
less  intensive  in  the  former  than  in  the  latter. 

In  summing  up  the  results  of  this  examination,  I  would 
condense  them  as  follows  : 

i.  The  process  is  an  acute  myositis  and  perimyositis, 
grafted  on  a  chronic  plastic  or  formative  process. 

2.  The  plastic  process  has  led  to  a  new  formation  of 
connective  tissue  of  the  perimysium  externum  as  well  as 
of  the  perimysium  internum.  This  process  became  pro- 
gressive by  repeated  recurrences  of  myositis,  leading  to  a 
diminution  of  the  contractile,  and  to  an  increase  of  the 
fibrous  connective,  tissues. 

3.  The  result  of  the  chronic  process  is  fatty  and  waxy 
degeneration.  Both  have  invaded  the  perimysium,  as  well 
as  the  muscle  tissue  proper. 

4.  Neuritis  and  perineuritis  are  secondary  to  myositis 
and  perimyositis. 

Before  entering  into  consideration  of  the  case  itself,  if 
we  now  take  a  brief  review  of  that  which  has  heretofore 
been  done  in  acute  disorders  of  the  muscular  tissue,  we  will 
see  that,  notwithstanding  inflammation  of  muscles  ought 
a  priori  to  occur  as  easily  as  inflammation  of  other  tissues, 
as  a  matter  of  fact,  it  was  universally  supposed  that  such 
inflammation  of  the  muscles  themselves  was  impossible, 
until  Virchow,1  in  his  remarkable  thesis  of  1852,  showed 
this  view  to  be  erroneous.  Even  at  present  there  are  many 
observers  to  whom  the  existence  of  a  primary  myositis 
savors  somewhat  of  a  myth.  This  condition  of  affairs  can 
only  be  due  to  the  fact  that,  although  inflammation  of  the 
muscles,  be  it  due  to  operative  measures  or  traumatism  of 
various  kinds,  or  to  propagation  of  the  inflammatory  pro- 
cess from  neighboring  parts,  is  often  produced,  nevertheless 

1  Virch  w>,  Ueber  Parcnchymatoscr  Entzundung,  Archiv.  f.  Patholog.  Anat. 
und  Physio'ogic.  1882,  Vol.  4,  p.  261-323. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  J  \  3 

the  myositis  itself  rarely  comes  nnder  the  observation  of 
the  physician.  The  slight  forms  cause  so  little  inconven- 
ience to  the  patients,  and  the  severe  forms  are  of  so  rare 
occurrence,  that  even  when  these  severe  forms  are  encoun- 
tered intra  vitain,  a  disunity  of  opinion  as  regards  the  diag- 
nosis and  character  of  the  affection  has  been  the  result. 
Our  knowledge  of  the  microscopical  changes  produced  by 
the  process  has,  with  perhaps  the  exception  of  the  more 
minute  changes,  remained  the  same  as  it  was  left  by  Vir- 
chow.  According  to  this  observer,  the  pathological  changes 
occur  either  in  the  muscular  fibre  itself,  in  the  interstitial 
connective  tissue,  or  in  both,  and  it  is  often  impossible  to 
determine  from  which  of  these  the  process  primarily  origi- 
nated. The  contractile  substance  becomes  involved  in  a 
number  of  regressive  changes — hyperaemia,  turbid  swelling, 
change  in  color,  loss  of  longitudinal  and  transverse  stri- 
ation,  then  fatty  or  waxy  degeneration,  or,  in  very  acute 
cases,  destruction  of  the  fibrillae  and  softening. 

The  processes  occurring  in  the  interstitial  connective 
tissue  are  of  a  more  active  nature  ;  here  we  have  the  forma- 
tion of  pus,  granulation  and  fat  tissue,  or  tendon  and  bone 
tissue,  which  substances  were  supposed  to  force  themselves 
between  or  supplant  the  contractile  elements.  Thus,  accord- 
ing to  the  tendency  of  the  changes  of  the  medullary  cor- 
puscles, we  have  either  a  fibrous,  a  purulent,  or  an  ossifying 
myositis.  The  category  in  which  our  case  belongs,  micro- 
scopically, is,  as  already  stated,  that  of  a  parenchymatous 
myositis. 

Upon  entering  upon  the  clinical  aspect  of  this  case  we 
are  confronted  by  an  important  question.  Is  the  affection 
here  a  primary  or  a  secondary  one  ?  Of  secondary  affec- 
tions of  the  muscles  not  due  to  local  causes,  we  have  pain 
and  swelling  due  to  muscular  rheumatism.  Etiologically 
and  anatomically,  we  know  nothing  as  to  the  character  of 
this  affection.  Clinically,  we  only  know  that  beyond  the 
pain  and  swelling  there  is  no  analogy  between  the  two 
affections. 

So  also  after  polyarticular  rheumatism  occasionally, 
many  muscles  are  affected  in  a  similar  manner ;  but  in  our 


-  I  4  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

case  there  is  no  history  of  joint  involvement  at  any  time. 

After  variola,  Wagner1  has  seen  similar  occurrences. 

The  muscular  implications  occurring  in  consequence  of 
scorbutus,  glanders  and  syphilis  need  only  be  mentioned  to 
be  disposed  of.  Not  so  is  it  with  the  muscular  changes 
occurring  during  typhoid  fever.  To  these  more  than  a 
passing  notice  must  be  given.  Changes  in  the  muscles  of 
typhoid  fever  patients,  resembling  very  much  the  changes 
described  by  Virchow  as  above  stated,  were  observed  by 
Zenker2  in  1864.  He  found  degeneration  of  the  striated 
fibres  in  the  most  varied  groups  of  muscles,  and  as  has 
been  shown  by  later  observers  these  changes  are  almost  as 
characteristic  as  the  changes  of  the  intestinal  mucous 
membranes.  The  adductors  of  the  thighs  and  the  recti 
abdominis  are  the  muscles  chiefly  involved.  A  medium  or 
pronounced  degree  of  waxy  degeneration  is  here  found, 
sometimes  associated  with  granular  degeneration.  A  cer- 
tain number  of  fibres  still  retain  their  normal  transverse 
striation.  The  extraordinary  fragility  of  the  muscles  is 
shown  by  the  frequency  with  which  transverse  ruptures  are 
encountered.  Microscopically,  Zenker  differentiates  the 
granular  and  waxy  degeneration,  the  first  produced  by 
interspersion  of  finest  molecules  in  the  contractile  muscular 
substance,  the  latter  consisting  of  a  transformation  of  the 
contractile  substance  into  a  waxy,  homogeneous,  colorless, 
shining  mass,  with  complete  disappearance  of  the  trans- 
verse striae  and  destruction  of  the  muscular  nuclei,  the 
sarcolemma  alone  remaining  intact.  In  addition  Zenker 
also  noted  degeneration  in  the  form  of  discoid  separation 
and  fibrillary  splitting.  The  connective  tissue,  vessels  and 
nerves  show  no  changes,  but  in  many  cases  a  proliferation 
of  nuclei  takes  place  in  the  perimysium.  Although  the 
comparison  of  the  microscopical  findings  in  our  case  with 
those  of  Zenker  show  many  points  of  identity,  still  it  is 
evident  that  there  are  also  points  of  difference.  But  even 
were  the  results  of  the    microscopical  examination  abso- 

•  Archiv.  der  Hcilkundc,  1872,  p.  107,  Vol.  xiii. 

*  Zenker,  Leber  der  Veranderungen  der  Wilkurlichen  Muskeln  in  Typhus 
Abdominalis,  Ix-ipzig,  1864. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  J  \  5 

lutely  identical,  we  would  not  be  justified  in  considering  the 
processes  as  clinically  analogous.  Indeed  we  have  long 
believed  and  have  publicly  expressed  the  opinion  that 
from  an  examination  of  muscles  alone,  it  is  impossible  to 
decide  to  which  clinical  variety  of  muscular  disorder  a 
given  case  belongs.1  This  idea  also  receives  support  from 
Waldeyer,2  who  in  myositis,  mechanico-experimentally  pro- 
duced, found  the  same  histological  changes  as  in  typhoid 
myositis.  Therefore  it  is  necessary  in  a  review  of  condi- 
tions analogous  to  those  presented  in  our  case  also  to  give 
particular  attention  to  the  clinical  aspects. 

The  clinical  symptoms  differ  materially  in  our  case  and 
in  typhoid  myositis.  In  the  latter  the  course  is  of  a  light 
character  with  slight  pains  and  slight  tenderness  to  pres- 
sure, whereas  in  our  case  the  other  extremes  were  noted. 
We  have  no  hesitancy  in  excluding  the  fact  of  our  patient 
having  had  typhoid  fever  over  a  year  prior  to  the  occur- 
rence of  the  described  affection,  as  entirely  free  from  any 
etiological  significance. 

The  next  class  of  cases  which  bear  a  certain  analogy  to 
ours  are  those  described  by  Scriba.3  The  principal  point 
emphasized  by  these  cases  is  that  we  may  have  an  acute 
myositis  due  to  infectious  inferences.  Here  the  infection 
was  caused  in  three  cases  by  a  furuncle  and  in  one  by 
a  carious  tooth.  The  fifth  case  is  valueless  for  comparison, 
as  it  did  not  present  a  pure  myositic  picture.  These  cases 
presented  slight  fever,  severe  pain  in  the  muscles  affected, 
with  swelling.  The  affected  muscles  were  greatly  increased 
in  size  and  were  of  a  bony  consistency  to  the  touch,  and 
could  be  traced  from  origin  to  insertion,  like  a  plaster  cast. 
The  process  was  always  limited  to  isolated  muscles  and 
the  contiguous  muscles  were  soft  and  painless.  The  cases 
all  ended  in  complete  cure  in  several  weeks,  either  with  or 
without   suppuration.      In   the   second    case  microscopical 

1  Discussion,  N.  Y.  Neurological  Society,  March  5,  1888. 

2  Waldeyer,  Ueber  die  Veranderungen  der  Quergestreiften  Muskeln  bei  der 
Entzundung  und  dem  Typhus  Process,  etc.,  Virchow's  Archiv.,  Vol.  34. 

3  Scriba,  J.,  Myositis  Acuta,  Deutsche  Zeitschrift  f.  Chirurgie,  Leipzig,  1885, 
p.  497-5°2- 


J  I  6  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

examination  of  a  teased  preparation  of  a  piece  of  muscle 
was  made.  The  transverse  striation  was  found  to  be  almost 
entirely  absent.  The  sarcolemma  were  from  two  to  three 
times  larger  than  is  normally  the  case.  The  perimysium 
externum  was  slightly  infiltrated  with  medullary  corpuscles 
and  the  perimysium  internum  was  only  very  slightly  impli- 
cated. Scriba  considers  the  affection  very  rare  even  in 
Japan,  and  was  unable  to  obtain  the  history  of  a  single 
similar  case  from  other  physicians.  In  Europe,  also,  the 
affection  was  entirely  unknown  prior  to  this  publication. 
The  points  of  variance  between  these  cases  and  ours  are 
also  evident. 

This  completes  the  review  of  the  acute  secondary  in- 
flammatory muscular  disorders.  Of  the  acute  primary  or 
so-called  idiopathic  disorders  still  less  is  known. 

Under  the  name  of  acute  and  subacute  myositis,  a  class 
of  cases  has  been  described  by  various  observers,  Strauss,1 
Clark,-  Treves,3  Devis,1  Walther,5  Hepp6  and  others,  giving 
as  causes  cold,  blows  and  muscular  over-exertion. 

Xosologically  this  affection  stands  in  the  same  rank  as 
acute  periostitis  and  osteomyelitis,  with  which  it  has  in 
many  cases  been  confounded.  It  is  undoubtedly  an  acute 
infectious  disease  with  a  tendency  to  suppuration  differently 
localized  according  to  the  preceding  infection.  All  the 
muscles  of  the  body  become  affected.  A  typical  course 
cannot  be  given,  but  it  is  undoubtedly  a  serious  disease, 
beginning  with  dull,  increasing  pains,  which  render  the  use 
of  the  affected  muscle  impossible.  The  muscle  swells, 
becomes  hard,  abnormal  positions  ensue  (due  to  approxi- 
mation of  the  attachments),  suppuration  takes  place,  caus- 

1  Strauss,  Jaccond's  Dictionnaire,  Vol.  xxiii.,  p.  362. 

2  Clark,  F.  IV ,  British  Med.  Journal,  1887,  ii.,  p.  69. 

3  Treves,  Brit.  Med.  Journ.,  1886,  ii.,  p.  1215. 

*  Drvis,  Tr.  Pathol.  Soc.  London,  1881,  p.  273-75. 

•  Walther,  Deutsche  Zeitsch.  f.  Chirurgie,  1885,  p.  285-87.  Gives  table  of 
19  cases, of  which  cases  12  (Maas)  15,  16,  17  and  18  (Scriba)  do  not  belong  here, 
but  must  be  classed  as  secondary  affections. 

6  H<pp,  Paul,  Ueber  einen  Fall  von  acuter  Parenchymatoser  Myositis, 
welche  Geschwulste  bildete  und  Fluctuation  vortauschte,  Berliner  Klinische 
Wochenschrilt,  1887,  p.  389. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  J  \  J 

ing  single  large  or  several  small  abscesses,  and  the  severe 
cases  end  fatally,  the  lighter  ones  recovering. 

Only  one  more  class  of  cases  remains  to  be  described, 
and  to  this  class,  of  which  only  three  cases  have  been  thus 
far  reported,  our  case  belongs.  As  these  cases  are  of  such 
rare  occurrence,  and  they  all  have  been  described  within 
the  last  two  years,  I  may  be  pardoned  if  I  enter  upon  them 
somewhat  closely.  A  few  cases  have  been  described,  prior 
to  these,  nnder  other  names,  which  probably  also  belong 
to  this  class. 

These  cases  clearly  show  the  existence  of  an  acute  in- 
flammation, rapidly  affecting  nearly  all  of  the  voluntary 
muscles,  characterized  chiefly  by  pain  and  swelling,  and 
ending  in  death  within  a  more  or  less  short  period  of  time. 
They  show  us  that  we  may  have  an  acute  primary  progres- 
sive inflammation  of  the  muscles,  the  chronic  form  of  which 
alone  has  been  hitherto  known.  The  first  case  is  that  of 
Wagner.1  Female,  aet.  34.  Years  ago  had  typhoid.  Now 
tuberculous.  Since  end  of  June,  without  exposure  to  draught 
or  cold,  pains  in  joints,  back,  neck,  shoulders,  and  legs. 
Received  in  hospital,  July  19th,  1886.  Well  nourished, 
strongly  built.  Muscles  of  neck  painful  to  pressure.  Stiff- 
ness in  both  shoulder  joints,  but  freedom  from  pain.  Slight 
oedema  of  back  of  hands  and  forearms  as  well. 

July  24th. — Paresthesia  in  both  forearms.  CEdema  the 
same.     Nerves  not  sensitive  to  pressure. 

July  28th. — Arms  also  swollen,  forearms  most.  Skin 
tense,  so  that  contours  of  muscles  could  not  be  distin- 
guished.    Muscles  feel  doughy.     Movements  impeded. 

August  7th. — Swelling  has  decreased,  Erysipelatous 
redness  on  flexor  surface  of  left  arm. 

August  17th. — Redness  has  spread. 

August  24th. — The  thighs  have  become  affected.  Cough 
and  dyspnoea. 

August  29th. — Disorders  of  deglutition  and  spontaneous 
attacks  of  dyspnoea.     Death. 


1  Wagner,  E.,  Ein  Fall  von  acuter  Polymyositis,  Deutsches  Archiv.  f.  Klin. 
Medizin,  Vol.  40,  1887,  p.  241. 


AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Autopsy. — Extensive  muscular  disease.  Slight  cedema 
of  both  upper  extremities.  Slight  tuberculous  phthisis  of 
lungs.  Diffuse  bronchitis.  Severe  emphysema.  Hyper- 
emia of  brain  and  cord.  The  muscles  which  were  micro- 
scopically changed  were  the  biceps,  triceps,  and  brachialis 
internus.  These  were  of  a  peculiar,  stiff  consistency,  but  at 
the  same  time  more  fragile  than  normally.  In  the  forearm 
the  flexors  are  chiefly  affected,  but  irregularly,  spots  and 
stripes  of  very  pale  appearance  alternating  with  darker 
parts.  Nearly  all  the  muscles  except  the  glutei,  muscles  of 
the  calf,  and  the  abdominal  muscles,  are  affected.  Brain, 
spinal  cord,  and  peripheral  nerves  normal.  The  majority 
of  specimens  for  microscopical  examination  were  taken 
from  the  biceps.  Serous  infiltration,  fatty  and  waxy  degen- 
eration of  the  muscle  fibres,  were  the  characteristics  most 
marked.  The  interstitial  connective  tissue  showed  prolifer- 
ation of  nuclei,  and  single  multinucleated  giant  cells  were 
also  observed.  Processes  of  new  formation  were  found  in 
the  muscular  substance,  as  well  as  in  the  perimysium. 
Only  in  a  few  places  was  the  perimysium  internum  increased. 
The  adventitia  of  the  small  arteries  was  somewhat  rich  in 
nuclei.  The  nerve  endings  in  the  muscles  were  not  exam- 
ined. 

The  second  case  is  that  of  Unverricht.1  The  patient  was 
a  male,  ret.  24,  who  had  been  well  until  two  weeks  prior  to 
presentation.  Etiologically  nothing.  For  a  few  days  drag- 
ging pains  in  arms  and  legs,  which  increased  in  severity 
until  walking  was  impossible. 

Examination  showed  a  medium-sized,  well  nourished 
individual,  of  good  muscular  development.  Organs  of  chest 
and  abdomen  normal.  Complains  of  pains  in  all  extremi- 
ties and  back.  Motion  of  extremities  intact,  but  painful  ; 
force  normal,  no  paresthesia.  No  fever,  nor  disorders  of 
digestion.  After  a  week,  slight  swellings  of  the  extremi- 
ties and  also  of  the  face.  Increase  of  the  swelling.  Mus- 
cles painful  to  pressure.  The  joints  free  from  exudation, 
and  painless.     At  this  stage   the  extremities  were  swollen 

1  Unverricht,  Polymyositis  acuta  progressive,  Zcitschrift  f.  Klinische  Med., 
1887,  p.  534. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  J  1 9 

to  thick,  formless  masses,  whereas  the  body  was  not  affected. 
Later,  the  thorax  became  painful  to  pressure,  and  swollen. 
Three  weeks  after  entrance  to  hospital,  pains  in  swallow- 
ing ;  fluid  food  alone  could  be  taken?  Thoracic  muscles 
very  painful,  breathing  abdominal,  pneumonia,  death. 

Autopsy  showed  brain  and  medulla  normal.  The  mus- 
cles showed  extensive  and  remarkable  changes,  chiefly 
limited  to  certain  groups.  Color  in  general,  dark  reddish 
brown,  but  upon  section  many  muscles  are  found  colored 
in  irregular  spots.  Pale,  somewhat  transparent,  light  gray 
strips  alternate  with  dark  red  spots.  All  these  muscles  are 
swollen  and  fragile.  The  changes  are  most  marked  in  the 
extensors  of  the  extremities,  whereas  the  flexors  are  almost 
entirely  unaffected.  The  pectoralis  major  affected  in  parts. 
The  deltoids  extensively,  biceps  slightly.  Extensors  of 
forearms  very  much,  triceps  free,  muscles  of  ball  of  thumb 
free.  Extensors  of  thighs  and  toes  very  much,  but  flexors 
of  thighs  and  legs  only  slightly  affected.  Abdominal  mus- 
cles, muscles  of  back,  and  intercostals  slightly  implicated. 
Muscles  of  tongue,  eyes,  and  diaphragm  not  affected.  The 
idea  of  trichinasis  had  been  expressed,  but  not  a  single  tri- 
china was  found. 

Microscopically,  the  results  corresponded  to  the  macro- 
scopical  examination.  The  interstitial  connective  tissue 
was  infiltrated  with  medullary  bodies.  Muscular  substance 
in  all  stages  of  degeneration,  some  places  showing  normal 
muscle,  and  the  immediately  contiguous  place  being  severely 
degenerated.  Loss  of  transverse  striation  ;  hygroscopic  ; 
granular  and  waxy  degeneration.  In  other  places  fatty  de- 
generation was  found.  Regeneration,  and  increase  of  mus- 
cular nuclei  not  present.  Spinal  cord  and  peripheral  nerves 
were  unchanged. 

The  third  case  is  that  of  Hepp.1  Patient,  female,  set.  36. 
Family  history  good.  Previous  history  unimportant.  Sick 
since  March,  1886 ;  did  not  feel  well  during  two  to  three 
weeks  ;  then  eruption  on  face  of  red,  thickly  settled,  elevated 
and  non-itching  spots.     Next  day  spread  to  back,  neck, 

1  Hepp,  Paul,  Ueber  pseudo  Trichinose,  eine  besondere  Form  von  acuter 
parenchymatoeser  Polymyositis,  Berl.  Klin.  Wochenschrirt,  1887,  p   297. 


720  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

and  mucous  membrane  of  mouth.  After  a  week,  disap- 
peared. Then  increasing  pains  in  neck  and  back ;  legs 
swollen,  but  not  the  thighs.  Took  to  bed.  After  eight 
days,  swelling  of  face  and  right  arm,  then,  after  three  days, 
of  left  arm.  Swelling  of  face  disappeared,  that  of  arms  in- 
creased. Spontaneous  pains  rare,  but  very  severe  upon 
slightest  motion.  Then  stiffness  of  extremities  ;  could  not 
bend  or  extend  arms  ;  legs  not  so  bad. 

Examination  shows  slight  redness  of  face  and  chest. 
CEdema  of  face,  extremities,  and  chest  ;  feet,  ankles,  and 
hands  free.  Arms  swollen  to  a  hard  cylindrical  mass;  pec- 
toralis  major  in  contracture  ;  hard,  stiff,  and  non-elastic. 
Muscles  of  neck  and  lower  extremities  the  same,  but  not  so 
marked.  No  pains  when  quiet.  Joints  free  ;  passive  move- 
ments free  and  painless  ;  extended  movements  difficult  on 
account  of  contracture  of  muscles.  Active  movements  not 
possible.  Facial  muscles  and  tongue  not  affected.  Voice, 
pupils,  sensorium,  special  senses  not  affected.  Tendon 
reflexes  absent.  Affected  muscles  do  not  react  to  either 
electrical  current.  Increase  of  disorder,  affection  of  mus- 
cles of  deglutition,  death  on  May  22d.  Anatomically, 
affected  muscles  yellowish  and  pale.  Everything  else  nor- 
mal. 

Microscopical  Examination. — Absence  of  trichinae.  Waxy 
or  hyaline  degeneration  near  apparently  normal  fibres  ; 
others  in  which  transverse  striation  indistinct,  and  in  still 
others  entirely  absent.  Others  showed  all  stages  of  hyaline 
transformation,  from  the  cylindrical  hyaline  fibre  to  com- 
plete disintegration  into  granular  detritis.  In  no  place 
granular  or  fatty  degeneration.     Spinal  cord  normal. 

The  following  two  cases  have  been  published  under 
other  names,  but  probably  also  belong  in  this  category. 
First,  by  Wagner.1  Woman,  aet.  43.  Well  until  a  few  days 
prior  to  entrance  into  hospital. 

Status,  Oct.  ijth,  1861. — Badly  nourished,  pale,  small. 
Both   arms  very  much   swollen  up  to  elbows.     Forearms  to 

1  iYagrur,  E.,  Fall  einer  seltencn  Muskelkrankheit,  Archiv.  der  Heilkunde, 
1863,  Vol.  iv.,  282  and  83.  Additional  remarks  in  the  article  on  Polymyositis  by 
the  same  author.     Loc.  Cit 


AMERICAN  NEUROL OGICAL  ASSOCIA  TION  J  2  1 

hands  less.  Reddened,  oedematous  ;  great  pain  on  pres- 
sure. Lower  extremities  not  swollen,  but  have  a  feeling  of 
tension.     Difficulty  in  swallowing  fluids. 

igth. — Swelling  of  upper  extremities  less. 

20th. — More  swelling. 

21st. — Arms  very  much  swollen.  Death  occurred  dur- 
ing the  following  night. 

Microscopical  examination  showed  intense  and  exten- 
sive changes  in  all  the  muscles  of  the  upper  part  of  the 
body.  Partly  fatty  metamorphosis,  partly  colloid  degener- 
ation. In  many  places  both  forms  of  degeneration  were 
found  in  one  and  the  same  fibrillae.  Numerous  diffuse,  very 
small  foci  of  pus  corpuscles,  and  increase  of  the  nuclei.  The 
intermuscular  and  subcutaneous  connective  tissue  did  not 
show  any  proliferation  of  connective  tissue  bodies  or  pus. 

Second  Case. — Marchand.1  Patient  male,  set.  23.  Sick 
since  five  weeks.  Began  with  gradually  increasing  mus- 
cular pains  and  corresponding  disorder  of  function.  At 
the  same  time  oedematous  swelling  without  albuminuria 
occurred.  Diagnosis  of  trichinosis.  The  respiratory  mus- 
cles became  affected  and  death  ensued.  The  autopsy  re- 
vealed an  intensely  diseased  condition  of  the  muscular 
system,  not  equably  distributed,  but  affecting  principally 
the  extensors  of  the  extremities,  partly  also  the  muscles  of 
the  chest  and  neck  as  well  as  the  adductors  and  flexors  of 
the  thighs.  The  muscles  were  increased  in  size.  No 
trichinse  were  found.  Microscopical  examination  showed 
granular  and  fatty  as  well  as  hyaline  degeneration  of  the 
primitive  fibres.  Spinal  cord  and  peripheral  nerves  nor- 
mal. 

Now,  having  found  the  proper  place  for  our  case,  there 
are  two  questions,  applicable  to  this  entire  class,  which 
must  be  answered  before  any  final  conclusion  as  regards 
the  position  if  any  which  it  bears  to  the  chronic  forms  of 
primary  dystrophies  can  be  arrived  at.  The  one  is  the 
question  of  trichinosis  in  the  production  of  analogous  con- 
ditions, and  the  other  is  that  of  the  relation  which  multiple 
neuritis  bears  to  these  cases.     In  all  the  cases  above  cited 


1  Breslauer  Aerztliche  Zeitschrift,  1880,  p.  264. 


y  2  2  AMERICAN  NE I  'ROL  OGICAL  A SSOCIA  TION. 

as  being  cases  of  polymyositis,  the  similarity  of  the  symp- 
toms to  those  observed  in  cases  of  trichinosis  is  marked, 
and  all  of  the  authors  with  the  exception  of  Wagner,  in  his 
first  case  (1861),  had  even  more  than  a  suspicion  that 
trichinae  were  the  cause  of  the  severe  muscular  disorder. 
Also  in  two  cases  reported  by  Kussmaul  and  Maier,1  which 
although  accepted  by  others  as  cases  of  polymyositis,  I 
have  purposely  excluded,  this  conviction  is  expressed. 
Hepp  even  goes  so  far  as  to  give  the  name  "  pseudo-trichi- 
nosis" to  the  complaint,  a  name  which  has  received  its 
well-merited  criticism  and  censure  from  others.  In  none  of 
the  cases,  however,  were  trichinae  found  in  the  muscles, 
except  in  Wagner's  second  case,  and  here  in  about  three 
hundred  muscular  sections  three  trichinae  were  found  ; 
these  were  encapsulated  and  estimated  to  be  about  four 
months  old,  so  that  also  in  this  case  their  influence  upon 
the  production  of  the  myositis  must  be  excluded. 

In  our  case  the  question  is  effectually  disposed  of,  not 
only  by  the  absence  of  trichinae  from  the  microscopical 
specimens,  but  also  on  account  of  the  long  duration  of  the 
disease. 

That  multiple  neuritis  may  produce  symptoms  similar 
to  those  observed  in  our  case  cannot  be  gainsaid.  But  if 
we  take  into  consideration  the  facts,  that  during  the  entire 
course  of  the  disease  there  was  freedom  from  spontaneous 
pains;  there  was  no  pain  produced  by  pressure  over  the 
nerve  trunks ;  there  were  no  disturbances  of  sensation ; 
there  was  no  actual  paralysis  of  any  muscles,  the  inhibition 
of  movements  being  due  entirely  to  the  pain  produced  by 
them  ;  there  was  no  reaction  of  degeneration  in  any  of  the 
muscles,  and,  finally,  considering  the  intense  swelling  of 
the  muscles,  we  believe  that  neuritis  as  the  primary  affec- 
tion may  be  unhesitatingly  excluded.  All  of  these  negative 
symptoms  taken  together  are  valuable,  a  single  one  by 
itsell  of  course  proves  nothing. 

Owing  to  the  changes  found  in  a  few  of  the  intramuscu- 


1  Ucber  eine  bisher  rrii  lit  beschriebene  Krkrankun^  (Periarteritis  nodosa)  die 
mit  morbus  Briy,'htu  und  rapid  fortschreteinde  algemeiner  Mu>kellahmungeinher- 
Deutsches  Archiv.  f.  Klin.  Med.,  Vol.  1.,  p.  484. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  723 

lar  nerves  it  is  to  be  greatly  regretted  that  pieces  of  the 
larger  nerves  could  not  be  obtained  for  examination, 
although,  as  above  expressed,  it  is  evident  from  the  micro- 
scopical examination  that  the  neuritis  is  secondary  to  the 
myositis. 

The  frequently  cited  cases  of  combined  neuritis  and 
myositis  described  by  Eisenlohr,1  as  well  as  the  recent 
article  of  Senator2  upon  the  same  subject,  go  far  to  prove 
that  the  inflammatory  process,  whether  it  primarially  origi- 
nates in  the  nerves  or  in  the  muscles,  does  in  many  cases 
not  remain  confined  to  the  primarily  affected  tissues,  but 
secondarily  involves  the  muscles  if  the  nerves,  the  nerves  if 
the  muscles  were  originally  involved.  In  Eisenlohr's  and 
Senator's  cases  the  presence  of  disorders  of  sensation  with 
paralysis  of  the  muscles,  in  addition  to  the  other  symptoms, 
make  the  primary  involvement  of  the  peripheral  nerves 
probable. 

Another  question,  and  one  whieh  cannot  be  disposed  of 
so  easily,  is  the  possible  relationship  between  our  case  and 
cases  like  ours,  and  primary  progressive  muscular  atrophy  ; 
in  short,  is  our  case  perhaps  a  case  of  progressive  muscular 
atrophy  in  which  the  inflammatory  stage  is  more  marked, 
clinically,  than  usual,  due  to  the  myositis  being  more  of  a 
parenchymatous  character  ?  Would  we  not  possibly,  if  we 
examined  our  cases  of  the  chronic  forms  with  a  view  par- 
ticularly to  the  history  of  the  initial  stage,  find  analogous 
conditions  to  those  presented  by  our  case,  or  at  least  a  his- 
tory of  muscular  rheumatism  so-called  ?  In  other  words, 
are  not  some  cases  of  primary  progressive  muscular  atrophy 
the  resultants  of  light  cases  of  polymyositis  parenchyma- 
tosis  ?  We  believe  that  there  is  considerable  evidence  in 
favor  of  these  views,  and  we  do  not  stand  entirely  alone  in 
possessing  this  opinion.  Wagner  insists  and  Unverricht 
admits  the  possibility  of  their  cases  being  acute  cases  of 
primary  progressive  muscular  atrophy.     Cases,  in  fact,  of 

1  Eisenlohr,  Idiopathische  subacute  muskellahmung  und  atrophie,  Central- 
blatt  f.  Nervenheilkunde,  1879,  p.  100,  Vol.  ii. 

2  Senator,  Acute  multiple  myositis  bei  neuritis,  Deutsche  Med.  Wochenschrift", 
1888,  p.  449.  Discussion  in  Verein  f.  Innere  Medizin,  meeting  May  28,  1888. 
Berl.  Klin.  Wochenschrift,  p.  493,  1888. 


724  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

the  acutest  possible  kind,  Wagner's  cases  showing  a  dura- 
tion of  three  and  eight  weeks  respectively,  and  Unverricht's 
a  duration  of  six  weeks. 

None  of  these  cases  however,  showed  any  atrophy,  but 
it  cannot  be  said  that  this  might  not  have  developed  if  the 
life  of  the  patients  had  been  more  prolonged.  At  any  rate 
the  proof  of  a  relationship  between  these  very  acute  cases 
and  the  chronic  ones,  would  be  a  very  difficut  one  to  fur- 
nish, unless  an  intermediary  can  be  found  which  will  serve 
as  a  connecting  link.  This  link  we  believe  to  possess  in 
our  case. 

We  admit  that  if  we  compare  this  case  with  typical  ones 
of  primary  progressive  muscular  atrophy,  the  disparity  is 
evident,  but  we  must  not  forget  that  we  are  dealing  with 
an  unusual  case,  the  assignment  of  which  to  any  of  the  well 
known  types  of  disease  meets  with  difficulty.  But  let  us 
compare  the  two  affections,  and  the  following  points  of  sim- 
ilarity and  dissimilarity  will  become  apparent.  The  first 
objectionable  point  in  our  case  is  the  late  occurrence, 
namely,  at  the  age  of  32.  Still,  we  know  that  rare  cases  of 
the  pseudo-hypertrophic  form  do  not  begin  until  the 
eighteenth  or  twentieth  year,  and  that  Schultze's,1  which, 
although  a  very  unusual  case,  he  classes  under  this  form, 
did  not  begin  until  the  twenty-seventh  year,  we  also  know 
that  in  the  primary  atrophic  form  the  occurrence  may  take 
place  as  late  as  the  sixtieth  year.2  We  here  speak  of  the 
pseudo-hypertrophic  and  atrophic  forms,  'almost  in  one 
breath,  because  we  all  know  that  the  separation  of  the  two 
forms  is  not  absolutely  certain  on  account  of  intermediary 
cases,  which  cannot  easily  be  placed  in  one  or  the  other 
category. 

The  second  objectionable  point  is  the  mode  of  origin. 
This  in  all  cases  of  polymyositis,  as  also  in  ours,  was  acute, 
a  mode  decidedly  at  variance  with  that  of  progressive  mus- 
cular atrophy.  But  even  here,  exceptions  to  this  rule  are 
furnished   by  the  so-called  rheumatic   forms,  a   number  of 

1  Schultze,  /'.,  Ueber  den  mit  Hypertrophic  Verbundenen  progressiven  Mus- 
kelschwund,  Wiesbaden,  1886. 

*  Cowers,  Manual  of  Disorders  of  the  Nervous  System,  1888,  p.  395. 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  725 

cases  of  which  have  been  compiled  by  Fredreich,1  who  has 
also  added  one  of  his  own. 

The  duration  of  the  affection  in  the  cases  of  Wagner, 
Unverricht  and  Hepp,  was  so  short,  that  the  main  stumb- 
ling block  for  comparison  seems  to  lie  there.  In  one  case 
the  duration  of  two  and  a-half  years  is  also  short,  but  still 
it  is  a  step  towards  the  shortest  duration  of  authentic  cases 
of  progressive  muscular  atrophy  (8-10  years).  As  worthy 
of  note  is  the  fact  that  in  these  short  cases  death  has  gen- 
erally been  due  to  involvement  of  the  respiratory  muscles, 
as  it  was  also  the  cause  in  ours. 

Now  the  points  of  complete  similarity  may  be  mentioned. 

(1.)  There  was  in  our  case,  the  same  symmetrical  distri- 
bution of  affected  muscles  as  is  found  in  cases  of  primary 
progressive  muscular  atrophy. 

(2.)  The  degeneration  always  affected  single  muscles 
and  parts  of  muscles  (degeneration  individuelle),  and  not 
entire  muscular  masses  (atrophie  en  masse).  This  was  very 
characteristic  microscopically  ;  here  this  degeneration  indi- 
viduelle could  be  traced  down  to  the  single  bundles,  where 
single  fibres  in  each  bundle  were  always  seen  to  be  affected, 
and  not  the  entire  bundle. 

(3.)  Sensory  disorders  were  absent. 

(4.)  Reaction  of  degeneration  was  not  present. 

An  endeavor  to  class  the  case  among  any  of  the  so-called 
"types,"  taking  into  consideration  the  distribution  of  the 
atrophy,  would  be  entirely  fruitless, as  the  patient  died  so  soon 
after  the  onset  of  the  atrophy  that  the  possible  ultimate 
distribution  of  the  same  cannot  even  be  surmised.  Further- 
more, we  believe  that  the  lines  separating  the  various  known 
groups  are  entirely  too  tightly  drawn,  which  is  clearly 
shown  by  such  cases  as  Barsickow2  and  Zimmerlin.3 

1  Freidreich,  N.,  Ueber  Progressive  Muskelatrophie,  Berlin,  1873. 

iBarsicow,  Zwei  Familien  mit  Lipomatosis  muscular,  progress.  Diss.  Halle, 
1872.  In  one  of  these  families  the  affected  patients  generally  showed  involve- 
ment of  the  muscles  of  the  legs  and  back,  but  in  one  case  the  mu:cles  of  the  arms 
and  back  were  affected.  In  the  other  family  the  legs  alone  were  usually  affected, 
but  in  some  members  of  the  same  family  the  shoulder  muscles  became  affected 
first  and  then  the  muscles  of  the  legs  became  involved.  How  are  these  cases  to 
be  classified  ? 

3  Zimmerlin,  Mendel's  Centralblatt,  1885,  No.  3.  In  one  family,  two  cases 
of  juvenile  form  and  third  beginning  in  face,  with  pseudo-hypertrophy  ol  lower 
limbs. 


"J 26  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Microscopically  the  results  of  the  process  in  our  case  was 
seen  to  be  the  same  as  those  in  progressive  muscular  atro- 
phy, namely,  destruction  of  the  muscle  by  inflammation  as 
well  as  by  degenerative  processes.  While  last  year,  in  our 
paper  on  pseudo-hypertrophy,  we  took  occasion  to  express 
surprise  at  the  complete  similitude  between  the  results  of 
the  microscopical  examination  in  that  case  and  those  ob- 
tained by  Friedreich'  in  a  case  of  spinal  progressive  mus- 
cular atrophy,  we  this  year  must  call  attention  to  the  great 
analogy  presented  microscopically  by  our  case  of  a  year  ago, 
with  the  one  of  to-day.  Without  again  entering  upon  the 
details  of  either  case,  we  beg  to  note  the  following  quota- 
tions from  the  paper  on  Pseudo-hypertrophy.  "I  am  con- 
vinced that  in  my  patient  the  disease  is  essentially  a  chronic 
inflammation  invading  both  the  perimysium  and  the  muscle 
fibre  "  "I  may  here  say  that  I  cannot  agree  with  Gowers 
and  Buss,  that  the  proliferation  of  connective  tissue  is  the 
primary,  and  the  disease  of  the  muscular  tissue  is  the  sec- 
ondary process.  Either  the  reverse  of  this  is  true  or  the 
process  occurs  simultaneously  both  in  the  muscle  and  the 
perimysium."  :  These  citations  sufficiently  show  the  simi- 
larity of  the  findings  in  the  two  cases.  From  the  arguments 
here  adduced  we  can  come  to  no  other  conclusion  than  that 
in  this  case  of  polymyositis  progression  we  are  dealing  with 
a  form  of  primary  myopathy,  closely  allied  if  not  identical 
with  some  forms  of  primary  progressive  muscular  atrophy. 

The  following  paper  was  read: 
PROGRESSIVE    MUSCULAR    DYSTROPHIES:    THE 

RELATION    OF   THE    PRIMARY   FORMS   TO 
ONE  ANOTHER  AND  TO  TYPICAL  PRO- 
GRESSIVE MUSCULAR  ATROPHY. 

BY  B.  SACHS,  M  D. 
The  diseases  to  be  discussed  in  this  article  have  passed 
under  so  many  different  names  that  it  will  be  necessary,  first 
of  all,  to  state  what  shall,  and   what   shall   not,   be    under- 
stood   by   the    term    "Progressive    Muscular  Dystrophies." 

'  Friedreich,  Loc.  Clt.,  case  IC,  p.  37. 

*  Jacoby,  G.  1 1'..  Microscopical  studies  in  a  case  of  pseudohypertrophic 
paralysis,  Journal  of  Nervous  and  Mental  Disease,  Vol  xiv.,  1887,  Sept. ,  Oct. 

•  This  article,  with  full  refe  ences,  was  published  in  the  N.  Y.  Medical 
Journal,  December  8  and    15,  1888. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  J2J 

This  term  is  intended  to  designate  those  forms  of  dis- 
ease in  which  a  primary  progressive  wasting  of  some  or  all 

of  the  muscles  of  the  body  is  the  most  characteristic  feature, 
and  in  which  this  wasting  (atrophy)  may  or  may  not  be 
associated  with  true  or  pseudo-hypertrophy  of  some  mus- 
cles. These  primary  progressive  dystrophies  are  our  chief 
concern  ;  we  have  nothing-  to  do  with  muscular  atrophy 
following  cerebral,  myelitic,  or  peripheral  nerve  disease. 
One  form  of  disease,  however,  which  is  undoubtedly  due  to 
changes  in  the  spinal  cord  we  must  draw  into  the  discus- 
sion. I  refer  to  the  typical  progressive  muscular  atrophy. 
This  must,  in  fact,  be  the  basis  upon  which  our  discussion 
shall  proceed,  for  a  very  large  number  of  the  cases  and 
different  forms  of  disease  which  we  shall  have  to  consider, 
were  once  classed  under  this  term.  "Progressive  muscular 
atrophy"  was  for  many  years,  and  with  many  authors  still 
is,  a  mere  clinical  designation,  just  as  locomotor  ataxy  was 
a  mere  clinical  term  until  the  pathological  anatomy  of  the 
disease  was  established,  and  the  term  was  finally  restricted 
to  cases  of  tabes  dorsalis. 

Duchenne  distinguished  two  forms — progressive  muscu- 
lar atrophy  of  the  adult,  and  progressive  atrophy  of  infancy. 
The  latter  will  come  up  for  consideration  together  with  the 
new  type  of  muscular  atrophy  which  Landouzy  and  Dejerine 
have  described  and  advocated.  The  former  type  remains 
almost  in  all  particulars  as  Duchenne  described  it.  Modern 
authors,  including  Charcot,  Leyden,  Striimpell,  Hammond, 
Gowers,  and  others,  have  been  able  to  add  but  very  little  to 
Duchenne's  original  description.  The  chief  characteristics 
of  this  form  are  as  follows  : 

Progressive  Muscular  Atrophy  (type  Aran-Duchenne). — 
This  form  begins  in  a  large  majority  of  cases  with  an 
atrophy  and.  corresponding  weakness  in  the  small  muscles 
of  the  hand  (thenar  and  hypothenar).  The  atrophy  spreads 
from  muscle  to  muscle  ("atropine  individuelle ").  Begin- 
ning as  a  rule  with  the  adductor  pollicis  longus,  it  involves 
next  in  order  the  opponens  pollicis  and  deep  muscles  of  the 
thenar ;  from  these  it  extends  to  the  hypothenai,  the  inter- 
ossei,  the  flexors  and  extensors  in  the  forearm.     At  this 


"28  AMERICAN  NEUROLOGICAL  ASSOC IA  TION. 

stage  the  disease  may  remain  stationary  or  it  may  spread  to 
the  flexors  in  the  upper  arm,  to  the  deltoid,  possibly  the 
triceps,  and  finally  to  the  muscles  of  the  trunk,  the  shoul- 
ders, and  the  back.  Duchenne  recognized  the  fact  that  the 
atrophy  may  begin  in  exceptional  cases  in  the  trunk,  in  the 
shoulders,  or  in  the  legs.  Certain  it  is  that  in  those  cases 
in  which  the  atrophy  begins  in  the  hands,  the  legs  are  not 
affected  until  very  late  in  the  course  of  the  disease.  One 
marked  exception  to  this  rule  has  occurred  in  my  own  prac- 
tice in  the  case  of  a  woman  aged  40,  in  whom  the  atrophy 
attacked  almost  simultaneously  the  small  muscles  of  the 
thenar  and  the  anterior  muscles  of  the  thigh.  This  case 
had  all  the  other  symptoms  of  typical  progressive  muscular 
atrophy. 

The  atrophied  muscles  in  progressive  muscular  atrophy 
exhibit  fibrillar  contractions  and  for  a  long  time  retain 
their  faradic  contractility.  There  may  be  a  diminution  of 
faradaic  or  galvanic  excitability  proportionate  to  the  wast- 
ing of  some  muscles,  and  a  complete  or  partial  reaction  of 
degeneration  may  be  present  in  other  muscles.  The  march 
of  the  disease  is  steadily  progressive.  Heredity  is  a  strong 
factor  in  the  disease,  as  is  shown  by  the  remarkable  series 
of  cases  published  by  Naunyn  and  Eichhorst  in  the  Berliner 
klinischc  Wochcnschrift, and  by  the  account  of  the  Weathers- 
bee  family  given  in  the  later  editions  of  Hammond's  treatise, 
although  the  latter  cases  probably  belong  to  the  peroneal 
type  to  be  discussed  later  on.  Osier's  cases  also  give 
strong  proof  of  heredity. 

With  the  exception  of  the  factor  of  heredity,  all  the 
clinical  features  as  given  above  were  known  to  Duchenne. 
For  many  years,  too,  the  clinical  features  of  progressive 
muscular  atrophy  were  beyond  question.  All  discussions 
that  followed  related  to  the  question  whether  this  disease 
was  of  spinal  or  peripheral  origin.  Duchenne  first  regarded 
the  disease  as  of  peripheral  origin,  but  in  his  third  edition 
retracted  this  view,  convinced,  as  he  says,  by  the  patho- 
logical and  anatomical  facts  gathered  by  Charcot  and 
Joffroy,  Lockhart  Clarke,  Hayem,  and  others.  To 
Clarke,   and    above    all    to  Charcot  and  his  school,  we  owe 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  729 

the  advances  made  (in  the  years  i860  to  1870)  in  our  knowl- 
edge of  the  pathology  of  progressive  muscular  atrophy. 

The  main  changes  found  are  these  :  a  sclerotic  and  pig- 
mentary atrophy  of  the  ganglion  cells  of  the  anterior  horns  ; 
inflammatory  changes  in  the  neuroglia ;  increased  size  of 
the  blood-vessels,  and  proliferation  of  the  cellular  elements. 
In  fresh  preparations  granular  corpuscles  are  found,  and 
according  to  the  degree  and  stage  of  the  disease  the  ante- 
rior gray  cornua  are  reduced  in  all  diameters,  and  the  gan- 
glion cells  either  atrophied  or  entirely  lost.  The  anterior 
nerve  roots  are  affected  secondarily  to  the  lesion  of  the 
gray  substance.  The  nerve  fibres  are  not  all  destroyed,  a 
number  of  them  remaining  intact.  Those  that  are  destroyed 
exhibit  the  appearances  of  simple  atrophy — a  point  to 
which  Charcot  alludes  as  distinguishing  these  cases 
from  infantile  spinal  paralysis. 

The  theory  of  the  disease  was  and  is,  that  the  inflam- 
mation spreads  slowly  from  the  ganglion  cells  of  the  ante- 
rior horns  along  the  anterior  nerve  roots,  without  destroy- 
ing as  many  of  these  fibres  as  is  the  case  in  infantile 
poliomyelitis.  The  atrophic  changes  in  the  muscles  are, 
on  this  hypothesis,  the  direct  result  of  the  irritation  which 
begins  in  the  cells  of  the  anterior  horns  and  is  propagated 
thence  through  normal  or  only  half  wasted  nerve  roots  to 
the  peripheral  muscular  fibre. 

The  earlier  pathological  investigations  erred  in  various 
respects  ;  first  of  all  that  changes  in  the  spinal^cord  were 
not  noted,  the  white  columns  of  the  cord  were  not  care- 
fully examined  ;  in  consequence  of  this  inadvertence  in  the 
examination  of  pathological  specimens  and  on  account  of 
insufficient  clinical  description  many  cases  of  amyotrophic 
lateral  sclerosis  were  recorded  as  cases  of  progressive  mus- 
cular atrophy.  It  is  Charcot's  great  merit  to  have  done 
pioneer  work  in  this,  as  in  so  many  other  neurological 
problems.  In  France,  Charcot  succeeded  in  making 
his  tephro-  {polio-)  myelite  chronique  parenchymateuse  the 
anatomical  substratum  of  Duchenne's  progressive  muscular 
atrophy. 


~;0  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

From  this  time  onward,  German  investigators  play  a 
very  important  role  in  the  solution  of  the  problem  under 
discussion,  attacking  the  problem  both  from  the  patho- 
logical and  from  the-  clinical  standpoint.  Bamberger  and 
Recklinghausen  published  two  cases  of  Duchenne's 
atrophy  in  which  no  changes  could  be  found  in  the  spinal 
cord  post-mortem,  but  it  was  not  until  the  appearance  of 
Friedreich's  great  monograph  that  the  possible  periph- 
eral origin  of  progressive  muscular  atrophy  was  again 
pushed  into  the  foreground. 

Friedreich  claimed  that  the  changes  found  in  the  ante- 
rior nerve  roots  and  in  the  anterior  cornua,  in  cases  of 
progressive  muscular  atrophy,  were  secondary  changes, 
and  to  this  he  allowed  no  exception.  According  to  Fried- 
reich's views,  progressive  muscular  atrophy  is  a  primary 
chronic  myositis  which  is  followed  in  due  course  of  time  by 
secondary  changes  in  the  nervous  system.  The  inter- 
muscular nerve  filaments  are  the  first  to  he  affected,  and 
from  these  nerve  filaments  an  ascending  neuritis  travels 
along  the  peripheral  nerve  trunk  to  the  anterior  roots  of 
the  spinal  cord  segment ;  the  neuritis  of  these  anterior 
nerve  roots  may  spread  to  the  cord  and  here  set  up  chronic 
myelitic  changes  which  will  vary  greatly  in  degree  and 
distribution  ;  the  extent  and  character  of  the  changes  will, 
according  to  Friedreich,  depend  upon  the  extent  of  the 
muscular  affection.  The  changes  in  the  peripheral  nerve 
fibres  and  in  the  ganglion  cells  of  the  anterior  horns  are  the 
result  of  the  impaired  motor  functions  of  the  affected  mus- 
cles (op.  cit.,  p.  1 1 8  and  124). 

On  this  theory  alone,  Friedreich  insisted,  can  we  explain 
why  in  certain  cases  a  widespread  muscular  atrophy  is 
associated  with  changes  in  the  cervical  segment  only,  as  in 
the  cases  of  Dumenil,  of  Lockhart  Clarke  and  Gaird- 
ner,  in  the  cases  of  Clarke  and  Cooper,  Clarke  and 
Johnson,  and  others,  in  which  changes  were  found  in 
the  spinal  cord,  and  none  in  the  nerve  roots.  Friedreich 
claims  that  the  nerve  roots  were  not  properly  investigated  ; 
on  the  other  hand,  the  cases  of  Recklinghausen,  of  Fried- 
reich and   Cruveilhier,    of  Trousseau    and    his  own    cases 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  7 3  1 

(Nos.  4  and  21),  proved  to  him  that  changes  may  occur  in 
the  muscles  themselves,  or  in  the  nerve  trunks  and  anterior 
nerve  roots,  and  not  in  the  spinal  cord  ;  but  Charcot  (op. 
cit.,  p.  209,)  very  correctly  protests  that  all  these  cases 
upon  which  Friedreich's  proof  rested  were  examined  before 
the  present  successful  histological  methods  for  staining  the 
spinal  cord  had  come  into  vogue,  and  that  they,  therefore, 
prove  nothing. 

While  Friedreich's  judgment  unquestionably  erred  in 
regard  to  many  of  these  cases,  the  error  can  be  explained, 
since  many  of  the  cases  upon  which  he  based  his  views  are 
now  known  to  belong  to  other  forms  of  muscular  atrophy 
in  which  there  is  no  accompanying  change  in  the  spinal 
cord.  As  regards  typical  progressive  muscular  atrophy  the 
investigations  of  later  years  have  put  the  spinal  origin 
beyond  question,  although  as  Schultze  has  shown  in  his 
excellent  monograph  there  are  but  two  cases  of  Duchenne's 
atrophy  (cases  of  Pierret-Troissier  and  of  Strumpell 
in  which  the  anterior  gray  matter  was  the  only  part 
affected  and  alone  responsible  for  the  widespread  muscular 
atrophy.  To  this  last  we  might  add  the  case  of  Wood  and 
Dercum,  if  the  clinical  history  were  not  unsatisfactory. 
Schultze  arrives  at  his  conclusions  by  excluding  even  those 
cases  in  which  the  nuclei  of  the  medulla  had  become  invol- 
ved by  extension  of  the  process.  Without  wishing  to 
depart  from  the  subject  before  us,  I  may  intimate  that  these 
pathological  researches  prove  that  although  progressive 
muscular  atrophy  is  of  spinal  origin,  and  is  a  distinct  clin- 
ical entity,  it  is  not  necessarily  a  morbid  entity,  and  in 
most  cases  represents  an  early  stage  of  one  of  several 
spinal  cord  diseases. 

It  is  now  time  to  retrace  our  steps  and  note  the  develop- 
ment of  our  knowledge  regarding  pseudo-hypertrophic 
muscular  paralysis. 

The  history  of  this  form  can  be  related  in  few  words. 
The  clinical  features  as  laid  down  by  Duchenne,  Griesinger, 
Seidel,  and  others  have  been  universally  accepted.  These 
authors  and  all  who  followed  them  fastened  upon  the 
increase  in  the  size  of  some  muscles  as  the   characteristic 


732  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

symptom  of  the  disease,  and  have  largely  disregarded  the 
widespread  muscular  atrophy  which  is  present  in  many 
cases  of  pseudo-hypertrophy. 

The  earliest  cases  of  pseudo-hypertrophy  of  muscles 
were  described  by  Meryon  in  1.852.  Similar  cases  had 
been  described  by  Charles  Bell  in  1830,  but  were  not  valued 
at  their  true  worth,  and  Meryon  even  claimed  that  his 
cases  were  intimately  related  to  Cruveilhier's  (Aran- 
Duchenne's)  atrophy.  Oppenheim  in  1855  published  a 
thesis  at  Heidelberg  on  progressive  muscular  atrophy  in 
which  he  reported  a  number  of  cases  of  pseudo-hypertrophy, 
without,  however,  making  a  distinction  between  these  cases 
and  Duchenne's  type.  It  was  Duchenne  again  who,  in  a 
paper  (22)  published  in  1 861,  first  called  attention  to  the 
increase  in  the  volume  of  certain  muscles  as  the  important 
feature  in  the  disease,  and  in  his  "Electrisation  localisee" 
established  this  type  of  disease  for  all  times.  Since  that 
time  innumerable  cases  have  been  published,  enabling 
Gowers  in  1879  to  Dase  kis  studies  upon  a  series  of  220 
cases ;  some  of  these,  however,  evidently  belonging  to 
other  categories.  The  clinical  features  have  been  verified 
so  many  times  over  that  we  need  not  in  this  paper  analyze 
all  the  cases,  but  can  without  hesitation  present  the  general 
features  of  the  disease. 

Pseudo-Muscular  Hypertrophy,  or  pseudo-muscular  scle- 
rosis (Jaccoud),  atrophia  musculorum  lipomatosia  (Seidel) 
is  a  disease  of  early  youth,  the  vast  majority  of  cases 
beginning  before  the  age  of  six.  Boys  are  affected 
somewhat  more  frequently  than  girls,  and  there  is  good 
proof  of  heredity.  The  disease,  although  largely  affecting 
boys,  being  most  frequently  inherited  through  the  mother. 
Meryon's  cases  appeared  to  form  an  exception  (vide  Gow- 
ers, op.  cit.,  p.  24).  The  first  symptoms  are  a  weakness  in 
the  muscles  of  the  leg,  a  waddling  gait,  and  an  apparent 
increase  in  the  size  of  some  of  the  muscles  of  the  leg.  In 
many  cases  the  calves  only  are  hypertrophied,  in  others 
the  calves  and  thighs,  and  in  rarer  cases,  like  one  now 
under  my  observation,  the  disease  is  limited  to,  or  at  least 
begins  in,  the  thigh  muscles. 


AMERICAN  NEUROLOGICAL  ASSOCIA TION.  JT>Z 

Author  s  Case  I.:  {Pseudo-Hypertrophy). — A. K., aged  io; 
mother  has  six  children  ;  one  died  of  "brain  fever,"  and  one 
of  croup.  Four  living  ;  one  older  than  patient ;  all  healthy. 
No  history  of  heredity.  Patient,  a  stout  child,  a  newsboy, 
had  first  teeth  at  four  months  ;  when  one  year  old  began  to 
walk.  At  one  and  a  half  years  showed  weakness  and 
could  not  walk  alone,  was  provided  with  some  sort  of 
machine  with  which  he  learned  to  walk.  Was  treated  for 
rickets.  Youngest  sister  has  distinct  rickets  at  present. 
No  change  until  last  December,  when  parents  noticed  that 
he  was  getting  lamer.  Mother  states  that  thighs  were 
always  large  ;  had  difficulty  in  finding  trousers  that  would 
fit  the  boy  in  the  thighs.  Boy  could  never  walk  as  other 
children  did  and  could  never  run  after  others.  He  now 
complains  of  great  fatigue  and  when  walking  throws  him- 
self down  on  the  grass  from  mere  fatigue.  Examination 
shows  increase  of  volume  of  anterior  thigh  muscles  of  both 
sides,  most  marked  in  the  middle  portion  of  the  vasti. 
Calves  not  hypertrophied ;  no  other  atrophy  anywhere 
except  in  the  serratus  anticus  of  the  right  side.  Grasp  of 
both  hands  normal  ;  knee  jerks  present ;  all  electrical  re- 
actions normal.  With  the  assistance  of  Dr.  Peterson  I 
excised  two  pieces  of  muscle  from  the  left  vastus  externus, 
which  will  be  referred  to  in  a  later  section  of  this  paper. 
The  wound  healed  readily,  boy  complains  of  greater  weak- 
ness in  the  leg  from  which  pieces  of  muscle  were  removed. 

Duchenne  made  out  three  stages  of  the  disease.  In  the 
first,  difficulty  in  standing  and  walking,  and  weakness  of 
muscles  of  lower  extremities  and  of  sacro-lumbar  region. 
In  the  second  stage  the  hypertrophy  becomes  the  promi- 
nent feature,  spreading  to  various  muscles  of  the  body,  and 
in  the  third  stage  there  is  increased  feebleness  of  the  mus- 
cles of  upper  and  lower  extremity  of  the  trunk.  Other 
authors  recognize  a  weakening  of  the  sacro-lumbar  region 
and  in  a  general  way  a  weakness  of  the  upper  extremities, 
but  in  view  of  Erb's  recent  studies  it  is  due  to  Gowers  to 
state  that  he  called  attention  to  the  fact  that  in  many  cases 
of  pseudo-hypertrophy  the  "infraspinati  and   deltoids  are 


734  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

often  increased  in  size.  .  .  .  The  latissimus  dorsi  is 
commonly  much  wasted,  and  so  also  is  the  lower  (sterno- 
costal) portion  of  the  pectoralis  major.  .  .  .  The  fore- 
arm muscles  are  rarely  affected." 

To  complete  the  clinical  picture  we  must  in  addition 
refer  to  the  lumbar  lordosis  (probably  due  to  the  weakness 
of  the  extensors  of  the  hip),  to  the  occasional  presence  of 
contractures,  and  to  the  peculiar  difficulties  in  rising  from 
the  ground  (the  patient  climbing  up  upon  himself)  which 
are  present  in  some  cases,  but  not  necessarily  in  all,  and  to 
which  Gowers  attaches  too  much  importance  in  making  it 
the  cardinal  symptom  of  the  disease.  My  patient  has 
distinct  pseudo-hypertrophy,  but  rises  from  the  floor  with 
the  greatest  ease.  In  a  general  way  it  is  to  be  noted  that 
there  are  no  fibrillar  contractions  in  the  affected  muscles, 
no  changes  in  the  electrical  reaction,  except  diminished 
excitability  to  both  currents,  no  sensory  disturbances,  and 
the  patellar  reflex  rnay  or  may  not  be  present.  As  a  typi- 
cal example  of  pseudo-hypertrophy  and  for  some  special 
reasons  I  will  cite  the  following  case  now  under  my  obser- 
vation : 

Authors  Case  II. — M.K.,  girl,  aged  \2\  ;  mother  has  one 
other  child  living  and  healthy.  One  son  died  at  age  of  24  of 
meningitis.  Patient  first  seen  by  me  two  years  ago.  History 
showed  that  child  had  severe  fright  at  age  of  ten  months. 
Child  has  always  been  very  nervous  ;  learned  to  stand  and 
walk  at  usual  age,  but  had  diphtheria  at  age  of  four,  since 
when  the  disease  has  become  much  worse.  Legs  first  grew 
thin.  The  calves  increased  in  size  about  four  years  ago.  Child 
has  always  had  characteristic  difficulty  in  walking  and 
rising  from  the  floor.  Examination  shows  decided  weak- 
ness in  posterior  group  of  leg  and  thigh  muscles  ;  calf  and 
thigh  muscles  distinctly  hypertrophied.  Nerves  and  mus- 
cles of  lower  legs  react  well  to  faradic  current,  much  more 
readily  on  indirect  than  direct  excitation.  No  atrophies 
anywhere  in  the  body,  none  around  shoulder  girdle,  hands 
normal.  Child  has  difficulty  in  getting  upon  a  chair  and  in 
descending  comes  down  with  a  bound. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  735 

Thigh,  left,  13-^  inches;  right,  13^-  inches. 

Calves,  left,  10^  inches  ;  right,  lofe  inches. 

Examined  the  child  again  after  two  years  ;  found  condi- 
tion very  much  the  same.  Thighs,  left  side,  16  inches ; 
right,  15^-.  Calf,  left  side,  11  inches;  right,  10^,  showing 
that  the  growth  of  the  calf  muscles  has  not  kept  step  with 
the  growth  of  thigh  muscles.  Muscles  of  calf  and  anterior 
thigh  muscles  still  appear  large.  Resistance  to  passive 
movements  very  much  diminished,  particularly  in  extensors 
of  thighs.  Atrophy  of  sternal  portion  of  the  sterno-cleido- 
mastoid,  left  shoulder  stands  out  more  prominently  than 
right,  but  shows  no  hypertrophy.  All  arm  and  forearm 
thin,  distinct  atrophy  in  the  muscles  of  the  interosseous 
spaces,  grasp  very  weak,  right  18,  left  18.  In  walking,  both 
feet  assume  valgus  position.  Arms  are  in  marked  contrast 
to  legs.  Length  of  arms,  25  inches  ;  length  of  legs,  2& 
inches.  Electrical  examination :  All  muscles  respond 
promptly  to  faradic  current,  except  interossei  and  vasti  of 
both  sides,  which  require  very  strong  currents.  Galvanic 
response  diminished  in  interossei  and  in  muscles  of  thenar 
but  formula  not  altered. 

Having  agreed  to  accept  the  foregoing  description  and 
histories  as  typical  of  what  is  ordinarily  called  pseudo- 
muscular  hypertrophy,  we  must  now  devote  a  little  more 
attention  to  the  pathological  anatomy  of  the  disease.  Cases 
of  pseudo-hypertrophy  with  autopsies  are  relatively  few, 
and  for  that  reason  the  evidence  must  be  carefully  sifted. 

Middleton,  in  his  very  carefully  prepared  paper,  collect- 
ed seventeen  cases  of  pseudo-hypertrophies  with  autopsies; 
one  of  these  must  be  excluded  from  the  list  as  being  a  clear 
case  of  amyotrophic  lateral  sclerosis.  Schultze  (op.  cit  .,  p. 
36,)  has  added  to  this  list  the  two  cases  of  Middleton,  one 
by  Berger,  two  cases  described  by  Giinther,  one  by  Pick, 
and  one  by  Friedreich  (op.  cit.,  p.  347),  making  twenty- 
three  cases  in  all. 

Of  these  twenty-three  cases,  those  of  Friedreich,  Meryon 
(case  2),  Kesteven,  Baeg,  Brigidi,  Ross  (case  1),  and  of 
Giinther  must  be  excluded,  either  because  the  spinal  cord 


736  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

was  not  examined  microscopically  or  because  the  ex- 
amination was  not  properly  made.  Of  the  fifteen  remain- 
ing cases,  the  spinal  cord  and  anterior  nerve  roots  were 
found  absolutely  normal  in  ten,  and  in  five  others  the  changes 
that  were  found  could  not  be  held  responsible  for  the 
changes  in  the  muscles.  These  ten  cases  are  un- 
objectionable in  every  point ;  their  clinical  histories  are 
very  similar  in  every  respect  and  are  sufficient  proof  of  the 
fact  that  pseudo-hypertrophy  of  the  muscles  is  not  depend- 
ent upon  changes  in  the  spinal  cord. 

In  the  endeavor  to  increase  this  list,  I  have  carefully 
searched  for  earlier  cases  with  autopsies,  in  our  own  litera- 
ture in  particular,  which  might  have  escaped  Schultze's 
notice,  and  have  furthermore  endeavored  to  collect  cases 
which  have  appeared  since  the  publication  of  Schultze's 
monograph,  but  the  total  increase  is  not  great. 

First  of  all,  attention  should  be  directed  to  Gibney's 
case,  which  was  presented  to  the  American  Neurolog- 
ical Association  two  years  ago.  The  history  of  the  boy, 
aged  16  at  death,  who  had  been  under  observation  for  ten 
years,  is  a  typical  one  of  the  disease.  There  was  first  dis- 
tinct enlargement  of  the  calves,  followed  later  on  by 
atrophy.  A  brother  is  affected  in  the  same  way.  Dr. 
Amidon,  who  examined  the  cord,  reports:  "The  only 
lesion  appeared  to  be  in  the  ganglion  cells  of  the  anterior 
horns.  .  .  .  About  one-half  of  the  cells  seemed  to  have 
disappeared,  leaving  no  trace.  The  remaining  ones  are 
poorly  defined,  small,  and  in  many  instances  processless. 
Lesion  more  marked  in  the  dorsal  than  in  lumbar 
region." 

Through  the  kindness  of  Dr.  Amidon,  I  have  been  per- 
mitted to  re-examine  the  specimens,  and  I  hope  he  will 
permit  me  to  say  that  the  case  may  be  used  to  show  that 
there  are  no  serious  cord  changes  in  pseudohypertrophic 
paralysis.  Processless  ganglion  cells  mean  as  little  in  the 
spinal  cord  as  processless  pyramids  mean  in  the  cortex  ; 
and  a  diminution  in  the  relative  number  of  cells  in  any  one 
section  is  a  point  exceedingly  difficult  to  determine,  and,  if 
present,  is  more  apt  to  be  a  secondary  than  a  primary  affair. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  J^7 

I  hope  that  both  Drs.  Gibney  and  Amidon  will  agree  to  this 
view  of  their  case. 

The  only  other  cases  of  pseudo-hypertrophic  paralysis 
with  autopsies  which  I  have  been  able  to  find,  were  these  : 
Westphal  reported  the  cases  of  two  sisters,  both  affected 
with  pseudo-hypertrophy,  in  the  one  case  characterized  by 
unusual  increase  in  the  volume  of  many  muscles.  West- 
phal found  no  changes  whatever  either  in  the  cord  or  in  the 
peripheral  nerves.  Coming  from  so  distinguished  an  author, 
these  facts  deserve  the  greatest  consideration. 

Middleton  has  described  another  interesting  case 
with  enormous  pseudo-hypertrophy  and  a  wide-spread 
atrophy,  including  even  the  masseters  ;  but  the  cord  did 
not  harden  well,  and  a  microscopical  examination  could  not 
be  made.  The  case  is,  therefore,  useless  for  our  present 
purposes. 

Further  autopsies  on  typical  cases  of  pseudo-hypertrophy 
are  extremely  desirable  ;  but  Westphals  cases,  together 
with  the  others  analyzed  above,  place  the  non-spinal  origin 
of  pseudo-hypertrophy  beyond  question. 

These  facts  do  not  appear  to  be  properly  appreciated  as 
yet,  for  we  find  that  Dr.  Inglis  very  recently  reports 
several  cases  of  pseudo-hypertrophy,  and  assuming  that  all 
pathologico-anatomical  facts  point  to  the  spinal  cord  as  the 
seat  of  the  disease,  Dr.  Inglis  gets  over  the  discomforting 
negative  facts  by  stating  that  "  the  cases  in  which  the  post- 
mortem examination  shows  the  cord  visibly  intact  do  not 
invalidate  this  idea  (the  spinal  origin  of  pseudo-hypertro- 
phy) ;  and  that  the  defect  in  the  distal  ends  of  the  motor 
fibres,  while  not  in  every  case  accompanied  by  atrophy  of 
the  central  cells,  is  yet  the  indication  of  an  impaired  activ- 
ity of  those  cells." 

It  is  more  surprising  still  to  find  Hammond  disre- 
garding the  evidence  of  the  last  ten  years,  and  adhering  to 
the  spinal  theory  of  pseudo-hypertrophic  paralysis,  and 
even  going  so  far  as  to  entitle  the  disease  "  pseudo-hyper- 
trophic spinal  paralysis."  Hammond's  conclusions  are 
based  on  cases  of  Barth  (40),  Miiller,  and  Lockhart 
Clarke.       Barth's     case    is     one     of    amyotrophic    lateral 


7  58  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

sclerosis  ;  Muller's  case  was  complicated  by  cerebral  dis- 
ease, and  therefore  useless  for  the  determination  of  the 
anatomical  lesion  ;  while  Lockhart  Clark's  case  showed 
changes  which  are  not  primary,  and  which  Gowers,  whose 
case  this  was,  acknowledged  (in  the  Lancet  for  1879)  to  have 
been  possibly  due  to  the  paralysis  of  long  standing  and  to 
the  frequent  pulmonary  troubles. 

At  this  stage  of  our  studies  let  us  note  that  careful  clini- 
cal investigation  and  post-mortem  examinations  have 
shown,  among  other  facts,  that  a  wide-spread  atrophy  is 
common  to  progressive  muscular  atrophy,  type  Aran- 
Duchenne,  and  pseudo-hypertrophy  ;  but  that  the  absence 
of  all  changes  in  the  central  nervous  system,  the  absence 
of  fibrillar  contractions,  and  the  absence  of  reaction  of  de- 
generation, in  cases  of  pseudo-hypertrophy,  separate  it 
widely  from  the  former  disease.  Later  on  we  shall  see  that 
a  very  intimate  relation  exists,  however,  between  pseudo- 
hypertrophy and  certain  other  forms  of  muscular  dystrophy 
which  were  formerly  included  under  the  general  heading  of 
Progressive  Muscular  Atrophy. 

The  process  of  distinguishing  these  forms  from  progres- 
sive muscular  atrophy  was  of  slow  development,  and  with 
the  steps  of  this  process  we  shall  become  best  acquainted 
by  alluding  to  a  few  excellent  articles  published  between 
the  years  187c  and  1880. 

Lichtheim  was  one  of  the  first  to  take  up  the  cud- 
gels for  Friedreich's  theory  of  progressive  muscular  atrophy. 
In  1878  he  published  a  paper  on  a  case  of  "Progressive 
Muscular  Atrophy  without  Disease  of  the  Ganglion  Cells  of 
the  Anterior  Horns." 

This  case  cf  Lichtheim  was  followed  up  by  one  of  Erb 
and  Schultze  ind  one  of  Kahler.  The  former  authors 
endeavored  to  disprove  Lichtheim's  case  by  a  case 
of  typical  progressive  muscular  atrophy  with  changes  in 
the  cord.  ErL's  criticisms  were  quite  severe,  but  they  have 
lost  all  of  their  force  since  Schultze  showed  in  later  years 
that  the  changes  which  he  and  Erb  found  were  not  sufficient 
to  account  for  the  muscular  changes,  the  cells  that  were 
atrophied  being  now  known  to  be  in  no  physiological   con- 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  739 

nection  with  the  muscles  that  were  atrophied  ;  and,  further- 
more, Erb  has  since  decided  that  Lichtheinvs  case,  though 
a  very  important  one,  belongs  to  the  type  which  Erb  (34) 
first  described  a  few  years  later.  And  to  this  most  impor- 
tant class  of  cases  we  must  now  devote  our  attention. 

Erb"s  Juvenile  Form. — Erb  described  this  new  form  of 
disease  in  his  "  Elektrotherapie,"  but  sufficient  attention 
was  not  paid  to  this  juvenile  form  until  Erb  again  called 
attention  to  it  in  a  lengthy  article  on  the  subject  published 
in  1884. 

The  following  is  a  typical  case  of  Erb's  juvenile  form, 
the  history  of  which  will  bring  out  clearly  enough  the  differ- 
ences of  this  form  and  typical  progressive  muscular  atrophy. 

Erb's  Case  I. — Male,  aged  46.  No  hereditary  history, 
no  syphilis  ;  several  acute  diseases  in  childhood.  ■  At  the 
age  of  15  noticed  that  the  right  arm  was  weaker  and  thinner 
than  the  left.  No  pains  or  paraesthesiae.  Trouble  did  not 
grow  worse  until  about  the  age  of  40 ;  at  that  time  the 
legs  and  left  arm  became  involved ;  no  sensory,  vesical,  or 
sexual  disturbances. 

Examination  revealed  changes  in  the  following  mus- 
cles : 

Wasted :  Both  pectoralis  major  and  minor,  both  trapezii, 
latissimus  dorsi,  serrati  ant.  maj.,  rhomboids  with  exception 
of  upper  portion  of  right  rhomboid  superior,  both  sacro- 
lumbal and  longissimus  dorsi,  deep  neck  muscles,  levator 
anguli  scapulas  right  >  left,  brachialis  anticus  right  >  left, 
supinator  longis  (both  sides),  triceps  right  >  left,  gluteal 
muscles  right  >  left,  iliopsoas  right  >  left,  quadriceps,  ten- 
sor fasciae  ;  anterior  leg  muscles  weak  with  exception  of 
tibialis  anticus ;  abdominal  muscles,  diaphragm  paretic. 

Normal :  Sterno-cleido-mastoid,  levator  anguli  scapulae, 
dexter,  coraco-brachialis,  flexors  and  extensors  of  forearm, 
thenar  and  hypothenar,  adductors,  flexors  of  leg,  calf  mus- 
cles, small  muscles  of  foot. 

Hypertrophied :  Deltoid  left  >  right,  infraspinati  mus- 
cles, both  teretes. 

Not  ataxia  ;  patellar  reflex  present ;  no  fibrillar  contrac- 
tions ;  diminished  electrical  excitability  of  muscles,  but  no 
trace  of  reaction  of  degeneration. 


74-0  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

The  other  cases  of  Erb  resemble  this  one  in  even- 
respect,  except  that  in  at  least  one  of  his  patients  a  later 
examination  revealed  an  incipient  hypertrophy  of  the 
calves. 

Erb  has  taken  the  trouble  to  hunt  through  the  older 
literature  and  proves  very  conclusively  that  similar  cases 
have  been  described  by  Aran,  Duchenne,  Friedreich,  Ross, 
and  others,  either  as  cases  of  progressive  muscular  atrophy 
or  of  pseudo-hypertrophy.  Erb  thus  summarizes  the  chief 
features  of  this  juvenile  form  :  It  is  a  progressive  wasting 
with  weakness  of  certain  groups  of  muscles,  beginning 
either  in  childhood  or  early  youth,  involving  as  a  rule  the 
muscles  of  the  shoulder  girdle,  the  upper  arm,  the  pelvic 
girdle,  the  thigh  and  the  back  ;  the  forearm  and  leg  mus- 
cles remaining  intact  for  a  very  long  time.  The  atrophy 
may  be  associated  with  true  or  pseudo-hypertrophy  of 
some  muscles.  Fibrillar  contractions  and  reaction  of  de- 
generation are  never  present.  No  sensory  or  visceral  dis- 
turbances. He  adds  that  the  wasting  is  distributed  in  a 
typical  manner.  The  pectorals,  trapezii,  latissimi  dorsi, 
the  serrati,  the  rhomboids,  as  well  as  most  of  the  upper  arm 
muscles  and  supinators  are  apt  to  be  wasted,  while  the  del- 
toids, supra  and  infra-spinati  are  either  normal  for  a  long 
time  or  hypertrophied.  The  preservation,  furthermore,  of 
the  hand  and  forearm  muscles  give  a  very  striking  clinical 
picture. 

This  disease  Erb  has  chosen  to  call  the  juvenile  form  of 
progressive  muscular  atrophy — a  very  unfortunate  term, 
since  many  of  the  cases  exhibited  no  symptoms  until  the 
patient  was  well  advanced  in  years,  and  others  again  began 
in  early  infancy.  Erb's  description  has  been  accepted  by 
Nothnagel,  Schultze,  Charcot,  Eulenburg,  Remak,  Gowers, 
and  many  others. 

Upon  the  exact  distribution  of  the  atrophy  and  hyper- 
trophy as  demonstrated  by  his  cases,  Erb  lays  the  very 
greatest  stress.  According  to  his  view,  well-preserved 
forearms,  atrophied  upper  arms,  hypertrophied  deltoids,  and 
efficient  scapular  muscles  would  be  almost  sufficient  for  a 
diagnosis  of  his  special  form.     In  the  lower  legs   an   almost 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  74 1 

analogous  wasting  occurs  :  thighs  and  glutei  well  wasted, 
while  leg  muscles  and  calves  are  well  preserved. 

The  question  arises,  whether  Erb  did  not  attach  too 
much  importance  to  this  exact  topographical  distribution 
of  muscular  atrophy  and  hypertrophy.  He  claims  perfect 
identity  between  his  juvenile  form  and  pseudo-hypertrophy  ; 
page  518  he  says  :  "  If  this  disease  occurs  in  earliest  child- 
hood and  is  not  associated  with  any  considerable  lipoma- 
tosis, the  disease  is  what  has  been  termed  hereditary  mus- 
cular atrophy.  If  it  happened  to  be  associated  with  early 
developed  and  excessive  lipomatosis,  particularly  in  the 
lower  extremities,  it  is  synonymous  with  so-called  pseudo- 
hypertrophy." "But  all  of  these  forms  are  identical  with 
one  another  and  merely  represent  different  manifestations, 
different  march  of  the  disease  (Verlaufsweisen)  and  varying 
degrees  of  intensity  of  the  same  disease." 

The  relation  to  hereditary  muscular  atrophy  I  will  dis- 
cuss later  on,  but  as  for  its  relationship  to  pseudo-hyper- 
trophy, is  it  not  curious  that  Erb's  form  is  so  far  less 
frequent  than  the  ordinary  pseudo-hypertrophy  ?  To  be 
sure,  this  might  be  explained  in  a  number  of  different  ways. 
First,  the  accuracy  of  description  has  been  at  fault  in  many 
cases.  Most  authors  have  had  the  hypertrophy,  and  that 
only,  in  mind,  and  have  not,  with  the  exception  of  Fried- 
reich and  Gowers,  paid  much  attention  to  the  atrophy  in 
the  upper  extremities  ;  and  if  detected,  most  authors  have 
described  the  atrophy  so  poorly  that  a  clinical  picture  such 
as  Erb  discovered  cannot  be  made  out  from  their  descrip- 
tion. This  is  true  not  only  of  older  writers,  but  also  of 
those  that  have  written  since  the  appearance  of  Erb's  paper. 
x  have  analyzed  all  recent  cases  of  pseudo-hypertrophy  for 
the  purposes  of  clinical  differentiation,  but  in  the  fewest 
cases  have  even  the  functional  motor  disturbances  been 
stated  with  sufficient  clearness  to  permit  an  inference  as  to 
the  wasting  of  certain  muscles,  and  definite  statements  with 
regard  to  the  atrophy  of  this  or  that  muscle  are  entirely 
wanting  in  the  majority  of  cases.  I  wish  incidentally  to 
remark  that  every  case  of  pseudo-hypertrophy  should  be 
examined  with  the  greatest  care  regarding  the  condition  of 


742  AMERICAN  NEUROLOGICAL  ASSOCIATION,. 

the  upper  extremities  and  the  smallest  amount  of  atrophy 
or  hypertrophy  of  any  muscle  should  be  distinctly  noted.  I 
have  found  a  slight  change  in  the  faradic  response  of  sym- 
metrical muscles  a  valuable  hint  in  getting  at  an  incipient 
wasting  with  corresponding  paresis.  Such  a  condition 
would,  in  at  least  one  case,  have  escaped  my  notice  if  I  had 
not  examined  both  pectorals  and  had  found  that  the  one 
gave  a  much  more  lively  response  to  the  faradic  current 
than  the  other  did. 

And  yet,  allowing  for  all  these  possible  errors,  an  exam- 
ination of  American  cases,  for  instance,  has  convinced  me 
that  Erb's  juvenile  form  is  very  much  rarer  in  this  country 
than  typical  speudo-hypertrophy  is.  In  England,  Ormerod 
Ross  and  Dreschfeld  are  the  only  ones  who  have 
described  cases  resembling  Erb's  form,  and  Ormerod's 
case  contains  several  atypical  features.  In  this  country 
none  have  to  my  knowledge  been  published  as  cases  of 
Erb's  juvenile  form,  though  as  Seguin  has  pointed  out  Mas- 
tin's  cases  of  hereditary  ataxia  may  be  cases  of  Erb's  form. 
I  have  not  been  able  to  get  at  the  original  paper  of  Mastin. 

During  the  past  two  years  I  have  waited  patiently  for  an 
example  of  Erb's  form  to  turn  up,  without,  however,  meet- 
ing with  a  single  one.  This  disease  may  be  as  much  less 
frequent  in  America,  as  the  Landouzy  and  Dejerine  type  is 
less  frequent  in  Germany  than  it  is  in  France.  Further- 
more, the  thought  naturally  occurs  to  one  that  Erb's  special 
form  may  represent  in  many  instances  a  late  stage  of 
pseudo-hypertrophy,  and  that  the  majority  of  cases  of  this 
disease  dying  at  an  early  age  never  reach  this  stage.  And 
yet  we  must  not  forget  that  Erb  has  described  several 
cases  of  his  typical  form  beginning  at  a  very  early  age  ; 
and,  on  the  other  hand  again,  we  well  know  that  cases  of 
typical  pseudo-hypertrophy  may  be  associated  with  atrophy 
in  the  upper  extremity,  without  this  atrophy  assuming 
Erb's  characteristic  distribution,  as  proved  by  my  own  case 
M.  K.    cited  above. 

In  view  of  such  cases  as  this  one  and  the  reasoning 
followed  above,  it  seems  to  me  that  the  topographical  dis- 
tribution of  the  atrophy  or  hypertrophy  cannot  be  depended 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  743 

upon  to  prove  the  close  relationship  between  pseudo- 
hypertrophy and  the  juvenile  form.  And  that  for  the 
present  pseudo-hypertrophy  deserves  the  rank  of  a  special 
form.  Their  relationship  seems  to  me,  however,  to  rest 
upon  several  cardinal  symptoms. 

First.  Upon  a  progressive  wasting  beginning  in  early 
life  associated  with  hypertrophy  at  any  time  during  the 
course  of  the  disease. 

Second.  Upon  the  entire  absence  of  fibrillar  contrac- 
tions. 

Third.  Upon  the  absence  of  the  reaction  of  degenera- 
tion. 

Fourth.  Upon  the  absence  of  changes  in  the  spinal 
cord,  the  autopsy  in  Lichtheim's  case  going  to  prove 
this  last  statement. 

Fifth.  Upon  the  occurrence  of  both  forms  in  various 
members  of  a  single  family. 

These  cardinal  symptoms  several  other  forms  of  mus- 
cular atrophy  have  in  common  with  the  two  forms  just 
discussed. 

We  have  now  to  turn  our  attention  to  another  type,  to 
the  so-called  hereditary  form  of  progressive  muscular 
atrophy.  This  type  was  created  by  Leyden  and 
warmly  advocated  by  Moebius.  According  to  Leyden 
this  form  is  characterized  as  follows : 

The  Hereditary  form  of  progressive  muscular  atrophy 
attacks  several  members  of  the  same  family.  It  appears  at 
an  early  age,  as  a  rule  between  the  eighth  and  tenth  year, 
in  one  case  not  before  thirty.  Males  are  more  apt  to  be 
attacked  than  females  (the  elder  Eulenburg,  however,  de- 
scribed the  affection  in  three  sisters  of  one  family).  The 
disease  begins  invariably  with  weakness  in  the  back  and 
lower  extremities  and  in  these  regions  a  wasting  of  the 
muscles  is  first  observed.  After  a  lapse  of  years  the  mus- 
cles of  the  upper  extremities  may  be  involved.  Occasion- 
ally the  patient  may  attain  to  an  old  age.  Atrophy  may 
become  so  extreme  that  the  patients  are  absolutely  help- 
less. The  march  of  the  disease  is  steadily  progressive. 
Electrical  reactions  normal ;  no  fibrillar  contractions.    The 


744  AMERICAS'  NEUROLOGICAL  ASSOCIATION. 

atrophy  is  associated  with  hypertrophy,  particularly  of  calf 
muscles.  No  sensory  disturbances,  no  disturbance  of 
speech,  of  deglutition  or  ocular  movements. 

Leyden  records  the  case  of  a  man  thirty-seven  years  of 
age,  who  had  trouble  in  walking  from  early  childhood  on, 
and  who  had  decided  atrophy  of  back  and  thigh  muscles, 
with  vast  increase  of  calf  muscles,  without  any  involvement 
of  shoulder  and  arm  muscles.  The  general  symptoms  were 
of  the  kind  stated  above.  Leyden  counted  among  this 
class  of  cases  a  well-known  one  of  Meryon,  the  cases 
of  Oppenheimer,  Hemptenmacher,  of  Bernhardtand  of  Eich- 
horst;  but  all  of  these  cases  have  been  considered  by  most 
other  and  later  authors  to  belong  to  the  type  of  pseudo- 
hypertrophy. Leyden  has  been  followed  by  Moebius,  by 
Zimmerlin,  by  Landouzy  and  Dejerine,  by  Schultze,  and 
others,  in  the  description  of  this  type  ;  but  of  these  Moe- 
bius and  the  French  authors  alone  can  be  said  to  be 
advocates  of  this  special  form. 

In  my  opinion,  there  is  not  sufficient  reason  to  create  a 
separate  type  of  disease  on  the  points  laid  down  by  Leyden. 
First,  all  iorms  of  muscular  atrophy  may  be  and  often  are 
hereditary.  This  is  particularly  true  of  pseudo-hypertrophy. 
Second,  cases  with  distinct  heredity  often  start  in  the  upper 
extremities,  and,  third,  all  cases  beginning  with  weakness 
and  atrophy  in  the  back  and  leg  muscles  are  not  neces- 
sarily hereditary,  as  we  shall  see  when  we  come  to  the  con- 
sideration of  the  peroneal  type  of  progressive  muscular 
atrophy. 

As  regards  the  first  point,  in  the  cases  of  Oppenheim, 
Freidreich,  and  Hemptenmacher,  the  disease  began  in  the 
muscles  of  the  back,  but  spread  to  the  upper  extremities 
instead  of  the  lower.  Barsikow  has  described  a  num- 
ber of  cases  occurring  in  two  families.  In  the  members  of 
one  family  the  disease  attacked  the  back  and  leg  muscles, 
in  the  other  family  the  spreading  of  the  atrophy  was  not 
uniform,  attacking  the  leg  muscle  in  one  member  and  in 
another  the  shoulder  first  and  then  the  leg  muscles. 

Zimmerlin  (loc.  cit.)  published  seven  cases,  four  in  one 
family    and     three     in   another.       In   one   family    the    four 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  745 

cases  are  distinctly  of  the  juvenile  type,  while  in  the  second 
family  the  two  cases  began  in  the  upper  extremities,  leav- 
ing the  legs  intact,  while  in  the  third  case  there  was 
involvement  of  upper  and  lower  extremities  and  even 
involvement  of  face  muscles — an  approach  to  the  type 
Landouzy-Dejerine. 

Schultze  (loc.  cit.)  describes  the  cases  of  two  brothers, 
one  affected  with  typical  pseudo-hypertrophy,  and  the 
other  with  a  general  wasting  of  the  upper  and  lower  ex- 
tremities. In  this  country,  Harrington  has  reported 
seven  cases,  in  which  the  onset  was  in  the  legs  in  some,  in 
others  in  the  legs  and  arms  simultaneously,  and  in  still  others 
the  legs  were  affected  first,  and  only  a  year  later  the  arms. 
Ormerod's  cases  of  muscular  atrophy  in  three  children  after 
measles,  might  be  used  to  show  the  same  differences  in  the 
mode  of  onset. 

We  have  therefore  good  reason  for  insisting  that  Ley- 
den's  hereditary  form  is  not  entitled  to  rank  as  a  special 
type  of  progressive  muscular  atrophy ;  that  pseudo-hyper- 
trophy and  Erb's  juvenile  form  are  distinctly  hereditary, 
and  furthermore  that  cases  with  a  distinct  heredity  are  by  no 
means  necessarily  characterized  by  an  atrophy  first  attack- 
ing the  muscles  of  the  back  and  thighs.  All  of  Leyden's 
cases  would  properly  come  under  the  head  of  pseudo- 
hypertrophy or  of  Erb's  juvenile  form,  and  the  peroneal 
type. 

The  next  type  of  progressive  muscular  atrophy,  the  type 
fascio-scapulo-humeral,  type  Landouzy-Dejerine,  the  infan- 
tile progressive  muscular  atrophy  of  Duchenne,  cannot  be 
disposed  of  so  easily. 

Cases  of  progressive  muscular  wasting  with  involvement 
of  face  muscles,  have  always  been  considered  rare.  Du- 
chenne described  several,  Remak  Mossdorf,  Bernhardt, 
Kreske,  and  Westphal,  have  each  described  one  or  two 
cases ;  but  Landouzy  and  Dejerine  (loc.  cit.)  have  suc- 
ceeded in  calling  renewed  attention  to  this  form,  have 
made  the  most  careful  examinations,  and  have  obtained 
a  post-mortem  examination  in  one  case.  For  this  reason 
it  is  just  to  refer  to  the  features  of  this  type  as  laid  down 


746  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

by    Landouzy  and    Dejerine,    who  have  seen  more   cases 
than  all  other  recent  authors  taken  together. 

The  Type  Landouzy  Dejerine. — This  form  of  progressive 
muscular  wasting  begins,  as  a  rule,  in  early  life,  and  in  the 
majority  of  cases  in  the  muscles  of  the  face,  giving  rise  to 
what  the  authors  term  the  "fades  myopatJiique"  The  lips 
are  considerably  thickened,  and  constitute  the  "  bouche  de 
tapir T  Great  stress  is  laid  upon  this  tapir-mouth  appear- 
ance. Later  on  in  the  course  of  the  disease  the  atrophy 
spreads  to  :he  shoulder  and  arm  muscles;  the  supra  and 
infra  spinati,  the  subscapularis,  the  flexors  of  the  hand  and 
fingers  remain  normal.  The  muscles  of  deglutition,  masti- 
cation, and  respiratory  and  laryngeal  muscles,  as  well  as 
the  ocular  muscles,  remain  normal.  In  exceptional  cases 
the  disease  may  begin  in  the  shoulder  or  arm  muscles  or 
even  in  the  lower  extremities.  The  disease  is  distinctly 
hereditary.  Fibrillar  contractions  and  reaction  of  degener- 
ation are  never  present. 

In  their  first  paper,  Landouzy  and  Dejerine  published 
cases  occurring  in  two  different  families  ;  in  the  first  the 
disease  could  be  followed  up  through  five  generations. 
Cases  that  are  described  relate  to  a  father  and  four  sons, 
five  other  children  not  having  been  affected.  The  history 
of  one  son  is  characteristic. 

The  trouble  began  at  the  age  of  three  with  atrophy  of 
face  muscles  ;  no  other  symptoms  observed  up  to  the  age 
of  17.  From  that  time  on,  atrophy  was  noticed  in  the  mus- 
cles of  the  shoulder  and  arm,  spreading  to  the  trunk.  At 
the  age  of  21,  atrophy  had  become  extreme — "nothing  but 
skin  and  ^one  " — -facies  myopathique  and  bouehe  de  tapir. 
Sensation  normal,  sphincters  also,  patellar  reflex  lost,  elec- 
trical excitability  diminished  in  proportion  to  the  wasting, 
but  no  reaction  of  degeneration.  At  the  age  of  24,  death 
of  phthisis. 

Autopsy. — Atrophy  determined  as  follows:  frontalis, 
orbicularis  palpebrarum,  zygomatici,  orbicularis  oris,  and 
buccinator  of  both  sides  (levator  anguli  oris  normal), 
trapezius,  deltoid  (infra  and  supra  spinati,  subscapularis, 
teres  major  and  minor  normal)  biceps,  brachialis  internus, 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  747 

and  coraco-brachialis,  triceps,  supinator  longus  and  exten- 
sor radialis  (supinator  brevis,  flexor  digitorum  sublimis  et 
profundus  normal),  extensor  pollicis  longus  and  extensor 
indicis  (extensor  digitorum  communis,  extensor  digiti  minimi, 
extensor  ulnaris  normal),  abductor  longus  and  extensor 
pollicis  brevis  slightly  wasted,  abductor  brevis  pollicis 
wasted,  other  thenar  and  hypothenar  muscles  normal. 
Lumbricalis  distinctly  wasted  and  interossei  slightly  wasted, 
pectorals  wasted,  serrati  and  sacro-lumbar  normal.  Lower 
extremities  not  so  carefully  examined  ;  glutei  were  atro- 
phic ;  no  marked  lipomatosis  anywhere  ;  no  changes  in  the 
nervous  system.  Diseased  muscles  revealed  simple  atrophy 
of  primitive  muscular  fibres  ;  slight  traces  of  increase  of 
interstitial  connective  tissue  and  of  fat.  No  increase  in 
muscular  nuclei. 

The  histories  of  the  cases  of  Remak  and  of  the  other 
authors  quoted  are  very  similar.  In  some  the  atrophy  set 
in  in  the  extremities  first,  and  in  the  face  later  on.  In  Re- 
mak's  case  both  sides  of  the  face  were  involved  ;  in  Kreske's 
the  one  side  only. 

The  similarity  between  this  form  and  Erb's  will  be  ap- 
parent to  every  one  at  a  glance  ;  it  is  practically  Erb's  form 
plus  involvement  of  face  muscles.  Erb  never  observed  this 
complication  in  his  own  cases,  and  Landouzy  and  Dejerine 
argue  that  their  cases  are  different  on  account  of  the  ab- 
sence of  lipomatosis  and  the  presence  of  facial  symptoms. 
As  for  Erb  never  having  observed  the  facial  atrophy  in 
any  of  his  cases,  it  is  worth  noting  that  in  a  later  paper 
Landouzy  and  Dejerine  publish  a  case  (No.  6)  of  their  form 
in  which  the  face  muscles  appeared  normal  during  life,  but 
on  post-mortem  examination  revealed  decided  morbid 
changes.  It  is  possible,  therefore,  that  the  changes  were 
present  in  some  of  Erb's  cases  without  so  excellent  an 
observer  as  he  being  able  to  detect  them.  If  this  is  allowed 
(and  the  French  authors  themselves  admit  the  possibility  of 
this),  there  is  no  just  reason  for  making  a  separate  type  for 
such  cases  as  they  describe.  They  deny  the  resemblance 
between  the  two  forms  in  consequence  also  of  the  invari- 
able absence  of  lipomatosis  ;  but  Westphal  again  seems  to 


748  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

have  found  a  decisive  case  which  shows  that  the  face  mus- 
cles may  be  associated  with  typical  pseudo-hypertrophy, 
and  it  must  be  remembered  that  Landouzy  and  Dejerine 
grant  that  they  have  found  hypertrophied  fibres  in  some  of 
the  muscles.  We  cannot,  therefore,  see  the  propriety  of 
creating  a  separate  type  such  as  Landouzy  and  Dejerine 
have  described.  There  is  a  slight  difference  between  their 
cases  and  those  of  Erb  in  the  topographical  distribution  of 
the  atrophy,  and  even  this  is  doubtful  ;  while  their  cases 
resemble  Erb's  form  in  the  involvement  of  the  upper  arm 
and  shoulder  muscles  chiefly,  in  the  presence  of  hereditary 
influences,  in  the  absence  of  fibrillar  contractions,  and  ab- 
sence of  reaction  of  degeneration. 

I  wish,  however,  to  enter  a  special  plea  for  the  recog- 
nition of  still  another  type — the  peroneal  type  of  progressive 
muscular  atrophy. 

This  form  was  first  described  by  Charcot  and  Marie 
and,  independently  of  them,  by  Dr.  Tooth,  of  England, 
in  a  Cambridge  thesis.  Charcot  and  his  associate  reported 
five  such  cases,  Tooth  four  cases,  and  Herringham  has 
recently  reported  one  case  in  a  family  in  which  various 
members  in  successive  generations  have  been  similarly 
affected.  To  this  list  I  am  able  to  add  one  case  of  consid- 
erable interest,  and  similar  cases,  although  not  designated 
by  this  title,  have  been  described  by  Hammond  (Weathers- 
bee  ail),  by  Ormerod,  by  Schultze,  and  no  doubt  some 
other  of  the  cases  of  hereditary  muscular  atrophy  would 
more  properly  belong  to  this  class. 

This  special  form  of  progressive  muscular  atrophy  be- 
gins in  early  youth,  or  may,  as  in  one  of  Charcot's  cases, 
attack  a  person  beyond  the  age  of  puberty.  It  shows  dis- 
tinct family  inheritance.  According  to  Herringham,  as  a 
rule,  boys  inherit  the  disease  through  the  mother,  as  has 
been  shown  to  be  the  rule  in  cases  of  pseudo-hypertrophy. 
The  atrophy  begins  in  the  lower  extremities,  first  attacking 
the  extensor  hallucis  longus,  then  the  common  extensors 
of  the  toes,  and  then  the  peronei ;  the  small  muscles  of  the 
foot  may  be  affected  as  well.  The  calf  muscles  atrophy  a 
a  little  later,  while  the   muscles  of  the  thighs  offer  greater 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  J 49 

resistance  and  do  not  undergo  atrophy  until  the  disease  has 
well  run  its  course.  Several  years  after  the  onset  of  the 
disease  in  the  legs,  the  hands  become  involved  ;  the  inter- 
ossei,  the  muscles  of  the  thenar  and  hypothenar,  as  well  as 
the  muscles  of  the  forearm  become  wasted;  the  muscles  of 
the  shoulder,  of  the  neck,  trunk,  and  face  remain  normal. 
The  atrophy  need  not  be  entirely  symmetrical.  Fibrillar 
contractions  occur  occasionally;  the  reaction  of  degeneration 
is  present  in  some  muscles ;  the  skin  reflexes  remain  nor- 
mal. 

My  own  case  is  as  follows : 

R.  J.,  a  Russian  girl,  aged  12,  was  referred  to  my  depart- 
ment at  the  Polyclinic  by  Dr.  Gibney.  She  is  the  third 
child  of  healthy  parents;  two  born  later  died,  one  of  diph- 
theria, and  one  of  cerebral  trouble  after  a  fall.  No  disease 
similar  to  the  one  from  which  this  patient  suffers  has  been 
known  in  any  branch  of  the  family.  While  carrying  this 
child,  the  mother  was  considerably  troubled  with  swollen 
feet  and  legs,  possibly  of  nephritic  origin,  but  is  now  a 
healthy,  stout  woman.  The  child  was  asphyxiated  when 
born  ;  no  doctor  in  attendance.  Patient  began  to  walk  at 
nine  months  ;  had  a  slight  fall  at  the  age  of  ten  months 
without  doing  any  injury  to  herself.  At  the  age  of  three, 
mother  noticed  that  there  was  something  wrong  with  the 
right  knee,  and  in  the  hospital  at  St.  Petersberg  a  plaster 
of  Paris  splint  was  put  on.  This  the  child  wore  for  seven 
weeks.  She  could  walk  perfectly  well  after  that,  played  as 
well  and  ran  as  fast  as  any  child.  Has  had  a  number  of 
diseases — measles  at  the  age  of  one  year,  small-pox  at  the 
age  of  four,  scarlet  fever  at  six,  typhoid  fever  at  six  and  a 
half.  In  spite  of  all,  recovered  and  walked  perfectly  well. 
Came  to  this  country  one  year  ago  ;  nine  months  ago  fell 
on  left  hip,  and  for  some  weeks  had  pain  in  left  hip.  While 
recovering  from  this  fall,  she  noticed  that  she  had  difficulty 
in  moving  the  toes  of  the  right  leg.  This  is  now  five  months 
ago.  The  impairment  of  motion  gradually  grew  worse  until 
the  child  was  not  able  to  move  the  toes  at  all.  Never  had 
pain  on  her  right  side.  Her  present  manner  of  walking 
developed  very  slowly.     At  first  sight  her  gait  seemed  to 


75° 


AMERICAN  NEUROLOGICAL  ASSOC  I  A  TION. 


be  characteristic  of  poliomyelitis.  Child  complains  of 
fatigue,  particularly  in  mounting  stairs  ;  no  other  special 
symptoms.  Patient  was  a  bright  girl ;  no  hysterical  ten- 
dencies. The  history  shows  that  the  present  condition  of 
paresis  developed  slowly  and  was  not  preceded  either  by 
convulsions  or  fever  ;  furthermore,  that  there  was  no  pain 
accompanying  the  paresis  at  any  time.  Has  distinct  feeling 
of  movement  under  the  skin. 

Examination. — Girl  of  medium  size.  Upper  extremities, 
good  grasp  with  both  hands  43.  Forearm  muscles  and 
hand  muscles  well  developed  ;  supinators,  also  biceps  and 
deltoids  well  marked,  the  latter  not  hypertrophied.  Trapezii 
and  rhomboids  of  normal  strength  ;  right  pectoral  a  little 
thinner  than  left.  Right  shoulder  blade  shows  slight 
winged  appearance.  Right  serratus  slightly  weakened. 
Distinct  wasting  of  the  right  leg,  thigh,  and  of  the  right 
gluteal  region.  The  leg  muscles  of  the  right  side  more 
distinctly  atrophied  than  the  thigh  muscles.  The  child 
cannot  lift  toes  of  right  foot  while  resting  the  heel  on  the 
ground.  The  same  movement  can  be  performed  fairly  well 
on  the  left  side.  Cannot  raise,  herself  on  tiptoes  on  the 
right  side,  but  can  do  so  with  the  left  foot.  Posterior  sur- 
faces of  thighs  proportionately  less  developed  than  anterior 
surface.  Right  extensor  quadriceps  very  weak  ;  left  weaker 
than  normal,  but  stronger  than  on  right  side.  Evident 
atrophy,  therefore,  of  anterior  tibial  and  posterior  tibial 
group  of  right  leg,  of  posterior  thigh  muscles  and  the 
glutei  muscles  of  right  side.  In  the  lying  position,  10  centi- 
metres below  lower  edge  of  the  patella,  right  leg,  23^  cm.; 
left  leg,  24^  cm.;  18  centimetres  below  iliac,  right  thigh, 
37  cm.;  left  thigh,  39  cm. 

Knee-jerk  absent  on  right  side ;  on  left  ;idc  it  was 
impossible  to  obtain  the  knee-jerk  for  several  weeks  ;  it  is 
now  present,  however,  and  very  lively.  Occasional  fibrillar 
contractions.  No  sensory  disturbances  anywhere.  No 
rectal  or  visceral  symptoms.  The  triceps  tendon  reflex 
present  on  both  sides,  but  weak.  Occasional  fibrillar  con- 
tractions have  been  noticed. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  J 5  j 

Electrical  Examination. — Faradic  examination  of  all 
nerves  and  muscles  gives  satisfactory  responses  except  in 
the  case  of  the  right  peroneal  nerve  which  exhibits  dimin- 
ished faradic  excitability.  On  faradic  excitation  of  peroneal 
nerve,  tibialis  anticus  muscle  contracts  very  feebly.  Ser- 
ratus  also  responds  more  powerfully  on  the  left  side  than 
on  the  right  to  current  of  moderate  strength.  Left  pecto- 
ralis  major  does  not  respond  as  well  as  right  to  faradic  cur- 
rent. Galvanic  examination  satisfactory.  The  following 
alone  need  be  mentioned.  Examination  with  the  10  ctm. 
square  electrode  :  Right  peroneal  nerve,  KCC,  2\  ma.; 
AOC,  3^-  ma.;  ACC,  6^  ma.  Left  peroneal  nerve,  KCC, 
2\  ma.;  AOC,  3^  ma.;  ACC,  6^  ma.  Right  tibialis  anticus 
muscle,  direct  examination,  KCC,  7  ma.;  ACC,  8  ma.  Left 
tibialis  anticus,  KCC,  44-  ma.;  ACC,  6  ma.  Electrical  ex- 
amination thus  shows  a  decided  diminution  of  response  to 
the  faradic  current,  and  to  the  galvanic  current  as  well  in 
the  tibialis  anticus  of  the  right  side,  the  KCC  being  almost 
equal  to  the  ACC.  Ormerod  would  have  said  that  the 
peroneal  nerve  showed  reaction  of  degeneration  with  re- 
gard to  the  anode,  but  this,  I  insist,  is  nothing  morbid.  We 
have,  therefore,  slight  electrical  changes  in  a  single  muscle  ; 
the  other  muscles  of  the  peroneal  group  respond  normally. 

The  diagnosis  in  this  case  could  have  rested  only 
between  acute  anterior  poliomyelitis,  a  peripheral  neuritis, 
or  this  form  of  progressive  muscular  atrophy.  The  mode  of 
onset,  gradually  and  without  pain,  without  fear  or  convul- 
sions, argues  against  a  poliomyelitis  anterior  acuta,  as  well 
as  against  peripheral  neuritis.  The  atrophy,  too,  is  not  as 
great  as  we  would  expect  in  a  case  of  spinal  infantile  palsy. 
All  of  the  symptoms — the  paralysis  proportionate  to  the 
wasting  of  the  muscles,  the  absence  of  the  knee-jerk,  and 
the  slight  changes  in  electrical  reaction  can  be  best  ex- 
plained by  the  diagnosis  we  have  made.  Furthermore,  the 
disease  is  not  retrogressive  as  poliomyelitis  acuta  would  be, 
but  gradually  progressive,  and  the  slight  indications  of  this 
progression  in  the  muscles  of  the  trunk  lend  further  sup- 
port to  the  view  of  a  progressive  muscular  atrophy,  which 


•;  r  2  AM  ERR  'AN  XE  L  'ROL  OGICAL  ASSOCIA  TION. 

is  strengthened  still  more  by  the  occasional  presence  of 
fibrillar  contractions. 

The  diagnosis  in  such  cases  as  these  must  be  made  with 
the  greatest  care,  but  I  have  no  doubt  that  some  of  the 
cases  which  have  hastily  been  put  down  as  cases  of 
peripheral  neuritis  will  prove  to  be  cases  of  this  type. 
From  poliomyelitis  anterior  acuta  it  will  not  be  difficult  to 
differentiate  this  disease,  nor  from  neuritis.  It  will  be  more 
difficult  to  distinguish  between  these  cases  and  those  of  a 
widespread  atrophy  following  traumatic  joint  lesions,  in 
which,  as  I  have  seen  a  number  of  times,  the  atrophy  may 
spread  with  surprising  rapidity  and  may  affect  the  entire 
extremity.  We  must,  therefore,  either  rely  upon  the  his- 
tory in  these  cases,  upon  the  presence  or  absence  of  fibrillar 
contractions,  or  must  exclude  a  purely  traumatic  atrophy 
in  case  the  atrophy  jumps  from  the  affected  part  to  some 
other  portion  of  the  body. 

In  many  cases  of  progressive  muscular  atrophy  of  the 
typical  form,  the  histories  show  that  the  disease  was  first 
noticed  after  some  accident.  The  question,  therefore, 
arises,  whether  it  may  not  be  possible  for  a  typical  pro- 
gressive muscular  atrophy  to  develop  after  a  joint  lesion  in 
a  subject  predisposed  to  this  disease. 

We  have  now  to  consider  the  relations  of  this  peroneal 
form  of  progressive  muscular  atrophy  to  the  other  primary 
dystrophies  which  we  have  discussed. 

It  will  be  seen  at  once  that  the  anatomical  distribution 
is  entirely  different  from  the  four  forms  of  primary  myo- 
pathies discussed  above.  If  the  atrophy  spreads  to  the 
upper  extremities,  it  involves  the  muscles  more  after  the 
fashion  of  a  Duchenne's  atrophy  than  after  the  fashion  of  a 
pseudo-hypertrophy  or  an  Erb's  form  of  atrophy.  The 
analogy  to  Luchenne's  form  becomes  still  closer  when  we 
consider  that  this  peroneal  form  is  distinguished  from  the 
other  myopathies  by  the  occasional  presence  of  fibrillar 
contractions  and  by  alterations  in  the  reaction  of  degener- 
ation. The  spreading  of  the  atrophy  from  the  muscles  of 
the  big  toe  and  the  small  muscles  of  the  foot  to  the  mus- 
cles of  the   legs   and   thighs   reminds  one  of  the  manner  in 


AMERICAN  NEUROLOGICAL  ASSOCIA TION  753 

which  the  atrophy  spreads  in  the  upper  extremities  in  cases 
of  typical  progressive  muscular  atrophy.  There  seems 
therefore,  to  be  good  reason  to  separate  this  form  from  the 
simple  muscular  myopathies  and  to  make  it  a  subdivision 
of  typical  progressive  muscular  atrophy.  This  form  might 
be  properly  entitled  the  leg  type,  in  contradistinction  to 
the  hand  type  which  would  represent  the  ordinary  form  of 
Duchenne's  progressive  muscular  atrophy. 

If  the  ordinary  progressive  muscular  atrophy  is  a  polio- 
myelitis anterior  chronica  cervicalis,  the  leg  type  might 
represent  a  poliomyelitis  anterior  chronica  lumbalis.  But 
this  is  speculative  pathology  and  needs  corroboration,  as 
indeed  all  the  clinical  and  anatomical  features  of  this  form 
do. 

In  the  preceding  pages  I  have  given  an  account  of  the 
commonly  received  forms  of  progressive  muscular  wasting. 
Some  cases  will  surely  be  found  that  cannot  properly  be 
classed  under  any  one  of  these  heads.  Schultze's  case,  for 
instance,  had  some  of  the  features  of  pseudo-hypertrophy, 
some  of  those  of  Erb's  form,  and  in  the  presence  of  the 
fibrillar  contractions  and  reaction  of  degeneration  in  some 
muscles  approached  to  the  type  of  typical  progressive  mus- 
cular atrophy.  I  have  had  occasion  to  observe  one  case  in 
a  child  about  seven  years  of  age  in  which  there  was  a  gen- 
eral wasting  of  all  the  muscles  of  the  body  excepting  those 
of  the  head.  The  power  of  the  legs  and  arms  was  weak, 
without  there  being  any  actual  paralysis.  There  was  a 
winged  appearance  of  the  scapulae,  but  there  were  no  other 
disproportionate  atrophies  or  hypertrophies  anywhere  in 
the  body.  The  wasting  was  an  entirely  uniform  one.  Such 
a  case  as  this  one  is  mentioned  by  Charcot  in  his  recent 
volume  and  by  Gowers  in  his  text-book.  Baeg  (loc. 
cit.)  and  Oppenheim  have  reported  cases  with  involve- 
ment of  the  face,  tongue,  laryngeal  and  ocular  muscles, 
which  it  is  impossible  at  present  to  classify  under  any  of 
the  ordinary  forms  of  progressive  muscular  atrophy. 

There  is  good  reason,  therefore,  for  allowing  that  there 
are  mixed  cases  of  progressive  muscular  atrophy,  and  that 
the  exact  rank  of  these  cases  cannot  be  determined  at  pres- 


754  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

ent,  except  that  according  to  their  cardinal  symptoms, 
they  should  be  classed  either  with  .the  spinal  or  primary 
myopathies. 

The  study  of  the  histological  changes  in  the  various 
forms  of  progressive  muscular  atrophy  is  omitted  in  this  ab- 
stract. 

From  the  survey  of  the  histological  researches  in 
various  forms  of  muscular  atrophy,  we  conclude  that  an 
examination  of  muscular  changes  may  help  us  to  differenti- 
ate between  typical  progressive  muscular  atrophy  and  the 
primary  myopathies  ;  and  again,  if  Hitzig  be  correct,  be- 
tween pseudo-hypertrophy  and  Erb's  juvenile  form.  There 
does  not,  however,  appear  to  be  a  marked  distinction  be- 
tween Erb's  juvenile  form  and  the  remaining  primary  dys- 
trophies, the  histological  changes  in  the  peroneal  form 
being  still  undetermined. 

The  argument  which  has  been  held  throughout  these 
pages  leads  to  the  following  conclusions : 

i.  Progressive  muscular  atrophy,  type  Aran-Duchenne, 
is  due  to  spinal  cord  disease.  The  peroneal  type  of  pro- 
gressive muscular  atrophy  bears  close  resemblance  to  this 
form  and  may  possibly  have  a  similar  pathology. 

2.  Duchenne's  type  of  progressive  muscular  atrophy 
might  be  termed  the  hand  type,  while  the  peroneal  form 
would  represent  the  leg  type. 

3.  Pseudo-hypertrophy  is  not  of  spinal  origin.  Lipoma- 
tosis is  a  mere  incident  in  the  course  of  the  disease,  and  is 
associated  with  wide-spread  atrophy  in  various  parts  of  the 
body. 

4.  There  is  a  close  relationship  between  pseudo-hyper- 
trophy and  Erb's  juvenile  form  of  progressive  muscular 
atrophy,  but  not  an  absolute  identity.  This  close  relation- 
ship is  marked  by  the  onset  of  the  disease  at  an  early  age, 
by  its  occurrence  in  various  members,  of  a  family 
by  the  entire  absence  of  fibrillar  contractions  in  both  forms, 
by  the  absence  of  reaction  of  degeneration,  and  by  the 
occurrence  of  lipomatosis  some  time  during  the  course  of 
the  disease.     They  differ  from  each  other  in  the  distribution 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  755 

of  atrophied  muscles  and  possibly  in  their  histological  con- 
ditions. 

5.  Hereditary  muscular  atrophy  does  not  deserve  the 
rank  of  a  separate  clinical  entity,  all  forms  of  primary 
myopathies  being  occasionally  hereditary. 

6.  The  type  Landouzy  and  Dejerine  is  closely  related  to 
Erb's  form,  the  additional  involvement  of  the  face  muscles 
not  being  a  sufficient  basis  for  a  marked  clinical  differ- 
entiation. 

7.  Pseudo-hypertrophy  and  Erb's  form  should  be  re- 
garded as  the  two  representative  forms  of  primary  progres- 
sive dystrophies. 

8.  Primary  progressive  dystrophies  are  distinguished 
from  spinal  progressive  dystrophies  by  their  cardinal  symp- 
toms— the  onset  at  an  early  age,  the  occurrence  of  true  or 
false  hypertrophy,  the  absence  of  the  reaction  of  degenera- 
tion, and  the  absence  of  fibrillar  contractions. 

This  paper  cannot  be  properly  closed  without  reference 
to  the  subject  of  classification.  The  term  "  progressive 
muscular  atrophy"  has  been  variously  used  both  to  desig- 
nate the  fact  of  a  general  and  progressive  muscular  wasting, 
and  also  as  to  the  proper  name  for  Duchenne's  type  of 
atrophy.  This  has  led  to  great  confusion,  and  it  would  be 
well  if  the  term  "progressive  muscular  atrophy"  were  to  be 
used  in  a  generic  sense  merely,  and  if  some  other  name 
were  found  for  Duchenne's  type.  Erb's  suggestion  seems 
to  me  to  be  a  good  one,  and  I  therefore  propose  to  desig- 
nate the  type  Aran-Duchenne  as  spinal  progressive  amy- 
otrophy. 

If  my  argument  against  the  validity  of  anatomical  dis- 
tribution of  atrophies  or  hypertrophies  as  a  basis  for  classi- 
cation  be  accepted,  the  classification  of  muscular  atrophies 
could  be  reduced  to  the  following  simple  form : 

1.  Amyotrophia  spinalis  progressiva  ; 

a.  Hand  type ; 

b.  Leg  type  =  peroneal  form. 

2.  Primary  progressive  dystrophies  ; 

a.  Pseudo-hypertrophy ; 

b.  Erb's  form. 


y  5  6  AMERICAN  NEUROLOGICAL  ASSOC  I  A  TIOX. 

DISCUSSION  ON  DRS.  JACOBV  AND  SACHS'  PAPERS. 

Dr.  P.  C.  Knapp  distinguished  between  the  primary  and 
the  secondary  myopathies.  There  was  hypertrophy  of  the 
fibres  in  the  former  and  atrophy  of  the  fibres  in  the  latter. 
The  primary  process  in  primary  muscular  dystrophies  was 
not  the  chronic  interstitial  inflammation.  The  increase  of 
nuclei  in  the  fibre  indicated  an  inflammatory  process,  and  it 
was  more  in  accord  with  our  present  idea  of  these  degenera- 
tions to  suppose  that  this  was  primary  and  the  interstitial 
change  secondary.  This  would  reduce  the  process  to  the  type 
of  similar  degenerations  in  the  liver  and  kidneys  and  in  the 
cord,  in  tabes,  Similar  degenerations  might  affect  the  cor- 
tex, perhaps;  the  spinal  motor  tract,  possibly;  the  periphe- 
ral motor  nervous  mechanism,  certainly;  and  also  the  mus- 
cles. The  primary  myopathies  of  the  muscles  were  analo- 
gous to  the  changes  in  other  parts  of  the  motor  tract. 

I  think  that  we  could  yet  divide  clinically  cases  into 
those  of  peripheral  or  central  origin.  Dr.  Sachs  had  said 
that  there  were  no  fibrillary  contraction  in  the  former. 
When  the  speaker  returned  to  New  York  he  would  be  glad 
to  show  him  a  case  in  which  there  were  such  fibrillary  con- 
traction. Even  pseudo-muscular  hypertrophy  was  mixed 
with  atrophy.  He  thought  it  wiser  to  acknowledge  no 
conclusions  rather  than  to  adopt  false  conclusions,  even 
though  they  should  be  those  of  Dr.  Erb. 

Dr.  W.  A.  Hammond,  in  reply  to  Dr.  Sach's  criticism  of 
his  book  stated  that  the  first  edition  of  this  book  was  writ- 
ten eighteen  years  ago,  and  the  last  edition  four  years  ago. 
It  was  therefare  hardly  fair  to  bring  him  into  court  for  any 
conclusions  therein  contained.  He  did  not  agree  with  the 
trenchant  manner  in  which  the  author  had  dismissed  the 
harpoon.  All  we  knew  upon  the  subject  had  been  obtain- 
ed by  means  of  the  harpoon.  It  was  easier  to  criticise 
than  to  experiment.  Later  he  might  accept  the  classifica- 
tion presented,  but  for  the  present  he  would  not  change, 
but  would    sustain    the  position  of  Dr.  Gray. 


AMERICAN  NEUROLOGICAL  ASSOCIA TION.  757 

Dr.  G.  L.  WALTON  referred  to  a  case  of  the  peroneal 
type  and  yet  myopathic  in  origin.  Heredity  was  traced  into 
the  beginning  of  the  seventeenth  century.  The  patient  was 
62  years  of  age,  and  had  been  affected  for  twenty  years.  Her 
mother  had  died  at  87,  having  been  affected  since  her 
thirty-fifth  year. 

Dr.  J.  J.  Putnam  reported  a  case  of  hereditary  dystrophy, 
in  which  there  were  no  gross  signs  of  pseudo-hypertrophy 
but  the  microscope  showed  hypertrophic  as  well  as  atrophic 
fibres.     Specimens  were  exhibited. 

Dr.  SACHS  reminded  Dr.  Hammond  that  he  had  been 
appointed  to  open  the  discussion,  and  hence  had  had  to  as- 
sume a  critical  attitude.  He  had  only  intended  to  make 
the  broad  distinction  between  spinal  and  primary.  The  pres- 
ence or  absence  of  fibrillary  contractions  and  of  the  reaction 
of  degeneration  were  important  and  had  distinct  bearing 
upon  the  differential  diagnosis. 

Dr.  GEORGE  W.  Jacoby. — In  discussing  this  subject  of 
primary  myopathies,  a  subject  which  during  the  last  few 
years  has  received  so  much  attention  at  the  hands  of  com- 
petent observers,  and  of  which  the  present  state  of  our 
knowledge  has  been  so  thoroughly  and  ably  set  forth  to- 
day, it  would  almost  seem  that  personal  views  and  opinions 
only,  can  be  given  by  each  participant,  as  American  liter- 
ature upon  the  subject  is  very  scant,  this  being  due  to  a  great 
extent  to  the  rarity  of  certain  "types "  in  this  country.  This, 
at  any  rate,  has  been  my  own  experience ;  for,  outside  of 
cases  of  pseudo-hypertrophic  paralysis  in  its  various  stages, 
and  some  cases  in  which  the  myopathic  origin  was  doubt- 
ful, I  have  seen  little. 

I  can  only  consider  it  a  misfortune  that  the  tendency  has 
for  so  long  a  time  been  to  subdivide  the  muscular  atrophies 
more  and  more,  not  resting  content  with  a  simple  division 
into  spinal  and  primary  muscular  form,  but  also  to  subdi- 
vide these  latter,  until  every  deviation   from   the   so-called 


75©  AMERICAN  NEUROLOGICAL  ASS0L1A  HON. 

typical  course  must  needs  receive  a  special  designation  and 
be  looked  upon  as  a  special  form  of  muscular  disorder,  with 
the  gratuitous  hypothesis  by  some  that  each  special  form  is 
dependent  upon  a  special  cause.  This  tendency  has  hap- 
pily during  the  last  few  years,  owing  to  the  efforts  of  Char- 
cot and  Erb,  received  a  decided  check,  so  that  to-day  only 
can  we  say  that  we  are  on  the  right  path  towards  a  correct 
comprehension  of  the  subject.  How  much  still  remains  to 
be  decided  is  shown  by  the  fact  that  even  the  fundamental 
division  into  spinal  and  muscular  forms  cannot  in  all  cases 
be  sharply  made.  The  possibility  of  this  division  has  been 
considered  unassailable  ;  and,  although  it  cannot  be  denied 
that  there  are  many  cases  in  which  we  can  at  once  say  that 
they  are  purely  spinal,  many  others  that  are  purely  muscu- 
lar, still  there  are  two  classes  of  cases  which  under  certain 
circumstances  may  make  the  differentiation  as  to  their  spinal 
or  muscular  character  impossible  during  life.  The  cases  to 
which  I  refer  are,  first,  those  in  which  there  are  no  distinct 
nervous  systems,  in  which  there  is  no  heredity,  which  show 
neither  hypertrophy  nor  pseudo-hypertrophy,  begin  in  the 
shoulder  muscles,  and  occur  in  adults.  The  second  class 
consists  of  the  type  described  by  Charcot  and  Tooth  as 
peroneal,  and  here  I  include  also  the  cases  of  Schultze  pub- 
lished in  1884.  Schultze  is  perhaps  more  justified  in  con- 
sidering his  cases  peripheral  than  is  Tooth  ;  for,  in  the  cases 
of  the  former  observer,  fibrillary  twitchings  were  absent. 
W  hether  these  cases  are  really  of  peripheral  origin,  as 
assumed,  is  a  question  upon  which  I  have  my  serious  doubts. 
The  difficulty  in  separating  the  just-mentioned  forms  be- 
comes apparent  when  we  consider  that  fibrillary  twitchings 
and  reaction  of  degeneration  have  also  been  found  to  be 
present  in  certain  purely  muscular  forms. 

If  then  we  have  trouble  at  the  very  beginning  of  our 
classification,  how  much  more  difficult  will  it  be  to  prove 
that  the  various  forms  of  primary  myopathic  disorders  are 
really  different  "  types,"  and  not  simply  variations  in  the 
localization  of  one  and  the  same  process.  It  seems  to  me, 
from  all  we  now  know,  that  if  we  take  into  consideration 
the  published  cases  of  the  juvenile  and  of  the  pseudo-hyper- 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  759 

trophic  form,  each  with  involvement  of  the  facial  muscles  ; 
Duchenne's  infantile  forms  now  considered  neuropathic, 
varying  to  such  an  extent  that  they  as  often  show  the  juven- 
ile as  the  pseudo-hypertrophic  character  ;  cases  of  pseudo- 
hypertrophy which  later  show  a  complete  picture  of  Erb's 
juvenile  form  ;  cases  of  pseudo-hypertrophy  occurring  in 
adults,  and  classed  under  the  juvenile  form  by  Erb  ;  finally, 
the  various  forms  occurring  in  one  and  the  same  family 
(Zimmerlin,  Barsickow), — considering  these  facts,  I  believe 
that  we  must  admit  a  clinical  entity,  that  all  these  so-called 
types  are  simply  fortuitous  localizations  of  one  affection,  no 
matter  in  what  light  the  process  itself  may  be  considered. 
The  difficulty  in  understanding  these  myopathies  is,  how- 
ever, not  solely  due  to  the  varying  clinical  characteristics, 
but  also  to  our  lack  of  definite  knowledge  regarding  the 
minute  muscular  changes, and  on  account  of  the  darkness 
surrounding  their  pathogenesis.  Microscopically,  we  find  a 
coincidence  of  appearances  which  can  only  fortify  our  posi- 
tion as  regards  the  unity  of  the  various  forms.  Muscular 
examinations  have  been  confined  chiefly  to  cases  of  pseudo- 
hypertrophy, under  which  I  include  Schultze's  very  com- 
plete examination  of  his  atypical  case,  and  the  case  of 
infantile  muscular  atrophy  by  Landouzy  and  Dejerine 
(Revue  de  Med.,  1888).  In  addition  to  this,  muscular  ex- 
aminations of  the  juvenile  form  have  been  made  by  Erb  and 
Hitzig  during  the  last  few  years.  In  all  these  examinations 
attention  has  been  mostly  given  to  the  changes  found  in  the 
connective  tissue,  and  the  changes  in  the  muscles  themselves 
have  been  very  much  neglected  ;  the  only  differences  found 
in  the  various  forms  being  that  now  the  formation  of  fat 
or  proliferation  of  connective  tissue  preponderates,  now 
there  is  simple  atrophy  in  the  muscular  fibres,  and  again,  in 
other  cases,  waxy,  fatty,  or  fibrous  degeneration. 

More  or  less  the  same  changes  are  always  seen  by  vari- 
ous observers  in  the  various  cases,  but  the  interpretation  of 
that  which  is  seen  is  not  always  the  same.  It  would  seem 
that  the  only  reliable  differential  point,  microscopically, 
between  muscles  from  the  spinal  and  those  from  the  muscu- 
lar forms  lies  in  the  presence  or  absence  of  hypertrophic 


760  AMERICAS'  NEUROLOGICAL  ASSOCIATION. 

fibres.  That  is  to  say,  the  presence  of  hypertrophic  fibres 
always  excludes  the  spinal  origin  of  the  disease,  the  ab- 
sence, however,  of  such  fibres  not  proving  anything,  as 
shown  by  my  case  of  pseudo-hypertrophy  published  last 
year.  I  myself  do  not  believe  that  this  test  is  always  reli- 
able, particularly  in  view  of  a  case  recently  published  by 
Hitzig.  This  case  was  one  which  began  with  paresthesias 
and  was  followed  by  loss  of  use  of  the  upper  extremities 
through  atrophy  in  a  year  and  a  quarter.  Finally  symptoms 
of  severe  irritation  occurred,  cramps  and  extended  muscular 
twitchings  with  increased  reflexes.  The  periosteal  reflexes 
of  the  lower  extremities  and  the  patellar  tendon  reflexes 
were  very  much  increased.  This  case,  which  I  think  we  all 
would  diagnose  as  spinal,  Hitzig  diagnoses  as  muscular,  for 
the  only  reason  that  he  found  hypertrophic  fibres  present 
microscopically. 

I  think  that,  allowing  the  diagnosis  between  the  spinal 
and  muscular  seat  of  the  affection  to  depend  entirely  upon 
a  single  symptom,  is  going  entirely  too  far,  particularly 
when  the  clinical  symptoms  are  at  variance  with  that  which 
we  are  accustomed  to  see.  Now,  as  regards  the  microscop- 
ical changes  found  in  the  muscles,  we  must,  I  think,  differ- 
entiate between  the  processes  which  seem  to  occur  either 
alone  or  together.  These  processes  are  primarily  degener- 
ation and  inflammation,  processes  which,  in  my  opinion,  to 
a  great  extent  determine  the  clinical  symptoms  and  course 
of  the  disease.  It  would  appear,  a  priori,  that,  in  examining 
muscular  tissue  microscopically,  there  ought  not  to  be  any 
difficulty  in  deciding  what  is  inflammatory  and  what  is  de- 
generative. As  far  as  the  changes  produced  by  acute 
inflammation  are  concerned,  I  think  no  one  will  doubt  the 
possibility  of  diagnosing  this  process  microscopically.  My 
paper  on  polymyositis  presented  to-day  clearly  illustrates 
that.  In  my  specimens  of  this  case  we  can  trace  the  process 
almost  step  by  step.  We  have  here,  referring  to  the  mus- 
cular fibre  itself,  a  proliferation  of  nuclei  in  the  body  and  at 
the  periphery  of  the  fibre,  without  any  change  being  ob- 
served in  the  surrounding  contractile  matter.  These  nuclei 
increase   until  we  have    the    appearance  of  a  giant    cell,  the 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  76 1 

sarcolemma  being  still  present.  Then  the  muscle  fibre 
breaks  up  into  indifferent  or  medullary  corpuscles,  some  of 
which  are  still  nucleated.  The  sarcolemma  sheath  is  now 
indistinct,  and  it  is  difficult  to  clearly  separate  the  muscle 
fibre  from  the  adjacent  perimysium,  which  also  is  largely 
composed  of  similar  bodies.  In  other  places  we  see  the 
process  commencing,  not  by  the  appearance  of  nuclei  in  the 
body  of  the  fibre,  but  by  a  breaking  up  in  toto  of  the  fibre 
into  clusters  and  lumps,  these  then  growing  up  to  the  size 
of  nucleated  medullary  corpuscles. 

These  are  changes  which  we  see  in  all  tissues  when  acute 
inflammation  occurs,  as  also  in  secondary  inflammation  of 
the  muscles  from  the  various  causes  enumerated  in  my 
paper. 

But  when  we  come  to  the  later  stages — the  products  of 
the  acute  inflammation — then  it  is  truly  difficult  to  say 
whether  we  are  dealing  with  products  of  inflammation  or 
with  primary  degenerative  processes.  Every  one  will,  how- 
ever, admit  that  if  by  the  side  of  the  acute  inflammation  I 
see  changes  which  are  similar  to  degenerative  changes,  I  am 
warranted  in  concluding  that  these  changes  are  not  primary, 
but  are  the  results  of  the  inflammation. 

Unfortunately  all  our  cases  of  chronic  primary  myo- 
pathies show  little  or  nothing  of  the  acute  stage  when  the 
microscopical  examination  is  made,  and  therefore  we  stand 
before  such  processes  as  "proliferation  of  connective  tissue," 
"simple  atrophy,"  "  waxy  degeneration,"  "fatty  degener- 
ation," without  being  able  in  each  individual  case  to  say,  Is 
this  a  primary  process,  or  is  it  the  result  of  an  inflammation  ? 
While  now  I  would  not  go  as  far  as  Friedreich  and  consider 
every  case  inflammatory  because  an  increase  of  nuclei  is 
present,  still  I  think  that  if  I  am  able  to  show  that  an  acute 
inflammation  of  the  muscles  can  produce  changes  identical 
with  those  observed  in  the  chronic  myopathies,  it  is  not 
unreasonable  to  suppose  that  some  of  these  myopathies 
may  be  of  inflammatory  origin.  Clinically,  also,  cases  have 
been  described  of  pseudo-hypertrophic  paralysis  with  cure, 
which,  in  my  opinion,  can  only  be  understood  upon  the 
hypothesis  of  an  acute  myositis   (Donkin,  Brit.  Med.  Jour., 


762  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

1882,  I.,  p.  537;  Fawsitt,  Lancet,  1887,  II.,  p;  158).  Partic- 
ularly is  this  the  case  in  Fawsitt's  case,  which  presented 
muscular  pains  preceding  the  symptoms  of  the  pseudo- 
hypertrophy. 

Even  Gowers  concurs  in  the  opinion  that  this  is  a  true 
case  of  pseudo-hypertrophic  paralysis.  Now,  I  personally 
cannot  conceive  of  a  complete  regeneration  in  a  primary 
degenerative  process,  but  I  can  easily  believe  that  we  have 
here  an  inflammation  which  has  stopped  short  of  degener- 
ation. 

It  seems  to  me  probable  that  these  primary  muscular 
affections,  including  progressive  myositis,  myositis  ossifi- 
cans, and  also  Thomsen's  disease,  are  all  due  to  an  embry- 
onal malformation  (shown  in  my  case  to-day  by  the  small 
size  of  all  the  fibres),  a  malformation  of  the  muscle  plate 
rendering  the  future  muscles  particularly  susceptible  to 
pathogenic  influences.  What  these  influences  are  can  of 
course  not  be  stated  ;  they  need,  however,  not  be  physical 
in  character,  but  may  be  chemical,  due  to  atmospheric  influ- 
ences, etc.  This  tendency  to  disease  will  in  one  patient  or 
family  localize  itself  in  that  group  of  muscles  which  is  most 
inhibited  in  its  development.  That  even  gross  defects  in 
the  development  of  the  muscular  system  occurs  is  shown  by 
the  fact  that  the  latissimus  dorsi  and  lower  half  of  the  pec- 
toralis  are  sometimes  congenitally  absent  in  cases  of  pseudo- 
hypertrophic paralysis.  What  form  the  disease  will  take 
will,  in  my  opinion,  depend  entirely  upon  the  cause  of  pro- 
duction ;  and  if  this  be  chemical  or  atmospheric  (infectious), 
the  probabilities  are  that  it  will  begin  as  a  myositis  ;  if  due 
to  other  causes,  dependent  perhaps  upon  an  altered  influ- 
ence of  the  nervous  system,  then  we  will  have  a  primary 
degeneration.  I  cannot  conceive  of  a  primary  degeneration 
independent  of  nerve  influences.  Any  further  remarks 
which  I  might  be  inclined  to  make  in  this  direction  would 
only  be  a  repetition  of  statements  already  made  in  my  paper 
on  polymyositis. 

Dr.  L.  C.  Gray  stated  that,  while  pseudo-muscular 
hypertrophy  was  probably  of  peripheral  origin,  he  thought 
the  question  was  still  open  to  doubt.  He  referred  to  Gib- 
ney's  and  Amidon's  cases. 


m\m\\mtm$  gotf$. 


NATIVE  MINERAL  WATERS  IN  KIDNEY 
TROUBLES. 

By  Dr.  WILLIAM  C.  WILE. 

Not  a  few  of  the  mineral  waters  of  the  United  States 
have  become  noted  for  their  value  in  various  diseases  of  the 
kidneys.  The  most  prominent  of  these  which  have  proved 
of  greatest  value  are  the  Buffalo  Lithia  Water  of  Virginia 
and  the  Bethesda  Water  of  Wisconsin.  Both  are  warmly 
endorsed  by  the  leaders  of  the  profession  of  this  country, 
the  first  especially  in  those  conditions  where  a  slushing  out 
of  the  kidneys  is  desirable,  and  in  renal  calculi;  the  latter 
in  diabetes  and  Bright's  diseases.  Of  both  we  have  had 
ample  and  extended  experience,  the  results  valuable  to 
ourselves  and  patients. 

In  a  recent  outbreak  of  nephretic  colic  in  our  own  per- 
son, the  attack  under  the  Buffalo  Lithia  Water,  of  the  Buf- 
falo Lithia  Springs  of  Virginia,  was  speedily  cut  short,  the 
stones  quickly  passed,  and  the  debris  which  followed  showed 
a  thorough  cleansing  of  the  kidneys  and  bladder  of  all  for- 
eign substances.  All  of  the  reflex  symptoms  and  sequelae 
were  promptly  relieved,  and  we  feel  under  a  deep  debt  of 
gratitude  to  this  most  excellent  water  for  wonderful  relief 
from  suffering  and  disease. — New  England  Med.  Monthly, 
Dec.  15th,  1888. 


TO  MEDICAL  MICROSCOPISTS. 


In  behalf  of  "The  American  Association  for  the  Study 
and  Cure  of  Inebriety,"  the  sum  of  one  hundred  dollars  is 
offered  by  Dr.  L.  D.  Mason,  vice-president  of  the  society, 
for  the  best  original  essay  on  "  The  Pathological  Lesions  of 
Chronic  Alcoholism  Capable  of  Microscopic  Demonstra- 
tion." 


764  MISCELLANEOUS  NOTES. 

The  essay  is  to  be  accompanied  by  carefully  prepared 
microscopic  slides,  which  are  to  demonstrate  clearly  and 
satisfactorily  the  pathological  conditions  which  the  essay 
considers. 

Conclusions  resulting  from  experiments  on  animals  will 
be  admissible.  Accurate  drawings  or  micro-photographs 
of  the  slides  are  desired. 

The  essay,  microscopic  slides,  drawings,  or  micro-pho- 
tographs are  to  be  marked  with  a  private  motto  or  legend, 
and  sent  to  the  chairman  of  the  committee  on  or  before 
October  1st,  1890. 

The  object  of  the  essay  will  be  to  demonstrate  :  first, 
Are  there  pathological  lesions  due  to  chronic  alcoholism  ? 
secondly,  Are  these  lesions  peculiar  Or  not  to  chronic  alco- 
holism ? 

The  microscopic  specimens  should  be  accompanied  by 
authentic  alcoholic  history,  and  other  complications,  as 
syphilis,  should  be  excluded. 

The  successful  author  will  be  promptly  notified  of  his 
success,  and  asked  to  read  and  demonstrate  his  essay  per- 
sonally or  by  proxy,  at  a  regular  or  special  meeting  of  the 
"Medical  Microscopical  Society"  of  Brooklyn.  The  essay 
will  then  be  published  in  the  ensuing  number  of  The  Journal 
of  Inebriety  (T.  D.  Crothers,  Hartford,  Conn.)  as  the  prize 
essay,  and  then  returned  to  the  author  for  further  publication 
or  such  use  as  he  may  desire. 

The  following  gentlemen  have  consented  to  act  as  a 
committee : 

Chairman— W1.  H.  Bates,  M.D.,  F.R.M.S.,  Lond.,  Eng., 
(President  Med.  Microscopical  Soc,  Brooklyn,) 

175  Remsen  St.,  Brooklyn,  N.  Y. 

John  E.  Weeks,  M.D., 

43  West  1 8th  St.,  New  York. 

Richmond  Lennox,  M.D., 

164  Montague  St.,  Brooklyn,  X.  Y. 


VOL.  XIII.  December,  1888.  No.   12 

THE 

Journal 

OF 

Nervous  and  Mental  Disease. 


(Original  gurtfrte*. 


THE  WHITECHAPEL  MURDERS:  THEIR  MEDICO- 
LEGAL AND  HISTORICAL  ASPECTS.1 

By  E.  C.  SPITZKA, 

NEW    %ORK. 

IT  is  when  approaching  the  consideration  of  this  repul- 
sive subject  that  we  appreciate  the  old  writer's  defini- 
tion :  "Man  is  an  ape  without  the  tail,  who  walks  on 
his  hind  legs,  is  gregarious,  omnivorous,  restless,  menda- 
cious, thievish,  salacious,  pugnacious,  capable  of  many- 
arts,  the  foe  of  the  rest  of  animate  creation  ;  the  worst  foe 
to  his  own  kind."  2 

The  original  Bluebeard  of  history  far  exceeded  in  de- 
structiveness  the  Whitechapel  assassin.  Like  Tiberius  the 
Roman  emperor,  he  sacrificed  hecatombs  of  children  to  his 
lusts,  in  a  solitary  chateau  in  France,  whose  ruins  still 
mark  the  site  of  this  horrible  blot  on  humanity.  He  was  of 
the  family  of  the  proud  Montmorenci,  a  companion  in  arms 
of  the  Maid  of  Orleans,  and  in  good  repute  as  a  soldier. 
The  following  extracts  from  his  manuscript  confession  I 
cite  from  Julian  Chevalier :  3 

1  Remarks  made  in  discussing  Mr.  Austin  Abbott's  paper  on  the  same  sub- 
ject beiore  the  Society  of  Medical  Jurisprudence,  New  York. 

2  "Simia  homo  sine  canda  pedibus  posticis  ambulans,  gregarius,  omnivorus, 
inqiuetus,  mendax,  froax,  salax,  pugnax,  artium  variarum  capax,  animaluim  re- 
liquorum  hostis,  sui  ipsis  irimicus  teterrimus. " 

3  Inversion  of  the  Sexual  Sense,  quoted  in  Amer.  Journal  of  Insanity,  1887, 
p.  360. 


7  66  E.    C.    SPITZ  A' A. 

"  I  do  not  know  how,  but  of  my  own  self,  without  coun- 
sel of  any  one,  I  concluded  to  act  thus,  solely  for  the 
pleasure  and  luxury  it  afforded  me.  In  fact  I  found  incom- 
parable delight  in  murder,  doubtless  by  the  instigation  of 
the  devil.  It  is  eight  years  now  since  this  diabolical  idea 
came  to  me.  One  day,  being  by  chance  in  the  library  of 
the  cstle,  I  found  a  Latin  book  describing  the  lives  and 
customs  of  the  Caesars  of  Rome.  It  was  written  by  a 
learned  historian  of  the  name  of  Suetonius.  The  said  book 
was  adorned  with  pictures  very  well  painted,  which  showed 
how  these  pagan  emperors  lived  ;  and  I  read  in  this  beau- 
tiful history  how  Tiberius,  Caracalla,4  and  other  Caesars 
slaughtered  children,  and  took  pleasure  in  torturing  them. 
Upon  this  I  determined  to  imitate  the  said  Caesars,  and  on 
that  very  evening  I  commenced  to  follow  up  in  earnest  and 

carry  out  the  text  and  the  pictures  in  the  book 

I  abused  these  children  for  the  ardor  and  delectation  of 
luxury  which  their  sufferings  caused  me.  Afterwards  I 
caused  them  to  be  slain  by  these  fellows.5  Sometimes  I 
made  them  cut  the  throats  of  the  children,  severing  the 
heads  from  the  bodies.  Sometimes  I  crushed  their  skulls 
by  blows  of  a  heavy  stick.  Sometimes  I  removed  their 
limbs  ;  removed  their  entrails,  hung  them  on  iron  hooks  to 
cause  them  to  languish,  and  while  they  were  languishing 
in  death,  I  had  connection  with  them.  Sometimes  I  did 
the  same  after  they  were  dead.  Oh,  I  had  great  pleasure 
in  seeing  the   most  beautiful  heads  of  these  children   after 

they  were   bloodiest As   to  those   slain,  their 

bodies  were  burned  in  my  chamber,  except  some  very 
beautiful  heads  which  I  kept  for  relics." 

In  this  same  confession  he  begs  the  king  abjectly  to 
spare  his  life,  and  allow  him  to  expiate  his  crimes  by  retir- 
ing to  a  monastery,  in  connection  with  the  statement,  that 
he  had  retired  from  the  king's  service,  as  otherwise  he 
would  have  been  unable  to  resist  the  same  furious  impulse 
to  slay  the  young  Dauphin  of  France,  the  son  of  the  king 
(Charles  VII.). 

*  An  error  ;  he  probably  meant  Caligula. 
Henriet  and  Ponton,  his  assistants,  who  were  also  executed. 


THE    WHITECHAPEL  MURDERS.  767 

Whether  this  latter  statement  was  false  and  made  to 
work  on  the  king's  feelings,  it  is  now  impossible  to  deter- 
mine. It  assuredly  conflicts  with  his  former  statement  that 
he  owed  his  inspiration  to  Suetonius.  The  whole  tone  of 
the  confession,  the  frequent  involuntary  exclamation  of 
"beautiful,"  "luxury,"  and  such  like  terms,  when  describ- 
ing the  revolting  and  horrible,  indicate  to  my  mind,  that 
he  was  nothing  more  nor  less  than  a  degenerated  voluptu- 
ary. Certainly  he  was  not  an  impulsive  lunatic,  for  he  had 
assistants,  and  continued  his  excesses  for  eight  years,  en- 
trapping, outraging,  vivisecting  and  destroying,  according 
to  his  own  confession,  over  nine  hundred  children  of  both 
sexes,  or  one  every  third  day.  I  am  not  inclined  to  credit 
his  statement  about  the  Dauphin.  If  he  had  had  the 
"furious  impulse"  at  that  time,  who  can  doubt  that  in  that 
age  he  could  have  gratified  it  over  and  over  again  on 
others,  as  he  in  fact  did  later  on.  It  is  inconsistent  with 
what  I  can  find  in  the  records  of  similar  cases  that  he 
should  have  had  an  impulse  to  destroy  the  Dauphin,  with- 
out an  accompanying  sexual  motive.  It  is  improbable 
that  he  should  reach  the  age  of  thirty-six  before  yielding  to 
the  impulse.  It  is  more  likely  that  his  earlier  excesses 
had  led  to  a  condition  in  which,  as  Shakespeare  has  it, 
"desire  outliveth  performance  ;"  that  he  exhausted  all  arti- 
fices to  stimulate  his  weakened  powers  ;  and  coming  across 
the  work  of  Suetonius,  it  exercised  a  horrible  fascination 
over  him.  No  one  will  claim  that  his  associates  in  crime 
were  insane.  But  the  very  fact  that  it  is  more  difficult  to 
conceive  how  two  persons  could  be  found  so  brutalized  and 
callous  as  to  do  ior  money  or  interest  what  de  Retz  did  in 
obedience  to  the  most  powerful  passion — however  perverted 
— shows  how  careful  we  must  be  in  allowing  the  horrible 
nature  of  a  crime  to  rank  as  a  proof  of  insanity.  From 
those  men  to  whom  "  the  shriek  of  torture  "  of  the  violated 
virgin  "is  the  essence  of  their  delight,"  and  "who  would 
not  silence  by  a  single  note  the  cry  of  agony  over  which 
they  gloat,"  exposed  in  the  Pall  Mall  Gazette-*  from  the 

6 Modern  Minotaur,  in  "The  Maiden  Tribute,"  1884.  Fielding,  in  his 
"Jonathan  Wild,"  speaks  of  one  of  his  characters  as  "well  knowing  that  there 
are  certain  dispositions  so  brutal  that  cruelty  adds  a  great  savour  to  their  pleas- 
ures."    Montaigne  says :   "Lust  seeks  stimulation  in  pain." 


768  E.    C.    SPITZKA. 

country  boy  who,  after  excessive  self-abuse,  developed  a 
penchant  for  intercourse  with  ducks,  geese  and  other  ani- 
mals, his  gratification  being  exalted  by  their  dying  agony, — 
there  is  an  unbroken  chain  of  cases,  showing  how  the  acts 
of  Gilles  de  Retz  and  the  Whitechapel  murderer  may  evo- 
lute  on  a  basis  of  voluptuous  exaltation  associated  with 
sexual  failure.  There  is  the  case  of  the  Russian  physician 
who  when  sober  was  sexually  normal,  but  when  intoxicated 
could  obtain  gratification,  accompanied  by  ejaculation,  only 
as  the  blood  flowed  from  wounds  made  with  a  lancet  on  the 
buttocks  of  his  mistresses/  Numbers  of  women  found  dead 
with  evidences  of  violation,  exhibit  injuries  pointing  to  an 
association  of  murderous,  or  shall  I  call  it  "  wild-beast"  in- 
stinct, with  the  libidinous  motives  of  their  destroyer.  Thus 
Mrs.  Ebenbauer  was  found  with  the  vagina  torn  apart  by 
fingernails  and  the  left  nipple  bitten  off."  The  body  of  a 
young  girl  was  found  in  South  Carolina,  about  1865-1866, 
frightfully  hacked  about  the  vulva,  and  three  negroes,  dis- 
covered to  be  the  perpetrators,  were  lynched  after  confes- 
fession.  Even  the  paederasts,  at  the  height  of  their  disgusting 
and  forced  orgasm,  are  guilty  of  similar  acts.  Thus  the 
"  passive  "  paederast,  Richeux,  had  had  his  throat  cut  by  his 
"active"  partner,  and  the  dead  body  was  then  placed  in 
the  attitude  of  the  antique  statue  "  Hermaphrodite."  Letel- 
lier  was  similarly  murdered  by  Pascal,  and  Binel  by  an- 
other. Both  victims  showed  extensive  scrotal  ecchymoses, 
proving  that  the  murder  had  been  preceded  by  violent 
manipulation  of  the  genitals.9  Indeed.it  is  asserted  that 
the  "active"  paederast  delights  in  grasping  and  clasping 
the  throat  of  his  partner.  Frank,'0  after  carefully  studying 
the  case  of  a  brakeman  who  had  been  committed  to  an  asy- 
lum after  having  knocked  down  a  girl,  cut  open  her  genitals 
to  permit  his  entry,  and  failing,  cut  her  throat  "  without 
knowing  why,"  decides  that  he  was  of  limited   intelligence 

Tarnowsky,  Die  krankhaften  Erscheinungen  des  Geschlechtsinnes.  Berlin, 
1886,  p.  61. 

"  iardieu.  Attentats  contre  les  meurs.  3d  edition,  p.  116,  German  transla- 
tion. 

•Tardieu,  Op.  tit.,  p.  168. 

K>  Vierteljahrshchrift  f.  gerichtliche  Medizin,  xlvii.,  p.  200,  1887. 


THE    WHITECHAPEL  MURDERS.  769 

and  not  insane.  In  the  case  of  Tirsch,11  who,  after  a  life 
history  of  insubordination,  theft,  and  immoral  attacks,  ani- 
mated in  his  fifty-fifth  year  by  a  hatred  of  the  entire  female 
sex  because  one  of  that  sex  had  rejected  his  proffers  of  mar- 
riage, solicited,  forced,  and  killed  an  old  woman,  robbing 
her  clothes  and  money,  and  cutting  off  the  breasts  and 
genitals,  which  he  boiled  and  ate.  The  subsequent  history 
did  not  reveal  the  existence  of  any  pronounced  form  of  in- 
sanity, but  rather  an  angry  disposition  culminating  in  peri- 
odical outbreaks  of  fury,  as  to  whose  exact  nature  the 
reporter  appears  to  have  been  in  doubt.  In  the  case  of  a 
Parisian  military  officer,  who  being  enamored  of  a  woman, 
applied  leeches  to  her  anus  and  vulva,  so  that  the  flowing 
blood  might  incite  his  passion,  sequestration  was  followed 
by  furious  mania,  and  later  by  dementia  which  continued 
until  his  death.12  Here,  as  in  the  cases  where  sexual  per- 
version and  cannibalistic  propensities  marked  the  incipient 
development  of  senile  or  paretic  dementia,  the  morbid 
nature  of  the  act  was  proven  by  its  close  chronological 
association  with  marked  insanity.  The  same  cannot  be 
said  of  two  cases  which  have,  I  think,  undeservedly  been 
held  up  as  reproaches  to  French  medical  jurisprudence  : 
Menesclou  and  Leger.  Menesclou13  was  guillotined  in  1880 
at  Paris,  after  having  been  pronounced  of  sound  mind  by 
Motet,  Lasegue,  and  Brouardel.  Aged  only  nineteen,  he 
had  violated  a  girl  of  four,  choked  her,  and  cut  the  body 
into  pieces.  At  the  anthropological  laboratory  both  frontal 
lobes,  the  two  upper  temporal,  and  part  of  the  occipital 
gyri  were  alleged  to  have  been  "  softened."  Such  exten- 
sive softening  it  is  impossible  to  conceive  in  a  young  person 
without  accompanying  motor  and  sensory  symptoms  that 
would  have  placed  his  irresponsibility  beyond  a  doubt. 
Their  absence  militates  against  the  genuineness  of  the  rec- 
ord.    Leger  at  the  age  of  twenty-four  left  home  to  seek  a 

11  Maschka,  Prager  Vierteljahrschrift,  1886,  i.,  p.  79. 

12  Brierie  de  Boismont,   cited   by  Lunier:   Annales  Medico-Psychologiques, 
1850,  p.  107,  from  Gazette  Medicale  de  Paris,  July  21.  1849. 

13  Affaire  Menesclou,   Annales  d'Hygiene   publique  et  de  medicine    legale, 
1880,  p.  439. 


■JJO  E.    C.    SPITZKA. 

situation  ;  instead  he  wandered  about  over  a  week  in  the 
woods,  overcome  by  a  desire  to  eat  human  flesh.  He  cap- 
tured a  girl  aged  twelve,  violated  her,  mutilated  the  sexual 
organs,  tore  out  the  heart,  ate  it,  drank  her  blood,  buried 
the  body,  and  denied  his  act  when  captured.  He  was  guil- 
lotined, and  Esquirol  found  adhesions  between  the  pia  and 
dura.11  Unfortunately  but  little  of  the  life  history  of  either 
Leger  or  Menesclou  can  be  utilized  in  determining  what  re- 
lation the  post-mortem  findings  could  have  had  to  their 
sexual  aberrations.  This  brings  me  to  the  consideration  of 
the  case  of  a  French  nobleman,  who  wanted  but  the  oppor- 
tunities he  would  have  had  in  the  middle  ages  to  have 
graduated  into  another  Marshall  de  Retz  or  a  Whitechapel 
assassin. 

Donatien  Alphonse  Francois,  Marquis  de  Sade,  was 
born  1740.  His  father  was  distinguished  as  a  literateur.  He 
entered  a  regiment  as  a  cadet,  and  was  expelled  on  account 
of  his  immoral  life.  In  1772  he  was  sentenced  to  death 
in  contumaciam  for  sodomy  and  attempted  poisoning.  He 
evaded  the  death  penalty  by  flight ;  but  returned  to  France, 
and  probably  with  the  aid  of  assistants  carried  out  a  num- 
ber of  excesses,  undiscovered,  similar  to  the  following. 
The  strollers  on  one  of  the  Parisian  streets,  one  evening  in 
1777,  heard  groans  as  if  from  a  remote  apartment  in  a  de- 
serted house.  The  door  having  been  forced,  other  doors 
were  encountered  which  were  forced  in  turn  ;  and  in  one 
room  a  nude  female  was  found  tied  down  on  a  table  and 
pale  as  death  from  loss  of  blood.  There  were  two  wounds, 
one  at  each  bend  of  the  elbow,  as  if  made  by  a  phlebotom- 
ist,  one  in  each  breast,  and  corresponding  ones  on  the 
vulva.  Her  story  was  as  follows  :  In  the  ordinary  course 
of  her  "  profession  "  she  had  been  solicited  by  the  Marquis, 
who  invited  her  to  sup  with  him  and  his  associates.  After 
the  supper  she  was  tied  down,  assured  that  only  a  little 
blood  would  be  drawn,  and  that  a  surgeon,  or  at  least  one 
who  used  surgical   instruments,  had  made  the  wounds   in 

"George!  The  cases  of  Leger,  Feldtmann,  etc.  Translated  into  German 
by  Amelung.      I)arm->ndt,  1827. 


THE    WHITECHAPEL  MURDERS.  yji 

question.  As  soon  as  the  blood  flowed  freely  he  threw  him- 
self on  his  victim.  She  however  alarmed,  cried  out,  and 
the  Marquis  and  his  accomplices  fled  on  hearing  the  doors 
forced.  Otherwise  it  is  probable  the  wounds  would  have 
been  stanched  and  the  victim  silenced  by  the  means 
usually  effective  with  her  class.  He  was  arrested,  tried, 
convicted,  and  imprisoned  in  the  Bastile.  From  here  he 
was  transferred  to  the  asylum  at  Charenton  for  alleged  in- 
sanity. In  1790  he  regained  his  liberty,  and  published  sev- 
eral prurient  books.15  It  was  his  attempt  to  issue  a  collected 
edition  of  these  works  which  led  Napoleon  I.  to  order  his 
rearrest  and  confinement  in  Charenton,  where  he  died,  leav- 
ing several  posthumous  manuscripts  of  a  like  character. 

In  his  case  neither  periodical  impulses,  epileptiform  nor 
vertiginous  seizures  existed.  His  perversion  ran  like  a  red 
thread  through  his  entire  mental  organization.  Yet  I  believe 
that  a  consideration  of  the  case  of  the  Roman  emperors,  whose 
example  had  so  marked  an  effect  on  De  Retz,  Sade's  proto- 
type, will  show  that  unlimited  indulgence  and  absence  of 
responsibility  are  competent  to  make  sexual  monsters  out 
of  mere  voluptuaries.  Tiberius  after  excessive  normal  in- 
dulgence retired  to  Capri,  where  he  finally  employed  per- 
sons nicknamed  Spintrii  to  devise  modes  of  sexual  pleasure. 
It  is  difficult  to  indicate  in  decent  language  the  successive 
steps  by  which  he  reached  the  murderous  acme.  It  may 
suffice  to  say  that  in  the  early  part  of  this  phase  of  his 
career  an  aspirant  to  his  favors  offered  him  the  choice  as  a 
present  between  Parrhasius'  painting  of"  Atalante  exciting 
Meleager  per  os"  or  one  million  sesterces,  and  that  Tiberius 
chose  the  former;  that  the  performances  of  the  "animal 
with  three  backs'  was  devised  to  stimulate  his  desires  when 
they  waned,  the  "little  fish  boys"  when  they  were  extin- 
guished ;  and  that  then  he  entered  on  a  course  of  horrible 
butcheries  of  the  youth  of  both  sexes,  which  served  as  a 
model   to   De   Retz.16     Nero,   after   indulging  in   the   worst 


15  "Justine,  ou  Malheurs  de  la  vertu,"  Paris,  1791;  "Pauline  et  Belval," 
and  "Juliette,"  1798. 

16  Suetonius,  translated  by  Stahr,  p.  239. 


77  2  E.    C.    SPITZKA. 

incests,  dressed  the  emasculated  Sporus  as  empress,  and  he 
himselt  acted  the  part  which  Sporus  acted  to  him,  to  his 
"husband"  Doryphorus,  imitating  the  while  the  cries  of  a 
ravished  virgin.  He  committed  paederasty  with  young  An- 
lus  Plantius  prior  to  having  him  executed  ;1T  and,  finallv, 
having  had  men  and  women  tied  to  stakes,  and  himself 
clothed  in  the  skin  of  a  wild  beast,  he  threw  himself  on 
them  with  fierce  cries  to  bite  off  their  genitals.1"  A  long 
series  of  these  debauches  could  be  named,  who  like  their 
numerous  modern  imitators  delighted  in  epilating  the  mons 
veneris  of  their  concubines.19  Epilepsy,  and  the  form  of 
insanity  rendered  popularly  familiar  through  the  case  of  the 
late  King  of  Bavaria,  were  rife  in  the  family  of  the  Caesars. 
Caligula,  who  had  the  bloodiest  propensities  of  all,  who  an- 
ticipated Ludwig's  architectural  craze,  was  a  true  epileptic, 
and  nothing  served  him  better  to  convince  him  that  a  child  he 
had  by  Cssonia  was  really  his  than  its  wildness,  for  it  bit, 
scratched,  and  tortured  all  other  children  who  came  near  it.-" 
He  himself  cut  down  an  assistant  at  the  sacrifices,  laughing 
out  wildly,  as  he  did  on  another  occasion  among  his  senators, 
when,  being  asked  the  cause  of  his  merriment,  he  replied, 
"  because  a  single  word  from  me  and  all  these  throats  are 
cut."  The  existence  of  neurotic  taint  in  the  family  of  the 
Caesars  does  not  prove  that  their  sexual  aberrations  were 
necessarily  due  to  insanity.  It  shows  that  they  are  more 
likely  to  assume  certain  guises  in  the  insane  than  in  the 
sane.  Tiberius  was  not  a  lunatic  nor  an  epileptic,  and  his 
excesses  more  nearly  resemble  those  of  De  Retz  than 
do  those  of  Caligula  and  Domitian.  As  I  hinted  before, 
example,  opportunity,  and  license  operating  on  a  mind  not 
strong,  turned  by  flattery,  and  meeting  temptation  at  the 
hands  of  hordes  of  willing  purveyors,  will  sink  into  loathe- 
some  luxuriousness  even  when  not  insane.  Thus  Elagaba- 
lus,-1  coming  from  Syria,  "abandoned  himself  to  the  grossest 
pleasures  with  ungoverned  fury,  and  soon  found  disgust 
and  satiety  in  the  midst  of  his  enjoyments.  The  inflamma- 
tory powers  of  art  were  summoned  to  his  aid  ;  the  confused 

>~  //>.,   p.  403.      W  lb.,  p.  403.      '"Domitian,  lb.,  p.  548.      ■"//>.,  p.  291. 
•'  (Jihlxjn,  '•  Decline  and  Kail  of  the  Roman  Empire,"  i.,  p.  100. 


THE    WHITECHAPEL  MURDERS.  773 

multitude  of  women,  of  wines,  and  of  dishes,  and  the  studied 
variety  of  attitude  served  to  revive  his  languid  appetites. 
A  long  train  of  concubines  and  a  rapid  succes- 
sion of  wives,  among  whom  was  a  vestal  virgin  ravished  by 
force  from  her  sacred  asylum,  were  insufficient  to  satisfy 
the  impotence  of  his  passions.  The  master  of  the  Roman 
world  affected  to  copy  the  dress  and  manners  of  the  female 
sex,22  ....  and  dishonored  the  principal  dignities  of 
the  empire  by  distributing  them  among  his  numerous  lov- 
ers." 

To  come  down  to  the  case  of  the  Whitechapel  assassin, 
there  are  very  few  cases  in  the  literature  of  the  subject  that 
nearly  approximate  his  case.  None  are  exactly  like  it. 
Long  series  of  murders  on  women,  done  in  the  same  man- 
ner and  committed  from  evidently  similar  motives  are  on 
record,  but  they  were  all  committed  in  comparatively  de- 
serted localities.  Only  one  was  continued  after  the  mur- 
derer knew  that  the  hue  and  cry  had  been  raised  and  skilled 
measures  adopted  for  his  capture.  But  while  he  mutilated 
his  victims  in  the  same  way  as  the  Whitechapel  unknown, 
Bertrand  selected  bodies  of  the  dead  and  not  the  living. 
At  Gainesville,  and  near  Austin,  Texas,  ten  murders,  ter- 
ribly similar  in  every  detail,  were  committed  in  1887.  The 
first  blow  was  with  an  ax,  and  afterwards  the  bodies  so 
mutilated  that  they  fell  apart  on  being  lifted  up.  The  kill- 
ing was  uniformly  done  in  bed,  the  victim  was,  as  a  rule, 
dragged  into  the  yard  and  there  hacked  to  pieces.  Most 
of  those  destroyed  were  colored  servants.  In  his  tenth 
case  he  failed  to  complete  his  task,  the  victim  escaping 
with  her  life.  The  perpetrator  has  not  been  discovered. 
The  cases  of  Andrew  Bichel :a  and  Bertrand  resemble  the 
Whitechapel  one  in  the  fact  that  both  revelled  among  the 
intestines,  the  former  of  living,  the  latter  of  dead  subjects. 
Both  describe  their  penchant  as  irresistible  and  the  delight 
they  experienced  as  indescribable,  and  probably  the  White- 
chapel fiend  experiences  the  same.     Bertrand  had  a  period- 

22  Like  Lord  Cornbury,  Colonial  Governor  of  New  York,  nephew  of  Lord 
Clarendon;  see  Spitzka  :  "  A  Historical  Case  of  Sexual  Perversion."  Chicago 
Medical  Review,  Aug.  20,  1881. 

-;i  Feuerbach,  cited  by  Kraflt-Ebing,  Arch.  f.  Psychiatrie,  vii.,  p.  302. 


774  E-    C-    SPITZ  A' A. 

ical  fever  accompanied  by  headache,  which  was  relieved  by 
his  violation  of  sepulcher,  and  followed  by  a  sense  of  lassi- 
tude. During  his  fury  he  bruised  and  lacerated  his  hands 
without  feeling  it.  The  discovery  of  his  penchant  was 
made  by  himself  in  the  following  way.  A  young  girl  hav- 
ing been  placed  in  the  grass,  the  diggers  were  driven  away 
by  a  thunderstorm  ;  before  their  return  he  went  to  the 
grass,  and,  as  if  at  random,  beat  the  body  with  a  switch. 
This  gave  him  such  pleasure  that  he  returned  two  days 
later,  dug  up  that  body,  cut  it  into  pieces,  and  reburied 
them.  In  this  case,  as  in  the  others,  he  long  denied  the 
very  feature  which  might  have  convinced  his  physicians 
that  he  was  insane,  namely,  the  sexual  motive.  He  had 
his  full  consciousness  during  his  escapades.  For  two  years 
he  violated  bodies  in  various  cemeteries  around  Paris,  es- 
caping sentinels,  repeatedly  fired  at,  dislocating  an  infernal 
machine  which  had  been  set  at  the  place  where  he  usually 
cleared  the  walls,  but  finally  blown  up  by  one,  escaping, 
and  discovered  by  coming  to  have  his  wounds  dressed. 
Experts  who  have  described  his  and  similar  cases  are 
inclined  to  regard  them  as  a  case  of  periodical  mania  in  the 
guise  of  necrophilism-' or  sexual  furor.  At  the  same  time 
it  is  admitted  by  the  best  authorities — Westphal,  Krafft- 
Lbing  and  Tarnowsky — that  the  mere  existence  of  anthro- 
paphagy,  necrophilism  or  sexual  perversion  when  unac- 
companied by  other  evidences  of  nervous  or  mental  disease, 
is  not  sufficient  proof  of  insanity.  What  shall  we  say  of 
the  prominent  clergyman  who  has  a  prostitute  chalked,  so 
as  to  resemble  a  corpse,  placed  in  a  shroud  on  a  catafalque, 
and  the  room  hung  in  black  ;  who  then  recites  the  offices 
of  the  dead,  and  when  arrived  at  a  certain  point — permit 
me  to  draw  the  curtain-  here  ;  our  record  is  already  over- 
loaded with  bewildering  horror  ! 

It  is  not  and  cannot  be  disputed,  that  the  impulse  to 
perform  murderous  acts  may  be  pondered  and  debated  over 
in  the  mind  of  the  assassin,  obscurely  (to  us)  associated 
with  sexual  motives  and  finally  yielded   to.     The  case  is  on 

-•  hor  detail.-  -ec  Lunier,  Ann.  Med.  Psychologique,  1849,  p.  351. 
I. a  prostitution  contemporaine,  by  L.  Taxtil,  p.  171. 


THE    WH1TECHAPEL  MURDERS.  775 

record26  of  a  young  man  who,  seized  with  the  desire  to 
associate  sexually  with  and  murder  a  woman,  went  with  a 
prostitute,  accomplished  the  first  part  of  his  purpose,  but 
reflecting  that  it  would  be  disgraceful  to  be  reported  and 
convicted  as  the  murderer  of  a  prostitute,  he  deferred  the 
latter  part.  He  then  went  to  a  restaurant,  wrote  and  trans- 
mitted a  letter  to  the  police  acknowledging  that  he  had 
this  impulse,  and,  indeed,  before  the  authorities  arrived,  he 
stabbed  one  of  the  waitresses.  On  examination,  it  was 
found  that  he  was  subject  to  vertigo  and  to  fainting  seizures. 
Le  Grand  du  Saulle  and  Falret  pronounced  him  irrespon- 
sible on  the  ground  of  epilepsy.  Lasegue  assumed  the 
existence  of  periodical  mania.  I  must  admit  that  the  his- 
tory of  this,  as  of  similar  cases,  is  defective  in  the  exhibition 
of  the  raison  d'etre  of  the  impulse,  an  admission  which  is 
unfortunately  to  be  made  with  reference  to  many  other 
sensational  and  intrinsically  interesting  and  startling  rec- 
ords. 

If  the  inscription  on  a  window-shutter,  stating  that  he 
had  twenty  to  kill  and  would  then  surrender  himself,  signed 
"Jack  the  Ripper,"  be  really  the  writing  and  signature  of 
the  Whitechapel  assassin,  it  may  put  an  entirely  different 
aspect  on  the  case.  If  it  be  a  genuine  expression  of  inten- 
tion it  is  impossible  to  account  for  it  on  the  theory  of 
impulsive, periodical  or  of  epileptic  insanity.  It  is  not  incon- 
sistent with  sexual  perversion,  that  he  might  have  written 
this  to  mislead.  Indeed,  it  would  not  surprise  me  if  this 
person  were  an  acquaintance  of  an  author  of  eminence,  un- 
bosomed himself  to  him,  and  thus  utilized  in  a  sensational 
tale.  It  would  not  be  the  first  time  that  a  subject  of  sexual 
perversion  had  entered  the  lists  as  a  writer,27  and  no  artifice 
that  ingenuity  could  devise  or  industry  execute  would  be 
too  cunning  for  one  of  this  class.  I  look  upon  the  revela- 
tion of  his  identity  with  the  highest  degree  of  curiosity,  and  I 
am  prepared  to  learn  that,  like  the  Texas  and  Westphalian 
assassins,  he  may  discontinue  his  work  and  remain  forever 
unknown.     Such  a  mind  is  not  immune  to  the   influence  of 

26  Annales  d'Hygiene  publique  et  de  Med.  legale,  1875. 

27  See  the  cases  of  Numa  Numantius  and  the  Marquis  de  Sade. 


776  £.  c  spnzKA. 

fear  and  the  necessity  of  caution,  and  as  regards  the  last 
phase  in  the  history  of  the  Texas  and  Westphalian  assas- 
sins it  may  remain  an  unsolved  alternative  between  latencv 
of  the  impulse  and  suicide  of  the  assassin.  Strange  motives 
crop  out  among  impulsive  lunatics.  Singular  antipathies, 
romantic  notions  of  revenge,  pseudo-philanthropic  ideas, 
mysterious  associations  of  certain  numbers,  may  all  bear  a 
part  in  the  horrible  scheme  to  which  the  Whitechapel  fiend 
appears  to  have  devoted  himself,  if  paranoia  be  one  of  his 
mental  loads.  If  so,  we  may  look  for  peculiarities  in  dress, 
peculiarities  of  writing,  and  peculiarities  of  countenance  in 
him.  But  whatever  theory  we  indulge  in  this  wide  field  of 
speculation,  one  prominent  fact  remains  as  the  most  unpre- 
cedented in  the  history  of  murderous  sexual  frenzy.  Newly 
married  husbands,  as  in  the  case  cited  by  Mead,  have  in 
this  state  torn  their  wives  to  pieces,  and  been  found  with 
the  bleeding  entrails  wound  round  their  hands  or  strung 
about  the  neck  of  the  victim.  But  in  addition,  in  the  White- 
chapel case,  the  uterus  was  uniformly  found  missing,  and  in 
one  case  the  left  kidney.  What  did  the  assassin  remove 
these  for?  The  greater  probability  is  that  he  devoured 
them  ;  the  lesser  that  he  preserved  them  as  De  Retz  pre- 
served the  heads  of  the  murdered  children,  as  the  frotteurs 
of  Paris  preserve  the  handkerchiefs  they  steal  from  the 
women  whose  odor  attracts  them,  and  as  the  stealers  of 
aprons,  of  women's  shoes,  and  of  drawers  exposed  on  wash- 
lines,  establish  a  collection  of  these  objects.  It  is  less 
likely  that  he  removes  them  for  some  superstitious  reason," 


*■  I  have  seen  it  stated  in  the  Newgate  Calendar  quoted  in  Lichtenberg's  de- 
scriptive text  of  Hogarth's  works,  that  many  English  murderers  believed  that  the 
devouring  of  the  heart  of  an  innocent  child  would  render  then  immune  to  dis- 
covery bnd  pun^hment  by  earthly  justice.  In  a  letter  received  while  this  article 
is  going  to  press,  Dr.  Richard  Gundry  of  the  Catonsville  Asylum  referring  to  the 
witch-candle  superstition  of  the  Middle  Age-,  cites  the  following  startling  case  oi 
this  singular  belief  which  appears  to  crop  out  at  "strange  times  and  strange 
places,"  to  use  my  correspondent's  words.  He  writes:  "A  le^al  friend  gave  me 
a  sketch  cf  a  trial  in  old  slavery  times  of  an  old  half-witted  negro  for  the  murder 
of  a  woman  after  consulting  a  white  fortune-teller,  who  told  him  that  if  he  melted 
togethei  the  uterus,  one  ovary,  half  the  vulva  and  one  mamma  of  a  white  woman, 
then  making  a  candle  of  it  that  it  would  render  tiim  invisible  when  he  had  it 
during  his  stealing  excursions.  He  was  convicted  and  hanged  on  the  Eastern 
shore  of  Maryland.  The  fortune  teller — as  the  testimony  of  a  black  was  not 
then  admitted  in  evidence — escaped  scot-free."  Of  this  case  Dr.  Grundy  has 
promised  further  details 


THE    WH1TECHAPEL   MURDERS.  yjj 

or  utilizes  them  in  the  preparation  of  some  nostrum. 

I  do  not  believe  that  the  ten  Whitechapel  murders  are 
the  only  acts  of  the  kind  of  which  the  unknown  has  been 
guilty.  Either  he  has  performed  similar  acts  on  the  living 
in  deserted  localities,  where  the  cunning  he  has  since  ex- 
hibited so  manifestly  would  aid  him  in  obliterating  every 
trace  of  his  deed,  or  he  has  served  an  apprenticeship  on  the 
dead  body,  be  he  butcher,  medical  man,  or  amateur.  It  is 
not  easy  to  remove  the  human  uterus  without  a  fair  knowl- 
edge of  pelvic  topography,  and  he  who  endeavors  to  expose 
and  remove  that  organ  on  the  strength  of  an  experience 
acquired  among  the  lower  animals  need  well  be  a  good 
homologist. 

Finally  I  would  suggest  that  not  the  least  probable  the- 
ory is  that  the  same  hand  that  committed  the  Whitechapel 
murders  committed  the  Texas  murders.  We  can  well  pic- 
ture the  man  to  ourselves:  of  Herculean  strength,  of  great 
bodily  agility,  a  brutal  jaw,  a  strange,  weird  expression  of 
the  eyes,  a  man  who  has  contracted  no  healthy  friendships, 
who  is  in  his  own  heart  as  isolated  from  the  rest  of  the 
world  as  the  rest  of  mankind  are  repelled  by  him.  Perhaps 
some  other  part  of  the  world  is  destined  to  be  startled  by  a 
series  of  similar  butcheries,  and  his  discovery  and  appre- 
hension (the  latter  a  task  of  great  difficulty  I  imagine)  will 
permit  us  to  study  with  more  satisfaction  than  in  its  present 
hypothetical  condition  this  singular  subject. 

The  English  medical  and  secular  journals  have  been 
strongly  censured  for  attributing  the  Whitechapel  murders 
to  an  American.  Undoubtedly  they  did  this  on  absurd 
grounds  and  in  a  cockney  spirit ;  but  to  any  one  familiar 
with  the  Texas  homicides  of  a  year  ago,  the  theory  that 
both  acts  were  committed  by  one  and  the  same  person  does 
not  seem  unreasonable.  At  the  last  meeting  I  noticed 
among  the  audience  two  men  who  were  undoubtedly  cases 
of  sexual  perversion,  who  came  to  hear  Mr.  Abbott's  paper  ; 
and  there  have  been  stranger  freaks  in  history  than  would 
be  the  fact  of  the  Whitechapel  murderer  sitting  among  us 
at  this  very  moment. 

We  must  not  forget,  in  estimating  the  true  nature  of  the 


-~S  E.    C.    SPITZ K A. 

murderous  impulse,  that  among  animals  such  impulses  are 
often  associated  with  sexual  life.  The  female  mantis  religi- 
osa  devours  the  head-piece  of  her  mate,  while  the  abdominal 
segment  (apparently  undisturbed)  completes  the  marital 
act.  Certair  female  spiders  devour  their  mates  post-coitu. 
Again,  the  gorilla — according  to  evolutionists,  a  near  rela- 
tive of  our  species — when  he  has  disabled  a  foe,  delights  in 
tearing  out  his  entrails  and  revelling  in  massacre.  In  the 
sacking  of  cities,  infuriated  soldiers  have  frequently  been 
guilty  of  combined  acts  of  butchery  and  rape.  The  wild 
beast,  as  stated  at  the  opening  of  this  article,  is  slumbering 
in  us  all.  It  is  not  neccessary  always  to  invoke  insanity  to 
explain  its  awakening. 

Note.- -Countless  instances  are  on  record,  showing  that  bloody  propensities 
and  mutilation  are  apt  to  be  directed  against  the  sexual  organs.  The  beasts  who 
disgraced,  and  eventually  aborted  the  French  Revolution,  after  hacking  the 
body  of  the  beautiful  and  virtuous  Princess  Lamballe  to  pieces,  mounted  her  head, 
hands,  feet  and  vulva  on  pikes,  and  paraded  these  parts  before  the  prison  win- 
dows of  her  whom  they  styled  Madame  Veto  (Marie  Antoinette). 


$ot\tty  sports. 


PHILADELPHIA   NEUROLOGICAL   SOCIETY. 

Stated  Meeting,  November  26,  1888. 

The  Vice-President,  Charles  K.  Mills,  M.D.,  in 
the  Chair. 


Dr.  Mills  made  some  remarks  on  the  classification  of 
DYSTROPHIES, 

arranging  them  into  cases  of  muscular,  neural,  spinal,  and 
cortico-spinal  origin.  He  referred  to  the  classifications  of 
Erb,  Gray,  and  Sachs.  Speaking  of  dystrophies  as  compli- 
cating or  added  affection,  he  said  that,  in  a  considerable 
list  of  cases,  a  dystrophic  condition  is  a  marked,  but  not 
the  only  feature,  of  certain  well-known  nervous  diseases, 
as,  for  example,  glosso-labio-laryngeal  or  bulbar  paralysis, 
ophthalmoplegia  externa  or  progressive  paralysis  of  the 
external  ocular  muscles,  and  true  poliomyelitis  in  its  vari- 
ous types — acute,  subacute,  and  chronic. 

Atrophy  of  the  tongue  is  occasionally  seen  as  an  isolated 
affection,  but  more  commonly  in  association  with  other  dis- 
eases, such  as  ophthalmoplegia  externa,  glosso-labio-laryn- 
geal paralysis,  or  regular  or  irregular  forms  of  sclerosis. 
Whether  an  isolated  affection  or  simply  on  incident  or 
another  disease,  it  may  be  unilateral  or  bilateral.  Ray- 
mond and  Artaud  have  recorded  a  case  of  unilateral  degen- 
eration of  the  hypo-glossal  nucleus  in  tabes,  and  other 
cases  with  acute  apoplectic  onset  have  been  reported. 
Westphal  demonstrated  a  similar  interesting  specimen  from 
a  patient  who  had  ophthalmoplegia  externa  and  complete 
paralysis  of  both  eyeballs,  and  atrophy  of  the  antero- 
lateral portion  of  the  left  side  of  the  tongue. 


-go  PHILADELPHIA   XEUROLOGICAL    SOCIETY. 

With  almost  every  form  of  sclerosis  described  as  a  sepa- 
rate disease,  a  dystrophy  may,  at  times,  be  associated,  as 
his  own  experience  had  shown.  In  posterior  spinal,  lateral, 
amyotrophic  lateral,  or  disseminated  sclerosis,  early  or  late 
may  develop  progressive  muscular  atrophy  of  one  or  more 
extremities  ;  or  a  bulbar  paralysis  of  either  the  glosso-labio 
laryngeal,  or  of  the  external  ocular  type.  Such  cases  are 
included  in  the  list  to  be  presented  at  the  present  meeting. 
It  might  be  worth  while  to  discuss  the  question  of  the  iden- 
tity or  not  of  progressive  muscular  atrophy  and  amyo- 
trophic lateral  sclerosis,  some  authorities  denying  the  justice 
of  any  distinction.  Charcot  regarded  the  degeneration  of 
the  pyramidal  tracts  as  primary,  and  the  affection  of  the 
horns  as  secondary,  and  hence  the  name  given  by  him. 

Besides  the  joint  affections  which  occur  in  the  course  of 
posterior  sclerosis  and  other  spinal  diseases,  cases  are 
sometimes  seen  in  which  widespread  disease  of  the  joints  is 
associated  with  equally  widespread  atrophy  to  which  Gow- 
ers  devotes  a  few  pages,  and  which  has  been  discussed  by 
Duchenne,  Vulpian,  Paget,  and  others.  The  atrophy  which 
commonly  attends  inflammation  of  the  joints  is  not  to  be 
altogether  explained  by  disuse.  The  joint  disease  may  be 
the  cause  of  the  atrophy,  or  the  two  may  be  associated  and 
due  to  a  common  cause.  Paget  speaks  of  these  cases  as 
reflex  atrophies  due  to  disturbance  of  some  nutritive  nerv- 
ous centre,  irritated  by  the  painful  state  of  some  of  the 
sensitive  nerve  fibres.  In  some  of  the  cases  of  widespread 
arthritic  atrophy  the  joints  are  extremely  painful,  and  in 
some  not. 

Dr.  MilU  presented  notes,  and  exhibited  patients,  illus- 
trating some  unusual  forms  of  dystrophies. 

CASE  I.  Progressive  muscular  atrophy  of  traumatic 
origin. — J.  G.,  aged  forty-four  years,  white,  born  in  Ger- 
many, laborer,  was  admitted  to  the  Philadelphia  Hospital, 
March,  [884.  In  June,  1876,  he  fell  from  a  scaffold  and 
su-tained  severe  injuries  in  the  cervical  region,  for  which 
he  was  treated  at  the  Pennsylvania  Hospital  for  two  years, 
when  lie  was  discharged,  able  to  do  light  work.  In  Decem- 
ber he  resumed  work  as  a  stonecutter,  and  considered  him- 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  78  I 

self  well  up  to  February,  1884,  when  he  fell  from  a  scaffold, 
and  again  hurt  his  spine,  this  time  in  the  dorsal  and  lumbar 
region.  During  five  weeks  after  the  accident  he  lost  all 
control  of  the  bladder.  On  several  occasions  after  his 
admission  he  passed  blood  with  his  urine.  Four  weeks 
after  the  accident  he  felt  two  constricting  bands,  one  at  the 
level  of  the  nipple,  and  the  other  just  below  the  umbilicus. 
The  upper  band  tightened  at  the  least  movement  of  the 
arms,  almost  preventing  respiration,  and  on  attempting  to 
rise,  the  lower  band  tightened.  He  complained  also  of  a 
burning  sensation  in  the  soles  of  his  feet. 

In  1884  it  was  noted  that  he  was  able  to  walk ;  but  had 
marked  atrophy  of  the  muscles  of  the  shoulder  and  arm. 
The  thumb  was  strongly  flexed,  and  the  fingers  were  con- 
tractured.  He  also  had  some  atrophy  of  the  muscles  of  the 
lower  extremities.  Recent  examination  shows  extreme 
wasting  of  the  muscles  of  the  upper  half  of  the  body,  at 
least  as  far  as  the  face.  Most  of  the  muscles  of  the  neck 
are  visibly  atrophied,  but  the  trapezius  and  sterno-mastoid 
are  in  good  condition.  The  muscles  are  uniformly  atro- 
phied in  the  upper  half  of  the  body.  On  tapping  the 
pectoral  muscles  over  the  ribs,  local  elevations  occur.  No 
fibrillary  tremors  are  noticeable.  There  are  irreglar  con- 
tractures of  the  hand  and  a  striking  appearance  of  the 
thumbs.  The  second  phalanx  is  flexed,  and  the  first  drawn 
backward  at  a  right  angle.  The  muscles  of  the  legs  are 
atrophied  to  a  less  degree.  Knee-jerk  is  exaggerated  and 
ankle  clonus  marked,  most  on  the  left  side.  Faradic  con- 
tractility is  retained  to  a  current  of  moderate  strength. 
Partial  degeneration  reaction  with  galvanism  is  present. 

Case  II.  Progressive  muscular  atrophy  of  traumatic 
origin. — N.  S.,  aged  thirty-four,  white,  born  in  Germany,  a 
sailor,  during  his  infancy  was  sickly,  but  after  the  age  of 
two  years  was  strong  and  healthy.  He  denied  any  specific 
history.  He  had  malarial  fever  in  the  summer  of  1884,  for 
three  weeks,  but  recovered  perfectly  so  far  as  he  knows. 

About  three  years  ago  while  working  in  a  rolling-mill, 
a  ball  of  red  hot  molten  iron  was  dropped  into  water  and 
exploded,  and  one  of  the  fragments  struck  him  in  the  right 


PHILADELPHIA  XEUROLOGICAL  SOCIETY. 

forearm,  inflicting  a  severe  wound  ;  the  bones  were  exposed 
and  the  tendons  laid  bare.  The  wound  healed  slowly,  and 
he  was  under  treatment  for  eleven  weeks.  His  arm  was 
not  quite  healed  for  nearly  fifteen  weeks,  although  he  was 
able  to  do  some  work  with  it.  He  went  back  to  the  mill 
and  for  about  six  months  his  arm  gave  him  no  trouble, 
when  he  began  to  notice  gradual  wasting  and  loss  of  power 
in  it,  which  slowly  extended  to  the  shoulder,  the  other  arm, 
and  later  to  the  neck,  etc.,  as  now  observed. 

He  presents  advanced  atrophy  of  the  muscles  of  the 
forearm  and  shoulders  of  both  sides.  The  muscles  of  the 
neck  generally  are  atrophied.  When  the  patient  bows  his 
head,  after  reaching  a  certain  point  the  head  suddenly  falls 
forward,  and  in  lifting  the  head  the  muscles  of  the  back  and 
neck  are  brought  into  strained  and  unnatural  action.  He 
can  only  keep  his  head  erect  by  resting  the  occiput  on  the 
back  of  his  neck.  The  atrophy  has  not  yet  spread  much 
over  the  lower  half  of  his  body. 

He  has  fibrillary  tremors,  especially  in  the  muscles  of 
the  chest  and  neck. 

Both  knee-jerks  are  exaggerated,  and  he  has  slight 
ankle-clonus.  He  complains  of  considerable  pain  in  the 
legs  and  arms.     His  pupils  are  normal. 

Farado-contractility  is  retained,  partial  degeneration  re- 
action. 

CASE  III.  Diffused  sclerosis,  chiefly  amyotrophic  lateral, 
with  bulbar  paralysis. — J.  S.,  sixty-six  years  old,  has  been 
in  the  Philadelphia  Hospital  for  many  years.  His  mental 
powers  are  generally  enfeebled,  but  his  memory  for  past 
events  is  fairly  good. 

He  has  considerable  tremor  ;  his  head  sometimes  shakes, 
and  sometimes  his  trunk  and  entire  body.  Both  hands  are 
very  much  atrophied,  the  thenar  and  hypothenar  eminences, 
interossei,  etc.,  wasted.  He  has  an  apparently  double 
wrist-drop.  His  fingers  are  usually  a  little  flexed.  He  can 
elevate  his  arms,  but  they  are  weak  ;  the  muscles  high  up 
in  the  limbs  are  slowly  getting  worse.  The  left  upper  ex- 
tremity is  weaker  and  more  wasted  than  the  right.  While 
his  hands  have  the   appearance  of  double  wrist-drop,  they 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  783 

are  not  completely  helpless  ;  he  can  with  a  strong  effort 
extend  his  hands  and  fingers.  The  thumbs  are  usually  car- 
ried across  the  palms. 

Both  legs  are  in  a  spastic  condition,  having  a  tendency 
to  remain  contracted  in  extension.  The  feet  assume  a 
slightly  varus  position.  There  is  a  spasm  of  the  adductors 
of  the  thighs.  The  muscles  of  the  legs  respond  to  fara- 
dism,  but  it  requires  a  strong  current,  which  is  probably 
due  to  the  condition  of  the  skin.  His  senses  of  touch  and 
pain  are  retained.  He  has  incontinence  of  urine.  Both 
knee-jerks  are  exaggerated,  and  muscle-jerks  marked. 

The  right  pupil  is  larger  than  the  left.  The  iridic  re- 
sponse to  light  is  diminished.  He  has  no  true  facial  paral- 
ysis, but  poor  control  of  the  muscles  of  expression  ;  he 
cannot  with  facility  draw  his  mouth  to  one  side  or  the 
other,  and  he  has  little  power  in  the  oral  muscle,  as  in 
whistling.  The  general  bulk  of  the  tongue  is  small.  The 
contours  of  the  face  are  more  strongly  marked  on  the  left 
side  than  on  the  right.  He  complains  of  difficulty  in  swal- 
lowing. Testing  with  water  and  bread,  the  difficulty  seems 
to  be  in  the  constrictor  muscles  of  the  pharynx.  His 
method  of  speaking  is  peculiar.  He  speaks  with  great 
effort,  the  difficulty  being  in  phonation,  as  well  as  articula- 
tion. At  times  his  speech  is  explosive  or  stormy  in  char- 
acter ;  sometimes  it  is  hesitating,  but  it  is  not  distinctively 
of  this  character.     Smell  and  taste  are  preserved. 

Farado-contractility  in  the  muscles  of  the  forearm  is  re- 
tained. When  a  strong  current  is  used  on  the  extensor 
muscles  of  the  forearm,  while  these  contract,  the  flexors 
contract  so  much  more  strongly  that  the  movements  of  the 
extensors  are  obscured,  an  observation  which  would  seem 
to  show  that  when  one  group  of  muscles  are  much  atrophied 
and  weakened,  extra-polar  diffusion  of  the  current  to  antag- 
onistic muscles  might  lead  to  the  mistake  of  supposing  that 
the  muscles  tested  did  not  respond. 

CASE  IV.  Unilateral  atrophy  of  the  tongue  in  an  old  man, 
with  senile  dementia. — J.  C,  aged  eighty-six,  a  laborer,  had 
an  insane  grandfather  ;  has  had  acute  rheumatism,  and 
malarial  fever,   has  been   a  moderate  drinker,   but  denies 


784  PHILADELPHIA  XEl'ROLOGICAL  SOCIETY. 

venereal  disease.  For  several  months  he  has  suffered  from 
incontinence  of  urine  and  feces,  and  has  had  some  trouble 
in  micturition. 

He  has  a  peculiar  defect  of  speech  ;  when  he  talks  his 
articulation  is  a  little  indistinct  and  tremulous.  His  tongue 
is  distinctly  atrophied  on  the  left  side.  The  imperfection 
of  speech  appears  to  be  due  to  this  lingual  atrophy,  and 
weakness  of  the  oral  muscles.  He  has  some  tremor  of  both 
hands  and  arms.  He  appears  to  be  weak  on  the  left  side, 
but  there  is  no  well-defined  paralysis.  He  is  irascible  and 
irritable,  and  it  is  hard  to  fix  his  attention.  At  times  his 
mind  seems  to  wander,  and  he  is  often  querulous  and  wor- 
rying. The  arcus  senilis  is  highly  marked,  and  his  blood- 
vessels are  extremely  atheromatous. 

Case  V.  An  irregular  form  of  sclerosis  with  kemi-atrophy 
of  the  tongue. — J.  W.  J.,  thirty-six  years  old.  About  six- 
teen years  before  coming  under  observation  had  a  chancre, 
and  since  then  has  had  various  attacks  of  sore  throat.  Ten 
years  ago  he  first  noticed  slight  numbness  in  the  left  foot 
beginning  in  the  toes.  This  feeling  extended  slowly,  so 
that  the  entire  left  side  of  the  body  became  weak  in  about 
two  years.  He  retained  power,  however,  on  that  side  for 
nearly  three  years,  when  the  left  arm  began  to  fail.  He 
began  to  lose  power  in  the  right  leg  about  three  years  after 
the  first  attack  of  numbness  in  the  left  foot.  In  about  two 
years  later  he  became  almost  helpless  in  the  right  leg.  The 
right  arm  has  not  been  affected.  He  began  at  a  date  he 
could  not  fix  to  have  tremor  of  the  tongue,  which  wasted 
on  one  side.  His  bladder  has  never  been  affected,  except 
that  he  has  sometimes  suffered  pain  during  micturition. 
For  nearly  two  years  he  was  so  helpless  that  he  could  not 
leave  the  house.  Under  specific  treatment  he  got  well 
enough  to  go  out,  and  for  five  or  six  years  has  kept  about 
the  same. 

Examination  shows  no  headache.  He  has  abundant 
secretion  of  saliva,  and  has  fair  control  over  the  facial  mus- 
cles. 

The  right  half  of  his  tongue  is  practically  normal.  The 
left    half  presents   a   remarkable    appearance  ;     it   is   much 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  785 

smaller  than  the  right,  and  is  irregularly  atrophied,  so  that 
its  border  presents  an  unevenly  eroded,  or  corrugated  look. 
It  is  in  constant  tremulous  motion. 

The  left  hand  always  feels  cold  to  the  touch,  but  has  a 
flushed  appearance.  Sensation  in  the  right  leg  and  both 
arms  is  well  preserved  for  touch,  pain,  and  temperature. 
The  left  hand  is  numb  and  sensation  is  diminished.  Sensa- 
tion in  the  face  is  preserved.  The  left  knee-jerk  is  exag- 
gerated ;  the  right  well-marked  ;  ankle  clonus  is  decidedly 
on  the  left,  slight  on  the  right ;  muscle-jerk  is  decided  on 
the  left.     He  walks  with  a  cane,  dragging  the  right  leg. 

Both  faradic  and  galvanic  contractility  are  retained.  At 
times  he  complains  of  dizziness.  When  he  lies  down  in  any 
position  but  upon  the  right  side,  he  feels  as  if  he  would  fall 
face  forward. 

CASE  VI.  Simple  muscular  atrophy  associated  with  old 
joint  disease. — \V.  C,  aged  thirty-two,  white,  is  very  pale 
and  emaciated.  Atrophy  of  his  legs  is  especk  lly  marked, 
in  the  right  leg  and  thigh  more  than  in  the  left.  Foot-drop 
is  marked  on  the  right  side.  Patella  reflex  is  retained  in 
both  legs,  and  about  normal  ;  ankle  clonus  is  absent.  The 
legs  seem  stiff,  and  the  patient  cannot  move  either  of 
them.  He  is  totally  unable  to  walk  or  stand.  The  paral- 
ysis of  the  right  leg  is  more  complete  than  the  left.  He 
does  not  appear  to  be  able  to  move  leg,  foot,  or  toe.  His 
right  leg  is  extremely  atrophied  or  emaciated  from  the  hip 
down.  The  right  hip-joint  shows  signs  of  old  inflammation 
with  adhesions,  and  other  secondary  changes,  so  that  the 
thigh  is  absolutely  immovably  fixed  to  the  pelvis.  On 
handling  the  hip-joint  no  pain  is  experienced.  The  left  leg 
is  thin,  but  shows  much  less  wasting  than  the  right.  The 
middle  of  the  right  thigh  measures  11  ]^  inches;  of  left 
thigh,  13V,  inches  ;  middle  of  right  leg,  8}4  inches  ;  of  left 
leg,  g}(  inches.  The  right  leg  from  the  anterior  superior 
spinous  process  to  the  internal  malleolus  measures  28)4  in- 
ches ;  the  left  leg,  32^  inches.  Sensation  appears  to  be 
perfect.  Farado-contractility  and  galvano-contractility  are 
normal. 

CASE  VII.  Idiopathic  muscular  atrophy. — D.  S.,  aged 
thirty-one,  white,  born  in   Pennsylvania,  is  one  of  twelve 


j 86  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

children,  six  of  whom  died  of  convulsions.  One  sister  is 
hysterical,  and  all  of  the  others  are  subject  to  fits.  The 
patient  has  two  older  brothers,  aged  respectively  forty  and 
forty-two  years,  affected  like  himself.  The  disease  came 
on  them  in  childhood,  as  in  his  own  case.  He  had  spasms 
from  infancy  until  he  was  twelve  years  old. 

At  age  of  eight  years  it  was  noticed  that  he  could  not 
go  up  stairs  without  putting  his  hands  on  his  knees.  He 
continued  slowly  to  get  worse,  soon  walking  with  a  cane. 
He  learned  barbering  at  sixteen,  and  was  able  to  work  at  it 
for  ten  years.  At  twenty-three  he  had  to  use  crutches. 
Until  1882  the  weakness  was  confined  to  the  legs;  it  then 
began  to  involve  the  arms,  which  pained  him  when  he 
raised  them  to  shave. 

He  has  no  difficulty  in  speech  or  swallowing.  His  sight 
is  good.  The  face  shows  very  slight  smoothing  out,  and 
weakness  of  the  right  side.     The  irides  respond  to  light. 

He  exhibits  universal,  or  almost  universal,  wasting, 
although  in  varying  degree,  of  the  muscles  below  the  head. 
His  upper  extremities  are  very  thin,  particularly  the  upper 
arm  and  forearm.  His  hands  are  also  wasted,  but  the  the- 
nar and  hypothenar  eminences  and  interossei  muscles  are 
not  so  much  wasted  comparatively,  considering  the  stage 
of  the  affection,  as  the  muscles  of  the  forearms,  hands,  and 
trunk.  The  deltoid  muscles  are  also  not  absolutely  wasted. 
The  left  deltoid  is  less  wasted  than  the  right.  Marked 
atrophy  of  the  trunk  muscles  is  well  shown  when  he  at- 
tempts any  movements  of  the  trunk,  for  which  he  is  inca- 
pacitated except  to  a  small  degree.  The  latissimus  dorsi 
and  the  pectorals  are  in  an  advanced  stage  of  atrophy. 
The  muscles  of  the  lower  extremities  show  wasting  as 
above — the  right  muscles  probably  in  the  most  advanced 
stages.  The  patient  thinks  his  disease  began  in  the  thighs. 
In  the  lower  extremities  are  well-marked  vaso-motor 
changes.  The  feet  and  legs  are  purple  or  reddish  in  color, 
and  colder  than  they  should  be,  this  mottling  being  most 
marked  in  the  region  of  the  knees  and  thighs. 

The  knee-jerk  and  muscle-jerk  are  abolished.  Faradic 
and  galvanic  contractility  are  retained. 


PHILADELPHIA   NEUROLOGICAL    SOCIETY.  j8j 

Sitting,  this  patient  can,  by  an  effort  of  the  will,  cause 
the  muscles  of  the  thigh  to  contract  almost  like  fibrillary  or 
involuntary  contractions,  and  yet  he  cannot  use  the  same 
muscles  for  their  usual  physiological  purposes.  He  cannot, 
for  example,  kick  out,  or  cross  the  legs,  and  yet  he  can 
produce  by  a  willed  effort  waves  of  muscular  movement  in 
the  quadriceps  and  other  muscles. 

Dr.  J.  P.  Crozer  Griffith  reported  a 

CASE    OF   ARTHRITIC    MUSCULAR    ATROPHY. 

S.  K.,  twenty-two,  single,  American.  Father  died  of 
consumption,  and  a  paternal  uncle  has  had  rheumatism  for 
the  last  ten  years.  In  other  respects  the  family  history  is 
negative.  The  patient  had  typhoid  fever  when  about  three 
years  of  age.  Some  time  in  his  fourth  year  he  had  a  fall, 
injuring  his  back  ;  and  soon  after  this  a  posterior  curvature 
developed,  which  progressively  increased  up  to  the  age  of 
fifteen,  since  which  time  it  has  remained  stationary.  About 
two  years  after  the  commencement  of  the  curvature  he 
became  unable  to  walk,  and  remained  so  for  two  or  three 
years  ;  after  this  time,  however,  he  was  able  to  walk  per- 
fectly well,  and  to  attend  to  his  business,  which  was  that  of 
a  huckster.  The  present  illness  began  about  a  year  ago 
with  a  rheumatic  inflammation  of  the  left  knee,  for  which 
local  remedies  were  employed,  and  which  did  not  hinder 
him  from  going  about.  In  a  few  months,  however,  all  the 
larger  joints  grew  swollen  and  painful.  Six  months  ago  he 
became  unable  to  walk,  and  went  to  the  Hospital  at  Scran- 
ton,  where  he  seemed  to  get  better  for  about  two  weeks, 
but  after  this  little  improvement  could  be  noticed.  While 
in  this  hospital  he  began  to  waste,  and  says  that  in  about 
two  months  he  was  as  much  atrophied  as  when  Dr.  Griffith 
first  saw  him.  He  states  distinctly  that  on  entering  the 
hospital,  his  limbs  were  not  at  all  wasted. 

The  following  brief  notes  were  made  upon  his  case  at 
the  time  of  his  admission  to  the  University  Hospital,  June 
13,  1888: 

The  patient  complains  of  constant  pain  in  the  larger 
joints,  increased  by  motion.     He  is  anaemic,  and  his  face  is 


-88  PHILADELPHIA  XELROLOGICAL  SOCIETY. 

thin  and  has  a  delicate  appearance.  The  arms  are  much 
wasted,  and  are  held  flexed,  being  more  comfortable  in 
this  position.  The  elbows  are  swollen  and  painful,  and 
there  is  a  tendency  to  abrasion  from  pressure  on  the  con- 
dyles. There  is  some  degree  of  contracture  of  the  flexors 
of  the  forearm,  especially  on  the  right  side.  Motion  of  the 
shoulder-joints  is  painful.  There  is  extreme  kyphosis,  oc- 
cupying all  the  lumbar  and  most  of  the  dorsal  regions.  The 
vertebras  are  not  tender  on  pressure.  The  hip  and  knee- 
joints  are  held  flexed,  but  are  not  fixed.  The  left  knee- 
joint  is  somewhat  swollen,  the  right  little  if  at  all  so.  The 
legs  and  thighs  are  greatly  atrophied  ;  the  thigh  measuring 
only  seven  and  a  half  inches  at  its  upper  third.  The  ankle- 
joints  appear  nearly  free  from  disease.  The  patellar  reflex 
could  not  be  obtained.  The  examination  of  the  thoracic 
and  abdominal  viscera  was  negative,  except  for  a  few  rales 
in  the  lungs,  and  a  faint  systolic  murmur  in  the  heart. 

The  course  of  the  case  while  in  the  hospital  is  interest- 
ing, inasmuch  as  the  various  plans  of  treatment  tried  during 
the  four  months  appeared  to  have  little  or  no  influence 
upon  the  disease. 

The  diagnosis  of  the  case  was,  however,  of  great  inter- 
est, for  atrophy  developing  so  rapidly  and  reaching  such  a 
degree,  with  the  coexistence  of  a  posterior  curvature  of  the 
spine,  raised  the  question  whether  the  disease  of  the  joints 
might  not  be  of  the  nature  of  a  spinal  arthropathy.  Yet, 
the  long  immunity  which  the  patient  had  enjoyed  from  any 
evidences  of  disease  of  the  nerves  or  cord,  and  the  manner 
in  which  the  affection  of  the  joints  had  developed  and  pro- 
gressed, rendered  it  much  more  probable  that  it  was  of  a 
rheumatic  nature,  and  that  the  case  was  a  well-marked 
instance  of  arthritic  muscular  atrophy,  i.  c,  as  Paget  ex- 
plained it,  "a  reflex  atrophy,  due  to  the  disturbance  of  some 
nutritive  nervous  centre  irritated  by  the  painful  state  of  the 
sensitive  nerve  fibres."  Nevertheless,  some  doubt  is  thrown 
upon  the  genuineness  of  this  case  by  the  presence  of  de- 
cided wasting  on  the  distal  sides  of  the  affected  joints,  and 
by  the  absence  of  patellar  reflex,  both  of  these  being  rather 
more   characteristic    of  a    neuritis,   while    the    reflexes    are 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  789 

usually  increased  in  arthritic  muscular  atrophy.  It  is  pos- 
sible, however,  as  Bury  has  pointed  out,  that  in  addition  to 
the  joint  inflammation,  or  independentl>  of  it,  there  might 
have  developed  a  rheumatic  neuritis  of  certain  nerves. 

Dr.  F.  X.  Dercum  reported 

A   CASE   OF   ARTHRITIC    MUSCULAR   ATROPHY   OF 
GOXORRHCEAL   ORIGIN. 

H.  L.,  a  man  aged  thirty-six,  of  average  stature  and 
rather  slight  build,  presented  himself  at  the  University 
Hospital  with  the  following  history.  Fourteen  years  ago 
he  had  a  small  venereal  sore  which  healed  rapidly,  was  not 
followed  by  secondary  symptoms  and  was  probably  benign 
in  character.  Previous  to  and  since  this  time  he  had  been 
entirely  well.  In  the  middle  of  April  last  (1888),  however, 
he  contracted  gonorrhoea.  The  attack  does  not  seem  to 
have  been  of  more  than  ordinary  severity  and  ran  an  aver- 
age course.  Three  weeks  after  its  commencement  he  no- 
ticed great  pain  and  some  swelling  on  the  right  elbow. 
One  week  later  the  right  knee  became  similarly  affected 
and  he  was  obliged  to  take  to  his  bed.  One  after  another 
the  various  joints  of  the  extremities  were  attacked  though 
the  patient  no  longer  remembers  their  sequence.  He  sim- 
ply tells  us  that  shortly  after  the  appearance  of  pain  in  the 
right  knee,  both  ankles,  the  opposite  knee,  both  shoulders, 
and  the  joints  of  the  left  arm  were  affected. 

Four  weeks  after  the  involvement  of  the  right  elbow, 
wasting  of  the  muscles  of  the  upper  arm  on  the  same  side 
was  noticed.  Next  the  muscles  of  the  opposite  arm  and  of 
the  legs  were  observed  to  be  growing  smaller.  Gradually 
in  an  order  which  the  patient  unfortunately  cannot  recall, 
the  bulk  of  the  muscles  of  the  upper  and  lower  extremities 
were  involved. 

He  was  confined  to  bed  some  eight  weeks,  when  the 
pain,  in  a  measure,  subsided.  It  persisted,  however,  and 
is  still  marked  at  the  present  time.  At  first  the  weakness 
of  the  muscles  was  so  great  that  even  walking  was  impos- 
sible.    In  the  beginning  of  July,  however,  he  had  improved 


790  PHILADELPHIA  NEUROLOGICAL  SOCIETY. 

so  as  to  be  able  to  take  a  few  steps.  Since  that  time  he 
has  gained  sufficiently  to  walk  short  .distances  and  to 
ascend  a  stairway,  though  the  latter  is  still  a  difficult  feat. 

Though  the  pain  in  the  joints  had  for  a  long  time  been 
insufficient  to  interfere  with  movement,  his  arms  continued 
until  lately  to  be  almost  useless.  A  constant  [attendance 
of  a  relative  was  necessary  to  assist  him  in  eating,  dressing, 
and  the  ordinary  acts  of  life. 

His  present  condition  is  as  follows  :  All  of  the  muscles 
of  the  upper  and  lower  extremities  and  some  of  the,  back 
appear  to  have  suffered.  The  wasting  is  most  marked  in 
the  shoulders  and  upper  arms.  The  face  has  not  been 
attacked.  The  affection  is  quite  symmetrical  except  in  the 
back,  where  extreme  wasting  of  the  lower  portion  of  the 
trapezius  and  of  the  rhomboid  muscles  of  the  right  side  is 
contracted,  with  but  slight  wasting  of  these  muscles  upon 
the  left.  Fibrillary  tremors  are  readily  observed  in  various 
situations.  No  change  is  noted  in  the  myotatic  irritability, 
unless  it  be  that  the  knee-joint  is  slightly  increased.  Elec- 
trical examination  shows  that  no  qualitative  change  has 
taken  place.  Slight  diminution  to  both  currents  is,  how- 
ever, noticeable.  If  the  statements  of  the  patient  are  to  be 
trusted,  he  is  undoubtedly  improving.  He  tells  us,  for 
instance,  that  he  has  had  a  distinct  gain  in'the  arms  during 
the  past  month. 

Dr.  F.  X.  DERCUM  also  exhibited  a  patient  with 
A  SUBCUTANEOUS  CONNECTIVE  TISSUE  DYSTROPHY. 
This  case  is  one  which  has  been  described  in  full  in 
the  University  Medical  Magazine,  and  it  is  therefore  un- 
necessary to  give  the  details  of  it  here.  It  is  a  case  of 
dystrophy  of  the  connective  tissue.  Here  we  have  enor- 
mous hypertrophy  of  the  connective  tissue  which  is  in  an 
embryonal  state  ;  with  this  there  are  associated  many  of  the 
symptoms  of  myxcedema.  The  woman  noticed  some  three 
years  ago  that  the  arms  were  increasing  in  size.  Some  six 
months  later  she  began  to  have  pain  in  the  right  arm,  and 
this  symptom  has  been  confined  almost  entirely  to  the  right 
side.    The  pain  is  not  in  the  nerve  trunks  alone,  but  diffused 


PHILADELPHIA  NEUROLOGICAL  SOCIETY.  Jgi 

through  the  mass  of  tissue.  Upon  the  right  side  there  are 
also  some  anaesthetic  patches,  variable  in  extent.  These 
are  present  both  on  the  arm  and  leg.  There  are  other  sen- 
sory symptoms,  such  as  impairment  of  vision,  diminution  of 
hearing,  and  decided  impairment  of  taste  and  smell.  These 
are  all  most  marked  on  the  right  side.  The  muscles  of  the 
palm  are  a  little  wasted.  There  are  qualitative  changes  in 
the  reaction  to  the  galvanic  current. 

The  bulk  of  the  enlargement  is  due  to  mucous  tissue. 
She  is  the  subject  of  crises  of  pain  which  are  similar  to 
those  found  in  myxoedema,  and  these  attacks  are  attended 
with  hardening  of  the  part  where  the  pain  is  located.  There 
is  at  present  a  little  mass  in  the  posterior  cervical  triangle 
of  the  right  side,  which  forcibly  reminds  one  of  the  supra- 
clavicular swelling  described  by  writers  on  myxoedema.  I 
cannot  feel  the  thyroid  gland.  While  there  is  marked  dys- 
trophy of  the  subcutaneous  connective  tissue  and  some 
changes  in  the  muscles,  the  skin  is  not  involved.  This  is  a 
distinguishing  feature  between  this  case  and  myxcedema 
proper.  In  the  early  history,  however,  sweating  was  scanty 
or  absent.  Slowness  of  thought  or  slowness  of  movement 
are  not  marked.  There  has,  however,  been  decided  speech 
involvement  a  number  of  times,  which  has  appeared  to  be 
associated  with  the  crises.  Xot  only  would  the  neck  and 
arms  swell,  but  the  tongue  and  soft  palate  would  also  swell. 
There  has  also  been  bleeding  from  various  mucous  surfaces, 
as  the  mouth,  throat,  bronchial  tubes,  and  stomach.  The 
case,  therefore,  presents  many  of  the  symptoms  of  myxce- 
dema. My  explanation  of  the  peculiar  hardening  of  the 
tissue  is  that  there  is  some  obstruction  to  the  lymph  out- 
flow. Punctures  made  during  the  attacks  of  pain  resulted 
in  the  appearance  of  lymph-like  fluid. 

Dr.  H.  C.  WOOD  said  that  the  wasting  of  muscles  about 
an  inflamed  joint  has  long  been  noted.  It  is  seen  in  almost 
every  case  of  chronic  rheumatism.  Charcot  has  pointed 
out  that  this  is  independent  of  the  extent  of  the  joint  inflam- 
mation. It  may  occur  after  very  slight  injuries.  It  is  al- 
most always  the  extensors  that  suffer,  as  was  illustrated  by 
the  case  shown  by  Dr.  Dercum.    He  is  thoroughly  in  accord 


792  PHILADELPHIA   NEUROLOGICAL   SOCIETY. 

with  those  who  insist  upon  the  necessity  of  amalgamating 
the  various  so-called  nervous  diseases.  He  thinks  that 
there  are  very  few,  possibly  not  more  than  eight  or  nine, 
organic  diseases  of  the  nervous  system.  We  make  one  dis- 
ease of  chronic  inflammation  or  degeneration  of  one  tract  of 
the  cord,  and  when  the  same  change  is  found  in  another 
tract  it  is  given  a  different  name  ;  or  if  two  regions  happen 
to  be  affected  together,  we  have  still  another  disease.  We 
must,  of  course,  for  the  sake  of  convenience,  talk  about 
locomotor  ataxia  and  lateral  sclerosis,  etc.  But,  in  doing 
so,  we  must  understand  that  these  are  not,  properly  speak- 
ing, distinct  diseases — but  simply  clinical  groups  of  cases, 
each  group  characterized  by  certain  symptoms  due  to  the 
original  position  of  the  lesion — but  the  lesion  identical  in 
character,  and  occasionally  so  situated  as  to  make  cases 
whose  clinical  features  partake  of  those  of  several  groups. 

Dr.  William  Osler  regaided  one  of  the  cases  of  Dr. 
Mills  as  a  characteristic  example  of  amyotropic  lateral 
sclerosis.  The  spinal  form  of  progressive  muscular  atrophy 
in  its  later  stages,  usually  shows  signs  of  lateral  sclerosis, 
and  the  picture  presented  by  the  patient  of  wasted  arms  and 
spastic  legs  is  extremely  common.  In  chronic  cervical 
pachymeningitis  the  clinical  features  are  very  similar.  The 
condition  of  the  neck  is  no  evidence  that  there  is  anything 
the  matter  with  the  cervical  vertebrae. 

There  is  one  practical  point  in  regard  to  the  arthritic 
atrophies.  He  has  frequently  seen  good  results  follow  the 
use  of  massage,  electricity,  rubbing,  and  the  like,  if  used 
early.  If,  however,  the  condition  is  allowed  to  go  on  for 
months,  it  may,  and  often  does,  result  in  permanent  disa- 
bility and  uselessness  of  the  joint. 

It  is  not  improbable  that  the  case  presented  by  Dr.  Der- 
cum  may  be  allied  to  reported  instances  of  neuritic  and 
spinal  trouble  following  gonorrhoea.  Many  years  ago,  Gull 
and  others  called  attention  to  spinal  troubles  to  which  they 
gave  the  names  of  reflex  paraplegia,  in  association  with 
genito-urinary  disorders.     Many  of  these  cases  have  been 


PHILADELPHIA   NEUROLOGICAL    SOCIETY. 


793 


shown  to  be  forms  of  myelitis,  such  as  occur  in  other  micro- 
bic  affections. 


Dr.  F.  X.  DERCL'M  regarded  the  case  which  he  presented 
as  one  of  atrophy  following  gonorrhceal  rheumatism.  He 
thought  that  we  must  agree  that  we  have  two  forms  of  in- 
flammation or  degeneration  in  the  cord,  one  which  origi- 
nates in  the  connective  tissue,  and  one  which  originates  in 
the  nervous  tracts.  We  are  so  in  the  habit  of  speaking  of 
the  inflammation  of  the  columns  that  we  are  apt  to  forget 
that  these  affections  are  really  forms  of  degeneration. 
Doubtless  in  these  tract  degenerations  the  essential  factor 
is  frequently  a  feeble  vitality  impressed  upon  the  parts  dur- 
ing the  development  period.  We  must,  he  thought,  make 
a  distinction  between  the  diseases  affecting  the  sensory  and 
those  affecting  the  motor  tract,  but  whether  we  make  a  dis- 
tinction between  degeneration  of  the  upper  and  of  the  lower 
segment  of  the  motor  tract,  seems  to  be  immaterial.  In 
tabes  dorsalis  we  have  degeneration  of  the  sensory  tract, 
and  in  myelopathies  degeneration  of  the  motor  tracts. 

Dr.  James  Hendrie  Lloyd  said  that  Dr.  Osier  had 
referred  to  the  view  he  took  of  one  of  the  cases  presented 
by  Dr.  Mills,  a  traumatic  focal  lesion  with  secondary  degen- 
eration. If  we  are  to  assume  that  this  is  a'case  of  amyotro- 
phic lateral  sclerosis,  it  differs  from  many  cases  of  that 
affection  which  we  have  seen,  in  its  etiology,  at  least.  In 
this  case  there  was  a  distinct  history^of  traumatism,  the 
patient  being  thrown  by  an  explosion  upon  a  pile  of  iron, 
striking  the  back  of  his  neck  and  his  arm.  This  was  fol- 
lowed in  a  few  months  by  rapid  atrophy  of  all  the  muscles 
of  the  shoulder  and  arm  on  both  sides.  Later,  this  was  fol- 
lowed by  paralysis  of  a  peculiar  character  of  the  neck  mus- 
cles. This  is  followed  by  a  descending  degeneration, 
evidently  in  the  lateral  tracts,  shown  by  exaggerated 
patellar  reflex,  distinct  ankle-clonus,  and  rectus-clonus, 
without  atrophy  of  the  muscles  of  the  legs. 


794  PHILADELPHIA    NEUROLOGICAL  SOCIETY. 

His  view  is,  that  there  was  a  local  injury  of  the  cervical 
portion  of  the  cord,  causing  atrophy  of  the  cells  in  the  an- 
terior cornu,  and  that  possibly  from  the  injury  he  has  had  a 
descending  lateral  degeneration  through  the  motor  tract. 
There  is  at  present  another  case,  very  similar  to  this  one, 
in  the  Philadelphia  Hospital.  It  is  the  case  of  a  man  who 
fell  from  a  scaffold,  and  has  never  walked  since.  He  has 
progressive  atrophy  of  the  neck  and  upper  extremities,  with 
the  symptoms  in  the  legs  of  lateral  sclerosis.  The  cause, 
in  his  case,  is  distinct,  and  can  scarcely  be  denied. 


TRANSACTIONS  AMERICAN  NEUROLOGICAL 
ASSOCIATION. 

FOURTEENTH    ANNUAL   REPORT. 
Continued  from  November  Number. 

A    CASE    OF    FOCAL    EPILEPSY    SUCCESSFULLY 

TREATED  BY  TREPHINING  AND  EXCISION 

OF  THE   MOTOR  CENTRES. 

By  JAMES  HENDRIE  LLOYD,  M.D., 

AND 

JOHN  B.  DEAVER,  M.D. 
Medical  Report  by  Dr.  Lloyd. 

The  following  case  was  admitted  into  the  nervous 
wards  of  the  Philadelphia  Hospital  under  the  writer's  care, 
early  in  the  past  spring  : 

J.  W.  G.,  aged  thirty-five  years,  American  born.  Mother 
died  of  phthisis,  father  of  paralysis.  Patient  has  had  the 
usual  diseases  of  childhood.  He  denies  positively  ever  hav- 
ing had  any  venereal  disease.  When  fifteen  years  old  he 
was  struck  on  the  head  with  a  ball-bat,  from  which  blow  he 
became  unconscious  and  was  confined  to  bed  for  one  week. 
Further  details  of  his  condition  at  that  time  are  not  obtain- 
able. His  fits  did  not  begin  until  six  years  after.  Fourteen 
years  ago  he  had  his  first  seizure  while  asleep.  In  this  he 
bit  his  tongue.  The  question  arises  whether  this  was  his 
first  fit,  or  whether  really  it  was  not  rather  his  first  discov- 
ered fit  by  reason  of  the  wound  of  his  tongue.  Probability 
is  lent  to  the  latter  supposition  by  the  fact  that  many  of 
his  seizures  have  been  nocturnal.  Nine  months  after  his 
first  discovered  fit  he  had  his  first  seizure  during  the  day. 
After  this  time  he  had  them  varying  in  number  and  inten- 
sity until  admitted  to  the  hospital.  He  described  his  seiz- 
ures as  follows :    He  would  have  a  decided  sensory  aura 


jg6  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

commencing  in  the  fore  and  middle  fingers  of  the  left  hand, 
extending  up  the  arm,  through  the  neck  to  the  left  side  of 
the  head,  when  the  convulsion  wojuld  begin.  He  has 
stopped  the  aura  at  times,  and  thereby  the  fit,  by  tightly 
compressing  the  wrist.  The  aura  lasted  quite  an  appreci- 
able time,  and  gave  him  ample  notice  of  the  explosion. 

During  the  time  of  the  patient's  early  sojourn  in  the 
hospital  his  seizures  were  mostly  nocturnal.  He  was  con- 
scious of  many  of  these.  He  said  they  lasted  but  a  short 
time,  involving,  as  a  rule,  only  the  left  face  and  arm,  and 
that  he  did  not  always  lose  consciousness.  He  also  said 
that  he  has  had  occasional  attacks  involving  both  sides  of 
the  body,  but  his  accounts  of  these  were  not  clear,  and  it  is 
probable  that  his  consciousness  was  lost  or  obtunded  in 
these  greater  attacks.  The  few  minor  attacks,  which  hap- 
pened in  the  daytime,  occurred  during  the  absence  of  any 
trained  or  intelligent  observer,  but  several  of  his  fellow- 
patients  confirmed  in  the  main  his  own  account. 

In  order  to  render  the  diagnosis  more  positive  and  the 
description  more  exact,  Dr.  F.  \V.  Talley,  resident  physi- 
cian, began  a  systematic  nocturnal  watch  upon  the  patient, 
without  the  latter's  knowledge,  sitting  up  in  constant  vigil 
several  nights  in  succession.  During  the  first  night  nothing 
was  observed,  although  the  patient  said  in  the  morning  that 
he  was  sure  he  had  had  one  or  two  slight  seizures.  In  the 
second  night  Dr.  Talley  succeeded  in  observing  a  charac- 
teristic attack,  which  he  describes  as  follows  : 

The  fit  commenced  in  the  left  arm.  The  fingers  were 
flexed  over  the  thumb,  the  hand  flexed  at  the  wrist,  the 
forearm  flexed  upon  the  arm.  The  head  was  drawn  over 
to  the  right  side,  the  right  arm  and  leg  then  became  rigid. 
The  head  soon  began  to  rotate  to  the  left,  the  fingers  of  the 
left  hand  relaxed,  the  mouth  opened  and  was  drawn  to  the 
left  side  with  the  right  angle  depressed.  As  soon  as  the 
face  reached  the  median  line  a  series  of  clonic  spasms  be- 
gan in  the  left  arm  and  left  side  of  the  face.  (In  two  of  his 
most  severe  attacks  clonic  spasms  were  observed  in  his 
right  arm.  The  pupils  were  widely  dilated  and  fixed. 
Consciousness  appeared  to  be  preserved,  partially,  at  least, 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  Jg  J 

throughout.  The  spell  was  of  very  brief  duration.  Follow- 
ing the  fit  there  was  well-marked  paresis  of  the  left  arm 
and  left  side  of  the  face. 

These  memoranda  by  Dr.  Talley  very  faithfully  describe 
the  main  features  of  the  attack.  The  frequency  of  the  seiz- 
ures, on  account  of  which  the  patient  had  applied  to  the 
hospital,  increased,  and  they  occurred  both  day  and  night, 
so  that  they  were  soon  observed  by  the  nurses,  members  of 
the  resident  staff,  and  by  several  of  the  neurological  and 
surgical  staffs,  who  were  called  in  consultation.  The  great- 
est number  of  seizures  recorded  in  one  day  was  twenty- 
eight,  at  which  time  the  patient  seemed  to  be  passing  into 
a  veritable  epileptic  status,  being  confined  to  bed,  and  be- 
coming very  dull  and  altered  in  his  mental  condition. 

The  paresis  of  the  left  face  and  arm  at  this  time  began 
to  be  very  noticeable.  The  face  was  relaxed,  the  angle  of 
the  mouth  depressed,  and  the  right  or  sound  side  drawn 
over  perceptibly.  The  orbicularis  palpebrarum  muscle  was 
not  involved.  The  tongue  was  not  paralyzed  (?).  The 
pupils  were  equal  and  responded  to  light  and  accommoda- 
tion. The  arm  was  perceptibly  weakened,  especially  in  the 
flexors  of  the  fingers  and  wrist,  the  biceps,  and  the  deltoid. 
These  muscles  were  not  wasted,  and  did  not  present  any 
reactions  of  degeneration.  On  those  days  when  the  patient's 
fits  were  infrequent  this  paretic  state  of  the  muscles  im- 
proved considerably  in  the  longer  intervals,  and  was  most 
marked  just  after  a  seizure.  There  was  no  alteration  or 
retardation  of  tactile  sensibility.  An  examination  of  the 
eye-grounds  at  this  time  by  Dr.  de  Schweinitz  revealed 
nothing  indicative  of  organic  cerebral  changes. 

The  onset  of  these  seizures,  upon  which  special  stress 
was  laid  both  in  the  diagnosis  and  subsequent  surgical 
treatment,  was  always  the  same,  and  verified  by  numerous 
observations.  The  left  hand,  especially  the  two  fingers,  was 
the  seat  of  the  signal  symptoms,  both  sensory  and  motor, 
and,  however  varied  the  extent  of  the  convulsive  wave  in 
different  seizures,  there  was  never  any  variation  from  this 
constant  initiation.  The  convulsive  area  varied  consider- 
ably, from  a  slight  twitching  of  the  affected  face  and  arm, 


798  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

with  no  apparent  loss  of  consciousness,  to  an  almost  univer- 
sal bilateral  convulsive  explosion,  always  worse,  however, 
on  the  left  side,  with  decided  obscuration  of  consciousness. 
This  loss  of  consciousness  was  not  always  as  great  as  it 
appeared,  for  once  after  a  severe  seizure,  during  which  I 
asked  him  some  test  questions,  he  answered  them  correctly 
as  soon  as  he  regained  control  of  his  muscles.  The  patient 
complained  but  little  of  headache  and  said  it  had  never 
troubled  him  ;  the  slight  degree  of  it  from  which  he  suffered 
in  the  hospital  appeared  to  be  an  effect  of  his  rapidly  in- 
creasing seizures.     He  had  no  gastric  irritability  whatever. 

It  seemed  very  evident  to  my  mind  in  studying  this  case 
that  we  had  a  focus  of  discharge  in  the  region  of  the  junc- 
tion of  the  middle  and  lower  third  of  the  ascending  frontal 
convolutions  on  the  right  side,  possibly  involving  also  con- 
tiguous portions  of  the  ascending  parietal  convolutions  in 
which  experiment  seems  to  have  demonstrated  centres  for 
the  hand  and  wrist.  The  nature  of  this  irritative  lesion  did 
not  appear  very  clear  to  me,  although  I  was  inclined  to 
think  it  might  be  old  scar  tissue  and  thickened  membranes, 
the  results  of  his  injury.  I  considered  the  long  duration  of 
his  affection  to  contra-indicate  a  tumor,  especially  as  he 
had  neither  headache,  vertigo,  vomiting,  nor  changes  in  his 
eye-grounds  ;  although  the  focal  nature  of  the  discharge 
and  the  more  or  less  constant  paresis  of  the  convulsed  mus- 
cles were  very  suggestive  of  a  new  growth.  I  saw  no 
reason  to  doubt  the  man's  sincerity  on  the  subject  of  syph- 
ilis, but  I  classed  him  with  the  rest  of  mankind  and  gave 
him  the  benefit  both  of  the  doubt  and  the  iodides.  He  did 
not  improve.  A  consultation  was  held  with  my  colleague, 
Dr.  John  B.  Deaver,  of  the  surgical  staff,  and  an  operation 
discussed.  At  a  subsequent  consultation  with  Drs.  Deaver 
and  Sinkler  the  operation  was  decided  upon,  with  the  con- 
currence also  of  Drs.  Mills,  Dercum,  and  de  Schweinitz, 
who  kindly  saw  the  case  by  invitation. 

On  the  12th  of  June  Dr.  Deaver  operated  in  the  pres- 
ence of  the  above-named  physicians  and  with  the  assistance 
of  Dr.  J.  William  White.  The  details  of  the  operation  and 
the   surgical   aspects   of  the   case  will   be  narrated   by  Dr. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  799 

Deaver.  It  had  been  decided  beforehand  that  the  incision 
should  be  simply  an  exploratory  one  in  case  nothing  was 
discovered  in  the  membranes  or  cortex,  unless  by  faradic 
stimulation  we  should  succeed  in  locating  the  irritative  area 
in  the  cortex,  in  which  case  it  should  be  cut  out.  By  fol- 
lowing Reid's  and  Horsley's  lines,  Dr.  Deaver  exposed, 
with  an  inch  and  a  half  trephine,  an  area  which  appeared  to 
include  both  sides  of  the  central  fissure  (Rolandic)  in  the 
region  of  the  junction  of  the  lower  and  middle  thirds  of  the 
ascending  convolutions.  This  area  was  afterward  much 
enlarged,  especially  in  the  anterior  direction,  by  the  Hop- 
kins' modification  of  Rongier's  forceps.  Nothing  abnormal 
whatever  was  discovered  in  the  bone,  membranes,  or  cortex 
by  gross  inspection.  The  difficulty  of  identifying  the  parts 
was  so  great  that  exploration  was  soon  begun  with  a  fara- 
dic current,  and  with  very  gratifying  results.  Upon  faradi- 
zing  a  point  back  of  the  fissure  of  Rolando,  more  properly 
the  wrist  centre,  according  to  Ferrier,  muscular  contractions 
occurred  as  follows :  turning  in  of  the  thumb  on  the  palm, 
flexion  of  the  fingers,  flexion  of  the  wrist,  extending  to 
flexion  of  the  elbow  (biceps  action).  I  cannot  say  that  it 
was  verified  topographically — *.  e.,  by  appearance  of  fissures 
and  convolutions  seen  in  the  wound,  what  exact  centres 
were  here  excited.  It  was  behind  what  appeared  to  me  to 
be  the  Rolandic  fissure.  The  difficulty  of  identifying  fis- 
sures and  convolutions  in  a  small  trephine  wound  appears 
to  me  to  be  extraordinary.  What  is  of  greater  importance 
was,  however,  here  accomplished  ;  the  reproduction  of  the 
exact  muscular  movements  which  occur  in  the  fit.  At  a 
point  farther  front  and  below,  and  in  front  of  the  fissure 
seen  in  the  middle  of  the  wound  (Rolandic?),  faradic  stim- 
ulation caused  marked  contraction  of  the  face-muscles  of 
the  affected  side.  The  mouth  began  to  contract,  and  was 
drawn  toward  the  left  side  with  a  tremulous  motion,  and 
soon  the  tongue  began  to  protrude  toward  the  left  corner 
of  the  mouth.  Soon  the  left  thumb  began  to  be  contracted 
and  adducted  into  the  palm  ;  the  fingers  were  contracted 
into  the  palm  and  about  the  same  time  the  face  muscles  be- 
gan to  contract  more  actively,  while  the  head  was  drawn 


goo  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

to  the  left  side,  and  the  left  eyelid  began  to  work.  At  the 
same  time  the  hand  was  gradually  closed,  and  contraction 
of  the  forearm  and  arm  began,  while  the  latter  was  drawn 
from  the  side  to  an  angle  of  forty-five  degrees  (deltoid  ac- 
tion), and  contractions  of  the  biceps  occurred.  At  no  time 
in  the  course  of  the  faradic  applications,  anywhere  within 
the  area  exposed  by  the  trephine  and  forceps,  did  any  con- 
traction of  the  leg  muscles  occur. 

I  observed  especially,  in  making  these  applications  o( 
faradism  to  the  cortex,  that  considerable  areas  of  it  did  not 
appear  excitable  at  all  to  the  strength  of  current  employed, 
at  least  did  not  give  muscular  response  anywhere, 
while  the  two  comparatively  narrow  points  above  men- 
tioned reproduced  almost  exactly  the  muscular  contrac- 
tions of  the  epileptic  seizures,  and  seemed  to  stand  for  more 
"  centres  "  than  the  diagrams  of  those  who  have  experi- 
mented would  allow  to  any  such  narrow  areas. 

In  the  absence  of  any  visible  organic  lesion  it  was  de- 
cided to  excise  these  portions  of  cortex.  The  possibility  of 
a  sub-cortical  tumor  was  not  ignored,  but  there  was  abso- 
lutely no  evidence  of  such  in  any  alteration  of  the  vascular 
supply  or  of  the  consistency  of  the  brain  tissue.  The  parts 
did  not  bulge  into  the  wound,  nor  was  the  color  of  the  gray 
matter  in  any  way  changed.  Accordingly,  Dr.  Deaver  ex- 
cised from  the  region  back  of  the  central  fissure  a  portion 
about  twelve  millimetres  square,  carrying  the  incision  well 
down  to  the  white  matter.  Two  small  portions  were  re- 
moved from  the  excitable  region  anterior  to  the  central 
fissure.  Further  exploration  by  means  of  these  incisions 
failed  to  detect  any  tumor.  My  attention  had  not  been 
called  at  that  time  to  the  distinction  which  Franck1  makes 
between  the  faradic  excitability  of  the  gray  and  that  of  the 
underlying  white  matter.  This  distinction  is  that  the  gray 
matter  gives  rise  to  a  series  of  clonic  spasms  in  the  related 
muscles,  epileptiform  in  character,  continuing  even  after  the 
faradism  is  withdrawn,  while  the  white  fasciculi,  when  fara- 
dized,  cause  a  tonic  contraction  which   ceases  at  once  on 

1  Lccons  sur  les   Fonctions  Motrices  du  Cerveau,  etc.,  par  le  Dr.  Francois 
Franck,  Paris,  1887,  p.  107. 


AMERICAN  NE UR0L0G1CAL  A SSOCIA  TION.  80 1 

withdrawing  the  poles.  I  am  quite  positive  that  the  con- 
tractions caused  in  our  patient  by  stimulating  the  gray- 
matter  were  epileptiform — and  if  my  memory  serves  me, 
after  this  lapse  of  time,  the  white  fasciculi  at  the  bottom  of 
the  wound  were  also  touched  and  caused  but  a  momentary 
tonic  contraction. 

The  patient's  condition  after  the  operation  may  be  briefly 
epitomized  as  follows,  prefacing  with  the  remark  that  he 
was  watched  by  competent  observers  day  and  night  and  the 
nursing  records  kept  in  a  book. 

It  was  observed  from  the  first  that  he  slept  with  his  left 
eye  partly  open.  The  legs  moved  freely  and  were  never 
paralyzed.  The  left  arm  was  markedly  paretic,  lying  quite 
flaccid  by  his  side  ;  he  would  occasionally  raise  it  by  taking 
hold  of  it  with  his  right  hand.  His  left  face  was  also  par- 
etic. Late  on  the  first  night  he  had  his  first  convulsive 
movement ;  it  was  only  a  slight  twitching  of  the  left  side  of 
the  mouth  which  was  thus  drawn  to  the  left  side.  These 
twitchings  of  the  face,  accompanied  occasionally  by  twitch- 
ing of  the  left  hand  and  forearm,  continued  at  intervals  dur- 
ing the  first  six  days,  when  they  ceased,  and  the  patient  has 
never  had  any  convulsive  movement  whatever  since.  They 
were  not  so  severe  as  before  the  operation,  nor  so  wide- 
spread. About  the  third  day  there  was  some  stiffness  of 
the  fingers,  which  may  possibly  be  explained  by  irritation 
of  the  white  fasciculi  during  the  process  of  healing  of  the 
cortical  wound.  There  was  at  this  time,  according  to  the 
nurse's  records,  a  difference  in  temperature  of  the  two  sides, 
the  left  axilla  being  from  one  to  one  and  a  half  degrees 
higher.  After  one  of  his  twitching  spells  the  patient  spoke 
of  the  spells  returning,  but  he  never  mentioned  his  aura. 

On  the  fifth  day  his  muscular  condition  was  as  follows : 
The  flexors  of  the  wrist  and  fingers  were  almost  quite  par- 
alyzed. The  biceps  was  much  weakened.  The  pronators 
and  supinators  were  paretic.  When  told  to  raise  the  arm 
he  would  reach  for  it  with  his  sound  hand,  and  when  re- 
strained in  this  he  would  raise  the  affected  arm  with  a  sort 
of  fling  and  evidently  with  the  aid  mostly  of  the  shoulder 
and  chest  muscles.    All  his  attempts  to  move  the  paralyzed 


802  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

muscles,  especially  to  close  his  fist,  were  accompanied  by 
analogous  movements  of  the  right  arm.  All  the  muscles 
of  expression  of  the  left  face  were  affected,  as  well  as  the 
left  side  of  the  occipito-frontalis.  He  had  control  of  the 
orbicularis  palpebrarum.  When  he  laughed  the  muscles  of 
the  paretic  side  appeared  to  respond  almost  as  well  as  those 
on  the  sound  side  ;  which  seemed  to  show  that  a  cortical 
paralysis  is  not  absolute  as  far  as  bilaterally  associated 
movement  is  concerned.  The  patient  is  right-handed,  and 
has  never  been  aphasic. 

From  about  the  sixth  until  the  eighteenth  day  the  patient 
cannot  be  said  to  have  been  at  any  time  in  his  normal  men- 
tal state.  He  became  dull,  then  lachrymose  and  incoher- 
ent, and  for  a  part  of  the  time  had  marked  maniacal  delirium 
with  hallucinations  of  sight  and  hearing.  The  surgical 
condition  did  not  seem  adequate  to  account  for  this.  The 
operation  and  subsequent  treatment  had  been  conducted 
with  strict  antiseptic  precautions,  and  the  patient  never  had 
a  serious  rise  in  temperature.  There  appeared  to  be  head- 
ache at  times,  as  he  frequently  attempted  to  pull  off  his 
dressings.  There  was  at  this  time  much  oedema  of  the 
scalp.  While  he  was  at  his  worst  there  was  some  priapism, 
and  one  of  the  resident  physicians  was  confident  that  the 
patient  had  masturbated.  I  doubt  if  the  patient  in  his  con- 
dition at  the  time  was  conscious  of  it.  The  pupils  were 
dilated  and  the  eyes  expressionless.  There  was  one  invol- 
untary passage  of  urine.  During  his  most  delirious  and 
restless  stage  it  was  thought  that  he  did  not  move  his  left 
leg  as  much  as  the  right,  but  if  so,  this  was  the  only  time 
the  leg  was  affected.  His  left  face  became  much  more 
flushed  than  the  right.  From  this  ominous  condition  he 
began  gradually  to  improve  toward  the  end  of  the  third 
week,  until  he  could  sit  up,  and  so  gradually  began  to  get 
about.  By  the  end  of  the  fifth  week  he  was  practically  well, 
and  had  recovered  some  of  his  lost  muscular  power. 

The  following  memoranda  have  been  made  quite  re- 
cently (three  months  after  the  operation)  of  the  patient's 
condition.  He  has  had  no  convulsive  seizures  whatever 
since  his  convalescence. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  803 

Sensory  condition.  (Patient  blindfolded).  In  the  left,  or 
affected  hand,  he  feels  the  slightest  touch  with  the  blunt 
points  of  an  aesthesiometer.  There  is  no  retardation.  On 
the  forefinger  he  does  dot  discriminate  the  blunt  points  one 
inch  apart,  but  he  tells  the  sharp  points  one-quarter  inch 
apart.  In  the  other  fingers  and  on  the  right  hand  he  dis- 
criminates better.  With  weights  varying  from  two  to  twelve 
ounces,  patient  is  able  to  tell  the  heaviest  by  cutaneous 
pressure  as  well  on  affected  as  sound  side.  (The  paralyzed 
hand  has  a  more  delicate  skin  from  disuse.) 

The  patient  is  not  able  to  distinguish  form  when  an  ob- 
ject is  placed  between  his  forefinger  and  thumb ;  thus  he 
appears  quite  unable  to  tell  a  small  square  object,  a  silver 
quarter,  a  silver  dollar,  a  small  flower,  or  a  penknife.  It  is 
evident,  however,  that  this  is  not  a  sensory  but  a  muscular 
defect,  because  his  fingers  are  still  so  paretic  that  he  holds 
these  small  objects  in  the  most  awkward  way,  and  cannot 
move  or  twist  them  about  in  his  fingers  ;  hence  he  is  not 
able  to  bring  his  sensory  nerve  endings  in  rapid  contact 
with  the  outlines  of  these  things.  This  cannot,  therefore, 
be  quoted  as  a  proof  that  muscular  sense  is  in  the  motor  cor- 
tex.    His  sensation  to  pain  and  heat  is  perfect. 

Motor  condition.  With  a  dynamometer  his  right  hand 
registers  130,  his  left  hand  20.  He  makes  a  great  effort, 
straining  even  with  his  facial  muscles.  The  paretic  face  is 
slightly  flushed.  He  says  there  is  no  difference  in  the 
sweating.  In  the  left  face  the  tactile  sense  is  quick  and 
perfect.  He  cannot  close  the  left  eye  by  itself,  but  closes 
both  together — a  further  evidence  that  bilaterally  associated 
movements  are  not  lost  in  cortical  paralysis.  The  left  face 
is  still  markedly  paretic  and  the  tongue  deviates  to  the  left. 
The  muscles  especially  paralyzed  in  the  arm  are  the  flexors 
of  the  fingers.  The  forefinger  and  thumb  are  notably  weak 
and  awkward.  He  has  good  control  of  the  flexors  of  the 
wrist.  The  biceps  contracts  firmly.  He  says  he  has  a  feel- 
ing of  weakness  about  the  shoulder,  and  his  arm  moves 
awkwardly,  but  the  deltoid  and  individual  muscles  are 
apparently  about  normal.  The  regain  of  power  is  rather 
greater  than  was  expected. 


804  AMERICAN  XE UROLOGICAL  A SSOCIA  TION. 

Dr.  Allen  J.  Smith  makes  the  following  report  of  the 
appearances  of  the  excised  tissue: 

"  Three  pieces  were  referred  to  me  for  examination  ;  one 
governing  arm  alone  and  the  other  two  arm  and  face  move- 
ments. Stained  by  YVeigert  method.  Those  sections  from 
piece  governing  arm  alone  (post  to  fissure  of  Rolando),  each 
showed  numerous  foci  of  infarction,  apparently  recent  and 
possibly  due  to  some  violence  to  the  tissue  during  oper- 
ation. There  was  possibly  some  degeneration  in  the  corti- 
cal substance,  but  at  most  very  slight.  In  the  large  pieces 
governing  arm  and  face  (taken  from  anterior  to  fissure  of 
Rolando)  there  is  a  distinct  degeneration  of  the  large  multi- 
polar pyramidal  cells,  with  the  same  foci  of  hemorrhage  as 
in  the  smaller  pieces.  A  number  of  these  large  cells  seem 
to  be  in  a  condition  approaching  fatty  metamorphosis,  and 
small  granular  bodies,  like  fat  drops  make  up  the  bulk, 
which  is  less  than  usual,  and  in  most  cases  shrunken  away 
from  the  walls  of  tissue  about  the  cells.  These  degenerated 
cells  refuse  to  take  the  stain  as  well  as  their  comrades  that 
are  undegenerated." 

In  closing  the  account  of  this  case  it  seems  proper  to 
offer  a  few  special  observations.  As  far  as  I  am  aware, 
there  have  been  two  cases  operated  on  in  which  no  discov- 
erable lesion  was  present  and  in  which  the  irritable  area 
was  mapped  out  with  faradism  and  removed.  There  may, 
of  course,  be  others.  The  two  to  which  I  refer  are  one  of 
Mr.  Horsley's  cases,-  and  one  operated  on  by  Dr.  Keen,  of 
Philadelphia.  The  propriety  of  the  operation  is  to  be 
decided  upon  in  individual  cases,  and  cannot  yet  be  made 
the  subject  of  a  general  rule  ;  it  must  depend  largely  upon 
special  features,  as,  for  instance,  the  strictly  focal  character 
of  the  fits,  their  severity  and  frequency,  and  the  extent  to 
which  they  destroy  usefulness  or  jeopardize  life.  Macewen  3 
discusses  the  propriety  of  removing  large  wedges  of  brain- 
cortex,  and  lays  much  too  great  stress,  it  seems  to  me, 
upon  the  evils  of  producing  hemiplegia  in  trying  to  cure 
fits — to  which  it  may  be  said,  in  the  light  of  this  case  that, 

*  British  Med.  Journal,  April  23,  18&7. 
liritihh  Med.  Journal,  August  II,  1888. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  805 

first,  in  curing  focal  epilepsy  it  may  not  be  necessary  to  cut 
out  such  large  wedges  as  to  produce  hemiplegia,  and,  sec- 
ond, the  evils  of  a  partial  monoplegia  are  certainly  not  to 
be  compared  with  the  direful  effects  of  frequently  repeated 
epileptic  seizures. 

SURGICAL   REPORT   BY    DR.  JOHN   B.  DEAVER. 

J.  W.  G.,  on  June  11,  1888,  the  day  previous  to  the  oper- 
ation, had  his  bowels  moved  freely  with  a  saline  purgative  ; 
his  urine  carefully  analyzed  and  examined  microscopically, 
showing  it  to  be  normal ;  and  his  chest  examined  with 
negative  results.  He  was  given  a  warm  water  bath,  fol- 
lowed by  a  boric  acid  bath,  then  the  entire  scalp  was 
closely  shaved,  washed  with  turpentine  and  scrubbed  with 
soap  and  water,  then  washed  with  ether  and  alcohol,  when 
it  was  enveloped  in  a  towel  wrung  out  of  1  :  1000  solution 
of  the  bichloride  of  mercury.  Here,  I  feel  justified  in  say- 
ing that  part  of  the  success  of  all  operations  is  attributable 
to  the  careful  preparation  of  the  patient.  During  the  oper- 
ation the  following  day,  June  12th,  the  most  strict  antiseptic 
precautions  were  observed. 

Operation,  June  12th,  1 1  A.  M. — The  patient  was  placed 
on  the  table  for  operation.  A  hypodermatic  injection  of 
one-quarter  grain  of  sulphate  of  morphia  was  given  imme- 
diately before  the  anaesthetic  was  administered,  the  object 
being  to  contract  the  arterioles  and  thus  lessen  the  amount 
of  bleeding.  Chloroform  was  administered  until  the  patient 
was  fully  under  its  influence,  when  sulphuric  ether  was  sub- 
stituted and  continued  throughout  the  operation.  In  the 
presence  of  the  neurological  staff  of  the  hospital,  and 
assisted  by  my  colleague,  Dr.  J.  William  White,  I  first 
mapped  out  upon  the  scalp  of  the  right  side  of  the  head, 
the  seat  of  operation,  the  fissures  of  Sylvius  and  Rolando 
by  using  Reid's  lines  (see  Lancet,  1884,  p.  359),  which  I  will 
describe.  First,  draw  a  line,  which  runs  from  the  lower 
border  of  the  orbit  through  the  centre  of  the  bony  meatus 
of  the  ear.  To  find  the  fissure  of  Sylvius,  draw  a  line  from 
a  point  one  and  one-quarter  of  an  inch  behind  the  external 
angular  process  of  the  frontal  bone  to  a  point  three-quarters 


806  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

of  an  inch  below  the  most  prominent  part  of  the  parietal 
eminence.  Measuring  from  before  backward,  the  first 
three-quarters  of  an  inch  of  this  line  will  represent  the 
main  fissure  and  the  rest  of  the  line  the  horizontal  limb. 
The  ascending  limb  starts  at  the  point  indicating  the  ter- 
mination of  the  main  fissure — i.  e.,  two  inches  behind  the 
external  angular  process,  and  runs  from  this  vertically 
upward,  for  about  an  inch.  The  fissure  of  Rolando  is  found 
by  drawing  two  lines  from,  and  perpendicular  to,  the  base 
line  to  the  top  of  the  head,  one  passing  through  the  depres- 
sion in  front  of  the  ear  and  the  other  through  the  posterior 
border  of  the  mastoid  process.  The  fissure  of  Rolando  is 
now  represented  by  a  line  drawn  from  the  point  of  inter- 
section of  the  posterior  vertical  line  with  the  line  connect- 
ing the  nasal  eminence  with  the  external  occipital  protu- 
berance, indicating  the  great  longitudinal  fissure,  to  the 
point  of  intersection  of  the  anterior  vertical  line  with  the 
line  representing  the  fissure  of  Sylvius,  upon  either  side  of 
which  are  the  ascending  frontal  and  parietal  convolutions 
containing  the  centre  we  wished  to  remove  in  this  case. 

I  prefer  Reid's  lines  to  Broca's,  Lucas  Championniere's, 
Hare's,  or  Wilson's  method  of  locating  the  fissures,  as  I 
have  proven  them  upon  the  cadaver  to  be  quite  as  correct 
as  any  of  the  others,  and  I  think  simpler  and  more  compre- 
hensible ;  and  again,  as  they  map  out  more  fissures  than 
do  the  others,  as  brain  surgery  advances  they  will  be  more 
useful.  Over  and  a  little  in  advance  of  the'  middle  third  of 
the  line  representing  the  fissures  of  Rolando  after  all  the 
layers  of  the  scalp,  including  the  periosteum,  had  been  dis- 
sected up  by  making  a  large  horseshoe-shaped  flap,  with 
its  convexity  downward  and  forward,  thus  favoring  drain- 
age, a  trephine  one  and  a  half  inches  in  diameter  was  ap- 
plied to  the  skull  and  a  section  of  bone  corresponding  in 
size  to  that  of  the  trephine  removed.  Thus  far  both  the 
soft  parts  and  the  bone  were  perfectly  normal,  there  being 
not  the  slightest  evidence  of  depression  of  the  latter.  The 
dura  mater,  which  now  presented  at  the  bottom  of  the 
wound  intact  and  normal,  was  incised  and  reflected,  thus 
laying    bare    the  arachnoid  and  pia  mater,  both  of  which 


AM  ERIC  AX  NE  UROL  OGICAL  A  SS0C1A  TIOX.  8o  J 

membranes  to  the  naked-eye  appearances  were  healthy. 
Before  incising  the  hemisphere  (to  make  sure  we  were  over 
the  proper  area)  Dr.  J.  Hendrie  Lloyd  applied  electrodes 
which  had  been  wrapped  with  sublimated  cotton,  and 
which  was  lying  in  a  I  :  iooo  solution  of  the  bichloride  of 
mercury,  to  the  surface  of  the  brain  thus  far  exposed,  with 
the  result  of  bringing  about  movement  of  the  fingers  and 
wrist  but  not  of  the  forearm,  when  I,  with  a  pair  of  Hopkins' 
modification  of  Rongier's  forceps,  cut  away  several  small 
pieces  of  bone  from  the  anterior  margin  of  the  opening 
made  by  the  trephine,  Dr.  Lloyd  again  applied  the  elec- 
trodes when  the  forearm  was  flexed  and  supinated,  the 
angle  of  the  mouth  elevated,  and  the  face  muscles  con- 
tracted. A  saturated  solution  of  boric  acid  containg  four 
per  cent,  of  hydrochlorate  of  cocaine  was  now  applied  to 
the  arachnoid  and  pia  mater  to  contract  the  blood-vessels 
of  the  latter  membrane.  With  an  ordinary  sized  scalpel, 
held  perpendicularly,  three  pieces  of  brain  tissue,  each 
three-quarters  of  an  inch  in  depth,  were  removed,  one-half 
an  inch  square  in  size,  back  of  the  fissure  of  Rolando,  and 
two  smaller  portions  anterior  to  the  Rolandic  fissure. 

The  cut  vessels  of  the  pia  mater  were  ligated  with  fine 
juniper-oiled  catgut,  and  hot  water  applied  to  the  surface 
to  check  the  oozing  ;  the  latter  proved  to  be  very  efficient. 
A  few  strands  of  heavy  juniper  catgut  were  placed  in  the 
bottom  of  the  wound  and  the  flaps  of  the  dura  mater  ap- 
proximated over  it  and  sutured  with  catgut.  Again,  a  few 
strands  of  heavy  juniper  catgut  were  placed  in  the  wound, 
resting  on  the  sutured  dura  mater,  the  skin  flaps  approxi- 
mated and  sutured  with  silver  wire.  The  wound  was 
dressed  antiseptically  (bichloride  of  mercury  being  used), 
and  the  patient  sent  back  to  the  ward. 

The  temperature  of  the  patient  after  the  operation  was 
97°  Fahrenheit;  in  the  evening  of  the  same  day  990;  pulse 
98;  respiration  15.     Ordered  milk  and  lime-water. 

June  ij. — Temperature  99*0,  pulse  94,  respiration  16. 
Dressings  not  soiled ;  bowels  moved  slightly.  Ordered 
potass,  bromide,  gr.  xx,  every  four  hours. 

ijt/i. — Dressings  slightly  stained  ;  wound  dressed,  when 


8o  8  AMERICAN  NE  UR  OL  OGICAL  A  SSOCIA  TION. 

found  to  be  completely  sealed.  No  discharge.  Pulse, 
respiration,  and  temperature  normal. 

i5t!l- — Dressing  not  disturbed.  No  pain.  Pulse,  respir- 
ation, and  temperature  normal. 

16th. — Dressings  slipped.  Wound  had  to  be  dressed. 
No  discharge. 

17th. — Patient  not  quite  so  well  ;  is  restless,  showing 
some  evidence  of  cerebral  irritation.  Complains  of  some 
pain  in  the  head.  Pulse  84,  respiration  16,  temperature 
ico°  Wound  dressed  and  found  healthy.  Xo  discharge. 
The  scalp  behind  the  wound  is  oedematous.  Ordered  ice- 
bag  to  the  head,  and  calomel,  \,  with  Dover's  powder,  gr. 
ij,  every  three  hours. 

18th,  11  p.  m. — Patient,  while  asleep  and  dreaming,  tore 
off  his  dressings.  Wound  dressed,  when  the  inner  dressing 
alone  was  found  slightly  stained  with  bloody  serum,  other- 
wise healthy.  Scalp  still  cedematous.  Patient's  general 
condition  much  better.  Bowels  were  moved  after  the  ad- 
ministration of  a  simple  enema. 

igth. — Wound  dressed,  six  sutures  removed,  allowing 
three  to  remain.  The  points  from  where  the  sutures  were 
removed  were  touched  with  solid  stick  of  nitrate  of  silver. 

21st. — Patient  more  restless  than  the  day  previous. 
Pulled  at  the  dressings,  necessitating  a  redressing  of  the 
wound,  which  was  found  free  from  discharge,  and  healthy. 
Pulse,  respiration,  and  temperature  normal. 

2jth. — Patient  attempted  to  remove  his  dressings,  but 
was  not  successful.  The  dressings  were  removed,  when 
the  wound  was  found  to  be  healed.  The  three  remaining 
sutures  taken  out,  and  the  points  corresponding  to  the  site 
of  the  sutures  touched  with  solid  stick  of  nitrate  of  silver. 
The  part  of  the  scalp  covering  the  trephine  opening  was 
quite  prominent,  and  upon  palpation  fluctuation  was  de- 
tected. I  made  an  incision  into  the  scalp  here  at  two 
points,  evacuating  bloody  serum  only.  I  then  introduced 
a  small  rubber  drainage  tube  and  dressed  the  wound. 
Pulse,  respiration,  and  temperature  normal.  Patient  com- 
plains of  no  pain  ;  tongue  dry;  calomel  and  Dover's  pow- 
der stopped.     Ordered  whiskey  half  an    ounce,  two   grains 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  809 

of  quinine  every  four  hours,  and  also  three  drops  of  turpen- 
tine, in  emulsion,  every  six  hours. 

27th. — Wound  dressed,  drainage  tube  behaving  nicely, 
very  little  discharge. 

28th. — Bowels  were  moved  after  an  enema  had  been 
given. 

2QtJi. — Wound  dressed.  Still  some  little  serous  dis- 
charge through  the  drainage  tube.  Stopped  emulsion  of 
turpentine,  but  continued  with  the  quinine  and  whiskey. 

July  1. — Bowels  moved  twice  during  the  night.  Patient 
comfortable  and  doing  well  in  every  respect. 

2d. — Wound  dressed.     Drainage  tube  removed. 

3d. — Three  weeks  since  the  operation,  patient  allowed 
to  sit  up. 

4th. — Bowels  moved. 

6th. — Wound  dressed,  very  little  discharge  of  serum 
from  tract  of  drainage  tube. 

12th. — Wound  dressed.  Still  a  little  discharge  of  serum 
from  tract  of  drainage  tube.  No  pain  or  tenderness  on 
pressure.  The  pulsation  of  the  brain  at  the  centre  of  the 
flap  covering  the  trephine  opening  in  the  skull  was  very 
marked. 

iyth. — Wound  all  healed.  No  further  dressing  applied. 
Patient  entirely  well.     Walks  about  the  hospital. 

The  deductions  which  I  would  draw  from  this  case  are 
that  this,  as  well  as  other  cases,  proves  that  excision  of 
parts  of  the  brain  can  be  dene  with,  I  may  say,  perfect  im- 
punity ;  therefore,  in  the  case  of  a  lesion  the  nature  of 
which  is  doubtful,  and  which  in  a  short  time  will  destroy 
the  patient's  usefulness  if  not  his  life,  why  not  here,  as  well 
as  in  the  abdominal  cavity,  make  an  exploratory  incision  ? 
I  think  our  success  is  due,  largely,  in  these  cases  to  the  pre- 
caution taken  in  regard  to  strict  cleanliness. 

Since  Mr.  Macewen  has  practised  putting  back  the  but- 
ton of  bone  removed  in  trephining  and  obtaining  union, 
you  may  ask  yourselves,  Why  did  I  not  likewise  ?  Not- 
withstanding I  had  subjected  the  large  button  of  bone,  as 
well  as  the  small  pieces  removed  in  my  case,  to  the  proper 
treatment,  preparing   them    to  be  reposited,  I  do  not  think 


8  1 0  AMERICAN  XE  i  'ROL OGICAL  A SSOCIA  TIOX. 

it  worth  while  to  place  back  so  large  a  piece,  as  I  had  seen 
this  done  in  the  practice  of  two  of  my  friends,  and  in  both 
cases  it  necrosed  and  had  to  be  removed  ;  neither  did  I 
have  at  hand  the  proper  instrument  with  which  to  divide 
the  large  piece  of  bone  into  small  pieces  or  resolve  it  to 
bone-dust.  Had  I  done  the  latter  and  placed  it  in  the 
wound,  it  would  not  have  been  safe,  owing  to  my  not  hav- 
ing absolute  apposition  of  the  flaps  of  dura  mater,  in  which 
event,  the  brain  would  have  been  subjected  to  irritation, 
from  the  presence  of  the  small  particles  of  bone.  The  last 
examination  made  of  this  case,  September  14,  1888,  by  Dr. 
Lloyd  and  myself,  shows  the  opening,  with  the  exception 
of  a  point  at  its  centre,  a  quarter  of  an  inch  square,  to  be 
filled  in  with  bone.  At  the  point  referred  to  very  slight 
pulsation  of  the  brain  can  be  detected.  Here  we  have  had 
regeneration  of  bone  from  the  periosteum,  therefore.  I  am 
now  well  satisfied  with  the  course  I  pursued  and  feel  sure 
before  long  the  entire  opening,  made  in  the  skull  at  the 
time  of  the  operation,  will  be  closed  by  bony  plate. 

DISCUSSION"   OF    DRS.  LLOYD   AND    DEAVER'S   PAPER. 

Dr.  David  Ferrier,  of  London,  congratulated  the 
gentlemen  upon  the  success  of  the  operation.  It  was  per- 
haps, however,  a  little  early  to  say  that  the  case  was  cured. 
In  several  cases  of  his  own  of  the  true  Jacksonian  type  of 
focal  epilepsy  without  loss  of  consciousness  he  had  excised 
and  the  patient  had  not  been  cured.  He  referred  particu- 
larly to  the  case  of  the  son  of  a  medical  man  in  whom  after 
a  blow  on  the  side  of  the  head  there  had  been  epileptic 
seizures,  beginning  in  the  left  hand.  Lister  had  trephined, 
expecting  to  find  a  spicule  of  bone;  but  the  skull  was  not 
even  thickened.  Horsely  had  subsequently  repeated  the 
operation,  but  the  attacks  had  not  subsided.  Even  though 
begun  as  a  local  lesion,  the  removal  of  this  lesion  does  not 
always  effect  cure,  the  system  having  apparently  become 
habituated  to  the  attacks.  The  sooner  such  cases  were 
operated  upon  the  better.  The  motor  paresis  in  Dr.  Lloyd's 
case  favored  the  assumption  of  an  organic  lesion.  Cases 
having  an  organic   lesion  were   more  apt  to  recover.     He 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  8  I  I 

inquired  whether  the  paresis  referred  to  continued  between 
the  intervals  of  the  attacks. 

Dr.  Lloyd  replied  that  it  was  diminished  during  the 
intervals,  but  that  it  never  entirely  disappeared. 

Dr.  Ferrier  referred  to  the  symptoms  of  postep  c 

hemiplegia  as  possibly  of  the  same  character.  Cases  of 
operation  for  traumatic  lesion  with  thickening  of  the  mem- 
branes do  well.  He  referred  to  the  case  of  a  young  man 
who  received  an  injury  over  the  posterior  extremity  of  the 
superior  frontal  and  the  ascending  frontal  convolutions 
when  eight  years  of  age.  Ten  or  twelve  years  had  elapsed 
before  the  operation,  when  he  was  having  as  many  as  three 
hundred  fits  in  fourteen  days.  The  cicatrix  and  thickened 
tissue  was  removed.  Three  years  had  since  elapsed  and 
the  patient  remained  so  much  improved  as  to  be  able  to 
earn  his  living. 

The  case  of  Dr.  Lloyd  was  interesting  also  as  a  physio- 
logical experiment.  He  understood  that  there  was  paraly- 
sis after  the  operation  while  the  tactile  sense  was  perfect, 
any  difficulty  in  distinguishing  objects  being  evidently  due 
to  impairment  of  the  mechanism  upon  which  associated 
movements  depends.  The  speaker  inquired  whether  Dr. 
Lloyd  had  tested  the  sensibility  by  passive  movements. 
The  case  was  interesting  as  a  proof  that  after  the  removal 
of  the  motor  centres  the  tactile  sensibility  was  preserved. 

Mr.  Victor  Horsley,  F.R.S.,  of  London,  referring  to 
the  question  of  recurrence  in  epilepsy,  cited  a  case  in  which 
the  facial  region  was  excised  after  stimulation  with  fara- 
dism.  Lingual  equilibrium  was  obtained,  which  was  not 
present  before  the  operation  and  the  fits  were  absent  for 
three  weeks,  when  they  returned.  The  speaker  referred  to 
another  case,  ia  which  after  excision  of  a  focus  there  had 
been  no  fits  for  two  years,  and  to  another,  operated  upon 
twenty-three  months  ago,  in  which  there  had  been  no  fits 
since.  He  would  not,  however,  venture  to  say  that  the 
case  was  cured.  In  his  opinion  five  years  should  first  have 
elapsed.  To  free  the  patient  from  epileptic  attacks  for  six 
months  or  two  years  would,  however,  restore  mental  power 
and  was  no  insignificant  result.     He  agreed  with  the  pre- 


8l2  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

vious  speaker  that  the  operation  should  be  done  as  early  as 
possible.  The  faradization  of  the  cortex  for  the  purpose  of 
diagnosis  was  a  step  in  advance.  He  had  himself  irritated 
the  corpora  quadrigemina  in  one  case  without  unfavorable 
symptoms. 

Referring  to  the  muscular  sense,  the  speaker  stated  that 
it  had  two  phases,  that  of  moving  the  segment  and  that  of 
moved  it.  In  some  cases  the  last  was  impaired  without  the 
impairment  of  the  first.  He  referred  to  Mr.  Steadman's 
method  of  gauging  the  appreciation  of  muscular  sense  by 
seizing  the  segment  by  the  side. 

In  regard  to  the  surgical  aspect  of  the  operation,  drain- 
age did  not  require  that  the  convexity  of  the  flap  should  be 
downward.  In  his  second  case  he  had  sloughing  of  the 
dura  from  division  of  the  temporal  artery  by  this  pro- 
cedure. He  now  cut  the  convexity  of  the  flap  upward  and 
backward.  With  the  patient  lying,  full  drainage  was  se- 
cured. The  speaker  used  the  spray  for  the  purpose  of  con- 
tinuous irrigation.  He  had  tried  intermittent  irrigation, 
but  found  that  it  did  not  do  so  well. 

DR.  W.  W.  Keen  stated  that  he  found  irrigation  un- 
necessary, washing  with  sponges  being  all  that  was,  in  his 
opinion,  required. 

DR.  Gray  was  glad  to  hear  so  conservative  a  rule  as 
five  years  for  determining  the  cure  of  focal  epilepsy.  Even 
in  idiopathic  epilepsy  the  duration  of  the  intervals  between 
the  attacks  varied  enormously  at  different  times.  In  sev- 
eral cases  in  his  experience  the  fits  had  been  absent  for 
three  or  four  years.  In  one  case,  that  of  an  intelligent 
man,  there  was  cessation  for  ten  years.  In  regard  to  the 
question  of  cure  in  reflex  epilepsy,  he  referred  to  a  case  of 
petit  mal,  in  which  the  cure  of  a  vaginitis  was  followed  by 
recovery,  also  to  a  case  of  the  laryngeal  type  in  which 
there  was  cessation  for  several  years  after  the  removal  of 
the  growth.  He  also  referred  to  a  case  in  which  the  con- 
vulsion was  limited  to  the  hand.  Frank  W.  Rockwell  had 
cut  down,  incised  the  dura,  and  found  a  growth  of  a  dark 
color,  supposed  to  indicate  a  gliomatous  formation  ;  he  did 
not  excise,  but  the  convulsions  were  absent  for  four  months 


AMERICAN  NE UROL  OGICAL  A SSOCIA  TION.  8  1  3 

following.  Now,  however,  they  were  as  bad  as  before.  In 
another,  a  case  of  intracranial  syphilis,  the  convulsion  was 
limited  to  one  upper  extremity,  and  operation  was  deter- 
mined upon.  The  operator,  however,  not  believing  in  anti- 
sepsis, the  patient  died  from  violent  acute  encephalitis,  the 
brain  being  honeycombed  with  pus. 

Dr.  Dana  had  understood  Dr.  Lloyd  to  state  that  there 
was  some  disturbance  of  the  sensibility  in  the  fingers  ;  he 
had  also  stated  that  there  had  been  a  loss  of  the  sensory 
aura  present  before  the  operation.  It  was  hardly  fair  to 
say  that  the  cutaneous  sensibility  was  not  disturbed. 
Further,  the  part  excised  was  small,  the  sensory  centres 
occupied  a  space  larger  than  those  of  the  motor  centres. 

Dr.  Mills  shared  Dr.  Ferrier's  impression  that  true 
cutaneous  sensibility  was  not  destroyed  in  this  case.  The 
method  of  examination  with  the  sharp  and  blunt  points  of 
the  aesthesiometer  was  defective.  Great  variations  would 
be  found  even  in  the  present  company  in  regard  to  these 
tests.  The  personal  equation  made  a  great  difference. 
Blindfolded,  this  patient  would  instantly  detect  the  gentlest 
impression,  the  lightest  touch  or  breath  upon  the  skin. 
When  given  objects  of  peculiar  shapes,  he  would  fail  to 
recognize  them,  apparently  because  unable  to  run  the 
fingers  over  them   as  in  the  other  hand.     His  difficulty  lay 

chiefly  in  motor  inability  to  apply  the  tests. 

Mr.  HORSELY  stated  that  so  far  as  he  knew  he  had 
been  the  first  to  propose  the  blindfold  test,  the  patient  with 
his  forefinger  indicating  the  point  touched.  He  referred, 
too,  to  the  fact  that  if  the  representative  of  a  whole  seg- 
ment was  removed  with  marked  loss  of  tactile  sensibility, 
recovery  proceeded  from  the  proximal  end  downward,  the 
same  as  the  anaesthesia  of  hysteroid  cases. 

Dr.  Seguin  would  place  upon  record  the  fact  that  the 
patient  operated  upon  by  Dr.  Weir  last  year  is  now  in  a 
fair  condition  of  recovery.  During  the  summer  he  had  had 
a  few  convulsions,  affecting  the  right  hand  and  cheek. 
There  is  no  headache  or  choked  disk.  There  is  more 
paresis  of  the  right  arm  than  in  the  summer.  There  was 
unquestionable  anaesthesia  of  the  cheek,  hand  and  forearm 
to   contact   tests   as  well   as  to   the    esthesiometer.      The 


8  1 4  AMERICAN  NEUROLOGICAL  ASSOCIA  TIOX. 

patient  does  not  feel  slight  contact  tests  unless  there  is 
some  indication  in  the  temperature  of  the  object  applied. 
He  estimates  small  differences  in  weights.  There  is  also 
anaesthesia  of  the  lower  part  of  the  face,  the  lips,  and  the 
inside  of  the  cheek. 

Dr.  Godfrey,  of  Bridgeport,  has  recently  found  that 
the  patient  does  not  taste  sugar  upon  the  right  side  of  the 
tongue.  The  wound  in  this  case  involved  a  piece  of  the 
cortex  and  adjacent  white  matter  one  inch  in  diameter  and 
of  considerable  depth,  as  the  growth  had  to  be  scooped  out. 

Dr.  FERRIER  asked  what  was  the  character  of  the  sen- 
sibility in  the  leg  and  trunk. 

Dr.  Seguix  replied  that  in  the  leg  it  was  normal.  In 
the  trunk  he  could  not  say. 

Dr.  Ferrier  asked  what  was  the  situation  of  the  tumor. 

Dr.  SEGUIX  replied  that  it  occupied  the  caudal  extrem- 
ity of  the  second  frontal,  extending  partly  under  the  prae- 
central,  covering  the  face  and  arm  centres. 

Dr.  Ferrier  asked  whether  it  extended  to  the  longi- 
tudinal tissue. 

Dr.  Seguix  replied  that  it  was  situated  two-thirds  ot 
the  way  down  to  the  fissure  of  Sylvius. 

Dr.  Ferrier  asked  what  was  the  size  of  the  tumor. 

Dr.  Seguix  replied  that  it  was  about  eighteen  mm. 
across  and  almond-shaped.     It  was  a  sarcomatous  growth. 

Dr.  Lloyd  stated  that  he  had  not  referred  to  the  path- 
ological examination  in  his  case,  because  not  yet  complete ; 
but  he  had  been  told  by  the  pathologist  this  morning  that 
there  was  evidence  of  degeneration  in  the  large  pyramidal 
cells.  When  he  had  said  that  the  patient  was  cured,  he 
had  simply  meant,  that  so  far  the  patient  had  been  relieved. 
Previous  to  the  operation  he  had  been  having  as  many  as 
twenty-eight  convulsions  in  a  day,  and  since  the  operation 
he  had  not  had  one  authentic  attack.  If  in  the  future 
recurrence  takes  place,  he  would  not  neglect  to  report  it. 
While  the  tests  for  muscular  and  tactile  sensation  were  not 
very  exact,  perhaps,  he  thought  that  the  patient  did  have 
some  difficulty  in  locating  the  point  of  contact,  he  would 
mistake  one  finger  for  another.  It  seemed  to  the  speaker 
that  the  fact  of  a  sensory  aura  in  the  case  showed  that  sen- 
sation was  inherent  in  the  cortex. 


A   CASE    OF   ACUTE    FATAL   NEURITIS   OF 
INFECTIOUS   ORIGIN  ;    WITH    POST- 
MORTEM   EXAMINATION. 

By  JAMES  J.  PUTNAM,  M.D., 

OF   BOSTON. 

The  following  case  is  one  of  generalized  neuritis,  of 
inflammatory  and  disseminated  character,  involving  the 
nerves  to  a  greater  or  less  extent  from  their  roots  to  their 
terminations,  and  associated  with  changes  in  the  muscles 
on  the  one  hand,  and  with  alterations  in  the  central  axis  on 
the  other,  which  may  have  had  a  slight  share  in  produc- 
ing the  symptoms. 

Death  occurred  from  asphyxia  on  the  seventh  day  ;  and 
at  the  autopsy,  besides  the  signs  of  neuritis,  the  lungs  were 
found  crowded  with  small  nodular  haemorrhages,  and  the 
spleen  enlarged. 

The  patient  was  under  the  care  of  Dr.  M.  A.  Morris,  of 
Charlestown,  who  kindly  asked  me  to  see  him  in  consulta- 
tion. This  I  did  once  only,  and  that  at  the  beginning  of 
his  illness. 

The  notes  which  Dr.  Morris  has  kindly  placed  at  my 
disposal,  supplemented  by  my  own,  cover  most  of  the 
essential  points.  I  did  not  have  conveniences  for  making 
an  electrical  examination,  and  was  partly  deterred  by  the 
agitated,  restless  state  of  the  patient  from  investigating  cer- 
tain symptoms  as  thoroughly  as  I  ought  to  have  done. 

At  that  time,  however,  while  the  diagnosis  seemed  clear, 
the  fatal  issue  of  the  case  was  not  anticipated. 

The  patient  was  a  man  twenty-eight  years  of  age,  in  good 
health  in  all  respects,  and  free  from  constitutional  disease 
of  every  kind.  He  was  of  a  highly  nervous  temperament, 
and  his  father  and  mother  are  reported  as  having  been  also 
of  nervous  temperament,  but  otherwise  well.     The  patient 


S  1  6  AMERICAN  NEUROLOGICAL  ASSOCIA  TION. 

himself  had  been  formerly  laid  up  with  what  was  called 
nervous  prostration,  but  at  the  time  of  his  illness  was  in  his 
usual  health.     He  did  not  use  liquor  to  excess. 

On  Friday  evening,  November  28th,  1886,  he  rode  from 
Boston  to  his  home  in  Charlestown  on  the  front  platform  of 
a  horse-car,  in  a  heavy  rain  storm,  and  got  thoroughly 
drenched.  Before  morning  he  awoke  with  pain  in  the  left 
shoulder  and  across  the  back. 

On  the  following  day  he  complained  of  a  feeling  of  stiff- 
ness in  his  muscles  all  over  the  body ;  his  gait  was  weak 
and  unsteady,  and  he  felt  a  general  sense  of  feebleness  in 
all  his  movements. 

The  next  day  he  was  only  with  difficulty  able  to  stand  or 
walk.  In  the  evening  of  this  day  (the  third  of  his  illness), 
he  was  first  seen  by  Dr.  Morris,  who  found  him  complaining 
of  pain,  not  only  in  the  left  shoulder,  but  also  in  the  ante- 
rior muscular  mass  of  both  thighs  and  of  numbness  in  the 
toes  of  both  feet.  He  had  also  noticed  that  he  had  had  no 
early-morning  erection  of  the  penis  since  his  illness  began, 
which  had  previously  been  habitual. 

I  will  here  remark  that  the  patient  had  been  excessive 
in  sexual  intercourse, during  his  married  life  of  several  years 
duration,  but  not  so  for  the  period  shortly  preceding  his  ill- 
ness. 

There  was  no  pain  in  the  back,  nor  girdle  sensation,  nor 
any  weakness  of  the  sphincters  ;  the  pupils  were  normal  ; 
his  gait  was  very  unsteady,  the  legs  tending  to  cross  one 
over  the  other,  so  that  he  nearly  fell  to  the  floor  ;  the  heart 
was  beating  regularly ;  temperature  and  respiration  were 
normal  ;  heart  sounds  normal.  Dr.  Morris  ordered  5  grs. 
of  sodium  salicylate  every  two  hours,  for  the  relief  of  the 
pain. 

The  next  morning  he  found  the  patient  perspiring  freely, 
and  without  pain,  except  in  the  hip-joint  when  he  rolled 
over  in  bed.  He  was  unable  to  walk,  falling  forward  on 
the  floor  when  he  attempted  to  do  so.  The  numbness  of 
the  feet  had  increased,  but  there  was  no  noticeable  loss  of 
sensation  to  ordinary  tests  ;  there  was  pain  on  pressure  over 
both  sciatic  nerves  and  also  on  deep  pressure  over  both  post. 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  8  I  J 

tibials.  The  pulse  was  80,  temperature  normal,  respiration 
20. 

On  the  29th  (the  fourth  day  of  his  illness),  the  symptoms 
had  still  further  increased,  but  were  of  the  same  character 
as  before.  The  pulse  was  80,  temperature  990  F.,  respira- 
tion 20.     The  patient  was  feeling  anxious  and  restless. 

On  the  following  day  the  pulse  and  temperature  were 
still  nearly  normal.  The  patient  found  it  difficult  to  raise 
his  legs  from  the  bed,  but  could  with  some  effort  draw  them 
up  and  push  them  down. 

On  December  1st  (the  sixth  day  of  his  illness),  the  pulse 
was  84,  temperature  9930  F.  The  patient  had  been 
unable  to  draw  the  legs  up  since  the  previous  night ;  he 
could  not  raise  his  left  hand  to  his  head,  but  could  raise  the 
right  with  moderate  effort ;  the  grasp  of  the  left  hand  was 
much  weaker  than  that  of  the  right  ;  he  could  flex  both 
arms  ;  the  calves  of  both  legs  were  tender  to  deep  pressure  ; 
there  was  some  strangling  on  attempting  to  drink,  and  slight 
cough  with  expectoration  of  frothy  mucous  ;  the  patient  was 
talkative  and  restless. 

On  December  2d  the  pulse  was  86,  temperature  99.20  F. 
The  patient  had  been  delirious  the  night  before  and  had 
not  slept ;  he  coughed  and  raised  a  great  deal  of  frothy  mu- 
cus ;  coarse  moist  rales  were  heard  over  both  upper  fronts; 
there  was  complete  paralysis  of  both  legs  ;  pain  on  pres- 
sure over  both  facial  nerves  ;  the  conjunctivae  were  con- 
gested ;  he  had  a  good  deal  of  difficulty  in  swallowing 
fluids,  but  took,  on  the  whole,  a  good  deal  of  nourishment. 

During  the  afternoon  of  this  day  (the  seventh  of  his  ill- 
ness), the  paralysis  of  the  upper  extremities  increased  nota- 
bly ;  the  cough  and  expectoration  and  the  injection  of  the 
conjunctivas  also  increased  ;  swallowing  became  very  diffi- 
cult. 

At  about  seven  in  the  evening,  while  propped  up  in  bed 
and  taking  some  nourishment,  he  suddenly  began  to  cough 
and  strangle,  and  became  insensible.  His  wife,  who  was 
feeding  him,  thought  that  a  small  bit  of  soft  bread  soaked 
in  chocolate  which  he  was  trying  to  swallow  might  have 
entered  his  trachea.     On  Dr.  Morris'  arrival,  forty-five  min- 


S  I  8  AMERICAS'  NEUROLOGICAL  ASSOCIA  7'IOA. 

utes  later,  the  pulse  was  found  to  be  120,  quite  strong  and 
regular ;  respiration  barely  perceptible,  slow  and  regular ; 
tongue  swollen  and  discolored.  There  was  no  evidence 
that  any  foreign  body  had  entered  the  trachea.  He  died 
half  an  hour  later,  to  all  appearance  from  paralysis  of  the 
respiratory  functions. 

I  saw  the  patient  on  the  fourth  day  of  his  illness,  and 
obtained  essentially  the  same  history  as  has  been  given. 

The  sequence  of  symptoms  was  reported  to  be  as  fol- 
lows : 

On  the  night  following  the  exposure,  he  had  pains  in 
thighs  on  motion,  pain  in  the  left  shoulder  and  back,  numb- 
ness of  the  toes  of  both  feet. 

The  next  day  he  found  it  difficult  to  raise  the  left  arm  at 
the  shoulder,  and  had  weakness  in  walking.  The  day  fol- 
lowing he  began  to  have  numbness  in  the  fingers.  At  the 
time  I  saw  him  all  motions  were  possible,  but  most  of  them 
very  feeble.  He  could  still  raise  the  foot  about  six  inches 
from  the  bed  with  the  leg  extended,  but  only  by  the  aid  of 
a  sudden  impulse.  The  movements  of  extension  at  the 
knee  were  fairly  good.  The  muscles  of  the  legs  were  flabby 
and  the  patient  was  unable  to  stand  alone,  but  from  weak- 
ness rather  than  loss  of  co-ordinating  power,  and  closure  of 
the  eyes  did  not  increase  the  difficulty.  Deep  pressure  in 
the  regions  indicated  was  painful,  but  there  was  certainly  no 
marked  loss  of  sensibility  to  touch  or  pricking,  though  only 
rough  tests  were  used,  the  patient's  restless  condition  not 
inviting  to  more  critical  investigation. 

In  view  of  the  paresthesia,  local  tenderness,  steady  in- 
crease and  wide-spread  bilateral  distribution  of  the  muscular 
symptoms,  and  yet  the  absence  of  complete  paralysis,  the 
diagnosis  of  multiple  neuritis  seemed  to  be  justified,  but 
there  was  no  indication  at  the  time  of  my  visit  of  paralysis 
of  the  heart  or  lungs. 

The  autopsy  was  made  on  the  day  after  death,  Decem- 
ber 3d,  by  Dr.  R.  H.  Fitz,  who  has  kindly  given  me  the 
following  notes  : 

"  Right  side  of  heart  distended  with  liquid  blood  ;  both 
lungs  injected  and  moderately  oedematous  ;  punctate  ecchy- 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION  8 1 9 

moses  throughout  the  lungs  in  every  part ,  spleen  enlarged 
to  nearly  three  times  the  normal  size,  soft,  injected ;  liver 
and  kidneys  deeply  injected  ;  nothing  abnormal  in  the 
appearance  of  the  brain  or  spinal  cord. 

"Pathological  diagnosis;  nodular,  pulmonary  haemor- 
rhages ;  acute  splenic  hyperplasia." 

A  portion  of  the  anterior  crural,  the  iliolumbar,  and  vagus 
nerves,  and  part  of  the  left  axillary  plexus,  a  portion  of  the 
diaphragm  with  filaments  of  the  phrenic,  part  of  the  deltoid 
muscle,  and  a  piece  of  one  lung,  were  removed  for  subsequent 
examination. 

It  is  to  be  regretted  that  these  nerves  and  others  were 
not  removed  in  their  whole  length,  especially  in  view  of  the 
fact  that  in  the  closely  similar  case  reported  by  Rosenheim, 
which  came  to  my  notice  within  a  few  days  after  this  exam- 
ination, localized  haemorrhages  were  here  and  there  found 
in  the  course  of  the  nerves. 

The  appearances,  however,  in  such  portions  as  were  re- 
moved, leave  no  doubt  as  to  the  general  character  of  the 
process. 

The  nerves  were  examined  both  fresh,  in  osmic  acid,  and 
after  hardening  in  Muller's  fluid.  The  same  pathological 
appearances,  though  varying  greatly  in  degree,  were  found 
in  all ;  but  the  best  specimens  were  obtained  from  the  axil- 
lary plexus  and  the  anterior  crural,  and  the  description  will 
therefore  be  based  mainly  upon  these,  so  far  as  the  exam- 
ination of  the  hardened  specimens  is  concerned. 

The  vagus  nerve  was  not  examined  after  hardening.  In 
the  fresh  state  the  most  marked  appearance  was  a  strikingly 
beaded  arrangement  of  the  myeline,  due  to  an  accentuation 
of  the  markings  of  Schmidt.  I  should  hesitate  to  regard 
this  as  certainly  pathological,  were  it  not  that  it  occurred  in 
connection  with  further  changes. 

The  myeline  was  eaten  out  near  the  annular  constrictions 
of  Ranvier,  but  this  may  have  been  a  purely  passive,  post- 
mortem change  (v.  below).  Here  and  there  the  myeline 
was  swelled  and  had  wholly  lost  its  characteristic  markings, 
and  in  spots  there  was  an  infiltration  of  cells  such  as  will  be 
described  further  on. 


820  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Of  the  phrenic,  only  a  few  terminal  filaments  could  be 
examined,  and  these  looked  perfectly  healthy.  Had  a  more 
extensive  examination  been  practicable,  changes  would 
doubtless  have  been  found,  because  a  certain  proportion  of 
the  muscular  fibres  of  the  diaphragm  had  wholly  lost  their 
transverse  striation,  and  looked  lustreless  and  granular. 

The  osmic  acid  appearances  in  the  other  nerves  were  of 
the  usual  kind,  but  the  larger  number  of  the  fibres  exam- 
ined looked  fairly  healthy. 

Sections  of  the  anterior  crural  nerve,  obtained  after 
hardening  and  stained  with  carmine,  showed  under  a  low 
power  a  streaked  or  mottled  appearance,  as  if  a  number  of 
nerve  tubes  here  and  there  had  been  blotted  out  and  a  new 
formed  substance,  taking  the  carmine  stain,  had  taken  their 
place.  When  the  sections  were  examined  with  higher 
powers,  the  outlines  of  nerve  fibres  were  seen  more  or  less 
altered  in  the  affected  parts  ;  yet,  nevertheless,  the  spots 
seemed  of  a  uniform   red   color. 

The  axis  cylinders  in  many  of  the  nerve  bundles  were 
to  all  appearance  normal,  or  nearly  so,  except  in  the  spots 
above  described  ;  but  in  some  bundles,  on  the  other  hand, 
the  same  series  of  striking  changes  had  taken  place,  which 
will  be  described  more  at  length  in  connection  with  the  ax- 
illary plexus. 

Here  and  there  were  foci  of  cell  formation  or  infiltration, 
but  on  the  whole  the  changes  were  less  marked  than  in  the 
left  axillary  plexus. 

The  lesions  met  with  in  the  axillary  plexus  were  of  the 
following  character: 

i.  Infiltration  of  small  round  cells  with  granular  con- 
tents, together  with  an  admixture  of  cells  of  other  kinds, 
especially  a  number  having  a  nucleus  of  about  the  size 
of  a  leucocyte,  and  granular  contents,  but  with  a  distinct 
body  of  a  pale,  homogeneous  protoplasm,  giving  to  the 
whole  cell  a  spherical  or  oblong  shape. 

These  were  by  far  the  most  numerous  toward  the  periph- 
ery of  the  nerve  bundles,  and  especially  between  the  sheath 
and  the  fibre,  and  next,  around  the  blood  vessels,  where 
they  often   formed   a   well-marked   ring,    spreading   thence 


AMERICAN  NE UROLOGICAL  A SSOCIA  TION.  8 2  I 

outward  among  the  nerve  fibres.  They  were  also  met  with, 
however,  remote  from  either  sheath  or  vessels,  following 
the  course  of  the  nerve  fibres  themselve  ;  so  much  so,  that  I 
have  some  preparations  of  isolated  fibres  surrounded,  at  a 
part  of  their  course,  by  quite  a  mass  of  these  cells.  Some- 
times they  were  collected  into  columns  which  lay  between 
and  parallel  to  the  nerve  fibres. 

I  was  not  able  to  make  out  that  any  of  these  cells 
lay  actually  inside  the  nerve  sheath,  except  possibly  in  one 
or  two  instances  ;  nor  did  the  nuclei  of  the  nerve  fibres  ap- 
pear to  be  increased  in  number.  Some  of  the  cells  were 
evidently  in  process  of  multiplication,  the  nucleus  being 
divided  by  a  sharp  line  into  two  parts.  Of  these  I  saw 
perhaps,  three  or  four  well-marked  instances. 

The  degree  of  this  cell-infiltration  varied  greatly  in  dif- 
erent  sections  from  the  same  nerve. 

Besides  the  cells  described,  there  were  numerous  spindle- 
shaped  cells  belonging  to  the  connective  tissue,  whether 
increased  in  number  or  not,  I  am  not  prepared  to  say,  and 
also  here  and  there  larger  granular  masses  which  may  have 
been  protoplasmic  with  particles  of  myeline,  or  may  have 
been  simply  altered  masses  of  myeline. 

There  were  also  large  and  highly  granular  cells,  with  a 
large  nucleus  and  irregular,  oftentimes  flattened  border, 
which  I  took  to  be  endothelial  cells,  normal  or  more  or  less 
altered. 

I  searched  for  so-called  "  Mast-zellen"  with  various  ani 
line  colors,  as  indicated  by  Rosenheim,  but   succeeded  in 
finding  only  one  or  two  that  seemed  to  be  characteristic. 

2.  The  next  most  striking  change  affected  the  axis- 
cylinders,  which  were  in  some  places  greatly  enlarged,  in 
others  more  or  less  atrophied,  in  other,  again,  entirely 
destroyed. 

The  distribution  of  these  changes  was  largely  by  nerve 
bundles  ;  that,  is,  one  bundle  might  show  nearly  normal 
axis-cylinders,  while  in  the  next  bundle  they  were  greatly 
altered.  In  some  sections  there  were  whole  (secondary) 
nerve  bundles,  in  which  scarcely  a  single  axis-cylinder  was 
to  be  seen  ;  in  others  all  the  different  changes  were  repre- 


82  2  AMERICAS'  NEUROLOGICAL  ASSOCIATION. 

sented,  showing  that  the  swelling,  atrophy,  and    disappear- 
ance were  parts  of  the  same  process  of  destruction. 

The  changes  were  also  much  greater  in  some  strands  of 
the  axillary  plexus  than  in  others. 


§$$$.. 

&     ■  • 

•   • 

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• 

e       U            o 

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;••#-■.*,•  >\ 

PLATE  I. 
Section  from  axillary  plexus,  illustrating  the  alteration  and  destruction  of  axis-cylinders. 

Some  of  these  swelled  axis-cylinders  occupied  the  entire 
thickness  of  the  nerve  tube,  and  even  the  nerve  tube  itself 
seemed  sometimes  to  be  distended.  In  other  cases,  the  sec- 
tions of  the  swelled  axis-cylinders  appeared  not  round  but 
crescentic,  occupying  half  or  two-thirds  of  a  nerve  tube. 

In  order  to  study  more  closely  the  position  and  character 
of  these  changes  in  the  axis-cylinder,  I  made  a  series  of 
longitudinal  sections,  and  also  of  isolated  nerve-fibre  prep- 
arations. Through  these  it  became  evident  that  the  swell- 
ing occurred  here  and  there  in  the  course  of  the  fibre,  and 
that  its  most  common  position  was  at  or  near  the  "annular 
constrictions  "  of  Ranvier  (or  "connecting  disk"of  Schieffer- 
flecker). 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  823 

In  some  cases  it  was  obvious  what  had  taken  place. 
The  axis-cylinder  had  become  swelled  into  a  bulbous  en- 
enlargement,  and  this  had  finally  burst  on  one  side,  leaving 
half  of  the  shell  to  give  rise  to  the  crescentic  sections.     In 


PLATE  11. 

Nerve  fibres  with  alterations  in  the  axis-cylinders  near  the  constrictions  of  Ranvier.    Hart- 
nack  Immersion,  one-tenth.  | 

other  cases  the  appearance  suggested  more  or  less  liquelac- 
tion  of  the  altered  axis-cylinder  (perhaps  the  myeline  as 
well);  for  the  disk  at  the  annular  constriction  and  the  ad- 


824  AMERICAN  NEUROLOGICAL  ASSOC  I  A  TION. 

joining  walls  of  the  nerve  tube  seemed  to.be,  as  it  were, 
plastered  with  a  substance  coloring  strongly  with  carmine, 
and  evidently  formed  of  the  products  of  degeneration.  It  is 
interesting  to  observe  that,  as  a  rule  at  any  rate,  the  disk 
had  not  been  broken  through,  but  remained  clear  and  dis- 
tinct, although,  as  is  shown  by  the  experiments  of  Boll, 
Hesse,  and  Schiefferdecker,1  on  the  action  of  water  and  other 
substances  upon  the  fresh  nerve,  the  osmotic  or  capillary 
current  setting  through  the  nerve  fibre  is  quite  competent 
to  break  down  the  connecting  disk. 

It  is  worthy  of  note  that  these  changes  of  the  axis-cylin- 
der, though  almost  always  near  the  connecting  disk,  are  not 
always  most  marked  exactly  at  that  point,  but  often  at  a 
little  distance  back. 

The  question  arises,  Were  these  changes  which  have 
just  been  described  wholly  or  in  part  post-mortem  in  char- 
acter ?  In  one  sense  I  think  this  question  can  be  confidently 
answered  in  the  affirmative.  That  is  to  say,  it  is  highly 
probable  that  the  swelling,  etc.,  occurred  after  the  death  of 
the  particular  nerve  fibre  ;  but,  on  the  other  hand,  it  is 
equally  probable  that  they  did  not  occur  in  the  process  of 
the  hardening  of  the  preparation.  My  reason  for  that  con- 
clusion is,  although  the  same  kind  of  change — that  is,  swell- 
ing and  vacuolization — is  said  sometimes  to  take  place  to  a 
certain  degree  during  the  hardening  of  healthy  nerves  in 
solutions  of  chromic  salts,  yet  I  have  never  seen  nor  read 
of  any  change  approaching  to  this  in  degree,  from  that 
cause. 

On  the  other  hand,  Schiefferdecker  describes,  as  the  re- 
sult of  the  treatment  of  fresh  nerves  with  water  and  dilute 
acids,  a  localized  swelling  of  the  axis-cylinder,  and  even- 
tually bursting  of  the  relatively  fluid  contents  through  its 
envelope,  which  seems  to  be  quite  analagous  to  that  which 
has  here  taken  place. 

It  is  probable  that  the  swelling  observed  in  such  cases  as 
this,  is  of  similar  origin  with  that  seen  in  acute  inflammation 
and  acute  anamia  of  the  spinal  cord. 


■Arch  f.  Micr.sc.  Anat.,  1887,  Bd.  ixx.,  435. 


AMERICAN  NEUROLOGICAL  ASSOC  1  A  TION.  825 

The  character  and  position  of  the  myeline  sheath  were 
also  of  interest. 

In  some  of  the  cross-sections,  stained  with  picro-carmine, 
the  nerve  tubes  could  be  seen  to  be  still  filled  with  the  re- 
mains of  myeline,  even  though  no  axis-cylinders  were  vis- 
ible. At  times  the  myeline  seemed  to  have  been  changed, 
so  that  it  took  up  the  coloring  matter  of  the  carmine  to 
some  extent,  and  it  was  doubtless  in  part  to  this  change 
that  the  mottled  appearance  of  the  cross-sections  was  due. 

Here  and  there  a  tube  would  be  entirely  empty  of  myel- 
ine for  a  considerable  distance,  both  in  those  cases  where 
the  axis-cylinders  were  preserved  and  in  those  where  they 
had  been  destroyed.  This  may  have  been  partly  due  to 
mechanical  violence,  or  to  changes  during  hardening,  but  it 
seems  hardly  possible  that  it  should  be  entirely  accounted 
for  in  this  way. 

The  myeline  at  the  annular  constriction  was,  in  the 
bichromate  of  potash  preparations, almost  always  absent  for  a 
certain  distance,  and  this,  also,  was  partly  coincident  with 
the  alteration  in  the  axis-cylinder  at  that  point,  and  partly 
independent  of  the  latter  change,  occurring  in  some  places 
where  the  axis-cylinder  ran  through  the  constrictions,  as  it 
sometimes  did,  uninterruptedly  and  with  clear  and  parallel 
outlines.  So  marked  was  the  displacement  of  myeline  at 
these  points  that  some  of  the  longitudinal  sections  seemed 
to  be  dotted  over,  under  a  low  power,  with  vacuole-like 
spaces. 

It  will  be  remembered  that  Neumann,  in  his  classical 
paper  upon  nerve  degeneration,  points  out  that  the  neigh- 
borhood of  the  annular  constriction  was  one  of  the  places 
where  the  degenerative  changes  in  the  myeline  were  earli- 
est observed. 

Dr.  Webber,  of  Boston,  has  noted  the  same  fact  in  some 
unpublished  experiments  of  his  own. 

To  a  certain  extent  the  changes  in  the  myeline  at  the 
annular  constrictions  are  probably  of  post-mortem  origin. 

It  is  well  known  that  Ranvier  long  ago  pointed  out  that 
when  nerves  were  exposed  to  the  action  of  water  and  other 
fluids  for  an   hour  or  so  after  death,  the   myeline   on   either 


826  AMERICAS'  NEUROLOGICAL  ASSOCIATION. 

side  of  the  connecting  disk  would  be  found  rarified  and  ap- 
parently eaten  away,  and  that  he  considered  this  change  to 
be  an  evidence  of  the  fact  that  nutritive  fluids  probably 
enter  the  nerve  at  these  points. 

Schiefferdecker,  in  the  interesting  paper  above  alluded 
to,  while  expressing  his  agreement  with  Ranvier  as  to  the 
fact  that  coloring  matters,  and  probably  nutritive  fluids, 
find  their  way  into  the  axis-cylinders  at  these  points,  does 
not  admit  that  the  myeline  is  dissolved  out  by  these  fluids 
as  Ranvier  suggested,  but  considers  that  it  is  displaced  by 
the  slight  mechanical  violence  in  removing  the  nerve  from 
the  body,  or  of  putting  it  slightly  on  the  stretch,  as  Ranvier 
was  in  the- habit  of  doing  as  a  preliminary  to  the  immersion 
in  osmic  acid. 

The  reason  that  the  displacement  of  the  myeline  took 
place  at  these  particular  points  is  believed  by  Schieffer- 
decker to  be  because  the  delicate  membranous  sheath  of  the 
nerve,  which  follows  the  outline  of  the  fibre  and  dips  down 
into  the  narrow  portion  at  the  annular  constrictions,  exerts 
a  lateral  pressure  where  the  angle  occurs,  when  it  is  put 
upon  the  stretch. 

In  other  words,  the  stretched  membranous  sheath  tends 
to  assume  the  form  of  a  cylinder,  the  end  of  which  is  as 
large  as  the  connecting  disk,  but  not  larger.  Consequently, 
that  part  of  the  myeline  which  occupied  the  neighborhood 
of  the  tapering  end  of  the  cylinder  is  compressed  and  dis- 
placed. 

This  explanation  entirely  concurred  with  the  results  of 
some  experiments  which  I  had  been  making,  and  which  will 
be  given  elsewhere  in  detail. 

In  order  to  test  the  point  further,  I  made  a  number  of 
careful  observations  upon  the  nerves  of  a  frog,  stretching 
some  of  them  with  a  weight  of  three  grammes,  and  leaving 
others  unstretched. 

The  results  of  the  experiments  were  such  as  to  entirely 
confirm  the  view  taken  by  Schiefferdecker. 

The  unstretched  nerves,  if  removed  with  care,  did  not 
show  these  changes  in  the  relation  of  the  myeline  to  the 
connecting  disks,  either  after  one  hour's  immersion  in  water 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  827 

or  other  fluids,  or  on  exposure  to  the  fluids  of  the  body  after 
death  for  twenty-four  hours  ;  whereas  the  nerves  stretched 
with  a  weight  of  three  grammes  showed  the  changes  very 
clearly,  as  Ranvier  described  them. 

Occasionally,  even  in  the  unstretched  nerve,  a  fibre  is 
seen  in  which  these  changes  are  observed,  but  not  with 
sufficient  frequence,  I  think,  to  invalidate  the  explanation 
offered.  I  believe  that  there  is  also  reason  to  think  that  the 
putrefactive  changes  which  go  on  during  the  twenty-four 
hours  or  so  after  death  may  make  this  change  occur  more 
rapidly,  but  this  point  is  still  under  investigation. 

The  nerves  in  the  present  case  were  not  exposed  to  any 
special  stretching  other  than  was  necessary  in  their  removal, 
and  it  is  therefore  probable  that  the  results  were  partly  the 
effect  of  pathological  change,  and  only  in  part  of  mechani- 
cal violence. 

I  have,  however,  seen  a  similar  change,  though  not 
nearly  to  the  same  extent,  in  a  healthy  nerve  removed  from 
the  body  at  an  autopsy  and  treated  with  the  same  reagents 
that  were  used  in  this  case. 

One  other  point  should  be  mentioned  in  this  connection, 
namely,  that  the  membranous  sheath  in  the  neighborhood 
of  the  connecting  disk,  as  seen  in  the  hardened  specimens, 
looked  as  if  it  had  been  exposed  to  pressure  from  within, 
making  it  bulge  slightly  outward.  I  have  no  explanation  to 
offer  of  the  exact  manner  in  which  this  effect  was  brought 
about ;  but  this  influence,  whatever  it  may  have  been  (pos- 
sibly the  result  of  decomposition),  may  have  had  its  share 
in  the  displacement  and  destruction  of  the  myeline  as  well. 

Changes  in  the  Deltoid  Muscles  and  Diaphragm. — Pieces 
of  the  deltoid  muscle  were  examined,  both  in  a  fresh  state, 
with  and  without  osmic  acid,  and  after  hardening  in  Muller's 
fluid.  In  the  fresh  specimens  the  only  change  observed  was 
that  now  and  then  a  fibre  was  seen  that  had  entirely  lost  its 
transverse  striation,  the  rest  of  the  fibres  being  apparently 
perfectly  healthy.  The  examination  of  the  hardened  speci- 
mens was  more  fruitful.  The  cross-sections  showed  the 
size  of  the  fibres  to  be  uniform  and  normal.  There  was  no 
trace  of  the  vacuolization  or  so-called  serous  atrophy,  and 


8  2  S  -  \MERICAN  A  El  ROLOGICAL  ASSOC] A  TIOA . 

apparently  no  deposition  of  fat  either  within  or  between  the 
muscular  fibres. 

The  morbid  changes  were  the  following  : 

First,  loss  of  transverse  striation,  limited  in  extent, 
sometimes  occupying  only  a  small  part  of  a  fibre,  the  ap- 
pearance presented  being  that  of  tine  granulation,  some- 
times with  traces  of  transverse  striation  here  and  there  in 
the  midst  of  the  altered  substance. 

Second,  marked  infiltration  of  ceils  in  the  connective 
tissue  and  around  the  vessels. 

Third,  a  localized  increase  in  number  of  the  muscle- 
nuclei,  which  sometimes,  but  not  always,  appeared  to  be 
more  marked  at  the  place  where  the  transverse  striation  was 
wanting. 

Fourth,  the  intra-muscular  nerves,  as  far  as  could  be 
judged  from  the  few  which  appeared  in  the  sections,  were 
almost  entirely  destroyed. 

Out  of  the  whole  number  of  fibres  making  up  a  small 
nerve  bundle,  one  or  two  atrophied  axis-cylinders  might  be 
seen,  as  dark,  shining  points,  in  picro-carmine  sections,  the 
rest  of  the  bundles  being  represented  by  altered  fragments 
of  myelinc  with  numerous  granular  round  cells  lying  amongst 
them. 

Fragments  of  the  diaphragm  were  examined,  fresh  and 
with  osmic  acid,  and  granular  fibres  without  transverse  stri- 
ation were  here  and  there  noted. 

Of  the  central  nerve  system,  the  medulla  and  spinal  cord 
were  examined.  The  brain  was  preserved,  but  has  not 
been  examined. 

In  the  medulla  and  spinal  cord  the  following  changes  were 
observed  :  I -" i r s t .  in  the  membranes  and  in  many  of  the 
nerve  roots,  both  anterior  and  posterior,  there  was  an  infil- 
tration of  round  cells  both  around  the  vessels  and  amongst 
the  fibres,  and  in  other  respects  the  nerve  roots  were  more 
or  less  changed,  the  degree  of  alteration  being  less  than  in 
the  peripheral  nerves. 

This  infiltration  was  rather  greater  in  the  lower  dorsal 
region  of  the  cord  than  in  the  lumbar  or  cervical  region,  or 
most  parts  of  the  medulla. 


AMERICAN  NE I 'ROL  OGICAL  A SSOCIA  TION.  829 

The  blood  vessels,  both  of  the  membranes  and  of  the 
central  axis,  were  everywhere  crowded  with  blood.  This  I 
take  to  have  been,  in  part,  the  resul^of  the  asphyxia  with 
which  the  patient  died  ;  in  part  the  sign  of  an  inflammatory 
process. 

Within  the  substance  of  the  cord  the  vessels  were  sur- 
rounded here  and  there  with  a  moderate  number  of  cells 
contained  in  the  peri-vascular  sheath,  and  the  central  canal 
was  filled  with  similar  cells. 

The  nerve  cells,  so  far  as  I  could  judge,  were  essentially 
normal.  Here  and  there  was  one  with  a  shrunken  or  other- 
wise altered  nucleus;  but  there  was  nothing,  in  my  opinion, 
that  might  not  be  accounted  for  by  post-mortem  changes. 
The  only  other  pathological  appearance  in  the  cord  was 
that  here  and  there  at  the  periphery,  especially  in  the  lat- 
eral column  near  the  post,  cornua,  and  in  the  ant.  column 
in  the  nerve  root  zone,  greatly  enlarged  axis-cylinders 
staining  feebly  with  carmine. 

The  condition  of  the  medulla  was  carefully  examined,  in 
the  hope  of  finding  a  satisfactory  cause  for  the  multiple 
pulmonary  haemorrhages.  There  was  a  general  filling  of 
the  vessels,  large  and  small,  and  here  and  there  an  accumula- 
tion of  lymphoid  cells  in  the  peri-vascular  sheaths,  and 
occasional  slight  haemorrhages  from  the  capillaries  and 
smaller  vessels. 

These  disturbances  of  circulation  were,  in  most  of  my 
sections,  more  marked  in  and  near  the  sensory  nucleus  of 
the  vagus  and  glossopharyngeus  than  elsewhere,  and  the 
haemorrhages  were  in  fact  only  seen  in  this  neighborhood. 
It  could  not  be  asserted,  however,  that  the  nucleus  appeared 
to  have  been  materially  injured. 

The  vagus  nerve  roots  were  affected  in  varying  degrees, 
and  one  section,  shows  a  more  excessive  infiltration  than 
perhaps   any  other   nerve   root  that  I  have  seen. 

It  is  easy  to  arrange  this  case  in  its  proper  pathological 
position  up  to  a  certain  point.  It  evidently  belongs  with 
such  cases  as  were  reported  by  Eichhorst  in  Virchow's 
Arch.,  vol.  69,  1876,  and  Rosenheim  in  the  Arch.  f.  Psych., 
vol.    18,    which   the    latter    has    discussed    so    ably;   and 


83O  AMERICAN  NEUROLOGICAL  ASSOCIATION. 

with  the  other  acute,  fatal  cases  of  multiple  neuritis,  none 
of  which,  I  think,  have  been  of  shorter  duration  than  this. 

In  Rosenheim's  and  Eichhorst's  cases,  to  be  sure,  haem- 
orrhoids existed  in  the  nerves,  visible  to  the  naked  eye,  in- 
dicating a  more  intensely  active  process  than  here.  On  the 
other  hand,  nothing  could  be  more  intense  than  the  con- 
gestion in  this  case  ;  and  the  evidences  of  minute  haemor- 
rhages and  cellular  infiltration  were  more  extensively  present 
than  in  most  of  the  other  cases,  involving  the  muscles, 
spinal  roots,  membranes,  and  even  the  central  nervous  axis 
to  a  certain  extent,  as  well  as  the  nerves. 

It  would  be  interesting  to  know  whether,  if  the  patient 
had  not  died,  the  spinal  changes  would  have  assumed  a 
greater  prominence,  and  a  poliomyelitis  or  a  diffuse  myelitis 
have  developed  itself. 

Certainly  the  topography  of  the  lesions  suggests  this 
possibility  ;  but  it  is  to  be  noted,  as  regards  the  question  of 
poliomyelitis,  that  the  posterior  nerve  roots  were  quite  as 
much  affected  as  the  anterior.  The  fact  that  the  changes 
in  the  white  columns  (enlargement  of  axis  cylinders)  were 
mainly  confined  to  the  periphery,  and  more  marked  in  the 
neighborhood  of  the  nerve  roots  than  elsewhere,  but  they 
did  not  seem  to  occur  in  the  posterior  columns.  The 
amount  of  accumulation  of  lymphoid  cells  in  the  peri-vascu- 
lar sheaths  of  the  central  gray  matter  was  perhaps  not  great 
enough  to  count  as  the  first  step  in  an  inflammatory  pro- 
cess, though  it  may  have  been  of  that  character ;  but, 
to  say  the  least,  one  can  hardly  doubt  that  it  would  have 
taken  little  more  to  precipitate  such  an  event,  especially  in 
view  of  the  fact  that  in  the  medulla  minute  haemorrhages 
had  actually  occurred. 

The  questions  of  chief  importance  in  connection  with 
this  case  are  :  first,  as  to  its  etiology,  and  especially  if  we 
can  gain  through  it  any  light  upon  the  supposed  toxic  origin 
of  generalized  neuritis  ;  next,  as  to  whether  these  acute, 
fatal  cases  exhibit  clinical  features  which  will  enable  us  to 
detect  them  at  their  onset. 

With  regard  to  the  first  point,  the  reasoning,  as  clearly 
expressed  by  Rosenheim,  and   endorsed   by  Leyden    in   his 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  83  I 

recent  address  before  the  Militar-artzliche  Gesellschaft  of 
Berlin,  is  that  the  great  majority  of  these  cases  are  truly  of 
toxic  origin,  the  source  of  the  poison  being  the  bacteria  of 
tuberculosis  or  other  constitutional  disease,  or  some  mineral 
or  other  poison.  The  bacteria  are,  however,  not  supposed 
to  themselves  be  present  in  the  nerve,  but  only  the  poison- 
ous substances  to  which  their  growth  gives  rise. 

In  this  way  the  distinctly  infectious  cases  are  brought 
into  a  parallel  with  the  cases  due  to  metallic  poisoning. 

Strumpell,  moreover,  in  a  recent  paper  upon  degener- 
ative changes  in  the  spinal  cord,  although  not  speaking 
especially  of  neuritis,  suggests  another  method  in  which 
these  processes  of  poisoning  may  be  started  or  propagated, 
namely,  through  the  action  of  the  products  of  decomposi- 
tion of  the  nervous  tissues  themselves.  Dr.  Spitzka  sug- 
gested last  year  a  similar  cause  for  the  outbreak  of  delirium 
grave. 

In  Rosenheim's  case  it  was  believed  that  the  primary 
source  of  the  infection  was  tuberculosis,  with  which  the 
patient  was  affected,  although  at  the  time  of  his  attack  in 
good  nutrition  ;  and  he  further  remarks  that,  in  his  opinion, 
scarcely  a  case  of  multiple  neuritis  has  been  observed  in 
which  no  infectious  constitutional  disease  was  present.  With 
this  view  I  cannot  wholly  agree  ;  nor  is  it  maintained,  so 
far  as  I  can  see,  by  Leyden,  who  himself  reports  the  onset 
in  one  of  his  rapidly  fatal  cases  as  being  apparently  due 
solely  to  a  condition  of  exposure  and  fatigue. 

In  my  case  the  patient  was  not  the  subject  of  any  con- 
tagious disease,  so  far  as  could  be  ascertained,  and  the 
wetting  to  which  he  was  exposed  was  the  only  cause  which 
could  be  discovered.  Nevertheless,  the  pathological  signs 
of  infection  are  even  stronger  in  my  case  than  in  Rosen- 
heim's and  others.  In  them  those  signs  consisted  almost 
solely  in  the  acute  onset  and  generalized  character  of  the 
disease,  together  with  the  fact  that  haemorrhages  were 
present  in  the  nerves.  In  my  case,  a  marked  hyperplassia 
of  the  spleen  was  also  present,  such  as  has  been  observed 
in  several  cases  of  Laudry's  disease,  but  not  often  and  never 
to  this  extent,  so  far  as  I  know,  in  cases  of  multiple  neu- 


I 


8^2  AMERICAN  NEUROLOGICAL  ASSOC  I  A  TION. 

ritis.  In  Rosenheim's  case  the  spleen  was  reported  as 
measuring  twelve  centimeters  in  length,  and  being  soft  in 
consistency. 

To  what  cause  to  attribute  the  multiple  and  nodular 
haemorrhages  scattered  through  both  lungs,  in  the  present 
case,  I  am  unable  to  decide.  In  view  of  the  absence  of 
haemorrhages  in  other  regions  of  the  body  it  would  be 
hardly  probable  that  those  were  due  to  the  local  action  of 
the  toxic  agent,  although  this  is  not  to  be  set  aside.  It 
seems  more  probable  that  the}'  were  of  the  same  origin 
with  the  multiple  haemorrhages  described  originally  by 
Brown-Sequard  as  due  to  certain  injuries  of  the  medulla, 
and  probably  of  vaso-motor  origin.  It  is  possible  that  the 
neuritis  of  the  vagus  nerve  may  have  given  rise  to  them, 
although,  so  tar  as  I  know,  such  a  result  has  not  previously 
been  demonstrated. 

It  is  noteworthy  that  in  this,  as  in  the  other  important 
cases  of  similar  kind,  the  toxic  agent,  whatever  its  char- 
acter, has  not  given  sign  of  its  presence  in  a  diffuse  way, 
but  only  here  and  there  in  foci  of  limited  extent.  This  is 
very  likely  due  to  the  fact  that  the  means  of  examination 
at  our  command  do  not  enable  us  to  detect  the  first  signs 
of  toxic  influence.  Even  if  we  had  any  such  evidence  as 
that  afforded  by  the  examination  in  Laudry's  disease,  which 
seems  to  be  universally  considered  as  most  probably  of 
infectious  origin,  to  show  that  loss  of  function  may  precede 
noticeable  alteration  in  structure,  yet  we  should  still,  from 
abundance  of  facts,  be  ready  to  consider  that  this  was 
possible. 

The  fact  that  such  a  large  proportion  of  the  nerve  fibres 
in  the  affected  districts  preserved  a  health}'  appearance 
cannot  be  taken  as  a  proof  that  they  were  performing  their 
functions  in  a  normal  manner. 

It  would  not  be  out  of  place,  before  Leaving  the  subject 
of  infection  and  its  possible  sources,  to  refer  to  the  group 
of  symptoms  characterized  as  a  new  infectious  disease  and 
described  recently  by  Weil  and  others  in  the  Deutches 
Arch.  f.  Klin.  Med.,  iXS;,   1888. 

Taken    as    a    whole,  this    is    not   to    be  confounded  for  a 


AMERICAN  NEUROLOGICAL  ASSOCIA  TION.  833 

moment  with  neuritis,  the  high  temperature  and  the  jaun- 
dice characterizing  it  as  belonging  in  a  different  category. 
It  is,  however,  noticeable  that  in  several  of  the  cases, 
severe  muscular  pain  and  other  signs  of  alteration  of  the 
peripheral  nervous  system  were  present. 

As  regards  the  clinical  aspects  of  the  case,  I  would  only 
mention  one  or  two  points. 

In  the  first  place,  the  absence  of  fever  throughout  the 
sickness  is  noteworthy.  This  was  also  noced  in  Rosen- 
heim's case,  and  referred  to  by  him  as  being  sometimes 
present  and  sometimes  absent  in  the  other  cases  that  he 
describes. 

The  mode  of  death  seems  to  have  been  by  respir- 
atory, rather  than  cardiac  paralysis.  At  any  rate,  the  res- 
piratory symptoms  were  the  striking  ones,  and  although 
shortly  before  death  the  pulse  had  risen  to  120,  it  is  reported 
by  Dr.  Morris  as  having  been  full  and  regular,  while  the 
respiration  was  scarcely  perceptible. 

The  distribution  of  the  muscular  symptoms  deserves  a 
moment's  comment.  Pierson  has  advanced  the  opinion 
that  the  paralysis  of  the  cranial  nerves  is  characteristic  of 
the  acute  cases.  This,  however,  is  not  endorsed  by  Rosen- 
heim, who  points  out,  very  properly,  that  these  paralyses 
are  seen  also  in  chronic  cases,  and  not  necessarily  in  acute 
cases  only,  although  when  present  they  indicate  a  wide 
generalization  of  the  disease,  and  may  be  of  bad  import. 
In  the  present  case,  the  signs  of  paralysis  of  the  cranial 
nerves  which  was  noticed,  consisted  in  the  difficulty  in  swal- 
lowing and  the  tenderness  over  both  facial  nerves. 

The  fact  that  the  left  shoulder  muscles  were  so  early 
and  so  severely  affected  was  to  me  of  special  interest, 
because  I  have  been  recently  collecting  cases  in  order  to 
test  the  diagnostic  value  of  this  distribution  of  symptoms. 
There  seems  to  be  no  doubt  that  although  the  extremities 
are  usually  the  first  to  be  involved,  in  the  multiple  neu- 
ritis of  every  cause,  yet  the  larger  muscles  uniting  the 
limbs  and  trunk  are  sometimes  affected  very  early. 

Finally,  I  would  call  attention  to  a  point  which  should, 
perhaps,  have   guided   us   to  the  recognition  of  the   serious 


8  34  AMERICAN  XEi'ROLOGICAL  ASSOC  I  A  TION. 

import  of  the  case,  which  was  early  presented,  namely,  the 
restless,  anxious  and  agitated  mental  condition  of  the 
patient,  which  seemed  at  first  out  of  proportion  to  the 
severity  of  his  symptoms. 

Notes. —  i.  Valuable  remarks  relative  to  the  significance  of  this  acute  swell- 
ing of  the  axis  cylinder,  may  be  found  in  the  Arch.  f.  Psychiatrie,  etc.,  18S7,  p. 
263,  (Auhangi,  Zur  activen  Verand,  der  Axen-cyl.,  bei  Entzundungen,  Dr.  M. 
Friedmann;  and  Bd.  XCVI.  der  Sitzb.der  Kais.  Akad.  der  VNissensch.  III.  Abth. 
Nov.  Heft.  1887.  Ucb.  die  Verand.  am  Ruckenmark  n.  Zeitweiser  Verschliessung 
der  Banchaorta.     J.  Singer  (Reprint,  p.  121. 

2.  Otto  Dees,  (Arch,  fur  Psych.,  etc  ,  1888,  p.  97),  the  latest  writer  on  the 
anatomy  and  physiology  of  the  vagus  nuclei,  mentions,  incidentally  as  his  opinion 
that  the  large  "  dorsal  "  nucleus  is  vaso  motor  in  function.  It  cannot,  unfor- 
tunat  ly,  be  stated  whether  in  the  present  case  the  fibres  and  ganglia  of  the  sym- 
pathetic system  were  healthy  or  diseased. 

DISCUSSION. 

Dr.  WEBBER  had  four  years  ago  had  a  large  number  of 
cases  under  observation  in  the  Boston  City  Hospital,  with 
three  deaths.  The  history  of  Dr.  Putnam's  case  was  similar 
to  that  of  these  fatal  cases.  The  changes  about  the  con- 
striction of  Ranvier  noted  by  Dr.  Putnam  he  had  found, 
especially  in  the  earlier  stages  of  the  disease  in  animals, 
his  experiments  were  upon  rabbits  and  guinea  pigs.  In 
one  fatal  case  he  had  found  but  little  change  about  the 
node  of  Ranvier ;  he  could  not  say  whether  there  was 
traction  used  in  removing  it  or  not.  Even  where  the 
nerves  were  extensively  altered,  there  would  be  some 
fibres  intact.  The  process  seemed  to  affect  the  coarser 
fibres  rather  than  the  finer.  At  the  time  when  there  had 
been  so  many  cases  in  the  course  of  a  few  months,  there 
had  also  been  prevalent  a  sickness  among  horses  attended 
with  weakness  and  temporary  paralysis.  He  had  tried  to 
obtain  nerves  from  the  horses,  but  did  not  succeed. 

Dk.  PYE  Smith,  of  London,  referred  to  a  case  of  his 
own,  in  which  both  alcoholism  and  gout  were  excluded. 
He  inquired  in  regard  to  the  position  of  gout  in  the  etiology 
of  the  affection  here.  He  understood  that  gout  was  rare  in 
the  States,  yet  in  speaking  with  Dr.  Welch,  of  Baltimore, 
he  had  learned  that  the  metatarso  phalangeal  articulation 
of  the  great  toe  often  showed  evidence  of  gout  on  autopsy. 


AMERICAN  NEUROLOGICAL  ASSOCIATION.  835 

The  speaker  inquired  also  in  regard  to  the  prevalence 
of  that  enigmatical  affection  called  Landry's  paralysis.  In 
Landry's  original  paper  there  was  but  little  to  correspond 
with  the  superstructure  which  had  been  reared  upon  it. 
Landry  had  stated  that  there  were  no  post  mortem  changes. 
The  speaker  thought  that  it  must  be  a  very  rare  condition.  It 
would  be  [especially  interesting  to  know  whether  cases 
examined  by  modern  methods  of  investigation  gave  equally 
negative  anatomical  results. 

Dr.  Van  Bibber  referred  to  a  case  of  his  own,  in  which 
the  faciaLnerve  had  been  affected.  The  attack  had  passed 
offhand  the  patient  recovered. 

Dr.  Dana  had  not  met  with  or  found  reported  a  case 
in  which  gout  had  given  rise  to  multiple  neuritis.  Local 
neuritis  was  not  uncommon  from  gout.  He  had  seen  one 
and  perhaps  two  cases  of  multiple  neuritis  from  rheumatism. 
In  one  case  there  had  been  for  several  years  attacks  of 
rheumatism  each  fall.  One  fall,  in  place.of  the  usual  attack, 
the  patient  had  an  attack  of  typical  multiple  neuritis. 

Dr.  Putnam  inquired  whether  any^entleman  had  met 
with  the  multiple  pulmonary  haemorrhages  present  in  his 
rase. 

Dr.  Webber  stated  that  in  the  fatal  case  which  he  had 
examined  there  had  been  no  such  haemorrhages,  burjn  this 
case  the  vagus  had  not  been  affected,  while  in  Dr.  Putnam's 

in  was. 

Dr.  Putnam  said  that  true  gout  was  rare,  at  least  in 
Boston.  Neuritis  did  accompany  rheumatism,  however, 
both  as  a  local  and  a  general  disease. 

In'regard  to  Landry's  "paralysis,  there  was,  he  thought, 
such  a  group  of  symptoms  not  due  to  multiple  neuritis,  and 
not  due  to  spinal'trouble. 

Dr.  SEGUIN  presented  Dr.  Shaw's  regrets  at  being 
absent  from  the  meeting,  and  exhibited  for  him  three  slides, 
representing  a  case  of  locomotor  ataxia. 


^UsccUatuous  JUtrs. 


The  Paris  correspondent  of  the  Wiener  Freie  Presse 
quotes  the  following  regarding  the  critical  analysis  made 
by  Dr.  Fauvel,  the  noted  Paris  laryngologist,  in  reference 
to  Mackenzie's  book  "Frederick  the  Noble": 

"  *  *  *  That  which  most  surprises  me  is  the  fact  that  medi- 
cation played  a  secondary  role  in  the  management  of  the  case.  I 
would  have  recommended  the  employment  of  Coca  Mariani  to  rouse 
the  flagging  energies  of  the  patient.'"  *  *  *  "My  investiga- 
tions, dating  back  to  1865,  establish  the  fact  that  Coca  is  a  potent 
agent  in  combating  debility.  I  have  also  shown  that  the  injection 
of  concentrated  Coca  (The  Mariani),  has  a  salutary  influence  on 
the  laryngeal  mucous  membrane,  alleviating  pain  and  congestion. 
In  Europe  this  remedy  is  relied  on  in  cases  of  debility  and  where 
pain  is  a  prominent  symptom."'  *  *  *  *  "  As  further  proof, 
the  case  of  General  Grant  is  cited,  in  which  Drs.  Fordyce  Barker, 
Geo  F.  Shrady,  J.  H.  Douglas,  and  Sands,  were  active.  Coca  was 
employed  in  this  case  with  success  (the  preparation  exhibited  being 
The  Mariani),  and  it  was  stated  by  the  attending  physicians  that 
without  the  use  of  this  drug  the  General  would  not  have  been  phy- 
sically able  to  undergo  the  strain  incidental  to  the  work  of  finishing 
his  Memoirs."' — Berliner  Tageblatt. 


INDEX   TO  VOL.  XIII. 

(NEW    SERIES.) 


ORIGIMA L  AR TICLES. 


Composite  Portraits  of  General  Paresis.     (Illustrated.)     By  William  Noyes, 

M.D l 

Pain  in  the  Feet.     By  Chas.  K.  Mills,  M.  D 3 

Report  of  a  Case  of  Anencephaly,  with  Microscopical  Study  bearing  on  its 

Relations  to  the  Sensory  and   Motor  Tracts.     (Illustrated.)     By  Chas. 

L.  Dana,  M.D 21 

On  Oil  of  Gaultheria  and  Salol  in  Rheumatism  of  Nerves  and  Muscles.     By 

F.  X.  Dercum,  M.D 33 

Note  on  Nitro-glycerine  in  Epilepsy.     By  Wm.  Osier,  M  D 38 

Note  on  Antipynn  as  an  Analgesic.     By  J.  C.  Wilson,  M.D 40 

Theine  in  Pain.     By  Thos.  J.  Mays,  M.D 42 

The  Heat  Centres  of  the  Cortex  Cerebri  and  Pons  Variolii.     (Illustrated.) 

By  Isaaa^Ott,  M.D 85 

Is  Atrophy  of  the  Conducting  Apparatus  of  the  Ear  Identical  with  Progres- 
sive Arthritis  Deformans?     By  S.  O.  Richey,  M.D 105 

Dental  Irritation  as  a  Factor  in  the  Causation  of  Epilepsy.     By  Albert  P. 

Brubaker,  M.D 116 

Parr,  noia— Systematized  Delusions  and  Mental  Degenerations.    By  J.  Seglas. 

Translated  by  William  Noyes,  M. D 157 

Glioma  of  the  Medulla  Oblongata.     (Illustrated.)     By  William  Osier,  M.D.     170 

Hygiene  of  Reflex  Action.     By  Heny  Ling  Taylor,  M.D 177 

Locomotor  Ataxia  confined  to  the  Arms  ;    Reversal  of  Ordinary  Progress. 

By  S.  Weir  Mitchell,  M.D 221 

Paranoia — Systematized  Delusions  and  Mental  Degenerations.    By  J.  Seglas. 

Translated  by  Wm.  Noyes,  M.D 225 

Ocular   Symptoms  in  Diseases  of  the  Spinal  Cord.       By  William   Oliver 

Moore,  M.D 229 

Ataxic  Lateral  Sclerosis.     By  J.  G.  Preston,  M.D 241 

Paranoia — Systematized  Delusions  and  Mental  Degenerations.    By  J.  Seglas. 

Translated  By  William  Noyes,  M.  D 285 

Ophthalmoplegia  Externa  Partialis.     By  M.  Allen  Starr,  M.D    300 

Notes  on  Five  Cases  of  Ophthalmoplegia.     By  E.  C.  Seguin,  M.D 317 

On  Some   Results   obtained   by  the   Atrophy  Method.     (Illustrated.)     By 

E.  C.  Spitzka,  M. D.,  and  R.  Mollenhauer,  M.D 349 

Paralysis  Agitans,  and  a  Consideration  of  some  Cases  of  this  Disease.     By 

Leonard  Weber,  M.D 356 

Paranoia — Systematized  Delusions  and  Mental  Degenerations.    By  J.  Seglas. 

Translated  by  William  Noyes,  M.  D 366 

Insanity  from  Bright's  Disease.     By  L.  Bremer,  M.D. .  .' 374 

Six  Cases  of  Epidemic  Cerebro-Spinal  Meningitis.     By  Charles  K.  Mills, 

M.D.,  and  W.  C.  Cahall,  M.D 387 

A  Case  of  Paramyoclonus  Multiplex.     By   Frank  A.  Fry,  A.M.,  M.D   .  .       397 
The  Oculo-motor  Centres  and  their  Co-ordinators.    (Illustrated.)    By  E.  C. 

Spitzka,  M.D 413 

Degeneration  of  the  Peripheral  Nerves  in  Locomotor  Ataxia.     (Illustrated.) 

By  John  C.  Shaw,  M.D 433 

Case  of  Post-epileptic  Hysteria.     Effect  of  Inhalation  of  Compressed  Air. 

By  Mary  Putnam  Jacobi,  M.D 442 

Skin  Products.     By  Wallace  Wood,  M.D 446 


n  INDEX. 

A  Contribution  to  the  Pathology  of  Trophic  Disorders  of  the  Muscular  Sys- 
tem.    By  David  Inglis,  M.  D '        477 

Is  Belief  in  Spiritualism  Ever  Evidence  of  Insanity,  Per  Se  ?     By  Matthew 

D.  Field,   M.D   489 

The  Relation  between  Trophic  Lesions  and  Diseases  of  the  Nervous  Sys- 
tem.    By  E.  C.  Seguin,  M.D.  533 

The  Antipyretics — Acetphenetidin  and  Antithermin.     By  Isaac  Ott,  M.D  ,  597 
On  Gold  as  a  Staining   Agent   for   Nerve  Tissue.     Bv    Henry  S   Upson, 

M.D '.    ....  685 

Muscle  Control.      By  Sarah  E.  Post,  M.D 690 

TheWhitechapel  Murders:  Their  Medico-legal  and  Historical  Aspects.    By 

E.  C.  Spitzka,  M.  I) 765 

CLINICAL    LECTURES. 

A  Clinical  Lecture  upon  Certain  Forms  of  Hysteria.     By  Landon  Carter 

Gray,  M.D 127 

A  Clinical  Lecture   on   Nervous   Diseases  :    Lead   Paralysis — Confinement 

Paralysis— Epileptic  Insanity — Paranoia.     By   M.  Allen  Starr.  M.D.,     452 

A  Clinical  Lecture  on  the  Differential  Diagnosis  of  Antero-lateral  Sclerosis 
and  Posterior  Sclerosis  of  the  Spinal  Cord.  By  William  A.  Hammond, 
M.D 496 

REVIEWS. 

Insanity:     Its  Classification,  Diagnosis,  and  Treatment.     By  E.  C.  Spitzkn, 

M.D 49 

Functional  Nervous  Diseases.    By  George  T.  Stevens,  M.D 51 

Jacksonian  Epilepsy.     By  Dr.  E.  Rolland 134 

Lectures  on  the  Motor  Functions  of  the  Brain  and  on   Cerebral  Epilepsy. 

By  Dr.  Francois  Frank 200 

A  Manual  of  Diseases  of  the  Nervous  System.     By  \V.  R.  Gowers,  M.D., 

F.R.C.P 325 

Hysteria  and  Brain  Tumor.     By  Mary  Putnam  Jacobi,  M.D 465 

Applied  Anatomy  of  the  Nervous  System.     By  A.  L.  Ranney,  M.D 595 

SOCIETY  PROCEEDINGS. 
The  American  Neurological  Society,  Fourteenth  Annual  Meeting  : 

Presidential  Address.     By  Dr.  J.  J.  Putnam 543 

Heat  Centres  in  Man.     By  Isaac  Ott,  M.D 551 

Clinical  Report  of  Cases  of  Epilepsy  following  Cerebral   Hemiplegia. 

By  E.  D.  Fisher.  M.D 554 

The  Relation  of  Renal  Diseases  to  Diseases  of  the  Nervous  System.    By 

Robert  T.  Edes,  M.D 566 

Nervous  Affections  following  Injury,  "Concussion  of  the  Spine," 
"Railway  Spine,"  and  "Railway  Brain."  By  Philip  Coombs 
Knapp,  M.  1) 621 

The  Cortical  Localizations  of  the  Cutaneous  Sensations.     By  Charles 

L.  Dana,  M.D 650 

On  a  Subcutaneous  Connective  Tissue  Dystrophy  of  the  Arms  and 
Back,  associated  with  Symptoms  resembling  Myxodcema.  By  F. 
X.  Dercum,  M.D ....  695 

Subacute  Progressive  Polymyositis.     By  George  W.  Jacoby,  M.  I  > 697 

Progressive  Muscular  Dystrophies:  The  Relation  of  the  Primary  Forms 
to  one  another,  and  to  Tvpical  Progressive  Muscular  Atrophy.  By 
B.  Sachs,  M.D ' 726 

A  Case  of  Focal  Epilepsy  successfully  Treated  by  Trephining  and  Ex- 
cision of  the  Motor  Centres.  By  James  Hendrie  Lloyd,  M. D. , 
and  John  B.  Deaver,  M.  D 795 

A  Case  of  Acute  Fatal  Neuritis  of  Infectious  Origin,  with  Post-mortem 

Examination.     By  James  J.  Putnam,  M.D 815 


INDEX.  in 

Philadelphia  Neurological  Society: 

Meeting  of  November  28th,  1887:    Antipyrin  as  an  Analgesic  -  Oil  of 

Gaultheria  in  Rheumatism  of  Nerves  and  Muscles 5^ 

Meeting  of  December  19th,  1887:  Theine  in  Pain. — Dental  Irritation 
as  a  Factor  in  the  Causation  of  Epilepsy.-  -Neuralgic  Headache  in 
Typhoid  Fever 62 

Meeting  of  January  25th,  1888:  Cholesteatoma,  with  Remarks  on  the 
Origin  of  the  Tumor.  (Illustrated). — A  Case  of  Local  Syncope 
and  Asphyxia  of  the  Fingers. — A  Case  of  Porencephalus,  with  Spe- 
cimen.    (Illustrated). — Specimen  from  a  Case  of  Parencephalus. .     203 

Meeting  of  February  27th,  1888:  Enlargement  and  Congestion  of  the 
Right  Arm  following  Exercise  of  its  Muscles. — Report  of  a  Case  of 
Rapidly  Fatal  Exophthalmic  Goitre. — Cardiac  Aneurism  from  an 
Insane  Man. — New  Form  of  Percussion  Hammer. — A  Further 
Demonstration  of  Wernicke's  Hemiopic  Pupillary  Reaction. — Spe- 
cimens from  a  Case  of  Probable  Alcoholic  Multiple  Neuritis,  with 
Brain  Envolvement. — The  Probable  Occurrence  of  Multiple  Neu- 
ritis in  Epidemic  Cerebro-spinal  Meningitis   246 

Meeting  of  March  26th,  1888:  Locomotor  Ataxia  confined  to  the 
Arms;  Reversal  of  Ordinary  Progress. — Six  Cases  of  Epidemic 
Cerebro-spinal  Meningitis. — Forcible  Feeding  of  the  Insane 328 

Meeting  of  October  22d,  1888:  Note  on  Pachymeningitis  Hsemorrha- 
gica. — Three  Cases  of  Spinal  Accessory  Spasm  Unsuccessfully 
Treated  by  Excision  of  the  Nerve.  — Case  of  Alcoholic  Multiple 
Neuritis. — Embolism  of  the  Middle  Cerebral  Artery;  Left  Hemi- 
plegia, Ulcerative  Endocarditis,  and  late  General  Convulsions,  and 
Skin  Infarcts 608 

Meeting  of  November  26th,  1888:  Classification  of  Dystrophies. — Case 
of  Arthritic  Muscular  Atrophy. — A  Case  of  Urethntic  Muscular 
Atrophy  of  Gonorrhceal  Origin. — A  Subcutaneous  Connective- 
tissue  Dystrophy 779 

New  York  Neurological  Society: 

Meeting  of  December  6ih,  1887:  Professional  Cramp. — Three  Cases 
of  Hemianopsia  — A  Case  of  Bitemporal  Hemianopsia. — Composite 
Portraiture  of  the  Insane 52 

Meeting  of  February  8th,  1888:  Rectangular  Prisms  in  a  Single 
Frame.— Specimens  Stained  by  Golgoi's  Method. — Neurasthenia 
and  Lithaemia 13 

Meeting  of  March   5th,   1888:     Thomsen's  Disease. —  Tumor   of  the 

Brain.      Basedow's   Disease 25 

Meeting  of  April  3d,  1888:  Basedow's  Disease. — Acute  Idiopathic 
Neuritis  of  the  Brachial  Plexus. —  Syrengomyella,  its  Pathology 
and  Clinical  Features   34° 

Meeting  of  May  1st,  1888:     Paralysis  Agitans,  with  Cases 467 

Meeting  of  June  5th,  1888:  Notes  on  the  Principles  of  Craniotomy. — 
Progressive  Muscular  Atrophy  in  Anaesthesia. — Degeneration  of 
the  Peripheral  Nerves  in  Locomotor  Ataxia 473 

New  York  Academy  of  Medicine: 

Meeting  of  April  5th,  1888:  A  Contribution  to  the  Diagnosis  and  Sur- 
gery of  Cerebral  Tumors 5 IO 

PERISCOPE. 

Anatomy  of  the  Nervous  System: 

The  Brain  Weight  in  the  Insane.— Contributions  to  the  Morphology 
and  Morhpogenesis  of  the  Crus  Cerebri. — Nuclear  Origin  of  the 
Ocular  Facial 69 


iv  INDEX. 

Contribution  to  the  Study  of  Cerebral  Localization.— An  Indian's 
Brain.— Heteropy  of  the  Gray  Substance  of  the  Spinal  Cord  —The 
Origin  of  Nervous   Symptoms  in  Anatomical   Alterations   of  the 

Sexual  Organs I,(> 

Note  on  the  Ascending  Antero-Lateral  Tract 215 

On  the  Minute  Structure  of  the  Corpora  Striata  and  Optic  Thaiami. .    .     515 

Physiology  of  the  Nervous  System: 

Anaesthetics  as  a  Factor  in  Insanity. — A  Case  of  Lingual  Mono-hemi- 
plegia  with  Cortical  Localization.—  Urine  of  Tabetics. — The  Dis- 
ease of  the  Tics  Convulsifs. — The  Lesions  in  Morphinomania,  and 
Presence  of  Morphine  in  the  Viscera. — Two  Peculiar  Forms  of 
Spasm. — On  the  Relation  of  Body-weight  in  the  Periodical  Psy- 
choses.— Early  Signs  of  Locomotor  Ataxia.— Thoughts  on  In- 
sanity        77 

On  the  Conception  of  Hysteria.— Upon  a  Peculiar  Deformity  of  the 
Body,  caused  by  Sciatica.— Paramyoclonus  Multiplex  and  Spasmo- 
philia         ,49 

Kxperiments  on  Special  Sense  Localizations  in  the  Cortex  Cerebri  of 

the  Monkey .       216 

A  certain  kind  of  Insomnia. — Puerperal  Insanity. — Paraplegia  follow  - 
Pneumonia. — Paralysis  following  Railroad  Accidents.  —  Retrograde 
Amnesia  following  Intense  Excitement. — Cerebral  Tumor,  with 
Haemorrhage.— Reflex  Psychosis  from  Traumatism. — Tabes  Dor- 
salis. — Nervous  Symptoms  of  Secondary  Syphilis 271 

Physiology  of  Movements  amongst  Hysterical  Persons 406 

Traumatic  Cortical  Epilepsy.  —  Nervous  Disorders  and  Secondary 
Syphilis. — Etiology  of  Basedow's  Disease.  Hypnotism  at  the 
Nancy  School.— A  Case  of  Pseudo-tabes. — On  the  Disease  Phe- 
nomena after  Concussion  of  the  Spinal  Cord  in  Railway  Accidents. 
— Primary  Actinomycosis  of  the  Human  Brain. — The  Diagnosis 
>i  Premature  Cranial  Synostosis. — Typical  Diphtheritic  Paralysis. 
— Dentition  among  Idiotic  and  Backward  Children.  -  Sleeping 
with  the  Head  North. — Inebriety  and  Mental  Disease: — Melan- 
cholia and  other  Depressive  Mental  Affections  in  Otopesic  Disor- 
ders of  the  Ear 


5'7 


Therapeutics  of  the  Nervous  System: 


Antithermics  as  Sedatives  of  the  Nervous  System. — Hypnotism  in  Ther- 
apeutics.— Therapeutics  of  the  Uric  Acid  Diathesis 81 

Galvanism  in  '.he  Treatment  of  Insanity. — Tasteless  Preparations  of 
Cascara  Segrada.  —  Pseudo  Angina  Pectoris.  —  Electricity  and 
Neurotherapy  in  the  Treatment  of  Cancer 153 

On  the  Treatment  of  Hydrophobia  by  Hyposulphites. — The  Treatment 

of  Neuralgia  in  General  Practice 217 

Treatment  of  Nervous  and  Mental  Diseases  by  Systematized  Active 

Exercise 279 

Cascara  Segrada  in  Rheumatism     410 

Treatment  of  Disease  by  Nerve  Pressure. — One  View  of  Neuralgia. — 

Neuralgia,  Chloroform,  and  the  Constant  Current ...    .      529 


RC        The  Journal  of  nervous  and 
321         mental  disease 
J78 
v.  15 

Biological 
&  Medical 
Serials 


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