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Volume 30. July, 1903. No. 7 


THE 


Journal 


OF 


Nervous and Mental Disease 





Original #rticles. 


A CASE OF PROGRESSIVELY DEVELOPING HEMIPLEGIA, 
LATER BECOMING TRIPLEGIA, RESULTING FROM 
PRIMARY DEGENERATION OF THE 
EY RAMP Ae RACTS? 


By CuHarrtes K. Mitts, M.D., 


CLINICAL PROFESSOR OF NERVOUS DISEASES IN THE UNIVERSITY OF PENNSYL- 
VANIA, NEUROLOGIST TO THE PHILADELPHIA HOSPITAL, 


AND 
WILLIAM G. SPILLER, M.D., 


ASSISTANT CLINICAL PROFESSOR OF NERVOUS DISEASES, AND ASSISTANT PRO- 
FESSOR OF NEUROPATHOLOGY IN THE UNIVERSITY OF PENNSYL- 
VANIA ; NEUROLOGIST TO THE PHILADELPHIA HOSPITAL, 


In this contribution the clinical and pathological details of a 
case of progressively developing hemiplegia, which later became 
triplegia, due to primary degeneration of the pyramidal tracts, 
will be presented, with a review of the literature of similar clinical 
cases. A summary of the literature of primary bilateral sclerosis 
will also be given. 


J. S., white, was admitted to the Philadelphia Hospital August 
9, 1897, where he died January 14, 1903. He was fifty-four years 
old when admitted. With the exception of a short time during 
which he was treated in the Men’s Medical Ward for diarrhea or 
dysentery, he was during this period of six years a patient in the 
Men’s Nervous Ward. 

Omitting some unessential points, his history as traced in the 
hospital records is as follows: The family history obtained has 








*Read at the meeting of the American Neurological Association, May 
12, I3 and.14, 1903. 

From the William Pepper Clinical Laboratory, Phoebe A. Hearst 
Foundation. 


185562 


386 MILLS AND SPILLER. 


no etiological value. He denied venereal disease. He was a heavy 
drinker and also used tobacco. He had had rheumatism six years 
before admission to the hospital. The earliest note referring to 
any nervous symptoms was made August 9, 1897, when a state- 
ment was recorded that two years before admission he had been 
paralyzed on the right side. It is probable that at this time (dur- 
ing 1890-1895) his loss of power first began to show itself. 

On September 28, 1897, the record stated that right hemiplegia 
(more correctly hemiparesis) was present, that the biceps-jerk 
and knee-jerk were increased, and that the plantar reflex was 
absent. Ankle clonus also was absent. 

On September 24, 1899, it was noted that he could use his 
right leg for various willed movements, but that it showed loss 
of power as compared with the left; also that there was some 
loss of power in the right arm as compared with the left. His 
grip measured by the dynamometer indicated fifty-five for the 
right and seventy-five for the left. Speech was a little thick. The 
knee-jerk on the right was much exaggerated, and the quadriceps- 
jerk and gastrocnemius-jerk were also increased. Both ankle- 
clonus and patellar clonus of moderate degree were present on the 
right. No note was made at this time as to the Babinski phenom- 
enon. Biceps-jerk, triceps-jerk and all muscle jerks in the right 
upper extremity were increased. The tendon and muscle re- 
sponses on the left were all present but not exaggerated as on the 
right, and patellar clonus and ankle clonus were absent on the 
left. Sensation for touch and pain was retained all over the body, 
and the stereognostic perception was undisturbed. The irides 
reacted to light and in accommodation, and other examinations 
for nervous phenomena gave negative results. 

On May 17, 1901, the patient complained that the right leg was 
weaker than it had been one year previous. The reflexes and 
other symptoms were much as before recorded. 

Although the case was seen from time to time no further notes 
as to his nervous symptoms were made until December 29, 1902, 
at which time it was recorded that the movements of the face and 
tongue were normal; the upper limbs could be moved voluntarily 
and fully in all parts; the grasp of the right hand was feeble, of 
the left normal; voluntary power in the right lower limb was very 
slight ; in the left lower limb it was a little better than in the right 
but much impaired. The right upper limb and both lower limbs 
were spastic, but contractures and wasting were not present. The 
biceps, triceps and wrist reflexes were much exaggerated in the 
right upper extremity, and in the left they were a little more 
prompt than normal. Patellar and Achilles reflexes were exag- 
gerated on both sides, but more so on the right; patellar clonus 
was present on the right but not on the left; ankle clonus was 
elicited on each side. The Babinski reflex was present but not 


PROGRESSIVELY DEVELOPING HEMIPLEGIA. 387 


very prominent on the right; it was absent on the left. Sensation 
to touch and pain was everywhere normal. 

This man suffered at times from severe intestinal and cardio- 
vascular symptoms. On August 6, 1897, he began to have severe 
pain in the abdomen with diarrhea, with numerous stools accom- 
panied by straining and pain. He was treated for these symptoms 
in the medical wards. The heart sounds at this time were feeble 
and accompanied by a low systolic murmur at the right base. 
The sounds were feeble on the left also, and were best at the ensi- 
form cartilage. On December 11, 1808, the records show that he 
had a soft blowing systolic murmur at the second aortic interspace. 
May 31, 1899, the patient complained of pain in the chest most 
marked over the precordia. A soft double systolic murmur was 
heard above the second cartilage. The heart’s action was weak 
and irregular. A few unimportant notes, chiefly negative, were 
made in September, 1899. The presence of the cardiac murmurs 
above described was reiterated. On January 17, 1902, the patient 
complained of constant and severe pain over the precordial re- 
gion; the heart sounds were very feeble. The pulse on the left 
side was imperceptible, owing to the atheromatous condition of 
the arteries and to the cardiac weakness. The pulse on the right 
side was perceptible but weak, and the radial arteries on both sides 
were hard and rigid. The patient suffered at this time and later 
from cardiac weakness and anginal pains for which he was treated 
with various remedies. 

About January I, 1903, he began to show signs of great weak- 
ness and rapid failure. He had at times attacks of vomiting. He 
lost flesh, his pulse became weak and intermittent, and the right 
lung became edematous. He died January 14, 1903, his death 
being preceded by a slight convulsion. 

The necropsy showed a serious pathological condition of the 
vessels and many of the viscera: chronic pleurisy and tubercu- 
losis with cavity formation; endocarditis, contracted kidneys 
and chronic marked atheroma. The heart muscles were soft and 
pale, the valves distorted, thickened and calcareous, the aortic ex- 
tensively atheromatous. Both kidneys were very firm, dark in 
color, with granular surface and irregular cortex. The stomach 
was decidedly contracted and the seat of chronic catarrh. Begin- 
ning at the junction of the transverse and descending aorta was a 
unilateral dilatation of this vessel, which increased in diameter to 
about 4 cm. This structure was atheromatous and contained 
a flattened clot. The brain and cord were removed for micro- 
scopical examination, of which the following is a record. 

The degeneration in the lumbar region was very distinct by 
the Weigert hematoxylin stain in the crossed pyramidal tracts, 
and more intense in the right than in the left. The direct pyram- 
idal tracts by this stain did not appear degenerated at this level of 


388 MILLS AND SPILLER. 


the cord. The nerve cells of the anterior horns were not distinctly 
altered, they were numerous and some were much pigmented, 
which, considering the man’s age, was not remarkable. The 
chromophilic elements were well formed and the nuclei central. 
It may be said that the nerve cells of the anterior horns of the lum- 
bar region had the usual appearance in persons of the same age. 
The anterior roots on each side in the lumbar region were normal. 

At the eighth cervical segment the degeneration of the right 
crossed and left direct pyramidal tracts was very distinct by the 
Weigert hematoxylin stain. The left crossed and right direct 
pyramidal tracts were much less degenerated. The nerve cells of 
the anterior horns of this region may be said to have been normal, 
although in examining a number of sections a few cells were found 
that were not aerials the nerve cells in general were remarkable 
for their excellent state of preservation. 

Sections from the lower cervical region stained by the Marchi 
method showed no recent degeneration in the right crossed and left 





Long-standing degeneration of the left direct pyramidal tract, recent 
degeneration of the right direct and of the left crossed pyramidal tracts. 


The dots in the crossed tract are not so large as those in the direct tract 
(Method of Marchi). 


direct pyramidal tracts. The left crossed and the right direct 
pyramidal tracts contained numerous small black dots, and those 
of the crossed tract were much smaller and less numerous than 
those of the direct tract. At the outer border of the right direct 


PROGRESSIVELY DEVELOPING HEMIPLEGIA. 389 


pyramidal tract the dots were smaller than in the median and inner 
portions of this tract. 

The anterior roots in the lower cervical region were normal. 
There was no distinct meningitis ; here and there a slight accumu- 
lation of round cells was found in the pia. 

Both pyramidal tracts were much degenerated in the oblongata 
and pons, but the left tract was much more degenerated than the 
right. The right pyramidal tract was much degenerated in the 
oblongata and pons by the Marchi method, while the left showed 
no recent degeneration by this method. About the middle of 
the pons, the left pyramidal tract contained a large proportion of 
normal nerve fibers, but a part of it was much degenerated. No 
degeneration could be detected in the foot of the right or of the 
left cerebral peduncle by the Weigert hematoxylin method, but de- 
generation by the Marchi method could be found in the middle 
portion of the foot of the right cerebral peduncle and also where 
the foot of the right cerebral peduncle becomes the lower part 
of the posterior limb of the internal capsule; the degeneration 
however was slight. No degeneration could be seen by the Marchi 
method in the foot of the left cerebral peduncle. 

Sections of the left paracentral lobule contained Betz cells 
that appeared normal. They were not numerous, but this does not 
mean that there had been a loss of the cells, as the number of these 
cells seems to vary greatly in different cases. 

Cellular infiltration of moderate intensity was found in the 
pia about the cerebral peduncles and pons, but it seems hardly 
probable that this could explain the long-standing degeneration 
of the pyramidal tract from the left cerebral hemisphere, and for 
this reason we have spoken of the degeneration of the pyramidal 
tracts as primary. No focal lesion could be detected anywhere. 


Summarized, this case was one in which hemiplegia gradually 
developed on the right side, the lower extremity being more 


markedly and probably earlier affected than the upper, the case 
therefore at first belonging to the clinical type of unilateral pro- 
gressive ascending paralysis. After several years the left lower 
extremity also became paralyzed, but not to the same extent as 
the right. The reflexes were all markedly exaggerated, the Babin- 
ski response being present. Sensory symptoms were absent. M1- 
croscopical examination showed intense and long-standing degen- 
eration of the right crossed and the left direct pyramidal tracts, 
the degeneration extending into the pons but not into the left 
cerebral peduncle; also comparatively recent degeneration of the 
left crossed and the right direct pyramidal tracts, traced by the 


390 MILLS AN DS SPILEER: 


method of Marchi into the lower part of the right internal cap- 
sule. No lesions, degenerative or focal, were found elsewhere in 
the brain or spinal cord; the case, therefore, was one of primary 
degeneration of the motor tracts, much greater and older in the 
right crossed and left direct pyramidal tracts. The case may be 
regarded as a corroboration of the clinical type described by Mills 
in the JoURNAL OF NERVOUS AND MENTAL DISEASE for April, 
1900. 

In the JourNAL or Nervous AND MENTAL Disease for April, 
1900, in a paper entitled “A Case of Unilateral Progressive 
Ascending Paralysis, Probably Representing a New Form of 
Degenerative Disease,” which was presented to the Philadelphia 
Neurological Society on December 18, 1899, an interesting case 
is detailed, reference being made to another somewhat similar 
case previously observed. The patient, a man fifty-two years 
old, about two years before coming under observation began to 
show signs of weakness in the right lower extremity, as indicated 
by his method of walking. The paresis came on slowly and 
insidiously. Weakness in the arm appeared for the first time 
eighteen months after the weakness was noticed in the lower 
extremity. This weakness soon became more and more evident, 
and was accompanied by the tendency to carry the arm raised 
against the body and flexed at the elbow. When first examined 
the paresis in the upper extremity, although easily determined, 
had not nearly reached the degree of impairment observed in the 
leg. The right side of the face was also slightly but undoubtedly 
paretic. The patient had had at one period some hyperesthesia 
in the right lumbar region and in the lower extremity, and later 
in the right upper extremity. Herpes appeared in the lumbar 
and lumbosacral regions, lasting for a short time. Wasting was 
distinct in the right lower extremity, the measurements showing 
a- difference of one and a half inches for the thigh, and five 
eighths of an inch for the calves. The various movements of the 
right leg were distinctly weaker than those of the left, but were 
nowhere absolutely abolished. Similarly all the movements of 
the right arm were distinctly impaired, but were nowhere abso- 
lutely lost. The dynamometer showed 180 for the right and 160 
for the left. Faradic contractility was retained. The affected 
limbs were not spastic nor contractured. Careful examination 


PROGRESSIVELY DEVELOPING HEMIPLEGIA. 391 


showed retention of all forms of sensation. The tendon and 
muscle phenomena on the right side were all somewhat exag- 
gerated. Knee-jerk was plus on the left side, but was consider- 
ably more exaggerated on the right. Patellar clonus was present 
on the right but not on the left, and the right side showed a slight 
ankle clonus, which was absent on the left. The plantar reflex 
was normal on the left; but on the right, while the Babinski 
reflex was not present, the normal response was distinctly less 
marked than on the left. It might be described as between nor- 
mal plantar flexion of the toes and the dorsal flexion of the 
Babinski reflex. 

This case has recently been made the subject of reinvestiga- 
tion by Dr. Hugh T. Patrick, who inclines to the opinion that the 
case is one of paralysis agitans without tremor, the disease up 
to the present time having attacked only one side of the body. 
His report of the case was presented at the meeting of the 
American Neurological Association, and will be found in its 
Proceedings, with the discussion of the case by Dr. Mills. At 
the time when the patient was examined by Dr. Mills, among the 
reasons for believing that the case was not paralysis agitans were 
the absence of spontaneous tremor; the presence of markedly 
exaggerated reflexes on the affected side, even including ankle 
clonus and patellar clonus; the existence of decided wasting on 
one side, especially of the lower extremity, and the absence of 
the facies of paralysis agitans and of a fixed position of the 
body and head. 

According to Sir William Gowers, both primary lateral sclero- 
sis and paralysis agitans are probably abiotrophies (Lancet, April 
12, 1902), and it may be that in the case under consideration the 
two abiotic diseases are conjoined. 

In the same paper in which this case is detailed a second case 
is reported. This patient was under the care of Dr. Mills seven- 
teen or eighteen years ago, and had previously been a patient of 
the late Dr. E. C. Seguin of New York, who believed that there 
was a cerebral lesion causing changes in the crossed pyramidal 
fasciculus analogous to lateral sclerosis. The view taken by 
Mills was that the changes in the crossed pyramidal tract were of 
the nature of a lateral sclerosis, but were primary and not sec- 
ondary to any cerebral lesion. The patient was a woman forty- 


392 MILLS AND SPILLER. 


three years old, who first noticed weakness in her leg while preg- 
nant with her last child, three years before coming under obser- 
vation. The left arm became paretic a few months after the left, 
leg. The reflexes were much increased on the affected side. The 
patient remained under observation for many months, the paresis 
of the leg and arm slowly increasing. Neither arm nor leg was 
contractured, and sensibility was preserved. The patient com- 
plained at times of pains like neuralgias in the limbs, and of 
nervous twitching in the leg and arm. This patient was alive 
three or four years ago, and had become entirely unable to walk, 
but just how she was affected was not learned. 

In the paper reporting these cases the differential diagnosis 
from an unusual form of unilateral disseminated sclerosis, from 
unilateral amyotrophic sclerosis, from a progressive hemiplegia 
due to slowly increasing focal cerebral lesion involving the motor 
subcortex or the internal capsule, from a degenerative motor 
neuritis, and from a functional hemiparesis was discussed. Rea- 
sons were given why the cases did not seem to fit in exactly with 
any one of these diagnoses. 

In addition, as has been indicated above, the diagnosis must 
be made from unilateral paralysis agitans. Syphilitic hemiplegia 
later becoming a triplegia might also have some points in com- 
mon, but could usually be separated by the presence of such con- 
comitant syphilitic affections as paralyses of the cranial nerves. 

In the Philadelphia Medical Journal, Feb. 9, 1901, Spiller has 
recorded the case of a man, forty-one years old, who began, four 
years before coming under observation, to feel weak in the left 
lower limb while walking. The weakness increased, and in 
about a year the left upper extremity also showed signs of feeble- 
ness. He was never unconscious and never had headache or 
vertigo or other signs of focal intracranial disease. When the 
case was recorded the movements of the left lower limb were 
spastic, but not ataxic; the toes of the left foot were scraped 
along the ground and the foot turned inward. Both knee-jerks 
were prominent, but the left much more so than the right. Ankle 
clonus was obtained on the left but not on the right, and the 
Babinski reflex was distinct on the left, but uncertain on the right. 
Sensation was normal. The resistance to passive movement and 
the grasp of the hand were decidedly weak. The left upper limb 


PROGRESSIVELY DEVELOPING HEMIPLEGIA. 393 


was weaker than the right; it was also spastic, but the weakness 
and spasticity were less than in the lower extremity. The left 
upper limb was held slightly flexed at the elbow and against the 
body, but no contractures were present anywhere. Speech was 
_ normal, but the mouth could not be drawn up as well on the left 
side as on the right. The tongue went slightly to the left on pro- 
trusion. Ophthalmoscopic examination by Dr. H. F. Hansell 
showed white atrophy of the left optic nerve. After giving the 
details of his case, Spiller discusses its probable diagnosis, and 
concludes that the cases reported by Mills and by him have the 
symptoms which one should expect from unilateral lateral scle- 
rosis, but he also called attention to the fact that other lesions 
might cause the same symptoms. The wasting is like that occur- 
ring in hemiplegia. 

Potts (JouRNAL oF Nervous AND MENTAL DISEASE, Oct. 
1901), under the title, “A Case of Progressive Unilateral Ascend- 
ing Paralysis Probably Due to Multiple Sclerosis,” has reported a 
case somewhat similar to the case described by the authors of this 
paper. The patient, a youth of nineteen, when about fifteen 
years old began to drag his right foot, this foot in walking 
showing a tendency to cross over the other. Two years after the 
impairment of power, diplopia appeared and remained for five 
months. It was discovered at about this time that the right leg 
was smaller than the left. Weakness in the right arm was 
first noticed about three and a half years after its appearance in 
the right leg. Examination showed that when the patient walked 
the right leg was rigid and the toe dragged. All movements of 
the leg were preserved but impaired. The right arm was dis- 
tinctly weaker than the left, but was not spastic. Both the arm 
and leg were decidedly atrophied, as shown by careful measure- 
ments. The adductor pollicis was not so large or firm as the left. 
The reflexes were prompt everywhere but exaggerated on the 
right, the Babinski response being present. The right side of the 
face showed slight paresis with some tremor on voluntary effort. 
Paresis of the muscles of the right side of the throat was present. 
Nystagmus was present especially when the eyes were turned to 
the right. There was paresis of the left inferior rectus, and pale- 
ness of the temporal halves of the discs. All forms of sensation, 
including stereognosis, were normal. A slight Romberg symp- 


394 MILES AND SP tLe, 


tom and tendency to incodrdination were sometimes shown. ‘The 
right hand and foot were colder to the touch than the left. Potts, 
while recognizing the resemblance between his case and the cases 
reported by the writers, holds that his case is probably one of 
disseminated sclerosis, and suggests that our cases might also be 
classed in this category, a view which we cannot accept. This 
diagnosis in Pott’s case may be correct, although it is also probable 
in this and similar cases of disseminated sclerosis that the degen- 
eration first and for a long time is chiefly confined to the pyramidal 
tract on one side. 

Gowers, in his paper on “Abiotrophy” (Lancet, April 12, 
1902), says truly “that the symptoms of systematic degeneration 
are not alone ground for the diagnosis of insular sclerosis, nor is 
the additional presence of nystagmus. Nystagmus on movement 
of the eyes is met with in many spinal degenerations of pure 
systemic type.” 

In his paper on “Chronic Progressive Hemiplegia,’ read at 
the present meeting of the American Neurological Association, 
Patrick describes a case which he regards as clearly indicating 
the progressively developing hemiplegia due to degeneration of 
the pyramidal tract of one side. During a recent visit to Chi- 
cago one of us (Dr. Mills) had the opportunity, through the 
courtesy of Dr. Patrick, of seeing this case, that of a young 
woman, eighteen years old, whose motor disability appeared 
about four years previously. The essential features of this case 
are the unilateral and progressive character of the paralysis 
which probably began first in the lower extremity, the exaggera- 
tion of the reflexes on the affected side, the absence of all forms 
of sensory disorder and of visceral symptoms, and the moderate 
wasting of the limbs and face. The reader is referred to Dr. 
Patrick’s paper for fuller particulars of this case. 

Another case of unilateral progressive ascending paralysis 
has been in our care at the University Hospital. 

From a study of the cases presented in this paper, and in the 
light of the pathological findings in the case with autopsy, it may 
be concluded that there is a form of progressively developing 
hemiplegia, usually of ascending type, sometimes becoming tri- 
plegia or even quadriplegia, due to a progressive primary degen- 
eration of the pyramidal tracts, which begins on one side and 


PROGRESSIVELY DEVELOPING HEMIPLEGIA. 395 


may extend to the other. This clinical picture may be produced 
by other lesions, but we believe that we have established the fact 
that primary progressive degeneration of one pyramidal tract 
occasionally occurs. This is a unilateral lateral sclerosis, and in 
this connection it is interesting to devote some space to the subject 
of bilateral lateral] sclerosis. 

In a recent address in London, Erb? spoke of the spastic 
spinal paralysis first described by him in 1875. he believes that 
sufficient cases have been published to show that primary bilateral 
sclerosis exists. The following cases he gives as indisputable, 
and capable of standing any criticism. 

Case 1. Minkowski.? Clinically the picture was one of spastic 
spinal paralvsis. Anatomically there was a nearly pure sclerosis 
of the crossed pyramidal tracts, with slight changes in the direct 
cerebellar tracts. 

Case 2. Von Strtimpell.* The patient was a man, aged 
sixty-three years, who had a brother suffering from the same 
disease. Clinically the case presented the typical picture of 
spastic spinal paralysis for at least twenty years. Anatomically 
there was a typical degeneration of the pyramidal tracts from 
the lumbar to the cervical region, and in addition a slight 
degeneration of the direct cerebellar tracts and a still more 
trifling degeneration of the tracts of Goll in the upper part of 
the spinal cord. Strumpell would, on this account, reckon the 
affection among the combined system diseases, but the degenera- 
tion of the pyramidal tracts was certainly the most essential lesion, 
and is to be regarded as primary. 

Case 3. Dejerine and Sottas.6 Clinically this was a pure 
case of spastic spinal paralysis of twenty-five years’ duration, 
death occurring from pneumonia in the sixty-sixth year. Ana- 
tomically there was marked sclerosis of the pyramidal tracts 
from the lumbar to the cervical cord, with slight partial sclerosis 
of Goll’s tracts in the cervical region. 

Case 4. Donaggio.6 The patient was a man aged sixty-one 
years. Clinically there was for two and a quarter years the typical 
picture of pure spastic spinal paralysis; death resulted from pneu- 
monia. Anatomically there was pure, exclusively primary degen- 
eration of the pyramidal tracts from the lumbar to the cervical 
region (a quite typical case). 


396 MILLS AND SPILLER. 


Case 5. Friedmann.?. The patient was a male, aged fifty- 
two years. Clinically for two years the picture was one of 
a spastic spinal paralysis (trace of disturbed sensation being 
present?). The patient suffered from apoplexy, death resulting 
from pneumonia. Anatomically there was classical primary de- 
generation of the pyramidal tracts only, there being a trace of 
degeneration in the direct cerebellar tracts as well as endarteritis 
obliterans of the basilar artery. 

Case 6. Von Striimpel.* Clinically a picture of spastic 
spinal paralysis was present, death occurring after the disease 
had lasted for thirty-five years. Anatomically there was quite 
typical moderate degeneration of the pyramidal tracts from the 
lumbar cord to the region of the pyramids. The direct cerebellar 
tracts were scarcely affected and the tracts of Goll very slightly 
in the upper cervical region. The anterior columns and brain 
were entirely free (belongs to the hereditary form). 

Cases 7 and 8. Bischoff.® The patients were two brothers 
who, from their eighth and tenth years respectively, suffered 
from spastic rigidity of the limbs, ascending slowly from the legs 
to the head. Intellectually development was poor, but otherwise 
clinically the typical picture was one of spastic spinal paralysis. 
Death took place from phthisis after about twenty years’ dura- 
tion. Anatomically there was a typical degeneration of the pyram- 
idal tracts, extending upwards beyond the oblongata, but 
not farther. The direct cerebellar tracts and Gowers’ bun- 
dles were all but free. Goll’s tracts were extremely affected. 
In the gray matter of the anterior columns there was atrophy of 
the ganglion cells (evidently occurring towards the end of life). 
The author calls the change in the spinal cord primary tract 
degeneration (quite analogous to the condition found by Striim- 
pell), and holds that thereby the existence of an infantile form 
of hereditary spastic spinal paralysis has been proved. 

Case 9. Ida Democh.’”® The case is clinically and anatomically 
somewhat complicated; clinically there was a typical picture of 
spastic spinal paralysis, combined with signs of chronic alcohol- 
ism, pains, tremors, etc. Anatomically there were primary de- 
generation of the tracts of Goll and congenital hydromyelia in 
the lumbar and dorsal cord; the direct cerebellar tracts were free; 
nevertheless, as proved by the author, this can be termed a case 


PROGRESSIVELY DEVELOPING HEMIPLEGIA. 397 


of primary degeneration of the pyramidal tracts in spastic spinal. 
paralysis. 

Case 10. A case clinically typical of spastic spinal paralysis. 
described by Ktthn, in which von Strumpell made the microscopical 
examination of the spinal cord. He found an essentially charac- 
teristic primary degeneration of the lateral columns. 

Erb regarded the sclerosis of the direct cerebellar tracts and 
the slight degeneration of the columns of Goll in some of these 
cases as of secondary importance. 

He thinks that the case described by Strumpell’* in 1894 as 
a primary isolated system degeneration of both pyramidal tracts, 
showing only slight transitions to amyotrophic lateral sclerosis, 
might come under this head. 

To this record we would add the case reported by us in this: 
paper, and also the case reported by one of us (Spiller??) in 
which there was primary degeneration of the pyramidal tracts 
with comparatively slight alteration of the nerve cells of the 
anterior horns of the spinal cord. 


Note—Since this paper was read, another communication by Erb on 
spastic spinal paralysis has been published in the Deutsche Zeitschrift fiir 
Nervenheilkunde, Vol. 23, Nos. 5 and 6. He refers to the ten cases men- 


tioned in his previous paper, and includes the well known case of Morgan 
and Dreschfeld. 


“Erb, Lancet, 1902, p. 970. 

*Minkowski, Deutsches Archiv f. klin. Med., Vol. 34, 1884. 

*Von Striimpell, Archiv f. Psych., 17, 1886. 

*Dejerine and Sottas, Archives de Physiologie Normale et Patholo-- 
gique, 1896, p. 630. 

*Donaggio, Rivista sperimentale di freniatria, Vol. 23, 1897. 

‘Friedmann, Deutsche Zeitschr. f. Nervenheilk., Vol. 16, 1890. 

*Von Striimpell, Neur. Centralbl., 1901, p. 530. 

*Bischoff, Jahrbiicher f. Psych. und Neur., Vol. 22, 1902. 

Ida Democh, Archiv. f. Psych., Vol. 33, 1900. 

*Von Striimpell, Deut. Zeitschr. f.. Nerv., Vol. 5, p. 225. 

“Spiller, JouRNAL oF NErvous AND MENTAL DISEASE, May, 1902. 


THE RESULTS OF SURGICAL TREATMENT OF BRAIN 
TUMORS. 


By M. Aten Starr, M.D., LL.D., 
OF NEW YORK. 


In order to estimate accurately the prospect of success in any 
surgical operation, it is wise to consider the results which have 
been attained in a iarge number of cases. And while, too great 
importance should never be attached to statistics, yet on the other 
hand, they possess a certain value and are never without an ele- 
ment of interest. In 1893, I was able to collect seventy cases of 
brain tumor in which an operation had been undertaken, and in 
1896 and 1897, I analyzed the results in two hundred and twenty 
cases in which a surgical operation had been attempted.” As a 
knowledge of the possibility of operation has become more wide- 
spread, and as the technic of brain surgery has become more 
perfect, reports of such operations have been more frequent, and 
it has been possible to collect 365 cases up to January I, 1903.° 
In the appendix to this article the cases which have been published 
since January 1, 1896, are tabulated, all those prior to that time 
being referred to either in Brain Surgery, or in the Medical Record 
for February 1, 1896, or in the article in the Montreal Medical 
Journal for November, 1897. 


TABLE OF RESULTS OF OPERATION FOR BRAIN TUMOR. 


Cere- Cere- 
bral. bellar. 
Total number’ of cases operated “tipon: Jue... eee ee 365 ars 50 
Cases in which the tumor was not found............. III QI 20 
Cases in which the tumor was found but not removed. 27 21 6 
Cases in which the tumor was removed and the patient 
died 3 sated. AAO ORR ee ee ee See eee 59 51 8 
Cases in which the tumor was removed and the patient 
recovered . ... se meeiy eis. cate ee < oer renee 168 152 16 


There are two elements which render the chances of success in 
the operation for brain tumors better at present than formerly. 
(1) The accuracy of diagnosis and the accuracy of localization 





*Brain Surgery, Wm. Wood & Co., 1893. 
*New York Medical Record, February, 1896. Montreal Medical Jour- 
nal, November, 1897. 
‘3 as cases have been gathered from the literature for me by Dr. O. 
ensel. 


SURGICAL TREATMENT OF BRAIN TUMOR. 399 


of tumor are today more easily possible than before. Given a his- 
tory of a slowly progressing disease with symptoms of headache, 
vomiting, vertigo, sensations of cerebral discomfort, progressive 
emaciation and feebleness, and a gradual loss of sight due to a 
choked disc, and the only probable hypothesis is the existence of a 
brain tumor. No other disease can produce this particular combin- 
ation of symptoms. Hence the diagnosis of the nature of the dis- 
ease is not difficult. 

The possibility of locating tumors has also become more defi- 
nite within the last twenty years. This diagnosis is wholly by 
direct observation of local symptoms such as (a) mental symp- 
toms, (b) motor or sensory aphasia, (c) local spasm and mono- 
plegia, (d) hemianopsia, (e) cerebellar staggering. 

The diagnosis is also one to be reached in part by elimination, 
for the absence of any one of these localizing symptoms just named, 
when the disease is clearly a brain tumor, makes it evident that the 
tumor is inaccessible. It is therefore possible at the present time 
to determine with considerable accuracy, frst, that a tumor is 
present, and, second, that the surgeon can reach it. 

The chance of success has also been materially increased by 
the newer surgical methods of access to the brain. It is true that 
successes had been obtained by the use of the ordinary trephine, 
the opening being enlarged by a rongeur. It is also true that the 
method of opening the skull by a horseshoe-shaped incision 
through scalp, periosteum and bone, by means of a gouge 
and chisel, has been attended by greater success. This method was 
a distinct improvement upon the method by the use of the trephine. 
But during the past three years these two methods have been su- 
perseded by the use of the electrical saws. In the larger hospitals 
it is perfectly possible to obtain a powerful electrical engine con- 
nected with a flexible tube, on the end of which revolving spools 
can be inserted. The method at present used by McCosh at the 
Presbyterian Hospital seems to me the best method as yet devised 
for entering the skull. A small bulb of the shape of a pear, about 
one-quarter of an inch in diameter, is attached to the electrical en- 
gine, and with this bulb four or five small holes are bored through 
the skull. ‘The cone-shape of the bulb allows the point to penetrate 
through the skull as it is revolved, and yet prevents the shaft from 
entering the skull or penetrating the dura. It requires but a few 
seconds with the powerful revolutions of this bulb, that are ob- 


400 M. ALLEN STARR. 


tained by the machine, to bore one of these holes. The number of 
holes and their position upon the skull are determined entirely by 
the area that it is desired to expose. If four holes are bored they 
are from one and a half to four inches apart. When these holes 
have been made the bulb is removed from the machine and there 
is substituted a small circular saw and the bone between these 
holes is quickly sawed through by it. A small projecting and pro- 
tecting tlange is screwed to the side of the circular saw so that 
the blade of the saw is exposed only for the depth of the skull as 
measured through the holes, and in this way the danger of sawing 
through the dura is wholly obviated. It requires hardly a minute 
when the saw is properly adjusted to saw through the skull from 
one hole to the next. In this manner the skull can be opened in 
from six to eight minutes after the original incision has been made 
throuzh the scalp. This method offers great advantages in the 
rapidity with which access can be had to the brain. 

Experience has taught that it is a great advantage in the ex- 
traction of tumors to have plenty of space, and it has also taught 
that these large bony flaps can be replaced and will unite without 
any danger. The bony flap is turned downward, as a rule, the 
lower edge of the flap not being sawn entirely through, but 
cracked. It is left attached to the periosteum and skin. ‘The incis- 
ion in the scalp will be determined in its shape by the incision 
which it is proposed to make in the bone. This may be rectangular 
or polygonal. Much time is saved in the operation by making the 
bony flap of large size, as in former operations it was often neces- 
sary to delay for the enlargement of the bony opening after the tu- 
mor had been found. By the use of this methoa, I have frequently 
seen the brain exposed within ten minutes of the time of the be- 
ginning of the operation; while in prior methods from eighteen to 
twenty-five minutes were often expended in this preliminary stage. 

Another factor in success in these operations is the fact that we 
have come to the conclusion that extensive cutting of the brain and 
exsection of parts of the brain are not necessarily attended by 
danger, provided the hemorrhage can be arrested. I have seen 
large areas, two to three inches in diameter, cut out of the brain, 
to a depth of two to three inches, and I have seen the patients re- 
cover. While the difficulties attendant upon the extraction of a 
deep tumor are many, and while the chances of subsequent recov- 
ery. first, from the operation, and, second, from the symptoms, are 


SURGICAL TREATMENT OF BRAIN TUMOR. 401 


much less in such deep tumors, yet it must be conceded that a tu- 
mor lying one or two inches below the surface may be reached. 

For these reasons it seems to me probable that the statistics of 
the next ten years will show a very much greater percentage of 
successes than do the statistics up to the present time. 

The operation for cerebellar tumors appears to me to be of 
great difficulty and danger. But one-tenth of each hemisphere of 
the cerebellum can be reached by the surgeon through the occipi- 
tal fossa. This I have determined by measurements of the surface 
many times in the cadaver. The surface which is accessible is one 
which is very rarely the seat of a cerebellar tumor. Cerebellar tu- 
mors lie either in the middle lobe of the cerebellum directly be- 
neath the tentorium, a point which cannot be reached from the 
lower surface of the cerebellum, or else they lie in the sulci be- 
tween the cerebellum and the pons and medulla oblongata, upon 
the base of the brain, a point which is equally inaccessible. For 
this reason failures are numerous in operations for cerebellar tu- 
mor, and after a considerable experience (I have had nine such 
cases operated upon without any success) it seems to me futile to 
attempt this operation. 

The causes of failure are: First, mistakes in the diagnosis of 
the location of the tumor. Ina certain percentage of tumors these 
mistakes are inevitable. Certain local symptoms of tumor which 
appear to point to a clear localization do occur in some cases when 
the tumor is at a considerable distance from the point where it is 
supposed to lie. The local symptoms are therefore not infallible 
in their indication. 

Secondly, some tumors, even when accessible, cannot be re- 
moved. ‘They are infiltrating gliomata without any boundary and 
with a vascular, softened tissue about them which prevents enu- 
cleation, and this variety of tumor is particularly liable to return 
even if removed in part. 

Thirdly, the dangers of hemorrhage and the dangers of menin- 
gitis are less dreaded at present than formerly, proper asepsis pre- 
venting the latter complication in all cases. 


402 M. ALLEN STARR. 


APPENDIX BY DR. O. HENSEL. 


VARIETY OF TUMOR REMOVED AND RESULTS. 


1893-1903. 

Recovered. Died. 

Sarcoma « 2. > 7 8ybeie ale pees oan Cle Pentel coke ee eae Bie eae a 34 Ve 
Melanosarcoma: 2). Suc aoe ceca ae ns cae as ee I — 
Cystosarcoma ‘72.5 [os ene cnn cl cccnee ete oat eee eee I — 
Gliosarcoma ({::2ts'}oc aie tr ries. eek wa Srl aut, 5 — 
Glioma ois 6 oS adcn she Jaap mm Etat eis, ees ear a nee Oe 8 5 
Neuroglioma ico % <2 ide A ees fata ies an cher eater mie ine nn eae — 
Perithelioma . .4, bVevjty Se ete ecko s-a le So ee enn — 
Endotheltomar. 0045 Wc er Caen onc ve ee Sine ae eu neces 3 % 
Carcinoma: occ. 0% ii Se en oe eas Tah al eee I — 
Hydatid: Cyst.) .\. s:c5heeeeeeeen out k o's 2, cg win euaeme site nate ate 4 I 
Cyst cio 5.c.odn 0 nosd' Ree ee I ee. Gs pas ac Ae ee eee ee a 22 7 
Tubercle?) s.\5 o.oo sien tec asl OTs. «5 tie er pate Ohne ee een II 4 
Gutnma ys. 2 oo ieee ie 2 ke se 3 en ee 5 2 
Fibroma.-: .| 3c5.A.020e) oy eet ces eee ss BL Ones I 2 
ANSIONG Gunes ee ae ise iene eM eG ic Se shtbye Sent VS 4 —_ 
Osteoma “3 22 vse siwidie cd oR Goals oa o Soal ee RE ane me — 
Not: stated 5°. actor Nain ie mmen net 00 4.0. ys, re oe nee 16 9 
120 46 


TUMOR TREPHINED FOR BUT NOT FOUND. 


Central Region.—1-2. Bramwell, Boston Med. Journ., Dec., 22, 1900, 2 Cases, 
glioma right motor region, no tumor found, “death in 9 months.— 
3. Hoppe, Journ. of Amer. Med. Assoc., Feb. 2, 1901, Tubercle in lenti- 
form nucleus of right side, extending to within 1% inch of cortex in 
ascending frontal and parietal regions and inward and downward to 
internal capsule. Death in 6 hours.—4. Hoppe, ibid., Gliosarcoma, 
extending 2 inches from tip of Ist frontal convolution, back along 
longitudinal fissure to 2 inches posterior to fissure of Rolando. Death 
on same day.—5. Hoppe, ibid., Multiple cysts. Trephined at lower 
extremity of fissure of Rolando. Death from cerebral hemorrhage.— 
6. Schulze, Deutsche Zeitschrift f. Nervenheilk., 1806. Sarcoma in 
left facial center, death.—7. Clarke, Glasgow Med. Journ., 48, p. 13. 
Motor area trephined, not found, death, no autopsy. 

Frontal Region.—8. Hitzig, Therap. Wechenschrift, 1806. Glioma, right 
frontal lobe, death soon after operation.—9g. Zenner, Transactions of 
American Neurological Association, May, 1897. Subcortical growth in 
prerolandic gyrus.—10. Stochow, Jnaugural Dissert., Erlangen, 18096. 
Tumor, left frontal lobe on autopsy.—11. Hahn and Ruheman, Deutsche 
med. Wochenschrift, 1806. Trephined in frontal region, not found. 
Was in 2d and 3d frontal convolution. Improvement.—12. Clarke, 
British Med. Journ., Oct. 13, 1900. Glioma, left frontal lobe, not found, 
death next day.—13. Armitage, Lancet, Nov. 26, 1898. Cortical growth, 
superior and middle frontal convolution.—14. Gordinier, American 
Journ. of Med. Sciences, May, 1809. Glioma, second left frontal con- 
volution. 

Parietal Region.—15. Williamson, British Med. Journ., July 6, Igot. 
Sarcoma at right parieto- -occipital fissure, death in I month.—16. Ros- 
solimo, Arch. f. Psych., xxix. Cavernous angioma of left paracentr. 
lobe, death in 15 hours of hemorrhage.—17. Lambotte, Annals de la 
Soc. Belg. de Chir., 1896. Trephined in occipital region. Was in 
angular gyrus. Death. 

Temporal Region.—18. Gessler and Bayha, Wiirtemb. aret. Correspbl., 
1897. Tumor in temporal lobe, death in 6 days. —19. Starr and Weir, 


SURGICAL TREATMENT OF BRAIN TUMOR. 403 


Medical News, Aug. 7, 1897. Glioma.—z20. Transactions of the Amer- 
ican Neurological Association, May 5, 1897. Sarcoma in left temporal 
lobe.—21. Starr, British Med. Journ., Oct. 16, 1897. Glioma, trephined 
for in left 3d frontal convolution, death. 

Occipital Lobe.—22. Barette, Soc. de Chirurg. de Paris, Nov. 11, 1897. 
Neuroglioma of occipital lobe, compressing longitudinal sinus and 
causing a swelling in the frontal region, which could not be removed 
on account of hemorrhage. 

Deeper Parts of Brain.—23. Mingazzini, Deutsche Zeitschrift f. Nerven- 
heilk., 1900. Sarcoma in right island and corpus striatum.24. Broca, 
Arch. gen. de Méd., 1896. Tumor of chiasma, could not be found, 
ventricles drained, death in 2 weeks.—25. McBurney, Med. Record, 
1896. Sarcoma of left centrum ovale and base. Death.—26. McCosh, 
Med. Record, 1896. Tumor of corpora quadrigemina. No change 
after operation.—27. Bury, British Med. Journ., Nov., 1896. Tubercle 
of optic thalamus. Death in 2 months.—28. Glaser, Langenbeck’s Arch., 
i, 1901. Glioma, region of calamus scriptorius, death in 34 hours.— 
29. Rohner, Rev. Méd. de l’Est., xxx, 1898. Basal tumor.—3o. D’Alloco, 
La rif. med., 1897. Optie thalamus.—31. Gordinier, Alb. Med. Annals, 
1898. Centrum ovale, died.—32. Thomas and Hamilton, Journ. of Exp. 
Med., 1897. Corpus callosum, died.—33. Taylor, Journ. of Exp. Med., 
ii, 6. Optic thalamus, died.—34. Thompson and Ferguson, Glasgow 
Med. Journ., 56, p. 424-429. Tubercle, suspected in motor area, found 
on autopsy in lenticular and caudate nuclei.—35. Starr, British Med. 
Journ., Oct. 16, 1897. Large sarcoma in basal ganglia, under area ex- 
posed. Death, 2 weeks.—36. Schulze, Deutsche Zeitschrift f. Nerven- 
heilk., 1896. Gliosarcoma at right side of base with hydrocephalus of 
left lateral ventricle. 

Cerebellum.— 37. Ziegenweide, Psych. en neurol. Bl., 1899. Suspected 
in cerebellum, on autopsy found between right cerebellum, tentorium 
and pons.—38. Heidenhain, Arch. f. klin. Chirurgie, 64, p. 848. Sar- 
coma of upper and lower worm. Death in 7 hours.—37. Stieglitz, 
Gerster and Lilienthal, American Journ. of the Med. Sciences, Vol. iti, 
p. 509. Gliosarcoma of right cerebellum, meningitis.—40. Borelius, 
Neur. Centralbl., 1897. Fibroma of right cerebellum. Death soon after. 
—41-42. Janz, Schmidt's Jahrb., 1897. Two cases, tumor cerebelli, not 
found, death.—43. Gerster, American Journ. of the Med. Sciences, 
May, 1806. Cerebellar tumor, not found.—44. D’Alloco, Rif. med., 
1897.—45. Starr, British Med. Journ., Oct. 16, 1897. Glioma, right 
cerebellum, ventricle drained, improvement, death in 8 days.—46. 
Starr, ibid., Cerebellar tumor, not found. Operation had to be stopped 
owing to hemorrhage. Discharged in same condition.—47. Descos, 
Lyon Méd., xcii. Not found, death. 

Region Not Stated or Indefinite —48. Koster and Schiller, Neurol. Central- 
biatt, 1807. Sarcoma. left hemisphere. Death, 2 months after slight 
improvement.--49. Gould, Clin. Soc. of London, Jan. 11, 1898.—50. 
Sidney, British Med. Journ., 18908, p. 215.—51. Swolfs, Journal de Neu- 
rologic, 1897, No. 24—52. Hirsche, Wiener klin. Wochenschrift, 18096, 
No. 5.—53. Nicoll, Glasgow Med. and Chirurg. Soc., March 4, 1898.— 
54. Fisher, Transactions of the American Neurological Association, 
May, 1897.—55. Langdon, ibid.—s56. Spencer, Therap. Gazette, 1808. 
Operated in occipital region, recovered.—57. Phillips, British Med. 
Journ., 1898. Recovered.—58. Spencer and Keene, Therap. Gazette, 
Recovered.—s9. Sinkler, Journ. of Nervous and Mental Disease, xxi, 
p. 796. Death in 54 days—6o0. Hitzig, Therap. W ochenschrift, 1806, 
Sarcoma, left hemisphere, death in 3 weeks.—61. Hitzig, ibid. Pa- 
tient’s condition not changed.—62. Ruheman and Hahn, Deutsche med. 
Wochenschrift. 1806. Operated on cerebellum, position (?) No 
autopsy.—63. Gibson, Edinb. Med. Journ., Feb., 1806. 


404 W. ALLENS Txt ick: 


TUMORS FOUND, NOT REMOVED. 


Central Region.—64. Krauss, New York Med. Journ., July 30, 1808. 
Trephined over left arm center and found hard mass 1 inch below 
cortex which could not be removed. Recovery.—65. Wiener, New 
York Med. Journ., 1898. Glioma of arm, face and speech centers, too 
large for removal.—66. Elliot, Boston Med. and Surg. Journ., 1806. 
Multiple sarcomata of left motor zone, removal intended for a second 
operation, but death before this after slight improvement.—67. McBur- 
ney, Med. Record, 1896. Glioma of central convolutions which could 
not be extirpated. Result (?).—68. Henschen, Mitth. aus dem Grenzge- 
biet der Med. und Chir., 1898. ‘Too large and diffuse tc be removed.— 
69. Henschen, ibid., too large and diffuse to be removed; death in 8 
months.—7o. Starr, British Med. Journ., Oct. 16, 1897, Glioma, motor 
area, could not be removed owing to hemorrhage. Death 24 hrs.— 
71. Eskridge, Denver Med. Times, June, 1896. Glioma, Rolandic area. 
—72. Fisher, New York Med. Journ., April 16, 1898.—73. King, Chicago 
Clinical Review, April, 1897. Glioma. 

Frontal Region.—74. Schulze, Deutsche Zeitschrift fiir Nervenheilkunde, 
1896. Gliosarcoma of right frontal lobe. Operation interrupted owing 
to hemorrhage. Death next day.—75. Patel, Lyon Méd., xciii, 830. Sar- 
coma. 

Parietal Region—76. Nonne, Neurolog. Centralblatt, 1809, p. 229. Sub- 
cortical sarcoma, left paracentr. lobe. Death 5 months. 

Cerebellum.—77. Scheede, Deutscix med. Wochenschrift, 1900, No. 30, 
Cystic glioma in worm. Death.—78. Saenger, Neurolog. Centralblatt, 
1899, p. 1117. Tumor between pons, medulla and cerebellum, slight 
improvement.—7g. Saenger, ibid., Partial recovery.—8o. Joffé, Deutsche 
med. Wochenschrift, 1897, No. 5. Fibrosarecoma of right cerebellum. 
Operation interrupted on account of collapse. Death in 12 hours. 

Region Indefinite or Not Stated.—81. Jolly, Beri. klin. Wochenschrift, 1899, 
No. 29, Glioma, too diffuse for removal. Death, 21% years.—82. Col- 
man and Ballance, British Med. Journal, March 11, 1896, Cystic glioma 
in centrum semiovale. One cyst evacuated. Death in 10 months.— 
83. Labbe, Bull. et Mem. de la Soc. Anat., 55x, 9, 702, Glioma. 


TUMOR REMOVED. RECOVERY. 


Central Region.—&4. Leszynsky, Med. Record, Sept. 28, 1901. Endothelioma 
of right arm and leg center.—85. Hoppe, Journ. of the Amer. Med. 
Assoc., Feb. 21, 1901. No recurrence after 7 years. No complete cure. 
Right foot and arm center.—86. Hoppe, ibid. Blood cyst from dura 
over left leg center. Died 18 months in epileptic attack—87. Mayde, 
Wiener klin. Rundschau. Small cyst, finger center.—88&. Heidenhain, 
Archiv fiir klinische Chirurgie, 64, p. 848.  Subcort. cystic sarcoma 
in right arm center.—89. Treyer, "Rev. méd. de la Suisse romande, 
1900, 5 and 6. ‘Tubercle, right face and arm area. Slight paresis re- 
maining.—go. Treyer, ibid. Tubercle, slight paresis remaining.—olI. 
Krauss, New York Med. Journ., July 30, 1898. Sarcoma, left leg center. 
Death, 2 weeks.—g2. Krauss, ibid. Infiltrating glioma at junction of leg 
and arm center, only partly removed. ‘Death, 3 weeks,—o3. Oliver and 
Williamson, British Med. Journ., Nov. 26, 1898. Sarcoma fissure of 
Rolando. Recurrence.—94. Oliver and Williamson, ibid. Subcortical 
angioma in lower part of left motor region.—95. Stieglitz, Gerster and 
Lilienthal, Centralbl. f. Chirurg., 1897. Sarcoma, left motor area, re- 
covery.—96. Duncan and Maylord, Glasgow Med. Journ., 1897. Sar- 
coma of right motor area, improvement.—97. McBurney, Med. Record, 
1896. Cysts in arm center. Improvement, then death in 6 weeks due 
to recurrence.—o8. Seydel, Centralbi. f. Chirurg., 1896. Fibroma in 
dura opposite left arm center. Recovery with paresis in leg. — 99. 
Hirsche, Centralbl. f. Neurol., 1806. Diffuse sarcoma of left motor 


SURGICAL TREATMENT OF BRAIN TUMOR. 405 


zone. Partial excision, slight improvement.—100. Devic and Cour- 
mont, Rev. de Méd., 1897. Glioma.—t1o1. Sick, Deutsche med. Wochen- 
schrift, 1897, No. 2. Tubercle at lower end of gyrus postrolandicus.— 
102. Cabot, Bost. Med. and Surg. Journ., June, 1897. Cyst punctured 
twice in 1% years.—103. Champonniere, Wiener klin. Rundschau, 1897, 
No. 49. Sarcoma of central convolutions, improved.—104. Kronlein, 
Beitrage z. klin. Chir., 1896, p. 253. Tubercle in left arm center.—105. 
Czerny, Deutsche med. Wochenschrift, 1896, No. 11. Cystic sarcoma. 
motor area.—106. Morison, British Med. Journ. Subdural cyst, motor 
area.—107. Voisin, XJ/. Internat. Med. Congr., Aug. 24, 1897. Tumor 
of central convolutions.—108. Washburn and Lane, Clin. Soc. of Lon- 
don, March 17, 1897. Endothelioma, left motor region.—109. Fried- 
lander and Schlesinger, K. k. Gesellsch. f. Aerzte in Wien, Jan. 21, 
1898. Gumma, lower end of anterior central lobe.—110. Doyen, 27. 
Congress der deutsch. Gesell. f. Clur. Tumor of central convolution.— 
111. Carriere, Congrés de Neurolog. Toulcuse, Aug., 1897. Neurogli- 
oma of motor area.—112. Eliot, Boston Med. and Surg. Journ. Cyst 
in lower arm center, evacuated. Death in 3 months.—113. Bonhoeffer, 
Monatschr. f. Psych., 1898, No. 3. Glioma, upper one-third of right 
central. Death, 3 months.—114. Dallas and Mongeri, Gaz. med. d’Orient, 
1897. Sarcoma, lower end of the left postcentral convolution. Death 
in 4 months of cachexia.—115. Zenner, Transactions of the American 
Neurological Association, May, 1897. Tumor of central convolution. 
Death 9 months after second operation.—116. Abrahams and Tait, 
Occid. Med. Times, June, 1896. Recovery.—117. Armstrong, Montreal 
Med. Journ., May, 1896. Cyst, recovered.—118. Braymer, Charlotte 
Med. Journ., Nov., 1896.—119. Corine and Doyen, Bull. de la Soc. d. 
1. Anat. de Paris, Dec., 1897. Improved.—120. Crowley, Transact. 
Medical Soc. of Calif., 1898. Sarcoma, improved.—121. Dreyfus, Lyon 
Méd., 1898. Gumma, improved—122. Eskridge and Parkhill, Méd. 
News, 1896. Cyst, improved.—123. Eskridge and Parkhill, ibid. An- 
gioma, improved.—124. Grisson, Neurol. Centralblatt, 1808. Cyst, re- 
covered.—125. Hossler, Neurol. Centralblatt, 1897. Improved.—126. 
Mareau, Arch. med. d’Angres, 1897. Improved.—127. Mayer, Annals 
of Surgery, 1898. Cyst, improved.—128. Nedwill, Lancet, 18908. Hy- 
datid, improved.—129. Stratton and Crowley, Pac. Med. Journ., 1808. 
Sarcoma, improved.—130. Tauber, Arch. de Psych. russ, 1896. Im- 
proved.—131. Putnam and Richardson, Boston Med. and Surg. Journ., 
cxl, p. 129. Sarcoma, motor area, not found at first but removed at 
second operation at same site. Death, 6 months.—132. Gibson, Trans. 
of Med.-chirurg. Soc. of Edinburgh, N. S., xv, p. 27. Glioma, motor 
area.—-133. Sinkler, Journ. of Nervous and Mental Disease, xxi, p. 
796. ‘Trephined at right facial center, not found, but found and partly 
removed at second operation. Death, 1 month.—134. Morestin, Bull. 
et Mem. de la Soc. Anat., 65 i, 249. Sarcoma of cranium, pressing on 
motor area. 

Frontal Region.—135. v. Wagenburg, Psych. en neurol. Blad., 1898. Sar- 
coma, recovery with slight paralysis.—136. Esteves, Prog. Med., Dec. 
23, 1899. Hydatid cyst, recovery.—137. Graff, Deutsche med. Wochen- 
schrift, 35, 1899. Cyst, recovery after evacuation.—138. Thomas and 
Keene, Amer. Journ. of the Med. Sciences, Nov., 1896. Gliosarc, re- 
covery with facial paresis and amaurosis.—139. Rossolimo, Arch. f. 
Psych., xxix, p. 528. Cystic gliosarcoma, death 10 months from re- 
currence. —140. Naumann, Hygiea, 58, p. 155. Sarcoma _ periost. 
cranial, pressing on frontal lobe.—141. Carle, Rev. de Chirurg., Feb., 
1899. Sarcoma, recovery.—142. Tubenthal, Deutsche med. Wochen- 
schrift, xxv. Cyst, evacuation, recovery.—143a. Fescher, Deutsche 
med. Wochenschrift, xxiv, 52. Gumma, recovery.—143b. v. Bergman, 
Berliner klin. Wochenschrift, 38, p. 219. Tumor, frontal region; re- 
covery. 


406 M. ALLEN STARR. 


Parietal Region.—144. Clarke and Lansdowne, British Med. Journ., April 
19, 1901. Two tumors (encaps. sarcoma) removed within a few 
weeks.—145. Heidenhain, Arch. f. klin. Chir., vol. |xiv, p. 848. Tu- 
bercle, paracentr. lobe, recovery.—146. Bayerthal, Miinch. med. W ochen- 
schrift, 1899. Tubercle, paracentral lobe, much improvement. — 147. 
Richardson, Boston Med. and Surg. Journ., 1896. Removed on second 
trephining.—148. Brissaud, Bullet. de Chir., May, 1896. Tubercle 
posterior end of the left Sylvian fissure—r149. Starr, British Med. 
Journ., Oct. 16, 1897. Fibrocyst, inferior parietal lobe. Recurrence in 
4 months.—150. Mulls and Keene, Journ. of Nervous and Mental Dis- 
ease, 27, p. 244.  Endothelioma, superior parietal convolution.—151. 
Pitt and Lane, Clin. Soc. Transact., 20, p. 164. Sarcoma, recovery.— 
152. King, Chic. Clin. Rev., April, 1897. Sarcoma, left superior parietal 
region, recovery.—I153. Walton, Boston Med. and Surg. Journ., 144, p. 
205. Subcortical parietal cyst, recovery. 

Temporal Region.—154. Hoppe, Journ. of Amer. Med. Assoc., Feb. 21, 1901. 
Cyst, first temp.-sphenoid lobe. Recovery with slight aphasia.—155. 
McCosh, Med. Record, 1896. Angioma of pia in left temporal region. 
Complete recovery.—156. Broca, Centralbl. f. Chir., 1897, Neuroglioma of 
left temporal lobe. Cure.—157. Hobart, K. k. Gesell. f. Aerzte in Wien, 
June 17, 1808. Gumma, right temporal region.—158. Barr and Nicoll, 
British Med. Journ., Oct., 1897. Sarcoma in temporal region. Death 
in 2%4 months.—159. Nicoll, Lancet, Oct. 29, 1898. Sarcoma originat- 
ing from middle ear; intracranial portion removed. Death in 2% 
months. 

Occipital Lobe.—160. Hoppe, Journ. of Amer. Med. Assoc., Feb. 2, 1901. 
Glioma, left occipital lobe. Well after 3 years—161. Kocher, Schweiz. 
Correspbl., 27, p. 397. Osteoma growing from occipital bone; recov- 


ery. 

Deeper Parts of Brain.—Heidenhain, Archiv f. klin. Chir., vol. \xiv, p. 
848. Melanosarcoma of tela choroid and ependyma of descending 
cornua. Entire right temporal lobe extirpated.—163. Bastianelli, Boll. 
de la Soc. Lancis, p. xv, t. Sarcoma of anterior fossa pressing eyeball 
forward. 

Cerebellum.—164. Schede, Deutsche med. Wochenschrift, 1900, No. 30. Gli- 
oma, recovery.—165. Collins and Brewer, Med. Record, May 15, 1897. 
Subcortical right cerebellar tubercle, partly removed. Death, 2% 
months.—166. Guthrie, Practitioner, 1898. Cerebellar cyst, improved. 
—167. Moran and Kerr, Virg. Med. Semi-monthly.. Cyst, improved. 
—168. Gibson, Transac. Med. Chirurg. Soc., Edinburgh, N. S., xv, 
27. Fibrosarcoma cerebellum, removed; recovery.—169. Murri, Lancet, 
1897. Fibrosarcoma, left cerebellum. Incomplete removal, slight 
improvement.—170. Parkin, British Med. Journ., 1896, p. 1776. Gli- 
oma; recovery.—171. Bevor, Ballance and Lumm, Brain, 1897. Fibro- 
sarcoma, anterior part, right cerebellum.—172. v. Bergmann, Berliner 
klin. Wochenschrift, 38, p. 219. Cerebellar cyst; recovery. 

Region Indefinite or Not Stated.—173. Ziehe and Roth, Deutsche med. 
Wochenschrift, 1897, 19. Perithelioma.—174. Weissgerber, Miinch. 
med. Wochenschrift, 1896, No. 16. Cyst in cortex.—175. Kosynski, 
Medyzyna, 1898, No. 1-3, 5.—176. Lundmark, Ups. Lok. For., 1808. 
Cancer, not improved.—177 O’Hara, 4ustralas. Med. Gazette, 1808. 
Hydatid, recovered. —178. Vance, Australas. Med. Gazette, 1808. 
Hydatid, improved. 

VI. TUMOR REMOVED, DEATH. 


Central Region.—179. Hirschfelder, Pac. Med. and Surg. Journ., April, 
1896. Glioma of right post-central gyrus. Death, 7 days.—180. Bre- 
ganski and Wrzesmowski, Centralbl. f. Chir., 97. Sarcoma of left 
Rolandic area. Died of meningitis.—181. Schulze, Deutsche Zeitschrift 
f. Nervenheitlkunde, 1896. Sarcoma of left anterior central convolution. 


SURGICAL TREATMENT OF BRAIN TUMOR. 407 


Death of hemorrhage.—182. Stieglitz, Gerster and Lilienthal, Cen- 
tralbl. f. Chir., 1897. Sarcoma in left arm, face and speech center. 
Death from hemorrhage.—183. Ballance, Med.-Chir. Transact., vol. 
Ixxix. Cystic angiosarcoma, left arm center. Death due to hemor- 
rhage. Had been evacuated four times and removed once before.— 
184. Dinkler, Wanderversamml. der Siidwest-deutschen Irrenirste, 
May 22, 1899. Fibroma, death in 12 hours.—185. Booth, Transactions 
of the American Neurological Association, May 6, 1897. Tumor, left 
leg center. Death in 4 hours from hemorrhage.—186. Ziehen, Zeitschr. 
f. prakt. Aerste, 1898, No. 1. Fibroma, left motor zone. Death, 8 
days from meningitis—187. Hawkes, Intercolon. Med. Journ., Dec., 
1897. Hydatid cyst, left fissure of Rolando. Death in 3 days.—188. 
Schnitzler, Centralbl., f. d. g. Therap., Feb., 1898. Tubercle, right arm 
center. Death in 26 hours of edema of brain.—189. Taylor and Eliot, 
Boston Med. and Surg. Journ., 1896. Endothelioma.—1go. Starr, British 
Med. Journ., Oct. 16, 1897. Sarcoma of left upper motor area, death 6 
hours, hemorrhage. 

Frontal Region.—ig1. Taylor, Boston Med. and Surg. Journ., Jan., 1896, 
Endothelioma left frontal region. Death in several hours,—1o92. Starr, 
British Med. Journ., Oct. 16, 1897. Cyst, right upper frontal region, 
removed, recurred; infection with death after second operation.—193. 
Starr, British Med. Journ., Oct. 16, 1897. Cyst, frontal region, evacu- 
ated. Death in 6 days. 

Parietal Region.—194. Rychlensky, Medyzyna, 1897, 1 and 2. Glioma in 
paracentral lobe. Death two days after evacuation of cyst—195. Stef- 
fenson, Med. News, 1xxvi, p. 175. Tumor in angular, supramarginal 
and first temporo-sphenoidal lobe. Death in 2 hours. 

Temporal Region.—196. Stewart, Northwest Lancet, 1897. Sarcoma. 

Deeper Parts of Brain.—197. Dinkler, Wanderversamml. der Siidwest- 
deutschen Irrenarszte, May 22, 1899. Tumor in white substance of left 
cerebrum. Death of shock.—198. Krogius, Rev. de Chirurg., 16, p. 
434. Endothelioma of middle fossa; death. 

Cerebellum.—tg9. Pershing, Med. News, 1898. Glioma. 

Region Indefinite or Not Stated.—200. Hitzig, Therap. Wochenschrift. 
Large endothelioma of dura. Death in collapse—zo1 and 202. Lund- 
mark, Ups. Lok. For., 1898. Two cases; died soon after operation. 


Submitted for publication, Jan., 1903. 


A CONTRIBUTION TO THE PATHOLOGY OF PARAMYO- 
CLONUS MULTIPLEX (FRIEDREICH’S TYPE).* 


By J. RAmMsAy Hunt, M.D., or NEw York, 


INSTRUCTOR IN NEUROPATHOLOGY IN THE CORNELL UNIVERSITY MEDICAL SCHOOL ; 
NEUROLOGIST TO THE CITY HOSPITAL; ASSISTANT 
PHYSICIAN TO THE MONTEFIORE HOME. 


The peculiar type of muscular contractions described by 
Friedreich under the name of paramyoclonus multiplex is of very 
rare occurrence. The uncertain mechanism of its production and 
the controversy attending its classification and position among 
the motor neuroses warrant a brief review of the literature as 
an introduction to the clinical and pathological report which is to 
follow. 

Historical. The history of paramyoclonus multiplex began in 
the year 1881 with the description of a case by Friedreich,’ pre- 
senting the following peculiarities: The patient was a man with 
lung tuberculosis, aged fifty, who, following a violent fright, 
developed quick clonic contractions of the muscles of the proxi- 
mal segments of the upper and lower extremities. The contrac- 
tions resembled in character those induced by the electric current, 
the individual muscles springing forward as though excited by 
an invisible electrode. It was particularly noted and emphasized 
that individual muscles, such as the sartorious and supinator 
longus, would spring forward in independent contractions which 
singly are incapable of voluntary innervation. Moreover, there 
was an absence of synergetic muscular action, so that the loco- 
motor effect attending such coordinated muscular contraction 
was absent. When the contractions were very strong, however, 
a slight movement resulted. Occasionally, owing to the great 
rapidity of the contractions, the muscle was thrown into a state 
of momentary tetanus. There was cessation of the movements 
during sleep. These muscle contractions were increased by 
nearly all forms of peripheral and mechanical stimuli. They 
were diminished or entirely inhibited by voluntary movement, so 


Si ae the Pathological Laboratory of the Cornell University Medical 
chool. 


PATHOLOGY OF PARAMYOCLONUS MULTIPLEX. 409 


that little inconvenience was caused by performing acts of every- 
day life, in this respect presenting a marked contrast to the co- 
ordinated movements of cerebral origin. The knee-jerks were 
greatly exaggerated. The gross motor power suffered no im- 
pairment. The electrical reactions were normal. This was essen- 
tially true of the psychical and sensory functions. At times pain- 
ful flexor spasms of the thigh occurred. There were absolutely 
no stigmata of hysteria. 

The peculiar features of this affection, viz., the spontaneous 
contraction of individual muscles not singly under the control of 
the will, and the absence of synergetic muscular action in the 
affected members, were so at variance with the known character- 
istics of muscular contractions of cerebral origin as to render 
some other explanation probable. Friedreich, after a careful con- 
sideration of all the possible sources, as the brain, spinal cord, 
nerves and muscles, proposed the hypothesis which referred the 
symptoms to an excessive irritability of the anterior horn cells of 
the cord. This theory was in harmony with the special clinical 
features of the case, i.e., the single muscle contraction, the ab- 
sence of synergetic action, the great exaggeration of the knee- 
jerks, and their diminution as the motor symptoms subsided, the 
great susceptibility of the contractions to peripheral stimuli, and 
their cessation on voluntary innervation of the part. 

In the course of a few years the accuracy of Friedreich’s ob- 
servation was confirmed on many sides by notable observers. 
Among the earlier recorded cases were those of Lowenfeld,* 
Remak,® Seeligmiller,* Francotte,> Homén,® Allen Starr,” Bech- 
terew® and Marie.® It was but natural that Friedreich’s descrip- 
tion, based on one case, should undergo considerable enlargement 
and some variation, as the literature was enriched by other ob- 
servers, and that even new forms and types should be added. 
Thus, in 1886, Seeligmtller described a congenital case; Unver- 
richt?® in 1891 added a family form associated with epilepsy, 
and Gucci"? an hereditary form in 1893. Some of the more im- 
portant semeiological deviations from the original Friedreich 
type which have been subsequently described are as follows: That 
the muscular contractions are not limited to the proximal seg- 
ments of the extremities, but that all the voluntary muscles may 
be involved with the sole exception of those moving the eyeballs. 


410 J. RAMSAY HUNT. 


Voluntary movement has not in all cases seemed to soothe or in- 
terrupt the contractions ; indeed, the contrary effect has been noted. 
In some cases peripheral stimuli have failed to increase the symp- 
toms. The knee-jerks, although usually exaggerated, have been 
found occasionally of normal intensity or even diminished. In 
two cases they were absent. The electrical reactions have been 
essentially normal. In a few cases only was a slight qualitative 
increase noted. Rarely contractions have persisted during sleep. 
Pains and paresthesias have been observed accompanying and fol- 
lowing the paroxysms. Fright as an etiological factor was by no 
means constant, and a variety of predisposing and exciting causes 
are on record. 

Classification. But a small proportion of the cases now repos- 
ing in the literature under the title paramyoclonus multiplex or 
its abbreviated form, myoclonus multiplex, are typical examples 
of this affection. Many cases are hardly recognizable if Fried- 
reich’s conception is adhered to, some observations having more 
in common with convulsive tic, maladie de tic, chorea and hysteria. 
In some observations the peculiar features which led Friedreich 
to separate this from the other motor neuroses, i.e., the isolated_ 
contraction of a muscle not singly under voluntary corre! and the 
absence of locomotor effect, have been completely ignored. Cases 
are recorded as paramyoclonus multiplex in which the affection 
was characterized by convulsive movements of a paroxysmal char- 
acter very far indeed from the individual shock-like muscle con- 
traction which usually first becomes apparent when the surface of 
the body is exposed, and which interferes but little with voluntary 
movement. This statement will receive more weight when the 
tabulations of Unverricht are considered, who collected and clas- 
sified the cases recorded up to the year 1891. Of the forty-eight 
cases collected, Unverricht accorded to only six the dignity of 
paramyoclonus multiplex, and to eleven cases a resemblance only 
to the paramyoclonus; eleven cases he considered uncertain, and 
the remainder were grouped with hysteria, chorea, or the tic 
forms. 

A survey of the more recent literature shows the same confu- 
sion to prevail. Nearly all forms of myoclonia in the broadest 
sense of the term are included under this head, while the pure 
cases of paramyoclonus form but a small minority. 


PATHOLOGY OF PARAMYOCLONUS MULTIPLEX. 4ITI 


It must be observed, however, that muscular contractions iden- 
tical with or closely resembling those of the essential form of 
paramyoclonus are found associated with or dependent upon other 
conditions. Thus, in hysteria and the traumatic neuroses, twitch- 
ings resembling paramyoclonus are recorded; and as a sequela of 
joint affections and then presumably of reflex origin. They are 
also described in conjunction with epilepsy, the so-called myo- 
clonus epilepsy. Rarely muscular spasms of an entirely different 
type, 1.e., the tic convulsif, maladie de tic, are accompanied by 
movements of a paramyoclonic nature. 

In the other forms of myoclonia the Friedreich type may be 
very closely simulated, but attention to the characteristics just 
outlined usually renders differentiation possible. Dejerine’? em- 
phasizes the strong resemblance which some hysterical movements 
bear to this affection. Indeed, some observers, as Moebius,'® re- 
gard paramyoclonus as a manifestation of hysteria. Moebius, in 
support of the hysterical nature of the affection, mentions the 
difficulty incurred in determining the contraction of an isolated 
muscle not individually under voluntary control when such con- 
tractions are lightning-like. This may be true of the periods of 
great exacerbation, but would hardly be applicable to the whole 
course of the disease. Furthermore, it is impossible to reproduce 
these contractions at will, which, according to our present concep- 
tions, woul “exclude hysteria. Schultze’* regards the paramyo- 
clonus multiplex as a generalized form of tic convulsif. Many 
observers, as Oppenheim,” Unverricht, Risien-Russell,*® Allen 
Starr and Wollenburg,'* view this affection as an independent 
form of motor neurosis. Others, as Raymond,’* would fuse the 
various myospasms together under a generic term as myoclonia, 
considering them as allied in nature and differing only in degree, 
the degenerative tendency representing the common basis and 
essential factor in the production of them all. This would include 
the maladie de tic, tic convulsif, electric chorea of Henoch-Ber- 
geron, paramyoclonus multiplex, myokymia, and fibrillary twitch- 
ings. 

Pathogenesis. Diversity of opinion is not confined to the clas- 
sification of this affection, but the origin and the mechanism of its 
production are the subject of controversy. Pathological anatomy 
has thrown no light upon the subject. The theories which today 


412 J. RAMSAY HUNT. 


receive serious attention are those of the cerebral and the spinal 
origin. Whether the latter consists of a derangement of the motor 
portion of the reflex arc (Friedreich) or of the sensory portion, as 
advocated by Vanlair,!® is secondary to the question at issue. 

According to our present knowledge, the evidence is strongly 
in favor of a spinal origin of the Friedreich type of paramyo- 
clontus multiplex. The electrical stimulation of the motor cortex 
with the most delicate electrode fails to produce a contraction of 
an individual muscle. On the contrary, the result is a movement, 
a synergetic muscular action. We may assume with a certain 
degree of probability that movements rather than individual mus- 
cles are here represented. The medullary centers, on the other 
hand, have a more individual relation with the respective muscles 
under their control, although the exact nature of this relation is 
still a subject under investigation. It will be remembered in this 
connection, however, that Sano?® advocates an individual muscle 
representation in the anterior horn cells, based on experimental 
studies. 

Those rare cases in which paramyoclonic twitchings have 
occurred in the course of organic disease of the cerebral cortex 
must be considered in this relation. Examples of such are paresis, 
chronic meningitis with cortical atrophy (Murri**), chronic 
uremic edema of the cortex (Levi and Follet??), and myoclonus 
epilepsy (Unverricht, Clark and Prout?*). These cases are by 
some observers considered confirmative of a cortical origin. It, 
however, minute pathological changes of the cerebral cortex were 
capable of inducing this type of muscular contraction, they should 
be of more frequent occurrence, considering the vast number of 
such conditions, constantly under observation. In view of this 
rarity, a co€xisting alteration of the spinal centers is more prob- 
able; and in the family affection, characterized by the association 
of myoclonus and epilepsy, we are dealing with a degenerative 
affection of the cerebrospinal axis, the epilepsy referable to the 
upper, the myoclonus to the lower centers. The few cases of 
hemimyoclonus (Minkowsky,?* Bernhardt,?> and Seeligmiiller?*), 
usually cited as evidence of the cerebral origin, weigh but lightly 
in the balance. 

Very interesting and suggestive from an etiological point of 
view and corroborative of the spinal theory are those cases of 


PATHOLOGY OF PARAMYOCLONUS MULTIPLEX. 413 


paramyoclonus multiplex occurring in conjunction with articular 
affections. Chauffard’s?* case of hemiparamyoclonus followed 
directly on an attempt to break up old joint adhesions in the right 
knee and hip. Levi and Follet report a case of paramyoclonus 
multiplex complicating spondylose rhizomelique with the usual 
joint manifestations. The articular muscular atrophies and the 
old theory offered in explanation, the perversion of the functions 
of the anterior horn cells (Paget, Charcot) arise in this connec- 
tion. Raymond?* demonstrated experimentally that if the pos- 
terior roots are cut before the articulation is disturbed, this atrophy 
will not occur. This is almost indisputable proof of its reflex 
origin. If pathological reflex stimuli from the articulation can 
affect the trophic function of the anterior cells, is it not reason- 
able to infer that the motor function may be perverted in a similar 
manner with a resulting hyperexcitability? It is a common 
observation that the tendon jerks are exaggerated in muscles 
which are the seat of this atrophy, the knee-jerks in affections of 
the knee joint, the Achilles jerk in ankle joint disease. This 
exaggeration would hardly be expected in atrophic muscle groups 
unless accompanied by an unusual irritability of the reflex cen- 
ters. Gowers*® cites an interesting case in this connection. A 
young man, following an injury to the left knee, developed an 
acute atrophy of the quadriceps extensor. When seen two years 
later the atrophy still persisted, the left knee-jerk was exagger- 
ated, and there was in addition a well-marked ankle clonus upon 
the left side. This same condition was persistent one and a half 
years later, and with the associated ankle clonus would seem to 
prove that the functional and trophic changes in the anterior 
horn cells in joint affections may not only be of long duration, 
but may extend to neighboring centers. The muscles from a case 
of articular atrophy were examined by Darkschewitz®®. A ma- 
jority of the muscle fibers were found to have undergone a 
diminution in size, averaging about half the normal diameter. 
These atrophic changes in the muscle fibers, in an affection where 
presumably the trophic function of the anterior horn cells has 
been restricted by some inhibitory influence, receive additional 
significance from the muscle changes found in my case of par- 
amyoclonus multiplex, an affection presumably due to an exag- 
geration of the function of the anterior horn cells. Here the 


414 J. RAMSAY HUNT. 


diameter of the muscle fibers was two or three times in excess of 
the normal. 

As further evidence in favor of the spinal origin of the pecu- 
liar contractions under consideration may be mentioned the re- 
lationship existing between paramyoclonus multiplex, myokymia 
and fibrillary twitchings. Between the fascicular contractions 
and the muscle waves and the individual muscle contractions of 
paramyoclonus there are transition forms; a series of gradations, 
so that one condition merges imperceptibly into the other. The 
myoclonus fibrillaris multiplex of Kny*t represents such a transi- 
tion form. Thus, in one case the affection may bear the stamp of 
a myokymia, yet simple fibrillary waves occurring and occasion- 
ally the whole muscle undulating; so in paramyoclonus certain 
undulations may occur. Dana,*? in a recent communication, em- 
phasizes the relationship of myokymia and paramyoclonus multi- 
plex. The dependence of myokymia and fibrillary contractions 
on disease of the lower nervous mechanism is fairly well estab- 
lished, and has been recently discussed by Walton.** The 
etiology in some of the recorded cases (cited by Walton) : lead- 
intoxication (Huber) ; following in the wake of old poliomyelitis 
(Williamson, Walton), low grade neuritis (Biancione), sciatica 
(Gowers), bear no other interpretation. This receives additional 
weight from the accompanying pains, paresthesias and electrical 
disturbances not infrequently observed. 

There is still another peculiarity observed in these three forms 
of muscle contraction, and that is the passive attitude manifested 
by the patient towards them. The muscle contractions and undu- 
lations are felt as such, but otherwise cause little or no disturb- 
ance, save occasionally a cramp or a pain. This is largely ac- 
counted for by the usually complete preservation of the power of 
performing voluntary acts and the absence of strong convulsive 
movements of a coordinated type. It is also possible that their 
origin in the lower centers, far removed from the psychical sphere, 
may also play a role. 


Remarks. 1. The term paramyoclonus multiplex, or myoclonus 
multiplex, should be reserved for that form of myospasm charac- 
terized by multiple, spontaneous, isolated contractions of indi- 
vidual muscles. 


PATHOLOGY OF PARAMYOCLONUS MULTIPLEX. 415 


II. This type is peculiar and distinctive, and receives its most 
logical explanation in a disturbance of the spinal centers. 

III. This type should be carefully separated from the cerebral 
type of the myospasms which are characterized by movements of 
a more or less coordinated type, as are observed in the maladie de 
tic, tic convulsif and the convulsive tremor of Pritchard and 
Hammond. 

IV. The contractions of paramyoclonus multiplex are closely 
related to the myokymia and fibrillary contractions. 

V. Paramyocionus multiplex may occur as an idiopathic or a 
deuteropathic affection, in the latter complicating various organic 
and functional diseases of cerebral! and spinal origin. 


Case REporrt.* 

These observations were made in the surgical wards of Belle- 
vue Hospital, service of Dr. B. B. Galludet, through whose 
courtesy I was permitted to study and publish the case. 

History. July, 1901. The patient was a man, aged forty- 
nine years, Hungarian by birth, tailor by occupation. His admis- 
sion to the surgical ward was for the treatment of a tuberculous 
affection of the left ankle joint, which was discharging from 
several sinuses. An operation had been performed upon the joint 
at the New York Hospital a few months before. This was his 
sole complaint on admission, and the surgeons discovered by 
accident the curious muscular contractions with which he was 
afflicted and which apparently caused him no concern. It was 
ascertained that these had made their appearance about six 
months before without pain or paresthesia, first in the upper, 
soon after in the lower extremities. There had been no preceding 
illness except the joint affection before alluded to. He was of 
moderate habits, denied venereal disease, and no family neurotic 
taint was discoverable, but owing to his long exile from Hungary 
his knowledge in this direction was imperfect. No member of his 
family, to his knowledge, had ever had a convulsion. A few 
months before the onset of the disease, being poor and in feeble 
health, he had written to Hungary requesting money from his 
family with which to return home. This had been promised him, 
but in due time instead of a money order he received a letter con- 
taining a refusal. He despaired of ever being able to return to 
his native land, became sad and depressed, and a few weeks later 
the twitchings began. As he related this story his eyes filled with 
tears, and on subsequent allusion to it he always showed pro- 


*Read, with presentation of specimens, before the New York Neuro- 
logical Society, February, 1903. 


416 J. RAMSAY HUNT. 


found emotion. The twitchings had not interfered with the 
ordinary acts of life, as dressing, walking or holding a newspaper, 
and had caused him but little annoyance; toward the end of the 
day he would feel rather fatigued. 

Physical Examination. The man is of medium height, well 
made, body weight well preserved. Facial expression is quiet and 
melancholy. Skin pallid, mucous membrane a fair color. The 
face free from tremor or movement of any kind. Dressed and 
sitting in a chair, as when I first saw him, no abnormal move- 
ments of any kind were visible, except an occasional playing of 
the fingers. Locomotion and station were naturally somewhat 
interfered with by virtue of the joint affection, but were entirely 
unaffected by the muscular contractions. The pupils and pupil- 
lary reactions were normal, as were all the cranial nerves. No 
nystagmus. After removal of the clothing, the picture presented 
by the patient was a strange and unusual one. The muscles of 
the arms and shoulder girdles, thighs and buttocks displayed the 
greatest activity, individual muscles springing forward in con- 
traction with the greatest rapidity and variation; sharp, shock- 
like contractions following one another with regularity and 
rhythm. The whole body of a muscle contracted as if stimulated 
by an invisible electrode. These contractions were unaccom- 
panied by any locomotor effect. Occasionally, a barely perceptible 
flexion, extension or supination resulted from a particularly 
violent or prolonged contraction. It was further noted that while 
symmetrical muscles were involved, the contractions were by no 
means synchronous or isochronous. The movements were all 
clonic, no tonic contractions being noted. Contractions were 
noted in the following muscles: Deltoids, pectorals, scapular 
group, biceps, triceps, supinators, gluteal groups, extensors and 
flexors of the knee, and the sartorius; an occasional contraction 
was noted in the forearms and in the calves of the legs. The 
greatest play of movement was in the proximal segment of the 
extremities. The abdominal muscles and the diaphragm were 
quite free. The intensity and rapidity of these contractions could 
be modified in various ways. Mechanical stimulation of the skin 
and muscle increased them, while a coordinated act, such as 
grasping or picking up an object, caused their cessation or a very 
marked diminution. In walking and standing this diminution in 
the lower extremities was very noticeable. The contractions were 
most severe in the recumbent posture, less while standing, and 
almost disappearing while walking to and fro. An unusual and 
important peculiarity of these spasms was the contraction of in- 
dividual muscles, as the sartorius and supinator longus, the 
isolated contraction of which cannot be produced at will. There 
were apparently isolated contractions of the brachialis anticus 
and coraco-brachialis, but this could not be determined with cer- 


PATHOLOGY OF PARAMYOCLONUS MULTIPLEX. 417 


tainty. The muscular system was quite well developed and 
showed no evidence of pathological hypertrophy or atrophy. The 
gross motor function was undisturbed. The myotatic irritability 
was increased. No electrical examination was made. Sensation 
was undisturbed. The tendon and skin reflexes were all present 
and very active; the knee-jerks especially were much exaggerated. 
Flexor response to plantar stimulation. No stigmata of hysteria. 

The man was quiet and uncomplaining and shunned the so- 
ciety of his fellow-patients. He presented no evidence of mental 
enfeeblement. A few weeks later acute symptoms developed, 
death ensuing apparently from a generalization of the tuberculous 
process; as the thoracic and abdominal cavities were not opened, 
the immediate cause of death must remain unknown. It is inter- 
esting to note that the muscular contractions persisted the whole 
time during which he was under observation, varying, however, 
in intensity, and, according to the statement of the house-surgeon, 
were observed for twenty minutes after the respiratory and car- , 
diac functions had ceased. According to the nurse’s statement, / 
the contractions ceased during sleep. . 

Histological Examination. The autopsy was performed forty- 
eight hours after death. The brain, spinal cord, and the right 
radial and anterior crural nerves were removed and placed in 
IO per cent formalin solution. Portions of the right supinator 
longus, right sartorius, and left trapezius muscles were also 
removed. 

Brain. Sections were prepared from the Rolandic area on 
both sides and from the frontal, temporal and occipital lobes, 
according to the Nissl, Weigert-Pal, Marchi and Van Gieson 
methods. No evidences of pathological changes were discoverable 
in nerve structures, meninges, vessels or glia. The outlines of the 
cortical cells and their processes are well preserved. A few cells 
are moderately pigmented. The nuclei, nucleoli and their refrac- 
tive bodies are quite distinct. The nuclear network, however, is 
broken up and appears granular and homogeneous, remaining un- 
stained or receiving a faint bluish tint. The Nissl granulations 
are coalescent and rather clumpy, staining intensely blue. The 
slight alterations in the nuclei and Nissl bodies are dependent on 
cadaveric changes. 

Spinal Cord. Sections were prepared from various levels of 
the cord by the Nissl, Weigert-Pal, Marchi and Van Gieson 
methods. They were essentially normal. The spinal sticho- 
chromes of the anterior horns were absolutely normal. Cell 
bodies, processes, nuclei and nucleoli, no excess of pigmentation. 
The Nissl granulations, while somewhat coarse and rounded, are 
normal in distribution and arrangement. The vessels of the gray 
matter of the cord, especially in the cervical and upper dorsal 
regions, are distinctly thickened. The vessels in the lateral 


418 J. RAMSAY HUNT. 


columns are also slightly sclerosed. This thickening involves 
chiefly the adventitia; nowhere was obliteration of the lumen 
observed. 

The capillaries of the brain and cord are distended with blood. 

Peripheral Nerves. The peripheral nerves, the inter-muscular 
nerve fibers and the muscle spindles were normal. 

Muscles. The muscles were fixed and hardened in formalin, 
alcohol and Muller’s fluid, and stained by the carmine, hematoxy- 
lin, Van Gieson and the Marchi methods. The supporting struc- 
tures (endomysium and perimysium) were normal, as were the 
blood vessels. 

The picture presented by the muscles on transverse section is 
striking, the diameter of the muscle fibers reaching an unusual 
size (see Figs. 1 and 2). Of the larger fibers which form the 





Fig. (13 Fig. 2. 


Fig. 1—Right supinator longus muscle from case of paramyoclonus 
multiplex. 
Fig. 2—Normal muscle. Same enlargement as Fig. 1. 


majority in any given field, the diameter averages 150 micromil- 
limeters and, in many, 175 micromillimeters. In contrast to this 
are very small fibers having crescentic forms or flattened out on 
the periphery of the large fibers. Of these smaller fibers some are 
below the normal standard. The fields of Cohnheim are quite 
distinct. Instead of finding the nuclei of the sarcolemma sheath 
confined to the periphery of the muscle fiber and just beneath this 
membrane, as is customary in man, they are found scattered as 
well between the sarcous elements (Fig. 3). This is not true of 
all the fibers, but is observed in a large number and in all sections 
studied. Sometimes as many as three or four nuclei occupied a 


PATHOLOGY OF PARAMYOCLONUS MULTIPLEX. 419 


central position in a single fiber, usually only one or two. They 
are identical! in staining properties with those of the sarcolemma 
sheath. On longitudinal section the transverse striation is distinct 
and well preserved ( (Fig. 4). In the smaller fibers only is it 
at times indistinct or absent, these showing in addition a tendency 
to longitudinal cleaving. The nuclei of the sarcolemma sheath 





Fig. 3—Sartorius muscle. Paramyoclonus’ multiplex. Fibers hyper- 
trophied with centrally situated nuclei. 


are increased in number; their structure and size are normal. 
Small clumps of a dark brown or yellow pigment are observed scat- 
tered over both the transverse and longitudinal sections, in the 
latter especially in relation with the sarcolemma nuclei. No de- 
generation and no vacuolization of the sarcous substance is 
present. No degenerations were demonstrable by the Marchi 
method. 


Remarks. The peculiar character of the muscular contrac- 
tions in the case just described entitles it to a place among those 
rare cases of essential paramyoclonus multiplex. The histological 
examination of the spinal cord and biceps muscle from the 
original Friedreich case was carried out by Schultze.*4 The 
result was an entirely negative one. This and my own case con- 
stitute, I believe. the only examples on record of this type of 


420 J. RAMSAY HUNT. 


paramyoclonus multiplex with systematic histological examina- 
tion. The examination of the nervous system in my case was 
entirely normal. The muscle fibers, on the other hand, while 
retaining their normal structure, were considerably hypertrophied. 





Fig. 4—Muscle showing transverse striations. Paramyoclonus multi- 
plex. 


They were twice or three times the size of normal fibers from 
corresponding muscle utilized as control preparations. Muscle 
fibers vary considerably in size even under normal conditions. In 
general, the larger the muscle the larger is the muscle fiber. In 
man the minimum diameter is given as IO micromillimeters; the 
maximum as 100 micromillimeters. In the case under considera- 
tion, the larger proportion of the muscle fibers on transverse sec- 
tion averaged a diameter of 150 micromillimeters, many measur-- 


PATHOLOGY OF PARAMYOCLONUS MULTIPLEX. 421 


ing 175 micromillimeters. This increase in size of the fibers w2s 
not universally distributed over the microscopic field. In rdéund 
numbers, two thirds may be said to have presented thischange. 
Many of those remaining were below the normal standard, so 
that the contrast was very evident. 

Another peculiarity was the presence of sarcolemma nuclei 
between the sarcous elements. This is a peculiarity of the so- 
called red fibers of the lower vertebrates, a form of muscle which 
is more active, and capable of more prolonged contraction, than 
the white fibers which constitute human muscle, although such 
red fibers are scattered in very small number throughout the 
muscular system in man. 





Fig. 5—Sartorius muscle from a case of chronic progressive chorea 
{control preparation]. Same enlargement as Fig. 3. 


It is interesting and significant to observe that changes similar 
to those just mentioned have been described in cases of myotonia 
congenita (Erb,*° Dejerine and Sottas**), the hypertrophic stage 
of the muscular dystrophies, and in those rare cases of true mus - 
cular hypertrophy, of which examples have been described by 
Friedreich,*7 Auerbach,** and Berger*®. If such alterations in the 
size and nuclear constituents of the muscle fiber were simply the 
result of overaction, and secondary only to violent and prolonged 


422 J. RAMSAY HUNT. 


muscular action, they should occur in long-standing spasmodic 
‘affections of cerebral origin. In one of the cases used as a con- 
trol preparation in the present study, a chronic progressive chorea 
of fifteen years’ duration, the muscles were found absolutely nor- 
mal (Fig. 5). It is suggestive that in the muscular dystrophies 
and hypertrophies and in myotonia and in paramyoclonus multi- 
plex, which represent obscure affections of the muscular and 
neuromuscular systems respectively, muscle changes essentially 
similar should be encountered. Hajos’ *® case of paramyoclonus 
multiplex with the electrical reactions of Thomsen’s disease is of 
interest as furnishing clinical evidence of this relationship. We 
are far from understanding the true significance of the relations 
existing between the peripheral motor neurone and the muscle 
fiber, tissues having~a different structure and derivation and yet 
intimately related; the fate of the one resting entirely upon the 
integrity of the other—the so-called trophic function or influence 
of the anterior horn cells. 

In articular muscle atrophies, this trophic influence in some 
obscure way appears to undergo a reflex inhibition. In the Dark- 
schewitz case the muscle fibers had suffered a reduction of one 
half their natural size. 

As this trophic influence may under certain conditions be so 
perverted as to cause disintegration or atrophy of the muscle 
fibers, it is reasonable to assume the possibility of an increased 
trophic function with a resulting hypertrophy. If the Friedreich 
theory of the irritability of the anterior horn cells is accepted in 
explanation of the motor phenomena of paramyoclonus, these 
muscle changes may well represent a concomitant increase of the 
trophic function of these same cells, and this would constitute im- 
portant objective evidence of the spinal origin of paramyoclonus 
multiplex. 


BIBLIOGRAPHY. 


ae x Friedreich. “Paramyoclonus Multiplex.” Virchow’s Archiv, Bd. 
Ree hee 5 

2. Lowenfeld. ‘“Paramyoclonus Multiplex (Friedreich).” Baierische 
Intelligenz-Blatt, 1883. 

3. Remak. “Myoclonus Multiplex.” Archiv f. Psych., Bd. 15, S. 852. 

4. Seeligmuller. “Ein Fall von Paramyoclonus Multiplex (myoclonia 
congenita.)’’ Deutsche med. Wochenschr., 1886, No. 24. 


PATHOLOGY OF PARAMYOCLONUS MULTIPLEX. 42 = 


5. Francotte. “Cas de paramyoclonus multiplex.” Annal. de la Société 
médic. chirurg. de Liége, 1887. Ref. in Virchow- Hirsch. 
bs 6. Homén. “Un cas de paramyoclonus multiplex.” Archiv. de Neur., 
1887. 

7. Allen Starr. JouRNAL oF NERVOUS AND MENTAL DISEASE, 1887. 
“The Paramyoclonus Multiplex.” . 
3 a Bechterew. “Paramyoclonus Multiplex.” Archiv f. Psych., Bd. 16, 

9g. “Paramyoclonus Multiplex.” Progrés Médical, 1886, Nos. 8 and 
12. (Marie.) 

10. Unverricht. ‘“Die Myoklonie.” Leipzig u. Wien, 1801. 

11. Gucci. “Paramyoclonus Multiplex.” Ref. Neur. Sapa ae 1893 

12. Dejerine. “Sémiologie du systeme nerveux.” P. 608 
e 13. Mobius. ‘“Paramyoclonus Multiplex.” Schmidt’s Jahtb., 1888, 

a ei 9 

14. Schultze. “Ueber Chorea Poly- und Monoklonie.” Neur. Cen- 
tralbl., 1897, S. 609. 

15. Oppenheim. “Lehrbuch der Nervenkrankheiten.” S. 8709. 

16. Risien-Russell. Albutt’s “System of Medicine” (Paramyoclonus 
Multiplex). 

17. Wollenburg. “ Paramyoclonus Multiplex.” Nothnagel, Spec. 
Pathol. u. Therapie. 

18. Raymond. “Un cas de myoclonie.” Clinique du Systéme Nerveuse, 
Quat. Série, p. 467. 

a 19. Vanlair. “Des myoclonies rhythmiques.” Revue de Médecine, 
1880. 

20. Sano. “Les localizations des fonctions motrices dans la moélle 
epiniére.” Anvers-Bruxelles, 1898, p. 28. 

21. Murri. “Paramyoclonus Multiplex.” Ref. Jahresb. f. Neurol. u. 
Psych., 1900. 

22. Levi and Follet. “Paramyoclonus symptomatique.” Revue‘ de 
Med., 1900. 

23. Clark and Prout. “Myoclonus Epilepsy.” Amer. Journ. of In- 
sanity, Vol. 49, 1902. 

24. Minkowsky. “Ueber einen Fall von Hemimyoclonus.” Naunyn’s 
Mittheilungen aus der midwin. Klinic zu Konigsberg, Leipzig, 1888, S. 503. 

25. Bernhardt. “Fall von Hemimyoklonie.” Berlin klin. Wochenschr., 
1893, No. 18. 

26. Seeligmiller. “Paramyoclonus.” Eulenberg’s Realencyclopadie, 
2. Auflage. 

27. Chauffard. “Hemiparamyoclonus réflexe d’origine arthropathique.” 
La Semaine Méd., 1890. 

28. Raymond. Revue de Méd., 1890, p. 374. 

29. Gowers. “Diseases of the "Nervous System.” Vol. 1, 3d edition, 

60. 

5 "se. Darkschewitz. Neur. Centralbl., 1891, p. 
Kny. “Ueber ein dem Paramyoclonus eitiplex (Friedreich) 
Rretrede Krankheitsbild.” Archiv f. Psych., 1888, Bd. 19, S. 577. 

32. Dana. The Transactions of the New York Neurological Society, 
Medical News, March 7, 1903. 

33. Walton. “Contribution to the Study of the Myospasms.” JouRNAL 
oF Nervous AND MENTAL DISEASE, July, 1902. 

34. Schultze. “Ueber den Paramyoclonus Multiplex (Friedreich).” 
Neur. Centralbl., 1886, No. 16. 

35. Erb. “Die Thomsensche Krankheit.” Leipzig, 1886. 

36. Dejerine and Sottas. “Sur un cas de maladie de Thomsen suivi 
d’autopsie.” Revue de Médecine, 1895, p. 24. 

37. Friedreich. Eulenberg, Realencyclopadie, 1873, Bd. 9, p. 354. 

38. Auerbach. Virchow’s Archiv, Bd. 53, p. 234. 


424 J. RAMSAY HUNT. 


39. Berger. Deutches Archiv f. klin. Med., Bd. 9, 1872, p. 363. 
40. Hajos. “Ein Fall von Myospasmia Spinalis.” Ung. med. Presse, 
No. 34. Ref. Jahresb. f. Nerverg u. Psych., 1898 


Note.—For further bibliographical references consult the monographs 
of Unverricht (“Die Myoklonie,” 1891) and Gaupp (“Ueber Myoklonie,” 
Inaugural Dissert., Tubingen, 1898), also Risien-Russell (Albutt’s “System 
of Medicine”), and Wollenberg (Nothnagel, Spec. Path. u. Ther.). 


Society Proceedings. 


NEW YORK NEUROLOGICAL SOCIETY. 
March 3, 1903. 
The President, Dr. Pearce Bailey, in the chair. 


Tabes Associated with Hemiplegia—Dr. Joseph Collins presented a 
man, forty-two years of age, a bar tender by occupation. When twenty- 
four years old he had had a chancre, for which treatment was given. 
A year later an iritis developed, and disappeared after two months’ treat- 
ment. There was nothing further until eight years ago, when he was 
seized with an attack of vertigo, which was associated with an aphasia 
lasting several days. There was no paralysis. Four years later there 
was a similar attack associated with vomiting. Last August the man fell 
in an attack in which he was only partially unconscious. Examination 
showed a right-sided hemiplegia, and this had continued ever since. On 
coming to the hospital, there was found in addition a very marked atrophy 
of the right shoulder and an absence of both knee-jerks. The pupils were 
small and regular, and reacted to accommodation but not to light. There 
were incontinence of urine and manifest ataxia. The case was presented 
as one of tabes, the latter probably antedating the attack of thrombosis 
from which the hemiplegia originated. Coincident with the attack of 
cerebral thrombosis there must have been an obliteration of one of the 
cornual branches of the anterior spinal artery. In reality, this case pre- 
sented three conditions: tabes, cerebral thrombosis and a destructive polio- 
myelitis of very limited extent. Tabes and hemiplegia were rarely asso- 
ciated. 

Dr. J. Ramsey Hunt said that he had examined this case in the City 
Hospital. He had been doubtful about its being an anterior horn disease, 
and inclined to the opinion that there was a plexus lesion. 

Dr. M. G. Schlapp said that in some of these cases of hemiplegia cer- 
tain groups of muscles were markedly atrophied. The electrical examina- 
tion should decide whether the case was of central or peripheral origin. 

Dr. J. Fraenkel said that in only a few of the cases of tabes with hemi- 
plegia had the knee-jerk returned, and this had only been temporary. 

Dr. C. L. Dana said that he had had a short time ago under observa- 
tion a man with tabes whom he had seen the very day of the occurrence 
of the stroke. There had not been any return of the knee-jerk, and he 
thought this could only occur in the early stage. 

Dr. Collins said that there had been no suspicion of the existence of 
tabes before he had examined this man, and he had been deeply interested 
in the presence of the marked muscular atrophy. 

A Case of Major Hysteria (?).—Dr. Collins then presented a woman, 
forty-four years of age, a cook by occupation. There was no history of 
alcoholism or of venereal disease. The present trouble began four years 
ago with an involuntary twitching of the hands and a loss of sensation 
in the hands and arms. This loss of sensation had gradually spread over 
the entire body. She had no pain, but felt tired and walked with difficulty. 
The gait was not strictly ataxic, but was rather shuffling and choreic. 
There was a peculiar condition of the left lower extremity, the lower third 
being shrunken without any hardening or thickening of the skin. Exam- 
ination showed universal analgesia and more or less thermal anesthesia 


426 NEW YORK NEUROLOGICAL SOCIETY. 


and analgesia. The knee-jerks and ankle jerks were exaggerated. There 
was slight disturbance of speech but not of intellection. She presented 
none of the ordinary stigmata of hysteria, and the color fields were of 
normal size. The woman had not improved under hospital treatment. 
According to the history, her father and sister were similarly affected, 
but the former lived to be over seventy years old. The case was presented 
without a positive diagnosis, because it did not seem to Dr. Collins to 
correspond to hysteria, syringomyelia or Huntington’s chorea. 

Dr. Schlapp was of the opinion that the case was one of hysteria, 
because the condition did not correspond to any known pathological lesion. 
The condition of the leg might have been brought about by a self-inflicted 
trauma. Two years ago he had presented to the Society a case of sup- 
posed atypical zoster, but subsequent investigation showed that the patient 
had produced the condition herself by means of carbolic acid. 

Dr. R. H. Cunningham said he was reminded of a number of cases 
that he had had in a family in Richmond, Va., in 1893. Choreic symptoms 
developed between the ages of fifteen and thirty in the father, two sons 
and two daughters. One of the daughters had hemianesthesia. He would 
look upon the case just presented as one of adult chorea. 

Dr. Collins said that he had been inclined to look upon the case as 
one of hysteria, yet this diagnosis presented many difficulties. After hav- 
ing observed the patient carefully for several months he was still more 
inclined to the diagnosis of major hysteria. 

Dr. Pearce Bailey said that he thought the ataxic gait was due to the 
anesthesia, and that the case was one of major hysteria. With regard 
to the other case, there seemed to be no doubt that the atrophy of the 
shoulder was distinct from the tabes. A fall on the point of the shoulder 
was quite frequently the cause of a paralysis with just such an atrophy. 

A Case of Spinal Tumor.—Dr. M. G. Schlapp presented a man, forty- 
four years of age, with a good previous history. About two years ago a 
peculiar twitching had been noticed in the muscles over the right shoulder, 
and about two months later he had begun to suffer pain at the root of the 
neck and extending into the trapezius muscle. After a time the right arm 
became weak, and subsequently the left side. This weakness was found 
to correspond to the muscles supplied by the anterior and posterior thoracic 
nerves on both sides. There was the Babinski symptom on each side. 
There were analgesia and diminished temperature sense on the left side. 
The diagnosis made was an extramedullary tumor involving the fifth and 
sixth cervical roots of the spinal cord, pressing upon the pyramidal tracts, 
and on Gowers’ tracts, diminishing the pain sense and temperature sense. 
The tumor lay on the right side, and probably involved the motor roots on 
the other side. He thought an intramedullary tumor could be excluded. 
The man was to be operated on. 

Dr. Pierce Bailey said he had seen this man last Fall, and at that 
time there was no sensory disturbance, and the pain dated back two years, 
but with intermissions. He had formed the opinion then that there was a 
degenerative lesion rather than a tumor. 

A Case of Cerebellar Tumor.—Dr. J. Ramsey Hunt reported a case of 
cerebellar tumor with degenerations of the posterior columns. The subject 
of this report was a man of forty-six who had been admitted to Bellevue 
Hospital in July, 1902, with typical symptoms of cerebellar tumor, although 
the tumor could not be localized. The cerebellar symptoms had begun 
three months before, and the patient was under observation for three 
months. During these six months there was a progressive diminution of 
the knee-jerks and Achilles jerks on both sides. It was thought to be due to 
degenerations in the posterior columns of the cord, as had been described 
in connection with tumors in the posterior fossa of the skull. There 
was very marked choked disk, and the man’s mental condition became 
one of apathy and somnolence. At the autopsy two small tumors were 


NEW YORK: NEUROLOGICAL SOCIETY. 427 


found, one springing from the dura mater in the median line, and en- 
croaching somewhat upon the right frontal lobe, and the other tumor 
was in the left cerebellar hemisphere. Both tumors were medium-sized 
round-cell sarcomata. The spinal cord presented evidence of greatly 
increased intracranial pressure. Specimens of the spinal cord, both trans- 
verse and longitudinal, were prepared, and they apparently showed degen- 
erations of the posterior columns, such as had been described in connection 
with tumor. The higher levels of the cord were most affected. Lissauer’s 
column was spared, as was the rule. The fibers in Clarke’s columns were 
also usually spared. These degenerations arose from the entrance of the 
posterior roots into the spinal cord. It was an anatomical fact, that where 
the posterior roots perforated the dura mater obliquely there was a con- 
striction, and that here the sheath of Schwann was lost. At the same time 
there was a constriction of the myelin substance, and some of the fibers 
were deprived entirely of this substance. The speaker then briefly dis- 
cussed the mechanical and toxic theories, and said that he presented the 
case as one favoring the mechanical theory. 

A Case of Cerebellar Tumor.—Dr. L. Pierce Clark reported the fol- 
lowing case: The subject was a man of thirty, who had had both gonorrhea 
and syphilis, and who used alcohol and tobacco to excess. The present 
illness began in October, 1901, with headache in the right occipital region. 
After a time he began to vomit in the mornings, and the right side became 
weak. lodide of mercury had been given without benefit. On examina- 
tion, there was choked disk in the right eye; the sixth nerve was bilater- 
ally weak; the muscles of the right leg were stiff and painful; the head 
was held stiffly and bent slightly to the right side; all the deep reflexes 
were exaggerated, particularly on the right side; there was double Babinski; 
the gait was characteristically cerebellar. A diagnosis was made of a 
syphilitic tumor in the middle lobe of the cerebellum involving the peduncle. 
On admission to the Presbyterian Hospital in January, 1903, for operation, 
an X-ray examination showed the tumor. The man died rather suddenly, 
and the autopsy disclosed a tumor of the cerebellum. Between it and the 
fourth ventricle was a large cyst filled with slightly turbid serum. Ap- 
parently the growth was a syphilitic gumma that had undergone syphilitic 
and calcareous degeneration. 

A Case of Spindle-Cell Sarcoma of the Cerebral Dura—Dr. B. Onuf 
reported this case and presented a specimen. The subject of the report 
had been first seen on May 2, Ig02, and at that time complained of a shoot- 
ing pain in the left ear and in the teeth, and of attacks of dizziness. There 
was only slight perception of light; the gait was staggering, there were no 
marked changes in sensation or in the reflexes; there was typical choked 
disk. A diagnosis of cerebellar tumor was made. Subsequently the man 
developed slight paresis of the left facial nerve with fibrillary twitchings 
of the muscles in this region, and the hearing on the left side became 
greatly impaired. In walking, the man deviated to the right. He died in 
December, and at the autopsy a tumor was found at the base of the left 
cerebellar hemisphere. It was a spindle-cell sarcoma. This could have 
been enucleated had it been in a more accessible situation. 

Dr. Schlapp said that about a year ago he had presented to the New 
York Pathological Society a case similar to the one presented this evening 
by Dr. Hunt showing degeneration of the spinal cord. The specimens 
from his case had been counterstained with acid rubin and the sheath of 
Schwann was stained. In all of the cases the degeneration extended to 
this sheath, especially in the cranial nerves, the trigeminus, the glosso- 
pharyngeus and the vagus nerves. He had expressed the opinion at that 
time that the sheath of Schwann might have some protective influence. 
He did not think the case tended to disprove the toxic theory. There were 
no sensory symptoms in the beginning, and probably the degeneration was 
at first confined to the fibers passing from the posterior columns into the 


428 NEW YORK NEUROLOGICAL SOCIETY. 


gray matter. The poison appeared to be selective in its action, involving 
only the reflex fibers. The degeneration was particularly marked in the 
sensory nerves. 

Dr. W. M. Leszynsky said that he had been interested in the fact that 
respiratory failure had preceded cardiac failure in Dr. Clark’s case. One 
of his own patients had died upon the operating table just as the cerebellar 
abscess was reached. The heart continued to beat for eight or ten minutes 
after the failure of respiration. If degeneration existed in the posterior 
columns it must act chiefly on the third or fourth lumbar segment in order 
to produce loss of knee-jerks; how, then, would one explain those cases 
in which the knee-jerk was absent for a time, then became well marked, 
and was alternately present and absent? 

Muscle Tonus and Tendon Phenomena; Their Relationship and In- 
terpretation.—Drs. J. Fraenkel and Joseph Collins presented this paper, 
which was read by Dr. Fraenkel. It was based upon tonometric examina- 
tions of 230 patients. The authors stated that at the present day the view 
most generally held was that the tendon phenomena were expressions of 
muscle tonus. General clinical experience showed a definite relationship 
between tendon phenomena and the tonicity of muscles. Hypertonia, 
next to exaggeration of the tendon jerks, was a symptom of 
disease of the pyramidal tracts. The tonometer used in_ this 
investigation was the invention of the house physician of the 
Montefiore Hospital. A total of 554 registrations had been made. The 
230 cases were distributed as follows: Apparently healthy, 32; cases of 
tabes, 25; of organic disease of the nervous system, 33; functional disease 
of the nervous system, 40; pulmonary disease, 70; heart disease, 12, and 
various other chronic affections, 18 cases. There were 71 registrations 
classed as hypertonia. It was found to be frequently, although not always, 
associated with exaggerated Achilles reflexes. Hypotonia was found to be 
frequently associated with loss or diminution of the tendon phenomena. 
There was a comparatively small number of neurogene hypotonias in pro- 
portion to the cases of general hypotonia. Neurogene hypotonia and ab- 
sence of diminution of the tendon reflex were found frequently associated. 
Neurogene hypotonia with exaggeration of the tendon reflexes was present 
in nine per cent. It was concluded that hypotonia with exaggeration of 
the tendon reflexes was present in nine per cent. It was concluded that 
hypotonia produced by damage of the ascending tracts of the spinal cord 
was accompanied by loss or absence of the tendon phenomena in every 
instance. In the cases of hypertonia absent or diminished reflexes were 
present in six per cent of the registrations. In the cerebral group there 
was found a larger percentage of hypotonias than of hypertonias. In the 
spinal group 100 per cent gave exaggerated tendon reflex and 95 per 
cent showed hypertonia. It had been learned that whenever the neuro- 
gene tone was markedly increased or decreased the tendon jerks were in- 
creased or decreased correspondingly. The authors concluded that disease 
of the posterior tracts caused hypotonia, and disease of the pyramidal 
tracts caused hypertonia. There was a large group of cases giving tonicity 
and normal tendon phenomena. 

Dr. G. L. Walton, of Boston, said that in the exhaustive discussion on 
teflexes and tonus opened by Crocq in 1901, the reader had reviewed the 
clinical and experimental evidence which tended to show that the reflexes 
generally corresponded to the tonicity. The exceptions to this rule he ex- 
plained as illustrations of the fact that the centers for tonicity (at the 
cortex) and those for the deep reflexes (in the basilar region) were sepa- 
tate. This explanation was not directly discussed, though the limitation of 
these functions to the regions indicated was seriously questioned. Drs. 
Fraenkel and Collins had reinforced in a most convincing way the results 
of Crocq, though their explanation of the exceptional cases differed from 
his materially. The question was too complicated to be discussed in its en- 


NEW YORK NEUROLOGICAL SOCIETY. 429 


tirety, especially in the absence of exact knowledge as to the seat of either 
the tonus or the reflexes, but such work as had been reported by Drs. 
Fraenkel and Collins furnished one of the definite steps by which one 
might gradually mount to a knowledge of this complex subject. We had 
been so long imbued with the notion that in man, as in the frog, the spinal 
cord was the center for reflexes and tonus that it was difficult to transfer 
our study of these functions to the brain. Even in case of disturbed reflex 
in cerebral disease we were still apt to think of the function of the brain as. 
limited to the withdrawal, or the increase of influence upon the cord, 
through the pyramidal tract. For a long time the hypotonicity and loss of 
reflex sometimes found at the onset of cerebral hemorrhage was attributed 
to the shock conveyed to the cord. At the discussion already alluded to 
the disputants, while recognizing the importance of the cerebral influence,, 
were by no means in accord with Crocq in limiting the reflex centers and 
the centers of tonicity to the brain. Dr. Walton said he had several 
times taken occasion to suggest that, instead of speaking of lower centers. 
controlled, or inhibited, by higher centers, inhibited perhaps in their turm 
by still higher centers, we should recognize the combined action of all cen- 
ters, cortical, basal and spinal, allotting to certain regions a predominating 
reflex function, liable to transference to a lower level on gradual withdrawal 
of upper level influence. According to this view each reflex movement 
might be regarded as a resultant of the activity of various loops of different 
lengths, connected with each other both laterally and vertically. The more 
he had observed the reflexes in cerebral disease the more he was inclined 
to accord to the cortex the chief rdle in the deep, as well as the super- 
ficial reflexes, and in the tonus. It was difficult, for example, to explain 
on any other basis the absence of deep and superficial reflexes in the fol- 
lowing case: The patient was unconscious and hemiplegic, with a tempera- 
ture of 105° F., and all reflexes absent up to the time of his death. The 
Kernig symptom was present, showing, probably, comparative hypertoni- 
city of the hamstrings, but the extremities were otherwise obviously hypo- 
tonic. Autopsy showed pneumococcus meningitis of the convexity with 
encephalitic invasion of the cortex. In other cases of meningitis the re- 
flexes were frequently preserved, but in one case of meningitis coming 
under his observation, in which both brain and cord were affected, during 
the stage of rigidity and obvious hypertonicity the reflexes were absent, but 
reappeared as relaxation set in, first on the side first relaxed. One must 
evidently look farther than to separation of the centers to explain such 
conflicting phenomena; in fact, different cases might require different ex- 
planations. Possibly it was partly a question of comparative tonicity. In 
the last case, for example, the hamstrings might have possessed hyper- 
tonicity so far in excess of the hypertonicity of the quadriceps femoris as. 
to “snub” the knee-jerk. In long standing infantile cerebral hemiplegia 
with contracture the deep reflexes were often absent, though hypertonicity” 
was apparent. Doubtless in some of these cases the contracture was i 
such position as to put the tendons on too great or too little stretch, thus: 
mechanically preventing the reflex. The combination of exaggerated re- 
flexes with hypotonicity was sometimes seen in Erb’s syphilis of the cord, 
especially in the early stages. In a recent conversation with Dr. Courtney 
he had suggested that the affection about the fibers of the pyramidal tract 
was sufficient to impede the transmission of voluntary impulse and of toni- 
city from the cortex, but the reflex stimulus passed the more rapidly, as im 
neurasthenia, uninhibited by the volitional mechanism. ‘Though not 
sure that he had thoroughly grasped the explanation of the readers on this: 
point, Dr. Walton felt that they had proceeded along logical lines. 

Dr. C. L. Dana thought the authors had established quite clearly the- 
relations of hypertonia to the reflexes, and had given to the neurological 
world tangible working data. He had not fully understood the explanatiom 
of the effect of the brain on hypotonus and hypertonus. Personally, he- 


430. NEW YORK NEUROLOGICAL SOCIETY. 


made use of a working hypothesis which fitted in very well with the ex- 
planation given in this paper. In all the sudden insults to the brain occa- 
sioned by hemorrhages producing profound hemiplegia there was always 
absence of the deep reflexes on the paralyzed side, and with it no doubt 
hypotonia; whereas there was not this loss of reflexes on the non-paralyzed 
side. After a time this absence gave place to an increase of reflex. If, 
however, the hemorrhages were more posterior and involved the sensory 
sphere, there was more definite and more prolonged absence of reflexes. 

Dr. B. Onuf referred to a case in which a tumor of the hip and shoul- 
der centers was diagnosed, and the tumor removed, with the result that a 
very marked hypotonia developed in the paralyzed extremity after the ope- 
ration, and was present even two months afterward. 

Dr. Collins said that Dr. Fraenkel was satisfied with having established 
the relationship between tonus and reflexes, and they were both particularly 
gratified with Dr. Dana’s statement that in his cases of cerebral hemiplegia 
he had observed that the farther posteriorly the lesion extended, either into 
the sensory cortex or the sensory representation of the capsule, so in propor- 
tion was the existence of hypertonia or the lateness with which it appeared. 
This clinical experience fortified very greatly the position taken in the 
paper. 

Dr. Fraenkel said that he too had been delighted at the confirmation 
of their position by the very large clinical experience of Dr. Dana. If 
their observations were correct they should be of value in connection with 
diagnosis of pure lesions of the pyramidal tract associated with hypertonia 
and of the posterior tract with hypotonia. 


PHILADELPHIA NEUROLOGICAL SOCIETY. 
March 24, 1903. 
The President, Dr. H. A. Hare, in the chair. 


A Case of Progressive Bulbar Palsy.—This case was exhibited by Dr. 
T. H. Weisenberg. The patient had presented herself at the nervous dis- 
pensary of the Polyclinic Hospital three weeks previously with the state- 
ment that four weeks before coming to the clinic she had suddenly lost the 
power of speech. This she attributed to the wearing of false teeth. She 
protrudes the tongue in a straight line and moves it from side to side. 
Uhere is a fine fibrillar tremor in the tongue. She can not pucker up the 
lips. There seems to be no involvement of the upper distribution of the 
seventh nerve. There is no apparent atrophy of the muscles of the tongue 
or mouth. She has typical bulbar speech. She swallows with difficulty. 
There is preservation of the pharyngeal reflex. The jaw-jerk is present. 
The knee-jerk is normal. The gait and station are normal. On laryngo- 
scopic examination, no gross change is observed. 

Dr. Charles W. Burr called attention to the fact that it was rare in a 
case of this kind to find such great involvement of the speech with such 
slight palsy of the lips as was present in this woman. As a rule in disease 
of the bulb when the speech becomes so bad as not to be understood there is 
marked palsy of the muscles of the tongue and lips. 

Dr. William G. Spiller said that a curious feature about this case was 
that the loss of speech came on suddenly. This he thought was an error 
of observation on the part of the patient, although such a loss may occur 
suddenly, probably from hemorrhage. This he considered a case of true 
bulbar paralysis, not a case of pseudo-bulbar paralysis. 


431 PHITADELPHIA, NEUROLOGICAL SOCIETY. 


A Case of Tuberculous Meningitis with Secondary Infection.—This 
was reported by Drs. S. S. Kneass, W. F. Hendrickson and Joseph Sailer. 
The patient, a man aged twenty-nine years, was admitted to the Hospital 
of the University of Pennsylvania, March 15, 1902. His illness began 
with headache, nausea, vomiting, diarrhea and soreness and stiffness in the 
back. He had been treated for typhoid fever until March 8. He had 
gradually improved with the exception of the pain in the head. On March 
12, in the third week of the disease, he became delirious. 

Examination on admission showed moderate leucocytosis, diazo reac- 
tion negative, Widal reaction negative. On account of the cerebral symp- 
toms, lumbar puncture was performed, and examination of the fluid showed 
the presence of a diplococcus. The patient was apathetic, but intelligent, 
answering properly, and did not complain of pain. Both pupils reacted 
normally. There was general hyperesthesia to all forms of sensation. Res- 
piration was abdominal and the abdomen was retracted. There was a loud, 
short systolic murmur. Examination of the lungs was negative. The knee- 
jerks were absent, but there was no spasticity. The patient developed 
edema of the lungs, and on the second day after admission became coma- 
tose. Under the use of digitalis the edema of the lungs cleared up, but he 
died on the roth. 

Autopsy.—The heart was not enlarged,—no valvular lesion. The lungs 
were congested and edematous. The kidneys normal. The brain showed 
marked congestion, and at the base a puriform exudate into the meninges. 
Numerous tubercles were found on the meninges,and smears showed a larg2 
number of tubercle bacilli. The lungs presented a number of microscopic 
miliary tubercles. The meninges also showed marked infiltration of the 
lymphoid cells. The interesting feature of the case was the mistake in 
diagnosis based upon the presence of the Micrococcus tetragenus found in 
the spinal fluid. As far as the authors were aware this was the only case 
in which this had been found. The primary focus of the miliary tubercles 
was not found. 

Dr. Alfred Gordon said that the most recent cytological studies of 
the cerebrospinal fluid threw considerable light upon the question of men- 
ingitis. These tend to show that lymphocytosis of the cerebrospinal fluid 
is a characteristic feature of an inflammatory condition of the meninges. 
It would be, therefore, interesting to know the result of the cytological ex- 
amination in Dr. Sailer’s case. 

Hemiplegia without Gross Lesions in a Case of Plumbism and Ne- 
phritis—This paper was read by Dr. Charles W. Burr. The patient was a 
man aged fifty-five years, admitted to the hospital February 3, 1903, in an 
unconscious condition. He had worked in the salts of lead. There was 
palsy of the right arm and leg and of the right side of the face. Both knee- 
jerks were fairly active. There was some extension of the great toe .on 
stroking the sole of the foot on the paralyzed side. The man was stupid 
and delirious but not absolutely unconscious. On the second day, he be- 
came completely unconscious, and seventy-two hours after the onset of 
the paralysis, which had been sudden, he died. There was a distinct lead 
line on the gums, hyaline casts and a line of albumin were found in the 
urine. No gross lesion was found in the brain, and the only lesion discov- 
ered was chronic inflammation of the kidney. There was no arterial sclero- 
sis in the brain or other part of the body. 

A Medullary Nucleus not as yet Described.—A brief report of this was 
made by Dr. E. L. Mellus, of Baltimore. 

Dr. Joseph Sailer thought that Dr. Mellus had proved the point for 
which he contended. What he had shown was certainly a nucleus. He 
congratulated the Society on the honor done it by Dr. Mellus in making 
the first report of the discovery to it. 

Dr. William G. Spiller said that there was a distinct group of cells in 
the area referred to. There is also a similar group of cells in the human 


432 PHILADELPHIA NEUROLOGICAL SOCIETY. 


brain, although in the dog the cells are much larger. He raised the question 
whether this might not be a part of Dieters’ nucleus. Whether or not it is 
to be considered a part of Dieters’ nucleus, it is a distinct group of cells 
and has as much right to be considered a special nucleus as von Bechte- 
rew’s nucleus which also may be regarded as a part of Dieters’ nucleus. The 
determination of this question will rest with the discovery of the function 
of these cells. 

A Case of Complete Brachial Monoplegia—This case was presented 
by Dr. G. M..Dorrance. The patient was a man aged twenty-four years, 
who had come to the nervous clinic of the Polyclinic Hospital. In July, 
1902, while working in a shaft an iron bucket fell, striking him on the 
left shoulder. He was rendered unconscious and remained in that condi- 
tion for seven days. Since the accident he has not been able to use the left 
arm. The muscles have gradually wasted and the reactions of degeneration 
are present. The case was presented especially with reference to the pro- 
priety of operative procedure. 

Dr. F. Savary Pearce said that he had presented a somewhat similar 
case about a year ago. There was degeneration-reaction throughout the 
brachial plexus distribution, and there seemed to be no help for the man, 
and amputation was finally done. Microscopic examination of the nerves 
of the brachial plexus showed widespread degeneration. It was Dr. 
Pearce’s opinion that in a case of this kind, where there was so much de- 
generation and the member was useless, similar operations should be 
done. ‘There was no delay in healing of the stump in the case Dr. Pearce 
reported, and the man was relieved of an incumbrance, much to his delight. 

Dr. William G. Spiller referred to a case which he had seen in which 
Dr. Keen had exposed and resected the musculospinal nerve. A year and 
a half later there was almost complete return of power. In some cases 
there has been tearing and thickening of the nerves, and resection of the 
thickened portions and bringing the ends together has been followed by 
good results. 


Periscope. 


ARCHIVES DE NEUROLOGIE 


(No. 86, 1903, February. ) 


1. Contribution to the Study of “Folies” by Contagion. G. Carrier. 
2. On Obsessions and Impulsions (Episodic Syndromes in Degenerates). 
Dr. Soutzo, Jr. 


1. Contribution to the Study of Folies by Contagion.—The author 
states that “morbid contagion in mental troubles may be defined as the 
action of suggestion exercised by a diseased mind upon one or several 
sane minds, which reproduce it, each according to his individual disposition, 
either as a simple belief in the disordered idea or in insane manifestation 
of every form. This state created by contagion has been denominated in 
the nosological classification of folie, under the name of folie ad deux, delire 
a@ deux, etc., expressions which we think too general and which we replace 
by folie par contagion.” The author states that this definition has the 
advantage, first, of comprehending the numerous observations published 
on this subject, and second of being general; folie a deux being only a 
special effect of suggestion in the morbid psychical sphere; suggestion 
which acts in so many diverse forms in normal psychical life.’ I. The 
article proceeds with an extensive bibliography of the subject, beginning 
with Baillarger in 1857, who in that year first described folie a deux, and 
mentioning among others Oscar Woods, Jelly, W. Griffin and R. Dewey. 
II. In order that folie by contagion exist, there must be two principal 
pathogenic elements: contagion and morbid suggestibility or predisposition. 
“Morbid contagion is the raison d’étre of all forms of folie by imposition, 
of folie by communication, of folie by transmission or by the simultaneous 
existence of insane phenomena.” This was long denied by the authors, 
as Regis, etc., but is now fully established. Suggestion, the authors say, 
has three factors: imitative, persuasive and intermental action; this last 
factor being, according to M. Tarde, the conditions under which one mind 
is able to act upon another. III. The author reviews the determining 
causes of the development of folies by contagion. There are three groups 
of causes; the first accentuates the suggestive elements; the second ad- 
dresses itself to predisposition, and the third to impression. In the first 
group are Ist, a long life in common and as intimate as possible; 2nd, 
habitual ascendency of the unsound upon him or them of sound mind, 
etc. In the second group: general wretched condition, illness, intoxi- 
cations, debilitatng vices, etc., physiological states, like puberty, menstru- 
ation, pregnancy, accouchment, lactation, menopause. The third group: im- 
pressions produced by insane phenomena. IV. In all folie by contagion 
there are two elements: an active subject, contagious element; a passive 
subject, element receptive. “The active subject in general exhibits 
intellectual faculties more vigorous, a will and an energy more powerful 
than the passive subject: he is, in a word, more suggestive. His intellect, 
however, may not be superior, may even be inferior to that of the passive 
subject, the acuteness of the insane phenomena suffices to create the sug- 
gestive state. The passive subject is one whose intellectual faculties are 
enfeebled in various degrees by a predisposition whether hereditary or 
acquired; in a word, he is suggestible. He may reject the morbid im- 
pressions when the influence is withdrawn; or he may appropriate, develop 


434 PERISCOPE. 


and transform them and give them a form quite personal. The author 
recognizes three clinical forms of folie: folie imposed, folie simultaneous 
and folie communicated. The author does not agree with the opinion of 
Marandon, who thinks that the passive subject never has hallucinations, 
and that he should not be classed as insane. He cites the cases of a young 
man and a young woman, in which the latter became the active subject of 
folie imposed. The young man had cohabited with the woman as his 
mistress for several years. She developed insanity of the alcoholic type, 
ideas of persecution, jealousy, hallucinations of hearing and sight, dis- 
orders of taste and smell. Her delusions led her to complain to the police, 
and her jealous threats frightened the young man. MHe consulted his 
physician, but under delusion said that the persecutions complained of by 
the woman were realities. The physician advised that he have the woman 
taken to an infirmary. He did this a few days thereafter. A month after 
the woman’s admission, he became quite restored to mental health, and 
the woman, after four months of isolation and treatment, was discharged 
cured. The difference between folie imposed and folie communicated is 
that in the former there is merely a transmission of delusions, while in the 
latter the patient evolves delusions of his own, in addition to those imposed 
on him. The patients must be separated for their treatment. The author 
furnishes at considerable length two other cases under his observation, 
one where the patient was the active agent in the folie by contagion, and 
the other where the patient was the passive agent. The author concludes 
that passive subjects of folie imposed must of necessity be considered in a 
suggestive state and consequently in a medico-legal point of view irrespon- 
sible, so long as they are in that state. 

2. On Obsessions and Impulsions (Episodic Syndromes in the Degener- 
ate). Degeneracy betrays itself, says the author, by a certain number of 
physical signs generally grouped under the domination of stigmata. The 
external manifestations of morbid syndromes are obsessions, impulsions, 
inhibitions, perversions of instinct, various delusional troubles, all of which 
arise from disequilibration of cerebral departments. Obsession and impul- 
sion have two elements: a center entering suddenly into function, by itself, 
without being solicited by the need of movement, and a momentary impo- 
tence of the will to escape the phenomenon which imposes itself. There 
is a rupture of the harmony of cerebral centers and exuberance of certain 
of them. We believe that we may affirm that volitional element has no 
action in the genesis of obsession. It has been claimed that obsession is a 
malady of the will. As we see it, says the author, all that occurs, occurs 
without exercise of the will, and if this last appears to intervene, it is in 
impulsion only, and in such a case it appears simply suspended, momentarily 
annihilated as a sequence of the struggle which it opposes against a 
very superior force, a force due to the exaggeration of one or several psy- 
chical centers in a state of excitement. The obsedant idea in the degener- 
ate is born with the individual, remains a long time latent, until the moment 
when an appreciable cause makes it break forth; then increasing little by 
little it reaches a maximum and constitutes the morbid troubles called epi- 
sodic syndromes. The author sets forth with much detail five cases of 
syndromic states: ideas of homicide, suicide, doubt, theft, perversions, etc. 
The first was of a single woman, thirty-three years of age, with conscious 
ideas impelling to homicide, suicide, with fears of all instruments capable 
of causing death, like knives, needles, pins, etc.; there was perversion of 
sexual instinct, also onanism. She entered a private hospital, “was sub- 
mitted to two seances of hypnotism,” suggestion gave some tranquility, and 
finally distractions, reading, and above all an alimentation sufficiently abund- 
ant, joined to daily moral treatment, improved her state, so that now she 
has only some abdominal troubles and headache. There were no signs 
of degeneracy, but clear indications of hysteria. The author remarks that 
the syndrome of impulsion, contrary to the claims of certain clinicians, 


PERISCOPE. 435 


did not lead fatally to action. The second observation is upon the case 
of a woman of thirty-four, married at the age of nineteen, had 6 children 
and 2 miscarriages. One son at the age of 16, after typhoid fever, had 
committed suicide. This misfortune rendered her sad, but under medical 
care she recovered perfect health. Without any appreciable cause she 
once attempted suicide by poison, and twice left her home with the idea of 
suicide; once, thinking of her 5 children, she returned home, and the third 
time remained in a forest five days without eating, hoping to die by starva- 
tion. Admitted to the asylum she said: “I don’t know, the idea of suicide 
came to me suddenly without any reasons. It is stronger than I.” In 
this case the syndrome of suicide was the only one; its access was sudden, 
and there was no resistance on the patient’s part. Such individuals are 
scarcely responsible for their crime. The third observation was of a 
woman of forty-one, married. There was a history of gross sexual per- 
version, onanism. She had impulses to break crockery, to kick at stones 
in the street, to give blows to persons who were passing beside her. She 
was for three years a janitress, and believed that in rendering her accounts 
to the manager she had paid over a sum less than she owed. From that 
moment she became sad and preoccupied and doubted whether she had 
not lost some banknotes. In the street she was impelled to rummage the 
pockets of people, believing that they contained banknotes. Taken to the 
hospital she saw banknotes everywhere; at sight of notes her face became 
red, she briskly recoiled and feared to touch them. By degrees, under the 
moral treatment of the physician, which had great influence with her, she 
became less anxious and at the end of six months entirely re-established. 
At the present time she is lucid and touches banknotes without emotion 
and recognizes the absurdity of her former ideas. In this case there is a 
co-existence of a certain number of obsessions and impulsions, which appear 
little by little during a period of five years and ends by a cure, which is 
the usual termination. Observation four is a case of impulsion to theft 
and suicide in a woman of forty-five. She was severely ill with typhoid 
fever, had chorea, hysterical crises. She was employed at a dressmaker’s 
shop; at thirty-seven she took up this work again at Paris, but the hand- 
ling of the silk enervated her greatly and brought on “crises” almost every 
week. A second and more severe attack of typhoid rendered her more dull, 
and at the same time arose the impulsion to theft. The impulsion appeared 
suddenly and was followed always by the act, resistance almost nil. The 
object of her theft was always silk, and by preferance red silk, and the act 
was accompanied by sexual orgasm. For a theft at the Bon Marché she 
was condemned to six months in prison. (A note says that she was re- 
ported to have undergone sixteen sentences for numerous thefts in shops. ) 
She was brought to the asylum after having thrown herself from a window 
on the second floor of the house where she lived; she remained there three 
months. After an hysterical crisis, she attempted to throw herself before 
a railroad train, but was prevented by her daughter. The next day, with- 
out being completely dressed, she took a cab and went to a shop, where 
she stole a package of silk. She was arrested and taken to the Infirmary. 
At the hospital she seems debilitated, rubs her hands constantly, is 
restless, weeps at intervals. The author considers this an example of the 
possible co-existence of mental troubles, syndromic and _nervous. It shows 
hereditary degeneracy, re-enforced by fibrile troubles. Observation 5: Case 
of a married woman, who was brought to St. Anne in 1902 for the third 
time. Her first morbid episode occurred thirteen years ago, when she had 
fear of needles, glass and fire. She could not see a candle lighted without 
fear of seeing it kindle a fire. In buying an object, after paying for it, she 
doubted she had not paid less than the sum due. She became anxious 
and frequently wept and was taken to the asylum for the first time. She 
was discharged after three months completely cured. After an interval 
of 11 years, she was seized with depression, multiple hallucinations of 


436 PERISCOPE. 


hearing, sight, ideas of culpability, of persecution, and some of her former 
ideas of doubt. She left the asylum in 30 days, again entirely cured. She 
passed two months in the country, returned to Paris in October, 1901, and 
by degrees new ideas entered her brain. She became very religious, went 
to church every day, though before she did not even go on Sunday. She 
told her husband that she was poisoned, etc. Her troubles became aggra- 
vated, and in February, 1902, she was again admitted at St. Anne. Mystic 
ideas predominated: she complained of suffocation, palpitation, night vis- 
ions, etc. After three days she became lucid, all had disappeared; she 
only felt general fatigue. This clinic shows us three forms of trouble; 
all belong to the same base—degeneracy. There were not three maladies. 
belonging to three periods, for then there would be three different con- 
ditions, one attached to each of the morbid periods. The author concludes: 
“Finally from this exposition of what the clinic has shown us, we think 
that we should state some particulars concerning a certain number of im- 
portant syndromes. ‘The group of obsessions and impulsions to homicide 
and suicide present some special characteristics. The obsessional idea is 
more tenacious, the struggle on the part of the subject is increased by the 
will, which opposes itself with a greater energy; in fine, the moral torture 
reaches a maximum. In what concerns the performance of the act, we 
should add, and with much justice, that Magnan distinguishes two varieties. 
of impulsions. In the first variety, the onset is sudden, automatic, with no 
anterior resistance or reflection in the subject (see second case above) ; 
in the second variety, the person holds himself for a long time as master 
of the obsedant idea, or rather at the same instant that he sees himself 
on the point of yielding, he has recourse to the aid of a member of his. 
family or other such help; ‘he gets the start of his environment’ (il prévient 
son entourage), according to the expression of Magnan (see second case 
above). In fine, in the medico-legal point of view persons, who commit 
crimes under the influence of these morbid impulsions are not responsible, 
and such persons, as well as the criminal-born of Lombroso, are only, as. 
we have seen, the unbalanced, belonging to the great family of degenerates. 
The second syndrome, the folie of doubt, demands also some comment, 
because of the different interpretations which it has received from alienists.. 
Falret, Sr., who first described folie of doubt in an admirable manner, 
commits the great fault of isolating it too much. He makes of the syn- 
drome a distinct malady of progressive character and a definite prognosis: 
incurability. Le Grand du Saule, in his monograph, associates it with the 
delirium of touch; to his mind this intimate association exists of necessity, 
and the appearance of the delirium of touch marks the debut of a second 
period in the morbid entity, formed by this association. There are at this: 
time among the clinicians a certain number who still entertain these opin- 
ions. As for Magnan and ourselves, we are far from looking upon the 
folie of doubt under such an aspect; it constitutes merely a syndrome,. 
which may exist in the clinic, either by itself or at times associated with the 
delirium of touch, and that only by preference, for we may meet it also: 
with other syndromic states. The prognosis is habitually favorable, but 
on the cardinal condition of never neglecting the patient, of having hin 
each day under one’s eye, and of instituting for him a continuous medical 
and moral treatment. This view is, besides, justified by all our observa- 
tions. The other syndromes set forth in our cases give a precise idea of 
the general characteristics indicated at the commencement of this essay. 
Briefly, in conclusion, we think that we may affirm that this study shows. 
us once more that episodic syndromes, varied as they may be, belong to 
the same foundation, mental degeneracy; on the other hand, it permits us. 
to place upon the solid foundation of the clinic, in the medico-legal appre- 
ciation, faulty and criminal acts committed by individuals belonging to 
the great class of degenerates.” Mr. Ricuarps (Amityville). 


PERISCOPE. A37 


ARCHIVES D’EDLECTRICITE MEDICALE 
(No. 120, 1902, December. ) 


1. An Adjustable Inductance for High Frequency Resonators. H. Guit- 
LEMINOT. 

2. On the Use of an Electrolyte in Parallel to the Primary Current of a 
Coil for the Production of X Rays and High Frequency 
Currents. Borpier and Nocier. 

3. Anesthesia by the High-frequency Brush Discharge in the Ablation 
of Protruding Hemorrhoids and Hemorrloidal Condylomata. 
BILLINKIN. 

4. Electric Cerebral Inhibition in Man. Stré&pHaNneE LeEpUuCc. 

5. Measuring the Diameters and the Area of the Heart upon the Radio- 
scopic Screen without Drawing. A New Arrangement Adapted 
to Any Screen. H. GUILLEMINOT. 

. Death and Accidents by Industrial Electric Currents. F. BatTe tt. 

. Congress at Berne. Exhibition of Apparatus for Medical Electricity 
and for the Production of X Rays. 

1. Inductance for Resonators——The awthor describes his method of 
more accurately tuning resonators by the introduction of an adjustable 
self-induction coil in the primary oscillating circuit, a device that was 
employed by Tesla about 13 years ago. 

2. Electrolytes in the Primary Circuit of Induction Coils.—The writers 
recommend shunting the terminals of the primary by a small cell composed 
of lead plates submerged in very dilute sulphuric acid. Under certain 
conditions of current the relative spark length of the coil is stated to be 
considerably increased. 

3. Electrical Anesthesia in the Excision of Hemorrhoids, etc.—In this 
paper the author fully describes his mode of using a high-frequency brush 
discharge applied to the anus to produce anesthesia and constriction of 
the neighboring blood vessels. With suitable apparatus properly used 
a painless and practically bloodless operation can be performed. 

4. Cerebral Inhibition.—A description of a method of producing partial 
inhibition of the sensori-motor cerebral centers by causing a rapidly inter- 
rupted electric current to traverse the brain and spinal cord. The negative 
electrode is placed upon the forehead and the positive on the lumbar spine. 
A 50-volt generator of low internal resistance is used to supply the current 
in conjunction with an adjustable shunt rheostat, while the current is inter- 
rupted by means of a Gaiffe mercury interrupter. The sensations of the 
subjects, Prof. Malherbe and Alfred Rotixeau, upon whom the investi- 
gations were made, were as follows: “When the current was at a maximum 
we could still hear as in a dream what was said; we were conscious of our 
inability to move and to communicate with our colleagues; we perceived 
the touches, the pinching, and the pricks upon our arms, but the sensations 
were dulled like those from a limb fast asleep, etc.” No disagreeable after- 
effect resulted. 

5. Measurement of the Heart Area, etc-—A short desciption of the 
author’s new disposition of his previously-described frame with horizontal 
wires and sliding balls, designed to measure the diameters and the area 
of the heart, projected orthogonally upon the fluorescent screen. In its 
new form the frame is placed on the fluorescent side of the screen, and 
the measurements are read distinctly from the accompanying centimeter 
scale on glass. 

6. Death by Electric Currents—A lengthy and complete paper which 
should be read in full to be appreciated. The paper is an extensive sum- 
mary of Prof. Prevost and Dr. Battelli’s investigations upon this import- 
ant subject, and also contains some very interesting remarks upon the 
electrocution of criminals in this country. Briefly stated, the author finds 
that low-tension continuous or alternating currents kill by causing cardiac 


es f(a 


438 PERISCOPE. 


fibrillation; high tension alternating currents at 1,200 volts or more kill 
on the contrary by inhibiting the respiratory center. Alternating currents 
of from 240 volts to 600 volts produce in dogs cardiac fibrillation and often 
permanent arrest of respiration. High-tension currents, according to the 
author, do not produce cardiac fibrillation, but possess the property of 
causing a fibrillating heart to beat coordinately after it has been subjected 
to a previously applied low tension current. Upon the subject of criminal 
electrocution the author says: “With the introduction of the new method 
employed in electrocutions (a high-tension current followed by a low- 
tension current), the inhibition of the nerve centers is followed by cardiac 
paralysis. Thus burns are avoided, and the signs of life cease most rapidly. 
Electrocution, as all other methods of capital punishment, is a disgrace to 
our civilization, but it is the least repugnant because consciousness is 
immediately lost and the condemned is not disfigured, nor is the execution 
bloody.” 
(No. 121, 1903, January. ) 


1. Measuring the Actinic Power of the Radiants Employed in Photo- 
therapy. A New Actinometer. BorpiEr and NOGIER. 

2. On Intra-rachidian Stimulation in Man as a Therapeutic Procedure. 
J. BERGONIE. 

On the Maximum Power of Currents Employed in Medicine and the 
Way to Obtain Them. H. GUILLEMINOT. 

Electrotherapy and Orthopedics. FE. ALBERT-WEIL. 

The Present State of Electrodiagnostics. Lupwic MANN 

A Five-Cell Electric Bath or Perineal Bath. FEtix ALLARD. 


1. Measurement of Actinic Power in Phototherapy.—As the authors 
consider it highly advisable to gain some idea of the intensity of the violet 
and ultra-violet rays to which the subjects are subjected in phototherapy, 
they have devised a special form of actinometer by which it is claimed 
that not only the relative intensity of violet rays can be accurately meas- 
ured but also the intensity of X rays. 

2. intra-rachidian Electrical Stimulation. — A paper describing the 
effects of faradic excitation of the cord and nerve roots in three patients 
in whom the lumbar puncture was performed several times. The patients 
apparently experienced no pain and, luckily, experienced no evil after- 
effects. 

3. Maximum Intensity of Currents in Medicine-—A paper based upon 
mathematical and theoretical considerations from which the author con- 
cludes as follows: (1) If a generator with unchangeable constants is 
employed in conjunction with a variable external resistance, the maximum 
intensity of current will be obtained by making the external R. equal to 
the internal ry. (2) If the resistance of the external circuit is unvariable 
and several generators are employed, g elements in parallel must be united 
into t groups in series, so that ies in order to obtain the maximum 


current. 

4. Electrotherapy and Orthopanis —-This paper is merely a brief sketch 
written to show that the use of electricity exerts considerable benefit in 
orthopedics, “but one must not forget that its value depends upon the 
manner of its application.” The writer fears from his experience that the 
use of the galvanic current in atrophic paralyses in children is inapplicable, 
owing to the pain produced by the electrodes. 

5. Electrodiagnosis—A long summary discussing the merits and de- 
merits of the various commonly employed methods used in electrodiagnosis, 
which is unsuitable for abstraction. 

6. Electric Perineal Bath—A description of an apparatus consisting 
of five vessels suitably connected to a switch board, so that one of special 
shape, in which the patient sits, serves as one electrode while the remain- 
ing four in which the hands and feet are inserted, form the other electrode. 


A 


PERISCOPE. A439 


(No. 122, 1903, February.) 


. On the Electric Treatment of Basedow’s Disease. TH. GUILLOoz. 

2. How to Understand the Contra-indications to the Electric Treatment 
of Uterine Fibromyomata. M. LAQUERRIERE. 

3. The Treatment of Gonorrheal Arthritis in the Acute Inflammatory 
Stage by Strong Continuous Currents. Louis DELHERM. 

4. The Action of Ozone Upon the Bacillus and the Toxine of Diphtheria. 

F, ArLtvinc and M. TrRonpe. 


1. Zreatment of Basedow’s Disease. The author reports two cases 
of Basedow’s disease considerably ameliorated by the electro-cataphoretic 
method of treatment, in which iodine was introduced into the tissues by a 
strong continuous current. 

2. Treatment of Fibromyoma. After discussing the various varieties 
of electric treatment and specifying those forms of this trouble to which 
the different varieties of current are most applicable, the author gives a 
number of absolute and relative contra-indications which should be read 
in the original to be appreciated. 

3. Treatment of Gonorrheal Arthritis by the Continuous Current. 
The author advises that in cases of hydarthrosis, or gonorrheal arthritis a 
galvanic current of from 20 to 60 m. a. be applied as soon as possible 
once or twice a day. Large kaolin electrodes are to be used. 

4. Action of Ozone on the Diphtheria Bacillus—These authors find 
that by exposing cultures of Loeffler’s bacillus to ozonized air (.025 gram 
to I liter the effect on the bacilli is as follows: (1) Ozone cannot kill 
the bacilli in a nutritive liquid. (2) It can attenuate their growth for 
48 hours, although the proliferation after this period is less marked than 
in ordinary cultures. (3) It diminishes the virulence of the bacilli so 
that inoculated guinea pigs survive, and in those that die only lesions at 
site of the inoculation are found. When the toxin was exposed to 
200 liters of the above-mentioned ozone mixture, the animals survived a 
I cc. injection, although the control animals died in 24 hours from a dose 
of 0.5 cc. R. H. CUNNINGHAM. 


Me 


JOURNAL DE NEUROLOGIE 


(Vol. 7, 1902, No. 21, November 5.) 


1. Sensorial Excitations as a Cause of Epileptic Seizures.. Cu. FERE. 
2. Occipito-Cerebellar Syndrome. L. MARCHAND. 
3. Exophthalmic Goiter. Treatment by Thymus. A. BIENFAIT. 


1. Sensory Excitation in Epilepsy—The author emphasizes the fact 
that sensorial as well as sensory excitations may provoke epileptic attacks, 
and relates the following cases: (1) In an idiot of eighteen years, subject 
to both diurnal and nocturnal attacks of grand mal, the diurnal seizures 
were found constantly to follow sensorial excitations. Sudden noises, 
sudden variations in intensity of light, a current of air, and even a strong 
odor sufficed to bring on a fit. (2) In a man of sixty-five years of age, 
epileptic from his youth, and having two or three fits monthly, loud noises 
and sudden changes in light intensity would often bring on an attack, 
The author saw a typical grand mal seizure produced in this case by a sud- 
den blow on the table behind the patient. The lesson taught is that in 
epileptics careful investigation into the exciting causes of their attacks 
should be made, and attention should be paid to any idiosyncrasies in this 
particular which they may present. ; 

2. Occipito-cerebellar Syndrome.—The author describes the case of a 
woman of forty-two years of age, who had had occasional attacks of epi- 
lepsy for five years. Seized suddenly with headache, diarrhea and vomit- 
ing, she speedily developed loss of vision, going on to nearly complete 
blindness, staggering gait, Romberg’s symptom and exaggerated reflexes. 


440 PERISCOPE. 


The ophthalmoscopic examination showed double pupillary stasis. She 
also had several fits. After eight days the gastrointestinal symptoms 
improved, but the next day she went into status epilepticus. Learning at 
this time that her husband had been syphilitic, the author began intra- 
muscular injections of biniodide of mercury and iodide of potassium. She 
commenced to improve, and in about two months had regained her vision, 
and the headache and motor symptoms had disappeared, though the epi- 
leptiform attacks persisted. The author thinks that there is no doubt 
about the syphilitic origin of the symptoms, and diagnoses a gumma at 
about the insertion of the falx cerebri into the tentorium. 

3. Exophthalmic Gotter, Treatment by Thymus.—The author discusses 
the pathogeny of Basedow’s disease, and narrates some experiments of his 
own upon rabbits, in which incisions into the medulla about and into the 
restiform bodies produced some of the symptoms of this disease. That 
these symptoms probably arise from this region he thinks is shown by the 
results of experiment and by the finding there of lesions in a certain number 
of cases of Basedow’s disease. Certain other maladies, notably tabes, 
which are progressive, have occasionally been found to cause some of the 
symptoms of Basedow’s disease when they extend to the medulla. These 
symptoms, again, may arise reflexly or be neurotic in origin; and, lastly, 
the center in question may be susceptible to the action of certain poisons. 
The author thinks that the thyroid and thymus glands may in some way 
be complimentary in action, hence suggests the use of extract of the latter, 
and gives a report of a case in which he used this remedy with some, 
though not very positive benefit. 


(Vol. 7, 1902, No. 22, November 20.) 
1. Dementia Przecox. F. MEEUus. 


1. Upon the basis of his observations in 47 cases, the author discusses 
the etiology of, and attempts to construct a symptomatology for, dementia 
precox. The disease, he thinks, is not limited to early life, but may arise 
at a later period, and should be considered as a special form of mental 
trouble, with characteristic mental and motor symptoms, proceeding cer- 
tainly to dementia. The characteristic negativism, stereotypy, etc, he 
regards as due to disturbance of association, which prevents regular and 
orderly discharge of impulses, resulting in inhibition, broken by sudden 
and irregular or ill-timed explosions. The term dementia precox he re- 
gards as too indefinite, and suggests that it be replaced by that of “hebe- 
phreno-catatonic dementia.” 

(Vol..7, 1902, No. 23, December 5.) 
1. Theory of Reflexes Cutaneous and Tendinous. C. HELDENBERGH. 
2. Congenital Facial Diplegia. O. DEcRoLy. 

1. Reflexes.—A discussion of the physiology and pathology of reflexes, 
which embodies no original investigations,and does not lend itself readily to 
review. 

2. Congenital Facial Diplegia with Ocular Paralysis and Trouble with 
Deglutition.—Report of a case of this kind in an infant of seven weeks old. 
The author is inclined to think it due to a lesion of the bulbar nuclei. 

(Vol. 7, 1902, No. 24, December 20.) 
1. The Intracellular Network of Golgi in Nerve Cells. S. SouKHANOFF. 
2. Chronic Poliomyelitis. Dr Bray. 

1. Intercellular Network.—A review of the findings of Golgi and Ver- 
atti, with a description of the intracellular network as demonstrated by the 
author himself, especially in the cells of the sympathetic ganglia, by the 
method of chrome-silver impregnation of Veratti. The author does not 
regard this intercellular network as conductive in function, but rather as 
analogous to the intracellular canalicull. 

2. Chronic Poliomyelitis—The author describes the case of a man 
sixty years old, who subsequent to a fall developed atrophy of the hand 





PERISCOPE. 441 


muscles of the Duchenne-Aran type, with some kyphosis in the upper 
dorsal region. From a consideration of the situation of the special nuclei 
of the hand muscles, in the lateral region of the anterior horn, and their 
blood supply differing from that of the other cells of the region, he draws 
the inference that in this case there was a vascular lesion produced at the 
time of the injury, and the cells of the nucleus in question atrophied in 
consequence, while the other cell groups in that part of the cord escaped. 
ALLEN (Trenton). 


NEUROLOGISCHE CENTRALBLATT 
(Vol. 22, 1903, No. 1, January 1.) 


1. A Contribution to the Feeling of Consciousness. <A. PIcK. 

2. Concerning Hysterical Confusion and Mental Aphasia. A. WESTPHAL. 

3. Concerning a Developmental Defect of the Nose (An Undescribed 
Stigma of Degeneration). H. GuppEn. 


1. Feeling of Consciousness.—Pick considers in this paper the 
bekanntheits Geftthl as a condition in hysteria, sexual neurasthenia, epi- 
lepsy, etc., and discusses the psychology of the conditions. 

2. Hysterical Confusion.—Westphal reports a case of hysteria with a 
confusional condition in which the patient cannot answer questions, and 
when she did answer them the simplest questions were wrongly inter- 
preted or wrong answers were given. The question as to whether true 
clonus is present in hysteria, is, according to the author, determined posi- 
tively in this case. 

3. Nasal Stigma of Degeneration.—Gudden pictures a patient with a 
defective development of the cartilage and tissue of the ale of the nose and 
considers it a stigma of degeneration. 


Vol. .227 Nose2,21003, January. 16.) 


1. Concerning Disturbances of Sideward Movements (Flank Gait) in 
Hemiplegics. v. Schuller. 

. Hedonal and the Nervous System. v. LAmMpPSAKow. 

. Autogenous Nerve Regeneration. A. BETHE. 

. Answer to No. 3. E. MUNZER. 

. Hysterical Confusion and Mental Aphasia. A. WESTPHAL. 


1. Concerning Disturbances of Sideward Movements (Flank Gait) 
in Hemiplegics.—The author says this is a new differential symptom for 
the diagnosis of organic hemiplegia from functional hemiplegia. It de- 
pends on the fact that a hemiplegic patient can walk sideways towards his 
palsied side with little or no difficulty, but on account of the spasticity and 
lengthening of the palsied leg, he has considerable difficulty in walking 
sidewise in the opposite direction, and must needs drag the paralyzed leg. 

2. Concerning the Action of Hedonal upon the Animal Economy.— 
V. Lampsakow gives the results of his psychological study of a new hyp- 
notic, hedonal. He finds that it is an active and harmless hypnotic: much 
stronger than urethan, without any disturbance of the heart or respiratory 
organs; that it can be given preparatory to the administration of chloro- 
form to facilitate narcosis; that it is more valuable as a hypnotic in anemic 
weak patients than chloral, and that it may be given by mouth or rectum, 
but cannot be administered hypodermically. 

3. Autogenous Nerve Regeneration—A. Bethe presents a_ contro- 
versial article with Miinzer concerning statements of the latter in a pre- 
vious article in this Centralblatt. 

4. Answer to No. 3 (Bethe) by E. Minzer. 

5. Concerning Hysterical Confusion and Mental Aphasia.—Westphal 
renders a medico-legal contribution to disturbances of memory in func- 


tional conditions and malingering of mental disturbances. 
McCartuy (Philadelphia). 


np w dN 


442 PERISCOPE. 


ALLGEMEINE ZEITSCHRIFT FUR PSYCHIATRIE. 
(Vol. LX, 1903, Heft. 1 and 2.) 


. On Ganser’s Symptom. LUCcKE. 

. Induced Insanity. F. Witte. 

. Cases of Simulation. Bo tte. 

Graudenz Penal Institution. SANDE. 

Contribution to Study of Paranoia. H. SCHNEIDER. 
. Conception of Hypochondria. A. Pick. 

. Exhibitionists before the Law. G. Burct. 

. Asylum at Strelitz. SERGER. 


1. On Ganser’s Symptom. Although not previously unknown, Ganser 
in 1897, called special attention to a peculiar condition in hysterical sub- 
jects, characterized especially by confusion, childish bearing and an ap- 
parent inability to answer simple questions as to names, dates, and other 
ordinary matters, or to recognize persons or objects formerly well known. 
Common among ‘those who have come into conflict with the law, the con- 
duct of these persons under examination may readily arouse a suspicion 
of simulation. In consequence of the presence of other definite symptoms. 
of hysteria, however, Ganser thinks the manifestation a genuine symptom- 
complex, and in this he is supported by other observers. The author dis- 
cusses this symptom and gives the histories of four illustrative cases. The 
matter he considers important on account of its medico-legal bearing, as 
the symptom is especially common in prisoners with hysterical mental 
disturbances. The diagnosis between this symptom and simulation upon 
the part of the patient, is to be made upon the presence of hysterical stig- 
mata, periodical attacks of anxiety, confusing of persons, and terrifying 
hallucinations, together with a characteristic stupid and at the same time 
tense expression of countenance, and generally confused appearance of the 
patient. The symptom has been described by Nissl as occurring in kata- 
tonia, but the author regards it as being due in these cases to a hysterical 
groundwork. 

2. Induced Insanity.—The histories of two cases, one that of a man 
of 59 years, presenting a typical example of paranoia with expansive and 
persecutory delusions, the other that of a woman of 51 years, of neuro- 
pathic constitution and heredity, and addicted to the abuse of alcohol, the 
housekeeper of the first patient. The second patient, in consequence of 
the troubles of her employer, being left without resources, began to drink 
more heavily than usual, and developed a psychosis of strongly alcoholic 
character, with hallucinations and delusions of persecution. Interned in 
the same asylum as her employer, the picture changed to one of paranoia 
with expansive and persecutory delusions, almost identical in character 
with those of the former. The author thinks that the influence of the 
stronger personality of the man, acting for years upon that of the weaker 
and less educated woman, already predisposed through neuropathic consti- 
tution and alcoholic indulgence, is responsible for the clinical developments 
in the case. 

3. Some Cases of Simulation.—Clinical histories of six cases of this 
character. Not suitable for abstraction. 

4. The New Insane Department of the Graudenz Penal Institution.— 
Not suitable for abstraction. 

5. A Contribution to the Study of Paranoia.—A clinical history ex- 
tending over the thirty-six years of life of a typical paranoiac, with a2 
lengthy discussion. 

6. On the Conception of Hypochondria.—The author thinks that hypo- 
chondriacal delusions are often built up upon a material basis. To illus- 
trate his views he gives histories of the cases of two middle aged women 
in each of whom gonorrheal trouble of the genital organs led to depression 
with persistent hypochondriacal delusions. One case was improved by local 


OI QANAPWH H 


PERISCOPE. A43 


treatment, but in the other the morbid ideas persisted in spite of subsi- 
dence of the genital disease. 

7. Exhibitiomsts before the Law.-—As adviser to the court the author 
has had occasion within four years to examine twenty-five persons accused 
of exposing their genital organs in public. He thinks that in the great ma- 
jority of cases this act is a manifestation of mental disorder. Each case 
he thinks should be considered under the following heads: (1) Is the act 
due to mental weakness? (2) To uncontrollable impulse? (3) Is it the 
result of an imperative conception (“Zwangshandlung”)? (4) An acci- 
dental occurrence? (5) Due to carelessness? (6) Is it the voluntary act 
of a mentally normal individual ? 

Under 1 he includes both congenital and acquired mental weakness. 
In these cases the act may be due to lack of ethical feeling, and of inhibi- 
tory contra-conceptions. It is observed in imbeciles of various grades, in 
paralytic and senile dementia, in epileptic delirium, after trauma, and in 
the pathological reaction to alcohol common in epileptics and neurotic sub- 
jects. 

(2) The cases due to uncontrollable impulse may result from sudden 
vivid hallucinations or delusions, and sometimes coming on from time to 
time appear to be a manifestation of periodical insanity (“periodical sexual 
psychopathy”). 

(3) The cases in which the act is the result of imperative conceptions, 
the author separates from those due to impulse. The presence of an im- 
perative conception alone does not necessarily make the patient legally 
irresponsible, but it may be accompanied by an effort of such intensity as 
to cause an obnubilation of consciousness, in which case self-control is 
lost and mental irresponsibility may ensue. 

(4) Exhibition may occur accidentally through forgetfulness about 
adjusting their clothing upon the part of weak-minded or mentally con- 
fused individuals. 

(5) Especially in old and feeble-minded persons there may be such 
carelessness as urinating or adjusting a truss in the street. 

(6) Lastly, exhibition may be deliberately practiced, generally under 
great sexual excitement, by mentally normal individuals, usually upon 
meeting one of the opposite sex in a lonely place. In each case an inquiry 
into all the circumstances of the case attending the misdeed should be 
made, and if possible the statement of the patient in his own language 
should be secured. By so doing the physician will often be able to detect 
gaps in the memory which indicate the presence at the time of some dis- 
turbance of consciousness (epilepsy?). Each case should be judged upon 
its merits. A history of repeated exhibitions, especially in a very public 
place before numerous witnesses, points almost unerringly to mental aber- 
ration. 

8. The Asylum at Strelitsz—Description of a newly erected building for 
180 patients. Unsuitable for abstraction. 

ALLEN (Trenton). 


BooR Reviews. 





INTERNAL SECRETIONS AND THE PRINCIPLES OF MEeEpIcINE. By CHARLES 
E. pe M. Sajous; M.D eVol. 11) llustrated> “Fo A. Davis) Co.) s1003. 
The first volume of this remarkable work contains eight hundred pages 

almost exclusively solid reading matter, the illustrations being chiefly 

upon plates. It is an attempt to arrive at new theories and principles re- 
garding certain obscure points in physiology, by a careful study of the 
observations and experiments of others. While it has generally been the 
practice of the world to accord the highest praise to the original investi- 
gator, it must not be forgotten that the man who organizes the mass of 
facts collected by others, puts them in an available form, and deduces 
from them new ideas regarding their essential relations, may contribute 
more to the actual advancement of knowledge than the accumulator. It 
must not be forgotten that the physicist, Young, takes his rank among the 
world’s great men although his actual laboratory work in physics was com- 
paratively insignificant; that Herbert Spencer has done much to mould 

English thought in biology, although he was not a great original inves- 

tigator. To those who can accomplish both—that is, collect the facts and 

analyze them, as did Darwin—highest rank in science is ever accorded. 

Dr. Sajous is the analyst. He has made, he believes, some valuable dis- 

coveries regarding the rdle of the adrenals and the pituitary body. Briefly 

stated, his theory is that the adrenal secretion poured into the blood en- 
dows the hemoglobin and the plasma with an affinity for oxygen, that the 
plasma carrying the oxygen then circulates among the tissues and ac- 
complishes the internal respiration. This function gives the internal secre- 
tion of the adrenals an overwhelming importance. The adrenal glands are 
controlled by the anterior portion of the pituitary body, and the functional 
efficiency of this is in turn sustained by the secretion of the thyroid gland. 

These views are sufficiently novel; the question arises: What claim 
have they to our credence? The first chapter deals with the physiology 
of the adrenal glands. To us the conclusions in many cases appear to be 
strained. The proof offered is inadequate. The experimental material is 
obviously carefully selected, but even then does not suffice to confirm the 
deductions. Take, for example, the section on the physiological effects of 
poisons, in which the facts are stated by the investigators entirely without 
reference to the adrenal glands, and yet changes are explained by Sajous 
with reference to these organs. Take, for example, the relation of the 
adrenal glands to chlorosis: the conclusions must appear to any clinician 
to be forced. Of course the reviewer must guard against too general 
condemnation of any strikingly revolutionary hypothesis, and it is impos- 
sible to give an adequate analysis of the book in the brief space allotted 
to this review. There is one point, however, to which we feel that atten- 
tion should be called, that is the statement that the posterior pituitary 

body is the chief center of the nervous system to which the afferent im- 

pulses go and from which the efferent impulses arise, so that it practically 

governs the brain. To one who has studied the histology of this organ 
it seems incredible that a mass so scantily furnished with cells or nerve 
fibers could possibly accomplish all that is ascribed to it. If its embry- 
ology is studied it appears more than reasonable to assume that it, like the 
pineal gland, is a relic of a former organ, and comparative anatomy lends 
color to this view. What then, has Dr. Sajous to offer against it? Very 
little indeed: Its position, which we admit is central enough; the fact 
that injections of its substance are said to increase the blood pressure; and 


BOOK REVIEWS. 445. 


the fact that Berkeley’s investigations have shown that it actually does 
contain parts of neurones. 
Perhaps we have been rather harsh with this book, but we feel that 
Dr. Sajous has not made out an entirely good case for the plaintiff.. 
Nevertheless, it is well written, indicates a vast amount of industry, 
and is exceedingly suggestive. The publishers have done their part well. 
SAILER. 


A SysTEM oF PuysioLocic THERAPEUTICS. Edited by Sotomon So is. 
CoHEN, A.M., M.D., Senior Assistant Professor of Clinical Medi- 
cine in Jefferson Medical College, etc. Vor. V, PropHyLaxis, PEr- 
SONAL HYGIENE, Civic HYGIENE, CARE OF THE SICK, by JosEPH McFar- 
LAND, M.D., Professor of Pathology, Medico-Chirurgical College, 
Philadelphia; HENry LrerrFMANN, M.D., Professor of Chemistry in 
the Woman’s Medical College, Philadelphia; ALserr Axsrams, A.M., 
M.D., formerly Professor of Pathology Cooper Medical College, San 
Francisco, and W. Wayne Bascocx, M.D., Lecturer on Pathology 
and Bacteriology, Medico-Chirurgical College, Philadelphia.  Illus- 
trated. Vor. VI, DiETOTHERAPY and Foop IN HEALTH, by NATHAN S. 
Davis, Jr., A.M., M.D., Professor of the Principles and Practice of 
Medicine in Northwestern University Medical School; Physician to 
Mercy Hospital and Wesley Hospital, Chicago. Philadelphia, P. 
Blakiston’s Son & Company. 

In the preface of Volume V of this series we read, “The following 
pages contain an epitome of what is essentially the natural history of 
medicine.’ Such is the broad scope adopted by the editor, who takes a 
special pleasure in this volume “because of his success in having the sub- 
ject of prophylaxis brought into close relation with that of treatment at 
so many points. The artificial conditions of civilization, the diversity, com- 
plexity and strenuosity of the activities of modern life, the reciprocal influ- 
ence of individuals upon communities and of communities upon individ- 
uals render it necessary in a work of this kind to consider problems in 
economics, engineering, manufacturing, architecture, pedagogics, commer- 
cial intercourse, taxation, municipal government, etc. These have been 
brought together and studied in their bearing upon the subject and on each 
other, and are placed before the reader in as concise form as would seem 
possible. The bacteriology of the infectious diseases, the distribution of 
animal parasites, and the whole subject of the spread of disease by insects 
and other agencies form very important portions of the book. The care 
of the sick-room is discussed from the physician’s point of view as a 
worthy department of therapeutics. The recent theories of immunity, 
artificial defences against disease, hygiene in cities, disposal of waste, dis- 
posal of the dead, hygiene of women at special periods, care of patient,. 
and special nursing are headings which indicate some of the contents; but 
in a limited review of this many-sided treatise it is impossible to dwell 
upon the subject-matter in any details. Suffice it to say that we believe 
this to be one of those books which belong in the library of every 
physician. 

In Volume VI we have a treatise on Foods, and as this subject has 
been dealt with by numerous authors, this addition to the list demands 
less notice from the reviewer than does the preceding volume of the 
series. The consideration of diet is not merely a question of how to feed 
the sick, but also of what is proper feeding for those who are in health; 
and this prophylactic phase of the subject is not forgotten by the author. 
In a food the chemical composition is important, but it does not indicate 
the suitability or unsuitability of that food for human consumption. The 
author, therefore, after describing the chemical nature of the fundamental 
food-bodies and their transformation in digestion, proceeds to determine 
which of these enter into the composition of the various food-stuffs 
(eggs, cereals, meat, etc.), and by what means and to what extent food- 


446 BOOK REVIEWS. 


stuffs are rendered wholesome. First the diet in health at different pe- 
riods of life, infant feeding, the diet of brain-workers, and the ill effects 
of food are given detailed treatment; then follow chapters on the feeding 
of the sick in the different infectious diseases, diseases of the blood, kid- 
neys, digestion, circulation, etc. A chapter is devoted to feeding in ner- 
vous diseases, and includes diet-tables for neurasthenia and epilepsy. Un- 
doubtedly the book is a mine of information about all the ordinary foods 
and their modifications, with their uses in health and disease, and even 
the subject of rectal feeding is not neglected. Each of the volumes in 
this series so far published 1s authoritative in its particular field, and the 
editor is to be congratulated on his choice of contributors. 
W. A. BASTEDO. 


MepicaLt Microscopy, designed for students in laboratory work and for 
practitioners, by T. E. Orertet, M.D., Professor of Histology, Pathol- 
ogy, Bacteriology and Clinical Microscopy, Medical Department, 
University of Georgia. With 131 illustrations. Philadelphia. P. 
Blakiston’s Son & Co. . 1902. 

Microscopy is a new and growing science in which those who grad- 
uated more than a decade ago received for the most part but scanty in- 
struction. But the more complete works on the subject offer a bewildering 
mass of material from which it is difficult for the unskilled to cull what 
will be of service to him. This has been kept in mind in the compilation 
of this treatise, and where possible the simpler processes have been chosen, 
and usually but one method given whereby to reach a certain result. 
The choice of material has been excellent, sufficient details being 
included to enable even a novice to fix, section and_ stain tis- 
sues, to prepare bacterial cultures or slides, to stain the blood 
or count its corpuscles, to determine the tubercle or other bacilli in 
the sputum, and to appreciate the significance of sediments in urine. The 
saliva, stomach contents, feces, vaginal secretions, etc., are not dwelt upon 
at length. The many illustrations, some of which are colored, are an im- 
portant addition to the text; a few of thé micro-photographs, however, 
would be unrecognizable without their labels. We can recommend this 
book as a practical guide not only to the uninstructed but also to those 
who have had their course in microscopical studies. W. A. BAsTEDO.— 


Hews and Wotes. 


THE STEVENS’ TRIENNIAL PrizE of Columbia University for original 
research was awarded to Doctors L. Pierce Clark and Thomas P. Prout of 
New York upon “Status Epilepticus: A Clinical and Pathological Study 
of Epilepsy.” 

A USEFUL WoRK on diagnosis—Hill’s Reference Chart, noted in our 
advertising pages, is a very handy little volume on diseases of the nervous 
system and of the muscles. It will be found particularly serviceable to 
those interested in nervous diseases. Write to the publishers for a copy. 
See page xxix of our advertising forms. 

PATHOLOGIST AT CrAIG CoLtony.—Dr. B. Onuf has been appointed resi- 
dent pathologist at the Craig Colony for Epileptics at Sonyea, N. Y. 

Dr. Onuf is a graduate of Zurich, Switzerland. He acted for two years 
as assistant to Prof. Forel at the Insane Hospital Burghoelzli at Zurich, 
afterwards devoting eight months to the study of ophthalmology with Prof. 
Haab in Zurich. Later he located in Brooklyn, N. Y., where he began to 
devote himself to neurology. He was affiliated with Dr. Sachs’ clinic in 
New York for a number of years, and later with the nervous clinic at Long 
Island College, where he gave clinical and didactic instruction to the 
students. He served as neurologist to St. Catherine’s Hospital and con- 
sulting neurologist of the dispensary of the Jewish Hospital in Brooklyn. 
From 1896 to 1902 he was associate in pathology at the Pathological Insti- 
tute of the New York State Hospitals. 

Among his scientific contributions may be mentioned a monograph writ- 
ten in conjunction with Dr. Joseph Collins, entitled “Experimental Re- 
searches on the Central Localization of the Sympathetic with a Critical 
Review of its Anatomy and Physiology.” 

In selecting a pathologist for the colony, the chief aim was to utilize 
the unusual opportunities given at the colony for studying the causes of 
epilepsy. The work is to be not only pathological but also clinical, and it 
is from this combination that fruitful results are hoped for. 

RECENT Procress IN MATTERS PERTAINING TO THE CARE OF THE INSANE 
IN THE STATE OF NEw YorkK.—Some of the measures of improvement in 
the care of the insane of the State of New York carried through during 
the past few months by the Lunacy Commission are as follows: 

1. The Pathological Institute has been reorganized and more than sixty 
of the medical men connected with the staffs of the fourteen State hospitals 
have been instructed during the past winter at the Institute on Ward’s 
Island in the recent development of psychiatry along clinical, pathological, 
psychological and clinical lines. The legislative appropriation for the 
Institute is now $25,000 annually. 

2. The hospitals have been opened to medical internes in the same 
manner as general hospitals. Last year sixteen clinical assistants entered 
the service in this way, and this year the number is nearer thirty. 

3. The legislature recently passed the Lunacy Commission’s bill for 
the appointment of a medical inspector to ensure a more thorough inspec- 
tion of the thirty-nine institutions under its charge, viz.: 23 private retreats, 
2 criminal asylums, and 14 State hospitals for the insane. Such inspection, 
especially of the private asylums, in which there are about 1,000 patients, 
has never been adequate. 

4. To remedy overcrowding the Lunacy Commission proposes to con- 
struct a new hospital in the territory north of Albany and Troy on the 
colony system—a scheme similar to that of the Craig Colony for epileptics 
will be carried out. The site will be selected and plans made this year. 


448 NEWS AND NOTES 


This colony for 1,500 to 2,000 patients should be ready inside of three years. 
5. Three tuberculosis hospitals, each with a hundred beds, will be con- 
structed this summer at a cost of $90,000 at Middletown, Utica and Bing- 
hamton, on the grounds of the State hospitals located there; and the plans 
made by Dr. Peterson and the State architect embody the main features 
of such hospitals described in the King Edward Prize Essays. In the 
meantime tent life for the tuberculous insane has been in vogue at the 
Manhattan State Hospital East (under Dr. Macdonald) for two or three 
years and for a shorter time at Binghamton and other of the State hospitals. 
6. The country colony for a few of the working classes of the insane, 
as an offshoot of the Utica State Hospital, has been enlarged. A similar 
colony has been established at the Willard State Hospital, and two are in 
existence at the State Hospitals at Binghamton and Poughkeepsie. 

7. A new departure this year is the creation of a summer camp for 
between 40 and 60 insane on the lake shore, about fifteen miles from the 
Rochester State Hospital, which is now in operation to the great delight 
of both patients and attendants. 

8. The feature of nurses’ homes having been found so useful at some 
of the hospitals two additional ones will be put up this summer, one at 
Kings Park State Hospital, -Long Island, for 300 nurses, and one at the 
Gowanda State Hospital for 100. 

go. Six or seven residences for superintendents and separate houses 
for the medical staffs will be put up this season at as many of the State 
hospitals, thus removing the officials from the central main buildings and 
utilizing the vacated space for patients. 

10. A bill providing for emergency commitments, recommended by the 
Lunacy Commission, was passed by the legislature at the last session. 
Copies of this law have been sent to all examiners in lunacy of the State. 
It is believed that this will mean great good to the insane and prevent the 
all too frequent incarceration of urgent cases in jails and station houses. 

tI. The improved ration brought about during the past six or eight 
months, though entailing an additional cost to the State of a hundred 
thousand dollars per year or more, has added greatly to the comfort of the 
patients and to the satisfaction of the medical officials and various visiting 
boards. 

12. A strong effort is being made by the Lunacy Commission to increase 
the number of deportations of alien insane, and through the efforts of New 
York State the federal government passed a law making the limit three 
years instead of one; i. e., an immigrant becoming insane within three years 
after landing in the United States may be returned to his own country. 

13. The movement for the establishment of reception hospitals for 
acute curable cases in the large cities has gained strength. While the bill 
for the psychopathic hospital for New York city, which was to be the first 
of several such reception hospitals, failed to pass this year, it is believed 
that success will attend the Commission’s efforts during the coming session. 


Volume 30. August, 1903. No. 8 


= 





THE 


Journal 


OF 


Nervous and Mental Disease 


Original Articles. 


MYOCLONUS MULTIPLEX AND THE MYOCLONIAS; REPORT 
OF CASES AND AN ATTEMPT AT CLASSIFICATION. 


By Cwar.es L. Dana, M.D., 
PROFESSOR OF NERVOUS DISEASES, CORNELL UNIVERSITY MEDICAL COLLEGE. 
iN. 

Myoclonia is a general term covering all the diseases in which 
myoclonus or muscle-twitching is a prominent symptom. This is 
the definition of Foster’s Dictionary, and the use of the word in 
this general sense is the proper one. It has, however, been used 
by Seeligmuller (1887) to indicate the same thing as paramyoclo- 
nus multiplex, and Unverricht used it (1891) in about the same 
way. 

Friedreich reported his case of paramyoclonus multiplex in 
Virchow’s Archivs, Vol. 86, 1891. During the ten years fol- 
lowing a number of cases which were more or less like his were 
put on record. When Unverricht published his ‘‘Myoclonia” 
(1891), he recognized that his cases were different from those of 
Friedreich, and he separated them into a group, called the “fa- 
milial myoclonias.” Following Unverricht, there came reports of 
a number of cases of myoclonia, some of which resembled this 
“familial” type, and some, more or less (rather less than more), 
the original case of Friedreich. The history of these is given in 
the monograph of Lundborg: “Ueber Degeneration und degen- 
erierte Geschlechter in Schweden,”’ published in 1891, and the 
more recent monograph of Clark and Prout, American Journal 


450 CHARLES L. DANA 


of Insanity, No. 2, 1902. The criticisms upon these various pa- 
pers indicated different views. Thus Wollenberg and Boettiger 
concluded that the Friedreich type of case belonged to hysteria, 
and that there really was no such independent disorder as para- 
myoclonus. The “familial” type of Unverricht was thought to 
belong to the “degenerative chorea” of Huntington. In this view 
Moebius coincided. Schultz, on the other hand, placed the Fried- 
reich type amongst the forms of convulsive tic and the Unverricht 
type amongst the degenerative choreas. Marie was of the opin- 
ion that paramyoclonus is a special disorder, and with this view 
Oppenheim, Bechterew and Strumpell appear to agree. 

The view which I entertain differs somewhat from any of 
those expressed heretofore, though it is most in harmony with 
that of Schultz. It seems to me that the cases which were most 
in harmony with [riedreich’s original case, belong to the group 
of myokymias, or mneuro-muscular spasms without special 
locomotor effect. and are spasms dependent upon a _ dis- 
turbance of the peripheral motor neurones. There are certainly 
groups of cases of this kind, as is shown by those recently re- 
ported by Hunt'. Most of the other cases reported as paramyo- 
clonus belong to the category of hysteria, or functional neuroses. 
or to convulsive tics. The “familial group” of myoclonias de- 
scribed by Unverricht and Lundborg seem to me to belong cer- 
tainly to the degenerative choreas, though they are pretty widely 
separated, as a rule, from the ordinary group of Huntington’s 
chorea, being much more severe in their manifestations, and rapid 
in their course. 

A further discussion of the reasons for this grouping will be 
given later. 

The following cases illustrate four different groups or types 
of myoclonia. 

1. Myoclonia of the spinal and peripheral type, including my- 
okymia, fibrillary myoclonus of Kny, and Friedreich’s paramyo- 
clonus multiplex. 

2. Myoclonia of functional and hysterical type. 

3. Myoclonia of the convulsive tic type. 

4. Myoclonia of degenerative chorea and epilepsy. (Myoclo- 
uus-epilepsy, myoclonia of family type.) 


1 
Hunt: Journat or Nervous AND MENTAL DISEASE, June, 1903. 


MYOCLONUS MULTIPLEX 451 


Personal Cases. Case 1—Myokynua and myoclonus (para- 
myoclonus of Friedreich). The following case showed very 
typically the phenomena of myokymia, with at times myoclonia 
and myotonic contractions with locomotor effect, irregularly dis- 
tributed and involving muscles not under voluntary control. It is 
a case resembling in many ways that of Friedreich’s, though the 
dominant feature was the myokymia, and resembles in this more 
the fibrillary myoclonus of Kny. 


Summary.——-Male, 23, workman, family and personal history 
negative. At 22 had twitchings of muscles, and painful 
spasms of legs and arms. Improved, but twitchings never en- 
tirely left him; cramps ceased recently. Entered hospital for 
general weakness, and diffuse pains in bones of legs, pelvis and 
head. No objective signs of any organic disease. Muscles of 
all parts of body in continual play of fascicular and fibrillary 
spasm, causing irregular tremor in fingers and toes, and some- 
times locomotor effect of finger and leg. Fascicular spasm in 
thighs increases and culminates in myoclonus and myotonus of 
one or both hamstring muscles. Similar myoclonus in biceps. 
No painful spasm now. 


Male, aged twenty-three years, single, Slav, was brought to 
Bellevue Hospital, complaining of pains in the legs and arms, and 
great general weakness. He stated that one year ago he had had 
a severe attack of pains which were called rheumatic. He at that 
time had also muscular contractions such as were still present and 
had had at times “‘cramp-like” contractions of the muscles of the 
legs and arms. He improved, but continued to have at times 
cramps, pain, and muscular twitchings. Of late this condition 
had grown worse. The patient was brought to the hospital, com- 
plaining of weakness and pains in the legs, thighs and head. He 
was a rather small man, somewhat emaciated, but with fairly 
good muscular development. His body was covered with a fine 
eruption which was found to be due to scabies. 

As the patient lay in bed fine fibrillary spasms could be seen 
playing over nearly all the muscles of the body. They were very 
exquisitely marked in the face, where they affected especially the 
small muscles, such as the buccal, risorius, and nasal. The con- 
tractions were not very frequent, not more than one or two being 
seen at a time, and they occurred in single “flashes,” jumping 
from one spot to another, they affected the two sides about 
equally. No general metor effect resulted. Similar phenomena 


452 CHARLES L. DANA 


occurred in the forearms and in the intrinsic muscles of the 
hands, the lumbricals and interossei. Here they recurred fre- 
quently, causing slight locomotor effect and a condition like a 
fine tremor, only the fingers were also irregularly flexed, 
abducted and adducted. When the long flexors were involved 
the fingers were rhythmically flexed a trifle, the movement some- 
times running into a tonus with contraction of the fingers. The 
movements occurred in the forearms, arms, shoulders, pectoral, 
abdominal and posterior trunk muscles; here they were more 
violent, but were less frequent and caused no locomotor ef- 
fect, except that occasionally the biceps would move the fore- 
arm. The calves and intrinsic muscles of the toes were affected 
just as were the upper extremities. On making the patient lie on 
his face the movements could be seen most strikingly of all in the 
muscles of the calf, posterior part of the thigh, and in the but- 
tocks. Here then were frequent fibrillary contractions and also 
wave-like contractions running along the muscle from center to 
periphery. On flexing the leg at right angles to the thigh, the in- 
ner hamstring muscles would begin to contract more vigorously 
and finally ended in a distinct myoclonus or more often in a tonic 
contraction which held the leg flexed for several seconds. The same 
thing occurred in the outer hamstring muscles and sometimes in 
both, holding the leg in flexion. Thus there were here fibrillary 
contractions, wave-contractions, finally ending in a distinct clonic 
or tonic contraction of the whole muscle, sometimes with loco- 
motor effect. The phenomenon occurred in muscles such as the 
inner hamstring, not under direct voluntary control. The con- 
tractions could be brought out by manipulating the leg, and by 
blows of the hammer. They were unaccompanied with pain, and 
the flickering spasms occurred at times 40 to 60 times a minute. 
The myoclonus and myotonus were observed only when the leg 
was flexed and the muscles relaxed. A similar condition but 
much less marked was present in the biceps. The myokymia 
continued during sleep. There was no atrophy, contracture or 
paralysis. The general muscular irritability was much increased and 
immense myoid tremors could everywhere be easily produced. The 
electric reactions were not tested. The muscular power was fairly 
good. The deep and skin reflexes were normal. There was no 
sensory disturbance of any kind. The special senses were nor- 
mal. He had no stigmata of hysteria. The patient complained 
of general pains, which seemed to be mainly in the bones. There 
was no tenderness or swelling of joints or muscles. His mind at 
first seemed at times confused. He presented no objective symp- 
toms of any visual disorder, or of disease of the central nervous 
system. The blood and urine were normal, eosinophiles normal. 
He could walk, but his weakness kept him in bed. He improved 


MYOCLONUS MULTIPLEX 453 


and the eruption grew less under mercurial treatment, but the 
muscular phenomena were unchanged. 

Taking the whole history of the case it will be seen that he 
had painful cramps as in Friedreich’s case, clonic twitchings of 
the muscles of the thighs and arms, not of the peripheral seg- 
ments, muscular contractions of the whole body of a muscle, 
sometimes with and sometimes without locomotor effect, and 
that muscles were affected not under voluntary control. In all 
these respects, the phenomena were like those of Friedreich’s 
case, but in addition he had a widespread and remarkable myo- 
kymia, involving nearly all the muscles. The spasms could not 
have been of cerebral origin, certainly not cortical, and it seems 
to me that the seat of the trouble must be either in the spinal 
cord or peripheral motor neurone,—which is the pathology attri- 
buted by Friedreich to his case. 

It shows a close relation between ordinary myokymia and 
the severer types of bundle clonus, to which the term paramyo- 
clonus multiplex, if used at all, should be applied. 


Case 2.—Paroxysmal myoclonus of functional (hysterical 
and family type. Sunmmary.—Male, aged forty-two; mother 
suffered from similar attacks. Healthy till the age of eleven 
years, when he was kicked in the head by a horse. One month 
later seizures began, which have lasted thirty-one years, gradually 
lessening in severity. Seizures come on in groups of short at- 
tacks lasting one to five days. Seizures are characterized by 
some fibrillary tremor, irregular clonic movements, tonic con- 
tractions with and without locomotor effect and violent rhyth- 
mical movements affecting the face, neck, shoulder and arm mus- 
cles and, to some extent, the legs. Muscles of the back are some- 
times involved. The muscles involved are symmetrical but not 
synchronous in their clonic movements. 





E. P. B., single, farmer, aged forty-two. Father healthy but 
of nervous temperament; no phthisis or inebriety, no nervous or 
mental disease in family. His mother was a healthy woman but 
during her pregnancy she had attacks of muscular twitchings 
and jerkings known as “shaking spells.”” These came on period- 
ically during the day and even interfered with her sleep. They 
occurred in the latter part of the pregnancy during which she 
was carrying the patient. After the birth of the child the attacks 
disappeared. The patient had one healthy sister and lost one sis- 
ter when she was a baby. He was perfectly healthy until his 
eleventh year. He was then kicked on the left side of the face by 


‘454 CHARLES L. DANA 


a horse and knocked down, and remained unconscious for three- 
quarters of an hour. About one month later while sitting quietly 
‘in the house he had the first attack of his spasmodic trouble. 
These attacks would last with intermissions for twenty-four 
hours, beginning in the night sometimes and lasting till the next 
night. He would then go for a few days or a week without any, 
then they would come on again. At times he would have them 
with short intermissions of a day or two, all one summer, then 
they would go away for some weeks, then return again. His 
trouble continued in this way with various remissions till first 
seen by me, when he was thirty-four years old, at which time he 
had had the attacks for twenty-three years. During all this time 
he had no epileptic attacks and nothing resembling epilepsy. He 
had managed to get his education and attend to his work as a 
dairyman, spending some time occasionally at sanitariums for 
treatment. 

The year before | saw him he had had an attack of sciatica 
affecting both legs. This lasted for a month. He had a second 
attack about four months before I saw him which had lasted all 
summer. Qn account of the pains in the legs and the other at- 
tacks, he had lost weight, being reduced from 158 to 105 pounds. 

When first seen by me at my office he was not having the at- 
tacks, and presented the appearance of a nervous, rather anemic 
and badly nourished man. There was no objective trouble with 
the muscular system, though the muscles were rather poorly de- 
veloped. There was some tremor of the hands, rather more in the 
right, and a little tremor in the legs. The dynamometer showed 
30 for right and left hands. There was some fibrillary twitching 
of the muscles of the back. The skin reflexes were exaggerated. 
The deep reflexes were normal. There was no disorder in the 
sensory sphere, the special senses were normal. He had no anes- 
thesia nor ataxia. Bladder and sexual organs were normal. 

When the attack came on he was seized with certain rhyth- 
mical movements of the head; the hands would shake rhythmi- 
cally, also the feet, and the lids would quiver. The muscles of 
‘tthe trunk were not involved, but the muscles of the back of the 
neck would contract and harden, pulling the head back slightly in 
‘clonic twitches. When called to see him in one attack at night I 
found his head moving rapidly antero-posteriorly. Also his arms 
would be shaken to and fro, but not synchronously, one arm 
would move more than the other. The trunk and leg muscles did 
‘not at that time move very much, though his eyes would: blink 
and his feet and legs would be twitched in irregular clonic move- 
ments. He had no pain. The spells would last half a minute. 
then recur every minute or two, and in this way they would go on 
for one to five days. They would keep him from sleeping, un- 


MYOCLONUS MULTIPLEX 455 


less he took some narcotic, then he would go to sleep and the at- 
tack would cease. During an attack there was considerable pal- 
‘pitation of the heart, he perspired profusely after the attacks and 
they would leave him exhausted. Consciousness was never dis- 
turbed. | 

The muscular movements of these attacks, therefore, con- 
sisted of violent tremors, tonic contractions: of the body muscles 
without motor effect, clonic contractions irregular in distribu- 
tion and fibrillary contractions of the body of the muscle which 
could be observed in between the attacks as well as in the most 
violent, to precede them. The attacks would occur in short in- 
‘termissions, every half minute or so, and would last several 
minutes, and this would go on for from one to five days. These 
groups of attacks would thus recur every few days, sometimes 
every week or two, and sometimes intermit for several months. 

The patient was not improved by the various measures em- 
ployed by me, including hyoscine, hypnotics and_ tonics. 
He was hypnotized five times, without any special benefit. He 
was under my observation for one month. He then disappeared, 
and I heard nothing from him till a short time ago, five years af- 
ter my first observation, when he wrote me that his general 
health was excellent and the nervous trouble very much milder, 
so that when the attacks came on he practically suffered little 
He states that when they come on he goes to bed, as he is more 
comfortable there, and passes the time reading until they are 
over. He had had no epilepsy or hysteria. He is satisfied that it is 
a family disorder and accepts his affliction philosophically. 


Case 3.—Myoclonia of convulsive tic type. Summary.—Male, 
aged forty, no heredity. Abscess of thyroid following typhoid 
fever; soon after developed clonic, tonic and fibrillary spasms, 
mainly clonic, affecting first and mostly muscles of abdomen, 
back and neck; less, those of face, and of forearm; least, those 
of lower extremities; cease during sleep; no pain; spasms are 
mostly codrdinate, causing grimaces, wry-neck, movements of 
shoulders and trunk, isolated muscle spasm without locomotor ef- 
fect, fibrillary and fascicular spasm not marked. Is able to walk 
and use his hands in delicate work. Spasms vary in intensity 
without absolute cessation. In four years has gradually im- 
proved. No organic disease, general health fair; no epilepsy, 
mental condition good. 


R. M., aged forty years, traveling salesman', The family 


*Notes are by Dr. Joseph Fraenkel and myself. 


456 CHARLES L. DANA 


history is negative and there is in particular no evidence of dis- 
ease of the nervous or muscular system in the ancestry. Except 
for the usual diseases of childhood the patient has been well all 
his life. He denies venereal infections and has been a man of 
moderate habits. In November, 1896, he had typhoid fever, 
which kept him in bed for six weeks. The disease ran a mild 
course without serious complications. During its course, how- 
ever, a swelling over the thyroid region began to form, which be- 
came an abscess. Fight weeks afterwards this abscess broke 
spontaneously, discharging pus. At the same time the right 
lower extremity became “awkward and lame,” and the patient 
began to stoop. Shortly afterward he began to have what he 
called “spasms in the stomach.” He was treated with hyoscya- 
min for this. Slowly the spasmodic discharges began to spread, 
and by March, 1897, they were very general. In May, 1897, 
he was treated with thyroid extract, and he says that he was de- 
lirious and out of his mind for four weeks. In August, 1897, 
another tumor of the size of an egg began to form in the thy- 
roid gland, in the location of the previous one. This tumefaction 
was removed by Dr. Lilienthal, on October 5, 1897. According 
to a report received from the Mt. Sinai Hospital this tumor was 
a thyroid cyst. After leaving the hospital the patient says he 
was well and free from spasms for a period of ten days. They 
then returned and became continuous, so that he was admitted in 
August, 1898, to the Montefiore Home, having been ill for over 
one and a half years. During this time, the spasms, which began 
in the arms and abdominal muscles, had become generalized. The 
muscles of the tongue, face, throat and neck had become involved. 
He would thrust out his tongue and grimace, as in tic, or would 
throw his head back or twist it to one side, as in wry-neck. He 
had no pain at any time. Immediately after getting up in the 
morning the spasms were comparatively slight, but they increased 
in intensity and reached the climax about four o’clock in the after- 
noon. Upon going to bed the patient was compelled to take a 
hypodermic injection of gr. 1-100 hyoscine, and then had a good 
night’s rest. Still at no time of the day, except when he was 
asleep, did the spasms cease entirely. They were worse when he 
was excited, and were mildest when he was quietly occupied. He 
was able to shave himself and to do various kinds of dexterous 
work with his hands. 

Status praesens.—Patient is of medium size, rather poorly 
nourished, and his skin shows various tattooed figures. He is 
otherwise free from scars, except a small one over the thyroid re- 
gion, slightly adherent to the deeper tissues. The skin is of a 
dirty hue and not very elastic. The muscles are fairly well de- 
veloped; there are no localized or individual hypertrophies ap- 


MYOCLONUS MULTIPLEX 457 


parent ; the muscles are, on the contrary, when not agitated by the 
spasms, rather flabby and hypotonic. The usual attitude of the 
patient is a bending forward one, amounting at times almost to a 
complete doubling up of the body. The head is bent forward 
to the left and the chin turned to the right. When walking the 
attitude is the same. He seems to be drawn to the left and shows 
a sort of left-sided latero-pulsion. It is very difficult for him to 
assume the erect posture on account of spasms of the abdominal 
muscles, and attempts increase the spasms. 

Temperature 9912 (by mouth); pulse between 130 and 150; 
pulse is soft, volume rather small; respiration varies from 12 to 
18, the rhythm and vigor being constantly interfered with by 
the spasms. : 

The thoracic and abdominal viscera are normal. 

When the patient is observed, while sitting quietly on the 
chair, there is a ceaseless and varying play of muscular spasms. 
These spasms both affect individual muscles and physiologically 
connected muscle groups, and are essentially clonic, run- 
ning often into a tonus. The muscles of the trunk, neck 
and face are affected most. The contractions of the extrem- 
ities are very much less than those of the rest of the body and the 
upper extremities show more violent and frequent spasms than 
the lower; in fact, the lower extremities are, but for the occa- 
sional clonic spasms in the quadriceps, almost entirely free; in the 
upper extremities the muscles nearest the shoulder joint are af- 
fected most. The muscles of deglutition and mastication are also 
affected. There is frequent grinding of the teeth, and swallowing 
is sometimes interfered with, morsels dropping out of the mouth 
and fluid passing through the nostrils. There are at times noisy 
and irregular respirations, due to spasms of the diaphragm. Af- 
ter a number of these severe spasms the patient is covered with 
perspiration and is considerably exhausted. The frequency of 
the spasms varies from 10 to 60 per minute. 

In the psychical sphere it is noteworthy that the patient cries 
easily ; otherwise no defects are apparent. 

Cranial nerves, special senses, gross motor power and cuta- 
neous sensibility are absolutely undisturbed. 

Pupillary and skin reflexes are good; tendon reflexes of mod- 
erate intensity and easily demonstrative when free from spas- 
modic contraction. Rectal and vesical sphincters are normal} 
the patient states, however, that he is unable to urinate except 
when he is sitting down, and that the spasms cease entirely dur- 
ing defecation and micturition. 

The sexual functions are normal. The electrical excitability 
of muscles and nerves is rather increased, the direct stimulation 


458 CHARLES L. DANA 


-of the muscles is easily exhaustible. The mechanical irritability 
-of muscles is slightly increased. 

A second examination was made three months later. There 
1s now a persistent tonic spasm of the abdominal muscles which 
‘holds: the patient in a stooping position. The recti mus- 
cles are thus contracted nearly all the time. They relax only 
during sleep and for short periods during the day. The pectoral 
muscles show frequent, bilateral clonic twitchings, at times at the 
rate of about 50 a minute. Choreic, irregular, not bilateral twitch- 
ings are seen from time to time in the muscles of the arms; there 
is here and there a twitching of the biceps and triceps muscles 
alone, particularly on the left side. The platysma myoides shows 
clonic twitchings on the right or left side, but not simultaneous- 
ly. The right sterno-cleido-mastoid muscle and upper trapezius 
undergo clonic twitchings and tonic spasm, pulling the head to 
the left, as in wry-neck. Similar spasms of the left sterno-cleido- 
mastoid muscle frequently occur, turning the head to the right. 

On the whole, the left spinal accessory nerve is more affected 
than the right, and the spasms are more tonic on this side. Clo- 
nic tonic bilateral facial spasms producing prolonged (1.e., for 
two seconds) grimace occur, and along with them there occur 
irregular clonic contractions involving the tongue and_ face 
muscles. 

The patient used to grind the teeth when asleep, but now there 
is a continual grinding of the teeth and smacking of the lips, as in 
forms of tic and chorea. There is no nystagmus or disturbance 
of ocular muscles. 

The gluteal muscles go from a state of wavy, fibrillary twitch- 
ing into a tonic spasm when the patient is put on his back (See 
Case 1), while the irregular choreic contractions of the lower ex- 
tremities occur at the same time. To mechanical irritation most 
of the muscles respond with myoid tremor. 

Third examination, June, 1900, three and one-half years after 
the onset of the disease: 

The patient’s condition is somewhat improved. Still he is 
in almost constant movement. The spasms continue to affect 
chiefly the musculature of the neck, shoulders and upper arms, 
and trunk, the lower extremities being comparatively free; the 
deep muscles of the back are not affected as much as at the last 
examination. The number of convulsions per minute is variable. 
the finer fibrillary contractions occurring as high as forty; the 
coarser grosser movements occur as high as ten per minute. 

The spasms are mostly clonic in character, but also fibrillary 
and tonic. These movements result in the flexion and extension 
of the forearms, abduction and elevation of the arms, a flexion of 
head on thorax, and very slight flexion of trunk on thighs. The 


MYOCLONUS MULTIPLEX 459 


peripheral portions of all four extremities are least affected, the 
movements being greatest in the upper thoracic portions of the 
body and neck. The diaphragm is still irregularly affected, caus- 
ing irregular breathing, and to some extent the speech, patient 
breathing and speaking in intervals. The movements are to 
some extent symmetrical as to muscles involved, yet not as to 
time of involvement. Contractions occur irregularly, affect the 
biceps, then jump to fingers, then to head, then to forearms. They 
affect usually coordinate groups of muscles, but also individual 
muscles. [ibrillary twitchings, involving very small limited por- 
tions of muscle, and twitching of distinct muscle bundles are 
seen, the rest of the muscle being apparently at rest. The move- 
ments of patient are well nigh continuous under observation, 
though when unobserved distinct intervals of quiet are apparent, 
though even then fibrillary contractions are evident. 

Effect of position upon movements.—Recumbent posture di- 
minishes movements of trunk, but to a less extent other move- 
ments. 

Standing increases markedly movements of trunk and some: 
what the movements of legs. 

Noteworthy that muscles most concerned in standing are least 
affected, but upper extremities are threshed wildly about. 

Standing on one foot possible for a length of time, equal to 
that possible to a normal person. 

Standing with eyes closed, feet together is normal. 

Fixation of attention steadies the spasm. 

Volitional movements steady spasm, patient being able to 
shave himself and to do delicate manual work. Things do not 
drop from hands. 

Irritation of skin.—Tickling, pinching, sticking, pressure and 
cold increase the twitching. 

Emotion has a decided staying influence, he asserts. 

Alcohol has no effect. Sleep inhibits the movements entirely. 
Spasms never rhythmical. Tonic spasms are apparent in ante- 
rior muscles of neck, yet upon closer investigation they consist 
of many rapidly occurring clonic contractions. 

Sensibility—No paresthesias. Pains.—In right side of neck 
‘and lower and upper extremities. Tactile sense, normal. Pupils 
equal and normal. Ocular movements normal, but affected by 
general spasms. Facial innervation equal. Pharyngeal reflexes 
diminished. No reflexes in upper extremities. Musculature 
fair in volume, no atrophies. Myotatic irritability increased: 
Mvoidism excessive. 

Abdominal reflexes lively. Cremasteric present. Knee-jerks 
‘markedly diminished. Achilles ditto. Plantar reflex present; 


460 CHARLES L. DANA 


flexor response. Gross motility normal. No ataxia. Electrical 
examination: normal reaction. ; Seo 

Pulse 108, full. Respiration variable, 22. Marked prom- 
inence of superficial veins of upper extremities and abdomen 
(caput medusze). Lungs normal. Heart: no murmurs. Liver 
apparently enlarged. 

Fourth examination on March 25, 1902. The patient walks 
well, but his position is that of extreme kyphosis. There is con- 
tinual nodding spasm of the head with occasional grimaces of 
the face. There are no spasms of the eye muscles. The neck 
muscles are occasionally contracted in tonic spasms which relax 
at the end of three or four seconds. There are continual rhythmi- 
cal tonic spasms of the pectoral muscles, drawing the shoulders 
together, and of the abdominal muscles, pulling the trunk for- 
ward. The upper arms are affected in the same way, with oc- 
casional tonic spasms involving the whole musculature of the 
arm, so that there is no actual movement of the forearm. The 
forearms and hands are not affected by any spasms. There are 
movements of the back muscles drawing the scapule together. 
He has occasional movements of the intercostals and diaphragm, 
and owing to this he has, at times, difficulty in breathing. His 
spasmodic condition, has, on the whole, improved, but he has lost 
flesh and looks anemic and weak. 

At the present time, 1903, seven years since the malady de- 
veloped, he is much improved, but has still facial grimaces, and 
neck spasms like those of wry-neck. Mental condition good. 


Case 4—Myoclonia of type of degenerative chorea, or myo- 
clonus-eptlepsy. Summary.—In 1890, I reported in Brain, p. 71, 
a case of “Chronic Chorea with Autopsy.” The patient, a male, 
aged eighteen years, negative family history, began to suffer with 
attacks of the chorea of Sydenham at the age of six years. These 
became chronic and associated later with epileptic attacks. For 
more than six years the patient suffered from attacks of chorea 
of a mild type, and occasional nocturnal epilepsy, which did not 
prevent him from going to school and afterwards to work. The 
movements increased in violence and extent, and he was finally, 
at eighteen years, obliged to give up work and go to a hospital. 
At that time he had not only clonic and choreic movements, but 
tonic contractions of the muscles of the trunk, fibrillary and 
wave contractions of the muscles, tremor and not infrequently 
attacks of an epileptic character. He developed pneumonia and 
died. I reported the case as one of chronic chorea with epilepsy, 
but as it appeared in the later stages it would certainly be classed 


MYOCLONUS MULTIPLEX 461 


amongst the cases of myoclonus epilepsy, if that classification is 
adopted. | 

Case 5.—Myoclonia of type of degenerative chorea. Sum- 
mary.—In 1894, under the title of ““The Microbic Origin of Cho- 
rea, Case with Autopsy,” American Journal of the Medical Sci- 
ences, January, 1894, I reported a case of a very singular charac- 
ter in a man aged thirty-four years, who had a good family his- 
tory, who developed rheumatism in the tenth year followed by 
Sydenham’s chorea. This chorea recurred every two or three 
years, until finally, eight months before he was seen by me, he 
developed violent choreic and clonic movements, affecting all the 
muscles of the body, with tonic spasms of the neck and back at 
times, and rhythmical movements of the head and arms. The 
case in these last stages resembled Case 2. He subsequently 
died and an autopsy was made. This man did not have any epi- 
leptic attacks, but had a combination of choreic convulsive tic, 
tonic and rhythmical spasms. The multiple myoclonus, however, 
was in the last year of his life the dominant feature of the case. | 

Cases 6, 7, 8.—Cases of myoclonia of the type of convulsive 
tic. In Thompson’s “American System of Practical Medicine,” 
under the head of “Choreic Tic” I reported a series of three cases 
of children who began with what appeared to be ordinary choreic 
symptoms. In these cases there was first a condition of ordinary 
choreic movements affecting the face and arms, later tonic and 
choreic spasmodic movements of the muscles of the neck, causing 
the patient to appear to have a combination of convulsive tic, or 
wry-neck, and chorea. 

These three cases I called forms of choreiform tic, because 
beginning with a chorea, like that of the infectious or Sydenham’s 
type, they later developed symptoms of wry-neck and had other 
tic-like spasms. They belong with the myoclonias of the convul- 
Sive tic type, like Case 3. 


I have tried to determine the features of myoclonic disorders 
which ought to be brought out in a description and utilized in 
classification. Perhaps I have not all, but they seem to be about 
as follows: 

I. The cause. 

2. The association with other diseases. 

3. The mode of onset. . 


462 CHARLES L. DANA 


. The duration. 

The persistence or remittance, or intermittance. 

The groups of muscles or the limbs affected. 

The symmetry, or bilateral synchronicity. 

. The quickness, or electric character of the spasm. 

. The involvement of muscular groups used coordinately. 

10. The involvement of incoordinated groups. 

11. The involvement of single muscles not under vente 
maces 

. The motor, or locomotor effect of the twitch. 

13. The fibrillary twitching and the twitching of bundles or 
large masses of the muscle. , 

14. The predominance of 10, 11, 12 and 13, if several types 
exist together. 

15. The association with tonic or rhythmical spasms, or with 
epilepsy and mental deterioration. 

16. The association with pain, atrophy or paralysis. 

17. The condition in sleep, or under anesthesia. 

18. The controi of the spasm by the will. 

1g. The influence of emotional excitement on the spasm. 

20. The termination. 

It is assumed that there is no organic disease and the trouble 
is not symptomatic of such condition. 

Now applying all the tests of character to known and common 
spasmodic disorders, we find an agreement in the peculiarities of 
chorea, as it ordinarily develops, i.e., the infectious or Syden- 
ham’s type. Nor is there difficulty with symptomatic or degen- 
erative chorea of Huntington. 

I think that French and American neurologists also agree. 
pretty well as to what is meant by the different types of spas- 
modic tic, tic coordine, or the tic neurosis of Collins. It includes. 
to my mind, not only facial tic, but torticollis, and many local tics, 
as of the diaphragm and larynx, of the trunk muscles, and it may 
even be generalized as in what I have called progressive or 
‘“choreic tic” (myoclonia of the tic type). It is degenerative in 
origin, and it is a cortical disorder. (I admit cornual or nuclear 
tics.) It is often a kind of occupation or habit neurosis. It is 
slow in onset, chronic in character, very nearly continuous in its 
manifestations. It usually affects the face, neck, the larynx, ar- 
ticulatory muscles, diaphragm or larynx, but it may affect the 


CON ANS 


MYOCLONUS MULTIPLEX | 463, 


legs. (1 have reported such a case in a boy who had a jumping 
tic, as well as a speech and facial one.) It is not symmetrical in 
its distribution. The movements are lightning-like and cause 
locomotor effects. 

There are with it usually no fibrillary twitchings or bundle 
movements. The clonus may, however, in severe cases, 
be prolonged into a tonus, and this is the tendency in severe cases 
Rhythmical tremor and epilepsy may be associated with it. There 
is no pain, atrophy or paralysis, but rather a tendency to muscu- 
lar hypertrophy. It ceases during sleep, it can be controlled in a 
measure by the will, and is made worse by excitement. It is only 
rarely curable. 

The majority of reported cases of paramyoclonus multiplex 
can be placed in this group as myoclonias of the tic type. 

There is another group of myoclonic disorders which has 
passed under the name of paramyoclonus multiplex. 

Its characteristics, if there is such a disease, are claimed to 
be these: 

It is caused oftenest by fright or some psychical disturbance. 

Its onset is rather sudden and the duration rather chronic, i.e., 
months or several years. The spasms intermit, or remit. The 
muscle groups affected are mainly those of the shoulders, upper 
arms, thighs and trunk, and the face and periphery are rarely 
involved. Both sides of the body are affected, but not synchro- 
nously. 

The movements are lightning-like, and the muscles affected 
are those of physiological groups, but single muscles and some- 
times those not under control of the will may be affected. There 
is usually decided locomotor effect. There may be tonic and 
rhythmical spasm (Cases 4 and 5 or group I of Unverricht). The 
movements cease during sleep and are to a certain extent con- 
trolled by the will and increased by emotional excitement. 

This type of disorder is distinguished from the tic neuroses 
by the intermittent duration of the spasms, the involvement of 
large groups of muscles producing bodily movements and tre- 
mors, the absence of spasm of small muscle-groups, causing uni- 
lateral facial grimaces and wry-neck movements. The rather 
favorable course. The neurosis should be placed among the 


464 CHARLES L. DANA 


hysterical, or functional groups. My case (Case 2) shows it may 
be a family type and not associated with hysteria. 

A fourth group of myoclonias includes myokymia and allied 
spasms. It is characterized by persistent fibrillary and wave- 
like contractions of the body of the muscles. Higher and more 
intense types of this condition show also clonus and tonus of in- 
dividual muscles. The so-called Friedreich’s myoclonus multi- 
plex, the fibrillary myoclonus of Kny would go in this group. 
They are essentially intrinsic spasms, grosser kinds of fibrillary 
tremor. So far as I can make out Friedreich’s original case was 
one of this kind, and I agree with Dr. Hunt that they are periph- 
eral or spinal in origin. 

Thus I would group the myoclonias under the head of: 

1. Myoclonia of Friedreich, or peripheral type, including 
myokymia. 

2. Myoclonia of the functional or hysterical type. 

3. Myoclonia of the convulsive tic type, this last type being 
characterized by many associated spasms, choreic and tonic. 

4. Myoclonia of the degenerative chorea or “familial” or my- 
oclonus-epilepsy type, which is closely related with the third. 

5. Myoclonia, of the type of the infectious and symptomatic 
choreas. Although there is sometimes a mixture or fusing of the 
above groups, they are essentially different disorders, and as a 
rule can all be easily recognized and easily distinguished from 
each other. All cases of paramyoclonus multiplex, reported as 
such, can be grouped in one or the other. Hence there is no need 
of that much misused term. 

The Myoclonias and their Synonyms.—The following some- 
what interesting list of myoclonias and choreas shows how ex- 
tensive the nomenclature of muscular spasm has become. I 
have tried to assign them to the five groups above enumerated. 
Probably the arrangement is not perfectly correct, or complete. 
but it is approximately so. -I have excluded rhythmical spasms 
because myoclonia means essentially an irregular spasmodic dis- 
order, a muscle “tumult” (klonos), or twitch, or succession of 
twitches, not an orderly or rhythmical phenomenon like a tremor, 
though rhythmical spasm may be part of the general picture. 

I. Paramyoclonus multiplex, of Friedreich; astasic myoclonia, 


MYOCLONUS MULTIPLEX 465 


of Vanlair; multiple spinal myoclonus, of Lowenfeld; fibrillary 
chorea, of Morvan; fibrillary myoclonus, of Kny. 

II. Functional, or hysterical myoclonus multiplex, chorea 
major, chorea electrica, of Henoch. 

III. Myospasmia ; memory-spasms, of Friedreich; habit 
chorea; chorea variable des degenerés; convulsive, or spasmodic 
tic; tic general; Tourette’s disease, myriadrit; palmus; tic neu- 
rosis, of Collins. | 

IV. Degenerative chorea, hereditary chorea, Huntington’s 
chorea; myoclonus-epilepsy ; myoclonus, of Unverricht, of “fam- 
ilial” type; myoclonia congenita of Seeligmuller (?) ; hereditary 
degenerative chorea of Sachs. 

V. Infectious chorea, chorea minor, Sydenham’s chorea; cho- 
rea electrica of Dubini (?); chorea electrica of Bergeron; senile 
chorea of Gowers (°?). 

The stasic myoclonia of Vanlair is apparently a myoid tumor. 

As there has been so much discussion over the nature of 
Friedreich’s original case, I append here a translation of the his- 
tory without adding the author’s comments. : 


APPENDIX. 


TRANSLATION OF THE ORIGINAL RFPORT OF A CASE OF PARAMYOCLONUS MULTI- 
PLEX. BY PROF. FRIEDREICH. 


Ludwig Berlein, fifty years old, carpenter from Mosback (Baden) was 
taken ill in 1877, with sudden fever, and the appearance of a right-sided 
pneumonia, following which were developed a chronic induration with 
shrinking of the upper lobe of the lung, and a dilation of the bronchi of 
the same lobe. From that time on the patient suffered from dyspnea, 
chronic cough and mucopurulent expectoration. Lately, also, there 
appeared progressive emaciation and weakness, which interfered with his 
work, so that the patient was admitted to the clinic on January 17, 1878. 
Under the use of liver oil, morphine in the morning, strengthening diet 
and careful nursing the patient’s strength and nourishment improved. 
Cough and expectoration diminished to a slight remainder, and the patient 
was able to return to his previous occupation on the 8th of April. But in 
the fall of the very same year the above-named phenomena returned with 
renewed violence, so that after a temporary stay in a few other hospitals 
the patient was for a second time admitted to the clinic on April 29, 1880. 
The symptoms of bronchitis in the region of the cirrhotic parts of the lung 
were developed to a high grade, while the lung itself did not expand any. 

The left lung was perfectly sound. No fever. No change in the heart 
or abdominal organs. Two of the sick man’s sisters were said to have 
succumbed to pulmonary tuberculosis. ; 

During the first as well as during the second stay of the patient in the 


466 CHARLES L. DANA 


clinic a most peculiar affection of a set of muscles in the upper and lower 
extremities became noticeable. This showed itself in the form of short 
rapid contractions, reappearing at short intervals, which affected the biceps 
and triceps of both arms, and supinator longus of the forearms exclusively. 

At the same time chronic spasms showed themselves in the upper part 
of the thigh involving the vastus externus and internus and especially the 
rectus femoris, also to a less extent the abductors, and further the biceps 
and semitendinosus were affected, while the rest of the muscles of the 
upper part of the thigh were entirely intact. Here and there a muscle of 
the back or face was slightly affected by this disturbance, which confined 
itself to that particular muscle exclusively. 

Here it was not merely fibrillary or fascicular twitchings but also 
spasms which involved the whole of the muscle which swelled forward 
in a mass, and bulged every time, even when the contractions of the muscles 
were not marked enough to produce a noticeable locomotor effect on the 
limbs to be moved. Only at times, at an unusually marked contraction, 
one could notice a slight change in the part to be moved, e. g., during 
many contractions of the biceps a slight flexion of the forearm or during 
some of the spasms of the supinator longus a slight supination of the hand. 

The spasms of the rectus femoris produced a short and rapid forward 
movement of the knee joint, that of the biceps and semitendinosus a rapid 
movement of the part affected, following the tendons which limit the 
popliteal space. 

The spasms, however, were unrhythmical throughout and varying in 
extent, even though they were separated from each other only by short 
intervals. (It may be mentioned here, by the way, that by placing the 
stethoscope on the affected muscles in the moment of their contraction a 
loud and clear sound, resembling the first heart sound in every respect, 
could be appreciated.) 

Although the affection offered a perfect symmetry in its art, as the 
very same muscles were affected on both sides, yet every muscle showed a 
complete independence in relation to its individual contractions. Now 
it was this muscle, now that muscle, which twitched all for itself without 
any relation to the others, and if it sometimes happened that the contraction 
of a muscle on one side took place synchronously with another muscle of 
the same or other side, or even at times if two symmetrical muscles con- 
tracted at the same time, it was only an accidental coincidence, as it may 
be understood that such an occurrence was made possible by the frequency 
with which the spasmodic contractions appeared in each single muscle. 

The frequency and intensity with which the contractions of each single 
muscle ensued were not the same on different days or at different times 
of the day, and in this regard a considerable difference could be noticed. 
During the times of greater agitation there were 40 to 50 contractions per 
minute in one and the same muscle, while during the hours of greater rest 
only 10 to 20 contractions could be counted. Only rarely did it happen 
that the spasm ceased entirely, or almost entirely, within one-quarter 
or one-half hour. 

Were the spasms of less frequency, so were they also of less intensity, 
and vice versa. Frequency and intensity always stood in equal relation. 
It often happened that in one or the other muscle, contractions followed 
each other very quickly with increasing rapidity, and passed over into a 
short tetanus lasting about one or two seconds, which was always accom- 
panied by painful sensations in the muscles. In general, the spasms were 
strongest and most frequent when the patient lay quietly in bed without 
carrying out any active motions of the extremities. Especially during the 
»vening when the patient attempted to give himself over to the quiet rest 

f slumber, these cramps in the contracting muscles increased until they 


MYOCLONUS MULTIPLEX 467 


produced painful sensations, and thus going to sleep was rendered difficult. 

However, if sleep once set in, all the spasms ceased entirely while it 
lasted. Yet it often happened that the patient was frightened out of his 
sleep by a sudden very painful, crampy movement of both legs, so that 
the latter were jerked up against the abdomen. The adjoining individual 
contractions of the above-named muscles were then always of singular 
intensity, and it lasted hours until these quieted themselves. But many 
times, even during the day, although much more rarely than during the 
night, when the patient lay quietly in bed, there appeared flexion cramps 
of this sort in the lower extremities, similar to those that are known to 
appear in cases of acute myelitis. 

As soon as one undertook real motions and prolonged active contrac- 
tions of the affected muscles the spasms immediately disappeared, and the 
former movements were in no way injured by them. 

Thus the patient was not at all disturbed at his work; as soon 
as the muscles weakened and began to rest, the spasms returned. So 
during the active extension or flexion of the forearm there were no 
traces of any spasms in the biceps and triceps of the same side, while the 
spasm of these muscles of the other quietly lying down continued without 
weakening. 

The lower extremities were in analogous condition, only that in the 
thigh the painful contractions of the affected muscles continued also during 
upright position, but here also they entirely disappeared during 
locomotor actions, as walking. The rough motor power of the affected 
muscle was in no way affected, and only with the greatest effort could one 
flex an extended or extend a flexed extremity of the patient against the 
patient’s will. 

Station and locomotor co6rdination were very little affected. 

The electric irritability of the affected muscles, as well as those in- 
nervated by the same nerve trunk, according to repeated examinations by 
Prof. Schultze with both kinds of currents, was normal throughout; the 
mechanical irritability also showed no deviation, and a stroke on the biceps, 
etc., either by a percussor or with the edge of the hand, showed an idio- 
muscular swelling in no way higher or more prolonged than one often sees 
in most healthy individuals. On the other hand, there was an unmistak- 
able increase of reflex irritability of the muscle to skin irritation. Even 
the effect of cool air on the skin of the exposed extremity increased the 
frequency and intensity of the spasm. On one occasion during 
a prolonged exposure, while the patient was being examined, the whole 
right arm was in painful and violent convulsive tremor, which lasted for 
one minute. The other skin irritations, such as pinching, pricking, etc., 
also increased the spasms, and as one would grasp the arm with his hand 
and squeeze firmly for some time, the spasms of the biceps and triceps would 
immediately become stronger and more frequent, and often followed each 
other in such rapid succession that they passed over into a short, lasting 
tetanus. Here, as it was mentioned above, there could be found no ground 
for the existence of an increase in the direct mechanical irritability of the 
muscles, and so this phenomenon was evidently the expression of an in- 
creased reflex irritability of the muscles. From the plantar surface one 
could also bring forth unusually strong reflexes of the lower extremities, 
and even a slight tickling was sufficient to call forth convulsive tremors 
of the legs, which repeated themselves after coming to rest a number of 
times. Tickling of the inner side of the thigh showed marked, although 
not unusually strong, cremasteric reflexes. 

As far as the tendon reflexes were concerned, striking over the tendo- 
Achillis call forth only very weak contractions of the muscles of the thigh, 


468 CHARLES L. DANA 


and no foot phenomena could be brought out, so that in this respect the 
normal relation existed. 

In strong contrast to this there was a marked increase of the patellar 
reflex; even a slight tap on the tendon of the quadriceps-extensor or liga- 
mentum patellze was sufficient to produce the most lively and many times 
repeating extensions of the legs; and when one stretched the tendon of 
the quadriceps by pulling the patella down, the spasm of the affected muscle 
appeared, and there ensued painful cramps, which of themselves passed 
over into an intense tonus, during which time the extremity was strongly 
extended and the patella drawn forcibly upwards. 

On the other hand, irritation and extension of the ligamentum patelle 
by pressing it from below upward over the knee joint had no effect, nor 
were the spasms of quadriceps influenced by it in any way. 

All these phenomena which have been described, as well as the muscular 
spasms and increased skin and patella reflex, were more marked on the 
right than on the left side. There were no symptoms which would refer 
to any vasomotor or secretory disturbances. The skin sensations remained 
normal in every way, and in the same way touch and pain, and differences 
in temperature were appreciated and localized quickly and precisely. Few 
phenomena appeared which could be interpreted to mean an injury to the 
deep muscular sense. ‘There was no atrophy of the affected muscles, ex- 
cepting the general emaciation and bad nourishment of the whole body, 
referable to the chronic lung disease. 

The physical functions were normal; headache, vertigo, etc., bothered 
him most. The activity of the higher mental senses was also undisturbed. 
The pupils were of equal size, somewhat narrow, their reaction to light and 
accommodation active and normal throughout. There was no tever at 
any time. Pulse 80 to 90. Some complaints of palpitation. The digestive 
functions were undisturbed. The secretion and excretion of urine were 
normal. 

The patient attributed the cause of these muscular spasms to a violent 
fright which he had five years previous at the bursting of a circular saw, 
and which affected him so thoroughly that he became “purely white” in 
his face, and at the same time he began to appreciate a sensation of weak- 
ness in his whole body; not until fifteen minutes had elapsed was he able 
to recover himself to any degree. At that accident, however, he received 
no injury or mechanical shaking up of his body. 

About 14 days afterwards the patient noticed these spasms for the 
first time, and they grew worse later on, but they did not disturb him at 
his work. Besides that the patient said that he felt the combined sensations 
of pain and pressure in the arms and legs a number of years before that 
fright, always, however, only during rest, never during his work or any 
other active movements. 

There was no hereditary predisposition to neurosis. 

The patient during his double stay at the clinic was treated with liver 
oil, with special consideration of his lung disease and in behalf of his 
improvement of nutrition through which a favorable effect was intended, 
although the muscular affection remained the same. During the month of 
March, after only a few galvanizations undertaken by Prof. Schultze, the 
spasms rapidly began to diminish in intensity, and after a number of days 
disappeared without leaving a trace. 

The increase in the skin and patella reflex diminished in quick succes- 
sion, so that by the end of April the normal relations were restored in this 
respect also. The patient was discharged from the clinic by the middle of 
May. 


CHRONIC PROGRESSIVE HEMIPLEGIA, WITH REMARKS ON 
TWO CASES OF UNILATERAL PARALYSIS AGITANS 
WITHOUT TREMOR. 


By Huey T. Patricx, M.D., Cuicaco. 


M. K., eighteen years old, of German parentage, was first seen 
September 20, 1903. The family history is negative, both parents 
are living and well, She is the last of five children, there having 
been one miscarriage eleven years after her birth. The first three 
children died of diphtheria. The fourth child, born two years 
after the third, is living, three years older than my patient, and is 
strong but nervous. The patient was born at full term after 
a normal labor, walked at eleven months and talked at eighteen 
months, but not plainly until five years old. Excepting the or- 
dinary diseases of childhood, from which she made perfect recov- 
eries, she was well, strong and active until the age of thirteen or 
fourteen. Both the patient and her mother are emphatic in their 
statement that she had perfect use of all extremities until the be- 
ginning of the present trouble. She has never had convulsions, 
has developed mentally in a normal way, was bright as a school 
child, a rapid writer, and acquired unusual skill at fancy work. 
Menstruation began at eleven years, has always been regular and 
also painless until about a year and a half ago, when she had been 
working very hard. Since then there has been some but not ex- 
treme dysmenorrhea. At about thirteen she began to be rather 
irritable, impatient and emotional, as is the elder sister, and the 
mother attributes the change to the influence of this sister. 

Shortly before the age of fourteen years a slight clumsiness of 
the right foot was noticed and writing began to cause fatigue of 
the forearm. After a few months the limp had become very ap- 
parent, the child was no longer able to run well and disability of 
the hand was distinct. At the age of fourteen years and three 
months, six to nine months after the onset, the patient left school, 
and she remembers that at that time she could still write well and 
do fancy work well, though with considerable effort. Gradually 
the weakness on the right side increased, but when fifteen years 
old she was still well enough to take a place as domestic with some 
acquaintances. She states that at this time she could carry a child 
on her right arm, and could use the right hand pretty well in 
washing and drying dishes, but was quite unequal to the task of 
buttoning her clothes or those of the children. Steadily the dis- 





"Read at the meeting of the American Neurological Association, May 
12, 13 and 14, 1903. 


470 HUG Hwee PAT RICK 


ability grew and although her employers were unusually consider: 
ate, she was obliged to give.up the place and go home in the 
spring of 1902, when seventeen and a half years old. Since that 
time her condition seems to have changed very little except as 
regards some symptoms apparently functional. As before noted, 
dysmenorrhea appeared just before she came home, and at the 
same time she became more irritable and emotional. 

Soon afterward she began to notice that often on rising the 
neck was swollen, but would return to normal in an hour or two. 
This was not a mere sensation, as the mother says it was plainly 
visible. Indeed, this transient swelling, apparently of the thyroid 
gland, continues, and for the last three or four months the right 
side has remained slightly enlarged. At times the face flushes 
smartly, and at such times she has headache. ‘These flushes are 
sometimes, not always, coincident with menstruation. 

During the whole course of the trouble there has been no pain 
whatever, no tremor, jerking or convulsions, no dizziness, tinni- 
tus or vomiting, no affection of vision, speech or mentality, no 
involvement of the sphincters, and the general health has remained 
good. 

She is at present a ruddy, well-grown, well-developed woman, 
five feet five inches tall, and weighs 140 pounds. Mentally she is 
normal. Results of examination of thoracic and abdominal 
viscera, blood and urine were negative. The special senses, pupil- 
lary reactions, fundi oculorum and cranial nerves reveal nothing 
abnormal, except paresis of the seventh and motor root of the 
fifth as hereinafter mentioned. Nothing in the history or exam- 
ination indicates inherited or acquired syphilis. 

There is an incomplete right hemiplegia, and the patient states 
that it seems to her that sensation is not so good on that side. She 
also says that sometimes the right hand and leg feel numb, espe- 
cially at the menstrual time, but repeated careful examinations 
have shown sensation to be perfectly normal in all its qualities, 
including the localization of sensations, the sense of position and 
of motion and stereognosis. 

Voluntary movements of the right facial muscles are slightly 
less perfect than of the left. With the face at rest the right eye- 
brow is a little lower than the left, and a trifle of facial asymmetry 
is noticed, the right side being slightly smaller than the left. On 
raising the brows to wrinkle the forehead horizontally the left eye- 
brow rises a little higher, and in showing the teeth the left corner 
of the mouth is retracted more than the right. The eyes are 
closed equally, and no excess of associated movement of the right 
side can be demonstrated. 

The muscles supplied by the motor root of the fifth nerve 

show more difference. When the patient bites the teeth strongly 


PROGRESSIVE HEMIPLEGIA 471 


together, masseter and temporal on the right side can readily be 
felt. to contract less powerfully than on the left. Biting a pencil, 
she makes noticeably smaller indentations with the right side. 
Indeed, the patient asserts that on this side she can bite my finger 
only a little harder than I am able to endure. The pterygoids 
are clearly involved. Movement of the lower jaw toward the 
right brings the space between the canine and bicuspid teeth to 
the middle line, while toward the left the space between the 
lateral incisor and canine reaches the same point. When an 
effort is made to protrude the inferior maxilla straight forward 
beyond the upper, it deviates to the right to the extent of about 
three-fourths the width of the upper incisor. In opening the 
mouth ad maxvimum the middle point of the jaw makes a curving 
deviation toward the right, curving back toward the middle line 
on closing, but even at rest the interincisor space, or median line. 
of the lower jaw is slightly to the right. 

The right half of the tongue seems to me slightly smaller than 
the left, but it is not wrinkled or flabby, lies straight in the mouth, 
and is protruded straight. Neck muscles show no noticeable dif- 
ference, except those going to the shoulder. The right shoulder 
is shrugged somewhat less powerfully than the left, and all 
movements at the shoulder joint are weaker on the right side. 
The arm can be elevated to an angle of about forty-five degrees 
above the horizontal. Flexion and extension of the forearm on 
the arm show more difference, pronation and supination and 
movements at the wrist are weaker still, while the greatest weak- 
ness is evident in the flexors and extensors of the fingers and in 
the small hand muscles. Grasp of the left hand is unusually good 
for a woman; with the right hand the dynamometer can be held, 
but the index cannot be made to move. Power to pinch between 
the extended fingers is nil between the index and middle, scarcely 
perceptible between middle and ring, somewhat better between 
the little and ring fingers. There is some power in the thumb, 
so that objects can be held after a fashion between thumb and 
forefinger. For instance, she can still manage to do some crochet 
work by holding the needle in the right hand and moving the 
work in the left. 

In walking, the right arm is not carried flexed and pronated, 
as is so frequent in ordinary cerebral hemiplegia. It hangs by 
the side, and while it doesn’t “dangle” vertically, as does the arm 
in advanced progressive muscular atrophy or poliomyelitis of the 
shoulder type, the hand does swing flabbily to and fro with every 
step, and gives one the general impression of flaccidity. The 
most pronounced feature of the gait is a decided limp on the right 
side. The gait is neither ataxic nor spastic, nor is there very 
marked “‘steppage,” but foot-drop is plain and the outer border 


472 HUGH T. PATRICK 


drops more than the inner, so that in the forward swing the foot 
is in the equino-varus position. The patient toes distinctly neither 
out nor in. The right foot is raised higher than the left, it 1s not 
swung around in the arc of a circle, the toe does not catch the 
floor, but the heel does not come down first. Watching the 
patient walk one would say that the right leg was shorter, but 
careful measurement shows a scant one half inch difference. In 
the lower extremity the gradation of paresis is much as in the 
upper. That is, in a general way, the proximal muscles are 
strongest, those toward the distal end the weakest. Standing on 
the right leg the patient can flex the knee a little and straighten 
it again if she is steadied. Dorsal flexion of the foot is practically 
nil. With the patient recumbent the point of the foot can be 
moved upward not at all, but the toes can be very slightly ex- 
tended. The calf muscles are good, but below normal. Standing 
on the right foot alone she can just manage, when steadied, to 
raise the heel from the floor. Inversion and eversion of the foot 
are impossible. Flexion of the toes is possible but feeble. 

Aside from this deterioration of power toward the ends of 
the limbs, there is no localized paralysis; even no great prepon- 
derance in relation to physiological groups excepting as between 
the front and back of the leg. Flexors, extensors, rotators, ad» 
ductors and abductors seem to be about equally involved. 

The same applies to muscular volume. In no muscle or 
group of muscles is there unmistakable atrophy, but arm and leg 
on the right side are smaller in all their parts. The measurements 
in Gnches ware >> 7\nm; snightye pews let, wie, flexed, sieht: 
12; left, 1234; forearm, right, 934; as 1034 ; three inches above 
wrist, right, 7; left, 8; hand, right, 634; left, 734; over knuckles, 
Be 634; left, 734; calf, right, 134%; Wh 1538; foot-arch, right 

834 ; left, 91%; foot-ball, right, 8'4 ; left 9; thigh, six inches above 
patella, right, 203g; left, 22%. Trapezius, deltoid and scapular 
muscles are also perceptibly smaller on the right. These differ- 
ences are not such as are ordinarily found in anterior horn and 
peripheral disease, and, considering that the patient was less than 
fourteen when the trouble began, it seems reasonable to attribute 
them, at least in part, to lack of development. This hypothesis is 
supported by the discrepancy in the hands around the knuckles 
(34 inch) and in the feet (3¢ and % inch), where there is very 
little muscular tissue. Skiagraphs also lend support to this view 
as they show the bones of the right hand to be smaller than those 
of the left. The electric examination indicates that lack of de 
velopment would hardly explain all of the difference. While 
there is no reaction of degeneration nor even partial reaction of 
degeneration, there is certainly more change than is found in the 
cerebral palsies of children, lateral sclerosis or multiple sclerosis ; 


PROGRESSIVE HEMIPLEGIA A73 


even more than I have ever been able to detect in cerebral hemi- 
plegia with muscular wasting—so-called cerebral atrophy. The 
muscles showing the greatest diminution in size are the small 
hand muscles, the tibialis anticus and the peronei, and in these 
there is quite marked quantitative change. 

Despite the general appearance of flaccidity the pyramidal 
tract evidently bears the brunt of the lesion. All the deep re- 
flexes are greatly exaggerated on the right side, including the 
scapulo-humeral and McCarthy’s reflexes. It is even easy to 
demonstrate that the right masseter jerk is greater than the left, 
and a short-lived supinator clonus is easily elicited. There is only 
an indication of ankle clonus, but Babinski’s extensor response is 
typical, and may be obtained by pinching the leg as high as the 
middle of the calf. All reflexes on the left side are normal. Con- 
tractures are absent, with the exception of some slight shortening 
of the calf muscles. The foot may easily be brought to a right 
angle with the leg, but to get it much beyond this requires con- 
siderable force, and even strenuous pushing will not dorsally flex 
it to the extent that can easily be accomplished on the normal 
side. None of the excess of associated movement, so generally 
present in the cerebral palsies of childhood, can be found. 

There is no trace of incoordination or tremor of any kind; 
no fibrillary twitching, no nystagmus, no speech defect, no dys- 
phagia. Phonation is normal, and laryngoscopic examination 
shows normal movements of the vocal cords. As before stated, 
sensation is normal. 

The apparent flaccidity, as shown by the dangling arm, foot- 
drop and moderate steppage, and the presence of real spasticity 
as shown by great exaggeration of the reflexes and Babinski’s 
sign, present a very peculiar clinical picture. The case is en- 
tirely unique in my experience and an inconsiderable search of 
the literature has disclosed nothing just like it. Progressive 
muscular atrophy, amyotrophic lateral sclerosis, syringomyelia, 
multiple sclerosis, muscular dystrophy, neuritis, spinal tumor and 
hysteria may easily be excluded. It is difficult to imagine any 
gross cerebral lesion which could cause all the symptoms of this 
case and yet cause no sensory disturbance, no headache, vomi- 
ting, dizziness or optic neuritis, no more involvement of cranial 
nerves, no spasm, twitching, tremor or incoordination, no inter- 
ference with speech and no mental deterioration. Degeneration 
of the upper motor neurones would seem best to explain the con- 
dition, but there is not nearly so much spasticity as in primary 
lateral sclerosis, and there is more diminution in muscular volume 
than I have seen in cases of that disease. I am unwilling to make 
a diagnosis. Perhaps I would better say I am unable, but I 
think the case more closely conforms to the clinical type proposed 


474 HUGH T. PATRICK 


by Dr. Charles Kk. Mulls than to any form of disease with which | 
am acquainted, and his hypothesis of pathology, “a slowly in- 
creasing degeneration of the pyramidal fasciculi or of the cere- 
bral motor neurone system,” seems to suit the symptoms of my 
patient. | 

About three years ago Dr. Mills? reported a case which he 
called unilateral progressive ascending paralysis, and which he 
thought probably represented a new form of degenerative disease. 
As he stated in that report, the patient had been sent to him by 
me, and when [ first saw the case just described, my first thought 
was that I had to do with a second example of the same affection. 
His patient I had not seen since July, 1900, eight months after his 
visit to Dr. Mills. To my written request for a further examina- 
tion the patient quickly responded, and on reexamination I made 
a diagnosis quite different from that of Dr. Mills. My only sur- 
prise is that I had not thought of it before. I believe the man to 
be suffering from paralysis agitans, unilateral as to distribution 
(the so-called hemiplegic form), and without tremor. I believe 
this to be correct because all the symptoms except an attack of 
something like herpes can be explained by this diagnosis, and be- 
cause I have now under observation another case almost exactly 
like it, in which the tremor is beginning to develop. Briefly, the 
case is as follows, my description agreeing essentially with that 
of Dr. Mills. 

At the time of his first visit to me, September 26, 1899, 
M. J. P. was fifty-two years old, and the trouble had begun 
twenty months before. His wife first noticed that his right foot 
occasionally caught the floor or rugs, and before long he noticed 
it himself and made a conscious effort to lift that foot better in 
order not to stumble. After about eight months he was con- 
scious of a dull ache in the extremity, and a few months later 
was sure that the right lez was not only more clumsy, but was 
weaker than the left—-at any rate it felt weaker and was more 
easily fatigued. Five months before coming to me (fifteen 
months after the inception) he became aware that he carried the 
right arm against the side and crooked at the elbow, and soon 
afterward it began to grow a little stiff and was filled with a dull, 
heavy ache. Why this in itself did not suggest the diagnosis to 
me I am unable to comprehend, because only a year and a half 
before I had seen a gentleman sixty years old who complained of 
exactly the same thing (the leg being unaffected), which case I 
at once recognized as paralysis agitans, sine agitatione, a diag- 
nosis confirmed by the subsequent appearance of all the classical 
signs. With the stiffness (in the case now under consideration ) 
came some disability in the fingers. In writing the patient grasped 


?Mills. Journal of Nervous and Mental Disease, April, 1900. 


PROGRESSIVE HEMIPLEGIA Aas! 


the pen too firmly, and in a few minutes hand and fingers would 
grow quite stiff and the arm would ache so that he could not con- 
tinue. Buttoning clothing and other finger acts became difficult. 
Since that time the disability of the hand has been more promi- 
nent, at least more annoying than that of the leg. It has also 
been more progressive. Indeed, the patient affirms that the lower 
extremity is about as good now (April, 1903) as it was three 
years ago. 

At the time of my first examination no record of measure- 
ments was made, but I noted the patient’s statement that eight 
months previously the right thigh had been found to be one inch 
smaller and the calf one-half inch smaller than the left. Dr. Mills 
found a difference of one and one-fourth, and five-eighths respec- 
tively, and eight months later I found the differences to be one 
inch and five-eighths inch. The upper extremity showed no wast- 
ing. Aside from some increase in the disability of the hand, the 
present condition is so nearly that of three and a half years ago 
that the same description may serve for both, with such small ex- 
ceptions as will be noted. 

As regards the lower extremity, it is first to be noted that 
the disability is more apparent than real. To the patient there 
is a feeling of stiffness and clumsiness; to the observer the leg 
in action looks rather stiff and clumsy, but there is no spasticity, 
a scarcely perceptible paresis and no incoordination. On passive 
motion there is a little more resistance on the right side than on 
the left, but it is no more marked in quick or sudden movements 
than in slow ones—a nice distinction between the rigidity of par- 
alysis agitans and that of pyramidal tract disease. ‘The patient 
can stand on the left foot and easily pass the right over an object 
twenty-six inches high. He can run at fairly good speed, the only 
peculiarity being that he raises the right foot a little higher, and 
has not the same spring on that side; even hopping is well exe- 
cuted. He can stand on the right foot alone and let himself down 
until the thigh is at an angle of about forty-five degrees, and then 
rise so that he stands erect on the one leg, and he can stand on 
the right toes or on the heel. Especially the last I consider to be 
a severe test. Thigh measurements eight inches above the pa- 
tella are eighteen and a half and nineteen and a half inches; 
calves, twelve and five-eighths and thirteen and one-fourth. In 
other words, the difference now is what it was more than four 
years ago. 

Since the beginning, arm and hand movements have steadily 
but gradually progressed for the worse. The fingers are more 
clumsy, the arm and hand are weaker, the movements of even the 
larger joints less free. Putting the hand into the hip or even 


476 HUGH T. PATRICK 


side pocket of his trousers is a slow matter and requires some 
effort. To button the collar behind is almost impossible, and 
buttoning it in front is no easy matter. For six months he has 
been unable to button on the left cuff. The shoulder muscles are 
all strong, perhaps fractionally weaker than on the other side; 
the two biceps muscles seem to be equal, the right triceps not 
quite so strong as the left. Pronation and supination of the fore- 
arm are equal on the two sides, as are flexion and extension at 
the wrist. At the time of Dr. Mills’ examination the grasp of 
the right hand was stronger than that of the left (180—160), 
now the right is weaker (85—95).* Adduction and abduction 
of the fingers are slightly weaker on the right. As late as July, 
1900, the right arm and forearm were slightly larger than the 
left; now the right arm is one-fourth inch smaller than the left; 
the forearms are equal. The same quick fatigue of the arm and 
aching on exertion remain. But the great discrepancy between 
the two hands is not in strength, but in freedom and’ promptness 
of movement—the disability characteristic of paralysis agitans. 
Apparently there is no movement of the fingers that cannot be ex- 
ecuted, but no movement can be done quickly. For instance, 
movements of the fingers as in playing the piano can be executed 
with sufficient amplitude but only with extreme slowness. Small- 
est objects can be picked up with certainty but not quickly. This 
deliberateness of movement applies as well to muscles of the 
arm. Alternate flexion and extension at the wrist cannot be done 
rapidly, although as just noted, the strength is normal. The tooth 
brush is now used in the left hand, because with the right he can- 
not make the usual quickly alternating movements at the wrist. It 
is impossible for the patient to make a sudden movement, such as 
one would make in attempting to catch a fly. On command, a 
rectangular movement is very much slower on the right side. 
That is, if told to swiftly raise the hand from the knee ten or 
twelve inches, and then carry it ten or twelve inches horizontally 
one way or the other, the starting, the change of direction and 
the stopping take place slowly. This lack of prompt response 
to volition is less evident in movements at the shoulder. Last 
summer the patient played golf and could do so fairly well, but 
his swing was rather slow. 

Movements of the face seem to be slightly better on the left 
side but the difference is so small as to be indeterminate.** The 
frontalis acts equally on the two sides, but after some seconds of 
continuous action the right side tires a little, and the eyebrow 
drops a trifle. Masseters, temporals and pterygoids are equal. 


*My dynamometer is evidently much stiffer than that of Dr. Mills. 


**Since reading this paper I have examined a case of unilateral paraly- 
sis agitans in which the facial difference was much greater than in this one. 


PROGRESSIVE HEMIPLEGIA 477 


Achilles-jerk, knee-jerk, wrist-jerk and triceps-jerk are all 
brisker on the right side. An evanescent trace of ankle clonus 
can sometimes be elicited. Dr. Mills found patellar clonus. Ap- 
parently this varies as I have been unable to get it. The jaw- 
jerk is absent, as is Babinski’s sign. 

While comparing the muscular strength of the arms I was 
suddenly struck by a phenomenon that seemed to present the 
key of the situation. On demand the patient was forcibly supin- 
ating the left fore-arm against resistance, when I noticed that the 


(y 


Veet vor ae yaaa 4 $5 
LILES Poe he Lid 


ae Lol laste, he 


, 
Ke OS aa 
Fig. 1. Written slowly and carefully. 


right hand had assumed the position typical of paralysis agitans: 
and was shaken by a rhythmic tremor like that of this disease. 
The motion of this tremor seemed to be largely rotatory, that is. 
of pronation and supination. On retesting in the same way, the 
tremor was not so pronounced, but the motion was more a flexion 
and extension of the fingers, like that so often seen in paralysis 
agitans. I afterward noticed that the fingers are habitually car- 
ried in the position of paralysis agitans, though without tremor. 
For a long time, the patient does not know just how long, exer- 
tion of the right hand or arm has caused not only an aching pain 
but also tremor. This has been particularly evident during and 


478 HUGH T. PATRICK 


after some strain, as in buttoning the collar behind. At the pres- 
ent time this is very easily elicited by attempts to move the ‘fin- 
gers rapidly as in playing the piano, and this tremor, though 
transient, is indistinguishable from that of Parkinson’s disease. 
When the patient lies on the back and holds the right leg in a ver- 
tical position, it soon begins to ache, and is shaken with a rhyth- 
mic tremor affecting principally the quadriceps extensor. On the 
left side the same maneuver causes less tremor beginning later. 
When the patient forcibly raises the naso-labial folds and wrin- 
kles the nose, there is an almost rhythmic tremor or jerking 
on the right side, the rate being about six per second. Tremor 
is quite evident in writing. If he takes plenty of time his pen- 
manship is very good, but shows tremor in numerous letters. 
(Figure 1). If he tries to write rapidly, tremor is so bad as to 
make the product almost illegible (Figure 2). For several years 


PII oie ue 


pte (2 Pop Ane Lcr ee 


rE =< Face Sn sie 
t 


Fig. 2. Written rapidly. 


a very annoying symptom has been a feeling of stiffness and 
drawing below the right occipital region, or in the right upper 
neck, leading the patient to frequently rub the place and forcibly 
move the head about in an effort to relieve it. Eighteen months 
ago the palm of the right hand began to perspire in excess. It 
is always moist, and last summer it often dripped sweat. Else- 
where there is no excessive perspiration. Lately, the patient has 
noticed that the skin on the back of his right hand is smoother, 
does not present the distinct reticulation seen on the other hand; 
looks more like parchment. 

Sensation, codrdination, stereognosis, special senses, fundi 
oculorum, mentality and speech are normal. There is no fibril- 
lary twitching, intention tremor or nystagmus. Pain, headache. 
dizziness, vomiting, tinnitus and paresthesia have been absent. 
Sphincters are good and sexual power intact. During the last 
year a curious sequel of intercourse has been observed. Begin- 
ning ten or fifteen seconds after the termination of coitus, the 
right leg becomes rigid in extension, and is seized with a rapid 


PROGRESSIVE HEMIPLEGIA 479 


tremor or clonus lasting about fifteen seconds. This is unaccom- 
panied by any pain like that of muscular cramp. 

On January 18, 1903, the patient was put on I-100 grain hyos. 
cine hydrobromate t.i.d. Eight days later he reported that he 
was Sleeping better, that the tense feeling in the neck was gone. 

and that the right side felt less clumsy. He could wrinkle the 
nose without the tremor formerly noticed, and forced supination 
of the left forearm, while causing the fingers of the right hand 
to assume the typical Parkinson position, induced no tremor 
Writing was easier and caused less discomfort and tremor. 

For purposes of comparison I wish to report in brief the fol- 
lowing case: 

T. K., a merchant, fifty-four years old, was referred to me 
December 30, 1901. Except the fact of rheumatism in the mother, 
the family history is negative. At intervals for twenty or thirty 
years the patient has had lumbago. Once it iasted two or three 
months. Twenty-five years ago he had rheumatism in the right 
ankle for some days. He has been somewhat troubled with 
hemorrhoids, 1s constipated, has taken a laxative every night for 
four years. 

A year and a half before my examination he began to have 
pain about the middle of the right arm whenever he put the 
hand into his hip pocket, sometimes on other backward move- 
ments. This lasted for ten months, from May, 1900, to March, 
1go1, and during part of this time the middle joint of the right in- 
dex finger was swollen and tender. During the following sum- 
mer, Igor, the right upper extremity became weaker—as the pa- 
tient expressed it. That is, in writing the hand soon became fa- 
tigued, and in rowing the right arm and shoulder tired before 
the left. Like the preceding patient, he began to carry the arm 
semi-flexed, and it felt rather rigid and clumsy. The disability 
gradually increased, writing became more difficult, and caused a 
tired ache in the arm and shoulder. A very short time before 
coming to me the right knee had begun to feel slightly rigid, and 
for a few days he had been annoyed by the heel occasionally catch- 
ing the ground. In the upper part of the neck on the right side was 
a distressing sensation like a drawing or pressure. 

Examination revealed a state of affairs very much like that 
of the preceding case: On the right side a plastic rigidity, unlike 
that of pyramidal tract disease, like that of paralysis agitans ; 
slowness and clumsiness of movement, no real paralysis; the right 
extremities slightly smaller than the left, and the deep reflexes 
of the right leg more active than those of the left. There was 
no tremor except after some physical exercise, when the whole 
right arm trembled. The fingers of the right hand were habit- 


480 HUGH. T. PATRICK 


ually carried in the position typical of paralysis agitans, and he 
presented the characteristic facies of this disease. 

Since that examination his condition has changed very little, 
except that the leg is slightly more involved, the foot catches the 
ground more frequently, and he walks with a slight “hitch” on 
the right side. He left his business and has taken excellent care 
of himself. Beginning about December 1, 1902, he has noticed 
that the left elbow seems rather stiff and a little sore, especially 
when the arm has been for a long time in the same position. 
Strong efforts at pronation, supination, or flexion of the left arm 
against resistance cause an accentuation of the Parkinson atti- 
tude of the right hand and generally some tremor. 

In this case there would seem to be no cause to doubt the 
correctness of the diagnosis, paralysis agitans. But excepting 
the facies, the other case, the one examined by Dr. Mills, pre- 
sents. almost exactly the same symptom-group: the same ache 
and fatigue on exercise, the same slowness and clumsiness of 
movement without paralysis and without ataxia, the same way 
of carrying the arm, the same position of the fingers, the same 
sort of discomfort in the suboccipital region on the affected side, 
the same sort of tremor induced in the same way, the increase of 
deep reflexes and diminution of muscular volume on the affected 
side. That one began in the leg and the other in the arm seems 
to me to be important. I agree with Dr. Mills that the attack 
of more severe pain and skin eruption (herpes?) of the first case 
does not constitute an essential feature. Unilateral distribution 
of paralvsis agitans is the rule in the incipiency. Marked unilat- 
eral paralysis agitans without tremor is unusual, but it is far from 
being unrecognized in the literature. A greater difficulty in these 
two cases, especially in the first one, M. J. P., is the combination 
of diminished muscular volume and increased reflexes. After all. 
the former symptom is very inconsiderable in degree, and while 
the latter is not the rule in paralysis agitans it is not rare. In my 
opinion, lack of use is too often proposed to explain reduction in 
size of an extremity, and | am not prepared at present to assert 
that this will account for the difference of one inch in the thighs 
and five-eighths of an inch in the calves, but I do think that it is 
quite as reasonable to thus explain it, or to simply say that it is 
an unusual manifestation of paralysis agitans as it is to invoke 
the aid of a new and not yet understood disease. Indeed, Jolly® 
speaks of the diminution of muscular volume which ordinarily 
appears in the course of paralysis agitans. Besides, degenera- 
tion of the pyramidal tract alone would explain it no better. The 
appearance of tremor during or immediately after exertion, and 
in the involved but not trembling extremity on forced activity of 


‘Jolly: Handbuch of Ebstein and Schwalbe, Vol. IV, p. 865. 


PROGRESSIVE HEMIPLEGIA 481 


the other side, are manifestations of paralysis agitans often no- 
ticed in incipient cases or old ones without tremor. 

Ten months after Dr. Mills’ report Dr. Spiller* published 
another case under the same title, but I am inclined to think that 
the disease is not the same. His case showed distinct spasticity, 
ankle-clonus and Babinski’s sign, but was peculiar in presenting 
optic atrophy on the affected side. Furthermore, the patient occa- 
sionally found some difficulty in retaining the feces. Judging from 
his report I should say that he probably had to .do with some affec- 
tion different from any of the cases in this report. 

To summarize, I would say that my first case apparently be- 
longs to the clinical type indicated by Dr. Mills, but that my 
second case, the one reported by him, certainly affords no basis 
whatever for the creation of a new type, as it is an example of 
unilateral paralysis agitans without tremor. 


‘Spiller: “A Case of Unilateral, Progressive, Ascending Paralysis.” 
Philadelphia Medical Journal, February 9, 1901. 


THE WORK OF A NEUROLOGICAL DISPENSARY CLINIC.* 


By Smita Ety Jevuirre, M.D., and L. Prerce Ciarx, M.D., 


CLINICAL ASSISTANTS. 


During the year 1902 there were 1,780 new patients suffering 
from some well-defined form of nervous disease who presented 
themselves for treatment at the Vanderbilt Clinic. Of these 953 
were females and 827 were males. This number does not, how- 
ever, represent all of the new cases applying to the clinic for 
treatment. This number was 2,044, 1,068 being women and 976 
men. At least 134 of these did not present symptoms referable 
to the nervous system, and in 130 patients no definite diagnosis 
could be made. The total number of visits made by these patients 
was 10,121, thus making an average of about five visits per pa- 
tient. Inasmuch as many of the patients come once only it is 
probable that the average number of visits is between seven and 
eight. A number of patients came once a week throughout the 
year. In this connection it is of interest to note that a few pa- 
tients suffering from slowly progressive affections have been 
coming to the clinic almost monthly ever since the clinic was 
opened in 1&8o. 

Contrasting these figures with those of the first year of the 
clinic’s opening, it is found that the number of patients who have 
come for treatment has been doubled. Thus in 1888-1889 there 
were 944 patients or, for the first twenty-three months of the 
clinic’s opening, there were 1,888 cases, less by 200 than the num- 
ber for the twelve months of 1902 alone. 

Mental Diseases.—In attempting to present an analysis of this 
material we have deemed it of interest to consider at first the 
purely mental diseases that have come for diagnosis and treat- 
ment. The commonest forms of mental affection presenting 
themselves have naturally been in children. In these deficient 
development is represented by idiocy in six cases, imbecility in 
54, making a total of 60 cases or an incidence of about three per 
cent. 


*Report of Clinic of Dr. M. Allen Starr, 1902. 


WORK OF A NEUROLOGICAL DISPENSARY 483 


It may also be of interest to note here that the Board of Educa- 
tion of this city has already taken steps to establish supplementary 
schools for backward children (called secondary schools on the con- 
tinent of Europe). A few schools for this class are in successful 
operation, being maintained at other hours in the same school 
building as the regular schools. Obviously some systematic exam- 
ination should be made in every child dismissed from the regular 
school system by school teachers or medical inspectors because of 
its mental deficiency. Such examination should be made by properly 
qualified physicians appointed by the Board of Education, or, as 
Dr. Starr suggests, the city might be divided into districts and the 
schools refer their cases to the nearest neurological clinic. As to 
whatever arrangements are employed all agree upon the necessity 
of supplemental schools, and the importance of systems of medico- 
pedagogical training for the defective. 

The insanities are not well represented in dispensary work. 
In men, general paresis was the commonest affection, 23 (one 
per cent) presented unquestioned evidence of this affection, and 
as would be expected, always in the early stages. There were 
no women with paresis, which seems rather peculiar, inasmuch as 
syphilis, the most important etiological factor of paresis, is almost 
equally common in women, particularly in the lower strata of so- 
ciety. Probably the less exacting symptomatology for general 
paresis in the past few years accounts for the increased number 
of cases for this year’s statistics, and for the apparent increase of 
the disease in general during the past decade. At present the 
signs of cerebral syphilis, plus positive evidence of mental aliena- 
tion, are considered by many as sufficient data for an early diag- 
nosis of general paresis. 

Taking into account the essentially systematized and persecu- 
tory nature of the fixed delusions in paranoia, and the personal 
well-being of such patients, it is surprising that as many as seven 
men and one woman presented themselves at a neurological clinic. 
In most instances the patients come to the clinic for the secondary 
development of distressing hallucinations of hearing. The occur- 
rence of melancholia in six men and in 24 women should be con- 
sidered in the light of the older classification of the disease and 
not in the restricted sense of Kraepelin as a type of insanity of 


484 JELLIFFE AND CLARK 


the involution period. In other words it includes manic-depres- 
sion as well as true melancholia. 

Senile dementia was diagnosticated in three cases. There was 
one patient recorded suffering from mild puerperal mania. 

Cerebral gumma, and cerebral syphilis with mental symptoms, 
were diagnosticated in six instances. Therefore, the total num- 
ber of patients with mental trouble was 131, or seven per cent. 
This is not a great number in a large neurological clinic when one 
recalls that patients suffering from mental disorders prefer to visit 
more or less voluntarily a clinic of this type, which, of course, does 
not possess detention wards or even hospital wards of any sort, a 
feature which should not be lost sight of in establishing out-clinics 
with psychopathic hospitals in close connection with large neuro- 
logical! dispensaries. 

Nervous Diseases (Functional).—Dividing the neurological 
cases into those usually classed as functional and those organic, 
there were 873 (49 per cent) of the former, and 776 (44 per 
cent) of the latter, distributed as the following brief record in- 
dicates. 

Neurasthenia is par excellence the disease of dispensary pa- 
tients. A more complete analysis of these cases is contemplated 
in a further communication. Here it may be said that there were 
416 (23 per cent) patients who presented themselves for treat- 
ment, in whom this affection was diagnosticated, 250 in men and 
166 in women. Apart from the marked sexual element in 62 male 
cases and 38 menopause neuroses, the cases of neurasthenia pre- 
sented no particularly interesting features. The foreign popula- 
tion contributed over eight-tenths of the neurasthenics. Among 
men the Russian Jews preponderated. 

Hysteria is given as the diagnosis in 80 cases. There was a 
history of major hysteria in but three cases. The remainder rep- 
resented badly trained individuals of unstable nervous organiza- 
tion. 

The convulsive disorders were represented by 135 (19.5 per 
cent) cases of chorea, of which 128 were of the usual type of this 
disease. ‘There were five cases of chronic chorea and two patients 
with hemichorea, i.e., cases of chorea of the latter class which 
remained persistently unilateral. 


WORK OF A NEUROLOGICAL DISPENSARY 485 


Epilepsy, next to neurasthenia, contributed the largest inci- 
dence with 180 cases (ten per cent). An analysis of these cases 
is contemplated elsewhere. 

Convulsive tics were not common, there being only 24 cases, 
about one per cent, of which 15 were of the ordinary type of 
spasmodic tic. Seven were obviously of the early type, and six 
were of tic douloureux. Women preponderated in the ratio of 
two to one. 

There were 15 stammerers. The proportion of stammering 
in the general population would from these figures seem to be 
very small, but in view of the fact that we have no definite means 
of determining the general proportion of stammerers, some figures 
as recently published by M. Chervin of Paris in a monograph may 
be of interest here. As stammering is a cause of exemption from 
military service, it is possible to determine its frequency in differ- 
ent continental nations. It appears that of 1,000 conscripts ex- 
amined the number rejected is as follows: 


Per 1,000 
PAC ARNE CMe ey rin ole ib abet yo eee a Caen 7.50 
SI WICZOR ECAR nye. star ashe te abe tater eee ates R22 
DATO CALI CUES es Sea's Sooo) cide. 6 of ah eR ee 2.87 
PUIStLIASE LUO ALY |. SU srs s cstin pete erin 2.20 
TSC OAL Peta aie. Wein o'a cet See rene pete 2.10 
DMR RU Ren oles vec cre win he Pane eae ee 0.86 
TRUS La ag soars ot ice wig sca aya ial siete element eset aie 0.19 


Comparing these numbers with those that represent the fre- 
quency of nervous affections, he finds that in France the nervous 
affections are exactly twice as numerous as the cases of stammer- 
ing; in Belgium they are four times more numerous, in Italy 
seven times, in Switzerland eight times, and in Russia thirteen 
times. No statistics of stammerers in the United States are 
given. 

There were three patients with motor speech defects, and three 
patients with simple idiopathic tremor. 

Paralysis agitans showed 17 cases, eight men and nine women. 
They did not present any features apart from the usual types. 


486 JELLIFFE AND CLARK 


The etiological statistics of the disease throw no new light on 
its pathogenesis. 

Organic Lesions (Peripheral Nerves).—-Yhe peripheral nerve 
lesions of one type or another were numerous. They represented 
379 cases (21 per cent), distributed equally between neuralgias 
145 cases, neuritis 117 cases and peripheral palsies 117. Of this 
large number of peripheral nerve cases men were affected in 244 
and women in 135 cases, showing the greater incidence of men to 
this type of lesion. 

Of the neuralgias, sciatica was the most common, 48 cases ; su- 
praorbital in 16 (9 male and 7 female) ; intercostal 14 (3 male, 
11 female) ; facial 25 (15 male, 10 female); generalized neural- 
gia in 18 (13 male, 5 female) ; brachial in one, coccygeal in one, 
ulnar one. 

Neuritis was general in 12, traumatic in 18, lead in 11, alcohol 
in 7, occupation in 8, arthritic in 6, diphtheria in 3, typhoid in 1, 
circumflex I, ulnar I. 

. Peripheral palsies were represented by 117 cases. Facial pal- 
sies were most common in 41 (17 male, 24 female) ; musculo- 
spiral in 35 (29-6). Erb’s palsy was represented by 5 cases, the 
ulnar nerve in 5, circumflex in I, lead palsy 5, larynx I. 

Affections of the spino-peripheral neurone were present in but 
46 cases. Of these anterior poliomyelitis was diagnosed in 24 cases. 
With reference to the incidence of these cases, 16 cases showed an 
initial history of fever, headache and vomiting. There was a his- 
tory of initial convulsions in one case, and no recorded histories 
in seven. On the question of causation the history is negative in 
16 cases, and given as due to a fall, measles, infections, dentition 
and pneumonia in I case each. The months of invasion are of 
interest. There was I case in January, none in February, 1 in 
March, none in April or May, 1 in June, 6 in July, 8 in August, 
2 in September, none in October or November, 1 in December 
and no date given in 4. 

Chronic anterior poliomyelitis was present in six cases, pre- 
senting the picture of progressive muscular atrophy. These were 
all in men. 

Ophthalmoplegia was present in 11 cases. These patients 
were all men. 


WORK OF A NEUROLOGICAL DISPENSARY 437 


Tabes dorsalis was present in 32 patients. Only two of these 
were women. 

Of these 32, record of 25 was kept—all males. The following 
occupations were represented: one each, driver, carpenter, farmer, 
soldier, bookkeeper, tailor, stone-cutter, fireman, janitor, butcher, 
lithographer, sleigh-maker, musician, cigar maker, butler; 2 bar- 
keepers, 3 salesmen, 2 cooks, 2 laborers. The earliest age at on- 
set was 28, the latest 49, although one patient is put down as 14 
years of age. It is doubtful if this early case is one of tabes. The 
average age of this series of 25 is about 35 years. 

Bearing on the question of etiology, it was found that 14 had 
had syphilis, two had led extremely dissipated lives and nine pre- 
sented no evidences nor history of syphilis, nor other etiological 
factor. In ten of the 14 presenting syphilis the initial lesion had 
been acquired 20, 8, 10, 28, 26, 18, 13, 30, 15, and 19 years pre- 
viously, respectively. No special hereditary factors were present 
in any. In one there was senile dementia, in another grand mal 
epilepsy, in another tuberculosis, in the parents. 

A few interesting facts concerning the earliest symptoms may 
be recorded. There were, as earliest symptoms, neuralgic pains in 
11, perforating ulcer in I, gastric crises in four, general weakness 
in the legs in 2, blindness in 4, ataxia in 3, and myosis in 1. The 
knee-jerks were absolutely lost in 24 and diminished in 1. The 
Argyll-Robertson pupil was present in 21 instances. There was 
normal light reaction in 3; myosis and optic atrophy in 1. Other 
detailed analyses are left for a special paper. 

Friedreich’s ataxia was found in 3 patients, 2 men and I 
woman. 

Lateral sclerosis was present in 6 men and one woman. 

Amyotrophic lateral sclerosis was present in 3 cases. 

Multiple sclerosis was found in 6 men and in 4 women. 

Myelitis was present in only two cases, certainly bearing out 
the recent contentions of Starr, Gowers and Risien Russell, that 
myelitis is really a rare affection. | 

Ataxia paraplegia was present in 5 men, and spastic paraplegia 
in 2 men. 

Tumors of the spinal cord were present in two patients, one 
man and one woman. 


488 JELLIFFE AND CLARK 


Brain Affections.—Organic diseases of the brain were ob- 
served in 85 cases. Eighteen of these were in children presenting 
the symptoms of infantile cerebral palsies. Causation is here 
represented as whooping-cough in one, trauma in two, prolonged 
labor in four; the rest were negative. One patient was diplegic. 
Monoplegia was present in two men and two women. Hemiple- 
gia was present in 58 patients, an incidence of 2.7 per cent. Forty- 
three in men and 15 in women. Two patients had aphasia. ‘Tumor 
of the brain was present in four cases, three men and one woman; 
two cases of cerebral gumma were diagnosed. 

Syphilis of the brain was diagnosed in 12 cases (3 men, 9 
women). 

Vascular Lesions.—\Vasomotor affections were diagnosed in 
16 patients, angioneurotic in 4, flushings in 3 and erythromelalgic 
symptoms in 9 patients, 6 men and 3 women. 

Exophthalmic goiter was present in 8 women. 

Miscellany.—Alcoholism in 43 males, 1 female; muscular dys- 
trophy, 3 males, 1 female; atheroma 3; arteriosclerosis 12; concus- 
sion of brain 3; fracture of skull 1; headache, 10 males,75 females ; 
hemicrania 2; herpes 1; hemianopsia 1; insomnia 2 males, 11 fe- 
males; pachymeningitis 4 males, 1 female; optic atrophy 2; pares- 
thesiz 5 males, 11 females; senility 1; incontinent bladder 1; local 
atrophy I. 


Society Proceedings. 


THE PHILADELPHIA NEUROLOGICAL SOCIETY. 
April 28, 1903. 
The President, Dr. H. A. Hare, in the chair. 


Poliomyelitis in the Adult Involving All Four Extremities —Dr. John 
K. Mitchell exhibited this case. C. R. Wadley, aged twenty. There is 
nothing in the history, either personal or family, of interest. The boy was 
in ordinary health and has never suffered any injury until August 15, 
1901, when he suddenly suffered for a day or two with stiff neck and pain 
in the back. Two days later he lost consciousness, according to the account 
which he has given, and remained unconscious for twenty-four hours. He 
had fever for a week following, but no vomiting, diarrhea, or convulsions. 

On recovery from the fever he was completely paralyzed and could 
not move his head. Sensation remained perfect. Motion gradually re- 
turned, first in the head, then in the upper right arm, then in the lower left 
arm, then in the upper left leg and then in the lower right leg. 

In the autumn of 1902 he was admitted to the Orthopedic Hospital. 
He was then entirely unable to stand. He could use his hands very little 
and could not raise his legs from the bed. When he endeavored to sit up, 
he was unable to get his spine straight from weakness in the back muscles. 
The worst parts at that time were the lower right arm and hand, the upper 
left arm, the upper right leg and the lower left leg. The affected parts 
were very cold and presented slight contractures. He had no knee-jerk and 
the plantar reflex was very small, cremasteric reflexes were absent and the 
abdominal slight. There was fair reaction to faradism in the arms; very 
poor in the legs. There was no degenerative reaction, KCL greater than 
AnCL everywhere. 

He has improved very slowly, but steadily, and the only member which 
seems unsusceptible of betterment is the right hand, in which the destruc- 
tion of the intrinsic muscles has been so complete that he has very little 
use of it, and very little prospect of a valuable member. In every other 
way there is a change for the better, and the boy is able to walk, supported 
in the wheeled-crutch, and can take a few steps with assistance even 
without the degree of support which this apparatus gives. 

The case was shown as an interesting example of widespread and 
irregular distribution of a poliomyelitic paralysis at an age when patients 
are commonly exempt. 

Dr. A. A. Eshner referred to a typical case of anterior poliomyelitis in 
a boy seven or eight years of age involving all four extremities. At the 
same time he had under observation a boy five or six years of age with 
flaccid paralysis of the extremities who was at first thought to be suffer- 
ing from anterior poliomyelitis, but who later exhibited derangement of 
speech and incodrdination of movement which led Dr. Eshner to ‘believe 
that the trouble was of cerebral origin. 

Dr. H. A. Hare said that there had been admitted to his ward in the 
Jefferson Hospital, six or seven weeks ago, a woman about nineteen years 


490 PHILADELPHIA NEUROLOGICAL SOCIETY. 


of age, with the statement that she was convalescent from typhoid fever 
and was universally paralyzed. There was a history of five weeks’ fever 
which careful questioning reduced to two weeks. The temperature had 
ranged as high as 105° F. When admitted she was absolutely paralyzed 
in the upper extremities and could slightly move one leg. There was no 
interference with speech or intellect. The hands presented a rhythmic 
tremor resembling that of chorea as it is seen in the dog. The emaciation 
was marked. There was exaggeration of the reflexes both at the elbow and 
at the knee, but not in the feet. Under careful nursing, massage and tonics 
the patient rapidly improved so that in ten days she could move all four 
extremities. At the end of that time she, unexpectedly, left the hospital 
and has been lost sight of. 

Dr. John K. Mitchell believed that one reason why the limit of proba- 
ble beginning improvement was within one or two years was because in 
bad cases the unaffected muscles atrophied from disuse. As showing that 
even very old cases are not insusceptible to improvement he referred to a 
case of fifteen years’ standing in a girl eighteen years of age. When she 
came under observation there was almost complete paralysis of both legs. 
She was able with difficulty to shuffle across the floor a distance of thirty 
feet. She is now, after a year’s: treatment with massage and electricity, 
able to walk a mile with the aid of a stick. 

A Case of Brachial Monoplegia of Spinal Origin.—This report was 
made by Drs. W. G. Spiller and T. H. Weisenberg. The patient had been 
in the service of Dr. Spiller at the Philadelphia Hospital. The clinical 
history was very incomplete, but there was sufficient to show that the man 
had had a paralysis of one upper limb. An area of sclerosis was found in 
the lower cervical region in the lateral column and anterior horn on the 
side corresponding to the paretic limb. This sclerosis was evidently the 
result of thickening of the blood vessels of the affected part. The case was 
important as an example of monoplegia of spinal origin in an adult. 

A Case of Thonisen’s Disease, Associated with Pseudo-muscular Hy- 
pertrophy.—This case was reported by Dr. Horace Carncross. The pa- 
tient, a young man aged twenty-one years, was troubled with rigidity after 
resting. At birth he was a large child, weighing fifteen pounds. When nine 
months old he weighed forty-two pounds. When he was two years of age 
stiffness of the hands was noted and later of the legs and other parts of 
the body. If he fell he could not get up until after the lapse of five min- 
utes. At this time he was very strong. At the age of six years he went to 
Girard College. From ten to fifteen years of age he was not as strong as 
before, or as his development would indicate. At the age of seventeen he 
began to waste. He has great difficulty in getting up in the morning. In 
going up stairs the first two or three steps give him much trouble, after 
that he goes up more easily, and at the second flight he can run. All the 
muscles are rigid, including those of the tongue. 

The sensory symptoms are negative. The patellar reflex and biceps- 
reflex are absent, except on reinforcement. The electrical reactions are 
normal, except that the muscles respond sluggishly. The eye-grounds 
are normal, and the pupils react normally. The family history is negative, 
except that the mother had recurrent attacks of what were spoken of as 
facial paralysis, but which from the history were more probably attacks of 
facial spasm. 

Dr. F. X. Dercum referred to a case which he had presented before the 
Society some years ago,—that of a bricklayer who when he started to work 
would suffer from a tonic spasm of the muscles. In that case there was no 
family history suggesting Thomsen’s disease. He had merely termed it a 
case of myotonia. The present case he considered an anomalous one, but 
he thought that it was a muscular dystrophy associated with myotonia. 


PHILADELPHIA NEUROLOGICAL SOCIETY. 491 


He believed that a study of these cases showed that our conceptions of the 
various types of dystrophy needed widening and readjustment. 

Dr. D. J. McCarthy referred to three cases of Thomsen’s disease which 
he had seen in Jolly’s clinic in Berlin. In two of those cases the symptoms 
were no more marked than in the case shown tonight. The occurrence of 
facial spasm in the mother, and the fact that in the patient the condition 
had been present from birth, he considered of interest. 

A Note on Periodic Insanities with the Report of Three Cases of In- 
termittent Melancholia.—Dr. Alfred Gordon read this paper. 

Dr. F. X. Dercum said that mania, melancholia and circular insanity 
were essentially recurrent diseases. The practical point brought out by the 
paper was that irregular, intermittent melancholia was unfavorable as to 
prognosis. Ordinary melancholia yields a more favorable prognosis, but 
the attacks are liable to recur after rather prolonged intervals. Our sus- 
picion should always be excited when the onset of melancholia is sudden 
and the recovery abrupt. It usually means recurrence after a relatively 
short interval as compared with ordinary melancholia. 

Dr. John K. Mitchell referred to the fact that even in ordinary melan- 
cholia, recovery may occur suddenly. The line separating simple melancho- 
lia and the recurrent variety is very indistinct. 

Senile Dementia.—This paper was read by Dr. Pickett. 

Dr. F. X. Dercum regarded the present admirable communication as 
a worthy companion paper of Dr. Pickett’s previous communication on de- 
mentia precox. The paper was full of suggestions and brilliant generali- 
zations. Some were quite startling, while others were in keeping with 
what we should expect. 

Dr. Charles K. Mills said that with regard to the occurrence of other 
types of insanity than senile dementia in old age, he was quite sure that this 
was the case, and had seen a few striking illustrations. He referred to the 
case of a man eighty years of age who during his previous life had had 
at least five or six attacks of melancholia. He had retained his general 
mental vigor. At the age of eighty years he developed a typical attack of 
melancholia of the same type as he had previously had, although perhaps 
more severe. . 


Periscope. 





CENTRALBLATT FUR NERVENHEILKUNDE UND PSYCHIATRIE 


(15 January, 1903.) 
. On the Limits of Psychiatric Knowledge. R. Gaupp. 


ht 


2. On a Peculiar Katatonic Symptom-Picture Removed by an Operation. 
K. BONHOEFFER. 

3. Ophthalmoplegia Interna Traumatica. ERNst SCHULTZE. 

4. The Trend of Investigation in “Psychologic Studies.” WW. WEyYGANDT, 


1. On the Limits of Psychiatric Knowledge—Gaupp says: Our science 
is not merely a branch of natural science, but the symptoms to be studied 
belong mainly to another field of labor, not entered by the explorer of nat- 
ural science. It is a mistake to believe we can localize the psychical ele- 
ments and thus make the psychical processes understood. Pathological his- 
tology will never do much for general psychopathology, especially not re- 
garding the laws of psychical phenomena of healthy and sick persons. 
There is no possibility of understanding psychical events by their material 
bases, which we do not know in individual cases. Chemical science too 
cannot explain the psychical phenomena,—it being nothing else than molec- 
ular mechanics, which cannot be compared with psychics. The facts of 
anatomy and chemistry not helping in the investigation of psycho-pathologi- 
cal phenomena, our etiological knowledge is defective, and a difference of 
opinion arises regarding the axiom that like causes have like effects. It is 
said, for instance: Because one drinker suffers from delirium tremens, a 
Second one from mania with jealousy, a third one from Korsakoff’s psy- 
chosis, it cannot be that the same causes produce the same effects. How- 
ever, not one cause alone, but several of them result in psychoses; we may 
recognize only one, and so this one may appear to have several effects. 
These difficulties lead to the conception of exogenous and endogenous 
causes of psychoses; some authors speak about predisposing and exciting 
causes. We have made some progress regarding the exogenous, but less 
about the endogenous causes. The expressions “degeneration” and “psy- 
chopathic disposition” show the uncertainty and vagueness of our opinions. 

We know very little as to the individual psychological attributes of the 
predisposed and their specific affinities for certain diseases. We do not 
know the happenings in the brain of the healthy, the predisposed and the 
diseased. Therefore we are often unable to appreciate what the real cause 
is, and what it only seems to be. 

The laws of conservation of energy and psychophysical parallelisms are 
applicable within the psychical sphere. The question is: Can science dis- 
cover that application? Experimental psychology can explain many psychi- 
cal phenomena. Self-observation combined with the observation of others 
is the best method of investigating psychical phenomena. We have made 
little progress during the last decades in the scientific exploration of psycho- 
logical disturbances. There has been a dearth of psychology, of the knowl- 
edge of psychical casuistics. Pathological anatomy has become the only 
hope of the future, according to the general belief; and this the writer en- 
deavors to combat by his explanations. 

2. On a Peculiar Katatonic Symptom-Picture Removed by an Opera- 
tion.—Bonhoeffer declares that so-called katatonic symptoms are not pathog- 
nomonic of a special disease. Negativism, flexibilitas cerea, verbigeration, 


PERISCOPE 493 


rhythmical movements, and stereotpy are observed in diseases altogether 
unlike. Even if such symptoms are permanent, one has to be cautious in 
making the diagnosis “katatonic dementia.” The operated case reported by 
the writer shows that on the basis of traumatic hystero-epilepsy symptom 
groups occur, very much resembling the later stages of katatonia. 
_ 3. Ophthalmoplegia Interna Traumatica.—Ernst Schultze reports a case 
in which an isolated paralysis of the ciliary muscle and sphincter iridis ex- 
isted. Ophthalmoplegia interna is mostly found with tabes and paralysis 
caused by lues. But in this case it was most probably the result of a hem- 
orrhage in the region of the oculomotor nucleus. 

4. The Trend of Investigation in the “Psychologic Studies.’—(To be 
continued)... 


(1903, No. 2, February 15.) 
1. On the Psychophysiology of Negativism. RacGnar Voor. 
2. Critical Remarks on H. Schmaus’ “Lectures on the Pathological Anato- 
my of the Spinal Cord.” F. Nisst. 
3. The Trend of Investigation in the “Psychologic Studies.” W. Wey- 
GANDT. 
4. Recent Studies on Alcoholism. Hopper. 
__ 1. On the Psychophysiology of Negativism.—According to Vogt nega- 
tivism can be explained like the other katatonic symptoms by the supposi- 
tion of a higher “persevering” power of the cortex. The perseverance of 
one motor impulse diminishes the susceptibility to other movements. In 
many cases the patients try to make a requested movement, but during this 
trial contrary impulses arise. If you ask a katatonic patient to shut his 
eyes, sometimes opening and closing movements vie with one another, until 
finally the eyes are suddenly closed. 

Vogt believes that with every movement of a group of muscles the an- 
tagonists also become innervated. This condition of innervation of the 
muscles, and the intensified “perseverance” of the psychomotor phenomena 
in katatonics, explain negativism sufficiently. If now katatonic patients 
find often that they have great difficulty in making the required movements, 
they think such requirements a vexation and they become morose, thinking 
it perhaps unnecessary to try to fulfil the request. Thus negativism appears 
frequently to be wilful perversity. 

2. Critical Remarks on H. Schmaus’ “Lectures on the Pathological 
Anatomy of the Spinal Cord.’—Niss| says that these lectures contain all 
that we know at present about pathological changes of the medulla spinalis. 
He thinks it important that the author is a pathological anatomist, while 
before him neurologists and psychiaters have described the pathological 
anatomy of the nerve centers. This separation of one branch leads to one- 
sided opinions about it. Schmaus has tried to describe the anatomical 
changes in the spinal cord more correctly than it has been done before, from 
the anatomical standpoint. Nissl objects to the co-operation of a neurolo- 
gist, to whom Schmaus committed the clinical part of his lectures. Then 
he alleges that Schmaus is in error regarding the lymphatic spaces. Nissl 
claims to have proven by experiments that the adventitious sheaths are the 
only true lymphatic spaces, and that the membrana adventitia of the vessels 
forms a biological margin between the ecto- and meso-dermic structures 
of the nervous system. 

3. The Trend of Investigation of “Psychologic Studies.”—Weygandt 
gives a full review or critique of the first volume of reports issued from 
the laboratories under the direction of Emil Kraepelin of Heidelberg. 

4. Recent Studies on Alcoholism.—To be continued. 

(1903, No. 3, March 15.) 
1. On Hydrotherapy in Psychoses. W. ALTER (Leubus). 
2. The Trend of Investigation in the “Psychologic Studies.” W. Wey- 
GANbDT (Concluded). 


494 PERISCOPE 


3. Recent Studies on Alcoholism. Hoppe (Konigsberg). 

1. “On the Hydrotherapy of Psychoses.”—The author considers hydro- 
therapy to be the best of all sedative measures. He has tried it in 79 per 
cent of his patients, not only on cases of furious excitement and grave 
acute insanity, but also on deeply depressed, hysterical and demented pa- 
tients. He employed cure-baths of 1 to 6 hours’ duration; prolonged baths, 
not less than twelve hours, and wet packs continued from one and one- 
half to twelve hours. The cure baths were given to sleepless patients, and 
to paranoiacs having outbreaks or exacerbations. The emotional manifes- 
tations of hebephrenic and katatonic patients could be largely controlled 
by cure-baths. For hysterics the wet packs surpassed the prolonged baths. 
In the remissions of paresis prolonged baths of gradually lowered temper- 
ature seemed to lengthen the period of remission. 

Baths lasting more than twelve hours have been an absolutely effective 
remedy in all states of grave excitement; also in subduing hallucinations 
in dementia precox, the prolonged baths have been very useful. The au- 
thor did not in any case abandon the prolonged bath on account of a nega- 
tive result. Repeatedly he continued it for very long periods. Occasionally 
it was continued six, eight, fourteen and twenty-three days. The author 
mentions a case of puerperal “exhaustion psychosis,” in which a cure re- 
sulted from a bath of seventy-two hours. In mild hysterical cases and in 
convalescent patients who cannot sleep, Alter recommends wet packs: 
arteriosclerosis and heart disease do not contraindicate the measure. Hy- 
drotherapy requires the strictest individualization to secure the benefits of 
it; but properly used, it permits a great reduction in the use of calmative 
drugs. Alter nevertheless gives opium to melancholics in increasing 
doses, supporting the medication by systematic wet packs which always 
hasten the effect of the drug. Generally all psychoses had a milder, more 
subacute course under the new treatment. 

3. Studies on Alcoholism.—To be continued. 


(1903, No. 4, April 15.) 


t. On Paralyses after the Employment of Creasote Phosphate. L. LoEwEN- 
FELD. 

The writer believes that his observations upon this condition are unique. 
Creosote phosphate, under the name “Phosphot (e),” is put on the market - 
by a manufacturing chemist as a remedy against tuberculosis. A colleague 
of Loewenfeld’s tried the preparation in three cases of pulmonary tuber- 
culosis in doses of one gram injected into the gluteal mass. Good results 
were observed, as regards the lung affection, after 15 or 16 doses; but in 
each case paralytic manifestations in the upper and lower extremities 
appeared. The manufacturers of the drug say that others have reported 
similar results. Loewenfeld gives a full description of two cases of this 
paralysis. The lower leg- and foot-muscles are first affected; the knee-jerk 
remains; sensory symptoms are slight; bladder and bowel are not affected. 
Tn one of the cases atrophy was present for some time in the peroneal 
region. The writer gives reasons for thinking that the paralysis is not 
altogether peripheral, and concludes that this, like most toxic paralyses, 
is a neurone disease, the ventral gray horns and the peripheral motor 
nerves being affected simultaneously. The phosphoric acid part of the 
compound surely cannot be the cause of this palsy; and the creasote in it 
is only half of what is contained in “creasotal,’ so that Loewenfeld is at 


a loss to account for this untoward effect of creasote phosphate. 
Pickett (Philadelphia). 


, 


PERISCOPE 495 


JOURNAL OF MENTAL SCIENCE 
(Vol. 49, 1903, No. 1, January.) 


Some Features in the Intimate Structure of the Human Cerebral Cor- 
tex. JOHN TURNER. 

Insanity in Imbeciles. A. F. TREDGOLD. 

The Training of Nurses in Institutions for the Insane. BEpForp 
PIERCE. 

Case Taking in Large Asylums. D. F. RAmBAUT. 

Treatment of Phthisis in Asylums by Urea and its Salts. J. L. BusxkIn. 

The Alkalinity of the Blood in Mental Disease. RosBert PuGu. 

The Abnormalities of the Palate as Stigmata of Degeneracy. FE. H. 
HARRISSON. 

Insanity from Hasheesh. JoHN WARNOCK. 

1. Structure of the Human Cortex.—These new features described by 

Dr. Turner are (1) A beaded net-work which involves pyramidal cells of 

the cortex cerebri and which have not, hitherto, been observed in the human 

brain, but only around the nerve cells of some of the lower animals (guinea 

pigs and rabbits) when subjected to the influence of methylene blue injected 

into the tissues during life; and (2) an intercellular plexus of extremely 

fine fibrils which has, he believes, never before been actually demonstrated 

in any brain, human or otherwise. 

The technic employed by the author is a modified methylene blue 
method, as described in the autumn number of Brain, 1900. The peri- 
cellular network which he has first described for human brain consists in 
man of fine dark fibrils, on which, at varying distances, are small dark 
beads, or sometimes rings, which, as a rule, are the nodal points of the 
meshes. The size of the mesh and the coarseness of its fibrils also differ, 
so that sometimes one meets with a big-meshed net, having relatively few 
beads and with very delicate fibrils, at others the beads are larger, very 
closely clustered together or even partially coalescing and the fibrils much 
coarser. So far as he has yet been able to determine, this network is met 
with only within the cells of the pyramidal type. It could be seen over 
these in all the layers where they are met with except the skin layer and 
probably the innermost or lower of the spindle-cells. This network he 
believes to be of nerve structure, as it is found along the dendrites, and this 
is evidence, he believes, that these parts themselves are concerned in the 
conduction of nervous impulses. On the question of thorns the author 
believed these to be artefacts. The paper is well illustrated and is one of 
much suggestive interest, particularly as the author takes up a number of 
related physiological questions. 

2. Insanity in Imbeciles—Insanity is rarely met with in the more pro- 
nounced grades of amentia. In the middle grades of imbecility, however, 
such a complication is far from being infrequent, and out of over 200 imbe- 
ciles whom the author has examined in the asylums of the London County 
Council, more than one-half at one time or another had been insane. The 
subject has not been discussed at all in England, and it deserves more at- 
tention. It is found, he thinks, that those imbeciles who subsequently be- 
came insane have for some years before the actual outbreak been prone to 
sudden fits or irritability, bad temper, moroseness or sulkiness often accom- 
panied by acts of violence; or that they have been in the habit of wander- 
ing away from home, or that they have evinced a restless disposition. This 
mental instability appears to the author to be by far the most important 
factor in the causation of insanity in these patients. Uncontrollable idea- 
tion, with resultant delusions, uncontrolled emotional action are two very 
characteristic features in these imbeciles. .They have emotional storms 
which are very common. : 

As for clinical types of insanity, the author says these are mania of 


— 


Se aN 


496 PERISCOPE 


melancholia, mania being the most common form occurring in about 55 
per cent of all cases: melancholia (probably the older definition of meian- 
cholia here being meant). in 40-to 45 per cent. Delusional insanity is very 
rare and general paresis occurred in only two or three per cent. 

3. The Training of Nurses.—This is a short paper on the general topic 
of administration that contains very little that can be abstracted. The author 
in general praises the methods that are practised in our own institutions, 
and speaks of them as being adaptations of general hospital methods to 
asylum life. 

4. Case Taking.—A short note on how to keep case books. 

5. Treatment of Phthisis by Urea.—This is a short paper on the action 
of urea in the treatment of tuberculosis, in addition to some remarks about 
infection and disinfection in asylums. The physiological chemistry quoted 
in the paper is very fragmentary and belongs to an earlier generation. As 
to the exact value of urea in tuberculosis the latest researches do not bear 
out Harper’s extravagant claims. 

6. Alkalinity of the Blood in Mental Disease.—R. Pugh pursues his 
method for determination of the alkalinity of the blood as already spoken 
of in our abstract of his article on alkalinity of the blood in epilepsy in 
Brain already presented, q. v. He summarizes his work on epilepsy in the 
present paper and discusses the blood conditions in general paresis, 
mania and in melancholia. His conclusions are as follows: (1) The alka- 
linity of the blood is physiological in chronic mania, melancholia and de- 
mentia. (2) It is lowered in cases of mania, during the period of excite- 
ment. (3) It undergoes marked variations in epilepsy, e. g.: a. It is below 
normal during the inter-paroxysmal period; b. it undergoes a sudden 
and pronounced fall immediately prior to the onset of the fit; c. it under- 
goes a further diminution after the fit is over. This after-diminution de- 
pends upon the length of time, the severity of the muscular spasms, and the 
degree of the alkalinity in the inter-paroxysmal period; d. there is a gradual 
return of the blood to its normal alkalinity, which takes place in five to 
six hours; e. there is a relationship between the degree of the alkalinity 
and the onset of fits, e.g., the higher the alkalinity the less liable is the 
patient to have a fit; f. it is impossible to elevate and maintain the alkalin- 
ity within physiological limits for any appreciable length of time by the 
administration of drugs. (4) It undergoes a diminution in dementia para- 
lytica. This diminution is constant and well marked, and is probably due 
to the products of degeneration in the circulation. The variations in the 
diminution met with depend upon the type, progress and duration of the 
disease. 

7. Abnormalities of the Palate-—The author first gives a summary of 
the various points of view of others, and the relationship between types 
of palate and mental qualities and describes twelve different kinds of 
palates and comes to the amazing inference: The palate of insane heredity 
is essentially a palate which is shallow or, at any rate, of the average depth 
in front, whatever its other characteristics may be. His general conclusions 
are summed up as follows: (1) Abnormalities of the palate are common 
in the insane; (2) these abnormalities may be roughly classified into two 
large groups, of which the former contains the palate of the sepa ree 
psychopath and the latter the palate of the general degenerate; (3) the 
former palate is variable in its general type, but as a whole is shallow, or, 
at any rate, of the average depth in front; (4) the latter palate is ‘also 
variable in its general type, but is in the main characterized by an increased 
depth at the level of first bicuspids. 

The general criticism that may be offered is that the author makes’ 
generalizations from the few cases studied rather than from a general 
survey of the whole field. 

8. Insanity from Hasheesh—The author’s experience in Egypt as di- 


PERISCOPE. | 497 


rector of the Egyptian Hospital for the Insane at Cairo puts him in a 
position to speak authoritatively on this interesting topic. Large quantities 
of cannabis are used by the inhabitants of the Egyptian towns, where the 
drug is mostly consumed by smoking in the gozeh and in cigarettes. Hash- 
eesh users usually degenerate morally, and for this reason, if for no other, 
the habit is disapproved of in Egypt. Insanity from hasheesh belongs to 
the toxic group and in many regards is similar to that caused by opium, 
alcohol, cocaine, etc. The author compares the insanity from hasheesh 
along lines known for alcoholic intoxication. Thus he describes (1) Tem- 
porary intoxication, in which the smoker becomes dull and drowsy, feels 
pleasantly exalted and is at peace with the world. This is the common 
state to be observed among habitués of hasheesh cafes. There is very 
frequently a staggering gait, and if the hasheesh smoker is annoyed or inter- 
fered with he is liable to become excited, irritated and loses control. The 
author contrasts hasheesh, opium and alcohol by saying that the mental 
pose of the hasheesh smoker is more subjective than alcohol and less so 
than that of the opium user. The alcoholic is the most objective and de- 
monstrative of the three. (2) Delirium from hasheesh, which is usually 
accompanied by hallucinations of sight, hearing, taste and smell. There is 
great exaltation, much restlessness and sleeplessness with motor phenomena 
of staggering, although there is no tremor or ataxia. Physical excitation 
and gastro-intestinal disorders do not occur. (3) Mania varies in degree 
of acuteness from a mild, short attack of excitement to a long, furious 
mania, ending in death. (4) Chronic mania may result. (5) Chronic 
dementia usually is a final stage of the preceding forms. (6) Cannabino- 
mania is employed by the author to describe the condition of many hasheesh 
users between the attacks of the other forms. The user is usually a good- 
for-nothing, lazy fellow, who lives by begging and stealing, and pesters 
relatives for money to buy hasheesh. 

The author gives some statistics bearing on the amount used, and a 
number of interesting and important legal suggestions. He believes that 
hasheesh is a much more dangerous drug in Egypt than India. 


(Vol. 49, 1903, No. 2, April.) 
‘I. Bacteriological and Clinical Observations on the Blood of Cases 
Suffering from Acute Continuous Mania. L. C. Bruce. 
2. The Case of an Unrecognized Degenerate Punished by the Law. 
E. GOoDALt. 
3. Nomenclature of Mental Diseases. A. R. URKUHART. 
4: The Care and Treatment of Persons of Unsound Mind in Private 
: Houses and Nursing Homes. E. W. WHITE. 
54 Lunacy and the Law. T. O. Woop. 
6 Note on a New Case Book Form. W. R. Dawson. 
7) Notes on Hallucinations, IJ. Conotty Norman. 

1. The Blood of Acute Continuous Mania.—L. C. Bruce of Murthly 
contributes a series of observations on the blood in acute mania. A few 
years ago he made some observations on the blood in insanity and was 
unable to find any micro-organisms and he devised a new method of 
making aseptic mecrotic areas subcutaneously and then subsequently 
studying this area to ascertain the bacteria found therein. Acting on 
this theory he took a case of acute mania, an adult woman, and with anti- 
septic precautions injected into the soft tissues of the flank two c.c. of 
turpentine. An abscess formed and on the third day after the injection 
he aspirated some fluid and obtained a small culture of a small diplo- 
bacillus. Since this time he has made 24 similar observations and has 
observed the diplobacillus in seven instances. It has been found only in 


<= 


498 PERISCOPE. 


cases of acute continuous mania, although other forms were studied. The 
details of the cultural characters are given. In a further portion of his 
paper he gives the results of the study of the leucocytes in fifty cases of 
acute insanity. Adopting 6,000 to 10,000 leucocytes per cubic mm. as his 
normal, he has studied leucocytosis in those who became chronic and those 
experimented on as previously reported and recovered, and in those in whom 
abscess was made in a chronic case which did not recover. In recent cases 
he finds that there is a high leucocytosis, thus bearing out the later con- 
tention that acute manias are always of infectious origin. This leucocytosis 
is mostly in the polymorphonuclear cells. In the second class of cases 
the leucocytosis tends to remain between 12 or 60 and 16,000, but the 
polymorphonuclear cells are rarely over 50 per cent. In his third group 
of cases leucocytosis was high, but gradually sank and recovery took place, 
mental improvement, the author declaring to be in proportion to the 
leucocytosis. His general conclusions are as follows: (1) If these blood 
observations are correct, they practically prove that acute continuous 
mania is-an acute infective condition, and that when recovery takes place 
a condition of immunity is established. (2) They prove that, although 
the patient apparently recovers, the disease remains latent; hence the per- 
sistent leucocytosis, a point which might be of great importance in life- 
insurance examinations; (3) an examination of the blood is a valuable 
aid to prognosis, as for instance: If a case of mania has lasted for a 
month and remains maniacal and sleepless. The blood examination gives 
a leucocytosis of 14,000 per c.mm. of blood, with a percentage of 60 or 
below 60 of the multinucleated cells. The chances of an immediate or early 
recovery are poor. On the other hand, if the blood examination gives a 
leucocytosis of 18,000 or 20,000, with the multinucleated cells in a _ per- 
centage of 70 or above 70, the prognosis is good. It is well when exam- 
ining the condition of the blood to aid prognosis, to examine the blood 
on at least two consecutive days. 

2. Degenerate Punished by the Law.—The case is that of a man, 
thirty-five years of age, who showed, on transferral to an asylum from 2 
prison to which he had been condemned for twelve months’ hard labor, 
symptoms of congenital deficiency with depressions, visual and aural hallu- 
cinations and agitation. The patient’s ancestry was bad, and he had been 
in jail nine times previously. Anthropological measurements are also 
given in the paper. The author’s conclusion is that the type of punishment 
meted, i. e., that of short-term imprisonments and discharge for this class 
of cases is useless and injurious to the individual and unjust to society. 
The prison is not a proper place for this type of criminal. He is mentally 
diseased and should be shut up for life in an asylum or reformatory. 

3. Nomenclature of Mental Disease. Vhe author gives some sug- 
gestions on the classification of the insane in which there is very little new 
and nothing striking or noteworthy. 

4. Care of Insane in Private Houses and Homes.—The paper the 
author considers the natural outcome of Sir William Gowers’ recent ad- 
dress on the care of the insane. It takes up the advantages of certified 
single care, and that they are privacy, domesticity, visits of friends, avoid- 
ance of the stigma of treatment in a lunatic asylum; whereas the dis- 
advantages are the absence of skilled medical treatment, unskilled nursing, 
monotony, insufficient moral control, interference of friends, limited 
supervision, want of tact and business capacity on the part of the custodian. 
These are the advantages or disadvantages in the care and treatment of 
the duly certified person of unsound mind in private houses. As to the 
taking charge of a person of unsound mind not under service in a private 
house or nursing home the author’s advantages and disadvantages are 
much the same, the want of official supervision being perhaps the most 


PERISCOPE. 499 


serious of all the disadvantages. There are a number of useful suggestions 
in the paper, but they do not have very ready usage here. 

5. Lunacy and the Law.—T. O. Wood discusses several features in 
the English Lunacy Law, which are of secondary interest to those prac- 
ticing under different regulations. 

6. Note on a New Case Book Form.—This is a short note on the 
method of keeping clinical histories and has no particular points one way 
or another. 

7. Hallucinations——The author here gives the histories of thirteen pa- 
tients suffering from different forms of hallucinations. The paper is too 
detailed to admit of ready abstraction, but it contains many interesting 
suggestions, bearing more particularly upon the theory of psycho-motor 
verbal hallucinations, whereas he does not discuss any of this type. Those 
a are given show interesting connections with the forms described by 

eglas. 

8. Clinical Notes and Cases.—This number also contains Notes on 
some Pathological Cases, by M. J. Nolan, the swallowing of foreign bodies, 
such as nails, bristles, etc., by dements; a case of suppurative cholangitis; 
melancholia with universal acute eczema; senile melancholia associated 
with aneurisms of the aorta and rupture, and also a few Cases of Abdominal 
Surgery in the Insane, by Robert Jones; A Case of Hebephrenia, by W. 
R. Dawson; a Case of Thoracic Aneurism in a Secondary Dement, Simu- 
lating Mediastinal Growth, by Robt. Pugh; and Status Epilepticus Com- 
plicated with Scarlet Fever, by G. W. Greene. JELLIFFE. 


BRAIN 
(Vol. 25, 1902, Winter, No. 4.) 


1. Some Observations on the Primary Degeneration of the Motor Tract. 
F. W. Mort and A. F. TrepGoLp. 

On the Pallio-tectal or Corttco-mesencephalic System of Fibers. 
CHARLES E. BEEVor.and Sir Victor Horsey. 

3. A Case of Arrested Development of the Cerebellum and its Peduncles; 
with Spina-Bifida and Other Developmental Peculiarities in 
the Cord. W.B. WarrINGTON and K. Monsarrat. 

4. Toxic Degeneration of the Lower Neurones, Simulating Periphery 
Neuritis. STANLEY BARNES. 

5. On Certain Blood Changes in Idiopathic Epilepsy. Ropert PuGu. 

1. Primary Degeneration of the Motor Tract. The authors describe 
the clinical course and microscopical appearances in four cases: two 
amyotrophic lateral sclerosis, one of progressive muscular atrophy and one 
of chronic rheumatoid arthritis with muscular atrophy. They say that 
degeneration of the motor tract is the anatomical lesion present in severe 
diseases having distinct clinical features. Thus it occurs in Friedreich’s 
disease, in combined lateral and posterior sclerosis and in general paralysis, 
but in these other neurone systems are also affected. Degeneration may 
also result from local lesions as in the anterior poliomyelitis, polioen- 
cephalitis, embolus, etc. And lastly, cases exist in which not a degenera- 
tion but an arrest of the development of the motor tract occurs, appar- 
ently due to simple agenesis. It is with the primary degenerations, how- 
ever, that occur in amyotrophic lateral sclerosis, progressive muscular 
atrophy, bulbar paralysis or primary spastic paraplegia that the paper deals. 

Speaking of the nature of the morbid processes they believe that the 
changes in these cases are those of a sub-acute or chronic degeneration 
of a portion or the whole of the motor tract, that is of the upper segment 
alone, of the lower alone, or of both segments together. The cases they 
describe demonstrate that the change is a slow attack of individual neu- 


to 


500 PERISCORE. 


rones. The cells become shrunken and irregular in outline, the Nissl 
bodies gradually disappear, their space is taken by a large collection of 
yellow pigment, the nucleus becomes smaller and its outline displaced. 
Later it is displaced to the periphery of the cell and finally disappears. 
There is true degeneration in the nerve fibers and in the end organs. 
Neuroglia gradually takes the place of the atrophied nerve fibers causing a 
secondary sclerosis. The authors believe that this progressive degenera- 
tion is due to the fact that the neurone has reached the stage at which its 
inherited vitality is exhausted and that this presents a probable indication 
of presenile decay, but they present no evidence one way or another. 

On the question of the pathological relations between the upper and 
lower motor segments they say that while there can be no doubt of the 
existence of trophic action between the upper and lower parts of the 
efferent tract, in some cases the presence of degeneration in one portion 
resulting from degeneration in the other seems to be rather the exception 
than the rule, and they consider that it is now well established that disease 
may involve ‘either segment separately or both together, and if each seg- 
ment of the motor tract is specially susceptible to the influence of par- 
ticular poisons it seems legitimate to conclude that there may be different 
hereditary tendencies in the two tracts, in some persons there may be a 
premature tendency to decay in the upper portion. in others in the lower 
portion, and in still others throughout the entire motor system. Other 
neuronic involvement was present in some of the cases. - These were con- 
sidered secondary by the authors and were discussed under two heads, 
association fibers and efferent fibers. 

2. Pallio-tectal System of Fibers——An investigation of fibers com- 
eat the crus cerebri in a number of animals, 20 cats, 11 monkeys, 1 dog 
and 2 badgers. Local lesions in the cortex had been made by Horsley. 
While tracing the degerations which resulted from such lesions the authors 
especially followed out the connections which have for some years been 
known to exist between the cortex and the mid-brain. The Bush modi- 
fications of the Marchi method were used and serial sections studied. The 
results obtained are very detailed and the original should be consulted, but 
the general statement may here be made that as the research was founded 
chiefly on observations on the cat, representing the carnivora, and the 
macaque monkey, representing the primates, the results are to be under- 
stood as applicable only to the higher of these animals in which there is a 
well-developed non-excitable area (frontal) in front of the so-called motor 
or excitable cortex. The general scheme of the pallio-tectal system is 
stated by the authors to be as follows: From the frontal cortex no fibers 
can be traced to the mesencephalon; from the temporo-sphenoidal cortex 
very few fibers; while from the occipital lobe a fair number, and from the 
excitable cortex a large number of fibers can be followed to the corpora 
quadrigemina and mesencephalon. The course taken by the different 
group of fibers is then traced by the authors. We can not give the details 
in this place, but refer the reader to the original. 

3. Arrested Development in the Cerebellum.—The authors describe in 
full the clinical history of a case of restricted development of the cerebel- 
lum, and then describe the macroscopical appearances of the brain and cord; 
the histology of the medulla, cerebellum, pons and membranes with the fol- 
lowing results. A child, aged six weeks, presenting a lumbar spina bifida 
ruptured at or before birth, and now healed; hydrocephalus, paraplegia 
of both lower limbs. Death from intercurrent gastro-enteritis. 

(1) In the brain. Arrested development of the cerebellum and of its 
efferent and afferent fibers, and of their nuclei of origin; of the restiform 
bodies, the olives, accessory olives, external arcuate fibers and nuclei arcu- 
ati, middle peduncles and transverse fibers of the pons, pontal nuclei, 
vestibulo-cerebellar tracts, superior peduncles, gray nuclei of cerebellum, 
red nuclei of tegmentum; possibly the cerebro-pontal tracts. 


PERISCOPE. SOI 


; (2) In the cord. General attenuation of this structure throughout, di- 
vision at the level of the fourth dorsal vertebra into two equal halves; 
marked enlargement of the central canal which divides with the division 
of the cord; the presence of various irregular cavities in the cord and 
disintegration of its central parts in the lower dorsal region; normal 
development of the gray matter with well-formed ganglion cells; scanty 
development of white matter, its place being taken by tissue of neuroglial 
structure. 

(3) The coverings of the cord. The whole cord as far as the upper 
cervical area, embedded in a fine connective tissue with large vascular 
channels; the laminz and spines of the fourth and fifth lumbar vertebre 
deficient; an exostosis dividing the canal at the level of the fourth dorsal 
vertebra. In an appendix they give a complete bibliographical summary 
of cerebellar atrophies aranged on the basis of their proper pathogeny. 

4. Toxic Degeneration of the Lower Neurones.—Dr. Barnes reports 
the histories of seven cases in which the clinical picture resembles in many 
respects that of peripheral neuritis and yet in other ways corresponds 
to the type of progressive muscular atrophy. The clinical histories are 
given very thoroughly, and his conclusions are very interesting. These 
may be summarized as follows: (1) There is a clinical type which is 
usually the sequel of acute specific fevers, which resembles the paralysis 
seen in multiple neuritis, but which is associated with great atrophy of the 
hand muscles. It usually begins about the second or third week after the 
febrile condition and involves the muscles from the periphery to the trunk 
to a varying extent. It may progress for a few days only, or for several 
months. Sensory signs are present, but slight in degree. Although the 
condition somewhat resembles progressive muscular atrophy, the prognosis 
and etiology. of the two conditions are probably widely different from one 
another. 

(2) After a certain stage, when once definite improvement has begun, 
relapses are not common, and there is a constant tendency to improvement. 
Even years after the subsidence of the acute condition considerable improve- 
ment may still take place, the small muscles of the hands being the last to 
recover. Contractures are rarely developed. 

(3) Probably the condition is one of toxic degeneration of the lower 
neurones, the motor neurones being more particularly affected. 

5. Blood Changes in Idiopathic Epilepsy. Dr. Robert Pugh of Clay- 
bury presents the results of the examination of forty cases of epilepsy in 
which differential counts of the leucocytes have been made, and the study of 
the alkalinity of the blood carried on. The author concludes that in epi- 
lepsy there are marked variations in the alkalinity of the blood, most of 
which manifest themselves by diminution of alkalinity. The average alka- 
linity during the (a) interparoxysmal period is lower than the average 
of the contro] cases. (b) There is a sudden pronounced fall immediately 
prior to the onset of the fit. (c) There is a certain diminution after the 
fit is over. Accounting for the interparoxysmal diminution the author 
suggests two hypotheses: (1) It may be explained by the gradual accu- 
mulation of toxines of an especial nature in the blood, and (2) that it may 
be the result of deficient metabolism, general metabolism being known to 
be below par in epilepsy. Accounting for the pronounced fall in the 
alkalinity immediately prior to the onset of the fit. The most likely origin 
of the acids the author claims are either (a) neuronic, (b) muscular. In 
the first case, the increased amount of acid being derived from the muscular 
and the glandular tissues. The author says that the exact role which the 
diminution in the alkalinity of the blood plays in the production of an 
epileptic attack is difficult to estimate. It is of utmost importance for any 


502 PERISCOPE. 


cell in the body to have a proper adequate and pure supply of blood, and 
this applies especially to cerebral neurones, as they are extremely sensitive 
to a change in environment. The author believes that he has obtained 
good results in the treatment of epilepsy by maintaining the alkalinity of 
the blood within physiological limits, but unfortunately he says it is im- 
possible to elevate and maintain the alkalinity by the administration of 
drugs. 

With reference to the leucocytes, there is a distinct leucocytosis, par- 
ticularly after the attack. The author’s general conclusions are as follows: 
(1) The alkalinity of the blood in the interparoxysmal period is lower than 
the average of the control cases; (2) the diminution is gradual and pro- 
gressive and is more marked in those cases suffering from gastric catarrh 
and constipation; (3) there is a marked sudden and pronounced fall im- 
mediately prior to the onset of the fit; (4) there is a further fall in the 
alkalinity after the fit is over; this diminution is seen from three to ten 
minutes after the attack; (=) this after-diminution depends upon the 
duration and severity of the muscular twitching, and upon the degree of 
the alkalinity in the interparoxysmal period; (6) there is a gradual return 
of the blood to its normal alkalinity, which takes place in five to six hours, 
the rise being more marked in the first hour. 

JELLIFFE. 


LE NEVRAXE 
CVoLY LV.) Base. 13451002.) 


8. On the Form and Development of the Protoplasmic Prolongations 
of the Spinal Cells in the Higher Vertebrates. T. GEIER. 

g. Researches on the Central Acoustic Tracts: The Bulbo Mesenceph- 
alic Acoustic Tracts. VAN GEHUCHTEN. 

10. The Inhibitory Fibers of the Heart belong to the Pneumogastric 
Nerve and not the Spinal Nerve. VAN GEHUCHTEN. 

8. Form and Development of Protoplasmic Prolongations.—Dr. 
Geier has been studying the dendrites of the spinal cells of the horn fibers, 
using kittens and rabbits for investigations. Golgi’s method was used. 
He finds that the dendrites of the anterior horns are smooth in contour 
and differ from the posterior horns which have an irregular contour. 
The spinal dendrites extend in a straight line, while those in the poster- 
ior horn are irregular and sinuous. The dendrites in the cells of the an- 
terior horns have few and insignificant collateral appendices while those 
of the posterior horns are quite complex. There are many variations in 
the dendrites of the new-born animal as contrasted with those of the 
adult, for full details of which the reader is referred to the original. 

9. The Upper Auditory Tract—Van Gehuchten here presents re- 
sults of an extended series of experiments performed on rabbits and stud- 
ied by the Marchi method. Five series of experiments are given which 
lead Van Gehuchten to different conclusions than those heretofore held. 
In the first group of cases he tore the seventh nerve out through the stylo- 
mastoid rim. In this way the ventral fibers of the trapezoid body were 
involved. Serial sections showed that degenerated fibers were found pass- 
ing into the trapezoid body vertically above and below the actual level 
of the lesions. In the trapezoid these fibers could be traced to the oppo- 
site side; they turn upwards, those ventrad passing in front of and those 
dorsad behind the trapezoid nucleus. These two degenerated bundles 
so united to form a compact strand of fibers which lay in contact with 
the lateral aspect of the inferior nucleus of the lateral lemniscus. Tracing 
this strand of fibers upward it was found to turn outward and then back- 
wards finally entering and forming the more superficial part of the lat- 


PERISCOPE. 503 


eral fillet. From this place onward the fibers could be traced to the pos- 
terior quadrigemina where they terminated close to the superior nucleus 
of the lateral lemniscus. In the second series of cases, similar degenera- 
tions were found. In a third series a lesion was made by cutting down- 
ward and outward through the floor of the fourth ventricle, dividing both 
the dorsad and ventrad fibers of the corpus trapezoid. Similar con- 
clusions as those already outlined were reached by this method of inves- 
tigation. The fourth series of experiments was made to ascertain the 
cells of origin of the two strands of the corpus trapezoid tract. If a 
lesion was restricted entirely to the accessory nucleus of the eighth 
nerve degenerations corresponding to those just described resulted. 
On the question of the relation of the medullary striz in the secondary audi- 
tory path the author found that attempts to cut these on the floor 
of the fourth ventricle were unsuccessful but they were found destroyed 
in an experimented animal in which the seventh nerve had been torn out 
and had ruptured the acoustic striz. Degenerated fibers can be followed 
from the point of injury to their raphe where they crossed dorsad to 
the upper fibers and the trapezoid body until they became posterior to 
the olivary nuclei. They then turned upwards, lying behind the dorsal 
trapezoid tract and internal and ventrad to the motor fifth nucleus. 
They entered the lateral lemniscus at the upper border of the upper cerebral 
peduncle, being mingled with the fibers of the dorsal strand of the corpus 
trapezoid. They finally ended in the nucleus of the posterior quadri- 
gemina itself, thus tracing the fibers of the secondary auditory path 
higher than those previously described. The author was unable to verify 
the opinion of Held that neither the dorsal nor ventrical auditory paths 
could be traced to the inferior corpora quadrigemina or cortex. Thus 
the author holds that the central auditory path is in reality a bulbo 
mesencephalic rather than a bulbo-cortical one. The illustrations are 
numerous, there being over 62 illustrations accompanying this extremely 
interesting and suggestive article. 

10. Inhibitory Fibers of the Heart.—Van Gehuchten controverts the 
old idea that the inhibitory fibers of the heart arise in the spinal acces- 
sory and pass to join the vagus by its internal branch. 

He concludes that (1) the inhibitory fibers of the heart do not come 
from the spinal accesory nerve but are derived from the vagus itself. (2) 
His investigations on the innervation of the larynx (see abstract of last 
number) go to prove that all of the bulbar fibers of the spinal accessory 
are distributed to the muscles of the larnyx; the eleventh nerve has an 
exclusive medullary origin and (4) the vagus gives off a superior and 
inferior system of fibers exclusively motor, including motor fibers destined 
to all the muscles of the larynx exclusive of the crico-thyroid, which is 
supplied by the inferior laryngeal nerve and a secondary series of inhibi- 
tory fibers to the heart. JELLIFFE. 


REVUE DE PSYCHIATRIE ET DE PSYCHOLOGIE EXPERIMENTALE 
(January, 1903.) 
1. Tests in Psychopathology. Ep. TouLousrE and N. Pr&éron. 
2. Experimental Researches on the Psychology of Memories. N. VASCHIDE 
and CL. VurRPAS. 
3. Study of Morbid Obsessions. 

1. Tests in Psychopathology.—The aim of this article is to indicate 
the lines along which the development of psychopathological tests must 
proceed if they are to be more exact and comparable. In their introduction 
the authors critically review the work of Guicciardi and Ferrari and of 
Tamburini, Badaloni and Brugia. They then proceed to a brief statement 


504 PERISCOPE. 


of their own methods illustrated by their application in the domain of 
memory. They believe in the general principle that the methods for the 
study of the abnormal mind should be the same as those used for the study 
of the normal, for the abnormal mind differs only from the normal in 
showing exaggeration of certain characters or defect of others—differences 
only of more or less. Applied to an experimental study of the memory 
of sensations their method would involve the use of a definite multiple of 
the previously determined minimum perceptible stimulus in the sensory field 
under consideration. In this way only can results comparable as between 
different subjects be obtained as no stimulus is felt the same by all. There 
is no absolute in psychology, only the relative. In the study of the memory 
of perceptions the optimum or quantity best perceived is used as a basis, 
while in the study of the memory of ideas sentences constructed of identical 
length, in the same style, containing the same number of ideas disposed in 
the same way are used, thus detaching as far as possible the idea from its 
setting. The article closes with a few words on the calculation of errors. 

2. Psychology of Memories (continued). 

3. Morbid Obsessions.—The authors have studied for this article in all 
ninety-seven cases. They have studied only those cases in which the 
obsession was the essential psychopathic symptom, not differentiating for 
their purposes the phobias from the morbid obsessions. The results of 
their studies are as follows: 

Of the 97 cases examined 76 were men and 21 women. ‘The occupa- 
tions were distributed as follows—8 clergymen, 11 merchants, I1 office 
employees (all men), 14 domestics (all women), 17 artisans, and 29 per- 
sons in different intellectual professions. The greater part of the obsessed 
were thus from intellectual pursuits; 92 per cent of all cases showed here- 
ditary tendencies. Of 94 cases 7 only showed no afflicted relatives, 38 
showed I or 2, 30 cases had 3 to 5, and 19 cases 6 or more. Thus in the 
great majority of cases at least 3 members of the family had been afflicted. 
Of &8 cases 7 showed no heredity, in 32 heredity existed on one side only, 
and in 49 on both sides. One-third of all cases showed a homogeneous 
heredity. A study of the mental life of these cases shows them to have 
been possessed of a peculiar character from early life, marked by indecision, 
irritability, desire for solitude, painful and disagreeable emotions, egotism 
and often hypochondriacal ideas. In 77 of the cases the phenomena mani- 
fested themselves at twenty years of age, in II cases after twenty years. 
The development was usually progressive and by insensible degrees. This 
progress, however, may be interrupted by exacerbations, especially as a result 
of influenza, menstrual difficulties, puberty, etc. Occasionally as an accom- 
paniment of the obsession is found epileptoid, hysteriform, vertiginous or 
syncopal attacks, and sometimes complicating this condition sexual per- 
version, sexual excitability (4 cases), masturbation (42 cases), or other 
sexual anomalies (28 cases). Occasionally these cases dement, and then 
arises the question of differential diagnosis between pure morbid obsessions 
and dementia precox with obsessions. 

(February, 1903.) 
1. The Mental State in Cerebral Tumors. A. VicouRoUx. 
2. Experimental Researches on the Psychology of Memories. N. 
VASCHIDE and CL. VurRPAS. 

1. Mental State in Cerebral Tumors—The author deals with these 
three points in this article; first: have these psychic troubles characters 
which point to the presence of a tumor? second: are they of such a nature 
as to indicate its location? third: can they be classified? After a careful 
teview of the opinions of writers on this subject the authors answer these 
queries negatively. Psychic symptoms may or may not accompany a tumor 
in a given location, and their nature is independent of the nature of the 
tumor as such and may be the result of accidental conditions, such as inter- 


PERISCOPE. 505 


ference of circulation, meningitis, the impregnation of the brain by toxic 
products of disassimilation, surrounding inflammation and many other 
causes. Finally the author concludes, with Ball, that when a true psychosis 
is found associated with a cerebral tumor, there is every reason to be- 
lieve that the association is a simple coincidence. 

2. Psychology of Memories (concluded).—An experimental study con- 
fined solely to the domain of psychology and having little interest from 
the standpoint of psychiatry. Wo. A. WuiTeE (Binghamton, N. Y.) 


MISCELLANY 


~ ah AND THEIR DANGERS. Dr. Nestor Tirard (Lancet, April 11, 
1903). 

In a treatise on some dangers of hypnotics the author draws the fol- 
lowing conclusions: He says that he is convinced that in the employment 
and in the selection of a hypnotic sleeplessness is perhaps the least im- 
portant factor to be considered, although it may be the sole symptom of 
which complaint is made. The cause must be ascertained, together with 
any indications of idiosyncrasy. The co-existence of other diseases must 
influence the selection of the hypnotic, and even when, for the individual 
case, a suitable hypnotic has been found, risks of repeating moderate doses 
must be borne in mind. Generally the dose has to be gradually increased, 
especially when the cause has not been ascertained or satisfactorily dealt 
with, but with some drugs, e.g., sulphonal, trional and tetronal, the danger 
appears to lie in the total quantity taken, even though each dose may have 
been small. But perhaps the greatest danger of all is incurred when the 
patient is given a prescription for a hypnotic, and this danger has certain 
analogies with the medicinal employment of alcohol. Many of us believe 
that at the height of fever or in conditions of collapse, alcohol is often 
necessary, but it is never recommended to our patients for indefinite use, 
still less for increasing doses. Armed with a prescription for a hypnotic 
patients commonly go on taking the drug long after the relief of the special 
circumstance for which it was prescribed, and the prescription may be 
used to facilitate the acquisition of large quantities of a dangerous drug 
obtained, perhaps, at several establishments in small amounts. Notwith- 
standing the relief which many have derived from the use of hypnotics, 
he is in favor of any step which tends to prevent their administration, 
except by the medical man or under his immediate directions. He has seen 
so much of the dangers of hypnotics that he would prohibit their sale to 
the public or would allow them only to be dispensed to a freshly-dated pre- 
scription, which should be retained by the druggist or returned to the pre- 


scriber. JELLIFFE. 
NERVE SUTURE AND NERVE DEGENERATION. P. B. Henriksen (Lancet, April 
II, 1903). 


In a study on the subject of nerve suture and nerve degeneration, the 
author says, considering the question of whether a degenerated nerve 
can be supposed to be to some extent conducting: This question may be 
solved in two ways—either by proving conducting elements in the degen- 
erated nerve or by proving effects of the nerve function during the degen- 
eration period. According to what has formerly been mentioned, the new 
fibers must be supposed to be formed of elements in the peripheral part 
of the nerve. What are these elements, and at what time can they be shown 
as continuing courses fit for conducting a nerve impulse? When a nerve 
is divided the weight of a corresponding muscle will diminish rapidly. By 
weighing the muscle twelve days after dividing one peroneal nerve of a 
rabbit it was found that the muscle corresponding to the divided nerve 
weighed 4.77 grams, while the muscle on the other side weighed 6.98 


506 PERISCOPE. 


grams—a difference of 33 per cent. When the nerve is united again 
motility comes earlier than the electrical reaction. In several of the ex- 
periments the difference seemed to be considerable, as the animals could 
use the operated limb as well as the other limb long before 
electrical reaction was _ observed. If the muscles have thus. re- 
sumed their activity, and in consequence of a _ return of nerve 
conduction, one may suppose that this also may be shown by changes 
in the microscopical appearance of the muscles or in the cessation of atrophy 
or by increasing weight. To examine these circumstances, the third series of 
experiments was made in the following way: The peroneal nerve was di- 
vided on both sides. On the one side one of the ends was pulled out through 
the slit in the fascia and fixed subcutaneously, while the slit for the rest 
was closed with catgut. In this way the nerve was prevented from uniting. 
On the other side the divided nerve was permitted to unite. The animals 
were killed after some days’ interval, and both the united nerve and the 
central and peripheral ends of the non-united nerve were hardened for 
microscopical examination. The muscles supplied by the peroneal nerve 
were carefully dissected out as similarly as possible on both sides and 
were then immediately weighed. A piece of the muscles was cut out from 
corresponding places of the muscles on both sides and hardened in formalin 
for microscopical examination. JELLIFFE. 


MASSAGE IN Locomotor ATAXIA. Dr. de Frumerie (Le Progrés Médical, 

Feb. 28, 1903). 

In every manual treatment it is necessary first to determine whether 
the effect desired is stimulation or sedation. In tabes the author confines 
his massage to sedative measures, avoiding any brusque or energetic move- 
ments which so often lead to hyperesthesia. The suitable types of man- 
ipulation for this disease are superficial or deep effleurage, vibratory motion 
of the abdominal viscera, and prolonged compression, the last sometimes 
overcoming the lightning pains when energetic measures have had no effect. 
For paralysis of the bladder the organ should be emptied of its infected 
urine and one-third filled with boric acid solution; then the curved fingers 
are pressed down behind the pubes and gentle tremulous motion set up. 
The perineal region may be subjected to effleurage and continuous pres- 
sure. When there are contractures, one must avoid the contracted muscles, 
the flexors, and by every means possible try to strengthen their antagonists, 
the extensors. The flexors then should be slowly and cautiously stretched 
by passive motion. Where there are no special contractures, a general 
stretching or extension may be brought about as follows: The patient lies 
on a bed and places the feet against the chest of the operator; then, without 
bending his knees, he is seized by the hands and pulled forward, the oper- 
ator at the same time giving him a tremulous movement. This affects the 
spinal cord, the sciatics, the ligamentous and muscular tissues of the back, 
and the brachial plexus, without fear of injury to the femoral neck, which 
is so fragile in certain tabetics. BASTEDO. 


MYASTHENIA Gravis. Charles S. Myers (Journal of Pathology and Bac- 

teriology, Sept., 1902). 

Three signs may be described as pathognomonic of myasthenia gravis. 
They are (1) ready fatigue of certain or general voluntary movements 
either to a succession of tetanizing currents applied to the nerve or to 
volitional impulses descending from the brain. (2) The exacerbations and 
reniissions shown in the course of the disease, and (3) the tendency to a 
fatal implication of the muscles innervated by the bulb. To these must 
be added other very important general signs mainly of a negative character. 
(4) There is no reaction of degeneration; the muscles react to a faradic 
current of normal intensity, or more often require one somewhat stronger 


PERTSCOPE: S07 


than normal. (5) The muscles, as a rule, show neither atrophy nor fibril- 
lar contraction. (6) Sensation and intelligence are unimpaired. (7) 
The reflexes may be normal, are often feeble, but perhaps most frequently 
are somewhat exaggerated. Clonus is absent. (8) Purely voluntary 
muscles are alone affected. The mechanisms of defecation and micturition 
are never impaired. (9) The myasthenia, although often unequally marked 
on the two sides, is almost invariably bilateral. Myasthenia gravis is dis- 
tinguished from hysteria by absenee of stigmata or disturbance of sensa- 
tion; from clonic bulbar paralysis by the extraordinary remission and ex- 
acerbation of symptoms, the general absence of muscular atrophy, of fibril- 
lary contractions and degenerative electrical variations. Of 22 cases on 
which autopsies were performed, 8 showed no _ pathological condition 
of the nervous system. In 3 cases minute aneurisms or vascular dilata- 
tions were noted; and in 2 the cerebral arteries appeared thickened. Eight 
cases examined by Nissl’s method, in 3 slight chromatolysis was found. 
Hemorrhages in the central nervous system always recent and frequently 
numerous were found in 6 cases. The peripheral nerves and muscle fibers 
were examined several times, yielding varying changes in the muscles and 
rarely changes in the nerves. The writer does not believe that either the 
muscles or the higher parts of the brain are primarily affected. The disease 
probably arises from some autogenetic-toxine. The end plate is affected 
and with it the entire neurone, secondarily. W. B. Noyes. 


Tue D1acGnosis oF BRAIN ApscEsses. Herman H. Hoppe, M.D. (Journal 

American Medical Association, March 14, 1903). 

Given a certain group of signs and symptoms which lead us to suspect 
the presence of a brain abscess, the first point is tracing the source of 
infection. Bergman says that without the Streptococcus pyogenes aureus 
there cannot be a brain abscess. But to find the external source of infection 
is difficult. Bergmann divides brain abscesses into four groups. (1) 
Traumatic abscess caused by an open scalp wound or a fractured skull. 
(2) Those abscesses resulting from a purulent inflammation of bone or 
bony cavities, (a) otitic abscess, (b) rhinogenetic abscesses, (c) abscesses 
due to caries of the bones of the skull. (3) Tuberculous abscesses. (4) 
Metastatic abscesses. The symptoms of brain abscess may be grouped as 
follows: (1) Symptoms due to deep-seated suppuration, (2) symptoms 
due to intracranial pressure, (3) focal symptoms. Fever and other signs 
of sepsis, chills, localized pain and tenderness, vomiting and, at times, 
distinct mental symptoms are important symptoms. Optic neuritis is more 
frequent than in brain tumor, but not so well developed. If it is absent 
the abscess is either very acute or small. It is most marked in abscess of 
the frontal lobe. Focal symptoms help much to make the diagnosis if the 
abscess is present in the psychomotor area, little if present in the occipital, 
temporal or frontal lobes. The closer the abscess to gray matter, and the 
greater the destruction of tissue, the more focal signs are developed. A large 
abscess of the centrum ovale may exist without focal signs. 


W. B. Noyes. 


Pook Reviews. 


A TREATISE ON HuMAN ANATOMY IN ITs APPLICATION TO THE PRACTICE 
oF MEDICINE AND SuRGERY. By Joun B. DeAver, Surgeon in Chief to 
the German Hospital, Philadelphia. In three volumes, illustrated by 
499 plates nearly all drawn for this work from original dissections. 
Vol. III. Abdomen, Pelvic Cavity, Lymphatics of the Abdomen and 
Pelvis, Thorax and Lower Extremity. P. Blakiston’s Son & Co., 
Philadelphia. 

The arrival of the third volume of Deaver’s Surgical Anatomy has 
been anxiously awaited by all possessors of the first two volumes, and 
their fondest anticipations have been fully realized upon their receipt of 
the final volume which has more than kept up the high standard already 
established by the first two. 

The excellence of the plates from an artistic standpoint and their cor- 
rectness as to anatomical detail, can hardly be surpassed. In the text the 
author has not gone into the minute anatomical description of the different 
organs, yet he has indicated most of the surgical procedures which may 
be required and has presented it in a clear and concise manner. 

Volume III takes up the Abdomen, Thorax and Lower Extremity. 
The surface anatomy of the abdomen and thorax is beautifully depicted 
with tracings of the main vessels and contained organs, giving the anterior, 
posterior and lateral views; then follow descriptions of the superficial and 
deep fascize and the muscles. The anatomy of the inguinal canal is well 
brought out and is made perfectly clear by the numerous illustrations. The 
peritoneum, the reflections of which the student is apt to find a stumbling 
block, is made perfectly plain by means of four full page plates. The 
abdominal and thoracic organs are all described and beautifully depicted, 
particularly the heart and lungs. The lower extremity has its surface 
anatomy marked out and particular attention is given to the anatomy of 
Scarpa’s triangle, the gluteal region and femoral hernia, also the popliteal 
space. The joints of the lower extremity are fully described, and the de- 
formities commonly met with, as well as the surgical procedures indicated 
for their relief. Dislocations are also touched upon as well as excisions, 
the lines of incision for which are indicated not only for the joints them- 
selves but for the bones of the foot. Fractures are lightly gone over, 
likewise amputations, ligation of arteries and nerve stretching. 

The author has left little ground for criticism in this work, and the 
only one we could possibly make would be in reference to the female pelvic 
cavity. Ina field where so much work is done at the present day, not only 
by the gynecologist but the general surgeon, we think a plate showing the 
relations of the ureter and uterine artery would be greatly appreciated, 
as the former structure is so frequently injured in doing a hysterectomy. 
Although the author advocates, as does Kelly, the passing of bougies into 
the ureters to mark their course, in reality this is seldom done, and fre- 
quently it is impossible on account of the tumor which necessitates the 
hysterectomy, distorting the bladder to such an extent as to render the 
passage of bougies exceedingly difficult, if not impossible. 

The author tells us in his preface that as originally planned the work 
was to contain 200 illustrations. Vol. III contains 178 alone and the text 
has been constantly revised and much added, especially with reference 
to surgical procedure. He certainly deserves the congratulations of the 
medical profession, particularly the surgeons, for bringing to completion 


BOOK REVIEWS. 509 


this work, which has cost him sixteen years of painstaking labor. Every 
practitioner doing any surgery will find this work of exceedingly great 
value, and the student of anatomy will find the illustrations a great aid 
to thorough comprehension of the subject. CyHas. F. ADAMS. 


OrGANnic Nervous Diseases. By M. ALien Starr, M.D., Pu.D., LL.D. 
Illustrated with 275 engravings in the text and 26 plates in 
colors and monochrome. Lea Brothers & Co., New York and Phila- 
delphia, 1903. 

The author of this work is so well known, both at home and abroad, 
and his experience has been so extensive, that we may expect much from 
him in a book on nervous diseases. The statements made by him, as he 
himself says, are based in a large degree upon the pathological and clinical 
material accumulated during the past twenty years. A careful examination 
of the work shows that he has carried out his intention of utilizing his 
personal observations without ignoring neurological literature. The de- 
scriptions are clear, and the work, while it will be read with interest by 
the specialist in neurology, will be easily understood by the undergraduate 
student. 

A short chapter on the structure of the nervous system is the intro- 
duction to several chapters on diseases of the nerves. These are followed 
by chapters on organic diseases of the spinal cord and of the brain. The 
neurone doctrine is taught. 

In regard to trophic lesions, Starr says that the explanation of these 
changes is to be found in the interruption or perversion of sensory impres- 
sions and that “nature, lacking its accustomed guide to repair and mis- 
Jed by abnormal impressions, produces effects which are needless under 
the circumstances, or fails to produce those which ordinarily would be 
required.” Physicians and nurses may read with prickings of conscience 
that bedsores may be entirely prevented if by extraneous care pressure and 
irritation are avoided, as in health would occur by change of position and 
care of the skin. This is not unlike a statement made by Strtimpell years 
ago, and yet there are still physicians who are unwilling to explain bedsores 
entirely by mechanical causes. Starr has little belief in the origin of tro- 
phic disturbances in alteration of special trophic or of vasomotor nerves. 

He has never seen a case of true ascending neuritis, although he has 
seen many cases of painful affection of the extremities above the level 
of the neuritis that were hysterical in nature. As regards those cases that 
are not hysterical, Starr’s explanation is that “mild irritation long con- 
tinued produces in a nerve center a hypersensitive state by what is known 
as a summation of impulses. In this state slight impressions are believed 
to be intense and local impressions become generalized and widely re- 
ferred. This state may be induced by neuritis long continued, and has been 
mistaken for an ascending neuritis.” Ascending neuritis has been re- 
garded by other neurologists as an extremely rare affection, and yet some 
practitioners seem to make the diagnosis in ignorance of this fact. 

Starr believes that neuralgia has, in every chronic case, some organic 
lesion, and that in acute cases some temporary malnutrition of the sensory 
fibers is present. It is hard to doubt the correctness of this statement, 
especially if one has made many clinical and pathological studies. Starr 
accepts this teaching so readily that he does not hesitate to place neural- 
gia among the organic nervous diseases. Aconitine is the best remedy, in 
his opinion, for tic douloureux, and he administers it in pill or tablet form, 
preferring the French pills of Chapoteaux. Each of these contains 1-500 
grain, and the remedy must be used with sufficient frequency to produce 
constitutional effects. He begins with one pill every four hours and de- 
creases the intervals each day one-half honr, until one pill every two 


§10 BOOK REVIEWS. 


hours is taken or symptoms are present, such as tingling of the tongue and 
fingers, a sense of general weakness, and feebleness of the pulse. He 
combines with the aconitine a fiftieth of a grain of strychnine during the 
first two days, and then 1-100 of a grain when the aconitine is being 
given every two hours. Sometimes he substitutes caffeine or sparteine 
for the strychnine. A cardiac stimulant should be used when large doses 
of aconitine are given, and sudden muscular efforts should be avoided. 
Other remedies are mentioned. As regards the strychnine treatment in 
massive doses. as recommended by Dana, Starr says he has seldom seen 
any benefit result from this treatment, but has seen severe strychnine poi- 
soning ensue. We should like to have further opinion in regard to the 
aconitine treatment, because most cases of severe tic douloureux are 
treated successfully usually by operation. 

In Starr’s experience all syphilitic nervous lesions, whether central or 
peripheral, yield more promptly to the combined use of inunctions of mer- 
cury and large doses of iodide of potassium, than when either is employed 
alone. While he does not deny the possibility of multiple neuritis oc- 
curring as a result of syphilis, and even mentions two or three possible 
cases he regards this cause as very rare. Alcoholic neuritis, in his expe- 
rience, as in that of Gowers and others, is relatively far more frequent 
among women than among men. It is important to emphasize the word 
relatively, as alcoholism is so much more common in males. 

Starr does not attempt to distinguish sharply between chronic ante- 
rior poliomyelitis and progressive muscular atrophy of spinal origin; 
indeed, the latter is regarded by him as one of the types of the former. 
The sharp distinction made by some authors between these two forms of 
muscular atrophy has always seemed to the reviewer somewhat arbitrary. 
Amyotrophic lateral sclerosis 1s described as distinct from the progressive 
spinal muscular atrophy. 

The primary lesion of tabes dorsalis, according to Starr, lies in the 
posterior spinal ganglia and in the ganglia of the cranial nerves, and 
possibly in the ganglia of the sympathetic nervous system. This is a very 
positive statement, and expresses an opinion that is by no means universal. 
According to the figures afforded by Starr’s cases, about seventy per cent 
of tabetic patients have had syphilis. He is unwilling to admit that there 
is “no tabes without syphilis.” In regard to the much disputed question 
of antisyphilitic treatment in tabes, he advises that this treatment should 
be employed whenever a history of previous infection is obtained, or 
whenever its existence is strongly suspected. 

No one doubts that chronic myelitis may develop as the result of an 
acute myelitis, when a certain amount of damage in the spinal cord is pro- 
duced, but we have the very positive expression of opinion from Starr 
that myelitis may be from its onset a slow process, and thus chronic from 
the start. 

The views concerning operation in injury of the spinal vertebre are 
conservative and wise, if the reviewer may be permitted an expression of 
his own opinion. ‘There should be some reason to hope for removal of 
compression before operation is attempted. “If there is evidence, by 
X-ray examination,” says Starr, “of an existing compression of the cord 
by displaced bone, this should always be removed. If, however, there is 
no such evidence an operation should be refused.” The reviewer has 
seen a person with fracture of the vertebra, who had recovered partially in 
course of time, placed in a much more serious condition by exposure of 
the spinal cord. Nothing is said regarding operation upon the spinal col- 
umn in spinal caries. Laminectomy may cause distinct increase in the 
severity of the symptoms in this disease, as in a case recently seen by 
the ‘reviewer. 


BOOK REVIEWS. SII 


Much might be written concerning the excellent chapters on the 
diagnosis and localization of cerebral disease, on the cerebral atrophies of 
childhood, on encephalitis, paresis, abscess and tumor of the brain, etc., but 
this review can not be more than a brief notice of a thoroughly praise- 
worthy book, and a feeble attempt to show that the author speaks in no 
uncertain terms on many disputed subjects, and reveals a wealth of clini- 
cal and pathological observation that makes his text-book one of the best 
on organic nervous diseases in existence. 

The temptation to mention the results of Starr’s cases of brain tu- 
mors is, however, too great to resist, because it is well known that for a 
long period this has been one of the cerebral disorders to which the author 
has devoted especial attention. One must read with a feeling akin to 
sadness and disappointment that but nine per cent of tumors of the brain 
are open to operation, and that, therefore, in the vast majority of cases 
we cannot give the patient any hope. 

Let us wish a hearty reception to this recent and most excellent text- 
book on organic nervous diseases. It is elaborately and judiciously il- 
lustrated. SPILLER. 


A Text-Book oF LEGAL MEbICINE AND ToxicoLocy. Edited by FREDERICK 
Peterson, M.D., Chief of Clinic, Nervous Department of the College 
of Physicians and Surgeons, New York; and WALTER S. HAINES, 
M.D., Professor of Chemistry, Pharmacy and Toxicology, Rush 
Medical College, in affiliation with the University of Chicago. Two 
imperial octavo volumes, illustrated. Philadelphia, New York, Lon- 
don: W. B. Saunders & Company, 1903. Vol. I. 

The scope of this work is outlined by the editors in their preface in 
the following words: “The object of the present work is to give to the 
medical and legal professions a fairly comprehensive survey of forensic 
medicine and toxicology in moderate compass. We believe this has not 
been done in any very recent work in English. A number of manuals of 
limited size and scope have been presented on the one hand, and on the 
other certain systems of legal medicine of almost encyclopedic dimen- 
sions. Both find fields of great usefulness; but there is still left a broad 
ground intermediate between the two which we trust the present work 
will fill, and it was in this hope that the hook has been planned and ex- 
ecuted.” 

The work is made up of a series of comprehensive articles on the 
different departments of forensic medicine by men of acknowledged 
ability and wide reputation, and while a detailed review of the work as a 
whole is hardly possible in a short space, certain of the articles merit 
more than passing mention. 

The Introduction by the editors contains in a short space much sound 
advice for both expert and attorney which if more generally followed 
would do much to relieve expert testimony of the discredit with which it 
is now too often received. “The Technic of Medicolegal Postmortem Ex- 
amination,” by Ludvig Hektoen might well be read by any practitioner of 
medicine, especially the country practitioner, who may often be placed in 
a position where he is forced to do a postmortem for the coroner, for 
upon his knowledge of methods, especially in poison cases, may rest the 
conviction of the guilty or the acquittal of the innocent. 

Articles worthy of special mention are those on “Identity,” and “Sud- 
den Death,” by James Ewing; “Death and Injuries by Lightning and 
Electricity,” by Smith Ely Jelliffe; “Wounds,” by Lewis Balch; “Speech 
Disorders,” by Frank Warren Langdon; while the views expressed in the 
articles on “The Stigmata of Degeneration,’ by Frederick Peterson, and 
“Idiocy, Imbecility, and Feeble-Mindedness,” by Frederick Peterson and 


512 BOOK REVIEWS. 


Smith Ely Jelliffe, have already become standard through the former 
author’s text-book of ‘Mental Diseases.” 

The article on “Insanity,” by J. T. Eskridge, is especially valuable 
because of the short, clean-cut definitions and clear phraseology. A some- 
what unfortunate typographical error, however, occurs on page 630 in the 
use of the word “effects” for “affects” in the following quotation: “ ‘Wahu- 
sinn’ is a mental disorder in which the delusions and hallucinations are 
rapidly combined into a complete whole, intimately associated with strong 
effects. In Verrticktheit the effects are only accidental elements of the 
clinical history and disappear rapidly.” 

An important chapter dealing with a subject quite new to works of 
this character is that on “The Destruction and Attempted Destruction of 
the Human Body by Fire and Chemicals,” by Walter S. Haines. It is an 
excellent study founded both on experimentation and several notable cases 
among which the Luetgert case tried in Chicago in 1897 figures largely. 

The work of the publishers has been well done, the paper and print 
are good, the illustrations numerous and some of them of unusual excel- 
lence. On the whole we can warmly recommend the work to those desir- 
ing light on the subject matter of which it treats, and only trust that the 
second volume will maintain the high standard of excellence attained by 
the first. Wm. A. Waite (Binghamton). 


Hews and Wotes. 


Dr. F. W. Lancpon has accepted the position of visiting consultant to 
the Cincinnati Sanitarium since the death of Dr. Everts. 


Pror. E. KRrAEPELIN, of Heidelberg, has been appointed Professor of 
Psychiatry at Munich. 


Dr. OrPHEUS Everts, long and favorably known to American alien- 
ists, died at his home in Cincinnati on June 19, 1903, in his seventy-seventh 
year, after an illness of some weeks marked by general failure of nutrition. 

Dr. Everts served throughout the Civil War as surgeon in the Army of 
the Potomac; later he was Superintendent of the Indiana Hospital for the 
Insane, and was one of the experts called by the U. S. Government in the 
trial of the assassin of Garfield. He was a welcome contributor to the 
medical press and to general literature. For the past twenty-four years he 
has been Medical Superintendent of the Cincinnati Sanitarium. 


Volume 30. September, 1903. No, 9 


THE 


Journal 


OF 


Nervous and Mental Disease 


Original Articles. 


GIGANTISM AND LEONTIASIS OSSEA, WITH REPORT OF 
PEL OASH Ob Ete GANT i WILKREN 5S; 


By PeEtTer Bassog, M.D., 


RESIDENT ASSISTANT PATHOLOGIST, PRESBYTERIAN HOSPITAL; ASSOCIATE IN 
PATHOLOGY, BUSH MEDICAL COLLEGE, CHICAGO. 


The clinical features of this case have been studied by a num- 
ber of prominent men both in this country and Europe in 
the course of the past ten years. So far as | know, the first de- 
scription of the case was given by Dana, in 1893, in an article 
entitled: “On Acromegaly and Giantism with Unilateral Facial 
Hypertrophy.” (13.) He first reports a case of acromegaly in 
an Indian 6 ft. 7 in. tall, then in introduction to this case remarks: 


“The following case seems to be very apposite in this connec- 
tion, because together with a gigantic general growth, there is a 
special hypertrophy of part of one extremity. It might be called 
a case of somatomegaly, a name suggested to me by Dr. Frank P. 
Foster, with a hemiacromegaly of the head. In plainer language, 
the individual is a professional giant with an enormous special 
development of one-half of the face.” 

Dana’s description is as follows: “Lewis Wilkins, aged nine- 
teen, single; occupation, freak; was born in Minnesota. His 
father was a native of New York; his mother, of Canada of 
English stock. His parents were healthy people of average size. 
He has six brothers and sisters, all of ordinary height. He was 
the second child. He was always large for his age, though not 


514 PETER BASSOE. 


remarkably so. He grew steadily, however, until by the age of 
seventeen he was over seven feet. He is now nearly twenty years 
old, and has grown one and a half inches in the last year. His 
present height is seven feet four inches, his weight three hundred 
and twenty-five pounds. His general proportions are for the most 
part good, but his feet and hands are particularly enormous, and 
the left side of the face shows a remarkable osseous hypertrophy, 
involving the frontal bone, upper and lower jaws. The hyper- 
trophy corresponds closely with the distribution of the left trigem- 
inal nerve. It gives his face a curious twisted and asymmetrical 
look, which is shown imperfectly in the photograph. The first 
impression is that he has a right hemiatrophy of the face. Closer 
inspection reveals, however, an enormous thickening of the left 
upper alveolar processes. The bone bulges out above the teeth 
as though he had a gumboil. The palatal arch is also greatly 
enlarged on the left side. The lower jaw is less affected, but is 
larger and longer on the left side. The teeth are white and even, 
and are not enlarged. The orbits are alike, but the left brow, and, 
indeed, the whole frontal bone bulges out so as to give a curious 
deformity to the skull. The thickening reaches back as far as the 
coronal suture and stops there. The head in brief is large, meas- 
uring 65.5 cm. in its greatest circumference. The osseous hyper- 
trophy makes the naso-bregmatic are very large, vis., 18.5, while 
the binauricular arc, measured through the bregma, is relatively 
smaller, as it does not go over the hypertrophied area. The meas- 
urements are: Greatest circumference of head, 65.5 cm. (2534 
in.) ; naso-occipital arc, 43 cm. (17 in.); naso-bregmatic arc, 
18cm. (7% in.) ; binauricular arc, 37 cm. (14% in.) ; from angle 
of jaw to symphysis of chin, right side, 13 cm. (5% in.), left side 
18 cm. (7% in.), a difference of 2 inches. The circumference of 
the chest at the mammary line was 471% in. and the expansion 3 
inches. This shows that he has a thorax of not excessive size pro- 
portionately. It is a good deal smaller than that of the Indian 
giant, whose height was 6 ft. 7 in. and whose chest measured 50 in. 
The hands were enormous, measuring 26 cm. (10% in.) from the 
tip of the middle finger to the process of the ulna; the circum- 
ference of the open hand around the middle of the palm, 27 cm. 
The feet are relatively still larger. He wears a shoe just a foot 
and a half long, while the actual total length of each foot is 
35.5 cm. (14 in.), and the circumference around the instep is 
29.2 cm. (11% in.). There is no especial asymmetry of physique 
except in respect to the face, as described. The left shoulder, 
however, is a little higher; he is decidedly round-shouldered, and 
there is a slight dorsolumbar lateral curvature of the spine. He 
has no cutaneous eruptions, no pigmentation or discoloration. He 


GIGANTISM AND LEONTIASIS OSSEA. 515 


has thick, coarse hair, but no beard. His muscular system is but 
moderately developed: the grasp of his hand is weak; he does 
not like to climb stairs; he has not much strength. He has good 
co-ordination ; is a good shot. His knee-jerks are slow and feeble. 
Vision is good in both eyes, and he has no contraction of the 
visual field. The pupils react normally. The eyes are small, the 
palpebral fissure measuring 3 cm. His intelligence is good. He 
sleeps well and eats well. He has a prodigious appetite, and on 
one occasion ate 27 plates of ice cream at one sitting, thereby win- 
ning a wager that he could eat more than two men. No un- 
pleasant after-effects were reported. He has slight headaches at 
times. His pulse beat and respiration and his heart action were 
normal. I could not say whether the thyroid was changed in size. 
It is certainly present.”’ Dr. Dana, in conclusion, remarks: “The 
interest of this case lies first in the giant growth, and next in 
the progressive facial hemihypertrophy. That giantism is some- 
times associated with acromegaly has been shown by my own case 
and that of others cited. This patient has some symptoms belong- 
ing to acromegaly, viz., the enlargement of the bones of the left 
side of the face, beginning at about puberty, the kyphosis and 
scoliosis, the enormous feet, the coarse hair, feeble muscular de- 
velopment, and prodigious appetite. The progressive facial hyper- 
trophy is very interesting on account of its rarity and its associa- 
tion with giantism.”’ 


On April 24, 1896, Mr. Wilkins was presented to the Vienna 
Medical Society by Lamberg. The proceedings as given by the 
Wiener klinische Wochenschrift (29) were as follows: 

“Lamberg presented Wilkins. The man, age twenty-two 
years, has healthy parents. Growth was normal until the fourth 
vear. Then he grew rapidly until the sixteenth year. At eighteen 
he reached the present height, 245 cm. He is 20 cm. taller than 
the giant skeleton in the Vienna Anatomical Museum. He pre- 
sents some skeletal abnormalities, viz., scoliosis, asymmetry of 
the pelvis, and a tumor of bony hardness, originating from the left 
upper jaw, which perhaps also causes a narrowing of the left nasal 
cavity. There is also considerable swelling of the left half of the 
forehead. The intelligence is proportionate to his age. The 
genital functions are normal. Lamberg considered the case as one 
of acromegaly. 

“M. Sternberg: Only three skeletons in museums are larger, 
the Irsh giant at Dublin (259 cm.), one at St. Petersburg (254 
em.), Patrick O’Byrne, London (249 cm.). Giants frequently 
present morbid features, general dystrophies or vegetative disturb- 
ances. About 40 per cent have acromegaly. Doubtless there are 


516 PETER BASSOE. 


also quite normal giants. He does not consider Wilkins a case of 
acromegaly. The prominence of the lower jaw is lacking as well 
as deformities of the soft parts of the mouth and nose; the tongue 
is normal, the hands are proportionate, etc. Abnormal is the great 
development of the left half of the face. The lips are also some- 
what thickened on the left side, so we may speak of a hemihyper- 
trophia facialis, principally ossea. The deviation of the axis of 
the left eyeball and the narrowing of the left nasal cavity point 
to bony changes in the orbit, and the slowness of movements and 
phlegmatic temperament to intracranial hyperostoses and exos- 
toses. Buhl’s case, Hassler, is probably the most analogous of 
the known cases. 





Fig. 1 Mr. Wilkins and his brother. 


‘Schlesinger accentuated that acromegaly was clinically suff- 
ciently sharply limited to exclude this case. Above all, the en- 
largement of the soft parts, almost always present in acromegaly, 
was lacking. The lips and tongue are approximately normal. So 
is the position of the teeth, which is almost always altered in acro- 
megaly on account of the enlargement of the lower jaw. Schlesin- 
ger asked about the eve findings, as ocular disturbances are fre- 
quent in acromegaly, such as bitemporal hemianopsia, optic atro- 
phy and paralysis, due to the frequency of hypophysis tumors. 

“Lamberg: ‘The eye findings are normal.’ ” 

In his exhaustive treatise in Nothnagel’s “Spec. Pathologie,” 


GIGANTISM AND LEONTIASIS OSSEA. S17 


Sternberg (43) again discusses this case and groups it together 
with Buhl’s and one of Sirena’s as ‘“‘pathological,” non-acromeg- 
alic gigantism, the “pathological” features in this group being 
tumor-like exostoses (leontiasis ossea and hyperostoses). In con- 
nection with leontiasis he says (p. 86) : “If the disease is extensive 
and associated with gigantism, a confusion with acromegaly is 
likely, as actually happened in the case of the giant Wilkins (Lam- 
berg). Here was to be considered that the enormous hands and 
feet were proportionate to the excessive size of the body, and that 
a close examination showed the presence of bone tumor, with 
absence of acromegalic changes of bones and soft parts.” 

Schmidt, in his treatise on gigantism (41) takes the same view 
of the case, being positive that this case is not one of acromegaly, 
but analogous to that of Buhl. The latter case will be considered 
in detail later. 

Mr. Wilkins was admitted to the service of Professor Bevan 
at the Presbyterian Hospital, June 28, 1902. The writer wishes 
to thank Professor Bevan for his kindness in allowing him to use 
the following history, which was obtained by the interne, Dr. 
Pearsall : 

Lewis Wilkins, age 28. Family history: Father, age 55; 
mother, age 60; both well. Four brothers and one sister alive and 
well. All relatives and ancestors, so far as known, have been of 
normal stature. No history of tuberculosis or tumors in the 
family. 

Personal—Patient weighed 9 pounds at birth, and was normal 
in size until four years of age, when he began to grow rapidly, 
and at ten years was over 6 ft. in height, and continued to grow 
until about 18, when he attained his present height (8 ft. 2 in.). 
He has been on exhibition the past twelve years, and has traveled 
extensively in the United States and Europe.* 

Usual diseases of childhood. Malaria one year ago. Lateral 
curvature of spine for about twelve years. When eight years old 
he noticed a growth, size of a small marble, above the left eye. 
This has continued to grow slowly until four or five years ago, 
since which time he thinks it remained stationary until three 
months ago, from which time it has increased in size rapidly. 
About two years ago, he states, he saw Professor Virchow 
in Berlin, who, so he says, pronounced the growth a benign 
one, said it was on the external surface of the skull 





*In a pamphlet distributed at Mr. Wilkins’ exhibits in Germany it is 
stated that he did not grow in height from the age of 18 to 21, but gained 3 
inches from 21 to 22, when he reached 245 cm. It is also stated that his 
father measured 161 cni., his mother 170 cm. in height. 


518 PETER BASSOE. 


and would probably never cause him trouble. Gonorrhea 
four years ago, discharge lasting about three weeks; denies 
other venereal infection. Three months ago he would have 
severe pain in left frontal and temporal region each morning on 
rising, pain disappearing gradually by 10-11 o'clock. For the past 
month he has had continued pain in this region when awake and 
has required the constant use of opiates. About one month ago 
he lost the vision in the left eye. Thinks it has been weak for 
several years. One week ago he also lost the sight in the right 
eye. Says vision disappeared suddenly; saw dimly on retiring one 
evening and the next morning could not appreciate light. He has 
had several spells of vomiting during this time. These spells have 
not been closely connected with eating. He states that he has had 
no sensation over the left side of the face for about one month, 
and during this time has had difficulty in speech, his voice being 
thick and heavy. Two months ago he experienced ringing sensa- 
tions in the left ear and has since complained of earache. Says he 
is deaf in the left ear. Since his arrival at the hospital he has been 
dull; almost semi-stuporous. Has had several involuntary bowel 
movements. He was taken with diarrhea while on the way to 
Chicago from his home in Oklahoma. 

Physical Examination. Height 8 ft 2 in., according to state- 
ment of patient. Measures 56 in. around the chest. He is well 
proportioned. There is a growth on the left side of the head 
which extends from the median line outward and backward as 
far as the external auditory meatus and downward over the face 
to the alveolar process of the superior maxilla. This mass is firm 
except in an area a little larger than a silver dollar in front of and 
above the external auditory meatus which is soft and semi-fluctu- 
ating. The left eye is closed. The left upper lip is thicker than 
the right and droops. The pupils react neither to light nor dis- 
tance, and the left eyeball is immobile. The tongue does not de- 
viate on protrusion, and the muscles on both sides act in frowning 
or laughing. There is an area of anesthesia extending from the 
left ramus of the lower jaw to the external auditory meatus, and 
upward to the median line of the skull. The left half of the 
tongue is also devoid of sensation except for a narrow strip near 
the median line. 6-28, urine 1027. Acid. No albumin or sugar. 
No casts. Red cells and leucocytes present. 6-28, blood examina- 
tion, hemoglobin 85 per cent; reds, 4,876,000; leucocytes, 9,300. 
Temp., 98.4-101.4; pulse, 80-92 on day of admission. 7-1, urine, 
2,400; cc., 1.010, ac. No albumin or sugar. Urea, 1.75 per cent; 
temp., 98-100. Ophthalmoscopic examination showed a bilateral 
choked disc. | 

The diarrhea became more severe while in the hospital, the 


GIGANTISM AND LEONTIASIS OSSEA. 519 


stools were slightly bloody, pain and tenesmus were present. He 
gradually failed, and died July 10, 1go2. 

The autopsy was held immediately after death by Professor 
Hektoen, assisted by Dr. L. Loeb and myself. A relative who 
was present did not permit any measurements to be taken. For- 
tunately those taken by Dana nine years ago give us the relative 
proportions. A growth in height has undoubtedly taken place 
since that time, as Lamberg’s measurements and the patient’s state- 
ments show; also an increase in the circumference of the chest. 
The time allowed for the autopsy did not permit a more detailed 
description of the external appearance of the body than that given 
in the clinical notes. 

After the removal of the thoracic and abdominal viscera both 
carotids were injected with 4 per cent formaldehyde solution in 
order to harden the brain in situ. 

Anatomic Diagnosis.—Necrotic and ulcerative colitis and 
ileitis; cirrhosis of liver; chronic catarrhal gastritis; epitheliosis 
of esophagus; hemorrhagic broncho-pneumonia (right lower 
lobe) ; enlargement of thyroid; sarcoma in region of hypophysis ; 
extension of tumor to subcutaneous tissues; diffuse hyperostosis 
of frontal, left parietal, left temporal, and left superior maxillary 
bones ; calcification of left pleura and spinal arachnoid; compres- 
sion of brain; general gigantism. 

The abdominal cavity is empty and the peritoneum smooth 
and free from adhesions. The diaphragm reaches to the fourth 
interspace on both sides. 

Both pleural cavities are empty and there are no pleural adhe- 
sions, except between the right upper and middle lobes. 

The pericardium is smooth and the cavity contains no fluid. 

The thyroid weighs 112 grams; it is uniformly enlarged, and 
glistening on the cut surface as if the follicles were dilated with 
an unusual amount of colloid material. In the left lobe are two 
small, circumscribed, somewhat reddish nodules. 

There is no trace of the thymus in the corresponding fatty 
masses. 

The larynx and trachea show no changes. 

The lungs are crepitant throughout, much lighter and spongier 
than usual, especially in the case of the left lung. In the lower 
right lobe are two hemorrhagic areas with elevated bases, the 
longest diameter being 6 cm. In the pleura over the lower left 
lobe is a flattened calcareous district, I cm. square, and at the 
right of the left lung are calcareous glands. 

The heart is normal in shape and weighs 465 grams. There 
are no changes in the endocardium. The myocardium is firm and 
reddish brown. 


520 PETER BASSOE. 


The aorta is quite smooth throughout its entire extent. 

The spleen is large and its capsule smooth. Cut surface is 
reddish and of normal appearance. The spleen weighs 620 grams. 

The lymph nodes in various parts of the body are not enlarged. 

The pharynx is normal. 

The esophagus shows a number of flattened, whitish, firm, 
raised, nodular areas in the upper part of its course, generally 
arranged somewhat linearly. Otherwise the membrance is smooth. 

The stomach is very large. It weighs, including the duo- 
denum, 655 grams. The mucous membrane is thrown into huge 
wrinkles, not unlike cerebral convolutions, which cannot be 
straightened out on stretching the muscular coats. The mucous 
surface is covered with a turbid, tenacious mucus. 

The small intestine from the duodeno-jejunal junction to the 
ileo-cecal valve, measures 20 meters in length. The mucosa is 
normal in appearance until within about 50 cm. of the valve, where 
it appears granular, rough, and of a dirty greenish yellow color in 
areas, with rather superficial small ulcers. Just above the ileo- 
cecal valve the entire circumference of the ileum, for about 5 cm., 
is intensely necrotic. 

The large intestine is very voluminous; it measures in length, 
approximately, 4 meters. Its entire mucous membrane from the 
ileo-cecal valve to the anus is the seat of necrosis in the form of 
grayish, dirty, granular points and areas, and more especially of 
thickly disseminated, rather small ulcers with smooth floors as a 
general rule, and overhanging margins. In many cases the under- 
mining of the margins is so extensive that large submucous tun- 
nels are formed and neighboring ulcers may communicate with 
“one another by means of these passages. In the flexures, and espe- 
cially in the rectum, congestion of the mucous membrane is 
noticed. 

The liver is large, weighing approximately 4,000 grams; it has 
a granular and nodular surface, especially near the lower margin 
of the right lobe. There is some increase in consistency and more 
or less distinct breaking up of the surface into large islands of liver 
tissue by fibrous bands. The under surface of the liver shows 
anomalous formation of the lobes, the right being taken up largely 
by a large projecting mass with some constriction at the base of its 
junction with the main part of the liver. 

The gall bladder and bile passages do not show any changes. 

The pancreas is large, weighing 275 grams; it is normal on 
the cut surface. 

The ardenals are large, weighing 42.5 grams; they do not show 
any changes on the cut surface. 

The kidneys also are large, weighing together 525 grams. 


GIGANTISM AND LEONTIASIS OSSEA. Sal 


Capsule is free except over a rather large area in the left kidney, 
where there is an irregular, radiating, depressed scar. The sur- 
face is, in general, ero The cortex is unusually wide; the 
cortical markings distinct, and the glomeruli visible as reddish 
points. In the apices of several pyramids are small deposits of a 
granular, sand-like material. 

The mucous membrane of the ureters and of the bladder is 
smooth. ‘The bladder is distended with urine and is very large. 

The prostate is not as large, in proportion, as other organs. 
The same seems to be true of the seminal vesicles and testicles, 
the latter weighing 85 grams. 

Theretis a soft subcutaneous nodule almost as eee as a fist 





Fig. 2 Outer surface of skull-cap. 


behind the left ear; and another of greater firmness involving 
about two thirds of the left side of the forehead. The tumor tissue 
on section is pink and homogeneous. The frontal region of the 
skull is very thick, especially on the left side. The skull cap 
weighs 1,450 grams; it is 68 cm. in circumference, 25 cm. in 
length; from the obliterated interfrontal suture, lower end, to the 
right coronal suture, internal horizontal measurement, is 5.7 cm.; 
from the same point to the left coronal suture is 8.5 cm. In the 
median line the frontal bone is 8.5 cm. thick, and is softer than 
normal, especially on the left side. There is marked asymmetry, 
the interparietal suture being displaced to the right. Fissures for 
vessels are relatively shallow. In front of the coronal suture the 


522 PETER BASSOE. 


bone is rough from the presence of thickly-set depressions, vary- 
ing from 0.8 to 3.0 mm. in diameter. The remainder of the skull 
cap is smooth. The thickness varies from 2 to 8 mm. On the 
outside the interparietal suture presents a prominent ridge in its 
posterior half (see photograph). The parieto-occipital suture is 
also prominent. The base of the skull is greatly deformed. On 
the left side the anterior fossa is obliterated by the thickened 
frontal bone, and the middle fossa also is almost filled in with bone. 





Fig. 3 Base of skull. 


The sella turcica is wide, its floor partly eroded. In this region 
is a large tumor mass which has grown into the pharynx, orbits, 
and ethmoidal sinuses, and has destroyed the roof of the nose; the 
roof of the ieft orbit has been much more extensively invaded than 
the right. In the median line of the surface of the tumor exposed 
at the base of the skull after removing the brain is a projecting 
pedicle, darker than the tumor mass. This is found to be the in- 
fundibulum. It measures 3 mm. in diameter and is inserted into 


a round elevation 13x6 mm. of the same color as the stalk. The 


tumor itself is white on the surface, lobulated, the lobules 2 to 4 
mm. wide, separated by narrow, but deep, fissures. On section the 
superficial part of the tumor is white and distinctly lobular. A 


gelatinous fluid exudes from the cut surface. Deeper down it is. 


GIGANTISM AND LEONTIASIS OSSEA. Soa 


more homogeneous and there is more slimy fluid. Still deeper 
dark red bands permeate it. The portion of the tumor removed 
with the hypophysis weighs 150 grams, but at least as much more 
was scooped out in pieces or left behind. 

The brain weighs 1,540 grams. The distance from the frontal 
to the occipital pole is 18 cm.; transverse diameter, 14.5 cm. 
There 1s marked deformity of the left hemisphere to correspond 
with the obliteration of the anterior fossa of the skull. The left 
frontal lobe has been pressed upward and to the right. It termi- 





Fig. 4 Anterior view of brain. 


nates in a narrow strip along the median fissure. The lower end 
of the strip is 8 mm. above the pole of the right frontal lobe, its 
width 15 mm. at the base, 8 mm. at the lower end (see photo- 
graph). Farther to the left the brain substance has been com- 
pressed so that the inferior surface of the left frontal lobe is 
3.5 cm. higher than that of the right side. The left temporo- 
sphenoidal lobe also is smaller and compressed; its inferior sur- 
face measures 1.5 cm. antero-posteriorly, while the right measures 
3.7 cm. The convolutions of the brain are generally broad and 
flattened; the sulci shallow (see photograph). The left optic 
nerve is narrower than the right. The other cranial nerves appear: 
symmetrical. 


524 PETER BASSOE. 


The length of the medulla and cord, from the pons to the filum 
terminale, is 60 cm. Below the mid-thoracic region are many 
thickened, partly calcified patches on the inside of the dura. These 
are rough and granular on the inner surface; the attached surface, 
on separation ‘from the dura, is smooth. The largest of them 
measures 3XI.2 cm. To one of them a nerve-root is adherent. 

The sternum is 26.5 cm. long, the greatest width of the manu- 
brium 10.5 cm., of the body, 5.5 cm. 

Histological Examination. The soft tumor. All parts of it 





Fig. 5. Magnified 8 diameters. Showing relation of hypophysis to sur- 
rounding tissues, mostly tumor. 


were subjected to examination, and its structure was found to be 
essentially the same everywhere. It is made up of cells, mostly 
spindle-shaped, with large oval or round nuclei. Karyokinetic 
figures are numerous. The protoplasm of the cells stains faintly. 
heres is no suggestion of glandular or other epithelial structures, 
the cells having no definite arrangement. The texture is loose, 
there being a larze amount of finely granular intercellular sub- 
stance, stained lightly by hematoxylin. This is evidently in part 
the coagulated product of the abundant viscid material noted on 
gross examination. In the deeper part of the tumor the degenera- 
tive changes are more marked. There are large necrotic areas, 


GIGANTISM AND LEONTIASIS OSSEA. 525 


and also hemorrhages. -The reason for the lobulated appearance 
of the surface is found in the presence of fibrous bands running 
perpendicularly to the surface. Such trabecule are also seen in 
the deep portions. In places tumor cells, sometimes with karyo- 
kinetic figures, lie in them. In various parts, more particularly 
near the hypophysis, are bony spicules, some of which are rich in 
bone corpuscles, and probably newly formed. Here and there 
giant cells are seen. The tumor may be designated an osteo- 
plastic sarcoma with edema and mucoid degeneration. 





Fig. 6. Magnined 45 diameters. On one side of dura hypophysis tissue. 
On other side tumor with bony spicule. 


The Hypophysis and its Relation to the Tumor. Serial sagit- 
tal sections* were made of the lateral halves after a preliminary 
bisection through the infundibulum. A fibrous membrane (dura 
mater) was found separating the hypophysis from the tumor, the 
sharp border being plainlv visible to the naked eve on account of 
the difference in staining. At one point on the left side the tumor 
and the hvpophysis are in direct contact, but the border is sharp, 
and there are no transitional cell forms. Some enlargement of the 





*The writer wishes to thank Messrs. Foreman, Jackol, and Darmer 
for valuable aid in this tedious work. 


‘526 PETERGB ASSOLE, 


organ is present, the greatest length as seen in the sections being 
20mm. At this point it measures 8 mm. from above downwards. 
It appears flattened in all the sections. The histologic structure is 
-essentially normal. There are the usual large, highly eosinophilic 
-cells, arranged in elongated columns, or in clusters of about the 
size of renal glomeruli, “and smaller cells with cytoplasm stained a 
faint blue with hematoxylin, and rounded nuclei, also with more 
-or less glandular arrangement. In the extreme right portion of 
the anterior lobe this is the only cell type seen, and glandular ar- 





Fig. 7. Magnified 1,200 diameters. Showing finer structure of tumors. 
One mitotic figure in the center. 


rangement less apparent. There is a moderate number of spaces 
‘containing a colloid material and lined by epithelium. Engorged 
vessels are abundant. There are also numerous hemorrhages, a 
‘few foci consisting of densely-packed, small, round, deeply-stained 
mononuclear cells, an occasional amyloid body, and in places the 
large eosinophilic, epithelial cells are vacuolated. In places the 
trabeculz and adventitia of the small vessels have a hyaline ap- 
-pearance. ‘There are generally deposits of pigment at the margin 
-of such areas, indicating that they probably mark the site of old 


GIGANTISM AND LEONTIASIS OSSEA. 527 


hemorrhages. The posterior lobe is small and made up of a faintly 
fibrillar ground substance, stained lightly by hematoxylin, and 
containing a moderate number of long and narrow, deeply-stained 
nuclei; small vessels are numerous and engorged. 

The Skull. Section from frontal bone in median line: Less 
than half the section is compact bone in irregular islands, the re- 
mainder a loose reticular tissue, consisting of a fibrillar unstained 
matrix with a small number of long, narrow, nucleated cells. At 
one edge of the specimen the interstices between the islands of 





Fig. 8. Magnified 38 diameters. Frental bone in median line. 


bone are densely packed with spindle-cells like those in the soft 
tumor. 

Left side of frontal bone near external surface: Here the com- 
pact bone is even smaller in amount, lamellz imperfect. Haver- 
sian canals large and numerous. Most of the bone appears to be 
of recent formation judging from the number and size of the cells. 
Abundant osteoblasts are seen, mainly consisting of spindle-cells, 
with frequent mitotic figures. The texture of the tumor tissue in 
places is very loose, suggesting mucoid degeneration or edema. 

Section from inner surface of frontal bone differs from the 


528 PETER BASSOE. 


preceding by the larger amount of deposits of new-formed bone, 
rich in cells, and taking a deeper hematoxylin stain than the old 
bone. They form small round or irregularly shaped bodies, lying 
together with spindle-cells, osteoblasts, and certain large, faintly- 
stained oval cells in the spaces bounded by trabeculz of old bone. 
In notches in the surface of the latter osteoclasts are occasionally 
seen. Right sphenoid bone. Here the bony trabecule are also 
scarce, and enclose tumor tissue everywhere. In places are islands 





Fig. 9. Left side of frontal bone, showing sarcomatous invasion. 


of new-formed bone surrounded by osteoblasts and a few osteo- 
clasts. Sections from a rib show nothing abnormal.. 

The ganglion cells of the cerebral cortex are practically nor- 
mal. A few of them contain yellow pigment with lateral displace- 
ment of the nucleus. Marchi preparations of the cortex and sub- 
cortical white matter show no degeneration. There is a moderate 
amount of diffuse degeneration in the lower medulla and cervical 
cord. The roots are also slightly affected. In the cervical spinal 
ganglia a number of amyloid bodies are seen, the vessels of the 
capsule have thickened hyaline walls, a few of the small vessels 
contain thrombi. Many of the ganglion cells contain large masses 
of yellow pigment. The nuclei are distinct, generally centrally 


a ee ee eee 


GIGANTISM AND LEONTIASIS OSSEA. 529 


located ; their staining is very variable in intensity. There is some 
thickening of the smaller arteries in the lumbar region of the cord. 
The calcified patches in the spinal meninges are found to contain 
true bone. Both optic nerves are extensively degenerated, more 
so the left, as seen in Marchi preparations. 

Thyroid. The acini are generally distended with homogeneous 
colloid material. In places several acini appear to have coalesced. 
The blood vessels are few and small. 

Lung. In a section from the lower lobe of one lung the 
alveoli are completely obliterated, so that it is difficult to recognize 
lung structure. In most places the lung tissue is replaced by 
round and elongated connective tissue cells. Here and there are 
considerable areas of blood which is partly in blood vessels and 
some apparently free in the tissues. The connective tissue is well 
organized into strands in places; in other places the organization 
has not gone so far. In one smail area the alveolar walls may be 
made out, and the centers of the alveoli are filled with red blood 
corpuscles and leucocytes. Developing capillaries are seen in the 
tissue. These are filled with corpuscles. There are some pigment 
patches near the blood vessels. The pleura is thickened and 
creatly congested. 

Heart. In sections of the heart muscle there is seen a very 
slight increase in interstitial tissue; otherwise there are no 
changes. 

Spleen. The spleen is much congested, red corpuscles being 
diffused quite uniformly throughout the tissue. Malpighian cor- 
puscles are clearly marked. 

Lower [leum. In sections examined, the mucosa is absent. 
The submucosa is greatly infiltrated with round cells. Blood ves- 
sels are congested, and in some places there is hemorrhage into 
the tissues. In places the submucosa has undergone necrotic 
change and sloughed away down nearly to the muscular layer. 
The circular layer of muscle fibers also is infiltrated with round 
cells and in many places there are blood vessels distended with 
blood. In the submucosa can be seen thrombi, consisting of layers 
of fibrin, between which are red and white corpuscles. Fibrin also 
is deposited in shreds throughout the submucosa. 

Colon. The mucosa is much eroded in most places, and in 
some entirely absent. The surface is necrotic, so that only the 
lower parts of the glands are seen. The lumina of many of the 
glands contain mucous material.’ There is considerable round-cell 
infiltration. There is also hemorrhage into the tissues, and the 
vessels are greatly engorged. This condition extends also in the 
submucosa as far down as the muscular layer. Throughout the 
submucosa there are shreds of fibrin arranged usually in an ir- 


530 PETER BASSOE. 


regular network. Near the mucosa an amoeba may be seen occa 
sionally. 

Rectum. The rectum presents much the same appearance as 
the colon, except that the condition is much more marked. The 
mucosa has undergone necrosis, and sloughing has occurred. 
There are large spaces near the surface, some of them filled with 
blood and fibrin; others are empty. In some places the blood is 
confined to blood vessels, but frequently it is diffuse. There are 
numerous round cells, some polymorphonuclear leucocytes, and 
plasma cells. Amoebz are present in large numbers, most abun- 
dant in the upper part of the submucosa, but are also found in the 
other coats. They are usually spherical, but occasionally oval or 
oblong. They stain with eosin faintly. Usually the nucleus can 
not be seen, but frequently it is quite distinct, though not stained 
with hematoxylin. The amcebz are invariably vacuolated. They 
are found mostly in the solid tissues, but occasionally may be seen 
in the blood vessels or large lymph spaces. 

Liver. Interlobular connective tissue is increased in amount 
and distinctively isolates the liver lobules; this connective tissue 
does not extend into the lobules. The bile capillaries and blood ves- 
sels in this tissue show no changes. At the margins of the lobules 
the liver cells are not as distinct as elsewhere, and seem somewhat 
compressed. Elsewhere the liver cells are normal and the nuclei 
distinct. Occasionally fat vacuoles may be seen. The capsule of 
the liver is considerably thickened. 

Pancreas. The pancreas shows no changes. Numerous areas 
of Langerhans are present. 

Adrenals. There are a few areas of round-cell infiltration in 
the medulla and in the zona reticularis. Under the capsule in the 
cortex, there is seen congestion of the blood vessels. 

Kidney. The glomeruli completely fill their capsules in most 
cases. Many of them are congested and show round-cell infiltra- 
tion. The capsule is somewhat thickened. In places the capillaries 
between ‘the tubules are much congested; there are also many 
round cells in places. The renal cells are large, cell walls distinct, 
and nuclei clear and distinct. In the tubules is seen a small 
amount of granular material. In some places the cells lining the 
tubules are slightly swollen and granular. Frequently clear spaces 
are seen around the nuclei. In other tubules the lining cells are 
low and flat, the nuclei stain deeply, and the lumen of the tubule is 
filled by a granular material. 

Testicle. The seminiferous tubules show quite marked changes. 
Just inside the basement membrane the sustentacular and sperma- 
togenic cells have undergone a hyaline change. In some tubules 
the hyaline change has advanced to the center, while in others the 


eh Ae 


GIGANTISM AND LEONTIASIS OSSEA. 531 


hyaline area separates the normal cells from the basement mem- 
brane. Some tubules are apparently normal. There is some in- 
crease of fibrous tissue, and a few areas of round-cell infiltration, 

A bacteriological examination was made by Mr. E. H. Ruedi- 
ger of Rush Medical College, who kindly reported that no growth 
was obtained from the heart’s blood, and that two organisms were 
isolated from the intestinal ulcers, one a typical colon bacillus, the 
other an unidentified bacillus, which possessed some characteristics 
both of the Shiga bacillus and the ordinary colon bacillus. 

A chemical examination of the thyroid gland was made by 
Dr. H. G. Wells, who kindly furnished the following report: 

“One-half of the gland was received in alcohol, with the state- 
ment that the gland was symmetrical. The tissue was ground up 
finely in a meat chopper, and to the ground material was added 
the alcohol in which the tissue had been preserved ; the whole was 
then evaporated to dryness on the water bath, and then dried to a 
constant weight over sulphuric acid. The total weight of the dried 
gland so obtained was 13.80 grams, giving a total for the entire 
organ of approximately 27.60 grams. The normal weight of dried 
thyroid glands of residents of the United States has been found to 
be in the vicinity of 5 grams.* Portions of the dry powder were 
then analyzed by the modification of Baumann’s method, and the 
average amount of iodin of four determinations found to be 2.28 
mg. per gram of dried substance. The total amount of iodin in 
the entire gland was, therefore, 62.928 mg. Analysis of the glands 
of a series obtained in Chicago showed the average amount under 
normal conditions to vary from 1.5 to 2.5 mgs., with a total iodin 
content of about 10 mgs. Similar results were found with glands 
removed from residents of other parts of the United States. It is 
seen, therefore, that the gland of the giant contained a normal 
amount of iodin in each gram of gland substance, but on account 
of its greatly increased size the total amount was six times as 
much as normal. 

“Histological examination of the gland explains fully the analy- 
tic results. It is seen that the enlargement is of the type of simple 
colloid goiter, characterized by large aveoli distended by a normal 
colloid material. It has been shown by Wells (loc. cit.) and cor- 
roborated by A. Oswald,** that in goiters as a rule the amount of 
iodin is in direct proportion to the amount of colloid. In the goi- 
ters of the “parenchymatous” type characterized by a great hyper- 





*“The Physiology and Therapeutics of the Thyroid Gland and Its Con- 
geners.” H. Gideon Wells, Journ. Amer. Med. Assoc., Act. 30, Nov. 6 and 
rss 1807, 

*A Ostwald, Virchow’s Archiv., 1902, 169, p. 444. 


532 PETER BASSOE. 


plasia of epithelial cells, and containing but little colloid, there is a 
marked decrease in the amount of iodin in each gram of gland, 
corresponding to the small amount of colloid, but the total amount 
of iodin is about normal because of the great size of the thyroid. 
On the contrary the glands of which this is a type show a colloid 
containing about normal quantities of iodin in each gram, and con- 
sequently with a greatly increased total amount. When the 
amount of colloid is very large Ostwald has found that part of it 
may not contain iodin. It seems possible that the parenchymatous 
goiters may be the result of a deficiency in supply of iodin in a 
condition to be transformed into thyroiodin, so that the gland hy- 
pertrophies in the effort, which is apparently successful, to obtain 
enough iodin for the requirements of the body. The colloid goi- 
ters may result from an increased requirement for thyroiodin in 
the economy, with normal supply of iodin, leading to the formation 
of much colloid with a normal proportion of iodin so long as the 
supply is adequate. That this giant, particularly with a diseased 
hypophysis, should have a large amount of iodin in his thyroid 
was to be expected and agrees with the theory. The result also 
shows that in this case of giantism the goiter was not different 
from simple goiter, at least so far as histology and iodin content 
indicate.” 
(To be continued.) 


STUDIES UPON THE CEREBRAL CORTEX IN THE NORMAL 
HUMAN BRAIN AND IN DEMENTIA PARALYTICA. 


By G. ALFrep Lawrence, M.D., Pu.D., or NEw York. 


INSTRUCTOR IN DISEASES OF THE MIND AND NERVOUS SYSTEM, NEW YORK 
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL 


Introductory. The following contribution to the study of the 
cerebral cortex in the normal human brain as compared to that 
in dementia paralytica, does not include much that is new to the 
pathology of the latter, but aims to present the subject in a some- 
what different manner than has heretofore been done. The 
writer’s perusal of many anatomical and pathological articles has 
often been unsatisfactory to himself, owing to many generalized 
statements of conditions found without any adequate illustrations 
of what was really to be seen. It has been the endeavor in this 
article to present and describe photomicrographs of actual sec- 
tions from a practically normal human brain histologically by way 
of comparison, and to follow these by photomicrographs of sec- 
tions of a brain of a well marked case of dementia paralytica. 
These photomicrographs have been supplemented by drawings. 
The possibilities as well as the limitations of photomicrography in 
preparations stained by the Nissl method, it seems to the writer, 
are fairly well brought out in this article, and this was one of the 
objects sought in its presentation. That photomicrographs show 
structure and arrangement in but one plane of limited thickness 
is true. It is also true, however, that they show exactly what is 
there and the exact relation to other parts, and there is no personal 
equation such as is bound to occur in any drawing. A drawing, 
on the other hand, is always more or less composite, does not 
show exact relationship, and involuntarily the point to be illus- 
trated is made to assume undue prominence. In work of this kind 
artefacts are constantly to be looked for and avoided, and the 
entire process of preparation, as well as the history of the case, 
must be also carefully considered before any conclusions should 
be drawn. 





*Submitted in partial fulfilment of the requirements for the degree of 
Doctor of Philosophy in the Faculty of Pure Science, Columbia University. 


534 G. ALFRED LAWRENCE. 


When it is considered how extremely thin the human cortex is, 
1.5 to 3.5 millimeters; that its exterior surface is estimated at 
about 200,000 square millimeters; that it is intricately arranged in 
convolutions of varying size and direction; that it is exposed to 
injury prior to death, at the autopsy, during transportation, and 
also in the various manipulations of fixation, imbedding, section- 
ing, staining, decolorizing and mounting, it can readily be seen 
how artefacts may result by the time the specimen is prepared for 
examination. This was forcibly brought to the notice of the 
writer in the examination of some sections but a short time ago. 
Owing to a dull microtome knife the nuclei of a number of the 
cells were completely carried outside of the cell-body and the cell- 
bodies themselves broken and cracked in places. This was at first 
regarded as a pathological process until attention was called to 
the fact of the nuclei all being extruded in the same direction, 
and the breaks and cracks presenting a ragged and irregular ap- 
pearance. Even when the greatest care is used there will be a 
variation in thickness in different sections—one being somewhat 
thinner and the next correspondingly thicker than actually regis- 
tered by the microtome, although most carefully imbedded, so that 
variations in the thickness are also to be considered. Further- 
more, in fixation, shrinkage or swelling may occur, the latter 
being demonstrated by Donaldson (1891), who placed fresh nerves 
in a solution made up of 2.5 per cent of potassium bichromate, 
plus one-sixth its volume of 95 per cent alcohol for three weeks. 
He then washed them for one day in water and placed them in 95 
per cent. alcohol for three or four days, and finally in 80 per cent 
alcohol, using six olfactory bulbs, six olfactory tracts, and three 
pairs of optic nerves of the sheep. This was exactly the same 
treatment to which his specimens of human nerves had been sub- 
jected. The volume of specimens of olfactory bulbs subjected to 
this treatment and afterwards placed in 80 per cent alcohol was 
found to be 5.2 per cent greater than fresh specimens, those of the 
olfactory tracts 8.8 per cent greater, while the optic nerves showed 
but 2.6 per cent increase in volume. Imbedding in celloidin did not 
affect the volume, while some stains, as acid fuchsin, produced no 
change, whereas Delafield’s hematoxylin caused swelling, and thus 


ee 


DEMENTIA PARALYTICA. 535 


increase in volume. Hammarburg (195) found by experimenting 
with small blocks of cortical tissue that by accurate measurements 
blocks hardened in Muller’s fluid for three days showed a volu- 
metric increase of 11.7 per cent. Other blocks hardened in Mul- 
ler’s fluid for three weeks, and then, transferred to alcohol and 
left in the latter for fourteen days, showed, on the other hand, a 
shrinkage in volume of 43 per cent. In alcohol, 95 per cent, at 
the end of twenty-four hours, a shrinkage in volume of 20.5 per 
cent was observed. This shrinkage is furthermore found to vary 
with different blocks from the same region of the same brain, and 
it is found that there is no constant relation between pieces from 
brains of various grades of hardening. Thus the method of fixa- 
tion must always be taken into consideration. Again, in staining 
under exactly similar conditions, one section on a slide will be 
found more intensely stained than another section on the same 
slide, or even one part of a section will be found more intensely 
stained than some other part of the same section. 

In the subsequent decolorization still greater variations may 
occur, for, if carried too far, important structures may be com- 
pletely decolorized. If carried to the other extreme it is impos- 
sible to differentiate the various parts. The only way to avoid 
either extreme is by repeated examination of the sections under 
the microscope while the process is being carried on, as under 
similar circumstances one section in a given time may become 
much more decolorized than another. In regard to mounting of 
sections stained by the Nissl method, as all were that have been 
employed in this article, xylol-damar has given the greatest satis- 
faction to the writer. With this mounting medium there was no 
subsequent shrinkage, and thus a resulting exposure of the sec- 
tions, also no decolorization was to be observed at later periods. 
In some sections mounted for over three years, no decororization 
was observed, even after several exposures to the intense light 
necessary for photomicrographic purposes, and frequent expo- 
sures to light in their examination under the microscope. Canada 
balsam was also used, but in time the sections were found par- 
tially or completely decolorized. Benzene-colophonium has a 


536 G. ALFRED LAWRENCE. 


tendency to shrink and crack and thus expose portions of the sec- 
tions in some cases. 

It is desired to emphasize the importance of careful attention 
to all these details at the beginning of the article, in order to 
impress upon the reader the necessity of the greatest care and 
conservatism in the interpretation of any changes found in the 
specimens under observation, and, furthermore, the correct in- 
terpretation of the same. Before going on to the main subject of 
the article, a brief historical review of work in this line will be 
given. 

Historical. The first study of the internal structure of the 
nerve cells began over fifty years ago when Remak (1841) called 
attention to a fibrillary structure inside the axis cylinder and cell- 
body of certain nerve cells. Later, Max Schultz (1872) studied 
nerve fibers and cells from various parts of the central nervous 
system of different animals with elaborate descriptions of his find- 
ings. He dealt with a description of the fibrillary appearance of 
the interior of the cell-body largely. This doctrine of the nerve 
cell was afterwards strongly supported by Boll (1873), Schwalbe 
(1885), and Ranvier (1878). Opposite views were, however, 
held by Arndt (1874), and Key and Retzius (1876). Arndt, in 
1874, described the structure of the spinal ganglion cells and 
spoke of the presence in them of different kinds of elementary 
spherules which varied in size and general appearance. Key and 
Retzius stated that the ground substance of the spinal ganglion 
cells was homogeneous, but that in it numerous strongly refrac- 
tive, round, oval granules were present, and they thought the ap- 
pearance of a concentric striation or fibrillation could be simu- 
lated through the arrangement of the granules in rows. Flem- 
ming (1882) saw granules within the cells which would stain 
with nuclear and azo dyes and hematoxylin, but nevertheless 
affirmed a fibrillary structure of the central cells and of a tortuous 
or much curved threadwork within the spinal ganglion cells be- 
tween the granules. In recently published articles (1896) he still 
maintains that fibrils exist inside the nerve cell protoplasm. 

Dogiel (1893) has also expressed himself in favor of the 
views of a fibrillary structure for certain at least of the nerve 


DEMENTIA PARALYTICA. 537 


cells. In 1885 Nissl published the first of a series of articles 
in which he calls particular attention, in tissues hardened 
in alcohol and stained in basic aniline such as majenta red and 
methylene blue, to certain structures. By Nissl’s method these 
are brought especially well into view, and their arrangement in 
the protoplasm and their significance for the function of the cell 
can be studied. 

These structures had been previously observed by Flemming 
and Benda (1882), but by less perfect methods. Nissl at first 
stained tissues hardened in alcohol with magenta red or meth- 
ylene blue, and cleared in oil of origanum. This has been modi- 
fied in several ways, so that at present his treatment is as follows: 
Small blocks of tissue are hardened in 96 per cent alcohol and 
fastened by Weigert’s method with gum arabic, without imbed- 
ding. The sections are received in 96 per cent alcohol and stained 
in a watch glass. The stain is to be heated over the spirit flame 
until small bubbles arise which make a crackling noise (65° to 
70° C.); sections are then transferred to aniline-oil-alcohol until 
differentiated. The process of differentiation is ended when no 
more coarse clouds of color go off into the fluid. The section is 
then transferred to the slide, dried with filter paper, after which 
some drops of oil of cajeput are applied, and the sections are 
again blotted with filter paper. A few drops of benzene are 
poured on the sections, blotted again, and finally some benzene- 
colophonium added, a cover glass placed over the section, and the 
slide heated until all the benzene gas has been driven off. Upon 
cooling, the section is thus permanently mounted. 

The stain is made as follows: Methylene blue, B. pat., 3.75 
grams; Venetian soap, 1.75 grams; distilled water or soft water, 
1,000 c. c. The differentiating or decolorizing fluid has the fol- 
lowing composition: Aniline oil, colorless, 10 parts; alcohol, 96 
per cent, ninety parts. Nissl obtains his aniline oil directly from 
the factory at Hochst and keeps it carefully protected from the 
light. The benzene-colophonium is prepared by pouring benzene 
upon colophonium (white rosin) and alowing it to stand for from 
twenty-four to thirty hours. This results in a fluid transparent 
mass which can be brought to the desired thickness either by the 


538 G. ALFRED LAWRENCE. 


addition of more benzene or by allowing it to evaporate, and then 
it is ready for use. In mounting, while driving off the benzene 
gas by heating over the flame, the material may catch fire, but if 
the flames are blown out immediately no injury is done, and the 
alterations produced by the burning are quite characteristic and 
easily recognizable. The above description has been given in 
detail as it is the classical method, which, as above and with 
various modifications to be described later, has been used by the 
writer in this article. This method distinguishes within the cell- 
body always two and sometimes three constituents. One of these 
constituents of the protoplasm stains entirely blue by this method, 
and is spoken of by’Nissl as the stainable or visible formed part 
of the nerve cell. The second part remains entirely unstained, and 
is spoken of by him as the unstainable or the visible unformed part 
of the nerve celi-body. In addition to the above, in many nerve 
cells, pigmentary deposits are visible which have been especially 
studied recently by Rosin (1896). Nissl has prepared a somewhat 
elaborate classification of cells according to the character and ar- 
rangement of the stainable portion to the non-stainable portion 
of the cell-body in different cells in different parts of the central 
nervous system. This stainable substance shows a series of dif- 
ferent forms; smaller and larger granules of regular or irregular 
shape, arranged in groups or rows. These stainable masses are 
sometimes arranged in threads, smooth or rough, and varying in 
thickness, course, and length. Often larger structures, regularly 
or irregularly shaped, are seen, which stain with varying degrees 
of intensity, some appearing homogeneous, others showing a 
complex internal construction difficult to describe. 

Three varieties of these larger bodies are especially to be 
noted, (1) the so-called “nuclear caps’ (Kernkappen), stainable 
masses in the form of regular or irregular cones hollowed out like 
a cap and corresponding to one pole of the nucleus upon which it 
rests. There may be two such caps within one cell-body at 
opposite poles, and occasionally, according to Nissl, three such 
caps may exist within a single cell. (2) So-called “wedges of 
division” (Verzweigungs-Kegeln), stainable masses completely 
filling the angle at the point of division of a nerve cell process: 


DEMENTIA PARALYTICA. 539 


(3) Spindles, oblong spindle-shaped stainable bodies, thick in the 
middle and thinner at both ends, the latter sometimes tapering 
off into thread-like filaments. These spindles may be one or two- 
sided. Any one of these forms may be vacuolated. Nissl makes. 
a rather elaborate classification of these ganglion cells according 
to their internal morphology, after spending years in the most 
exact investigations of various nerve cells in the different nerve 
centers of man and animals. He has come to the conclusion that 
definite types or variations of nerve cells exist which are constant. 
not only in the same animal but often exist characteristically in 
homologous localities in a whole series of animals. According to: 
him, all the cells in the nerve centers, except the so-called chromo- 
phile nerve cells, can be divided into two main classes. The first 
class includes the nerve cells which possess a well marked cell- 
body surrounding the nucleus completely on all sides, the proto- 
plasm having a distinct contour. These are called somatochrome 
nerve cells. The second class (sub-divided into two groups, cyto- 
chrome and caryochrome) includes those cells in which, in Nissl 
preparations, the nucleus is most in evidence, the nucleus has a 
clear contour, but only indications of a cell-body are present, an 
appearance due to either the scanty development of the cell-body 
or to the predominance in it of the unstainable substance. 

These cells often look as if they were naked nuclei, though 
by Golgi’s method it can be shown that they may possess definite: 
axones and dendrites. In some of these cells the stainable sub- 
stance may be present, but very unevenly distributed, at different 
points in the cell, the nucleus appearing as if only partially sur- 
rounded by protoplasm. WNissl classifies these cells with such an 
ill-defined cell-body, the nucleus appearing only partially sur- 
rounded and not exceeding in size the nucleus of a neuroglia cell 
or of an ordinary leucocyte, as “granules” (Korner) or cyto- 
chrome nerve cells. These cells are present in great numbers in 
the granular layer of the cerebellum, also in the cerebral cortex 
and the olfactory bulb—being different varieties and not identical. 
The second subgroup of cells, in which the cell-body is only indi- 
cated but the nucleus is of the size of an ordinary nerve cell, or 
at least larger than that of a neuroglia cell, he designates as: 


540 G. ALFRED LAWRENCE. 


caryochrome nerve cells. There are varieties of these as in the 
substantia gelatinosa Rolando, and those of the ganglion ha- 
benula—these types being designated at present by letters of the 
Greek alphabet. A majority of the nerve cells fall in the first 
group—the somatochrome cells—where the cell-body, in the light 
of morphology, has apparently greater relative importance than 
the nucleus. In this group are a series of types of nerve cells to 
be distinguished from one another partly through differences in 
the nuclei, but chiefly through different relations of the stainable 
and unstainable constituents of the cell-body. 

These somatochrome cells were originally divided by Nissl 
into four groups, but now he includes them all in three groups as 
follows: 

Group I. Arkyochrome nerve cells—stainable portions of 
cell-body in Nissl preparations in the form of a network, branches 
of which appear to be distinctly connected. Nissl notes, however, 
that in many of these cells processes can be made out into which 
the distinct network of the perinuclear part of the cell-body can 
go over, thus forming a parallel-striped arrangement. These 
arkyochrome cells Niss] subdivides into enarkyochrome forms 
and ampharkyochrome forms. The former shows the stained 
constituents arranged in the form of a network, which differs 
from the latter in that the intensely stained radiating nodal points 
of the network are connected in the cell-body by deeply stained 
thick bridges so that a further connected network of very deeply 
stainable substances is observable. Both these sub-groups of 
cells are widely distributed throughout the central nervous sys- 
tem. The former have been observed by Nissl in the spinal cord, 
but are most numerous in the large dorsal nucleus at the proximal 
end of the medulla. What he formerly classified as Group III, 
arkyostichochrome nerve cells, are now included in this first 
group (1897a). He describes these cells as presenting a striated 
appearance with a network-like structure united in a most intricate 
manner. 


The Purkinje cells of the cerebellar cortex were given as typi- 
cal examples of cells of this sort. (See Plate IX, Fig. 27). 
Group II. Stichochrome nerve cells, stainable substance ar- 


DEMENTIA PARALYTICA. 541 


ranged in stria, running in same direction, and usually parallel 
to contour of cell-body, in part also with surface of nucleus, 
These striz, made up of different stained elements, threads, spin- 
dles and granules, are more or less isolated and in rows. Nissl 
describes four types of these cells represented by (1) nerve cells 
of motor nuclei, (2) large cells of cornu Ammonis, (3) certain 
cells of cerebral cortex, and (4) certain cells of spinal ganglia. 

Group III. Gryochrome nerve cells, stainable substance en- 
tirely made up of small granules distributed in threads or heaps. 
Nissl does not give an illustration of these cells, but states that 
they are to be found particularly but not exclusively in the corpus 
striatum. Nissl states further that transitional forms exist which 
are difficult to definitely classify, but that the cells of a wholly 
definite structure are situated throughout the animal series in 
homologous localities. He has also shown that all these types of 
cells may, under certain circumstances, show different staining 
relations (1894a), that is, the individual members of a certain 
eroup of cells belonging to one type may be palely, moderately, 
or intensely stained. This difference seems to depend upon the 
concentration of the stainable substance in the cell-body. The 
darkly stained cells he designates as pyknomorphous cells, in 
which stainable portions are arranged relatively most closely; 
intermediate stages are designated as parapyknomorphous cells; 
while very feebly stained cells are designated as apyknomor- 
phous, in which stainable masses are not arranged close to one 
another but are somewhat widely separated by the non-stainable 
constituents of the cell-body. Nissl furthermore mentions that 
often the nucleus shows modifications which correspond in 
greater or less degree to the staining intensity of the cell-body, 
so that in an apyknomorphous cell the unstained nuclear sub- 
stance is relatively more abundant than in the pyknomorphous 
cells. This holds in the somatochrome cells, and to a less degree 
in the caryochrome and cytochrome cells. 


Supposed to be more or less in the nature of an artefact are 
the so-called chromophile nerve cells which one finds often single 
or in small groups along with the other nerve cells, but in which 
the stainable substance seems to be evenly diffused throughout 


542 G. ALFRED LAWRENCE. 


the cell-body, making it impossible to distinguish a stainable from 
an unstainable constituent in the cell. Nissl (1896c) states that 
they are always relatively smaller than pyknomorphous cells. The 
explanation of these forms is not as yet entirely satisfactory, but 
they are supposed to be due to the action of the reagents em- 
ployed, though under certain circumstances they may have a 
pathological significance. Another nomenclature has been intro- 
duced by Flesch (1897), in which he speaks of chromophilic cells 
and chromophobic cells with transitional forms, and attributes the 
differences to variations in the internal chemistry of the cells, this 
latter depending in part upon differences in the devolopment, in 
part upon differences in metabolism or function. 

Von Lenhossek (1895) gives a very accurate description of 
the appearances within the cells of the ventral horn of the spinal 
cord and in the cells of the spinal ganglia. He has found that 
thionin stains as well if not better than methylene blue, and 
Barker (1899) has obtained similar results, but states that crys- 
talline deposits have been more frequent in preparations stained 
with thionin than in those stained with methylene blue. In ma- 
terial hardened in Lang’s solution or other corrosive sublimate 
solutions, the writer has at times detected crystalline deposits, 
whether stained with thionin, methylene blue or methylene violet, 
and attributed the same to the fixative fluid and not to the stain 
at all, as no crystalline deposits have been observed with other 
fixative agents—alcohol, formalin, and Van Gehuchten’s fluid— 
regardless of which stain was used. 

It would be interesting to know whether corrosive sublimate 
fixation was used by Barker in the above mentioned preparations. 
Van Gieson uses polychrome to a considerable extent as a stain, 
but it seems to the writer to give a paler and less distinct stain 
than either methylene blue or methylene violet, and has a tend- 
ency to fade after a time. Referring to von Lenhossek again, he 
objects to the term “granules” for the stainable substance, the 
masses being ordinarily much too coarse to be so designated. He 
has given accurate descriptions of their characteristics and ar- 
rangement in various animal species. This stainable substance of 
Nissl he designates as “chromophile corpuscles,” and later uses 
the term “tigroid masses” (1896). 


DEMENTIA PARALYTICA. 543 


De (Quervain (1893) has suggested that the chromophilic 
bodies or corpuscles are aggregations of fine granules, but von 
Lenhossek refuses to admit that all such bodies represent aggre- 
gations of minute granules. Schaffer (1893) first described the 
peculiar behavior of the axone and adjacent portion of the cell- 
body known as the axone hillock as regards Nissl staining, this 
space being entirely free from this stainable substance of Nissl. 
With Kronthal’s method the axone and axone hillock stain in- - 
tensely in methylene blue, but Benda (1895) found that when 
specimens thus prepared were cleared in creosote this region lost 
its color and only the stainable substance of Nissl in the cell-body 
and dentrites retained its color. He found one exception, how- 
ever. In the basal axones of the pyramidal cells of the cerebrum, 
especially of those known as the giant pyramidal cells of Betz, just 
at the beginning where a collateral is coming off at right angles, 
a small wedge-shaped granule, triangular in section, takes up the 
methylene blue, the axone itself not staining at all. These dif- 
ferent results obtained by differences in technique emphasize the 
writer’s previous statement of the necessity of a full knowledge 
of the history of the case and every detail of technique before com- 
ing to any conclusions in a given case. 

With this brief review of the more important literature on the 
internal structure of the nerve cell we will now turn to the ar- 
rangement of the cells in the cortex. To go into the literature of 
this subject in detail would be sufficient material for an article in 
itself, so that it will be passed over as briefly as possible. Table I 
shows the arrangement of the cells as described by the more im- 
portant contributors to this subject. As early as 1782 Gennari 
divided the cortex at the posterior pole of the cerebrum into three 
layers, an external and internal gray layer separated by a white 
layer (so-called line or band), the “line of Gennari.”’ Vicq d’Azyr, 
in 1786, described this region as also made up of an inner and 
outer gray layer between which was a white layer (line or band), 
the “line of Vicq d’Azyr.” Meckel, in 1812, stated that the gray 
layer of the cortex is single in all parts but the occipital region and 
cornu Ammonis. In the occipital region a band of white substance, 
the line of Vicq d’Azyr, separates the gray substance into an 


544 G. ALFRED LAWRENCE. 


external and internal. gray layer, so that the structure of this 
part of the brain is more complex than the rest of the external 
cortical region. Coming down to 1840 Baillarger first examined 
the cortex carefully, and described three gray and three white 
layers, or six layers in all, alternating gray and white. From his 
descriptions the line of Gennari or Vicq d’Azyr, in the occipital 
region, received the additional name of the “line of Baillarger.” 
In 1841 Remak examined the cortex microscopically as well as 
macroscopically, but without the use of staining agents, and de- 
scribed a four-layered type made up of two gray and two white 
layers alternating with one another. 

Somewhat later (1852) Kolliker described a three-layered 
plan, the inner layer appearing of a yellowish red color, the mid- 
dle of a grayish color, and the outer of a whitish color. 

Berlin, in 1858, first used stains in his work, hardening pieces 
of the cortex in chrome salt and staining with carmine. He de- 
scribed six layers as the type, the upper five from the character 
and arrangement of the cells and the lower as a layer free from 
cells. He describes the layers from within outwards toward the 
surface, reversing the usual order of all other authors, and lead- 
ing to considerable confusion, unless this fact is carefully noted. 
Clarke, in 1863, described eight layers as the common type, and 
Luys the following year, 1864, described just one half that num- 
ber, or four layers, as the common type. Arndt, in 1867, de- 
scribed a five-layered type, and Meynert in the same year divided 
the cortex into a motor and a sensory region, the former anterior 
to the fissure of Rolando, and the latter posterior to the same. 
He described five layers as the common type, and eight layers as 
the type in the occipital region. Cleland, in 1870, described 
rather a complex arrangement of the cortex into a four-layered 
type, the third layer being separated from the fourth by what he 
designated as the “primary pale band.” The “deep pale band’ 
is included in and forms the lower part of the fourth layer. 
Henle in the same year described a four-layered type made up of 
(1) the outer layer, (2) outer spherical cell layer, (3) pyramidal 
cell layer, and (4) inner spherical cell layer. Charcot, the fol- 
lowing year, 1871, described the layers of the cortex as five in 


DEMENTIA PARALYTICA. 545 


number, (1) superficial layer, (2) small pyramidal cell layer, 
(3) larger pyramidal cell layer, (4) granular cell layer, and 
(5) fusiform cell layer; approximating that used by many of the 
subsequent authors. Lewis, in 1876, described five layers as the 
type for the motor area and six layers as the type for the sensory 
area. Major in the same year, 1876, described six layers as the 
common type, and Krause, also in the same year, described seven 
layers as the common type. Betz, in 1881, made the division into 
five layers as the type for the motor area, but divided the sensory 
region into eight layers as the type—a classification somewhat 
similar to Meynert’s, but with a different nomenclature. 

Golgi, in 1883, using his impregnation method, divided the 
cortex into three layers as the type, (1) superficial or small 
pyramidal cell layer, (2) middle or larger pyramidal cell layer, 
and (3) internal or irregular cell layer. Schwalbe, in 1885, de- 
scribed a curious arrangement of the cortex into four layers, the 
upper two known as the “outer Hauptzone” or chief zone, and 
separated from the lower into two layers, known as the “inner 
Hauptzone” or chief zone by the “boundary zone” or “line of 
Baillarger.’’ Obersteiner’s (1887) division into a five-layered 
type is similar, except as to the nomenclature, to that of Char- 
cot’s common type, Lewis’ motor type, and Betz’s motor type. 
Cajal, in 1890, recognized the same three layers as Golgi in the 
common type, but added a fourth layer, which he called the first 
or molecular zone, then followed the second, or zone of small 
pyramidal cells; the third, or zone of large pyramidal cells, and 
the fourth, or zone of polymorphous cells; thus making four 
layers in all. Golgi’s first layer is thus seen to include the first 
and second layers of Cajal. In the occipital lobe, Cajal describes 
an additional layer of vertical fusiform cells between the first or 
molecular layer and the layer of small pyramidal cells, the other 
layers being similar to his common type, and thus making five 
layers in this region. Gowers, in 1893, adopted practically the 
same division into a five-layered motor type and six-layered sen- 
sory type as described by Bevan Lewis in 1876. Hammarberg, 
in 1895, described six layers as the type, with numerous varia- 
tions in different parts of the cortex. Edinger, in 1896, describes 


546 G. ALFRED LAWRENCE. 


four layers, similar to Cajal as the type, and Starr (1896), in 
his atlas of nerve cells, also describes a similar arrangement. 
Nissl (1898) describes a four-layered type as follows: First, or 
layer poor in cells; second, or layer of pyramidal cells containing 
2 equals layer of small pyramidal cells (equals 2 of Meynert’s 
layers) plus 3 equals layer of larger pyramidal cells (equals 3 of 
Meynert’s layers); third, or layer of small cells (equals 4 of 
Meynert’s layers) ; and fourth, or internal (6) plus external (5) 
zone of the layer of medullated fibers (equals 5 of Meynert’s 
Jayers). Region 5 equals ganglion cell layer, and region 6 equals 
spindle cell layer of Hammarburg. It will be seen that there is 
much variation and not a little confusion in adjusting these 
various arrangements and classifications to one another, and in 
order to simplify the matter as much as possible the writer sug- 
gests that as the large and small pyramidal cells are so inter- 
mingled and merged into one another, they should be included 
in one layer, thus making three layers the common type, as fol- 
lows: First, or superficial layer, corresponding to the first laver 
of Cajal and Edinger; second, or pyramidal cell layer, corre- 
sponding to the second and third layers of Cajal and Edinger; 
and third, or spindle cell layer, similar to the fourth layer of 
Cajal and Edinger. This arrangement differs from Golgi’s three- 
layered type in that the latter recognized no superficial or tangen- 
tial fiber laver, but includes this as the upper part of his first, or 
layer of small pyramidal cells, whereas in the writer’s arrange- 
ment one pyramidal cell laver includes both the large and small 
pyramidal cell lavers of Golgi. The third layer of Golgi and of 
the writer are the same as the fourth layer of Cajal and Edinger. 
This classification into three layers as the type will be used for 
convenience in the subsequent description of the plates. That 
there are variations from the type in different parts of the cortex, 
of course, is recognized by all who have worked in this field to 
any extent, and, furthermore, specialized parts of the cortex have 
a specialized arrangement, as the cornu Ammonis, for example. 
In turning now to the pathological investigations by means 
of the Nissl stain (1898), they are found to have been exhaustive 
and varied, including most parts of the central nervous system 


DEMENTIA PARALYTICA. 547 


in both man and animals and in many forms of disease. A brief 
review only will be given of the contributions containing descrip- 
tions of researches by Nissl’s stain in that form of mental de- 
rangement known as dementia paralytica, or general paresis. 
Nagy (1894) carried on his investigations by means of the Nissl 
stain, and found the greatest changes in dementia paralytica, in- 
cluding various stages of cell degeneration up to complete de- 
struction of the same—the cells most altered being those of the 
frontal lobes, and least changed those of the occipital lobes. 
Changes of a high grade were also shown in the cells of cases 
dying after severe epileptic insanity—here the gyrus rectus and 
cornu Ammonis being affected the most. In chronic forms of in- 
sanity similar changes were found, but the number of cells en- 
tirely destroyed was undoubtedly smaller than in the above men- 
tioned forms of illness. In acute hallucinatory confusional 
insanity only the beginning stages of alteration were found; simi- 
larly in mania. He finally states that each form of mental de- 
rangement showed the highest grade of change in which the 
clinical picture of the worst suffering was present, while in the 
curable forms there were found corresponding slight changes. 
Belmondo (1896) employed the Nissl method in investigating 
the alterations in the nerve cells in dementia paralytica, and did 
not find changes of great gravity—at most the cell protoplasm 
being much diminished and disintegrated; now and then pigmen- 
tary atrophy, as much in the Rolandic region as the frontal lobe, 
is found, and in other parts a diffuse chromatolysis is to be seen. 
He condemns the expression meningo-peri-encephalitis, which im- 
plies a conception of an inflammatory process. 

Boedecker and Juliusburger (1897) examined sections of 
cortex from the central and parietal convolutions of three cases 
of dementia paralytica by the Niss! method. They found thick- 
ening of the pia with septa projecting into the cortex, containing 
blood vessels whose walls showed no special thickening but were 
surrounded by rich deposits of pigment granules, which latter 
were also found here and there, distant from the septa in the 
cortical network. In regions most affected the cortex did not 
present its well known layering. There was to be seen a thickly- 


548 G. ALFRED LAWRENCE. 


compressed granular crowding with different shaped granules ; 
thin, spindle-shaped, round, or oval, with strongly colored ones 
lying adjacent to those only slightly colored. There was increase 
of blood vessels and hypertrophy of the interstitial network, with 
corresponding decrease in the number and size of the cells. 
Many cells were considerably diminished in size, markedly 
shrunken, entirely without processes, and intensely colored. At 
times a differentiation into nucleus and granular cell-body was 
not possible, owing to complete chromatolysis, and very seldom 
were cells found with a strongly colored nucleus, strongly colored 
fine granules about the same, with larger granules at the peri- 
phery of the cell-body—a partial chromatolysis. 

By the Marchi method these investigators determined a de- 
generation of the fibers from these cells extending into the spinal 
cord. They conclude the process to be an intense degeneration 
and proliferating one, going on hand in hand—degeneration of the 
cells and proliferation of the interstitial network, with increase of 
blood vessels. Crisafulli (1897) notes a great variety of changes. 
in dementia paralytica. The cellular changes are most advanced 
and diffuse in the frontal lobes, but are not limited to that 
region. He examined sections from the frontal, parietal, occipi- 
tal and temporo-sphenoidal lobes of both hemispheres. He found 
pallor, granular disintegration, and loss of chromatic substance. 


Often the cell-bodies were atrophied or contained an excess of 


yellowish pigment, and their numbers were reduced. The nuclei 
were often eccentric, and all stages of the destruction of the 
nucleus were observed. While the alterations shown by Nissl’s 


method were not less constant than those demonstratable by other 


methods, Crisafulli does not consider them characteristic of the 


disease or in any way different from those seen in some other 


mental diseases. They are, however, more or less grave and 


diffuse and not limited to a single cortical center; with varying 


degrees of degeneration of the nerve cells. He further states 
that, provided the nerve cell element degeneration is not greatly 
advanced, it is impossible to find any alteration of the blood ves- 
sels, and, finally, that when the psychosomatic condition of the 
paralytic is not greatly aggravated and death intervenes from 


———- 


DEMENTIA PARALYTICA. 549 


other causes, it is possible that the pathological report will note 
some elements which are not degenerated, although there may be 
various alterations. His article is illustrated by eight figures 
showing cells in various conditions of degeneration. 

Angladi (1898) reports a case of acute dementia paralytica 
in which death occurred after a series of epileptiform convulsions 
when the patient was at the age of thirty-seven years. The 
autopsy showed peri-encephalitis. Preparations were made from 
the ascending frontal convolutions and the anterior part of the 
frontal lobe of the left hemisphere. He states that not a single 
one of the pyramidal cells preserved its normal characteristics, 
and the transformation in the great majority of cases semed to 
be various stages of the same process—various stages of chro- 
matolysis, vacuolization, eccentricity of the nucleus up to rupture 
of the cell wail and extrusion of the nucleus and, finally, com- 
plete destruction and disappearance of the cell. The chromatic 
substance is first attacked, and some few cells relatively healthy 
showed about the nucleus the first stages of dissolution. De- 
struction of the achromatic network was shown by formation of 
vacuoles at the periphery of the cell, increasing gradually up to 
complete destruction of the substance of the cell. The nucleolus 
becomes vacuolated and disappears. The nucleus is attacked 
by central chromatolysis and disappears m situ, or becomes 
eccentric, or the cell-body may rupture and the nucleus be ex- 
truded, becoming irregular, compressed or shriveled. The con- 
tour of the cells is always irregular, and the prolongations either 
broken or tortuous. He states that the cells of the medulla and 
cord show identical alterations. Angladi finally concludes by 
stating that we do not know whether these lesions are the cause 
or the result of the malady, and asks the question, “Are the 
lesions primary or secondary to an alteration of the vessels or 
interstitial “tissue ?” 

Berger (1898) examined the anterior horn cells of the spinal 
cord in twelve cases of dementia paralytica and found lesions 
affecting principally the chromatic substance in 83 per cent of 
the cases. He failed to find a strict parallel between these cellu- 
lar lesions and those of the fibers and cortex, or between them 


550 G. ALFRED LAWRENCE. 


and the clinical symptoms of the disease. He illustrates his 
article by figures of these cells. 

Niss] (a6a), in 1896, stated that he maintains the same posi- 
tion as Kraepelin, namely, that one sees in dementia paralytica a 
general disease with the histopathology directed especially to the 
cortex. The pathological changes in the blood vessels are obscure, 
and the relation of the glia to the blood vessels is complicated, 
also the condition of the lymphatic vessels. Some authors regard 
the disease as an inflammatory process, others that a chronic in- 
terstitial inflammation enters into it, others that it is a parenchy- 
matous process, and still others that it is a histopathological pro- 
cess in which the specific tissue is diseased primarily. Nissl notes 
that an inflammation without the blood vessels sharing in it can- 
not be thought of. He states that the appearance of the paralytic 
cortical disease can be present without the blood vessels being 
diseased and without the blood vessels containing any elements 
of an inflammatory process. Also there may be a high grade of 
disease of the tissue (Gewebe) in excess of any disease of the 
blood vessels, and only a slight involvement of the tissue, and 
vice versa, a severe tissue damage with only insignificant disease 
of the blood vessels. Also direct inflammatory blood vessel 
changes with infiltration of the walls of the same with leucocytes 
and “‘mastzellen,” which may rarely pass out into the adjacent 
regions. In some cases this inflammatory alteration of blood ves- 
sels results in a massive production of decay of numerous 
neurones. These inflammatory changes in the blood vessels have 
nothing directly to do with the chief paralytic process, and are 
only found in the cortex when sepsis-producing bacteria are 
present. It therefore follows that the paralytic cortical disease 
can be regarded either as the result of disease of the blood vessels 
or as an inflammatory process. Almost all cases of dementia 
paralytica show a slight or severe disease of the blood vessels. 
There may be also a leptomeningitis, disease of the beginning 
part of the aorta, an injury to the diplee, brittleness of the bones, 
or there may be a general arterio-sclerosis. If it is not a disease 
of the arteries or an inflammatory process, it may be a primary 
disease of the glia or of the cortical neurone. Changes in glia 


 ——_— 


DEMENTIA PARALYTICA. ars 


are progressive in kind (mitosis of glia nuclei, hypertrophy of 
glia cells, and increase of glia fibers) with regressive changes in 
the cortical neurone—an acceptation that results of investigation 
directly contradict, since we tind in the most luxuriant increase 
of glia that the nerve cells are only slightly or not at all changed, 
and vice versa, in the most severe nerve cell changes the increase 
of glia may be only slight. The acceptation of a primary glia 
fiber increase is absurd, since the glia fibers are an intercellular 
substance. Nissl therefore concludes that the cortical disease of 
dementia paralytica is a primary disease of the cortical neurone; 
at the same time with the regressive changes in the cortical neu- 
rone goes the progressive changes in the glia cells. Histo- 
pathological investigations of paralytic cortical disease has to deal 
chiefly with the following difficulties: (1) a paralytic diseased 
cortex and the, to us, available cortex of the dead paralytic are 
two different things. Entire series of original circumstances that 
damage the neurones of the cortex without having anything to 
do directly with the paralytic process is to be noted, as the com- 
plete closure of a blood vessel which only indirectly bears upon 
the original process. Also death of a paretic from typhus fever, 
septic pyemia, etc. The problem is extremely difficult, as there 
is no specific disease of the cortical cells, and, furthermore, there 
is no paralytic cortical cell disease, although there is a paralytic 
cortical disease. The kind of disease of the cortical tissue is 
worthy of being pointed out. (2) It is not sufficient to know that 
the cortical neurone is diseased, but it is important to know 
which cortical neurones are damaged. Attention to the kinds of 
nerve ceils directly diseased is important for the real conception 
of the disease process, and also for the critical examination of the 
plan of the cortex and its functions. Nissl differentiates the 
following forms of disease of the cells of the cortex in dementia 
paralytica: (1) Acute progressive disease. In certain cases the 
disease ends with the complete destruction of the elements of the 
cortex. (2) The chronic disease progresses slowly, resulting in 
either a pigmentary degeneration or in a decay of the cell-body 
and nucleus, and ends with so-called cell sclerosis. (3) The 
severe disease of the cortex which runs either an acute or sub- 


552 G. ALFRED LAWRENCE. 


acute course and terminates with the death of the cell. The 
necrotic cells persist commonly either bleached out or having the 
appearance of colliquation or of vaucolization of the ground work. 
(4) The combined form of the disease, in which the cell may be 
acutely diseased without either a cure following, or, on the other 
hand, the ordinary course being taken that terminates with the 
destruction of the cell. Midway in its course the disease process 
is arrested and takes on the symptoms of the chronic disease. The 
severe cortical cell disease is entirely overlooked by former 
authors. It differs in that the nucleus is also involved and a pro- 
cess of liquefaction takes place in the same. It becomes smaller, 
shrunken, the contours become homogeneous and tinged, the nu- 
cleolus sinks to the nuclear wall, which latter is irregular and 
shriveled into folds, the network cannot be distinguished, and 
vacuoles and crystals may be formed. In the necrotic cells cal- 
careous deposits may be found, as is seen in other cortical cell 
diseases, as sclerotic elements. These chalky or calcareous con- 
cretions occur in the form of fine granules, crumbs, placques, or 
stalactitic masses, which are intensely colored with methylene 
blue. The entire cell may be bleached or only a single part, as 
some of the fine dendrites or only a single dendritic process, or only 
the nucleus, or, finally, only the nucleur membrane. This calcifi- 
cation, moreover, is an exceedingly important phenomena, since 
we are entitled to conclude that partially calcified cells are no 
longer functionally active and are necrotic. Under similar condi- 
tions in acute diseases we recognize the phenomenon of death in 
the affected cells. If one places the preparations in alcohol after 
twelve hours postmortem, any mistake in this direction may be 
obviated. Whoever grasps the histopathology of the cortical cells 
will guard against any mistake in regard to the above mentioned 
death phenomena. Ewing, in 1898, used the Nissl method in 
observations upon the changes found in ganglion cells of the cen- 
tral nervous system in various pathological conditions, and stated 
that various grades of chromatolysis were found in the cortical 
cells in dementia paralytica. 

Ballet (1898) exhibited sections from the paracentral lobule 
of both a normal and a paretic brain, stained by the Nissl method. 











DEMENTIA. PARALYTICA. 553 


In the normal brain, under a magnification of forty-five diameters, 
the four layers of Schwalbe and Ramon y Cajal were easily dis- 
coverable, but in the paretic sections, in marked contrast, they 
were recognized with difficulty; also in the latter, great numbers 
of capillaries were noted in the third layer and white subcortical 
substance, the nerve cells were less numerous, and in all cases less 
distinct and lost in the midst of a mass of nuclei. At 130 diame- 
ters the contrast was still more marked, and at 250 diameters 
vascular lesions were noted consisting of enormous. dilatation of 
the capillaries and arterioles, the investment of these vessels by a 
casing of lymphatic corpuscles which distended the adventitious 
sheaths, and the accumulation of pigment at certain points, par- 
ticularly in the neighborhood of the bifurcations. These altera- 
tions are also revealed by hematoxylin and picro-carmine, and 
have been described for a long time by all observers, but the Nissl 
method shows the changes more clearly than any of the others. 

In addition to these changes one may mention the multiplica- 
tion of the white corpuscles and their migration from the vessels 
by diapedesis, as due in part perhaps to the proliferation of cellu- 
lar elements of the neuroglia which accumulate in the interstitial 
tissue, principally in the neighborhood of the vessels or about the 
nerve cells. At 600 diameters one easily distinguishes the small 
white cells (lymphocytes), with small nuclei deeply colored and 
with but a small amount of protoplasm; large white globules with 
protoplasm somewhat abundant and with voluminous nuclei 
irregular in form and less impregnated than those of the lympho- 
cytes by the methylene blue; and, finally, polynuclear leucocytes. 
But interest in Nissl’s method is chiefly in the study of the lesions 
of the nerve cells. At 600 diameters one sees the profound altera- 
tions undergone by these cells. In examining the elements of the 
third layer (large pyramidal cells) or the giant cells of Betz, there 
is a tendency in them to lose their triangular shape and become 
oval or rounded, the protoplasmic prolongations are atrophied and 
but slightly visible, the chromophilic granules for the most part 
undergo a process of disintegration and are reduced to a sort of 
fine powder or dust, or are entirely dissolved in the mass of proto- 
plasm. The author then discusses the nature of the process, 


554 G. ALFRED LAWRENCE. 


some authors (Magnan, Mierzijewski, Mendel). claiming the 
primary disease to be that of the neuroglia framework—an inter- 
stitial encephalitis. Others on the contrary (Tuezeck, Ziegler, 
Binswanger, Joffroy, Pierret) claim it affects primarily the 
nervous tissue, either the nerve fibers or the nerve cells; thus being 
a parenchymatous encephalitis. The more Ballet studies the 
pathological anatomy of dementia paralytica the more he is con- 
vinced that the first and most important lesions are those of the 
blood vessels. These are seen in every case, while those of the cells 
are inconstant, variable in degree, and subordinated to those of 
the vessels. This is not to say that the cellular alterations may be, 
as some authors claim, the result of the mechanical choking of the 
cells by the proliferating interstitial tissue which makes their 
pathology more complex, but he thinks the result is due less to the 
compression by the thickened neuroglia than to the difficulties of 
assimilation, owing to either the circulatory obstruction or the 
action of the toxines carried by the blood. Ballet then discusses 
the relation of syphilis to dementia paralytica, and states that the 
pathological anatomical findings in the two cases are practically 
identical, and advocates a syphilitic etiology for the disease. 

In this historical review of the literature on the pathological 
conditions found in dementia paralytica by the employment «of the 
Nissl method, it is to be noted that but few of the contributions 
were accompanied by figures illustrating the various pathological 
findings described in the text. 


(To be continued. ) 


CASES OF COMBINED MORPHINE AND ATROPINE 
POISONING: 


By Puiuip ZEnNeER, A.M., M.D., 


CINCINNATI. 


These cases were deemed worthy of report because none like 
them, so far as I could learn, have been published. They seem to 
indicate that poisoning with the two drugs combined is especially 
dangerous, notwithstanding their supposed antagonism. 

The first case was reported at the time of its occurrence some 
years ago. The patient was a nurse, of twenty years, who had 
taken with suicidal intent, hypodermic tablets each containing one 
quarter of a grain morphine, and I-150 grain atropine. Nothing 
was known of this at the time, and it was only discovered hours 
afterwards when, after a careful search, some tablets were found 
under her pillow. It was supposed, judging from the number of 
tablets remaining in the bottle wherein they were contained, that 
she had taken about eight of them, but that may have been far 
from the mark. 

She was found to be unconscious at 6 p.M. I saw her a few 
hours later. At that time she was profoundly unconscious. There 
was complete flaccid paralysis of all the extremities. The face was 
expressionless, eyes slightly divergent, the pupils of medium size 
and irresponsive to light. Pulse was 120 per minute, of fair force 
and volume. Temperature 100. Respiration eleven per minute, 
and very irregular. Marked cyanosis, knee-jerks could not be 
elicited. Urine contained no albumin, specific gravity 1,012. 

All efforts at resuscitation were futile—washing out the stom- 
ach, introduction of coffee through the stomach tube, hypodermic 
injections of whiskey and ether, applications of the electric brush, 
etc. The breathing was the ominous feature throughout, quiet, 
never stertorous, but irregular, the interval between the respir- 
ations becoming gradually longer and longer. The pulse, which 
was good, though rapid, throughout, could be felt for some time 


*Read at the meeting of the American Neurological Association, May 
TZ, 13. and 14, 1903. 


556 PHILIP ZENNER. 


after the breathing had ceased. The pupils gradually became 
more dilated, though never to the degree of full dilatation. She 
died at 3.30 A. M. 

The second case was a young girl of thirteen years, who had 
chorea for about two weeks. Her restlessness was so great that 
the physician left for her some hypodermic tablets, each containing 
morphine gr. one-eighth, and atropine gr. 1-200. She received of . 
these tablets one at 8 P. M., one at 9 P. M., one at IO P. M., one at 
II P.M., one at 11.30 P. M., and one at I2 P. M.; that is, six tab- 
lets within four hours. She fell asleep an hour or two after the 
last tablet had been taken, and slept soundly until 6 A. M., since 
which time she was dozing and waking, and when awake delir- 
ious, until I saw her. I made a hurried call about 11.30 A. M., the 
only time I ever saw her. She seemed asleep when I stepped into 
the room, but soon awoke, and was quite restless. At times she 
would squirm about and scream, “Oh, that cramp,’ doubtless on 
account of abdominal pain. ' She gave sufficient answers to 
questions to indicate that she was fairly conscious, those in attend- 
ance stating that she was now more lucid than she had been at 
any time during the day. Her temperature was 104° F. Pulse 
was rapid and thready. Scarcely to be counted, but about 130. 
She was very cyanotic. Her heart could not be carefully ex- 
amined, and her restlessness prevented a satisfactory examination 
of reflexes. She had vomited everything she had taken that 
day. 

As nearly twelve hours had passed since taking the last of the 
atrophine and morphine and her mind was becoming more lucid, I 
thought the prospects for recovery fair, even though her condi- 
tion appeared critical. Nevertheless I telephoned at once to her 
physician, telling him she ought to be stimulated and carefully 
watched. A few hours later he said her pulse was fair, and he 
thought she was doing well. He did not see her again. Perhaps 
she was doing well, but about 8 p. mM. she was seized with severe 
convulsions and died within an hour. I have little definite infor- 
mation of her condition subsequent to the time of my visit. 

I saw so little of this second case that I can scarcely make a 
comparison of the two cases. The most striking difference was 


COMBINED MORPHINE AND ATROPINE POISONING. 557 


in the pulse, which was very good in the one and bad in the other. 
That may have been due to the fact that the proportion of atropine 
was much larger in the latter. 

I know of but two reported cases of a somewhat similar charac- 
ter, and these I mentioned in my former report. 

The first was that of a man of sixty, who took by mistake a 
tablespoonful of a mixture containing equal parts of liniment of 
belladonna and tincture of opium. Two and one half hours after 
swallowing the mixture he was unconscious, pulse 140, breathing 
rapid, pupils dilated and sluggish. Twenty-four hours later he ap- 
peared to be out of danger. Four hours subsequently he sat up 
in bed to take a drink and fell back dead. 

The second case was a woman of seventy-nine, who took by 
mistake ten grains extract belladonna, ten grains of extract of co- 
nium, and eighty minims of tincture of opium. Two hours later 
she lay in profound coma, breathing hurried and noisy, pupils di- 
lated, pulse 130, feeble and intermittent. The patient was resus- 
citated to the extent that she took nourishment fairly well, but she 
died forty-eight hours subsequently of exhaustion. 

These two cases are, perhaps, not to be compared with my own, 
as age and enfeeblement may have led to the fatal termination. 
But nevertheless so far as they go, they seem to lend support to 
the view already expressed, that poisoning with a combination of 
the two drugs is peculiarly dangerous. 


A NOTE ON PERIODIC INSANITIES WITH REPORT OF THREE 
CASES OF INTERMITTENT MELANCHOLIA-* 


By Atrrep Gorpon, M.D., 


INSTRUCTOR IN NERVOUS DISEASES, JEFFERSON MEDICAL COLLEGE, 
NEUROLOGIST TO DOUGLASS MEMORIAL HOSPITAL, 


PHILADELPHIA, PA. 


The periodicity of certain forms of insanity has not been fre- 
quently the subject of a special study by the alienists. The reason 
of it lies probably in the fact that cases of this nature are rarely 
met with in institutions. Yet, outside of asylums, they are not as 
rare as it may appear. 

The writer has had the opportunity to have under his personal 
observation quite a number of cases in and outside of asylums. A 
close study of them leads him to consider the subject of sufficient 
importance from both the scientific and practical points of view, so 
that he considers himself warranted to report the result of his 
observations. 

Under the term Periodic Psychoses we understand attacks of 
mental derangement occurring at certain intervals, during which 
the patient is more or less free from mental disturbances. Some 
alienists, especially the older ones, maintain that the intervals 
between the attacks must be of equal duration in order that the 
psychosis be called periodic insanity. The reading of the records, 
however, shows that the duration of the intervals and of the attacks 
of the psychoses are not at all characteristic features of periodic 
insanities. Their duration varies. 

The periodic psychoses known are mania, melancholia, and 
paranoia. Krafft-Ebing and Kraepelin also include the circular 
insanities. 

While mania is more likely to occur periodically than the other 
forms, melancholia is by no means infrequent. The reason why the 
periodicity is often overlooked is that it is not easy to keep this 
class of patients under observation a sufficient length of time. 


*Read before the Philadelphia Neurological Society, April 28, 1903. 


PERIODIC INSANITIES. 559 


Among all the cases that came under my observation, there are 
three that I have had the good fortune to have under my care for 
the last four years, and thus have had an unusually good opportu- 
nity to follow the individual attacks step by step and keep complete 
records. A close study of them showed me the remarkable uni- 
formity in the character of the onset of the attacks, in the character 
of the termination of the attacks, in the age, in the family history, 
and in the fact that each subsequent attack was more and more 
pronounced. A still closer study will make us see clearly that in 
patients presenting the periodic forms of insanities, there is un- 
doubtedly an unusually pronounced degenerative basis, upon 
which are built these occasional outbreaks of depression with or 
without delusions. The histories of the cases are as follows: 


Mrs. E. O., aged thirty-five, was seven times pregnant. Four 
years ago, after her fourth confinement, in the midst of apparently 
perfect health, she became suddenly depressed and felt she could 
not do her work. As soon as she commenced to work she imagined 
she could not continue because she feared not to be able to do it 
properly. Soon her worriment increased, because she could not 
do anything for her children, whom she loved very dearly. She 
used to prepare the food for them, and now she found herself in- 
capable of doing it. Conscious of this condition, the patient soon 
reached a state of complete discouragement. She ceased to take 
an interest in her household, in her husband and children. The 
painful moral depression became associated with the idea of physi- 
cal and moral impotence which showed itself in the lack of con- 
fidence in herself and in the absence of initiative and determina- 
tion. The patient’s life was s dominated by sad ideas; she could not 
take pleasure in anything; everything and everybody became to 
her a source of constant irritation and suffering. Tortured by the 
complete inability to accomplish anything and to render the slight- 
est service to her family, to whom she was previously a devoted 
mother and wife, she could not understand why she suffered so 
much. She then arrived at the conclusion that she was a worthless 
being condemned to perish. At the same time the struggle be- 
tween the state of consciousness of this miserable existence and 
the inability to accomplish anything put the patient in a state of 
constant anxiety which had its effect also upon her vegetative life. 
She lost totally her appetite and would never ask for food; her 
digestion suffered considerably. The special senses became also 
affected; the taste and smell were so perverted that she rejected 


560 ALFRED GORDON. 


almost every article of food with disgust. It was astonishing to 
hear the husband telling how small was the quantity of food the 
patient received: Only two or three times a day she would take a 
spoonful of milk and a couple of slices of bread. She soon began 
to lose in weight. The respiration was slow and superficial. The 
pulse was small, filiform and accelerated. Pain in the precordial 
region was frequent. The blood examination at different periods 
showed a condition similar to that of chlorosis with the exception 
of a marked leucocytosis (22.000 per ccm.). 

If we add to these symptoms headache, partial insomnia, with 
frightful dreams and occasional visual hallucinations, the picture 
of the patient’s condition will be complete. _ 

The mental state just described remained almost unchanged 
for two months. Only now and then a ray of hope would make 
its appearance. She would cease to groan and moan, complain less 
and speak less of self condemnation; then the somatic symptoms 
would become ameliorated. These slight remissions would last 
only a few hours. 

At the expiration of two months, one morning the patient 
awoke in a calm and peaceful manner, called her children, began 
to caress them and offered to prepare breakfast for the family. 
The mental faculties became clear and normal. She began to take 
an interest in her surroundings, in her own personality; briefly 
speaking, the melancholic state by which she was tortured for two 
whole months disappeared entirely. 

She became pregnant again and felt well during ten months. 
Three weeks after the confinement, which was normal, suddenly, 
and without any preliminary symptom, the old mental trouble re- 
turned. Again the same complaint of worthlessness, the same in- 
difference to her surroundings, again the same state of anxiety 
which made her this time speak of suicide. The knowledge of the 
fact that this was her second attack made her fear that her case 
was lost, that she would never get well, and therefore the symp- 
toms of anxiety and the somatic symptoms were more pronounced. 
The visual, also auditory, hallucinations occurred very frequently. 
This state of depression lasted two months. Exactly like in the 
first attack, this second one also terminated abruptly, and again she 
became normal. A third pregnancy occurred. Six weeks after 
the confinement the old trouble returned. Without any prodromal 
symptom she became markedly depressed. The self condemnation 
with the delusions of worthlessness, also the tendency of suicide, 
hallucinations and the painful emotional state recurred. 

Shortly speaking, the patient passed through a state of mental 
disturbances almost identical in its evolution with the first two 
attacks, with this difference, however, that the last attack lasted 





PERIODIC INSANITIES. 561 


four months, while the first two attacks lasted only two months. 
The termination was also abrupt. 

The patient is now perfectly well. A year elapsed since the 
last attack. She is not pregnant. 

In her family history I could elicit two cases of insanity—in a 
sister and grandmother. She had eight children, two of whom 
died with hydrocephalus, one died immediately after birth; one of 
diphtheria. 

Her personal previous history shows that she suffered from 
obsessions at the age of sixteen, and was always considered highly 
irritable. 

Case 2. Mrs. B. B., aged thirty-one, came under my observa- 
tion three years ago with a typical melancholia. Delusions of un- 
pardonable sin of a religious character, hallucinations, both visual 
and aural, and an array of neurasthenoid symptoms. All these 
symptoms were present at the time I first saw her. From the pre- 
vious history of the case I could detect ane previous attack, which 
was evidently mild in character, but was undoubtedly present. The 
second attack, in which she came under my care, was sudden, with- 
out a preceding physical indisposition or any mental disturbance. 
As a woman of means, she enjoyed life, and was mentally lucid. 
One morning, after having spent the previous, night in a theater, 
she awoke in a state of depression, and from that hour on the 
above-mentioned symptoms gradually developed. 

A peculiar fact to note is that this attack, as well as the first, 
which I did not witness, began with a facial neuralgia which lasted 
only one day. 

The condition lasted three months. The termination of the 
disease was strikingly abrupt. Six months later, apparently with- 
out any cause, the patient again became depressed. Here again 
the above mentioned neuralgia was present on the first day of the 
attack and then gradually disappeared. All the symptoms of the 
previous attack repeated themselves, but they became more pro- 
nounced. The hallucinations tormented her considerably, so that 
the patient made repeated attempts at suicide. Equally the soma- 
tic symptoms were of a more marked character. The management 
of this attack was also more difficult than that of the first attack. 
The duration was also longer. It took six months for her to re- 
cover, but he termination was as abrupt as in the previous attack. 

The family history shows that all her sisters are of a highly 
nervous temperament. An uncle died of paretic dementia and a 
grandmother died in an insane asylum. At the age of fourteen 
the patient presented for a short period symptoms of obsessions 
and agoraphobia, and at fifteen chorea twice during the same year. 

Case 3. Mrs. R. P., aged thirty-four, had two attacks of 


562 ALFRED GORDON. 


melancholia, before she came under my care. Her husband, a man 
of intelligence, gives a clear account of her previous illness. After 
a confinement she developed a phlebitis, from which she recovered 
at the end of six weeks. During convalescence she suddenly be- 
came depressed. The condition grew.worse and worse, so that she 
finally presented distinct symptoms of simple melancholia without 
delusions. The prominent symptoms were a pronounced depres- 
sion, and indifference to the surroundings; the patient would spend 
her time in groaning and moaning, and lost interest in everything. 
The first attack lasted six weeks, after which the recovery came 
on abruptly and unexpectedly. 

Six months later a similar attack occurred without any prelim- 
inary illness. The character of it was exactly like that of the first, 
but it lasted three months. Again the patient recovered suddenly. 

I have had her under my observation for the last three years, 
during which time she had two attacks. The first of the latter also 
came on in the midst of apparently perfect health. Besides the 
painful emotional state, she presented also delusions of personal 
worthlessness and self condemnation, which at times led her to 
attempts at suicide. The condition, which lasted six months, was 
decidedly of a more serious nature than during the first two at- 
tacks. 

After a recovery, which set in-also unexpectedly, the patient 
remained in good health for eight months. After this interval of 
well being, another attack occurred. 

This time she developed within a very short period a typical 
melancholia, with delusions of unpardonable sin; her sufferings, 
she says, are all due to her being untrue to the Lord. Her retribu- 
tion, she says, is just and she must die for it. She is also tortured 
by frightful dreams, in which she sees her own body. cut and 
burned by some invisible agents in punishment for her lack of re- 
ligious ardor. There is no use, she says, to atone, as her wrong- 
doings were too numerous. Occasionally she has auditory hallu- 
cinations. She refuses food; spends her time in crying; lost all 
interest in her surroundings. ~ 

It is a little over a year that this attack has lasted, and the 
patient shows no sign of improvement. 

The patient’s family history is interesting. Three sisters were 
committed twice, an uncle on her father’s side is a paranoiac. At 
the age of ten she had epileptiform convulsions. 


Such is the brief account of three typical cases of intermittent 
melancholia. 
The evolution of the disease, as well as other features, are so 





PERIODIC INSANITIES. 563 


different from the common type of melancholia that they deserve 
a special mention. 

One could see that in all of them there were no morbid symp- 
toms immediately preceding the onset of each attack. While the 
ordinary melancholia develops in an insidious and progressive 
manner, so that the patient or his relatives cannot as a rule indicate 
the time when exactly the state of depression begins, in the periodic 
melancholia of the intermittent type the onset is strikingly sudden. 
Feeling perfectly well a day before, the patients awake in the 
morning with svmptoms of sadness. Sometimes a localized physi- 
cal pain will be present at the beginning, as in Case 2, in which 
each attack commenced with a facial neuralgia of short duration. 

The duration of the attacks as well as of the intervals between 
the attacks presents no characteristic features, although some of 
the cases reported by other writers show a remarkable uniformity. 

Inasmuch as the onset of the attacks is characteristic by its 
suddenness, their termination is equally abrupt or rapid, while an 
attack of ordinary melancholia disappears only gradually and very 
slowly. 

As a last interesting observation, I wish to call attention to the 
state of mind of the patients between the individual attacks. It is 
singular to note the comparative mental lucidity, which is rather 
an unexpected phenomenon in view of the repetition of the attacks. 

The cases which served as basis for the present study did not 
_ induce me to consider periodic insanities as a separate disease or 
to create a new form of melancholia. My intention was merely to 
present a modest contribution on an important variety of melan- 
cholia which has not received sufficient attention. I say an im- 
portant variety, as it is not an indifferent matter for the patient 
and his friends to know whether he is suffering from an ordinary 
melancholia, which is, generally speaking, a curable mental 
affection, or from a variety of the same affection which has a 
tendency to repeat itself and become more and more aggravated 
with each new attack, and which by virtue of the repetition shows 
that there is a profound underlying degenerative make-up. 

Krafft-Ebing,? from an extensive statistical study, shows how 


?Allg. Zeitsch. f. Psych. Bd. 26, 1860. 


564 ALFRED GORDON. 


great is the rdle of heredity in periodic insanities. Although 
melancholia belongs to the group of mental affections in which a 
neuropathic tendency is frequently present, in the periodic variety 
of melancholia a mentally morbid heredity is still stronger. This 
fact creates a special state of degeneration, which predisposes 
strongly to periodic outbreaks of insanity. Ziehen’s* careful statis- 
tical studies are in accord with Krafft-Ebing’s. 

The three cases which I have just reported also show the de- 
generative tendency. 

If this is the case, the prognosis in periodic insanities is cer- 
tainly extremely unfavorable; the patient may recover from an 
individual attack, but the tendency to a repetition will be always 
present. This tendency is created by a special make-up of the 
mentality, which cannot be radically altered. Moreover, a careful 
reading of the records of others and my own cases showed to me 
that almost each subsequent attack presented a more serious clin- 
ical picture and was of longer duration than the one preceding. 
It is therefore evident that periodic melancholia is of a far more 
seriotis nature than the ordinary type of melancholia. 

These few thoughts suggested themselves to me as being of 
some importance from a practical standpoint. ; 








*“Psychiatrie,” 1804. 


Society Proceedings. 


NEW YORK NEUROLOGICAL SOCIETY. 
April 7, 1903. 
The President, Dr. Pearce'Bailey, in the chair. 


Birth Palsy—Syringomyelia—Dr. Edward D. Fisher presented a man, 
twenty-five years of age, who had had a birth palsy, apparently the result 
of a tedious labor and a forceps delivery. There were present the charac- 
teristic athetoid movements, but the epileptic attacks had ceased in child- 
hood. When fifteen years old he began to notice a wasting of the muscles 
of the left hand and forearm along with some disturbances of sensation. 
Subsequently the right hand became similarly affected. On examination, 
there was found to be almost complete loss of pain and temperature sense, 
and the tactile sense was not good., There was no sensation on either side 
to the strongest faradic current. There was absolute loss to both the 
faradic and galvanic currents in both hands. In the forearm there was a 
diminished reaction. The condition just described had progressed slowly 
during the past ten years. The reflexes were greatly exaggerated on both 
sides. The case had been previously diagnosticated as progressive muscu- 
lar atrophy, but Dr. Fisher would make a diagnosis of syringomyelia, prob- 
ably originating in a slight spinal hemorrhage. The patient was very intel- 
ligent and in perfect health. He had presented no bulbar symptoms. 

Dr. B. Sachs thought the association of syringomyelia with an infan- 
tile cerebral palsy was unique. The suggestion of a hemorrhage occurring 
simultaneously into the cervical portion of the cord at the time of the cere- 
bral palsy appeared to him a good one. Recently cases of congenital spastic 
paraplegia had been reported which were known to have been produced by 
hemorrhage into the cord lower down. The speaker said that a few days 
ago he had seen a case of apoplexy in an elderly person resulting in a left- 
sided hemiplegia. After a few days very slight motion returned in the left 
hand, and he was astonished to find that he could secure fairly good mo- 
tion of the paralyzed hand when asked to close the other hand. This ob- 
Say was common in children, but he had not before noticed it in 
adults 

Dr. Pearce Bailey said that a few years ago Schultze described hemor- 
rhages into the spinal cord occurring in young infants in connection with 
difficult labor, and the subject had assumed a medico-legal interest. In the 
cases of hematomyelia that he had seen he had never been able to observe 
them long enough to see the progression of the symptoms. 

Suture of Popliteal Nerve; Perfect Restoration of Function.—Dr. 
Russel A. Hibbs presented a boy of fifteen years who had come to the Or- 
thopedic Hospital on October 6, 1902, with a history of having fallen upon 
a knife seven weeks previously and injured the leg. On October 9 he was 
operated upon, and on exposing the site of the injury it was found that 
the popliteal nerve had been divided. It was accordingly sutured with a 
practically perfect result. While the voluntary power in the muscles sup- 
plied by this nerve was lost, there was still some sensation, which was ap- 
parently accounted for by the fact that a few fibers of the nerve remained 
intact. The limb was kept slightly flexed for six weeks after the operation. 


566 NEW YORK NEUROLOGICAL SOCIETY. 


Dr. M. Allen Starr thought surgeons as a rule did not recognize the 
great importance of suturing nerves at the time of such injuries, for, it 
was not uncommon for persons so afflicted to seek relief a considerable time 
after the injury. There could be no question that a divided nerve would 
not unite spontaneously in the majority of cases, and it was equally cer- 
tain that by nerve suture a good result was usually secured. He had seen 
one or two interesting cases in which nerve suture had been essayed in chil- 
dren in whom the brachial plexus had been injured at birth. Four success- 
ful cases of this kind had been recently reported. The operation consisted 
in laying bare the brachial plexus, finding what nerves were torn, and 
uniting them. 

Dr. William M. Leszynsky said that in injuries of the hand special 
care should be taken to determine whether or not the nerves had been in- 
jured. He had recently seen a case in which the divided tendon had been 
sutured and the divided ulnar nerve had been entirely overlooked. As a 
result, a neuritis of this nerve had developed before he saw the case. Al- 
though rather late, an operation had been advised in the belief that even 
late operations were often successful. 

Dr. Fisher said that he had had under observation for some time a facial 
paralysis that dated from childhood, the patient being a woman of thirty. 
After a while a faradic response from the facial muscles was obtained; 
hence he thought one could hardly place a time limit after which nerve 
suture would afford but little prospect of benefit. 

Dr. Hibbs said that in his case the original wound had been treated at 
a hospital, but the nerve injury had not been noticed. 

Paralysis Agitans (?)—Dr. J. Ramsay Hunt presented a man of 
forty-three, a cigar roller by occupation. The present affection dated 
back four years. It had first been noticed that the right hand was weak 
and tremulous, but he had continued at work for three years. Last July 
the head also became tremulous,and the right leg felt heavy. When first seen, 
about one month ago, examination showed tremor of the right hand with- 
out rigidity; a slight atrophy of the right forearm; a tendency to monotony 
of speech and a rather expressionless face. The question arose as to 
whether this was an occupation-atrophy or, as he was inclined to believe, 
a case of paralysis agitans. 

Dr. Hunt also reported a case at the Montefiore Hospital which had 
presented the characteristic picture of paralysis agitans for several years 
before death. An autopsy on the brain was alone permitted. The vessels 
showed marked arteriosclerosis. There was an excessive degree of pig- 
mentation and some rounding of the processes of the cells in the cortex 
and in the portion of the cervical cord removed for examination—in short, 
those changes that had been regarded as occurring frequently in paralysis 
agitans. The specimens were exhibited under the microscope. 

Elephantiasis Ossium.—Dr. I. Abrahamson presented a woman of 
thirty-six showing a peculiar glossy appearance of the skin of the forehead 
and a remarkably wide supraorbital ridge. Examination revealed a ptosis 
of the right eye, a double divergent squint, and a marked contraction of 
both inner fields of vision. According to her husband, the changes in her 
outward appearance had been progressive. The malar bones were enlarged, 
and apparently the hands and feet were growing larger. The condition was 
possibly due to luetic disease of the apophysis, because there was specific 
disease of the eyes. 

Dr. Starr remarked that the appearance of the eyebrows pointed strong- 
ly to the case not being one of acromegaly or myxedema, but of elephantiasis 
ossium. The case appeared to be in an early stage. 

Dr. Leszynsky said that acromegaly could be excluded by the condi- 





NEW YORK NEUROLOGICAL SOCIETY. Say, 


tion of the visual field, as in that disease there was usually a bitemporal 
hemianopsia. 

Paralysis Agitans. A General Discussion—Dr. B. Sachs said that he 
was of the opinion that this was distinctly a disease of the senile period. 
In this period the two most important factors were emotional excitement 
and some prolonged and exhausting disease. The point of differential diag- 
nosis to which Charcot had attached so much importance, the non-involve- 
ment of the head in paralysis agitans and its involvement in multiple 
sclerosis, seemed to him a point not well taken, for he was sure he had 
seen involvement of the head in fully 75 per cent of cases of paralysis 
agitans. Charcot’s attempt to differentiate sharply between these two af- 
fections seemed to him to have been carried beyond a justifiable limit. 
He had seen cases giving the symptoms of multiple sclerosis, and yet later 
on develop a distinct picture of paralysis agitans. There was a young 
man at the Montefiore Hospital whom he had first seen when only about 
eighteen years old, and who developed the typical carriage, tremor and 
speech of paralysis agitans. As the years went on he developed nystagmus 
and a marked exaggeration of all the reflexes, and his speech was now as 
much that of multiple sclerosis as of paralysis agitans. He also recalled 
the case of a young woman first seen by Professor Mendel in Berlin, who 
made the diagnosis of hysterical tremor. When seen by the speaker 4 
few months later, she presented what appeared to be the first symptoms of 
multiple sclerosis. At the present time, she presented the typical picture 
of paralysis agitans. This experience led him to think that there must be 
some relationship between these two diseases, and the case presented this 
evening by Dr. Hunt gave color to this view. With regard to the treatment 
of paralysis agitans he was accustomed to make use of hyoscine and the or- 
dinary sedatives, and probably all present believed that no drug did much 
good. The only treatment that was fairly satisfactory was the use of some 
form of vibratory therapeutics. 

Dr. Stuart Hart said with regard to the records of Dr. Starr’s clinic 
at the Vanderbilt Clinic, that out of 219 cases of paralysis agitans there 
recorded, 139 were males and 80 females. Under thirty years of age there 
developed 2 cases, both males. The disease commenced in 88 cases between 
fifty and sixty years of age. Among heavy workers there were 45 males; 
among those particularly exposed to cold there were 24 cases; among the 
lighter trades there were 24 cases; among those working in factories were 
14 cases. In 6 cases it was stated that the mother had paralysis agitans, 
and in 3 the father was said to be so affected, while in several other cases 
brothers or sisters were said to be similarly affected. Forty patients be- 
lieved that the disease arose from anxiety or worry, and half of these 
directly attributed it to fright. In quite a number of instances the history 
stated that the tremor had developed very shortly after some trauma of 
the part first exhibiting the tremor. 

Dr. Joseph Collins presented an analysis of 50 cases of paralysis agitans. 
Of this number 34, or 68 per cent, were males, and 16,orf 32 per cent, females. 
The average age at which the disease developed was 51% years, the 
youngest being 32 and the oldest 72 years old. They were divided accord- 
ing to occupation as follows: Merchants, 7; workmen, 8; laborers, 5; 
tailors, 4; clerks, 1; clergymen, 1; drivers, I; carpenters, 1; plasterers, I; 
engineers, 2; gardeners, 1; houseworkers, 9; captains, 1; no occupation, 
7. The nationalities were: United States, 8; England, 1; Ireland, 16; 
Germany, 7; Holland, 1; Russia, 6; Austria, 1; not given, 10. The attri- 
buted cause was: Worry in 7 cases; alcohol, 1; excesses, 1; excitement, I; 
shock, 1; refrigeration, 1; hard work, 1; pneumonia, I; grief, 1; bite of 
cat, 1; unknown, 34. In 7 cases there was a history of injury; in 1 of ope- 


568 NEW YORK NEUROLOGICAL SOCIETY. 


ration; in I of hard work; in 1 of syphilis; while in 40 cases there was no 
special history of this kind. There was a history of neuropathic heredity 
in 13 of the cases, or 26 per cent, and a history of paralysis agitans in 
the parents or uncle in 6 instances. The average duration when first seen 
was four years, the longest being 20 years, and the shortest 5 months. The 
part to first show trembling was, left upper extremity in I1 cases; left 
lower extremity in 8; right upper extremity in 15; right lower extremity 
in I; upper in 7; lower in 2; right upper and lower in 1; left upper and 
lower in I; and all extremities in 4 cases. The initial symptom was: trem- 
bling in 24 cases; pain in II; unsteadiness in 3; numbness in 2; nervous- 
ness in 1; stiffness in I; inactivity of fingers in 1; weakness in 1; loss of 
power of right hand in 1; headache in 1; and not given in 4 cases. The 
relation of curvature of the spine was investigated specifically in only 
the last 20 cases, and was noted in 7 cases. He was convinced that paraly- 


sis agitans was a disease of early senility occurring as the reward of 
virtue. 


Dr. M. Allen Starr said that he had had a fairly large experience with 
paralysis agitans, yet it did not bear out Dr. Collins’ statement about the 
frequency of the disease among the Celts, and its comparative rarity 
among Hebrews. He could recall quite a large number of patients among 
Jews, and a number among the Germans. In hospital and clinical work 
one was apt to get a one-sided view of such matters, because of the large 
proportion of persons of certain nationalities at such places. Nor did his 
observations bear out what the last speaker had said about heredity; prob- 
ably four or five per cent would represent the proportion showing heredi- 
tary influence. Anxiety and trauma appeared to him to bear a distinct re- 
lationship. He had never seen a patient absolutely cured of paralysis agi- 
tans, hut he had observed a very marked improvement in one, and a great 
variahjlity of symptoms in a number of other cases. The disease did not 
appear to be a steadily progressive one. He had found that the Swedish 
massage, skilfully administered, after a prolonged hot bath, gave these 
patients so much relief that they were willing to keep up such treatment 
for years. The great majority of his patients had found benefit from hy- 
oscine in doses of 1-100 of a grain, given from two to five times a day. 

Dr. Leszynsky said that dispensary and hospital patients were not 
benefited, but with private patients it was quite different. Four times 
within the past ten years he had had the opportunity of making the diagno- 
sis very early in the disease. The disease certainly presented remissions at 
times, and traumatism certainly exerted a distinct influence. Most of these 
patients were very amenable to suggestion, and in this way could be bene- 
fited by treatment. He had not observed good effects from hyoscine except 
for a very short time, because most of the patients complained of the ac- 
tion of this drug. As systematic exercise had been recommended he had 
tried the Swoboda system of exercises, which call for voluntary effort 
entirely, and the patients appeared to be benefited thereby. 

Dr. Joseph Fraenkel said that in the past ten years he had seen many 
cases of paralysis agitans and had witnessed 10 autopsies. It was rare 
to find a person suffering from paralysis agitans who was gray-haired or 
old-looking, and the autopsies showed a remarkable freedom from arterio- 
sclerosis. These persons were rarely addicted to the use of alcohol or ex- 
hibited evidence of syphilitic infection, and to this extent he would indorse 
Dr. Collins’ statement that this disease was “the reward of virtue.’ He 
saw nothing to support the theory that this was a disease of senility. It 
was common to oberve a marked hypertrophy of the skin in these pa- 
tients. A characteristic feature was the difficulty of stopping the patient 
when on any one line of thought and changing him to another. A pseudo- 
nystagmus was often observed. Although the tremor ceased at night, the 





f 


NEW YORK NECOROLOGICAL SOCIETY. 569 


paralysis agitans patient presented the same attitude in sleep as when 
awake. He agreed with Dr. Collins that very little could be done for these 
patients by treatment of any kind. 

Dr. Harlow Brooks said that he had only studied four cases of paraly- 
sis agitans post-mortem, and the findings were so conflicting that he was 
very “skeptical about any lesions claimed to be characteristic of the dis- 
ease. He was of the opinion that deformity of the spinal column was very 
common in persons who were not very well developed, basing this opinion 
upon many observations made in the deadhouse as well as in examining 
during 1808 the recruits for service in the regular army. He thought that 
fully 7 out of 50 such recruits would show as much spinal deformity as Dr. 
Collins’ cases, even though these persons were of sufficiently good phy- 
sique to be accepted in the army. 

Dr. Collins said that his statistics with regard to the Celts might be re- 
futed, but to do so the actual figures must be presented and not cases re- 
called from memory. He believed also that the more paralysis agitans was 
treated the worse it became. 

Dr. Hunt said he understood that the premature senility referred to 
the nervous system, and not to the arterial tree when used in connection 
with paralysis agitans. 

Dr. Pearce Bailey was of the opinion that two-thirds of the cases 
of paralysis agitans began after the age of sixty. A disease which could 
become fairly well developed in the course of a few weeks could hardly 
be regarded as an organic disease of the nervous system, and he was in- 
clined to think that the evidence was rather in favor of its being a disease 
of the muscular system, resulting possibly from the action of certain tox- 
ins. He believed it was distinctly induced by trauma, either psychic or 
physical, for there were too many definite and striking clinical records of 
this kind. The disease usually first appeared in the hands, and yet in cases 
of injury to the legs the disease was more apt to begin in the legs. A large 
proportion of the persons coming to Dr. Starr’s clinic suffering from 
paralysis agitans were apparently right-handed workers. 

A Specimen of Brain Abscess.—Dr. Joseph Collins presented this speci- 
men removed from an Italian laborer, forty years old, who had not been 
sick up to two months before his admission to the City Hospital, since 
which time he had suffered from headache only. On January 14 he became 
stuporous. There was no paralysis, paresis or spasm, in fact, no objective 
symptom other than stupor. Examination on February 3 showed the head 
to be drawn over to the right side and flexed, and the right upper extrem- 
ity partly flexed at both joints. There was a peculiar elastic resistance of 
the right upper extremity on extending it. Kmnee-jerks were absent. 
The plantar jerk on the right side was lively, but could not be elicited on 
the left side. The body temperature remained about normal, and the 
pulse varied from 68 to 90, and the respirations between 20 and 22. Dr. 
Collins’ diagnosis was circumscribed non-purulent encephalitis, and be- 
cause of the motor symptoms on the right side the lesion was thought to 
be in the left cerebral hemisphere. However, the lesion was found to be 
a focus of comparatively recent yellow softening situated on the right 
convexity, involving that portion of the first temporal convolution lying 
immediately below the supramarginal and angular gyri, and _ sep- 
arated from these by the Sylvian fissure. It involved the posterior arm of 
the internal capsule, and extended apparently into the extraventricular ra- 
diations emanating from the lower third of the posterior central gyrus. 
The internal capsule was not involved in its passage between the basal 
ganglia. No thrombus could be found. The special interest of the case lay 
in the fact that the motor symptoms were on the right side and the lesion 
was found on the same side. 


Periscope. 


MISCELLANY 

Cardiac Neuroses.—Pick, in his capacity as the chief of the Vienna 
Military Hospital, observed 41 soldiers between eighteen and thirty years 
of age, with a syndrome of symptoms approaching the character of Base- 
dow’s disease, but at the same time differing so essentially from it as to 
merit special consideration. The patients suffer from palpitation and op- 
pression at the least effort, and complain of muscular fatigue. At the phy- 
sical examination they all presented symptoms of a certain degree of a 
hypertrophy of the thyroid gland, usually of the left lobe, but the goiter 
was never pulsatile. The pupils are unequal, the right one rather dilated, 
but reacting to light; the mydriasis can hardly be ascribed to pressure of 
the right sympathetic through the lobe of the thyroid for the hypertrophy 
of the latter is too insignificant to cause such disturbance. All the subjects 
suffer from a very irritable heart, and the slightest effort suffices to in- 
crease abnormally the heart beats; so that in one minute the beats will 
jump from 70 to 140 per minute. The heart, as asserted by Kraus in other 
cases of thyroid hypertrophy, is rather dilated than hypertrophied. The cu- 
taneous capillaries are very irritable and all the patients present marked der- 
mography. Axillary hyperidrosis, anesthetic pharynx, but without other 
symptoms of hysteria. Some show tremor of hands when extended with eyes 
closed, others some cardiac arrythmia. Unable to form a positive diagno- 
sis the author supposes the syndrome of symptoms to be a disguised form 
of Basedow’s. JELLIFFE. 


The Various Reflexes in Diabetes.—It has been observed by Landouzy 
Rosenstein and others that the patellar reflex is either diminished or entirely 
absent in cases of diabetes mellitus. Pitres (Soc. de Bul. de Bordeaux, 
Nov. II, 1902) undertook to investigate the condition of other reflexes in 
this affection. With this in view he examined 32 diabetics, and he finds the 
following : 


Patellar. Cutaneous. Cremaster. Plantar. Pupillary. 


Abolished... ay cpa: 13 6 19 16 I 
Weakened gris? o 8 6 2 O 
Exaggerated ))a 2 6 4 6 O 
Normal as eaee ce sane I 3 8 3I 


It would thus seem that the cutaneous reflexes are, even more often than 
the patellar, either abolished or weakened. At times the tendon reflexes 
are first to disappear, at other times it is the cutaneous; of the latter we 
find at one time the cremasteric weakened or abolished, at other times the 
abdominal or the plantar, while the others are either exaggerated or nor- 
mal. This great variability is observed also in other pathological states, 
especially in tabes, and this renders it somewhat difficult to explain the 
significance of the loss of reflexes. Contrary to the above, the pupillary re- 
flexes are almost always preserved in diabetes. In the single case in 
which the author found them absent there was arteriosclerosis, diabetes 
with glycosuria and moderate polyuria. In the other cases the reaction 
of the pupils to light, accommodation and pain were perfectly normal. 
The conclusion may thus be drawn that although the condition of the cu- 
taneous and tendon reflexes may not seem in the way of a differential 





\ PERISCOPE. STL 


diagnosis between true tabes and diabetic pseudotabes, the character of the 
pupillary reflex and of the epigastric sensibility as well as the cremasteric 
reflex may be utilized in difficult cases to distinguish one affection from 
the other; inasmuch as the Argyll-Robertson pupil and the epigastric and 
testicular analgesia, so commion in true tabes, are not observed in diabetes. 
TELLIFFE. 


RIVISTA SPERIMENTALE DI FREMATRIA 
_ (Vol. xxviii, Fasc. iv, Dec., 1902.) 
1. The Correlation between Psychic and Organic States. Sirvio Ton- 
NINI. 


2. A New Anomalous Process in the Sphenoid Bone of Man. TENCHINI 
and ZIMMERL. 

3. Peripheral Facial Diplegia. PANEGRossI. 

4. A Contribution to the Study of Precocious Malignant Syphilis of the 
Brain. PANICHI. 

5. The Toxic Principles of Aspergillus Fumigatus and Flavescus and Their 
Relation to Pellagra. CENI and Besta. 

6. The Nervous Lesions and the Pathogenesis of Amyotrophies of Articu- 


lar Origin. PIGHNI. 
7. A Contribution to the Study of Lingual Hemiatrophy. BIANCONE. 
8. The Toxicity of the Blood of the Insane. CrEnr and PIn1. 
9. Hemorrhagic Encephalitis with Special Reference to the Tuberculous 
‘ Variety. Bompiccl. 
10. Hypothermy in the Epileptic. Brsta. 
11. The Assistance Rendered to Insane in Italy. TAMBURCNI. 
12. The Action of Gastro-intestinal Juice on Aspergillus. CENT. 

1. The Correlation between Psychic and Organic States.—The author 
employs the term correlation to express that close and varied connection 
which unites and co-ordinates the organic functions with the psychic ones, 
and these last with the psychic acts as manifested to the eye, etc. Disease, 
-degeneration, mental sanity have all their proper psychic and psycho-organ- 
ic correlations, and these correlaries are to be found not solely in patho- 
logic conditions; for correlation is a biological function, and without it 
there is no life. To give an idea of the importance practically of these 
organic and psychic correlations, it is sufficient to take some examples 
from the sphere of the sexual life which exerts such a direct influence on 
the development and orientation of psychic life. Thus sexual perversions 
are always associated with certain organic and psychic secondary sexual 
characteristics. The author brings forth a case in point, that of a man of 
fifty-seven who was accused of seducing a young woman, but who claimed 
to be impotent. Physical as well as a thorough psychological examination 
by the author concerning all the man’s habits, mode of thinking, etc., 
proved to the jury conclusively that the man could not but have been per- 
fectly potent. Theauthor makes the proposition that psychological examination 
and investigation should be carried out not only in cases of suspected mental 
alienation, but in all cases that lack proof of a committed crime; as such 
an examination requires knowledge and skill it should generally be en- 
trusted only to an experienced psychiatrist. This province has, however, 
been invaded to some extent by Criminal Anthropology, with its practical 
tendencies to fix the correlation between the physical and psychical charac- 
ter of certain criminal types. Thus the mobile physiognomy, the erratic 
look, the uncertain gait of the thief are but dynamic symbols approaching 
the author’s psycho-organic correlations. A great importance is to be 
attached to gesture, to various signs and motor phenomena which very fre- 
quently serve as substitutes for language. The author brings forth examples 


572 PERISCOPE. 


from the creations of the great writers of the present time (as Tolstot, 
Victor Hugo, Zola, Bourget, etc.), showing how their deep psychological 
insight into human nature enabled them to comprehend and present in their 
works the correlation between the physical and psychic states of the 
presented types. 

2. A New Anomalous Process of the Sphenoid Bone in Man.—Of in- 
terest to the student of anatomy. 

3. Peripheral Facial Diplegia—Double paralysis of the facial nerve 
of peripheral origin, although known to Christison (1835), Bell (1836), 
and others, is of rather rare occurrence, and quite difficult to diagnosticate ; 
nor is the etiology of the affection always easy to determine. The author 
describes three cases with an undoubted clinical picture of the affection. 
What strikes the observer in all the three cases is the fixed look and the 
peculiar aspect of the immobile, expressionless, mask-like face, the per- 
fectly smooth forehead, the eyes open wider than normal, the nostrils 
fallen in, the naso-labial sulcus smooth, the cheeks flattened, the lower 
lip hanging down. The patients were unable either to frown, or to close 
their eyes; could neither spit, whistle nor blow, and also found it difficult to 
pronounce certain letters—all this showing that the motility of all the mus- 
cles of the face that serve mimicry was completely abolished. In differen- 
tiating this paralysis from a central nuclear affection of the nerve the au- 
thor considers first the fact that both the inferior as well as the superior 
facial were involved in the paralysis; secondly in one of the cases the par- 
alysis was localized exclusively in the area occupied by the seventh nerve, 
an occurrence which is frequent in paralysis of peripheral origin, but 
rather rare in that of nuclear affection, in which together with the facial 
there are also attacked other cerebral or spinal nerves. As distinguished 
from a labio-glosso-pharyngeal paralysis it is to be noted that this last, 
with very few exceptions, does not extend to the upper part of the face, 
nor is mimicry in any way affected, and while in peripheral facial diplegia 
both sides of the face may be attacked simultaneously, in the labio-glosso- 
pharyngeal paralysis the lips suffer first, and then progressively the tongue, 
the palate, the larynx, etc., muscular atrophy ensues alongside of the 
paralysis and both advance slowly. The slowness in the advance of the 
disease, and the early atrophy as found in superior polioencephalitis serve 
to exclude this malady; moreover, in this affection the paralysis of the 
facial muscles is always associated with that of the muscles of theeye,a rather 
rare occurrence in facial diplegia. Atrophic paralysis of the muscles of the 
face is also observed in certain cases of progressive muscular atrophy of the 
juvenile type of Landouzy-Déjerine. But the whole facial aspect of these 
cases is different from that presented by the patients in question, and this 
facial appearance is but an insignificant part of the clinical picture of the 
affection; moreover, in these cases the atrophy and paralysis of. the 
muscles of the face is even of a slower development than in labio-glosso- 
laryngeal paralysis. From the time of Christison (1835) up to Davanil 
(1850) there was but one monograph in the literature of this affection; 
next we find Wachsmuth (1864), who was the first to understand the 
disease better than his predecessors and who gave to it the name of 
diplegia. He was followed by Pierreson in 1867, and then of late 
Stintzig (1803), Hirbschman, Bregman, and quite recently Raymond, have 
all devoted considerable time to this disease. The author presents an 
elaborate and very instructive summary of ninety cases of this affection, 
so far found in literature, with the designation of the symptoms, course, 
etiology and termination of each. This summary is valuable enough to 
present by itself a full monograph on the subject. 

4. Malignant Syphilis of the Brain.—The patient, a man of twenty- 





PERISCOPE. 573 


seven years, was admitted to the hospital with paresis and a beginning 
disturbance in the motility of the tongue. This condition seems to have 
ensued rapidly during one night; and to it were soon added paralysis of 
the left half of the face, conjugate deviation of the eyes to the right; 
continuous yawning. The anamnesis of the patient is somewhat indefinite, 
except that he became recently a hard drinker, and contracted syphilis 
over a year previous to admission; two months previous to this admission 
he began to suffer with irregular fever, and vague pains in the articulations ;. 
more recently with intense headache, of a diffuse and continuous character. 
During observation in the hospital the cardiac symptoms (formerly mitral 
insufficiency) grew worse, and the frequency of the heart beats increased 
up to 130 and 160 per minute. Notwithstanding the energetic anti- 
syphilitic treatment resorted to while in the hospital the improvement was 
very insignificant. A month before the fatal issue the condition of the 
patient was as follows: Patient prefers to lie on right side with head and 
eyes turned toward same side; when grinding his teeth the left corner of 
mouth remains immovable; in frowning the left side of forehead is almost 
flat; eyes present some nystagmus. The tongue is deviated toward the 
left, but is quite mobile; shows some slight fibrillation. The left upper 
extremity is flexed at a direct angle and lies near the trunk, but pre- 
serves voluntary as well as passive motions. The left lower extremity 
is bent at an obtuse angle to the knee, admits of no movement whether 
active or passive. Patient urinates freely, but the function of defecation 
is somewhat affected. Left pupil wider and less active than the right. All 
the reflexes abolished on the left side; thermic and tactile sensibility con- 
siderably diminished on same side; hearing also abolished on same. 
Bilateral hemianopsia of the right halves of both retine. The patient 
remained almost all the time in a state of sopor, from which he would 
awake with some difficulty. Thé anatomical diagnosis on autopsy was as 
follows: A dissecting aneurism of the second branch of the right Sylviar 
artery (middle cerebral); aneurism of the fourth branch of the left Syl- 
vian; softening of the gyri of dextra insula, and hemorrhage in the right 
capsule of the thalamus. The microscopic examination of the lesions 
established beyond doubt the syphilitic origin of the disease (syphilitic 
arteritis, syphilitic aneurism). 

5. The Toxic Principle of Aspergillus —An experimental study on the 
toxicity of Aspergillus fumigatus. 

6. Amyotrophies of Articular Origin.—A continued article. 

7. Hemiatrophy of the Tongue——A continued article. 

8. The Toxicity of the Blood of the Insane——A rather unsatisfactory 
account of a series of experimental studies to determine the toxicity of 
the blood of patients suffering from various forms of insanity. The 
authors are forced to confess that notwithstanding the considerable number 
of experiments it was impossible to establish definitely any difference 
between the serum of normal individuals and that of insane. Whatever 
toxicity was demonstrated was observed in the blood of maniacs and 
epileptics. The toxic power of the blood of individuals affected by various 
psychopathic maladies (maniacs, alcoholics, paralytics, paranoiacs, epi- 
leptics, etc., did not present any notable variations; nor was there any 
variation in the different forms of one and the same disease, as in the 
periods of calm and excitement. It would seem as if the present methods 
of experimentation were not sufficiently reliable to enable one to control 
and definitely establish the degree of toxicity of the blood serum in the 
various maladies in question. 4 ; 

9. Hemorrhagic Encephalitis—A_continued article. 

10. Hypothermy in Epileptics—The case serving as the basis or this 


574 PERISCOPE. 


observation was that of an epileptic, twenty-eight years of age, who had 
been suffering from epilepsy for the last ten years. During the last two 
years the attacks occurred four or five times a month and were followed by 
a state of depression and mental confusion. Patient is rather of a taciturn 
disposition, but well physically and without any degenerative stigmata. 
Nutrition good, functions of organic life normal. The morning tempera- 
ture was 35.2 deg. and kept low for about 18 days; during this time there 
occurred oscillations between 35.1 deg. and 36.4 deg. There was no symp- 
tom to indicate any abnormal condition or even slight disturbance whether 
physical or mental. The author ascribes this low temperature to some 
special condition of the metabolic processes of the epileptic. It is quite 
possible that the same toxic agent which acts on the nervous system 
producing the condition of epilepsy may be the cause of the hypothermy 
in these cases. 

11. The Condition of the Insane in Italy.—An historial essay on the 
present condition of the asylums for the insane in Italy, showing a recent 
increase in the number of the insane population of the land, and an over- 
crowding of the institutions for the maintenance of the insane. The 
author proposes various provisions for relieving the congestion in the 
asylums, and especially a system of family care of the insane. 

12. The Action of the Gastro-Intestinal Juice on the Spores of Asper- 
gillus—This is a complement to article 5, on the relation of the spores to 
the genesis of pellagra. ALEX. Rovinsky (New York). 


NEUROLOGISCHES CENTRALBLATT 
(1903, No. 3, Feb. 1.) 
1. The Isthmostriatic Tract (or Bulbo-striatic Tract) of Pigeons. A. 

W ALLENBERG. 

2. A Remarkable Complication of a Case of Migraine. L. HorertMayr. 

3. A Contribution to the Knowledge of Disseminated Encephalomyelitis. 
E. BANCKE. 

4. Ear Reflex. W. ALTER. 

1. Isthmostriatic Tract.—Wallenberg failed to obtain degeneration of 
the isthmostriatic tract in a pigeon by unilateral disturbance of the cere- 
bellum even if the centra! nuclei of the cerebellum were involved. Division 
of the sensory root of the fifth nerve between the bulb and the Gasserian 
ganglion resulted in degeneration of the dorsal and lateral periphery of 
the nuclei. It was then possible by the Marchi method, to trace the tract 
as far as the anterior portion of the base of the brain. In the frontal lobe 
this tract of fibers divides into four bundles, which terminate in different 
parts. The terminal sensory trigeminal nucleus, therefore, is in direct un- 
ion with the basis of the frontal lobe without the intermediary of the 
thalamus. 

2. Migraine-——A woman, fifty-seven years of age, who had ceased to 
menstruate six months before. Father and sister had suffered from mi- 
graine; one of her children was hysterical and had headache. Patient had 
migraine for forty years. Lately attacks were more frequent and constipa- 
tion and the menstrual flow would aggravate symptoms. Had taken large 
doses of migrarine every day previous to special attack. This attack began 
with a pulling up of cne eye and one eyeball, hemiatropia, collapse and the 
fear of death. She was semiconscious for several days without sleeping. 
When disturbed would repeat the syllables “noten’” and “nieten.” There 
was obstinate constipation and agrypnia. On the sixth day the face as- 
sumed an expression of pain. Twitchings of both arms and legs appeared. 
During sleep she was quiet. On the tenth day consciousness returned, after 





PERISCOPE. 575 


which she improved slowly, but had occasional hallucinations and some 
disturbance of the field of vision. The symptoms were those of ophthalmic 
migraine and toxine infection. It is possible that coprostasis was the ex- 
citing cause. 

3. Disseminated encephalomyelitis—To be continued. 

4. Ear Reflex.—Alter describes a new skin reflex which is obtained by 
striking the ascending ramus of the inferior maxilla resulting in a vigor- 
ous contraction of the attoleus aurem with elevation of the ear. He found 
this in a paretic dement with left-sided facial paralysis and status epilep- 
ticus, by striking on the right side. On investigation he found it 19.4 per 
cent of patients with paretic dementia. It differs considerably on the two 
sides. Alter does not arrive at a definite conclusion regarding its meaning. 


(1903, No. 4, February 15.) 
1. A Contribution to the Casuistry of the Relation of Hair in Cases of 
Mental Diseases. W. HEINICKE. 
2. The Biology and the Functional Activity of the Central Nerve Cells. 
P. KRONTHAL. 
3. A Contribution to the Knowledge of Disseminated Encephalomyelitis. 
E. BANCKE. 

1. Hair in Mental Disease —Henicke reports the case of a girl twenty- 
one years of age suffering from dementia precox. Symptoms had first 
appeared at the age of thirteen. She had occasional periods of excitement, 
in one of which it was observed that the pupils were dilated ad maximum 
and that an almost silver white band of hair passed from the forehead 
to the right parietal bene. The hair remained in this condition for four 
days and then rapidly returned to its normal condition. Three days later a 
second attack occurred, accompanied by a similar dilatation of the pupils, 
but the coloration of the same band of hair was observed one to two 
hours before attack. During the height of the attack the hair became al- 
most silver white. The following day it returned slowly to its normal 
blonde color. Microscopical examination showed that this change of color 
was due to the filling up of the sheath with air, and when the air was. ex- 
pelled, the hair returned to its normal color. The manner in which the air 
accumulates cannot be determined. 

2. The Central Nerve Cells.—Kronthal begins with a consideration of 
phenomena which follow stimulation of the gray matter of the cortex. 
These he considers as due to the excitation of the nerve fibers. It is note- 
worthy that changes of diet do not affect the nerve cell, and that the central 
nervous system, even in starvation, suffers less than any other part of the 
body. Some substances, as narcotics, act upon nerve cells as upon other 
forms of protoplasm. Ganglion cells in the process of division have never 
been found. The hypothesis that man is born with a large mass of reserve 
cells he assumes as impossible. Kronthal occasionally has observed a 
strange cell in the nerve cell which he thinks is a leukocyte. Kronthal be- 
lieves, therefore, that the nerve cell is due to a coalescence of leukocytes, 
that it is no organism, and that it is not alive. The functions of the nerv- 
ous system are accomplished by the neurofibrils which unite the nerve fi- 
bers. The functions of the nerve cells have not been definitely determined. 

3. Disseminated Encephalomyelitis—A school teacher, thirty-nine 
years of age, with mental symptoms of dementia precox, had meningitis 
in childhood. Five and one-half years before death she began to limp on 
left side. Examination showed excessive spasticity and contractures in left 
leg, the latter disappearing completely during chloroform narcosis. A 
plaster cast was put on, which, after 17 days, had to be removed on account 
of extensive decubitus. About a month later paralysis of the bladder and 


576 PERISCOPE. 


rectum and lower extremities, with loss of sensation, appeared. Later still 
paralysis of the right arm. After four months she died. There was a 
fresh internal hemorrhagic pachymeningitis. Microscopically numerous 
areas of degeneration in various stages were found throughout the brain 
and cord, which are described in detail. A secondary gliosis was present 
which was characterized by the presence of large cells with oval nuclei. 
Bancke believes that the case was one of dementia precox in which infec- 
tion was produced by the bedsore. TT. H. WEISENBURG (Philadelphia). 


MONATSSCHRIFT F. PSYCHIATRIE UND NEUROLOGIE 
(1903, April.) 
. A Case of Isolated Agraphia. C. WERNICKE. 
. Hyperesthesia of the Nails (Onychalgia nervosa). H. OppENHEIM. 


ke 


2 

3. Epileptic Mania with Remarks upon the Loss of Ideas. H. Hem- 
BRONNER. 

4. The Origin and Course of the Oculo-Motor Nerve in the Mid-Brain. 
N. MAJANO. 


1. Isolated Agraphianw—A woman forty-six years of age noticed a 
gradually increasing weakness of the right hand which suddenly increased 
to paralysis of the right arm and leg with contractures. Eight days later 
there were twisting of the mouth, and complete loss of speech, although 
the patient appeared to understand what was said to her. Gradually speech 
improved and then grew gradually worse and remained stationary. At this 
time there was paralysis with spasticity of the arm and leg, anarthria, good 
repetition, and some spontaneous speech. She understood words fairly 
well, but there was complete agraphia. Memory was defective and the pa- 
tient remained in this condition during all the period of observation. 
Therefore the predominant symptom and the only complete one is the iso- 
lated agraphia. Only a few similar cases are reported in the literature. 
The characteristic of all these cases is that the lesion is on the left side. 
Nevertheless, Wernicke does not share the opinion of Dejerine that there 
is a unilateral optic word center, at Jeast he does not believe that the ex- 
istence of such a center is proved by these cases. 

2. Hyperesthesia of the Natls—Oppenheim reports three cases char- 
acterized by extraordinary sensibility of the finger-nails so that even slight 
mechanical injuries caused intense pain. Even trimming the nails caused 
pain. In all cases there was congenital neurasthenia. There are a few 
references to this condition in the literature, although it does not appear 
to have been recognized as a particular form of hyperesthesia. 

3. Epileptic Mania—Heilbronner continues his article with a discus- 
sion of his cases. He calls attention to the undoubted false perception 
that sometimes occurs in epileptics, and then commences to discuss the 
flow of ideas. He does not believe that there is any necessary relation be- 
tween these and the readiness of speech, in fact in many cases speech 
may be distinctly inhibited although the patients complain of a continual 
series of thoughts passing through their heads; that is to say, there may be 
a flow of ideas without any motor excitement. It does not appear that the 
flow of ideas is the result merely of an increased psychological motor irri- 
tation, not even in mania. In this condition there is motor excitement, but 
the flow of ideas is independent of it. It is always important to compare 
the inclination to speech with the psychical representations that the patient 
has prepared. It must be admitted, however, that the whole subject is in 
a very unsatisfactory state. 

4. Oculomotor Nerve.—Majano continues his article with a careful 
study of the literature of the origin and course of the oculomotor nerve. 


PERISCOPE. 577 


He concludes partially as a result of these studies, and chiefly from his 
own experience, that the sublongitudinal or predorsal fasciculus has its ori- 
gin in the anterior nucleus of the anterior corpora quadrigemina; that the 
ventral portion of Meynert’s ligament arises from the dorsal median region 
of the copora quadrigemina; that the sublongitudinal fasciculus passes 
obliquely forward and downward toward the median line, enters the cap- 
sule of the red nucleus, and some of the fibers then pass down to the root 
fibers of the oculomotor, but the main portion decussates and unites with 
the root fibers of the oculomotor of the opposite side. The mechanism 0: 
the pupillary reflex then would consist of the following three parts: the 
peripheral sensory neurone arising from the bipolar cells of the retina and 
forming the pupillary fibers of the optic nerve which pass to the dendrites 
of the ganglion cells of the lateral portion of the anterior ce*pora quadri- 
gemina. Second, the central neurone which consists of the ganglion cells 
of the lateral portion of the anterior corpora quadrigemina, and the direct 
or crossed fibers of the predorsal fasciculus which unite with the root fibers 
of the oculomotor nerve, and with the collaterals of the axiscylinder ana 
sympathetic cells of the ciliary ganglion of the same or the opposite side; 
third, the peripheral motor neurone, which consists of the cells of the ciliary 
ganglion and the fibers arising from them which innervate the sphincter of 
the iris. The pupillary reflex is, therefore, primarily dependent upon the 
anterior corpora quadrigemina of the opposite side. The direct pupillary 
reaction is stronger than the indirect on account of the double decussation 
of the neurones concerned in it. The unilateral reflex paralysis is more 
pronounced on one side, occurring when the neurones between the anterior 
corpora quadrigemina and the ciliary ganglion are degenerated. If the 
ciliary ganglion and the ciliary nerves are destroyed then total paralysis 
occurs. The consensual reaction: is not destroyed by longitudinal section 
of the chiasm. J. SATLER (Philadelphia). 


DEUTSCHE ZEITSCHRIFT FUR NERVENHEILKUNDE 
(Band 22, Heft 3-4.) 


12. Skin Reflexes and Their Nerve Tracts. MUNCH-PETERSEN. 

13. Contribution to the Knowledge of Tumors of the Spinal Cord. Mryer. 

14. Multiple Sclerosis Developing into a Picture of Transverse Myelitis. 
FLATAU and KOELICHEN. 

15. Acute Cerebral and Cerebrospinal Ataxia. LUTHJE. 

16. Contribution to the Diagnosis of Tumors in the Frontal Lobe. AvEr- 
BACH. 

17. A Case of Relapsing Bilateral Ptosis, with Myasthenic Manifestations 
in the Upper Extremities. BycHowsky. 

18. Cystic Meningitis in Racemose Cysts of the Central Nervous System. 
ROSENBLATH. 

12. Skin Reflexes and Nerve Tracts——Munch-Petersen contributes a 
valuable article upon the reflexes of the skin, first discussing the history of 
some of the more important reflexes, and then defining them as involuntary 
movements which are produced by irritation of the skin, he then speaks 
of the atypical form which can be obtained in almost any part of the body, 
and then mentions the so-called typical forms which include the plantar, 
cremaster and abdominal reflexes. The degree of irritation required indi- 
cates inversely the activity of the reflex. There seems to be some rela- 
tion between the skin reflexes and the tickling reflexes. He believes 
the plantar reflex has a single reflex center; discusses most thoroughly the 
Babinski phenomenon, calls attention to the fact that there is dorsal flexion 
of the toes during walking in persons who possess it; and discusses some 


5 78 PERISCOPE. 


interesting time estimations that he made upon this reflex by the aid of 
kinometographic studies. Investigations have convinced him that the move- 
ments of the toes are irregular when the soles of the feet are irritated. He 
believes that there is a distinct relation between the gait and the plantar 
reflex, that is to say, they are typical or atypical together. With regard to 
the arcs by which these reflexes are accomplished, he makes the following 
statements. When sensation is lost the reflex is lost; when increased the 
reflex is increased; therefore, sensation is an essential condition for the 
reflexes. If, however, the reflex is produced by sensation, the sensitive 
part of the reflex arc must have its center in the cortex of the cerebrum. 
The relation of the plantar reflex to the gait indicates that it has some rela- 
tion to a motor center in the Rolandic cortex. Analogy indicates that the 
skin reflexes have their sensitive as well as their motor centers in the cor- 
tex of the cerebrum. A study of these reflexes in different conditions 
seems to lead to the same result. In diseases of the peripheral nerves or in 
total lesion of the spinal cord the skin and tendon reflexes were entirely 
lost. Voluntary motion and sensation were also lost, and, therefore, there 
was reason to believe that the tracts of these different functions were 
identical as far as the point of solution of continuity. Munch-Petersen has 
found that when the plantar reflexes were in part preserved the motor tracts 
were not entirely destroyed. Studies of apoplexy also lead to the conclu- 
sion that at least as far as the internal capsule, the reflex tracts and the 
tracts for voluntary motion were identical. In cases of recent apoplexy 
with a persistent plantar reflex the prognosis is more favorable. Further, 
in those cases in which there is ataxia in motion, dorsal flexion during walk- 
ing is found in those cases in which the Babinski phenomenon is present. 
Babinski’s phenomenon he believes is due to a degeneration of the pyrami- 
dal tracts which gives rise to a paralysis of the plantar flexures or to ataxia. 
In hysteria the skin reflexes are influenced, but show no qualitative altera- 
tions from the normal. During hypnosis suggested anesthesia diminishes 
or abolishes the skin reflexes; suggested hyperalgesia increases them. In 
conclusion Munch-Petersen calls attention to the following experiment. 
If the sole of the foot is irritated with a needle the foot is drawn upward; 
if a threat is made to irritate the sole of the foot with a needle, the foot is 
also drawn up, finally in some cases the mere sight of the needle is suffi- 
cient to produce an involuntary movement of the foot. Therefore, we can- 
not state certainly that the skin reflexes are not produced by an act of the 
will, but only that this activity of the will does not reach the highest phase 
of consciousness. The skin reflexes are in all probability located in the cor- 
tex of the brain. 


13. Spinal Cord Tumor.—A girl fourteen years old had severe pain and 
paresthesia of the left upper extremity accompanied by some weakness. 
Fifteen months later she developed spastic paralysis of the left leg; three 
months later there was flaccid paresis of the right arm and spastic paresis 
of the right leg. About the satne time she had pain in the middle of the 
cervical region of the spinal column and tenderness upon pressure over the 
fourth and fifth vertebrae. In the course of the next six months she 
developed almost complete spastic paralysis of the legs. There was some 
atrophy of the arms on both sides and hypalgesia and hypesthesia on the 
ulnar sides. There was some disturbance of the bladder and rectum. 
The order in which the symptoms appeared was rather against tumor of 
the spinal column, and they were rather difficult to make agree with tumor 
of the cord itself, therefore there was reason to believe that the meninges 
were involved. It was not possible to decide whether it was extra- or intra- 
dural although the early development of the bone symptoms speaks in favor 


PERISCOPE. 579 


of the former. These symptoms Meyer believes in agreement with Bruner, 
are not trustworthy. The segments or roots involved were apparently the 
fifth, sixth and sexenth, and probably on account of the hypesthesia and hyp- 
algesia on the ulnar sides of the arms, the eight cervical and first dorsal 
segments. The clinical symptoms were remarkable, partly for the varia- 
tion from time to time in the areas of disturbed sensation, and the frequent 
involuntary flexion of the legs. At the autopsy the stomach was found 
to be enormously dilated. This was possibly the result of the lesion of the 
spinal cord. A tumor was also found on both sides of the dura, constricted 
at the point at which it passed through this membrane. It was about three 
by one cm. in size, shaped something like an egg; its surface was smooth, 
it was firm in consistency, and directly involved the sixth, seventh and 
eighth cervical and dorsal segments. It also involved the left side of the 
cord and pressed from the anterior surface backward. Histologically it 
proved to be a fibro-sarcoma. Operation was not performed partly because 
hypertrophic cervical pachymeningitis was suspected, and partly because the 
condition of the patient was so bad. 

14. Mutiple Sclerosis and Transverse Myelitis—Flatau and Koelichen 
report the case of a woman sixty years of age who had been exposed to 
cold. After this she developed fever, had pain in the legs, no control of the 
bladder, and obstinate constipation. She became bedridden, was unable 
to walk or turn over in bed; there was almost complete paralysis of the 
right leg, although she was able to flex the thigh, and still had slight power 
of adduction; there was almost complete paralysis of the left leg, the 
movements being even less than on the other side. There was slight spas- 
ticity of the flexors of the right thigh. Although the legs were emaciated 
there were no muscular atrophies. There were some slight sensory disturb- 
ances, loss of the patellar reflex on the left side and great diminution on 
the right. Severe irritation of the sole of the foot caused withdrawal of 
the leg. There was a bedsore over the sacrum and over both trochanters. 
The patient gradually grew worse and died. At the autopsy nothing was 
found macroscopically in the brain and spinal cord. A very careful de- 
scription with illustrations is given of the results of the Kneisel, Weigert 
and Marchi methods. The changes found could be classified in two groups: 
first, early degeneration with degeneration of the myelin fibers not involv- 
ing the blood vessels or neuroglia; and second, advanced areas of degenera- 
tion with involvement of the blood vessels and the neuroglia, and the 
presence of a great number of compound granular cells. The authors 
regard the case as an atypical form of multiple sclerosis. There were very 
slight changes in the nerve cells and in the axis cylinders, which they con- 
sider characteristic of this disease, and they classify multiple sclerosis 
therefore as a diffuse process involving inflammation of the blood vessels 
of the nervous system, especially the spinal column. In an editorial note 
Striimpell states that he believes the case to be one of acute disseminated 
myelitis, and not multiple sclerosis. 

15. Cerebral and Cerebrospinal Ataxia.—Lithje reports the following 
three cases of acute ataxia. A boy of ten years was suddenly attacked by 
headache, prostration and vomiting. There were no mental symptoms for 
the first two days, when the patient became violently delirious, there were 
signs of bronchitis in both lungs with a roseola eruption. The fever lasted 
for about five weeks, gradually falling to normal. The patient throughout 
the greater portion of the time was unconscious, then became confused, 
had to be fed, had peculiar twitchings in the muscles of the face. The 
Widal reaction was positive. A month after the temperature had become 
normal the patient began to show signs of returning intelligence, and a 


580 PERISCOPE. 


month later it was impossible to make a careful examination. At this 
time, aside from a rather exaggerated emotional state, his intelligence was 
normal. Speech was deep, somewhat nasal and monotonous, pauses fre- 
quently occurred between words and syllables, and the different syllables 
were sometimes enunciated in an explosive manner. The motor power 
was not altered. At any attempt at voluntary motion, however, there was 
extreme ataxia and sometimes associated movements of the other arm when 
one of the upper extremities was moved. Walking was entirely impossible ; 
sensation was normal; the reflexes were increased; and there was ankle- 
clonus. The patient gradually improved, was able to sit up alone, the 
ataxia disappeared to a large extent, although it was more pronounced in 
the left than in the right arm, and was still evident in the legs. There 
was bilateral disturbance of the stereognostic sense. “wo months after 
convalescence from the fever, speech was still gravely disturbed. The second 
case, a sister of the first, nine years old, was brought to the hospital suffer- 
ing from a severe attack of typhoid fever. She was unconscious for 
weeks, and five weeks after onset of the disease began to have twitchings 
in the face and rhythmical lateral movements of the head. During con- 
valescence examination showed that speech was toneless, the syllables were 
pronounced slowly, occasionally explosively; there was marked ataxia in 
the movements of the arms and legs, especially the latter; the pattellar re- 
flexes were exaggerated, and there was distinct ankle-clonus. When the 
patient attempted to stand there were violent oscillations which were not in- 
creased by closing the eyes. Sensation was not disturbed. She gradually 
improved, but when discharged; had difficulty in walking, and the speech 
was still monotonous and scanning. The third case, a six-year-old brother 
of the two preceding cases, was brought to the hospital suffering from ty- 
phoid fever, which also proved to be a severe attack. During the attack 
he had dilatation of the right pupil, was unconscious, later confused, and 
also developed rhythmical lateral movements of the head. When excited 
he had disseminated erythematous eruption over the head and face, ex- 
quisite ‘ataxia in the head and trunk, and no control of the sphincters. 
There was no disturbance of sensation, but the stereognostic sense was not 
tested. Speech was slow and monotonous and the syllables were separated. 
The tendon and skin reflexes were exaggerated. This patient rapidly im- 
proved and was discharged almost well. The cases are very similar, and 
Luthje believes they belong to the pure cerebral form of acute ataxia. In 
one case, however, the symptoms indicated involvement of the cerebellum. 
He discusses the differential diagnosis of spinal, bulbar and cortical ataxia 
and is inclined not to exclude the latter because hemiparesis and hemi- 
plegia did not exist; because the clinical course showed that whatever the 
lesions were they were exceedingly slight. He believes that the disturbance 
of the stereognostic sense is one of the most important signs of the cere- 
bral origin of the disease. The disturbance of speech did not indicate bul- 
bar, but rather cortical involvement. He concludes with a careful study 
of the literature, having found and abstracted sixteen cases, in many re- 
spects similar to his own. Some of these were purely cerebral, and a 
few evidently cerebrospinal in origin. In an annotation he states that four 
months after the patients were discharged the two younger were almost en- 
tirely well; speech was slightly slow, and the patellar reflexes were ex- 
aggerated. In the first case the speech was still scanning and monotonous 
and the reflexes were exaggerated and there was still slight ataxia in the 
extremities. 

16. Frontal Lobe Tumors.—Auerbach reports the case of a woman 
forty-eight years of age who had always suffered from migraine. Usually 


PERISCOPE. 581 


she had been industrious, but she began to neglect her work, became irrita- 
ble, complained of fatigue, had increasing headache, and often refused to 
leave her bed. From time to time she vomited. The condition gradually 
grew worse, she ceased to take interest in things, often refusing to eat 
unless urged. She was apathetic, unclean, and slept considerably. There 
was some swelling of the face. The nervous system, with the exception 
of increased patellar reflexes without ankle-clonus or Babinski’s phenome- 
non, and slight tremor of the hands on motion, was negative. Intelligence 
seemed to be considerakly diminished. Memory for recent events was im- 
paired; there was no tendency to joke. ‘There was a suspicion of myxe- 
dema; the patient was given thyroid tablets without benefit. She had an 
apoplectiform attack during which she was unconscious for half an hour, 
but subsequently recovered, when it was noted that she had difficulty in 
fixing the eyes, the pupils were dilated, swallowing was difficult and the 
patient was bent forward and complained of pain in the spinal column. 
Examination of the eyes showed choked disks. Later she developed stiff- 
ness of the neck, and pain upon movement of the head, gradually grew 
worse, became comatose and died. At the autopsy the frontal lobes were 
found flattened, the dura was adherent in this region, and the veins were 
more congested here, especially over the left frontal lobes. The base of 
both frontal lobes was occupied by a tumor about the size of an apple, ex- 
tending from the anterior perforated substance forward. The surface of 
the tumor was somewhat nodular; the mass had about the consistency of 
liver tissue, and the color varied from pink to dark red. Microscopically 
it proved to be a fibrosarcoma, probably arising from the dura of the base. 
The diagnosis presented many difficulties. At first Professor Edinger, 
who also saw the case, thought of precocious senile dementia, or arterio- 
sclerosis in the vessels of the brain. Later tumor of the frontal lobes was 
suspected, but the only symptoms were the headache and the psychical dis- 
turbances. Of the latter, disturbance of memory and loss of the power 
of attention, the loss of any initiation or apparently voluntary action, were 
the most prominent features. Auerbach discusses the theory that intelli- 
gence is located in the frontal lobes. He believes that in the human brain 
they are to be regarded as the most important center of association. Among 
the interesting symptoms are the apoplectiform attack, the occurrence of 
choked disks, the absence of disturbance of equilibrium, and the absence 
of a tendency to make jokes. There is apparently no other case in which 
the tremor of the hands was so marked. Among the negative symptoms it 
may be mentioned that the temperature was not elevated at any time, and 
smell apparently was not disturbed. Toward the last, in addition to the 
tendency to fall forward, and the pain in the neck, slight paresis of the 
left facial nerve had developed. Operation was not performed, chiefly on 
account of the objection of the relatives. 

17. Relapsing Bilateral Ptosis.-—Bychowsky reports the following in- 
teresting case. A girl of fifteen years gradually developed ptosis. In the 
morning she noticed that the eyelids felt heavy, and toward evening she 
was unable to lift them. The condition lasted three days when electricity 
was employed and she recovered. At the age of nineteen the ptosis again 
suddenly recurred. It was complete and was not accompanied by contrac- 
tions, so that it was easily possible to raise the lids. The eye muscles ap- 
peared to be normal; the pupils reacted promptly; the patient’s nutrition 
was good; there were no paralyses of the muscles of articulation, although 
the speech seemed to be slightly nasal. The patient was given galvanic cur- 
rent and felt better, although the ptosis persisted. Finally, however, during 
the night it suddenly disappeared. At the age of twenty-one a third at- 
tack occurred. On this occasion the patient had severe headache, but the 


582 PERISCOPE. 


symptoms otherwise seemed to be the same as in the last attack. The elec- 
trical reactions of the muscles of the eye were normal. Jt was noted, how- 
ever, that the muscles of the arms became very rapidly fatigued upon exer- 
tion, so that after lifting them five or six times they were practically par- 
alyzed. During the application of the electricity to the muscles of the face 
the ptosis suddenly disappeared and there was not myasthenia of the muscles 
of the eye; it persisted, however, in the muscles of the arms. In the 
course of four days, however, this had also vanished. Bychowsky gives 
a careful discussion of the literature of myasthenia and recurrent paralysis, 
and reaches the conclusion that his case belongs to the group of myasthenic 
paralyses. It also bears a certain relation to the Vertige paralysant of 
Gerlier, and the kubisagari of Miura, probably identical conditions. In a 
postscript he mentions the fact that at the age of twenty-two the patient 
had a fourth attack during which Bychowsky was able to determine the 
presence of the myasthenic reaction in the ocularis and biceps, and the ex- 
tensors of the fingers on both sides. This reaction persisted for a time and 
then the patient improved. 

18. Cystic Meningitis—Rosenblath reports the following case. A man 
of forty-seven years was suddenly attacked by trembling of the limbs so 
that he was obliged to sit down. This continued for two weeks and ren- 
dered him incapable of even dressing himself. Later he began to have 
headache on the left side, was depressed and stopped work. A careful 
examination failed to show any changes in the motility, sensation, or the . 
reflexes. Finally the patient complained of inward tremor; there was no 
obvious oscillations of the limbs. Later he developed extremely severe 
headache and pain and stiffness in the neck. Then there were attacks of 
* vertigo causing him to fall down. It was then observed that he had choked 
disk. The forehead was tender to percussion, but motility, sensation and 
the reflexes were normal. There was neither ataxia nor tremor. The at- 
tacks of vertigo were sudden, causing him to fall heavily although he rarely 
lost consciousness. His intelligence gradually altered, his memory was im- 
paired, and occasionally he seemed confused. Sometimes he had hallu- 
cinations of vision. His mind gradually failed; he developed agraphia and 
alexia, became more and more apathetic, and toward the end had vomiting. 
There were some anesthesia in the right half of the body; his temperature 
rose, he had a tendency to sleep, and finally died of dyspnea, and paralysis 
of the muscles of deglutition. At the autopsy some calcareous infiltrated 
cysts and some clear cysts were found in the neighborhood of the chiasm 
at the foot of the third frontal convolution on the right side; at the top of 
the temporal lobe and over the pons and medulla. A large cyst was found 
also in the posterior portion of the left lateral ventricle. A few cysts were 
also found in the upper portion of the cervical enlargement. Around these 
cysts there was occasionally cellular infiltration, particularly in the neighbor- 
hood of the blood vessels. A diagnosis of cysticercus racemosus of the 
brain was made. It is probable that the symptoms were produced rather by 
the involvement of the meninges and the blood vessels in the neighborhood 
of the cysts than by the cysts themselves. Rosenblath believes that cysti- 
cercus racemosus of the brain is not so very rare; death usually occurs 
slowly, the symptoms lasting one or two years, although they may last 
longer; and Zincker has believed that in two of his cases the symptoms per- 
sisted for seventeen or eighteen years. The earliest symptoms are those of 
neurasthenia; later there is weakness of the limbs, pain and stiffness of the 
neck, then attacks of weakness associated with tremor of the extremities ; 
headache and vertigo are quite common. Cramps have been described in 
about half of the recorded cases; they may be slight twitchings of the arms 


PERISCOPE. 583 


and legs, or they may resemble epilepsy. Not infrequently paresis may 
occur. The eyes may become prominent, there may be diplopia or ptosis. 
In many cases there is sudden transient blindness, and in a few hallucina- 
tions of vision. Aphasia is rare. Cerebral vomiting is very common. As 
a general rule patients become demented, but occasionally they are maniacal. 
It is possible that many of these symptoms are due to vital phenomena on 
the part of the cysticercus, although it seems to be certain that the major- 
ity are, dependent upon changes in the blood vessels. It is most difficult to 
distinguish this condition from cerebral syphilis. 
J. SAILER (Philadelphia) 


JOURNAL DE NEUROLOGIE. 
(1903, VIII, No. 1, January 5.) 
1. Methods of Improving the Organization of the Belgian Asylums. J. 
Croco. 
1. A discussion of the method of caring for the insane in Belgium and 


in other countries, with suggestions as to their improvement, which is not 
suitable for review here. 


(1903, VIII, No. 2, January 20.) 
I. Facio-scapulo-humeral Hemiatrophy. A. DeEpray. 
2. Case of Hystero Syphilis. THoorts. 
3. Note on the Babinski Reflex. C. HELDENBERGH. 

1. Facio-scapulo-humeral Hemiatrophy.—A report of a case of this 
character beginning subsequent to fracture of the wrist. The author 
thinks that the long continued sensory irritation due to the wrist injury 
may have sufficed to determine a functional disturbance in the trophic nerve 
cells situated in neighboring medullary segments, hence the atrophy. There 
was paradoxic electric reaction in the atrophied muscles, faradic irritability 
and,to a less extent, galvanic irritability being increased. There was some 
improvement under the continued use of faradism with rubbing and suit- 
able diet. ; 

2. A Case of Hystero Syphilis—Report of a case of hemiplegia and 
hemianesthesia, in a man of twenty-seven years of age, formerly syphilitic, 
in which the combination of symptoms, and the lack of effect from syphilitic 
treatment, caused the author to conclude that the trouble was of hysterical, 
and not of organic origin. 

3. Note on the Babinski Reflex.—A short discussion of the method of 
production of this reflex which the author thinks the type of abnormal 
cutaneous reflexes, an extrapyramidal, or “spino-mesencephalic” reflex, as 
he calls it. 


(1903, VIII, No. 3, February 5.) 


1. Multiple Sclerosis. BoucHARD, 
2. Bilateral Atrophic Paralysis of the Tongue. DEcRoLv 


1. Multiple Sclerosis, Movements During Repose—Description of a 
case observed during six years (from the age of sixteen to that of twenty- 
two years), which presented the following sequence of events. At first 
headache, vertigo, drooping of the upper lids and deviation of the right eye 
outwards, next loss of power, and exaggerated reflexes in the lower limbs, 
with continuous involuntary movements in them, these later being replaced 
by similar movements in the upper extremities. Speech then became diffi- 
cult, of a scanning character, and finally unintelligible, while the legs 
grew so stiff as to make walking impossible. These symptoms, 
which took a year for their development, remained stationary for a long 


584 PERISCOPE. 


time, and then began an improvement which proceeded to a remarkable 
degree, to ‘almost a cure.” The patient’s mental condition, however, re- 
mained defective. The author discussing the diagnosis considers especially 
Friedrich’s disease, cerebellar heredo-ataxia, Parkinson’s disease and mul- 
tiple sclerosis. He concludes that while involuntary movements during 
repose are rare in the latter disease—a few cases of the sort have been 
reported—the clinical picture upon the whole corresponds best to that of 
multiple sclerosis. 

2. Suboccipital Vertebral Disease, with Bilateral Atrophic Paralysis 
uf the Tongue.—A description of a case of this character which began 
with pain in the head and neck, paralysis of the left arm and leg next ap- 
pearing, and extending later to the right arm and leg. The man coming 
under treatment at this time extension, on the inclined plane, was made 
with so much improvement that he was able to get about and to work 
again. The bone disease progressing, however, the head became gradually 
displayed backward, and the tongue underwent complete atrophy, probably 
from pressure upon both hypoglossal nerves. Next, in spite of treatment, 
the paralysis of the limbs again increased, and the patient had become 
completely bedridden at the time of the report. 





(1903, VIII, No. 4, February 20.) 


1. Differential Diagnosis of Epilepsy. KowALevsxKy. 
2. Sarcolysis in Muscular Regression. DEBuck and DEMoor. 


1. Differential Diagnosis of Epilepsy.—Will be abstracted when com- 

pleted. 
2. Sarcolysis in Muscular Regression.—Muscle is composed of two dis- 
_ tinct morphological elements. (1) The sarcoplasm or non-differentiated 
protoplasm, with the nuclei, the nutritional element. (2) The myoplasm 
or differentiated protoplasm, the functional element. 

The first is the one reacting to morbid agents. From the study of nu- 
merous preparations the authors are corivinced that the muscle fiber plays 
an active rdle in its own regression, that it tends to return to an embryonic 
plasmodial, and cellular state, and that in this process the nuclei exercise 
an active biochemical or hystolitic. influence, a phenomenon which they 
call ‘‘sarcolysis.” The muscle cells play in this process a phagocytic rdle. 
These “sarcolytes” they think after repassing the embryonic stage can un- 
dergo a metaplasia, being transformed into connective tissue, and in this 
way a great part of the connective tissue, which replaces atrophied muscular 
fibers is produced, a “muscular autosclerosis.” . 


ALLEN (Trenton). 


Volume 30. October, 1903. No. 10. 





THE 


Journal 


OF 


Nervous and Mental Disease 


Original #Hrticles. 


THE SIGN OF THE ORBICULARIS IN PERIPHERAL FACIAL 
PARALY S(S: 


By Dr. Grorce W. JAcosy. 


The divergence of views as to the course of the central neu- 
rones of the facial apparatus has always been very great. 

All of our knowledge had been derived from pathologico- 
anatomical, and experimento-physiological observations; clinical 
study failed to cast any material light upon the subject, because 
all deductions from clinical observations were dependent upon the 
assumption that in facial paralysis due to central affections, the 
temporo-facial branch of the facial nerve was not involved, and 
that in ordinary hemiplegia the upper part of the face entirely es- 
capes being paralyzed. 

In order to explain this non-involvement of the upper facial, 
certain older authors questioned whether the upper facial had 
any cortical origin whatsoever, and believed that its only central 
source was from the nucleus of the fourth ventricle. Others 
(Huguenin, Chvostek and Hallopeau), while admitting a cortical 
origin, assume that the upper facial reaches the facial nucleus 
from the cortex by means of a course, separate from that of 
the lower facial; while still other and later observers have 
assumed that separate centers exist in the cortex for the up- 
per and lower faciai, that for the lower facial lying in the lower 
extremities of the frontal convolutions, while that for the upper 


*Read at the meeting of the American Neurological Association, May 
12, 13 and 14, 1903. 


586 GEORGE W. JACOBY. 


facial was variously assumed to lie in the second frontal convolu- 
tion at its junction with the precentral (Ferrier, Horsley, Hitzig 
and Duret), or in the inferior parietal lobule ( Mendel, Exner and 
Paneth, and Obersteiner ). 

More recent clinical observations have, however, shown that 
the assumption of non-involvement of the upper facial in hemiple- 
gia is a mistake. The recognition of this long dominant error in 
clinical knowledge is due in great part to the sign of the orbicu- 
laris (Signe de Vorbiculaire de la paupiere). This name was first 
suggested by Révilliod to describe a symptom which was already 
known but which he above all others has most carefully studied 
and utilized for scientific deductions. 

This symptom consists in the inability of a hemiplegic, volun- 
tarily to close the eve upon the paralyzed side, except in conjunc- 
tion with the other eye. 

Thus in cases of hemiplegia, the temporo-facial branch of the 
facial nerve is often so slightly affected as to lead to doubt whether 
the upper facial territory is involved at all. 

If in such a case the hemiplegic be asked to close both eyes 
together, he is able to do so without difficulty; he is also able to 
close the eye upon the sound side while keeping the eye upon 
the affected side open, but he is unable to reverse this procedure 
and close the eye upon the paralyzed side while keeping that upon 
the unaffected side open. 

This sign of the orbicularis was found by Reévilliod as well as 
by subsequent observers, Boiadjiew, and Bard, to be present 
in almost all hemiplegics, and this not only for a short time after 
the apoplectic attack, but frequently persisting for a long time af- 
ter all other signs of paralysis have passed away. 

Every subsequent investigator has been able to corroborate 
these earlier observations, so that as a result of this, and other 
clinical signs which do not concern us here, it is today universally 
admitted that the upper facial is involved in all central affections 
of the facial nerve, although to a less extent than is the lower fa- 
cial. 

This being acknowledged, it is also clear that the various as- 
sumptions regarding the dissociate cortical origin of the upper 
facial are superfluous and the most modern authors agree with 
Mills who sums up the central course of the facial as follows: 





SIGN OF ORBICULARIS' IN FACIAL PARALYSIS. 587 


“The central neurones of the facial apparatus arise from the motor 
cells of the lower extremities of the central convolutions. Together 
they form a tract which passes by the corona radiata and the inter- 
nal capsule about its knee to the tegmentum, decussating in the 
latter to enter the facial nucleus of the other side.” 

If, however, the implication of the upper facial in the central 
paralysis is a generally recognized fact, it must be admitted on 
the other hand also that the upper facial in such paralysis 1s al- 
ways relatively free, that it is rarely as much involved as the mid- 
dle and lower facial or as much as the upper facial is involved in 
peripheral paralysis. 

This fact requires explanation ! 

Why is the upper facial relatively free in central paralysis ? 

A priori,it may be reasoned, the functions of the upper and low- 
er facial territories differ materially, the upper being utilized more 
for emotional movements, while the middle and lower serve more 
for voluntary ones; that emotional movements are as a rule bi- 
lateral, while voluntary ones may be either unilateral or bilateral ; 
that, furthermore, inasmuch as the voluntary movements in cere- . 
bral hemiplegia due to lesion of the pyramidal tracts, are the ones 
most affected, it will be comprehensible that the middle and lower 
facial muscies will be more markedly involved than those supplied 
by the upper branch of the facial nerve. 

This reasoning presupposes a special path, not through the in- 
ternal capsule, for emotional movements, or it warrants the 
assumption that each upper facial is innervated from both hemi- 
spheres. While the first assumption is by many considered cor- 
rect, it would, however, in the case of cortical or subcortical lesions 
(that is, involvement of the purely voluntary motor paths), neces- 
sitate equable paralysis of all parts of the facial, which is con- 
trary to all clinical experience. 

The other assumption was first advanced in a general way by 
Broadbent, and is almost universally accepted as a fact. 

Broadbent’s hypothesis in the main represents the following 
ideas : Many muscles of the body are used only in conjunction with 
their fellows of the opposite side; others while usually used alone 
may be and frequently are used conjointly with their fellows. 
Those muscles which are always used alone are represented only 
unilaterally in the cortex; those that are used conjointly are bilat- 


588 GEORGE W. JACOBY. 


erally represented, so that unilateral movements can be excited 
only from one, the opposite hemisphere, while bilateral movements 
can be excited from either hemisphere, and finally those muscles 
which are sometimes used alone and at other times conjointly 
are connected with both hemispheres, but are generally excited 
from one, the opposite hemisphere, only. 

The synergic action of the orbiculares palpebrarum, during 
repose or during a state of unconsciousness, shows that they 
must have a bilateral innervation and that they must, therefore, 
be excitable together from either hemisphere. As a result of edu- 
cation and under influence of the will each orbicularis may. in its 
action become independent of the other, and must then be ex- 
citable individually from the contralateral hemisphere. Such con- 
joint and independent actions can be explained only by the as- 
sumption of a chiasm formation, an interlacement composed of 
two crossed and two direct tracts. Therefore Révilliod, starting 
from the hitherto accepted premise that the sign of the orbicularis 
is never present in peripheral paralysis, but is found only in 
central affection, seeks this chiasm formation at a point on the 
motor path between the cortex and the nucleus. Revilliod says: 
“Tf indeed, as the sign of the orbicularis has demonstrated, the su- 
perior facial is really implicated in ordinary hemiplegia together 
with and by means of the same focus as the lower facial and the 
extremities, then it must form part of the same tract, called pyram- 
idal, and course with it from the cortex to the oblongata, passing 
by way of the internal capsule. But in order to assure the synergy 
of the two sides of the upper face, this nerve must divide before 
reaching its nucleus, into two branches, the one crossed, the other 
direct, the latter returning to the face upon the same side as the 
hemisphere from which it emanates,” and “the crossed branch 
would consequently always be accompanied and assisted into its 
end ramifications, by the direct branch which comes from the 
hemisphere of the opposite side.”’ This explanation Révilliod il- 
lustrates by a diagram of the motor tract in which the decussation 
of nerve fibers is shown to be complete for the lower facial (and 
the extremities) but is assumed to be incomplete for the synergic 
muscular groups of which the orbiculares form a morphological 
part. 


—_* 


SIGN OF ORBICULARIS IN FACIAL PARALYSIS. 589 


Révilliod’s assumption may be endorsed but at the same time 
may be considered insufficient. 

If we recall that the upper facial also in other pathological 
conditions than that of central hemiplegia may show a comport- 
ment different from that of the middle and lower distributions ; 
that in bulbar paralysis it is almost the rule to find the upper facial 
relatively less implicated than the lower facial, and that even in 
purely peripheral facial paralysis the temporo-facial branch is not. 
infrequently much less affected than is the lower facial, then we 
are entitled to assume, not only as has been done by others, that 
the upper facial is especially resistant to pathological influences, 
but also that a decussation of fibers must take place at the facial 
nucleus itself and that this decussation is mainly made up of those 
fibers which act synergically. 

This question of decussation of facial fibers is one which ana- 
tomical and physiological investigations, as well as pathological 
studies, have been unable to answer definitely. 

A priori, and reasoning from analogy it would seem that such 
decussation must exist. Clinically. we know that in complete 
hemiplegia, not only is, as has already been emphasized, the orbic- 
ularis palpebrarum relatively free, but also that the eye muscles, 
the muscles of the trunk and of the larynx, in short all those 
muscles which usually functionate in pairs and give rise to bilateral 
associated movements are comparatively unaffected. 

This can be explained only if we admit the existence of com- 
missures joining the nuclei of origin of the motor nerves of the 
two sides, such commissure then assuring functional physiological 
synergy, and reciprocal subserviency in pathological implication 
of the nucleus upon.one side. 

As a general principle the existence of such decussation be- 
tween the homologous nuclei of all motor cranial nerves is ad- 
mitted (see Edinger), but it is not admitted as a fact by all ob- 
servers for all cranial nerves. 

Thus as regards the facial, we find that Adolf Meyer, C. 
Mayer, Van Gehuchten and Bischoff have furnished proof in op- 
position to the doctrine of decussation between its roots. 

On the other hand, Obersteiner, von Bechterew, Flatau, 
Marinesco, Bruce, Kotelewsky, Mills, Pardo and Bary are sup- 


590 Sa GEORGE W. JACOBY... 


porters and have furnished anatomical proof of the existence of 
such decussation. 

Recent observations of Ramon y Cajal are also in accord here- 
with and clearly show that fibers belonging to the seventh nerve 
decussate in the raphe. 

Of special interest and value in this connection, are the exper- 
iments of J. and N. Aspisow. ‘These observers after having, by 
means of electric excitation, located the cortical center for the up- 
per facial in dogs, excised this center and after proper lapse of 
time examined the brain. 

In addition to secondary degeneration through the corona ra- 
diata, internal capsule, crus and pons, the degenerated fibers could 
be plainly traced from the homolateral, across the raphe, to the 
contralateral facial nucleus. 

Against all this anatomical proof, however, stood the clini- 
cally accepted fact that the sign of the orbicularis was absent in 
peripheral paralysis. As a result of my examination of all the 
cases of peripheral facia! paralysis which I have seen in hospital 
and private practice, since the last four years, 1 am able now to 
say that this so-called fact is an error, and that the sign of the or- 
bicularis can be found in many peripheral cases if sought for at 
the proper time. 

Already in 1894 Mann, in calling attention to the fact, which 
had also been recorded by a number of others, that the orbicularis 
oculi in some cases of peripheral paralysis is not nearly so much 
involved as the other facial muscles, and that this same muscle in 
cases which are improving shows an early regeneration, also states 
that in these same cases the patients were able to close the eyes at 
a time when the attempt to corrugate the forehead failed; the 
forehead upon the paralyzed side remaining smooth but the eye 
closing. 

If this investigation be probed further, it will be found that 
while many such patients can at this time close both eyes together, 
the independent closure of each eye is possible only for the eye 
upon the unaffected side. 

Before this test can be utilized for deductions or conclusions of 
any kind, it must, however, be first shown that the independent 
closure of each eye exists physiologically in the majority of indi- 
viduals. This has been demonstrated by Boiadjiew, who tested 


SIGN OF ORBICULARIS IN FACIAL PARALYSIS. 591 


750 healthy persons, and found that 484 or 64.54 per cent could 
close each eye independently ; 126, or 16.80 per cent, could close 
only the left eye without at the same time closing the right; 64, or 
8.53 per cent, could close only the right eye without at the same 
time closing the left; 76, or 10.13 per cent, could close neither the 
left nor the right eye independently of the other. 

This investigation, therefore, shows that two-thirds could close 
either eye independently and that, therefore, this capability 1s 
sufficiently frequent to allow its absence to be utilized as a clinical 
symptom, provided the patient can give a history of previous it 
dependent control. 

There is no necessity for giving a large number of cases in or- 
der to demonstrate the frequent occurrences of a symptom which 
any observer may easily corroborate. Let us take a few typical 
cases which present points of special interest. 

Thus, W. W. O., male, aged thirty-seven, was seen on October 
16, 1899; he had then been afflicted with a peripheral paralysis 
of the right facial nerve since a few days. There was marked 
lagophthalmus, with inability to corrugate the forehead, complete 
R. D.-in all the muscles supplied by the facial nerve, including 
the orbicularis oculi; no disorder of taste nor of hearing. Ten 
days after onset of the paralysis, with R. D. still existing in all the 
facial muscles, including the orbicularis, and while still unable to 
corrugate his forehead, to whistle or to blow out a light, he could 
close both eyes together, but could not close the right eye inde- 
pendently of the left. He could close the eye upon the sound 
side, alone; he could close the affected eye when the other eye 
was closed, but he could not close the affected eye alone when the 
unatfected eye was kept open. 

Two weeks later he was able to close each eye freely and inde- 
pendently of the other, as he had always been able to do prior to 
the onset of the paralysis. 

The following case shows the long persistence of an untreated 
facial paralysis, the improvement comparatively soon after treat- 
ment was instituted and the supervention of the sign of the orbic- 
ularis contemporaneously with the onset of improvement. 

A. L., a young boy, was operated for mastoiditis ; after coming 
out of the narcosis it was noted that he had a complete left-sided 
facial paralysis. For one and one-half years he was subjected to 


592 | GEORGE W. JACOBY. 


much treatment on account of his ear trouble, but no attention was 
given to the facial paralysis. At the time when I first saw him he 
still showed complete paralysis of the entire facial with marked 
R. D. in all the muscles supplied by this nerve, no faradic re- 
sponse being obtainable in a single muscle. After five months’ 
electrical treatment, faradic reactions set in in the temporo-facial 
as well as in the lower facial, but not so marked here as there; at 
the same time functional improvement took place in the upper fa- 
cial alone and he was soon able to close the eye completely. He 
could, however, not close the affected eye without also closing the 
sound one. 

Four weeks later, while still showing R. D. in the entire upper 
and lower facial territory, he was able freely to close each eye sep- 
arately. 

The mother states that prior to the facial involvement he was 
able to wink each eye alone. 

The last case which I will briefly relate is of interest because 
it was a case of peripheral facial paralysis with apparent freedom 
of the orbicularis, which, however, through the presence of the 
sign, was shown to be an ordinary case with but slight involve- 
ment of the upper branch. 

The patient, a middle-aged woman, was seen in March, 1900, 
three days after the acute onset of a right-sided facial paralysis. 
Examination showed marked involvement of the lower facial, as 
shown by the interference with mouth movements (whistling, 
blowing, grinning, etc.), with apparent freedom of the upper fa- 
cial. She was able to close both eyes completely and easily. 
When each eye was tested separately it was, however, found that 
she could close the ieft eye alone with ease, but that she could not 
close the right at all except in conjunction with the other eye. 

She made a rapid and complete recovery and was then able to 
close each eye singly as she had been able to do prior to the onset 
of the paralysis. 

Without citing any more cases I desire to call attention to a 
result of my investigation which seems to me to bear some prog- 
nostic significance. As well as it has been recognized that in 
peripheral paralysis of the facial nerve, the orbiculo-frontal 
branches are frequently less implicated or recuperate earlier than 
the other branches, so also it is well known that marked spasm and 


SIGN OF ORBICULARIS IN FACIAL PARALYSIS. 593 


twitchings may occur in the orbiculo-frontal territory, at a time 
when the voluntary path is being reéstablished, and at a time in 
which reduced electrical excitation still exists. In what percent- 
age of cases such spasms occur, I do not know, but the number is 
probably not small; I am, however, able to state with certainty 
that in no case which I have followed during the last four years 
has such spasm occurred after the sign of the orbicularis, which 
had been present, had passed away; or I may say in all cases in 
which the spasm has occurred the patient was not able to close each 
eye independently at the time of the onset of the spasm. 

In conclusion [ would summarize the result of my studies as 
follows: 

1. The statement of Bard, that the sign is invariably lacking in 
peripheral facial paralysis and 1s, therefore, a distinguishing mark 
of central affection, is incorrect. 

2. The presence of the sign in peripheral paralysis is further 
proof of the existence of commissural fibers between the nuclei of 
the 7th nerves. 

3. The sign is of clinical value in so far as its presence in per- 
ipheral paralysis shows that complete recovery has not yet oc- 
curred. 

4. The secondary over-action in the orbicularis palpebrarum, 
which is late in appearance and always coincides with some re- 
covery in power, does not occur in those cases in which the sign 
having been present has passed away. 


LITERATURE. 


Huguenin, Jahresbericht, f. d. med. Wissenschaft, 1873. 

Chvostek, Oest. Zeitschr. f. prak. Heilkunde, 1870. 

Hallopeau, Revue Mensuelle de Médecine et de Chirurgie, Paris, 1879. 

Ferrier (see Boiadjiew). 

Horsley (see Boiadjiew). 

Hitzig (see Boiadjiew). 

Duret (see Boiadjiew). ) 

Mendel, Berliner klin. Wochenschr., No. 48, 1887; Neurol. Centralbl., 
No. 23, 1887. 

Exner and Paneth, Archiv f. die gesammte Physiologie, 4, p. 349. 

Révilliod, L.. Revue Médical de la Suisse Romande, Oct., 1 

Boiadjiew, Georges D., “Le signe de l’orbiculaire de la paupiére,” etc. 
Thése inaugurale, Genéve, 1892. 
Bard, L., Lyon Medical, Feb. 10, 1901. 
Mills, C. K., “The Nervous System and Its Diseases,” Philadelphia, 
1808. 
sc ae Va Lancet, Jan. and Feb., 1874, see Grasset, J., “Maladies du 
systéme nerveux,” Paris, 1879, Vol. I, p. 245. 

Adolf Meyer, Journal of Experimental Medicine, Nov., 1897. 


594 GEORGE W. JACOBY. 


Mayer, C., Wiener Jahresberichte f. Psychiatrie, 12. 

Van Gehuchten, “Le nerf facial,’ Journal de Neurol. et d’Hypnologie, 
No. 6, p. 169, 1898. - 

Bischoff, E., Neurol. Centralbl., No. 22, 1890. 

Obersteiner, “Anleitung beim Studium des Baues des nervésen Central- 
organes,” Leipzig, 1896, p. 410 and 411. 

Von Bechterew, W., “Die Leitungsbahnen im Gehirn und Rucken- 
mark,” Leipzig, 1894. 

Flatau, E., Zeitschr. f. klin. Med., 32, 3 and 4, p. 280, 1897. 

Marinesco, Revue Neurologique, 6, 2, p. 30, 18908. 

Bruce, A., Scottish Med. and Surg. Journ., 3, 5, 1808. 

Kotelewsky, Sitzungsbericht d. russisch- med. Gesellschaft zu Warschau, 
{1, 4, 1808. 

Pardo, G., Schmidt’s Jahrb., Vol. 262, p. 191. 

Bary, Neurol. Centralbl., No. 17, 189¢. 

Mann, L., Berliner klin. Wochenschr., 1894, p. 1,192. 

Ramon y Cajal, “Beitrag zum Studium der Medulla Oblongata, des 
Kleinhirns und des Ursprungs der Gehirnnerven,” 1896. 

Aspisow, J. and N., “Ueber die centralen Bahnen des oberen Astes des 
N. facialis”; abstracted in Jahresbericht tiber die Leistungen und Fort- 
schritte auf dem Gebiete der Neurologie und Psychiatrie, 1901, p. 33. 


GIGANTISM: AND LEONTIASIS OSSEA, WITH REPORT OF 
THE CASE OF THE GIANT WILKINS. 


By Perrer BaAssore, M.D., 


RESIDENT PATHOLOGIST, PRESBYTERIAN HOSPITAL; ASSISTANT IN PATHOLOGY, 
RUSH MEDICAL COLLEGE, CHICAGO, 


(Continued from page 532.) 


In view of the findings in this case one must admire the keen- 
ness of Sternberg’s judgment in excluding acromegaly and point- 
ing out the analogy with Buhl’s case (to be related later). The 
relation of acromegaly to gigantism, and of both to disease of the 
hypophysis, has been extensively discussed of late. Thanks to 
this fact a number of exhaustive reviews of the cases of all more 
or less scientifically studied giants exists. The most thorough 
ones are those by Sternberg (43), Meige (31), and Woods 
Hutchinson (27). All authors agree that giants frequently pre- 
sent acromegalic symptoms, and that hypophysis disease is the 
rule in acromegaly. A most daring generalization is that of 
Massolongo (30), who says: ““Acromegaly is nothing but delayed, 
abnormal gigantism.” Meige quotes and indorses this statement 
and gives the easy explanation that, when the disease commences 
in youth we get a case of gigantism; when in adult life, acro- 
megaly ; if commencing in youth and continuing into adult life we 
get a combination of the two. After an extensive review of cases* 
he formulates the following statements (loc, cit. p. 458): “1. Ac- 
romegaly never precedes gigantism. 2. Acromegaly sets in during 
the course of about one-half of the cases of gigantism. 3. When 
acromegaly is associated with gigantism, the latter always appears 
first.” Woods Hutchinson sums up the result of his studies of 
gigantism as follows: “1. The greater part of the overgrowth is 
found at or near the tips of the segment-crescents, as in acromeg- 
aly, differing from the latter mainly in that it is not exclusively 
confined to the tip of the segment or last division of the limb. 


*Among these our Wilkins appears as two, the author having failed 
to observe that Dana and Lamberg described the same man. 


596 PETER BASSOE. 


2. The facial part of the skull is enlarged out of all proportion to 
the cranial, particularly in the region of the lower jaw. 3. The 
condition, whether it be regarded as normal or morbid, is one that 
distinctly tends to shortness of life, and would appear to have an 
average duration of scarcely more than twenty years. 4. The 
mental and physical vigor of the giant is distinctly below par, and 
his death usually comes either from a steady progressive increase 
of this weakness, or from some trifling accident, or usually mild, 
intercurrent disease. 5. Sexual powers appear in the great ma- 
jority of cases to be far below normal. 6. There is a decided 
preponderance of males among the victims of this condition; in 
all of which statements there is a decided parallelism with acro- 
megaly. Last of all, and from the point of view of this essay, of 
greatest interest, is the fact that the one morbid condition which 
is peculiar to both of these disturbances of nutrition, the enlarge- 
ment of the pituitary body, is found to be present in a large ma- 
jority of cases of both.” After stating that the material as yet 
is meager, he says that we are “justified at least in the tentative 
conclusion, until some evidence to the contrary can be adduced, 
that acromegaly and gigantism are simply different expressions 
of one and the same morbid condition; in other words, that acro- 
megaly is a general overgrowth tendency which does not, for some 
reason, begin to express itself until after adult stature has been 
reached, and which consequently expends itself upon those points 
in the body at which growth last ceased—the extremities of the 
segment-crescents and the distal extremities of the appendages. 
Second, that gigantism in a large majority of cases is this same 
condition manifesting itself in childhood or before complete 
stature has been reached, and the growth in consequence is more 
symmetrical and less strictly confined to the last segment of the 
arches and appendages. In most cases, however, the tendency 
appears to be for these last segments to grow in an unsymmetrical 
and excessive manner.” After a discussion of the conditions 
found in the hypophyses of acromegalics, giants and dwarfs, he 
further concludes: “1. That the pituitary body is still functional. 
2. That disturbances of its metabolism are the principal factors in 
both acromegaly and gigantism, the difference between the results 
being simply due to the stage of individual development at which 
the disturbance of the function begins. 3. That the nature of the 


GIGANTISM AND LEONTIASIS OSSEA. 597 


overgrowth in both these diseases is primarily on the order of a 
pure functional hypertrophy; later, however, losing some of the 
definiteness of its impulse, and either producing immature tissue 
of a mixed type or resulting in simple hemorrhagic exudation, 
with either cyst formation or complete breaking down of the 
tissue mass. 4. That it seems probable, although upon this head 
the evidence is still uncertain, that some part is played by this 
body in ‘dwarfism,’ rickets, and the dwarf forms of cretinism. 
5. That a reflex disturbance of its function may possibly underlie 
the dystrophy accompanying pharyngeal adenoids. 6. That it 
would appear to be a sort of ‘growth center’ or proportion- 
regulator of the entire appendicular skeleton.” The author finally 
hints that chorea may be due to disturbance of the hypophysis, 
and promises a further report on the subject. 

Sternberg (43) states that about 20 per cent of all acro- 
megalics are over 177 cm. (5 ft. 10 in.) tall, and that about 4o per 
cent of all giants have acromegaly, but denies the identity of the 
two processes which up to that time had been advocated by Klebs, 
Massolongo, Brissaud and Meige. He believes there are “‘nor- 
mal’’ giants, i.e., well-proportioned over-grown people. As such 
he regards Virchow’s case, Winkelmeyer (48), whose. height is 
given as 227.8 cm. Hutchinson does not consider him “normal,” 
as his height at the hip line, as determined by the position of his 
hand in the picture, is 64 per cent of the total height, instead of 
the normal 55 per cent. Sternberg classifies the “pathological” 
giants as follows: “1. Acromegalics—about 40 per cent of all 
giants. 2. Cases with multiple tumor-like exostoses (leontiasis 
ossea and hyperostoses). Often the signs of compression of the 
brain and cranial nerves. Here he groups Buhl’s case, Hasler 
(10), 227 cm.; Sirena’s (42) first case, 240 cm., and our case, 
Wilkins, 245 cm. (Reference given to Lamberg’s report). 
3. Cases with facial hemihypertrophy. Dana’s case.* 4. Cases 
with multiple curvatures of the bones, as scoliosis, curved hu- 
merus, genu valgum, of similar appearances as in rickets; for 
instance, Bollinger’s giantess (6) and Zitterland’s case, Berlin 
skeleton 3040 (51). 5. Gigantism in hereditary syphilis, case of 
Fuchs (18). 6. Precocious development and rapid growth in cases 
of testicular tumors in children. Sacchi’s case (38).” 


*T suspect Wilkins is the case referred to. Reference is given to the 
article in which his case is reported. 


‘598 PETER BASSOE. 


Meige, who quotes this classification, finds it a little artificial. 
This may be true, but it probably goes into generalizations as far 
as the facts warrant at present. 

Sternberg sees two possibilities for an etiologic relationship 
between gigantism and acromegaly. First, the latter may induce 
a cartilaginous proliferation in a still ununited epiphysis; or, 
secondly, in gigantism a disposition to general dystrophies, and 
particularly to acromegaly, may exist. 

Schmidt (41) inclines to the iatter view, and considers the 
acromegalic features as something complicating the gigantism, 
the same being true of the frequent scolioses, genua valga, etc., 
and the rarer hyperostoses of the bones of the head, as seen in 
our case, which is, together with that of Buhl, quoted as one in 
point (from Lamberg’s report). 

As Buhl’s case (10) is in many respects similar to our own, 
it deserves special mention. It was that of a man, Thomas Has- 
ler, who was normal up to the age of nine years, when a rapid 
growth commenced. This is said to have followed a kick on the 
cheek by a horse. Some years later huge hyperostoses of the 
facial and cranial bones appeared and were larger on the injured 
side. At twelve he measured six feet. He died at twenty-five. 
His height then was 227 cm., or 235 cm. (7 ft. 8% in.) with the 
back stretched; the weight, 155 kg. There were no lesions of the 
viscera. All epiphyses, including those of the trochanters, were 
sharply outlined. The skull showed enormous exostoses. The 
lower jaw was enlarged in all directions, very irregular, its 
height at the middle of the chin 12 cm.; thickness, 9 cm.; the left 
side was the thicker. The upper maxillz were also thick. On 
the left side the processus frontalis, the nasal, malar, ethmoid 
and lachrymal bones were greatly thickened, the floor of the orbit 
raised, the left wall of the nose displaced to the right. The left 
frontal bone measured 6 em. (23% inches) in thickness, the left 
temporal,1.5 cm.; the right, 1 cm. The left side of the occipital 
and parietal bones also thick. Both in the frontal and parietal 
bones superficial porous islands were found. The interior of 
the skull was diminished on the left side, the sella turcica dis- 
placed to the right. The brain weighed 1,465 grams, and was 
much decomposed at the time of the autopsy. The hypophysis 


GIGANTISM AND LEONTIASIS OSSEA. 599 


is not mentioned. Buhl attributed the patient’s death to compres- 
sion of the brain.* 

Hutchinson’s hypothesis that the hypophysis is a “growth 
center or proportion-regulator of the entire appendicular skele- 
ton” is a bold one, considering, how few actual facts we possess 
concerning the functions of that organ. Benda in quoting the 
above statement (4) says that Hutchinson is bolder than himself. 
The physiologists seem unable to agree about a single function of 
the hypophysis, and some deny its having any function at all. 
The studies of Andriezen (2) on the larval amphioxus, amma- 
cetes, balanoglossus and other lower animals are very fascinating. 





Fig. 10. Base of skull in Buhl’s case. 


He observed carmine solutions passing from the buccal to the 
neural cavity through the hypophysis and infundibulum. He 
says: “A water-vascular system permeating the body-tissues, and 
serving for the in-bringing of oxygen and the out-taking of 
waste products, and having inlets and outlets communicating 
with the aqueous medium in which the animal lives, preceded, in 
point of time, the development and elaboration of a true blood- 
vascular system.”” He believes that the anterior or glandular por- 
tion of the hypophysis in these embryos secretes a substance which 


modifies the fluid passing in from the buccal cavity, while the 





*A glance at the picture of the skull will show the close resemblance 
to our case. As the original communication is difficult of access this» 
drawing is reproduced here. 


600 _ PETER BASSOE. 


posterior or nervous portion controls that secretion. His 
predictions of the symptoms following extirpation are also inter- 
esting, as they were confirmed by the experiments of Vasalle and 
Sacchi (47). 

Cyon has performed many experiments and written a number 
of articles on the physiology of the hypophysis. In the most 
recent one (12) he relates how he irritated the organ in various 
ways through an opening made in the pharynx. He claims the 
following functions for it: I. (a) It serves to regulate intra- 
cranial blood pressure, (b) regulates metabolism. 2. It regu- 
lates cerebral pressure in two ways, (a) mechanically, each in- 
crease in pressure irritating it, causing slower and stronger heart 
beats and increased rapidity of venous circulation, particularly 
of the thyroid, thus relieving the brain; (b) chemically, as it 
produces substances, probably two in number, one of which irri- 
tates the vagus, the other the accelerators. 3. Effect on metabo- 
lism takes place through similar action of its products on the 
vagus and the sympathetic, seen in increased oxidation and de- 
creased weight. 4. Tonic excitation of the vagus depends on 
excitation of the hypophysis due to pressure exerted on it. 
5. Continued excitation, especially electric, of the hypophysis, 
causes as after-effects severe epileptiform spasms, most easily 
explained by circulatory disturbances in certain parts of the 
brain. In rabbits electric irritation caused persistent erections 
and increased diuresis; the latter also followed the injection of 
extract of the hypophysis. Cyon believes that the effect upon 
the circulation is due to a stimulation of thyroid activity, regula- 
ting the circulation through the carotids. Hypophysin, the most 
important substance obtained from the hypophysis, has an action 
similar to, but more intense than that of iodothyrin. In thyroid 
disease the hypophysis may for some time take up the function 
of the thyroid. Thus, enlarged hypophyses were found in thy- 
roidectomied rabbits, and the roof of the hypophysis cavity often 
ossified, which, according to Cyon’s theory, ought to facilitate 
the function of the gland. But in spite of his conviction of the 
correctness of his views, Cyon is unable to explain acromegaly 
either by hyper—or hypo—function. Certain symptoms, such as 
impotence in men and amenorrhea in women, he interprets as due 
to a loss of function. 


GIGANTISM AND LEONTIASIS OSSEA. 601 


Enlargement of the hypophysis has been described as follow- 
ing thyroidectomy by Hofmeister (26), Stieda (45), Gley (19), 
Goldberg (20), and others; in cretinism by Bourneville and 
Bricon (7), Dolega (14), Osler (36), Groén (21), and others. 
Le Count (32) states that in acromegaly the thyroid has been 
recorded as reduced in size four times, as cystic or the seat of 
colloid degeneration, twice, and as normal in appearance five 
times. Ponfick (37) reports two cases of myxedema in which the 
glandular atrophy and increase in fibrous tissue were so much 
more marked in the hypophysis than in the thyroid that it seemed 
probable the change had begun in the former organ, which Pon- 
fick suspects may be closely related to the production of myxe- 
dema. 

Friedman and Maas (17) disagree with Cyon’s views, and 
from a number of extirpations of the hypophysis conclude that it 
is not essential to life, and state that, in their experiments, its 
absence led to no change in any organ, particularly not in the 
thyroid. 

Castelli (11) gives as the effects of extirpation: More rapid 
heart action, slower respirations, psychic depression, tetanic- 
clonic cramps, and cachexia, ending in coma and death. He be- 
lieves it is concerned in the rendering harmless of toxines arising 
in the organism—which is, in turn, denied by Cyon. 

Biedl and Reiner (5) also attacked Cyon’s views, and claim 
that electric irritation of most places of the brain has the same 
effect as when applied to the hypophysis. 

With such lack of definite knowledge as to its functions, it is 
no wonder that the role played by the hypophysis in disease can 
only be guessed at for the present. No one can deny the fact 
that it is diseased in most cases of acromegaly and in many 
giants, but whether this is the cause or merely itself a phenom- 
enon of the disease cannot be stated. It is also probably true that 
the majority of the hypophyses tumors observed in acromegaly 
are to be considered as hyperplasia of the glandular portion. 
They have been given a great variety of names, but as Benda (4) 
well puts it, the names given differ more than the descriptions, 
and the histological picture in a given case may vary so much 
that one may find microscopic fields to fit almost any tumor name. 
In four such cases Benda succeeded in demonstrating glandular 


602 PETER BASSOE. 


structures and transitional forms between these and the irregular 
sarcoma-like portions found. In the present case it was con- 
fidently expected to find such transitional forms, and not until the 
serial sections through the hypophysis had demonstrated the ex- 
istence of a sharp border at every point, was the glandular origin 
of the tumor definitely abandoned. 

Many cases of hypophysis disease without acromegaly or 
other disturbance of growth are on record, as Handford’s case 
(22), Woolcombe’s case of psammoma (49), Beadle’s two cases 
of gumma and tubercle respectively (3), Breitner’s of adenoma 
(8). In this country Hektoen (23) has reported a case of gum- 
ma associated with a thick skull, Stewart (44) and Hinsdale (25) 
of sarcoma with no acromegalic symptoms. Recently Taylor and 
Waterman (46) reported a case of a sarcoma involving the optic 
commissure, but its connection with the hypophysis was _ not 
proven, and there is no mention of an examination of the sella 
turcica after the removal of the brain. In an autopsy on a de- 
mented female epileptic, aged 38 years, at the lowa State Hos- 
pital, Mount Pleasant, the writer found an hypophysis that 
weighed 59 grams. The skull, particularly the frontal bone, 
was thick. The brain weighed 1,040 grams. The woman was 
very small and had no acromegalic symptoms. In an insane, 
tuberculous subject, likewise with no acromegalic features, a 
small calcareous nodule was found in an otherwise normal hypo- 
physis. 

The following instance of gigantism, associated with a tumor 
of the pineal body, while the hypophysis was normal, is of con- 
siderable interest. It is reported by Oestreich and Slawyvk (35). 
A male child had been delivered by forceps and been long asphyx- 
iated. There were spasms of the glottis at the age of three 
months. The child developed normally the first three years, then 
it became morose and the body began to grow rapidly, particularly 
the penis. Walking became difficult. July 4, 1898, four years 
old, it was admitted to the Berlin Charité. Height 108 cm., 
weight 20 kg., muscles and skeleton powerful. Its size was that 
of a normal child of seven or eight years. Skin normal. Head 
symmetrical, circumference 53 cm. (4 cm. above normal, accord- 
ing to the authors). There were sluggish reaction of the pupils 
to light, slight convergent strabismus, and a bilateral choked disc. 


GIGANTISM AND LEONTIASIS OSSEA. 603 


Sight appeared impaired. Mamme, hypertrophic; penis, g cm. 
long; pubic hair, 1 cm long. Extremities of natural length. Sen- 
sations normai. After three weeks of clonic convulsions the child 
died Aug. 12, 1899. An autopsy was held. Anatomic diagnosis : 
I. Cystic psammo-sarcoma of the pineal gland. 2. Internal hydro- 
cephalus. 3. Gigantism. The skull was irregularly thinned. The 
posterior part of the third ventricle was occupied by an irregular, 
partly cystic tumor, the size of a small apple, in the position of 
the pineal body. Vhe tumor also shows firmer parts and sand- 
like areas. The thyroid and hypophysis were normal, the thymus 
of proportionate size and normal histologically. The tumor was 
found to be a spindle-celled sarcoma, and the authors consider it 
the cause of the giant growth. 

In spite of the title of the article, ““Gigantism and Tumor of 
the Pineal Gland,” and the explicit statement that the hypophysis 
was normal, Meige, in his previously quoted article (p. 472), in 
referring to this case, says that Oestreich and Slawyk described 
an acromegalic giant in whose /jypophysis a tumor was found! 

The presence of calcified patches in the spinal meninges of our 
case is of some interest. The deposit of externally generally 
smooth, internally rough flattened plates of bone on the inner sur- 
face of the dura has been designated “‘arachnitis ossificans”’ (40). 
According to Zanda (50) the bone formation takes place from the 
dura after adhesions with the arachnoid have been formed. They 
are most frequent in connection with regressive changes, such as 
those of old age, chronic insanities, and diseases of the spinal 
cord. Sainton and State (39) describe a case of acromegaly in a 
man 54 years old, with numerous such sand-paper-like patches 
enveloping the cord in the thoracic and lumbar regions, and con- 
sidered them the cause of the cramps and pains in the extremities 
present. Similarly located bony or bone-like patches in acromeg- 
alics have also been described by Duchesneau (15), Henriot (24), 
and Finzi (16). In our case, it will be remembered, calcareous 
nodules were also present in the pleura and peribronchial lymph 
glands. Von Moraczewski (33) has shown a tendency to reten- 
tion of lime and phosphorus in acromegalics, and Meige sees here 
a chance for a new proof of the identity of acromegaly and 
gigantism, if such a condition is found in the latter, as we might 
then presume that in the growing giant the osteogenetic function 


604. | PETER BASSOE. 


is exercised only at the epiphyseal junctions, while, after the ces- 
sation of growth, the osseous hyper-function leads to the forma- 
tion of aberrant calcareous deposits. ? 

Heredity does not seem to play a significant part in the etiol- 
ogy of gigantism. In most cases the other members of the family 
are reported of ordinary stature and in good health. Thus “Lady 
Aama,” the French giantess reported by Hutchinson (28), was 
the youngest of fifteen children, all the others being normal. It 
the sources of information of De Neuville (34) were even ap- 
proximately reliable, a tendency to giant growth has existed in 
certain families. According to him, Robert Hales, an English- 
man born in 1820, measured 7 ft. 6 in., his father 6 ft. 6 in., and 
his mother 6 ft. An ancestor who lived at the time of Henry VIII 
measured 8 ft. 8 in. Five sisters averaged 6 ft. 3 in.; the tallest, 
7 ft. 2 in., died at 20 years of age. Four brothers averaged 6 it. 
6 in. Hales himself measured 62. in around the chest, 64 in. 
around the waist. Louis Frenz, born 1800, measured 7 ft. 6 in. 
He said one sister was “nearly as tall,’ and one brother ‘‘still 
taller.’ Achard and Loeper (1) report the case of a male acro- 
megalic giant, height 212 cm. (6 ft. 11 in.) whose father measured 
195 cm., paternal uncle 210 cm., and a sister 180 cm. According 
to Meige, the Chinese giant Chang, himself 8 ft. tall, said he had 
a sister 8 ft. 4 in. 

Nearly all giants have been poorly developed sexually. With 
the possible exception of Winkelmeyer (Virchow’s “normal” 
giant) none have left children, and all of them have been short- 
lived. Hutchinson gives the average age at death in eight giants 
as 21.3 vears, the extremes being “in childhood” (the tall girl of 
Basle) and 25 years (Buhl’s case, Hasler). According to Meige, 
the Chinese giant, Chang, must have reached 51 years. 

The changes in the skull in our case are difficult to understand, 
partly on account of the complicated condition, partly because of 
the small number of analogous cases and the incomplete descrip- 
tions to be found of them. While there are many good gross de- 
scriptions and accurate measurements, histologic examinations 
have rarely been made. An attempt will be made here to review 
briefly the more important cases of cranial hyperostosis which are . 
likely, at least in part, to be of a similar nature. 

In 1697 Malpighi (69) described a skull weighing 3,618 


GIGANTISM AND LEONTIASIS OSSEA. 605 


grams, with effaced sutures, a tumor of cherry size near the 
saggital suture, and here and there small marble-like eminences. 
The temporal bones were particularly large, the base of the skull 
thick, the orbits small. 

Tarin (89) in 1753 described a thickened frontal bone with 
prominent angular processes. 

Jourdain (67) and later Ribel (77) described the case of For- 
cade, the son of a French surgeon. He was well up to the age of 
12 years when an abscess at the inner canthus of the right eye 
was opened and discharged for a long time. During this time an 
almond-sized prominence appeared on the nasal process of the 
right superior maxilla, and increased in size so that at the age of 
15 years the boy was unable to breathe through the nose on ac- 
count of it. Then, the lower jaw, nasal and malar bones, and 
floor and sides of the orbit became involved. Later, exophthal- 
mos, blindness, and speech troubles appeared. The patient, who 
was below middle stature, died at the age of 45 years. The dried 
skull weighed 8 Ibs. 3 oz., the lower jaw alone 3% lbs. There 
were huge exostoses of ivory hardness on the lower jaw and on 
the inferior margin of the orbits. The bones of the cranial vault 
were thick, with flat exostoses and very hard, the frontal and 
maxillary sinuses obliterated ; cranial cavity not diminished in size. 
The facial muscles were fibrous in appearance and adherent to the 
periosteum. The bones outside the skull were unusually delicate. 

Sandifort (78) described a skull thickened by about one inch 
with abundant spongy substance between the two thickened tables. 
On the interior, especially of the frontal bone, were numerous 
rough projections. 

Jadelot (66) described and recognized as pathologic a skull 
which a previous writer (Wendelstedt) had contended must have 
belonged to a preadamic giant, at least 13 ft. tall, and which 
Cuvier, from the condition of the teeth and sockets, in turn had 
shown to have been that of a child of six or seven years. It 
weighed 3,913 grams, measured 236.9 mm. in length, 151.1 mm. 
in height, and 203 mm. in biparietal diameter. The thickness 
varied from 19.8 to 40.2 mm.; the diploé was more compact than 
the outer and inner plates. 

Saucerrotte (79) describes a man, 39 years old, the circumfer- 
ence of whose head was 797 mm.; the lower jaw, the hands, feet, 


606 PETER BASSOE. 


spine, ribs, sternum and clavicles were large, with hyperostoses. 
The lips were thick. The position of this case is somewhat uncer- 
tain. Virchow, Paget, and Marie each claimed it for the diseases 
named by them, leontiasis ossea, ostitis deformans, and acromeg- 
aly respectively. Ilg (65) and later Gruber (61) report a case 
whose skull is the now famous one of the Prague Anatomic Mu- 
seum. A girl of ten years, previously healthy, was taken with 
amaurosis, followed by severe headaches, delirium and epilepti- 
‘form attacks. At sixteen she became deaf, at seventeen unable to 
swallow solid food, lost the sense of smell, and became bed-ridden. 
During this time she had several attacks of erysipelas. She died 
in 1804, 27 years old. The dry skull without the lower jaw, teeth 
and nasal bones weighed 4,200 grams. The _ fronto-occipital 
diameter was 197.6 mm., the biparietal 171.2 mm., the thickness 
varied from 19.8 to 52.6 mm., the occipital bone being the thickest. 
The external surface was uneven, the sutures had mostly disap- 
peared, the prominences, particularly the external occipital pro- 
tuberance, were enlarged. There were compact exostoses on the 
inner side of the frontal bone and greater wing of the sphenoid. 
The sella turcica was unusually shallow and narrow, and all for- 
amina diminished in size. Diploé was only present in the frontal 
and parietal bones, in other places replaced by hard bone. The 
capacity of the cranial cavity was 1080 c.c. The specific gravity 
of the bone was 1.94. Microscopic examination: “The medullary 
canals narrow, surrounded by concentric bony lamella, mostly 
without sharp borders, the peripheral lamella darker than normal. 
Ground substance fibrillar, darker, with numerous powder-like 
dark granules. Bone corpuscles not clearly outlined, globular, or 
at least more globular than spindle-shaped; there are also some 
abnormally large spindle-shaped corpuscles. The ductuli chali- 
cophori increased in size and number, with fewer anastomoses 
than normally.” This is probably the first histologic examination 
ever made of a hyperostotic skull. 

A very thick skull in Spurzheim’s collection was described by 
Kilian (68). Its thickness was from 27 to 54.1 mm., latter in 
parietal region. 

A still thicker one was found near Miinster and recorded by 
Bojanus (54). Its weight without the lower jaw was 4,000 


GIGANTISM AND LEONTIASIS OSSEA. 607 


grams, its thickness 27-67 mm. Most sutures were obliterated, no 
diploe present. The orbits narrow, their walls thickened. 

Breschet (55) reports a congenital case in a child who died 
at the age of 18 months in a tetanic spasm after having suffered 
with convulsions from birth, with only brief intermissions. All 
the cranial bones, except at the base, were: thickened, in places 
measuring one inch. The anterior fontanelle had not disappeared. 
Bones of the face not involved. 

The skull in Vrolick’s (g1) case weighed 1,305 grams, 
measured 199 mm. in length, 150 mm. in width, rough externally. 
The stitures, with the exception of the squamous, were obliterated. 
The frontal bone was 15-20 mm. thick, occipital 20 mm., right 
parietal 7 mm., left 15 mm., sella turcica narrow and deep. 

In 1851 Albers appeared with a monograph on the subject 
(52), in which he denied the inflammatory nature of cranial 
hyperostosis and any connection with rickets, considering the 
condition one of hypertrophy with deposit of lime salts. 

Schutzemberger’s case (81) is thought by Baumgarten to 
bear resemblance to the Ilg-Gruber case. The patient died in 
convulsions at forty years after having suffered from headaches, 
epileptiform attacks, and mental enfeeblement for some years. 
The skull was thickened and hard, diploé and sutures absent. 
The cavity was small, thickening being mainly at the expense of 
the inner table. The foramina were slightly diminished in size. 

Huschke’s case (64) was that of a woman seventeen years old 
whose skull weighed 3,224 grams and measured 228 mm. in 
length and 157 mm. in width. The thickness of the frontal bone 
was 10-35 mm., of parietal 22-35 mm., of occipital 16-40 mm. 
The diploé was mostly replaced by hard bone. The author con- 
sidered the lesion due to rickets, a view which has been proven 
untenable by Virchow, Schmidt and others. 

Gaddi (60) described a skull found in 1862. It weighed 
3,660 grams. Surface rough, sutures obliterated. The bones 
of the face very large, the superior maxillze particularly enor- 
mous. The lower jaw weighed 422 grams. ‘The only other bone 
found, the second cervical vertebra, was also enlarged. 

The first thorough sifting and elaboration of this accumulated 
material was made by Virchow, who also proposed the name 
leontiasis ossea (90), which was suggested to him by the leonine 


608 PETER BASSOE. 


appearance, in the case of Forcade in particular. He expressed 
the opinion that the process corresponds to elephantiasis of the 
soft parts, and that erysipelas plays an important part in the 
etiology. The latter assumption has not been borne out, though 
in a few cases the onset has been coincident with erysipelatous 
attacks, for instance, two of the cases of hyperostosis in epileptics 
related by Sommer (84). Virchow called attention to the fact 
that the hyperostotic bone was sometimes described as soft and 
spongy, but more commonly as hard and ivory-like, and showed 
that the latter condition is of two kinds, either an osteosclerosis 
which is secondary to the spongy condition or an eburnation 
which is primary. A concentric arrangement of the lamelle indi- 
cates an osteosclerdsis, one parallel to the surface eburnation. 
The case of Bickersteth, fully reported by Murchison (70), 
is probably to be considered one of leontiasis, although the hyoid 
bone and the fibula were also involved. At the age of fourteen 
years enlargement of the facial bones commenced, that of the 
fibula at twenty-seven. Death occurred at thirty-four, preceded 
by symptoms of compression of cranial contents, severe head- 
aches, exophthalmos and blindness of the left eye. At the autopsy 
the superior maxillary bones were found enlarged, the inferior 
maxillz enormously so. All bones of the cranial vault were in- 
volved except the occipital. The skull was covered externally 
with excrescences, the orbits, nasal and external auditory open- 
ings reduced in size. Histologic examination was confined to the 
fibula, “as it was not considered necessary to injure the cranium.” 
Wrany (93) reports a case where the disease commenced in 
the lower jaw, which is unusual. -The skull was thickened and 
hard, the sutures obliterated internally. The frontal bone meas- 
ured 12 mm., the parietal 6 mm., the occipital at the inion 20 mm. 
in thickness. The posterior wall of the sella turcica was atrophic 
and perforated. The inferior maxilla was thickened in all parts 
except the condyles, the superior maxilla and lachrymal bones 
were also involved. No bone outside the skull was involved. 
Le Dentu (56) reports a case of hyperostosis of the facial 
bones of two years’ duration in an eighteen-year-old girl. A 
piece was excised and pronounced to be sarcomatous by com- 
petent men at the College de France. Le Dentu did not accept 
the diagnosis as healing took place after excision, and designates 


GIGANTISM AND LEONTIASIS OSSEA. 609 


the condition a “diffuse non-syphilitic periostosis.” However, 
Baumgarten and Schmidt are inclined to consider the diagnosis 
of sarcoma correct. This controversy is of interest in connection 
with our own case, where we evidently have to deal both with 
leontiasis ossea and sarcoma. 

Skull No. 205 in the Museum of the Breslau Pathologic In- 
stitute, described by Fischer (59) as an instance of leontiasis, is 
not mentioned in the treatises of Baumgarten (53) and Schmidt 
(82). The left side of the frontal and both parietal bones were 
involved. The tumor-like thickening of the frontal bone meas- 
ured 36.5 cm. in circumference, 15 cm. in length, 6.5 cm. in 
height, 12.5 cm. in width. The bone was of ivory hardness, 
uneven, the inner surface covered with coarsely granular osteo- 
phytes. The cavity of the skull was very little narrowed. He 
also mentions the case of a man, eighteen years old, with a similar 
tumor the size of a fist at the right frontal eminence, which had 
existed for six years without any symptoms of compression. 
Fischer also describes the skull of a woman, who died of pul- 
monary tuberculosis, with bony tumors of the left temporal bone, 
sphenoid bone, and left side of the lower jaw. 

In 1881, Paquet (72) presented before a surgical society a 
woman, twenty-two years old, on whose left upper jaw a tumor 
was first noticed at the age of three years. It had grown rapidly 
the last two years only, before that very slowly. The left eye 
was compressed and nasal fossa almost obliterated. The tumor 
was resected and histological examination showed most of it to 
be hyperostosis, but it was sarcomatous in the region of the 
antrum and palate. Baumgarten is of the opinion that two dis- 
tinct affections were present, namely a hyperostosis, probably 
congenital, and a sarcoma of two years’ standing. 

The osteoporotic and much thickened parietal bone found in 
an Egyptian tomb, preserved in the Museum of the Royal College 
of Surgeons, London, and described by Eve (58), if an instance 
of leontiasis, is probably the oldest specimen of that disease in 
existence. | 

Silcock (83) reported the case of a man, who, at the age of 
twenty-three received a blow on the left forehead followed in 
five days by epileptic attacks and in a year by a bony tumor. A 
year later, when it had reached the size of a Tangerine orange, 


610 | PETER BASSOE. 


trephining was performed, the bone found 35 mm. thick and beset 
with small exostoses, and the left frontal sinus obliterated. No 
histologic examination was made, a fact to be regretted, as it 
would be desirable to establish histologic points of differentiation, 
if possible, between such rapidly growing exostoses and the 
slowly advancing typical leontiasis. 

In the same year (1890) appeared Poisson’s (74) account of 
a patient with onset at sixteen of hyperostoses of the superior 
maxillz and obliteration of nasal cavity and antrum. Histologic 
examination showed a rarefied condition of the bone. <A trophic 
disturbance of neuropathic origin is considered as the basis of the 
trouble. 

In 1892 F. Baumgarten published his thesis entitled, “La 
leontiasis ossea” (53), in which a thorough review of nearly all 
recorded cases is given, together with a discussion of the etiology, 
pathology, symptoms, and diagnosis of the affection. No new 
cases are reported, but further details given of a case previously 
reported by Pean (73), who had extirpated multiple tumors of 
the palate, upper and lower jaws in a woman, twenty-two years 
old. At the age of nine the first tumor had appeared in the right 
palatal vault. Histologically all the tumors presented the same 
structure. Baumgarten hesitates whether to call them fibro- 
sarcoma, osteo-fibroma, or osteo-fibro-sarcoma. The tumor of 
the lower jaw was surrounded by a fibrous capsule. There was 
no extension to the cranium. Baumgarten does not consider this 
a case of leontiasis. However, considering the long duration, it 
seems to the writer that this may be another instance of sarcoma 
arising in hyperostotic bone. 

Starr (86) reported a case of leontiasis ossea or, as he pro- 
posed to call it, ‘“‘megalo-cephalie,’ in a woman fifty-two years 
old, with onset at the unusually late age of forty-four. There 
was general hypertrophy of the bone over the entire calvarium, 
more marked just behind the temples. The head measured 24 
inches in circumference. The cavities of the nose and mouth 
were encroached upon, the soft parts of the head and neck also 
thickened. Many nervous symptoms were present. Thyroid ex- 
tract was tried without effect. 

In 1895, Horsley (63), reported five cases of leontiasis ossea 
which he defined as “the development of bony new formation re- 


GIGANTISM AND LEONTIASIS OSSEA. 61I 


sembling an overgrowth of diploe, and attacking the cranial bones 
(by preference the frontal), or more rarely the facial bones, espe- 
cially the jaws.”’ In a summary he says: “In all five cases the 
disease began in childhood or in early youth. In the three cases in 
which the disease attacked the eyebrow and roof.of the orbit early, 
the displacement of the eyeball downwards occurred before any 
notable swelling appeared above in the supraorbital ridge. In the 
same three cases the region of the external frontal process was the 
focus of the malady. In no case was there any evidence of syphilis 
nor any really direct history of traumatism. In all cases the prom- 
inent symptom of distress was the pain produced by the entangle- 
ment and pressure upon the branches of the fifth nerve passing 
through, or by the affected bones. In the cases where operation 
was possible the mass was readily removed piecemeal, starting 
from the border of conjunction with the healthy bone.” 

Case 1. Male, age I9, onset at 15 with swelling above left 
brow, headache, vomiting, epileptic fits. Thyroid gland enlarged. 
Swelling of vertex, affecting frontal, right temporal, part of 
parietal and occipital bones. No operation. Case 2. Female, age 
26, for five years swelling of left side of head. In 1888 the thick- 
ened bone was removed by operation. Recurrence, a second 
operation in 1894, with relief of all symptoms. Case 3. Male, 
age 28, onset at 20 with exostoses on each side of nose. Five 
years later protrusion of right eyeball and optic atrophy. Right 
superior and inferior maxillary bones were resected. Three years 
later operation on left side of face which had become involved. 
Case 4. Female, age 13, swelling of left side of frontal bone, re- 
sected. Case 5. Male, age 35, swelling of right side of frontal 
bone for at least 17 years. Resection of diseased portion of bone 
with relief of pain. Horsley gives the following anatomic de- 
scription: “Outer surface of tumor in every case smooth, perios- 
teum thickened. When the latter was stripped off the diseased 
bone presented a marked contrast to the normal, in being notably 
more vascular, the surface being extensively filled with minute 
foramina, the branching of superficial vessels very prominent, 
and the color a deep red as compared with that of normal bone. 
There was no demarkation between the tables and the diploé. 
Histologic examination was complete only in cases 2 and 5. The 
outer, rather harder portion of the bony mass consisted of 


612 PETER BASSOE. 


normal trabeculze of bone separated by unusually wide medullary 
spaces. The lamellz in the bone trabeculz were well marked, but 
homogeneous throughout from the margins of the medullary 
spaces inward. In this region the medullary spaces were filled with 
a delicate, almost myxomatous connective tissue in the meshes of 
which hardly any characteristic medullary corpuscles appeared, 
except at the periphery of each space, where a complete row of 
osteoblasts was present in most cases. The central, softer and 
more friable portions of the tumor presented very different ap- 
pearances from the foregoing. The medullary spaces were very 
large, the bony trabeculze in process of active absorption and 
medullary tissue replaced by a neoplastic, fibrous growth. To 
consider these changes in further detail the alteration in the mar- 
row may be taken most conveniently first in order. The medul- 
lary tissue of the outer portions of the tumor has already been 
stated to consist chiefly of a delicate fibrous tissue. From this 
condition to one in which the whole medulla was converted into a 
dense feltwork of fibrous reticular substance, every stage could 
be found. In the progress of this metamorphosis the individual 
fibers appeared to become thickened and to take a brownish stain 
with hematoxylin. While in the extreme stages the greatly thick- 
ened fibers assumed a more granular appearance, the whole sug- 
gested an osteogenic condition. Soon after the fibers became 
denser the osteoblasts disappeared and their place was taken by 
osteoclasts. ‘The bony trabeculz, as soon as the medullary tissue 
became obviously altered, showed notable changes, until in the 
most advanced areas of disease every bone trabecula exhibited 
by change in the staining reaction (deeper color) and morpho- 
logical alteration of the cells, a marked reversion to a chondroid 
stage, and furthermore the margins and the surfaces of the tra- 
beculz displayed many false Howship’s lacune.” The extreme 
rarity of histologic descriptions renders the reproduction of this 
one in extenso justifiable. Horsley concludes by saying: ‘Leon- 
tiasis ossea is a pathologic entity in which both osteoplastic and 
osteoclastic processes are represented, and that it is a hopeless 
condition, for which operation, if extensively practiced, offers 
considerable relief.” 

In 1896 a valuable article, entitled “Hyperostosis cranii,” by 
Putnam (76), appeared in this country, with four new cases, 


GIGANTISM AND LEONTIASIS OSSEA. 613 


statistics of fourteen typical cases, and a brief critical review of 
the literature. Case 1. Female. Mother and sister had “suffered 
with their heads.’’ At three, some disease of ankle, followed by 
separation of pieces of bone. Bright in youth but inclined to 
drowsiness. Onset at 19 with headache, tinnitus, later deafness, 
head gradually broadening. For years a purulent discharge from 
ears. Bilateral facial paralysis before death, also dimness of 
vision in one eye. Died at about 30. Autopsy showed a general 
purulent periostitis crani. Diffuse thickening of cranium, most 
marked anteriorly, 1.5 cm. Bones with a worm-eaten appearance 
from caries. Weight of skull nearly twice the normal. Orbits 
and sella turcica smaller than normal. Grooves for vessels prac- 
tically absent. Diploeé ivory-like. Case 2. Male. Two bean- 
sized lumps noticed at the top of the head at five. They finally 
reached the size of 2% inches in diameter and 1% inch in height. 
Prominent occipital protuberance and temporal ridges. Slight 
optic neuritis, eyes prominent. [Epileptiform convulsions began 
at seven; deafness and dementia before death, at 22. No autopsy. 
Case 3. Man, observed at 50 years, had noticed that his head was 
growing larger for ten or twelve years, enlargement attended by 
neuralgic pains, impaired hearing, insomnia. Case 4. Female, 
age 35. Enlargement of head first noted in the region of left 
parietal eminence at 23. Burning sensations and numbness of 
face. Circumference of head 65.5 cm. Surface of cranial bones 
irregular from presence of exostoses. A case observed by Dr. 
Prince is also reported by Putnam in the same article. Male, 
struck on the forehead by a pulley, two years after noticed swell- 
ing of frontal bone, followed by symptoms of compression and 
death six years after the injury. The autopsy showed marked 
thickening of the skull in the mid-frontal region, of the temporal 
ridges, and particularly of the orbital plates. 

Following Putnam’s article is a report by Edes (57) of a 
woman, age 52, whose head had been growing larger for some 
years. Six years later (1902) this case was found by Prince 
(75) to have developed into one of ostitis deformans, almost all 
of the long bones in the body having become affected. There was 
also a general myasthenia. 

White’s case (92) was that of a man, 32 years old, with a 
prominent bony ridge running horizontally round the back of the 


614 PETER! BASS OE. 


head, reaching within an inch of outer canthi of both eyes. This 
had appeared a short time after a fall from a window at the age 
of three years. Later in childhood he had fractured the left 
femur, at 22 the right femur, at 29 the right shoulder became 
stiff. The maximum circumference of the head was 24% inches. 
Facial bones normal. Slight nystagmus and bilateral deafness ; 
no headache. General health good. According to Prince (loc. 
cit., p. 810), this case later came to autopsy, recorded by Collier. 
Unexpectedly a condition of syringomyelia was found which had 
not given rise to the usual sensory symptoms. Prince thinks the 
bony changes were very likely of the nature of the trophic lesions 
dependent on that disease. 

Noble (71) reported a case of a young man with extreme 
bulging of the nose and lower part of the forehead, the eyes being 
five inches apart. The disease had commenced with the appear- 
ance of a bony growth in the upper part of the right nostril, four 
months after the injury of the nose by a fall at the age of 
eighteen. 

Young’s patient (94), a man who died at 46, had prominent 
superior maxillary bones and supraorbital ridges with obliteration 
of the antra and frontal sinuses, and narrowing of the right orbit 
and both nasal cavities. Cranial bones of normal thickness, sella 
turcica normal. 

_Hinsdale’s (62) patient, a woman, died at 71. There was 
diffuse hyperostosis of the skull, thickness varying from 14 mm. 
in temporal, to 35 mm. in occipital bone; circumference of head 
71 cm. Diploe reduced in amount, bone unusually soft and fria- 
ble. The skull-cap weighed 1870 grams. The lower half of the 
head was not enlarged. The epiphyses of both femurs were en- 
larged and covered with friable exostoses, and the long bones of 
the lower limbs were slightly bowed. Acromegaly or myxedema 
were excluded. The enlargement of the head was first noticed 
at sixty-four. ; 

Sommer (84) contributes an article on cranial hyperostoses 
in the insane. Epileptics are particularly frequently affected. 
The anterior half of the base, especially the sphenoid, is most fre- 
quently involved. Twenty cases were studied. 

Stack’s case (85) was that of a woman who, at the age of 
three years, injured the forehead by a fall. The wound sup- 





! 


GIGANTISM. AND LEONTIASIS OSSEA. 615 


purated. [Enlargement of the head was first noticed at the age of 
seven. She died at 21. At the autopsy the skull was found 
greatly thickened, the half skull without the lower jaw weighing 
7\%% lbs. The thickening was greatest in the frontal bone. The 
bone was very soft. The lower jaw weighed 1 lb., and is de- 
scribed as follows: “The whole of the horizontal ramus was en- 
larged and rounded; the compact shell was expanded and _ filled 
with very porous bone, containing a quantity of very slimy, 
gummy material, which poured out when cut into.” The naso- 
pharynx contained a firm white tumor attached to the hard and 
soft palate, found on histologic examination to be a fibro-sarcoma 
with numerous myeloid cells. Brain and hypophysis normal. 
There were scoliosis, a soft and distorted pelvis, bent femora and 
tibiz, changes which led Prince to suspect that the case was a 
combination of hyperostosis and osteomalacia. 

Schiller (80) reports a case from Czerny’s clinic. Male, age 
30. A brother was delivered by embryotomy on account of ab- 
normal size of thorax. Patient delivered by forceps as head was 
unduly large. Abnormal increase in size of head continued until 
age of t9 years, when it became stationary. The only symptom 
was frequent headache. The circumference of the head was 61 
cm. The head was weighed, hanging over the edge of the table, 
when the patient was anesthetized. Its weight was between 5 and 
5.5 kilograms, while that of normal heads in the same position 
was 2 to 2.5 kilograms. There were prominences of the frontal 
and parietal bones, seen in X-ray pictures to be due to actual bony 
thickening. Facial and other bones not involved. 

In the appended table a summary of the causes just recorded 
is given. Although they undoubtedly do not constitute a clinical 
entity, in our present state of knowledge it seems convenient to 
consider them together as all more or less possess the characteris- 
tics of Virchow’s leontiasis ossea. In many of them, such as 
some of Horsley’s cases, there may be only a resemblance to leon- 
tiasis, in others the latter may be a part of a more general disease, 
but as the nature of leontiasis itself, as well as of nearly all of the 
allied disorders, is unknown, only arbitrary distinctions can be 
made, when the phenomena overlap. Hence, we will consider 
these cases together, first as to their 


616. PETER BASSOE. 


Etiology—Heredity seems to play no part. The sexes are 
about equally affected. Onset nearly always in childhood or early 
youth, even before birth, if we include Breschet’s and Schiller’s 
cases. Of the five cases with onset after twenty-five, those of 
Starr, Edes, and Hinsdale were complicated by disease of other 
bones, and possibly belong to ostitis deformans. ‘Trauma is said 
to have preceded the onset six times. Of these cases Buhl’s was 
complicated by gigantism, Stack’s by osteomalacia, White’s prob- 
ably was due to syringomyelia, Noble’s and Silcock’s were of such 
rapid course as to suggest a true tumor. The erysipelas and sup- 
purative inflammations present in a few cases were evidently 
merely complicating or accidental. Baumgarten’s view that the 
disorder is trophic and developmental is probably the best at 
present. 

Morbid Anatony and Histology—Sternberg (87) divides thé 
cases into diffuse hyperostoses with involvement, rarely even, of 
all cranial and facial bones (cases of Malpighi, Jadelot, 
Sandifort, Ilg-Gruber, Gaddi), and localized tumor-like hyperos- 
toses, such as the case Forcade, and those of Buhl and Bickersteth- 
Murchison. Such a line, however, seems rather artificial. As to 
the bones involved, the following may be learned from 30 fairly 
completely reported cases in our table: 


Cranial, upper, facialiandslower jaw ee IO 
Cranialvonly ((or at least sprincipally) saree eer 10 
Cramal atid: upper aacial eee eee ee 4 
Cranialand ‘lower? 3aver ee ee ee ee 2 
Upper/and:lower jaws!" oe. a ee eee eas 
Upper. jaws Onby cra... ore ceeeereck Seve ee enn I 


Of the cranial bones the anterior part of the frontal is usually 
most affected. Of 22 cases the disease is stated to have com- 
menced in the cranial bones I1 times, upper facial Io times, and 
lower jaw once (Wrany’s case). The affected cranial bones are 
generally harder than normal, with absence of diploeé, and obliter- 
ated sutures. Exceptions are the cases of Stack, Hinsdale, Buhl, 
and our own, where the hyperostotic cranial bones were abnormal- 
ly soft. The weight of the skull is often enormously increased, as 
well as the thickness of the vault, as the frontal bone in our 
case, 85 mm. The external surface is generally rough, often with 


GIGANTISM AND LEONTIASIS OSSEA. 617 


large exostoses, while the internal surface is most commonly 
smooth. Narrowing of the cranial cavity, orbits, nasal cavities, 
sinuses, and foramina for nerves and vessels is common. The af- 
fected facial bones are usually the seat of nodular exostoses, dif- 
fuse thickening being much rarer than in the skull. Histologic 
examinations are too few to admit of any generalizations. The 
association with sarcoma in as many as five cases, those of Paquet, 
Stack, Pean-Baumgarten, Le Dentu, and ours, must be more than 
a coincidence. The descriptions in these cases lead us to infer that 
the sarcomatous process started in the periosteum of the diseased 
bone. In only one of these cases, that of Le Dentu, is it possible 
that the entire process in the bone was due to sarcoma. One may 
also suspect that some of the more acute cases following injuries, 
as those of Silcock and Noble, really were instances of osteosar- 
coma. The complications with gigantism (cases of Buhl, Sirena 
(42) and ours), with syringomyelia (White), osteomalacia (Stack), 
ostitis deformans (Edes), and acromegaly (Saucerrotte), and 
possibly a case of Sternberg’s (87), are extremely interesting and 
suggest an etiologic relationship between all these obscure con- 
ditions. 

Symptoms—Most of these are explained by pressure on the 
brain or nerves. Headache is the rule. Anosmia, blindness, ocu- 
lar paralysis, neuralgic pains, numb or anesthetic areas, tinnitus, 
deafness, dysphagia, speech troubles, epileptiform convulsions, 
mental disorders, have all been recorded. Optic neuritis was re- 
corded in Putnam’s case, that of Edes, and ours. The course is 
very slow, but nearly always progressive, usually extending over 
ten to thirty years. 

Diagnosis—Ostitis deformans usually begins after forty, and 
the long bones are here involved. When it begins in the cranium, 
a differential diagnosis is extremely difficult or impossible until 
the long bones become involved. Recently Prince (75) has advo- 
cated the view that the two perhaps are only different manifesta- 
tions of the same disease, and probably trophic disorders, that the 
underlying cause may be found in the nervous system which he 
makes a plea to examine more closely in the future. Acromegaly. 
—The enlargement of the hands, feet, tongue, and other soft parts, 
makes a distinction easy in a pronounced case, but, as stated, here 
we also have combinations of the two. Sarcoma.—Diagnosis may 


618 PETER BASSOE. 


be very difficult when the maxillary bones are affected, particularly 
in the case of multiple, slowly growing tumors. Slow growth and 
gradual enlargement of the skull are in favor of hyperostosis. 
The tendency for sarcoma to arise from hyperostotic bone must 
be borne in mind. 

Prognosis—Unfavorable, as the tendency is for the encroach- 
ment on cavities and foramina to progress steadily. 

Treatment—V ery little 1s to be expected until the underlying 
inorbid tendency can be directly antagonized. Operation may af- 
ford relief or even cure, if performed early, but in most cases the 
disease is too diffuse for surgical interference, and the reappear- 
ance of the disease at some other point is likely when excision 
of the primary focus may be possible. This indeed is to be ex- 
pected if we are dealing with a developmental trophic disorder. 

In conclusion the writer wishes to thank Professor Hektoen 
for placing the autopsy material at his disposal and for much val- 
uable aid and advice. 


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11. Caselli. Studii anatomici e sperimentali sulla fisiopatologia della 
eglandula pituitaria. Reggio nell’ Emilia, 1900. 

12. v. Cyon. Zur Physiologie der Hypophyse. Archiv f. d. gesammte 
Physiologie, Bd. 87, p. 565, 1901. 

tate On: Acromelagy and Gigantism, with Unilateral Facial 


GIGANTISM AND LEONTIASIS OSSEA. 619 


Hypertrophy. JourNAL or Nervous AND MENTAL Disease, Vol. 20, p. 
725, 1893. 

14. Dolega. Ein Fall von Cretinismus, beruhend auf einer primiaren 
Hemmung des Knochenwachsthums. Ziegl. Beitr., Bd. 9, p. 488, 1801. 

15. Duchesneau. Contribution a l’etude anatomique et clinique de 
l’acromégalie. These, Lyon, 18o1. 

16. Finzi. Quoted by Meige, /. c., p. 441. 

17. Friedman und Maas. Ueber Exstirpation der Hypophysis cerebri. 
Berliner klin. Wochenschr., Bd. 37, No. 52, 1900. 

18. Fuchs. Hereditare Lues und Riesenwuchs. Wiener klin. Woch- 
enschr., 1895, p. 668. 

19. Gley. Recherches sur la function de la glande thyroide. Archiv 
de physiologie normale et pathologique, Oct., 1892, p. 311. Quoted by 
Mitchell and Le Count, /. c. 

20. Goldberg. Der Einfluss der Schilddriisenexstirpation auf die Ent- 
wickelung junger Thiere, besonders ihrer Schidel und Gehirn. Archiv f. 
Path., Bd. 3, H. 5 und 6, 1897. Quoted by Mitchell and Le Count, /. c. 

21. Gron. Myxodem. Hypertrofi af Hypophysis cerebri. Norsk Maga- 
zin far Laegevidenskaben, 1894, p. 734. 

22. Handford. Large Tumor of the Pituitary Body. Increased Knee 
Jerks, no Acromegaly, no Glycosuria. Brain, 1892. 

23. Hektoen. Gumma of the Hypophysis. Transactions of the Chicago 
Pathological Society, Vol. 2, p. 129, 1806. 

24. Henriot. Quoted by Meige, l. c., p. 441. 

25. Hinsdale. Akromegaly. Medicine, 1808, p. 441. 

26. Hofmeister. Zur Physiologie der Schilddriise. Fortschr. d. Med., 
1892, No. 4, p. 81. 

27. Hutchinson. The Pituitary Gland as a Factor in Acromegaly and 
Gigantism. New York Med. Journ., March 12, 1808. 

28. Hutchinson. A Case of Acromegaly in a Giantess. American 
Journ. of Med. Sciences, Aug., 1895. 

29. Lamberg. Riesenwuchs. Wiener klin. Wochenschr., 1896, p. 350. 

30. Massolongo. Sull ’Acromegalia. La riforma medica, No. 157-158, 
July, 1892. Quoted by Meige, /. c., p. 423. 

31. Meige. Sur le gigantisme. Archives générales de medicine, Oct. 
1902. 

32. Mitchell and Le Count. Report of a Necropsy in a Case of Acro- 
megaly. With a Critical Review of the Recorded Pathologic Anatomy. New 
York Med. Journ., April 15, 1899. 

33. v. Moraczewski. Stoffewechsel bei Akromegalie unter der Be- 
handlung mit Sauerstoff, Phosphor, etc. Zeitschr. f. klin. Med., 1901, 
No. 4. 

34. de Neuville. Nains et géants. Revues des revues, Jan. 1, 1808. 

35. Oestreich und Slawyk. Riesenwuchs und Zirbeldrtisen-Geschwulst. 
Virch. Archiv, Bd. 157, p. 475, 1899. 

36. Osler. Internal Secretions Considered in their Physiological, 
Pathological and Clinical Aspects—Sporadic Cretinism in America. Trans. 
of the Amer. Assoc. of Phys. and Surg., 1807, p. 169. 

37. Ponfick. Myxddem und Hypophysis. Zeitschr. f. klin. Med., Bd. 
38, I, 1899. ; 

38. Sacchi. Di un caso di gigantismo infantile, pedomacrosomia, con 
tumore del testicolo. Rivista sperimentali di freniatria e di medicina legale, 
21, p. 149, 1895. 

39. Sainton et State. La forme douloureuse de l’acromégalie. Revue - 
neurologique, Vol. 8, p. 302, April 15, 1900. ; . 
40. Schmaus. Vorlesungen tber die pathologische Anatomie des 
Ritckenmarks. Wiesbaden, 1901, p. 314. ; 

41. Schmidt. Der allgemeine Riesenwuchs. Makrosomie. Lubarsch- 


620. | PETER BASSOE. 


Ostertags Prgepnisse d. allg. Path. u. path. Anat. des Menschen und der 
Thiére, Bd. 5, 1 

42. a Osservazioni anatomo-pathologiche sul cadavere di un 
gigante. Contributo alla macrosomia e sifilide ereditaria tardiva. La 
riforma medica, 1894, 2, p. 783. 

nas: Sternberg, Masinilivns Die Acromegalie. Nothnagel’s Spec. 
Pathol. u.. Ther., Bd. 7, 2. Theil, 1897. 

44. Stewart, Jas. The Symptomatology of Tumors Involving the 
Hypophysis Cerebri. Philadelphia Med. Journ., May 27, 1899. 

45. Stieda. Ueber das Verhalten der Hypophysis des Kaninchens 
nach Entfernung der Schilddrtise. Zieg]. Beitr., Bd. 7, p. 537. 

46. Taylor and Waterman. Tumor in the Region of the Hypophysis. 
Boston Med. and Surg. Journ., Nov. 6, 1902. 

47. Vasalle and Sacchi. Quoted by Hutchinson. 

48. Virchow. Riese Winkelmeyer aus OberOsterreich. Zeitschr. f. 
Ethnologie, 1885, p. 496. 

49. Woollcombe. A Case of Virchow’s Psammoma of the Pituitary 
Body, with Remarks as to the Function of that Structure. British Med. 
Journ., June 23, 1894. 

50. Zanda. Ueber die Entwickelung der Osteome der Arachnoidea 
Spinalis. Ziegl. Beitr., 5, 1890. 

51. Zitterland. De duorum sceletorum praegrandium rationibus. Dis- 
seratio. Berlin, 1815. 

LEONTIASIS OSSEA, ETC. 

52. Albers. Osteosclerosis cranii cum hyperothophia. Jenaische An- 
nalen, Bd. 2, 1851. 

53. F. Baumgarten. La leontiasis ossea (Hyperostose des os de la 
téte). Paris, 1892. 

54. Bojanus. Ueber den ungewOohnlich verdickten Menshenschadel 
der Darmstadter Sammlung. Froriep’s Notizen aus dem Gebiete der Natur- 
und Heilkunde, Bd. 15, No. 317, 1826. 

55. Breschet. Hyperostose du crane chez un enfant de dix-huit mois. 
Acad. de Med., Jan. 28, 1834. Abstract in Schmidt’s Jahrbtcher, 1834, No. 
2, p. 384. 

56. Le Dentu. Periostose diffuse non syphilitique des os de la face et 
du crane. Revue mensuelle de méd. et de chir., 1879. 

57. Edes. A Case of Hyperostosis of the ‘Cranium. Amer. Journ. of 
Med. Sciences, July, 1896, Vol. 112, p. 21. 

58. Eve. Part of an Ancient Egyptian Skull affected with Osteo- 
porosis. Trans. London Path. Soc., Vol. 39, p. 269, 1888. 

59. Fischer. Der Riesenwuchs. Deutsche Zeitschr. f. Chir., Bd. 12, 
D157; 1979503 | 

60. Gaddi. Iperostosi scrofolosa cefalo-vertebrale. Modena, 1864. 
Quoted by Baumgarten. 

61. Wenzel Gruber. Monographie eines merkwutrdigen osteoscleros- 
tischen Kopfes des anatomisch-physiologischen Museums in Prag. Beitr. 
zur Anat., Physiol., Chir., etc., Prag, 1847. 

62. Hinsdale. Case of Hyperostosis Cranii. JOURNAL OF NERVOUS AND 
MENTAL DISEASE, Vol. 23, p. 803, 1806. 

63. Horsley. Five Cases of Leontiasis Ossium, in Three of Which the 
Disease was Removed by Operation. Practitioner, London, Vol. 55, p. 12, 
1895. 

64. Huschke. Ueber craniosclerosis totalis. rachitica und verdickte 
Schadel tiberhaupt. Programm, Jena, 1858. 

65. Ilg. Einige anatomische Beobachtungen, enthaltend eine Berich- 
tigung der zeitherigen Lehre vom Baue der Schnecke des menschlichen 
Gehororganes, nebst einer anatomischen Beschreibung und Abbildung eines 
durch ausserordentliche Knochenwucherung sehr merkwurdigen Schadels. 
Prag inet, 


GIGANTISM AND LEONTIASIS OSSEA. _., 621 


| 


66. Jadelot. Description anatomique d’une téte hunidine extraordinaire 
Agee d un essai sur l’origine des nerfs. Paris, 1700. 

Jourdain. Traité des maladies et des operations reéllement chir- 
rennet de la bouche. Paris, 1778, T. 1, p. 280. 

68. Kilian. Anatomische Untersuchungen uber das neunte Hirnner- 
venpaar, nebst angehangten Bemerkungen tiber das anatomische Museum 
der Universitat Strassburg. Pesth, 1822. 

69. Malpighi, Opera posthumi, p. 49. London, 1697. Quoted by 
Baumgarten. 

70. Murchison. On a Peculiar Disease of the Cranial Bones Hyoid 
Bone, and Fibula. Trans. Path. Soc. of London, 1866, p. 24 

ete Noble. A Case of Leontiasis Ossea. Brit. Med. The 1896, 2) 
p. 1637. 

72. Pacquet. Soc. chirurg. April 20, 1881. Quoted by Baumgarten. 

73. Péan. Gazette des Hopitaux, 1889. Quoted by Baumgarten. 

74. Poisson. Hyperostose diffuse des maxillaires superiéurs. La 
semaine médicale, 1890, p. 2. 

75. Morton Prince. Osteitis Deformans and Hyperostosis Cranii. A 
Contribution to their Pathology, with a Report of Cases. Amer. Journ. 
of Med. Sciences, Nov., 1902, Vol. 124, p. 796. 

76. Putnam. Hyperostosis Cranii. Amer. Journ. of Med. Sciences, 
July, 1896, Vol. 112, p. 1. 

77. Ribel. Dissertation sur les exostoses. These, Paris, ete 

78. Sandifort. Museum anatomicum. Leyden, 1792. Quoted by Baum- 
garten. 

79. Saucerotte. Mélanges de chirurgie, p. 407, 180T. 

80. Arnold Schiller. Ueber einen Fall von tumorartiger Hyperotose 
des Schadels. Mitinch. med. Wochenschr., Vol. 48, p. 1560, 1901.. 

81. Schiitzenberger. Ostéosclerose généralisée du crane, etc. Gazette 
médicale de Strassbourg, 1856, No. 4, p. 137. Quoted by Baumgarten. 

82. Schmidt. Die Hyperostose der Gesichts- und Schadelknochen 
(Leontiasis ossea). Lubarsch-Ostertags Ergebnisse der allg. Path. u. 
path. Anat., Vol. 5, p. 943, 1808. 

83. Silcock. Hyperostosis of Frontal Bones, and Orbital Walls, Asso- 
ciated with Epilepsy and Treated by Trephining. Trans. Clin. Soc. of Lon- 
don, Vol. 23, p. 266, 1890. 

84. Sommer. Hyperostose bei Irrenschaideln. Allg. Zeitschr. f. Psy- 
chiatrie, Bd. 54, p. 704, 1897. 

85. Stack. A Case of Diffuse Leontiasis Ossea. Bristol Med. Chir. 
Journ., Vol. 18, p. 316, 1900. 

86. M. Allen Starr. Megalo-Cephalie, or Leontiasis Ossea.. Amer. 
Journ. of Med. Sciences, Dec., 1894. 

87. Sternberg. Die Vegitationsst6rungen und Systemerkrankungen 
der Knochen. Nothnagel’s Spec. Path. u. Ther., Vol. 7, 1890. 

88. Sternberg. Beitrage zur Kenntniss der Akromegalie. Zeitschr. 
f. klin. Med., Bd. 27, p. 86, 1895. 

89. Tarin. Osteographie, etc., Paris, 1753. Quoted by Baumgarten. 

see Virchow. Die krankhaften Geschwilste, Bd. 2, p. 23, Berlin, 1864 
-1865. 

gt. Vrolick. De Hyperostosi Cranii. Amstelodami, 1848. 

92. W. Hale White. A Case of Leontiasis Ossea, Megalo-Cephalie, 
or Hyperostosis Cranii. Brit. Med. Journ., 1896, 1, p. 1377. 

93. Wrany. perce: Marillarium. Jahresbericht liber die Leis- 
tungen, etc., 1867, I. 

04. Young. A Case of Leontiasis Ossea. Brit. Med. Journ., 1896, 2, 


Pp. 1303. 


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STUDIES UPON THE CEREBRAL CORTEX IN THE: NORMAL 
HUMAN BRAIN AND. IN. DEMENTIA PARALYTICA. 


By G. AtFrrep LAwrence,, M.D., Pu.D., or New York. ’ 


INSTRUCTOR IN DISEASES OF THE MIND AND NERVOUS SYSTEM, NEW YORK 
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL 


(Continued from page 554.) 


Technique. Turning to the technique employed in this work, 
first will be described a method used in transporting material con- 





Pig. uAL 


siderable distances in the minimum amount of space, and prepar- 
ing the same in the shortest possible time. 

On several occasions the writer was enabled to secure more 
than one brain at the same time, and at a considerable distance 
from the laboratory. It was desired to place small blocks from 
various parts of each of the brains in various fixative media in the 
shortest possible time, and to put them into the smallest possible 


DEMENTIA PARALYTICA. 631 


space for transportation. The smallest size of tin boxes known as 
“Miller’s patent seamless box” (lig. A) were secured at trifling 
cost at Eimer & Amend’s, in New York city; though any small 
box would answer the purpose. These measured but 2.5 ¢c.c. in 
diameter and 1.25 c. c. in depth. One gross of these boxes occupy 
only a space of 15 c. c. square by 5 c. c. in depth. By piercing a 





Fig. B. 


hole in both the cover and bottom of these boxes a free circulation 
of the fixative medium is secured—as mentioned, any other small 
box or phial admitting of the free circulation of the fixative me- 
dium could be used; but these chanced to be the most convenient 
and available receptacles to the writer. By placing a bit of ab- 
sorbent cotton or cheesecloth in both the bottom of the box and in 
the cover the specimen is perfectly protected. A square box of 
black pins (Fig. B), such as can be secured at any drygoods 
store at trifling cost, was purchased. Small squares of cardboard 


632 G.- ALFRED: LAWRENCE. 


were cut out and numbered in duplicate, using a lead pencil.’ Each 
number, with its single duplicate, was placed upon a pin and re- 
turned to its position in the box. ‘The various fixative fluids 
desired were carried in small glass jars with ground glass covers. 
Al! these preparations are made in advance so that at the autopsy, 
upon removing the brain, small pieces can be taken from any part 
of the cortex, each one placed in a separate small tin box with a 
number from one of the pins. The other or duplicate-number is 
left upon the pin, and the latter thrust into the space on the brain 
surface from which the block was taken (Plate I, Fig. 1). The 
small tin box is then thrown into whatever fixative fluid is desired, 
and the fluid enters and fills up the interior by means of the open- 
ings above described, the whole process taking less time than re- 
quired in explanation. In this way a large number of blocks can 
be taken from one or more brains without any possibility of con- 
fusion, and in a minimum amount of time, and likewise take up a 
minimum amount of space, requiring no writing or labeling of 
specimens at the time. After all blocks desired are removed the 
brain is carefully placed upon cotton in a tin pail of the required 
size in whatever fixative fluid is desired, and other brains can be 
treated similarly. 

At the laboratory subsequently the exact locality from which 
blocks were taken can be noted at leisure in the most accurate 
manner. The writer has by this method taken blocks from vari- 
ous parts of two separate brains, placed them in half a dozen 
different fixative fluids, and packed them up, together with the 
two brains in tin pails of suitable diameter, placing everything in 
a hand bag of medium size, and carried the same many miles on 
the train without the slightest inconvenience or knowledge by 
others of the contents of the hand-bag. The fixative agents em- 
ployed in this work were alcohol absolute, alcohol 95 per cent, 
formalin 10 per cent solution (40 per cent formaldehyde, 1 part 
by volume, water 9 parts by volume), Van Gehuchten’s fluid 
(alcohol absolute 60, chloroform 30, and glacial acetic acid I0 
parts by volume), and Lang’s solution (mercuric chloride 5 
grams, sodium chloride 6 grams, acetic acid 5 grams, and water 
100 grams). ‘The most satisfactory results have come from fixa- 
tion in Van Gehuchten’s fluid, and the alcohols. In the employ- 
ment of the latter more or less shrinkage results, but this can be 


DEMENTIA PARALYTICA. 633 


recognized, and the chromatic substance within the cell is usually 
well marked. Van Gehuchten’s fluid was used as follows: Small 
blocks, not more than .3 to .5 c. c. in thickness, were immersed in 
Van Gehuchten’s fluid and left for twelve hours. They were then 
placed in 95 per cent alcohol, where they remained until desired 
for use. No changes in the contour of the cells were observed to 
result, and the chromatic substance in these cells was well shown 
in the subsequent staining. Blocks to be imbedded were then 
placed in absolute alcohol, and, for the paraffin method, trans- 
ferred to xylol, and left in the latter for several hours till thor- 
oughly permeated. They were then placed in paraffin—melting 
point about 50° C., for from 45 minutes to one hour, and then 
transferred to another paraffin bath of the same melting point for 
the same length of time, so as to secure complete penetration and 
the removal of all xyloi. Vhe blocks were then imbedded and sub- 
sequently sectioned by a Minot microtome serially. The sections 
were made varying in thickness from 2 to 15 microns, those from 
6 to 10 microns being found best for study of the arrangement 
and internal structure of the cells. The celloidin method was also 
employed, but it was more difficult to secure thin sections when 
desired, and especially tc arrange them serially. A thin smear of 
egg albumin was placed upon a perfectly clean slide, several con- 
secutive sections placed upon the same, and then a small quantity 
of water by means of a pipette allowed to flow under the sections. 
This was gently warmed upon the water bath or over an alcohol 
lamp until the sections were perfectly flattened out. The water 
was drawn off and the sections allowed to dry. This treatment 
permitted all subsequent manipulations with the sections upon the 
slides, without their floating off or becoming disturbed or injured. 
The slides were then placed in xylol to dissolve out all paraffin 
and run down in successive grades of alcohol from absolute alco- 
hol to 30 per cent alcohol, and from the latter immersed in water. 
The sections were then stained upon the slide by means of an 
aqueous solution of methylene blue, as given by Nissl (methylene 
blue, 3.75 grams; Venetian soap, 1.75 grams, and distilled water 
1,000 ¢. c.), or by a I per cent aqueous solution of methylene 
violet or a I per cent aqueous soiution of thionin. A counter 
stain of erythrosin was used in some cases after treatment with 
methylene blue, giving the achromatic substance a pink color in 


634. G. ALFRED LAWRENCE. 


contrast to the blue color of the chromatic substance. The routine 
method was to gently heat the slide covered with the stain for two 
minutes over an alcohol lamp, keeping the slide in constant mo-- 
tion, and only allowing it to become sufficiently heated so that the 
steam would come from the surface, but no bubbling of the dye 
in solution. The dve was then gently washed off, the slide im- 
mersed in water, and then run wup- into 30, 50, 70, 8o, 
95 per cent, alcohol, absolute alcohol plus xylol equal parts, 
xylol, and finally mounted in xylol-damar. Some slides were 
placed, after immersion in water following the staining 
process, in anilin-oil 10 parts, absolute alcohol 90 parts, and 
subsequently treated as described by Nissl, and finally mounted in 
benzene-colophonium. ‘The first method, however, gave the most 
satisfactory results in the hands of the writer, and which, as seen, 
embodies various modifications of the original Nissl method. Sec- 
tions prepared in the routine method above described have been 
frequently examined under the microscope, also frequently ex- 
posed to sunlight, and at times to the powerful rays of the electric 
arc in the photomicrographic work, but were in nowise faded or 
injured after a period of two years from the time of preparation. 

In the imicrographic work the most painstaking care was em- 
ployed in every detail of the work. Achromatic objectives of 
various power with compensating eye-pieces in different combina- 
tions were used so as to produce different magnifications up to 
1,400 diameters. jul-immersion lenses were not used, as the 
above combination secured the greatest possible depth under such 
high powers. The time of exposure varied from a few seconds in 
the low power photomicrographs to five minutes in some of those 
magnified 1,400 diameters. 

Materiai. Some twenty brains were secured, and sections 
made from various parts of them all and studied in connection 
with this article. Three brains of cases electrocuted at Ossining, 
and in which the autopsy occurred imimediately afterwards and 
the materia! placed in various fixative media, were secured. The 
photomicrographs representing the practically normal brain histo- 
logically in the first part of this article were taken from one of 
these brains, marked A (Plate I, Fig. 1), a man thirty-six years 
of age who had been confined in Sing-Sing State Prison for over 
two years and leading the regular routine prison life during that 


DEMENTIA PARALYTICA. 635 


period. The autopsy was held immediately after death by electro- 
cution. The body was well nourished, and no pathological condi- 
tion of the central nervous system or other organs was found. 
Small blocks, .3 to .5 c. c. in thickness, from various convolutions 
of the brain were placed in the various hardening or fixative 
agents described above, and the brain itself immersed in 95 per 
cent alcohol. The blocks were subsequently imbedded in paraffin, 





Plate I, Fig. 1. 


sectioned serially, stained, differentiated, and mounted as already 
described. 

Brains from three cases of dementia paralytica were also se- 
cured and studied. Sections from the one marked B (Plate X, 
Fig. 29) were used to illustrate this article in its pathological por- 
tion. The paralytic dement from which brain B was taken was a 
lawyer, had a collegiate education, was single, no history of syph- 
ilis, and family history negative. Was native of the United 
States. The disease began at about the age of twenty-eight years 
with the usual change of character, followed by grandiose ideas 


636 G. ALFRED LAWRENCE.. 


and maniacal excitement. Asylum treatment for over a year 
caused his symptoms to clear up sufficiently so that he was dis- 
charged. For nearly two years he was in a fairly quiet condition. 
He then broke out in a long period of excitement, lasting over a 
year, followed by terminal dementia lasting for one and a half 
years before death, which latter was uncomplicated. Duration of 
the disease was thus over five and a half years, during which 
period there was a remission lasting two years, in which he did 
not require asylum treatment. There was contracture of both 
arms and legs for three months preceding death. Mentally he 
was a little brighter during that time. At death the body was 
immediately placed upon ice, and the autopsy performed fifteen 
hours later. The body weighed 78 pounds at death and was 
flexed. Two small cavities, each the size of a pea, were found in 
the apex of the right lung. The lymphatics were somewhat en- 
larged. Heart was atrophied. There was meningeal thickening. 
The ependyma in the posterior part of the floor of the fourth ven- 
tricle was very slightly granular. The membranes were anemic, 
and there was no edema or fluid. The convolutions, especially in 
the region of the central convolutions, are widely separated from 
one another; but, as will be described later, this is largely due to 
mechanical causes in subsequent fixation. In addition to these 
brains over a dozen were secured from other sources, mostly from 
the New York City Morgue, of persons who had committed 
suicide or died suddenly from accident or homicide, with autopsy 
performed within a few hours after death. 

Normal Cortex. The descriptions and plates herein contained, 
and illustrating the normal human cortex, are not intended to give 
the idea of being in any way a complete exposition of such a vast 
subject; but it has been the aim to give photomicrographs with 
accompanying descriptions of typical sections and cells from vari- 
ous regions of the cortex, as a basis of comparison with sections 
taken from corresponding regions of the cortex in a case of de- 
mentia paralytica. Neither is this contribution intended to be in 
the nature of an atlas, being much too limited in scope for such a 
work; but to illustrate as far as practicable the structures found 
in what can be considered a fairly normal brain, with the condi- 
tions found in a brain of one dying from dementia paralytica. 
Various regions of the normal cortex from brain A, one of the 





DEMENTIA -PARALYTICA. 637 


electrocuted cases (Plate I, Fig. 1), with its accompanying plates 
will be first described, and then will follow a like description of 
the corresponding region with its accompanying illustrations of 
the brain of the case of dementia paralytica, brain B (Plate X, 
Fig. 29). Plate I, Fig. 1, above referred to, shows the left hemi- 
sphere of Brain A, natural size; a normal brain, with well marked 
convolutions and sulci. The small pieces of cardboard with their 





Plate I, Fig. 2. 


contained figures show the particular point from which the subse- 
quent blocks were taken, and also illustrate the method of exact 
localization of blocks described under the heading of technique. 


Frontal Region——Turning now to the several cortical re- 
gions, various portions of the first, second and third frontal 
convolutions were examined in different brains, and typical of 
this region is the section shown in Plate I, Fig. 2, which, with 
minor modifications, is similar to that of all portions of this re- 
gion, and will now be described in detail. The block from which 
this section was taken comprised a part of the external surface 
of the first, or superior frontal convolution, including the entire 
width of the gyrus for a distance of .4 cm., and taken from the 


638 G. ALFRED LAWRENCE. 


position shown by the figure 1, Plate I, Fig. 1. The gyrus at this 
point measures .6 cm. in width, so that the actual size of this sec- 
tion is .6 cm. in width by .4 cm. in depth, and it is 6 2-3 microns 
in thickness. 

The block at autopsy immediately after death was placed in 
Van Gehuchten’s fluid, where it remained for twelve hours, when 





it was placed in alcohol 95 per cent until ready for use. It was 
then imbedded in paraffin, sectioned serially with a Minot micro- 
tome, stained for two minutes in warm methylene blue, decolor- 
ized in alcohol, cleared in xylol, and mounted in xylol-damar. 
Plate I) Pie. 2, referred tovabove, shows the section under a 
magnification of 14 diameters. The section has been broken in 
manipulation, but shows the general striated arrangement of 
the cells radiating outward from the white medullary center to 
the surface; also the layering of the cortex. The strip of cor- 


DEMENTIA PARALYTICA. 639 


tex outlined in ink on the plate at @ is that porti’ a shown in 
Plate II, Fig. 3, under a magnification of 100 diameters. The 
outer pale layer, the thicker cellular layers, and the inner med- 
ullary white portion can easily be differentiated even with this 
‘magnification. 

The outer layer is found to be fairly uniform in thickness in 
this section, but we will find later that there may be a consider- 
able variation, not only in the thickness of this layer, but also 
of the other layers, and consequently of the entire cortex. The 
radial arrangement of the cells from the medullary white sub- 
stance is especially well shown under this magnification, and a 
more general and comprehensive view of both the normal ar- 
rangements and of derangements and disturbances due to path- 
ological changes can be made out under this magnification than 
by higher powers in which but minute areas are seen. These 
latter high magnifications are of course also necessary for the 
complete study. of all the details of such variations or patholog- 
ical changes. Plate II, Fig. 3; magnified 100 diameters, is that 
portion of the section outlined in ink in Plated hicwa matin). De- 
colorization has been carried on here to such a degree as to 
make many of the cells appear somewhat pale and washed out, 
and to cause a complete decolorization of many of the neuroglia 
cells. This, however, admits of a better study of the arrange- 
ment of the internal structure of the cells, as a too deep coloriza- 
tion does not sufficiently differentiate the chromophilic granules 
and network. The outer surface of the cortex is here seen to be 
smooth and regular. Immediately beneath is the first or superfi- 
cial layer, pale in color, .25 mm. in thickness, and characterized 
by a paucity of cells irregularly arranged and appearing upon 
a colorless background, which we know from sections treated 
by the Weigert method to be made up of large numbers of 
densely packed nerve fibers and processes. In the plate are seen 
for the most part neuroglia cells, but under a high power pk 
and there nerve cells are found, rounded, spindle-shaped, 
polygonal in form, with a nucleus filling up almost the ies 
cell-body, and with no visible dendritic processes, or at most 
but one or two extending vertically or at right angles to the 
surface of the cortex. The cell-body contains but a small mass 
of chromophilic substance, usually forming a narrow band about 
the nucleus with thickenings where the dendritic processes are 
given off. The cells with no visible processes of course may 
have such extending in a direction outside of the plane of the 
section. Fig. C shows one of these cells containing no visible 
processes, with a rounded cell-body, a large rounded nucleus 
almost filling up the same and surrounded by a uniformly thin 
band of chromatic substance. Fig. D shows another cell from 


640 G. ALFRED LAWRENCE. 


this same region with a single proces vertical to the surface of 
the cortex. Here again the large rounded nucleus almost fills 
up the cell-body and is surrounded by a thin band of chromatic 
substance thickened at the point where the dendritic process is 
given off, and extending into the same for a short distance. Fig. 
E shows a similar cell, but with two processes extending in a 
nearly horizontal direction. The thin chromatic band is here 
thickened at both extremities. The greatest diameter of the 
cell in Fig. D is vertical, while in Fig. E it is horizontal, in Fig. C 
of course being practically uniform. Occasionally cells are seen 
with one process vertical and the other horizontal, as in Fig. F, 
this being polygonal in shape. The nuclei in all of these cells 
are well defined, large, and contain a small amount of chroma- 
tin in the form of a poorly differentiated network, and at some 
point containing a distinct nucleolus. According to Nissl’s clas- 
sification of nerve cells these would be known as karyochrome 
nerve cells. The neuroglia cells are smaller, rounded or oval in 
shape, contain a nucleus, and are much more numerous in this 
layer than the comparatively scarce nerve cells. The second or 
pyramidal cell layer, to simplify. the layering of the cortex to the 
greatest extent, as previously described, is made to include both 
the large and small pyramidal cells. This measures in the plate 
(Plate II, Fig. 3) 1.40 mm. in depth. This layer thus includes 
the large and small pyramidal cell layers and the ganglionic cell 
layer of Hammarberg, and the large and small pyramidal cell 
layers of Golgi and of Cajal. (See Table I.) Hammarberg 
(1895) in his description of this region states that the layer of 
small pyramidal cells does not form a distinct layer, but grad- 
ually passes over into that of the third layer of large pyramidal 
cells, so that the two in his division make a layer .80 mm. in 
depth. He further states that the under border of the third 
layer is difficult to determine, so that there is no distinct fourth 
layer. This fourth layer is then described as containing small 
pyramidal cells less thickly distributed than in the layer above, 
intermingled with which are some smaller irregular cells, giving 
the appearance of a region poor in cells; and he notes further 
that in many places the difference is so slight that it does not 
make a separate layer. His fifth layer is described as a .7o mm. 
thick ganglion cell layer, made up of somewhat larger and 
more closely packed pyramidal cells. These layers,—second, 
third, fourth and fifth layers of Hammarberg, are all included 
in this second layer of the writer, and in this section measures 
about 1.40 mm. in thickness. It is made up of pyramidal cells 
varying in size in all parts of the layer, so that in any region, ex- 
cepting a band below the middle portion to be described later, 
pyramidal cells of different size may be seen in close proximity. 


DEMENTIA PARALYTICA. 641 


As a rule, however, the larger pyramidal cells are found mostly 
in the deeper portion of the layer. But here as elsewhere are 
to be seen the small pyramidal cells interspersed. There are also 
to be seen some rounded and irregular cells throughout this 
layer. Just below the middle of this second layer is seen a belt 
some .30 mm. in width, in which small pyramidal cells decidedly 
predominate and containing but few larger and medium sized 
pyramidal cells. This region is comparable to the fourth layer 
of Hammarberg, but as it contains no elements differing from 
the region above and below, but simply varies in the relative 
number and size of the same, it does not seem to the writer 
worthy the designation of a separate layer with the resulting 
increase in the number of layers. Both above and below this 
belt large and small pyramidal cells are intermingled; the large 
pyramidal cells increasing in proportion from above downward. 
Fig G (G of Plate Il, Fig. 3) shows the details of structure of 
one of these small pyramidal cells under a high magnification 
(x 1,300. No. 3 ocular, 1-12 in. oil immersion objective, Leitz). 
By focussing in different planes the large, broad, apical, den- 
dritic process is seen extending vertically towards the surface of 
the cortex. It contains chromophilic granules arranged with 
the long axis parallel to the axis of the cell. The cell-body 1s in 
the form of a pyramid with rounded sides. The large nucleus is 
irregularly oval with the long axis parallel with the long axis of 
the cell. The nucleolus is centrally located and surrounded by 
the slightly stained nuclear contents. From the lower portion 
of the cell-body are given off three dendritic processes, one of 
which subsequently branches into two processes, at which point 
‘a mass of chromatin is seen, one of the so-called “wedges of 
division” (Versweigungs-Kegln) of Nissl. These dendritic 
processes contain no chromophilic granules, but at the point 
where they are given off from the cell-body are found aggrega- 
tions of chromophilic granules which also surround the nucleus 
on either side, their long diameter extending in general parallel 
with the long axis of the cell. Plate II, Fig. 4, is a photomicro- 
eraph of this same cell as stated, indicated by the letter G in 
Plate II, Fig. 3, and shown in Fig. G of the text as already de- 
scribed. In order to secure a focus by which the cell processes 
could be seen even faintly the nucleus and nucleolus are almost 
entirely out of the plane of focus, the latter showing faintly how- 
ever. Immediately about the nucleolus there is a slightly pale 
area, a portion of the nucleus. ‘The contents of this cell-body 
itself present for the most part the appearance of a very dark, 
almost homogenous, intensely stained chromatic substance, and 
gives only a partial idea of the real structure and arrangement 
of the granules as seen in Fig. G. The contour of the nucleus 


642 G. ALFRED LAWRENCE. 


cannot be distinctly made out, nor the relative position of the 
nucleolus in the same. The individual chromophilic granules 
cannot be distinguished excepting at the base of the right lateral 
dendritic process. The apical dendritic process appears as a 
mere shadow, owing to its being out of the plane of focus. The 
basal dendritic process show almost as well as in Fig. G, except- 
ing the branching of the one at the left which is but faintly indi- 
cated. The small mass of chromatin at this point—the so-called 
“wedge of division,” of Nissl—is also but faintly indicated. The 





Plate II, Fig. 4. 


general contour of the cell, points from which the dendritic 
processes are given off, and position of the nucleolus are accu- 
rately represented. Hada plane been selected showing the nu- 
cleus accurately some of the processes would have been entirely 
out of focus. Other cells adjacent to the one just described are 
seen to be less deeply stained and the chromatin is seen in the 
form of larger and smaller indistinctly rounded or elongated 
granules. It will thus be seen that there are limitations, and 
serious limitations too, in the use of photomicrographs, es- 
pecially under high powers, in such a study as this. It would 
require several photomicrographs at various planes to bring out 


DEMENTIA PARALYTICA. 643 


‘all the details shown in the single Fig. G, which of course is a 
composite taken by focussing in all planes under a magnification 
of 1,300 diameters, and showing certain, but not all, details of 
the different planes. Of course outlines are not so distinct in 
the real cell as must necessarily be made to appear in a drawing, 
and this latter might be compared to a dissection in which cer- 
tain parts are brought out prominently at the expense of the 
normal appearance of the whole in life. No one would hesitate 
to say, however, that Fig. G gave a much better idea though not 
an exact representation of the cell, than Plate II, Fig. 4, and 
that drawings are essential accompaniments of such plates in 
the full elucidation of a subject of this kind. These cells are 
known as stichocrome nerve cells of the somatochrome class. 
Fig. H shows one of the large pyramidal cells (the largest to be 
seen in the plate) under the same magnification as in Fig. G 
(x 1,300. No. 3 ocular, 1-12 in. oil immersion objective, Leitz). 
The internal structure of the large pyramidal cells is found to be 
made up of distinctly stained chromophilic substance in larger 
and smaller irregular granules, some so fine and closely ar- 
ranged as to completely fill up the cell-body, thus presenting a 
uniform field of closely packed minute granules without any spe- 
cial relation to one another. In other cells the granules are 
coarser and present a somewhat parallel arrangement about the 
nulceus and extending up into the main apical process for some 
distance and also into the basal lateral processes in the same 
general parallel manner. In other pyramidal cells there is a 
fine chromophilic network with larger and smaller aggregations 
of chromatin as nodes or enlargements of the network. In this 
figure the cell-body is pyramidal in shape with rounded contour 
merging above into the large apical dendritic process, which is 
finally lost to view as it enters another plane. Below at the 
base, both to the right and left, are given off several dendritic 
processes, some of which are seen to branch a short distance 
from the cell-body. The large, slightly oval nucleus is centrally 
situated somewhat nearer the base of the cell than the apex, 
and contains a large, eccentrically placed nucleolus, surrounded 
by the pale, slightly strained, for the most part homogenous, 
nuclear protoplasm. Within the cell-body about the nucleus 
and extending into the apical process, and to a less extent into 
the basal dendritic processes, are chromophilic granules of 
rounded or elongated shape, and having a tendency to be ar- 
ranged in groups in places. Especially at the point where a den- 
dritic process is given off is frequently to be found a mass of 
these granules. Often a wedge or cap of chromophilic sub- 
stance is seen at the point where a dendritic process is to be 
given off, as at a, or where a process divides into two branches, 


644 ‘G. ALFRED LAWRENCE. 


as at b, the latter being one of the so-called “wedges of division” 
of Nissl. The granules vary in size and shape and are arranged 
in general in a direction parallel to the long axis of the cell- 
body and of the long axis of the dendritic process when extend- 
ing into the same. About the nucleus they are often arranged 
parallel to its wall. Five dendritic processes are given off from 
the base of this cell, three of which are seen to divide into two 





Plate II, Fig. 5. 


branches each; at b, showing one of the so-called “wedges of 
division” of Nissl, referred to above. Plate II, Fig. 5 is a pho- 
tomicrograph of this same cell indicated by the figure H in 
Plate II, Fig. 3, and already described and shown in Fig. H; 
here under a magnification of 1,400 diameters. The body of 
another somewhat smaller pyramidal cell is seen just behind 
the apical dendritic process of this cell and part of it almost in 


DEMENTIA PARALYTICA. 645 


the same place, so that it is difficult to differentiate the two. It 
will be seen that the nucleus and nucleolus are in good focus, 
but that the basal dendritic processes, excepting at their origin 
from the cell-body, can scarcely be distinguished. The shape of 
the nucleus, size and position of the nucleolus, and arrangement 
of the chromatin within the same is as well shown as in the 
figure. Also the shape and contour of the cell-body. The den- 
dritic processes, however, as mentioned above, are out of the 
plane of focus, so that only a very hazy, indefinite indication 
of the beginning of three of them can be made out. The large 
one at the left can scarcely be determined at all. The more 
central one at the left is faintly outlined, and at the point of bi- 
furcation the so-called ‘“‘wedge of division” of Nissl (B) is seen, 
but the division itself cannot be determined. Of the three pro- 
cesses given off from the base at the right the beginning of the 
one most centrally located can be very faintly seen and a faint 
outline of the other two, appearing as one in the photomicro- 
graph is seen. The apical dendritic process is so merged with 
the body of the cell just below it that it is difficult to determine 
its outline. The cell protoplasm is more differentiated however 
than in the preceding plate (Plate II, Fig. 4). Here chromophi- 
lic bodies are seen at the base on the right where the dendritic 
processes are given off, indicated by A both here and in Fig. H. 
Chromophilic granules are also seen fairly well indicated to 
the right and above the nucleus, in larger and smaller bodies 
without sharp outlines, which is the condition actually found in 
the cell. They are not sharply and definitely outlined as shown 
in Fig. H, which in that respect is not accurate, but merely 
diagrammatic. At the left and below the nucleus in the basal por- 
tion of the cell-body these chromophilic bodies are so closely 
aggregated as to give almost a homogenous dark appearance 
to that portion of the cell, and it is only by carefully focussing 
in various planes that the chromophilic bodies are made out. 
Here again the photomicrograph without the accompanying 
drawing would give one only a partial knowledge of the struc- 
ture of this cell. Cells of this type are to be classified as large 
stichochrome nerve cells of the somatochrome class. Inter- 
spersed among these larger and smaller pyramidal cells in this 
layer are some small irregular and rounded cells consisting of 
a large nucleus containing a nucleolus, and surrounded by a cell- 
body containing in the smaller cells a very narrow rim of 
finely granular chromophilic substance, in some places so nar- 
row as to be scarcely discernible. In other cells the cell-body 
is much more developed surrounding the nucleus and giving off 
several protoplasmic processes which go out in various direc- 
tions. Neuroglia cells similar to those of the first layer are 


646 G. ALFRED LAWRENCE. 


found interspersed among the nerve cells in all parts of the sec- 
tion. Small portions of capillary blood vessels are shown as at 
I in the plate (Plate II, Fig. 3, I) where the vessel is seen to di- 
vide into two branches below, and also at 2 (Plate II, Fig. 3, 2), 
showing a single small capillary extending only for a short dis- 
tance in this plane. The walls are seen to be exceedingly thin, 
made up of a single layer of nucleated cells, and containing red 
blood corpuscles. The walls of these blood vessels stand in 
marked contrast to the thickened and tortuous walled vessels 
found in the cases of dementia paralvtica later to be described. 
Below this is the third, or spindle cell layer about 1.20 mm. in 
thickness in this section. The spindle cells in this layer con- 
tain a large nucleus, with a distinct nucleolus, but no nuclear 
net work could be made out. The nuclei in many of them pre- 
sent the appearance of being too large for the cell-body, so that 
often, as in Fig. I, the cell-body seerns to be bulged out on one 
side to accommodate the large nucleus, giving an eccentric 
form, and resulting in a spindle with one side very promi- 
nent and the opposite side quite flattened. The chromatic sub- 
stance is arranged in no definite network and contains no dis- 
tinct chromophilic bodies, but consists of minute particles close- 
ly aggregated about the nucleus, especially at each pole and 
found in a lesser amount and in variable quantities in the re- 
mainder of the cell-body. In Fig. J the nucleus is situated ec- 
centrically at one end of the cell-body, so that most of the other 
cell contents are at the opposite end with a narrow band of 
closely aggregated chromophilic substance surrounding the nu- 
cleus at both ends. The nucleus in this cell is more elongated 
and oval in shape, with distinct nucleolus and otherwise pale, 
slightly stained contents. Other cells as Fig. K are more or 
less irregular in shape, in this case having the form of an irreg- 
ular inverted pyramid containing a large rounded nucleus near 
the base which is surrounded by a narrow band of dense chro- 
matic substance. About this is an irregular chromatic network 
containing nodal thickenings at some points. The nucleus con- 
tains a distinct nucleolus, but otherwise pale and but slightly 
stained contents. A large dendritic process is seen given off 
below and two dendritic process go off from the base and to one 
side. Fig. L shows another irregular shaped cell with a den- 
dritic process given off from one side in addition to those from 
each end. The large oval nucleus with distinct nucleolus and 
otherwise pale contents is centrally placed. Considerable chro- 
matic substance is seen in the larger cell-body with distinct. 
granules, forming an indistinct network at the point where the 
lateral dendritic process is given off, on the opposite side and 
also in the cell-body and at the base of each of the vertical pro- 


DEMENTIA PARALYTICA. 647 


cesses. Plate III, Fig. 6, is a photomicrograph, at a magnifi- 
cation of 1,400 diameters, of a group of the spindle and irregu- 
lar cells indicated by the letter ! in Plate II, Fig. 3. 

As will be noted, almost ali the forms shown in the above 
described figures are to be seen here. The cell lettered I, is 
similar in shape and structure to that of Fig. I, including the 
bulging out of the nucleus to one side, and showing an aggre- 
gation of chromatic substance in the form of a nuclear cap at 
both poles of the nucleus. An irregular network of chromatin 





Plate ILI, Fig. 6, 


is seen within the nucleus surrounding the nucleolus. But little 
chromatic substance, in addition to the two nuclear caps above 
described, is to be seen in the small cell-body. Again the cell 
indicated by the letter J is very similar to that seen in Fig. J, 
the nucleus being at one end of the cell-body near the base of 
that polar dendrite. The nucleolus is situated at the lower por- 
tion and to the left in the nucleus and with but little faintly 
stained chromatic substance surrounding it. About the nucleus 
in the cell-body and extending into both dendritic processes is 
to be seen considerable chromatic substance arranged in an 
indefinite network. The cell lettered K is irregularly pyramidal 


648 G. ALFRED LAWRENCE. 


in shape, approximating to that seen in Fig. K. The nucleus 
is very large and almost entirely fills up the cell-body. The 
nucleolus has the appearance of being without the nucleus, but 
is within the same adjacent to the wall at this point. A small 
amount of chromatin is seen in the lower part of the nucleus, 
otherwise it is for the most part pale. A process is seen given 
off above as the apical dendrite at the base of which are some 
few chromophilic granules. 

Two basal dendritic processes are given off, one to the right 
and projecting almost vertically downward, and the other to 
the left and almost horizontal in direction. At the base of these 
processes, especially the one to the left, are seen well marked 
chromophilic granules. Otherwise the cell-body is practically 
entirely taken up by the nucleus. The cell indicated by the let- 
ter L is somewhat similar to that of Fig. L in regard to having 
two polar dendritic processes, one of which coming off laterally 
here on the left side and only faintly indicated, being in a lower 
plane. The nucleus here also is seen to occupy the greater por- 
tion of the cell-body, the nucleolus being crowded over almost 
to the edge of the same. The nucleus contains only a slight 
amount of chromatic substance in its upper portion. Nuclear 
caps are seen above and below the nucleus in the cell-body, the 
one above being the larger, and surrounded by some small 
chromophilic bodies extending up into the dendritic process. A 
very slight amount of very palely colored chromatic substance is 
seen below the nuclear cap in the lower dendritic process. The 
lateral dendrite when seen in focus is found to contain a slight 
amount of chromatic substance more abundant at the base. The 
cell lettered M is regularly spindle in shape with two polar den- 
dritic processes, the lower one not in the plane of focus, and 
the upper one only partially so, and there are no lateral pro- 
cesses. The nucleus is not in distinct focus, so that its outline 
is indistinct. The nucleolus is seen at the lower part of the nu- 
cleus, and to the left side surrounded by a rather pale indefinite 
chromatic network. Below this is seen some dense chromatic 
substance in the form of a nuclear cap. The nucleus really oc- 
cupies almost the entire body of this cell extending from the 
dark mass below which has the form of an irregular nuclear cap, 
to the base of the upper dendritic process where there is a 
smaller nuclear cap of chromatic substance. A small amount 
of protoplasm above and below the nucleus in the cell-body 
extends for a short distance into the dendritic process from 
these nuclear caps. The other cells seen in this plate are sim- 
ilar in appearance and structure to those already described. 

(Plate illustrations referred to and not found will appear in the No- 


vember issue. ) 
(To be continued.) 


Periscope. 





NOUVELLE ICONOGRAPHIE DE LA SALPETRIERE 
(Vol. 16, 1903, No. 1, January-February. ) 


. Chronic Hypertrophic Acrocyanosis. M. Pénu. 
. A Case of Progressive Facial Hemiatrophy. CALMeTtTe and PacEs. 
3. Acquired and Progressive Chronic Trophoedema. J. Sricarp and Laic- 
NEL-LAVASTINE. 

4. A Case of Macrodactylia. F. Lejras. 

5. Macrodactylia. CayLa. 

6. In Regard to the So-Called Sense of Position. CLAPAREDE. 

7. Les Urologues. HENry MEIGE. 

8. A ‘Note Upon Three Designs of Jordens. JEAN HEITZz. 

1. Chronic Hypertrophic Acrocyanosis.—The pathology of the extremi- 
ties, acropathology, is yet a limited field in medicine. The types at present 
known are Raynaud’s Disease, L’Osteoarthropathie hypertrophiant pneu- 
monique of P. Marie, and Acroparesthesia of Schultz. The characteristics 
of these processes are the localization and the sensory vasomotor or trophic 
type of the symptoms. It is not always possible to differentiate sharply 
each variety from the others on account of their complexity. In addition 
to Raynaud’s disease, there are three main types in which asphyxia is con- 
stant and chronic; they are acrocyanosis with sensory symptoms, with 
atrophy, and with increase in the volume of the soft parts. The author of 
this paper, after giving a literature resumé of cases previously described, 
gives one of his own which evidently belongs to the third class. Case.— 
Young man, twenty-five years of age, neuropathic history, alcoholic, tuber- 
culous, presented during a period of ten years’ intermittent attacks of 
cyanosis of hands and feet. The asphyxia became in time permanent, and 
was accompanied by pain so severe that he had to give up his daily work. 
In addition, the hands increased in volume without any corresponding 
lesion of the bone (radiograph). There were never any sensory disturb- 
ances and no attacks of local syncope. The following were considered in 
the differential diagnosis: L’osteoarthrop hypertrophiant pneumonique of 
P. Marie, acromegaly, acroparesthesia, erythromalalgia, and Raynaud’s 
disease. 

2. Facial Hemiatrophy.—A case of progressive facial hemiatrophy in 
a young girl, fifteen years old. There are ewo theories to account for this 
disease: First, primary atrophy of the subcutaneous tissue; second, a lesion 
in the facial nerve, sympathetic, or the trigeminal, the so-called nervous 
theory. Brissaud’s theory seems more reasonable. “In the presence of a 
hemilateral affection, involving the seventh, fifth and twelfth nerves, it is 
natural to think of a lesion in the cerebrospinal axis. “This paper is illus- 
trated by some remarkable photographs. 

3. Chronic Trophedema.—A classification of edemata based upon the 
evolution of the symptoms, and not upon the etiology or pathogenesis, 
seems with our present knowledge the most simple and effective. Henry 
Meige, in a series of studies, has described a type to which he has given 
the name of chronic trophoedema. The following divisions and subdivi- 
sions are at present recognized: 1. Acute Edemata: (a) infectious, 
(b) neuropathic; 2. Hysterical Edemata; 3. Chronic Edemata: (a) de- 
pending upon various chronic diseases of the heart, lungs, nervous sys- 
tem, etc.; (b) chronic edema of elephantiasis; (c) tropho-edema (Meige). 
This paper is based upon a case of chronic acquired tropho-edema. Girl, 


tN) a 


650 7 POD PRRISCOPE: 


twenty-seven years of age, neuropathic heredity; as a result of a trauma of 
the left foot a painful edema appeared, localized at the site and a little 
above the contused region. This edema was at first transient, but gradu- 
ally became permanent, and progressively involved the leg, thigh, buttocks, 
of the same side. Process was a slow one, taking in all two years. 

4. Macrodactyly.—A case of local gigantism in a child thirteen years 
old. The median finger of the left hand was enormously enlarged. There 
was no hereditary history. This finger measured 15 cc. in length, 12 cc. in 
circumference in the middle of the first phalanx; finger was amputated. 
‘The article is illustrated by radiographs and photographs. 

5. Macrodactyly.—A further case of macrodactylia in a boy seventeen 
years old. 

6. Sense of Position.—A discussion of Bonnier’s paper on the sense of 
position, which appeared in No. 2, 1902, of this Journal. (Not adapted to 
abstract. ) 

7, 8. Historical and literary notes on medicine in art. 

ScHwas (St. Louis). 


(Vol. 16, 1903, No. 2, March-April.) 


1. Syringomyelia; Arthopathy of the Shoulder (Muscular Atrophy and 
Thermoanalgesia of a Transverse Type). E. Brissaup and 
BRUANDET. 


2. An Old Lesion of the Red Nucleus. Secondary Degeneration. PIERRE 
Marie and GEorGES GUILLAIN. 

3. A Case of Late Hereditary Syphilis of a Cerebrospinal Form. RiIcHon. 

4. A Case of Symmetrical Sclerosis of the Occipital Lobe. L. MARCHAND. 

5. A Case of Progressive Myopathic Atrophy, with Sensory Symptoms. 
M. LANNots and A. PAROT. 

6. Enormous Deformity of the Right Tibia (Forreau de Sabre) in a 
Tabetic. -J. SABRAZES. 

7. A Case of Phocomelia and Hemimelia. P. HALsron. 

8. Some Examples of Edemata in Art. HENrt MEIGE. 


t. Syringomyelia —Man, forty-nine years, with tuberculosis,.of the 
lungs and a scapulo-humeral articulation very much deformed and aug- 
mented in volume. The diagnosis of syringomyelia was based upon the 
arthropathy, muscular progressive atrophy of the left upper extremity, and 
a dissociation of sensibility localized in both arms. The man died of tuber- 
culosis. Microscopical examination of the cord showed typical appear- 
ances of syringomyelia. The shoulder joint showed trophic changes of a 
very interesting nature. The articular capsule had disappeared together 
with the ligaments. The long head of the biceps was absorbed; its inser- 
tion in the glenoid cavity could not be recognized. Villous vegetations filled 
the joint. In the muscles of the subscapular, supra, and infraspinous 
regions ossiform nodules could be demonstrated. 

2. Lesion of Red Nucleus.—An old lesion found in the red nucleus and 
causing secondary degeneration of various nerve tracts gave the subject 
matter of this paper. On account of the rarity and limitation of the lesion, 
a study of sections above and below it seemed to promise interesting re- 
sults. The subject of this study had infantile cerebral palsy, from which a 
left hemiplegia remained. At the age of twenty-seven years he became in- 
fected with syphilis, death occurred at forty-nine, with progressive demen- 
tia. No cortical or meningeal lesions could be demonstrated. On the left 
side, exactly in the red nucleus, a lesion was found. It was either an old 
tubercle, which had passed into the sclerotic state, or an old limited focus 
of softening. Posteriorly and anteriorly to the red nucleus the structures 
are normal, showing the sharp limitation of the lesion. It could be com- 
pared in fact to a veritable experimental destruction of the red nucleus. 


PERISCOPE. 651 


Cross sections above and below the lesion showed very interesting fiber 
degenerations, the most important of which are degeneration of the cerebel- 
lar peduncle, the central tract of the calotte, and the posterior longitudinal 
bundle. Very excellent plates illustrate the article. 

3. Tardy Syphilis—This is a very careful histological study of a case 
of tardy congenital ‘syphilis in which the lesions were localized chiefly in 
the cerebrospinal system. The etiological diagnosis could only be made 
from a study of the lesions. Boy, age eleven years, without visible lesions 
or stigmata of inherited syphilis. Fistulous lesion of the parietal bone ac- 
companied by Jacksonian epilepsy. Unsuccessful surgical intervention. 
Persistence of the epileptiform convulsions, accompanied by hemiplegia, 
with contracture. Progressive decline in intellect, deafness, blindness. 
Cachexia and terminal tuberculous infection. Autopsy: Fibrous meningo- 
encephalitis, basal gummatous meningitis, cavity formation in the cerebel- 
lum, infiltration of spinal meninges. Examination of the skull showed 
evidences of an extension of the fibrous encephalitis into the bony sub- 
stance. The evolution of this condition is thus summarized: The brain 
already structurally deformed, with probably a certain degree of hydro- 
cephalus, a condition not rare in congenital syphilis, became the seat of a 
gummatous neoplasm. A gumma arising from the periosteum, or osseous 
tissue, perforated the inner table and attacked subjacent tissue, producing 
adhesions. The meningeal encephalitis developed slowly at first and led 
to a sclerosis of the hemispheres, causing the symptoms of cortical irrita- 
iton, that is the epilepsy, and later the hemiplegia. The lesions then be- 
came more diffuse, extended to the cord, the base of the brain and to the 
white matter of the cerebellum. The specific nature of these lesions is very 
evident on account of the evolution of the process and their anatomical 
character, as well as by the existence of a veritable syphilitic stigma in the 
cerebral malformation. 

4. Sclerosis of Occipital Lobe.-—This case is interesting not only be- 
cause it confirms the previous work on visual localization, but because it 
determines the group of symptoms which follow a symmetrical sclerosis of 
the occipital lobe. The slow course of the disease, and the definite lesion 
leading to a complete destruction of the occipital lobe add particularly to 
the interest of the case. Girl, nineteen years old; epilepsy; almost complete 
blindness; central vision for light alone remains, but the patient cannot 
recognize objects. The eyes are normal. Patient died in status epilepticus. 
Autopsy: The external and internal surfaces of both occipital lobes are 
covered by a membrane penetrating into the cerebral substance. The pia 
mater is adherent. The convolutions are much atrophied. The internal 
surface presents the same appearance. Microscopical examination shows 
sclerosis with numerous foci of softening and a great increase in neuroglia. 
The preservation of a visual field to light around the point of fixation in 
this case is of great interest, and seems to uphold the theory of V. Mona- 
kow, to the effect that the fibers corresponding to the macula are distributed — 
in the whole extent of the cortical field of vision. 

5. Myopathic Atrophy.—The distinction between muscular atrophy of 
myopathic and nervous origin is gradually being given up, and an inter- 
mediate variety, which includes many irregular forms, is being substituted. 
Various transitional types belong here. Such a one forms the subject of 
this paper. Clinical résumé: Man, thirty-eight years old; no family 
disease; neuropathic heredity; traumatism at seven years; first appearance 
of symptoms at ten years by lancinating pain and paresis of the muscles. 
Slow progressive development with a persistence of the pain and pseudo- 
hypertrophy of the lower extremities; muscular atrophy in all four ex- 
tremities, symmetrical in respect to nerve root distribution and almost total 
in respect to segmental distribution; face not involved. | Pseudo-hyper- 


652 PERISCOPE. 


trophy of lower extremities, tendon contractures, abolition of tendon re- 
flexes; almost complete disappearance of electric excitability, subjective and 
objective sensory disturbances. 

6. Tabetic Arthropathy.—Cases of tabes with evidence of syphilis other 
than the metasyphilitic nervous lesions, are always of great interest. A 
number of cases belonging to this variety are increasing rapidly. The case 
here described is that of a man, forty years old, symptoms of tabes appear- 
ing at thirty-eight, as follows: Gastric crises, ocular symptoms, diplopia, 
Argyl-Robertson pupil, abolition of knee reflex. No history of acquired 
syphilis. Evidence of hereditary syphilis is present in the characteristic 


dental malformation and in a sword-like deformity of the right tibia (En’° 


Fourreau de Sabre). ‘The character of the tabes in this case is very simi- 
lar to that which is found in infantile tabes depending upon hereditary 
syphilis. 

7. Phocomelus.—Description and photograph of a case of Phocomelia 
and Hemimelia. 

8. An Art Study. SCHWAB. 


JOURNAL DE NEUROLOGIE 
(1903, VIII, No. 5.) 
The Differential Diagnosis of Epilepsy. KowALevsky. 
2. Incipient Tabes. Dr Buck. 


1. Epilepsy—In a very complete review, the author compares the 
symptoms of epilepsy with those of apoplexy, hysteria, eclampsia and con- 


vulsions from other sources, the paretic seizure and vertigoes. Sketching, 


the characteristics of epileptic psychical disturbances, he gives the chief 
points distinguishing them from acute mental symptoms due to other 
causes. He then considers the characteristics from a diagnostic and prog- 
nostic point of view, of epilepsies of different kinds with the special indi- 
cations for their treatment. Of particular interest are his remarks on epi- 
lepsy of syphilitic origin. 

2. Incipient Tabes.—The author exhibited at a meeting of the Belgian 
Neurological Society, the case of a man of thirty-one years, without alco- 
holic or syphilitic history, but acknowledging abusus Veneri, who pre- 
sented the following symptoms: Fatigue in walking, slight dragging of the 
feet, with dysesthetic sensations in the lower limbs, slight diminution of 
the pain sense in the area of distribution of the second sacral segment, 
slight ataxia and Romberg, exaggeration of the patellar and arm reflexes, 
loss of the plantar, Achilles tendon, cremasteric and pharyngeal reflexes. 
His pupils reacted to light and accommodation. No change in the elec- 
tric reactions, sphincters normal, constant genital irritation with tendency 
to priapism. The diagnosis of incipient tabes he bases upon the sensory 
troubles, and especially upon the loss of the Achilles tendon reflex, and 
quotes a number of authorities in support of this view of the case. 

ALLEN (Trenton). 


(Vol. 8, 1903, No. 6, March 20.) 


1. Tuberculous Polyneuritis with Exaggeration of the Tendon Reflex in 
the Rabbit. D. Dr Buck. 
2. Infantile Cerebral Palsy. BaAsTIN. 
AAANG ODE, DUCK. 
1. Tuberculous Polyneuritis. It is well known that in multiple neuritis, 
the tendon reflexes are occasionally found to be exaggerated. This has 


been accounted for in three ways: (1) As due to increased irritability of - 


the centripetal fibers (the nerve not being totally degenerated); (2) as 
due to increased irritability of the muscular fibers, and (3) as due to the 


PERISCOPE. 653 


action of the poison of the disease upon the nerve cells in the cord, in- 
creasing their irritability. The author, after reviewing briefly these tneories, 
as put forward by different writers, describes his findings in the case of a 
rabbit affected with neuritis in the posterior extremities, in the course of a 
general tuberculosis, in which the tendon reflexes were exaggerated. The 
muscles of the affected limbs were practically normal, the nerves showed 
marked parenchymatous neuritis, and there was diffuse degeneration of 
the columns of the cord. The cells of the anterior horns, and of the spinal 
ganglia, on the contrary, were normal. These findings seem to dispose of 
the muscular theory, and to give little support to that of cell irritation, but 
point rather to increased irritability of the nerve fibers as a cause of the 
symptom. However, the author thinks that the question as to the cutting 
off of inhibition by the severing of the paths from the superior to the in- 
ferior nerve centers, is to be considered, on account of the degeneration 
found in the pyramidal tracts. 

2. Infantile Cerebral Palsy.—A case, history and demonstration, bring- 
ing out nothing specially new. 

3. Note on Case of Tic.—The demonstration of a case of involuntary 
movements of the facial neck and shoulder muscles. The author diagnoses 
the case as one of tic, and in connection with it discusses the pathogeny of 
this disease and of the allied conditions of myoclonus, chorea and athetosis. 
He seeks to explain the difference between true tic and the other conditions 
in question in the existence of two sets of cortico-spinal fibers, the pyrami- 
dal, or direct, and the extrapyramidal, or cortico-mesencephale-spinal. In 
true tic (or mental tic, as he calls it) the impulse passes from the psycho- 
motor region of the cortex by the direct way. In other involuntary move- 
ments, on the contrary, it passes down by the extra-pyramidal tracts, or 
depends upon a reflex irritation radiating from the spinal cord. The author 
some years ago formulated the theory that the localization of the irritation 
giving rise to “clonic involuntary hyperkinesias” should be found in the 
basal ganglia or in the extrapyramidal motor fibers descending from them. 
Proof of the correctness of this has, in the meantime, been accumulating, 
he thinks, and he refers in this connection to the papers of Redlich, Probst, 
Rothman, Sorgo, and others, who have studied the results of lesions in this 
region. 

(Vol. 8, 1903, No. 7, April 5.) 


1. Circular Insanity and the Circular Forms of Psychoses. S. Souk. 
HANOFF and P. GANOUCHKINE (also see Arch. de Neurologie, 
May, 1903). 

2. Medical Graphology. Mure. D. PEPPEE. 

1. Circular Insanity—The author gives the results of a study of 86 
cases of circular insanity from the Moscow Psychiatric Clinic, and draw 
the following conclusions. This form of insanity is nearly three times more 
frequent in women than in men; it constitutes 1.94 per cent of all the cases 
(4,434) received. It is twice as frequent as mania, and only one-third as 
common as melancholia. In its etiology, heredity is quite as important as 
in mania, in which it was found to play a roéle in 84 per cent of all cases. 
Two-thirds of all cases of circular insanity begin between the ages of six- 
teen and twenty-five years. In the majority of cases the disease is ushered 
in by depression. They then take up the question of the occurrence of 
psychoses in circular forms, and narrate some interesting cases, in some 
of which the disease, though showing alternating phases, was evidently due 
to organic changes in the brain. 

2. Medical Graphology.—A discussion, from a diagnostic point of view, 
of the characteristics of handwriting. The author, a handwriting expert, 
makes certain suggestions as to conclusions as to character and state of 


654 PERISCOPE. 


mind of an individual which may be drawn from a study of his or her 
handwriting. 
(Vol. 8, 1903, No. 8, April 20.) 


1. The Patellar Reflex in Neuroses. L. SCHNYDER. 
2. Dolorific Assymetry. J. loreyko and M. STEPHANOWSKA. 

1. Patellar Reflex.—The author calls attention to the extreme difficulty 
in securing relaxation of the limb when examining the condition of the 
patellar reflex in nervous subjects, the patients usually seeming unable to 
keep from contracting either the extensor or the flexor muscle of the leg. 
He regards this as constituting a symptom of some value as indicating 
nervous irritability, and compares its method of production with that of 
the muscular rigidity found in myotonia congenita, in catalepsy, and the 
negativism of certain mental diseases, and in hysterical contraction. To 
illustrate his views he gives short clinical histories of ten patients suffering 
from neurasthenic, hysterical and mild mental symptoms, in whom this 
phenomenon was present. 

2. Dolorific Assymetry.—It has long been known that there is a differ- 
ence in general sensibility upon the two sides of the body, greater upon 
the right in right-handed persons, and upon the left in left-handed ones. 
Van Biervliet has shown that the proportion is usually as 10 to 9. Starting 
out from the above facts, and from the researches of Goldscheider and Von 
Frey, which seem to show proof that there are special nerve fibers, respec- 
tively for pressure, for pain, and for temperature sense, the authors carried 
on a series of experiments with a view of ascertaining if there is any differ- 
ence in the acuteness of the pain sense upon the two sides. In their measure- 
ments they made use of the algesimeter of Chéron. Their experiments were 
performed upon 52 subjects, mainly university students, fourteen of this 
number being left-handed. The points chosen for pricking by the instru- 
ment were exactly symmetrical areas on the anterior surfaces of each fore- 
arm, just above the wrist. The following are the results obtained: Two of 
the subjects were practically insensible to pain. Of the remaining fifty, three 
persons showed greater sensitiveness upon the right side, but in two of these 
even, the result was doubtful. All of the remaining forty-seven showed 
greater sensibility to pain upon the left side, both right-handed and left- 
handed persons being included in the number. Taking the average of the 
elgesimeter readings for all of these, the sensibility of the two sides was 
found to be as 10 to 9 in favor of the left, conforming to the figures of Van 
Biervliet. Experimenting upon other regions (the finger tips, back of the 
hand, temples), the authors still found sharper pain sense in these cases 
always on the left. They make no attempt to explain the cause of the 
difference. C. L.- Auten, Trenton. 


PSYCHIATRISCHE, NEUROLOGISCHE, WOCHENSCHRIFT 
(Vol. 4, 1903, No. 48.) 

The Treatment of Epilepsy According to the Toulouse-Richet Method. 
—Halmi and Bagarus. Fifteen cases of epilepsy which had been under 
observation in the hospital for some time were selected for the investi- 
gation. For ten months these patients were treated with 3-5 gms. of bro- 
mide daily, then followe@ two months without any medicinal treatment, 
at the end of which time the Toulouse-Richet method of treatment was 
applied for one month. During the first half of this period 3 gms. of bro- 
mide were given, when the dosage was reduced to 1.5 gms.; diet consisting 
of 2 litres of milk, 2 eggs, and for the men 750 gms., for the women 500 
gms. of salted bread. Following this period of treatment they returned to 
the simple bromide treatment. In view of the great variation in the number 
of attacks monthly during treatment with simple bromides—in one case 


PERISCOPE. 655 


19-31, in another 3-104 attacks, it would seem manifestly unfair to accredit 
a cure unless there was improvement in a large majority of the cases. 
Furthermore, in the nine months without change of treatment, nine cases 
showed spontaneous improvement. During the two months when the 
bromides were withdrawn the attacks increased in seven and diminished in 
three cases, and two patients died, but the total number of attacks fell to 
273, or nearly one half of the total number in the two months when the 
bromides were withdrawn. Still, during six of the ten months in which 
the simple bromides were given, the total number of attacks was less than 
during the test month. Furthermore, a close study of the individual cases 
which seemed most improved reveals the fact that just as great improve- 
ment had previously occurred during the treatment with the simple bro- 
mides. In the final period of seven months the total number of attacks in 
the thirteen remaining cases rose to 324, but later fell to 2109, in spite cf 
the fact that the bromides were entirely withdrawn in five cases. Besides 
this doubtful effect in the number of the convulsions, this method of treat- 
ment had an appreciable sedative influence upon all psychical processes. The 
patients were less restless and exhibited a retardation which, in some cases. 
almost reached genuine stupor. In two cases it produced a fatal intoxica- 
tion. In conclusion, the Toulouse-Richet method neither cures nor benefits, 
and greatly enhances the danger of bromism. 
GV.OlaNG  1O03e NOvain) 

The author (Waltenberg), after citing the theoretical and practical 
reasons for the abolishment of the “isolation cell’? in the treatment of 
maniacal patients, presents the results accomplished during the past six 
years (1896-1902) at Lubeck, by the substitution of the constant watch, and 
the prolonged bath. He observes that during this period a greater degree 
of quiet prevailed, and there was a proportionate less demand for narcotics. 
The plotted curves accompanying his paper show the gradual fall of the 
percentage of women reported restless at night (11.3 per cent to 3.2 per 
cent), and a similar fall in the use of narcotics (3.6 per cent to I.2 per cent). 

(Vol. 5, 1902, No. 2.) 

The Prognosis and Therapy of Intemperance. SAUERMANN-BONN. 

The author calls attention to the increasing prominence of institutions 
for the treatment of inebriates, the reports of which record from 15-80 of 
recoveries, to the prominent role played by the “after treatment” in the 
third conference of the German inebriate institutions, and cites the method 
instituted at the Swiss Institution Ellikon by the establishment of a society 
of discharged patients for the purpose of mutual aid in maintaining absti- 
nence. Their results are 70 per cent of recoveries from 1896-1900. His 
statistics relative to the prognosis are based upon 246 replies from members 
of the Red Cross Abstinence Society. He concludes (1) that recovery 
from alcoholic intemperance is synonymous with prolonged abstinence; 
(2) the frequency of defective heredity and a psychopathic constitution has 
led to the belief that a large number of alcoholics are incurable. The real 
basis for this belief lies in a lessened resistance to the action of alcohol; 
the drink custom and other accompanying influences only give opportunity. 
The patient cannot be cured of hereditary intolerance, he can only be freed 
from alcohol. Recovery from acquired intolerance is possible. (3) The 
necessity of prolonged abstinence and the great tendency to relapse demands 
prolonged attention after dismissed from treatment. (4) Secret abstinence 
societies are well adapted to exercise this extended cure. They not only 
prevent but lessen the danger of relapse. (5) Temperance abstinence 
societies should affiliate with public institutions for the treatment of alco- 
holics. (6) The fact that abstinence can be secured without institutional 
treatment will make it possible in many cases to shorten the time of treat- 
ment now prescribed (from six to twelve months). In spite of these re~ 


656 PERISCOPE. 


‘ 


sults he believes that in the majority of cases institutional treatment is 
necessary. In this treatment, employment of the patients is essential for 
their betterment, and conduces to economy in their support at the institu- 
tion. DerenpborF (Middleton, Conn.). 


ARCHIVES DE NEUROLOGIE 
(Vol .XV, 1903, No. 88, April.) 

1. Historical and Critical. Physio-psychology of Women in Religious 
Orders; the Nuns of Port Royal (Fifth Series of Five Obser- 
vations). CHARLES BINET-SANGLE. 

2. Upon Some Clinical Particularities of Facial Neuralgia and Its Treat- 
ment by Electricity. A. ZIMMERN. 

3. Fibromatose and General Paralysis. Dr. A. CULLERRE. 

1. Women in Religious Orders, ctc.—Vhe author presents an interest- 
ing study (to be continued) of the lives and mental and physical experiences 
of three nuns of the famous convent of Port Royal, since destroyed (near 
Paris, France). The facts are obtained from various historical, biographi- 
cal and statistical works cited by the author, and the study carries us back 
to the year 1661, the time of the Jansenist controversy, when the nuns, upon 
pain of dismissal to other and, in the Catholic sense, orthodox communi- 
ties, were required to sign a “formulary” condemning certain five proposi- 
tions contained in Jansen’s treatise upon the theology of St. Augustine. 
When we consider that the propositions were upon such subjects as Free 
Will, Divine Grace and Predestination, we cannot wonder that the sisters, 
who had sought rest for their souls behind the convent veil, should have 
been driven into torment of mind, when compelled to decide whether they 
were bound in conscience by the decision of the church on those subjects, 
while in their own understanding, they held different views. Under stress, 
some would sign, and thereupon be seized with mental torture, dreading the 
fate promised to liars and hypocrites. Mind acted on body and aggravated 
physical maladies. The author, after stating at much length the story of fif- 
teen years of bodily illness and of occasional moral suffering, in the life of 
the nun Margarite Dupré, and relating particularly an account given of her 
entire relief, in answer to a special prayer, from all her bodily illness for 
three months, makes the following summary of her case. 

Character.—Haughty and of a “nature prompt and lively,” she bacame 
under the influence of religious suggestions, reserved, quiet and humble. 
She called herself “a poor ignorant’? and busied herself with labors to the 
most lowly. 

Sadness.—She exhibited a predisposition to sadness. In 1661, dysen- 
tery declared itself upon an occasion of mental distress. In 1662 her ab- 
scesses of the liver were accompanied “with great spiritual suffering.’ In 
1664, during her exile to the “Anonciades of S t.Denis,” the news that cer- 
tain nuns of Port Royal had signed the formulary plunged her into dejec- 
tion. Herself urged by the archbishop of Paris to surrender, “she passed 
five days in weeping, in despair of her condition, distracted between the fear 
of offending God in signing and having always to suffer for not signing,” 
“in pain and transported with agony.” She finished by submitting and 
gained only new disquietude. The day of her return to Port Royal, she 
remained in a corner of the church “praying and weeping.” At that time 
“she slept little at night.’ Finally, being convinced that the signature was 
a wrong act, she accused herself of her fault “in terms most humble and 
most touching and with great abundance of tears.” “From that moment 
she felt the greatest joy that she had ever experienced, mingled with heart- 
felt grief for her sin.” She continued to deplore it and had frightful re- 
morse on account of it. 

Suggestibility.—She said ad propos of the pseudo miraculous, as the 


’ 


PERISCOPE 657 


author calls it, remission of her illness: “I have not only received that grace 
by the intercession of our dear mother, the deceased abbess Mother An- 
gelique, but also some other grace, very secret and very considerable, that I 
am not able to publish; and I can give assurance that I am never inspired 
to demand anything of God that I do not obtain it, by her intercession.” 
This gives the measure of her suggestibility. She had made her pro- 
fession at a convent of the Congregation of Notre-Dame in Flanders, when 
“at the end of two years the 18 December, 1651, she was received at Port 
Royal, without dot.” There she receives the suggestions of Antomé Sin- 
glier, director of the nuns and of the abbess Jacqueline Arnaued, who, says 
she, “takes possession of my heart.’ Having refused to sign the antijan- 
senist formulary of 1661, she was in 1664 exiled to the Annonciade of Saint- 
Denis. Here she made nine novines daily. In the first months, she gloried 
in her resistance, but at the end of ten months of captivity, “she allowed her- 
self to be so carried away by considerations of blind obedience to her su- 
perior, that forgetting everything else, she signed the formulary purely and 
simply under the direction of M. de Pérefixe,’ and she did it “with great 
uneasiness of mind.” ‘She was then ill and feared to die in criminal dis- 
obedience.” “She signed also the new formulary by the mandate of the 
archbishop.” Returned to Port Royal and again submissive to Jansenist 
suggestion, she retracted her signature and refused to sign the formulary 
of 1665. Besides, wishing to multiply the proof of her repentance, she 
made several copies of her retraction, which she cast from the windows 
and underneath the walls of the monastery, at that time blockaded. She 
died at Port Royal in 1666. As to the supposed miraculous answer to 
prayer, the author considers it either merely a coincidence or that it was 
produced by “auto-suggestion.”’ 

The second observation is upon the case of the nun, Anne-Marie de 
Flécelles de Brégy, who was a relative of Cardinal de Retz. She had a 
strength of character which nothing could move. “I am seized,” she writes 
in 1664, when of the age of thirty-one years, “with a certain fear, that I 
have not enough of fear.” And a propos of the nuns, who had signed the 
antijansenist formulary, it has put me in such a trembling and terrible fear 
lest God should abandon me, that I have instantly supplicated him for 
grac eto cling to him and to suffer all my life humiliations, afflictions and 
maladies of every sort to obtain the help of his grace and the gift of per- 
severance never to abandon the truth.” “Why shall I not tremble? Why 
shall I not fear, when we see those fall, by whom one expected the salva- 
tion of Israel—It is a sorrow the most affecting in the world.” 


She was exiled to the Ursulines of Saint Denis, but returned the next 
year and signed with her blood a declaration that she persisted in her re- 
fusal to sign and disavowed all that she should be made to do in her last 
illness. She resisted to the end, dying at the age of fifty-one. 

The third observation is similar in character. The author’s conclusions 
are to follow in later number. 


2. Treatment of Facial Neuralgia.—This is the conclusion of a pre- 
vious contribution, relating to the department of Electrotherapy in the 
Charcot Clinic. The author finds it difficult to explain that certain mono- 
graphies no longer insist upon the electrical treatment of facial neuralgia 
and that others pass it by in entire silence. Does not, he says, Gilles de la 
Tourette affirm that if medical means fail, there still remains surgical treat- 
ment, treatment full of dangers and chances, but outside of which there is 
nothing to try? Does not Mauclaire also say that when medical means 
have been utilized without success, the physician “ought to give place to the 
surgeon,” and does not this author counsel to operate at once and without 
waiting, under the pretext that to wait is to give the nevrite ascendency and 
to the encephalic lesions time to evolve? And he adds: “Although the re- 


658 PERISCOPE. 


sult should not be perfect (Trousseau affirms that he has never seen a 
complete cure of tic douloureaux of the face), we can say with Monod that 
one year of well being in the course of an affection which imposes veritable 
torture constitutes a benefit appreciated by the patient, so much more, as 
the intervention is free from dangers (nevrectomy).” The author, con- 
trary to this opinion, will not admit that after a conscientious trial of 
medical methods, the physician effaces himself without hesitation before the 
surgeon. A place, an important place, he says, should be reserved for elec- 
tric treatment, which, in all cases, we should have interest to attempt be- 
fore dreaming of a surgical intervention, however light. The author men- 
tions the various surgical methods and gives some statistics of the great 
danger of a fatal result in gasserectomy, and in view of the benefit to pa- 
tient shown in some fifteen cases that he reports at-length, he states that 
he thinks that “course to pursue’ should be the following: 


(1) In cases of neuralgia, with well determined etiology, we should 
have recourse to their specific treatment. (2) In neuralgias of a mild type, 
we should commence by resorting at first to the usual medications, free to 
recur in case of insuccess to electricity, which will bring about almost cer- 
tainly a complete cure. (3) In neuralgias of a grave type, after one 
has established the inefficacy of medical treatments, administered in a 
methodical fashion (among them opiatic treatment) we should submit the 
patient to electrization, during a time sufficiently long to judge of the ef- 
fects obtained (minimum three months) and we should not decide to em- 
ploy a surgical intervention, except in case of absolute insuccess. In last 
analysis a peripheric operation might be tried (névrectomy). But it is only 
in despair of the case (en désespoir le cause) and before the formal de- 
mand of the patient or the positive threat of suicide, that we should re- 
solve to propose gasserectomy. 


3. Fibromatosis and General Paralysis.—The author, in presenting the 
case of a woman afflicted with dermofibromatose, and of whose desperate 
condition he gives a photograph, asks: Is the affection, known under the 
name of the Malady of Recklinghausen always congenital? Is it due to 
an anatomic alteration of the nervous system? It is not yet incontestably 
established. Still we understand that the authors admit that, in subjects 
affiicted with this malady, there exists a certain congenital feebleness of the 
mervous system, which places them in a category apart from degenerates. 
Upon this point, the case we present and which, believe us, offers a case 
hitherto unique of general paralysis in a woman afflicted with congenital 
and probably hereditary dermofibromatose, may have a certain interest. 
The patient was a woman, aged forty-seven, a street vendor, married and 
with one child; admitted to the hospital in April, 1901; chronic alcoholism, 
dementia, impulsion to suicide, vague idea of wealth and afflicted with gen- 
eralized fibromatose of the entire external tegument The back from the 
neck to the sacrum is literally covered; upon a foundation of little sessile 
fibromes are attached numerous soft excrescences with large pedicule, par- 
ticularly in the median region. The patient affirms that “she had that from 
birth,’ and that her mother was afflicted with similar tumors. June 1 she 
was attacked with erysipelas of the face, following an excoriation of the 
nose, which later was cured. June 6 an epileptiform attack. In December 
further series of like attacks. January 5, 1902—Grippal enteritis of grave 
form, followed with cachexia, slough of sacrum and progressive marasmus. 
May 6.—After a series of attacks, the patient, profoundly cachectic, suc- 
cumbed. 

Comments.—We do not know whether, aside from alcoholism, we can 
attribute any other cause in this case of general paralysis. We are ignorant, 
notably, whether this patient has had syphilis. The only thing besides 
which appears to us interesting in this observation, is the coincidence of 


PERISCOPE. 659 


fibromatose, an affection congenital and familial, as the patient said (and 
there is no reason to suspect her veracity, for she has never varied on this 
point in spite of her state of dementia), and of peri-encephalitis, a malady 
held as the most accidental of psychopathies, and considered generally as 
developing ordinarily otherwise than from predisposition and in individ- 
uals with brain primitively well constituted. Or, if fibromatose is the in- 
dex of a congenital feebleness of the nervous system, following the exact 
expression of the authors, this case should be added to those already num- 
erous, where we see general paralysis attack the predisposed, the degen- 
erate, even also imbeciles. In 1888, L. F. Arnaud published two cases of 
general paralysis in imbeciles, recalled two analogous observations, one of 
Morel, the other of Christian, and attributed the congenital cerebral fee- 
bleness of the patients to the alcoholism of parents. In 1893, my interne, 
Gagnerot, in his thesis, entitled, “Of Predisposition in General Paralysis,” 
gave some examples of paralysis, grown upon the soil of degeneracy. In 
1897, L. Chappelletti published an article upon general paralysis in imbeciles. 
In 1808, I myself, in the Annales Medico psycho-logiques, gave observation 
of the same kind and advanced the opinion that “almost all general paraly- 
tics of the rural class are weaklings.” ‘The observations which I have col- 
lected since are not of a nature to make me change my opinion. 
RicHarps (Amityville). 


NEUROLOGISCHES CENTRALBLATT 
CV oly22" 1003," No; 5) March 4) 


1. The Acromial Reflex. W. v. BECHTEREW. 

2. The Carpo-metacarpal Reflex. W. v. BECHTEREW. 

3. New Contribution to the Physiology of the Tendon Reflexes. Prelimi- 
nary Contribution. A. E. STCHERBAK. 

4. Vesical Incontinence and Paralytic Manifestations in the Extremities 
in Focal Softening in the Subcortical Ganglion. A. HoMBERGER. 

5. Further Contributions upon the Developmental (Myelogenetic) Regions 
in the Human Cerebral Cortex. P. FLECHSIG. 

1. Acromial Reflex.—Bechterew calls attention to a periosteal reflex 
obtained by striking with the percussion hammer, the acromial portion of 
the scapula and the coracoid process. This reflex consists ordinarily in a 
flexion of the forearm, sometimes in an inward rotation of the hand and 
in exaggerated cases in a flexion of the fingers. These movements are pro- 
duced by a contraction of the cervico-brachialis and biceps muscles. The 
reflex is obtained in any condition where there is a heightening of the re- 
flexes as in organic hemiplegias and in amyotrophic lateral sclerosis. 

2. Carpo-metacarpal Reflex.—Bechterew describes a periostal reflex 
obtained by striking the carpus and the adjoining metacarpal region result- 
ing in a flexion of the fingers with the exertion of the thumb. The pa- 
tient’s hand should be held with the dorsum upwards. It is obtained in 
organic lesions situated above the cervical swelling, especially in organic 
hemiparesis or hemiplegia, as of cortical or capsular origin. 

3. Physiology of Tendon Reflexes.—Stcherbak records some interesting 
experiments upon animals. By means of a tuning fork rapid vibrations to 
the hind leg of rabbits were applied, which resulted in a heightening of the 
knee reflex, knee clonus, which could be produced by tapping, and passive 
movement of the knee joint and spastic tremor. These phenomena could 
be produced by irritation of the other foot. Rapid passive movement 1000 
to 1500, also produces a similar condition. Cutting the spinal cord above 
the center for the knee reflex and applying rapid vibration produced a 
heightening of the knee reflex, but no clonus or spastic tremor. These vi- 
brations had no influence upon the animal’s general condition or muscle 


660 PERISCOPE. 


tone. Vibrations applied to the spine, especially the lower dorsal region, 
produced a spasticity of all the muscles of both hind extremities. Stcher- 
bak concludes as a result of these experiments that by means of vibration 
we can so influence the lower, somatic portion of the nervous system, that 
phenomena are produced which we usually ascribe to the higher or psychical 
apparatus, and that these phenomena may be latent for some time after- 
wards. ay 

4. Subcortical Ganglion—Homberger describes the symptoms of ten 
cases in which numerous minute areas of softening were found in the 
corpus striatum and thalamus. In six of the cases the lesions were bilateral. 
Incontinence of urine was present in all the cases. Micturition was of the 
automatic type. There was partial paresis of the lower extremities, and 
increase of the reflex. The upper extremities were also somewhat af- 
fected. Forced laughing and crying and occasional hemichorea and hemi- 
athetosis were present. Homberger concludes the following as the result 
of lesions in the corpus striatum and optic thalamus: (1) Unilateral lesions 
cause transient incontinence and a permanent increased desire for urina- 
tion; (2) bilateral lesions cause permanent incontinence of urine, which 
does not differ from the spinal form; (3) the subcortical innervation of the 
bladder is bilateral; (4) superficial lesions do not cause incontinence; (5) 
bilateral areas of softening in the basal ganglia cause disturbance of station 
and paralysis which differ from those cases where the lesions involve 
the cortical fibers of the internal capsule. 

5. Lhe Developmental Areas of the Cortex.—Flechsig gives the result 
of his study of six more brains with regard to the date of the appearance 
of medullary sheaths in the various tracts of fibers proceeding from or to 
the cortex. This makes a total of 52 brains which he has examined. He 
modifies slightly his previous statements: (1) Flechsig divides the cortex 
into 36 regions.. He adds a new area to the first parietal’ convolution, mak- 
ing three areas. This region is found near the intraparietal nucleus and 
resembles the subangular convolution in size, the arrangement of its fibers 
and the date of appearance of the myelin sheaths. He is not certain that 
fibers from the corona radiata enter this region. A new area is distinguished 
in the upper portion of the occipital convolution, making three areas in 
the sight region; (2) regarding the order of development the following is 
of importance. The motor convolutions show the most marked develop- 
ment in the more fully developed fetuses. Ina brain of a 34 c.m. long fetus 
he found a well developed bundle of fibers which were traced to the olfac- 
tory sphere, while the fibers of the cerebral convolutions were not differen- 
tiated. Unless this is an exceptional case, the olfactory sphere should be 
designated No. I, and the central convolution as No. II; (3) it is possible 
to distinguish between the motor and sensory bundles of fibers. The motor 
fibers are found anterior to the central fissure and the sensory fibers pos- 
terior to this. In the supra and subangular convolutions the types are not 
distinct: (4) in 1901 Flechsig demonstrated that to every sensory (cen- 
tripetal) bundle there corresponds a motor one. He considers now that 
the projective system of the brain cortex is composed of similar conjugate 
pairs of bundles; (5) the order of development of the brain sulci has an 
important bearing upon the order of development of the myelin sheaths. 
The areas indicated as primary appear very early while the sulci termed as 
terminal appear late. This is not definitely proven, but the relation is es- 
tablished. 

(Vol. 22, 1903, No. 6, March 16.) 


1. Contraction of the Sphincter Iridis in Pupils Immobile to Light, in Ac- 
commodation and Convergence Reaction. M. RoTHMAN. 

2. Anatomical Changes After Crushing the Roots of the Spinal Cord in 
Dogs. S. BICKELES. 


PERISCOPE. 661 


3. Neurotonic Pupil Reactions. J. Piirz. 

1. Pupillary Changes.—Rothman reports a case of a girl twelve and 
one-half years of age who had occasional periods of unconsciousness dur- 
ing childhood. At five years of age she developed periodical attacks of mi- 
graine. After one of these headaches it was noticed that the right pupil 
was dilated at maximum and was absolutely immobile. The left pupil was 
normal. Potassium iodide was given. After a period of five months there 
was a slight reaction of the pupil in accommodation and convergence. 
During the whole period of observation, three and one-half years, no reac- 
tion to light was observed. In the course of time the right pupil regained 
its normal size, but would remain contracted 30 to 40 seconds after accom- 
modation and convergence. The case represents an isolated paralysis of 
the right sphincter iridis, the lesion probably being a small hemorrhage in 
the oculomotor nucleus. 

2. Crushing the Spinal Roots.—Bickeles crushed the anterior and pos- 
terior spinal roots of dogs either with pincers or ligatures for five minutes. 
The dogs were killed from seven weeks to two and ofe-half months after 
operation. Examination showed in the posterior roots a large number of 
fine regenerated fibers, the number depending upon the length of time 
elapsing after the operation. Bickeles also found what he believed to be 
regenerated nerve fibers in the intramedullary portion of the compressed 
posterior roots. This, however, was not very active, probably due to the 
increase of neuroglia tissue and a sclerosis. Examination of the posterior 
roots of dogs who died two to two and one-half weeks after operation 
showed an absence of centrifugal fibers. In the anterior roots a band of 
fibers was found which were traced as coming from the posterior roots. 
Degeneration was always on the same side as the injury. 

3. Neurotonic Pupil Reactions.—Piltz discusses the inportance of pu- 
pillary phenomena. In 37 cases of progressive paralysis, Ir did not respond 
to light on either side; 10 in whom the light reaction failed in one and 
was poor in the other; 7 in whom the reaction was poor in both sides; 4 
in which only one pupil reacted poorly and 5 in whom the light reaction 
was normal. In 63 cases of tabes, in 37, both pupils failed to react to light; 
in 6 the pupils on one side failed, the other being slow; in 15 both pupils 
reacted slowly; in one, the pupil on one side reacted poorly, the other nor- 
mally, an din 2 cases the light reactions were normal. Impairment and reac- 
tion manifests itself either that the pupil does not contract as much as it 
should or that it does not contract as rapidly as normally. It also mani- 
fests itself in a persistence of the narrowing of the pupil for some time af- 
ter reaction. Four cases are recorded with the later phenomenon. 

WEISENBURG (Philadelphia). 


MISCELLANY 


A Note on TRAUMATIC SyRINGOMYELIA. Alfred Gordon (Philadelphia 

Medical Journal, May 9, 1903). 

The writer reports a case of a woman aged forty years who, ten years 
before, had slipped and fallen on her back. This was followed by numb- 
ness and a sensation of pins and needles, and burning and aching in both 
hands. The pain disappeared but the numbness persisted. The hand would 
not be pained by burning, though covered by blisters. Three years ago a 
red swelling on the palm of the hand developed, which increased. A subse- 
quent dislocation of the arm was painless. The motor power in both lower 
and right upper extremities was normal. The left arm was weaker and 
larger than the right, each finger being larger than the corresponding finger 
of the right hand. The subcutaneous tissue seemed hypertrophied. No 
hysterical stigmata were noted. The skin was soft and thickened. The 
reflexes and reaction to Farradism were diminished on the left arm. 


662 PERISCOPE. 


Anesthesia of side of face and head was present. Temperature sense 
(heat and cold) were lost over the whole left arm and half the thorax 
to sternum and the middle line of the spine. Loss of pain sense was 
identical with thermo-anesthesia. Very little muscular wasting was present. 
The case was evidently a typical sensory dissociation characteristic of 
syringomyelia, also trophic changes of the tissue underlying the epidermis. 
The cause was probably the traumatism causing a hemorrhagic focus, de- 
veloping into a gliosis or cavity of the spinal cord. Trophic disturbance in 
syringomyelia of the nature of edematous swelling of paralyzed limbs are 
not rare. A hard edema due to hyperplastic process in the subcutaneous 
tissue was described by Marinesco under the name “main succulente.’”’ The 
vasomotor and trophic centers for the bones and integument are situated in 


the gray matter of the posterior cornua, about the eighth cervical. 
Noyes (New York). 


Do Our PRESENT Ways oF LivING TEND To THE INCREASE OF CERTAIN 
Forms oF NERvowS AND MENTAL Disorpcr? Charles E. Atwood (New 
York Medical Journal, June 13, 1903). 

Insanity is increasing slightly, especially degenerative types. Neuras- 
thenia is increasing. This increase is found mostly in the immigrant popu- 
lation, 75 per cent of the insane of the State and 80 per cent of the cases 
of neurasthenia at the Vanderbilt Clinic being either foreign born or of 
foreign parentage. 

Our present methods of living entail an increased mental strain, the 
number of sensory impressions and variety of ideas forced upon us by our 
increasing interests permit scarcely time for the reception of impressions, 
and no time for their proper assimilation. Emotional stresses, e.g., those 
caused by sudden and great reverses of fortune; profound impressions in- 
duced by fanatical doctrines, impressions induced by certain lurid daily 
newspaper are deleterious to the neurotic. Over indulgence in eating and 
drinking tends to arterial sclerosis. “Tendency to auto-infection is assisted 
by irregular living, and auto-infection is a recognized cause of certain 
forms of insanity and certain neuroses. The immigrant suffers the most 
on account of competition with a superior race, deficient alimentation and 
resultant enemia, other concomitants of poverty, and faulty hygienic condi- 
tions. The consumption of alcohol per capita in this country has increased, 
and our women are drinking more and more each year. This has a tend- 
ency to establish a faulty heredity and induce a strong predisposition to 
nervous disorders. AuTHOR’sS ABSTRACT. 


BRACHIAL ParALysis—Post Narcotic. F. J. Cotton and S. W. Allen 

(Boston Medical Journal, May 7, 1903). 

The writers report four cases of post-anesthetic paralysis, and collect 
thirty from general literature. The patient is anesthetical with the arms 
drawn up over the head, and after recovery one or both arms are found 
paralyzed. There is little or no pain and slight sensory disturbance. The 
muscles of the shoulder and arms are affected in a varying degree—some- 
times all are involved; sometimes the shoulder is spared, and the hand and 
arm muscles are alone affected. Ina few days there is beginning of return 
of function, more usually in the hand, then a slower return of power in the 
extensors to the deltoid and to the rotators of the shoulder. As the func- 
tion returns many of the cases present a paralysis approximately of the 
“Erb” type (deltoid, biceps, brachialis anticus and supinator longus). In 
a very few cases there is involvement of the sympathetic root communi- 
cating with the first dorsal root, signified by pupillary and other ocular 
changes. Later, soreness of the nerve trunks and of the muscles may ap- 
pear. Reflexes are usually normal. Electrical tests rarely show a partial 
reaction of degeneration; usual reactions are normal. There are three 


PERISCOPE. 663 


possible mechanisms by which these paralyses may occur: (1) Pressure 
on the plexus, (a) exerted between the clavicle and transverse processes 
of the vertebre, and (b) between the clavicle and the first rib; (2) tension 
on the roots or plexus from the position of the arm; (3) tension from 
position of the head or neck, the arm being abducted. 

Noyes, New York. 


IMPERATIVE Conceptions. L. Harrison Mettler (Medical Record, April 4, 

1903 ). 

Imperative conceptions or ideas are those involuntary, unrelated per- 
sistent notions that spring up in the minds of many victims of nervous 
disease. Though found in many states of mental and physical debility, they 
belong essentially and entirely to the psychoses. A sharp distinction should 
be made between the imperative conceptions of the sane and the insane. 
In the sane the person’s judgment remains unaltered; he tries to resist them 
and often succeeds. The imperative conceptions of the insane become for 
the time being the patient’s very ego. The insane delusion is deeper and 
more influential than the imperative conception, entering into the constitu- 
tion of his ego, and coloring and outlining his objective world. The so- 
called imperative idea, on the other hand, is recognized by the patient to 
be a mere subjective phenomenon, annoying and persistent though it may 
be. It may involve all the faculties of the mind, not alone the imagination, 
but there are usually no distinct hallucinations or delusions with these im- 
pulsive conceptions. Insane delusions are, primarily, the result of a dis- 
eased cortex ; imperative conceptions are the result generally of disease out- 
side the brain. Noyes (New York). 


NEURITIS FROM WHooPING CouGH. Charles E. Aldrich (N. Y. Medical 

Journal, June 6, 1903). 

‘Neuritis may attend or follow any of the acute infections, especially 
those characterized by prolonged high fever, marked disturbance of nutri- 
tion and great prostration. The author reports a case of a child aged four, 
who, after whooping-cough, developed weakness, pain in the legs, weak- 
ness of grasp of hands, nasal speech and regurgitation of fluids from the 
nose, diminution of knee jerks and loss of touch and pain sense in the 
hands and feet. Recovery came after twelve weeks. Various forms of 
paralysis have been observed to complicate or follow whooping-cough. 
Literature proves that it is rare. Sixty-two cases reported were cerebral 
in origin. Several cases of general peripheral neuritis were collected from 
literature. W. B. Noyes, New York. 


DEVELOPMENT AND CARE OF CHILDREN. J. C. Cook (Journal of the Ameri- 

can Medical Association, June 6, 1903). 

The changes in the nervous system from birth to maturity afford us 
many examples of the differences between the child and adult. At birth 
the central nervous system, as well as the peripheral, is almost entirely un- 
medullated. Hence we find the fibers of the spinal cord, the medulla, corpus 
quadrigeminus and the pons varolii mainly somatic. The motor nerves 
receive their attachments much earlier than the inhibitory centers are 
developed, hence the objectless movement that characterizes the unmeasured 
exercise of the young. Thus maturity is gradual, and full growth is only 
reached between puberty and adult life. It is our duty to guard and con- 
serve every atom of energy through this period of unfolding and budding 
life, realizing that they are bundles of possibilities unsolidified, which begin 
at the beginning and end we know not where. The study of biology 
teaches that the higher the organism, the slower the development, hence 
the necessity of a long period of protection and care. Take with this the 
long periods of stress and functional demands on the nervous system and 


664 PERISCOPE. 


we can realize the greater necessity for a wise and careful guardianship. 
The writer urges strict control of the question of child labor, and advises 
a commission of five members, at least two of whom shall be physicians, 
to have jurisdiction over all educational and labor questions. 


W. B. Noyes, New York. 


EFFECTS OF THE STREPTOCOCCUS ON THE CorTICAL NERVE CELL IN MENIN- 
citts. Leonard K. Hirshberg (Maryland Medical Journal, July, 1903). 
Autopsy: Male, thirty-nine years. Clinical diagnosis: Fractured skull, 

cerebro-spinal meningitis, myocarditis, endocarditis, pyemia, pneumonia at 

base of right lung.. Anatomical diagnosis: Purulent traumatic cerebro- 
spinal meningitis, depressed fracture of skull; rupture of dura, depression 
and bruising of right cortex; fatty liver. Brain: Subarachnoid space con- 
tains exudate, consisting of two zones. Inner zone, in contact with cortex, 
consists of network of fibers, including many cells with long vesicular 
nuclei, surrounded by much less staining cytoplasm. Probably proliferated 
endothelial cells from serous surfaces and lymph spaces of membrane. Few 
poly morphs nuclear leucocytes in the zone. Outer zone consists, almost, 
of poly morps nuclear leucocytes. Tissues of pia richly infiltrated and 
thickened by exudate of pus cells, in which numerous proliferated endo- 
thelial cells are made out. Weigert’s method shows moderate number of 
streptococci in exudate. Cortical sections, from area of Rolando, stained 
by Nissl, show disappearance of tigroid bodies from cells. Many cells also 
exhibit loss of nuclei. Cells shrunken and distorted where nuclei remains. 

Nuclei swollen, vesicular, limiting membrane at times in contact with body 

wall of cell. Eccentricity frequent as to nuclei and nucleoli. Direct or im- 

mediate action of the toxin of the streptococcus seem probable. 

J. E. Crarx, New York. 


THE Eprteptic Aura. William P. Spratling (Medical News, July 18, 1903). 

Four types of auras are studied: (1) Psychic, (2) sensory, (3) motor, 
(4) irregular. In a close analysis of 815 males and 510 females, 36 per 
cent were found to have a sensory aura of some sort, 4 per cent had a 
psychic aura, and 2 per cent a motor aura. Of the entire number, 45 per 
cent had some aura, 55 per cent none. The sensory auras are not only 
common, but extremely varied, affecting any of the special senses, including 
marked perversions of the same, and being brief or rather prolonged. 
Visual auras predominate, and appear either as flashes of light or colors, 
or optical delusions, or temporary blindness. The epigastric aura appears 
in 15 per cent of all cases, and is the most frequent. The problem in 
epilepsy is to determine whether the initial disturbance, the thing that 
breaks up the rythmic periodicity of the respiratory impulse, is to be sought 
in the respiratory center primarily, or whether it lies somewhere in the peri- 
phery, in the stomach, or elsewhere, and represent the original source of 
the epilepsy. For instance, when a case with epigastric aura suffers from 
periodic indigestion, gastric catarrh or flatulence, the probability is that the 
same cause makes the aura and the flatulence, and there is some subtle 
agent in the unknown field of chemical pathology. 

W. B. Noyes, New York. 


Volume 30. November, 1903. No. II. 


THE 


Journal 


OF 


Nervous and Mental Disease 


Original Hrticles. 


THREE CASES OF TUMOR INVOLVING THE SPINAL CORD; 
TREATED BY OPERATION. 


By Dr. JAMEs J. PUTNAM 
AND 
Drie Wi. ELLIOTT 


These cases are reported in order to show the benefit that may 
result from operations for tumors involving the spinal cord, even 
when it is not possible to effect a complete cure; and also to illus- 
trate the danger with which such operations are attended. 

In the first case to be described the result was favorable to a 
degree far exceeding our expectations. It may be that the opera- 
tion was only partially responsible for the eventual improvement, 
but it cannot possibly be doubted that it furnished the controlling 
factor. 


Case 1. The patient, who was a young man, twenty-three years 
old, in the employ of the West End Railroad Company, was 
brought to Dr. Putnam in December, 1897, and gave the following 
history: 

He said that, just three years before, he was doing a job of 
work which required him to mount on one of the tall ladders 
reaching to the trolley wire, and that while descending he missed 


*Read at the meeting of the American Neurological Association, May 
12, 13 and 14, 1903. 


666 JAMES J. PUTNAM AND J. W. ELLIOTT. 


his hold and fell. He grasped the ladder as he went down and in 
that way broke his fall, but at the same time his neck received a 
sudden twist. He picked himself up without help and walked a 
distance of about a quarter of a mile, suffering only from pain in 
the neck; and then took a car home. 

That night he suffered from pains in the neck, and for two or 
three weeks afterward he stayed in the house, not feeling able to 
work. There was no disturbance of motion or sensation of any 
kind, except that his head was held somewhat askew, and that 
attempts to turn it to the left caused pain in the neck. 

Six weeks after the accident he went to work again, and 
worked for another year, feeling well, but not able to turn his 
head quite freely from side to side. Then he again received some 
slight injury, in consequence of which the neck once more became 
actively troublesome for a time. 

In December, 1896, that is, a year before the first examination 
was made, he was off work for two weeks; then he worked again 
until April, 1897, when he gave up for good and all, on account of 

renewed pain in the neck. 
| In the following month, that is, in May, 1897, he fell while 
running—perhaps because he tripped, perhaps because new symp- 
toms were coming on—and on this occasion also the neck was 
painfully jarred. 

From that time on he was unable to run, though for several 
months more he could walk, he thinks, nearly as well as ever. 

The evidence up to this point makes it clear that the original 
injury was the primary factor in setting up the subsequent morbid 
process, and this conclusion seems the more justified from the fact 
that he was never able to turn his head freely after his first acci- 
dent, and less well to the left than to the right. 

In July, 1897, his gait became awkward, and in August his 
hands began to feel numb and would shake on use. 

For several weeks before the first examination his back and 
sides had been feeling weak, and breathing had been getting more 
and more difficult. There had been no paralysis of the sphincters. 

The physical examination made on December 27, 1897, showed 
that the movements of both arms were weak, and that the difficulty 
of motion increased distally. Thus, his fingers were semi-flexed, 
and further flexion or extension was impossible; flexion and ex- 
tension at the elbow were possible, but very feeble; abduction at 
the shoulder was better but also feeble, and not so good on the 
right side as on the left. Passive extension-movements of the 
fingers excited strong clonus. 

The prick of a pin was felt fairly well on both hands, but, un- 
like the motion, it was better for the left side than for the right. 
f Brown-Séquard complex.] Light contact was felt on both hands 


667 TUMOR INVOLVING THE SPINAL CORD. 


and arms, and this form of sensibility seemed to be less affected 
than that of pain. The movements of the legs were also weak, but 
were all possible. The right leg was stronger than the left. The 
knee-jerks were greatly exaggerated, and ankle clonus was pres- 
sent. The respiration was labored, and the accessory muscles of 
inspiration were called strongly into play. The temperature, by 
the mouth, was 99.7° F. On palpation in the pharynx the bodies 
of the upper cervical vertebrze seemed to be unusually prominent. 

The presence of this group of signs—the involvement of all 
four limbs, of all the costal muscles, and even of the diaphragm— 
made it obvious that the patient was suffering from a lesion high 
in the cervical region, and a lesion of such a character as to affect, 
in some measure, the whole thickness of the cord, the centripetal 
as well as the centrifugal tracts. The whole course of the disease, 
the history of neck-injury resulting perhaps in partial dislocation 
of the cervical vertebre, the prominence of the upper cervical 
bodies in the pharynx, all pointed to an affection of the bony struc- 
tures, while the high exaggeration of the wrist-jerks and knee- 
jerks bore out the idea that the nutrition of the cord was being 
impaired rather by pressure, with its attendant circulation disturb- 
ances, than by a destructive lesion primarily involving the neural 
tissues themselves. 

It was thought at first that the bone disease was tuberculous, 
but Dr. Walton, who made an examination at a later period, 
favored the diagnosis of a sarcomatous growth at the seat of in- 
jury, and this proved to be correct. 

The patient was at once referred to the Massachusetts General 
Hospital, which he enfered on December 28, 1897, coming under 
the care of Dr. F. C. Shattuck. At entrance his temperature was 
100.2° F., pulse 112, respiration 30. The thoracic and abdominal 
organs were normal. The arms were constantly held semi-flexed 
and the fingers nearly closed, but he was able to walk up and down 
stairs with the aid of one man. 

After staying a few days, the patient was discharged at his 
own request, but soon found his legs getting weaker and _ his 
breathing more labored, though he did not lose weight. 

A few months later he was again seen by Dr. Putnam, and 
operation was advised, at least for exploration. With this in view 
he re-entered the hospital on June 19. At this period his fingers 
were immovable, and his arms and legs utterly helpless, though 
not absolutely paralyzed. Micturition was voluntary, but the 
movements of the bowels were secured with difficulty. The ten- 
don reflexes were highly exaggerated, as before. 

The head was partly extended, and could be moved to about 
three-quarters of the normal extent, in all directions; a resistance 
could be felt deep on the left side of the neck, at the level of the 


668 JAMES J. PUTNAM AND J. W. ELLIOTT. 


second and third cervical vertebrze. A prominence corresponding 
to the body of the second cervical vertebra was to be felt in the 
pharynx. 

An attack of difficult breathing precipitated the operation, 
which was made on June 20, the day after his entrance. 

Operation. The patient was placed face down, with his head 
bent sharply forward over the end of the operating table. An in- 
cision was made from the occipital protuberance down in the 
median line nearly to the seventh cervical spinous process. The 
first, second and third vertebree were exposed and their laminz 
removed. The posterior surface of the axis was found to be 
eroded, so that on grasping it with forceps it came away as a thin 
shell of disintegrated bone, disclosing a small grayish lobulated 
tumor, the size of an acorn. This had every appearance of a sar- 
coma and was removed with scissors and forceps. It seemed to: 
involve the dura and perhaps the cord itself. The base was 
curetted, and the curette followed the disease around into the body 
of the second vertebra, care being taken not to injure the vertebral 
artery. A quantity of the disease was then removed from the 
vertebra in front of the cord. Horsley’s spine forceps were found 
to be admirable for cutting the laminz in this very deep region. 
The operation was difficult and severe. 

The wound was closed without drainage, and the patient made 
a good recovery from the operation. His respiration at once be- 
came much easier than before the operation. There was no pain, 
and the wound healed by first intention. Within three days the 
patient discovered that he could move his legs better than before, 
flex and extend his right hand at the wrist, and move his thumb: 
and fingers. 

The pathological report on the specimen removed was as fol- 
lows: 

“An irregular mass of tissue with some spicule of bone on it. 
Microscopic examination showed solid masses of irregular round. 
cells interspersed with large multinucleated ones. Giant-cell sar- 
coma.’—Win. Whitney, Pathologist. 

On June 29 he could flex both forearms on arms to a right. 
angle, and could also flex both thighs. _All voluntary motions 
were much increased over what was possible before the operation. 
Improvement was reported in movements of arms, legs and neck. 
Respiration was quiet and natural. July 2, slow but steady im- 
provement was reported in movement of arms, legs and neck. 

July 11 he was discharged from the hospital, “relieved.” 

On April 18, 1899, the patient was re-examined at his house 
and gave the following report: 

He left the hospital a good deal relieved, he said. After get- 
ting home he at first lost a little, but then improved again so that,. 


TUMOR INVOLVING THE SPINAL CORD. 669 


with assistance, he could move about the room a little. He could 
also lie on his side, in bed, which before the operation had been 
impossible. After this he grew worse once more and was pretty 
poorly for several months, although he never lost all that he had 
gained. 

In October, that is, three months after leaving the hospital, the 
improvement recommenced, and from that time on it had con- 
tinued without interruption. 

At the time of this examination he could raise his hands freely, 
though rather awkwardly, to the head and above the shoulder, 
could feed himself with the left hand, and could hold a book and 
turn the leaves. His fingers were stiff and weak, especially the 
little finger, but all movements of them were possible, whereas be- 
fore the operation they were wholly incapable of motion. The legs 
were stiff, but here also all movements were possible, even those of 
the toes, though the attempt to move them would bring on exten- 
sion clonus. He was not able to walk wholly alone. He could 
turn the head freely to the right, and could move it forward and 
back, but could not turn it much to the left. The breathing gave 
him but little trouble, and was both costal and diaphragmatic. He 
had no pain. His flesh and color had improved. ‘The bowels 
moved freely and the micturition was normal. The knee-jerks 
were very markedly exaggerated, as well as all the deep reflexes 
of the four limbs. His sensibility to contact, pricking and changes 
of temperature was almost, if not quite, perfect over all parts of 
the body below the head. The sense of position was good. The 
improvement continued, so that on the following Thanksgiving 
Day he was able to walk downstairs and take part in the family 
dinner. . 

A final examination was made on January 2 of the present 
year, 1903, with the following results: 

The patient reports that he had been steadily gaining, and 
that he is now keeping a small store entirely alone. His physical 
condition is as follows: 

The gait is very spastic. On turning round he loses his bal- 
ance easily, and he sways on attempting to stand with eyes closed. 
There is no ataxia of the arms, and the grasp of both hands is 
strong. The wrist and elbow jerks are markedly exaggerated, 
but there is no muscular atrophy of the hands. The knee-jerks 
are very lively on both sides, and ankle clonus is present. There 
is no disturbance of sensibility of the hands or face. The pupils 
are of moderate size and react normally. The pulse and respira- 
tion are both normal. All movements of the head are apparently 
normal, except that of rotation, which seems somewhat restricted. 
His neck looks short, as if his head had settled somewhat be- 
tween his shoulders. ‘There is no sign of recurrence of the new 
growth. 


670 JAMES J. PUTNAM AND J. W. ELLIOTT. 


This case is especially interesting in two respects: (1) Al- 
though new growths of the cervical region have several times 
been reported, this is the first instance in which an operation has 
been made for a tumor at this level, the one which comes nearest 
to it being that which is described in the recent and interesting 
report by James W. Putnam, William C. Krauss and Roswell 
Park,? when a sarcoma was successfully removed from the neigh- 
borhood of the fourth and fifth cervical segment. (2) It is im- 
portant as showing how much can be accomplished even where 
the disease with which the surgeon has to deal is of the degree of 
malignancy that belongs to the sarcomas; and how long the 
tendency to recurrence may be delayed. It was equally true of 
the case described by J. W. Putnam, Krauss, and Park, that the 
tumor was sarcomatous, and the symptoms were equally serious 
with those exhibited by our patient, the disorder of sensibility, 
indeed, even greater; yet here, also, improvement seems to be still 
going on after an interval of eight months. 


Case 2. This patient was a woman, Armenian by birth, mar- 
ried, thirty-two years old. She was first seen by Dr. Putnam in 
February, 1902, on account of intense pain through the body and 
thighs, increased by the slightest movement, and for muscular 
weakness, which, together ‘vith the pain, kept her immovably 
confined to bed. 


The preliminary examination seemed to justify the diagnosis 
of new growth, probably carcinoma, involving the spinal cord, 
and on this account she was referred to the Massachusetts Gen- 
eral Hospital, where she came under the care of Dr. Elliot. The 
following notes are taken from the surgical records: 

It appeared that twenty-one months before her entrance to 
the hospital she had been operated on in Worcester for a cancer 
of the breast, the tumor having been developing for nine months 
previous to operation. About a year after this she was shaken up 
in a street railway accident, and one week later she began to feel 
shooting pains in the sacral region. Shortly afterwards the lum- 
bar region and both flanks became involved, then the left leg, and 
finally the right leg. In the legs the pain mainly followed the 
course of the sciatic nerves. So far as she knows, the sensibility 
of the skin and the muscular power were at that time unimpaired. 
The pain was always worse on the left side than on the right, and 
when severe it radiated to the front of the abdomen. From this 


* American Journal of the Medical Sciences, Jan., 1903. 


TUMOR INVOLVING THE SPINAL CORD. 671 


time she grew steadily worse and became eventually unable to 
walk, so that for four or five months she had been in bed. Every 
movement increased the pain, and recently it had become so dis- 
tressing that she could not be moved in the slightest degree with- 
out extreme suffering. 

The physical examination showed the heart and lungs to be 
normal, and the abdominal organs also normal. The muscles of 
the legs were flabby, but not markedly atrophied. There was no 
edema anywhere, and no tenderness on pressure over the nerve 
trunks. An examination of the back showed a small knuckle of 
protruding bone involving the spines of the last dorsal and the 
two upper lumbar vertebre. 

While at the hospital she had poor nights, sleeping but a few 
hours at a stretch, and suffered from intense, cramplike pains in 
the thighs after resting in one position for any length of time. 
Several one eighth grain doses of morphia were required every 
night to secure even tolerable comfort. 

The original diagnosis having been confirmed, operation was 
decided upon and was performed as follows: 

An incision ten inches long was made over the lower dorsal 
and upper lumbar region, and the laminz of the last dorsal and 
two first lumbar vertebree were removed. On opening the canal 
a new growth, of carcinomatous appearance, was found presenting 
immediately beneath the bone. It surrounded the nerve roots on 
either side of the cord, and extended into the tissues outside the 
vertebre. This was removed so far as possible by excision and 
curetting, and two nerve roots on each side, which were at the 
level of the growth, were divided, inside the spinal canal. The 
dura was not opened. 

In the afternoon the patient suffered from shock, but revived 
under the use of intravenous infusions and strychnine. During 
the next few days she gained strength and was fairly comfortable 
when at rest, though suffering greatly when moved. Her condi- 
tion varied greatly, and on some days she suffered continuously. 
The wound healed by first intention. Three weeks later she was 
reported as looking well and suffering very little pain, but with 
considerable paresthesia in the limbs. One week afterward, that 
is, on March 22, she could move the legs more freely, without 
pain, and suffered but little pain on being moved by the nurse. 
The improvement in these respects was so great that on March 
26, when she slipped out of her chair one day by accident, very 
little pain was excited. On April 4, that is, nearly a month after 
the operation, she was reported as feeling well except for slight 
dragging sensations in the right thigh. On April 7 she was dis- 
charged much relieved, and it was felt that the purpose for which 
the operation had, been made, namely, the relief of pain, had been 


672 JAMES J. PUTNAM AND J. W. ELLIOTT. 


accomplished so far as could possibly have been expected. 

The plan of dividing posterior nerve roots had been formed 
before the operation was begun, and it was even felt that, if no 
other course offered itself, it might be justifiable to divide the 
cord above the new growth, so imperative was the need of reliev- 
ing the extreme suffering. 

On leaving the hospital it was found possible to transport her 
to her home in Worcester, and here she remained living in com- 
parative comfort, still suffering much pain, but not of the same 
severity as before the operation. 

In June a convulsion occurred, followed soon afterward by a 
second. This seemed to indicate the development of malignant 
growth in the brain, and within a few weeks from the appearance 
of these symptoms the patient died. 


The best indication of the value of the operation is afforded 
by the recognition on the part of the patient and her husband that 
the excessive severity of the pain had been considerably tempered. 
Indeed, the testimony increases that we should not wait for the 
assurance of absolute success in the case of either cerebral or 
spinal tumors. The notable improvement recorded by Dr. J. J. 
Thomas,* from operation on a myeloma of the spine with com- 
pression of the cord, is another illustration of the justice of this 
view. 


Case 3. This patient was a man of fifty-four, married, of 
good previous health, who entered the Massachusetts General 
Hospital in the service of Dr. F. C. Shattuck, on January 5, 1902. 

The hospital records state that five years before, while suffer- 
ing under the strain of excessive work, he began drinking cham- 
pagne, and then whiskey, and he finally took up to the amount of 
half a pint or a pint a day. Three months previous to his en- 
trance he stopped this habit absolutely. He had never had spe- 
cific disease. Seven years before entrance he had an attack of 
what was called rheumatism, in the muscles of both sides of the 
trunk, and was then in bed eight or nine days, suffering intense 
pain. Since then he had had occasional attacks of a similar sort, 
but less severe. The pain was sharp and lancinating in character, 
but did not entirely encircle the body. Two years before en- 
trance he awoke one morning with queer feelings in his head 
and left half of his body. There was no loss of power, but a 
sense of numbness and more or less impairment of cutaneous 
sensibility, accompanied by dizziness. After a few moments he 


*Boston Medical and Surgical Journal, 1901, Vol. 145, p. 367. 


TUMOR INVOLVING THE SPINAL CORD. 673 


seemed perfectly well again, except that the dizziness persisted 
for some time. Six weeks later, while at work in his office, he 
again became dizzy and faint, and this time he lost power in his 
left side and had a recurrence of numbness, together with ting- 
ling sensations. These signs were most marked in the arm. 
After a few hours his muscular power began to return, although 
the left arm never fully regained its strength and afterward 
remained subject to numbness and tingling. Six months before 
his entrance he began to suffer from pains of intense, radiating 
character, beginning in the back of the neck and extending 
through the left shoulder and arm. In the morning on waking he 
often used to find his head drawn to the left side. The muscles 
of the hands gradually became weak and atrophic, so that the 
fingers could not be used for any delicate work; also considerable 
cutaneous hyperesthesia developed. Two or three months later 
there was some involvement of the other arm. In spite of the in- 
tense pain, he attended to his business regularly. About two 
months before entrance he began to suffer from a painful girdling 
sensation from the level of the ensiform cartilage to the groin. 

There was no pain in the legs, but they would often shake 
violently. There was no disturbance of micturition, nor any 
loss of control over the rectal sphincter. These symptoms were 
soon folllowed by a loss of power of movement of the legs, 
which lasted for three weeks, though it finally passed away to 
a great extent. The muscles of the legs grew wasted at this per- 
iod in some degree. No mental symptoms occured at any time, 
nor any headache or vomiting. At times the voice was noticed 
to be a little husky. 

An examination of the blood showed Hgb. 95 per cent; leu- 
cocytes 9g8oo. 

The physical examination at the time of his entrance into the 
hospital showed his thoracic and abdominal organs to be neg- 
ative, and his general condition of nutrition normal. The wrist 
reflexes were also normal, but the knee-jerks much increased. 
The Babinski reflex was present on both sides, but most marked 
on the right. The cremasteric reflex was normal. There was no 
disturbance of sensibility of the skin of the head and neck. All 
the muscles of the hands and arms were more or less atrophied, 
more especially those of the left arm. This atrophy was most 
marked in the interossei. No hyperesthesia could be made out 
at any level, but slight stimulations would frequently excite 
spasms of pain across the shoulders. The grip was weak on both 
sides, more so on the left. The breathing was almost exclusively 
diaphragmatic. 

An examination of the cutaneous sensibilities of the chest and 
abdomen showed an interesting dissociation of the sensory func- 


674 JAMES J. PUTNAM AND J. W. ELLIOTT. 


tions of the skin. Thus, from the level of the nipple in front and 
spine of the scapula to the crest of the ilium, behind, and to just 
above the pubes, in front, there was an almost entire loss of the 
sensibility to heat and cold, pain, space, and pressure, while the 
sense of contact in this area was nearly normal. ‘The cutaneous 
sensibility of the legs was abolished. 

The muscles of the legs were almost completely paralyzed, 
and toe-drop was marked, but atrophy was not present to 
any extent. Reflex spasms were frequently induced by slight 
stimulation of the feet. 

Massage gave great relief, and the patient used to rest quiet- 
ly after it. 

On January 7th, the patient was examined by Dr. Putnam 
and Dr. Taylor (also afterward by Dr. Walton), who reported 
that the signs indicated disease in the lower cervical region, 
which was primarily external to the cord; that is, either a cer- 
vical pachymeningitis or a new growth. It was also thought to be 
conceivable that the case might be an unusual one of syringo- 
myelia. It was believed that hemiplegic symptoms pointed prob- 
ably to an independent vascular disease of the brain, unless pos- 
sibly both might have been due to multiple sarcomata. 

Operation was recommended, though the outlook was not 
considered as promising. It was believed that the lesion must 
extend high enough to affect the nerves of the fifth or sixth 
cervical segment, and that it was most severe at the level of the 
seventh segment. The fact that so much pain was present and 
was increased by motion, made it probable that the lesion was 
meningeal, at least in part. The prognosis without operation 
was considered poor, especially in view of the involving of res- 
piration. 

Potassium iodide having been given in large doses without 
relief and, moreover, being constantly required to relieve the pain, 
the patient was transferred on February 4th, to the East Sur- 
gical Service, and was operated upon, on February 7th, by Dr. 
Elliot, as follows: 

An incision ten inches long was made from the base of 
the head to between the shoulder blades, and the laminz of the 
first dorsal and the four lower cervical vertebrze were removed. 
As soon as this was done, a new-growth, of grayish translucent 
appearance, was found encircling the cord and dura like a collar. 
It occupied the posterior and left lateral part of the extradural 
space, and was adherent to the dura, though easily stripped from 
it. This growth had extended longitudinally for a distance 
of three or four inches, and had spread into the various openings 
between the vertebrz. A long and careful dissection was made, 
for the purpose of removing all visible disease. The dura was 


TUMOR INVOLVING THE SPINAL CORD. 675 


not opened except at one point, where the growth was found 
adherent, but from this opening a large amount of cerebrospinal 
fluid escaped. 

The operation was a severe one, and at times the respiration 
was very poor—partly, perhaps, on account of the patient’s 
position. He reacted well, however, to stimulation afterwards, 
and slept quietly in the afternoon with the aid of morphine. 

The next day he was found to be in great pain, with a tem- 
perature of 106 F. and with very rapid breathing. On the second 
day, February oth, the temperature had risen to 108 F. The 
breathing was still more labored, and the patient was semi-con- 
scious. His pulse gradually became weaker, and he died about 
au Vi. 

In spite of this unfavorable result, Dr. Elliot felt that the po- 
sition of the growth and the fact that it was possible to remove 
it almost wholly without any serious injury to the spinal cord 
made the operation appear thoroughly justifiable, and that in 
another similar case the good result which was anticipated might 
readily follow. 

The report of the pathologist, Dr. J. H. Wright, was as 
follows : 

Baste ourcicalnmtevenss oervice of Drabiiot. Feb.) 7, 1002. 
Laminectomy. 

“The material received for examination from the operation 
consists of several pieces of grayish translucent homogeneous 
fairly firm tissue and the lamine or parts of laminz of three ver- 
tebre. 

“This tissue is intimately adherent to parts of the posterior 
ligaments belonging to these laminz. 

Microscopical examination of sections from the tissue show 
that it is composed of small cells and coarse fibered connective 
tissue. The cells have little or no cytoplasm and seem to consist 
of nothing more than nuclei which are generally rounded in out- 
line and generally about the size of lymphoid cells. The nuclei 
are also present. In some places the cells are scattered among 
the connective tissue fibers. In other places there is little connec- 
tive tissue and the tissue seems to be made up largely of the small 
cells. Some capillary blood vessels are present. 

“Diagnosis: Fibrosarcoma, probably originating in the pos- 
terior ligaments of vertebre. 

el WRIGHT.:: 


This case thoroughly recalls that reported by Henschen,* of 
Upsala, and Lennander, by whom the operation was performed. 


*Cited at considerable length in the Neurological Jahresbericht of Men- 
del and Jacobson; for 1901. 5th Jahresbericht, p. 507. 


676 JAMES I PGTNAMEAND JAW yELLIOT 


Here, also, a similar congeries of symptoms to those which 
our case presented was held to point to a growth between, the 5th 
cervical and the ist dorsal segment, and in fact a spindle-shaped, 
flat tumor was found. It proved to be non-malignant in charac- 
ter and complete recovery followed its removal. It cannot be 
doubted that our patient would at least have improved greatly, 
had the operation not been followed by the rapidly fatal symp- 
toms of the first days. The cause of these symptoms is not clear, 
though this occurrence after opening of the spinal canal is unfor- 
tunately, not unfamiliar. 

Finally, this occasion may be taken for reporting that the 
patient from whose spinal canal a fibroma was removed by Dr. 
J. C. Warren in 1808,’ has continued to improve steadily and is 
now comparatively free from annoying symptoms. 

A summary of the published accounts of operation for tumors 
of the spinal region has been so recently given in the paper by 
J. W. Putnam, Krauss and Park, that it is unnecessary to give 
further details in this place. 


"Report by Drs. J. J. Putnam and J. C. Warren; Amer. Journ. of 
Med. Sciences. Oct. 1899. 


A METHOD FOR THE RELIEF OF PAIN IN TUMORS OF THE 
BRAIN.* 


By Witit1Am Brownine, M.D., 
OF BROOKLYN. 

The hopeless character of most cases of this kind and the lim- 
ited extent of our resources in treating them are generally recog- 
nized. A few cases can be approached surgically (with a view 
either to the radical removal of the growth, or occasionally to re- 
lief by drainage, or to the symptomatic relief of pressure that a 


trephine-opening affords). A small number respond somewhat to 
thyroid, a few remain latent, more are amenable to specific reme- 


dies, and many are temporarily benefited to an appreciable extent 
by iodide. The X-rays have been found in a few cases to tem- 
porarily numb the pain. These methods are more likely to prove 
palliative than radical. This brief summary about covers our 
scanty therapeutics, and even so makes a better showing than 
many may suppose possible. Granting all these exceptions, how- 
ever, a majority of cases remains, and in these we are at a loss to 
know how to meet the conditions. In default of anything better, 
we grope around for means of symptomatic relief, and usually end 
by making continuous use of opiates in some form. The latter 
agents, however, are objectionable for several reasons; they ob- 
tund consciousness more or less, and in the long run aggravate 
pain by increasing constipation. 

So long consequently as in the majority of cases of intracranial 
neoplasm we are unable to apply radical or curative measures, so 
long shall we need symptomatic agents. This is particularly true 
of the frequent and most distressing symptom, pain in or about 
the head. It is the sufferer’s chief complaint, and it is especially 
for its relief that the present plan aims. 

While the principal merit of the method to be suggested? is 
that of relieving symptoms, this is done in a less objectionable 


*Paper read before the Brooklyn Society for Neurology, Dec. 18, 1902. 


*In the discussion of a paper at the 1901 meeting of the American 
Neurological Association, I briefly mentioned this means of relative relief 
in brain tumors. Attention had previously been called to the value of vaso- 
motor depressants and sedatives in the headache of syphilis (Brooklyn 
Med. Jour., 1889, 675), especially in the later forms, and that may have 
dated in part back to Seguin’s use of aconitia and gelsemium for trigeminal 
neuralgia as early as 1870. 


678 WILLIAM BROWNING. 


manner both from the patient’s standpoint and from our own 
than is afforded by narcotics. Nor does it in any way interfere 
with the use of these if such becomes necessary. 

One unquestionable advantage of the use, which, as you know, 
I have so strongly advocated for a number of years, of the vascu- 
lar agents (whether to increase or depress the blood-pressure), 
is that they act in an intelligible way and not in some presumed 
or speculative manner. Their influence can be pretty definitely 
foretold and its effect controlled; hence the remedy can be fitted 
to the case. In other words, they are rational remedies and meet 
the demand for both honesty and exactness in practice. 

The method in the present instance is very simple. It con- 
sists in the administration of such depressants as aconitia, vera- 
trum® or gelsemium* in doses sufficient to soften and control the 
pulse. The amounts required are not far from those which were 
recommended in the abortive treatment of apoplexy (N. Y. Med- 
ical Journal, 1902, Feb. 15). The remedy can be continued as 
required, though the condition of the circulation should be fre- 
quently observed and the amount of the drug regulated according 
to the necessity of the case and the way it is borne. The dosage 
in any particular case is kept where it does not dangerously reduce 
the pulse on the one hand, and yet controls the pain on the other. 

This plan may not at any and every instant completely stop 
pain, but it holds it within bearable limits, and may be all that is 
required even when the course of the trouble extends over many 
months. It appears to accomplish quite as much as the method of 
symptomatic trephining, which was proposed for a similar pur- 
pose, and to do this without any of the operative drawbacks. 

Doubtless the thoroughness with which pain can be controlled 
in any given case will depend somewhat upon the manner in 
which it is produced. Clinically we have, besides those relatively 
fortunate cases without pain, certain types, and we can trace the 
source of the pain to at least three factors: (1) There is the local 


"It has been suggested that, as veratrum has a tendency to produce 
nausea, it is undesirable for this purpose, unless it is the only agent 
of the kind at hand. 


“My attention has been called to experimental work indicating 
that gelsemium “exerts no influence on blood-pressure.” Clinically, how- 
ever, it does affect the pulse, when given in full doses. A better effect might 
follow its combination with one of the others. As aconite can be given 
hypodermically it is as yet the best agent for our purpose. 


RELIEF OF PAIN IN TUMORS OF THE BRAIN. 679 


and more or less general increase of intracranial pressure, as oc- 
curs most typically in intrasubstantial growths. Where the pain 
is thus directly due to pressure, it is less intense, but may be 
more continuous, like a deep ache. In this form marked relief 
may be expected. (2) Then there is the paroxysmal augmenta- 
tion of arterial pressure in certain cases, to which reference will 
be made more fully. It is in these attacks doubtless that the ter- 
rific pain-seizures occur, and correspondingly this form should be 
relieved most of all by depressants. It is really here that we most 
need analgesics, and that opiates fail except to stupefy. (3) But 
when on the contrary the pain is the result of direct implication 
or stretching of external structures, as the meninges or outgoing 
nerves, and we get instead neuralgias and localized pains, then 
the good to be realized from depressants may be only propor- 
tionate to the degree in which pressure is a factor. And in fact 
it is supposed that in this last type of cases pain is especially likely 
to be felt. 

It is fair to ask whether this plan has any injurious effect on 
the course of the trouble itself. Nothing of the sort has been ap- 
parent in any case, nor is there any theoretical reason for suspect- 
ing harm. So far as one can decide, life has if anything been pro- 
longed. On paralysis if present it can hardly have much effect 
either way. Other, in part paroxysmal symptoms, as vomiting, 
dizziness, spasms, are as a whole favorably influenced. The 
growth of the neoplasm itself is not visibly affected, certainly not 
accelerated. Consciousness and the individual’s personal control 
of himself is much better preserved. Moreover, remedies of this 
kind exert a very favorable influence on a certain tendency in these 
cases to brain-hemorrhage. This complication is specially fre- 
quent in and about the growth itself. Though such hemorrhages 
are more apt to be numerous than individually large, yet they de- 
cidedly aggravate the symptoms of the tumor, and anything tend- 
ing to prevent their occurrence will be of advantage. Hence, 
aside from the pain, these remedies act on the other phases and 
manifestations of brain-tumor favorably if at all. 

In occasional cases the depressive agents may also have some 
diagnostic or differential value. 

The points that first suggested a trial of these agents were 
the increased intracranial pressure, and the pulsatory character 


680 WILLIAM BROWNING. 


often of the pain. In such cases, where warranted by a strong 
pulse, it seemed proper to seek relief by depressants. Gradually it 
became evident that in most cases their use practically did away 
with the need for morphine. Recently a more striking basis for 
explaining the good effects in some conditions has been afforded 
by the work of Dr. Harvey Cushing’. | 

Perhaps his conclusions, so far as they bear on the present 
question, can be indicated by a few quotations. Speaking “of the 
alterations in the cerebral circulation as they are influenced by 
varying degrees of compression,’ he says: “When, however, the 
local process is in the near proximity of, or, if remote, when its 
effects are so far reaching that the vital centers of the bulb are 
compromised, the one symptom which with regularity is called 
forth, and which betokens a serious alteration in the local circula- 
tion, is a persisting rise in blood-pressure, which may or may not 
be associated with a pronounced vagus pulse, with respiratory 
changes, etc. The length of time experimentally during which 
these reactions can endure is considerable, even under the extreme 
degree of elevation—over 200 mm. of mercury from a level of 90 
or 100 mm., in many cases—to which we have pushed the blood- 
pressure.” This increased force of the current he figures as an 
effort of nature to overcome an obstruction. Yet the occurrence 
of this phenomenon presupposes an already existing increase of 
the intracranial pressure in the posterior fosse—a condition that is 
frequently produced by tumors. The same paroxysmal or longer 
elevation of the blood-pressure may also have to do with the fre- 
quent occurrence of brain hemorrhages in these cases. And yet 
in the case of a brain tumor it does not appear that any particular 
good is accomplished by this heightening of pressure. Certainly 
it must augment any ache. It affords therefore an added indica- 
tion for the use of depressants in easing and preventing the suf- 
fering of these patients. 

It is hardly necessary to give details of cases; and the still 
inevitable ending makes their recital less inviting. If the argu- 
ment appears sound, you can readily make use of the idea in 
suitable cases and arrive at your own conclusions. The claim that 
I present is simply that this in an improved palliative in a most 
distressing class of troubles. 





°*Amer. Journ. of the Med. Sciences, Sept., 1902. 


PRiGhES  bICEhPS:, AND FINGER ICLONUS. 


By THEODORE H. WEIsENBURG, M.D., 


INSTRUCTOR IN NERVOUS DISEASES, UNIVERSITY OF PENNSYLVANIA, ASSISTANT 
NEUROLOGIST TO THE PHILADELPHIA HOSPITAL. 


Theoretically, there is no reason why clonus of the triceps 
and biceps muscles should not be obtained when the tonicity of 
these muscles is increased, but such phenomena probably have 
not been described. The different text-books on nervous 
diseases (Gowers, Oppenheim, Mills, Strumpell), and Stern- 
berg’st work on the tendon reflexes make no mention of the 
phenomena. 

Triceps clonus was first obtained by me in the following 
case: 

J. N., aged fifty-seven years, was admitted to the Philadel- 
phia Hospital, April 1, 1903. At present he is in the insane 
department. Diagnosis: General paresis. History of syphilis 
and alcoholism was obtained. The symptoms began two and a 
half years ago. He has ideas of grandeur, hears voices, stum- 
bles over syllables. He has some tremor of the lips, and Argyll- 
Robertson pupils, and the left pupil is larger than the right. 
The tendon reflexes are markedly exaggerated, and ankle and 
patellar clonus are obtained on both sides. He has no sensory 
changes, and no bladder nor rectal disturbances. Tapping the 
right triceps tendon above its insertion into the olecranon, pro- 
duces a distinct clonus of that muscle, which is easily exhausted. 

Triceps clonus was obtained more typically in a second case, 
and is fully described in the following report: 

W. K., aged sixty-six years, was admitted to the service of 
Dr. William G. Spiller, in the Philadelphia Hospital, July 30, 
1903. His father died with hemiplegia. The patient had not 
contracted syphilis, but was alcoholic. Four years ago he had 
a right-sided hemiplegia with aphasia. At present he drags the 
right leg when walking. The lower distribution of the right 
seventh nerve is paralyzed. The right upper limb is contrac- 


*Sternberg, M. Leipzig ii. Wien., 1893. “Die Sehnenreflexe und ihre 


Bedeutung.” 


682 THEODORE H. WEISENBURG. 


tured at the elbow and wrist, and the fingers are flexed. The 
right knee is also* contractured, but all these contractures can 
be overcome on forced passive movement. The tendon reflexes 
are very much exaggerated on both sides, more so on the right 
side. He has ankle clonus, but no patellar clonus. Babinski’s 
sign is present. There is complete right-sided hemianesthesia 
for all forms of sensation. Incomplete hemianopsia is present. 
Atrophy is present in both sides, and is more marked on the 
paralyzed side. 

The patient holds his paralyzed arm close to the chest, the 
forearm being flexed at a right angle to the arm, the hand being 
supported by the sound limb. On tapping the triceps tendon 
above its insertion into the olecranon a distinct clonus of the 
triceps muscle is produced, lasting at times three to four sec- 
onds. It is hard to count the vibrations with the eye or hand, 
but the number varies between twelve and twenty. Excitement 
increases the clonic movement, and at these times tapping even 
with the finger over the body of the muscle almost as high as 
its upper insertion, in fact a slight jar over any portion of the 
forearm or arm, will bring on the clonus. Indeed, the patient 
says that at times, while resting quietly, clonus of the triceps 
muscle will be produced independently of any stimulation. 

The clonus consists in rapid extension and flexion of the 
forearm upon the arm, the triceps muscle stands out promi- 
nently, and in the rapid up and down movement of this muscle 
its tendinous insertions can easily be made out. 

By striking the biceps tendon near the elbow joint with a 
percussion hammer, there is produced at times a clonus of the 
biceps muscle, causing flexion and extension of the forearm 
upon the arm. This is not nearly as constant as the triceps 
clonus, and can only be brought out on excitement. The result- 
ing clonic vibrations are comparatively slow, there being from 
five to seven in two to four seconds. 

Sometimes percussion over the biceps or triceps tendons will 
bring both clonus of the triceps and biceps muscles, the triceps 
clonus outlasting the latter. Again, striking the triceps tendon 
will at times bring on a clonus of the wrist besides the triceps 
clonus. 


TRICEPS, BICEPS AND FINGER CLONUS. 683 


Clonus of the fingers is rarely found. Gowers? says that in 
an increased excitable state of the flexors of the fingers, a con- 
traction, and sometimes by maintaining the increased tension, a 
clonus can be obtained. Sternberg merely mentions the possi- 
bility of finger clonus. No other mention of such a condition 
was found in the text-books referred to. 

W. M., aged fifty-seven years, was admitted May 30, 1903, 
to the service of Dr. C. S. Potts, in the Philadelphia Hospital. 
He had right-sided hemiplegia, which developed twenty-six 
years previously. The man is chair-fast. The right upper limb 
is contractured at the elbow and wrist, and the thumb is turned 
inward, and the fingers are clenched. The right leg is con- 
tractured at the knee. All the tendon reflexes are increased. 
There are no sensory changes. Atrophy is more marked in the 
paralyzed side. Wrist clonus is not obtained on suddenly extend- 
ing the tightly clenched fingers, the hand being held, but there 


is resulting clonic vibrations of the fingers upon the carpo- 
metacarpal joint. The movements are rapid, consisting in a 


flexion and extension, are easily exhausted, but soon return, the 
number of vibrations never being more than from five to seven, 
and lasting from one to one and a half seconds. Sudden exten- 
sion of one finger or two fingers will not produce the clonus, but 
sudden extension of three or of all the fingers will. 

I am indebted to my chief, Dr. William G. Spiller, for the 
privilege of reporting two of these cases, and to Dr. Potts for 
the privilege of reporting the third. 


*Gowers, Sir W. R., 3d ed., p. 23, “Diseases of the Nervous System,” 
vol. I. 


STUDIES UPON THE CEREBRAL CORTEX IN THE NORMAL 
HUMAN BRAIN AND IN DEMENTIA PARALYTICA. 


By G. ALFRED LAWRENCE M.D., Pu.D., or NEw York. 


INSTRUCTOR IN DISEASES OF THE MIND AND NERVOUS SYSTEM, NEW YORK 
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. 


(Continued from page 648.) 


Several neuroglia cells as at N, rounded or oval in shape, 
are to be seen here also interspersed among the nerve cells, 
and they increase in number proportionate to the nerve cell de- 
crease as the white medullary center is reached. Several capillary 
blood vessels are to be seen in this layer, cut in different planes. 
Their walls are made up of a single layer of thin nucleated cells 
and the vessels filled with red blood corpuscles. The cells of 
this layer belong to the somatochrome class and either the 
archyochrome or gryochrome group, depending on whether one 
regards the chromatic substance as making up a distinct net- 
work as in the archyochrome group or as small granules ar- 
ranged in threads or heaps as in the gryochrome group. It is 
difficult to determine a network of any distinctness in the ma- 
jority of these cells, and they seem to the writer to belong 
more to the gryochrome group. The entire cortex thus meas- 
ures in this section approximately 2.85 mm. in thickness as it 
is really an arbitrary division to state just where the gray cor- 
tex ends and the subcortical white medullary substance be- 
gins, there being a gradual transition from the one to other here 
as well as between the layers of the cortex. In order to ob- 
tain the approximate number and ratio of the nerve cells to the 
neuroglia cells an effort was made to count the same in various 
sections of the photomicrograph, counting the nerve cells 
first and marking each one as counted by black ink, and after- 
wards doing the same for the neuroglia cells. Upon subse- 
quently using a Zeiss ocular micrometer divided into millimeter 
squares in a No. 3 ocular with a No. 6 objective, thus giving a 
magnification of 390 diameters, it was found that the former 
method, in which only a magnification of 100 diameters was 
used did not show all the structures present, and those shown 
were not sufficiently distinct at times to determine accurately 
their real nature, whether neuroglia cells, portions of nerve 
cells, etc. With the above magnification,—390 diameters,—and 
upon focussing in various planes, it was found for instance that 
a single mass upon the photomicrograph could be resolved into 
two or more neuroglia cells close to one another and in slightly 
different planes. By using the above combination it was found 


DEMENTIA PARALYTICA. 685 


that one side of the millimeter square in the eye-piece corre- 
sponded to .033 mm. of the stage micrometer and thus of the 
surface of the section under observation, so that a square milli- 
meter of the ocular network was therefore equivalent to .03323, 
or .00999 square millimeters (practically .o1 square millimeters, 
which latter decimal was used for convenience in this work) of 
surface of the section under examination. The ocular microm- 
eter was divided into 36 squares and the number of nerve cells 
in each of these squares was counted and recorded in seven dif- 
ferent fields, in this case in different parts of the section, thus 
making 252 squares in all. The result was added up and di- 
vided by 252 in order to give the average number of nerve cells 
for each square. This number was equivalent to that contained 
in .Ol sq. mm. of actual surface of the section, or practically 
I-100 of a square mm. The total number of neuroglia cells in 
108 squares from three different fields was determined in the 
same manner, the resulting total being divided by 108 to give 
the average number of neuroglia cells for each sq. mm. of the 
ocular net-micrometer or .oI sq. mm. of actual surface of the 
section. These results multiplied by 100 thus will give the num- 
ber of nerve and neuroglia cells for each square millimeter of 
actual surface of the section. With this method the average 
number of nerve cells to each sq. mm. of the ocular net-microm- 
eter was found to be 1.1685; multiplied by 100 gives 116.85 as 
the average number of nerve cells to be found in each sq. mm. 
of this section in the second and third layers. In the region just 
below the middle of the second layer previously described as 
made up almost exclusively of small pyramidal cells these lat- 
ter are found very densely packed together, in many parts as 
many as 2.7 cells were found to each square on an average. 
This result multiplied by Ioo as before gives the high average 
of 270 nerve cells to each square millimeter in this narrow re- 
gion, whereas the general average for the entire second and 
third layer, not including this region, is but 93 nerve cells to the 
sq. mm., thus showing the great variation in regions of the 
same section closely approximating one another. The nerve 
cells of the first layer were so few and scattered that they were 
not included in this count. In the same way the average num- 
ber of neuroglia cells to the square millimeter of surface of the 
section was found to be 125. Counts were also made from a 
section from the first frontal convolution, somewhat anterior to 
that from which Plate II, Fig. 3, was taken. This latter block 
was hardened in alcohol, the section was Io microns in thick- 
ness, and similarly stained with methylene blue. Decolorization 
was not carried on to such an extent, so that the neuroglia cells 
were not decolorized, and the section being 10 microns in thick- 


686 G. ALFRED LAWRENCE. 


ness in comparison to 6 2-3 microns in Plate II, Fig. 3, the neu- 
roglia cells were found to be more numerous. This would 
seem to indicate that fixing in Van Gehuchten’s fluid and stain- 
ing the same length of time in warm methylene blue results in 
a somewhat greater decolorization of the neuroglia cells in the 
following differentiation than in sections hardened in alcohol 
and treated similarly in respect to staining and differentiation. 
As stated this section was 10 microns in thickness, whereas that 
of Plate II, Fig. 3 is but 6 2-3 microns in thickness; but it will 
be seen by the following figures that whereas there is only a 
slightly greater number of nerve cells in the former as compared 
to the latter the neuroglia cells are considerably in excess in the 
former. Here counts were made in seven different fields of 36 
squares each in various parts of the second and third layers for 
the nerve cells, and in all three layers for the neuroglia cells. 
The average number of nerve cells was found to be 1.27 to each 
sq. mm. of the ocular net-micrometer, which multiplied by 100 
gives 127 as the average number of nerve cells to the sq. mm. of 
surface of the section. In the same way the average number of 
nuroglia cells was found to be 1.64 to the square millimeter of 
the ocular net-micrometer, which again multiplied by 100 gives 
164, as the average number of neuroglia cells to each sq. mm. of 
surface of the section. The difference in the number of nerve 
cells in the two sections is not very great,—about Io per cent, 
but in the number of neuroglia cells it is much more marked,— 
over 30 per cent, due partly to the difference in thickness and 
partly to the greater decolorization of the first section described 
(Table Il). Hammarberg (1895) for counting nerve cells, and 
Popoff (1894) for determining the ratio of increase in neuroglia 
cells in acute and chronic cases of Asiatic cholera, used the 
ocular net-micrometer in a manner similar to that made use of 
in this article, but in each case in a different line of investiga- 
tion; the former in the study of idiocy, and the latter, as already 
stated, in Asiatic cholera. The number of nerve cells and of 
neuroglia cells, as well as their ratio to one another, varies in 
the different layers of the cortex. In the first layer there are 
but few nerve cells, whereas the nuroglia cells are about the 
same or even more in number than in the other layers, thus 
making a high ratio. In the second and third layers, however, 
the cells are the important elements and occupy the greatest 
amount of space, and although fewer numerically than the neu- 
loglia cells the latter are much smaller, less conspicuous, and 
the ratio is not so great. Then again the cells are not evenly dis- 
tributed, but have a tendency to be arranged more or less in 
irregular groups, so that in some places they are relatively 
widely scattered, whereas in others they are more closely ag- 


DEMENTIA PARALYTICA. 687 


. 


gregated, so that a number of counts in various parts of the 
field are necessary to get an approximate average of the num- 
ber of cells. The thickness of the section, degree of staining, 
and extent of differentiation or decolorization must also be 
considered in Nissl work, as too great decolorization will pre- 
vent some cells from being recorded in a photomicrograph, and 
an extremely thin section would not contain as many cells as a 
thicker one. Sections 6 2-3 and 10 microns in thickness (two 





Plate III, Fig. 7. 


and three clicks of the Minot microtome) were used in this 
work, and when well stained and decolorization is not carried 
too far, will show all cells to be found in such a plane. 

Central Region Turning now to the region posterior to this 
we come to the motor region of the cortex, comprising the an- 
terior and posterior central convolutions. This region is of 
especial interest in many ways, and has probably been more 
extensively studied than any other of the various regions of the 
cortex. Plate III, Fig. 7, is a photomicrograph magnified 14 


688 G. ALFRED LAWRENCE. 


diameters, taken from a section Io microns in thickness at the 
upper third of the anterior central convolution of Brain A. 
(Plate I, Fig. 1, 2.) This block was also fixed in Van Gehuch- 
ten’s fluid, imbedded in paraffin and sectioned serially by a 
Minot microtome. This section was then stained with warm 
methylene violet, differentiated in alcohols, 30, 50, 70 and 95 
per cent., and absolute, cleared in xylol and mounted in xylol- 
damar. The actual size of the section which includes the entire 
width of the gyrus, is .7 of ac. m. in width by .7 c. m. in depth, 
and taken from a block .4 cm. in thickness, the plane of the sec- 
tion being at right angles to the direction of the gyrus. At the 
point a and outlined in ink is the strip seen in Plate III, Fig. 
8, at a magnification of 100 diameters. The outer layer of the 
cortex is seen to be fairly uniform in thickness, with the excep- 
tion of the regions indicated at b and c. At bd this layer is con- 
siderably thicker than in any other part, gradually diminishing 
in thickness near a where it is of the average thickness. At the 
point c is seen a slight thinning of the cortex, which in Plate 
IV, Fig. 9, results in the entire disappearance of this layer and 
is intermediate in degree in Plate IV, Fig. 11. This condition 
will be more fully discussed in the description of these latter 
plates, and it will be simply stated now that this is an artefact 
probably due to manipulation. The general. radiating appear- 
ance of the cortex from the white medullary center to the per- 
iphery is well seen here. In the region of the lower part of the 
second or middle cortical layer even with this low magnification 
can be distinctly seen the giant pyramidal, or Betz cells ar- 
ranged singly or in groups. Below this the cortex becomes 
paler and finally merges into the central medullated white sub- 
stance. This magnification is especially good for studying the 
arrangement of the Betz cells. Beginning with the first group 
in the lowest part of the section on the right, which is the 
posterior surface of the gyrus, opposite I is a single Betz cell 
of moderate size; just above this, opposite 2 is a group of two 
Betz cells, one nearer the surface and above the other in the 
lower part of the second or pyramidal cell layer. Somewhat 
higher up, opposite 3, and somewhat deeper, are seen two very 
large Betz cells, one deeper and further from the surface, as 
well as higher up than the other. Opposite 4 are three Betz 
cells too far separated to be considered as a single group, so 
must be regarded as solitary cells. Just above them at 5 are 
three smaller cells, one above the other at about the same depth 
of the cortex. Opposite 6 are two small Betz cells, one nearer 
the surface than the other. Then for a considerable distance 
no Betz cells are to be seen until we reach a point opposite 7 
where a fair sized solitary cell is made out. Just above this 


DEMENTIA PARALYTICA. 68 9 


opposite 8 are two rather small Betz cells, and a short distance 
above at 9 a group of three containing two large and one small 
Betz cell. Opposite 10, and just below the lower ink mark are 
two very large Betz cells, one overlapping the other, giving the 
appearance of one in the plate. Just above the ink line opposite 
II is to be seen a group of four Betz cells, one large, and the 
other three smaller. These and those above and included be- 
tween the two parallel ink lines can be seen at a thagnification 
of 100 diameters in Plate JII, Fig. 8, this group being on the 
extreme right of the latter. Opposite 12 is a group of four Betz 
cells arranged radially, the upper of the two in the middle being 
the largest, and the lowest next in size. Opposite 13 1s a large 
solitary Betz cell, and above this and opposite 14 is a group 
of three Betz cells. Opposite 15 is another large solitary Betz 
cell, below which, and a little deeper in the cortex between it 
and the previously described group, is another Betz cell of me- 
dium size. Just above this is a group of two smaller Betz cells. 
Opposite 16 are three large cells in a group which are just to 
the left of Plate III, Fig. 8, and are intermediate in type be- 
tween the well defined Betz cells and the ordinary large pyram- 
idal cells, above this and opposite 17 is another group of four 
cells similar in type. Opposite 18 is a group of two Betz cells, 
one considerably larger than the other and nearer the surface 
of the cortex; in the same radial line is a medium sized solitary 
Betz cell. Just above this are five Betz cells opposite 19 and 
radially arranged in a row. Opposite 20 is a solitary Betz cell, 
and just above opposite 21 is a group of two Betz cells, one very 
large and the other quite small. Above this (to the left) are a 
number of pyramidal cells scarcely large enough to be consid- 
ered as Betz cells, although as previously noted there are inter- 
mediate forms which might be considered as very small Betz 
cells or very large pyramidal cells. Opposite 22 are seen three 
Betz cells rather scattered, the one in the middle being at a 
deeper level of the cortex. Opposite 23 is seen a small soli- 
tary Betz cell, and opposite 24 is another solitary Betz cell 
which is on the anterior aspect of the gyrus. Between it and 
the last described cell are quite a number of large cells interme- 
diate in type between the Betz cell and the largest pyramidal 
cells. Opposite 25 is still another solitary Betz cell. Then 
comes a region for a considerable distance in which are seen 
several large cells at this level, but hardly large enough to be 
considered as Betz cells until we reach that part of the cortex 
on the anterior aspect of the convolution opposite 26, where we 
see a group of two made up of a large Betz cell and a smaller one. 
Finally below this, at a considerable distance and opposite 27, 
is a group of three Betz cells, the one in the middle being large, 


690 G. ALFRED LAWRENCE. 


and the other two small. It will be seen that the Betz cells are 
larger and more numerous on the posterior aspect of the gyrus 
than upon the anterior aspect. There are thirty-one groups of 
these cells in all, 13 of which contain but a solitary cell, so can 
hardly be considered as a group, though of course many of them 
form part of a group, the remaining cells being in another 
plane. Ten of these groups contain two cells each, 5 cells each, 
and but two groups have four cells each, and one group has five 
cells, making 61 Betz cells in all in this section. Beginning pos- 
teriorly and following around to the lowest group on the ante- 
rior surface, the number of cells in each group as seen in the 
same plarie is as follows -——1, 2,2, 1, 1, 1,3, 2, 12)3).2, 4,4,.1793; 
Ti), 2,2, 2,41) Syl epee a eine: AN esc CoMemtencecncr 
in the cortex and thus at a greater distance from the surface in 
the posterior aspect of the gyrus than at the vertex or at the an- 
terior aspect. Of course the number of cells in this one plane 
does notrepresent in every case all the cells in a-group, but only 
those in this particular plane. As many of these groups are 
more or less spherical no one plane will show more than a part 
of such a group, and as stated above some of these solitary cells 
are the outer members of some of these groups. 

Plate III, Fig. 8, as previously stated, shows the strip a of 
Plate III, Fig. 7, under a magnification of 1oo diameters and in 
strong contrast to Plate II, Fig. 3, is to be seen the much larger 
number of neuroglia cells, the methylene violet stain seeming to 
have a stronger affinity for the neuroglia cells than the methyl- 
ene blue stain. The cortex in this plate is also seen to be more 
condensed and not so deep as in Plate II, Fig. 3. The first layer 
measure but .20 mm. in thickness in contrast to .25 mm. in the 
above mentioned plate. In this layer neuroglia cells are more 
numerous, with a few scarcely scattered nerve cells only to be 
made out under high magnification, and similar to those found 
in the first layer in Plate II, Fig. 3. The second or pyramidal 
cell layer is of special importance and interest. It is deeper 
than the corresponding layer in Plate II, Fig. 3, measuring 1.75 
mm. in thickness as contrasted to 1.40 mm. in the former. Here 
too in addition to the large and small pyramidal cells are found 
the giant pyramidal or Betz cells, irregularly distributed, singly 
or in groups, and at different levels, so that it is impossible to 
describe them as forming a distinct layer, although in this plate, 
with the exception of one cell, at a they appear to be placed in 
the lower part of this portion of the cortex now being described. 
In taking one section after another, however, it will be found 
that these cells are located at different levels, the majority be- 
ing in the lower portion of this second layer. They furthermore 
have a tendency to be arranged in groups containing from two 


DEMENTIA PARALYTICA. 691 


to ten cells, rarely more, and finally we find some sections con- 
taining no Betz cells at all. The pyramidal cells in the motor 
area are found to be larger in size on an average than those of 
the frontal region. The chromatic substance is not arranged in 
such large distinct bodies as in the Betz cells, but may be seen 
distributed in clumps of finer or coarser granules in different 
parts of the cell-body, especially about the nucleus and about 
the base, and at the beginning of the dendritic processes in 
the cell-body. Fig. M (M, of Plate III, Fig. 8), shows one of 
these cells under a high power, X1300 (No. 3, ocular, 1-12 inch 
oil immersion objective, Leitz). Here the finely granular chro- 
matic substance is distributed in a ring about the nucleus, a 
clump is seen at the base to the left where a dendritic process is 
given off and also clumps are seen at the base of the dendritic 
process on the right and other clumps in the upper part of the 
cell-body and in the apical process. In addition to this, small 
sized linear and rounded chromophilic bodies are seen in the 
upper part of the cell-body and apical process and also in the 
dendritic processes given off at the base. The nucleus here is 
large, rounded, centrally placed, and contains a round, deeply 
stained, prominent nucleolus, surrounded by slightly stained 
homogeneous nuclear substance. In some cells the finely gran- 
ular chromatic substance predominates in the cell-body, while 
in others the small chromophilic bodies are more prominent, 
whereas the majority contain both, as in the above described 
cell. In some of the smaller pyramidal cells the large nucleus 
almost fills up the cell-body, with but a narrow rim of finely 
granular chromatic substance surrounding the same and ex- 
tending into the apical and basal processes. These latter cells 
would be classified under the group of karyochrome nerve cells; 
whereas the larger pyramidal cells with the stainable substance 
arranged in striz in the same direction as the contour of the 
cell-body come under the head of the stichochrome nerve cells 
of the somatochrome class. Turning to the Betz cells and ex- 
amining these under a high power (No. 3 ocular 1-12 inch oil 
immersion objective, Leitz. X1300) they are seen to contain 
numerous distinct chromophilic bodies varying in size and shape. 
In Fig. N (N, of Plate III, Fig. 8) the upper part of the cell is 
not included in this section. From below are seen two dendritic 
processes given off from the under side of the cell-body, that is 
having the cell-body from a lower plane than figured in the 
drawing, upon the right side; and one slightly larger process 
from the left side. These at intervals contain distinct chromo- 
philic granules, for the most part linear in shape, with the long 
axis parallel to the axis of the process and extending for a con- 
siderable distance into the process—as far as they could be 


692 G. ALFRED LAWRENCE. 


traced in the section. About the middle of the left dendritic 
process is seen a large irregular chromophilic body at a point 
where a branch is probably given off, as wedge-shaped chro- 
matic masses are often found at the point of branching of a den- 
dritic process, Nissl’s so-called “wedges of division.” Within 
the cell-body the granules are seen to be elongated, rounded or 
irregular in shape, the first mentioned predominating; some 
much larger than others, and with the general arrangement of 
the long axis parallel to the sides of the cell-body. The nucleus 
is large, well defined, and placed in the upper part of the cell- 
body and nearer the right than the left side. There is a well 
defined, deeply stained nucleolus centrally placed and surrounded 
by a homogeneous, slightly colored nuclear substance, with no 
well defined network. At the base of the cell-body, occupying a 
space somewhat larger than the cell nucleus is a deposit of 
yellowish pigment, elliptical in outline, and entirely displacing all 
other cell contents. No other pigment is to be found in this cell. 
The arrangement of the chromophilic granules in strize in the same 
direction as the contour of the cell-body classifies it as a sticho- 
chrome nerve cell of the somatochrome class. Fig.o (o of Plate III, 
Fig. 8) shows another of these Betz cells examined under the 
same magnification of 1,300 diameters (No. 3 ocular, 1-12 in oil 
immersion lens, Leitz), in which the arrangement of the chro- 
mophilic bodies in striz parallel to the contour of the cell-body 
is very well marked. This arrangement extends far out in the 
basal process and high up in the apical process. The nucleus is 
situated more on one side of the cell-body than the other, and the 
nucleolus is not included in this plane. There are three dendritic 
processes to be seen, the apical extending for a considerable dis- . 
tance towards the periphery, and gradually decreasing in size, 
and two basal processes, the one to the left unbranched, while 
the one on the right gives off a large branch shortly after leaving 
the cell-body, at which point a is one of the so-called “wedges of 
division” of Nissl. There is no pigment in this cell, but in the 
one seen just below this in Plate III, Fig. 8, marked P, a large 
mass of yellow pigment is seen above and to one side of the nu- 
cleus at the base of the apical process. There are but few 
chromophilic bodies in this cell compared to the two previously 
described, the chromatin being for the most part in the form of 
fine granules arranged in larger and smaller masses in different 
parts of the cell. The Betz cell seen lying just below and to the 
right of this latter, and marked Q in Plate III, Fig. 8, also con- 
tains a small mass of pigment poorly defined, and lying just below 
the nucleus at the base of the cell. The other Betz cells seen 
in this plate contain no pigment. While discussing the Betz cells, 
and before proceeding to the description of the third layer, sev- 
eral other photomicrographs will be described as illustrating the 





. 
| 
| 


———— 


DEMENTIA PARALYTICA. 693 


grouping and structure of these cells. The first of these, Plate 
IV, Fig. 9, is a photomicrograph magnified 14 diameters of a 
section in close proximity to that seen in Plate III, Fig. 7, of the 
same size as this latter and treated in the same way, excepting 
that methylene blue was used as the stain here. Opposite a, and 
enclosed in ink lines, is the segment of the section shown in 
Plate IV, Fig. 10, under a magnification of 100 diameters. . The 
other layer is seen to vary in thickness, being much thicker at the 
posterior aspect, at b, than at the vertex or the anterior aspect. 





Bigs J; 


At c and d the second layer is seen at the surface, due no doubt 
to injury in manipulation, probably more from pressure than 
actual tearing, as the surface is smooth and continuous at both 
ends, with the adjacent surfaces. No doubt artefacts similar to. 
this, and of greater or less extent, must be carefully guarded 
against and considered in all work upon such a delicate and yield- 
ing tissue as the brain, especially when secured within a few 
minutes after death, as in this case, and before any post-mortem 
fixity results. The second layer shows the radial arrangement 
of the cells, but the most conspicuous feature is the distribution 
and arrangement of the Betz cells contained in the lower part 


694 G. ALFRED LAWRENCE. 


of this layer singly or in groups of varying number and size. 
Below this the less conspicuous third layer is gradually lost to 
view as it merges into the white medullary substance. The ar- 
rangement of the Betz cells will be described in detail as photo- 
micrographs of this magnification, 14 diameters, show their dis- 
tribution especially well. Beginning at the posterior portion of 
the convolution below the letter b, the first large Betz cell is to 
be seen opposite the figure 1, and is solitary, whereas just above 
and opposite 2, is a group of four Betz cells all of about the 
same depth of the cortex. Above this, opposite 3, is a large soli- 
tary Betz cell. Opposite 4 is a group of three cells arranged 
radially above one another. Opposite 5 is another solitary Betz 
cell. Above it a small portion of a Betz cell is seen which lies 
mostly in another plane, while below it small portions of three 
Betz cells are seen lying for the most part in another plane. 
Above this, and opposite 6, is a group of two Betz cells at the 
same depth, and one just above the other. Between 6 and 7 are 
seen cells, two in number, which might be regarded as inter- 
mediate in character between the large pyramidal and Betz cells, 
having a similar arrangement of chromophilic substance, but of 
intermediate size. Opposite 7 is a group of two Betz cells, and 
opposite 8 is another group of two Betz cells somewhat nearer 
the surface, and just under this latter group and deeper in the 
cortex is a solitary Betz cell. Opposite 9 is a group of two Betz 
cells, only a very small portion of the upper cell being seen in this 
plane. Opposite 10, a portion of a solitary Betz cell is seen, and 
opposite 11 1s still another solitary Betz cell. Opposite 12 is a 
group of three Betz cells, and just to the right of this and at the 
same level, is a part of a solitary Betz cell, while nearer to the 
surface and in the same radial line is still another small solitary 
Betz cell. Opposite 13 is a group of six Betz cells, two of which 
are large, and appear very prominently, the other four lying 
somewhat to the right, being smaller, but having the characteris- 
tic structure of the Betz cells. Opposite 14 is a solitary Betz 
cell, and next we come to the two groups seen under a magnifica- 
tion of 100 diameters in Plate IV, Fig. 10, and in this plate seen 
enclosed in ink lines and opposite figures 15 and 16. The first 
group, or that opposite 15, contains nine well defined Betz cells, 
while the adjacent group, opposite 16, contains six Betz cells, 
three large cells and the segments of three others, the greater 
part of these latter lying in another plane. Opposite 17 are four 
scattered cells at about the same depth of the cortex, and inter- 
mediate in size and structure, between the large pyramidal and 
the Betz cells. Opposite 18 is a large solitary Betz cell, above 
and below it being the cells intermediate in type just described. 
At Ig is a group of six, made up of one large Betz cell and five 
smaller ones about it. Above and below this are other pyramidal 


DEMENTIA PARALYTICA. 695 


cells at this level, and of the above described intermediate type. 
There are in all fifty-nine of these Betz cells in this section, ar- 
ranged singly or in groups; beginning posteriorly at 1, and 
proceeding around to the anterior and last group at 19, as fol- 
MUS tT A eins) SL e242, 12, N14 gee Lge eG 13 
I, 6, I, 9, 6, 1 and 6, thus making twenty-three groups in all, 
eleven of which contain solitary cells, four contain two cells, three 





Plate IV, Fig. 10 


contain three cells, one contains four cells, three contain six cells, 
and one nine cells, in the plane of this section. Of these cells thirty 
contain distinct pigmentary deposits, these being practically all 
of the larger cells. Quite a number of the others in the plane of 
the main portion of the cell would undoubtedly also contain pig- 
mentary deposits. The grouping, of course, is here described for 
only the plane of this section and the probability is that some at 


696 G. ALFRED LAWRENCE. 


least of these solitary cells are a part of a group,, the remaining 
cells lying in another plane. Furthermore, some of the groups 
described may contain additional cells lying in the plane above and 
below that of this section. Plate IV. Fig. 10, previously men- 
tioned, has a magnification of 100 diameters, and includes the strip 
@ outlined in ink in Plate IV. Fig. 9. Two groups of Betz cells 
are seen, one containing nine and the other six cells. Two other 
cells, a and b, though smaller yet in structure approach in charac- 


— 





Plate 1V3- Fig. 12 


ter the Betz cells. It will be noticed that the cortex is not so deep 
in this plate, the first layer being but .175 mm. in thickness, and 
the second but 1.20 mm. in thickness in comparison to .20 and 1.75 
mm., respectively, in Plate III. Fig. 8. It will be noted, however, 
that this strip was taken from the vertex of the section where 
the cortex is not so deep as on the posterior aspect from which 
Plate III. Fig. 8 was taken. These two groups of Betz cells are 
but 1.20 mm. from the surface of the cortex here in contrast to 
1.70 mm. in Plate III. Fig. 8, showing the variability in thickness 
of the cortex in close proximity, as both plates were made from 





Plate II, Fig. gate VII, Fig. 21. Peta tem Vell bos kao. 232 





Plate II, Fig. 3. 


Biarew Ui e ss. 


Plate VI, Fig. 17. 


Plateenval eae ene. 
Plate Ue ioe te 


PhatesV LS one 





Plate <y LE sic as 





DEMENTIA PARALYTICA. 697 


sections cut from the same block which was not more than half a 
centimeter in thickness. The Betz cells here have the same 
structural characteristics as those described in Plate II]. Fig. 8, 
and five-of the cells, marked c, d, e, f, and g, of the larger group, 
and two of the cells, marked 1 and 7, of the smaller group, contain 
distinct yellowish pigment. The larger of the two groups and 
containing nine Betz cells is made up of two very large cells cut 
in the plane of the nucleus, four smaller cells also cut in the plane 
of the nucleus, while the remaining three cells show only a small 
portion of the body of each cell here, the large portion of these 
latter being in another plane. Five of these nine cells contain de- 
posits of pigment, and all show the chromophilic granules, being 
seen especially well in the cells marked c, d, e, and h. The cells in 
this group are quite close to one another and do not take up a very 
large space. The smaller group to the left contains six Betz cells, 
three large and conspicuous, and three others, one to the right and 
two to the left of these large cells which lie only partially in this 
plane and are small in size. Two of the three large cells marked 
1 and 7 contain deposits of yellowish pigment at the base of the 
body of the cell, and all contain well defined chromophilic bodies. 
Plate IV. Fig. 11 is another photomicrograph ofa section from 
the same block as that from which the sections represented in 
Plate III. Fig. 7, and Plate IV. Fig. 9, were taken. This section 
is 10 microns in thickness, stained with methylene blue and other- 
wise similarly treated as the above mentioned plates. This mag- 
nification of 14 diameters shows the outer layer to be fairly uni- 
form in thickness, excepting at the points b andc. At 0 it is of 
relatively the same thickness as at the same point b in Plate IV. 
Fig. 9, about one and one-half times as thick as at d into which 
it gradually merges. At c where no outer layer is to be seen in 
Plate IV. Fig. 9, here the outer layer is distinctly seen but 
somewhat thinner than on either side, showing the artefact to be 
less in degree in this section. At athe group of cells represented 
in Plate V. Fig. 13, is seen, and each cell can easily be distinguish- 
ed and counted under this magnification of 14 diameters. The 
second layer here is also especially interesting in respect to the 
size, number and distribution of the Betz cells singly or in groups 
in the lower portion of the layer near the transition into the third 
or spindle cell layer. This latter is less distinct and lost below 
in the medullary white substance in the interior of the gyrus. A 
detailed description of the arrangement of these Betz cells will be 
given in order to compare the same with those of Plate ITI. Fig. 7, 
and Plate IV. Fig.9. Beginning with the first group at the lowest 
part of the section on the right, which is the posterior surface 
of the gyrus, opposite I, is seen a group of three large Betz cells. 
Above this some distance opposite 2, is a solitary Betz cell. Op- 
posite 3, is another group of three Betz cells at a slightly greater 


698 G. ALFRED LAWRENCE. 


depth. Above this and opposite 4 and 5, respectively, are large 
solitary Betz cells. Then there is a considerable interval where 
there are a number of large pyramidal cells but scarcely approach- 
ing the size of a Betz cell until the point opposite 6 is reached 
where a large solitary Betz cell is seen and just above it a group 
of two Betz cells somewhat smaller in size is to be noted. Oppo- 
site 7 is a solitary Betz cell at a greater depth. Just above this 
and slightly nearer the surface are several intermediate type cells 
arranged in two rows, one at a slightly greater depth than the 
other. Opposite 8 and at the same level as the preceding is a 
solitary Betz cell, and above this opposite 9 is a larger solitary 
Betz cell. At the same depth and slightly nearer the vertex is a 
group of two Betz, cells, one large and the other small. About 
midway between these and the surface of the cortex are seen sev- 
eral very large pyramidal cells, the so-called intermediate type 
between the Betz cells or giant pyramidal cells and the ordinary 
sized large pyramidal cells. Opposite I0 is seen a group of two 
very large Betz cells just below and to one side of a large blood 
vessel. Just above this and nearer the surface is a small solitary 
Betz cell. Opposite 11 are three groups of Betz cells, the first con- 
taining three, the second two, and the third above and nearer the 
surface consisting of a large solitary Betz cell. Opposite 
I2 is a large solitary Betz cell, considerably nearer the 
surface than the groups just described. A group of two large 
Betz cells, one just above the other, is seen opposite 13. This 
brings us to the large group opposite a and seen under a magni- 
fication of 850 diameters in Plate V. Fig. 13, containing eight 
Betz cells which will be described in detail later when discussing 
this latter plate. To the left of this group opposite 14 are seen 
three Betz cells of small size and somewhat separated from one 
another. To the left of these at a short distance are seen two 
Betz cells, one above the other. Opposite 15 are seen two groups 
of two each, the cells in the first group being somewhat separated 
from one another and one above the other. Opposite 16 is a well 
marked group of four Betz cells, two being very. large and the 
other two smaller in size. Below this and upon the anterior sur- 
face of the gyrus opposite 17 are two solitary Betz cells, one 
lower than the other and nearer the surface. Opposite 18 is still 
another smaller solitary Betz cell at a greater depth. For some 
distance below this no Betz cells are to be seen until opposite 19 is 
a solitary Betz cell. Just below this and slightly nearer the sur- 
face is a group of three of the intermediate sized cells. Opposite 
20 are two large solitary Betz cells, the lower larger one being at 
a slightly greater depth. Then comes another region barren of 
these cells until the point opposite 21 is reached where a small 
solitary intermediate size cell is seen, and below this a group of 
two of these same cells is to be noted, one at a greater depth than 


DEMENTIA PARALYTICA. 699 


the other. Opposite 22 is a very large solitary Betz cell. Just 
below this are two intermediate size cells, and still below this 


’ and at a slightly greater depth are three of these intermediate size 


cells. This includes all the Betz cells though, as above noted, here 
and there in different parts of this layer; but for the most part 
in the same relative position, are to be seen very large pyramidal 
cells approximating these Betz cells both in size and structure, 
and the writer thinks should be regarded as intermediate in type 
between the large pyramidal cells and the giant pyramidal or Betz 
cells,—a transition form, if they might be so called. There are 
twenty-eight groups of these Betz cells in all in this plate, varying 
in number from one to eight cells in each group, one to three being 
the usual number. Fourteen of these groups contain but one cell 
each, and these so-called solitary cells are usually of large size. 
There are eight groups containing two cells each, four groups of 
three cells each, but one group containing four cells, and one 
group containing eight cells. Taking the groups from the lower 
portion of the posterior surface in succession, as above described, 
and the number of cells in each of the twenty-nine groups is 
PMN iLEH DENSTTOLLOW SLi 3s Ie Qi oT TL Outs hee Deer neat sen, | 
2, 8, 3,2, 2, 2, 4, 1, I, I, 1, 1, making a total of fifty-five Betz cells 
in the section, and thus averaging about two cells to each group. 
The number of groups is somewhat more than in Plate IV. Fig. 9, 
in which there were twenty-three groups containing in all fifty- 
nine Betz cells, and somewhat less than in Plate III. Fig. 7, where 
there are thirty-one groups containing sixty-one cells. It will 
thus be seen that the average number of groups and total number 
of cells in these three sections from near-by portions of the same 
block are fairly uniform in regard to the arrangement and dis- 
tribution of the Betz cells. It is to be noted that more cells are 
found on the posterior aspect of the gyrus than on the anterior. 
In Plate III. Fig. 7, there are fifty cells arranged in twenty-five 
eroups on the posterior aspect of the gyrus, with but four cells in 
two groups at the vertex, and seven cells in four groups on the 
anterior aspect. In Plate IV. Fig. 9 there are thirty-seven cells 
arranged in nineteen groups on the posterior aspect of the gyrus, 
fifteen cells in two groups at the vertex, and seven cells in two 
groups on the anterior aspect. Finally, in Plate IV. Fig. 11, there 
are twenty-seven cells arranged in seventeen groups in the pos- 
terior aspect of the gyrus, nineteen cells in six groups at the ver- 
tex, and nine cells arraned in six groups on the anterior aspect. 
It will thus be seen that most of the Betz cells are on the pos- 
terior aspect of the gyrus and gradually diminish in number upon 
approaching the vertex until upon the anterior aspect there are 
but few to be seen. Table III. shows the above results in tabu- 
lated form. Upon referring to this latter it will be seen that the 
average number of cells in each section is fairly uniform—s5, 59 


700 G. ALFRED LAWRENCE. 


and 61 for the three sections; the grouping is somewhat more 
variable—23, 29 and 31, most of the cells singly or in groups of | 
two or more being upon the posterior aspect and vertex. This 
corresponds to the findings of Lewis and Clarke (’78) who ex- 
amined sections from various parts of the left anterior central con- 
volution and the posterior portion of the two upper frontal con- 





Plate V, Fig. 13 


volutions on the same side in several human brains microscop- 
ically, and made diagrams of the distribution of the Betz cells at 
various points instead of employing photomicrographs showing 
the number, arrangement and relation to other elements of the 
cortex of these Betz cells as in this article. Plate V. Fig. 13 is 
a beautiful photomicrograph of a group of these Betz cells mag- 
nified 825 diameters and taken from the point marked a in Plate 
IV. Fig. 11. Here is seen a “nest,” or group of these cells, eight 


DEMENTIA PARALYTICA. 7OL. 


in number. All of these Betz cells contain pigment excepting the 
one marked a which in size is not much larger than one of the 
large pyramidal cells, but in structure resembles the Betz cells. 
This pigment, varying in amount, is situated at the base of the 
cell below the nucleus, excepting in the cell marked b where it is 
just above the nucleus. In the cell marked c it extends down into 
the large basal dendritic process, given off to the right for a short 
distance. In the cells marked c, d, e, f and g, the cell body appears 
of a lighter color in the photomicrograph where this yellowish pig- 





Plate TV, Fig. 32 


mentary deposit is found. The cell marked c, sectioned outside of 
the plane of the nucleus, shows very well the general arrangement 
of the rounded or elongated chromophilic bodies in a direction 
parallel to the contour of the cell-body, thus classifying it with 
the others of similar type as stichochrome nerve cells of the 
somatochrome class. The cell marked e shows the general parallel 
arrangement of the chromophilic bodies in the apical process very 
well. The group, as a whole, is very compact and as each cell is 
cut in a somewhat different plane from the others most of the 
features of such a “nest” are thus brought out. Of course, there 
may be other cells in this group lying outside of the ones seen here 
—in the planes above and below this. Plate IV. Fig. 12 is a pho- 


702 G. ALFRED LAWRENCE. 


tomicrograph of a Betz cell magnified 1,400 diameters from a sec- 
tion adjacent to and upon the same slide as that from which Plate 
III. Fig. 8 was taken. The section is, therefore, similar in shape 
to the one in Plate III. Fig. 7, and this cell is situated in a posi- 
tion opposite to the letter d, and in the lower portion of the second 





Plate V, Fig. 14 


or pyramidal cell layer of this latter. The section is ten microns 
in thickness and stained with methylene violet. It can readily be 
appreciated from this photomicrograph that only an extremely 
thin plane can be seen under such a high magnification and not 
all of this even will be in sharp focus. The nucleus here is mostly 
below the plane of the section and the deeply stained nucleolus en- 
tirely so. Two dendritic processes are faintly seen coming off 
from the base of the cell, the one on the right but faintly shown 
as it is at a different level for the most part. The one on the left 


DEMENTIA PARALYTICA, 703 


is somewhat more distinct and chromophilic bodies are found to 
enter the base and extend for a considerable distance into the 
same. These bodies of varying size and in general rounded or 
linear in shape, are closely packed in most parts of the cell-body, 
excepting at the base where a large deposit of yellowish pigment, 
taking up about the same area of space, as the nucleus, is to be 
found. These chromophilic bodies are arranged in general par- 
allel to the contour of the cell-body and extend into both the 
basal dendritic processes and the apical process as far as they can 
be traced. A portion of another Betz cell smaller in size is seen 
above and to the left. About the larger cell are several neuroglia 
cells singly or in groups, and these are seen to be distinctly round- 
ed or oval with usually a ring of chromatic substance of varying 
thickness at the periphery and several irregular deeply stained 
bodies in the center. Twenty neuroglia cells in all are seen in 
this plate. Plate V. Fig. 14, is a photomicrograph of the same 
magnification,—1I,400 diameters,—as the preceding and taken 
from a section of the same block. The section of the same 
form and size as that seen in Plate III. Fig. 7, is ten microns in 
thickness, and stained with methylene blue instead of methylene 
violet, but otherwise treated in exactly the same way. One 
noticeable point about this plate is the absence of neuroglia cells, 
in marked contrast to Plate IV. Fig. 12, indicating again that the 
neuroglia cells do not retain the methylene blue stain with the 
same intensity as when similarly treated with methylene violet. 
Here is seen a group of two Betz cells, the upper one, at this 
plane broadly pyramidal in shape, and the lower one presenting 
an irregular spindle shape. This latter, however, is only the base 
of the cell, the process above and to the left and that below and to 
the right being basal dendritic processes, and the apical dendritic 
process extending upward beyond the base of the upper cell in a 
different plane. There are two other Betz cells just above and 
slightly to the right of these cells in the section, not shown in the 
plate, thus making the group consist of four cells in all. Both of 
these cells are cut in the plane of the nucleus and large, rounded, 
deeply stained nucleolus. The nuclear body also contains some 
chromatic substance arranged in an indefinite network. At the 
base of the lower cell and extending into the large basal dendrite 
to the right as far as it is seen in this section is a distinct mass of 
yellowish pigment displacing the other cell contents. In the plate 
it is of a lighter color than the rest of the cell. Above this in the 
cell-body about the nucleus, and extending into the other basal 
dendrite, are numerous rounded and linear chromophilic bodies. 
The upper cell shows three dendritic processes going off from the 
base of the cell-body on the right side, and two from the left side. 
These processes and the large apical process contain mostly linear- 
shaped chromophilic bodies, arranged in distinct striz, parallel to 


704 G. ALFRED LAWRENCE. 


the contour of the same. This arrangement also holds good at the 
periphery of the cell-body, the strize there too being parallel to the 
contour of the same, but about the nucleus the chromophilic bodies 
are so closely packed that it is more difficult to make out this par- 
allel arrangement. There is no pigmentary deposit in this cell. 
No neuroglia cells are to be seen in this plate, the methylene blue 
stain being used as stated above. Plate V. Fig. 15, from the same 
region and under the same magnification, 1,400 diameters, from 
a section ten microns in thickness and stained also with methy- 
lene blue, is an exceptionally fine photomicrograph of one of these 





Plate V, Fig. 15 


Betz cells, inasmuch as it shows the processes, especially the apical 
process, as far as the edge of the plate. It is usually difficult to 
obtain such an extent of surface of a cell in the same plane under 
such high magnification even when the microtome cuts in exactly 
the plane of the long axis of the cell. These dendritic processes 
are seen to be of no mean size, especially the apical process and 
the chromophilic granules extend far up into the same. Three 
processes are seen given off from the base, one at each angle, and 
the third descending from the center. The nucleus is distinct, cen- 
trally located, and contains a large nucleolus surrounded by an 
irregular chromatic network. The chromophilic granules are 


DEMENTIA PARALYTICA. 7O§5 


larger and smaller rounded and irregularly spindle-shaped granules 
in the triangular-shaped body of the cell, approaching to a more 
linear form in the processes. This is a stichochrome nerve cell of 
the somatochrome group. 

Turning again to Plate III. Fig. 8, the third layer will now 
be described. This is but .70 mm. in thickness as compared to 
1.20 mm. for the same layer in Plate II. Fig. 3. The nerve cells 
in this layer are similar in form and structure to those found in 
the above mentioned plate. The neuroglia cells are much more 
numerous in all the layers than in Plate Il. Fig. 3, due in large 
part, the writer believes, to the difference in the staining method. 
Capillary vessels, showing the walls made up of a single layer of 
nucleated flattened cells, are seen in several places, especially in 
the lower layer. Counts were made of the nerve and neuroglia 
cells in different regions in the manner previously described, using 
the same method and magnification. Counts of the nerve cells in 
eight different fields from various portions of the second and 
third layer were made, each field containing thirty-six squares, 
so that 288 squares were examined. ‘There were found to be an 
average of .g5 nerve cells to each square millimeter of the ocular 
net-micrometer, which multiplied by 100 gives 95 as the average 
number of. nerve cells found to the square millimeter in the second 
and third layer of the cortex in this section. ‘The first layer con- 
tained so few scattered nerve cells that no field was included 
for this portion of the cortex, as some fields here would contain no 
nerve cells whatsoever and would thus greatly reduce the general 
average where the Nissl stain is employed. On this account the 
nerve cell counts in this and all subsequent sections, as well as 
that of Plate II. Fig. 3, include only the second and third layers 
of the cortex. The nerve cells are thus fewer in number than 
in Plate II. Fig. 3, but they average larger in size, especially in 
the region of the large pyramidal and Betz cells; thus the frontal 
convolutions seem to to contain more nerve cells than the central 
convolutions. 

Neuroglia cell counts were made from three fields of thirty-six 
squares each or 108 squares in all from all three layers of the cor- 
tex. The average number of neuroglia cells was found to be 2.93 
for each square millimeter of surface of the ocular net-microme- 
ter, which multiplied by 100 gives 293 as the average number of 
neuroglia cells in each square millimeter of surface of the cortex 
from this section. The number in each square here varied from 
none in some squares to fourteen in one of the squares. The next 
highest number was eight, several contained seven, but most of 
them contained from one to four. Counts were also made from 
a section of the same thickness, ten microns, and from the same 
block as the preceding, but stained with methylene blue instead 
of methylene violet. With this exception the technique was ex- 


706 G. ALFRED LAWRENCE. 


actly the same in the two preparations. Counts were made from 
six different fields of thirty-six squares each, and the average 
number of nerve cells to each square mm. of the ocular net- 
micrometer from various parts of the second and third layers was 
.94. This result multiplied by 100 gives 94 as the average num- 
ber of nerve cells to each sq. mm. of surface of the section as 
compared to 95 in Plate III. Fig. 8, a remarkably small difference 
of only one cell to each square millimeter, both counts being made, 
the one entirely independent of the other. Counts were made 





Plate; Vin Big laG 


from seven different fields of 36 sq. mm. each from various parts of 
all three layers of the cortex to determine the average number of 
neuroglia cells. The average number to each square millimeter 
of the ocular net-micrometer was found to be .84, which multi- 
plied by 100 gives 84 as the average number of neuroglia cells 
to each square millimeter of the section as compared to 293 in 
Plate III. Fig. 8, where the methylene violet stain was the stain 
used. This further confirms the statement previously made that 
methylene violet has a greater affinity for these neuroglia cells and 
the latter retain this dye much more tenaciously than they do the 
methylene blue in the subsequent differentiation, whereas the 
nerve cells retain either dye about the same. The same fact is well 


DEMENTIA PARALYTICA. 707 


brought out in Plate IV. Fig. 12, and Plate V. Fig. 14, previously 
described. In the latter two, Betz cells are seen under a magnifica- 
tion of 1,400 diameters. The stain used here is methylene blue, 
and no neuroglia cells are to be seen. In Plate IV. Fig. 12, of 
the same magnification, but stained with methylene violet, twelve 
of these neuroglia cells are seen in the immediate vicinity of this 
large Betz cell. Sections were also prepared from blocks taken 
from the middle and lower thirds of this same convolution,—the 
anterior central,—and it was found that the general type of 
cortical lamination and histological structure remained the same. 
Plate VI. Fig. 16, is a photomicrograph of a section taken from a 
block including the entire anterior central convolution for a dis- 
tance of .4 mm. in its lower third and is representative of the 
entire lower portion of this convolution. The shape of the con- 
volution is seen to have undergone considerable modification as 
compared to the upper third, seen in Plate III. Fig. 7. This 
section is ten microns in thickness, fixed in alcohol 95 per cent., 
stained with methylene violet, the other technique being similar to 
previously described sections. The segment of cortex shown in 
Plate VI. Fig. 17, under a magnification of 100 diameters, was 
taken from the point indicated by the ink lines here and opposite a. 
It is seen from the mechanical arrangement of the cortex to be 
at the most acute angle and where the same is thickest. At the 
opposite less acute angle the cortex is not quite so thick, and in- 
- termediate between these angles, and also on the anterior and 
posterior surfaces the cortex is still thinner. It will be noted 
that the depth of the sulcus anteriorly at c where it passes over 
into the third frontal convolution and is thus adjacent to the 
motor speech area, is more shallow than the posterior sulcus or 
fissure of Rolando. ‘The first layer is irregular in depth, some- 
what thicker at the angle opposite a, and still thicker at b and c, 
whereas at the vertex it is thinner. The general radial direction 
of the cells from the medullary central white substance to the sur- 
face is fairly well seen here. In the second layer the most notice- 
able feature is the entire absence of the Betz cells which are so 
marked in the upper portion of the convolution. Some very large 
pyramidal cells, intermediate in size to the Betz cells and the 
ordinary larger pyramidal cells, are to be seen in this layer how- 
ever, as will be noted in the following (Plate VI. Fig. 17): 
This layer merges into the third or irregular cell layer, which 
latter is gradually lost in the white central substance of the gyrus. 
At the vertex in the cortical layer the section is cracked; this be- 
ing an artefact resulting from manipulation. The outer layer is 
seen to be also torn in places from the same cause. Plate VI. 
Fig. 17, is taken from the strip indicated in ink in Plate VI. Fig. 
16, and is magnified 100 diameters. The first layer is .25 microns 
in thickness and similar in structure to the same layer in the 


708 G. ALFRED LAWRENCE. 


upper portion of the convolution already described. In the second © 
layer, however, the greatest difference is found. The large Betz 
cells practically disappear in the lower third of this convolution, 
although large pyramidal cells simulating them in general struc- 
ture, but lacking the size, are found in the middle portion of this 
layer. In this lower third of the convolution the second layer as 
seen in this section is 1.50 mm. in thickness, and the large pyram- 
idal cells are seen arranged in irregular groups in its middle 
portion. Below them is seen a region a averaging .25 mm. in 
thickness in which small pyramidal cells are almost exclusively 
found. Below this larger pyramidal cells are seen, but not in great 
numbers. The divison: between this and the lower or spindle cell 
layer is not well marked, the latter measuring .go mm. in thick- 
ness. The cells here are irregularly polygonal or spindle shaped 
and do not differ from those in the same region in the upper part 
of this convolution. The total thickness of the cortex at this 
point is 2.65 mm., exactly the same as of the section shown in 
Plate III. Fig. 8. Counts of the nerve and neuroglia cells were 
made in this region in exactly the same manner as in the previously 
described regions. This section, as above stated, is ten microns 
in thickness and stained with methylene violet and in seven fields 
of 36 sq. mm. each from various portions of the second and third 
layers, the average number of nerve cells to each square milli- 
meter of surface of the ocular net-micrometer was found to be 
1.08, multiplied. by 100 gives 108 as the average number of nerve 
cells to each square millimeter of surface of the section in the 
second and third layer. The nerve cells in the first layer were so 
few and scattered that no counts of the same were made. In 
eight fields of 36 sq. mm. each from various portions of the three 
layers of the cortex in this section the average number of neu- 
roglia cells to the square millimeter of surface of the ocular net- 
micrometer was 2.48, multiplied by 100 gives 248, as the average 
number of neuroglia cells to each square millimeter of surface of 
the cortex of this section. Here again it will be seen that the 
methylene violet stain shows a larger number of neuroglia cells— 
248, while the nerve cells—108, are but slightly in excess of the 
average number in the two previously described sections of the 
upper portion of the anterior central convolution, and slightly less 
in number than in the sections described from the frontal con- 
volution (Table II.). 

Passing now to the region posterior to this, we come to the 
posterior central convolution of this central or motor region. 
This posterior central convolution is regarded as a transition 
region between that anterior to the fissure of Rolando, or motor 
region, and that posterior to the same region, or sensory region of 
those authors who divide the cortex into a sensory and motor type 
of cortical lamination. The first and third layers here are prac- 


DEMENTIA PARALYTICA. 709 


tically the same as in the region anterior to the fissure of Rolando. 
The second layer, however, lacks the regularity of the correspond- 
ing layer in the above mentioned region, but as will be seen in the 
plate (Plate VII. Fig. 19), there is nothing new or different in 
this layer from the corresponding layer in the plates already de- 
scribed. The large Betz cells seen only in limited portions of the 
region just anterior to this and contained in but a very small por- 
tion of this so-called motor region are replaced here by some 
smaller sized, irregularly situated pyramidal cells, singly or in 
groups, and of similar internal structure, and mostly to be found 





Plate VI, Fig. 18 


in the middle and lower portion of the layer. As typical of this 
posterior central convolution, a section was taken from a block 
including the middle portion of this convolution in its entirety for 
a distance of 4 cm. (5, Plate I. Fig. 1). The section is 6 2-3 
microns in thickness, fixed in 95 per cent. alcohol, and stained with 
methylene blue, technique otherwise similar to all other sections. 
Plate VI. Fig. 18, is a photomicrograph of this section, magnified 
14 diameters. The convolution here presents a peculiar mechanical 
formation, causing a great variation in thickness of the cortex in 
different portions, being over twice as thick at D as at the point a, 
from which latter point Plate VII. Fig. 19 was taken. This condi- 


710 G. ALFRED LAWRENCE. 


tion is not an artefact, as under high magnification no indication 
of disturbance of the relations of the cells is to be observed. At 
the vertex, however, there is an artificial break in the first and 
upper part of the second layer at two points. The first layer is 
seen to vary in thickness, being thicker at the acute angle below J, 
and gradually becoming thinner as it approaches the vertex, to 
become again thicker below a. The general radial direction of 
the cells is well seen, especially at the vertex and anterior aspect, 
as ata. At bD it is not quite so well made out, but exists to a fairly 
well marked degree when examined under a higher power. 
Pyramidal cells of considerable size are.seen in some parts of this 
layer, more especially in the middle portion, but in no case do 
they approach in size to the Betz cells, nor are they for the most 
part situated in the same portion of the cortex. The third layer 
is thin and soon lost to view in the medullary white substance. 
Plate VII. Fig. 19, is a photomicrograph of the strip a enclosed in 
ink lines in Plate VI. Fig. 18, and magnified 100 diameters. The 
first or upper layer at this point is somewhat irregular in contour 
and averages .20 mm. in thickness. It contains neuroglia cells 
and some scattered nerve cells similar in appearance and structure 
to those described in Plate II. Fi. 3, for the same region. The 
second or pyramidal cell layer is especially interesting, owing to the 
irregularity of the distribution. of its cells. At the upper portion 
the small pyramidal cells are seen closely aggregated together. 
Below this these cells become more scattered, and irregularly in- 
terspersed among them are medium sized and larger pyramidal 
cells. Some of the larger of these have a tendency to be ar- 
ranged singly or in groups and have an internal structure similar 
to the giant pyramidal or Betz cells found in parts of the anterior 
central convolution and in the posterior part of the first frontal 
convolution. The chromophilic granules are, however, of smaller 
size though similarly arranged in some of the cells. About the 
middle of this layer, opposite a, is seen another region in which 
the small pyramidal cells predominate, and in which there are 
scarcely any larger pyramidal cells. Just below this again are 
seen large pyramidal cells arranged singly and in groups, forming 
the lower portion of this second layer which measures about 1.45 
mm. in thickness and below gradually merging into the third or 
spindle cell layer. In addition to the spindle cells there are many 
irregular polygonal cells founds in this layer which at this point 
is about .60 mm. in thickness and only partially shown in the 
plate; the upper two-thirds being seen here. The lower third, not 
shown, is similar and gradually merges into the white medullary 
substance. The entire cortex is thus 2.25 mm. in thickness at this 
point, whereas, as above mentioned at point b in Plate VI. Fig. 18, 
it is over 5 mm. in thickness. Taking into consideration the varia- 
tions found in different parts of the same area, often quite near 


DEMENTIA PARALYTICA. jit 


together, and considering the general type of arrangements, it 
does not seem to the writer that this area varies to a very marked 
degree from the general type, or at least to such an extent as to be 
especially marked off from the other regions of the cortex. There 
is certainly a greater variation between different regions of the 
anterior central convolution as in the upper and lower portions, 
where some parts have no Betz cells and others have them vari- 
ously distributed, as well as other differences, than between this 
region and the frontal region as a whole. Those who separate the 
cortex into two types,—an anterior or motor type, and a posterior 
or sensory type,—regard this convolution as the transition region 
between the two. An examination of sections, both anterior and 
posterior to this convolution, shows that the same general plan of 
arrangement is carried out in all parts of the external surface of 
the cortex with only minor differences which do not seem sufficient 
to make such a marked distinction applicable anatomically, and 
certainly not histologically. The size and form of the cells and 
their general arrangement differs but slightly from that of the 
region anterior and posterior, with the exception of the Betz cell 
groupings in localized portions of the former. 

Nerve cell and neuroglia cell counts were made with the ocular 
net-micrometer here in this region in the same manner as in the 
other previously described sections. Eight fields of thirty-six 
square millimeters each, from various portions of the second and 
third layers of the cortex; were examined and 185.5 nerve cells 
were found to be the average number for each square millimeter 
of surface of the section. In the same manner the neuroglia cells 
were counted in eight fields from all three layers of the cortex 
and 109.2 neuroglia cells were found to be the average number for 
each square millimeter of surface of the section in the cortex. 
Here methylene blue was the stain employed with the resulting low 
average number of neuroglia cells, whereas the average number 
of nerve cells is found to be higher than in any of the previously 
described sections anterior to this region, and it will be seen sub- 
sequently that it is also higher than that found for the region 
posterior as well although the section is 6 2-3 microns in thick- 
ness, and some already described are 10 microns in thickness 
(Table II.). This, however, bears out the statement previously 
made that sections between six and ten microns in thickness con- 
tain practically all nerve cells that can be seen in one plane. 

Parietal Region.—Posterior to the region just described we 
come to the parietal region, made up of the superior parietal, 
supra-marginal, and supra-angular convolutions. The general 
arrangement of the layering of the cortex is fairly uniform 
throughout this region and the section represented in Plate VII, 
Fig. 20, from a block taken from the supra-marginal convolu- 
tion is typical of this region (7, Plate I, Fig. 1). The block was 


7 La G. ALFRED .LAWRENCE. 


fixed in Van Gehuchten’s fluid, stained with methylene violet, and 
other technique as for previous regions. The actual size of this 
section is 7 mm. in its greatest width, and 8 mm. in length, and it 
is 6 2-3 microns in thickness. As seen in the photomicograph, 
magnified 14 diameters, the convolution is wider above at the 
surface than deeper down in the sulcus. At the point @ is seen 
the position of the strip from which the photomicograph repre- 
sented in Plate VII, Fig. 21 was taken. At b and c, owing to the 





Plate VII, Fig. 20 


greater angle, the cortex is considerably thicker than at a. The 
shape of the convolution here is seen to be different again from 
any of the preceding, thus giving a somewhat different mechanical 
arrangement, with a broad flattened vertex and shorter anterior 
and posterior aspects. At the lower portion, on the right, a part 
of the cortex was cut away in removing the block. In the vicin- 
ity of a there are some minute artefacts, causing an irregularity 
of the surface here, and small fragments are partially torn away 
at two points. The first, or superficial layer, is fairly uniform in 
thickness, excepting opposite a, which will be discussed more 
fully in describing the next plate (Plate VII, Fig. 21), and upon 


Plate IX, Fig. 25. 


| 
| 
| 
j 


late XV, Fig. 45. 





Plate XV, Fig. 47. 











aaron, pea Blate MTV big. 43: Plate XV, Fig. 45. Plate XV, Fig. 47 


Plate IX, Fig. 25. Plate XI, Fig. 31. 


DEMENTIA PARALYTICA. 713 


the posterior and anterior aspects, where this layer is slightly 
thicker. The radial arrangement of the cells of the second layer 
is well shown, and the cortex is seen to be thicker at the angles 
b and c, as before mentioned. Throughout the middle and lower 
part of this layer well developed pyramidal cells are seen, some 
almost approaching in type small Betz cells. The third layer pre- 
sents nothing unusual, and gradually passes over into the white 
medullary substance. Plate VII, Fig. 21, shows the strip indi- 
cated in ink opposite a in Plate VII, Fig. 20, under a magnifica- 
tion of 100 diameters. The first or superficial layer is seen to be 
irregular at this point, about 20 mm. in thickness at the right of 
the plate, then increasing rather suddenly to .25 mm. for a short 
distance, when the outline suddenly descends, decreasing the 
layer at this point to .15 mm. It then gradually increases until, 
at the left of the plate, it is .22 mm. in thickness. The extreme 
thickness near the center, although the surface is only slightly 
torn at several points and scarcely noticeable, yet has the appear- 
ance of an artefact, due no doubt to the unequal pressure in the 
manipulation of removal, when the brain was in its natural soft 
condition, prior to any post-mortem changes. A short distance 
below the surface at this point the cortical substance itself is seen 
slightly broken, thus confirming the artificial nature of the irregu- 
larity and increase in depth. The nerve and neuroglia cells are 
similar to those found in this layer in the regions anterior to this. 
The second or pyramidal cell layer is 1.60 mm. in thickness, and 
contains small pyramidal cells exclusively in the upper portion. 
Very soon, however, larger pyramidal cells appear, and at about 
the middle of the layer are the greatest in size and most numerous 
of the layer. Some of these large pyramidal cells in point of size 
and structure appear intermediate between the large and giant 
pyramidal or Betz cells. They also tend to be arranged singly or 
in groups, with smaller cells about them. Just below the middle 
of this layer, at a, is found a region .20 mm. in thickness, con- 
spicuous by the almost entire absence of large pyramidal cells, 
and made up for the most part of small pyramidal cells. Below 
this large pyramidal cells again appear, intermingled with the 
small pyramidal cells, and the layer gradually passes over into the 
lower or spindle-cell layer. The pyramidal cells have the same 
internal structure as those in the region anterior to this, in the 
largest ones the chromophilic granules simply being larger and 
more conspicuous; thus these cells come under the same classifi- 
cation, according to Nissl, as those in the frontal and central con- 
volutions. The third or spindle-cell layer is .7o mm. in thickness, 
and not distinctly separated from the layer above. The arrange- 
ment of the cells and their form and size, as well as the internal 
structure, is in no way different from the corresponding layer in 
the cortex anterior to this. The total thickness of the cortex here 


714 G. ALFRED LAWRENCE. 


is then 2.50 mm., being .25 of a mm. thicker than in the section 
of the posterior central convolution previously described, .15 mm. 
less in thickness than the section shown in Plate III, Fig. 8, from 
the anterior central convolution, and .35 mm. less than in the sec- 
tion of the first frontal convolution shown in Plate II, Fig. 3. 
The variation in thickness is thus seen to be slight and no greater, 
and even not so great as can be found in contiguous portions of 
any one convolution. In other parts of the parietal region the 
arrangement of the cortical lamination is similar to that de- 
scribed above with minor modifications, due to differences in 
shape, etc., of the convolutions. Here nerve cell and neuroglia 
cell counts were made in the same manner as in previous regions, 
and the average number of nerve cells to the square millimeter of 
surface of the section was found to be 104, whereas the average 
number of neuroglia cells for the same area of surface of the sec- 
tion was 180.90. This is the lowest average of nerve cells in any 
region of this brain, with the exception of the upper portion of 
the anterior central convolution. The methylene violet stain 
makes the average number of neuroglia cells quite high, however, 
though considerably less than in the upper portion of the anterior 
central convolution. 

Temporal Region.—Below the parietal region just discussed 
we come to the three temporal convolutions—the first, second and 
third. Here the general arrangement of the cortical laminations 
and the cell structure is practically the same in the three convolu- 
tions, and bears a striking resemblance to that found in the frontal 
region. A block was taken from the anterior portion of the first 
temporal convolution near the apex (6, Plate I, Fig. 1), the entire 
width of the convolution and for a distance of .4 cm. The actual 
size of the section from this block represented in the photomicro- 
graph (Plate VII, Fig. 22) is 8.5 mm. at the widest point, and 
8.5 mm. in length on the right, and 6 mm. in length on the left, 
and it is 6 2-3 microns in thickness. The block was fixed in Van 
Gehuchten’s fluid, stained with methylene blue, all the other 
details of technique being similar to that employed for previously 
described sections. This photomicrograph is magnified 14 diam- 
eters, and here the shape of the gyrus is seen to be somewhat 
similar to that in Plate VII, Fig 20, but broader above, and also 
with a broader base. The vertex is flattened similarly, resulting 
in the more acute angle at b and the slightly obtuse angle at c, 
at which points the cortex is thicker than at the vertex or the 
anterior or posterior aspects. The cortex is seen to be uniformly 
thicker along the surface, opposite d, than upon the opposite 
aspect at and above and below a. The first or superficial layer is 
thicker at c than in other portions, and is somewhat broken in 
places along the vertex. The second layer varying in thickness, 
being thickest at the points mentioned above, where the entire 


DEMENTIA PARALYTICA. 715 


cortex is thickest, shows the radial arrangement of the cells very 
well, especially at the vertex and opposite a and b. The larger 
nerve cells appear quite conspicuous in the middle and lower por- 
tion of this layer in places. The third layer is quite uniform, dis- 
appearing in the white medullary central substance. Plate VIII, 
Fig. 23, shows the strip a of Plate VIII, Fig. 22 at a magnification 
of 100 diameters. Here the differentiation has been carried to 
about the same stage as in Plate II, Fig. 3, and the paucity of 
neuroglia cells is equally as apparent. Again the general arrange- 





Plate VII, Fig. 22 


ment of the cells in the two plates is remarkably similar. The 
first or superficial layer is here .25 mm. in thickness, and contains, 
for the most part, neuroglia cells and a few scattered nerve cells. 
The second or pyramidal cell layer measures 1.65 mm. in thick- 
ness, aS compared to 1.40 mm. in Plate II, Fig 3, being thus 
slightly thicker than in the latter. The cells are arranged prac- 
tically the same, however, the small pyramidal cells above inter- 
mingled with larger pyramidal cells in increasing numbers deeper 
down in the layer. Here again, at a point somewhat deeper than 
in Plate II, Fig. 3, is to be found a region at a, of the same thick- 
ness—.30 mm., where small pyramidal cells are found almost ex- 


716 G. ALFRED LAWRENCE. 


clusively, followed again by a region containing large pyramidal 
cells in considerable numbers in addition to small pyramidal cells. 
This layer finally passes over into a narrow (.40 mm. thick) third 
or spindle-cell layer. This layer is also similar to that of Plate 
II, Fig. 3, with the exception of its depth, the latter having a 
spindle or irregular cell layer, measuring 1.20 mm. in thickness. 
As will be seen by referring to Plate I, Fig. 2, the strip a repre- 
sented in Plate II, Fig. 3, was taken from the point of greatest 
curvature, where the cortex is usually the thickest, whereas Plate 
VIII, Fig. 23, was taken from the point a shown in Plate VIII, 
Fig. 22, from the side of the section where the cortex is thinner. 
The entire depth of the cortex is found to be 2.30 mm., as com- 
pared to 2.85 mm. in Plate II, Fig. 3, a difference of .55 mm. 
There are no larger pyramidal cells here intermediate in size be- 
tween the Betz cells and the ordinary large pyramidal cells, as were 
noted singly or in small groups scattered in the central and parie- 
tal convolutions already described, and, as we shall see, also occur 
in the occipital convolution. The internal structure of these cells 
and their classification are similar to that for the cells described in 
Plate II, Fig. 3. Nerve and neuroglia cell counts were made 
from this section, which, as above mentioned, is 6 2-3 microns in 
thickness and stained with methylene blue. Seven fields of 36 
sq. mm. each gave an average of 146 nerve cells to each square 
millimeter of surface of the section, and eight fields of the same 
size gave an average of 131.90 neuroglia cells to each square milli- 
meter of surface of the section. It will be seen upon comparing 
these figures with those from sections of regions more anterior 
and above, that they show a larger number of nerve cells than in 
the sections from the regions anterior to the fissure of Rolando, 
but a less number than that for the posterior central convolution, 
and more than from the parietal region. The neuroglia cells are 
about the same in number as in Plate II, Fig. 3 of the frontal 
region. ? 
(To be continued.) 


Periscope. 


ARCHIV FUER KRIMINAL ANTHROPOLOGIE 


(Vol. 12, 1903, Nos. 2, 3.) 
. Daktyloscopie. C. Wrinpt. 
. Rendering Latent Impressions Visible. F. PAut. 
Impressions of Elmira. Wunrry. 
Medical Experts in Psychiatry. J. Brrze. 
. Infanticide by Cold Bath. R. Morues. 
Alcoholism and Testimony. R. Po.tirz. 
. Signs of Death by Hanging. STRASSMANN. 
. Falsification of Seals. W. ScHttTze. 
. Preliminary Cross-Examination. H. Gross. 
10. Anatomical Seat of Criminal Tendencies. P. NAcKE. 
11. Legal Views of Crime. R. Morues. 
12. Reform Movement in Criminal Procedure. G. LELEWER. 
13. Legal Science in Greenland. D. B. OEFELE. 
14. Reading of Thoughts. H. ScHNEICKERT. 
I5. Superstition: Fortune-Telling and Quackery. W. ScHurze. 

1. Daktyloscopie. C. Windst points out the great value of the papillary 
lines at the finger tips for identifying criminals. The pattern remains the 
same throughout life, and even if a portion of the skin is torn off accident- 
ally, the new-formed skin will not alter the design. Even when bodies have 
been lying in water for weeks, they can be readily identified by impressions 
from the fingers. All patterns may be divided into four classes, which 
have received the following names: Bow (arcus), loop (lasso), whirl and 
combined pattern. A very extensive system of cataloguing the impressions 
from all ten fingers by means of arbitrary letters and fractions is described 
in detail. Compared with anthropometry, the method seems to be equally 
reliable and much simpler; it can be applied just as easily to children, 
females and cadavers. Occasionally the criminal himself helps in his iden- 
tification by leaving behind an impression of his fingers on glass, etc. By 
suitable methods these impressions can be rendered more visible and per- 
manent. 

2. How to Render Visible Latent Impressions. From F. Paul’s article it 
appears that many chemicals can be used to render visible and permanent 
accidental impressions of fingers on glass, paper, etc. The simplest method 
is to expose the object to the fumes of iodine. Silver-nitrate in 8 per cent 
solution also gives good results if the paper is then exposed to sunlight and 
treated with hyposulphite of soda. Other available substances are ink, 
many powders in moderate subdivision (calomel), permanganate of potash. 
With glass, the fumes of hydrofluoric acid may also be employed. 

3. The Reformatory in Elmira.—Wintry has visited Elmira and speaks 
very favorably of the management of the institution and the régime among 
the inmates. He believes that from 75 to 80 per cent of these are completely 
cured. 

4. Difference of Opinion Among Experts in Psychiatry.—J. Berze 
states that it is oftimes impossible to estimate correctly the mental capacity 
of a patient. This refers especially to those cases which are not really men- 
tally diseased but merely exhibit a deficient mental development. The in- 
dividual equation plays a prominent part here, since we possess no normal 


0 ON ANAWD 


718 PERISCOPE. 


standard by which to gauge the degree of intelligence. Even in acquired 
conditions there may be a psychical weakness rather than definite and char- 
acteristic symptoms, so that the difference from the normal is quantitative 
rather than qualitative. Almost insurmountable difficulties may be encoun- 
tered in distinguishing between temporary and permanent aberrations in 
neurasthenia, hysteria and epilepsy. Last, but not least, the expert will 
often be in a quandary to express an opinion in psychopathic deficiency, that 
intermediary condition which has underlying it neither a normal nor an 
abnormal mind. There is no proper place for these patients as yet; they 
belong neither in an insane asylum nor in prison, yet the expert is often 
forced to choose between the two. It is difficult to find a remedy for the 
difference of opinion so frequently encountered; even if separate institu- 
tions existed for these patients there would still be occasion for dispute, 
but the consequences would not be so serious. 

5. Attempt at Infanticide by Means of a Cold Bath—R. Mothes briefly 
records the case of a woman who had purposely left her infant in a cold 
bath. The court acquitted the woman of attempted murder, but recom- 
mended her punishment for the affliction of bodily injury which might have 
resulted fatally. 

6. Testifying Upon Alcoholic Disturbances Before Court.—Pollitz re- 
lates how difficult it may sometimes be to properly class alcoholic mental 
disturbances with reference to the ultimate psychical derangement which 
accompanies them. ‘There is a tendency on the part of the laity to look 
upon alcoholism more as a moral defect than a disease, and, in consequence, 
the judge and jury are frequently inclined to condemn too harshly. The 
matter is frequently complicated by the fact that it is difficult to make the 
proper diagnosis, especially if the expert sees the patient after weeks or 
months of enforced temperance. Alcoholic psychosis may be divided into 
four classes, viz.: Delirium tremens, acute hallucinatory insanity, the acute 
pathological intoxications, and, lastly, chronic delirium. Of these, delirium 
tremens forms the prototype; it is that peculiar condition where the afflicted 
is fully aware of his own condition, but mistakes completely his surround- 
ings. Prominent symptoms are optical delusions, marked suggestibility 
and motor unrest and a good recollection of the details of previous attacks. 
In the second type the delusions are more markedly of an acoustic character, 
the patients are better oriented, and the entire course is more chronic. 
Pathological intoxications are accompanied by a clouded consciousness. 
The recollection of the details is almost entirely lost, and sleep always fol- 
lows. Illustrative cases of these three conditions are given. 

7. Signs of Death by Hanging.—Strassmann had occasion to do an 
autopsy on an old man who first attempted to hang himself and then fired 
a bullet into his brain. As in a previous case recorded, tears in the mucous 
membrane at the laryngeal orifice were found. 

8. Methods Employed in the Falsification of Seals —A detailed article 
by W. Schiitze, stating how signatures, seals, etc., are commonly altered by 
criminals. 

9. Value of Preliminary Cross-Examination.—This article of H. Gross 
is directed against the suggestion to do away with the customary pre- 
liminary cross-examination. When properly conducted by an experienced 
judge it is the most valuable of the three commonly employed in Germany. 

10. The Anatomical Seat of Criminal Tendencies——P. Nacke does not 
believe with Lombroso that criminals and epileptics possess a prominent 
median occipital groove secondary to hypertrophy of the worm of the 
cerebellum. Prominent anatomists have shown that this condition is found 
almost as often in the brains of normal individuals (in 2 to 3 per cent), and 
hence cannot be looked upon as an atavistic change. Despite the many 
writings of Lombroso, the real anatomical seat of criminal tendency is as 
unknown to us as it ever was. 


PERISCOPE. 719 


11. Incorrect Legal Views as a Cause of Crime.—R. Mothes mentions 
several peculiar notions on legal points prevalent especially among the 
lower classes. They often constitute reminiscences of former laws, and not 
infrequently lead to or justify crime. 

12. The Reform Movement in the Trial of Criminals.—G. Lelewer dis- 
cusses the contemplated reform in criminal practice, and advises against 
too great leniency. 

13. Legal Science in Greenland.—The inhabitants of Greenland still 
possess very primitive ideas concerning law. According to D. F. B. Oefele, 
murder is very rare since the national character is peaceable and abhors 
dispute. A common practice, however, is to hasten the death of the old 
and dying. Married life is rather loose, and it is considered more of an 
advantage than a disgrace to possess children born out of wedlock. Dis- 
putes are usually settled by means of the so-called “drum dance,’ where the 
one who makes most noise is generally the victor. 

14. Reading of Thoughts.—H. Schneickert has been present at several 
seances and has found that the thoughts to be transmitted are always com- 
municated to the medium by a carefully studied and often complex system 
of signals. These are passed at moments when the attention of the public 
is diverted. Criminals frequently have a similar mute language, and part- 
ners should always be kept at a distance from each other, and all motions 
of their hands, face, etc., should be carefully watched. 

15. Superstition, Fortune-Telling and Quackery.—The superstition of 
the lower classes has frequently ruined reputations and destroyed family 
ties. In the case cited by W. Schtitze a perfectly innocent man was accused 
by almost all his acquaintances of arson because a “wise man” had thrown 
suspicion upon him. It is often very difficult to punish these quacks. In 
this case it took one and a half years to gather sufficient evidence. 

O. HENSEL (New York). 


ARCHIVES DE NEUROLOGIE 


(Vol. 15, 1903, No. 89, May.) 
1. A Study of Mania. SouKHANOFF—GANNOUCHKINE. 
2. 'New Observations on the Neurosis of Anguish. P. HARTENBERG. 
3. Physiopsychology among Religious Orders. BINET—SANGLE. 
4. Critical Review of Stigmata of Degeneration. 

1. A Study of Mania.—Drs. Soukhanoff and Gannouchkine of Univer- 
sity of Moscow founded their study upon material accumulated in the 
psychiatric clinic of Moscow. ‘The authors have been able to classify the 
“observations” of all patients, both interne and externe during fifteen years 
from 1887 to 1902. The total number of patients were 4,434, of whom 
2,840 were men and 1,594 were women. Among these, they recognize mania 
in but 40 cases, of whom 16 were men and 24 women. In the category of 
mania, the authors exclude from consideration all cases where, before or 
after the onset of mania, a depressive state was noted; these they classify as 
circular psychosis. All cases are also excluded where mania appears as a 
complication of general paralysis, a senile dementia, etc. “The above data 
indicate very clearly that mania is a very rare psychic malady.” 

Women are prone to suffer from mania more often than men, and if 
the number of male and female alieneés were equal, the ratio of men to 
women affected with mania would be as I to 2.68. Melancholia, particularly 
in women, appears as one of the most frequent of mental maladies; occurs 
almost seven times as often as mania. These views, they say, are those of 
other authors. Figures show that mania manifests itself most often be- 
tween the ages of 16 and 25 years. The age of earliest access, 13 years; 
latest at 66 years. 

. 2. New Observations upon Neuroses of Anguish—Hartenberg, after 


720 PERISCOPE. 


Freund of Vienna, and upon his own studies, classifies the subject: (1) 
General irritability, including often auditive hyperesthesia; (2) A state of 
habitual anxious expectation of some evil which threatens; (3) Crises of 
acute agony, beating of the heart, etc.; (4) Equivalents of crises, repre- 
sented by nocturnal fright, with distressing dreams, etc., variations of gen- 
eral nutrition, with periodic fattening or emaciation; (5) Phobies and ob- 
sessions. 

The first observation cited is that of a married woman, Madame L., 
twenty-six years of age, mother of a child of four and one-half years. 
She was in great mental distress, the origin of which was as follows: While 
absent from her home, “a friend of the house, made courtship to her and 
engaged her in a flirtation sufficiently advanced. There was great recipro- 
cal attraction; the situation became perilous for the honor of the young 
woman, when suddenly the gallant friend, seized with remorse, put an end 
to their relations. They almost.ceased from seeing each other.” This, in- 
stead of calming her for the future, induced bitter remorse. She was in 
continued inquietude. A thousand questions arise in her mind. “Does she 
still love her husband? Her child? She is.a great criminal. She ought to 
be punished. What misfortunes will happen to her, how escape them?” 
She weeps, is in despair, and calls for death to deliver her from her martyr- 
dom. Somatic troubles accompany the mental state, etc. The author insti- 
tutes a treatment tonic and reconstituent. While she improves in bodily 
health, sleeps, etc., the obsession, fear of punishment with scruples, re- 
proaches, ideas of suicide, continue, and after six months the mental trou- 
bles have subsided but not disappeared. The neurasthenia is rapidly cured; 
the neurosis of agony is not amended till much later. 

The author next propounds, with qualified approval, an hypothesis of 
Freund that neuroses of anxiety are caused by insufficiency of satisfaction of 
sexual want. He reports in his own practice the case of a widow, who af- 
terward remarried, which gave some evidence of Freund’s opinion. He also 
reports in much detail a case of the neurosis of anxiety produced by the 
emotions of automobilism. In 1899, M. F. commences automobiling, at first 
with a tricycle, then with a voiturette, and lastly with a carriage of six horse 
power. In May, 1899, he journeys from Nice to Macon, with four halts. 
The first three days pass without incident in spite of the great fatigue 
produced by the close attention required in guiding the carriage. ‘The 
fourth day, in getting out at Neufchateau for luncheon, he finds himself 
greatly indisposed. He experiences severe pain in the epigastric region, 
like that in extreme emotion. His teeth chatter, he shivers, has violent 
beating of heart, and is assailed with fear of sudden death. In Octo- 
ber following, after three days’ journey in the automobile, he dines 
with good appetite and sleeps at Avignon. Towards eleven o’clock he 
is awakened with an atrocious terror. It seems to him that it is the end, 
that his heart will break; that he will instantly die—all this subsides in half 
an hour. A medical consultation reveals no heart lesion, and attributes the 
symptoms to a gastric state. M. F. has given up the automobile. A propos 
of this: on page 480 of this number, there is a report of a meeting of the 
Society of Hypnology and Psychology, at which there were remarks upon 
the psychology of speed. 

HACHET-SOUPLET. Whoever is in a situation to increase at will his 
speed is entirely carried away by the intense impressions which he 
experiences; he loses self-mastery; he is intoxicated; there are born 
in him feelings which he has not in a normal state; pride, combative- 
ness, anger, hatred, spitefulness, violence. These feelings vary in form and 
degree, according as it concerns the driver of an omnibus, the coachman on 
his cab, the horseback rider, the automobiliste. 

BERILLON. There is a great analogy between the euphoria of speed and 
that of morphine. Those who allow themselves to be carried away with 


PERISCOPE. 721 


speed-making, for its own sake, without any end of utility, are most often 
degenerates, deprived of power of doing things in moderation, have lost em- 
pire over themselves and contend in a fury against the slightest obstacles. 

PauL Macnin. When we come to the question of speed, of tobacco or 
of alcohol, we have an affair of individuals, who in use, are unable to keep 
from abuse; are in effect deprived of all power of moderation, to the point 
of losing the instinct of self-preservation. One physician thought that 
speeding a horse involved a difference, as it was control of an intelligent 
being, to which replies, 

Lux. In Algeria I have been a witness of Arab fantasias. They are 
demi-fools, intoxicated by the dust, transported by a savage fury; have no 
longer any sense of moderation. Their euphoria resembles that of auto- 
mobilists, and the horses even are likewise seized with it. 

The author states, in summing up, that we may consider the clinical 
syndrome of the neurosis of agony as real and generally accepted at this 
day. But it remains not less true that there are some cases, where the affec- 
tion as described exists in a pure state, without any participation of neuras- 
thenia or of melancholia, and which spontaneously or under the effect of 
care is cured entirely, without ever turning into asthenic neurosis or into 
psychosis of anxiety. 

3. Physio-psychology Among Religious Orders: Nuns of Port Royal.— 
The author continues and concludes his studies of the seventeenth century 
monks and nuns of Port Royal, France. After giving minute biographies 
of several, he sums up by saying that he finds a neuropathic and religious 
heredity in one of the nuns and, in two, a religious heredity. Of three 
others, one was suffering from dysentery and suppurating hepatitis, and 
obtained relief in her troubles by auto-suggestion; the second was in gen- 
eral bad health; at twenty-seven had vomitings; at thirty-two, spitting of 
blood; the third also was in weak health, and died after five days of ‘“‘op- 
pression in the breech,” with continuous fever. Of the four, of which we 
know the age at death, the first died at fifty-one, the second at nearly 
seventy-four, the third at sixty-eight, and the fourth at eighty; the average 
of the four was sixty-eight. 

As to character, one passed as intelligent, another said she was “poor 
in spirit’ (Query: Does the author know of the beatitudes?), two pre- 
sented a predisposition to sadness, one to weakness and fear; all were of 
hypersuggestibility; three had a certain suggestive power. 

4. Stigmata of Degeneration.—This number contains a review of cer- 
tain articles by René and Henri Larger on the “Obstetric Stigmata of De- 
generacy.” Besides physical and mental stigmata there are also obstetric 
stigmata of degeneracy as seen in anomalies of gestation, such as sterility, 
twin-bearing, miscarriage, ectopic pregnancy, all the anomalies of the pla- 
centa, of the membranes, of the cord, all abnormal presentations, etc. These 
views are contested by Poiak and the accoucheurs: First observation— 
First husband normal; presentations normal in “OIGA”; second husband 
degenerate, presentation of the face. Second observation—First paramour 
normal, two successive presentations normal in “OIGA”; second paramour 
degenerate, presentation by the breech; the second paramour is a married 
man who has, simultaneously by his wife, a child born also by the breech. 
Third observation—Husband degenerate, three pregnancies with, each time, 
presentation abnormal with puerperal convulsions. The wife takes a para- 
mour perfectly normal; three new accouchments, all normal in “OIGA,” 
and without puerperal eclampsia. RicHarps, Amityville. 


722 PERISCOPE. 


MONATSSCHRFT FUR PSYCHRIATRIE UND NEUROLOGIE 
(Vol. 13, 1903, No. 5, May.) 


The Aphasic Symptom-Complex. E. StorcuH. 

Contribution to the Knowledge of Transcortical Aphasia. M. Bere. 

Contribution to the Further Knowledge of the Richness of the Cerebral 
Cortex of Human Beings in Myelinated Nerve Fibers. E. L. 
F. S. BRUCKNER. 

4. The Pathology of Paralysis of the Peroneus. S. DaAus. 

1. Aphasia.—Storch commences his article with a careful analysis of 
psychical perception. This is of psychological rather than of medical in- 
terest. He mentions, however, as one of the most important facts, that 
attention to any part of the body diminishes the way of irritability of the 
motor cortical cells that cover that part. Speech differs from the visual 
perceptions inasmuch that it is wholly dependent upon hearing. He an- 
alyzes the acoustic perceptions. He draws a sharp distinction between’ 
musical perceptions and phonetic perceptions, the two being entirely inde- 
pendent. (The paper is still unfinished.) 

2. Transcortical Aphasia.—The essential symptoms of transcortical 
aphasia are paraphasia, paragraphia, and echolalia. ‘The variation in the 
anatomical changes found in the cases that have hitherto been reported 
indicate that it is impossible to localize the lesion that gives rise to this 
condition. Berg tabulates eighteen cases that he has obtained from the 
literature, including one of his own. (The paper is still unfinished. ) 

3. Myelinated Fibers in Cortex.—Briickner continues his article upon 
the medullary fibers in the cortex of an eighteen-year-old Suaheli. He 
gives elaborate tables showing the results of his painstaking measurements, 
and a wealth of anatomical details that unfortunately cannot be reproduced 
in an abstract. He compares the results with those obtained in other 
human brains, particularly with that of a German child. Curiously enough 
the former in some respects was equally as well developed. In other re- 
spects also the brain resembled the infantile German type, particularly in 
the superior development of the right hemisphere. 

4. Pathology of Peroneus.—Daus calls attention to the frequency with 
which the peroneal nerve is paralyzed. He classifies these as follows: 
(1) Congenital; (2) acquired during extrauterine existence. These may 
be: A. Mechanical Causes.—I. Involving the central organs; (1) external 
injuries either to the head or back; (2) internal mechanical injuries: brain 
hemorrhage, brain tumors, or lesions or tumors of the cord. II. Affecting 
the peripheral and peroneal tract; (1) external cutaneous injuries. (a) stab, 
blow, or gunshot wounds; (2) burning; (2) injuries as a result of frac- 
tures or luxations; (3) rupture of the nerve, (a) simple over-stretching, 
(b) over-stretching as a result of tumors; (4) pressure, (a) pressure dur- 
ing sleep, (b) pressure during narcosis, (c) ligation, either external, as 
from a bandage, or internal as the result of scars or callus, (d) compres- 
sion, (e) in deformities of the knee, (f) paralysis during birth either of the 
mother or child, (g) tumors; (5) miscellaneous, (a) paralysis as a result 
of overexertion, (b) the hysterical paralysis of Charcot, (c) paralysis due 
to fright, (d) the paradoxical contraction of Westphal, (e) paralysis due 
to habit of Erb. 

B. As a result of toxic causes.—I. Directly toxic; (1) chemical: alco- 
hol, lead, arsenic, mercury; II. parasitic, (a) acute infectious disease: 
diphtheria, pertussis, exanthemata erysipelas, typhoid fever, pneumonia, 
influenza, gonorrhea, syphilis, beriberi, and malaria; (b) chronic infectious 
diseases: tuberculosis and leprosy; III. indirectly toxic: Chemical: Dia- 
betes, gout, rheumatism, skin diseases, and ascending neuritis. 

C. As a symptom or complication of organic disease of the central 


Ne 


Q 


PERISCOPE. 72.3, 


nervous system.—I. In tabes, in tabo-paresis, in dementia paralytica, multi- 
ple sclerosis, antero-poliomyelitis, and the peroneal type of progressive 
muscular atrophy. 

D. In old age. 

E. Of unknown cause. 

Daus quotes articles from the enormous literature on this subject, illus- 
trating each of these forms. (The paper is still unfinished.) 


(Vol. 13, 1903, No. 6, June.) 
1. The Capacity of the Skull (The Cranial Cavity) in Nursing Infants 
and Older Children. H. Prrster. 
2. Disturbances in Sensory Perception in Cases of Mental Disease. 
W. v. BECHTEREW. 
3. The Aphasic Symptom Complex. E. Srorcu. 
4. Contribution to the Knowledge of Transcortical Aphasia. MM. Bere. 

1. Skull Capacity.—Pfister has determined the capacity of the cranium 
by means of water, according to his own method, in 77 male infants, and 
77 female infants, ranging in age from thirteen days to eight years. The 
variability in the size of the cranium in both sexes is considerable. In the 
second year there may be a difference of as much as 200 cm., although the 
average is only 948 cm. in males and 907 cm. in females. The average re- 
sult for a certain period is as follows: 

I. To the end of the first month: Male, 415 cm.; female, 414 cm. 

II. To the end of the third month: Male, 503 cm.; female, 574 cm. 
III. To the end of the sixth month: Male, 651 cm.; female, 577 cm. 
IV. To the end of the tenth month: Male, 769 cm.; female, 684 cm. 
V. To the end of the fifteenth month: Male, 899 cm.; female, 883 cm. 
VI. To the end of the twenty-first month: Male, 1,030 cm.; female, 895. 

As a result of his studies he reaches the following conclusions: First, 
the cubic capacity of an infantile skull less about 6.5 per cent, gives approxi- 
mately the capacity of the cranium in the living individual. Second, the 
capacity of the cranium is larger at all ages in males than in females. The 
difference is less at birth and increases with age. Third, before the ninth 
month of life is completed about one-third of the total increase in the 
capacity of the cranium over that at birth, has occurred. Fourth, at the 
end of 2.5 years about two-thirds of the total increase in the capacity of 
the cranium has occurred. It is not known when the head ceases to enlarge. 
The individual variations in size are very considerable. 

2. Sensory Perception in Mental Disease-—Von Bechterew reports 
some curious cases in which patients had strange disturbances of the psychi- 
cal sense. A girl of twenty years, although touch,‘ pain and temperature 
senses were not distinctly abnormal, had a hallucination that her head, arms, 
legs and even the body were missing. The condition appears to be one of 
purely psychical anesthesia. In another instance, an army officer had such a 
hyperesthesia for the word “blood” that when it was spoken, he was some- 
times thrown into convulsive states. In still another case a patient had 
hallucinations of hearing associated with certain sensory disturbances. 
3. Aphasia.—Storch concludes his article upon the aphasic symptom 
complex. He discusses perception of letters, of words, and particularly the 
relations of these perceptions to the various forms of aphasia. He uses 
the term glosso-psyche to indicate the entire apparatus used in the formu- 
lation of letters and the spelling of words. He devotes considerable time 
to the discussion of spelling, and finally concludes with a classification of 
the various forms of aphasia. 

A.—Those without essential participation of the stereopsychic region: 
—intelligence and tact; (1) The proglossopsychical aphasias. The lesion 
lies peripherally to the glossopsychical fields (the subcortical forms, (a) 
subcortical sensory aphasia, or pure word-deafness: the lesion being in the 


724 PERISCOPE. 


left temperosphenoidal lobe; the glossopsychic region is slightly or not at 
all injured; the invalid can read and write; (b) subcortical motor aphasia: 
aphemia and pure word-deafness: the lesion being in Broca’s region. The 
glossopsychic region is almost intact; the patient understands speech, can 
read and write, but cannot speak. (II) Glossopsychic aphasias, (a) corti- 
cal sensory aphasia, the lesion having separated the glossopsychic region 
from the peripheral organs of hearing, and also injured the glossones. In 
addition to word-deafness there may be paraphasic manifestations, and dis- 
turbances of reading and writing; (b) cortical motor aphasia: the lesion not 
only separates the glossopsychic region from the phonetic nuclei in the 
medulla, but also has injured the latter. The understanding of speech and 
the ability to read and write are involved according to the extent of the le- 
sion; (c) pure glossopsychic aphasia: in which only the elements of glosso- 
psychic region are involved: therefore the understanding of speech, spon- 
taneous speech, repetition and reading and writing are injured; (d) total 
aphasia in which the whole glossopsychic region is destroyed. 

B.—Forms of aphasia with involvment of the stereopsychic region; (1) 
Pure stereopsychic forms, that is, certain varieties of transcortical motor 
and sensory aphasia, pure word-blindness, various form of agraphia and 
psychoses; (2) mixed stereoglossopsychic aphasias. 

4. Transcortical Aphasia.—Berg continues his article with a long de- 
scription of his own case. A man for forty-nine years had shown symp- 
toms of mental impairment for several months. The essential features of 
the case were that voluntary speech was preserved as far as the formation 
of words was concerned, but the language was completely paraphasic and 
incohert. The understanding for words and simple sentences was pre- 
served, but more complicated sentences produced hopeless confusion. Vol- 
untary writing showed pronounced paragraphia; the understanding of 
writing for words and simple sentences was preserved. The patient could 
repeat, could read, could copy, and could even write from dictation. The 
repetition of simple words was done intelligently. If more complicated sen- 
tences were given the paraphasic phenomenon sometimes appeared. In 
reading, copying and in writing from dictation the patient understood noth- 
ing. The echolala was typical. The patient was able to identify objects 
by sight and touch. Intelligence, memory and observation were all dimin- 
ished. The case, therefore, represents a form of transcortical aphasia, partly 
motor and partly sensory in character, and the lesion is probably a diffuse 
lesion in the brain. JosEPH SAILER (Philadelphia). 


ARCHIV FUER PSYCHIATRIE UND NERVENKRANKHEITEN 


(37 Band, 1903, I Heft.) 


. Concerning Korsakow’s Symptom-Complex. E. MEyEr and J. RAECKE. 

The Pathogenesis of Amyotrophic Lateral Sclerosis. H. HAENEL. 

A Contribution to the Pathology of Huntingdon’s Chorea. E. STIrr. 

. A Contribution to the Pathology of Chorea Minor. C. HUDOVERING. 

The Simple Demented Form of Dementia Praecox. O. DIEM. 

. The Value of the X-Rays in the Treatment of Diseases of the Spinal 
Cord. E. von Leypen and E. GRUNMACH. 

. Further Contributions to the Pathology of Sensory Aphasia. A. Pick. 

. The Occupation Neuroses of Telegraphers. E. CronBAcH. 

. Notes on the Criticism of Dr. M. Fekch on Two Cases of Cerebellar 
Palsy in Children. 

1. Korsakow’s Symptom-Complex.—An investigation of the question 
whether multiple neuritis may be followed by definite mental symptoms. 
The history of eight cases is given in detail. One improved greatly so that 
he was practically cured; one was improved; two remained unimproved and 
four died. Of the four cases that went to autopsy one showed fresh degen- 


AR 


io ON 


PERISCOPE. 725, 


eration in the crossed pyramidal tracts, another had minute hemorrhages 
into the gray cerebral substance, a third case showed an old apoplectic scar 
in the right thalamus and in the pons and the fourth had a large sarcoma in 
the right frontal lobe. The authors conclude that their cases show positively 
that Korsakow’s symptom-complex is not a disease sui generis, also de- 
cidedly not an alcoholic psychosis, but is present also in those diseases in 
which irreparable or severe destruction occurs in the central nervous system. 

2. Amyotrophic Lateral Sclerosis—The patient was a woman forty- 
five years old, with good heredity, previously in good health, married, 
with four children. Alcoholism and syphilis were excluded. Two: 
years previously it was noticed that the speech of the patient was awkward, 
also there began at that time a slowly increasing weakness in the right 
side, first in the arm, then in the leg. Speech was later suddenly lost al- 
though at the time of examination it was slow and indistinct, but intelli- 
gent, without paraphasia. The clinical diagnosis was bulbar paralysis and 
amyotrophic lateral sclerosis. Shortly before death atrophy of the small 
muscles of the hand, particularly on the right, was distinct. Babinski was 
marked on both sides. Patient became uncleanly in her habits. At ne- 
cropsy the kidneys were found small, granular and with shrunken capsules; 
the heart was hypertrophied and dilated. A microscopical examination 
was made of the cerebrum, spinal cord and muscles of the tongue with 
Nissl, Weigert, Van Gieson and carmine stains. No new facts are added. 
The author inclines to the belief of a vascular toxemia in his case. A satis- 
factory bibliography and an excellent photograph are appended. 

3. Huntingdon’s Chorea.—One case is reported in which Nissl’s thio- 
nin stain was used. Comparing his findings with those of other authors he 
makes the deduction that Huntingdon’s chorea is always dependent upon 
an inherited asymmetry of the cerebral cortex. The asymmetry can fre- 
quently be seen by the unaided eye. The disease begins in middle life with 
proliferation of the neuroglia in the motor centers. This proliferation may 
be either diffuse or circumscribed and is most marked in the second and 
third cortical layers; that is, the layers of the small and medium-sized 
pyramidal cells. At the same time the blood vessels become diseased, show- 
ing outwandering of the lymphoid cells into the perivascular spaces and 
occasionally hemorrhage. Almost always the small and medium-sized gan- 
glion cells become degenerated throughout, while the large ganglion cells 
in the innermost layer remain intact. 

4. Chorea Minor+—A case in which bacteriological examination of the 
blood and a part of the cord gave negative results. Interesting findings 
were inflammatory changes in the central nervous system, particularly 
marked in the motor pathways in the pons and medulla; rounded bodies, 
presumably colloid, which lay in the neghborhood of the blood vessels and 
also free in the brain substance; light grade of ependymitis and lepto- 
meningitis and a disruption of the cell nuclei in the cortex particularly in 
the pyramidal cells of Ammon’s horn. (Four beautiful plates show these 
conditions clearly.) 

s. Dementia Praecox.—Nineteen carefully recorded cases are added to 
the literature. The author makes a strong plea for the retention of the name 
to express a disease entity which when carefully studied shows a well-de- 
fined clinical picture. Se ee 

6. X-Rays in Cord Disorders—An inspiring article on the value of 
the Roentgen Rays in the diagnosis and treatment of affections of the spinal 
column with illustrative cases. Thirty patients in all were examined; in 
twelve the diagnosis was simply confirmatory, but in the other eighteen the 
diagnosis was first positively made or at least further amplified by the rays. 
In ten of the eighteen cases primary disease of the bony column was fol- 
lowed by paraplegia. These ten cases comprised compression of the dorsal 
medulla by tuberculous bony deposits; compression of the dorsal medulla 


726 PERISCOPE. 


by kyphoscoliosis, two cases; two new growths, one carcinoma, the other 
sarcoma; two cases of cervical myelitis from fracture, and one case of bul- 
bar paralysis, probably due to dislocation of the third and fourth cervical 
vertebre. In the eight following cases the previous diagnosis was veri- 
fied and much relief afforded by suitable treatment. One was dorsal mye- 
litis, one, syphilitic pachymeningitis and myelitis, and one, lumbar myelo- 
meningitis, and two cases of tabes dorsalis. In all of these distinct osteo- 
porosis was diagnosed by the rays. In another case diagnosed as tabes an 
osteoarthropathy of the spinal column was further diagnosed, and in still 
another case of tabes with arthropathies of both knees the diagnosis of 
osteoarthropathy of both knees was made and an osteoporosis of the spinal 
column was shown. 

7. Sensory Aphasia.—Will be abstracted when completed. 

8. Telegrapher’s Neuroses.—But sixteen previously reported cases could 
be found. The author first reviews the literature and then gives the history 
of his own case, which showed nothing of particular note. In eleven of the 
total cases it is interesting to observe that the affection began in the spring 
months. A neuropathic tendency is shown by nervous weakness in the 
immediate family in six of the cases, by apoplexy in three cases, by gout in 
two cases and by stomach trouble with convulsions in one case. Compli- 
cations with other diseases was noted in nine cases. The treatment prom- 
ises little. The therapeutic measures advised are great, change of scene, 
baths, cold water cure, faradism, galvanism, massage, gymnastics, change 
of occupation or of the method of work. Of these measures massage gives 
the best results, while change of occupation did not give the benefit one 
would expect. The use of the Morse instrument intermittently with the 
Hughs instrument is advised as a prophylactic measure. 

9. Cerebellar Palsy.—This is a caustic reply of Dr. Sommer to the crit- 
icism of Dr. Felch. (36 Bd. 3 Hft, S 895 et al.) 

F. WitTMER (New York). 


AMERICAN JOURNAL OF INSAN ITY 


(Vol. 59, 1903, No. 4, April.) 
. A Contribution to the Study of the Blood in Manic-Depressive Insanity. 
J. S. FIsHeEr. 
The Hallucinatory Delirium of Acute Alcoholism. C. S. WALKER. 
. The Progress of Psychiatry in 1902. A. R. URQUHART. 
. Puerperal Insanity. R. Jones. 
The Care of the Insane. C. G. WAGNER. 
Tent Life for the Insane. O. J. WILSEY. 
. A Graded and Systematized Plan of Outdoor Exercise for the Demented 
Insane. C. L. CARLISLE. 
. The Final Chapter in the History of an Extensive Injury to the Head. 
H. P. Frost. 
. Therapeutic Notes. R. DEWEY. 

1. Blood in Manic-Depressive Insanity—Owing to no account being 
taken of data that may have an influence on the condition of the blood, the 
author of this paper made his observations at the same time of the date 
under uniform relations as to food, baths, bodily temperature, etc. His 
blood counts were confined to five cases of manic-depressive insanity with 
care that the technic be identical. The first case was a female of nineteen 
with the maniacal form. On admission had hallucinations of hearing, con- 
sciousness clouded, disoriented as to time and place, memory defective, 
rambling in her conversation; no well defined delusions, great motor ex- 
citement with tendency to impulsive acts. No disease insight. Temperature 
always normal. Fifteen counts were made. The next case was a male of 


Lae 


9 NOunARwp 


PERISCOPE. 737 


thirty with the maniacal form, consciousness clouded, flight of ideas, etc., 
yet oriented, memory unimpaired. Six counts were made. The third case 
was a mixed form in a female of forty-seven. Consciousness somewhat 
clouded, some retardation of thought and action; no delusions, no interest 
in her environment. Twenty-two counts were made. Case four was the 
maniacal form in a female of thirty-three. She had hallucinations of hear- 
ing, consciousness clear, oriented as to time, place and persons, no memory 
defect, judgment biased by delusions, no disease insight, had little interest 
in her surroundings. Forty-five blood counts made. The last case was of 
the maniacal form in a woman of fifty-seven. No hallucinations, conscious- 
ness clouded, mistook those about, completely disoriented, psychomotor ac- 
tivity marked. Only four counts made. The results of his examinations 
he summarizes in a table and draws the following conclusions from his ob- 
servations: “1. There are no pathogenic blood changes in cases of maniacal 
phases of manic-depressive insanity. 2. Anemia is not a causative factor 
nor always an accompaniment of this psychosis. 3. The hemoglobin and 
red cells are frequently, if not always, increased during an attack of ex- 
-citement. 4. A leucocytosis is an almost constant accompaniment and, I 
believe, a result of psychomotor activity. 5. That an increase in weight 
accompanies mental improvement.” 

2. Hallucinatory Delirium of Acute Alcoholism.—The statement of an 
acute alcoholic detailing the characteristic hallucinations of this disease 
with the delusions arising therefrom. 

3. The Progress of Psychiatry in 1902.—Urkuhart mentions the paper 
of Dr. Warnock on Pellagrous Insanity and two papers by Dr. Mott, 
pathologist of the London County Council. The first deals with Stimulus 
in Repair and Decay of the Nervous System, setting forth the danger to 
neuropathics in the use of alcohol. He claims that stress is an important 
factor in the etiology of tabes. The second paper treats of syphilis as a 
cause of insanity. He states 70 to 80 per cent of paretics are found to have 
had syphilis and accepts the thesis: “No syphilis, no general paralysis.” 
Dr. F. G. Crookshank’s paper on “The Frequency, Causation, Prevention 
and Treatment of Phthisis Pulmonalis in Asylums for the Insane, as well 
as Dr. Eric France’s paper on “The Necessity for Isolating the Phthisical 
Insane,” has led to greater interest in this important subject, and the means 
for prevention urged are: early diagnosis, isolation, limitation of size of 
asylums, checking of overcrowding, improved ventilation, attention to 
dietary and sanitation in detail. Asylum Dysentery has been given careful 
study and is found not to essentially differ from ordinary dysentery. Night 
nursing has been given considerable study, with better care of patients at 
night. Marked advancement has been made in the matter of training nurses. 
The London County Council has established a Laboratory of Research at 
Claybury Asylum, where much attention has been given to clinical problems. 
Toxemia has been studied carefully and Dr. Ford Robertson claims all 
forms of insanity in normal persons is of toxic origin. An effort has 
been made, with some success, to treat incipient mental disorders in general 
hospitals. Some study has been given to asylum dietaries. Dr. Mercier’s 
two books, a small Text-book on Insanity, the other a systematic treatise 
on Normal and Morbid Psychology, are notable books. The paper de- 
votes itself solely to progress in England. 

4. Puerperal Insanity—The percentage of insanity due to pregnancy, 
parturition, the puerperal state and lactation, according to the report of 
the English Lunacy Commission, for five years, amounts to 6,4 in the private 
class and 8,1 in the poorer classes. At Claybury the statistics closely cor- 
respond to the above. Of 3500 admissions 259, or 7.4 per cent, suffered 
with insanity from the above specified causes, and are divided as follows: 
56 from pregnancy or 21.62 per cent, 120 occurred during the puerperal 
state, or 46.33 per cent, and 83 were associated with lactation, 32.43 per 


728 PERISCOPE. 


cent. The type of disease with pregnancy and lactation has nothing dis- 
tinctive, while that of the puerperal state is marked by intense delirium 
with wildness and hallucinatory delusions, with permanent religious and 
erotic traits. Some cases present some mental disturbance to develop to 
insanity in the puerperal period, others again present mental symptoms 
during the puerperal state to be markedly alienated during lactation. Only 
I2 per cent of the cases were unmarried, yet of the insanity of pregnancy 
25 per cent were unmarried, 8 per cent of the puerperal cases and only 3 
per cent of the lactation cases. In the insanity of pregnancy it is mostly 
of the depressed type, while in the puerperal cases a maniacal type pre- 
vailed, and of the lactation cases the majority were of the depressed form. 
In 40 per cent of the cases of puerperal insanity symptoms appeared within 
the first two weeks and more than a third of these during the first week. 
Almost without exception the early symptom was loss of sleep followed by 
restlessness, distrust and suspicion, irritability followed by delirious excite- 
ment. Hallucinations of hearing were six times more frequent in these 
cases than of any other of the senses. Disorientation as to time and sur- 
roundings is common, as well as that she fails to recognize her own identity. 
The confusional state is followed by uncontrollable and restless violence, 
attended by profound physical exhaustivun. The patient is often antagonistic 
to her husband, has erotic delusions, is immodest in conduct and language. 
Marked sexual excitement often exists. Suicidal thoughts are most com- 
mon in the lactation cases occurring in nearly half, while in insanity of 
pregnancy it was noted in 41 per cent, in the post-puerperal in 21 per cent. 
The tendency to injure the child more common to the lactation cases. A 
previous record of hysteria is found in quite a percentage of these cases, 
but it is hardly sufficient to advise hysterical girls not to marry. Brown hair 
and gray eyes predominate. The age of greatest incidence was between twen- 
ty-five and twenty-nine for the insanity of pregnancy, and that of the puer- 
peral period, while in the lactation cases from thirty to thirty-four. Heredity 
was present in 50 per cent and most so in the puerperal and pregnancy 
cases. This is considered the most favorable form of insanity, yet is very 
hazardous to the offspring. Insanity in early pregnancy is favorable and 
often recovers before confinement, while that of later gestation is apt to 
continue in an exaggerated degree and may become chronic. Most of the 
puerperal cases recover quickly, although permanent dementia may result. 
Cases of sudden onset show a slightly greater tendency to recover than 
those of gradual. Albuminuria, which is frequent, renders the prognosis 
grave. Gradual onset occurred in the cases becoming chronic and those 
dying. The death rate is the highest in the insanity of pregnancy and low- 
est in the puerperal cases. The pathology of these forms of insanity is not 
definitely established; some hold that various products of the changes in- 
cident to the processes of pregnancy and the puerperal state are the cause, 
in order words toxic, while in the lactational insanity the exhaustion of- 
ten incident to this process may be the chief cause. The treatment must 
naturally depend on the fundamental condition. The induction of abortion 
in insanity of pregnancy has not proven beneficial. The patients need con- 
stant. watching owing to their sudden outbursts of violence and suicidal 
ideas. Commitment to an asylum is generally best, unless the patient is so 
situated financially that she can have all the advantages of an institution 
provided in her own home. Puerperal cases should be treated at home if 
possible. The essential treatment is “compulsory superalimentation.” Sul- 
phonal is useful to induce sleep in motor excitement, paraldehyde is sat- 
isfactory, but not so good as a combination of chloral and bromide. A dull, 
listless condition may occur from which the patient is to be roused by a 
change in surroundings. Complications are to be treated according to 
their indications. 

8. The Care of the Insane—The last quarter of the nineteenth century 


PERISCOPE. 729 


has witnessed wonderful strides in the care of the insane throughout the 
world. Until very recently the bars, locks, crib-beds and massive furniture 
were appalling, to say nothing of the devices for mechanical restraint. Of 
course this innovation in the treatment of a class considered so dangerous 
met with violent opposition. Exercise was confined to the “bull-yard,” 
while now many patients are permitted almost unbounded liberty. Further 
occupation has been provided for most of the patients, instead of being 
compelled to spend their days on the ward benches, they are now helping 
in the shops, kitchen and farm work. Instead of the wards being bare of 
all ornamentation and hence cheerless and depressing, they are now com- 
fortably and attractively furnished. The treatment of the insane today 
consists of “pleasant and sanitary surroundings, good nursing, proper med- 
ical attendance, suitable diet, entertainment and congenial occupation.” One 
of the crying needs still is suitable buildings and appliances for the treat- 
ment of the acute cases, possibly recoverable under proper care, where 
association with chronic cases would be avoided, the appliances, both medi- 
cal and surgical, provided for correcting and relieving physical ailments to 
which the mental disorder is often due. This would be a saving to the 
State in the long run by making the patient again productive, instead of 
possibly dependent for the balance of his life. 

6. Tent Life for the Insane.—Dr. Wilsey cites in detail the benefit to 
a case treated in a tent nearly twenty years ago, and with marked and last- 
ing improvement and recovery, and believes “the complete change in the 
whole existence of the patient was the important curative agents,” and he 
warns us not to let means of diversion become monotonous, and those phy- 
sicians who are the most versatile in providing for the patients’ mental di- 
version will be the most successful. 

7. A Graded and Systematic Plan of Outdoor Exercise for the De- 
mented Insane.—The physical health demands the first attention in the 
amelioration of advanced dementia. A sclerotic state of the vascular sys- 
tem is largely responsible for the atrophic condition of the alimentary tract, 
resulting in more or less chronic states, which cause the defective meta- 
bolism. Consequently the dietary must be suited to this condition and 
therefore quality is more important than the quantity of food, and it must 
contain the largest possible amount of tissue-building material with the 
smallest possible amount of detritus. Digestive ferments and other medi- 
cation may be employed to improve the patient’s digestion. An improve- 
ment in the mental condition soon follows the betterment of the digestive 
process: the patient becomes more attentive, more tidy in his habits and 
more intelligent in his actions. The next essential is an abundance of exer- 
cise in the open air, and for this purpose the patient should begin with the 
simplest possible, one requiring little or no mental effort, and in time the pa- 
tient will be found capable of performing more complicated work and even 
making himself useful in the shop. The games and occupation should be 
adapted as much as possible to the patient’s individual liking. The faith- 
ful systematization and gradation of the amount and sort of out-door exer- 
cise has reduced the number of filthy cases to less than one-fifth of one per 
cent of the entire population of the hospital. The etiology and type of the 
disease must of course influence the possibility of either permanent or par- 
tial improvement. The most marked benefit has occurred in secondary de- 
mentia, particularly that following melancholia, while that following mania 
is less susceptible to instruction and suggestion. Dementia from organic 
brain disease is to be the least benefited. Great benefit is to be derived 
from this method of treatment in psychopathically inferior individuals and 
the allied forms of adolescent insanity, including hebephrenia and dementia 
precox. The results already attained warrant its further development and 


use. 
8. Extensive Injury to the Head.—This case has been frequently re- 


730 PERISCOPE. 


ported at various times from that of the receipt of the injury in 1857 until 
the patient’s death within the past year. The first account embraces the 
details of the accident, which consisted of the tearing away of nearly the 
whole of the right side of the calvarium from the superciliary ridge to the 
occipital bone. At the time the patient suffered only slightly from shock, 
but no signs of cerebral concussion, faintness or nausea. The wound soon 
healed with no further symptoms than a dull headache. This report ap- 
peared in the Buffalo Medical and Surgical Journal for October, 1873, with 
the statement that the patient was in vigorous health at the time and only 
experienced a sense of fulness in the head when stooping or exerting 
himself. The next report of the case was by Gray, published in the 
American Journal of Insanity, April, 1876. This was followed by Dr. 
Bergtold’s article in the Medical Press of Western New York, in 1888, 
written from his observation of the patient in the Buffalo General Hospi- 
tal the year previous. In 1883 a slight unsteadiness of gait appeared which 
in 1888 had become a genuine paralysis, affecting the left extremities and 
right side of the face. Memory intact, no aphasia or headache, yet occa- 
sional attacks of dyspnea of asthmatic character; no cystic paralysis, yet 
some loss of control of the rectal sphincter. Sleep and appetite good. De- 
ficiency of bone on right side of head with a depression of 5 x 6 inches. 
Special senses normal, speech slow and labored from paralysis. Mastica- 
tion and swallowing interfered with, tongue protruded to left, lower lip pen- 
dulous. Slight atrophy of trunk and extremities, left arm nearly powerless, 
spastic pronation of hand and flexion of fingers, spastic contraction of left 
leg which was dragged in walking. Cutaneous sensibility intact; muscles 
respond to galvanic and faradic currents. No delusions or hallucinations, 
but patient irritable and emotional. Dr. Bergtold drew the following con- 
clusions: “There probably began immediately subsequent to the injury an 
atrophy of the cerebral tissues situated beneath the site of the right parietal 
bone; this atrophy included the motor centers for the left arm and leg and 
the cortical centers for the facial and hypoglossal nerves; the atrophy, be- 
ing slow, the remaining right cortex took on vicariously the duties of these 
atrophying centers; there gradually occurred (within the past five years) 
degenerative changes in these right compensating parts and further compen- 
sation did not take place in the left hemisphere.” Thirteen years later he 
was admitted to the Buffalo State Hospital, being quite helpless and his 
mental faculties more affected. He was childish and irritable with par- 
oxysms of anger, when we would try to strike. He could use his right 
arm, but both legs were firmly flexed at the knee and the right leg could 
only be moved feebly. Left arm spastic and joints contracted. Knee-jerks 
exaggerated, especially on the right. ‘No paralysis of right side of face, 
tongue and lips paretic, eyelids drooping, tongue tremulous and 
atrophied, but protruded in the middle line without deviation; swallowing 
interfered with, speech almost unintelligible, drooling of saliva constant. 
Marked external strabismus, left eye noticeably protruding. Pupils unequal, 
sluggish in reaction to light and accommodation, vision imperfect, hearing 
about normal. Sensation apparently intact. Memory not seriously im- 
paired, appreciative and tidy. ‘No convulsions or attacks of unconscious- 
ness. Died two years after admission. Autopsy showed a large deficiency 
of bone of the skull, where the scalp was adherent to the dura, which was 
thickened. Whole right hemisphere flattened and atrophied, but no evidence 
of injury or loss of brain tissue. Convolutions noticeably smaller than on 
left, of a shrunken, atrophied appearance, sulci gapping. No atheroma of the 
blood vessels. After hardening the brain was sectioned according to Hamil- 
ton’s method, when a marked difference in the size of the hemispheres is 
shown. The most striking feature was a considerable area of degeneration of 
the subcortical white matter with numerous cavities just beneath the cortex 
and the hollowing out of certain convolutions. Slight softening of white 


PERISCOPE. AT 


matter through whole right hemisphere, yet no breaking down. Cavities 
confined to individual convolutions and not connected or noticeable exter- 
nally except by slight depression. No other marked changes. The exam- 
ination after staining showed a diffuse fibroid thickening and degeneration 
of the walls of the blood vessels in both hemispheres, but most marked in 
the right, the lumen being occasionally occluded. The vessels here showed 
a decided infiltration of round cells. The vessels on the right fuller than 
on the left. But few of the large pyramidal cells left and these shrunken 
and degenerated. A general increase of the neuroglia elements throughout 
the tissue. On the left side there is a slight degeneration of the tangential 
fibers in the cortex with projection fibers preserved; on the right tangential 
fibers absent at the top of the convolutions, yet seen at the sides. Degener- 
ation of both motor and sensory tracts in the medulla and cord, most 
marked in those from the right hemisphere. These conditions in the cord 
explain the exaggerated reflexes, ataxia, spastic rigidity and gradual prog- 
ress of the paralysis. The increased atmospheric pressure on the brain 
had diminished the capacity of the lymph canals and blood vessels, thus 
inducing the general atrophy from lack of nutrition, and this being progres- 
sive explains the character of the paralysis. The paper is accompanied by 
several photographs of the patient and the brain sections. 

9. Therapeutic Notes—Cascara.—Dr. Dewey extols the preparation 
known as “Kasagra,” it being palatable and efficient. He advises that it 
be given in a dram before breakfast followed by a glass of hot water, and 
one or two drams followed by water at bedtime. It has proven effectual in 
the great majority of cases, even in those where constipation is a habit. Ser- 
um treatment of morphine intoxication. The researches of L. Hirschlaff 
are reported, who prepared a serum from rabbits by giving them morphine 
in increasing doses, which he found efficacious in opium poisoning and mor- 
phine addiction. Use of iron of animal origin. Hemoglobin may be given 
successfully in anemia and chlorosis. Mental disturbances due to hypnot- 
ism. Prof. Mendel’s report is: “Careful distinction must be made between 
the cure of an affection and the alleviation of its symptoms by hypnotism. 
No physician claims that it is possible to cure with it an organic affection 
susceptible of demonstration with our modern diagnostic measures. But 
hypnotic or waking suggestion is undoubtedly capable of banishing, usually 
temporarily, but sometimes permanently, the most widely diverse symptoms 
of the affection, but without curing it. Success is dependent in this case, 
as in all cases of suggestion, o nthe greater or less skill of the suggestor, his 
personality, on external circumstances and on the degree of receptivity of 
suggestion by the patient. A number of cases are known, in which mental 
disturbances developed in predisposed individuals under hypnotization. 
Some of these cases occurred with charlatans, but in others the hypnosis 
had been conducted by physicians.” Arteriosclerosis. The causes are cited 
and the treatment outlined, of which intestinal antisepsis is an important 
factor. The diet advisable is given in detail. 

W. A. McCorn (Patterson). 


MISCELLANY 


Two CASEs oF SARCOMA OF THE SPINAL Corp. Senator (Prakt. Vratch., No. 

24, 1903). 

Tumors of the cord, until recently varieties inaccessible to treat- 
ment, have of late excited considerable interest. The author presents 
two highly instructive cases. In one case, that of a woman, sixty-nine years 
of age, there was a history of ten months’ duration, that began with a sen- 
sation of formication in the toes and pains in the feet; to this was later 
added inability to flex the knees, burning and pains in the soles, which 
spread upward to the hip joint. During the last six months patient lost all 
power of locomotion, suffered from convulsive twitchings in the lower ex- 


732 PERISCOPE. 


tremity, at times so pronounced and painful that the knees were forcibly 
flexed over the chest. There was also retention of urine. Patient lies re- 
cumbent on the back and is unable to move the lower extremities. Passive 
movements also hardly possible. Knee reflexes very much exaggerated. 
Babinski’s sign present. Percussion of the muscles calls out painful twitch- 
ings. Stroking of the soles or legs is attended with clonic contractions of 
the lower extremities and of the abdominal muscles. Abdominal reflexes 
absent. Sensation lowered in the lower extremities. This condition grew 
gradually worse until the sensation of pain and temperature entirely disap- 
peared, while that of touch disappeared over a still greater area, extending 
upward. Late in the disease there occurred curvature of the spine at the 
third lumbar vertebra. In the course of the disease the body of the patient 
grew, as it were, shorter, the chest approached the pelvis. The abdominal 
muscles were almost in a continual state of contraction. Dyspnea and at- 
tacks of tightness in the chest, Cheyne-Stoke’s respiration and marked 
slowness of the breath (eight per minute) supervened. Lumbar puncture 
during the early period of the disease brought forth 10 to 12 cc. of a 
limpid liquid, with but little albumin. After the second puncture 5 cc. of 
one-half per cent solution of socaine was introduced into the subdural space 
with remarkable improvement to the contractures and pains, which lasted 
for three hours. Of the drugs employed, scopolamine (hyoscyamine) seems. 
to have given the best results. The autopsy revealed a tumor of the dura 
mater, which was microscopically seen to be a sarcoma. The second patient 
was admitted to the hospital with pains in the back, inability to move the 
legs, and complaining of tormenting thirst. The trouble began seven 
months before with pains in the back, between the scapule, which would 
at times become so severe as to render her unable to work. Some four 
weeks before admission, the soles began to swell; this was followed by 
swelling of the abdomen, while two weeks ago patient became unable to 
move the left leg. There is no retention of either urine or feces. Patient 
recumbent on the back, indifferent, consciousness slightly impaired.. Knee 
reflexes exaggerated, Babinski’s sign present, ankle clonus indistinct. It is 
rather difficut to pick up the patient, as the spinal column is quite stiff. 
Patient complains especially of pains in the legs. Autopsy (patient died on 
the third day of admission to the hospital) gave the following: The heart 
slightly hypertrophied, lungs somewhat adherent, the thyroid gland hyper- 
trophied, full of cysts; the bladder distended, its mucous membrane covered 
with necrotic spots; ovaries thickened. The vessels of the brain markedly 
calcified; the spinal column much congested; in the region of the third and 
fourth thoracic vertebre, to the left, there is seen a hard swelling, which is. 
microscopically a fibro-sarcoma. The interesting feature of this case is the 
very rapid course of the disease. The first stage, what the author calls the 
stage of neuralgia, was quite short, while the stage of paraplegia, that usu- 
ally occupies months and years, was hardly extended over two weeks. 
Rovinsky (New York). 


CASE OF TUMOR OF THE SPINAL CorD, WITH Necropsy. Sinclair Gillis and 

Flashman (Australasian Medical Gazette, Nov. 20, 1902). 

Diagnosis based on history of numbness in left hand (seven months’ 
duration), followed by weakness in left hand and arm, and later by weak- 
ness in the right arm and in legs. Marked analgesia, anesthesia slight, 
except in left hand; anesthetic and analgesic areas being dissociated, thus, 
apparently indicating lesion of central gray matter in upper cervical region 
of cord. The existence of neuralgia, to a certain extent, in the left occipital 
region, tactile sense but slightly involved, indicated, possibly, syringomyelia. 
Subsequently there was great spread of analgesia (slight involvement of 
tactile sense), wasting of muscles of right palm, rigidity and weakness of 


PERISCOPE. 733 


right arm, followed by same condition in the left, spastic paralysis of lower 
extremities, involvement of sphincters, absence of pain, and, finally, death 
by bulbar paralysis. Postmortem: Brain and meninges normal. Attached 
to the spinal dura mater, on the right side, and a little posteriorly, about a 
quarter of an inch below the foramen magnum, was a growth the size of a 
shelled walnut. It was irregularly bossed, and attached to the dura by a 
narrow pedicle, and lay free in the subarachnoid space. It protruded 
through the foramen magnum one half inch, lying behind and to the right 
of the cord, which it compressed in the region of the first and second cervi- 
cal segments. Cord here somewhat softened. A horizontal section close 
below the foramen magnum bisected the growth, leaving the lower frag- 
ment attached a quarter of an inch below to the dura mater, and the upper 
by a fine filament, to the medulla. Cord not invaded by growth, and, be- 
yond softening in region of growth, microscopically normal, section of 
growth showed it to be a sarcoma, round celled variety. Nerve cells, all 
regions of spinal cord normal (Nissl method). Few scattered degenerated 
fibers in the ventrolateral white columns, especially ventral portion (Marchi 
method). Nearly whole medulla exhibited extensive fiber degeneration, 
probably due to pressure. Both inferior cerebellar peduncles showed well 
marked degeneration, affecting one-third of fibers, due to pressure on direct 
cerebellar tracts and external arcuate fibers. Pyramidal tracts slightly in- 
volved. Degeneration up into pons, limited to region of mesial fillet. 
J. E. Ctarx, New York. 


ARTERIO-SCLEROSIS AS A CAUSE oF ‘Nervous Disease. M. Allen Starr 

(Medical Record, July 4, 1903). 

A careful study of two hundred consecutive cases of apoplexy in private 
practice has shown that in 80 per cent of these cases there have been dis- 
tinct prodromata of the apoplectic attack. There were various symptoms 
which have usually been regarded as neurasthenic, pointing to a disturb- 
ance of function in the brain, chiefly in the cortical activity. Dulness and 
hebetude, difficulty of clear thinking or of remembering events of recent 
occurrence, or a general sense of perplexity. Others complain of a tem- 
porary sensation of numbness in one limb or one side of the body, or pains, 
or visual or auditory symptoms. Such symptoms are to be traced to mal- 
nutrition of the neurones, resulting from arterial disease. The writer ad- 
vises thorough investigation of the condition of the blood vessels, espe- 
cially the heart, and tension of the arteries, and when the condition of 
arterial sclerosis is recognized, appropriate treatment will make much of 
the so-called neurasthenia of middle age disappear. 

The majority of the diseases of the spinal cord are equally traceable to 
disease in the vessel wall. Anterior poliomyelitis, bulbar paralysis, and 
ophthalmoplegia, when not distinctly infectious, are due to rupture or 
thrombosis of some branch of the anterior spinal artery supplying the 
anterior gray horns of the spinal cord. Myelitis, whether disseminated or 
transverse, if not due to infection, is due to a rupture of a blood vessel 
which has suffered from disease. Spastic paralysis, commonly known as 
Erb’s syphilitic paraplegia, is now recognized as due to malnutrition of the 
dorsal region of the spinal cord, with consequent descending degeneration 
of the lateral columns. The cause of the malnutrition is syphilitic endar- 
teritis obliterating the spinal blood vessels. Senile paraplegia, in which a 
gradually advancing weakness culminates in a slowly progressive paralysis 
of the legs, with imperfect control of the rectum, is due to obliteration of 
the blood vessels, to the thickening of their walls, and to a consequent mal- 
nutrition of their parts. Combined sclerosis is due to the same cause. 
Disease of the peripheral nerves is occasionally due to endarteritis of the 
small vessels. The various forms of neurasthenia and neuralgia are fre- 


734 PERISCOPE. 


quently due to the same cause. Treatment by iodide of potassium is fre- 
quently indicated for a time in high tension pulse. The writer believes thy- 
roid extract is of use in some cases of temporary high tension pulse, and 
has noted especial results in cases of migraine, where the tension is usually 
high. W. B. Noyes, New York. 


MENINGITIS WiTHOUT ANATOMICAL Lesions. J. Birnbaum (Munchener 

medicinische Wochenschrift, July 21, 1903). 

It occasionally happens that patients die very suddenly with all the 
symptoms of a severe meningitis and yet only a slight exudate and perhaps 
a moderate degree of swelling and hyperemia of the brain is found post’ 
mortem. The history of the case reported by the author is unique in that 
the patient was ill for fifteen weeks, and that absolutely nothing was found 
post mortem in the meninges. Bacteriological examination, however, re- 
vealed the presence of a meningococcus, and the cerebrospinal fluid with- 
drawn during life showed a slight coagulum. The case was looked upon as 
one of meningeal sepsis without anatomical lesion. The cause was probably 
infection from a gum-boil which had been incised with extraction of the 
diseased tooth, two days before the acute onset of the illness. 

JELLIFFE. 


PROCEEDINGS OF THE ANNUAL SESSION OF THE GERMAN ASSOCIATION FOR 

PSYCHIATRY, AT JENA, April 20, 2I, 1903. 

The following critical summaries and papers were read and discussed. 
A critical summary upon the employment of isolation in the treatment of 
cases of mental disease, by Mercklin; papers upon the anatomical cortical 
region, by Vogt; upon the cytohistological localization of the human cortex, 
by Brodmann. A second critical summary upon the pronouncement of the 
Prussian Minister of Justice on the 9th of October, 1902, concerning the 
conduct of experts in the determination of irresponsibility, was read by 
Thomsen. A report upon the activity of the statistical commission named 
in the past year, was read by Hoche and Aschaffenburg, and a paper on the 
contribution to the knowledge of cretinism was read by Weygandt. Wol- 
lenberg demonstrated preparations of brain tumors. Liepmann read a 
paper upon the course of ideas. The third critical summary upon the idea 
and the significance of dementia, was read by Tucsek. Papers were read 
upon the construction of a sanitarium for nervous patients at the public 
expense, in Rasenmuhle, in G6Ottingen, by Cramer on the experimental 
studies with reference to the pathogenesis of acute psychosis, by Berger; 
upon the significance of special medication in the treatment of imbeciles, 
by Lacqer, and Binswanger demonstrated three cases of postsyphilitic de- 
mentia. JosEPH SAILER, Philadelphia. 


TABES AND THE MariTAL RELATION. A. Pitrés (Journal de Médecin de 

Bordeaux, July 12, 1903). 

The author here presents a statistical article based on a study of 240 
tabetics and dealing with the influence of tabes upon fecundity and the 
health of the-offspring in marriages in which one parent was afflicted with 
locomotor ataxia. The 31 celibates of this number are dismissed by the 
author without comment. The issue of the remaining 209 amounted to 483 
children; of whom 107 were still-born or died in the early months, and 286 
survived; making an average of 2.31 births to each couple, with but 1.36 liv- 
ing children. Carrying the analysis further, the author states that of the 
209 marriages, 42, or 20 per cent, were absolutely sterile, 32, or 15 per cent, 
resulted in still-births or death shortly after birth; while in the remaining 
135, or 60 per cent, there were living children in the relatively high propor- 
tion of 2.11 per family. The high mortality seen in the offspring of tabetics, 


PERISCOPE. 735 


the author believes, is attributable to the antecedent infection rather than 
indirectly to tabes; and this infection is, in the majority of cases, syphilitic. 
He cites figures which go to show that the mortality of children born before 
development of tabes in either parent was 44 per cent.; while those born 
after the appearance of tabes showed a mortality of but 28 per cent. This 
finding furnishes, in his opinion, additional proof of the statement made by 
Régis, to the effect that the offspring of tabetics have a better chance of 
life and health when born in the later stages of the parents’ disease than at 
a period nearer to the antecedent infection. As to the outcome of his inves- 
tigations looking to the determination of the influence of syphilis upon the 
mortality of tabetics’ children, the following figures are quoted: Of 77 male 
subjects who had undoubtedly had syphilis, 187 children were born, of 
whom 33 per cent were still-born or died in early infancy, and 67 per cent 
survived. Of 34 who denied antecedent syphilis, 81 children were born, of 
whom 20 per cent were still-born or died shortly after birth, and 80 per cent 
survived. With few exceptions, Pitrés finds that the surviving children of 
tabetics are uninfluenced by the parents’ disease; their physical and intel- 
lectual development proceeding normally as that of other children; and of 
the 286 children of tabetic parents, whom he kept under observation, many 
were alive at twenty years, and some had attained thirty and thirty-five 
years at the time of writing. In none did tabes or Friedreich’s disease de- 
velop, neither was there evidence of any other nervous affection. None 
showed signs of physical or mental degeneracy, nor was the influence of 
syphilis apparent in any. On the other hand, some developed diseases inde- 
pendent of all hereditary influence; such as tuberculosis, rheumatic cardi- 
opathies, etc. The great majority were, however, healthy in body and mind. 
JELLIFFE. 


CHOREA IN PREGNANCY. Cecil Wall (Brit. Jour. of Obstet., June, 1903). 

It has often been observed that the movements of a choreic patient are 
closely akin to those normally employed in the expression of emotions. In 
a young child, before the highest centers have developed coordinating con- 
trol, such movements are alone present; it is only by a process of education 
that spontaneous movements of early infancy become coordinated, and thus 
capable of purposive action. Rheumatism is undoubtedly, in the majority of 
cases, associated in some way with the chorea of childhood. So, too, during 
pregnancy, rheumatism plays an important part in the etiology of chorea. 
Buist found a personal history of rheumatism in 45 out of the 226 cases 
that he analyzed. The author’s statistics show that at least 16 of 37 patients 
had previously suffered from some form of rheumatism. Twelve more had 
had chorea in childhood without other rheumatic manifestations. Ante- 
cedent chorea may suggest a rheumatic taint, but cannot be taken as con- 
clusive evidence. In pregnancy, defective mental development seems to vie 
with rheumatism and previous chorea as one of the predisposing factors, 
rendering patients liable to an attack of chorea. The determining cause for 
chorea is not infrequently to be found in worry, for which the pregnancy is 
the chief cause; in case the patient is worried by the knowledge that her 
child is illegitimate. Fear of dystocia may be another inciting factor. 
Chorea in pregnancy seems to be determined by mental display, overstrain 
and shock. Secondly, the determining cause is only effectual when it acts 
upon a brain whose power of control is somewhat lowered by the pregnant 
state, and in addition is unstable in consequence of (1) antecedent chorea; 
(2) antecedent rheumatism or a similar debilitating condition; (3) a defect 
in development. JELLIFFE. 


Book Reviews. 


A Dictionary oF Mepicat Science. By Rostey Dunocuison, M.D., LL.D. 
Twenty-third Edition. Edited by Thos. L. Stedman, A.M., M.D. Lea 
Brothers & Co., Philadelphia and New York. 

Dunglison’s Dictionary has always occupied the first rank among the 
medical dictionaries of this country, and in its successive editions it has 
been brought more or less up-to-date. With the present edition, the 23d, 
it has undergone a much more radical revision than has ever before taken 
place in its history, bringing it once more into the foreground as a serious 
and trustworthy dictionary. 

Notwithstanding the immense number of new terms which have been 
added, the work has been kept within reasonable limits and the editor is to 
be congratulated on his careful work in the field of cross-reference and in 
his elimination of much waste matter. We can congratulate both editor and 
publisher alike on the successful accomplishment of this twenty-third 
edition. R. Brown (New York). 


Mikroskopisch-topographischer Atlas des Menschlichen Zentralnervensys- 
tems mit beuleitendem Texte von Dr. Otto Marburg (Ehemaligen As- 
siatiulin auw Neurologischen Institute der Weiner Universitat) Mit 
Eineun Gleitnost von Prof. Dr. H. Obsteiner. Mit 5 Abbildungan 
un Texte und 30 Tafeln nach Originalin des Akademischen Malers A. 
Kiss. Franz Deuticke, Leipzig and Wein, 1904. 

This work embraces the author’s well known systematic scheme of 
study of the central nervous system. His experience is shown in that this 
work is concise, lucid and practical. The Atlas is particularly timely as 
clinical neurology of today demands an accurate working knowledge of 
nervous anatomy. American colleges are just inaugurating this work. The 
_Atlas consists of 125 pages of descriptive text illustrated by five text figures 
and thirty full-page plate drawings. The latter are especially beautiful 
and clear. The sections are stained after Weigert-Pall and Czokor carmine. 
The serial and natural order in which the spinal cord, medulla pons, brain 
stems and brain are considered, renders it easy for the student to gain the 
essential and practical facts. Sections in three planes aid much in orienta- 
tion of the important anatomical structures. An introduction by Prof. 
Obersteiner accompanies the work. We can heartily recommend this work- 
ing atlas of the central nervous system to every thorough-going student of 
neurology. L. PrercE CLARK. 


Volume 30. December, 1903 No. 12 


THE 


Journal 


OF 


Nervous and Mental Disease 


Original Hrticles. 


ENORMOUS TUMOR OF THE POSTERO-PARIETAL REGION, 
WEIGHING OVER HALF A POUND; ABSENCE OF LO- 
CALIZING SYMPTOMS UNTIL LATE IN THE HIS- 

TORY OF THE CASE; OPERATION; DEATH. 


History of the case by Dr. Dercum. 
By F. X. Dercum, M.D., anp W. W. Keen, M.D. 


The following case, because of the extreme difficulty of local- 
izing the growth, of the nature of some of the symptoms present, 
and because of the enormous size of the tumor, is of unusual in- 
terest and importance. 

H. W., age twenty-six, single, formerly civil engineer, later 
hotel proprietor. Examined April 23, 1902. 

Family History. Mother died at the age of thirty-six with 
pulmonary tuberculosis. Father living and in good health. 
Patient has one sister, who is also living and well. 

Personal History. Was healthy at birth. At the age of one 
year, suffered from a discharge from the right ear and subse- 
quently lost his hearing upon this side to a very decided degree. 
An examination made some years later revealed a perforation 
of the drum. At long intervals, discharge from this ear recurred. 
During the past year or two the ear has again been a source of 
annoyance, as it has again been discharging a thick offensive 
fluid. 

The patient had the ordinary diseases of childhood, from 
which he made good recoveries. He has had, since childhood, 
no serious illness, that is nothing that confined him to bed. 
He had at various times occasion to consult physicians for indi- 


738 F. X. DERCUM AND W. W. KEEN. 


gestion and occasional attacks of headache. He had been edu- 
cated as a civil engineer, and some years ago, while working in 
some mines in Kentucky, had received at various times quite 
severe blows on the top of his head, but not severe enough to 
cause loss of consciousness. At another time his legs were seri- 
ously bruised by an accident. 

For a year past he has been manager of a hotel at a seaside 
resort, and in March, 1902, his hotel was suddenly placed in 
danger from fire. At this time he exerted himself very greatly in 
order to secure the safe exit from the hotel of his guests and 
other persons, and also to save their trunks and valuables. AI- 
though he had been placed under sudden and serious strain, he 
betrayed no special symptoms save some headache. This head- 
ache persisted, and he believed that it was in some way connected 
with his eyes. He thereupon consulted Dr. G. E. de Schweinitz. 
Dr. de Schweinitz reports that he found at this time no changes 
whatever in the eye-ground, nor any defect of any of the ocular 
muscles. About one month later, on April 23, the patient again 
visited Dr. de Schweinitz, and upon this second examination a 
double optic neuritis was observed. It was most marked in the 
left eye, the field of which was somewhat contracted. There was 
also paralysis of the right external rectus and a consequent 
diplopia. 

On April 23 he was first examined by myself. Questioned 
again as to his past history, he now recalled that for a number of 
months past he had noticed a little uncertainty of movement in 
the right arm, that he noticed occasionally that he would make 
a mistake in the act of picking up his pen, that is, that his fingers 
would not grasp the pen but would go a little to either side of it. 
He distinctly recalled that upon one occasion when about to help 
himself to butter he put his fingers instead of his knife into the 
butter. These acts of slight loss of control of the movements 
of the right arm were not, however, frequent. He also noticed 
awkwardness of movement in his legs, in trying to go upstairs 
two steps at a time. He added also that he had recently had 
several attacks of vomiting, especially in the early morning, be- 
fore he had taken any food. 

Present Condition. Complains of a dull headache. Asked 
to localize it, he states that it is more marked over the left eye. 
At times the headache is diffuse over the entire forehead. He 
has no headache over the parietal region, over the vertex or over 
the occiput. At times he has a feeling of tension about the head 
and at times also he is dizzy. Occasionally, if he stoops to pick 
up something from the floor, he is obliged to get up slowly; 
otherwise the pain in his head grows worse. Has no ringing in 


TUMOR OF POSTERO-PARIETAL REGION. 739 


the ears. Has not vomited for several weeks past, but not infre- 
quently feels inclined to vomit. 

Physical Examination. Gait normal. Station normal. States, 
however, that he has a feeling of uncertainty while making the 
Romberg test. Stands fairly well upon either leg alone. There 
is no intention tremor. Tongue protruded in the median line. 
The tongue is slightly tremulous. There is also a little tremor 
and ungteadiness of the lips. The left eyelid droops slightly. 
The right nasolabial fold is possibly a little shallower than the left. 
There is no inequality of the mouth. There is marked deafness 
of the right ear, which is due evidently to an old otitis media. 
The grip of the right hand is 84; the grip of the left hand is 74. 
There is no change in the handwriting, though the patient himself 
declares that it is somewhat shaky. There is no ataxia. Both 
knee-jerks are minus, but are well reinforced. There is no ankle 
clonus. The Achilles jerk is present and apparenty normal. 
There is no Babinski sign. There are no sensory losses, though 
the patient complains of a feeling of numbness upon the inner 
aspect of the lower portion of the right thigh and upon the inner 
aspect of the right calf. There is loss of stereognostic perception. 

His pulse is 70 and his temperature is 98.2. 

Urine Report. Amber; specific gravity, 1,025; reaction acid; 
no albumin; no sugar; urea, 1.6 per cent. 

Microscopic Report. Negative. 

Blood Report. Erythrocytes, 4,650,000; leucocytes, 10,200; 
hemoglobin, 70 per cent. 

Because of the history of long-standing disease of the right 
ear, and because of a possible brain abscess, it was thought wise 
to subject the ear to thorough surgical exploration. Dr. Charles 
K. Mills, who saw the case in consultation at this time, fully 
agreed with me as to the advisability of this procedure. 

Dr. de Schweinitz now made another eye examination, and 
reported as follows: 

Mr. W. has a paresis of the right external rectus. He has 
double optic neuritis with many hemorrhages of the succulent and 
inflammatory type. Beyond this the examination revealed noth- 
ing new. 

On May 12, 1902, the patient was operated upon by Dr. J. 
Chalmers da Costa. 

A two-inch semilunar incision was made over the right mas- 
toid, all structures being divided to the bone. The cartilaginous 
aural canal was then separated from the bony wall, and the mas- 
toid chiseled. This was found decidely hard and completely ossi- 
fied; the opening was enlarged with rongeurs, and the middle and 
posterior fosse of skull were exposed and explored. The dura 


740 F. X. DERCUM AND W.W. KEEN. 


and brain tissue were found apparently normal, and hence the 
dura was not opened; the parts were thoroughly cleaned, hemor- 
rhage controlled by torsion and ligature. A small strand of 
iodoform gauze was inserted, the aponeurosis was closed with 
catgut and the skin with silkworm gut. The drainage was re- 
moved at the expiration of forty-eight hours. 

The patient made an uneventful recovery from the operation, 
and for a time was better, being free from headache, vertigo or 
vomiting. On May 20, however, in the morning, he complained 
of some vertigo and nausea. About noon had his wound dressed; 
suffered from nausea. Induced vomiting by means of his finger. 
Felt some relief after this vomiting, though the nausea persisted 
more or less for the remainder of the day. In the evening com- 
plained of a slight headache. 

On May 25, 1902, he was re-examined by Dr. Mills and my- 
self. 

Station. A slight increase of sway. 

Right knee-jerk slightly diminished; left knee-jerk slightly 
diminished. 

Right ankle clonus slight disappearing ; left ankle clonus, zero. 

Right plantar reflex, zero; left plantar reflex, normal. 

Faint hypesthesia of the inner aspect of lower portion of right 
thigh and right leg. 

June 1, 1902. Symptoms as before. Tested for astereognosis 
upon the soles of the feet, it was found that he was somewhat un- 
certain as to the position of a pencil when the latter was placed 
in various positions upon the sole of the right foot. In one in- 
stance he clearly mistook the direction for transverse when it was 
longitudinal. Upon the sole of the left foot he made no errors 
whatever. Further, he did not recognize little balls of paper 
placed between the toes of the right foot as readily as when they 
were placed between the toes of the left foot. 

June 3, 1902. Re-examination by Dr. Mills and myself. 

Right knee-jerk, minus; left knee-jerk, minus. 

Right ankle clonus, slight disappearing; left ankle clonus, 
zero. 

Right plantar reflex, sometimes absence of response; left 
plantar reflex, normal. Other symptoms as before. 

June 7, 1902. This evening (about 7.30) complained of 
nausea and vertigo. This attack appeared rather suddenly and 
was quickly followed by an attack of vomiting. Vomiting was 
not followed by any relief, though it recurred at intervals; it was 
accompanied by considerable retching. The vomited material 
consisted of a thick viscid mucus and some bile. Nausea and 
vertigo had almost disappeared by the following morning, after 
patient had slept fairly well. 


TUMOR OF POSTERO-PARIETAL REGION. 741 


June 10, 1902. Examined by Dr. W. G. Spiller. Present, 
Dr. Mills and myself. 

Left knee-jerk, minus; right knee-jerk, more diminished. 

Sensation for touch preserved in each lower limb and appears 
to be equal upon the two sides. The same is true of pain sensa- 
tion. If hypesthesia is present upon the right side, it is exceed- 
ingly slight. 

Movement of the toes to irritation of the sole of the right foot 
is that of flexion of all the toes, except the great toe; the great toe 
does not move. Upon the left side the movement is that of 
flexion, including that of the great toe. The only difference be- 
tween the two sides is that the great toe of the right side dors not 
move at all. 

Left ankle clonus, zero; right ankle clonus, zero. 

The Achilles jerk is prompt upon the left side, while upon the 
right side, tapping the tendo-Achillis causes repeated contrac- 
tions, like ankle clonus. 

Patellar clonus is not present upon either side. 

Resistance to passive movements seems to be fully normal in 
each limb. 

He stands erect without swaying, even when eyes are closed. 

The gait is not peculiar. 

Hemiasynergy is not present in either lower limb when the 
patient is reclining. 

The grasp of each hand is good and apparently normal. 

The biceps jerk, triceps jerk and wrist reflexes are not very 
distinct upon either side. 

Sensation to touch and pain in the upper limbs is equal upon 
the two sides, and is normal. States that his right hand is numb, 
that this is so distinct that he is certain it exists and yet upon 
testing it cannot be determined. 

The patient states that since the operation, or possibly before 
the operation, he has been a little weak in the right lower limb, 
and also in the fingers of the right hand, arm and right leg; he 
complains of being awkward with the right hand. There is ap- 
parently some disturbance of sense of position. On attempting 
to put the first finger of the right hand on the first finger of the 
left hand, or vice versa, when eyes are closed, he has much diffi- 
culty in touching the desired objects. He is able to tell correctly 
any movement of his fingers or toes when his eyes are closed. 
Stereognostic perception is normal in both upper limbs. 

Hemianopsia is not present. The pupils are equal. There is 
no nystagmus in looking to either side. Movement of the facial 
muscles is normal upon either side. Movements of the muscles of 
mastication are normal upon either side. There is no word-deaf- 


742 F, X. DERCUM AND W. W. KEEN. 


ness, no word-blindness, and no symptom of sensory or motor 
aphasia. His memory is not quite as good as formerly. Says 
that he has become more irritable than formerly. Also that with- 
in the last twelve months he is not as good at figures as formerly ; 
he cannot add or multiply as well as formerly, and this change he 
regards as very perceptible, and is even greater than the failing of 
memory. He has more difficulty than he formerly had in under- 
standing the meaning of what he reads. 

The patient is not as able to tell whether a pencil is placed 
lengthwise or crosswise upon the sole of his right foot; he makes 
no error upon the sole of the left .foot. 

June 20, 1902. Re-examined by Dr. Mills, Dr. Spiller and 
myself. 

Lower limbs are well developed, although he says he is not 
as stout as a few years years ago, weighing about twenty pounds 
less at the present time. _ 

Resistance to passive movements of the thigh and leg, of 
each side, is normal and equal on the two sides. 

Sensation to touch and pain in the lower limbs normal, though 
possibly tactile sensation is slightly diminished in the right lower 
limb as compared with the left. This diminution, if present, is 
slight. There is a slight diminution in the right lower limb to 
pain, tactile and temperature senses. 

The patellar reflex on the right side is possibly slightly dimin- 
ished; on the left side a little more pronounced than on the right 
side. Ankle clonus not obtained on either side. Plantar irrita- 
tion upon the right side produces a slight movement of all toes 
in flexion, except the great toe, this not being moved at all; move- 
ment of the other toes is slight. On the left side, the movement 
of all the toes is that of flexion. 

The Achilles jerk is present on each side and is about normal. 

The gastrocnemius reflex is present on each side. These re- 
flexes, Achilles and gastrocnemius, being equal on both sides. 

Station erect is good with eyes closed. Gait normal. Stands 
well on each foot alone. Resistance to passive movement in the 
right upper limb is normal; the same in the left upper limb. 

Sensation to touch, pain and temperature is normal in the 
two upper limbs. There is possibly a slight diminution in the 
right arm, but this is questionable. 

Biceps jerk, triceps jerk and wrist reflexes are about normal 
upon the two sides. The sense of the position of the fingers and 
toes of each side seems to be normal, but he is not always certain 
of the right great toe. He seems to be able to tell correctly 
movements of the left great toe. Apparently there is no loss of 
the sense of position in the upper limbs, or at least the loss is not 


TUMOR OF POSTERO-PARIETAL REGION. 743 


pronounced. The movement of the right upper limb, when the 
eyes are closed, would suggest a slight loss of the sense of posi- 
tion. 

The stereognostic sense is well preserved in both hands, al- 
though he occasionally makes a mistake in trying to differentiate 
between a dime and a cent with the right hand. These mistakes 
are infrequent. He never, however, makes any mistake with the 
left hand. Upon the sole of the right foot, there is again noted, 
as at previous examination, a tendency to make errors as to the 
position of the pencil or penknife when placed upon the sole of 
the right foot. Upon the sole of the left foot no errors are made 
at any time. 

The patient was re-examined July 5 and July 29 and pre- 
sented no noticeable change of symptoms. On September 5, 
1902, he was re-examined by me. His symptoms were the same 
as at previous examinations, save that there was present an area 
of undoubted tenderness over the skull in the left post-parietal 
region. This area in front begins at eight and a quarter inches 
from the glabella and about half an inch from the sagittal suture. 
It extends as far back as to within one and three-quarter inches 
of the occipital protuberance. It is about two and three-quarter 
inches in its longitudinal diameter. It extends downward over 
the parietal region for about two inches. It appears to be oval 
in shape. The patch is sensitive upon superficial pressure and 
made worse upon deep pressure, and pain is also readily elicited by 
friction. The patient states that this area has been more or less 
noticeable since August 31. 

Of late the patient has suffered but little from headache, hav- 
ing had but one severe attack since he was last examined. His 
diplopia is about the same. Dr. de Schweinitz reports his vision 
as perhaps slightly better. There is little or no change in the 
paresis of the left external rectus. There is less swelling of the 
optic discs than there was. 

Because of the new symptom of tenderness in the post- 
parietal region, I submitted the patient to another examination 
on September 11, at which Drs. Mills and Spiller were also 
present. Strange to say this symptom of tenderness had at this 
examination almost or completely disappeared, so that it could 
not be confirmed by either of my colleagues. Otherwise the 
symptoms were as noted at previous examinations. It was 
thought by Drs. Mills and Spiller that possibly there was a 
slight awkwardness in the movement of the fingers of the right 
hand and of the toes of the right foot. Difference in the move- 
ment between the digits of the two sides of the body, however, 
was so slight as to be open to discussion. This remarkable symp- 


744 F. X. DERCUM AND W. W. KEEN. 


tom of tenderness, both superficial and deep, upon the post- 
parietal region never subsequently recurred, although new symp- 
toms made their appearance, while some of the old ones gradu- 
uly became more pronounced. 

On October 17, 1902, he again presented himself for an ex- 
amination, and it was now found that in addition to the symp- 
tums which he had presented before, there was a slight hypesthe- 
sia of the left side of the face. It was most marked over the 
middie distribution of the trigeminal and to a less extent exter- 
nally over the superior. Mr. W. was able to detect all tactile 
impressions directly, but hypesthesia was undeniably present. He 
also described a subjective sensation of numbness and a crawling 
sensation in the left side of the face; also that the left side of the 
face felt somewhat stiff. The slight difference in the nasolabial 
folds, noticed in the early history of his case, was still present, but 
had not become accentuated. There was no involvement of the 
muscles of mastication. The patient had had very little headache, 
and only a slight attack of nausea some two weeks ago. About 
this time his case was studied by Dr. William Osler, who, with 
myself, thought that this numbness of the face suggested a deep 
basic lesion upon the left side. Dr. William M. Sweet now made 
several careful skiagraphs of the head, but no shadows were re- 
vealed that seemed in any way to suggest the location of a tumor. 
After a consultation with Drs. Mills and Spiller, it was deter- 
mined to advise an exploratory operation of the base upon the 
leit side. The patient’s symptoms were at this time gradually 
becoming more pronounced, although the general symptoms were 
as before. The optic neuritis was now of high grade, with be- 
ginning degeneration of the optic nerve fibers, with resulting 
depreciation of vision (de Schweinitz). The fields were con- 
tracted, but there was no hemianopsia, the pupillary reactions 
were unchanged. There was a palsy of the right external rectus, 
thirty degrees, and a palsy of the right superior rectus (possibly 
inferior oblique) of eleven degrees. There was some widening 
of the palpebral fissures, giving the appearance seen in hydro- 
cephalus. 

On November 3, 1902, Dr. Keen made an osteoplastic flap 
in the left temporal region, but beyond determining a distinct 
resistance posteriorly, the operation resulted negatively as regards 
localization of the growth. Mr. W. made a perfect recovery 
from the operation and subsequently returned to his home. He 
was not seen again until December 17, 1902, when it was found 
that the hypesthesia of the left side of the face had disappeared. 
There was, however, a slight, but unmistakable hypesthesia 
present in the lower limb and to a less extent of the right upper 


TUMOR OF POSTERO-PARIETAL REGION. 745 


limb. The plantar reflex was not obtainable upon either side. 
The knee-jerks presented the same difference as at previous exam- 
inations, as did also the ankle clonus. The grip of the right hand 
was 65; that of the left hand, 60. The patient stood well upon 
either leg alone. The tongue was protruded in the median line. 
There was no facial inequality. The atrophic changes in the optic 
nerve were somewhat more marked than at the previous examina- 
tion. When tested for astereognosis, occasionally made errors 
with the right hand. No word-blindness. No word-deafness. 

The patient now passed from under my observation. I did 
not again see him until March 18, 1903. Dr. T. Percival Gerson, 
of Lansdowne, under whose care he was, reported that he had 
gradually become hemiplegic, there being a very gradual loss of 
power making its appearance in the right side of the body, right 
leg and right arm, also that there had been very decided loss of 
sensation upon the right side and awkwardness of movement. 

March 18, 1903. Examination by Dr. Dercum, together with 
Dr. Gerson. 

Mr. W. presented the following symptoms: He entered the 
room with a decided hemiplegic gait, dragging the right leg and 
allowing the right arm to hang at his side. He was not able to 
stand upon the right leg alone, while the loss of power in the 
right arm was also very marked. There was a decided hypesthe- 
sia of the right arm, right leg, right side of the face and head 
and right half of the trunk. This hypesthesia was not sharply 
demarcated by the middle line. It was most marked in the distal 
portions of the extremities and became less marked as the middle 
line of the trunk was reached. The area of but slightly impaired 
sensation extended from two to four inches from the middle line 
to the right. The right knee-jerk was much exaggerated. The 
left knee-jerk was about normal. There was now persistent 
ankle clonus upon the right side. The elbow jerk was present 
upon the right side, but not pronounced. There was a slight 
von Bechterew reflex upon the right side. 

The Babinski reflex was not present upon either side. Upon 
the left side the toes moved normally, but on the right side there 
was a slight movement of the four outer toes in flexion, while 
the great toe did not move at all. Right-sided homonymous hemi- 
anopsia was now present, although both visual fields were dis- 
tinctly contracted. This hemianopsia could readily be demon- 
strated and was quite well defined by the middle line. Wernicke’s 
symptom was not present. Astereognosis was now complete. 
There was also typical word-blindness. There was no word-deaf- 
ness. The patient had, however, a distinct difficulty in the use of 
substantives. He was unable frequently to give the name of 


746 F. X. DERCUM AND W. W. KEEN. 


common objects, such as a book, even though he examined the 
book both by vision and touch. The symptom of anomia was 
not complete, but it was undoubtedly present. At this examina- 
tion, tenderness in the post-parietal region was again sought for, 
but not elicited. 

Because of the new features presented by the case, I decided 
to again advise an operation, and submitted the question to my 
colleagues, Drs. Mills and Spiller, who concurred in its advisa- 
bility. Accordingly, on March 26, he was operated upon by 
Dr. Keen, who made a large exposure of the parietal region. 
The details of the operation are given by himself. The bone 
proved to be excessively vascular, and the operation had to be 
completed in three stages, the final result being the removal of 
an enormous sarcoma, weighing 264 grams. The mass was en- 
capsulated and was removed without much difficulty, but the 
patient succumbed to shock and operation shortly afterward. 


Although no autopsy was obtained, the fact that the tumor 
was encapsulated makes it exceedingly probable that only one 
sarcomatous mass was present in the brain, and that all of the 


symptoms were referable to this growth. The interest of this 
case lies in the extreme difficulty of the localization and in the 
indefinite and often misleading character of the symptoms. 


It is remarkable that cortical disturbances, such as unmis- 
takable astereognosis and alexia on the one hand and hemianopsia 
upon the other, were not present earlier in a case of tumor in 
this situation. The inference is justified that the growth origi- 
nated subcortically and only late in the course of the affection 
produced cortical phenomena by upward growth and hemianop- 
sia and basal phenomena by downward growth. In reviewing 
the symptoms we are impressed by the fact of the insignificant 
value of such a sign as a paralysis of one abducens or of a 
- trifacial hypesthesia. In the present instance they were undoubt- 
edly due to pressure from a distance, and as is well known, they 
frequently so occur from such cause. They are of themselves 
of little or no localizing value. However, the case does demon- 
strate the localizing value of astereognosis and slight muscular 
incoordination. In reviewing the history of the case, it will be 
noted that faint, but unmistakable astereognostic signs were 
present upon the sole of the right foot, and somewhat later upon 
the right hand, as were also faint, though somewhat inconstant 


TUMOR OF POSTERO-PARIETAL REGION. 747 


symptoms of incoordination of the right fingers and right toes. 
Lastly, the symptom of local tenderness and pain in the post- 
parietal region, which was present for a few days only, assumes 
a vast importance. It was so fugitive that it was not present 
at the examination made a week later by Drs. Mills and Spiller, 
and was apparently absent at the examination made by Dr. Osler, 
and yet that there was abundant cause for such a pain, the find- 
ing at the operation of a large exostosis of the internal table in this 
very situation most conclusively proves. 

To repeat, the history of the case and the very gradual evolu- 
tion of localizing phenomena justify the inference that the tu- 
mor began subcortically in the post-parietal region, and that it 
grew downward and upward very gradually. It would seem to 
me that it would be a perfectly justifiable expedient and far 
preferable to what was done by ourselves in this case, when 
symptoms of one-sided trouble, vague in character, make their 
appearance, not to attempt an exploration of the base, which is 
always a matter of extreme difficulty, but to make a free osteo- 
plastic exposure of the most probable area upon the lateral 
aspect. The free osteoplastic exposure is attended with little 
risk, and the exploration possible under the circumstances is, 
as a rule, very thorough. Had such a plan been attempted by us 
I am quite sure that the tumor would have been found, though 
early in the case it would doubtless have been found to be situated 
beneath the cortex. The lesson to be drawn from this case is to 
make free osteoplastic exposures in all cases yielding symptoms 
referable to one side of the cortex, no matter how slight these 
‘symptoms may appear to be. 

The tumor apparently grew very rapidly in the last few 
months of the patient’s life. The size and weight that it attained 
were truly enormous, and showed how very much pressure the 
brain can withstand without destroying the life of the patient. 


Surgical Report by Dr. W. W. Keen. 


I first saw Mr. White in consultation with Dr. Dercum on 
October 29, 1902. The reasons for operating at the point selected, 
and also for the site of the prior operation which Dr. DaCosta 
made on the right side in the spring of 1902, have already been 
given by Dr. Dercum. 


748 F. X. DERCUM AND W. W. KEEN. 


Operation November 3, 1902. I made a flap in the left tem- 
poral region (Fig. 1) practically the same as that for the Gas- 
serian ganglion, including chiseling the zygoma so as to get down 
as low as possible. First, with a gouge I made a.small opening in 
the bone, and then with the rongeur forceps enlarged it till it was 
4 to 5 cm. in diameter. The bone seemed to be unusually thick, 
two or three times the ordinary thickness in this position. Ex- 
posure of the dura showed that it was very resistant and bulged 
considerably. As soon as it was opened the brain protruded. I 
attempted to lift the temporo-sphenoidal lobe with a broad spatula, 
so as to gain access to the pons, where the tumor, it was thought, 
might possibly be. It was, however, evident that the protrusion 
of the brain was such that I should do very extensive damage to 
the brain tissue if I lifted it to the desired extent. The cortex 
did 1 ot seem harder than usual, though the sense of resistance in 
the bain as a whole was quite marked. 

I. order to determine whether there was any possible disten- 
sion by fluid, I punctured the lateral ventricle, but did not find 
any. The diminution of resistance when the ventricle was entered 
was very perceptible. I then incised the temporo-sphenoidal lobe 

a depth of 3.5 cm. and introduced my finger into the incision. 
The white substance was normal to the eye. To the finger there 
was a distinct increase of resistance to pressure posteriorly as 
compared with the other three directions. After making several 
attempts to lift the temporo-sphenoidal lobe, and failing to see 
even as far as the site of the Gasserian ganglion, | abandoned the 
operation. He made a perfectly smooth recovery, the highest 
temperature being 99.6 degrees. 

Second operation, March 26, 1903. First Stage. Owing to 
the development of new symptoms, especially hemianopsia, after a 
consultation with Drs. Dercum, Mills and Spiller, we decided that 
it would be wise to do a second operation. The site of the tumor 
was now more accurately located in the parietal lobe extending for- 
ward perhaps as far as the fissure of Rolando and well backward 
into the occipital lobe. It will be observed that when at the first 
operation I introduced my finger into the substance of the tem- 
poro-sphenoidal lobe, I recorded at that time that the resistance 
posteriorly was distinctly greater than in the other three direc- 
tions. This also would confirm this diagnosis as to the situation 
of the tumor. 

I outlined a flap, the anterior border of which crossed the 
fissure of Rolando about at its middle, and passed nearly verti- 
cally upward, 9 cm. long (Fig. 1). Parallel with the median 
line, but 2.5 cm. away from it, I made an incision 13 cm. long; 
this reached into the occipital lobe. The posterior incision was 


TUMOR OF POSTERO-PARIETAL REGION. 749 


12 cm. long, as indicated in the diagram. The hemorrhage from 
the scalp was exceedingly profuse. At every point where the 
bone was exposed sufficiently to chisel it, wherever a little vessel 
penetrated the skull, the blood poured out from the bone in a 
fountain nearly I cm. in height. These were stopped by Hors- 
ley’s wax, the vessels in the scalp being clamped. I then pro- 
ceeded to chisel the bone. Of course the incision was not all 
made at first, but in three sections, and the chiseling of one was 
completed before the next was begun. The bone also I found 
very vascular. Some of the veins of the diploé poured out dis- 
tinct streams of blood. These also were stopped by Horsley’s 





Fig. 1. 


wax, but in spite of this a large amount of blood was lost. I 
could not understand why, especially at the posterior portion of 
the median incision, I did not get through the bone. While I 
was operating, one of my assistants, Dr. Craig, opened a vein in 
the right arm and infused 20 ounces of salt solution, to which 
were added 20 drops of 1-1000 adrenalin solution. Finally, as 
the patient had lost so much blood, we decided that the vascu- 
larity of the parts showed that the tumor lay underneath the pro- 
posed flap, that it was a very vascular sarcoma, and that if I 
continued the operation there would be so large a loss of blood 


750 F, X. DERCUM AND W. W. KEEN. 


when I turned back the osteoplastic flap that it would probably 
cost him his life. I decided, therefore, to do the operation in two 
stages. 

After the operation his temperature, up to the 29th, rose to 
a little above 100°, but from the 29th to the 31st fluctuated be- 
tween 101° and 102.6°. In spite of the high temperature, he did 
not seem to be very sick, though his pulse was from 100 to 120. 

Second stage. On March 31 we decided to reopen the skull 
and operate on the tumor. As I anticipated, a very severe hemor- 
rhage from the tumor, I first clamped the common carotid with 
Crile’s clamp and obliterated the caliber of the artery. After re- 
opening the wound in the scalp, which was attended with very free 
bleeding again, I chiseled some places in the bone where I had not 
chiseled entirely through, especially in the portion parallel with the 
median line just posterior to its middle, and at last was able to 
turn back the flap. As soon as it was reflected, the difficulty of 
chiseling through the bone was explained. On the inner surface, 
just at the median edge of the flap and 3 cm. from its posterior 
end was a bony tumor, conical in shape, 2.5 cm. in height and 
2.5 cm. in diameter. The chisel had traversed this bony tumor, 
where the bone was about two to three times its ordinary thick- 
ness. With the rongeur forceps I removed the entire bony 
growth. The dura was very soft, and at one point there was a 
deep depression corresponding to the bony growth. The tumor 
was evidently partly cystic. I then opened the dura corresponding 
to the osteoplastic flap. A considerable amount, estimated to be 
seven and one-half ounces, of bloody serum, so bloody that at first 
I thought it to be pure blood, escaped. This led me to ligate the 
common carotid and remove the clamp. 

As soon as the brain was exposed, the entire opening in the 
bone, large as it was, was filled with a very large bulging sar- 
coma. It was so large and his condition was so critical, in spite 
of another infusion of a pint and a half of salt solution with 
30 drops of adrenalin 1:1000 solution, that my judgment was 
against any attempt to remove the entire tumor, but I scooped 
out with my fingers a large handful. The hemorrhage was free, 
but not alarming. Packing with iodoform gauze, douching with 
hot salt solution checked the bleeding, and I closed the wound 
after gnawing away a part of the edge of the bony flap in order 
to allow the end of the gauze packing to protrude. I also ordered 
five minim doses of the adrenalin every four hours hypoder- 
matically. 

On the day after this operation his temperature rose to 103.2° 
and continued between 100° and 102° for nine days. It then 
fluctuated between the normal and 100°; meantime the wound 


TUMOR OF POSTERO-PARIETAL REGION. 751 


had healed without incident. The packing was removed on the 
second day without any noticeable hemorrhage; the wound in 
the neck healed by first intention. 

On April 1, the day after the operation, he moved his right 
arm once, but then was completely paralyzed on the right side 
for a week. Movement then began both in the right arm and leg, 
and he gained so rapidly that, after sitting up in bed for two or 
three days, I got him out on a chair, and on the seventeenth day 
he was able to walk down stairs into the garden of the hospital. 

As his parents and he himself, appreciated the fact that if the 
tumor were not removed the end would be fatal, they consented 
to another and final attempt to remove the remainder of the 
growth. In view of his very good condition, Drs. Dercum, Mills, 
Spiller and myself, after a conference, determined upon the final 
attempt. 

Third stage, April 21st. The flap was reopened very 
readily, the adhesions giving way under moderate leverage. The 
same peculiarity noticed before, was again evident, viz,—abund- 
ant hemorrhage not only from the scalp, but that every vessel 
which penetrated the bone became a little fountain. Again Hors- 
ley’s putty stopped this quite effectually. After gnawing away 
the bone sufficiently and removing the diseased portion of the 
dura, I was able to reach the limits of the tumor. The tumor ex- 
tended 2 cm. in front of the anterior border of my original open- 
ing in the bone, I cm. inferiorly and 1 cm. posteriorly. It ex- 
tended in the middle line entirely to the falx. This large mass, 
which more than filled my entire hand, I was able to enucleate 
quite easily and cleanly. Fully one-half of the entire area of 
the falx was exposed as soon as the tumor was removed. The 
hemorrhage, especially from the middle and posterior portions of 
the wound was very profuse. Packing with iodoform gauze ar- 
rested it in part. Adrenalin was given together with a saline 
infusion continuously until 30 drops of 1:1000 solution of adre- 
nalin and a pint and a half of salt solution had been administered. 
No distinctly large vessels, which could be ligated were discov- 
erable. Accordingly I had to trust entirely to packing and hot 
water. The flow was so profuse that adrenalin locally would 
have done no good. The wound was packed as firmly as was 
deemed advisable, the wound closed and the patient put to bed. 
He was in very profound shock and died about half an hour 
after being placed in bed. A culture from the surface of the tu- 
mor was given to Professor Coplin, who reported that the mic- 
rococcus pyogenes albus in pure culture was found. No abscess 


752 F. X. DERCUM AND W. W. KEEN. 


existed but the surface of the tumor was softened over a small 
area. 


REMARKS. 


Weight. This tumor is the largest that I have ever removed 
from the brain. I have not compared it with any accurate 
list to see what others have exceeded it in weight, but so far as I 
know the only one which exceeds it, is that removed, with better 
success, J am glad to say, by Bramann. His tumor weighed 280 
egrms., 16 grms. more than this. The tumor here reported 
weighed 264 grms., more than half a pound. 

Hemorrhage, Gln) Téw,) jtybany. cases) lave ) bascetaeimore 
severe hemorrhage from both scalp and bone. This seemed to 
indicate that the tumor lay directly under the site of the final 
operations. In the bone, Horsley’s wax answered admirably 
in arresting the bleeding. At the final operation the hemorrhage 
from the brain was so great that even quite firm gauze packing 
did but little good. No known large sinus, vein, or artery was 
opened, but the hemorrhage was universal and severe. The ap- 
plication of Crile’s clamp and finally ligation of the common car- 
otid on that side modified it but little. 

Exposure of the Falx Cerebri. Only very rarely have I re- 
moved a tumor which exposed the falx. In this case the exposure 
covered at least one-half of the superficial area of the falx, though 
less than one-half of its length. 


Dr. Spiller examined the tumor and made the following 
report’ 

“At the earlier operation by Dr. Keen, a large portion of the 
tumor was removed. The mass removed was easily broken, 
and had in the fresh state the appearance of a sarcoma. The por- 
tion removed was hardened partly in formaline and partly in 
Muller’s fluid. After hardening had occurred the portion in for- 
maline weighed 27 grms., that in Muller’s fluid 49 grms. The 
part first removed has an irregular surface as though it had been 
torn away from a tumor mass. 

“The part of the tumor removed at the later operation is much 
larger than that removed at the earlier operation, and two- 
thirds of its surface are sharply defined and nodular, as though it 
had been sharply separated in this portion from the surrounding 
brain tissue. Approximately one-third of the entire tumor, if one 
may judge from the form of this large tumor, must have been 
removed at the earlier operation. One side of the large tumor has 
a torn appearance, and from here probably the first piece of tu- 
mor was removed. The upper surface of the tumor is flat. The 


TUMOR OF POSTERO-PARIETAL REGION. 753 


weight of the second portion removed, before any hardening 
fluid had been used, was 188 grms., so that the entire weight of 
the tumor, including hardened and unhardened tissue, was 264 
rms. 
“The tumor consists of small spindle-shaped cells without de- 
finite arrangement, and is not exceedingly vascular. It is a small 
spindle-cell sarcoma.” 


STUDIES UPON THE CEREBRAL CORTEX IN THE NORMAL 
HUMAN BRAIN AND IN DEMENTIA PARALYTICA. 


By G. ALFrrep LAWRENCE, PH.D., of NEw York. 


INSTRUCTOR IN DISEASES OF THE MIND AND NERVOUS SYSTEM, NEW YORK 
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. 


(Continued from page 716.) 


Occipital Region.—Coming to the posterior pole of the ex- 
ternal cortex, the typical structure of the occipital lobe is repre- 
sented by Plate VIII, Fig. 24, a section magnified 14 diameters 
from a block taken from the point indicated by the figure 8, Plate 
I, Fig. 1. The section is 6 2-3 microns in thickness, is 6 mm. in 
width at the widest portion, and 7 mm. in length, stained with 
methylene violet, fixed in Van Gehuchten’s fluid, other technique 
as previously described. This convolution is seen to be quite dif- 
ferent in shape from the two previously described of the temporal 
and parietal regions, having a broader base and narrower rounded 
vertex. The cortex is seen to be thickest on the lateral aspect D, 
thinner on the opposite lateral aspect c, and thinnest at the vertex 
in the vicinity of a; the central white medullary substance being 
reduced to a minimum. The outer layer varies in thickness, being 
thickest at'c. Above this it is broken away for a short distance, 
is quite thin at the vertex, and becomes somewhat thicker on the 
lateral aspect b. Above b the section is seen to be cracked, an 
artefact resulting from its fixation upon the slide, also at c numer- 
ous small breaks are noticed, due to the microtome knife. Oppo- 
site a, and enclosed in ink lines, is the segment of this section, 
represented in Plate IX, Fig. 25, under a magnification of I00 
diameters. The radial arrangement of the cells is well made out 
at the vertex, but not quite so readily seen on the lateral aspects 
of the gyrus here, but under a higher magnification can be dis- 
tinctly made out. About the middle of the second layer, especially 
at the vertex, some very large pyramidal cells are to be seen 
singly or in groups, and approaching the Betz cells in type in 
some cases. The third or lower layer presents nothing unusual, 
and disappears below into the white medullary substance of the 
interior of the gyrus. Plate IX, Fig. 25, is a photomicrograph of 
the segment a, enclosed in ink lines in Plate VIII, Fig. 24, at a 
magnification of 100 diameters. Here the cortex is found thinner 
than in any of the preceding plates, measuring scarce 2 mm. in 
thickness. The first layer averages only .15 mm. in thickness, and 





DEMENTIA PARALYTICA. 755 


in structure and arrangement of the cells is similar to this layer in 
the preceding plates. The second layer measures 1.15 mm. in 
thickness, containing small pyramidal cells above and quite closely 
packed together, but increasing in size below and being somewhat 
more scattered. About the middle of this layer a number of large 
cells are seen, many singly, but some arranged in groups in places. 





Plate VIII, Fig. 24. 


Some of these are even larger than those found in the parietal 
convolution, and are intermediate in size between the Betz or 
giant pyramidal cells and the large pyramidal cells. These latter 
are not very numerous in this region, the small pyramidal cells 
making up by far the greatest part of the cellular elements of this 
layer. Below the middle of this layer is to be found a region, at a, 
almost exclusively made up of small pyramidal cells about .25 
mm. in width. Between this and the lower border large pyram- 


756 G. ALFRED LAWRENCE. 


idal cells are again found intermingled with the smaller. The 
third or spindle cell layer is here .70 mm. in thickness, containing 
larger and smaller spindle and irregularly polygonal cells, the 
lower border being gradually lost in the white medullary sub- 
stance below. The nerve cells are found quite numerous and 
closely aggregated in this region, as counts by the same method 
and manner as in all previous sections, give here an average of 
164 nerve cells to the square millimeter of surface of the section, 
and 199 neuroglia cells, the section being 6 2-3 microns in thick- 
ness and stained with methylene violet. The cells are thus seen 





Plate IX, Fig. 27. 


to be more numerous than in any other region of the external 
surface of the hemisphere, with the exception of the posterior cen- 
tral convolution. The fact of the greater number of the pyramidal 
cells being small, permits of their closer aggregation, and no doubt 
is an important factor in the result of the nerve cell counts. The 
number of neuroglia cells averages higher than in any other 
region posterior to the fissure of Rolando, but they are less in 
number than in the anterior central convolution. 

This includes the plates of the external surface of the cortex, 
but for the purpose of comparison, several plates will be intro- 





DEMENTIA PARALYTICA. 757 


duced from other parts of the central nervous system. * The first 


of these is a photomicrograph, Plate IX, Fig. 26, of several large 


pyramidal cells from the layer of large pyramidal cells of the 
hippocampus major or cornu ammonis; between the alveus, repre- 
senting the white medullary substance of the ordinary gyrus, and 
the stratum radiatum containing the apical dendrite processes of 





Plate IX, Fig. 26. 


these hippocampal pyramidal cells. This plate and the two follow- 
ing are not presented as a basis of comparison with similar 
regions of the pathological brain subsequently to be described, 
but to give an idea of the appearance of these cells in a normal 
brain as seen in a photomicograph of a Nissl preparation magni- 
fied 1,400 diameters, as distinct types in Nissl’s classification. 


758 G. ALFRED LAWRENCE. 


These large cells of the cornu ammonis are given as one of the 
four types of Group II of the stichochrome nerve cells in his 
classification ; the other three types being (1) the nerve cells of 
the motor nuclei, (2) certain cells of the cerebral cortex, and 
(3) certain cells of the spinal ganglia. In shape these cells ap- 
proach the larger pyramidal cells of the external surface of the 
cortex, second layer, but are somewhat more slender, of a narrow 
pyramidal shape, have fewer basal dendritic processes, and a long, 
somewhat slender, apical dendritic process. The chromatic sub- 
stance here is made up of very small granules fusing into larger 
and smaller masses in places, so that in the photomicrograph it is 
difficult to differentiate and determine their arrangement accu- 
rately. In some of the cells, as in the cell to the extreme right of 
the plate, and partially out of the field, the rounded and linear 
granules above the nucleus, and extending into the apical process, 
are seen to have a general parallel arrangement. The nuclei of 
these cells are large, and contain a large, well marked nucleolus 
and a more or less irregular chromatic network. As this section 
was stained with methylene violet, numerous neuroglia cells are 
distinctly seen scattered among the pyramidal nerve cells. 

From the cerebellar cortex a photomicrograph was taken of 
two Purkinje cells, magnified 1,400 diameters, and shown in Plate 
IX, Fig. 27. The section from which this photomicrograph was 
taken was situated on the external surface of the left hemisphere, 
cut transversely to the horizontal axis of the same, fixed in alcohol 
95 per cent, stained with methylene blue; other technique similar 
to that of previously described plates. The section is Io microns 
in thickness. These Purkinje cells were given by Nissl as typical 
examples of what he formerly described as Group II, arkyosti- 
chochrome nerve cells of the somatochrome class, in which was 
presented a striated appearance, with a network-like structure, 
united in a most intricate manner, thus having characteristics of 
both the arkychrome and the stichochrome cells. He now classi- 
fies them as one of the types of Group I, the arkyochrome nerve 
cells. In the Purkinje cell, to the right, the base of each of the 
two large dendritic processes is seen, one going off to the right, 
the other to the left, subsequently to divide and subdivide in the 
internal layer, not shown in the plate. The Purkinje cell to the 
left shows only one of these processes in this plane, that going 
off to the left which divides in the same manner as above de- 
scribed for the other cell. The large rounded nucleus, with its 
centrally placed nucleolus, is fairly well shown in the cell to the 
right, and contains a fine network of chromatic substance. The 
chromatic substance of the body of the cell is made up of larger 
and smaller irregularly-rounded chromophilic bodies, arranged in 
an indefinite network extending up into the base of the dendritic 





DEMENTIA PARALYTICA. 759 


processes. A nuclear cap is seen above the nucleus of the Pur- 
kinje cell on the right. The closely-packed fine granular cells of 
the granular layer of the cerebellum are seen just below these two 
Purkinje cells, and are included in the class of cytochrome nerve 
cells in Nissl’s classification. They contain a nucleus almost 








Plate X, Fig. 28. 


filling the cell body, and which is surrounded by only a very nar- 
row rim of chromatic substance. Within the nucleus is a nucleo- 
lus, and in some of these nuclei several irregularly-arranged chro- 
matic granules are also seen. Between the Purkinje cells is a 
small nerve cell with rounded body and an apical dendritic pro- 
cess. It contains a nucleus, nucleolus, and some chromophilic 
granules irregularly arranged in the cell-body. 


760 G. ALFRED LAWRENCE. 


The last photomicrograph in the series of the normal histo- 
logical material is that shown in Plate X, Fig. 28, of a typical 
multipolar ganglion cell from the anterior horn of the lumbar 
enlargement of the spinal cord, under a magnification of 1,400 
diameters. The segment of cord from which the section was 
taken was fixed in Van Gehuchten’s fluid; this section is 6 2-3 
microns in thickness and stained with methylene violet. This cell 
is, according to Nissl’s classification, an arkyochrome nerve cell, 
Group I, of the somatochrome class, the chromophilic bodies being 
arranged more in the form of a network than in a parallel ar- 
rangement in the cell-body, though within the dendritic processes 
these bodies are more or less distinctly parallel in arrangement. 
The cell-body is irregularly polygonal in outline, with five large 
dendritic processes going off in different directions, and contain- 
ing at the base, and for a considerable distance, linear-shaped 
chromophilic bodies, arranged in a more or less parallel manner 
and spreading out and connected with the cell-body network. This 
latter is made up of irregularly-rounded and elongated chromo- 
philic bodies, arranged in an irregular network. The nucleus is 
large, rounded, slightly eccentric in situation, and contains a large 
rounded nucleolus and a pale indefinite network of chromatic 
substance. Numerous neuroglia cells are seen scattered about, 
singly or in groups, in the immediate vicinity of this cell. Part of 
another large ganglion cell is seen at the upper portion of the 
plate, on the left. 

This concludes the very brief discussion of the cortex of the 
normal brain, in which an endeavor has been made to present 
typical sections of the main divisions of the external surface of 
the cerebral hemisphere by means of photomicrography, upon 
which the greatest care was employed, in order to give an accurate 
idea of the usual appearance to be seen under the microscope in 
the study of such sections in contradistinction to the common 
diagrammatic figures that one usually associates with such work, 
and which do not show the actual arrangement and structure, but 
rather the ideal or embodyment in one figure of what is to be 
found in parts of many. The writer, on the other hand, does not 
wish to be understood as not favoring diagrammatic or schematic 
figures in work of this kind, as he regards them as highly im- 
portant and a valuable accessory to photomicrography and accu- 
rate drawings in the proper conception of the intricate structure 
and arrangement of the various portions of the nervous system 
as well as other systems. That there are minor variations from 
these plates in the different regions has been repeatedly stated, 
but the variation is only a minor one, and does not depart suffi- 
ciently from the type to be considered as more than a modifica- 
tion. Furthermore, in going over the various plates from the 


DEMENTIA PARALY TICA, 761 


different regions it will be seen that there is a general uniformity 
of arrangement and structure of the cells, and that one region 
does not vary to any great extent from that of any other region. 
This is well illustrated by comparing the plates from the frontal 
region with those of the temporal region, in which it would be 
difficult to determine the one from the other. The Betz cells in 
parts of the motor cortex are a conspicuous modification, but 
when-we consider that only a small part of the motor area con- 
tains these cells, and again that these cells, though large, represent 
but a minute fraction of the total number of cells in the cortex at 
this point it will be seen their presence makes but a slight modi- 
fication in the general cortical arrangement as a whole. The 
pyramidal cells intermediate in size between the large pyramidal 
cells and the Betz cells are of especial significance to the writer 
as perhaps indicating that, with increased specialization of func- 
tion, carried on through long periods of time, increased specializa- 
tion of the structure and size of the cortical cells is going on 
hand in hand, and that perhaps the so-called Betz cells, now 
almost entirely limited to certain portions of the central convolu- 
tions, some time in the future may be found in all parts of the 
cortex. Their large size, with resulting large amount of proto- 
plasm in the cell-body and large nucleus, the comparatively enor- 
mous amount of chromatic substance, as possibly stored up food 
products, all point to great capacity for storing up nervous energy 
to be given out when indicated as powerful efferent impulses, or, 
on the other hand, the capacity of receiving as equally powerful 
different impulses. Increased specialization in mental activity 
may result in greater numbers of nerve cells being set apart and 
increased in size and capacity for carrying out special functions. 
Paretic Brain.—Turning now to Brain B, the case of demen- 
tia paralytica, from which all the succeeding plates were taken, we 
see in Plate X, Fig. 29, a photograph of the left hemisphere of the 
brain, natural size. The macroscopic appearance at first sight 
would seem to indicate that there was marked atrophy and shrink- 
age in parts of several convolutions, especially the anterior central 
and frontal convolutions ; but a careful study of the sections taken 
from these regions shows this not to be altogether the case, or at 
least only to a slight degree. As any one who has studied brain 
topography to any extent well knows, there is much variation, not 
only in the shape and arrangement of any given convolution, but 
also in its size, so that great care should be observed in not mis- 
taking such normal variation for atrophy. A study of the various 
plates shown here under a magnification of 14 diameters, con- 
taining the entire cross section from the several convolutions in 
the brain and comparing them to the preceding brain will make 
this point clear. Here and there a considerable quantity of the 


762 G. ALFRED LAWRENCE. | 


cortex has been torn away with the pia mater, whereas in many 
places small depressions are seen in which only a very small por- 
tion of the superficial layer of the cortex has been torn away. The 
convolutions are here well marked and the sulci very deep, so that 
there is a large area of cortical surface. The sulci in the middle 
portion of the hemisphere are widely open, owing to the support 
being placed only in the middle of the median surface of the 
hemisphere, so that the weight of the poles, anterior and posterior, 
caused these latter to become depressed, resulting in this con- 
spicuous widening of the central sulci. The posterior pole of the 
brain—the occipital lobe—is practically normal macroscopically, 





Plate X, Fig. 29. 


and it will be seen later also microscopically, there being none or 
but very slight pathological changes in the cortex in that region. 
This photograph of the brain was taken before any blocks were 
removed, it having been previously fixed in 95 per cent alcohol. 
As each block was removed the exact location was noted and indi- 
cated in the photograph by the letters of the alphabet, and the 
place from which the block was taken enclosed in ink lines. 
Frontal Convolution.—This portion of the cortex is repre- 
sented by the block K, taken from the external surface of the first 
frontal convolution in its middle third, the exact location being 
seen in Plate X, Fig. 29, K. The photomicrograph seen in Plate 
X, Fig. 30, was taken from a section 10 microns in thickness, and 
is magnified 14 diameters. The gyrus here is somewhat narrow, 
and the sulci on either side were quite open and deep, and from 


DEMENTIA PARALYTICA. 763 


the macroscopic appearance one might at first be inclined to think 
that there was some atrophy of the gyrus; but a detailed study 
of sections from this region shows that this is not the case. 
Block K was fixed in 95 per cent alcohol; this section is I cm. in 
length, .63 cm. in width at its widest part, and, as above stated, 
IO microns in thickness, being stained with methylene blue; the 
other technique being the same as for all the other plates. The 
shape of the section is somewhat that of a truncated pyramid, 
broader at the base and narrow at the rounded vertex. This me- 





Plate X, Fig. 30. 


chanical arrangement makes the cortex thicker at the vertex than 
on the lateral aspects. At a, and enclosed in ink lines, is the 
segment represented in Plate XI, Fig. 31. The first or superficial 
layer is seen to vary somewhat in thickness, being thicker on the ' 
lateral surface below b, with another thickened portion below a, 
a third just to the left of the vertex, and finally at the lower part 
of the left lateral aspect. The second or pyramidal cell layer does 
not show quite as distinct arrangement of the cells in a radial 
direction as in the corresponding region of the normal cortex, 
and there is especially to be noted the numerous portions of 
minute capillaries of varying size and tortuosity, singly or 


764 G. ALFRED LAWRENCE. 


branched. This second layer passes over into the indistinct third 
layer, which is lost below in the pyramidal-shaped white medul- 
lary center, which also contains numerous capillaries. Plate XI, 
Fig. 31, is a photomicrograph, magnified 100 diameters, of a 
segment corresponding in position to a of a section adjacent to 
and from the same block as that shown in Plate X, Fig. 30. The 
section is 6 2-3 microns in thickness, and of the same length and 
breadth as that shown in the preceding plate. Decolorization has 
been carried on to a considerable extent, about to the same degree 
as in Plate II, Fig. 3, and thus causing the plate to appear rather 
pale. Additional causes are the paucity of large pyramidal cells 
in the second layer, and the shrunken condition of many of the 
cells, as well as other pathological alterations. The upper layer 
averages .20 mm. in thickness, and contains for the most part 
scattered neuroglia cells. The second or pyramidal-cell layer is 
1.69 mm. in thickness. Here is to be found a very similar ar- 
ra:.zement of the cells to that in the corresponding region of the 
no mal brain A. In the upper portion are to be seen the small 
py:amidal cells in considerable numbers, just below the super- 
fic.al layer. Then they become more scattered, with a tendency 
to an arrangement into larger and smaller irregular groups, the 
cclls becoming larger in the deeper portions. A little below the 
middle of this layer is found a narrow strip at a, where the small 
pyramids predominate almost to the entire exclusion of the larger 
ones, which latter, however, are seen above and below. Below 
this again are to be seen the larger pyramids, which finally give 
way to the irregular and spindle cells of the third layer. The 
nerve cells themselves show various changes. Many of them 
appear to be atrophied or shrunken, this process varying in degree 
in different cells. ‘This in many cases has resulted in the forma- 
tion of larger or smaller pericellular spaces as seen about many 
of these cells, as at P in this plate and in Fig. P of the text, for 
instance. Here a large pericellular space completely surrounds 
the cell. The basal dendrites are represented by only one small 
shrunken process given off at the left and extending but a short 
distance. The body of the cell is shrunken and irregular in con- 
tour. A large mass of yellowish pigment is seen at the base to the 
right. A small amount of finely granular chromophilic substance 
is found about and above the nucleus. The nucleus itself is dis- 
placed downward into the base of the cell-body, to the extreme 
left. It is small, irregular in outline, and contains a well defined 
nucleolus but no chromatic substance. The apical process is 
shrunken and irregular in direction, and contains traces of chro- 
mophilic substance in places. The chromatic substance in the 
large majority of these cells has become diffused and decreased in 
amount in variable degrees, so that a large number of the cells 


DEMENTIA PARALYTICA. 765, 


present the appearance of chromatolysis up to almost complete 
disappearance of chromatin in some of them. These latter present 
a pale, washed-out appearance, as shown by the cell marked Q in 
this plate and seen enlarged in Fig. Q, where only a small amount 
of chromatin is found in the apical process and a slight amount 
of pigment in the lower part of the base. Some cells show loss. 
of chromatin only about the nucleus, and are spoken of as in- 
stances of central chromatolysis. Others have a disappearance of 
chromatin at the periphery of the cell-body only, and this condi- 
tion is known as peripheral chromatolysis. The nuclei of many 
of these cells are found frequently displaced to one side, crowded 
into the base of a dendritic process, near the base of the cell-body, 
or near the base, or up into the proximal portion of the apical 
process. Many of these are irregular in shape and diminished in 
size. Quite a large proportion of the larger pyramidal cells con- 
tain light yellowish pigment in variable quantity and usually at 
the base of the cell, often extending into the base of a dendritic 
process. The cell P, above described, in addition to the pericellu- 
lar space, demonstrates these last two points, the nucleus being 
crowded into the base of the dendritic process given off on the 
left and a considerable deposit of pigment being found at the base 
and extending into the right dendritic process. The cells contain- 
ing this pigment are marked with a cross, adjacent to them, in 
this plate. It will be seen that they are to be found mostly in the 
middle and lower portion of this layer, and also some few scattered 
irregular-shaped cells in the third layer. The dendritic processes 
in many of these cells end abruptly beyond their base, and in but 
few cases can they be traced to any great distance from the cell- 
body. The apical process shares in this general atrophy, and 
often is curved and irregular in direction, instead of presenting a 
regular straight course towards the periphery of the cortex. In 
some cells the nucleus is difficult to distinguish, the limiting mem- 
brane being indeterminable and the nucleolus appearing to be in 
the midst and surrounded by only the cell-body, and usually in an 
eccentric position. Numerous blood vessels are here to be seen, 
all with thickened walls and pursuing a tortuous course. Large 
perivascular spaces are also seen about many of these blood ves- 
sels, as at d, for instance. The third, or spindle or irregular cell 
layer is here .go mm. in thickness, and is made up of irregular 
and spindle cells, some of the former, as some of the cells of 
the second layer, contain pigmentary deposits. Here also the 
chromatin is found in diminished quantity, and various stages of 
chromatolysis are seen. The nucleus is diminished in size in 
many cases and does not appear to be as prominent a factor as in 
the normal cells of this region. The cells as a whole appear 
smaller in size and more or less atrophied, containing less proto- 


766 G. ALFRED LAWRENCE. 


plasm in the cell-body as well as a diminished amount of chro- 
matin. The blood vessels are here also found to have thickened 
walls, and are tortuous in direction. At e is seen one of these 
vessels, with thickened walls and surrounded by a large perivas- 
cular space. The entire thickness of the cortex at this point is 
found to be 2.90 mm.; almost the same as in the corresponding 
region in Brain A, as seen in Plate II, Fig. 3. Counts were made 
of the nerve and neuroglia cells in various parts of this section in 
the same manner as in the previous sections, and in eight different 
fields of 36 sq. mm. each of the ocular net-micrometer from vari- 
ous portions of the two lower layers for the nerve cell counts, and 
in all three layers for the neuroglia cell counts. There was found 
to be an average of 100 nerve cells and 56.90 neuroglia cells to 
each square millimeter of surface of this section. The small num- 
ber of neuroglia cells being due to the methylene blue stain em- 
ployed and differentiation carried on to a considerable degree in 
a section 6 2-3 microns in thickness. In the section shown in 
Plate X, Fig. 30, 10 microns in thickness, and more deeply stained, 
the number of nerve cells is not quite so great, whereas the num- 
ber of neuroglia cells is almost six times as great, although the 
two sections are quite near together and from the same block. 
This is due to the neuroglia cells in Plate XI, Fig. 31, being al- 
most completely decolorized in the greater differentiation, where- 
as the cells, although paler, yet were not decolorized, and can all 
be made out. The same method of using the ocular net-microm- 
eter was employed here as in all the other plates, and counts were 
made from eight different fields of thirty-six squares each from 
different parts of the second and third layers of this section, and 
the average number of nerve cells was found to be 82.91 to the 
square millimeter of surface of the section, as compared to 100 
for the same area in Plate XI, Fig. 31, so that there are on an 
average less nerve cells in this section, Io microns in thickness, 
than in the section from which Plate XI, Fig. 31 was taken, which 
was but 6 2-3 microns in thickness, the same stain being used in 
both cases. The nerve cells, however, are more deeply stained in 
this latter section, and appear more distinct, and there are also 
more large cells. The neuroglia cells in eight different fields of 
thirty-six squares each from various parts of the three cortical 
layers average 303 to the square millimeter of surface of the sec- 
tion, as contrasted to 56.90 to the square millimeter in Plate XI, 
Fig. 31. Here increased thickness makes a difference in favor 
of this plate, and in addition to that the deeper stain with less 
decolorization cause all the neuroglia cells to appear more promi- 
nent. As stated before it was found that sections from 6 2-3 to 
IO microns in thickness contain all the nerve cells to be seen in one 
plane. As the neuroglia cells are much smaller in diameter and 








DEMENTIA PARALYTICA. 767 


often arranged in dense clusters, there may be a greater number 
in a section 10 microns in thickness than in one 6 2-3 microns in 
thickness. (See Table II.) 

Central Region.—Turning to the region posterior to the one 
just discussed, we come to the central region, or motor area, made 
up of the anterior and posterior central convolutions. Typical of 
the anterior central convolution in its upper portion is the section 
represented in Plate XI, Fig. 32, under a magnification of 14 
diameters. The exact location of the block from which this sec- 


ww 





Plate XI, Fig. 32. 


tion was taken is indicated by the letter D in Plate X, Fig. 29. 
The wide separation of the convolutions from one another, with 
resulting gaping sulci, is especially marked in this region. As 
previously mentioned, this is largely due to mechanical agencies, 
a central support permitting the opposite poles, owing to their 
weight, to become depressed and force open the sulci in this 
region during the process of hardening or fixation. In the re- 
moval of the pia mater, small portions of the adhering cortex have 
been removed in places. This is seen just below the letter O, and 
in many places in the convolutions both anterior and posterior to 
this. By referring back to Plate III, Fig. 7 of the normal brain 


768 G. ALFRED LAWRENCE. 


it will be seen that this section was taken from approximately the 
same relative position of the convolution as that seen in Plate IJ], 
Fig. 7, and, furthermore, the two convolutions are quite similar 
in shape; this convolution being somewhat broader and less 
rounded at the vertex than that of the normal brain, however. 
The outer cortical layer is here more irregular and torn than in 
Plate III, Fig. 7, and at the vertex of the convolution at b the 
outer part of the first layer is seen stripped off for some distance. 
This, of course, is an artefact, the detached part being more 
adherent to the stripped off pia than to the cortex below. This 
outer layer furthermore presents a somewhat irregular contour, 
being broken in places as at c and d. The layer is thicker oppo- 
site a, and on the left lateral aspect, than elsewhere. The second 
or pyramidal cell layer shows the general radial direction of the 
cells, but not so well marked as in Plate III, Fig. 7. The chief 
point of interest, however, is almost complete disappearance of 
the Betz cells, which are seen so prominently in this region in the 
normal brain in plates of this magnification (14 diameters). In 
photomicrographs of 100 diameters we will find this disappear- 
ance is not complete, and that the cells, although much atrophied 
and pale, so as to scarcely appear under the lower power, are 
much more apparent here, and are seen in all stages of dissolution. 
In this plate only scattered Betz cells are seen singly or in small 
groups at wide intervals, and these few are small, shrunken and, 
for the most part, pale. Fig. R is a drawing of the large Betz 
cell marked R in this plate. The nucleus is quite centrally situ- 
ated, with a large distinct nucleolus and some faint chromatic 
substance. Some few chromophilic bodies are seen interspersed 
among. the finely granular chromatic substance. The cell pro- 
cesses are pale, irregular, and soon terminate at a short distance 
from the cell-body. No pigment is found in this cell. Figs. S 
and TI show two other near-by cells, the former containing an 
eccentric nucleus, irregular, shrunken cell-body, with some pig- 
ment at the left of the nucleus. The processes being irregular and 
short. The cell in Fig. T is much shrunken and distorted, the 
nucleus irregular, a small nucleolus, and but little diffuse chro- 
matic substance. There are no basal processes, and the apical 
process is narrow and irregular in direction. Numerous capil- 
laries are seen with thickened walls, and some with perivascular 
spaces. The third layer is indistinct, and fades into the white 
medullary substance, where many large capillaries with thickened 
walls, tortuous course and perivascular spaces are found. At a, 
and enclosed in ink lines, is the segment of this section, corre- 
sponding in position to that seen in Plate XI, Fig. 33. This sec- 
tion is 8 mm. wide, 6.5 mm. long, and Io microns in thickness, 
fixed in 95 per cent alcohol, stained with methylene violet, and 


a ae 


Ta, IR 


DEMENTIA PARALYTICA. 769 


other technique similar to all the other sections. Plate XI, Fig. 
33, is the photomicrograph magnified 100 diameters of a segment 
corresponding to a of Plate X1, Fig. 32, and from a section taken 
from the same block, and but a short distance from the above. 
At this point the first or outer layer measures .25 mm. in thick- 
ness, whereas in Plate XI, Fig. 32, it would measure at least .40 
mm. in thickness. It contains numerous neuroglia cells, with here 
and there a small pale nerve cell in which is situated a small 
nucleus surrounded by a mere trace of chromatic substance. Be- 
low this is the second or pyramidal cell layer, measuring 1.30 mm. 
in thickness. In the upper parts the pyramids are seen to be small 
and quite closely packed together. About the middle of the layer 
they are seen to be much larger and more scattered. Below this 
again, at a, is seen a region containing for the most part only 
small pyramids, and this finally merges into the lower portion of 
this layer, where are seen the large and giant pyramidal cells. 
These latter, or Betz cells, are seen in irregular groups or “‘nests,” 
consisting of from one to several (six or more) cells. All of these 
cells show a diminished amount of chromophilic substance and 
no distinct granules. Various stages of advanced chromatolysis. 
are seen, from a general diffusion of the chromatic substance to 
almost complete absence of the same. The cells are for the most 
part shrunken, the nuclei small and indistinct, displaced in many 
cases, and the cell processes atrophied and tortuous. Many of 
these larger cells contain a varying amount of yellowish pigment. 
Fig. U shows the cell marked U in the plate. No processes are 
seen, the cell-body is shrunken and contains but a small amount 
of diffused chromatin, showing no structure and pale in color. 
The nucleus is small, shrunken and indistinct, with a pale nucleo- 
lus. No pigment is to be seen in the cell. To the left of the cell- 
body is a small pericellular space. Several neuroglia cells are 
seen in apparent direct contact with the cell-body and others in the 
pericellular space and the wall of the latter. The cell just below 
and to the left of this in the plate is similar in regard to the 
amount of chromatin, is pale, and the nucleus and nucleolus are 
not visible. Three processes are seen given off at the base, but 
atrophied and extending for only a short distance. A small peri- 
cellular space is seen about this cell also. The cell just below 
and to the right of this, and marked V in the plate and seen in 
Fig. V, shows the same grade of chromatolysis. The remnant of 
a shrunken and atrophied process is seen at the base on the right. 
The shrunken nucleus, with pale nucleolus, is centrally situated, 
and below this are found diffused pigmentary deposits. Through- 
out the cell-body, less in the upper than in the lower part, is 
scattered pale diffuse chromatic substance, and without any 
definite arrangement. A narrow pericellular space is seen along 


770 G. ALFRED LAWRENCE. 


the right side of this cell. The general contour and lack of struc- 
ture are seen in Fig. V. Here, too, neuroglia cells are seen lying 
upon and in close juxtaposition to the cell-body. Numerous blood 
vessels with thickened and tortuous walls and perivascular spaces 
are seen throughout this layer. The third or spindle or irregular 
cell layer here measures .go mm. in thickness, and is made up of 
shrunken spindle and irregular cells, pale, and-containing but a 
small amount of diffuse chromophilic substance. Many of them 
are surrounded by pericellular spaces of varying size. The letter 





Plate XI, Fig. 34. 


W indicates one of these spindle cells seen in the drawing, Fig. W. 
The polar processes are here filamentous, and distorted in direc- 
tion, the cell-body shrunken and containing but a small amount 
of diffuse chromatic substance, so that it is pale in color, the 
nucleus is small and indistinct, and contains a small nucleolus. 
The cell-body is partially surrounded by a distinct pericellular 
space, with a neuroglia cell upon the edge at one point. Numer- 
ous blood vessels with thickened walls and perivascular spaces are 
also seen in this layer. The entire depth of the cortex here is 
3.05 mm., all three layers being slightly thicker than in Plate III, 
Fig. 8, of Brain A, the first layer being .o5 mm., the second .15 





DEMENTIA PARALYTICA. 775 


mm., and the third .20 mm., thicker than in the latter. As varia- 
tions of this extent are found in sections of convolutions in close 
oroximity, and even in different parts of the same section in any 
brain, it seems doubtful to the writer whether we can attach any 
special significance to such a slight variation, due possibly to me- 
chanical causes, acting in embryonic or even post embryonic life. 
Counts of the nerve and neuroglia cells here show a decided fall- 








Plate XII, Fig. 35. 
ing off in number of the former. This section is 6 2-3 microns in 
thickness and ‘stained with methylene violet. The same method 
with the ocular net-micrometer was used, counting the nerve cells 
in eight different fields of thirty-six square millimeters, each in 
various parts of the second and third cortical layers, and the 
neuroglia cells in the same number of different fields in all these 
cortical layers. The average number of nerve cells to each square 
millimeter of surface of the section was found to be but 39.60, 
whereas the average number of neuroglia cells to the same area 
was found to be 204. The number of nerve cells is thus Seen to 
be much diminished as compared to Plate III, Fig. 8, the corre- 
sponding region of the normal brain A, where there are an aver- 


772 G. ALFRED LAWRENCE. 


age of g5 nerve cells to the square millimeter of surface of the 
section. The number of neuroglia cells is also less here, being 
204 in this plate in comparison to 293 in Plate III, Fig. 8. The 
latter section is, however, 10 microns in thickness, as compared to 
6 2-3 microns for this plate, and as previously noted, owing to the 
small size and close aggregation of the neuroglia cells, more . 
would be ndrmally found in the thicker section, although this 





Plate XII, Fig. 36. 


hardly accounts for the great difference, as both were stained in 
the same manner with methylene violet. Plate XI, Fig. 34, is a 
photomicrograph, magnified 14 diameters, from a section taken 
from the point L of the upper portion of the anterior central con- 
volution of Brain B (see Plate'X, Fig. 29), and as seen by refer- 
ring to this latter, is from a more inferior portion of this gyrus 


I 


a 


DEMENTIA PARALYTICA. 773 


than the section represented in Plate XI, Fig. 32. This section 
was fixed in 95 per cent alcohol, is 6 2-3 microns in thickness, and 
stained with methylene violet. The first layer is seen to be fairly 
uniform in thickness at the lower two-thirds, as seen at c. Above, 
and at the vertex, and also along the anterior aspect of the con- 
volution, as at d, the surface is more or less torn and irregular, 
due to carrying away of small fragments with the adherent pia. 
By referring to Plates XI, Fig. 32, and XIII, Fig. 39, the varia- 
tions in shape and mechanical arrangement of the convolution in 
adjacent portions will be noted. In Plate XI, Fig. 32, the vertex 
is broadly rounded and somewhat flattened. In Plate XIII, 
Fig. 39, the vertex is more narrow and pointed, while in this plate, 
intermediate in position between the above two plates the vertex 
is less pointed. Large perivascular spaces are noted in many 
places throughout this section, especially marked in the upper 
portion to the left of the vertex, where but a fragment of the 
blood vessel is to be seen only at the lowest point of an enormous 
perivascular space. ‘The radial arrangement of the cells is but 
poorly shown, the Betz cells seem to have disappeared almost en- 
tirely in the second layer, in marked contrast to the plates of the 
same magnifieation of Brain A. (Plates III, Fig. 7; IV, Fig. 9, 
and IV, Fig. 11.) Under a high magnification, however, the rem- 
nants of many of these Betz cells can be made out, showing vari- 
ous pathological changes. The other nerve cells also show a 
wealth of pathological change of varying degree and kind to 
which the nerve cell is subjected—all grades of ¢hromatolysis, 
pigmentation, atrophy, and shrinkage of the nerve cells and pro- 
cesses, with larger or smaller pericellular spaces. Numerous 
capillaries, with thickened walls and perivascular spaces, are seen 
scattered throughout the various parts of the section. The actual 
size of this section is 8 mm. wide at the point opposite d, 8.5 mm. 
long, and 6 2-3 microns in thickness. At the points a and b are 
seen the Betz cells, shown under a magnification of 1,400 diame- 
tersrin) Platese LT Fig; 25) and XI) Bigs sonar ithe tormer’ of 
these is a photomicrograph as stated, under a magnification of 
1,400 diameters of the nerve cell, indicated by the letter a in 
Plate XI, Fig. 34. By referring to this latter plate, and then to 
Plate X, Fig. 29, we can locate almost the exact position of this 
cell in the cortex of Brain B. The cell-body is seen shrunken and 
deformed, lying in a pericellular space partially surrounding it. 
The nucleus is eccentric, being crowded over to the extreme edge 
of the cell-body on the right side. It is also shrunken and indis- 
tinct, but contains a well-marked and prominent nucleolus. The 
apical process above and to the right appears quite sharply de- 
flected at a point but a short distance from the base, but this is 
not really the case, as the portion from a to the edge of the plate 


774 G. ALFRED LAWRENCE. 


is one of the walls of a blood vessel, the opposite wall not being 
seen in this plate at all. At the point a, this apical dendritic 
process appears to come in direct contact with this portion of the 
wall of the blood vessel, and is there lost to view. The other 
dendritic processes—seven in all—are shrunken, and contain a 
small amount of diffuse chromatin. Within the cell-body the 
chromatin is considerable in amount, and quite generally diffused 
in fine granules throughout the cell-body, lacking any definite 
structural arrangement. ‘There is a somewhat greater amount 
at the base to the left and below the nucleus, and also at the upper 
part of the cell-body. Above and to the left of the nucleus, where 
the cell-body appears most pale, and extending into the base of the 
dendritic processes here, is a considerable mass of yellowish pig- 
ment. Numerous neuroglia cells are seen in the vicinity of this 
Betz cell. Plate XII, Fig. 36, is also a photomicrograph, magni- 
fied 1,400 diameters, of another of these Betz cells trom the point 
b of Plate XI, Fig. 34.. Here there is but little diffuse chromatin, 
confined principally to the base of the dendritic process given off 
on the right. All the lower part of the cell-body, excepting this 
portion, contains palely yellow pigment. The nucleus is displaced 
almost to the extreme edge of the cell-body, and lies just below 
the two neuroglia cells seen at a. The nucleolus, on this account, 
can not be determined at this plane. On microscopic examination 
the nucleus is found to be shrunken and indistinct. Numerous 
neuroglia cells are seen upon and in the immediate vicinity of this 
cell. The basal dendritic process b, which is but faintly seen here, 
owing to its lying in a somewhat lower plane, has eight neuroglia 
cells in close apposition to it. The dendritic process on the right 
can be traced for some distance, is somewhat shrunken, and con- 
tains no chromatic substance. Another small dendritic process is 
given off from the base opposite the point c, and being in a lower 
plane, only its base is seen here. It is colorless, and extends but 
a short distance from the cell-body. The apical dendritic process 
contains no chromatin, and as seen, has several neuroglia cells 
surrounding it a short distance from its base. A large pericellu- 
lar space almost entirely surrounds the cell, excepting at the base 
to the left. Plates XII, Fig. 37, and XII, Fig. 38, are photomi- 
crographs of the same magnification (1,400 diameters), taken 
from an adjacent section of the same block as the two preceding 
plates, and are also 6 2-3 microns in thickness. This section was 
prepared in exactly the same way, with the exception that 
methylene blue was used as the stain instead of methylene violet. 
This will be at once apparent upon noticing the neuroglia cells, 
which are here pale and washed out, many to the point of com- 
plete decolorization, so as not to be seen at all. The Betz cell in 
the center of Plate XII, Fig. 37, is seen surrounded by a large 





DEMENTIA PARALYTICA. Tis 


pericellular space. All the processes, four in number, including 
the apical dendritic process, are pale, and terminate but a short 
distance from the cell-body. The nucleus is eccentrically situated 
near the wall at the left, is small, and contains a large nucleolus, 
but no nuclear network. Within the cell-body finely granular 
chromatic substance is found at the base below and to the right of 





Plate XII, Fig. 37. 


the nucleus. There is no pigment present. This cell presents an 
advanced stage of partial chromatolysis. Above and to the right 
is an almost indeterminable mass, which, under the 1-12 inch oil- 
immersion objective, appears to be the remnant of a capillary, 
surrounded by a large perivascular space. Other cells are seen 
here in various stages of disintegration, surrounded by large peri- 
cellular spaces, some containing none or only the remnants of den- 


776 G. ALFRED LAWRENCE. 


dritic processes, indistinct and shrunken nuclei, some distinct nu- 
cleoli and others none at all, and all in a more or less advanced 
state of chromatolysis, with but little of the diffused stained chro- 
matic substance present. The neuroglia cells that are visible at 
all are pale and poorly stained, while many are almost or com- 





Plate XII, Fig. 38. 


pletely decolorized. Plate XII, Fig. 38, is a photomicrograph of 
a Betz cell on the same section and but a short distance from the 
cells of the preceding plate, and under the same magnification 
(1,400 diameters). Here there is almost complete chromatolysis, 
there being but little finely granular, diffuse chromatic substance 
scattered in the cell-body, slightly more at the base than above 
the nucleus. The latter is small, rounded, centrally situated, and 





DEMENTIA PARALYTICA. 717 


contains a large, rounded, distinct nucleolus. The three basal pro- 
cesses are narrow, pale, and terminate at no great distance from 
the cell-body. The apical process is pale and slender, extending 
for some little distance before coming to an end. Part of a pale, 
atrophied cell is seen to the right of the same. The ghosts of 
several neuroglia cells may be seen here, but most of them are 
completely decolorized. 

Plate XIII, Fig. 39, as will be seen by referring to Plate X, 
Fig. 29, is from the lower portion of the upper third of the an- 
terior central convolution, from the point marked O, and is magni- 
fied 14 diameters. This section, as already mentioned, is found to 





Plate XIII, Fig. 4o. 


vary somewhat in shape from that of the preceding sections 
shown in Plate XI, Fig. 32, and Plate XI, Fig. 34, being narrower 
and more pointed at the vertex. From the strip marked a, and 
enclosed in ink, the structure and arrangement of the nerve cells 
were carefully studied, and both nerve and neuroglia cell counts 
made and will be referred to again later. The irregularity and 
difference in thickness of the first layer in different parts is to be 
noted, being especially thick at b, where it almost presents the 
appearance of an artefact, but under a high power no derange- 
ment of the structure can be made out. At a the layer is seen to 


778 G. ALFRED LAWRENCE. 


be very thin, owing to some of the surface of the cortex having 
remained adherent to and been stripped off with the thickened 
pia mater. Large perivascular spaces are to be especially noticed 
in the subcortical portion of the section. Here is to be noted the 
almost entire absence of the Betz or giant pyramidal cells in the 
iuwer part of the second layer, although some large pyramidal 
cells are to be found, they are not, however, so large nor are they 
arranged in such distinct groups as in the region higher up. Un- 
der higher magnification the remnants of some of these Betz cells 
are seen in various stages of necrosis and disintegration. The 
cortex lacks the distinct striated appearance seen in the sections 
of the normal cortex. This layer passes indistinctly into the third 
or spindle cell layer, which in turn is lost in the white medullary 
substance below. Numerous capillaries are seen, many with 
thickened walls and perivascular spaces throughout the section. 
This section was fixed in 95 per cent alcohol, sectioned 10 microns 
in thickness, stained with methylene violet, with other technique 
similar to that of all the previous sections. The actual size of the 
section is 9 mm. at its greatest width and 13 microns in length. 
The strip a varies from that of Plate XI, Fig. 33, only in the 
number and arrangement of the cells in the second layer. At this 
point the three layers are respectively .20 mm., 2.00 mm., and .go 
mm. in thickness. The first layer contains some few scattered 
irregular nerve cells and numerous neuroglia cells. The second 
layer contains small pyramidal cells above, increasing in size until 
a little above the middle of the layer is a strip some .30 mm. in 
width, in which are to be seen large pyramidal cells arranged 
singly or in irregular groups. Some of these cells almost ap- 
proach the giant pyramidal cells in size. Many of them show but 
a slight shrinkage and contain an almost normal amount of chro- 
matic substance. The chromophilic bodies, however, are not as 
numerous or as large as in the normal brain. Other cells show a 
complete absence of chromophilic bodies, but contain the chro- 
matic substance diffused throughout the cell in minute particles. 
Still others are pale, and contain but little chromatic substance. 
The nuclei are larger, less eccentric, and there is a less degree of 
atrophy of the cell-body and processes. Below this is a region of 
small pyramidal cells with only a few scattered larger pyramidal 
cells merging into the lower part of the layer, where large pyrami- 
dal cells are again seen scattered irregularly among the smaller 
cells. These large pyramidal cells are somewhat smaller than the 
giant pyramidal or Betz cells seen in the upper part of this con- 
volution. These cells show more advanced pathological changes, 
in some cases marked atrophy and shrinkage with large pericellu- 
lar spaces, atrophy of the dendritic processes, eccentricity and 
shrinkage of the nucleus, pigmentary deposits, complete absence 





DEMENTIA PARALYTICA. 779 


of or but a small amount of diffuse chromatic substance. The 
third layer presents the same general appearance as in the pre- 
ceding plate (XI, Fig. 33), with many cells much shrunken and 
atrophied and little or no chromatic substance within the same, 
and surrounded by pericellular spaces of varying size. Numer- 
ous large and small capillaries are seen scattered throughout this 





Plate XIILy Fig.330: 


section, with thickened walls and surrounded by larger or smaller 
perivascular, spaces. The entire. depth of thevcortex there is 3.10 
mm., the second layer being slightly thicker than in Plate XI, 
Fig. 33. The nerve cells were found to average but 36.50 to the 
square millimeter of surface of the section here; less than in any 
of the other plates, whereas the neuroglia cells average 289 to the 
square millimeter of surface of the section, almost as great a num- 


780 G. ALFRED LAWRENCE. 


ber as in the previous sections of the same thickness, ten microns, 
and stained with methylene violet. The most conspicuous differ- 
ence between this and Plate XI. Fig. 33, higher up in the convolu- 
tion, is the arrangement of the large pyramidal cells, the absence of 
the typical Betz cells, and on the whole less advanced pathological 
changes. Plate XIII, Fig. 40, is a photomicrograph magnified 
fourteen diameters of a section from the block B of Plate X, Fig. 
29, and is thus seen to be situated a little above the middle of the 
posterior central convolution. This section is 6 2-3 microns in 
thickness, 8 mm. in length, and 9 mm. in width at the widest point, 
was fixed in 95% alcohol, stained with methylene blue, and other 
technique similar to that of all previously described sections. This 
section at the vertex, especially to the left, shows the striated ap- 
pearance of cell arrangement very well, but upon the anterior and 
posterior aspects of the gyrus it is but indistinctly shown. The 
first layer is fairly uniform in thickness with broken spaces here 
and there, especially about the entrance of capillaries. This layer is 
somewhat thicker in certain places than in others. At a, for in- 
stance, it is thicker than at the vertex. This section has a broad, 
flettened vertex with considerable cortical area on both the anterior 
and posterior surfaces. The cortex opposite the angles c and b 1s 
somewhat thicker than elsewhere. This mechanical arrangement 
admits of a large, broad mass of fibres from various parts of this 
and the adjacent regions of the brain, leaving from and entering 
into relations with the cells of this portion of the cortex. The 
section is broken (an artefact) at the left and numerous capillaries 
are found scattered throughout all the cortical layers and also the 
white medullary center. The segment represented in Plate XIII, 
Fig. 41, was taken from a point corresponding to a, but from an 
adjacent section of the same block, and is magnified 100 diameters. 
It is from relatively the same position as the segment shown in 
Plate VII, Fig. 19, the strip a of Plate VI, Fig. 18, of the normal 
brain, but, as will be seen by referring to the latter, the shapes of 
the two sections are quite different. The distribution and arrange- 
ment of the cells in this plate is somewhat different from that in 
Plate VII, Fig. 19, also. In this latter, as already described, some 
large pyramidai cells are irregularly distributed in parts of the 
upper half of the second layer, followed by a narrow region made 
up almost exclusively of small pyramidal cells to be followed by 
larger pyramidal cells in the lower portion of this layer. In this 
plate, however, there are but few of the larger pyramidal cells in 
the upper portion of the second layer, there being practically only 
small pyramidal cells in this upper portion with the larger pyra- 
mids mostly in the lower portion of this second layer. The cell 
seen in the lower part near the center (a, Plate XIII, Fig. 41), 
approaches in size to the Betz cell type. The first or superficial 


DEMENTIA PARALYTICA. 781 


layer here contains nothing but capillaries and neuroglia cells and 
is .25 mm. in thickness. The second or pyramidal cell layer is 
1.40 mm. in thickness and shows not only numerous capillaries. 
with irregular and thickened walls, but also the cells in various 
pathological conditions. Chromatolysis is complete in many of 
these cells as in the large pyramidal cell marked a@ for instance, 
where only traces of minute finely powdered chromatin can be seen 
in some parts of the cell-body. Here also the nucleus is indistinct, 
with a well marked nucleolus, and the basal processes are much 
atrophied, terminating but a short distance from the cell-body. A 
small pericellular space is seen at the base of this cell-body. Many 
cells show eccentricity of the cell nucleus, shrinkage of the cell- 
body, various grades of chromatolysis, pigmentation, atrophy, and 
distortion of the dendritic processes and are surrounded by peri- 
cellular spaces. The capillaries are numerous, have thickened 
and irregular walls, and are surrounded by perivascular spaces of 
varying size and extent. Numerous neuroglia cells are also inter- 
spersed about the cells and capillaries in this layer. The third or 
spindle cell layer is only partially seen in this plate, and is about 
.go mm. in thickness (only upper portion shown in Plate XIII, 
Fig. 41), and is similar to that in preceding plates of the motor 
region, and contains for the most part shrunken and irregular 
spindle and polygonal shaped cells, with numerous neuroglia cells 
and capillaries interspersed among them. Most of these cells 
show the various pathological processes mentioned above for the 
pyramidal cells. The cortex here thus measures 2.55 mm. in 
thickness, almost the same as for the two upper layers in Plate 
VII, Fig. 19, but here the third layer is .go mm. in thickness as 
compared to .60 mm. in the above mentioned plate of the normal 
brain. Nerve and neuroglia cell counts were made here with the 
result that an average of 59.91 nerve cells and 134.37 neuroglia 
cells were found to the square millimeter of surface of the section 
as compared to an average of 185.50 nerve cells and 109.20 neu- 
roglia cells for the same area in the strip of cortex represented in 
Plate VII, Fig. 19, of the corresponding region of the normal 
brain. Both sections were 6 2-3 microns in thickness and both 
stained with methylene blue. The difference in nerve cells is very 
marked, whereas the difference in number of neuroglia cells. is. 
not so great, and as the technique was identical throughout in 
the preparation of the two sections, the marked pathological pro- 
cess shown in this latter, it seems to the writer must be attributed 
as the cause of this difference to a large extent at least. 

Parietal Region.—Plate XIV, Fig. 42, is a photomicrograph 
magnified fourteen diameters, of the parietal region from the 
point H. in Plate X, Fig. 29, this being a part of the supra-angu- 
lar gyrus and from the same relative part of the gyrus as the 


782 G. ALFRED LAWRENCE. 


corresponding plate (VII, Fig. 20) of the normal brain. The 
section was fixed in 95% alcohol, stained with methylene violet, 
and treated otherwise as the preceding plates. This section 
measures 6 mm. in width, 16 mm. in length, and is 6 2-3 microns 
in thickness. Its shape is long and narrow and quite different 
from that of Plate VII, Fig. 20. At the vertex of the convolution 





Plate XIV, Fig. 42. 


the first layer has geen cut away with the paraffin in preparing the 
block for sectioning serially with a Minot microtome, and, of 
course, this condition is an artefact. The first layer is seen to be 
fairly uniform in thickness with this exception. In the second 
layer it is difficult to determine the well marked striated arrange- 
ment of the cells, as seen in Plate VII, Fig. 20. Numerous peri- 
vascular and pericellular spaces are seen with or without the capil- 


DEMENTIA PARALYTICA. 783 


laries or cells, as the case may be. The third layer is indistinct 
and fades away into the white medullary center which also con- 
tains many pericellular and perivascular spaces. No doubt the 
fixation in 95% alcohol has produced some shrinkage, but by no 
means all, as the plates of the occipital convolution just posterior 
to this show a much less degree of shrinkage than is here present 
and not only every block taken from this brain was fixed in ex- 
actly the same way, but also some of the blocks from Brain A. 
At @ and surrounded by ink lines is the segment of the section 
shown under a magnification of 100 diameters in Plate XIV, 
Fig. 43, and as is here seen is taken from the lateral aspect near 
the vertex, instead of fromthe vertex as in the corresponding 
plate of the normal cortex (Plate VII, Fig. 21). . The first layer 
averages .25 mm. in thickness and contains numerous capillaries 
with thickened walls, and tortuous course with larger and smaller 
perivascular spaces. Numerous neuroglia cells are scattered 
throughout this layer. The second layer is here 1.50 mm. in 
thickness. Here, too, are seen numerous capillaries with thick- 
ened walls, irregular course, and large perivascular spaces. In 
the upper half of the layer the small pyramidal cells gradually 
are intermingled with larger pyramidal cells as the lower portions 
are reached, until just above a the largest pyramids of the sec- 
tion are seen singly or in groups in a comparatively narrow zone. 
Below and opposite a@ is a narrow zone, some .25 mm. in width 
in which there are practically no large pyramidal cells. Below 
this again is a very narrow zone at the lower part of this layer 
in which some few large pyramidal cells are seen scattered among 
the smaller and irregular cells. These cells present all stages of 
chromatolysis, pigmentation, shrinkage of the cell-body and pro- 
cesses and irregularity in direction of the latter, eccentricity and 
shrinkage of the nucleus and larger and smaller pericellular 
spaces. _Numerous neuroglia cells are scattered throughout the 
layer. The third, or spindle cell layer, measures scarce .50 mm. 
in thickness and contains for the most part shrunken and irregular 
spindle cells in larger or smaller pericellular spaces, in many in- 
stances in various stages of chromatolysis. Numerous neuroglia 
cells in many cases appearing in direct contact with the cell-body 
are seen in this layer, as well as in the above layer. The vascular 
changes are also similar. The entire depth of the cortex here is 
thus 2.25 mm., somewhat less than in Plate VII. Fig. 21, but 
about the same as on the lateral aspect of this latter plate. Nerve 
and neuroglia cell counts were made here in the same manner 
as in previous sections, and it was found that there was an average 
of 68.63 nerve cells and 192.70 neuroglia cells to each square 
millimeter of surface of the section as compared to 104 nerve cells 
and 180.90 neuroglia cells in the corresponding region of Brain A, 


784 G. ALFRED LAWRENCE. 


both sections being of the same thickness and stained in the same 
manner with methylene violet. 

Temporal Region.—Turning to the region below this we come 
to the temporal region represented here by a section from the 
first temporal convolution near its anterior extremity, from the 





Plate XIV, Fig. 44. 


point J in Plate X. Fig. 29, and shown under a magnification of 
fourteen diameters in Plate XIV. Fig. 44. This convolution is 
also much narrower than the corresponding convolution of Brain 
A, seen in Plate VIII, Fig. 22, thus having a somewhat dissimilar 
mechanical arrangement. To the right is seen the first temporal 
fissure and a portion of the second temporal convolution. The 
convolution measures 5.5 mm. in width and 8 mm. in depth from 


es ee re ee eee ee ee ee 


DEMENTIA PARALYTICA. 785 


the vertex to the point on the level with the bottom of the first 
temporal fissure and is 6 2-3 microns in thickness. The convolu- 
tion at this point is seen on the right to curve around and fuse 
with the second temporal convolution, being free above at }, 
which is the lower boundary of the fissure of Sylvius at the be- 
ginning of the posterior branch. At a and enclosed in ink lines 
is the segment of the section shown in the following plate under 
a magnification of 100 diameters. The first or superficial layer is 
quite uniform in thickness, broken in several places, especially 
above b on the superior surface. The second layer shows the 
striated arrangement of the cells only very indistinctly at some 
few points and contains many pericellular and perivascular spaces, 
some with and others without contents. The third layer is indis- 
tinct and fades into the white medullary center which is narrow 
and passes inferiorly over to connect on the right with that of the 
second temporal convolution. 

In Plate XV, Fig. 45, strip a of Plate XIV, Fig. 44, under a 
magnification of 100 diameters, the pathological conditions are 
seen to be well marked. The section is 6 2-3 microns in thick- 
ness and stained with methylene violet. Here the first layer aver- 
ages about .20 mm. in thickness and to the right a fragment of a 
blood vessel is seen at the surface, but penetrating the cortex in 
a different plane. In the center and reaching into the second 
layer is a large capillary with thickened walls, with larger caliber 
above and smaller below, being somewhat funnel shaped and sur- 
rounded by a large perivascular space. Some smaller fragments 
of capillaries and neuroglia cells are scattered about in the layer. 
The second or pyramidal cell layer is 1.50 mm. in thickness and 
presents very much the same general plan of arrangement as the 
corresponding region in the normal brain, as seen in Plate VIII, 
Fig. 23, and also in the region of the first frontal convolution, as 
Been inv Pigte | eiic, 3:and XI, hick si eeSmallepyranicdal cells 
almost exclusively are seen in the upper part of the layer below 
this gradually increasing in size to the middle of the layer. Then 
opposite @ is a narrow strip some .20 mm. in thickness in which 
there are small pyramidal cells almost exclusively. Below this 
again and “in the lower part of this layer are larger 
pyramidal cells, intermingled with smaller pyramidal and 
irregular shaped cells. Here, too, the majority of the cells are 
seen shrunken and surrounded by larger and smaller pericellular 
spaces. Various stages of chromatolysis, shrinkage and eccen- 
tricity of the nucleus and atrophy of the cell processes are to be 
observed. The blood vessels show the same pathological condi- 
tions as in the upper layer and numerous neuroglia cells are in- 
terspersed thickly everywhere. | 

The third layer is .80 mm. in thickness and presents the same 


786 G. ALFRED LAWRENCE, 


pathological conditions of the cells and blood vessels as previously 
described for this layer in Plate XIV, Fig. 43, of the parietal 
region. The entire depth of the cortex here is 2.50 mm., some- 
what thicker than the corresponding region of Brain A. Nerve 
and neuroglia cell counts were also made here and in a similar 
manner, an average of 56.74 nerve cells and 205.90 neuroglia 





Plate XV, Fig. 46. 


cells being found to the square millimeter of surface of the cor- 
tical portion of this section, as compared to-146. nerve cells and 
131.90 neuroglia cells to the square millimeter of the surface of 
the cortex in the corresponding region of Brain A. In the latter 
methylene blue was the stain used, the thickness of the sections 
being the same in both cases, and as has been seen in every in- 
stance the methylene violet stain has greater affinity for the neu- 
roglia cells than the methylene blue, whereas, the nerve cells stain 
about the same with the one as with the other. 


2... a Se eee 


DEMENTIA PARALYTICA. 787 


Occipital Region.—Plate XV, Fig. 46, is a photomicrograph 
magnified fourteen diameters of a section taken from the block J 
of Plate X, Fig. 29, situated in the upper portion of the lateral 
aspect of the occipital convolution. The section is 5 mm. wide, 
8 mm. in length and 6 2-3 microns in thickness, was fixed in 95% 
alcohol, and stained with methylene violet. As may be observed, 
upon the posterior aspect, the sulcus is very shallow, the cortex 
here fusing with that of the adjacent gyrus not far from the 
vertex, whereas anteriorly the sulcus is well marked and quite 
deep. The first or outer layer is thicker both on the posterior and 
anterior aspects than at the vertex and is quite uniformly regular 
in outline. The second layer is well marked and shows the 
striated arrangement of the cells quite as well as in Bram A, at 
this point. Numerous large cells, some of which quite approach 
the Betz cells in size and structure, are seen scattered in the middle 
and lower portions of the layer. The third or spindle cell layer 
below is gradually lost in the white medullary substance. Through- 
out the entire section the cells and their arrangement are well 
made out, the capillaries although having thickened walls and 
somewhat tortuous are less conspicuous, the pericellular spaces 
smaller and less numerous, and most of the cells are fairly normal 
and show no distinct pathological changes. At a and enclosed in 
ink lines is the position of the segment in the adjacent section 
from which Plate XV, Fig. 47, was taken. ‘This latter corre- 
sponds most favorably with Plate IX, Fig. 25, from the corre- 
sponding region of the normal brain and some of the nerve cells 
here in Plate XV, Fig. 47, are larger and more numerous than 
in the corresponding section from Brain A. The first or outer 
layer is uniform in outline and measures here but .15 mm. in 
thickness. It contains numerous neuroglia cells and some scat- 
tered small nerve cells similar to those described in Plate II, Fig. 
3, and seen in the text as Figs. C, D, E, and F. The second or 
pyramidal cell layer is of special interest and measures 1.40 mm. 
in thickness, being somewhat deeper than in Plate IX, Fig. 25, 
but with a similar arrangement of cells. Above are small pyra- 
midal cells only, then larger pyramidal cells are seen in the deeper 
portions until about the middle of the layer is a region containing 
very large pyramidal cells, same as the one indicated by the 
letter X, for instance, being similar in size and structure to the 
Betz cells. Below this at a is a region .30 mm. in thickness in 
which numerous small pyramidal cells are alone seen. Below this 
again is a narrow zone containing some larger pyramidal cells 
scattered amongst the small pyramidal and irregular cells. The 
cell marked in the plate by the letter X is seen magnified in Fig. 
X. It is very large, contains irregularly elongated and linear 
chromophilic bodies of considerable size and arrangement in a 


788 G. ALFRED LAWRENCE. 


more or less parallel direction to the cell-body and extending into 
the dendritic processes. The nucleus is large, rounded, distinct, 
and centrally located with a distinct rounded nucleolus and inde- 
finite chromophilic network within. No processes are given off 
at the base in this plane, but a large process is given off upon the 
right at the level of the nucleus and soon divides into two 
branches. Another process is given off to the left on the oppo- 
site side of the cell-body at a level just above the nucleus. The 
apical dendric process contains numerous linear chromophilic 
bodies extending for some distance into the same. ‘This is a 
stichochrome nerve cell of the somatochrome class, and, in size 
and structure, is similar to the Betz cell. The two cells to the 
extreme right are similar in structure but not as large as the 
above. There are no pathological changes to be determined in 
the cells of this layer. Several small capillaries are seen with 
somewhat thickened walls, indicating that possibly the blood ves- 
sel changes are the first to be found in the disease, but of course 
much more extended observation and study would be required 
to determine the full relation of all these pathological processes 
to one another. The third or spindle cell layer is here .go mm. in 
thickness and made up of spindle and irregular polygonal cells, 
quite normal in appearance for the most part; some, however, 
showing slight shrinkage, pericellular spaces, and slight begin- 
ning chromatolysis. Some capillaries with thickened walls and 
perivascular spaces are to be observed here also. The entire thick- 
ness of the cortex measures 2.45 mm. being .45 mm. thicker than 
in Plate IX, Fig. 25. Nerve and neuroglia cell counts were made 
here with the results that 62.50 nerve cells and 215.01 neuroglia 
cells were found on an average to each square millimeter of sur- 
face of the cortex here, as compared to 164. nerve cells and 199. 
neuroglia cells in the same area of the corresponding section of 
Brain A, both sections being 6 2-3 microns in thickness and 
stained with methylene violet. From a study of the above plates 
from these two brains, the cortex in Brain A, would seem to be 
thinner and more compact, whereas, the cortex of Brain B, on an 
average measures somewhat thicker, yet the cells seem more 
scattered, so that a very much higher average of nerve cells is to 
be found in the former, far more it seems to the writer than could 
be accounted for by the possible destruction of some of the cells 
in the sections of Brain B, due to pathological agencies. 


The careful detailed study of the sections from various parts 
of the different regions of Brain A, practically normal from a 
histological standpoint, and of corresponding sections of Brain B, 
a case of advanced dementia paralytica in the manner as described. 


ee 


~ 


PS a ee ee pa 


DEMENTIA PARALYTICA. 789 


in this article has led the writer to the following conclusions: 
I. Photomicrography is a useful and valuable adjunct to such 
work, giving greater accuracy in relations of parts to one another 
than is possible in drawings and showing conditions as they actu- 
ally appear to the eye of the observer in each particular plane 
when the sections are seen under the microscope. Powers of 14 
or 20 diameters show very well relations of the layers to one 
another, and also the relation of the groups of large cells; such as 
the Betz cells in the central regions, for instance. Powers of 100 
diameters are well adapted to the study of the more minute detail 
of these relations of the layers and of various cells to one another, 
and also some of the morphology of the individual cells can be 
made out. Powers of 1,000 to 1,500 diameters show the internal 
structure of the cell to excellent advantage, but only in the very 
limited plane at which the object is focussed. On the other hand, 
the disadvantage of photomicrography is that everything is shown 
in any one plane so that special parts or structures are not brought 
out as prominently as in schematic drawings, and on this account 
all such work should be accompanied by such drawings to make it 
more complete. It is furthermore often quite difficult to obtain 
any one plane showing most of the cell structure, to say nothing 
of all of the same. 

II. Artefacts of many kinds are to be found in such work, and 
should be carefully avoided and eliminated in every instance be- 
fore definite conclusions are drawn from any series of observa- 
tions. Pressure and other mechanical causes acting before death, 
that due to manipulation at autopsy, artefacts resulting from fixa- 
tion, imbedding, sectioning, staining, decolorizing, and even 
mounting, are all possibilities, and are often most difficult to deter- 
mine in contradistinction to the pathological changes. 

III. The method of transporting material by means of small 
metallic boxes or similarly sized phials, permitting of a free cir- 
culation of various kinds of fixative fluids, without injury, and 
also permitting of subsequent exact localization, the process re- 
quiring a minimum of time and space is, to the mind of the writer, 
of decided practical value in such work. This method is fully 
described in the text under the heading of “Technique.” 

IV. Nerve and neuroglia cell counts have been alluded to 


790 G. ALFRED LAWRENCE. 


above, but a few remarks upon method may be of value. The 
method of counting the same from photomicrographs of moderate 
magnification is not accurate, as cells may overlap or be arranged 
in dense groups or their images may not all be sufficiently distinct 
so as to differentiate them properly, especially does this apply to 
the neuroglia cells, which are very small and often closely aggre- 
gated. Photomicrographs magnified a thousand diameters or 
more, although showing all the cells visible, are much too limited 
in area. For these reasons the use of the ocular net-micrometer 
was found to be the best and most accurate for this work, using 
a stage micrometer to determine the relation of the ocular field to 
the actual size of the section. In this way the exact number of 
nerve and neuroglia cells can be determined for any number of 
fields and an average obtained for any area, as was done in vari- 
ous plates in the brains employed in this work, as seen in Table II. 
As will be noted by referring to this latter, there is considerable 
variability, in the number of nerve and neuroglia cells not only in 
different cortical regions but also from adjacent sections of the 
same region. ‘The stain is seen to play an important role here 
in the resulting average number of neuroglia cells, methylene 
violet having a greater affinity for these cells than methylene blue. 
Sections stained by the latter cannot always be depended upon to 
show all the neuroglia cells. In comparing the normal paretic 
brain there is marked diminution of the nerve cells in the latter as 
compared to the former, whereas the neuroglia cells, making due 
allowance for variability, are somewhat increased in number in 
the paretic brain. 

V. The thickness of the layers is not constant in different 
parts of the same gyrus, nor even in different portions of a single 
transverse section of a gyrus, to say nothing of different regions 
of the cortex. In the same way there is greater or less variability 
in the shape and mechanical. arrangement of each gyrus in con- 
trast to the other gyri making up the surface of the hemisphere 
and different parts of the same gyrus vary in this respect. This 
will be best observed by referring to the several plates of both 
Brains A and B, magnified 14 diameters, and of the various 
regions of the cortex. 

VI. After a quite extended perusal of the literature upon the 


DEMENTIA PARALYTICA. 791 


structure of the cortex as presented in the first portion of this 
article, the writer inclines to the view of a three-layered type of 
cell arrangement in the cortex, as the type with, of course, varia- 
tions in special parts, as the cornu ammonis, for instance. This is 
shown in Table I, and brief is as follows: 1, or superficial layer, 
containing but few nerve cells, many neuroglia cells, and many 
chiefly tangential fibers. The first two elements only are seen 
with the Nissl stain, whereas the latter element is most conspicu- 
ous with Weigert’s stain, and for this latter reason Ramon y Cajal 
designated it as the tangential fiber layer; 2, or pyramidal cell 
layer, to reduce the layering of the cortex to its lowest terms, and 
including the small, large, and giant or Betz pyramidal cells all in 
this one layer; 3, or spindle cell layer, including both the spindle 
cells which are in the majority and the less numerous irregular 
polygonal cells. Below these three layers is the sub-cortical white 
medullary substance. , 

VII. The study of the internal structure of the normal brain 
from a histological standpoint (Brain A) by the Nissl method 
shows four principal types of nerve cells: (1) The small rounded 
nerve cells of the first layer with or without one or more dendritic 
processes—rarely more than two, containing a rounded nucleus 
almost filling the body of the cell, this latter surrounded by a 
partial or complete narrow band of finely granular chromophilic 
substance. The neucleus contains a well marked neucleolus and 
slightly stained protoplasmic substance. These are co-called kar- 
yochrome nerve cells of Nissl’s classification. (2) The pyramidal 
cells of the second layer, of which there are four varieties (a) the 
small pyramidal cells, (b) the large pyramidal cells, (c) cells in- 
termediate in size and structure between the large pyramidal cells 
and the typical giant pyramidal or “Betz” cells, and (d) the giant 
pyramidal or “Betz” cells. In the smaller pyramidal cells it is 
difficult to distinguish distinct chromophilic granules, but the 
chromatin is arranged in larger or smaller finely granular masses 
in various parts of the cell-body, sometimes aggregated about the 
nucleus, at other times near the base or dendritic processes. The 
larger pyramidal cells, however, have the increasing amount of 
chromatic substance arranged in more or less distinct larger and 
smaller chromophilic granules, and these arranged in a direction 


792 G. ALFRED LAWRENCE. 


parallel to the surface of the cell-body. Still larger in size and 
more distinct in the arrangement of chromophilic granules in this 
general parallel manner are the intermediate variety of these 
pyramidal cells, which, although larger than the average pyramidal 
celi are considerably smaller than the typical Betz cell, and have 
a wider range of distribution not only in the vertical extent of the 
second layer of the cortex, but also in the different regions of the 
cortex, being found in the central, parietal, temporal, and occipital 
regions. Finally the largest in size and most distinct in structure, 
especially in the arrangement of the chromatic substance, are the 
giant pyramidal or Betz cells, in which larger size, large distinct 
nucleus and nucleolus, and also large parallel arranged chro- 
mophilic granules are seen in the cell-body, and often extending 
far up into the dendritic processes. These are localized, for the 
most part, in the lower portion of the second layer in certain areas 
of the central convolution and the posterior portion of the superior 
frontal convolutions. These pyramidal cells as a whole can best 
be designated as stichochrome nerve cells of the somatochrome 
class in Nissl’s classification, although the smaller pyramidal cells 
may simulate more the gryochrome nerve cells of this same class, 
owing to the indistinct arrangement of the chromatic substance. 
(3) The spindle cells found in the third layer and containing a 
very large nucleus with well marked nucleolus. The nucleus is 
often so large that it seems disproportionate to the size of the 
latter. The chromatic substance here is finely granular and ar- 
ranged in irregular masses or heaps about the nucleus, and ex- 
tending into the base of the dendritic processes, these latter, usu- 
ally two in number and opposite, producing a bipolar condition. 
These cells are gryochrome nerve cells of the somatochrome class. 
(4) Finally irregular or polygonal nerve cells are found in the 
second and third layers. These cells are irregular in shape, with 
three or more dendritic processes, a large nucleus containing a 
well marked nucleolus. In the cell-body are irregular finely 
granular masses of chromatic substance similar to the spindle cells 
in this respect, so could fall in the same classification as gryo- 
chrome nerve cells of the somatochrome class. In the cerebellum, 
the Purkinje cells, with their chromatic substance more or less 
arranged in a network, are classified as arkychrome nerve cells of 


DEMENTIA PARALYTICA. 793 


the somatochrome class, whereas the small nerve cells of the granu- 
lar layer, with small nucleus, appear only partially surrounded by 
the cell-body. are classified as cytochrome nerve cells. The four 
types of cells above mentioned, as found in the cerebral cortex, 
were seen in all the regions of the external surface of the hemi- 
sphere studied. In addition to these cellular elements of the nerv- 
ous tissue the neuroglia cells of the interstitial tissue were every- 
where to be seen, and in the walls of the blood vessels the vascular 
cellular elements were also to be found. 

VIII. Previous investigators, in the study of the cerebral cor- 
tex in dementia paralytica by the use of the Nissl method, have 
noted the following pathological changes: Various stages of cell 
degeneration up to complete destruction of the same, consisting of 
diminution, disintegration, and vacuolization of the cell proto- 
plasm, all stages of chromatolysis up to complete disappearance 
of the chromatic substance, shrinkage with deformity of the con- 
tour of the cell-body, atrophy of the dendritic processes, various 
degrees of pigmentation and pigmentary deposits in the cell-body, 
also adjacent to blood vessels; shrinkage with diminution in size, 
irregularity, compression, vacuolization, and eccentricity of the 
nucleus with even extrusion of the same from the cell-body by the 
rupture of the cell wall, or complete sclerosis of the nucleus with 
homogeneous and tinged contents or crystalline deposits, nucleolus 
displaced to nuclear wall or indistinguishable or vacuolated, cal- 
careous deposits in the form of fine granules, crumbs, placques, or 
stalactitic masses intensely colored with methylene blue and found 
in the bodies of the sclerosed cells, part or whole of cell entirely 
bleached, complete necrosis of cells, reduction in number of nerve 
cells, thickening of pia with septa projecting into the cortex, 
granular crowding of variously stained granules, obscure layering 
of the cortex, multiplication of white corpuscles, proliferation of 
neuroglia cells, increase in and dilatation of capillaries and arteri- 
oles, with thickening of walls of same by encasement of latter with 
lymphatic corpuscles, and finally proliferation of interstitial net- 
work. The writer has observed all of these changes excepting 
the following: vacuolization of the cell protoplasm was not ob- 
served in the paretic material examined in this work, no pigment- 
ary deposits were observed outside of the nerve cell bodies, al- 


794 _G. ALFRED LAWRENCE. 


though varying amounts were found in many of the nerve cells. 
No vacuolization of the nucleus or extrusion of the same was 
found here, no crystalline or calcareous deposits were made out 
in any of the cells, no septa were observed penetrating from the 
thickened pia into the cortex, multiplication of white corpuscles 
was not observed, and proliferation of neuroglia cells as seen from 
the nerve and neuroglia cell counts as tabulated in Table II. 
seems to have existed to but a slight extent in small localized 
places, as about some of the necrosed nerve cells. The writer 
does not mean to say that this may not occur in some cases, for 
on the contrary he is inclined to think it may occur under certain 
conditions, either localized or more general. Also no prolifera- 
tion of the interstitial network*Was observed here. About the 
nerve cells pericellular spaces of 'gtéater, or less extent were ob- 
served in many cases. , lm sotne ‘only a small portion of the cell- 
body, or a single dendritic process, was surrounded by a limited 
space; in many, however, a large portion of all the cell-body was 
thus surrounded. Perivascular spaces were also observed of 
varying size and extent about many of the blood vessels of the 
cortex. Pigmentation, in’ addition to being present in many of 
the nerve cells of the first and second layers of the cortex in the 
central regions, was also observed in cells of these layers in the 
frontal region as well; also in the parietal and temporal regions, 
but not in the occipital region. The pathological process here 
was most severe in the central and frontal regions, extending to a 
lesser extent, but still very marked, into the temporal and parietal 
regions, whereas the occipital region almost entirely escaped and 
appears practically normal. In the regions involved in this case 
the disease seems to be a chronic disease of the nerve cells with 
pigmentary degeneration and a necrosis of the cell-body, partial 
or complete, with accompanying involvement of the blood vessels. 
The relation of the vascular and cell changes to one another and 
the order of procedure in time is one that the writer believes re- 
quires much more extended investigation before it can be answered 
satisfactorily. 

In conclusion the writer gratefully acknowledges the kindly 
interest, suggestions, and assistance offered by Professor H. Fair- 
field Osborn, Dr. Oliver S. Strong, and Dr. Edward Leeming, of 
Columbia University; Dr. Ira Van Giesen, former Director of the 

















gcommon Typo | Motor Type | Sensory Type 


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Layer Layor 
Zone ees 
a latedaheteteeehes Small Small 
Zone of Pyramidal Pyramidal 
Small Coll Cell 
Pyramidal Tx 5 | 
II Layer Layer 
Cells) =s_- Fw n+ - ee ee np et! 
Large Large 


Pyramidal Pyramidal 


III III 
Zone Cell 
of gore Layer 
Largo Layér  ------------ 
Pyramidal Granular 
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Cells Ganglion IV 
L Cell 
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Iv Late Be eee 
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a White | White Contral 
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Vicq d'azyr Siaskelwuenes +2 ----------- A Be SR RS Re a ee a a eee eS 
1786 





Obersteinor 








Common |Occipital 


Sensory Type 


Common Type 








Common [Occipital 


Sensory Typo| Common Type 


Motor Type 


Common Type 


Comman Typa 













(ater Type 





Common | Occipital 
Typ 


Common Type Common Typo Motor Type Common TyPg Common Fe 













Superficial] Suporficital 


Pirst Tangential 
Pibor-I-Layor 

Second Tangontial 
EASIEST 





Superficial Superficial 


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Suporficial | Suporficial 
Tt I 







Superficial Suporficial] Suporficial 
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Grauer, oder 
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Cell Layer 












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Cell Layer 
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Baillargor's 
























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Grauer, oder 
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Polymorphous 



















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Reddish Gray 






Polymorphous 








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White Contral 


White Central 


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White Central 





Whito Central 







“hite Central Weisse Central}: 












Extornal 
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DEMENTIA PARALYTICA. 795 


New York State Pathological Institute; Dr. H. T. Brooks, Pro- 
fessor of Histology and Pathology at the New York Post-Gradu- 
ate Medical School, and Hospital; Dr. Philip F. O’Hanlon, Coro- 
ner’s Physician, New York City, and Dr. Robert T. Irvine, of 
Ossining, N. Y. 


LITERATURE, 


Anglade, D. “Sur les alterationes des cellules nerveuses de la cellule 
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Arndt, R. “Untersuchungen tiber die ganglion-Korper des Nerves 
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Ballet, Gilbert. “Les Lesions cérébrales de la paralysie générale 
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796 G. ALFRED LAWRENCE. 


tributo alla istologia path. della paralisi generale progressiva.” Annali di 
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De Quervain, Fritz. “Ueber die Veranderungen des Central nerven- 
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Donaldson, H. H. “The Size of Several Cranial ‘Nerves in Man as 
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Edinger, L. “Anatomy of the Central Nervous System in Man and 
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Flemming, W. “Beitrage zur Anat. u. Embryol. als Festgabe fur J. 
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Cf. also, “Ueber den Bau der Spinalganglienzellen bei Saugethieren, 
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“Ueber die Struktur centrallen 'Nervenzellen bei Wirbeltieren.” Anat. 
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Flesch, M. “Ueber Verschiedenheiten im chemischen Verhalten der 
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Gennari, Francisco. “De peculiaris structura cerebri, non-nulisque 
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“Pannae ex regis typg.” (1782.) 

Golgi, C. “Sulla fina Anatomia Organi Centrali del Sistema Nervosa.” 
(1885.) p. 65. Archiv. ital. de Biol. (1883.) Ref. 
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Hammdrberg, Carl. “Studien tiber Klinik und Pathologie die Idiotie 
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Henle, J. “Anatomie,” 2nd Ed. Vol. II, p. 306 (1876). 

Jelliffe, Smith Ely. “Biographical Contribution to the Cytology of 
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3 (1808), p. 441. 

Key, E. A. H., and Retzius, G. “Studien in der Anatomie des Nerven- 
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Krause, W. “Anatomie.” Vol. I, p. 439 (1876). 

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Lunatic Asylum Medical Reports. Vol. VI (1876), p. s. 


DEMENTIA PARALYTICA. 797 


Meckel, J. F. “Anatomie.” Vol. II, p. 443. ; 

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Nagy, A. “An agyking idigsijtjunek elvatozasarél elmebautalmaknae.” 
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“Ueber die Veranderurgen der Hirnrindenzellen bei Psychosen.” Neur. 
Cent. (1894), p. 820. 

Nissl, Franz. (a) “Ueber die Untersuchungsmethoden der gross 
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Tagebl. de 61 Versamml. Deutsch. naturf. u. aerzte in Koln (1888). Inter. 
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(c) “Die Kern d. Thalamus beim Kaninchen.” Tagebl. d. Naturforsch. 
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(d) “Ueber die Veranderungen der Ganglienzellen in Facialis Kern 
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(e) “Ueber experimentell erzeugte Veranderungen an den Verder- 
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(f{) “Mittheilungen zur Anatomie der Nervenzelle.” Allg. Ztschrft. 
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(k) “Bernhard von Gudden’s hirnanatomische experimentale Unter- 
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798 G. ALFRED LAWRENCE. 


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“Ueber Nervenzellenstructuren.” Vorhandl. d. Anat. genellsch., Jena 
(1896), Bd. X, S. 15-21. 


EXPLANATION OF PLATES. 


Plate I. Fig. 1. Brain A. Left hemisphere. Electrocuted case, nor- 
mal histologically. 
dicated by the figure 1 in Plate I. Fig. 1. Section 6 2-3 microns in thick- 
dicated by the figure 1 in Plate I. Fig .1. Section 6 2-3 microns in thick- 
ness stained with methylene blue and magnified 14 diameters. 

Plate II. Fig. 3. Brain A. First frontal conv. Strip a of Plate I, 
Fig. 2, magnified 100 diameters. 

Plate II. Fig. 4. Brain A. First frontal conv. Cell G. of Plate II, 
Fig. 3 magnified 1400 diameters. 

Plate II. Fig. 5. Brain A. First frontal conv. Cell H of Plate II, 
Fig. 3 magnified 1,400 diameters. 

Plate III. Fig. 6. Brain A. First frontal conv. Group of spindle 
cells J of third layer of cortex shown at J in Plate II, Fig. 3 magnified 
1,400 diameters. 

Plate III. Fig. 7. Brain. A. Ant. cent, conv. Upper third, taken 
from point indicated by the figure 2 in Plate L, Fig. 1. Section 10 microns 
in thickness stained with methylene violet, and magnified 14 diameters. 

Plate III. Fig. 8. Brain A. Ant. cent. conv. Upper third. Strip a 
of Plate III, Fig. 7 magnified 100 diameters. 

Plate IV. Fig. 9. Brain A. Ant. cent. conv. Upper third. Section 


‘? pike 


x 


DEMENTIA PARALYTICA. 799 


from same block and adjacent to that shown in Plate III, Fig. 7. Section 
IO microns in thickness, stained with methylene blue, and magnified 14 
diameters. 

Plate IV. Fig. 10. Brain A. Ant. cent. conv. Upper third. Strip 
a of Plate IV, Fig. 9, magnified 100 diameters. 

Plate IV. Fig. 11. Brain A. Ant. cent. conv. Upper third. Sec- 
tion taken from same block and adjacent to that shown in Plate IV, Fig. 9. 
Section 10 microns in thickness, stained with methylene blue, and magni- 
fied 14 diameters. 

Plate IV. Fig. 12. Ant. cent. conv. Upper third. Giant pyramidal 
cell from lower portion of second layer of cortex from section adjacent to 
that shown in Plate III, Fig. 7. Section 10 microns in thickness, stained 
with methylene violet and magnified 1,400 diameters. 

Plate V. Fig. 13. Brain A. Ant. cent. conv. Upper third. Portion 
a of Plate IV, Fig. 11, magnified 825 diameters. 

Plate V.. Fig. 14. Brain. A. Ant. cent. conv. Upper third. Two 
giant pyramidal cells from lower portion of second layer of cortex from 
section adjacent to that shown in Plate 1V, Fig. 9. Section 10 microns in 
thickness, stained with methylene blue and magnified 1,400 diameters. 

Plate V. Fig. 15. Giant pyramidal cell from Ant. cent. conv. Upper 
third, lower part of second layer from approximately the same region as 
the cells shown in Plate V, Fig. 14, and stained with methylene blue, Sec- 
tion 10 microns in thickness, and magnified 1,400 diameters. 

Plate VI. Fig. 16. Brain A. Ant. cent. conv. Lower third, taken 
from point indicated by the figure 4 in Plate I, Fig. 1. Section 10 microns 
in thickness, stained with methylene violet, and magnified 10 diameters. 

Plate VI. Fig. 17. Brain A. Ant. cent. conv. Lower third. Strip a 
of Plate VI, Fig. 16, magnified 100 diameters. 

Plate VI. Fig. 18. Brain A. Post. cent. conv. Middle third. Sec- 
tion taken from the point indicated by the figure 5 in Plate I, Fig. 1. Sec- 
tion 6 2-3 microns in thickness, stained with methylene blue, and magni- 
fied 10 diameters. 

Plate VII. Fig. 19. Brain A. Post. cent. conv. Middle third, upper 


- portion. Strip a of Plate VI, Fig. 18, magnified 100 diameters showing 


first and second layers and upper portion only of third layer. 

Plate VII. Fig. 20. Brain A. Supra-marginal conv. of parietal re- 
gion taken from point indicated by the figure 7 in Plate I, Fig. 1. Sec- 
tion 6 2-3 microns in thickness, stained with methylene violet, and magni- 
fied 14 diameters. 

Plate VII. Fig. 21. Brain A. Supra-marginal conv. of parietal re- 
gion. Strip a of Plate VII, Fig. 20, magnified 100 diameters. 

Plate VIII. Fig. 22. Brain A. First temp. conv. taken from point 
indicated by the figure 6 in Plate I, Fig. 1. Section 6 2-3 microns in thick- 
ness, stained with methylene blue, and magnified 14 diameters. 

Plate’ VIII. Fig. 23. Brain A. First’ temp. cony. Strip a of Plate 
VIII, Fig. 22, magnified 100 diameters. 

Plate VIII. Fig. 24. Brain A. Occipital conv. taken from point indi- 
cated by the figure 8 in Plate I, Fig. 1. Section 6 2-3 microns in thickness, 
stained with methylene violet and magnified 14 diameters. 

Plate IX. Fig. 25. Brain A. Occipital conv. Strip a of Plate VIII, 
Fig. 24, magnified roo diameters. 

Piste (Exec: 26. ' Brain A.» Large pyramidal cells from layer of 
large pyramidal cells of the hippocampus major or cornu ammonis. Sec- 
tion 6 2-3 microns in thickness, stained with methylene violet, and mag- 
nified 1,400 diameters. 

Plate IX. Fig. 27. Brain A. Purkinje and granular cells from cortex 


800 G. ALFRED LAWRENCE. 


of left cerebellar hemisphere. External surface. Section 10 microns in 
thickness, stained with methylene blue, and magnified 1,400 diameters. 

Plate X. Fig. 28. Brain A. Multipolar ganglion cell from ant. horn 
of lumbar enlargement of spinal cord. Section 6 2-3 microns in thickness, 
stained with methylene violet, and magnified 1,400 diameters. 

Plate X. Fig. 29. Brain B. Left hemisphere. Case of dementia par- 
alytica dying in advanced stage of terminal dementia with contractions. 
‘Normal size. 

Plate X, Fig. 30. Brain B. First frontal conv. taken from point in- 
dicated by letter K in Plate X, Fig. 29. Section 10 microns in thickness, 
stained with methylene blue, and magnified 14 diameters. 

Plate XI. Fig. 31. Brain B. First frontal conv. Strip a of section 
adjacent to that shown in Plate X, Fig. 30, 6 2-3 microns in thickness, 
stained with methylene blue, and magnified 100 diameters. 

Plate XI, Fig. 32. Brain B. Ant. cent. conv. Upper third taken from 
point indicated by letter D in Plate X, Fig. 29. Section I0 microns in 
thickness, stained with methylene violet, and magnified 14 diameters. 

Plate XI.. Fig. 33. Brain B. Ant. cent. conv. Upper third. Strip. 
a of section adjacent to that shown in Plate XI, Fig. 32. Section 6 2-3 
microns in thickness, stained with methylene violet, and magnified 100 
diameters. 

Plate XI. Fig. 34. Brain A. Ant. cent. conv. Upper third taken 
from point indicated by letter L in Plate X, Fig. 29. Section 6 2-3 microns. 
in thickness, stained with methylene violet, and magnified 14 diameters. 

Plate XII. Fig. 35. Brain B. Ant. cent. conv. Upper third. Giant 
pyramidal cell a of Plate XI, Fig. 34, magnified 1,400 diameters. 

Plate XII. Fig. 36. Brain B. Ant. cent. conv. Upper third. Giant 
pyramidal cell b of Plate XI, Fig. 34, magnified 1,400 diameters. 

Plate XII. Fig. 37. Brain B. Ant. cent. conv. Upper third. Giant 
pyramidal cell from section adjacent to that shown in Plate XI, Fig. 34, 
magnified 1,400 diameters. 

Plate XII, Fig. 38. Brain B. Ant. cent. conv. Upper third. Giant 
pyramidal cell from same section as that from which Plate XII, Fig. 37, 
was taken, magnified 1,400 diameters. Shows advanced chromatolysis. 

Plate XIII. Fig. 39. Brain B. Ant. cent. conv. Upper third taken 
from point indicated by letter O in Plate X, Fig. 29. Section is 10 microns 
in thickness, stained with methylene violet, and magnified 15 diameters. 

Plate XIII. Fig. 40. Brain B. Post. cent. conv. Middle third taken 
from region indicated by letter B in Plate X, Fig. 29. Section is 6 2-3 
microns in thickness, stained with methylene blue, and magnified 14 diame- 
ters. 

Plate XIII. Fig. 41. Brain B. Post. cent. conv. Middle third. 
Strip a of Plate XIII, Fig. 40, showing first and second layers of cortex 
and upper part of third layer, magnified 100 diameters. 

Plate XIV. Fig. 42. Brain B. Supra-marginal conv. of parietal re- 
gion taken from point indicated by letter H in Plate X, Fig. 29. Section 
6 2-3 microns in thickness, stained with methylene violet, and magnified 
14 diameters. 

Plate XIV. Fig. 43. Brain B. Supra-marginal conv. of parietal re- 
gion. Strip a of Plate XIV, Fig. 42, magnified 100 diameters. 

Plate XIV. Fig. 44. Brain B. First temp. conv. taken from region 
indicated by letter J in Plate X, Fig. 29. Section 6 2-3 microns in thick- 
ness, stained with methylene violet, and magnified 14 diameters. 

Plate XV. Fig. 45. Brain B. First temp. conv. Strip a of Plate 
XIV, Fig. 44, and magnified 100 diameters. 


DEMENTIA PARALYTICA. 801 


Plate XV, Fig. 46. Brain B. Occipital conv. taken from point indi- 
eated by letter J in Plate X, Fig. 29. Section 6 2-3 microns in thickness, 
stained with methylene violet and magnified 14 diameters. 

Plate XV. Fig. 47. Brain B. Occipital conv. Strip a of Plate XV, 
Fig. 46, magnified 100 diameters. 


ADDENDA, 


The writer also wishes to acknowledge with thanks the appro- 
priation of two hundred dollars from the Dyckman Fund of the 
Department of Zoology, Columbia University, towards the publi- 
cation of this thesis. 





Periscope. 


ALLGEMEINE ZEITSCHRIFT FUER PSYCHIATRIE 
(Vol. 60, 1903, No. 3.) 


1. Obituary. R. v. Krafft-Ebing. H. ScHute. 

2. Brain Weights in Dementia Paralytica. G. ILBERc. 

3. Periodical Insanity. C. EIsaTu. 

4. The Muscle Sense and Its Representation by Maupassant. O. KLucE. 
5. Contribution to Idiot Statistics. G. Heiman. 

6. Case of Mania of Forensic Interest. KOLPIN. 

7. Psychiatric Therapy. P. PRENGowsKY. 

8. Statistical Study. 

1. Obituary, R. von Kratft-Ebing.—A short sketch of the life and work 
of the late Prof. von Krafft-Ebing. 

2. Brain Weight in Dementia Paralytica.—The author gives the results 
of his investigations as to the weight of the brain and its different parts in 
102 male paretics dying in the Royal Saxon Asylum at Sonnenstein. His 
method was first to weigh the brain (removed after the thoracic organs), 
then dissecting it after Meynert’s method, to weigh separately, the brain 
muscle, brain stem, and cerebellum; next dividing the brain mantle, to weigh 
right and left hemispheres, later the frontal, and temporo-parieto-occipital 
portions, and the basal ganglia of each hemisphere. His results are ar- 
ranged according to the length of body of the patients in tabular form, be- 
ing compared in the same table with the weights given Pfliiger as normal 
for men of corresponding sizes. In other columns are placed the proportion 
of the weights of the different parts to the total brain weight, duration of 
the disease in months, and ages of the patients at death. His figures show 
that in long duration of the disease all parts of the brain lose weight, most 
of all the brain mantle and especially the frontal lobes, and that in the 
majority of cases there is a difference in weight between the two hemi- 
spheres, the right being more often the lighter. The article, a very compre- 
hensive one, bristles with figures. It should be consulted in the original by 
those specially interested. , 

3. Periodical Insanity.—The prevailing views with regard to periodi- 
cal insanity are those of Hitzig and Pilcz on the one hand, and of Kraepe- 
lin on the other. The former class as periodical, all mental disturbances oc- 
curring at regular intervals, each time with the same peculiar symptoms, so 
recognize a periodical mania, melancholia, amentia, paranoia, etc. Kraepe- 
lin on the contrary thinks that it is impossible to set a limit within which 
the periodical attacks begin and run their course, since irregularity is the 
rule, and regularity the exception, the latter being practically never found 
except in manio-melancholic insanity. Accordingly he does not admit that 
there is a periodical mania or periodical melancholia, but feels sure that 
sufficiently careful and long-continued observation will always detect a de- 
pressed and an exalted stage, though either may be but little marked. 

As a contribution to the literature of the subject, Eisath gives careful 
clinical histories of five cases, each observed for a number of years. In the 
first case, that of a female beginning at twenty-five; during twenty-one 
years, there were 13 attacks marked by depression, never exaltation. In the 
second, that of a female beginning at forty-six, there were 20 attacks of 
exaltation in I6 years, never depression. The third case was that of a 
woman in whom between the ages of seventeen and sixty-seven years, there 
were I2 severe attacks occurring at irregular intervals, and showing mixed 


PERISCOPE. 803 


excitement and depression, manio-melancholic insanity. The fourth and 
fifth cases respectively in a man and in a woman, though presenting a 
somewhat complicating symptom-complex, are regarded by the author as 
examples of dementia precox with a periodical course. Only in his second 
case does he think that the symptoms occurred with sufficient definiteness 
and regularity, to fulfil the requirements of Hitzig’s and Pilcz’s classifica- 
tion. On the whole he is inclined to take a position between that of Hitzig 
and Pilcz, and that of Kraepelin inclining to the opinion of the latter that 
periodicity alone is not a satisfactory criterion for the separation of psychi- 
cal diseases. 

4. On the Muscle Sense and Its Representation by Maupassant.—A ftter 
a short discussion of the muscle sense, from which our notion of the Ego, 
or sense of self, is in his opinion, almost entirely derived, the author studies 
the manifestations of altered self feeling due to the pathological disturb- 
ance of this sense as presented by Maupassant, especially in his novel “La 
Horla,” which was written after the gifted Frenchman was doubtless al- 
ready in the first stage of general paresis. 

5. A Contribution to Idiot Statistics—Unsuitable for abstraction. 

_ 6. A Case of Mania of Forensic Interest—Case of a man of twenty- 
six years, arrested for a number of small swindling operations, and found 
to be suffering from not very well marked mania. Of chief interest is the 
marked family and hereditary character of the mental trouble, which the 
author exposes at some length. 

7. Psychiatry Therapy.—The author calls attention to the skin as an 
organ of elimination and thinks that a failure of this organ to perform its 
function may be at the bottom of some psychoses of possibly toxic origin. 
In a case diagnosed as “periodical neurasthenia” he claims to have been 
able by the local application of cold, to produce an array of symptoms affect- 
ing the skin, the circulatory organs, and sometimes the digestive apparatus, 
with mental manifestations corresponding closely to those of katatonia, all 
of which could be made to disappear, by warming up the skin again. From 
clinical study, and from the above experimental evidence, he urges the ad- 
visability of avoiding drugs which tend to produce arterial spasm, caffein 
especially. The symptoms described he attributes to the production of ar- 
terial spasm, the consequent suppression of transpiration through the skin, 
and urges the rationality of encouraging sweating, and especially of the use 
of the prolonged warm bath as recommended by Kraepelin and others. 

8. Statistics of Patients in Institutions for the Insane, Idiotic and Ept- 
leptic—Tabular only. Unsuitable for abstraction. 

C. L. Atten (Trenton). 


MISCELLANY 
PATHOGENY OF THE ACUTE PsycHoses. H. Berger (Berliner klinische 

Wochenschrift, July 27, 1903). 

This is still one of the unsolved problems of psychiatry, and none of the 
numerous theories advanced have stood the test of experimental trials. The 
view which has lately met with the most support is that these phenomena 
depend on delicate chemical changes in the cortical cells, which occur with- 
out the production of any morphological alterations in the cells themselves. 
In this way the theory of a circulating toxin in the blood has gradually 
gained credence. Experimental proof of this theory has been sought by the 
author, who made the first trial upon himself. He injected, at intervals, 
serum, blood and cerebrospinal fluid from a patient suffering from acute de- 
mentia with hallucinations, without the least effect. This seems to show 
that the toxin, if present, must already be firmly united with the cerebral 
cells before the acute symptoms appear. In the belief that the toxin may 


804 PERISCOPE. 


have been found during the prodromal stage, the author also injected sub- 
cutaneously blood from a patient who was developing symptoms during her 
puerperium, which later turned out to be a dementia precox. ‘No effect was 
seen, but blood taken from the same patient four weeks later, during a fresh 
attack, and injected, was shortly followed by vertigo, and later by cardiac 
palpitation, cerebral pressure, and a marked feeling of fear. All these 
symptoms subsided on the following day. A similar experiment with the 
blood taken from a more advanced case in a condition of stupor at the time, 
was also followed by results which were much more marked and severe and 
did not subside for a week. The experiments were then continued on ani- 
mals, and a basis secured for further investigation in regard to the changes 
which specific toxins contained in the circulating blood may cause in the 
central nervous system. The details are not suitable for a brief abstract. 
They consist mainly of observations made with the serum secured from the 
goat, which had been made neurotoxic for dogs by the continued subcutane- 
ous injection of triturated cerebrum from the brains of dogs. Intracerebral 
injections of this goat serum in dogs was followed by well-marked patho- 
logical changes in the pyramidal cells of the cerebral cortex and later on a 
large aggregation of leucocytes around these degenerated cells. Similar 
pathological conditions have been found in patients afflicted with acute 
psychoses, and also in other cerebral diseases, but the author is not as yet 
prepared to draw final conclusions until further proof has been secured. 
JELLIFFE. 


MorPHINE AND OTHER PHENANTHRENE DERIVATIVES. P. Bergell and R. 

Pschorr (Zeitschrift f. Physiologische Chemie, Vol. 38, ‘Nos. 1, 2). 

It is taught by chemists that morphine is derived from phenanthrene, a 
cyclic hydrocarbon having the symbol C14H10; the basic character of mor- 
phine being determined, like that of all other alkaloids, by the presence of 
nitrogen. According to the authors, all the investigations that have so far 
sought to attribute the physiological action of morphine to single atomic 
groups, have been carried out amost entirely upon nitrogenous compounds 
related to morphine. The authors sought to determine to what extent the 
physiological action of morphine depends upon non-nitrogenous molecular 
groups, more particularly phenanthrene and its non-nitrogenous derivatives. 
They find that phenanthrene itself is inert, but that oxy-phenanthrene, or 
phenanthrol (C14H9OH) produces in mammals severe tetanic seizures. 
The position of the hydroxyl group in the molecule has no influence on the 
physiological effect. Similar symptom-complexes are produced by a carbon- 
and a sulpho-acid of phenanthrene. No narcotic effect was observed in this 
entire group. To what extent the effect of phenanthrol may be brought into 
relation to that of morphine which contains the phenanthrol-complex, and 
whether the behavior of this class of bodies affords any explanation of the 
tetanic components of morphine-action—both of these questions the authors 
consider as still unanswerable. Substantially different from the action of 
phenanthrol and its carbon-acids, is that of derivatives of phenanthrene- 
equinone. These substances, both in the test-tube and in the organism, 
show a decided power of forming methemoglobin, which power is to be 
attributed to the prepondering influence of the quinone group. None of 
these compounds produces the above described tetanic state. Epiosin, a 
methyl derivative of phenanthrene, also produces methemoglobinemia. It 
is significant that in pigeons, which show an extraordinary resistance to- 
ward morphine, severe toxic manifestations are produced by epiosin. Evi- 
dently there is some connection between the narcotic and other manifesta- 
tions of morphine and the methemoglobinemia produced by some of its 
derivatives. JELLIFFE. 



















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TABLE OF CONTENTS 


ORIGINAL ARTICLES 


& 
Enormous Tumor of the Postero-Parietal Region Weighing Over 
Half a Pound; Absence of Localized Symptoms Until Late in the 
History of the Case; Operation; Death. By F. X. Dercum, M.D., 


and, W..’W..\| Keen MED ir re Os eee rd Ne a2 co, 2. 7am 


Studies upon the Cerebral Cortex in the Normal Human Brain and 
in Dementia Paralytica. By G. Alfred Lawrence, M.D., Ph.D... .754 


Continued on Page IV 





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II 





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Ill 


TABLE OF CONTENTS II—Continued from page ll 


PERISCOPE 


ALLGEMEINE ZEITSCHRIFT FUER PSYCHIATRIE. Vol. 60, 1903, No. 3. 
1 Obituary, R. von Krafft-Ebing (800). 2 Brain Weight in Dementia 
Paralytica (800). 3 Periodical Insanity (800). 4 On the Muscle 
Sense and Its Representation by Mauspassant (801). 5 A Contribu- 
tion to Idiot Statistics (801). 6 A Case of Mania of Forensic Interest 
(801). 7 Psychiatry Therapy (801). 8 Statistics of Patients in Insti- 
tutions for the Insane, Idiotic and Epileptic (801). 


MISCELLANY. 


Pathogeny of the Acute Psychoses (801). Morphine and Other 


Phenanthrene Derivatives (802). 


Continued on page V1 





poh ob oh oh ch bh bh bh bh bh bed bh bh 


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TEGRIEY.....c 


This is what the pallid anzmic individual needs from whatever cause such blood 
poverty may arise. The best way to ‘‘ build blood” is to administer 


Pepto Mangan (“Gude’ 


This palatable combination of Organic Iron and Manganese contributes to the 
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and thus brings about a pronounced betterment in cases of Simple or Chlorotic 
Anemia, Amenorrhea, Bright’s Disease, Chorea, Dysmenorrhea, etc. 

In order to be sure of obtaining the genuine Pepto-Mangan ‘‘ Gude’’ prescribe 

an original bottle, holding Z xi. IT’S NEVER SOLD IN BULK. 


M. J. BREITENBACH COMPANY, Sole Agents for U. S. and Canada, 


LABORATORY, LEIPZIG, GERMANY. NEW YORK. 
Ep > Ep > aD > DPD ¢ Go MCW ap + POPDe > SD oD eo DPeOQPDe @] + @eD?> @*+@? @?*@? oD? es] 


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(Soluble Metallic Silver—Von Heyden.) (15 per cent. Collargolum Ointment—Von Heyden.) 


Collargolum is an Efficient, Harmless Blood and Tissue Disinfectant, 
whose remarkable catalytic power greatly increases the normal bactericide properties of 
the blood and inhibits the growth of pathogenic bacteria. Though not a specific in every 
case, it has given brilliant results in almost hopeless cases of puerperal sepsis, epidemic 
cerebrospinal meningitis, anthrax, septic endocarditis, etc. When rapid effects are desired, 
it should be intravenously injected; but in less urgent cases UNGUENTUM CREDE 
is usually most conveniently employed. Its use should be begun even when the presence 
of sepsis is only suspected. 


Recommended by Profs. Roswell Park, A. Jacobi, F. Forchheimer, Edwin Klebs, 
Walter B. Dorsett, H. J. Boldt, G. Biorkmann, Tillmanns, Dieckerhoff, Liebreich, 
Netter, Wenckebach, Drs. C. G. Cumston, S. Marx, J. D. Voorhees, and many others. 


CREOSOTAL @ DUOTAL 


(Creosote Carbonate— Von Heyden.) (Guaiacol Carbonate—Von Heyden.) 



















Non-toxic and Non-irritant Specifics for Tuberculosis, Pneumonia, etc. 


“One of the greatest life-saving discoveries of the century.”—D7. 7. L. Van Zandi, 
on Creosotal, Medical Record, Oct. 18, 1902. 

Creosotal and Duotal contain 92% and 912 of creosote and guatacol respectively—more 
than any other preparation—but never cause gastric disturbances, even in massive doses. 
Duotal is odorless and tasteless, while Creosotal is almost so. 

In tuberculosis they stimulate the appetite, diminish or entirely obviate night-sweats, 
fever, cough and expectoration, and produce a gain in weight. 

Of the greatest value in pneumonia, phthisis pulmonum, croup, whooping-cough, 
bronchitis and other catarrhal affections, typhoid, etc. 

Favorably reported upon by Profs, A. H. Smith, W. H. Thomson, R. W. Wilcox, 
L. Weber, James Tyson, G. Cornet, R. Kobert, v. Leyden, Dujardin-Beaumetz, and 
many others. 

(Betanaphtol-Bismuth—Von Heyden.) (Tribromphenol-Bismuth—Von Heyden.) 


For Practical Intestinal Antisepsis. An Odorless Substitute for lodoform. 


3 peel Coat se aug UB sree can Xeroform is anon-toxic, deodorizing and 
A Bearer desiccating antiseptic, sedative and haemos- 






the tannin preparations, and advantageously 
used in place of the caustic carbolic acid, 
naphtol, etc. 

It promotes the elimination of the tox- 
albumins from the intestinal tract, and 
soothes the inflamed mucous membranes. 

Orphol is indicated in all fermentative 
gastro-enteric processes and catarrhs, diar- 
rhoea, ptomaine poisonings, typhoid fever, 
etc. Being absolutely innocuous, 15-grain 
doses can be frequently repeated with perfect 
safety. In cholera infantum, 2 to 5-grain 


doses, administered every 3 or 4 hours, act 
admirably. 





Literature on Application. 


Schering @ Glatz, New York, 


tatic, diminishing suppuration and promot- 
ing granulation. It is employed in the most 
varied operative procedures, amputations, 
enucleations, cancer and periostitis opera- 
tions, deep abscesses, chancroid and’ sup- 
purative skin affections, as well as in oph- 
thalmic and gynaecological practice and for 
insufflation into the nose and the ear. 

Internally, in daily doses of 30 to 60 
grains, it is a very efficient remedy for adult 
cases of diarrhoea, dysentery, typhoid fever, 
intestinal tuberculosis, etc. 


Sole Agents for the United States. 





TABLE OF CONTENTS III Concluded 


IMPORTANT NOTICE 


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Hypophosphites, that prescribers who employ them for the 
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See 
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See 
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Page 24. 


ANALGESIC 






“Does not 
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SEDATIVE, ANTISPASMODIC, 


[See Merck’s Manual, page 92.] 


Thiocol Roche 


a water-soluble, odorless form of guaia- 
col, employed in coughs, bronchitis, 
pneumonia, and tuberculosis. It does 
not disturb the stomach—a point of 
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Ferds;Lessing) Niven Pinia.e). Pay 


LL MN ITIL 
Cough, Morphinism, 
Corneal Opacities 


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an 
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writes of Thiocol Roche as follows: 
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See Index pp. xii, xvi, xx. 


OAK (Gi: ks 


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comprise 
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The Hospital consists of six buildings 
connected by glass corridors. Apartments 
for patients are commodious, sunny and 
tastefully furnished. Special attention is 
paid to hydrotherapy and electrotherapy. 
Turkish and Russian baths are administer- 
ed by nurses skilled in massage. A flowing 
well furnishes an alkaline mineral water of 
therapeutic value. 

For terms and further information, ad- 
dress 


PROSIT:—A therapeutic, antacid table water from a flowing well 265 feet in 
depth; used in the Hospital and supplied in bottles and siphons. 


Cc. B. BURR, Medical Director FLINT, MICH. 





Ghe Milwaukee Sanitarium 


Wauwatosa, Wis. 
For Nervous and Mental Diseases 


Wauwatosa is a suburb of Milwaukee on the Chicago, Milwauke and St. Paul Railway, 
2% hours from Chicago, 5 minutes’ walk from all cars and trains. 


Physician in charge: RICHARD DEWEY, A.M., M.D. 


CHICAGO OFFICE, 34 Washington St.. Wednesdays 2to 4 P. M., (except in July and August). 
Telephone connections, Chicago and Milwaukee. 


A f 
She HIGHLANDS inci wih Mat Mena oe 
Nervous Diseases, the Alco- 


hol and Opium habits. Conducted on the plan of a Family Home in the 
Country. Established by Ira Russell, M.D., in 1875. For circulars, terms, etc., 


Address Frederick W. Russell, M.D.. Winchendon, Mass. 
VIII 








a 


Ne ge ee ee lk 


3 


DIRECTORY FOR PRIVATE INSTITUTIONS. 





‘‘Bournewood’”’ 


Dr. Henry R. Stedman having removed to his new 

S$ buildings in Brookline, Mass., 
will continue to receive patients with nervous or mental diseases 
for separate treatment or family care. Number limited to fifteen. 
Cases of the Alcohol habit not received. P. O. address South St., Brookline. 
Nearest station, Central, on the Providence Division of the N. Y., N. H. & 
H. R.R. Office in Boston: 33 Marlboro Street. Hours 10 to 12 Mondays, 
Wednesdays and Fridays, October to July. 


FALKIRK James F. Fergusen, M.D. 
Resident Physician and Proprietor 

On the Highlands of the Hudson, near Central Valley, Orange Co., New 
York. A Home for treatment of nervous and mental diseases, and the alcohol 
and opium habits. 

Falkirk is 800 feet above the sea level; the grounds cover 200 acres, are 
well shaded and command a magnificent view. The buildings are steam- 
heated and lighted by gas; the water supply from pure mountain springs. 
All the rooms face the southwest, the best methods in sewerage have been 
followed, and the arrangements for comfort and recreation include a sun- 
room, steam-heated in winter. 

Dr. Ferguson may be consulted at his office, 168 Lexington Avenue, New 
York City, Tuesdays and Fridays, between 11.30 a.m., and 12.30 p.m., and by ap- 
pointment, or may be addressed at Central Valley, Orange County, New York. 


Central Valley Orange County New Yerk 
Long Distance Telephone, “Central Valley, New Yerk.” 








Dr.Wm.B. Fletcher’s Sanatorium 6.” 92 224 Seatment 


tal Diseases. Special treatment of Diseases of Women by Dr. Mary A. 
Spink. For further information address Dr. Wm. B. Metcher, 218 North Ak 
abama St., Indianapolis, Ind. Long Distance Telephone, 381. 


INDIANAPOLIS, INDIANA. 





PARK VIEW SANATORIUM, Columbus, O. 


An ideal RETREAT for the private care and treatment of MENTAL and 
NERVOUS DISEASES. 

Treatment of Morphine Addiction and Alcoholism is unsurpassed in ease 
and comfort of administration, limited restrictions, and permanency of CURE. 

Elegent buildings and park. Delightful surroundings. 

Booklet on request. 


H. A. RODEBAUGH, M. D., Supt. 
664 Park Street, Columbus, O. 





Norwood Private Hospital 


For Mental and Nervous Diseases 


Accommodation for ten patients. Alcohol and drug cases not taken. 
Licensed and established in 1888. Railroad station, Norwood Central. P. @. 


Eben C. Norton, M.D. 


Norwood, Mass. 


DIRECTORY FOR PRIVATE INSTITUTIONS. 





The New York Institution 


for the Treatment of Stammering 


In this institution for the relief of speech defects, now in its twentieth 
year, the celebrated French and German methods are utilized, improved by 
the suggestions of a progressive American Physician. No misleading 
promises are made, yet no one is allowed to lead us in information or THE 
BEST METHODS OF TREATMENT for such affections, where drill in artic- 
ulation and the technique of speech, or minor surgical operations, are indicat- 
ed. Physicians may retain charge of patients sent, if desired. Suitable cases 
may reside in the institution and be under the doctor’s constant care. For out- 
line of treatment and testimonials from eminent men and pupils, ask for our 
new illustrated pamphlet. 


FEF. A. Bryant, M.D. 12 W. 40th Street, New York 
For nearly 20 years at 9 W. 14th Street 








Private Hospital Cor. Boylston St. and Chest- 
ror Mental Diseases nut Hill Avenue. 


Established 1879. Brookline Near Boston 
WALTER CHANNING, M.D. M h 
Superintendent. “ ‘Ze assachusetts 





Burn Brae 


A Private Hospital for Mentaland 
Nervous Diseases 


Founded by Robert L. Given, M.D. in 1859 
Extensive and beautiful grounds, Per- 
fect privacy. Located a few miles west 
of Philadelphia. 
Refers by permission to Drs. R. A. F. 
Pevrose, James Tyson, Charles K_ Mills, 
Wharton Sinkler,|William Osler, Thomas 
G. Morton, Barton Cooke Hirst, John H. 
Musser, Alfred Stengel, James Hendrie 
Lloyd, John A. Ochterlony,John Deaver, 
W. Lassiter. ! 
Proprietor, E. L. Given; Medical Su- 
perintendent, N. SS. Yawger, M.D 
For fullinformation address 


BURN BRAE, 
Clifton Heights, Delaware Co., Pa. 


Telephone Connection. 








« Under State License. 
Dr Kellogg G FOR THE_CARE AND TREATMENT OF 
bed NERVOUS AND MENTAL DISEASES 
H Select Cases and Limited Number ¢ 
OXUSe Modern appointments and handsome surroundings. 
Committed or voluntary patients received. Trains 


hourly to Riverdale Station, Hudson River Rallroad, or Van Cortlandt Sta 
tion, Putnam R. R. Address letters or telegrams to Dr. Theo. H. Kellogg, 


Corner Riverdale Lane and Albany Post Road 
N. ¥. City Telephone, 36 Kingsbridge Riverdale, New York City 





S @ rc) For ‘ the ; ep and 
treatment of nerv- 

oe Westport Sanitarium * precise 
, with special attention to chronic nervous cases. Modern appointments; home 

life: beautiful surroundings; large private grounds. Private attendants and cottage 
eare if desired. Committed or voluntary patients received. No accommodations for al- 
eoholics. For information and terms addres Dr. F. D. Ruland, Medical Superintea- 


dent. Wednesday, in New York City, 10 a.m.-12.30 p.m., at 47 East 78th Street. 
Long distance telephone at both addresses. 


Established 1890 Westport, Conn. 
X é 





DIRECTORY FOR PRIVATE INSTITUTIONS. 





Cromwell Hal tens senor, ana, private es 

tablishment for the Medical and 
Hygienic Treatment of Invalids. Neurasthenia and general invalidism are _ treated 
by the educational method combined with the necessary therapeutic and _ hygienic 
methods. Out-of-door living by means of cots, tents and permanent cabins is a spe 
cial feature. Insane, objectionable and incurable cases are  not_ received. Dr 
Frank K. Hallock, Medical ‘Director; New York Office, 819 Madison Avenue, 
first Tuesday in month, 2 to 4 hed, Cromwell, near Middletown, 


Boston Office, Hotel Vendome, third : 
Connecticut 


Tuesday in month, 2 to 4 p.m. 





RIVER. CREST 


(Duly Licensed by the State Commission in Lunacy.) 
ASTORIA, L. I. NEW YORK CITY 


For Mental and Nervous Diseases including Committed Cases and Voluntary Patients 


WELL equipped home, situated in the elevated, residential portion of Astoria, L. I., New 
York City, opposite the foot of 121st Street, and 1%4 miles from the 92nd Street (Astoria) 
Ferry. THE LOCATION, in a beautiful natural park of 30 acres is a fine one, com- 

manding views of East River, Long Island Sound, the Grant Monument, and the City. There is 
an attractive central building, with several roomy annex cottages, affording accommodations at 
@ very moderate rate, or expensive suites of rooms. There are separate, detached 
buildings, specially equipped for the modern care and treatment of cases of Alcoholism, 
Drug Addictions and Nervous Diseases. 

Physicians are invited to inspect our system of Electrotherapeutics and Shower Baths, 
so valuable in the scientific treatment of many diseases. 

For information and rates address: 


New York City Orrice: J, JOS. KINDRED, M,D., or WM. E. DOLD, M.D. 


1125 Madison Avenu : Ai ae : 
3 i icra Consulting Physician Physician in Charge 


Cor. 84th St. ; 
Hours 2 to 3 P. M. and Business Manager 
Tel. 1512—79th Street. TELEPHONE 36—ASTORIA. 








Riggs Cottage 


A private Institution for the care and treatment of Invalids and Mild 
Nervous and Mental Diseases, located in one of the healthiest sections of 
Maryland. Patients are surrounded with the attention and comforts of a 
retined country home. Yor Circular, Terms and References, address 

GEORGE H. RiGGS, M.D. 
Ijamsville, Frederick County, Md. 





Hall- Brooke A Licensed Private Hospital for Mental 


and Nervous Diseases 


CASES OF ALCOHOLISM AND THE DRUG HABIT 
An inviting Hospital for the care of acute mental diseases, with a 
refined home for the chronic mental invalid. The location is unsur- 
passed for healthfulness and charming environment. Committed and 
voluntary patients received from any locality. A separate depart- 
ment for drug cases. For detailed information and rates, address: 


New York Office with DR. D. W. McCFARLAND 
DE... LAWRENCE GREEN’S FARMS, CONN. 





784 Park Ave. 
Hours 12 to 1,30, and by appointment 


XI 


CONSULT THIS 
Directory for Private Institutions 


LIST UF PATRONS TO D.RECTORY 





Barnes,“Dr. Fy Gray Towers soe ae eee a eee Liha 18 
Bond, : Dr. G. MM. —Yonkers uy ie ee ek sie ee 10 
Brownrigg, Dr. A. E.—Highland Spring Sanatorium............ 15 
Broughtonyi Dri Rist ea eR ene Nee 14 
Bryant, Dr. bh. A.—School for Stanimerersuneu ase 2. eae 10 
Burr DrjGeBs—Oak Grove; Klint AV chien ieee eee 8 
Butler,7, Dr-Geo. > F.——AlmalSanatoritmer ee ean. se eee 12 
Caples, Dro Bo Mi——Watkesha, | Wise 1. se, eee a fas re eee ite 
Channing, Dr. Walter—Private Hospital for Mental Diseases...... IO 
Coe, Dr. Henry W. and Gillespie, Robert L—Mt Tabor Sanitarium 14 
CookDrG RO xford s@hio ae ® se es pee ete eee 22 
Crothers; Dr. "D. D-—=Walnit Modpe -blospitalae ats oes ee ee 14 
Cukier, X.—Hydriatic Institute....... be Unt MM Zo fe SO ae 21 
Dewey. D? Rim W duwatosariw iscua see eee ee oie) pee 8 
Dold.2Dr.. Wat. —_RivereCresthe an ate a sen eee ree te ees Il 
Dunham). Dri'S)A—Buttalous ig, re, aoe Renee ater eters 21 
Edes, Dr; (Robert? T.—-W arren Chambers, /Bostonmeiasice, | nee 13 
Ferguson, Drie James (hrancis—halkirk eae een eee et eee 9 
Fitch, .Dr. Av —Cedarwild ‘sanitaritinis, ere ee ee 23 








DEAR DOCTOR :— 

WHEN YOU HAVE A PATTENT REQUIRING SPECIAL TREAT- 
MENT, IT WILL BE TO YOUR INTEREST TO INVESTIGATE 
THE MANY ADVANTAGES OFFERED BY 


Ghe Alma Springs 


Sanitarium  wemcax 


Our Departments of 


Hydrotherapy 
wv Electrotherapy 
Mechanotherapy 
arp Physical Culture 


are under the direct management of the Medical Staff and complete in 
every detail. Our laboratories are in charge of competent men. Our 
ALMO-BROMO and ALMARIAN mineral waters are remarkably efficient 
in diseases of the kidneys, bladder, liver, stomach and in rheumatism and 
certain nervous diseases. 
Write for booklet and further information. 
Ghe ALMA SPRINGS SANITARIUM, Alma, Mich. 
GEORGE F. BUTLER, M.D., Medical Supt. 





XII 





DIRECTORY FOR PRIVATE INSTITUTIONS. 


“Health by Right Livin” || Famous Health Resort 


On Delaware and Lackawanna Railway; 
nine hours’ ride from New York; 
two hours from Buffalo. 


NO INSANE OR DRUG HABIT 
CASES RECEIVED. 


Fireproof building. All modern conveniences, 
delightful mountain and valley scenery and drives. 
Golf, Tennis, Croquet, etc. Pure spring water. 
Especially adapted for bladder i tp a dis- 








CUISINE OF THE VERY BEST—Hydrother- 
massage, electricity, Swedish 


apy, dietary, 
he he Jackson Health Resort movements, Nauheim baths, Sprague’s hot air 
baker, Moliere thermo-electric bath, rest cure, 
E Jac Livingston Co., For literature and information address, 


J. ARTHUR JACKSON, M.D., Secy. and Mgr. 





Waukesha Springs Sanitarium 
For the care and treatment of 


NERVOUS AND MENTAL DISEASES 


New, absolutely fireproof building. 


BYRON M. CAPLES, M.D., Superintendent, Waukesha, Wis. 





S Gl Ss - A health resort of the highest class. 
The most complete and modern bathing 
he en prings establishment in America, under skilled 
medical supervision. All approved forms of Hydrotherapy, including Hot Neptune 
Brine Baths and Carbonated Brine Baths (the Schott treatment) as given at the cele 
brated Nauheim Baths for Gout, Rheumatism, Neuralgia, Sciatica, Disases of the 
Nervous System, and of the Heart and Kidney. Also Electricity in every form, Mas- 
sage, Swedish Movements, Turkish and Russian Baths. Valuable Mineral Springs 
Muriated, Alkaline, Chalybeate, Iodo-Bromated and _ Brine, especially  effica- 
cious in Disorders of Digestion, Gouty Conditions, Diabetes, Anemia, Nervous Diseas- 
es and Chronic Affections of the Kidney. Climate Mild, Dry and Equable. No Mala 
ria. No Hay Fever. Location overlooks thirty miles of Seneca Lake. Sixty acres of 
private park. Golf links, tennis courts, bowling alleys, etc. All the appointments of 
first-class hotel. No insane or other objectionable cases received. Correspondence with 
physicians solicited. Send for illustrat- 
ed book. Wm. E. Letfingwell, President, Watkins Glen, N. We 
Watkins, N. Y. 





Greenmont-on-the-Hudson tentat pseases. 


v RALPH LYMAN PARSONS, M.D., RALPH WAIT PARSONS, M.D. 


City Office: oe 
16 East 43d St., Mondays and Fridays Ossining ; N. Ve 


from 3.30 to 5.30 p.m. 
Long D stance Telephonone 162L. Ossining N, Y, 


Dr. ROBERT T. EDES, 


Warren Chambers, 419 Boylston St. BOSTON, 
will receive medical cases (adults or children), not infectious 
and not insane, at his house in Reading, Massachusetts. 


XIII 





DIRECTORY FOR PRIVATE INSTITUTIONS. 


<= yy WALNUT LODGE HOSPITAL 





Hartford, Conn, 
Elegantly situated in the suburbs of 
the city, with every appointment for 
the treatment of this class of cases, 
including Turkish, Roman, Saline and 
Filectric Baths. Each one comes un- 
der the direct personal care of the phy- 
sician, and experience shows that a 
large proportion are curable. Applica- 
tions and all inquiries should be ad- 
dressed to 
T. D. Crothers, M. D., 

Supt. Walnut Lodge, Hartford. Conn. 
New York Office, 115 W. 49th St., the 

first Tuesday of every month from 

aT ebO ©) =p.) s 
ALCOHOL, OPIUM, AND OTHER DRUG INEBRIATES 


Crest View Sanitarium 
GREENWICH, CONN. 


A quiet, refined home for the treatment of chronic 
nervous diseases. No violent cases admitted. In the 
midst of beautiful scenery, 28 miles from New York. 


H. M. Hitchcock, M.D. 


DR. SPRAGUE’S SANATORIUM 


HIGH OAKS, LEXINGTON, KENTUCKY 


Cases of Nervous and Mental Diseases and Liquor and Drug Addictions Received 

Many years’ experience in treating these cases, a complete therapeutic equip- 
ment, and skilled nursing in’ beautiful home-like surroundings have given excel- 
lent results. The buildings, a large brick house and three cottages, are in the 
center of twelve acres of well-shaded grounds. Number limited to 19. Rates 
from $60 a-month upward. Long-distance telephone. 


Address Gro. P. SpracugE, M.D., Lexington, Ky. 


Mt. Tabor “*"4s Sanitarium — Nervous. Drug 


Ease”’ and Mental Diseases 


Cases classified and segregated. The mild,equable humid climate is often of vaive 
the relief of Nervous states, notably of the insomnia of neurasthenia. ~ 


Office, The Marquam, 
cibeht kta ds SSAC “ RELA CNRS Medical Directors 


MAPLEWOOD DR. NORBURY’S SANATORIUM 
For Nervous and Mental Diseases 
Will receive for private treatment, cases of mental and 
nervous disease and select habit cases. Modern facilities 
aoe Bae ie desirable location. Number of patients 
imited. 


CONSULTING STAFF: Frank R. Fry, M.D., St. Louis. C.G. Chaddoek, M.D., St. Louis. 
Hugh T. Patrick, M.D., Chicago 


FRANK PARSONS NORBURY, M.D., 420 State St., JACKSONVILLE, ILL. 


























Dr. Broughton’s Sanitarium 


ROCKFORD, ILL. 
For the care of Opium and other Drug Addictions, in- 
cluding Alcohol and special nervous cases. 


Address: R. BROUGHTON, M.D., 
2007 S. Main St., Rockford, III 


XIV 









DIRECTORY FOR PRIVATE INSTITUTIONS. 





A PRIVATE HOME FOR NERVOUS INVYALIDS 


A new and elegant home Sanitarium built expressly for 
the accommodation and treatment of persons suffering 
from the various forms of nervous and mental diseases such 
as neurasthenia, hysteria, melancholia, chorea, migraine, 
locomotor ataxia, aphasia, the difterent varieties of par- 
alysis, together with incipient brain diseases. 

_The building is located in the most aristocratic residen- 
tial portion of Kansas City, Missouri, immediately facing 
Troost Park and within easy access to electric and cable 
cars to all parts of the city, besides being furnished with 
all modern conveniences and them >stapproved medical 
appliances for the successf .1 care and treatment of nervous 
and mental disease. 

Reference: Any member of the regular profession in the 
Central States. Strictly Ethical Institution. 

For further particulars apply to 


JOHN PUNTON, M.D., Resident Physician, 
3001 Lydia Ave., Kansas City, Mo. 
Office Rooms, 530, 531, 532 and 5383 Altman Bidg. 
(No noisy or violent patients received.) 





lighland Spring 
Sanatorium ___ 


Among the Hills of New Hampshire, one hour’s 
lefrom Boston. New buildings, ideal surround- 
modern treatment for all kinds of medical 
not infectious nor violently insane. Number 
imited. For terms and particulars address, 


Robt. T. Edes, M.D., Consulting Physician. 
Warren Chambers, Boston, Mass. 


Albert E. Brownrigg, M.D., Supt. and 
Treas., Nashua, N. H. 


MISS MURDEN’S HOME 


Miss Murden has reopened her private house for the ‘reat- 
ment of nervous diseases by means of the rest-cure, electricity, 


water treatment, massage, etc. 


REFERENCES: 

NEW YORK—Dr. Pearce Bailey, Dr. J. Arthur Booth, Dr. Walter Lester Carr, 
Dr. Wm. H. Caswell, Dr. Margaret Cleaves, Dr. Joseph ‘Collins, Dr. Chas. L. Dana, 
Dr. Joseph Fraenkel, Dr. Virgil P. Gibney, Dr. William Hirsch, Dr. Geo. W. Jacoby, 
Dr. Edward G. Janeway, Dr. Smith Ely Jelliffe, Dr. Geo. Roe Lockwood, Dr. Fred- 
erick Peterson, Dr. Alex. A. Smith, Dr. M. Allen Starr, Dr. John 8S. Thatcher, Dr. 
W. Gilman Thompson, Dr. Henry F. Walker. 

PHILADELPHIA—Dr. F. X. Dercum, Dr. Chas. K. Mills, Dr. S. Weir Mitchell, 
Dr. Wharton Sinkler, Dr. J. Madison Taylor. 


68 West 38th Street, New York. Tel. 6816 38th St. 











SCIENTIFIC TRAINING FOR.... 


Stammeriné and Other Speech Defects 


MISS ADA LOCKWOOD 
434 Fifth Avenue, New York 


REFERENcES :—Dr. G. Hudson Makuen, of Philadelphia, Pa.; Dr. Bryson 
D. Delavan, Dr. Frederick Peterson, Dr. Frank E. Miller, Dr. Joseph Col- 
lins, Dr. James E. Newcomb, Dr. Smith Ely Jelliffe, Dr. M. Allen Starr, of 
New York City. 
XV 








Directory for Private Institutions “°"frresi 














Fletcher)’ Dre Wie Bio's 2505 ecw ck ee erent eave 18, ‘ 
i‘oster, Dr) C. A:—Grandview Sanitarium’ 4) 60.5; - oe eee oO %, 
Gorton, Dr. Eliot—Fair Oaks..... BOR. ACHPT ee. 3 bac See Ra See ais ts EP 7 
Groszimann spl) reds shen teecet a EE ane SUA rie shy ray See Lad os eee B 
Gundry, Dr. Richard F.—The Richard Gundry Home........... ZO é 
Hallock; Dp) FL. K.~-Cromwell Hates ei Ree a 
Harrison Dre .D.) A—Breezehurst ele ee MP eal Rox: A as : 
fttcheock, Dr.tHs Me=Crest WV lew sallitatiniass.):. oil. pent eee 
Jackson, Dr. J. Arthur—The Jackson Sanitorium.... ........... 13 
Kelloge: Dr. “Theo. Heck. aiie acter atc ere eee oo) a Ps Cn ava IO | 
Kindred, Dr. Ji ji—Astoriagiay [ire eee. . eesti # road f 
Leffingwell, Wm. E—The Glen Springs.................. BPM 3 1c ‘ 
Lockwood, Miss Ada........ Se PALE Mit cc oats 2 ah heen is | 
McFarland, Dr. D. W.—Hall-Brooke............ ate Poa La a 
Moody, Dr.\Ge H:—San Antonioty 1. asses) kee 26 
Murden; (Miss) Die ei tae agian een ee arte 6.~ s' afebortete ORE eeice 1 
Norbury, Dr. Frank Parsons—Maplewood.......... o avabel ebay aera 14 
Norton Dor (rian spetere thas saeeer tiers ee stb CRT at ee | 
Oppenheimer Institute....... Satie aos AAs pS RIO OME ES ob '¢ =: Leh cg ats \eaee see amaze . 
Parsons, Dr. Ralph W.—Greenmont-on-the-Hudson......... eae 4: ; 
(CONTINUED ON PAGE Xx.) ; 
] 
, 
: 


Ps 9 





“ DOCTOR BOND'S HOUSE x2 ex 


(Under license of the State of New York) 


Under the direct supervision of Dr. George F. M. Bond, former Acting Medical Superintendent New York City Asylum; former 
Assistant Medical Superintendent New York City Asylum; former Assistant Physician Bloomingdale Asylum; former 
Assistant Physician Utica State Asylum. 


Thirty minutes from New York City, overlooking the Hudson River and Palisades. A house 
strictly select, for the scientific treatment of selected cases of Mental and Nervous Diseases, and cases of 
Habit; perfectly appointed, absolutely free from any institution appearance or atmosphere, with 
complete hydrotherapeutic installation, sun parlor, first-class cuisine and exceptionally beautiful 
grounds and surroundings. Rooms single and en-suite. Number of patients limited to nine. 

For particulars and descriptive booklet address, 


DR. GEORGE F. M. BOND, 960 North Broadway, Yonkers, N. Y. 


NEw York OFFICE, 27 EAST 44TH STREET. TELEPHONE 883 YONKERS 
MONDAYS AND FRIDAYS FROM 3 TO 4 P.M. Inspection is most cordially invited 


XVI 


4 


ge. EPS 


ies 


DIRECTORY FOR PRIVATE INSTITUTIONS. 
FAIR OAKS 


SUMMIT, N. J. 3 


For the care and treat- 
ment of nervous dis- 
eases, selected cases of 
mental alienation, drug 
and alcohol] addictions. 
Voluntary cases prefer- 
red. Twenty miles from 
and the highest point 
within thirty miles of 
New York City. The 
institution is well equip- 
ped with modern ap- 
paratus. 72 trains daily 
to and from New York. 
The nervous invalid 
will find Fair Oaks an 
ideal place for rest and 
recuperation. address, 

Dr. Eliot Gorton 
(for fourteen years First 
Assistant Physician to 
the New Jersey State 
Hospital at Morris 
Plains) Summit, N.J. 

L. D. Phone 143 
New York City address 

Dr. T. P. Prout 

204 W.55th Street 
Tel. 1032r Columbus 


# DR. PETTEY’S RETREAT 3 











m Wy 
in FOR THE TREATMENT OF 4 
dh VA 
@ ALCOHOL AND DRUG ADDICTIONS wy 
fi ty 
4 Methods employed render the morphine addiction the most iy 
4} certainly and readily curable of all the chronic ailments. ei 


Qa 


ao E. PETTEY, M. D., 958 Davie Ave. Memphis, Tenn. 
. A 








THE CINCINNATI SANITARIUM 


A Private Hospital for Mental and Nervous Disorders, Opium Habit, Inebriety, Etc, 

Thirty years successful operation. ‘Thoroughly rebuilt, remodeled, enlarged and 
refurnished. Proprietary interests strictly non-professional. One hundred and fifty 
patients admitted annually. Detach:d apartments for nervous invalids, opium habit, 
inebriety, etc. Location retired and salubrious. Grounds extensive. Surroundings 
delightful. Appliances complete. Charges reasonable. Electric cars from Fountain 
Square, Cincinnati, to Sanitarium entrance. Long Distance Telephone, Park 135 

Dr. F. W. LANGDON, Medical Director; Dr. B. A. WILLIAMS, Senior Resident 
Physician. For particulars address The Cincinnati Sanitarium 


College Hill Station, K Cincinnati, Ohio. 
XVII 


DIRECTORY FOR PRIVATE INSTITUTIONS. 





Long Island Home Limited 


Dr. O. J. Wilsey, Physician in charge 
Two Assistant Physicans—a man and a woman 


For Mental and Nervous Diseases, Alcohol and Drug Habitues 
Voluntary Patients Received 


Special Features—Horses and carriages for the free use of patients; orchestra 
and frequent entertainments, Turkish baths, bowling alleys and gymnasium, croquet, 
ennis, billiards and pool; yachting on the Great South Bay. 

Rates— Minimum, $10 per week; special nurse $25; cottage from $50 up. 

Our three cottages offer superior accommodations. 

Monday, Wednesday and Friday from 12-1 p.m., No. 143 Hast 387th St., New York 


ty. 
Telephone Number, 2,955 38th St. Te ephone Number at the Home, 2 M, Amityville. 


at Amityville, Long Island, N. Y. 
On the Great South Bay 





DR. BARNES SANITARIUM 


“GREY TOWERS” 


STAMFORD, CONN. 
ni (50 minutes from New York City.) 


FOR MENTAL AND NERVOUS DISEASES 


With a separate, detached department for ALCOHOLIC and DRUG 
HABITUES. Under management of experienced competent alienists. Splen- 
did location overlooking the Sound and City. Rates reasonable for excellent 
accommodation. Alcoholic and drug habitués can commit themselves, or be 
legally committed, for one year or less. For terms and information, apply to 


Telephone: 104-4 Stamford. F. H. BARNES, M. D., Stamford, Conn. 








KNICKERBOCKER HALL 


COLLEGE POINT, NEW YORK CITY 
TELEPHONE 63, COLLEGE POINT 


A pribale Santtorium for the care and treatment of neurasthenia, neuro- 
tic disorders, mild mental diseases, inebriety, drug addiction and those 
requiring recuperation and rest. 

Situated upon the shore of Flushing Bay, amid a beautiful and well- 
shaded park, it commands an unsurpassed view of the East River, Long Is- 
land Sound, New York City, and the surrounding country. It is easily acces- 
sible from Manhattan by carriage, via East 99th St. ferry; and by railroad 
or trolley from East 34th St. From Brooklyn it can be reached by either car- 
riage or trolley. 

New York Office, 306 West 55th Seer 10.30 to 11.30 A.M. 


TELEPHONE, 1697 COLUMBUS 
For terms, etc., address, 


WILLIAM E. SYLVESTER, M.D., Medical Director 


XVIII 








DIRECTORY EOR PRIVATE INSTITUTIONS. 





Safe Geneva 
Sanitaria 


LAKE GENEVA, wis. 


DR. WM. G. STEARNS, 
Medical Superintendent. 


CHICAGO OFFICE, 
92 State Street 





20 Acres on Lake Shore 60 Acres of Oak Woods 
LAKESIDE 


For general and nervous diseases. Two homes with complete modern sanitarium equipment. 
No Mental Cases taken. 


OAKWOOD 


Acute cases received for diagnosis and treatment. Convalescing cases re-educated. Rates are 
as low as the most efficient treatment and the best trained nursing will permit. 











OAK LEIGH 


Educational Sanitarium 











For Nervous Diseases 
and Mental Affection in 
Children 


LAKE GENEVA, WIS. 


Dr. Mary E. Pocur, MEpicat Supt., 
CHICAGO OFFICE, 92 STATE ST., 
Hours, 10 to 1 Saturdays Telephone Central 4900 














XIX 





Directory for Private Institutions “7s” 








Perry, Dr. J. Frank—Blue Hills Sanitarium.......... boi A AS A de: 
Petters il) ream dete s S05 oe fitenet gee clears Fae eae Soe Pst curate ety 
Poprne; Dr lary B--Oalk Leigh ois, cies a hci. eee ree Pon Er Ke 
Prot, Dr oe Ps—Pair: Oaks ole neew anes cy eae Ce a ee 17 
Punton, Dr. John—Kansas City, Mo........... BB EPE es (a Ny res PUES 
Rigessr. Geo. bh ——Rives: Cotta ren eeameae rien ss ee apie sek as iy 
Rodebatrehy Dror As Columbus, Oniow ce. PS Gb oan ee) 
Russell, Dr. Fred. W.—Highlands........... | Oe BAA Simba el he 
Ruland. Ore P.D)..--W estport. Sanita rit meet cis fice 6 ape Jens ieee LG 
Savarese LT — (VMAS UN 4 tpt mis tohe ure he uetpteha betatate hs io! lo boc hota suis teen ees 
Sears, Dr. C. A.—Grand View..... | te het Cea anaco ma BA hides mis iy 
Sheets; (J.0(C.——Cincinnati Sanitaritim , yee vete tc 8 edit SRE 
Skinner, Dr. C. E—Newhope Sanitarium..... 50) RAPP Saya nie, 17H 
spracue, G. P-—Hich Oaks Sanitarium wim ds nuts ies ss eT oes Ai: 14 
Stearns, Dr. W. G.—Lake Geneva....... SERED Fs a5! tute tame 19 
Stedman,» Dr."Henry\Ri-—Bournewood? yu eee = he cere ee 9 
steme; Dr Hil Norwaysiag ite an PA PS i Se wy 26 
Sylvesters.Dro WiC olleo ai Pion boa. er mene ia clea Gueteeae 18 
Watson, Dre We L.—~Pelham.Manorecice ye ie ance eens Anode 
Wilsey,. Dr. ©." ] Lone Usland * Homes, cy sem umn: «olen es 18 
Yawger! N.S -Burn ) Braey nar ae re opment 1a caren IO 





che Richard Gundry Home 


HARLEM LODGE, Established 1891 


A weil equipped Sanitarium 
for the treatment of nervous 
and mental diseases, selected 
eases of alcoholic and opium 
habitues, and the various di- 
seases requiring removal from 
the invironments of home. 

For rates, address 


Dr. Richard F, Gundry 





Catonsville, Baltimore County, Maryland. 
Long Distance Telephone 94 Catonsville 


REFERENCES 
Dr. Landon B. Edwards, Richmond, Va. Dr. Henry M. Hurd, Baltimore, Md. 
Dr. Geo. J. Preston, Baltimore, Md. Dr. Wm. F. Drewry, Petersburg, Va. . 
Dr. Howard A. Kelly, Baltimore, Md. Dr. P. A. Murphy, Morganton, N. C. 
Dr. J. Allison Hodges, Richmond, Va. Dr. Francis T. Miles, Baltimore, Mé 


Dr. William Osler, Baltim»re, Md. % 


% 


XX 








| 





DIRECTORY FOR PRIVATE INSTITUTIONS. 


Dear Doctors:-When tonic, stimulating effect 
is indicated, no doubt Hydrotherapy is most 
useful. In cases where elimination of uric 
acid is desired, Hot Air Treatment and local 
scotch Douche will prove beneficial. 

You prescribe the best modern method of HY-= 
DROTHERAPY for your patient, by referring him 
to the HYDRIATIC INSTITUTE (The Nevada, 2,025 
Broadway, N. Y.)e Yours very truly, 

X. CUKIER. 


HYDRIATRIC INSTITUTE 


635 PARK AVE., Cor. E. 66th Street 


TELEPHONE 1960 PLAZA. 


treats patients sent by physicians for 


HYDROTHERAPY | 


BERTHA KRUVER ) pLoprietors 
JOSEPH TAUSZIK ( p 


PE VV iia 


PRIVATE SANITARIUM 


NEW HAVEN, CONN. 


QR THE TREATMENT, by Dry Super-heated Air, Electricity, Mechanical Vibration, rugs, 
EF ete., of Acute and Chronic Rheumatism, Arthritis Deformans, Gout, Sprains, Myositis, Myal- 

gia Neuritis, Neuralgia. Varicose Ulcers, Uric Acid Diathesis, and other Disturbances of 
Metabolism, Septicaemia and other General and Loca: Infections, Nervous Exhaustion and Diseases 
of the Peripheral Nervous System, Diseases of Female Pelvic Organs, Acute and Chronic Pleuritis, 
Peritonitis, and Nephritis, Pneumonia, Cancer, and all Non-contagious Pathological Conditions 
wherein the above-mentioned therapeutical agents are beneficial. 


Complete Modern Facilities for Surgical Operations, X-Ray Work, Microscopical 


and Chemical Diagnosis. 


The X-Ray and other laboratory facilities have been placed at the disposal of physicians 
throughout the State, and reports upon specimens submitted by them for chemical or bacteriological 
examination can usually be in their possession within twenty-four hours. 


Clarence Edward Skinner, M.D., LL.D., Physician in charge, 67 Grove St. 








CONSULTATION HOURS: 1lto12A.M., AND BY APPOINTMENT. TELEPHONE CONNECTION 





THE GROSZMANN SCHOOL 


For Nervous and Atypical Children 
“PINEHURST” 


WASHINGTON HEIGHTS 
Corner Fort Washington Avenue and Depot Lane, Manhattan Borough, 
New York CIty 

THE GROSZMANN SCHOOL has been established for the benefit of a small 
number of exceptional children whose individual needs require physical, mental 
and moral treatment by experts. 
The Members of the Medical Profession are requested to write for circular giving 
detailed information. Address: 


MAXIMILIAN P. E. GROSZMANN, Ph.D., Director 


Fort WASHINGTON AVE. AND Depot LANE, NEw York CIty 


XXI 








DIRECTORY FOR PRIVATE INSTITUTIONS. 


THE PINES 


A Private Sanitarium for 
Nervous Disorders and 
Morphine Habitues 
FOR WOMEN ONLY 


Insane not . admitted. 
Every facility for proper 
treatment. Careful super- 
vision at all times. 

Retired, accessible; sur- 
roundings beautiful. Mod- 
ern in all its appoint- 
ments, lighted by electri- 
city and heated by steam. 
Sanitation perfect. Send 
for descriptive circular. a 

Under the same control 
and Medical Management 
as the Oxford Retreat. 


~ OXFORD 
RETREAT 


A Private Hospital for the 
Treatment of 


Insanity, Nervous Disorders, 
Inebriety and Opium 


Habit 
FOR MEN AND WOMEN 








Facilities and advan- 
tages are unsurpassed for 
the proper care and treat- — 
ment of all forms of the 
above named disorders. 
Careful attention is given 
to the proper classification 
of patients. Average one 
attendant to every four 
patients. Supervision at 
all hours. Every needed 
convenience and any ac- 
commodation that may be 
desired. Retired and 
homelike. Site elevated, 
beautiful and salubrious. 
39 miles from Cincinnati, 
84 miles from Indianapo- — 
lis, 8 trains daily. Terms — 
moderate. For references, 
terms, etc., address 7 


G. F. COOK, M:D., 


Physician in Charge > 


OXFORD, Butler Co., 
OHIO 


XXII ( 














DIRECTORY FOR PRIVATE INSTITUTIONS. 


EXERCISE « 4ACLVE_AND_PASSIVE 
iwi 


AS A THERAPEUTIC AGENT 
DR. SAVAGE GYMNASIUM 


is the highest class and most scientifically conducted establishment in the 
city for the development of the human body. , 

Dr. Watson L. SavacE is prepared to co-operate with physicians hav- 
ing patients who need personally directed and scientifically administered 
exercise. 

In the following groups this has proved most beneficial: MUSCULAR 
DEFORMITIES, ERRORS OF NUTRITION, CHRONIC CONSTIPA- 
TION, NERVOUS CONDITIONS, GENERAL DEBILITY, or ANY 
CHRONIC CONDITION not yielding to other forms of treatment. 

Physicians will please remember that the department for special cases 
needing individual attention is entirely separate from the general gym- 
nasium. The patients are Nor exercised in classes, as every case is dif- 
ferent and each has a prescribed course. 


OBESITY A SPECIALTY 
TREATED SUCCESSFULLY without drugs. 


Special classes for business men and business women. 
Boys’ and Girls’ Classes. 

We issue no circular of the medical work. 

Circulars of the Gymnasium on application. 


Dr. Savage Physical Development Institute, Lid., 
308 & 310 West soth Street. NEW YORK. 
Telephone, No. 17 Columbus. 








(EDARWILD ie Pa ls Santa 


















APRIVATEHOSPITAL and IDEAL RESORT 


All classes of patients admitted. Sep- 
arate departments for the victims of 
Alcohol, Opium, Cocaine, and other 
Drug Habits. 


All desire for Liquors or Baneful 
Drugs speedily overcome with- 
out hardship or suffering 


No Gold or Other Cures (?); no 
Secret Remedies used; the most 
thorough investigation is cordially in- 
vited. 

A well-equipped Gymnasium, with 
competent Instructors and Masseurs, 
for the administration of purely hy- 
gienic treatment; also a Ten Plate 
Static Electrical Machine, with X-ray, 
and all the various attachments. 





A Sanitarium for invalids and 
neurasthenics. Mild cases of in- 
Sanity treated. Violent patients 


not desired. 





Location Convenient 
Grounds Commodious 
Terms Reasonable 


rs 


ADDRESS: 


Alice Lyon Fitch, M.D. 
DARIEN, CONN. 





Licensed by the Governor and Council 





J. Frank Perry, M.D., Supt, 





DIRECTORY FOR PRIVATE INSTITUTIONS. 


New York, 131-133 West 45th Street, 
Philadelphia, 841 North Broad Street, 
Pittsburgh, 110 W. North Ave., Allegheny, 
Detroit, Mich., 25 Piquette Avenue, 
Atlantic City, N. J., 2901 Pacific Avenue, 
Waterbury, Conn., 58 Center Street, 
Saratoga Springs, N. Y., 485 Broadway. 


Institutes for the treatment of alco- 
holic and drug diseases have been 
established at the above addresses. 
Send your patients to the nearest 
institute. For printed matter and 
general information write to the 
executive offices of the Oppenheimer 
Institute, 170 Broadway, New York. 


XXIV 


a 


DIRECTORY FOR PRIVATE INSTITUTIONS. 





Dr. D. H. Harrison’s Private Sanitarium 
Breezehurst Terrace. Whitestone, L.I., N- Y. City 


FOR MENTAL and NERVOUS DISEASES, Alcoholic’s, 
Narcotic Habitues’ Etc. 


Breezehurst Terrace is within easy driving distance of Manhattan and Brooklyn. 
N. Y. Office, 110 57th St., Telephone 260 Columbus. Brooklyn 
Office, 31 Sidney Place. Phone, 3017 Main. 
Sanitarium Telephone, 46-f-Flushing 
(LICENSED ) 


HOMIE PLAN D. A. HARRISON, Physician in Charge. 
WHITESTONE, L.I., N.Y. 





LOMA LINDA INSTITUTE 


“THE RETREAT FOR NERVOUS PERSONS” 


A select, quiet place, for a limited number, within twenty-eight minutes of 


Grand Central Station, New York & New Haven R. R. Select drug cases re- 


ceived. No Insane or other objectionable cases received. All modern. means, 
rest cure, electricity, massage, etc. For terms and particulars, address 


Dr. W. S. Watson, Mar., Pelham, N. Y., Box 89. 





DR. DUNHAM’S HOME Fer Selected Nervous Patients 


NO. 1392 AMHERST ST. 


The environment and surroundings are of the country sort. It is readily 
reached by the Park Zoo street car. Patients will be given the influences of 
the home while they may remain under the treatment of their own family 
physician. 


Address all communications to my office. 


* *# DR. SYDNEY A. DUNHAM mH 


239 DELAWARE AVENUE, BUFFALO, N. Y¥ 


XXV 


DIRECTORY FOR PRIVATE INSTITUTIONS. 


«“ NORWAYS” 


Dr. STERNE’S SANATORIUM 
FOR NERVOUS DISEASES 


1820 Gast Centh Street (facing Mloodruff Park) 
INDIHNHpOLIS, IND. 









A thoroughly modern, well-equipped institution for the 
treatment of nervous and other constitutional diseases, the vari- 
ous drug habits and alcoholism, and mental maladies. Separate 
building for the latter. Beautiful location and extensive 
grounds. 








For information apply to 


DroAL BER ve a swee RN 














DR. MOODY’S SANITARIUM 


San Antonio, Texas 


For the care and treatment of Nervous Diseases, selected cases of Mental 
Disease, Drug and Alcohol Addictions, and nervous invalids needing rest and re- 
cuperation. 

An elegant two-story brick building with porches and galleries up and down 
stairs. The interior is of excellent material and design, admitting abundance of 
sunlight and ventilation, elegantly furnished, electric lights, hot and cold water 
and excellent plumbing throughout. 

Modern Hydrotherapeutic, Electrotherapeutic and Gymnastic equipments. Lo- 
cation ideal, being upon an elevation overlooking the entire city, which has a 
population of 60,000. Grounds capacious, well shaded and well drained. Quiet 
and secluded, yet convenient to street car and to city. Within five minutes’ walk 
of Brackenridge Park covering 200 acres, with its lovely walks, drives, shades, 
sunshine and flowers. 

In San Antonio’s dry, healthful climate the opportunities during the entire 
year, for exercise, pure fresh air and sunshine are unsurpassed, and in these, all 
are encouraged by attractive outdoor games, by walks and by drives through the 
city and country. 

Address, G. H. MOODY, M.D. (for six years Assistant Physician to State 
Asylums at San Antonio and Austin, Texas), 315 Brackenridge Avenue, San An- 
tonio, Texas. 


XXXVI 


= Satyria“ 


The Ideal Genito-Urinary Tonic and Nerve Reconstituent 


A palatable combination of the active constituents of Muira-puama, Saw Palmetto, 
False Bitter Sweet, Phosphorus and Aromatics. 


Indicated in Prostatic Troubles, Cystitis, Urethritis, Sexual Debility and Impotency, 
DOSE—One teaspoonful or one tablet four times a day after meals. 
Full size bottle to physicians who will pay express charges. 


Satyria Chemical Co., St. Louis, Mo., U. S. A. 


















Mono 
InMalacial Fevers 


‘belives: as a stimulanf-jas ,welt as an. Antipuretic 
BO Analges i CX thos differing tin other Coal-tar 


__ (products.~ It has been used ‘jin the relief of rheumatism and neuralgic pains, and in the treatment of the sequetze 
of alcoholic excess) AMMONOL is also prepared in the form of salicylate, bromide, and lithiate. The pres- 
‘ence of Ammonia, in a more or less free state, gives it additional properties as an expectorant, diuretic, and 
corrective of hyperacidity—London Lancet. 


em, Che, Stimulant 





| 


J limmonol is one of the derivatives of Coal-tar, and differs from the numerous similar products in that it contains Ammonia in ackywe? 
~~ form = As a result of this, AMMONOL poséesses marked stimulating and expectorant properties. The well-known, 
cardiac depression induced by other Antipyretics has frequently prohibited their use in otherwise suitable cases. 

introduction of a similar drug, possessed of stimulating properties, is an event of much importance. sate 
possesses marked anti-neuralgic properties, and it is claimed to be especially useful in cases of dysmenorrhcea,—TZe. 
| 4 Medical Magazine, London, 


Che Ammonol Chemical 


MANUFACTURING CHEMISTS. NEW YORK, U.S.A. 
XXVII. 











Send for Ammonol 
Excerpta 248 page 
/ pamphler. 






Ammonol may be 
obtained fromall 
Leading Druagists 





eee eee 
Sy, mon 


BROMIDIA ., 


REST-MAKER FOR RESTLESS- 
NESS. IT CIVES CONSISTENT 
NERVE REST. IT DOES NOT 
LESSEN THE SUPPLY OF BLOOD 
TO ANY ORCAN OF THE ECON- 
OMY, AS THE BROMIDES ARE 
SURE TO DO. IT ISAHYPNOTIC. 


MULA:--15 rains each Chioral Hydrate ECTHOL 
rand, Bu Fas rifled Bra “Ext Carinabis ‘i 5 etaln tODIA 
Hyoscyamus te each fld. drachm PAPINE 


BATTLE & CO, cotenitos, ST.LOUIS, Mo., U.S.A. 





SAFEST 
CYOMOAI! pypnotic 


pareve. ao aor n HOT liquid, s milk wit 
befits re a Abaitaterte i) 





Prompt, Reliable; produces NATURAL sleep 
without untoward effects, and therefore 


SUPERIOR TO ALL OTHER HYPNOTICS. 
Full clinical reports to Physicians. MIE R CK @ CO., New York. 


i Ta RNA GBIN “stint tiegr 





MERCR’s (Tannin album. exsic.) Odorless entire intestines” 


MANUAL, 
Page 89. DIARRHEAS and tasteless. 
£ Clinical Reports on Request. MERCK & CcCO., New York 


XXVIII 


~ ARISTOCHIN 


Quinine Divested of its Disadvantages, 


CITARIN HEDONAL 


The Anti-Lithemic. The Promoter of Natural Sleep. 


THEOCIN ana AGURIN 


The Most Powerful Diuretics. 


PROTARGOL HELMITOL 


The Best Substitute for Silver Nitrate. The Urinary Antiseptic, Analgesic. 


SAMPLES AND LITERATURE SUPPLIED BY 


FARBENFABRIKEN of ELBERFELD CO. 


NEW YORK. 40 STONE ST. 


P. O. BOX 2160. 


PEACOCK’S BROMIDES CHIONIA 
“ a Eure Form of Bromides. From Chionanthus Virginica. 
ach fluid drachm represents 15 grains Recestablishes portal circulation with- & 


of the combined C. P. Bromides of Potas- P f 
sium, Sodium, Calcium, Ammonium and out producing congestion. Invaluable in if 
all ailments due to hepatic torpor. 


Lithium, DOSE: 
One to three teaspoonfuls according to DOSE: Onetotwo teaspoonfuls three 
the amount of Bromides required. times a day. 
Full size sample to physicians who will pay express charges 
PEACOCK CHEMICAL CO., ST. Louis 


Has many Advantages over other : Meee Promotes Normal Digestion by encouraging the 


Heart Stimulants ag lye flow of Digestive Fluids 
A Most Successful Treatment fir 


Each pillet represents one one-hundredth of iam INDIGESTION 
a grain CAcTINA, the active proximate 


principle of CEREUS GRANDIFLORA. A palatable preparation of PANAX 


SGHINSENG in an aromatic essence 
Dose: mm €6DOSE: One to two teaspoonfuls three times a day 
One to four pillets three times a day 
A full size bottle, for trial, to phy- 
SAMPLES. MAILED TO PHYSICIANS ONLY a sicians who will pay express charges 





XXIX 


PHYSICIANS 





are prescribing 


Glyco-Heroin-(Smith) —_“0ths 
Phthisis 


Bronchitis 


Unexampled and perfect satisfaction —in— Portyssis 


with 


Laryngitis 
Pneumonia 


In therapeutic qualities and physical characteristics, 
Guiyco-HERorn-(SmiTH) presents the highest 


progress of Medicine in the treatment Asthma 


of these diseases. 


--NOTE— 


GLYCO-HEROIN (Smith) is supplied to the druggist in sixteen ounce 
dispensing bottles only. The quantity ordinarily prescribed by the physi- 
cian is two, three or four ounces. 


—DOSE— 


The adult dose of GLYCO-HEROIN (Smith) is one teaspoonful, repeated 
every two hours or at longer intervals as the case may require. 

Children of ten or more years, from a quarter to a half teaspoonful. 

Children of three years or more, five to ten drops. 


MARTIN H. SMITH CO., 
NEw YorK, N, Y. 





SOLE BRITISH AGENTS 


Sample and literature THOMAS CHRISTY & CO. 
free upon application. Lonpon, E. C. 


XXX 


“= 


POLK'S MEDICAL REGISTER 





AND ,DIRECTOR 
WAS ESTABLISHED IN 1886. 


Do Not Be Deceived By Imitators. 
See that the name R. L. POLK & CO. 


iS ON THE ORDER BEFORE YOU 
SIGN IT. 


POLN’S is the only complete Medical Directory. 


POLNH’S is the only Medical Directory having an 
index to all physicians in the United States. 


POLNH’S has stood the crucial test of time with 
increasing popularity. It thoroughly covers 


the field. 


R. L. POLK & €O., Publishers, 
fo) ie Lod in eee kon ey Ye 
SUBSCRIBE NOW. 











GO, DOUCHE FOR ATION OF 
YCO-THYMOLINE SAL CAVITIES: 











Baume Analgesique 
Bengue 





(ANALGESIC Bam, Dr. BENGUE). 
(Menthol, Salicylate of Methyl and 
Lanolin). 


For rheumatic pains, neuralgia, ‘ ONDI COS 
gout, rheumatoid arthritis fw Mansa tnandl iinet Nyaa oma tet 


sciatica, 
NEXCEY Bas Wobarer-t a ee 


and pains of tabes. 


. . . The remarkable success of the 


BAUME ANALGESIQUE BENGUE since ads Intestinal eS 

its recent introduction in America is . ay cena 

entirely due to its intrinsic merits, Stomach, 1° Waves ¢. 0 ae 

and to its prescription by the medi- . : ae 

cal profession. and Utero-Vaginal 

Sole Agents for the United States and | | ae 
Canada 


Thos. Leeming § Co., 
73 Warren Street - Rew York, h, Y. 


KRESS & OWEN COMPANY 


PBI 2h O) Oe WO). Man We 8 2 Oy NEW YORK 





XXXI 


Improves 
The General Health 


Hydroleine supplies the fat-food so neces- 
sary in the treatment of Consumption. 





A pale, tired, feverish, coughing, sweating, thin 
patient, who has continued to lose flesh on plain cod- 
liver oil and its various mucilaginous compounds 
(called emulsions) will straightway right-about and 
gain flesh on Hydroleine—a pancreatized, predigested 
pure Norwegian cod-liver oil. 


Hydroleine favors digestion and assimila- 
tion, increases flow of bile, checks the cough 
and steadily improves the general health. 


Sold by druggists generally. 
Samples The Charles N. Crittenton Co, 


free to 115-117 Fulton Street, New York 
physicians Sole Agents for the United States 





MELLIN’S 
FOOD 


One great cause of sleeplessness in 
infants is improper or insufficient food. 

An infant will usually sleep well after 
taking food that satisfies and nourishes. 

Mellin’s Food satisfies and nourishes; 
contains enough to satisfy and the kind 
to nourish. 

SAMPLES OF MELLIN’S FOOD TO PHYSICIANS FREE. 


MELLIN’S FOOD COMPANY, BOSTON, MASS. 
XXXII | 














NEURASTHENIA 


I$ ANOTHER OF THE NERVOUS AFFEGTIONS IN WHICH 


ARSENAURO 


HAS DEMONSTRATED ITS THERAPEVUTIG EFFICIENCY. 


>. 


ee, ae 
— 







¢ 


q 


PUSH DOSAGE TO POINT EVERY GENUINE ‘wal 

OF SATURATION IN EACH ois scar | ee 
INDIVIDUAL PATIENT 

% CHAS. ROOME PARMELE CO, 45 JOHN ST.,N.Y. 





In capsules, each of which contains 4% of a milli. V 
gramme of pure Colchicine dissolved in 20 centigrammes S&B 
of Methyl Salicylate. 

When physicians write for Colchi-.Sal, Colchicine 
Salicylate or Colchicine Methyl Salicylate, they mean the 
original @olchi-Sal capsules, the standard remedy 
in all arthritic manifestations. 


Substitutes do not give the same happy physiological 


Gout 


AND 


Rheumatism 


Golchi-Sal contains no dye, the green color is 
the natural tint of the product. 













Se 
Pcie 7 










Sole Agents for the United States: 
E. FOUGERA & CO., New York. 


RXXiii 





Publishers’ Announcements. 


The Advertising UVepartment will be.cenducted solely on ethieal prinei- 
ples. It is expected that our readers will aid the Journal by showing 
our advertisers the courtesy of at least noticing their various an- 
nouncementasa, er im more actively interesting themselves im the adver- 
tisers’ behalf. f 


CONCERNING PROcTOR’S THEATERS. 


The ease and facility with which the children of actors adapt 
themselves to the calling of their parents is rather strikingly illus- 
trated in several conspicuous cases among the members of F. F. 
Proctor’s big stock companies in his various theaters. Take 
pretty and clever Florence Reed, for example. The daughter of a 
famous comedian, she made her first footlight bow with scarcely 
any training, and yet, so naturally did acting come to her, that in 
less than two years she has gained the distinction of playing 
“comedy leads” in a Broadway theater—namely, Mr. Proctor’s 
Fifth Avenue. But Miss Reed is not the only example of in- 
herited histrionic ability in the Proctor ranks. There is that ex- 
ceedingly capable young character actor, Albert Roberts, son of 
famous. “‘Bob” Roberts, the comedian and.stage manager; there 
is clever young Louis Owen, son of that fine old Shakespearean 
actor, William I. Owen, once one of Augustin Daly’s best liked 
players; there is little Louis Bond, who, while thus far only seen 
in minor roles, gives frequent evidence that he has no little of the 
cleverness that for years has made a public favorite of his father, 
Frederic Bond, and finally, there is Gerald Griffin, the popular 
“character” man of the Proctor forces, who, although hardly a 
stripling, is not yet so old that he cannot point back with pride to 
his distinguished ancestor, Mack Griffin, the Irish tragedian, and 
the best Othello ever seen in Dublin. 

The magnitude of a big theatrical enterprise like the seven 
theaters comprising F’. F’. Proctor’s circuit, is well illustrated by — 
some facts and figures connected with those prosperous and popu- 
lar playhouses. In these seven theaters there are employed week- 
ly: Nearly 150 stage hands, property men, scene painters, assist- 
ants, etc.; over 100 musicians, Over 400 attendants “‘in front,” 
such as officers, ushers, matrons, porters, cleaners, superintend- 
ents, ticket sellers, etc.; 30 local managers, assistant managers, 
press agents, typewriters, telephone clerks, etc., and about 300 


Continued on xl 


XXXIV 


DO NOT FORGET 


| 
the importance of a remedy ut 








that: pacifies the irritable stomach 
and intestines. This attribute of 


GRAY’S“TONIC= | 


makes it the most valuable 

Summer tonic and reconstructive 

in malnutrition, nervous exhaustion § 
and general debility. | 




















| THE PURDUE FREDERICK CO., ‘ 
: ; No. 15 Murray Street, New York. 





Bibliography of American Neurology and Psychiatry. 


TOXICOLOGY 


Roserts, J. C. Autointoxication in Relation 
to Mental and Nervous Disease. Amer. 
Medicine, 4, 1902, p. 664. 

SANDBOoRN, H. E. Alcoholic Psychoses in 
Women. Amer. Journ. of Inebriety, 24, 1902, 
p. 452. 

CroTHERS, T. D. Studies in the Etiology of 
Inebriety. Kansas City Med. Record, 19, 
1902, p. 362. 

Extiot, S. B. Restraint and Moral Measures 
in the Treatment of Inebriety. Quar. Journ. 
Inebr., 25, 1903, p. 24. 

Kettocc, J. H. The Treatment of Drug Ad- 
diction. Quar. Journ. Inebr., 25, 1903, p. 30. 

JeLuirre, S. E. Hypnotics, "Analgesics and 
Resultant Drug Addictions. Journ. Amer. 
Med. Assoc., 40, 1903, p. 571. 

Ruvu, A. A Plea for Early Treatment of the 
Alcohol, Morphine, Cocaine, and Allied Nar- 
cotic Drug Habits. Amer. Med. Compend., 
19, 1903, p. 25 

McCarthy, D. 7 The Changes in Peripheral 
Nerves Produced by Toxic Substances Ap- 
plied to the Skin. Univ. Penn. Med. Bull., 16, 
1903, p. 30. 

WALKER, W. K. A Brief Consideration of 
the Mechanism of Mental States Encoun- 
tered in Alcoholic Insanity. Med. News, 82, 
1903, p. 580. 


PSYCHOLOGY 


Wricut, H. A. What is the Function of the 
Cerebral Cortex? Amer. Med. Compend., 
18, 1902, p. I. 

Mettrer, L. H. Cerebral Localization and 
Brain Function. N. Y. Med. Journ., 75, 1902, 
pp. 969, 1042, 1093, 1120. 

Huser, J. B. The Influence of the Mind upon 
the Body. N. Y. Med. Journ., 77, 1903, p 
270. 

SANForD. Psychology and Physics. 
Review, I0, 1903, p. I05. 


Psychol. 


SLAUGHTER, J. W. A Preliminary Study of 
the Behavior of Mental Images. Amer. 
Journ. Psychology, 13, 1903, p. 520. 


Barker, L. F. The Functions of the Cerebel- 


lum. Journ. Amer. Med. Assoc., 38, 1902, 
p. 194. 
GILBERT, J. A. The Mind and the Body. Med- 


ical Record, 61, 1902, pp. 607, 741. 

Gipson, A. E. Relation of Consciousness to 
the Nervous System. Med. Record, 62, 1902, 
p. 812. 

Franz, S. I. On the Functions of the Cere- 
brum. Amer. Journ. Physiology, 8, 1902, p. I. 


Huser, J. P. The Mysteries of Life and Mind. 
Med. Record, 62, 1902, p. 251. 


%. B.—CUT THESE OUT, PASTE 
AMERIGAN NMEVROLOGIGAL (WORK. 


. &XXVi 


108. 


NEURALGIA 


Barser, H. T. Trifacial Neuralgia and Its 
Treatment. 'N. Y. Med. Journ., 75, 1902, p. 
450. 

Frazier, C. H., and Sprrer, W: G. A Bog 
ther Report upon the Treatment of Tic 
Douloureux by Division of the Sensory Root 
of the Gasserian Ganglion. Phila. Med. 
Journ., 10, 1902, p. 504. 

Pusey, B. The Genesis of Glioma Retine in 
Neuralgia. John Hopkins Hosp. Reports, 13, 
1902, p. 229. 

SINKLER, W. The Therapeutic Status of the 
Coal Tar Products in Neuralgia and Other 
Painful Conditions. Proc. Phila. Co. Med. 
SOCy tes 002, p,, 41: 

PAINTER, C. F. The Operative Treatment of 
Intercostal Neuralgia Occurring in the De- 
formities of the Chest following Potts’ Dis- 
ease and Scoliosis. Phila. Med. Journ., 8, 
IQOI, p. 1049. 

SIcKLER, E. H. The Relief of Pain in Neu- 
ralgic Conditions. The Medical Age, 20, 
1902, p. 52. 

Hitt, E. C. Pain and Its Indications—Neu- 
ralgia. Med. Standard, 25, 1902, p. 187. 

Curtis, G. L. Electric Ozonation in Neural- 
gia. Journ. Amer. Med. Assoc., 39, 1902, p. 
Bit, 


CRANIAL NERVES 


Barber, H. T. Trifacial Neuralgia and Its 
Treatment. N. Y. Med. Journ., 75, 1902, p. 
450. 


CHEATHAM, W. Optic 'Neuritis in the Young. 


Pediatrics, 14, 1902, p. 314. 
MerTTier, L. H. Facial Palsy of Syphilitic Ori- 


gin. Infantile Palsy. Chorea Minor Hysteri- 
cal Hemichorea. Clinical Review, 17, 1902, 
D.s173< 


Moyer, H. N. Cerebral Syphilis: Dementia 
with Nuclear Degeneration of Some Cranial 
Nerves and Atrophy of one half of Tongue. 
Journ. Nerv. and Ment. Dis., 30, 1903, p. 106. 


SPILLER, W. G. The Importance of the Lachry- 
mal Reflex in the Diagnosis between Organ- 
ic and Hysterical Anesthesia of the Face. 
Phila. Med. Journ., 9, 1902, p. 802. 


Fry, F. R. Focal Facial Epilepsy followed by 
Temporary Unilateral Paralysis of Face and 
Tongue. Med. Fortnightly, 22, 1902, p. 599. 


CocHILL, G. E. The Cranial Nerves of Ambly- 
stoma Tigrinum. Journ. Comparative Neu- 
rology, 12, 1902, p. 205. 

Reik, H. O. Catarrhal Otitis Media (Non- 
Suppurative) as a Factor in Etiology of Fa- 
cial Paralysis. St. Louis Med. Review, 46, 
1902, p. 83. 


ON CARDS, ANB KEEP AN INDEX OF 


HERE has never.been a time when the val- 
ue of Scott's Emulsion was so apparent 
and its superioiity so clearly demonstra- 
ted as at present. The great scarcity and 

high price of pure cod liver oil has resulted in an 
a’ most general adulteration and admixture of cod 
liver oil preparations. The necessity of guarding 
the public against these worthless articles is clear- 
lv withinthe duty ofevery physician. That Scort’s 
Emulsion remains absolutely unchanged and that 
its quality and purity are the same at all times is 
sufficient to show why it is the safest and most 
reliable emulsion made. Insist upon your patients 
getting Scott’s Emulsion. 


SCOTT & BOWNE, Chemists, 4 9-415 Pearl Street, New York City. 








LITHIA 
PuitalO wWartee 


Prof. GIUSEPPE LAPPONI 


Physician in Ordinary to the Late POPE LEO XiIIl. 
and to His Holiness POPE PIUS X 


Principal Physician of the Hospital of San Giovanni Calibrita (del Fatebene 
Fratelli) of Rome —Member of the Acadamy of Rome. 





Rome, August 24, 1903.—In the hospital of San Giovanni Calibrita (del Fatebene Fratelli) 
in Rome, directed by myself, I have largely experimented with the natural mineral water 
placed in commerce under the name of BUFFALO LITH A WATER and am 
glad to be able to attest that, by its richness of composition of Lithia, it is of marvelous effi- 
cacy, in cases of gout, of chronic, articular, and muscular rheumatism, of hepatic congestions 
and functional disorders, of gastro- -intestinal dyspepsia, of gravel and renal insufficiency, of 
light nephritic affections and of all the various forms of uric acid diathesis. 

The same water is also to be recommended highly in the initial processes of arteriosclero- 
sis and in obstinate forms of bronchial asthma. May also be used as a good table water. So 
much I declare for the truth. (Signed) Pror. GrusEPPE LAPPONI. 


TADDITIONAL MEDICAL. Proprietor, BUFFALO LITHIA SPRINGS, Virginia. 


XXXVii 


Bibliography of American Neurolosy and Psychiatry. 109, 


MULTIPLE SCLEROSIS 


SINKLER, W. A Case Exhibiting the Symp- 
toms of Both Tabes and Multiple Sclerosis. 
Phila. Med. Journ., 10, 1902, p. 590. 

SPILLER, W. G. A Report of Two Cases of 
Multiple Sclerosis with Necropsy: with Re- 
marks on Muscular Atrophy. Secondary De- 
generation and Loss of Tendon Reflexes with 
Increased Muscular Tonicity Occurring in 
this Disease. Amer. Journ. Med. Sciences, 
I25, 1903, p. OI. 

FRAENKEL, J. A Case of Congenital Multiple 
Sclerosis. Journ. Nerv. and Ment. Dis., -30, 
1903, p. 215. 

‘NerF, I. H., and Krincman, T. A Case of 
Multiple Cerebro-Spinal Sclerosis of a Spe- 
cial Anatomical Form with a History of 
Pronounced Family Defect. Amer. Journ. 
Insanity, 56, 1900, p. 431. 

Burr, C. W., and McCarruy, D. J. An Atypi- 
cal Case of Multiple Sclerosis. Journ. of 
Nervous and Mental Disease, 27, 1900, p. 
634. 

SPILLER, W. G. A Case of Malaria Presenting 
the Symptoms of Disseminated Sclerosis 
with Necropsy. Journ. of Nervous and 
Mental Disease, 27, 1900, p. 643. 

Potts, C. S. A Case of Progressive Unilateral 
Ascending Paralysis; Probably Due to Mul- 
tiple Sclerosis. Journal of Nervous and 
Mental Disease, 28, I90I, p. 550. 


NERVE TUMORS 

Kit1ani1, O. G. T. On Traumatic Keloid of 
‘the Median Nerve, with Observations upon 
the Absorption of Silk Sutures. Annals of 
Surgery, 33, I9O1, p. 13. 

LonG, 
Removal of Very Painful Neuroma. Western 
Med. Review, 6, 1901, p. 10. 

Ho.pen, W. A. A Case of Metastic Carcinoma 
of Optic Nerve with Peculiar Degeneration 
of Both Nerves. Archives of Ophthalmology, 
31, 1902, p. 427. 

Pocxiey, F. A. A Case of Tumor of Optic 
‘Nerve Sheath Removed by Kronleius Meth- 
od with Preservation of Eye and Good Vis- 
ion. Archives of Ophthalmology, 31, 1902, 
p. I14. | 

Cotttns, J. Tumors of the Central Nervous 
System—Remarks on Noteworthy Cases. 
Medical Record, 61, 1902, p. 241. 

CoLtitins, J. Spinal Cord Tumors—Tumors of 
the Central Nervous System. Remarks on 
Noteworthy Cases. Med. Record, 62, 1902, p. 
882. 

Aspott, F. C., and SHattuck, S. G. Neurofi- 
bromatosis of the Nerves of the Tongue and 
of Certain Other Nerves of the Head and 
Neck. Amer. Surg., 37, 1903, p. 321. 

TAytor, J. W., and Sprtter, W. G. A Case of 
Multiple Fibromata Confined to the Inter- 
nal Plantar Nerve. Journ, Nerv. and Ment. 
1D1st7'30; 1903; Pa 204 





F. A. Resection of Radial Nerve for. 


BRAIN SYPHILIS 


‘Patrick, H. T. The Somatic Signs of Brain 
Syphilis. Journ. Amer. Med. Assoc., 37, 
IQOI, p. IIOO. 


McBripg, J. H. Mental Symptoms of Cerebral 
Syphilis. Journ. Amer. Med. Assoc., 36, 1901, 
p. 297. 

Dewey, R. Psychosis in Cerebral Syphilis. 
Journ. Amer. Med. Assoc., 37, I90I, p. 1102. 


Hurp, A. W. Paresis and Cerebral Syphilis. 
Buffalo Med. Journ., 56, I90I, p. 629. 


BatLtey, P. Certain Clinical Types of Brain 
Syphilis. Medical Record, 61, 1902, p. 99QI. 


McCorn, W. A. Clinical Differentiation of 
Brain Syphilis and General Paresis. Brook- 
lyn Med. Journ., 16, 1902, p. 8o. 


Morton, L. J. Intracranial Syphilis and Hemi- 
plegia. Brooklyn Med. Journ., 16, 1902, p. 21. 


GotpsporouGH, F. C. On Syphilitic Disease 
of Cerebral Arteries. St. Louis Med. Re- 
view, 46, 1902, p. 128. 


Moyer, H. N. Cerebral Syphilis: Dementia 
with Nuclear Degeneration of Some Cranial 
Nerves and Atrophy of One-Half of Tongue. 
Journ, Nerv. and Ment. Disease, 30, 1903, 
p. 106. 


BRAIN TUMOR 


ALLEN, C. L. A Case of Cholesteatoma of the 
Brain. Journal Nervous and Mental Disease, 
29, 1902, p. 262. 


Mitts, C. K. The Surgery of Brain Tumors 
From the Point of View of the Neurologist, 
with Notes on Recent Cases. Phila. Med. 
Journ., 10, 1902, p. 826. 


Scuwazer, A. A Case of Cerebellar Tumor 
with Escape of Cerebro-Spinal Fluid through 
the Nose. St. Paul. Med. Journ., 4, 1902, 
DP. 757. 

SHERwooD, G. E. A Brief Résumé of Brain 
Tumors with Report of a Case. St. Paul 
Med. Journ., 4, 1902, p. 766. 


CHANNING, W., and KnowLton, W. M. A 
Case of Metastatic Adrenal Tumors in the 
Left Midfrontal and Ascending Frontal Con- 
volutions. Amer. Journ. Insanity, 59, 1902, 
3, Pp. 515. 

McFartanp, J. Angiosarcoma of the Hypo- 
physis Cerebri without Acromegaly. Proc. 
Phila) sPatiaas0c., 1003 sp.cz0. 

Wootsey, G. Fibroma and Cyst of the Brain. 
Amer. Surg., 37, 1903, p. 276. 

McFar.tanp, J. A Case of Remarkably Large 
Cyst of Cerebellum. Proc. Phila. Path. Soc., 
1903, p. 93. 

JANEWAY, T. C. Glioma of the Brain. 
Na Yon bathn DOG. 100273. Relay 


Proc; 


N. B.—-CUT THESE OUT, PASTE ON CARDS, AND KEEP AN INDEX OF 


AMERICAN NEUROLOGICAL WORK. 


XXXViili 


eevee? | 





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XXXiX 


PUBLISHERS’ ANNOUNCEMENTS. 


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