The Journal of nervous and mental disease

•t t Ir-S

TLhc journal

OF

IRervous anb Cental SKsease

OFFICIAL ORGAN OF

51>e Hmcrican Neurological association
<Xhe New JI)ork Neurological Society

Boston Society of ps^cbiatn? anb Neurologv
£he Philadelphia Neurological Society airt>
She Chicago Neurological Society

MANAGING fcOITOR AND PUBLISHER

Dr. SMITH ELY JELLIFFE
64 W. 56th Street, New York City

EDITOR vSSOCtATE EDITORS

Or. WILLIAM G. SPILLER Dr. W. P. SPRA FLING

Dr. E. W. TAYLOR

ADVISORY BOARO OF EDITOR*:

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

Dr. F. X. DERCUM Dr. JAS. J. PUTNAM

Dr. CHAS. K. MILLS Dr. B. SACHS

Dr. WH. OSLER Dr. WHARTON SINKLER

Dr. M. ALLEN STARR Dr. FREDERICK PETERSON

Dr. ADOLF MEYER Dr. WILLIAfl A. WHITE

VOLUME 34, 1907. Q /->

NEW YORK V \

64 West 56th Street y* *V
1906 ^

/

-p.

718

I

Vol. 34 January, 1907 No. 1

THE

Journal

OF

Nervous and Mental Disease

Original Brticles

PSEUDOHYPERTROPHIC MUSCULAR ATROPHY.
By Charles E. Ingbert, M.D., Ph.D.,

ASSISTANT PHYSICIAN STATE HOSPITAL FOR THE INSANE, OF INDEPENDENCE,

IOWA.

I. INTRODUCTION.

Cases of muscular atrophy may be of at least three distinct
types, viz. : ( 1 ) those due to lesions in the central nervous sys-
tem; (2) those due to lesions in the peripheral nerves; and (3)
those due to a primary lesion of the muscles themselves. The
last of these forms is also spoken of as a muscular dystrophy ;
and as the case here reported is of this form, it may be of in-
terest to see how this type is defined. I quote here Dr. Osier's1
definition. He says that it is a "muscular wasting, with or with-
out an initial hypertrophy, beginning in various groups of
muscles, usually progressive in character, and dependent on pri-
mary changes in the muscles themselves." Pseudo-hypertrophic
Muscular Atrophy is that form of muscular dystrophy which
affects infants, which is preceded by a pseudo-hypertrophy and,
which attacks first the muscles of the calves of the legs.

II. HISTORICAL STATEMENT.

The first cases of muscular atrophy mentioned in the literature
upon this subject were studied with no reference to the micro-
scopical condition of the spinal cord, the peripheral nerves, or of
the muscles themselves. The diagnosis was based entirely on the
history and on the clinical findings in the case; nor was any
serious attempt made to find the real cause of the various symp-
t. as that were observed. Thus Bell ( 1830) ,2 though he made no
microscopical examination of the tissues, was the first investi-

2 CHARLES E. INGBERT

gator to describe such cases of muscular atrophy as have of late
been called Pseudo-hypertrophic Muscular Atrophy. In 1836
he made the first clinical description of a case of Progressive
Spinal Paralysis. Aran (1850)3 was the first investigator to de-
monstrate changes in the spinal cord of cases of Progressive Spinal
Paralysis, while Meryon (1852)4 was the first to demonstrate that
in cases of Pseudo-hypertrophic Muscular Atrophy no micro-
scopical changes are present in the spinal cord, but that the
muscles had undergone a "fatty and granular degeneration."

Duchenne (1868)5 also recognized that this disease is inde-
pendent of all changes in the central nervous system and gave
it the name "Pseudo-hypertrophic Muscular Atrophy."

Charcot (1872)'5 discovered Amyotrophic Lateral Sclerosis,
and pointed out the differences between it and Progressive Spinal
Mucular Atrophy. Friedreich (1873)7 discussed fully the rea-
sons for separating the muscular dystrophies from the forms of
spinal muscular atrophy. Dejerine (1882) and others, showed
that numerous cases formerly supposed to be due to spinal lesion
were really due to multiple neuritis. Erb (1882)8 described the
form of muscular dystrophy which he called "juvenile," and later
(1884)9 gave a full account of the same. Landouzy and De-
jerine (1884) described the facio-scapulo-humeral form of mus-
cular dystrophy, and later (1885)10 gave a more extended discus-
sion of the same. Cowers (1879)11 collected and studied 160
cases of Pseudo-hypertrophic Muscular Dystrophy, and more than
140 cases have been reported, by various writers, since the pub-
lishing of his paper. Concerning the condition of the spinal cord
in this disease, Gowers (1899)12 wrote: "The motor nerves, when
examined, have been found normal. The spinal cord has been
found perfectly normal in most cases in which it has been ex-
amined . . ., the anterior gray matter was unaffected. Hemor-
rhages have been occasionally found. The neuroglia cells have
been found increased in number."

III. CLASSIFICATION'.

It is therefore evident that the forms of muscular atrophy
may well be arranged into three groups :

(a) Those due to changes in the spinal cord: Progressive
Spinal Muscular Atrophy, etc.

MUSCULAR ATROPHY 3

(b) Those due to changes in the peripheral nerves: Multiple
Neuritis, Progressive Xeural Muscular Atrophy, etc.

(c) Those due to primary changes in the muscles: The mus-
cular dystrophies.

Erb (1891)13 has classified the forms of muscular dystrophies
as follows :

I. Dystrophia Muscularis Progressiva Infantum.

1. Hypertrophic form,

a. With pseudo-hypertrophy or lipomatosis, Du-

chenne's Pseudo-hypertrophic Muscular Atro-
phy.

b. With real hypertrophy.

2. Atrophic form,

a. With primary involvement of the face (Du-

chenne's infantile form or the Landouzy-De-
jerine type).

b. Without involvement of the face.

II. Dystrophia Muscularis Progressiva Juvenum vel Adul-
terum (Erb's juvenile form).

According to another classification the types of the disease
and the muscle-groups affected are as follows :

1. Duchenne's pseudo-hypertrophy, — muscles of calves of

legs.

2. Erb's juvenile dystrophy, — muscles of arms and shoulders.

3. Sachs'-Hoffmann type, — peroneal muscles of legs.

4. Landouzy-Dejerine type, — muscles of face and arms.

5. Charcot-Marie-Tooth type, — muscles of forearms, legs, and

back.
The above classifications are given in order that the reader
may be better able to place the case here reported.

IV. CLINICAL HISTORY OF THE CASE REPORTED.

His mother, as well as his paternal grandfather died of can-
cer. One of his sisters was still-born, and a brother shows neu-
rotic tendencies. An aunt on his father's side has been confined
in an insane asylum. A cousin is said to have had cerebro-spinal
meningitis leaving one leg crippled. There is no history of any
other case of Pseudo-hypertrophic Muscular Atrophy among his
ancestors or relatives.

The following communication from the boy's father seems to
be of sufficient importance to warrant its insertion. He says:

4 CHARLES E. INGBERT

"I do not know that he was ever sick with any disease before
the onset of the trouble with his feet." — "I don't remember the
two days'sleeping spell to which you refer. The child did have
a seeming desire to be held and acted sort of droopy and whined
when not asleep as if in pain, and this lasted the greater part
of three months, I think. This was before anything wrong was
noticed about his ankles, and it was in his ankles that the
trouble made its first appearance. As I think I stated in the
other letter, for quite a long while the trouble was so slight that
we thought little of it. All the physicians consulted, and they
were not a few, made light of the trouble. They said it was
nothing worthy of notice. To me it seemed many times that the
calves of the boy's legs were large, and a great deal of the
time were devoid of feeling. For instance, one night when we
were living in Tacoma, Wash., a lot of children went out coast-
ing on the hill and took this boy with them. As he could not
walk, they hauled him up the hill on the sled, and when they
came in, the calves of his legs were nearly frozen without his
knowing it. He was then nine years old."

The first abnormality noticed was his going on all fours,
using the sides of his feet, when moving about on the floor. He
began to walk before he was two years old, but never learned
to walk well. He stumbled and fell frequently, as he was unable
to flex dorsally either his toes or his feet. When about six years
old he wore a brace for a short time. At ten, he found it neces-
sary to use a cane while walking; and at twelve, crutches. He
was always frail and this became more apparent as he grew
older. He was, however, intelligent and very fond of reading.
His arms seemed normal as regards strength, but the movements
of his hands were both slow and clumsy. When about twelve
years of age he experienced, occasionally, a difficulty in retaining
the contents of his rectum, though he was able to perceive the
inclination to evacuate his bowels. He seemed normally de-
veloped sexually, and never had any trouble in retaining the
contents of the bladder. Especially since twelve years of age,
have the calves of his legs been abnormally thin. He had always
considerable difficulty in going up stairs, and frequently lost his
balance. Except when very young, only the balls of his feet
touched the ground while walking. He was able to remain in a
sitting posture with no difficulty ; but was unable to arise from
this position without assisting himself with his hands. In aris-
ing from the prone position he would first roll over on his
face, get up on his hands and knees, then on all fours, and finally
raise his trunk by putting his hands on his knees. He showed a
lessened sensibility to cold in his feet and in the calves of his
legs, though the other sensations were apparently normal. In
the later years of his life his shoulder-blades were rather promi-
nent: but this was, no doubt, partly due to the emaciated condi-

MUSCULAR ATROPHY 5

tion in which he then was. He had attacks of both measles and
whooping-cough, but not until after the onset of his trouble.

The immediate cause of his death was an attack of typhoid
fever, which lasted six or seven weeks. During this attack he
was in the St. Luke's Hospital, Chicago, where he died Feb-
ruary 24, 1903, at the age of twenty years.

(The above history has been obtained from friends and rela-
tives since the death of the patient.)

V. POST MORTEM EXAMINATION.

This was made by Dr. H. G. Wells (1903),14 Chicago, and
showed the following conditions present:

"Anatomical Diagnosis. — Extreme emaciation ; typhoid ul-
ceration of the colon ; hypertrophic pulmonary emphysema ; pu-
rulent bronchitis ; bronchopneumonia ; hypostatic pneumonia of
left lung ; edema of the right lower lobe of lung ; acute lympha-
denitis, peribronchial and mesenteric ; hyperplasia of the aorta ;
hypertrophy of the left ventricle of the heart ; parenchymatous
degeneration of the liver and the kidneys ; fibrous pericholecys-
titis ; atrophy of appendix vermiformis ; hyperplasia of the
spleen ; omentum almost devoid of fat ; calcification of the peri-
pancreatic and mesenteric lymph nodes ; diffuse, chronic nephri-
tis ; decubitous ulcerations ; callosities over base of the left meta-
tarsal bones ; hyperplasia of the testicles ; fibrous increase in the
thyroid gland ; atrophy of the lower extremities with replace-
ment of fatty fibrous tissues ; contractures of the feet, both in
a spiral with big toe to plantar surface (pes varus et pes
equinus) ; slight scoliosis."

The heart muscle showed a slight increase in the interstitial
tissue. The recti muscles were nearly normal except that the
cross-striations, in some places, were scarcely visible, and some
fibers showed a lessened staining capacity. In the gastrocnemii
muscles there were only a few normal fibers, as here atrophy was
well marked, and the muscular tissue had the appearance of
broken bundles of narrow fibers separated by large amounts of
fibrous and adipose tissue. In places the muscle fibers were en-
tirely replaced by connective tissue. In other places the rhuscle
bundles had undergone degeneration to such an extent that only
the nuclei of the fibers were present. Some fibers that were ap-
parently nearly normal as regards degenerative changes, seemed
swollen. An attempt to regenerate the muscle fibers was also
observed in a few places. The small arteries in the muscles
showed in many instances a diffuse thickening. Organized
thrombi were also observed in a few small blood vessels.

The following study of the nervous tissues of this case was
commenced in the Neurological Laboratory of the University of
Chicago, and completed in the Pathological Laboratory of the
State Hospital for Insane, at Independence, Iowa.

6 CHARLES E. LXGBERT

VI. HISTO-PATHOLOGICAL EXAMINATION OF THE SPINAL CORD AND
THE ROOTS OF THE SPINAL NERVES.

The material here investigated was kindly furnished me by
Dr. H. G. Wells, of the University of Chicago.

Sections from different levels of the spinal cord were stained
according to the following methods, and a careful histological
examination made.

(a.) The Marchi Method. — The nerve tissue prepared ac-
cording to this method had been preserved in formalin and was
subsequently treated with Miiller's fluid for 20 days, and with
an osmic acid mixture for 7 days. After dehydrating in alcohol, the
tissue was imbedded in paraffin. Sections were made 20 micra
thick, cleared in xylol, and mounted in balsam.

Sections from the following segments of the spinal cord
were studied by this method: cervical VIII., lumbar III., IV..
V., sacral I. The result of this examination was negative.
Only occasionally were nerve fibers found having a black color.
We must consequently conclude that in these segments of the
cord there was practically no degeneration of nerve fibers.

(b) The Iron Hematoxylon Method. — The material studied
by this method was preserved in formalin, dehydrated in alcohol,
imbedded in celloidin, and sectioned 30 micra thick. After being
treated with an ammonio-ferric sulphate mordant, the sections
were washed in water and stained with hematoxylon.

Sections prepared according to this method were made from
the following segments of the spinal cord: thoracic VI., lumbar
III., IV., V. All these sections showed a fairly well marked
proliferation of the neuroglia beneath the ependyma of the cen-
tral canal of the spinal cord. The ependyma was consequently
in many places pushed into the central canal in well marked
folds. There was also a slight increase in the neuroglia of the
gray matter of the spinal cord. Some of the nerve cells have
shrunk so that they are surrounded by open spaces and stain
rather faintly indicating that chromatolysis has taken place. The
blood vessels in the meninges of the spinal cord are seen to be
much dilated in several places.

(c.) The Nissl Method. — This method is especially servicable
in demonstrating the Nissl-bodies, or the tigroid masses in the
nerve cell. When the cell body undergoes degeneration, the
Nissl bodies usually disintegrate and the cell content becomes
more homogeneous than it is normally — in other words, they
undergo chromatolysis. The nerve tissue studied by this method
was preserved in formalin. It was afterwards fixed still fur-
ther and dehydrated by alcohol, cleared in cedar oil-xylol and
imbedded in paraffin. The sections were made 10 micra thick,
stained with Nissl' s methylen blue, cleared in oil of cajeput and
mounted in colophonium.

MUSCULAR ATROPHY 7

The sections studied by this method were from the follow-
ing segments of the spinal cord: cervical VIII., thoracic VIII.,
lumbar III., IV., V., and sacral, I., I., III. These show a pro-
liferation of the neuroglia cells around the central canal, as well
as the congestion of the blood vessels of the meninges of the
spinal cord already mentioned. Chromatolysis of many nerve
cells is also evident. This is especially marked in the segments
below and including lumbar IV. In these segments there are
fewer cells present, especially in the lateral horn, and those pres-
ent more frequently show chromatolysis. In several instances the
nucleus is displaced so as to lie nearer to the periphery of the cell
body, and the side of the nuclear membrane nearest to the center
of the cell is, in several instances, thickened and wrinkled. The
dendrites of the affected cells also shows chromatolysis and have
frequently a shrunken appearance.

In concluding the study of the spinal cord of this case of
Pseudo-hypertrophic Muscular Atrophy, it is well to keep in
mind that this disease is considered one involving primarily the
muscles, that lesions in the spinal cord are rarely present, and
that when these lesions are present, they are considered secondary
or subsequent to the disease of the muscles. The investigation
here made substantiates this view except in one respect, viz.,
the lessened number of lateral horn cells in the segments of the
cord below and including lumbar IV., and the frequent chroma-
tolysis of the remaining cells in these segments.

Sano (i898)i:' has demonstrated that most of the mus-
cles of the leg below the knee are innervated by columns of
nerve cells in the lateral horn of the segments of the spinal cord
below and including lumbar IV. It is therefore but natural to
conclude that the chromatolysis observed, and the possible diminu-
tion in the number of cells of the lateral horn of lumbar V, is
secondary to the atrophy of the muscles.

Since this patient died from Typhoid Fever it is doubtful if
much importance can be given to the other findings, — the pro-
liferation of the neuroglia beneath the ependyma of the central
canal of the spinal cord, the slight increase in the neuroglia of the
gray matter, and the congested condition of the blood vessels of
both the cord and its meninges.

The fact that several of the ventral and lateral horn cells in the
lumbar region of the spinal cord had undergone chromatolysis led
to the investigation of the roots of the spinal nerves, especially the
motor or ventral roots, to determine whether or not these nerve
roots contain a smaller number of medullated nerve fibers than do
the normal nerve roots. As the author three years ago measured
the areas and counted the medullated nerve fibers of both the
motor and the sensory nerve roots from the spinal cord of a nor-
mal subject, such a comparison becomes possible. According to

8 CHARLES E. 1NGBERT

the author's results, published June, 190316, the dorsal or sensory
spinal roots of the left side have together an area in cross-section
of 54.93 mm2, and contain 653,627 medullated nerve fibers ; and
according to the results published in 190417, the ventral or motor
spinal roots of the left side have together an area in cross-
section of 26.50 mm2, and contain 203,700 medullated nerve fibers.
In other words the ratio of the areas of the cross sections of the
ventral and dorsal roots is as 1 12.07, while the ratio of the numbers
of medullated nerve fibers is as 1 13.2. From the author's results
similar comparisons can also be made for each pair of nerve
roots. The nerve roots investigated were studied both by Marchi's
and Pal-Weigert's methods. The Marchi method gave only nega-
tive results. The few black droplets present were not sufficiently
numerous to indicate much degeneration. But as this was a case of
long standing, it is most probable that the disintegrated myelin of
the degenerated nerve fibers had disappeared by absorption.

In using the Pal-Weigert method the material was first fixed
in formalin, and later in M tiller's fluid. It was then washed in
water, dehydrated in alcohol and ether, imbedded in celloidin, and
sectioned 30 micra thick. The sections were stained in Weigert's
hematoxylon, and differentiated with potassium permanganate,
oxalic acid, and acid potassium sulphate. After washing in water,
dehydrating in alcohol, clearing in creosote, they were mounted
in balsam.

In determining the areas of the cross sections of the nerve
roots, camera lucida projections were made on millimeter paper,
the square millimeters counted, and from these results were cal-
culated the true areas by dividing the results thus obtained by
the square of the magnification of the projections. In counting
the medullated nerve fibers a Zeiss microscope fitted with a Zeiss
objective, 4 mm., aperture 0.95. and oculus No. 6 was used. In
the oculus was placed an ocular micrometer ruled into square
millimeters. The counting was done by means of an automatic
register.

The following table shows a comparison of the areas of the
cross sections of the left nerve roots of the spinal cord of a large,
normal man, with similar areas from the nerve roots of this small
man here reported as suffering from Pseudo-hypertrophic
Muscular Atrophy.

Areas of cross-sections of nerve Areas of cross-sections of nerve

roots from normal cord. roots from abnormal cord.

Motor Sensory Motor Sensory

Roots.
Lumbar IV. 1.27mm2

V. 2.17 "

Sacral I. 1.98 "

II. 0.61 "

The nerve roots of the lower lumbar and the upper sacral
nerves only were investigated as the muscles of the calves of the

Roots.

Ratio.

Roots.

Roots.

Ratio.

2.93mm"

1 -.2.3

0.47mm2

1. 66mm2

i:34

3.20 "

1:1.5

1.28 "

1-99 "

1:1.6

3-44 "

1:1.7

1.49 "

2.34 "

1:1.6

1.92 "

1 :3-2

o.45 "

1.39 "

i:3I

MUSCULAR ATROPHY g

legs — those most atrophied in this case — are mainly innervated by
these nerves. The areas of the cross sections of the nerve roots
from the spinal cord of the case here reported are found to be
considerably smaller than those from the nerve roots of the normal
cord. This is probably partly due to the difference in the sizes
of the two subjects.

From the fore-going table it is evident that the ratio between
the areas of the cross sections of the motor and sensory roots of
the 4th lumbar segment differs in the two cases. The ratio of
the normal roots being i : 2.3 ; and that from the roots of the
case here reported 1 : 3.4. This is without doubt due to the fact
that the motor root (lumbar IV) is smaller that it should be.

To determine whether there is also a corresponding diminution
in the number of nerve fibers in these roots a count was made
of the nerve fibres in the motor root of the left spinal nerve of
the 5th lumbar segment. The result of this count was 5 171
nerve fibers as compared with 10,366 in the corresponding normal
root. That the different sizes of the two bodies from which the
material was obtained partly accounts for this seems evident.
This is. however, not the only reason for this difference.

In counting the fibers in the nerve root from the case here re-
ported it was noticed that there were practically no small nerve
fibers present. From the author's former investigation (1904) it
was determined that the corresponding normal nerve root contains
15% of small fibers (less than 7 micra in diameter). This differ-
ence in the number of small nerve fibers in the two roots compared
suggest the idea that possibly there was present a diminution in
the number of fibers without a corresponding proportionate dim-
inution in the area of the cross section of the nerve root from the
case here reported. That this is the case is seen from the fact
that the normal root contains, on the average, 4800 nerve fibers
per mm2, while the other root contains on the average 4040. It is
therefore evident that the root here investigated not only has a
smaller area than the normal root, but contains a smaller number
of fibres, as well as, a smaller number of fibers per mm2.

This diminution in the area of the cross section and in the
number of fibers in the root under discussion is without doubt due
to a degeneration of some of its nerve fibers and agrees well with
the fact already referred to that some of the motor cells of the
lateral and ventral horns of the lumbo-sacral segments of the
cord were undergoing chromatolysis — some having even dis-
appeared.

Boughton (1906)18 demonstrated that in the oculomotor nerve
of the white rat and of the cat the "small" fibers appear after the
period of most rapid growth. This fact suggested the idea that
the diminution in the number of small fibers in the roots here
studied might be due to the fact that the onset of the muscular

io CHARLES E. INGBERT

atrophy occurred at such an early period as to prevent the normal
growth of the "small" nerve fibers.

The fact that the ratios of the cross sections of the motor and
sensory roots from the other segments of the cords compared are
so nearly equal would seem at first thought to indicate that there
was no degenerative process here present. This conclusion is,
however, not necessarily correct. As was pointed out above there
is evidence of a greater diminution in the number of nerve fibers
than in the area of the cross sections of the nerve root investi-
gated. This makes it probable that in the other motor nerve roots
of the lumbo-sacral segments there is also present a diminution
in the number of nerve fibers.

VII. DIAGNOSIS.'

The diagnosis of Pseudo-hypertrophic Muscular Atrophy in
this case is based on the following facts:

1. The early onset. — The first symptoms were observed be-
fore the child was two years of age. It was apparent to the
father that something was wrong with the child's feet and ankles;
but this was not sufficiently marked at first to satisfy those who
saw the child that the trouble was of a serious nature.

2. The slow progress of the trouble. — The trouble was for
sometime unnoticed, and, when sufficiently advanced to be ap-
parent, was observed to grow worse only very gradually. He
gradually became emaciated and weak, and died at the age of
twenty years from an attack of Typhoid-Fever. During the last
days of his illness, a hypostatic pulmonary congestion was pres-
ent.

3. The calves of the legs first affected. — The first muscles
affected were those of the calves of both legs. These at first
seemed large to the father, but after a time became thinner than
in normal children.

4. The difficulty in walking. — He never learned to walk
well, and fell frequently when attempting to walk. This diffi-
culty was due to contractures, described under another heading.

5. The difficulty in arising from a sitting posture. — He in-
variably found it necessary to use his hands in arising.

6. The characteristic way of arising from the recumbent
position. — He would roll over on his stomach, get up on his
knees and elbows, then on all fours, and finallv bv placing
his hands on his knees, raise the trunk to the erect position.

7. Contractures and deformity of his feet. — This resulted

MUSCULAR ATROPHY n

first in pes varus — the walking on the outer sides of his feet;
and later in pes cquinus — the walking on the balls of the feet
and the heel not touching the ground. He was unable to flex
his feet dorsally and as the disease advanced, was compelled
to use canes and crutches in walking.

8. The scoliosis. — The spinal column showed a fairly well
marked lateral curvature.

9. The vaso-motor disturbances in the calves of his legs. —
His feet and the calves of his legs were, after the disease had
progressed a few years, generally cold and he seemed to have,
as might be expected, a lessened sensibility for cold sensations in
them.

10. The microscopical examination of the gastrocnemius
muscles revealed a condition characteristic of pseudo-hypertro-
phic atrophy.

11. An apparent disturbance of the function of the rectum. —
He experienced an occasional inability to hold the contents of
the rectum, especially when he felt the need of evacuating his
bowels. Since he felt the need of evacuating his bowels, there
may be some doubt that this disturbance is of nervous origin.
It is highly probable that his extreme emaciation, and that the
local ulceration of the rectum revealed by scars at the post-
mortem examination, were responsible for this disturbance of
function. The fact that there was no disturbance of the function
of the bladder also supports this view.

12. The prominent shoulder-blades. — It is not certain
whether this was due to the general emaciation or to an atrophy
of the muscles concerned.

13. The impaired function of the hands. — This, in all prob-
ability, was due to an atrophy of the muscles of the hand — a
condition not rare in this disease.

14. The unimpaired intellect.

It is to be regretted that we have no data as to the presence
or absence of fibrillary contractions in the affected muscles, as
to the condition of the deep reflexes, nor as to the electric reaction
of the muscles.

In favor of the diagnosis here made of Pseudo-hypertrophic
Muscular Atrophy, and against a possible diagnosis of Acute
Poliomyelitis Anterior, is the absence of such characteristic symp-
toms of the latter disease as: — (1) the fever attack, (2) the

12 CHARLES E. IXGBERT

acute onset, — sudden paralysis, (3) the partial recovery of the
affected muscles, etc.

VIII. CONCLUSION.

1. The most important pathological changes observed in the
muscle fibers of the muscles most affected in this case were : cross-
striations less marked, lessened staining capacity, pseudo-per-
trophy, fatty degeneration, etc. Some of the small blood vessels*
in the muscles show the diffuse thickening and organized thrombi.

2. The proliferation of the neuroglia beneath the ependyma
of the central canal, the slight increase in the neuroglia of the
gray matter, and the congested condition of the blood vessels of
the spinal cord were probably due to the Typhoid Fever from
which the patient died.

3. The chromatolysis of the nerve cells of the gray matter of
the cord, especially of the lateral horn, in the segments below
and including lumbar IV, is best explained by considering it
secondary to the degenerative changes in the muscles.

4. The column of nerve cells in the lateral horn of the lumbo-
sacral cord designated Xo. 7 by Sano15 seemed to show a diminu-
tion in the number of its cell bodies. This was most marked in
the 4th and 5th lumbar segments of the cord.

5. The roots of the spinal nerves of the 4th and 5th lumbar
and 1 st and 2nd sacral segments, both motor and sensory, were
found to have a much smaller area of cross-section than those
from a normal subject. Thus the area of the cross-section of the
left motor root of lumbar IV is only 0.47 mm2 as compared with
1.27 mm2 for the normal root. This makes the ratio of the areas
of the cross-sections of the motor and sensory roots here studied
1 : 3.4 as compared with 1 : 2.3 for that of the normal roots. This
difference in the ratios is due to the abnormal size of the motor
root mentioned. The small size of the roots, both motor and
sensory, is probably due to several causes. — the material being
from a small man, and some nerve fibers having undergone degen-
eration.

6. The left motor root of the 5th lumbar segment contained
by actual count 5. 171 medullated nerve fibers as compared with
10,366 for the normal root. In addition to the reasons given for
the small areas of the cross-sections of the spinal roots here stud-

MUSCULAR ATROPHY 13

ied, it has been suggested that possibly the early onset of this
disease prevented the "small" fibers from developing.

7. The muscles most markedly atrophied in this case were
those of the calves of the legs — muscles innervated by the cell-
bodies of the lateral horns of the lumbo-sacral segments of the
spinal cord. This atrophy probably accounts for the chromatol-
ysis of the motor cells referred to, as well as, for the diminution
in the number of medullated nerve fibers in the motor roots
counted (lumbar V).

8. The histo-pathological findings here reported add support
to the conclusion of other investigators that Pseudo-hypertrophic
Muscular Atrophy is primarily a disease of the muscles, and that
the changes in the spinal cord and in the spinal nerve roots are
secondary.

IX. BIBLIOGRAPHY.

'Osier, William. 1902. The Principles and Practice of Medicine, New
York, p. 933.

2Bell, Sir Charles. 1830. Nervous System, 2nd Ed., p. 160.

"Aran. 1850. Arch. gen. de med., xxiv., p. 42.

*Meryon. 1852. Med. Chir Trans. Vol. xxiv., p. 73.

6Duchenne, G., B. A. 1868. Archives generales de med., Paris.

"Charcot, J. M. 1872. Lecons sur les maladies du systeme nerveux,
Paris, 1880, ii., p. 192.

'Friedreich, 1873. Ueber progressive Muskelatrophie, Berlin.

BErb, W. H. 1882. Handbuch der Electrotherapie, p. 389.

'Erb, W. H. 1884. Deutsche Arch. f. klin. Med., March.
"Landouzy, L., and Dejerine, J. 1885. De la myopathic atrophique,
etc., Paris.

"Gowers, W. 1879. Lancet, London July.

"Gowers, W. 1899. Diseases of the Nervous System, Philadelphia,
3rd Ed., p. 578.

"Erb, W. H. 1891. Deut. Zeitschr. f. Nervenh., I., 13 and 173.

"Wells. H. G. 1903. University of Chicago, Post-Mortem Reports,
No. 38.

15Sano, A. 1898. Les localizations des fonctions motrices de la
moelle epiniere, Anvers, Bruxelles, p. 33.

16Ingbert, C. E. 1003. The Journal of Comparative Neurology, Vol.
xiii., No. 2, p. 53.

"Ingbert, C. E. 1904. The Journal of Comparative Neurology, Vol.
xiv.. No. 3, p. 209.

"Boughton, T. H. 1906. J. of Comp. Neur. and Psvch., Vol. xvi.,
No. 2, p. 15.

•I

JOT

MYOPATHY OF THE DISTAL TYPE AND ITS RELATION TO
THE NEURAL FORM OF MUSCULAR ATROPHY (CHAR-
COT-MARIE, TOOTH TYPE).*

By William G. Spiller, M.D.,

PROFESSOR OF NEUROPATHOLOGY AND ASSOCIATE PROFESSOR OF NEUROLOGY IN
THE UNIVERSITY OF PENNSYLVANIA.

FROM THE DEPARTMENT OF NEUROLOGY AND THE LABORATORY OF NEURO-
PATHOLOGY IN THE UNIVERSITY OF PENNSYLVANIA, AND FROM THE
PHILADELPHIA GENERAL HOSPITAL.

Various forms of muscular atrophy have been distinguished
and sharply separated from one another. While it is possible
to make these classifications for typical cases, the borderline
cases cause great confusion, and make clinical diagnosis at
times extremely difficult.

The primary neurotic muscular atrophy of Charcot-Marie and
Tooth was supposed to be so sharply defined that confusion
with other types of muscular atrophy could not occur. The
characteristics of the type as given by Charcot and Marie1 are :

Progressive muscular atrophy implicating first the feet and
legs, and not appearing in the upper limbs (hands and later
forearms) until several years later; the progression of the
atrophy being slow.

Relative integrity of the muscles of the limbs near the trunk,
or at least, much longer preservation of these than of the mus-
cles of the distal ends of the limbs. Integrity of the muscles of
the trunk, shoulders and face.

Fibrillary contractions in the atrophying muscles.

Vasomotor disturbances in the portions of the limbs atro-
phied.

No pronounced contractions of tendons in the atrophied
limbs.

Sensation usually intact, but sometimes affected.

Cramps frequent.

Reaction of degeneration in the atrophying muscles.
Commencement of the affection usually in childhood, the dis-
ease often found in several brothers and sisters, and sometimes
in the previous generations.

*Read before the American Neurological Association, June 4 and 5,
1906.

'Charcot and Marie. Revue de medecine, 1886, p. 97.

MYOPATHY OF THE DISTAL TYPE 15

Charcot and Marie based their conclusions on five cases of
their own, and on a few cases in the literature which they be-
lieved belong- to this type.

I think it well to emphasize the fact that Charcot and Marie
in their original paper acknowledged the possibility of implica-
tion of the muscles of the limbs near the trunk, at least to some
extent. They said that the muscles of the thighs seem to pre-
serve their power and volume during a certain period, but that
this integrity often is not real. The vastus internus is first in-
volved. In their summary at the end of their paper they speak
of relative integrity of the muscles of the limbs near the trunk,
or at least, much longer preservation of these muscles than of
those of the distal ends of the limbs. Unquestionably, however,
they emphasized the earlier and greater involvement of the
muscles at the distal ends of the limbs as the most characteristic
feature of the disease.

If we insist on one of the features emphasized by Charcot and
Marie; viz., the almost constant absence of all contraction of
tendons, many cases classed as progressive neurotic muscular
atrophy must be regarded as doubtful.

Cases conforming strictly to the type as described by Charcot
and Marie occur, and these probably have a distinct pathology.
Such a case is the following, which has been in the Philadelphia
General Hospital many years, several times under my care, and
so far as I know has not been reported :

N. Hutt, 59 years of age, hostler, was admitted Feb. 15, 1901,
at which time the following notes were made :

Chief complaint : Weakness in the arms and legs.

Family history : Father died at about the age of 60 years
from some affection of throat, with which he had been ill for
one month. Mother died at about the age of 60 years from a
second "stroke" of apoplexy. One brother died in infancy and
four brothers and three sisters are healthy. The patient is not
aware of any family diseases.

He has had only the milder diseases of childhood, and was
healthy as a boy and a man, except for the present complaint,
and typhoid fever at 17 years. He says he was a moderate user
of alcohol, positively denies venereal disease, and has never been
married.

History of present illness: He states that at the age of 15
years he began to have pains in the legs and feet, which
would last for a week or two, and incapacitate him for work.

If)

WILLIAM G. S FILLER

These attacks seem to have come on usually in the spring of
the year, and he would then be free until the next spring. He
had no weakness of the limbs, and was able to work as a hostler,
though at about the age of 35 he began to have pain in his
hands and arms, and he noticed that he was becoming weak in

Fig. 1. The neurotic form of muscular atrophy, hands and forearms in-
volved. (Photographed by Dr. Ralph Pemberton.)

the legs

These grew thinner and became somewhat deformed.
From that time until the present the progress of the disease
has been constant, though he has now much less pain than
formerly, and only in his feet. During the past five years he has
been unable to do any work. The atrophy of the muscles of the

MYOPATHY OF THE DISTAL TYPE

17

legs preceded that of the upper limbs ten years, according to
the patient's statement.

He is well nourished, pupils are equal and react to light.
Tongue is clean and shows no tremor. Chest and abdomen are
well formed, the expansion of the chest is fair, lungs are normal,
heart sounds are muffled and distant.

Fig. 2. The neurotic form of muscular atrophy, hands and forearms
involved. (Photographed by Dr. Ralph Pemberton.)

Examination of eyes by Dr. Shumway, Oct. 20, 1904: The
pupils are equal, respond promptly; eye movements are good.

Ophthalmoscopic examination: Haziness of lens, retinal
veins full and show pressure signs, result of arteriosclerosis,

i8

WILLIAM G. SPILLER

otherwise fundus is normal. Vision, O. D. 5-8; O. S., 5-10;
fields are normal.

Condition of the patient at my examination March 7, 1906:
The atrophy is intense in the hands (figs. 1 and 2), distinct in
the forearms, but the arms above the elbows are well developed.
Sensations for touch, pain and temperature are normal in the

Fig. 3. The neurotic form of muscular atrophy, feet and legs (not
thighs) involved. (Photographed by Dr. Ralph Pemberton.)

upper limbs. Sense of position is normal in the fingers. The
grasp of each hand is very feeble. The muscles of the trunk
and head are well developed. He raises the upper limbs above
the head with much power, and is able to dress himself and
handle his clothing with considerable skill, notwithstanding

MYOPATHY OF THE DISTAL TYPE 19

the intense atrophy of the hands. Biceps and triceps reflexes
are weak.

The lower limbs, above the knees, are well developed, and if
there is any atrophy here it is very slight. Below the knees the
atrophy is marked. The feet are inverted and talipes equino-
varus (fig. 3) is very pronounced on each side. The patellar
reflex and Achilles tendon reflex are lost on each side. The
toes are somewhat cyanotic. Sensations for pain, touch and
temperature are normal in the lower limbs. He is able to walk
without assistance and without crutch or cane, but his gait is
rather slow, with legs far apart and his feet turned inward. His
gait is somewhat steppage in character.

If we hold to the type of muscular atrophy as presented by
this patient ; viz., atrophy confined strictly to the distal parts of
the limbs, we shall be able to recognize the neurotic muscular
atrophy as a distinct type, with a distinct pathology. The cases
of this kind with necropsy are very rare, we are obliged to de-
pend on the findings of Marinesco, Sainton, and Dejerine and
Armand-Delille. Oppenheim includes the cases of Dubreuilh
and Siemerling, but Sainton regards the former as far from
typical, and does not refer to the latter, which should, I think,
be excluded.

In Siemerling's2 case there was great atrophy of all the ex-
tremities in the upper parts as well as in the lower, and of the
trunk ; flaccid complete paralysis of the lower limbs, so that all
voluntary movements of these limbs were lost. Siemerling
found degeneration of the posterior and lateral columns, most
intense in the lower thoracic and upper lumbar regions, degener-
ation of peripheral nerves and muscles ; atrophy of the cells of
the anterior horns, of the columns of Clarke, of the anterior
roots, and of the spinal ganglia.

He thinks there can be no doubt that the case belongs to the
spinal neurotic atrophy, but if we accept this opinion we cannot
limit the type to those cases in which the atrophy affects the
distal portions of the limbs, and the proximal portions and trunk
escape.

In the case of the neurotic muscular atrophy studied by Paul
Sainton3 the lesions were :

Sclerosis of the posterior columns, especially of the columns
of Burdach. Slight degeneration of both pyramidal tracts. Al-

*Siemerling Archiv. fur Psychiatrie, Vol. 31, 1898, p. 105.

"Paul Sainton Nouvelle Iconographie de la Salpetriere, Vol. 12, 1899.

20 WILLIAM G. SPILLER

teration of the columns of Clarke. Atrophy of the cells of the
anterior horns. Slight degeneration of the intramuscular
nerves. Slight sclerosis of the nerves of the forearms and legs,
very distinct only in the peroneal nerves. Atrophy of the muscle
fibers even causing complete disappearance of some fibers with
proliferation of connective tissue.

In this case the atrophy began in the upper limbs. The lesions
resembled those observed by Marinesco in his case, except that
Marinesco found the anterolateral columns intact. Judging
from these two cases Sainton regards as the lesions of this
form of muscular atrophy: sclerosis of the columns of Burdach
and Goll, atrophy of the cells of the anterior hornr, and altera-
tions of the peripheral nerves of varying intensity, sometimes
slight.

The lesions found by Dejerine and Armand-Delille* in a case
of neurotic muscular atrophy were degeneration of the pos-
terior columns, degeneration of some of the nerve cells of the
anterior horns of the cervical and lumbar regions without
diminution in the number, chronic meningitis, degeneration of
the muscles of the hands and feet, alteration of the intramus-
cular nerve fibers in the hands and feet (i.e., many nerve fibers
of small size, many empty nerve sheaths and a few nerve fibers
in the process of degeneration). The nerve trunks, the cutane-
ous sensory nerves, and the anterior and posterior nerve roots
with slight exception were normal.

The literature contains many cases reported as belonging to
neurotic muscular atrophy in which some atypical features were
present. Sachs'5 two cases were probably the first reported in
America. In his first case the patient had pronounced kyphosis
of the lumbo-sacral region, slight wasting of the infraspinatus
muscle, and decided diminution in the power of thighs as well
as of legs.

The younger brother of the first patient had general emacia-
tion of all parts of the upper extremities, very distinct atrophy
of the infraspinatus and marked general atrophy of the legs,
which seems to imply involvement of the thighs.

In discussing the cases together Sachs says the atrophy
caused a weakness of the thigh muscles as well as of the muscles

4Deierine and Armand-Delille. Revue Neurologique, 1003, p. 1198.
"Sachs, Brain, 1800, Vol. 12, p. 447.

MYOPATHY OF THE DISTAL TYPE 21

of the legs, and he speaks of atrophy involving all the muscles
of the lower extremities as common in the neurotic muscular
atrophy.

In one of Hoffmann's6 cases the lower limbs were wasted in
all parts, and chiefly below the knees, but the strength of the
thigh muscles was good. Fibrillary tremors were not observed.
In another case, Hoffmann found wasting of the upper part of
the left trapezius muscle and flattening of the supraspinous
and infraspinous fossae, without any loss of function. Fibril-
lary tremors were not seen. In another case he says the thigh
muscles were distinctly weak and much wasted, especially in
the lower part of the thigh. The thoracic muscles were poorly
developed and the ribs were prominent. In still another case
all the thigh muscles were much atrophied, as well as the mus-
cles of the buttocks and the lower part of the extensors of the
back. The patient had a distinct lumbosacral kyphosis, and
experienced difficulty in rising from the ground, such as is seen
in progressive muscular dystrophy. The legs were kept far
apart and the patient climbed upon himself as in muscular
dystrophy.

Hoffmann accepts involvement of the facial muscles as a
part of the neurotic atrophy.

In the case reported by George W. Jacoby,7 and recorded as
one of progressive muscular atrophy of the peroneal type,
severe pain was felt in the lower extremities when the child was
two years old. When she was four years old one leg was found
to be weaker and thinner than the other. Later atrophy of the
thigh on the side opposite to that of the affected leg was noticed.
There was marked lordosis and slight lateral curvature. The
muscles of both thighs were in a continual state of unrest, al-
most like fibrillary twitchings. The right foot was in equino-
varus position. There were no sensory disturbances, but there
was partial reaction of degeneration in the affected muscles.
The arms were not affected.

Jacoby acknowledged that the case was not typical, inasmuch
as the atrophy, although bilateral, was asymmetrical, one leg
being affected and the opposite thigh.

'Hoffmann. Deutsche Zeitsehrift fiir Nervenheilkunde, Vol. 1, p. 95-
7G. W. Jacoby, Journal of Nervous and Mental Disease, 1894, p. 259.

23 WILLIAM G. SPILLER

Sachs, however, concurred in the diagnosis of muscular
atrophy of the peroneal type.

In at least one of Diller's8 two cases (brother and sister), the
thighs also were wasted, and the patient climbed upon his lower
limbs as is seen in muscular dystrophy. He had left talipes equi-
nus. Response to electricity in the paralyzed legs was very
sluggish and reaction of degeneration was obtained.

In the first of the two cases reported by Given Campbell9 the
disease progressed in the lower limbs until these limbs became
useless and the muscles Of the thighs also were much wasted.
The deltoid muscles, especially the left were weak. The weak-
ness and wasting developed hand in hand, and began in the
peroneal group of muscles. The small muscles of the hands
were not affected. The muscles of the trunk were not wasted,
unless possibly the abdominal muscles to a slight extent.

I could add to these cases others to show that atypical fea-
tures have not prevented the diagnosis of muscular atrophy of
the Charcot-Marie-Tooth type, and therefore it is not surpris-
ing that cases of muscular dystrophy have been diagnosed
clinically as belonging to the type. In this connection it is in-
teresting to read Sachs' words published in 1889 (Brain) when
the peroneal type of muscular atrophy was little known. He
said: "There is a consensus of opinion, however, on this one
point, that the cases in question do not belong to the category
of primary muscular dystrophies." He was speaking of the
peroneal type of atrophy. Oppenheim and Cassirer10 showed
that this consensus of opinion no longer exists.

They pointed out that the clinical picture of the neurotic
muscular atrophy is not so sharp as Hoffmann believed, and that
the pathology is still uncertain. In their case the muscular
atrophy had existed about two years. The symptoms began
with severe pain in the lower and upper limbs. The distal por-
tions of the lower limbs, especially those innervated by the per-
oneal nerves, were affected, and in the upper limbs only a part
of the small hand muscles, and later the triceps and supinator
longus, were implicated. In some muscles incomplete reaction
of degeneration was obtained, in others all electrical response

"Diller. Philadelphia Medical Journal, March 17, 1900, p. 642.
"Campbell. Journal of Nervous and Mental Disease, 1900, p. 274.
"Oppenheim and Cassirer. Deutsche Zeitschrift fur "Nervenheilkunde.
Vol. 11, p. 143-

MYOPATHY OF THE DISTAL TYPE 23

failed. The tendon reflexes were diminished. The orbicularis
palpebrarum on each side was involved. Later the calf muscles
became atrophied. The diagnosis seemed to lie between chronic
multiple neuritis and neurotic muscular atrophy. The central
and peripheral nervous systems were normal, but the muscles
were much degenerated.

As regards the involvement of the orbicularis palpebrarum,
Oppenheim and Cassirer refer to the fact that in Sachs' cases
the infraspinati were atrophied, in a case of Hoffmann's the
upper portion of the left trapezius and the supraspinati and in-
fraspinati were atrophied, in a case of Donkin's reaction of de-
generation was obtained in the left trapezius, in a case of Hiile-
mann's the pictoral. romboid, latissimus dorsi muscles were
somewhat atrophied, in a case of Eisenlohr's the atrophy of the
upper limbs was like that of myopathy, but of the lower limbs
like that of the neurotic musclar atrophy. All these cases were
regarded as belonging to neurotic muscular atrophy, and yet
they showed some features in common with muscular dystrophy.
Especially interesting are two cases in sisters observed by
Dahnhardt, in one, the wasting resembled the neurotic muscular
atrophy, in the other the progressive muscular dystrophy.

Oppenheim and Cassirer concluded that the clinical picture of
progressive neurotic muscular atrophy may be caused by mus-
cular dystrophy, and that the pathology of the former is not
always the same and not as yet clearly defined.

Cowers11, in reporting a clinical case of distal myopathy in
1902, said he had not seen a similar case nor did he know that
one had been recorded. The patient, a boy, was eighteen years
old, and was the only member of the family affected. The symp-
toms first attracted notice when he was ten or twelve years old ;
then it was noticed that he often caught his toes against the
ground in walking. At a later date his hands were found to be
weak. The feebleness of hands and feet steadily increased until
it became pronounced. He was unable to flex the ankles, al-
though he could just extend the toes and could move each foot
slightly in and out by the tibialis anticus and the peronei. He
could extend the ankle joint by the calf muscles with some force.
The movements of the knee and hip were performed with good
power, the knee jerks were present, but the left was less than

'Gowers. British Medical Journal, July 12, 1902.

24 WILLIAM G. SPILLER

the right. The thigh muscles were of normal size ; the anterior
tibial muscles were distinctly smaller on the left side ; the calves
were rather large and firm, and were sufficiently large to suggest
a resemblance to pseudo-hypertrophic paralysis. The grasp
was extremely feeble, with the right hand he could not move the
dynamometer, and with the left he could only move the index
to 2 k° instead of 50 or 60. Extension was also feeble ; he could
get the fingers with the wrist into line with the forearm, but
could not fully extend them when the wrist was overextended.
The muscles of the forearms and hands were small, but pre-
sented no wasting comparable to that which is seen in progres-
sive spinal atrophy. Above the forearm the muscles had fair
power and presented no wasting; only a trifling atrophy of the
middle part of the trapezii could be observed. Electrical excit-
ability was lowered in the affected muscles in proportion to their
feebleness, and equally to faradism and voltaism.

The neck muscles were normal except the sterno-mastoids.
He could not raise the eyebrows at all, ar.d closure of the eyes
by the orbicularis muscles were weaker than normal.

Gowers said this case differed from all recognized, forms in
the purely distal distribution of the affection in the limbs and
the normal state of the muscles near the trunk. The case re-
sembled therefore the neurotic muscular atrophy, but the im-
plication of the sterno-mastoid, frontalis and orbicularis palpe-
brarum muscles probably prevented Gowers from classing the
case under this head.

In the case of myopathy of the Aran Duchenne type reported
by Dejerine and Thomas.12 the muscular atrophy was confined
to the upper limbs and the hands were much wasted. The
muscles of the head, neck, face, trunk and lower limbs were not
at all affected. Fibrillary contractions were seen in the upper
limbs. The symptoms began when the patient was 49 years
old, and lasted thirty-one years. It is not surprising therefore
that the case was regarded as one of myelopathy during the
lifetime of the patient. The spinal cord and nerves, even the
intramuscular nerves, were normal. The muscles were much
altered, many muscular fibers had disappeared, and those that
remained were much atrophied, many had lost the transverse

"Dejerine and Thomas. Revue Neurologique, No. 24, Dec. 30, 1904.

MYOPATHY OF THE DISTAL TYPE 25

and longitudinal striations, the sarcolemma nuclei were mul-
tiplied and some were enlarged.

The case of muscular dystrophy affecting the hands and feet
reported by C. Macfie Campbell13 was without necropsy. Other
members of the family were similarly affected. Fibrillary twitch-
ing in the interossei and short flexor of the thumb, and reaction
of degeneration in two of the atrophied muscles of the lower
extremities raises the suspicion that the case possibly may be-
long to the type of neurotic muscular atrophy.

These are the only instances in literature I know of where
muscular dystrophy gave distinctly the clinical signs of neurotic
muscular atrophy, but a case of this character with necropsy
has come under my observation. I hesitated during the lifetime
of the patient to make the diagnois of neurotic atrophy, al-
though the case was regarded by some as belonging to this
type. I hesitated because the thighs and upper arms and trunk
were also much atrophied, and I felt that the diagnosis should
be left open. The commencement of the atrophy in the lower
part of the lower limbs, the slight reaction of degeneration in
these parts, the talipes equino-varus on each side, the symmetry
and the later involvement of the upper limbs suggested the neu-
rotic form. The microscopical examination has shown a nor-
mal central and peripheral nervous system with much atrophy
and disappearance of muscle fibers.

G. R., age 28 years, was admitted to the Philadelphia General
Hospital Oct. 11, 1898, complaining of pain about the knee and
difficulty in walking.

Family history: Father died of heart disease at about 25 to
30 years of age, mother living and well, at 50 years of age.

The patient was married at 23 years or age. He has one child,
three years old, in good health. He uses neither tobacco nor
alcoholic drinks, and has been employed as a watch case engraver
since his fifteenth year.

Past medical history : He has had childhood diseases. When
ten years old he fell and injured his back and could not walk for
two months (the condition was diagnosed as spinal meningitis),
but he recovered the use of his limbs satisfactorily in about one
month after getting up. Three years ago he had an attack of
cystitis.

History of present illness : About two years ago he fell
from a street car, striking on his hip and back of his head,

"Campbell. Review of "Neurology and Psychiatry. March, 1906, p. 192.

26 WILLIAM G. SPILLER

badly bruising his right hip and thigh. He suffered no par-
ticular inconvenience from this at the time, except a slight but
constant pain in the knee joint. About six months later, upon
arising one morning, he fell to the floor and found himself
unable to walk, but this was probably not the first manifestation
of weakness. Two or three days later he was able to walk with a
cane, and after a few days could walk without it. He walked
without a cane about two weeks. During this time, while walking
along the street, he fell and had to be assisted to a car, and could
not walk during the remainder of the day. About a week after this
he was obliged to use the cane again, and has continued doing so
since. For the past year and a half the inability to walk has stead-
ily progressed, and coincident with this has been the muscular
wasting. No involvement of bladder has occurred, except a
cystitis three years ago, previous to his accident. He had noticed
weakness first in the left foot, later in the right foot, and three
months still later his upper limbs became affected. He stated
that the wasting began in the feet, extended to the legs and thighs,
and that the upper limbs were affected first in the distal parts.

Condition upon admission : He is a somewhat poorly nour-
ished adult male, of above average height ; pupils are dilated,
the left more so than the right, both react to light, accommodation
and convergence. Speech is normal. Tongue protrudes
straight and shows no tremor. Pulse is small, quite irregular;
arteries are soft.

Chest and lungs : Chest is somewhat emaciated ; expansion
is good. Lungs are normal.

Heart : Apex beat is visible and palpable in the 6th inter-
space, iV2 inches within the nipple line. First sound is loud and
strong ; second sounds are both accentuated. Liver and spleen
are normal.

Arms : Grip, right hand, is 21 ; left is 17. The arms are
emaciated, but not atrophied. Ataxia is not detected.

Legs : Marked general wasting of the muscles, apparently
equal in both legs. Foot-drop is marked. Toes are slightly
flexed. Spasticity of legs is not present.

Reflexes: Knee jerks are absent; no ankle or patellar clonus;
superficial reflexes are present. Tactile sensation is preserved and
normal. Pain and temperature sensations are normal.

Nov. 7, 1898 : Patient's physical condition is improved since
admission. No change in walking, or in rising from chair. He
is gaining slightly in weight, but complains of some pain in the
legs and ankles.

An examination of the eyes April 14, 1899, by Dr. Charles A.
Oliver showed healthy eyegrounds, paresis of left external
rectus and left superior oblique, with diplopia, which had been
present a few days. This was not persistent.

At this time he was unable to walk, and could not stand alone,

MYOPATHY OF THE DISTAL TYPE 27

although he could move his legs somewhat. Foot drop was
marked on each side. The legs could not be extended. Mus-
cular atrophy had been progressive.

On June 25, 1899, a note was made that the patient could
walk, but had inversion of the foot on attempting to walk.

Sept. 10, 1899, the patient was granted a two-days pass on
which he went out Friday. He was brought back by a patrol
wagon last night, having been picked up at Market St. ferry,
where he had suddenly lost all power of his legs. When ad-
mitted he was complaining of abdominal and lumbar pain, loss
of power in legs as well as a feeling of complete exhaustion.
This evening he is much better, and already can move his legs
fairly well, has lost much of the lumbar and abdominal pain,
and feeling of exhaustion.

Sept. 26, 1899. He has improved rapidly since his return ; he
can walk, but is still kept in bed.

April 13, 1901. Examination by Dr. Pearce. Both upper ex-
tremities, both above and below the elbow, respond quickly and
well to faradism. There is no reaction of degeneration. Elbow
jerks and biceps jerks are present, but much diminished. There
is no localized wasting in upper extremities. In the lower ex-
tremities there is marked quantitative change below the knees,
and very slight qualitative change in the anterior and posterior
groups of muscles. There is no sensory change anywhere.
Knee jerks are absent. Plantar reflex is present. No arthrop-
athies ; pupillary reactions are normal.

July 19, 1903. He has not walked for two and a half years.
Sensations of touch and pain are normal.

Aug. 20, 1903. Dictated by Dr. Weisenburg. Patient is
unable to walk ; he can flex the right thigh on the hip slightly ;
left thigh movement is very poor. No movements possible in
ankles ; he can flex or extend the toes of both feet very slightly.
Both feet are in a position of talipes equino-varus, the left
more than the right. Both feet are cold. Movements of both
upper limbs are free in all directions. Grip in the hands is al-
most nil. No power in elbows at all. Power in shoulders fairly
good. Both upper extremities, shoulders, back and chest are
wasted ; abdomen not so much. Wasting is about equal on both
sides. Thenar and hypothenar eminences on both hands are
almost absent. Atrophy of interossei is marked. In the fore-
arm the flexor group is more atrophied than the extensor ; the
biceps is atrophied on each side. Deltoid is slightly atrophied.
Pectoral muscles wasted, also the interossei on both sides.
Supraclavicular and infraclavicular fossae well marked, also
interscapular region. All muscles of the shoulder girdle are
atrophied, including the latissimus dorsi on each side. No
fibrillary twitching is noticed in the muscles. All reflexes in the
upper limbs are lost.

28

WILLIAM G. SPILLER

He has never had any urinary or rectal disturbances. The
pupils are equal, respond to light, accommodation and conver-
gence. No apparent weakness of left internal rectus or left
superior oblique. No involvement of 5th or 7th nerves. Tongue
protruded straight ; no tremor or atrophy. No atrophy of the
muscles of the face or neck.

At present the wasting in both lower extremities is about
equal. The femoral group on each side is very much wasted ;

Fig. 4. Piece of muscle from the sole of the foot in a case of myo-
pathy of the distal type. (Photographed by Dr. Alfred Reginald Allen.)

the calf muscles are wasted, as are the thigh muscles of each
side. All the reflexes in the lower extremities are lost. Plan-
tar irritation produces flexion of all the toes. Abdominal and
cremasteric reflexes are present and active.

He says he has dull pains in the legs' and arms, but has never
had any sharp shooting pains, nor any sensory disturbances like
pins and needles. Sensation is apparently normal.

MYOPATHY OF THE DISTAL TYPE

2Q

Oct. 12, 1904. Dr. Shumway: Right vision, 5-5; left vision,
5-6. External ocular movements are normal. Pupil reaction is
prompt. No diplopia in any part of the field. Fields full ; per-
fectly normal eyegrounds.

July 21, 1905. Examination by Dr. Pickett: Ankles are al-
most fixed in position of foot drop. The right knee cannot be
extended -completely. Strongest movements of the body are
extension of the feet (plantar flexion), supination of the fore-

Fig. 5. A piece of muscle from the sole of the foot in a case of myo-
pathy of the distal type. (Photographed by Dr. Alfred Reginald Allen.)

arm, then after this pronation and extension of wrist and fingers.
Preserved supinators and extensors make the forearm bulge
as if it and the bones were bent. His movements in dressing
are at times so irregular by the unequal strength of the differ-
ent muscles as to constitute a kind of ataxia.

Dec. 6, 1905. Patient's nervous condition is the same as de-
scribed above. He has a cough and expectorates moderately;

30 WILLIAM G. SPILLER

has night sweats, and the sputum shows the presence of tubercle
bacilli.

Urine analysis: Dec. 6, 1905. Yellowish; slight sediment;
acid reaction; Sp. Gr. 1010. No sugar or albumin. Micro-
scopic: red blood cells, a few; few calcium oxylates, epithelial
cells and debris.

He died Jan. 11, 1906.

This man was examined frequently and lectured upon by me
several times. He was repeatedly in my charge at the hospital.
His condition at the time of death was as follows :

The lower and upper limbs were greatly atrophied and equally
so at all parts. Contracture at the right knee was present, so
that the leg could not be fully extended upon the thigh. The
left leg could be fully extended on the thigh. There seemed to
be contracture at the right hip. Talipes equino-varus was pres-
ent on each side. No contractures were observed in the upper
limbs. Emaciation was shown also in the muscles of the trunk
and face. Slight lordosis was present in the lumbo-sacral re-
gion, and there was some protrusion of abdomen, probably
secondary to the lordosis. There was no evidence at the
necropsy of old spinal injury, and excepting the lordosis, there
was no deformity of the vertebrae. The wasting of the face may
have been caused by tuberculosis, as it was not present in 1903.

Sections from the cervical and lumbar regions of the spinal
cord stained by the hematoxylin method of Weigert or the
method of Marchi, by acid fuchsine, hemalum or thionin are
normal. A piece of muscle from the foot (fig. 4 and 5) shows
no recent degeneration by the Marchi method, but the long-
standing degeneration is pronounced, and is better shown by
other methods of staining. The fibrous and fatty connective
tissues are much increased, the muscle fibers are greatly atro-
phied. The longitudinal and transverse striations are well pre-
served, and the sarcolemma nuclei are increased in number in
some of the muscle fibers. Nerve bundles between the muscle
fibers stain well by the Weigert hematoxylin stain, as do also
sections of one of the plantar nerves. No degeneration is seen
by the Marchi method in the latter, but the blood vessels of the
nerve are thickened. A piece of muscle from the back of the
trunk appears normal.

CONSCIOUSNESS IN THE BRUTES.1
By George V. N. Dearborn, M.D., Ph.D.,

PROFESSOR OF PHYSIOLOGY, TUFTS MEDICAL SCHOOL, BOSTON.

The brutes cannot tells us humans directly whether they are
conscious or not, because they are "speechless" if for no other
reason. Opinions on the matter range from that of the zoophilist,
(who is apt to believe them all as richly endowed with thought
and fancy as himself) to the occasional physiologist, now rarer
and rarer, in whose vocabulary the term consciousness, save as
the name of an epiphenomenon in man, a "secretion" of the brain,
does not ever appear. Trite as the subject is, new biological
view-points give the matter even a somewhat novel appearace and
so lend new material to its philosophical discussion.

The problem may be approached from any one of at least
three sides, or from all three. The first of these is that of un-
technical common-sense, which means the pure reason beneath
a1l our notions, some times at fault. By "the man in the
s..* street" the brutes are considered conscious as a matter of
course, because he knows them to be built substantially like him-
self and because he sees them act practically as he would act under
like conditions, if the conditions were not too complex or too
abstract — and the average man knows himself conscious if he
knows nothing else, this being the essence of humanity. The
usual man then takes it for granted that the brutes, especially
the "higher" brutes are conscious by the innate criterion of
analogy, the perception of identity, by the doctrine of probability,
by the inherent chances of the facts as he sees them. It is likely
that no man could do better in principle than this, nor will he,
until the protozoa learn to talk ! The second side from

which the problem may be approached is that of epistemology
and metaphysics, and the more natural trend of this way of look-
ing is toward pan-psychism, the climax of rational idealism, at
no variance with science. A third way the matter may be dis-
cussed is in the light of biology, physiology, chemistry, and phy-

^ead before the American Philosophical Association in Philadelphia,
Dec. 29, 1904.

32 GEORGE V. N. DEARBORN

•

sics concurrently with psychology, the former gradually des-
scribing the details of the somatic process while the latter science
analyzes even more gradually by the aid of experiment further
and further into the description of consciousness — two "parallel"
lines of details which persistently refuse, and more and more
persistently, to "correspond." This third method of approach
rests also on analogy for any satisfaction it may result in, but on
an analogy so minute and sooner or later so complete that to
deny its consequences as to the consciousness of brutes is mere
obstinacy, the child's principle of self-supporting opposition. In
theory, this method carried out fully would amount to a demon-
stration to everyone and be the best which we could hope ever
to do. In practice, the details of the similarity in function and
structure between man and brute are not so complete but that
some still say, "We are conscious, but horses and crabs and but-
terflies are not," forgetful that this form of solipsism is natural
although illogical, and that probably could they think and speak
the horses and the crabs and butterflies would each so express
itself of all outside the limits of his own communication. The e\ i-
dence lacks only this mere affirmation of being universally conclu-
sive. The present paper attempts to approach the question as to
the consciousness of animals from what is practically this last
direction. It is the viewpoint of the physiologist, the vivisector,
the medical man, interested in the chemistry and the physics as
well as in the gross and minute anatomy of animal bodies from
ameba's to his own. It is also the viewpoint of the amateur psy-
chologist speculating where experiment is vain.

It seems to be more and more obvious that to trace out any
sort of a one-to-one correspondence between the terms of the
mind-series and the terms of a brain-series is impossible. Whether
these two be considered as causally or only as concomitantly re-
lated, whether the viewer be materialist or pan-psychist, the mem-
bers of these two empirical series cannot be made to correspond
and the likelihood of tracing out any exact back-and-forth relation
is more remote now than formerly, as detailed knowledge of the
two orders of events increases. I say this probably too dogmati-
cally for I say it somewhat feelingly, since the conviction comes
to me I confess with a tinge of disappointment. I started out on
this quest with a most unphilosophical but not unnatural bias, a
firm presupposition as a matter of course that psycho-physical

CONSCIOUSNESS IN BRUTES 33

parallelism between nerve and mind was very probable and that
only the details remained to be worked out. I have little idea how
it is with my hearers, but in myself the more I racked my ingenuity
in comparing the two series of processes back and forth, the bet-
ter, too, the details of the two series here and there became known,
the more hopeless the comparison seemed. Sometimes I tried to
make myself believe that it was only because the details were so
dim as yet, especially in the mental series, that the correspondence
did not appear and the two halves fit together like the sunset sky
and the skyline beneath it of hills and forest. This sort of har-
mony one would like to experience and 'add to his understanding
of "things as they are" ; it arouses one's scientific curiosity as
few things beside and the sense of being baffled is correspondingly
unpleasant. The pseudo-satisfaction of reducing consciousness to
a process of cortical "associative memory," as is now the fashion
among a certain school of physiologists, is a "satisfaction" as
remote as any which can be imagined, for after all the brain is
something different from a "phonograph," and mental process
unlike vibrations.

Like many others then in the same dilemma, students of both
mind and body, it seems to me inevitable that one should take
refuge in a purely logical syllogism and conclusion that somehow
or other there are not two series there at all, but only one, and
that the other inheres in this, that the body is a phenomenal aspect
of the mind or of mind. Idealism truly offers all men rational
satisfaction (but least when we try to orient in it our own bodies),
although at the same time we must sympathize with and try to
satisfy the natural realist, and even the out-and-out dualist when
he refuses to repress his human curiosity as to the magic means
by which the reason so readily fools, or let us say outreasons, its
hand-maid, sense. What the scientists need, indeed, to be taught
by students of philosophy in return for facts, is the truth, the
reality, and the importance of the idealistic view. Epistemology
should not exist for students of philosophy alone, and should not
for lack of cooperation, be considered by the average biologist
and physician and man of science a system of notions merely,
pleasant to discuss sometimes, but useless after all. If idealism is
worth its historic name, it is fit substratum for every science in
the schools, and its principles simple in themselves lend simpli-
city to many a complicated scientific snarl. On the idealistic basis

34 GEORGE V. N. DEARBORN

science gets a richness as well as a truthfulness which students of
science should not be allowed by their instructors to miss out of
their knowledge, a richness which develops into one's whole life.

The pan-psychistic aspect of the relations of mind and body
as processes, fails to show to common sense (and it is com-
mon sense which most of us are trying to impart) a working hy-
pothesis on which the scientific student may rest when, as usual,
he is not in a metaphysical mood. And of course the scientific
problem is quite independent of the philosophic problem though
not of the philosophic student, for his puzzles are also in part
those of the psychologist. So far as most of us know for a cer-
tainty, mind is inherent only in living tissues and it is inevitable
that every active inquiring imagination should insist on some sort
of parallelism if there is any sort of basis for any such concep-
tion. The fact that disembodied consciousness is to say the least
doubtful and a body therefore always accompanying mind to say
the least probable, makes this demand reasonable, and renders
necessary some sort of parallelistic theory if mind itself is to be
understood. The physiologist as a scientist is somewhat better
off, more independent of mind than the psychologist is of body,
as one sees evidenced in comparing the text-books of physiology
with those of psychology and in observing therein that whereas
the physiologies, the older ones, scarcely refer to mind, the psy-
chologies, the newer ones, refer everywhere to the bodily sub-
stratum.

Notwithstanding this dependence of an adequate empirical
psychology on the somatic process for guiding description in at
least some directions, no one has ventured to attempt to define a
plan for the psychophysical correspondence in general, and now
the problem seems, as has been said above, further from solution
than ever before although the light at present is greater than
ever. Never before was so much really known about the nervous
system with which it is customary to attempt to correlate mind,
Avhile systematized introspection continually shows us more of
the molecules, so to say, of mind. Psychophysical parallelism
must evidently take a new standpoint if it is to serve a useful
explanatory or even descriptive purpose.

The reason for this failure of correspondence more and more
lies partly in the change which our notion of the nervous system
has undergone very recently. It has lost some of the former im-

CONSCIOUSNESS IN BRUTES 35

portance accorded to it in the hierachy of the tissues and organs.
There are conditions inherent in the neurone theory of the struc-
ture of the nervous system which supported the belief that the
neurones were in a way the physical basis of mind ; for example,
they allowed of a belief in the existence of perfectly definite
centers in the brain and cord with which it was comparatively
easy to imagine that various psychical functions, for example
volitions, were connected in some way directly. Again, the nerve
cells might be similarly used, while that fugitive retraction-theory
of the neurones, although never really accepted as certain by any-
one, doubtless helped to make more tangible a vague correspon-
dence between a period of consciousness and the same period of
the functions of the nervous system. Now the tendency is more
or less away from the neurone theory. Many physiologists begin
to see in the nervous system an immensely complex reticulum of
very minute fibrils, combined mostly into axis-cylinders and here
and there surrounded and enmeshed by masses of different yet
neural protoplasm, the nerve-cells. These nerve cells are no
longer considered by many as wholly the functional centers of
the fibrils as a battery-element is the center of a telephone sys-
tem, but appear rather chiefly as organs for controling the nutri-
tion of the fibrillar network, having also important uses in coordi-
nating and changing more or less the impulses coming into them
over the fibrils. In short, the nerve-cells no longer have in many
minds the importance they seemed to have, while the fibrils, the
conducting paths, have acquired new meaning. It is the white
matter composed of fibrils which most largely serves the functions
of the nervous system, the chief of these functions being to con-
nect the separated parts of the body and the body at large with
the sense organs by which it is related to its environment. These
separated "organs" are not only the massive viscera, the muscles,
the brain, etc., but they are also single cells and groups of cells
in muscles, glands, and supporting tissues. From this point of
view the important use of the nervous system is to connect, to
coordinate, and to adjust by its own control over impulses which
are originated not within but outside of its substance, by forces
either mechanical or chemical or electrical. It is. by the newer
view, somewhat, but not much, more than a vastly complicated
system of protoplasmic bridges connecting more or less active and
extensive structures and the individual with its environment.

36 GEORGE V. N. DEARBORN

Some of these structures which the fibrils of the nervous sys-
tem connect exhibit their lack of dependence. In other ways the
predominance of muscular tissue in psychophysical processes is
equally obvious. In the perception of space and of time every
ultimate criterion is muscular in all probability, since time-per-
ception depends on bodily rhythms and space-perception, largely
at least, on movements (two-dimensional space getting its appre-
ciation from eye movements and three-dimensional from the con-
tractions of other muscles especially those of the arms and legs).
Even monocular and instantaneous perception of depth may con-
tain within it the universal influence of afferent and efferent im-
pulses connected with the tonal or more powerful contractile
movements of muscles. The category of causality seems to have
a quite similar origin in the individual consciousness, the child
obtaining this notion clearly only from his actual experience that
he can cause changes and things himself by the actuation of his
muscles. Thus the muscles, more than half the weight of the
body, concern themselves most intimately with the most basal
categories of the mind, which develop as the muscles' use and
control develop in the child. The unstriated and involuntary
muscles differ in no wise from this in principle, since they appear
to represent only another form adapted by force of the law of
habit to work even more automatically on its services very readily,
for example the heart and the glands. We need not review the
large amount of work on the contraction of muscle lately per-
formed ; here it is sufficient to summarily say that it is now
known that practically all the unstriated muscle of the body, and
the heart (although partaking of the nature of striated muscle)
can carry on their rhythmic action indefinitely when supplied
with nutriment, heat, etc., without nervous control : of this the
heart's apex, containing no known neural tissue, is the most
striking example. If we transfer our attention to the protoplasm
of simple animals instead of to the tissues of the "higher" forms,
we find quite analogous results. Thus Yerkes studying the move-
ments of the medusoid Gonionema (a jellyfish-like animal of
common occurrence), finds that the reactions of special organs
or parts are not dependent for their execution upon the functional
activity of the central nervous system, nor spontaneity of move-
ment, nor coordination, but that this last depends rather on the
rapid transmission of what is probably a muscular impulse, the

CONSCIOUSNESS IN BRUTES 37

ethers on stimuli inherent in the tissue itself (that is on nutri-
ment, ions, or what-not). In short the tissues and smooth muscle
in particular are automatic and depend on the nerves probably
only for coordination in cases where the impulses would not be
carried fast enough through the protoplasm itself, undifferentiated
into a conducting tissue. So far as the process of secretion by
epithelium is concerned it is nothing at all new that the varied
chemical reactions go on quite independently of nervous influence
save that which regulates their supply of nutriment and that
which controls the health of the protoplasm perhaps. This secre-
tory process is next in importance to the contraction of muscle.

Thus the nervous system is gradually being forced into its
proper place as a series of protoplasmic connections between parts
of tissues other than itself. If a blow on the forehead causes the
so-called loss of consciousness while an equal blow on the thigh
would cause only pain, it is perhaps because the blow in the for-
mer place by its concussion disturbs the nutrition of and partly
disorganizes a multitude of connecting fibers each bearing an im-
portant message, while the blow on the leg disturbs relatively
few connections and so causes "loss of consciousness" only in
the foot perhaps or up and down the leg. The nervous system
connects, coordinates, and adjusts the influences given out by
the body's varied bioplasm. What it conducts it does not create
(save in the sense discussed below) — it is at least as passive as
it is active. Its business is largely conduction, and in doing this
it gives the semblance of representing mind, partly because the
association of ideas does perhaps depend at once upon it, and
partly because the totality of a continuum, such as consciousness
empirically is, demands a unification in the physical basis which
unification it is certainly the function of the conducting nervous
system to supply.

In the hierarchy of the tissues of a mammal or even of any
vertebrate there are properly grades of value if we make active
service the criterion of usefulness. From such a viewpoint the
muscles are the master tissues, as indeed Foster calls them, for
it is they which most serve the purposes of the individual. Be-
sides, epithelium supplies the chemical products used in the
organic machine, the nervous system coordinates and adjusts
"internal relations to external relations," the connective tissue
binds the parts together structurally as does the nervous system

38 GEORGE V. N. DEARBORN

functionally, the bones support the body, etc. Formerly, not too
long ago, the nervous system was supposed to dominate and con-
trol the whole, not only coordinating but directing, the one tissue
in command, nearest to the soul, immediate agent of the individual
will.

Sometimes, as a mere matter of feeling, if you please, it seems
absurd to try to define any sort of correspondence between the
quite indescribable sentient experience and the body at all. Such
an attempt seems a contradiction. The sort of localization which
would call what we know as consciousness a product of the
material process seems almost an indignity, an insult, and the
impression is not premeditated but comes from an underlying
awareness of the utter contrast of the two kinds of events when
looked at casually, phenomenally and compared. Who can
imagine even that the manifold of joy and sorrow, heaven and
earth, past and present and to come of that we know and feel as
life is the outcome, the accompaniment even, save as cause, of
a small complex of physical currents or of vibrations in a brain?
In some moments such a comparison seems sheer nonsense and
absurdity, and in proportion to the smallness of the supposed
accompanying mass, to the simplicity of the supposed accompany-
ing process do the absurdity and the nonsense of such attempts
impress the mind. Only on empirical evidence which cannot be
denied is a psychophysical correspondence believable or even sup-
posable at all.

The notion of Descartes that the soul had its seat in the
pineal "gland" we hear now-a-days most often with a tendency
to smile and yet this mode of thinking is not wholly outgrown
as is evidenced by the present habit of locating consciousness in
the nervous system, or even in the cortex of the brain. The
absurdity of Descaries's supposition lies largely in the small size
of the pineal gland — there is an inevitable feeling that the more
definitely localized we consider consciousness the closer are we to
the old outworn conception of a substantial soul. Yet the custo-
mary mode of viewing the matter is not much different, only
that now the location has been extended to a brain cortex whose
gray matter, even in man. weighs only about one-fortieth of one
per cent, of what the body weighs and whose energy is in little
if in any larger proportion. The action of the white matter is
apparently as passive as that of any tissue in the body, so that

CONSCIOUSNESS IN BRUTES 39

although quite unmeasured it is insignificant compared with that
of the easily fatigued and injured gray matter in the nerve cells.
But I for one practically am quite as unable to relate conscious-
ness to the seventeen grams of gray matter in the human cortex
as to the two or three grams of the pineal gland although theo-
retically the former sort of tissue has claims which the unnervous
tissue of the conarium does not possess. Consciousness has the
earmarks (they may be specious) of experiences we know as
forceful or energetic, and it is not easy to see how so little energy
in a supposed physical concomitant could stand for experiences
at times so overwhelmingly significant and powerful. But if we
realize that the nervous system is the more or less passive distri-
butor of impulses and influences which originate without its area
in other sorts of protoplasm, we shall grade its status more
rierhtly. It is obvious that such is the case with those two large
thirds of consciousness called feeling and will, for much research
has shown conclusively that when feeling or willing is at all pre-
dominant in a period of consciousness, that practically every
portion of the organism is concerned either actively or passively,
in either case causing mechanical changes and the stimulation of
a myriad sense organs in all the tissues. How greatly indeed
feeling and will as aspects of mind predominate over cognition
we all realize, so that one is bound to admit, if he realizes how
perfect a unit the body is, that much of its protoplasm is con-
cerned in nearly all of consciousness. Two theoretical aspects of
mind, however, namely, "pure thought" and " pure sensation" are
apparentlv relatively confined to the nervous system, without in-
volving protoplasm outside it. The former of these, thought, we
shall consider later on ; the latter, pure sensation unaccompanied
bv elements of will or of emotion, is an abstraction as you all
realize for descriptive purposes only, rarely or never experienced,
for on the one hand the personal element is always present in
greater or less degree, and on the other hand it is only prac-
tically under artificial conditions that one sense organ or even
one sort of sense organ only is stimulated. But suppose a single
pain-spot on the skin to be incited to action and that affective
elements in the consequent consciousness are absent, — even then
the stimulation would only serve to direct the attention, the focus
of consciousness, without involving the great sensation-mass, for

40 GEORGE J'. N. DEARBORN

the instant submerged but by no means -abolished, as experiment
readily shows.

Another problem germain to the question of how far the ner-
vous system is adequate to represent consciousness in all sorts
of animals depends on that rather intangible inquiry as to the
extensity of consciousness, or rather perhaps, more precisely, as
to its having or not having as its basis a sensation-mass, although
the two problems are not theoretically quite the same. Is empirical
consciousness like the electric currents darting singly here and
there over an intricate system of telegraph wires, bearing with
them meaning of various sorts and one always more conspicuous
than the rest, or is it more like the mass of water making up a
• brook ? In other words, has consciousness only time-relations and
intensity or has it, is it, also something comparable in a figurative
sense to mass or substance as well as time relation, intensity, and
relative degrees of meaning? Is the varying focus of attention
all, or is there behind and beneath the attention focus of the
moment a sort of sensational substance like to a process? Is it
phenomena or noumena? Only a meaningful direction of expe-
rience or a meaningful reality? I for one confess my entire in-
ability to see it other than in the latter light, something real and
essential because complex, index of all reality besides, and in a
strictly figurative sense massive and substantial, made up mostly
of sensations.

The simile of the brook has much of suggestiveness in it —
the physical basis beneath it, the mass of on-flowing subconscious-
ness here and there disturbed by bodily conditions and determin-
ing largely the waves of attention on its surface, although these
are susceptible readily also to stimuli from without — all this is
a simile which is perhaps not only suggestive but to a degree
descriptive. Consciousness has a measure of extensity. Even
when the narrow ear drums receive the stimuli we notice it, for
we distinguish a difference between the violin solo and the music
of thirty playing in unison aside from that of intensity, while the
difference between a burn on the finger-tip and the sensation com-
ing from sinking into a bath of hot water is one of extensity
almost wholly. No explanation of this difference is so close at
hand as that based on a limited atomism in consciousness, but ar
atomism which the nervous system is quite inadequate to repre-

CONSCIOUSNESS IN BRUTES 41

sent. Witness the astonishing phenomena of the sub-conscious
mind ; hypnosis, split-off consciousness or personality, automatism,
and even of normal sleep and its varied puzzles in psychology.
These have begun to reveal to us that consciousness has a basis
and that in itself it is complex and multifold. Somehow the
consciousness so exhibited has too much of something akin to
extensity to be represented by the disparate currents along iso-
lated neural fibers or in nerve cells, particles of neural proto-
plasm scarcely less minute and themselves made up mostly of
fibrils. This complexity and this extensity argue for some sort
of representation in the animal body outside of a system of only
trivial mass and metabolism. Considered so, parallelism takes
on a new sense, the details of which because of their minuteness
and complexity may never be laid bare, no microscopes corre-
sponding to those which explore the structure of the tissue cells
being at hand to apply to conscious processes. In this way of
seeing the theory of psychical atomism, even, so much derided
formerly by some, acquires some sort of real significance, for be-
neath the discrete elements of consciousness is the cellular atom-
ism, so to say, of the animal body, —both body and consciousness
being empirical continua with more or less corresponding rela-
tions, each composed of parts not obvious to the unanalyzing view
yet each an individual series of empirical events.

(To be Continued.)

PERIPHERAL OBLITERATING ARTERITIS AS A CAUSE OF
TRIPLEGIA FOLLOWING HEMIPLEGIA.*

By Charles W. Burr, M.D.,

PROFESSOR OF MENTAL DISEASES, UNIVERSITY OF PENNSYLVANIA.

AND

C. D. Camp, M.D.,

INSTRUCTOR IN NEUROPATHOLOGY AND ELECTROTHERAPEUTICS, UNIVERSITY OF

PENNSYLVANIA.

FROM THE LABORATORY OF NEUROPATHOLOGY OF THE UNIVERSITY OF PENN-
SYLVANIA, AND FROM THE PHILADELPHIA GENERAL HOSPITAL.

We published in the American Journal of tlie Medical Sciences
for June, 1905, a paper entitled "Peripheral Obliterating Arteritis
as a cause of Triplegia following Hemiplegia, and of Paraplegia."
In it we described a not very infrequent but much neglected form
of palsy brought about by obliterating arteritis in the extremities
affected. In this condition the leg on the non-paralyzed side be-
comes as powerless as the other. Both thighs become flexed on
the abdomen and the calves on the thighs. There is marked rigid-
ity and some muscular wasting, not a local atrophy picking out
individual muscles but a general decrease in size. The skin is
mottled, bluish-red and looks and feels thin. The final condition
presents a clinical picture superficially resembling that seen when
diffuse myelitis has occurred in hemiplegia, but there is not true
palsy of the bladder and rectum. The condition must not be mis-
taken for the triplegia which sometimes occurs in syphilis as the
result of multiple cerebral and spinal lesions, nor for double hemi-
plegia or hemiplegia plus monoplegia resulting from bilateral
cerebral lesions. It slowly follows a single cerebral apoplexy, and
is caused not by secondary involvement of the spinal cord but by
disease of the arteries of the legs themselves. It occurs only in
old people whose arteries are diseased throughout the entire^ body.
There is no reason why it should not affect the arms as well as the
legs but we have never seen such a case.

During the past winter another instance of this condition has
come under our care and we now report it. The history of the
case is as follows:

W. E., a white man, 80 years old, was admitted to Dr. Burr's
service in the Philadelphia Hospital in March, 1904, and died in

*Read at the meeting of the American Neurological Association, June
4 and 5, 1906.

PERIPHERAL OBLITERATING ARTERITIS 43

January, 1906. On admission to the hospital he was suffering
from a partial right hemiplegia and aphasia. All that we could
discover concerning the history of his illness was that he had
had a stroke a few days previously. There was slight right-sided
facial palsy. He could move the tongue well in all directions.
There was paralysis of the right arm. Both legs were somewhat
weak but weakness was greater on the right side. There was no
disturbance of movement in the left arm or leg. The knee jerk
on the right side was somewhat decreased, on the left it was
normal. Stroking either sole caused slight flexion of all the toes
followed on the right side by extension of the great toe. Sensi-
bility was normal except in the right hand and forearm where
sense of touch and pain was lost. The skin over the hands and
feet was distinctly atrophic. The pupils were equal, reacted
promptly to light, slowly to accommodation. All movements of
the eyeballs were normal. The patient understood all that was
said to him but could speak very little using only single words.
He could recognize objects by sight and indicated that he knew the
use of them but could rarely call their name. He could recognize
objects by touch in the left hand but not in the right. He could
understand short written or printed words. After some days his
speech had improved a great deal and the anesthesia passed away.
At the first examination there were no contractures of either leg
or arm. By January, 1906, he was completely bedridden. Both
thighs were flexed upon the abdomen, the knees closely pressed
together, the calves flexed upon the thighs, and one foot crossed
over the other. This condition slowly increased for months. It was
not due to active spasm but apparently to shortening of the mus-
cles. The right arm was also markedly contractured, the left not
at all. The femoral pulse was palpable on either side, but the pop-
liteal pulses could not be felt. Both legs were cold, the feet bluish
and the toe-nails almost black. The right knee jerk could not
be obtained. (This may have been either on account of the great
rigiditv or because of the distortion of the knee from old disease
in it.) The left knee jerk was quite marked. Stroking the right
sole caused drawing up of the whole leg without any movement
of the toes. Stroking the left side caused no movement of any
kind. There was slight Achilles jerk on the right side, none on
the left. The biceps jerk was present on both sides. He had
lost all power of articulation except to say "yes" and "no." He
understood all simple verbal commands. Several days later he
became stuporous and died shortly after.

At autopsy the brain appeared superficially normal. There
was slight but not great atheroma of the arteries. There was
slight enlargement of the ventricles. The popliteal arteries on
both sides contained thrombi. The iliac arteries were much thick-
ened. On cross section of the brain a small area of softening was

44 BURR AND CAMP

found in the left internal capsule and another in the island of
Reil. The other lesions found at necropsy were chronic inter-
stitial nephritis, and chronic myocarditis.

Histological examination of the paracentral lobules showed
much congestion within the sections. The blood vessel walls were
orily moderately thickened and there was slight fibrous thickening
of the pia. The Betz cells, though exceedingly pigmented, ap-
peared normal by the thionin stain. The Mallory neuroglia stain
showed moderate subpial glial hypertrophy.

A series of sections of the right internal capsule showed it to
be normal by the hemalum-acid-fuchsin and Weigert hematoxylin
stains. On the left side a series of sections showed sclerosis in
the island of Reil and an area of degeneration of fibers in the
posterior limb of the internal capsule when stained by the Weigert
hematoxylin method. A series of sections of the cerebral pedun-
cles showed the left to be distinctly smaller than the right and
there was an area of degeneration occupying the middle third of
the left crusta, but otherwise the sections appeared normal. In
the pons serial sections showed degeneration of some of the
bundles of fibers of the pyramidal tract on the left side when
stained by the Weigert hematoxylin method, but no degeneration
on the right side. There was complete degeneration of the left
pyramidal tract in the medulla, but the right pyramidal tract
stained very well by the Weigert method. The small intramedul-
lary blood vessels were very prominent, caused rather by con-
gestion than by thickening of their walls. There was a fairlv
well marked subpial gliosis but no round cell infiltration about the
blood vessels nor in the pia. The cells of the nuclei of the cranial
nerves stained by the thionin method appeared to be in fairly good
condition.

Sections from the cervical region of the spinal cord stained by
the Weigert method showed an area of degeneration in the right
crossed pyramidal tract, and very slightly in the left direct pyra-
midal tract. The Marchi method revealed recent degeneration in
the same location. There was no degeneration in other parts
of the section. Sections stained by the hemalum-acid-fuchsin
method showed a well marked thickening of the walls of the finer
blood vessels making them appear unduly prominent. There was
an overgrowth of glia about the blood vessels and also a moderate
subpial gliosis. The nerve cells in the anterior horns stained by
the thionin method while intensely pigmented were otherwise
normal. Sections from the thoracic and lumbar regions of the
spinal cord do not require separate description, as the same con-
ditions were there present as in the cervical region, except that
there was no degeneration in the left direct pyramidal tract below
the level of the fourth thoracic segment.

To summarize : the findings in the central nervous system were

PERIPHERAL OBLITERATING ARTERITIS 45

only those found in an ordinary case of right-sided hemiplegia,
an area of sclerosis in the left cerebral hemisphere and the usual
secondary degeneration of the pyramidal tract on that side. There
was no evidence of a lesion on the opposite side. Other findings
in the brain and spinal cord cannot be regarded as pathological in
a man of the patient's age, as they are found in numerous persons
in whom during life there are no nervous symptoms.

Sections of the popliteal nerves stained by the hemalum-acid-
fuchsin method showed a marked increase of connective tissue
between the nerve bundles, and to a less extent within them.
There was no evidence of any inflammatory change, and by the
Weigert hematoxylin method the nerve fibers stained well. There
was no notable difference between the nerves from the two legs.
When stained by the Marchi method there was seen, in longi-
tudinal sections, black staining masses within the myelin not
having, however, a typically degenerated appearance.

Sections of the left external iliac artery showed marked ir-
regular thickening of the intima (endarteritis nodosa) and in one
portion a hemorrhage into the intima. There was marked fibrosis
of the media with calcification. Sections of the right external
iliac artery showed even more thickening of the walls and con-
striction of the lumen than the left. The left popliteal artery was
filled with a recent thrombus and its walls were greatly thickened,
especially the intima. A small blood vessel seen in the same sec-
tion, a branch of the popliteal, was almost completely occluded
by intimal thickening. The right popliteal resembled the left.

Sections of the right tibialis posticus muscle stained by hema-
toxylin eosin showed a moderate increase in the connective tissue
and of the connective tissue nuclei. The small intramuscular
nerve fibers stained well by the Weigert hematoxylin method, as
did also a nerve fiber seen within a muscle spindle. Sections of
the left tibialis posticus stained by the hematoxylin-eosin ap-
peared nearly normal. There was a slight increase in the amount
of connective tissue between the muscle fasiculi without any in-
crease of connective tissue nuclei. The muscles presented no ap-
parent increase in sarcolemma nuclei. Stained by the Marchi
method they showed distinct recent degeneration, a finely granular
fatty change, present in numerous fibers throughout the sections.

In the nerves there was but a slight fibrosis not abnormal when
the age of the patient is considered. The blood vessels showed
intense arterio-sclerosis more marked in the smaller arteries where
it produced obliteration in many. The muscles showed a distinct
degenerative change by the Marchi method of staining.

It is of course well known that peripheral arterial disease may
cause a palsy of the affected extremities. Many years ago Charcot
showed that disease of the larger arterial trunks is the cause of
intermittent claudication. It is well established that in many

46 PERIPHERAL OBLITERATING ARTERITIS

instances the motor disability of old age (often in senile para-
plegia for example) is frequently brought about not by cerebral
or spinal cord disease but by lack of muscular nutrition on ac-
count of poor blood supply through the much thickened and dis-
eased arteries and arterioles. This was the condition found in'
our patient. When there has been no preceding hemiplegia the
picture is simple enough but when the two are combined the
result resembles superficially a severe spastic myelitis.

Society proceedings

AMERICAN NEUROLOGICAL ASSOCIATION.

Thirty-second Annual Meeting, Held at Boston, June 4 and 5, 1906.

The President, Dr. Henry R. Stedman, in the Chair.

{Continued from page 779, vol. 2>Z-)

Myopathy of the Distal Type and Its Relation to the Neural Form of
Muscular Atrophy {Char cot -Marie Tooth Type.) — By Dr. William G.
Spiller. (See this journal, p. 14.)

Dr. B. Sachs said it was some time since this question had been brought
up before this association, and naturally one's views undergo a change, yet
he thought the change in views is not very great, and what changes there
are can be very readily explained. First of all it is a question of adhering
strictly to a type. He could never believe that all cases must present no
variations from that type, however, they must in the main adhere to the
form as laid down.

Now as far as the case Dr. Spiller presented is concerned, there was
involvement of face and shoulder muscles, and of course that is a case
Charcot himself would not have included under that special type, but it
seemed to Dr. Sachs a case of that type. This gradual atrophy of the
entire limb is so characteristic that it cannot be mistaken for another
disease. Dr. Sachs thought it was a form of the Charcot-Marie-Too'th
type, but an unusual form of the disease. With our present-day views of
the neurone it seemed to him that the way to look at all these progressive
muscular atrophies is to regard them as due to disease of various parts
of the secondary neurone. It matters not whether in some cases it is
purely spinal, or whether in some cases it is purely peripheral, clinically it
is important to maintain the well-established types. There is no doubt that
there are some causes at work producing the affection of the secondary
motor neurone with the muscular attachments.

Dr. Gordon said Dr. Spiller's paper shows how difficult it is to classify
these cases. We see them very frequently in hospital work.

As far as he could remember, in looking un the literature on the sub-
ject the earlier writers mentioned that in addition to the partial atrophy
there was almost always involvement of the muscles of the hands, and that
it was very difficult to divide sharply the classical types of the disease.
Take for example the question of reaction of degeneration. Quite fre-
quently we find R. D. in cases which, according to the general symptoma-
tology, should be placed among the myopathies. Moreover, not infrequently
we see cases which present some symptoms of one group of amyotrophy and
some symptoms of another group.

Recently Raymond and Guillain published a paper in the Presse
Medicate in which they called attention to an entirely new type of muscular
atrophy, but close reading of the record shows elements of all types of
muscular atrophy, so it is very difficult to define sometimes the cases of
muscular atrophy.

Dr. Spider said he believed we can recognize this distal type when the
atrophy is confined to the distal parts, but as soon as it extends into the
upper part of the limbs it becomes much more difficult of recognition. We
may then say that it is probably a case of the Charcot-Marie type, but
with the reservation that it may not be. Dr. Spiller was always doubtful

48 AM ERIC AX NEUROLOGICAL ASSOCIATION

regarding the diagnosis in his case, because of the involvement of the
upper portion of the limbs.

Peripheral Obliterating Arteritis as a Cause of Triplegia, Following
Hemiplegia. — By Dr. C. W. Burr and Dr. C. D. Camp. (See this journal,

P- 42.)

Dr. McCarthy thought this paper was something like Dr. Collins' paper
on arteriosclerosis. He called attention to this peculiar gait in his paper.
Erb recently has been calling attention to exhaustion of the upper extremi-
ties, not limiting it to the lower extremities. Many of these cases of
exhaustion of the lower extremities are senile types of paraplegia.

The matter of arteriosclerosis of the extremities is one which should be
carefully looked into. In his own autopsy work he made it a point to
examine the nerves. It is surprising to find arteriosclerosis in the peripheral
muscles. A thing which must appeal to everyone is the fact that arterio-
sclerosis is not a disease which affects the nervous system alone.

Brain Tumor Symptom, Complex with Termination in Recovery. — By
Dr. Herman H. Hoppe. (To be published in this journal.)

Symptoms Following the Occlusion of the Posterior Inferior Cerebellar
Artery.— By Dr. H. M. Thomas.

Case I. Man, aged fifty-eight. In hospital for pleurisy with effusion, and
cardiac disturbance. Sudden vertigo, pain in right side of face, tendency
to fall towards right. Vomited. Attack followed by slight ptosis of right
eye, right pupil smaller than left, no sweating on right side of face, tran-
sient lateral nystagmus. Some difficulty in swallowing. Pain and tempera-
ture perception disturbed on right side of face, left trunk and limbs. Ataxia
of right arm. Fidgety movements of both legs. Some improvement in
focal symptoms. Sudden death twelve days after onset. Autopsy. Throm-
bosis of right vertebral and posterior inferior cerebellar artery. General
arterial sclerosis, etc. Absence of marked microscopical lesions. Case II.
Man, aged forty-eight. Recurrent attacks, during a month, of numbness
in left side of face, vertigo, difficulty in speech, tendency to fall to left.
Never recovered from last attack. Examination six days after the last
attack. Vertigo from right to left, tendency to fall to left. Pupils prac-
tically equal. Crossed dissociated sensory disturbance. Left face, right
arm, body and. leg. Paralysis of left vocal cords. Sweating on right side
of face, not on left. Conjunctival, nasal and pharyngeal reflexes diminished
on left side. Slight ataxia in left arm, more marked in left leg. Condition
improved to a certain point and remained stationary nearly two years.

The similarity of these cases is evident and the symptoms point squarely
to a lesion of one side of the medulla. The author has collected about
twenty-five cases in the literature in which the symptoms indicated a similar
lesion, and in seven of these the autopsy showed a unilateral lesion in
the dorsal aspect of the medulla. These are the cases of Dumenil, Leyden,
Senator, van Oordt, Hun. Wallenberg and Babinski and Negeotte. The
positions of the lesions in these cases corresponded for the most part
accurately and involved more or less extensively the lateral part of the
medulla dorsal to the olive and implicated the following important struc-
tures :

(1) The lateral part of the reticular formation.

(2) The descending root of the V with its nucleus.

(3) Gowers' ventro-lateral ascending tract.

(4) The direct cerebellar tract and other fibres which pass into the in-
ferior cerebellar peduncle.

The lesion in each case was a necrotic process and Wernicke (1881),
who made the anatomical examination of Senator's cases, suggested that it
was due to an occlusion of the posterior-inferior cerebellar artery. Wer-
nicke directed special attention to this artery in 1895, when he reported
his cases clinically, and again in 1901 when he was able at the autopsy to
demonstrate the thrombosis of the artery as well as the area of necrosis in
the medulla almost exactly as he had predicted it. Other writers usually

AMERICAS NEUROLOGICAL ASSOCIATION 49

assume an occlusion of this artery, but none has demonstrated it. In the
author's first case, there was a thrombosis of the artery, but no softening
was found in the medulla, due, probably, to the rirh collateral circulation.
The posterior-inferior cerebellar artery has been studied by Duret and
Wallenberg.

Mr. M. T. Burrows, of the Johns Hopkins Medical School, at Dr.
Thomas' suggestion, examined the museum preparations and made a care-
ful injection of the artery, a drawing of which was shown. The anasto-
mosis between it and the neighboring arteries is very free, but varies in
different specimens. However, it appears that it very generally gives off
to the lateral aspect of the medulla dorsal to the olive a number of little
arteries which do not anastomose and are end arteries. This freedom of
anastomosis explains why the area of necrosis is so limited after the oc-
clusion of an artery with such a comparatively wide distribution, and indeed
why it may not occur.

The clinical picture in these cases is remarkably constant and sharp-cut.
The onset is sudden without loss of consciousness, and is ushered in by
intense vertigo, with nausea and vomiting and a tendency to fall to one
side. There is usually pain or some other sensory phenomenon on the side
of the face toward which the patient falls ; that is, the side of the lesion in
the medulla. There may be a difficulty of speech and an inability to
swallow, troublesome singultus and profuse sweating. Transient double
vision and weakness of the face on the side of the lesion are frequently
recorded. Upon physical examination, the most distinctive changes are in-
relation to sensation. There is very generally a crossed or alternate
sensory paresis involving the face on the side of the lesion and the contra-
lateral body and limbs. The sensory loss in the great majority of cases is
to pain and temperature alone, although in four cases all the sense qualities
were involved.

There is a marked tendency to fall toward the side of the lesion, and in
most cases there has been a disturbance of co-ordination in the arm and
leg on that side. The tongue is not generally affected, but the muscles of
the soft palate and those used in the act of swallowing have been paralyzed^
in a number of cases. The muscles of mastication are normal and the
facial muscles usually act well, although some slight asymmetry of the
face has been noted.

The condition of the eyes in some of the cases has been most interesting,
and it was to this point that Dr. Thomas wished to call particular atten-
tion. The pupil on the side of the lesion is smaller than its fellow, although
it reacts equally well. There is a slight ptosis causing the narrowing of the
visual aperture on the same side, and the retraction of the eyeball has also
been observed ; that is, the eye shows the condition characteristic of a
paresis of the cervical sympathetic, as was pointed out by Hoffman, in his
cases there was no abnormality in the secretion of sweat, and Hun's case
is the only one in which such an abnormality was noted, where there was
an increase of the secretion on the side opposite to the lesion. In both of
the author's cases, there was a loss or a marked decrease in the secretion
of sweat on the side of the lesion, and so completing the picture of paralysis
of the cervical sympathetic. In his second, no abnormality of the eye was
noted, but he thinks this may have been overlooked. In explanation of
the symptoms, the crossed disassociated sensory disturbance is believed to
be due to an involvement of the descending branch of the V and the tract
of Gowers', or tracts which ascend with it. The vertigo and tendency to
fall to the side of the lesion is explained by an involvement of fibres which
enter the cerebellum dv its anterior peduncle, or perhaps by a more direct
disturbance of. the vestibular nerve. The ataxy of the homolateral arm
and leg should be brought into relation to an interruption of tracts which
enter the restiform body; the direct cerebellar tract and fibres from the
nuclei of the dorsal column, and perhaps others, although one must think
of the tracts which descend from the cerebellum to the cord on the same
side.

50 AMERICAN NEUROLOGICAL ASSOCIATION

This paper in full will be published later.

The After-Care Movement, with Special Reference to Organization to
Help the Hospital Physicians.— By Dr. Adolf Meyer. (To be published
in this journal.)

Dr. Channing said he would like to endorse this work, and he hoped
the public understands that it is important that it should stand behind it
because it means so much to the people in every community.

Dr. Tomlinson said it may be of interest to know that the State Con-
ference of Charities in Minnesota last year began an organized effort to
establish after-care of the insane. This is at present a purely philanthropic
undertaking, and will necessarily have to be for some time. They were
trying to get physicians and philanthropic persons interested in the welfare
of patients discharged from the hospitals, and are organizing and perfect-
ing the machinery for carrying out this undertaking. The scheme, as out-
lined at the last meeting of the State Conference, is substantially the same
as that described by Dr. Meyer, but too short a time has elapsed for us to
report results.

Dr. Riggs said it is an experience common to all of us that after the
patient's return home he finds great difficulty, as a rule, in adopting him-
self to the new environment. The unstable brain responds only too readily
to every disturbing influence of his surroundings, and it is a matter of
months before it receives its final poise.

The necessity for such aid as Dr. Meyer suggests for those convalescing
from the psychoses has long been recognized by Dr. Riggs, and some six
years ago he read a paper on this subject at the annual meeting of the
Minnesota Association of Corrections and Charities at Faribault, advising
essentially the same course. Nothing could be more unfortunate than that
these persons should be thrown on the charity of the community, which is
hostile toward them.

Dr. Meyer said that the Manhattan Hospital has one paid agent, and
also some voluntary helpers, who visit the environment of patients who
have been discharged. As a rule the relations have been remarkably
satisfactory. The agent and helpers have been welcomed by the families
they have visited, and they have helped many unfortunates to be started
properly by the community.

Miss V. M. Clarke, Assistant Secretary of the State Charities Associa-
tion, has forwarded some circulars. Unfortunately they did not get here
for distribution at this session, but they will be distributed later.

The Insane Commission of the St. Louis City Jail, an Experiment in
Civic Medicine. — By Dr. Sidney I. Schwab. (To be published in this
journal.)

Dr. Channing thought this was a very admirable effort on the part of
the gentlemen concerned. He would like to ask who employs them, and
how many cases they have examined. He would also like to know how
they can afford the time it must take to give such an examination as they
ar i obliged to make.

Dr. Schwab, in answer to Dr. Channing' s question, said they were not
employed. Any judge has a right to say, "Will you come and help me
with the mental question of this case?" He has the right to ask three
physicians to examine an insane case and report. In the course of a year
they had examined thirty or thirty-five cases. In some cases a long ex-
amination was not needed. They were not obliged to examine them all at
a certain time. The cases waited in jail until they could be examined.
The court takes time to get around, so they had time enough. In St.
Louis the city jail physician is also the city physician, and he has a right
to ask them to examine a case, or the prosecuting attorney's office would
notify them.

A Case of Double Consciousness, Amnesic Type. — By Dr. Edward B.
Angell. The subject of the sketch, a frank, open-hearted Englishman, was
married on Christmas last, and within a few days had disappeared from

AMERICAN NEUROLOGICAL ASSOCIATION 51

•

home. Some ten days later a somewhat incoherent letter from him to his
wife located him, and he was brought home in a dazed and somewhat con-
fused state of mind. This mental condition so closely resembled hypnotic
state that it suggested a means of treatment. Under hypnosis, easily in-
duced, the suggestion was made that on awakening his mind would be clear.
Such was the result, and gradually he became alert, clear-minded and able
to discriminate between the unreal, dreamy states of consciousness and
the real facts of normal existence. For a dreamer of dreams his altered
personality disclosed him to be. The tale he told first differed materially
from a later one, while both became radically changed when normal con-
sciousness had become established. He had assumed a name under which
he was married, different from his own, insisted upon a genealogy, which
was fictitious, claimed a college education and a service in South Africa,
which he had not experienced; in fact, much of his memory registration
was absolutely wrong. Careful investigation disproved most of his ex-
periences. His tales were but creatures of an unstable imagination. His
consciousness, when in the abnormal state, so akin to hysteria, registered
fact and fiction alike; no discrimination being made between objective fact
and subjective image. Such is the condition of the hypnotic. There is a
subjective, unconscious falsification of memory, a species of amnesia, for
the real events of an uneventful existence and the gap is filled with
visions, with real unrealities, with plausible impossibilities. If the facts
of such dual existence could be proven much that has been accepted as
actual occurrences during the dispossession of the ego would be found
illusions. They are but shadows of reality, misty radiographs which
rapidly fade from the mind when Richard is himself again. In the present
instance the honesty of purpose and frankness of mind are unquestionable.
Whatever be the nature of this disturbance of mind it is real not fictitious.
Memory is unstable not character.

A Case of Alteration of Personality. — By Dr. Richard Dewey. An
alteration of consciousness of sixteen days' duration in a girl of twenty-
three, not amounting to double personality, being incomplete and of rudi-
mentary form. The symptom-complex embracing a history of migraine,
hysteria and an eroto-mania of homo-sexual character. The altered con-
sciousness being preceded by an evolution of systematized delusions (or
pseudo-systematized delusions invented by the patient). The altered per-
sonality consisting in an assumption by the patient of the name and
character of a person known to her and in authority over her. There being
also a total change of handwriting during the sixteen days, the same being
vertically upside down and horizontally reversed; *. e., running from right
to left.

A Case of Double Consciousness. — By Dr. Edward B. Angell.

Dr. Gordon said in the April number of the American Journal of the
Medical Sciences will be found an article by him on double ego that deals
with a case much like the cases described to-day. It was a case of a young
man above the average intelligence. It happened several times that the
manager of the place where he worked would give him an order to do a
certain thing and he would not obey, while in other circumstances he would
do it at once. Sometimes he would raise his hand to strike his wife, while
at other times he was known as a most loving husband. When reminded
of it, he would be surprised. The amnesia was complete. At the present
time the patient presents this peculiar condition. By a process of mental
analysis he has arrived at the conclusion that probably he is composed of
two beings. There is No. i and No. 2, and No. 2 is independent of No. 1.
He gave a number of instances in which he heard No. 2 ordering him to do
a certain act.

Now the question is in all these cases : What is the nature of the
disease which is responsible for this peculiar condition? Dr. Gordon be-
lieved the case which he reported to be one of epilepsy. Dr. Angell's case

52 AMERICAN NEUROLOGICAL ASSOCIATION

he believed to be a case of epilepsy. The attacks of motor aphasia are very
suggestive of epilepsy. Dr. Dewey's case, it seemed to Dr. Gordon, is a
clear case of hysteria.

Dr. Ans;ell said he appreciated the possibility of masked epilepsy as
being the cause of this condition. However, careful investigation failed to
reveal any indication of the motor symptoms of epilepsy, or even any
symptoms suggestive of petit mal.

On the Clinical Differentiation of the Various Forms of Ambulatory
Automatism. By Dr. J. W. Courtney. (Read by title.) The psychologic
distinction between the so-called epileptic fugues and the hysteric ambula-
tory automatisms presents great difficulties. This paper is a brief dis-
cussion of the psychopathology of these two types of phenomena and an
exposition of the writer's views upon the clinical symptoms which appear
to mark the line of cleavage.

Report of a Case of Huntington's Chorea in which Four Members of
the Family Were Affected. — By Dr. E. D. Fisher. (Read by title.) Father
first affected at forty-five. First son (who committed suicide) at thirty.
Second son at thirty-five. Third son at thirty.

Migraine and Hemianopsia. — By Dr. J. J. Thomas. (To be published
in this journal.) ;

Dr. Dana remembered distinctly the case of a woman thirty-three years
of age who had migraine and hemianopsia, and after one of the attacks
the hemianopsia continued. She came to his clinic and the headaches grew
better, but the hemianopsia continued. They had her examined by an
oculist, but examinations were negative. Dr. Dana believed with the
doctor that persistent hemianopsia is extremely rare, but even in young
people there is a permanent hemianopsia which shows no organic lesion.

Four Cases of Landry's Paralysis. — By Dr. J. W. Putnam. (Read by
title.) Case I. Male, aged thirty-four. Suddenly and without pain or
loss of consciousness paralyzed in the upper extremities. In forty-eight
hours the trunk muscles and muscles of lower extremities were paralyzed.
Case II. Child, aged five. Total paralysis of all voluntary muscles in
forty-eight hours. Death in fifty-five hours. Case III. Girl, aged sixteen.
Onset rapid; total paralysis in forty-eight hours. Death in five days.
Case IV. Male, aged fifty. Total paralysis in forty-eight hours, including
muscles of the throat. Recovery. In all cases the reflexes were absent.
There was bladder and rectum control. Sensation normal.

Peripheral Facial Diplegia and Palatal Involvement. — By Dr. George W.
Jacoby. (Read by title. To be published in this journal.)

A Fa>nily Form of Progressive Muscular Atrophy Beginning Late in
Life. — By Dr. William Browning. (Read by title.) A series of five cases,
three personally observed, in which the myelogenic form of atrophy began
at about fifty years of age and ran a fatal course in about two years.

A Study of the Sensory Symptoms of a Case of Pott's Disease of the
Cervical Spine. — By Dr. Frank R. Fry. (Read by title. To be published
in this journal.)

The Progression of the Sensory Symptoms in a Case of Pott's Disease
of the Spine. — By Dr. Frank R. Fry. (Read by title.) The pressure on
the cervical cord in this case was entirely from the front and very sym-
metrical and gradual, furnishing a good opportunity to study the relative
times of appearance of the various motor and sensory phenomena. The
paper is a partial record of these observations.

Multiple Miliary Metastatic Carcinomatosis of the Cerebrospinal Men-
inges.— By Dr. D. J. McCarthy. (Read by title.) A case of primary
sarcoma of the liver with a secondary nodule in the pancreas ; a local
carcinoma in the lung, with cavity formation. Large numbers of small pin-
head tumors scattered over the cerebral and spinal meninges. The lumbar
spinal ganglia presented secondary carcinoma. There was also a small
tumor on one of the dorsal roots. The gross appearance presented a pic-
ture resembling certain types of syphilitic and tuberculous meningitis. The

AMERICAN NEUROLOGICAL ASSOCIATION 53

clinical course of the disease was that of cerebrospinal syphilis.

Traumatic, Hemilingual Atrophy.— By Dr. Smith Ely Jelliffe. (Read
Ly title.) Hemilingual atrophy, due to differing causes, is not unknown.
Ascoli as late as 1894 gave a resume of 79 cases, since which time no less
than 15 or 20 more have been reported. Atrophy from trauma, however, is
much rarer, representing about fifteen per cent, of the entire number re-
ported. The present case is one of considerable medico-legal interest, as it
represents a hemilingual atrophy in a perfectly sound man following an acci-
dent. X-rav examination of the cervical vertebras reveals a partial disloca-
tion in the upper vertebra: with fracture of the spinous process of the third.
The case is interesting as one of hemilingual atrophy associated with a
lesion of the hypoglossal nerve at or about its exit at the anterior condyloid
foramen. Instances of at least five or six similar cases are reported.

Stereoscopic Radiographs of the Skull.— By Dr. Edward B. Angell.
(Read by title.) A suggestion in X-ray study of the brain.

Syphilis and Disseminated Sclerosis.— By Dr. B. Sachs. (Read by
title.)

A Contribution to the Pathology of Refrigeration Facial Palsy (Bell's
Palsy.)— By Dr. L. Pierce Clark. (Read by title.) The author has studied
two cases of this type. Dr. Taylor performed the operation of facio-hypog-
lossal anastomosis for the relief of the condition.

Case I. was typical, complete refrigeration palsy of the right side in a
woman aged 45. No family or personal history of rheumatism or syphilis.
Reaction of degeneration complete. Anastomosis performed at end of
four months. Piece of nerve excised for microscopical study showed in-
complete degeneration, with slight evidences of reparative process.

Case II. was also typical and complete in a woman aged 42, without
history of rheumatism, etc., but was of twelve years standing. There had
been no attempt at regeneration, and there was complete atrophy of the
muscles involved above the angle of the mouth, while below the latter
the muscles were partly atrophied and contractured. The miscroscopic
findings comprised complete degeneration of nerve fibers, without any
attempt of regeneration. As far as is known, but three similar cases have
been studied microscopically. Minkowski's case was believed by him to be
one of Bell's refrigeration type, but the changes reported indicate chronic
inflammation rather than primary degeneration. The case of Dejerine and
Theohari was clearly one of infectious neuritis in a cancerous patient dead
of pneumonia. Finally, Alexander's case was practically a duplicate of
the preceding. It thus appears that these three cases differ only in degree
and origin from the six recorded cases of neuritis, secondary to mastoiditis,
the latter being much more severe and extensive.

The two cases of the author, probably the first to be studied micro-
scopically, represent a purely refrigerative process; the action of cold as
a trauma upon a nerve enclosed in rigid bony walls. The congestion
arising from the cold brings about a secondary compression of all the
nerve structures in the bony canals, and more or less primary degeneration
in the periphery of the nerve is the consequence.

Circumscribed Hemorrhagic Cortical Encephalitis, with the Report of a
Case in Which the Lesion Was Limited to the Motor Zone, the Chief
Clinical Manifestation Being Jacksonian Epilepsy. — By Dr. Charles K.
Mills. (Read by title.) Circumscribed cortical encephalitis studied clini-
cally and its existence demonstrated by necropsy and microscopical examin-
ation, while not unique, is still so rare as to give value to the report of a
new case. The patient was an aged woman, who, during a few days before
her death, had a number of attacks of Jacksonian epilepsy of the arm-face
type, consciousness being retained. She was paretic in the arm and face.
No impairment of sensation was present. Necropsy and microscopical ex-
amination showed an area of hemorrhagic polio-encephalitis circumscribed
to the cortex of the arm and face areas in front of the central fissure.

54 AMERICAN NEUROLOGICAL ASSOCIATION

Lesions elsewhere in the brain were responsible for other symptoms than
the Jacksonian spasm and monoplegias.

The deduction of Strumpell that certain of the infantile palsies of
children were due to a circumscribed cerebral polio-encephalitis comparable
to the poliomyelitis causing the well-known form of spinal infantile par-
alysis has been corroborated in a very few recorded cases with necropsy. A
summary of the historv and literature of the subject is given.

Two Cases of Sfiinal Cord Surgery. — By Dr. W. C. Krauss. (Read by
title.) (i) Cyst of the spinal cord; operation, removal, incomplete re-
covery. (2) Compression of the spinal cord due to injury; operation; re-
turn of tendon reflexes. Incomplete recovery.

Herpetic Inflammation of the Geniculate Ganglion. — By Dr. J. Ramsay
Hunt. (To be published in this journal.)

Dr. Dana said he had heard Dr. Hunt discuss these points before, and
was familiar with the facts that he was to present, and he simply rose to
express his conviction that Dr. Hunt had made out a clinical entity. The
syndrome there is no question of, and the clinical type is almost absolutely
established.

He thought we could not quite do away with the ideas of the anatomists
who still look upon the geniculate ganglion as concerned with taste.

Dr. Mills said that Dr. Hunt's paper was one of the most valuable that
had been presented at this meeting, and we shall look hereafter with
interest for reports of cases of Hunt's disease.

Functional Simulation of Sensory Jacksonian Equivalent. — By Dr.
Howell T. Pershing. (Read by title.) Paroxysms of sensation like that
of faradic current beginning in left great toe and passing in regular order
to the groin; in later paroxysms extending to left side of trunk; still later
to shoulder, elbow and hand; then to lower face, causing metallic taste;
finally to upper face. Sensation followed by tonic rigidity of corresponding
muscles ending in closure of left eye. No clonic spasm. Right side never
affected. Consciousness never impaired. Attacks many times daily for
nine years. Under observation four years. Diagnosis of functional disease.
Reasons.

Spastic Paraplegia Complicated with Pregnancy. — By Dr. John Punton.
(Read by title.) Etiology. Report of a case with differential diagnosis.
Post-mortem findings.

Report of an Extraordinary Case of Hysterical Mutism. — Dr. John K.
Mitchell. (Read by title. To be published in this journal.)

Report of a Case of Brain Tumor with Autopsy. — By Dr. William M.
Leszynsky. (Read by title.) The patient was a man of twenty-five years
of age, who received a blow over the right temporal region two years be-
fore admission to the hospital. The symptoms were paroxysmal headache,
vomiting, bilateral papillitis with blindness, anosmia, diminished hearing,
and irritative symptoms affecting the right trigeminus. The motor tract
was not involved. A large tumor (endothelioma) was found compressing
the right temporal lobe.

Symptoms Simulating Brain Tumor Due to the Obliteration of the
Longitudinal, Lateral and Occipital Sinuses. A Clinical Case. — By Dr. C.
Eugene Riggs. (To be published in this journal.)

A Case of Anemia, with Peculiar Changes in the Nervous System. —
By Dr. Charles S. Potts. (Read by title.) The patient was a man of fifty-
nine. Nothing of note in the family or previous history. Ill seven years.
Vertigo, general weakness, dyspnea, and pains through the body. Marked
pallor of the skin and mucous membranes. Characteristic blood changes
of pernicious anemia. Marked weakness of both legs, the right weaker
than the left. Knee jerks and Achilles jerks increased on both sides.
Babinski reflex present in the right ; doubtful in the left. Death five days
after admission to the hospital. In the spinal cord and cortex of the brain
numerous minute cavities, not causing secondary degeneration and probably
representing pathological changes. This form of degeneration without any

AMERICAN NEUROLOGICAL ASSOCIATION 55

neurogliac proliferation unusual in anemic cords. Another unusual rinding
in anemic cords was degenerative changes in the cells of the anterior horns.
On Pathogenesis of Reflexes Apropos of a Case of Meningeal Tuber-
culoma of the Spinal Cord— By Dr. Alfred Gordon. Colored girl of
eighteen. Noticed six months prior to her admission to Philadelphia Hos-
pital a weakness in the right arm. Two weeks later weakness appeared in
the left arm and shoulder. A month later the lower extremities became
weak. Loss of control of bladder- and rectum accompanied the complete
paralysis of the extremities. The paralysis was flaccid from beginning to
the end. The patellar reflexes were abolished. No ankle clonus, no
Babinski. There were multiple bedsores. At no time patient complained
of pain. Typical signs of tubercular lungs were present. Post-mortem
record shows: Tuberculosis of lungs and pleura. On the right side of
the seventh cervical vertebra there is a tuberculous mass. A similar mass
is found in the spinal canal, and on the anterolateral surface of the dura
between the fifth cervical to the second thoracic vertebrae. The dura was
much thickened. Microscopical examination shows great destruction of
the cord between the lower cervical and upper dorsal segments. Above
this level degeneration affects the posterior columns, direct cerebellar
and Gowers' tracts, as far as the first cervical segment. The lower dorsal
and lumbar segments show degeneration in the crossed pyramidal tracts.
The most interesting changes are found in the meninges ; viz., a very
pronounced tuberculous pachymeningitis invading both surfaces of the
dura, the roots, the pia-arachnoid, and in some places also the tissue of
the cord. Besides many interesting points concerning the absence of pain,
the localization of the tumor, the extension of the pathological process, the
details of microscopical findings, the present case is important from the
standpoint of reflexes. According to some neurologists the lumbar cord
possesses an autonomous center, so that the patellar reflexes must have
for its existence the integrity of the lumbar cord. If this is suddenly
severed by a section of cervical or thoracic segments the patellar reflex will
disappear immediately after the shock, but will be re-established_ later, to-
gether with spasticity. According to others, not only the integrity of the
lumbar cord, but also of certain cerebral centers is indispensable for ob-
taining a patellar reflex, so that a permanent flaccid palsy, with loss of
patellar reflex, may ensue after a complete severance of the spinal cord.
In cases with slow and progressive transverse destruction of the segment
of the cord spastic paralysis exists from beginning to end. Raymond
(Rev. Neurol., 1902) and Senator (Deut. Ztschr. f. Klin. Med.. 1897) re-
port cases of psammoma which produced complete destruction of a cervical
segment and spastic paralysis existed during the entire course of the
affection. In the present case flaccidity existed from the beginning. The
duration of the affection was six months, a sufficient time for a descending
lesion to produce a spastic paralysis either by suppressing the inhibitory
influence of the brain or by stimulating the cells of the anterior cornua.
Assuming the existence of an autonomous center in the lumbar cord, which
in this case was totally severed from the encephalon, why did spasticity
not develop? Is not this case an illustration of the dependency of the cord
center upon cerebral centers ? We must conclude that the reflex mechanism
has multiple relations and the analysis of the accumulated observations
tends more and more to show that the exclusivism of Charcot and
Vulpian on one hand, of Bastian, Crooq, Collier and Buzzard on the
other, cannot be accepted, but that Grasset's views are more in conformity
with facts ; namely, that spinal, basal and cortical regions contain centers
for both reflexes and tonicity.

©ertecope

Deutsche Zeitschrift fur Nervenheilkunde.

(Vol. XXVII. Heft. 3-4)

10. A Case with the Symptom-Complex of Cerebral Tumor, with Termin-
ation in Cure (Pseudo-Tumor Cerebri). Cases of Pseudo-Tumor
Cerebri with Autopsy Findings, Terminating Fatally. Nonne.

ii. Do the Parathyroid Glands Play a Role in Human Pathology?
Lundborg.

12. Tetany, Pseudo-Tetany, and Their Mixed Forms in Hysteria.

CURSCHMANN.

13. Two Cases of So-Called Chronic Anterior Poliomyelitis in Father and

Son. Bruining.

14. Primary Lateral Sclerosis (Spastic Spinal Paralysis). Strumpell.

15. Obituary of Carl Weigert. Lichtheim.

10. Cerebral Tumor. — A man of 32 had a slowly developing weakness
in the right arm and right leg, and later, in the right half of the face.
There was also headache and nausea, and spasticity of the right side. In
both eyegrounds there was beginning optic neuritis, and spinal puncture
showed increase of pressure in the cerebrospinal fluid. No treatment was
employed, and the patient gradually improved, and eventually recovered
entirely. The second case, a man of 38, had vertigo, a sensation of pres-
sure in the frontal region, and some paresthesia in the right side of the
face and righ arm. This was later associated with weakness in the right
upper extremity. This increased and there was papillitis, then slow im-
provement, and finally complete recovery. Although there was no evi-
dence of syphilis, the patient had been given innunetions of mercury.
Third case, a woman of 43 developed diffuse, steadily increasing headache
with vomiting and progressive drowsiness. There was slow pulse, bilateral
choked di9c, tenderness over the head, weakness in the left facial region
and a cerebellar gait. She slowly began to improve, and in ten weeks she
was normal. Fourth case, a woman of 44, had intense headache, and oc-
casionally vomiting and attacks of vertigo. There was distinct choked
disc, a cerebellar gait and station, and excessive intracranial pressure as
revealed by spinal puncture. She was given mixed treatment, although
no signs of syphilis existed, and five weeks later had entirely recovered.
In fifth case, a woman of 47, had had a transient attack of blindness, fol-
lowed by attacks of vertigo and then intense headache, especially in the
occipital region. There were spasms in the right side of the face, weakness
and uncertainty in the right arm, bilateral choked disc, right facial paresis,
no pathological alterations in the reflexes, but a cerebellar gait. Later
there was vomiting and apathy. No signs of syphilis were present, but
syphilitic treatment was employed. The patient rapidly improved, and a
year later was well, excepting that there was beginning optic atrophy in
both eyes. The sixth case, a woman of twenty, had had epilepsy for four
months, always beginning in the right arm. The eyes were at first normal,
but later developed choked disc. There was paresis of the right facial,
increase of the tendon reflexes on the right side, but the spinal fluid was
normal in character and pressure. The diagnosis was uncertain, but was
made as probably tumor in the region of the left facial centre. The patient
had no further attacks, and rapidly returned to a normal state. The
seventh case, a man of twenty, had paresis of the left facial nerve ; paresis
of the left upper extremity, increase in the tendon and priosteal reflexes of

PERISCOPE

57

the left extremity, and some slight sensory disturbance. There was a
marked papillitis on both sides. Spinal puncture showed a marked in-
crease in intracranial pressure. There was vomiting, severe headache and
rapid increase of the paresis to complete paralysis. Upon mixed treatment
the patient rapidly improved, and three years later was entirely well
JSonne is disinclined to make a diagnosis of syphilitic new growth.

ii. The Parathyroids in Human Pathology.— Lundborg, of Upsala, who
has done such excellent work on convulsive disorders, here propounds the
proposition that the parathyroids have a definite relation to human pa-
thology, and particularly to the convulsive disorders, tetany, myoclonus,
myotonia, myatoma, myasthenia and paralysis agitans. Studies on thyroid
insufficiency have been followed by others on parathyroid insufficiency, an
excellent summary of which latter is here presented. In Lundborg's opinion
a heightened function of the gland brings about the condition known as
myotonia congenita. Myotonia and tetany have been observed frequently
a:L more .or less accompanying affections, and the author includes this
affection in his parathyroid intoxications. Occupying a close intermediate
relation Lundborg places myoclonus, concerning which affection he has
devoted some time. During his studies in myoclonus, being struck by the
frequent appearance of paralysis agitans among the myoclonus cases, he
was led to place this latter disease within the category of deficient glan-
dular sufficiency, being described by him as a chronic, progressive, hypo-
parathyroidism. He constructs an interesting diagram showing how the
affections of the thyroid, both as to diminished and to increased function
have their exact analogies in parathyroid disease. Thus on the side of in-
sufficiency myxedema is made analogous to paralysis agitans, stuporous
thyroid states _ with tetany, myoclonus 'has no thyroid analogue, hypo-
thyroid chronic has myotonia from thyroid poisoning. As for hyper func-
tioning, various psychotic states are paralleled by myatonia periodica, and
Basedow s disease has its analogue in myasthenic paralysis.

12. Tetany, Pseudo-Tctany, and Their Mixed Forms in Hysteria.—
Curschmann calls attention to the likelihood of confusing tetany with hys-
teria at times, since these patients with pseudo-tetany may show nearly all of
the objective signs of tetany itself. He cites a number of histories. In
the first patient true tetany was complicated by hysteria. The patient had
a hemitetany of the left arm and side of face, there was also an otitis
media and interna. A radical operation had been performed. A second
patient showed tetany with hysterical attacks. Chronic enteritis was also
present. The histories of three patients with Dseudotetany are then given
with a summary of the literature of Other similar cases. The author con-
cludes that practically all of the •symptoms of tetany can be found in pseudo-
tetany with the exception of the increased muscular activity to electrical
stimulation (Erb's sign). This sign constitutes for Curschmann the chief
differential diagnostic sign between true tetany and pseudotetany.

13. Poliomyelitis Anterior Chronica in Father and Son.—E ruining gives
the history of the coincidental development of this disease in a father aged
45, and son 23 years of age. No etiological factor is found, and the occur-
rence is regarded as fortuitous. A useful discussion of the differential
diagnosis of the atrophies, syringomyelia and neuritides is to be found in
the article.-

14. Primary Sclerosis of the Lateral Columns.— Striimpell returns to
the consideration of this condition and expresses the opinion that a primary
lateral sclerosis in the sense originally described by Charcot and later
studied by Erb, is a very definite disease process notwithstanding the many
recent expressions of doubt from many sides as to its true nature He
gives the complete histories with autopsy findings of three patients who had
been under observation many years. It is an uncommon disease, yet not
distinctly rare. I he symptoms on which most weight should be laid are
muscle rigidity, in the sense of hypertonia of the muscles, increase in

58 PERISCOPE

tendon reflexes. These are the first and most important symptoms, which
though related as to their pathogenesis are not identical.

Whether a paresis 'can occur in the primary sclerosis under discussion
is in StrumpeH's mind a question. The tibialis phenomenon has been
present in all of his pure cases. The Babinski reflex is not constant, but
nearly so. From the etiological standpoint Strtimpell groups his cases into
five sets, (i) A group in which family and hereditary influences speak for
some endogenous process. (2) The group of family infantile spastic
paralysis. (3) A group beginning at an advanced age with a rapid progress,
showing a tendency to diffusion of the process and allying itself somewhat
to anyotrophic lateral sclerosis. (4) Exogenous cases, with syphilitic his-
tory. (5) A hypothetical group occurring in women as a result of preg-
nancy and delivery. Sailer (Philadelphia).

American Journal of Insanity

(Vol. LXIL, No. 3, 1906.)

1. Melancholia. The Psychical Expression of Organic Fear. Wherry.

2. Gynecological Surgery in the Manhattan State Hospital West. Broun.

3. Surgery for the Relief of Insane Conditions. Witte.

4. Observations on Some Recent Surgical Cases in the Manhattan State

Hospital East. Knapp.

5. The Making of Clinical Records. Farrar.

1. Melancholia. — Reasoning that the emotions proceed from visceral sen-
sations and do not originate in the brain, the author considers melan-
cholia, a disease of the emotional sphere, to arise from abnormal visceral
conditions. He lays down the following propositions : 1. That there are
organic as well as ethical emotions. 2. That the relation of the body to
the mind is that of master to servant. 3. That the influence of the brain
has been overestimated in the production of abnormal mental states.

4. That the organic emotion of fear has its origin in visceral conditions.

5. That organic fear is a primitive instinct and necessary to the preserva-
tion of the individual. 6. That abnormal organic fear is the basis of
melancholia. 7. That melancholia is but the expression of abnormal vis-
ceral conditions. 1. The organic emotions are primary, dating back to
the time of unicellular existence, being an attribute of the cell itself.
They may be called instinctive and have to do with self-preservation and
reproduction and are primarily desire and fear. In the higher forms of
life they are tempered by experience, through which has been evolved
the faculties of reason and judgment. 2. The individual must, he thinks,
be considered as a whole, and instead of the mind dominating the body,
the mental content is made up very largely of the organic sensations,
especially being influenced by those arising from the viscera. The con-
sciousness of self which is made up of these organic sensations can hardly
be separated from the general mental state at any time. 3. Taking as an
example the action of alcohol or of morphin, the author thinks it in-
correct to assume that the symptoms observed after overdoses of these
drugs are due to their action upon the brain especially, but holds that
their effect upon other cells, as those of the liver, etc., with resulting
bodily sensations, are equally responsible. 4. In support of this proposi-
tion, he alludes to the depressing effect of disorders of the stomach, the
intense apprehension of heart disease, especially of angina pectoris, etc.
The author believes that the feeling of fear always arises from condi-
tions of the thoracic or abdominal viscera. 5. Organic fear has to do with
self-preservation, and is primitive, being traceable back to the cell itself.
"A continuous feeling of fear can only come from abnormal bodily cells
which are reacting to a disease whose toxicity is neither so overwhelming
as to prohibit the reception of sensory stimuli by the brain, nor so acute
as to awaken the attention of consciousness to the fact of its presence."

6. Analyzing the symptoms of melancholia, the author finds that they all

PERISCOPE 59

cluster around the feeling of fear. In pure melancholia there is no in-
tellectual impairment. Such impairment when present points to the inci-
dent of dementia which he holds is due to concomitant brain involvement,
and cannot correctly be considered as a result of melancholia. 7. That
melancholia is an expression of abnormal visceral conditions he thinks
is shown by the fact that it has always been known as the most, if not the
only, curable of mental disorders. Empirically it was found that to
effect a cure, treatment had to be addressed to the visceral disorder or to
abnormal nutritional state nearly always present. On the other hand, in
the presence of disease leading to definite changes in the brain, we in the
main stand powerless.

2. Gynecological Surgery. — The author proceeding upon the very
reasonable assumption that the same indications for surgical intervention
exist in the insane as in the sane; namely, that conditions interfering
with the patient's comfort or health, or threatening life, when possible
should be relieved by operation, has operated upon 242 women patients in
the Manhattan State Hospital West. Among these there were 62 abdom-
inal sections, 51 operations for displaced uterus and 129 minor plastic
operations. His 'results were : One hundred and twelve patients markedly
benefitted physically, and 107 patients notably improved. Five patients
died, but in only two of these could death be directly attributed to the
operation, 138 of these patients still remain in the institution, 104 have
been discharged. Of the latter number, 43 are recorded as having re-
covered mentally, and in .twenty of these recovery was materially hastened
as a result of the physical improvement following the operation. In no
case did the author attempt the removal of healthy ovaries and tubes with
a view of curing the insanity. On the contrary, he strongly opposes this
procedure. From his own experience, and from the statistics of other
operators, he thinks that insanity rarely occurs as a direct result of an
operation legitimately called for, though he is apparently of the opinion
that the removal of healthy pelvic organs on whatever ground is likely to
have a disastrous effect upon the nervous system. His various operations
with results are exposed in tabular form.

3. Surgery for the Relief of Insane Conditions. — In the estimation of
the value of surgical procedures in the insane, the author thinks that most
reporters have laid too little stress upon the element of time on the one
hand, and on the effect of the operative shock upon the innervation and
metabolism on the other. Operations for the relief of insanity, group
themselves mainly under those practiced upon the head, and those upon
the female pelvic organs. In the former class of cases, the trouble is un-
fortunately generally of too long standing for much likelihood o'f perma-
nent relief. Early operations offer distinctly more hope. The author
illustrates this by the histories of some cases, in most of which the out-
come was disappointing. He formulates his opinion as to the prospects
of relief o<f insanity by operations upon the female pelvic organs as fol-
lows: 1. Relief of the mental condition is not to be expected from opera-
tive interference where there is no actual disease of the pelvic organs.
2. In pelvic diseases complicating insanity often much good in improving
general health and comfort, and thereby aiding mental restoration may be
accomplished by the less heroic measures. 3. In the insane, as in the
sane, pelvic disease which is interfering with health or comfort, and is
remediable by surgical intervention should be treated by such measures as
are appropriate. 4. Surgical measures intended to annul proereative
power are indicated and justified in certain types of insanity.

4. Some Recent Surgical Cases. — Note on certain operations performed
at the above institution mainly by Drs. Guiteras and Lusk. Of interest
from a psychiatric point of view is the following: A man forty-two years
old having melancholia of four years duration (which had followed an
operation for appendicitis, with subsequent peritonitis), was noticed to be
failing mentally and to have some loss of power in the muscles of the

60 PERISCOPE

throat. He next became excited and had epileptiform convulsions, during
one of which he fell striking his head in the left frontal region. Remain-
ing unconscious after the injury for two days and presenting symptoms of
cerebral pressure, he was trephined over the seat of injury. 'No fracture
was found, but the dura buldging through the opening was incised, and
six drachms of fluid evacuated. The patient gradually improved after the
operation, though twelve days later he had another convulsion (attributed
by the author to an external cause). After some weeks he brightened up,
and eventually made a complete recovery both mentally and physically.

5. Clinical Records. — The author introduces the new department of
"Clinica'l Psychiatry" in this journal with some suggestions as to the
methods of making and keeping the clinical records of the insane, and
gives a provisional schema. (Allen) Trenton.

Journal de Neurologie

(Vol. XL, No. 5, 1006.)

1. Spasmodic Laughing and Weeping. Deroubaix.

2. The Patellar Reflex is Independent of the Surface of the Percussor.

Costex.

3. The Pathogeny of Hematoma Auris. Darcanne.

4. Kernig's Sign in General Paresis. Darcanne.

1. Spasmodic Laughing and Weeping. — The majority of authors have
located the lesion causing the above symptoms in the basal ganglia, re-
spectively in the optic thalamus, and in the corpus striatum. The author
reports two cases in which it was observed, and in one of these an autopsy
was obtained. In both cases there had been an apoplectic attack. The
first patient had general feebleness of the muscles of the face, tongue and
limbs, with mental impairment, which improved up to a certain point, no
definite speech trouble, but accesses of spasmodic weeping, not due to a
depressive affect, but which the patient himself declared to be purely in-
voluntary. A sort of spasmodic laugh could be provoked, but it was im-
mediately followed by weeping. The second patient, a man thirty-eight
years old, after a "stroke" presented left hemiplegia affecting especially
the arm, no aphasia or dysarthria, spasmodic laughter followed by weep-
ing, and accompanied by associated movements in the paralyzed left arm.
Death from another stroke. The autopsy showed atheroma of the cere-
bral arteries, with a large area of softening, which had destroyed the
lenticular nucleus, the anterior limb of the internal capsule, and all the
white matter of the frontal lobe, and of the central region, to the cortex, on
the right side. The optic thalamus, genu and posterior limb of the inter-
nal capsule were not affected, and on the left side of the brain there was
no macroscopic lesion. The author draws the following conclusions :
1. The function of emotive expression probably passes outside of the
pyramidal fibres, like the functions of coordination and tonus. 2. The
optic thalamus is the seat of the automatic movements of emotive expres-
sion (especially of laughing and crying). 3- Laughing and crying are
under the control of the cortex. 4. The cortico-thalamic fibres pass in
front of the knee of the internal capsule, probably by the lenticular
nucleus. 5. A lesion of the cortico-thalamic fibres in question suffices to
provoke the exaggeration of the emotive psycho-reflex ;_ that is to say,
spasmodic laughing and crying, either isolated or associated. The sim-
plest explanation consists in admitting the presence of crossed fibres in
the thalamo-facial fasciculus. 6. Spasmodic laughing and crying are not
in relation with the "conscious emotive constellation" of the patient. 7.
The substitution of crying for laughing in the same emotive convulsion
tends to prove that the" tbalamo-bulhar conduction of laughing and crying
is effected through a single -fasciculus whose fibers govern antagonistic
muscular groups. 8. There appears to be a clinical and anatomo-pathologi-
cal relation between the pseudo-bulbar. and the Parkinsonian syndrome.

PERISCOPE 61

g. The corpus striatum has a relation to the innervation of the sphincters.

2. The Patellar Reflex. — The author making some experiments with
his "reflexometer" has found that the force of the patellar reflex is inde-
pendent of the size of the percussion hammer, provided it is kept small
enough to impinge upon the tendon only. He also reports some experi-
ments upon the relation between the period of latency of the muscular
contraction and the intensity of the excitation. For these the myograph
in connection with his reflexometer was used. His subjects were mainly
precocious dements. He finds that the period of latency varies inversely
with the intensity of the stimulus, this intensity depending upon the force
of the percussion shock and the muscular tonus.

3. Hematoma Auris. — The author, after careful bacteriological exam-
ination of the blood from hematomata in five general paretics failed to find
bacteria in any case. He concludes that hematoma is always of traumatic
origin. He points out its infrequency in the women's wards where
roughness of attendants is less apt to manifest itself in boxing the ears;

4. Kernig's Sign in General Paresis. — In twenty-six female paretics
examined by the author, in ten Kernig's sign was present. Of these ten.
two were in the second and eight in the final stage of the disease. He
also found it in four males. Of the ten women exhibiting it, six had ex-
aggerated reflexes, six ankle chlonus, and five Babinski's symptom. He
thinks that Kernig's sign may have considerable importance, especially in
doubtful cases. Prognosticafly it would indicate progressive involvement
of the spinal cord.

(Vol. XL, No. 6, 1906.)

1. Second Note on the False Reminiscence. Fere.

2. Infantile Paraplegia, Insidious Onset, Stationary Condition, Then Ex-

aggeration. Bouchaud.
1. False Reminiscence. — Note on two cases of neurasthenia in which,
among other troubles, there were false reminiscences; i. e., the idea of
having previously seen persons or things which really presented them-
selves for the first time. Cure under treatment of the underlying condi-
tion.

■ 2. Infantile Paraplegia. — A child at the age of one year had a severe
infection (presumably pneumonia), which left her very weak, and at
twenty-ttwo months of age, she could not walk except to make a few steps
when" supported, her legs bending under her. Her condition remained
stationary until the age of six years, when the legs gradually grew weaker
until she could no longer retain the erect position. The author examining
her about two years later, found a flaccid paralysis of the legs, with some
atrophy and altered electrical reactions, loss of reflexes, no sensory trouble
or bladder disturbance, arms normal, mental condition good, and no
growth anomalies. He is inclined, by process of exclusion, to regard the
case as one of poliomyelitis with a recurrence, and discusses the various
theories put forward to account for such recurrences. Apparently he
leans toward the idea of a reinfection.

(Vol. XL, No. 7, 1906.)

1. Atypical Forms of Dementia Praecox. Crocq.

2. Location in the Cranial and Spinal Nerve Nuclei, in Alan and in the

Dog. Parhon and Nadejde.
1. Dementia Prcecox. — The author considers a class of cases which,
while evidently examples of dementia precox, seem to represent a milder
form of this disease and are capable of recovery to such an extent as to
be able to again fill a place in the world, providing that their duties are
mainly of an automatic character, and do not require much judgment. A
later remission with ultimate termination in dementia is, however, to be
feared. These cases coincide in the main with the heboidophrenia of
Becker and Kahlbaum. The author recognizes several forms, the first
consisting chiefly of mental deterioration, with loss of affective sentiments,

62 PERISCOPE

while rnemory and inferior acquirements may be retained, but without
excitement, depression or delusional ideas. A 'more severe condition con-
sists of the above symptoms with vague delusions, while in third form the
delusions are more marked, as is also the tendency to dementia. The last
variety, especially, tends after apparent recovery to irecur and eventually
to pass into the typical picture oif dementia prsecox, though for years such
patients may play a certain and even conspicuous role in the world though
recognized as "peculiar." He gives the histories of two typical cases.

2. Location in the Cranial and Spinal Nerve Nuclei. — Since the ques-
tion of the muscular localization in the spinal and bulbar nuclei is by no
means settled, the authors urge that no opportunity to examine a case
likely to shed light on this subject be neglected. Such cases are likely
to be found among the inmates of alms houses and asylums; for in-
stance, such persons as have lost a limb, or segment of one, have diseases
destroying one or more muscles, or poliomyelitis with atrophy sharply
localized in one or more muscles. They give here the results of examina-
tion in the case of a man in whom a cancer had destroyed nearly all the
tongue, the muscles of the floor of the mouth, the anterior belly of the
digastric on both sides, while on the left, the sterno-mastoid, the posterior
belly of the digastric, the stylo-hyoid and the platysma were affected.
From the degeneration of the cells found in the upper cervical, the bulbar
and the pontine nuclei, they make the following localizations. The sterno-
mastoid in the central group of cells of the first and second cervical
segments.

The muscles at the base of the tongue, in the external group of the
upper part of the hypoglossal nucleus ; the genio-hyoid in the anterior
group of the same region; the posterior belly of the digastric, the stylo-
hyoid, and stylo-glossus in the second ventral group of the facial nucleus,
the mylo-hyoid, in the lower part of the motor nucleus of the trigeminus
(probably the anterior belly of the digastric is also innervated from this
nucleus). It has been asserted that the mylohyoid is innervated from the
facial nucleus, but the results obtained in this case, and also those from
some further experimental work on dogs would indicate that it is repre-
sented in the trigeminus nucleus. These dog experiments also would seem
to show that the masseter, and probably the pterygoid is represented in
the posterior group of the motor trigeminus nucleus.

(Vol. XL, "No. 8, iqo6.)

1. Physical Troubles in States of Stupor. Soukhanoff and Petroff.

2. Penal Reform from the Anthropological and Psychiatric Point of View.

Van Ha mel.

1. Physical Troubles in States of Stupor. — Description of the case of a
man of thirty-eight years of age, who on two occasions, while a political
prisoner, had attacks of mental disturbance characterized by hallucinations,
illusions and delusions of persecution. Recovery from the first attack, but
the second has persisted. Attempt at suicide by biting the radial arteries.

The physical troubles consist in a peculiar retardation of respiration,
the number of respiratory movements varying from six to eight per min-
ute, rising to ten upon excitement, weakness of the pulse, and cyanosis
and edema of the lower limbs even when kept in bed, and a leg ulcer
possibly of trophic origin. Towards the latter part of the time there was
slight febrile movement and chronic inflammatory trouble of the lungs
was suspected, though on account of the shallow breathing of the patient,
satisfactory physical examination was impossible. The case is considered
as one of chronic confusion, or as probably belonging to the dementia
praecox group.

2. Penal Reform. — A report made at the recent Lisbon Congress of
Medecine, which exposes the author's views as to the aims which should
guide the administration of penal reform. Summarized they are as
follows : Penal reform should have as its aim, the diminution of crime.

PERISCOPE 63

This is an end at once practical and realistic, and should not have as its
point of departure any dogmatic religious, philosophical or ethical system.
The object should be to decrease the number of criminals, not to increase
the number of those punished. The combat against crime should be
regulated by scientific study of its causes — criminal etiology. These causes
are general and personal. The general causes are mainly social, the per-
sonal causes, anthropological. Penal justice should dispense measures of
social education to corrigible, measures of social protection to incorrigible
criminals. The distinction between young and adult criminals is of less
value than one based upon psychological state, social needs, and to what
extent they are a danger to the community. Much latitude should be left
to the judge in the choice between a number of educational and protective
measures. In order to assist him to make a proper choice, a psychiatric
service should be attached to each tribunal and to each correctional estab-
lishment. A great stumbling block is the divergence between legal and
medical views as to what constitutes oriminal responsibility. The legal
division of criminals into the two classes of responsible and irresponsible
is fallacious and should be abolished. In the study of the individual there
should be noted especially psychical state, dangerousness _ and whether
probably corrigible or incorrigible. The testimony of the trained physician
should form a part of each criminal procedure, though examination by him
is not necessarily indicated in every case. Two elements should decide
whether his services are needed or not: 1. The nature of the act of the
individual, and (2) the nature of the correctional measures whose appli-
cation is under consideration by the tribunal.

(Allen) Trenton.

Archiv fur Psychiatric und Nervenkrankheiten

(Vol. 40, Part 3-)

25. Frequency and Causes of Mental Disorder in the German Navy, with

a Comparison of Army Statistics. Podesta.

26. Globus and Aura. Max Buch.

27. Disease of the Ventral Horns in Tabes Dorsalis. (Conclusion.)

Michael Lapinsky.

28. Acute Juvenile Dementia. M. Fuhrmann

29. Three Cases of Organic Disease of the Brain with Psychosis. Otto

Kern.

30. Self-Accusing Insane. E. Meyer.

31. Spinal Cord Lesions and Progressive Paralysis and Their Significance

in the Explanation of Argyll-Robertson Pupil. Kinichi Naka

32. Paralysis and Trauma. C. Gieseler

33. Physiological and Pathological Sleepiness. Hans Gudden.

25. Mental Disease in Army and Navy. — Podesta, from the point of
view of a physician in the navy, calls attention to the increasing amount of
mental disorder in the army and draws comparisons between this situa-
tion and the occurrence of like disorders in the navy. The discussion of
the various types of disorder met with is extremely detailed and based on
much careful statistical study. He finds that in the later terms of service
general paralysis, epileptic insanity, paranoia and mania are frequent in
the army, but less so than in the navy, where especially paranoia, general
paralysis and alcoholic insanity are particularly pronounced. Neurasthenic
and hysterical conditions are likewise frequent in the navy, together with
a considerable amount of general weak-mindedness. The greater amount
of such difficulty in the navy is attributed to the peculiarity of the service.
A large proportion of the cases occur in the later years of service among
the officers. Service in the tropics is also held in a measure responsible.
As a study of secondary causes the article. is of much interest.

26. Globus and Aura. — This paper is a comprehensive attempt to ex-
plain on an anatomical and physiological basis the well recognized symp-

64 PERISCOPE

torn of globus, often, as the writer maintains, erroneously termed globus
hystericus. Buch is of the opinion that the popular conception that globus
is a pathognomonic symptom of hysteria is wrong, and that it very fre-
quently occurs in conditions quite distinct from this neurosis. Globus
hystericus, he thinks, is simply neuralgia of the sympathetic, and occurs
only in disorder of that nervous mechanism. That it occurs with hysteria
does not justify its acceptance as a symptom of that disorder. Among
twenty cases examined by him not one showed evidence of hysteria. In
two other cases in which hysteria was a possibility there was no globus.
As a basis for globus he finds chlorotic and anemic conditions conspicuous.
In general, the symptom is due not to a central nervous disturbance, but
rather to a local hyperexcitability of the sympathetic. Treatment by
iron and arsenic is successful.

27. Ventral Horn Disease in Tabes. — Lapinsky reaches the following
general conclusions in his exhaustive paper: That the statement of
Dejerine and his pupils that the atrophies and paralyses of tabes depend
upon peripheral neuritic alterations primarily has a limited application;
that cases occur in which a primary degeneration of the ventral horn cells
takes place; that in those cases in which the muscular atrophy depends
upon disease of the ventral horn cells the disease develops sub-acutely and
is not inflammatory; that the affection of the ventral horns appears in two
forms, either diffuse or in the form of localized areas of degeneration ;
that in the localized form of disease the affection bears no resemblance
to poliomyelitis because of the lack of evidence of inflammation; that both
localized and diffuse processes may coexist in the same case ; that altera-
tions of vessels, degenerated collaterals of dorsal roots, alterations in the
pyramidal tract, and atrophied ventral horn cells stand in relation to each
other; that the various pathological alterations determine the character of
the disturbance in the horn, and finally, that the paralyses, pareses, atro-
nhies and changes in the muscular system of spinal origin, are to be re-
garded as the result of a localized disorder of the spinal cord. An exten-
sive bibliography follows this article.

28. Acute Juvenile Dementia. — After commenting on Kraepelin's ser-
vice to psychiatry in bringing into prominence the symptom group of de-
mentia prsecox. Fuhrmann proceeds to report three cases which he re-
gards as belonging to the group of paranoid dementia praecox. The cases
are reported at ereat length, and lead, in general, to the following con-
clusions : An acute psychosis going on to dementia was observed in three
young adults, in all of whom there was a family history of alcohol in the
father. The initial stage in one instance resembled a delirium tremens, in
the others, an acute alcoholic hallucinosis. The interesting question is
raised as to whether such a psychosis in the descendants could result from
excessive alcohol indulgence in the parents, and the opinion is ventured
that the alcoholism of the father gave the psychoses of the sons their
peculiar alcoholic stamp, and further that there is reason to suppose that
the psychoses were directly caused by the alcoholism of the fathers. The
writer is not content with the term dementia praecox for these cases, and
gives the name acute juvenile dementia, with the possible qualification on
the basis of a degenerative alcoholic taint.

29. Brain Disease and Psychoses. — Kern reports three cases of struc-
tural disease of the brain associated with a psychosis. The first case during
life gave the general picture of catatonia; a preliminary melancholic stage,
sudden condition of agitation, later impulsive acts. The autopsy showed a
brain abscess in the left cerebrellar hemisphere. The second case showed
at the age of twenty-nine certain mental alterations associated with sleep-
lessness, followed by apathy, abulia, refusal of food, and suicidal ideas,
together with headache and twitching of the extremities. She was later
depressed, but suicide was never a prominent feature. The autopsy showed
a large glioma of the left parietal lobe and central ganglia. The third
case developed an acute psychosis at the age of twenty-eight, with con-

PERISCOPE 65

fusion and occasional violence, associated with excitement and motor un-
rest, which went on to a marked mental alteration. The autopsy showed
a rather small sarcoma in the white matter of the right frontal lobe, and
a lame hemorrhage in the right lateral ventricle. A discussion of the re-
lation of mental distubances to new growths and remarks on operative
interference conclude the article.

30. Self-Accusation. — Meyer discusses that type of mental disorder,
prevalent in the sixteenth and seventeenth centuries, and also in later
times, wherein the prevailing mental state is one of self-accusation. Cases
are reported and the medico-legal bearings of the psychosis are considered.

31. General Paresis and Cord Changes. — In this paper Naka gives an
exhaustive study of the now generally recognized alterations in the spinal
cord in general paralysis, together with a discussion of the Argyll-Robert-
son pupil. A careful historical consideration of the subject precedes the
writer's personal investigation, which covered the study of forty-three
spinal cords in progressive paralysis. In these forty-three cords he found
only once isolated degeneration of the pyramidal tracts, six times isolated
degeneration of the dorsal tracts, and thirty-five times combined disease of
the dorsal and lateral tracts. In but one case was the cord normal. In
twenty-three of the cases there was total failure of the pupils to react to
light, and in twenty-six increased knee jerks. In thirteen cases the knee
jerks were lost on both sides, in two normal and in two unequal. A cer-
tain number of the cases are reported in detail, and the paper, in general, is
a valuable statistical study of the spinal cord alterations in general
paralysis.

32. General Paresis and Trauma. — Giesler in this paper discusses the
difficult question of the relation between general paralysis and trauma.
Such an association has been assumed in a certain proportion of cases by
a large number of writers. Geisler reports six cases relative to this dis-
cussion. In these cases syphilitic infection did not definitely occur, al-
though there was a possible suspicion of its existence in two. It was also
shown that alterations of the skull or brain could not be brought into
association with previous trauma. This, however, is naturally maintained
not to prove that trauma may not have been a positive factor. It is, how-
ever, concluded that it is unlikely that even a very considerable trauma
can be the sole cause of general paralysis, although from the practical
standpoint it may be regarded as a contributive cause. Caution must,
however, be observed in estimating the etiological significance of trauma.

33. Pathological Sleep. — Gudden discusses the question of pathological
sleep on the basis of many carefully formulated cases. He concludes that
the most conspicuous sign of pathological sleep is a shifting in the return
of consciousness and the capacity for action; that the development of the
disturbance is often favored by the weakness or the failure of definite im-
pressions before going to sleep, which are of significance for the quick
return of consciousness on awakening; that in -a similar way long persis-
tence of states of anxiety before sleeping favors its development; that the
feeling of discomfort normally associated with early awakening plays a
part in the thoughts and actions of those overcome with sleepiness, and
that pathological sleep is often continued over a long period of time with
certain complications. E. W. Taylor (Boston).

Miscellany

Treatment of Selected Cases of Cerebral, Spinal and Peripheral
Nerve Palsies and Athetoses by Nerve Transplantation,
with Report of a Case of Athetosis Benefited by Operation.
By William G. Spiller, M.D. ; Charles W. Frazier, M.D., and J. J.
A.- Van Kaathoven, M.D. (The Amer. Jour, of the Med. Sciences,
February, 1906).
Dr. Spiller discusses the treatment of anterior poliomyelitis by nerve
transplantation, the results of which in selected cases have been very en-
couraging. The chief dangers in operating on cases of anterior poliomyelitis

66 PERISCOPE

are delayed union and overgrowth of connective tissue in the nerve at the
seat of the operation. It is hardly advisable to cut a healthy nerve entirely
across, as Kilvington suggests, on account of these dangers, but where the
fibers are small, as are those supplying the anterior tibial muscle, probably
a sufficient number of nerve fibers are cut in the healthy nerve by the
longitudinal slitting and the insertion of 'the diseased fibers within the slit.
In a number of cases there is a distinct difference in the degree of paralysis
of the flexor and extensor muscles in a hemiplegia developing in early life.
Athetosis only occurs when the paralysis is incomplete, but in severe
athetosis the patient has little or no voluntary control of his limbs, and the
flexors are usually much more powerful than the extensors in the upper
limbs. It was suggested by Dr. Spiller that there could be switched off, so
to speak, some of this excessive innervation of the flexors into the extensors
by nerve transplantation, in this way establishing a more nearly normal
relation between certain groups of muscles and their opponents, and by
the division of the nerves lessen the athetoid movements probably
permanently. This operation was tried on a man nineteen years old, 'who
had had athetosis all his life, except possibly during his first year. His
upper limbs were jerked about most violently, but the flexor muscles were
far more powerful than the extensors. The first operation was done on the
left extremity — lateral anastomosis of the divided median and ulnar nerves
to the musculo-spiral nerve. After this operation the movements were
almost entirely confined to the muscles of the shoulder. At a second opera-
tion on the left upper extremity the circumflex and musculo-cutaneous
nerves were divided and an end to end anastomosis effected between the
central ends of the one and the distal ends of the other. Seven and a half
months after the operation the results were encouraging, the patient is far
more comfortable than before, and there is nothing to indicate that the
athetosis will leturn. It is important to have established that, with partial
paralysis produced by operation on nerves, athetosis disappears. Though
the musculo-spiral nerve was not cut transversely, yet a partial return of
function occured in the distributions of the median and ulnar nerves. This
result justifies the end-to-side anastomosis which has been advised for the
treatment of anterior poliomyelitis when the paralysis is confined to one or
two muscles.

C. D. Camp (Philadelphia).

Tabes Dorsalis. By David Ferrier (The British Medical Journal, March
31, April 7 and 14, 1906).
After discussing the different theories of the pathogenesis of the disease,
the author adopts the hypothesis of Turner and Hauser that the essential
lesion is a dystrophy, similar to that, induced by certain toxic agents,
affecting the 'sensory protoneurone as a whole and manifesting itself by
degeneration of both the central and peripheral terminations of which the
intramedullary are the most vulnerable and are usually the first to exhibit
anatomical change. The author is in favor of ascribing a syphilitic origin
to the disease. Concerning a diptheroid bacillus as the cause, as expounded
by Ford Robertson, the author has made some supplementary researches
and gives as his verdict "not proven." The physiological pathology of
tabes is discussed with especial reference to the ataxy and the tabetic pupil,
the latter being explained by the degeneration of the ciliary ganglion.

C. D. Camp (Philadelphia).

Tetany. A Report of Nine Cases. By Campbell P. Howard, M.D. (The
Amer. Jour, of the Med. Sciences, February, 1906).
Nine cases are reported in detail, seven in adults. Six of the cases were
of gastric origin, one of purely intestinal origin, is "the only adult case in
the American literature of the past decade." The infantile cases both
showed signs of rickets. None of the accesory phenomena, Erb's, Trous-

PERISCOPE 67

seau's, Chvostek's or Hoffman's were constantly present. The author
adopts the etiological classification of Frankl-Hochwart. The pathogenesis
of tetany is still conjectural, but in one of the cases in this series there was
found evidence of abnormal activity of the cells of the parathyroid gland, a
suggestive finding. C. D. Camp (Philadelphia).

Researches on the Blood of Epileptics. By B. Onuf, M.D., and Horace
Lograsso, M.D. (The Amer. Jour, of the Med. Sciences, February,
1006).
The study of the formed elements of the blood was carried out on one
patient, a hystero-epileptic colored man. It was found that a leucocytosis
may be present directly before a seizure and is then, of course, not a purely
secondary phenomenon produced by the seizure. A grand mal seizure need
not necessarily be preceded or ushered in by a leucocytosis. There is no
absolute parallelism between seizure and leucocytosis in so far as, even
when a distinct leucocytosis is present, such may reach its height at differ-
ent periods in different seizures. The leucocytosis is in pant at least inde-
pendent of the seizures. C. D. Camp (Philadelphia).

Abscess of the Brain, with a Report of Five Cases. By H. F. Stoll, M.
D. (The Amer. Jour, of the Med. Sciences, February, 1906).
Five cases are reported in detail and a general review is given of the
course, symptoms, diagnosis and differential diagnosis of the disease. The
interesting feature of the first case is the etiology, which is considered
to have been a slight trauma to the head. The second was metastatic, the
primary focus being in the lung. In the fourth case, abscess of the right
tempero-sphenoidal lobe, the patient lost the use of English and was able
to understand only Swedish, his mother tongue. The treatment recom-
mended is a prompt operation when the diagnosis is "reasonably certain."

C D. Camp (Philadelphia).

Genius and Degeneration. By H. Edwin Lewis (The Alienist and
Neurologist, February, 1906).

Genius — stated to be the capacity for spontaneous imagination, or
imagination de novo, therefore unreal.

Talent— is skilful technique, applied to material or pre-existing things,
and is essentially real. As geniuses, Poe, Whitman, Rembrandt and Wagner
are contrasted with Shakespeare, Tennyson, Goethe, Holmes, Bonheur,
Alma Tadema, Sargent, Reynolds, Beethoven, Gounod, considered talented.
Genius is thought to be evidence of a degenerate and unhealthy mental
state, exhibited by the former ones mentioned, in certain of their produc-
tions, also by their varied erratic or insane characteristics, and manners
of life. As a preventative 'measure of possible mental retrogression, the
cultivation of more healthful tastes in literature, art and music is urged,
particularly in the training of young minds.

J. E: Clark (New York).

General Conditions and Insanity. By H. A. Tomlinson (Journal A. M.
A., March 17).
The author emphasizes the importance of general pathologic conditions,
especially of general metabolism, in insanity. "Mental aberration," he says,
"in its clinical and pathologic aspects, has to do primarily with the poten-
tiality of the nervous organization of the individual, and secondarily, with
the perverted or defective processes of metabolism, as they affect the nutri-
tion of the nervous system. In other words, we have to recognize that the
degenerative process which makes mental aberration apparent is primarily a
general one, affecting the vegetative functions." An analysis of the record
of the patients received at the St. Peter's Hospital during the past nine
years is used to illustrate his argument, and he concludes from all the data

68 PERISCOPE

that: "In dealing with insanity and its manifestations we are concerned
with the cerebral potentiality of the individual in considering its nature;
with heredity and environment in determining its form and sequence; while
the evidence of the involvement of the general organism in the degenerative
process must be our guide in anticipating its progress and termination."

Spinal Atrophy and Juvenile Dystrophy. By L. H. Mettler (Journal
A. M. A., June 16).
Dr. Mettler reports a case of amyotrophic lateral sclerosis, notable be-
cause associated with pupillary inequality, and one of juvenile dystrophy in
a lad of nineteen, which is discussed at some length. The cause was ob-
scure and Mettler thinks it possible that a transient infectious polymyositis
may have been present as its antecedent. The evidence is against a primary
cord or nerve degeneration and rather in favor of a primary muscular
affection. He discusses the differentiating points between spinal and
muscular atrophies and believes that localization of the atrophied areas is
an insufficient guide for distinguishing different types of this disease.
Typical cases are in fact very rare, and he agrees with Gov. :rs that it is
undesirable to make a separate variety of juvenile muscular atrophy, as Erb
has proposed. Spinal atrophies may also be juvenile and so may myositic
atrophies.

Hypertrophy of the Brain. By J. H. Haberlin (Journal A. M. A., June

3°)- . .

The author reports the case of a child, aged two, dying in convulsions,

in which the apparently symmetrically enlarged brain weighed 1,712 grams
{S2>XA ounces). The membranes were not adherent, there was no flattening
of the convolutions, no disproportionate increase in the size of the ven-
tricles and the gray and white matters were developed proportionatelv
Clinically, the case could not be differentiated from hydrocephalus.

Prognosis in Mental Disease. By Robert Jones (The British Medical
Journal, Dec. 16, 1905).
The average age of admission to the London County Asylum is forty-
two years. At this age the expectation of life in the sane is twenty-four
years, but the average age of those dying in the asylum is 50.7 years, or
about 15 years less. It is proven by statistics that there is always some
mental weakness after an attack of insanity. In cases of insanity under
twenty^ years of age relapses occur with much greater frequency than after
this age. The author finds the average duration of general paralysis of the
insane to be two years. Favorable factors in any case of insanity are :
"Normal sleep; gain in weight, accompanied by lessening of mental symp-
toms, with no lessening of mental symptoms it is a bad sign, especially in
adolescents indicating dementia ; a restoration of natural facial expression
and affection for friends ; and increased interest in his surroundings and
appearance. The cause of the'insanity has a direct bearing on the prognosis.

C. D. Camp (Philadelphia).

Drug Addictions.

■In the preliminary report of the Committee on Drug Addictions of
the Section on Nervous and Mental Diseases of the American Medical As-
sociation (Journal A. M. A., March 3), Dr. Smith Ely Jelliffe, the chairman,
states that it was not thought best to consider the whole enormous subject
of drug habits at this time, but rather to confine the inquiry to the subject
of opium addiction. All the committee can do at present is to formulate a
series of suggestions concerning lines of fruitful inquiry, and, therefore,
they have limited themselves to certain problems that seem at present most
promising for solution. The first of these concerns the spread and distribu-
tion of the habit, and it is suggested that valuable data may be obtained

PERISCOPE 69

through the pharmacists of a state or a community, through prison and
asylum physicians and through a study of the cures advertised in the public
press, etc. The second problem concerns proportion of the various forms
of addictions, and the third is that of the etiology, the causes that have led
to the habit, the factor of pain, the influence of environment, the reasons
of its prevalence among certain classes, etc. A psychologic study of the
euphoria of opium is also desirable. The pharmacology of opium, he
states, is in need of further investigation and the suggestion is offered that
hs further chemical study is not without its possible revelations The treat-
ment is naturally the topic of greatest interest, and this should be considered
from the social as well as from the individual point of view. From the
personal therapy side, the committee feels that the study of the abstinence
symptoms is of great importance, and that its study will certainly afford
verv fruitful results. The questions of the well-known phenomena of toler-
ance raise that of a possible immunity. Are antibodies formed or does the
body take on greater oxidating powers with increasing use of the drug, thus
producing the greater tolerance observed? These questions are still unde-
termined, but their study is offered as a fruitful task for the future.

Retrobulbar Optic Neuritis Following Childbirth. By C. J. Kipp
(Journal A. M. A., June 30).
Dr. Kipp reports a case of retrobulbar optic neuritis of one eye, recurring
after successive labors, and ending in atrophy of the optic nerve with
whitening of part of the eyelashes and eyebrow of the same side. No
heart or kidney disease could be detected and there was pain in the right
affected eye and supraorbital neuralgia. The left eye is normal, and in
other respects the patient continued to enjoy good health. It seems to him
probable that the pregnancies caused a vascular disturbance, a congestion
at or near the apex of the orbit, and that this produced pressure on the
optic nerve and its sheaths and also on the branches of the ophthalmic
division of the fifth nerve. Others observing somewhat similar cases have
attributed the optic disease to an autointoxication. For a full account of
the different views held, Kipp refers to an article by Dr. George S. Derby
(Arch, of Ophthalmology, xxxix., p. 9). So far as he knows, the case is
the only one in which the whitening of the eyebrows and lashes has been
observed in connection with retrobulbar optic neuritis. Only those portions
in the course of the supraorbital nerve were whitened and the change
occurred within a very few days, following the appearance of neuralgic
symptoms. A second case, similar to the first, but occurring after a first
labor, and with recovery of vision, is also reported by the author.

Tropical Neurasthenia. By W. W. King (Journal A. M. A., May 19).

The author describes neurasthenia as he observed it in Porto Rico, using
the term tropical rather to indicate local influences than as signifying a
particular type of the disorder. Comparatively few individuals, he thinks,
escape certain symptoms of nervous exhaustion if they live in the tropics
for a long period. Women are greater sufferers than men. While climate
does have a certain relaxing effect, he thinks its influence is overestimated
and that much should be attributed to the monotony of life, to the defective
diet and to the habit of individuals. The variety of symptoms is as great
as elsewhere, but he has noticed a lack of energy, a tendency to hypochon-
dria and digestive disorders, loss of weight, disturbed sleep and dull oc-
cipital headache as prominent features. The symptoms may disappear
gradually as the patient becomes acclimated, so to speak. Change of scene
and occupation and moderate exercise, not overdone, especially if combined
with amusement, are beneficial. Special symptoms may call for medicines,
but he has seen little good from any general medication directed to the
nervous system, aside from hygienic measures.

Book IReviews

Criminal Responsibility. By Charles Mercier, M. D. Clarendon Press,
Oxford, England, page 288.

The author in the preface quotes the dictum of an eminent jurist who
lays it down that all crimes consist of two parts, "the outward act, and
the state of mind which accompanies it." This clearly indicates that from
one point of view all crime is a problem in psychology. While the subject
of criminal responsibility has been treated exhaustively by Sir Fitz James
Stephen, still he was not a trained psychologist, and took rather the legal
view point. The time seems, therefore, ripe for a review of the subject
and from the point of view of the psychologist.

In entering into the question of responsibility the author considers
punishment from the three standpoints of retribution, determent, and
reform, and concludes that punishment as administered to-day is over-
whelmingly retributory, containing little if any of the elements of the other
two. As a result of these conclusions he comes to consider the problem
of responsibility from a point of view different from that ordinarily taken.
"A person is held responsible when the enlightened public opinion of his
age and country demands that he shall be made to sufferer in return for
pain that he has inflicted. Responsibility is, therefore, not a quality of the
person who has inflicted the pain, but a demand on the part of others that
he shall suffer."

From this rather extraordinary statement the author proceeds to ex-
amine the question of responsibility in detail in answer to the question,
"Whom ought we to punish?''

In general terms the answer to this question is that those ought to be
punished who do acts that are wrong (wrong being used in a general
sense and not in the legal sense of tort). This answer necessitates an
analysis of what is meant by act and by wrong. Acts are divided into
reflex, instinctive, automatic, habitual and voluntary. Voluntary acts are
the only acts in regard to which the question of responsibility can arise,
and they must be wrong acts, wrong being defined as the seeking of grati-
fication by "an unprovoked act of intentional harm." This statement
naturally leads to a discussion of the relation of volition to responsibility.
The actual act of volition is considered to be the last link in a chain, the
preceding links of which are respectively "intention, or desire to do the
act; choice; immediate motive or desire for the immediate consequences of
the act; and, in succession, more and more distant motives. * * *"

The author sums up this discussion by saying :

"Responsibility attaches to acts that are wrong, and to no others. A
wrong act is a voluntary act in which the actor seeks gratification by in-
flicting unprovoked harm upon others. Responsibility is the more un-
doubted, the more closely, more deliberately, the more frequently, the
will is concerned in the act.

"Therefore, to incur responsibility by a harmful act, the actor must
will the act; intends the harm; desire primarily his own gratification.
Furthermore the act must be unprovoked, and the actor must know and
appreciate the circumstances in which the act is done."

The author, by these conclusions and by his argument, commits himself
by implication to the doctrine of graded responsibility. He acknowledges
that a person may be irresponsible who could not be certified as insane, but
clearly believes that an act, the ultimate volition of which is preceded at
any stage by a morbid state of mind, should entitle the actor to relief from
full responsibility therefor. The author also commits himself to the alter-
nate proposition that insane persons are not always necessarily wholly

BOOK REVIEWS 71

irresponsible. On this point he says: "The majority of insane persons
are sane in a considerable proportion of their conduct; and when, in this
part of their conduct, they commit offenses, they are rightly punishable,"
but further, "Since the limits between the sane and the insane areas of
conduct of insane oersons, are ill-defined, no insane person should be
punished with the same severity that would be awarded to a sane person
for the same offense."

The book is a learned discussion of the subject of criminal responsibil-
ity written in the author's happiest vein, but naturally contains much that
will not be universally accepted. Especially is this true of the author's
position on the propriety of punishing the insane, a position he has held
for many years without, however, gaining many adherents. It is well
worth _ a careful reading, especially by all engaged in court practice in
cases involving the issue of insanity. White.

Die Geschwulste des rechten und linken Schlafelappens. Eine
klinische Studie. Von Dr. Albert Knapp, Oberarzt an der Kgl.
Universities Psychiatrischen und Nervenklinik in Halle. J. F.
Bergmann, Wiesbaden. 3.60m.
The study of tumors of the temporal lobes offers a most fruitful field
to the neurologist as well as to the surgeon, both from the standpoint of
exact localization and of operative interference. Tumors of the temporal
lobes, particularly of the right side, have been considered by many authori-
ties as particularly difficult of diagnosis. Bruns has said that tumors of
the right temporal lobes are among those which show the least of localizing
symptoms, and only when the pyramidal tracts are pressed upon is it pos-
sible to tell which hemisphere is involved, and Oppenheim has recently
declared that we never have the right to make a localizing diagnosis of
tumor of the right temporal lobe. Hence the need for a revision of older
observations and the introduction of newer methods, and particularly the
keener analysis of the mental signs of brain tumor. This has been done
by Knapp in the present monograph of 150 pages.

He first discusses the general historical aspect of the subject, then
passes to a review of the known general symptoms of temporal lobe
tumors of both the right and the left sides. Amnestic and optic aphasia
and their significance with the symptoms of asymbolia, apraxia and related
disturbances are next considered. Knapp points out that asymbolic,
apraxic, perseveration and echolalia symptoms are almost invariably as-
sociated in his patients with temporal lobe tumors with the classical
picture of Korsakoff's psychosis. It is recalled, however, that this syn-
drome has been observed in patients with tumors in other brain areas.

Sensory aphasia, Knapp says, is the only positive localizing symptom
on which one can count with reasonable certainty in left-sided tumors. In
right-sided tumors one must depend on the accompanying and accidental
symptoms of contiguity. Some of the more important of these indirect or
related symptoms consist in involvement of the optic tracts, the pyramidal
tracts, the sensory tracts, central ganglia, corpora quadrigemina, cere-
bellum, the five last cranial nerves, the facial, the trigeminus and the oculo-
motonus. These are all illustrated in the recital of the case histories of
ten patients.

Final notes on the differential diagnosis close this painstaking and
valuable monograph. Jelliffe

Bews ant) mote*

Announcement of $500 Prize by the Association for the Best
Essay on the Etiology of Epilepsy. — Dr. W. P. Spratling announced a
prize of $500 offered by the Association for the Study of Epilepsy for the
best essay on the etiology of epilepsy. This prize is given by persons in-
terested heart and soul in the work of the Association, and the conditions
governing the award are as follows :

All essays submitted must be in English, written in a clear, legible
hand or on the typewriter, on one side of the paper only, and they must
not contain more than 15,000 words. Essays must be in the possession of
Dr. W. P. Spratling, at Sonyea, N. Y., not later than Sept. 1, 1007.

The name of the person submitting the essay must hot appear on the
same, but be put in a sealed envelope on which is written a motto, and
which motto should also appear at the top of the first page of the essay.

All essays received will be placed in the hands of three physicians to
determine their merit. Two of these physicians are members of this As-
sociation ; the third a member of the American Neurological Association.

Announcement of the award will be made at the November, 1907, meet-
ing of the Association. The Association will not feel bound to award the
prize should no essay submitted be deemed of sufficient value to merit it.
Original research work into the etiology of epilepsy will be a leading factor
in fixing the aivard.

The Psychiatrical Society of New York has arranged for a series of
four lectures on problems of insanity, to be held under the auspices of the
Academy of Medicine, at 17 West 43d St., on Saturdays, Jan. 19, Feb. 2,
Feb. 16, and March 2, 1907, at 8.30 P. M. The purpose of these lectures
is to put within the reach of the medical profession, and also of the non-
professional leaders of sociological interests, a programme of work and
facts for orientation, with a view to the organization of a movement to-
ward, prophylaxis and the development of sound interests in this eminently
important topic. The first lecture will be given by Dr. Adolph Meyer, on
"Modern Psychiatry, Its Possibilities and Opportunities;" the second lec-
ture, by Dr. August Hoch, discusses the "Manageable causes of Insanity,
Exclusive of Hereditv;" the third lecture, by Dr. C. L. Dana, "The Data
of Heredity and Their Application in Psychiatry," and the fourth lecture,
by Dr. Allan McLane Hamilton, "The development of the Legal Regula-
tions Concerning the Insane." The medical profession and non-medical
persons interested in a movement towards prophylaxis and the best manage-
ment of mental disorders are cordially invited.

Professor Wollenberg, in Tubingen, has accepted the call to the chair
of psychiatry made vacant by the death of Professor Fiirstner at Strass-
burg. He entered upon his duties with the beginning of the winter semester.

Dr. Robert Gaupp has been made Professor at Tubingen to fill the
position made vacant by the call of Professor Wollenberg.

Dr. Ossipoff, of St. Petersburg, has been made A. O. Professor of
Psychiatry in Kasan.

Vol. 34 February. 1007. No. 2

THE

Journal

OF

Nervous and Mental Disease

Original Hrticlcs

1

ON HERPETIC INFLAMMATIONS OF THE GENICULATE

GANGLION. A NEW SYNDROME AND ITS

COMPLICATIONS.*

By J. Ramsay Hunt, M.D.,

OF NEW YORK.

CHIEF OF THE NEUROLOGICAL CLINIC AND INSTRUCTOR IN NERVOUS DISEASES
IN THE CORNELL UNIVERSITY MEDICAL COLLEGE.

(FROM THE PATHOLOGICAL LABORATORY OF THE CORNELL UNIVERSITY MEDICAL

COLLEGE.)

Under the general heading of herpetic inflammations of the
geniculate ganglion of the facial nerve, I have brought together for
the first time three separate groups of cases ; each group present-
ing distinct and clearly defined characteristics, but showing vari-
ous combinations and transition forms. Their union I believe
constitutes a new and distinct clinical entity.

The pathology of this affection is identical with that of herpes
zoster, of which it forms a part, the distinguishing features of the
clinical picture depending entirely upon the ganglion involved and
the nature of the structures surrounding it. Heretofore the
only recognized seat of an herpetic inflammation on a cranial
nerve was that of the Gasserian ganglion of the trifacial. Herpes
zoster in the distribution of one or more of its branches was the
result. I believe, however, that the geniculate ganglion situated
in the depths of the internal auditory canal at the entrance to the
Fallopian aqueduct may be the seat of this specific inflammation.
The peculiar situation of the ganglion within the confines of a
bony canal and its immediate relationship to the facial and the

♦Presented at the meeting of the American Neurological Association,
June 4 and 5, 1006.

74

/. RAMSAY HUNT

close proximity of the auditory nerve are responsible for the
characteristic complex of symptoms which results.

As was long ago pointed out by Barensprung and is now
definitely established by the elaborate clinical and pathological
researches of Head and Campbell, the primary or infectious form
of herpes zoster is dependent upon a specific inflammation of one
or more of the posterior spinal ganglia. Head suggested the
name, posterior poliomyelitis for the affection, and certain points
of resemblance were drawn between it and acute anterior polio-
myelitis. The ganglia involved are swollen by the products of
inflammation and by extravasation of blood, and in some cases
even the sheath and nerve roots may be involved in the inflam-
matory process. In very rare instances the anterior or motor
root, resting upon the sheath of the ganglion may be implicated
and paralysis result.

External petrosal.
Small superficial petrosal.—
Large superficial petrosol.^

Intumescentia ganglioformis.

„ .. . f Facial.
Seventh pair j Auditory

Fig. I.
The course and connections of the facial nerve in the temporal bone.
(Gray's anatomy.)

Such paralytic complications are, however, extremely un-
common, and the total number of recorded cases is so small that
they may be given in a few words. Herpetic inflammation of the
Gasserian ganglion has given rise to palsies of the neighboring
ocular nerves in 15 cases; in 12 cases the oculo-motor was the
nerve affected, in two cases the trochlear and in one case the
abducens. Paralytic complications of spinal zoster are recorded
even less frequently. Arm palsies were observed in eight cases,
to which I can add a personal observation, and a localized paralysis
of the abdominal muscles in one case. Where the herpetic in-
flammation attacks the geniculate ganglion, palsies are of much

HERPETIC INFLAMMATIONS 75

more frequent occurrence than in any other localization of the
disease. I have collected 56 cases from the literature to which
I can add 4 personal observations, making a total of 60 cases
in which palsies accompanied the inflammation in this situation.
This I would attribute to the peculiar location and relations of
the ganglion involved.

Clinically the cases of geniculate herpes resolve themselves
into three groups. The simplest expression of the disease is a
herpes of the auricle and external auditory canal. Within this
skin area is to be found the zoster zone for the geniculate ganglion.
In another group of cases there is added to the aural herpes a
paralysis of the facial nerve. This I explain by pressure of
the inflamed ganglion or in some cases by a direct extension of
the inflammation to the nerve. The most interesting, as well as
the most severe, type of the disease occurs when the acoustic
nerve is also involved. In this form there are with herpes auri-
cularis and facial palsy, various auditory symptoms, ranging in
severity from tinnitus aurium and diminution of hearing to
the more severe forms of acoustic involvement as seen in
Meniere's syndrome. In these cases I assume that the inflamma-
tory process has extended to the auditory nerve which is enveloped
in the same sheath, and courses in the same canal as the facial
nerve.

Each of these groups has separately been the subject of careful
study by many observers ; but their intimate clinical relationship
to one another, their common pathology and their common seat
of origin, the geniculate ganglion of the facial nerve, has not
heretofore been recognized.

I have already expressed my belief that the geniculate gang-
lion has its cutaneous representation and zoster zone in the auricle
and external auditory canal, and that herpes zoster in this region
may have facial and auditory complications. In regard to the
distribution of the zoster I wish to lay especial stress upon this
fact, that while these neural complications occur in auricular
herpes, they also accompany herpes facialis, herpes occipitalis and
cervicalis. It will be observed that in these forms of zoster, the
herpes facialis and herpes occipito-collaris, the zoster zones lie
immediately in front of and behind that which I have indicated
as the geniculate zoster zone. Thus the Gasserian, geniculate
and 2d and 3d cervical ganglia may be" regarded as forming a

76 J. RAMSAY HUNT

ganglionic series or chain, their cutaneous zones corresponding
to the face, ear, head and neck.

It is not difficult to find an explanation for the occurrence of
neural complications (facial and auditory) in those forms of
zoster in which the eruption is not in the auricle and therefore
is not in the geniculate area. The pathology of herpes zoster is
such that while the inflammation predominates or is centered
chiefly in one ganglion, other ganglia immediately above and
below this central focus may also show inflammatory changes, but
in a lesser degree. In fact, a series of ganglia may show milder
degrees of inflammation. So that while one ganglion may be
regarded as the central focus, evidences of inflammation are not
infrequently present in recent cases, in the ganglia immediately
above and below, diminishing in intensity from the central lesion.

As the Gasserian, geniculate, and upper cervical ganglia form
a continuous system of cutaneous zones, so they may be regarded
as forming anatomically a ganglionic series. It is therefore quite
natural that if the chief focus of inflammation is centered in
the Gasserian, subsidiary inflammatory changes may occur in the
other ganglia of this group, the geniculate, and the upper cervical.
In such an event the presence of facial and auditory symptoms
with herpes occipito-collaris or herpes facialis would be readily
explained. As a further evidence of multiple involvement of this
group of ganglia may be cited cases in which the zoster eruption
covers two distinct and separate zoster zones.

An idea of the relative frequency of these neural complica-
tions and their associated herpetic eruptions may be obtained from
the following statistics. In the 60 cases at my disposal for
analysis, all had a facial palsy of the peripheral type. In 19 of
these cases irritative or paralytic symptoms of acoustic origin
were present. In 32 cases the cutaneous manifestation was herpes
occipito-collaris, in 12 cases herpes facialis, in 12 cases herpes
auricularis, in 3 cases a combined herpes auricularis and occipito-
collaris, in one case herpes facialis and occipito-collaris combined.
I may also add that I have found but one case of herpes zoster
with an associated facial palsy in which the eruption was not
facial, auricular, or occipito-cervical.

With these introductory remarks I will proceed to a more
detailed description of the anatomy, pathology and symptomatol-
ogy of the affection.

HERPETIC INFLAMMATIONS

77

Anatomical Considerations. — Before proceeding to the clinical
aspect of my subject, it is of great importance that certain facts
pertaining to the anatomy of the facial nerve and its ganglion
should be known. The facial nerve clinically is generally re-
garded as a motor nerve. This from the anatomical standpoint
is not the case. Histological and embryological investigations dur-
ing the past ten years have shown conclusively that the facial is
a mixed nerve, possessing an afferent or sensory portion, which
is the nerve of Wrisberg, and a ganglionic structure, the genicu-
late, analogous in structure to the spinal ganglia of the posterior

Fig. 2.
Testut. — The auditory nerve in the internal auditory canal, i. Audi-
tory nerve. 2. Cochlear-branch. 3. Vestibular-branch. 4. Facial. 5. Nerve
of Wrisberg.

roots, the cell type of the geniculate corresponding exactly to that
of the spinal and Gasserian ganglia.

The facial enters the internal auditory meatus in company
with the acoustic and the nerve of Wrisberg. Within the auditory
canal the 7th which is above rests in a slight concavity formed
by the acoustic, the pars intermedia or nerve of Wrisberg lying
between. All these nerve trunks are united and held together
by a common sheath of connective tissue. At the bottom of the
canal the acoustic divides into its cochlear and vestibular branches,

/. RAMSAY HUNT

the nerve of Wrisberg and the facial entering the aqueduct of
Fallopius. Immediately after its entrance the facial swells into
the intumescentia ganglioformis, in which the nerve of Wrisberg
takes its origin. From this point the facial nerve proper is con-
tinued to its peripheral distribution through the Fallopian aque-
duct. As it lies in the entrance of the Fallopian aqueduct and the
Hiatus Fallopii, the geniculate has important connections with
other ganglia. It is connected with the spheno-palatine ganglion
(Meckel's) through the great superficial petrosal nerve, and with

Fig. 3-
Testut's Anatomy. — The facial nerve, geniculate ganglion and relations
with the otic. i. Facial nerve. 2. Geniculate. 3. Glossopharyngeal. 4. Jacobson's
nerve. 5. Small superficial petrosal. 6. Small deep petrosal. 7. Otic
ganglion. 8. Sympathetic ramus. 10. Middle meningeal artery. 11. Gas-
serian ganglion. 12. Ophthalmic branch. 13. Superior maxillary. 14. In-
ferior maxillary. 15. Spheno-palatine ganglion. 16. Vidian nerve. 17.
Auriculo-temporal nerve.

the otic ganglion (Arnold's) through the small superficial pe-
trosal nerve. At their entrance into the medulla oblongata the 7th,
8th and pars intermedia have the following relations ; the pars
intermedia lies between the facial and the internal root of the
acoustic. It sometimes joins one, sometimes the other of these
two nerves as it enters the bulb, terminating in the fasciculus
solitarius and the central gray column of the medulla. (Fig. 3.)

HERPETIC INFLAMMATIONS

79

From this brief resume of recognized and well founded facts
it will be observed that my views regarding the affection under
discussion finds only encouragement and support.

As the specific infection of herpes attacks only cells of the
spinal ganglion type, the geniculate may very properly be brought
within the sphere of its influence. Furthermore the intimate
relations existing between the facial, the geniculate ganglion, and
the terminal division of the acoustic would render all these struc-
tures liable to involvement when the seat of an inflammatory
process ; all the more because they are lodged in the depths of
an osseous canal, within a common sheath, which would tend to
resist expansion and increase the effect of pressure. (See Fig. 4.)

It may be added that the geniculate ganglion varies in size.

Fig. 4.
Testut. — Anastomoses of the facial and auditory nerves. 1. Facial.
2. Auditory. 3. Nerve of Wrisberg. 31. Geniculate ganglion. 4. Internal
anastomoses. 5. External anastomoses.

In some subjects it is scarcely visible to the naked eye ; in others
the swelling is double the caliber of the nerve. This may well
have a certain influence in determining the severity of the case,
anatomical peculiarities of the canal contributing.

The Zoster Zone for the Geniculate Ganglion. — Admitting the
sensory nature of this ganglion, its anology to a spinal ganglion
and its probable involvement in cases of herpes zoster, it is still
necessary to demonstrate the existence of a cutaneous area on
the head or face to represent it. This area must be independent
of other recognized zoster zones and in it should be found the
zoster zone of the geniculate. This zone, I believe, is situated

8o /. RAMSAY HUNT

within the auricle and external auditory canal. My argument bear-
ing on this part of the subject is briefly as follows : The peripheral
innervation of the external ear is effected through the fifth nerve,
branches of the cervical plexus, and the auricular branch of the
vagus. The anterior half of the auricle and the superior and
anterior walls of the external auditory canal are innervated by
the auriculo-temporal branch of the trigeminus nerve. This
nerve is a branch of the inferior division of the trigeminus, and
I wish particularly to emphasize the neural connections existing
between it and the geniculate ganglion through the otic ganglion
and the small superficial petrosal nerve. The otic ganglion rests
upon the inferior maxillary division of the fifth, just below its
origin from the Gasserian. The posterior surface of the auricle
receives its sensory innervation through the auricular branches
of the superficial cervical plexus, which also overlap the rim and
supply a posterior marginal area on its external surface. The
inferior and posterior walls of the canal are supplied by the small
auricular branch of the vagus, which also sends filaments to
the interior of the concha. The ganglionic representations of
sensation on the auricle and external auditory canal have been
divided between the Gasserian in front and the second and third
cervical ganglia behind. The anterior half of this region has
been referred to the Gasserian and the posterior half to the cervi-
cal ganglion. An eruption of herpes in this area has been re-
garded as emanating from disease of one or other of these
ganglia.

The eiror of the prevailing views will be shown by a study
of the anesthesia produced by the extirpation of these ganglia fcr
the relief of tic douloureux. In all of Krause's cases following ex-
tirpation of the Gasserian the sensation of the skin of the auricle
and external auditory canal was found to be preserved and normal.
In these operations during the tearing out of the ganglion, the con-
nections existing between the fifth nerve, Meckel's ganglion, the
otic ganglion, and the geniculate ganglion through the superficial
petrosal nerves may be separated. This might cause con-
fusion, by adding a geniculate anesthesia to that produced
by removal of the Gasserian. This may have happened in
some of Cushing's cases in which parts of the external au-
ditory canal were found anesthetic after extirpation of the
ganglion. The method of operation as practised by Frazier and

HERPETIC INFLAMMATIONS 81

Spiller is free from this disadvantage. It consists in cutting the
sensory root of the fifth on the central side of the ganglion. Jn
such a procedure as this there is no undue tension or tearing the
neural connections between the geniculate, and the second and
third divisions of the fifth are not implicated. No procedure
could be more exact for protecting the ganglionic area of the
Gasserian. Following this operation the sensation of the auricle
and auditory canal was found to be normal. The ganglionic inner-
vation of the second and third cervical ganglia has been studied
in a case of extirpation for the relief of obstinate occipito-cervical
neuralgia by Harvey Cushing. In outlining the anesthesia in this
case Cushing found the posterior marginal area on its externa1
surface anesthetic. The interior of the auricle and external audi-
tory canal had normal sensation.

If we now bring together and carefully adjust these respective
areas of anesthesia, produced by extirpation of the Gasserian and
the cervical ganglia, there still remains the interior of the auricle,
and the external auditory canal in which sensation is preserved.
In this area, I believe, it is to be found the cutaneous representa-
tion of the geniculate ganglion and its zoster zone.

It will be recalled that the peripheral innervation of this skin
area is furnished by the auriculo-temporal branch of the third
division of the fifth, and the auricular branch of the vagus. That
these fibers do not pass through the inferior division of the fifth
to the Gasserian is demonstrated by the anesthesia resulting from
section of the sensory root of the fifth, this area retaining its
sensation. If their afferent course is not through the trigeminus,
how do they reach the brain ? The relation of these sensory fibers
to the geniculate ganglion is established if we accept the occur-
rence of geniculate herpes with a zoster zone in the auricle. So
that it seems probable that these afferent fibers passing from the
auricle on their way to the geniculate follow one or other of two
routes, *. e., from the skin of the auricle through the auriculo-
temporal branch of the fifth, or the auricular branch of the vagus
to the seventh nerve, the afferent fibers passing to the geniculate
in the trunk of the facial nerve ; or they may possibly be continued
in the arriculo-temporal branch of the fifth to the otic ganglion
and thence via the lesser petrosal nerve to the geniculate. Of
these two routes, that through the facial is, in my opinion, the
more likely one.

82 /. RAMSAY HUNT

Clinical Types of the Disease.

Herpes Auricularis. — The simplest manifestation is to be found
in the characteristic and well-known picture of herpes zoster
of the auricle. There are the usual slight prodromes in the initial
stage of the infection, followed by fever and mild general symp-
toms. Then sharp, darting pains are felt in the ear, the preher-
petic pains, sometimes reaching a high degree of intensity. The
skin of the ear may assume a red, swollen, somewhat erysipelatous
appearance, until on the third or fourth day typical patches of
herpetic vesicles make their appearance. These are situated in
the concha, on the lobule, the tragus, the marginal portion of
the auricle (helix and antihelix), and within the auditory canal,
indeed, as rarely happens, on the membrana tympani itself. With
the appearance of the eruption the acute pains usually subside, the
ear still remaining swollen and tender.

At this stage the orfice of the external auditory canal may be-
come constricted by the swollen soft parts, so as to interfere with
the proper drainage and cleansing of the canal. The defect in hear-
ing which may result from this temporary occlusion of the meatus,
is purely mechanical and is not in any sense related to the disturb-
ances of audition which accompany another group of cases and
which is dependent upon involvement of the auditory nerve. In a
few days the vesicles dessicate, the swelling and edema of the
parts subside until at the end of a fortnight only a few scattered
zoster scars remain to tell the tale. The sensory symptoms may,
however, persist for a considerable time ; burning pains, itching,
paresthesia with impairment of the cutaneous sensation of the
parts. In old people more especially the sharp neuralgic pains in
the ear, the post-herpetic pains, may persist for a considerable
time. (Herpetic otalgia.)

In this class of cases it will be observed that the herpetic pains
and the herpetic eruption are localized within that skin area which
retains its sensation after extirpation of the Gasserian and the
second and third cervical ganglia. It was this area which I as-
signed to the geniculate ganglion as its cutaneous representation
and zoster zone.

Remarks. — Idiopathic herpes zoster of the auricle has long
been a recognized manifestation of zona. It is the herpes auricu
laris and herpes oticus of systematic writers. Dr. Anstie who
was personally afflicted with the disease gave a very vivid de-

HERPETIC INFLAMMATIONS 83

scription of his own case in "The Practitioner" of 1871. This
localization of zoster has always been regarded as belonging to
the trigeminal area, and due to disease of this nerve or its gang-
lion. If the observer favored the neuritic theory of herpes zoster,
the skin lesions on the auricle were ascribed to a neuritis of the
auriculo-temporal branch of the fifth nerve; if the ganglionic
theory was accepted, the lesion was placed in the Gasserian. Some
authors also speak of the auricular branches of the cervical nerves
as playing a role in aural herpes, but no mention is made of the
geniculate ganglion and its possible relation to this affection.

Compared with other manifestations of zona, the ear is an
infrequent localization. Gruber records five typical cases as oc-
curring in a series of 20,000 cases of ear disease.

To determine, if possible, the relative frequency of these cases,
I examined the annual reports of several of our large hospitals
for the eye and ear, with rather varying results. The total number
of cases recorded is surprisingly small, so small indeed that it
seems very possible that the affection not infrequently escapes
recognition. It may be that when seen in the early stage of intense
inflammation cases are regarded as perichondritis or inflammation
of the auricle, or when seen later after dessication of the vesicles,
as cases of eczema of the auricle. In the Manhattan Eye
and Ear Dispensary during the past ten years, with
a total of 47,600 cases, the diagnosis herpes of the
auricle was made in only two cases. In the Brooklyn
Eye and Ear Hospital, during the past five years, with
a total of 15,000 cases, the diagnosis was made but once. The
New York Eye and Ear Infirmary averages at the present time
10,000 out-patients a year, and is one of the largest institutions
of its kind in the world. During the past twenty-three years this
diagnosis was recorded but six times. The reports of the Massa-
chusetts Eye and Ear Infirmary show a much larger proportion
of these cases. In the past ten years with a total of 65,000 cases,
the diagnosis was made 33 times. In these tabulations it was not
possible to determine whether the cases were of the true infec-
tious type, or merely of secondary origin, but the infrequency with
which the diagnosis was made is worthy of note.

Herpes Auricularis zvith Facial Palsy. — In this manifestation
of the affection, there is superadded to the herpes auricularis, as
just described a peripheral facial palsy, which appears on the

84 /. RAMSAY HUNT

same side as the zoster. The time of the appearance of this pai^
varies, coming on in some cases simultaneously with the eruption,
in others it may be delayed a week or even longer. In the majority
of instances it appears on the second or third day. Too much
stress should not be given to the patient's statements in this
respect as the onset is often insidious and unobserved.

The paralysis is complete and involves all three branches of
the nerve, and has certain peculiarities. A conspicuous feature
is the frequent evanescence of the symptom, evidences of paralysis
lasting only a few days or a fortnight. Many of the palsies clear
up within three weeks or a month. There still remains, however.
a large group of cases in which the palsy is of a severe type,
reactions of degeneration persisting for a long time, leaving
permanent weakness and contractures of the face. It is also a
striking fact that in an unusually large number of these cases the
sense of taste is lost or altered. This is not surprising when one
considers that the seat of the lesion is in the geniculate, a level
where the taste fibers are still coursing with the facial.

I would explain the involvement of the nerve in this group
of cases by the pressure of an inflamed and swollen ganglion or
by the direct extension of the inflammation to the sheath and
connective tissue structures of the nerve. In light palsies prob-
ably inflammatory edema and pressure are the factors at play,
whereas in the more severe forms inflammation and structural
changes probably take place.

Remarks. — As has already been emphasized, a similar palsy
may complicate herpes facialis and herpes occipito-collaris. I
would explain the occurrence of the palsy in such cases by an
herpetic inflammation of the geniculate ganglion, based on the
well recognized tendency of this affection to produce inflamma-
tory changes in a series of spinal ganglia. The Gasserian, genic-
ulate and upper cervical ganglia constitute such a serial chain.

These cases of facial palsy complicating herpes of the ear,
face, and neck, have long been the subject of study and contro-
versy.

The old theories as to the origin of these palsies are as follows :
The prevailing opinion is that the same exposure to cold produces
both the herpes and the palsy, in which case the latter is regarded
as rheumatic in nature, the common form of Bell's palsy. Another
favorite theory was based on the infectious origin, the poison or

HERPETIC INFLAMMATIONS 85

toxin concerned in herpes zoster also producing a neuritis of toxic
origin. A somewhat fantastic hypothesis which found great favor
with certain observers was the following: The herpetic inflam-
mation is supposed to have extended along the peripheral fila-
ments of the trifacial nerve, this nerve having numerous points
of inosculation with the terminals of the facial. The inflammatory
process then passes by continuity of structure, directly from the
peripheral filaments of the trifacial to the termination of the facial,
in this way producing an ascending neuritis.

Herpes Auricularis with Facial Palsy and Auditory Symptoms.
— This is the most interesting as well as the severest type of the
affection. In this group to the herpetic eruption on the ear, face or
neck and facial palsy, are added symptoms pointing to involvement
of the auditory nerve. The proximity of the terminal divisions of
the auditory nerve to the facial and its ganglia, the common sheath
and narrow osseous canal in which they lie would render such an
auditory complication not only possible but probable. Contributing
factors may be severe forms of the inflammation or certain ana-
tomical peculiarities such as a large ganglion or a narrow bony
canal.

The auditory symptoms may be both irritative and paralytic
in character and make their appearance about the same time as the
facial palsy. First there is tinnitus aurium followed by progress-
sive diminution of hearing. In the more severe cases the symptoms
of Meniere's disease are also present. Disturbances of equi-
librium, vertigo, nausea and vomiting, nystagmus. In the course
of a few weeks the acute symptoms subside, the vertigo and dis-
turbances of the gait and equilibrium disappear, but the tinnitus
often persists for a considerable time and the hearing may be
permanently impaired.

Remarks. — In this group of cases as in that previously de-
scribed the auditory symptoms may complicate herpes on the neck
and face as well as on the auricle. In my series of 60 cases,
auditory symptoms of various degrees of severity occurred in
19 cases. Of this number the zoster was in the occipito-cervical
distribution in 9 cases, on the face in 4 cases, and on the auricle
and auditory canal in 6.

The uncertainty which has attended the classification of this au-
ditory group of cases and the doubtful nature of the affection, may
be gathered from a perusal of the titles of the more important com-

86

/. RAMSAY HUNT

munications. "Ueber ein Fall von gleichseitigen, akut aufgetre-
tene Erkrankung des Acusticus, Facialis und Trigeminus"
(Kaufmann, 1896). — "Ueber Polyneuritis Cerebralis menierifor-
mis" ( Frankl-Hochwart, 1899, and Berger, 1905). — "Zur Lehre
von der peripherischen Facialis Lahmung" (Hoffmann, 1899). —
"Beitrag zur Casuistik der multiplen Hirn Nerven Erkrankung"
(Hammerschlag, 1898). — "Herpes Zoster Oticus" (Korner,
1904). — "Trouble Auditive dans le Zona" (Lannois, 1904).

Fig. 5-

Osmic Acid Preparation, Counterstained with Rubin. I. Facial Nerve.

II., III., IV. Bundles of the Nerve of Wrisberg, Showing

Loss of Nerve Fibers and Sclerosis.

Pathological Evidence. — Recorded below under Case II is
the pathological report of a case of herpes occipito-collaris in
which a complete facial palsy supervened on the fourth day.
There were no symptoms referable to the auditory nerve. Evi-
dences of facial paralysis and objective sensory disturbances in
the occipito-cervical region were still present at the time of death,

HERPETIC INFLAMMATIONS

87

which occurred 87 days after the onset of the disease. Corre-
sponding to the cervical distribution of the herpes, old inflam-
matory changes were found in the tip of the third cervical gan-
glion, with loss of nerve fibers and islets of sclerosis in the corre-
sponding posterior root of the spinal cord. These could be traced
through the 1st, 2d and 3d cervical segments, with evidences of
myelin degeneration (granule cells and myelin droplets) in that

Fig. 6.

Marchi Method Intra-Medullary Degenerations in the Medial Root

of the Acoustic. Entrance of the Nerve of Wrisberg.

portion of the posterior column, immediately adjacent to the pos-
terior horns. Evidences of regeneration were also found in the
branches of the superficial cervical plexus. Such pathological
changes both in character and distribution are in accord with
the findings in similar cases.

It is, however, to the facial nerve that I would particularly
direct attention. The facial nerve, including the nerve of Wris-
berg, from its exit at the medulla to its entrance at the internal

88 /. RAMSAY HUNT

auditory canal, was treated by the osmic acid method and cut in
transverse sections. By this method the nerve of Wrisberg was
found to have lost a large number of its nerve fibers, with a com-
pensatory increase of connective tissue. (See Fig. 5.) Fortunately
that portion of the medulla which was treated by the Marchi
method corresponded to the roots of the facial, auditory and nerve
of Wrisberg, all of these structures taking their origin at the same
level.

The nerve of Wrisberg (pars intermedia) lies between the
origin of the other two nerves, sometimes it joins one, sometimes
the other, as it enters the substance of the medulla. Sections
through this level show distinct evidences of degeneration (myelin
droplets and granule cells) along the course of the internal root
of the auditory nerve, after its entrance into the medulla. See
Fig 6. In other words, we find in the nerve of Wrisberg, which
is the sensory root of the 7th and having its trophic centre in the
geniculate ganglion, the same extra- and intra-medullary changes
as were found in the spinal cord and posterior nerve root corre-
sponding to the 3d cervical ganglia.

Unfortunately that portion of the facial nerve removed and
which was supposed to contain the intumescentia ganglioformis
consisted only of membrane, so that the changes in the ganglion
itself cannot be given. But even in the absence of the geniculate
ganglion, the existence of well-markd degenerations in the nerve
of Wrisberg and its intrabulbar root is sufficient proof that this
structure was involved.

Case I. Herpes facialis and occipito-cervicalis with facial palsy

of short duration.

A woman, aged 66, on March 20, 1904, was exposed for one
hour to a sharp cold wind. It was snowing at the time and the
effects of the intensely cutting cold were keenly felt on the left
side of the face and neck. Two days later sharp darting pains
and tingling sensations developed in the left face, neck and occi-
pital regions. These pains were soon followed by an eruption of
herpes in the same distribution. Patches of vesicles were sparsely
scattered over the skin area of all three branches of the trigem-
inus nerve, as well as in the occipital and cervical regions. The
darting pains continued after the development of the eruption,
until seven days after exposure and five days after the appearance
of the vesicles, a complete left facial palsy was observed on
awaking in the morning.

HERPETIC INFLAMMATIONS 89

I saw the patient April 3, 1904, with Dr. Robert Denniston of
Dobb's Ferry. At the time there was total paralysis of the left
facial nerve in all its branches, with considerable sagging of the
parts, lachrymation and dribbling of saliva from the corner of
the mouth. Pressure over the 7th nerve in front of the ear caused
pain. There were no demonstrable objective sensory disturbances
of the left face or neck, and no tender points over the foramina
of exit of the trigeminus nerve. Hearing and taste were not
affected. There were no general cerebral symptoms and the pupils
reacted normally. The other cranial nerves as well as the motility,
sensation and reflexes of the extremities were entirely normal. The
urine contained a slight trace of albumin but was otherwise nega-
tive. Heart sounds of good quality, no murmurs. One of the
superficial cervical glands on the left side is slightly enlarged.

The sharp shooting pains continued for a week from this
date, coming on usually at 1 a.m. and lasting 3 or 4 hours, and
were very severe. They diminished in their intensity during the
next fortnight and soon after disappeared. Within one month
after the onset of the facial paralysis all trace of it had disap-
peared, and the patient has since enjoyed her usual robust health.
Case II. Herpes occipito-cervicalis with severe facial palsy
Autopsy and Histological Examination.

The patient, admitted to the City Hospital February 15, 1905,
was 48 years of age and a laborer. Periodic drinker. No vene-
real infections. The onset of the disease took place November
26, 1904, with sharp stabbing pains in the distribution of the right
occipitalis major and immediately behind and in the right ear.
With the sharp lancinating pains there was also present a burning
sensation on the right side of the neck. These prodromal pains con-
tinued about four days and were followed by a vesicular eruption
on the right side of the neck and the lower portion of the face
above the ramus of the jaw. On the 3d of December, three days
after the outbreak of the herpes a right facial paralysis was first
observed. The vesicles dried up leaving many small pigmented
scars. Paresthesias and burning sensations persisted with occa-
sional sharp darting pains in the affected area.

Status Praesens, February 18, 1905. — Complete right 7th
paralysis of the peripheral type. Behind the right ear, along the
ramus of the inferior maxilla and on the right side of the neck
are scattered, pigmented post-herpetic scars. These are in the
distribution of the 2d and 3d cervical segments. (Herpes occipito-
collaris.) In this same area, sensations of touch, pain and temper-
ature are diminished, especially over the angle of the jaw. Burn-
ing sensations and sharp neuralgic pains still persist in the scarred
area. Taste and hearing are unaffected. The other cranial nerves,
the pupillary and tendon reflexes are normal. Urine normal.

Electrical. — To Faradism there is no response of the facial
muscles on the paralyzed side when stimulated through the nerve.

90 /. RAMSAY HUNT

Directly applied to the muscles of the face the response is slow
and very much diminished.

On March 12, 1905, developed fever with evidences of pul-
monary consolidation of the upper and middle lobes of the right
lung. Died March 26, 1905, at 5 p.m. Clinical diagnosis, tuber-
culous pneumonia.

Autopsy, March 28, 1905, at 3 p.m. A complete autopsy was
performed by Dr. Oertel, pathologist to the City Hospital. The
right lung was found to be the seat of an extensive tuberculous
pneumonia. Gross examination of the brain and spinal cord was
negative. Some of the cervical and dorsal spinal ganglia, branches
of the superficial cervical plexus at its emergence from behind
the sterno-cleido-mastoid muscle were removed for histological
examination. The entire facial nerve from its exit at the medulla
to its entrance at the porus acousticus, the facial and its geniculate
ganglion in the Fallopian canal, both Gasserian ganglia and por-
tions of the pes anserinus of the facial were removed. The
methods used were the Nissl, Osmic acid, Marchi-hematoxylin and
eosin, Van Gieson and Weigert.

The Facial Nerve. — Teased osmicised preparations of the
pes anserinus show the presence of numerous fine pale fibers, with
rosary-like nodulations and swellings of the myelin sheath. In
many other fibers the myelin covering is thin and poorly stained
(pale), showing intervals and interruptions in its continuity.
There are no myelin droplets or granule cells and the whole
picture is regenerative rather than degenerative. The tissue re-
moved from the Fallopian canal and presumably consisting of the
intumescentia ganglioformis, unfortunately did not contain this
organ, so that a microscopical study of the geniculate was not
possible.

The whole trunk of the facial and including the nerve of
Wrisberg from its exit at the medulla to its entrance into the
auditory canal was treated by the osmic acid method. Trans-
verse sections were then made and counter-stained with acid-
rubin. By this method the fibers of the facial nerve proper were
found normal. In the nerve of Wrisberg, however, there was
demonstrated a very distinct and well marked loss of nerve fibers
with a resulting sclerosis and increase of connective tissue.

See Fig. 5.

Medulla Oblongata and Pons. — The cells of the facial nucleus
on the affected side under a low power are smaller, paler and more
rounded than normal, with absence or only slight indications of
the tigroid appearance of the Nissl bodies. Under a high power
the nucleolus is but faintly stained, and the nucleus is small,
irregular in outline and shrunken in appearance. In many cells
the nucleus shows a partial or complete dislocation to the periph-
ery. The Nissl bodies are broken up, the cell body presenting
a finely granular appearance. In some cells there is the typical

HERPETIC INFLAMMATIONS 91

powdery appearance of axonal degeneration. The cell body is
small, rounded and the processes broken off. The quantity and
quality of the cell pigment does not seem to vary in the two sides.
By the Weigert method the ascending root of the facial and the
root fibers in the pons show no variation on the two sides.

Transverse sections of the medulla at the exit of the facial,
the nerve of Wrisberg and the acoustic, show distinct evidences
of old myelin degenerations, granule cells and myelin droplets
in and along the course of the median root of the auditory
nerve (Fig. 6). The root of the facial and the external root of the
auditory are free from such evidences of degeneration.

Cord and Nerve Roots. — The examination of the 1st, 2d, 3d,
and 4th cervical nerve roots on the affected side, shows distinct
evidences of old degenerations in the posterior root of the 3d
cervical segment. Delicate islets of sclerosis are demonstrable.
These are quite destitute of nerve elements or contain only naked
and swollen axis cylinders. No remnants of myelin degeneration
were present in the nerve roots. The central tip only of the right
3d cervical ganglion was removed with the attached roots which
showed some thickening and proliferation of the connective tissue
of the sheath on its internal surface. In the spinal cord distinct
evidences of old myelin degeneration, myelin fragments, droplets
and granule cells, were found scattered along the mesial side
of the posterior horn and the adjacent white substance.
These evidences of degeneration could be readily traced through
the 1st, 2d and 3d cervical segments. The right Gasserian gang-
lion showed no evidences of inflammation or degeneration. The
teased osmic preparations of the branches of the superficial cervi-
cal plexus, show the same regenerative changes as were described
in the pes anserinus of the facial nerve.

Concluding Remarks. — Briefly summarized my conclusions are
as follows: The facial nerve like the trifacial is a mixed nerve.
Its sensory ganglion is the geniculate. The motor root of the
geniculate is the facial nerve proper and its sensory root is the
nerve of Wrisberg. Below the ganglion the peripheral divisions
are the facial nerve proper, the great and lesser superficial petrosal
nerves, the external petrosal and the chorda tympani. This
ganglion is of the spinal ganglion type and therefore in common
with other ganglia of this type, comes within the realm of true
herpes zoster.

The zoster zone for the geniculate is found in the interior
of the auricle and in the external auditory canal.

The only neural connections existing between the geniculate
ganglion and this cutaneous area are the auriculo-temporal branch

92 /. RAMSAY HUNT

of the 5th through the medium of the small superficial petrosal
nerve and otic ganglion and through the facial nerve proper. One
or both of these routes may be taken by the afferent fibers from
the auricle in their central course ; in my opinion the facial route
is the more probable one.

The ear-zone of the geniculate is intercalated between the
zone for the Gasserian in front and the cervical ganglion behind,
so that the zoster zones of the cephalic extremity are represented
by the Gasserian (face and forehead), the geniculate (ear),
the 2d and 3d cervical ganglia (occiput and neck). The zoster
inflammations while attacking chiefly one, not infrequently involve
more than one ganglion, milder changes showing in a series of
ganglia above and below, diminishing in intensity from the cen-
tral focus. For the same reason zoster in any of the zones of
the cephalic extremity, may be accompanied by inflammatory re-
action in the other ganglia of this group.

The pathology underlying the affection is the specific hemor-
ihagic inflammation of the ganglion as found in zona. As the
geniculate is lodged in a narrow bony canal and stands in close
relation to the 7th and 8th nerves, the characteristic syndrome
is produced.

This syndrome may be divided into three clinical groups :

1. Herpes zoster auricularis.

2. Herpes zoster in any of the zoster zones of the cephalic
extremity (Herpes auricularis, herpes facialis, and herpes occipito-
collaris) with facial palsy.

3. Herpes zoster of the cephalic extremity with facial palsy
and auditor}- symptoms (Tinnitus, deafness, vertigo, vomiting,
nystagmus and disturbances of equilibrium).

In the foregoing pages I have endeavored to outline as briefly
as possible the anatomical, pathological and clinical facts upon
which I have based the syndrome. For the sake of conciseness
and clearness, I have eliminated as far as possible all material
not absolutely necessary for a convincing argument. For the
same reason but few direct personal references have been made
to the work of the long list of able investigators, who were my
predecessors in this field. In a subsequent communication I hope
to be able to give the subject broader and more elaborate treat-
ment.

The abundant literature which has grown up in relation to

HERPETIC INFLAMMATIONS 93

this subject will be appreciated on scanning the bibliography
which is appended in full.

Neuralgic Affections of the Geniculate Ganglion and its
Divisions. (Otalgia.) A Preliminary Report.

As the facial is a mixed nerve, having a sensory-ganglion, a
cutaneous representation and zoster zone, the thought naturally
arises, may it not be the seat of purely functional derangements
similar to those occurring in the trigeminal area. May there not
exist otalgia referable to the sensory mechanism of the facial, as
there is prosopalgia originating in the fensory mechanism of the
trifacial.

That herpes zoster of the auricle may be followed by severe
neuralgic pains in the ear is well known. These herpetic otalgias
are secondary, and in accordance with my views on this subject
are dependent upon organic changes in the geniculate ganglion
of the facial nerve.

On considering the extreme sensitiveness and delicacy of
the organ of hearing, the high degree of its innervation, its
exposed situation through the external auditory canal, the pre-
disposition of such a mechanism to neuralgic disturbances would
seem very probable.

This is the case. Otalgia, earache of non-inflammatory origin
in its various forms is by no means an uncommon affection.

I would here mention briefly the branches and neural con-
nections of the facial nerve and ganglion.

I. The ganglion stands in relation to the interior of the auricle
and external auditory canal, its zoster zone (through the medium
of the facial nerve or the small superficial petrosal nerve?).

II. The ganglion is intimately connected with the tympanic
plexus. This is effected through the medium of the small and
large deep petrosal nerves which arise in the tympanic plexus
and join the small and large superficial petrosal nerves, on their
way to the geniculate.

III. The ganglion has also direct relations with the 2d and
3d divisions of the 5th, through the medium of the great and
small superficial petrosal nerves which pass to Meckel's and the
Otic ganglia respectively.

IV. It has reflex connections with the glosso-pharvngeal

94 /. RAMSAY HUNT

nerve through Jacobson nerve, which enters into the formation of
the tympanic plexus.

V. Another reflex connection is with the vagus through its
small auricular branch. This nerve sends an ascending and de-
scending filament to the facial as it crosses the Fallopian canal.

From these brief statements an idea may be obtained of the
intimate neural relation existing between the facial nerve and
ganglion and the tympanic cavity, auricle and external auditory
canal; as. well as the reflex neural connections with the trigem-
inus, glosso-pharyngeal and vagus nerves. A great many of the
otalgias are of reflex origin. In these forms there occur with caries
of the teeth and ulcerative affections of the tongue, pharynx and
larynx, neuralgic pains, localized in the ear. These cases are
quite common and the relation between the nerves sup-
plying the region of the mouth and naso-pharynx and larynx with
sensation and the tympanic cavity and auricle furnish an anatomi-
cal basis for the reflected pain.

The primary otalgia, idiopathic neuralgic affections of the
ear, are recognized by nearly all systematic writers. This group
of cases, however, as is the case with auricular herpes is divided
between the trigeminal and occipito-cervical nerves. If the pain
predominates in the anterior half of the auricle, they are usually
relegated to the trigeminal, or if in the posterior to the occipito-
cervical neuralgia. I believe, however, that there exists an otalgia,
an independent primary and idiopathic affection of the sensory
system of the facial nerve, and that this group will occupy the
same place and have the same significance as the other time-
honored clinical group of neuralgias..

BIBLIOGRAPHY.
ANATOMY AND PATHOLOGY.

Armand-Delille and Camus. (Autopsy). Neur. Central., 1903, p. 144.

Armand-Delille and Camus. Soc. de Neur. de Paris, February, 1903.

Barensprung. Charite Annalen, Vol. X.

Birmingham. The Nerve of Wrisberg. Journ. of Anat. and Phys.,
1895.

Cushing. A Study of the Trigeminal Field. Johns Hopkins Bull.,
July, 1904.

Cushing. Journ. Amer. Med. Assoc, 1905.

Dixon. The Course of the Taste Fibers. Edin. Med. Jour.. 1897, June

Dixon. The Sensory Distribution of the Seventh "Nerve in Man. Jour.
Anat. and Phys., Vol. 33, p. 471.

Frazier and Spiller. Division of Sensory Root of the Fifth for Tic
Douloureux. Jour. Amer. Med. Assoc, 1904. Univ. of Penna. Med. Bull.,
1901, Vol. 24, p. 343.

HERPETIC INFLAMMATIONS 95

Ferguson. Exostoses with Degeneration of the Vidian Nerve. Med.
News, 1800.

Friihvald. The Geniculate Ganglion. Sitzungsbericht der wien. Akad.
f. Wiss., Vol. 74, p. 9.

Gaskell. The Cranial Nerves. Jour, of Physiol., 1889, p. 153.

Hedinger. (Autopsy.) Deut. Zeit. f. Nervenheil., Vol. 24, p. 305.

Howard. The Pathology of Nasal and Labial Herpes (Autopsy).
Amer. Jour. Med. Sc, 1903.

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OTALGIA.

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No. 9.

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HERPES AURICULARIS.

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Vol. 1.

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p. 261.

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Sommers. Aural Herpes. Amer. Med. and Surg. Bull., 1896.

HERPES AND FACIAL PALSY.

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96 /. RAMSAY HUNT

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HERPES WITH SEVENTH PALSY AND AUDITORY SYMPTOMS.

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[

BRAIN TUMOR SYMPTOM-COMPLEX WITH TERMINATION IN

RECOVERY.*

By Herman H. Hoppe, A.M., M.D.,

PROFESSOR OF NEUROLOGY, MEDICAL DEPARTMENT OF UNIVERSITY OF CIN-
CINNATI (MEDICAL COLLEGE OF OHIO) J NEUROLOGIST TO THE
CINCINNATI HOSPITAL.

The title of this paper is not at all misleading to the neurolo-
gist. All of us are at times confronted with cases which present
the general symptoms of a brain tumor, together with focal signs
which seem to render not only the general diagnosis of a cerebral
neoplasm probable, but the focal signs are more or less marked,
even to such an extent that we have little hesitation in designating
the seat of the tumor. After a while, however, perhaps after
several remissions and exacerbations extending over a period of
years, these cases recover, showing, however, some defect, usu-
ally on the part of the eyes. Then death is caused by some other
disease, and the brain is found perfectly normal.

Both the cases which recover and those in which a negative
condition of the brain is found after death are of sufficient im-
portance to merit our attention.

I will briefly report three cases of this kind, two of which are
still alive, and one which died of tuberculosis, and in which an
autopsy was made.

Case No. i. — Cause of death, pulmonary tuberculosis. Under
observation 10 years.

Nov. i, 1895. Alice W., age 23, single, servant. Parents are
well, father very nervous. Has sisters and brothers. One sister
a confirmed neurasthenic with obsessions. No history of syphilis
nor any evidence whatever of it to be found on examination.
Patient has been well with the exception of an attack of la grippe
two years ago. Has had attacks of headache for 4 years with
occasional nausea. These attacks came on at night especially.
Two years ago headaches became very severe, had enlarged
glands in the neck at this time which were very painful. At
this time the pain was constant, located in the occipital region,
associated with pain in and behind both eye-balls. Has attacks
of jerking in the neck and back.

The headaches are subject to acute exacerbations, during

*Read at the meeting of the American Neurological Association, June
4 and 5, 1906.

98 HERMAN H. HOPPE

which patient walks the floor, tears her hair, screams and "seems
to lose her mind." During this time patient's character changed.
She became cross, querulous, was often unmanageable, subject
to fits of violent temper. There was some weakness of both legs
and staggering gait. The vision was diminished. These violent
headaches and other symptoms would last two or three months.
Then there would be a period of freedom from pain followed by
another siege of headache, etc. Seven months ago she began
to lose sight in the left eye. Could not distinguish objects. Legs
were often numb and cold. During entire summer the legs were
weak. Staggering gait came on at this time and has continued
ever since, being worse on arising in the ' morning and when
fatigued.

Examination. — Patient is of medium height, well built, 120
lbs. in weight. Intelligence good, memory good. Has violent
headaches. Vertigo when she leans forward. Typical choked
disk. Pupils equal and react to light, marked choked disk. No
derangement of external muscles of eyes. Vision of left eye
almost gone, has only light perception. Slight weakness of right
facial. Has typical staggering gait (cerebellar). Muscular power
and sensation normal. Left patellar reflex absent, right present.

Diagnosis. — Cerebellar Tumor( ?).

Patient was treated with iodide of patassium and later on with
proto-iodide of mercury.

The symptoms gradually disappeared after six months. Has
headache about once a week. Choked disks had disappeared, was
able to read large print with left eye, good sized scotoma in upper
and outer part of field. General weakness of arms and legs but
can walk well, no staggering gait.

Left patellar reflex absent, right normal.

A few months later had slight horizontal nystagmus, knee
reflex returning on left side. Complains of buzzing in the head.

After a total illness of three years, and about 14 months after
beginning of treatment, patient returned to her occupation, being
entirely well with the exception of some defect of vision in the
left eye.

Patient remained entirely well for six years.

July 9, 1902, aet 30. Has been at work 7 years. Patient
returned with statement that she occasionally had headache, in-
somnia, vertigo, but no vomiting, these symptoms would last but
a short time and would disappear.

Lately the headaches had again become more violent, they
were frontal, lateral and occipital, with occasional vomiting.
Staggering gait, states . that she cannot see with left eye at all
and only very little with the right. General weakness, can
come to office.

Examination. — Some mental hebetude, peculiar inclination of
head to right side probably due to defect of vision.

BRAIN TUMOR 99

Marked choked disks of both eyes. The examination is other-
wise negative. Patient was again placed on iodide of potassium.

In six or eight weeks all the above signs and symptoms dis-
appeared again. About one year later patient developed an
ordinary case of pulmonary tuberculosis.

I saw her once during the three years preceding her death.
She became mentally unbalanced. Mental confusion, became
violent at times because of suspicions of food being poisoned.
This period lasted for several months and gradually passed away.
The examination carefully made showed that there was an ab-
sence of all signs and symptoms pointing to any organic brain
lesion.

Died Dec. 20. 1905. The autopsy was limited to an exami-
nation of the brain. The brain was perfectly normal, normal
quantity of cerebro-spinal fluid. Dura mater and pia mater
normal. Nowhere any adhesions. Cortex carefully examined
microscopically was normal in every convolution. The ventricles
were absolutely not dilated, the basal ganglia normal. Cerebellum
was most carefully examined, no cicatrices, no atrophy, no ad-
hesions on surface of the cerebellum, fourth ventricle, peduncles,
pons, and medulla are all normal. The canal of Sylvius was open.
The foramen of Magendic was also normal.

Hence no signs of a meningitis, hydrocephalus or brain tumor
or abscess anywhere to be found.

Case II. Under observation 13^2 years.

Kate E., aet. 16, Buffalo, W. Va., was first examined by me
on Dec. 30, 1892.

Family History. — Father alive and well. Mother dead, cause
pulmonary tuberculosis. Has two sisters and one brother, all
of whom are well. Collateral family history negative.

Present trouble began in 1888, four years ago. Previous had
typical attacks of migraine or which were supposed to be such,
viz., headache, vomiting and general prostration, the attack lasting
usually 24 hours. Since onset of present trouble she has not had
any sick headaches.

Present trouble began with difficulty in hearing and seeing.
The difficulty in hearing manifested itself in gradually increasing
deafness, which began four year ago. At the same time there
was failing eye-sight in the right eye.

Menstruation, previously regular, has ceased for past ten
months.

Vision has gradually diminished in right eye until patient is
unable to see at all for past three years.

Turning of head to left causes pain in head and below the
ears, complete turning of the eyes upward also causes pain in
head.

Has had vertigo and vomiting for the past three years. Som-
nolence is very marked, is sleepy, sleeps often during the day.

ioo HERMAN H. HOPPE

Sleeps soundly at night. Never loss of consciousness, frequent
attacks of staggering with the vertigo. Has been deaf in right
ear for past three years :

About one year ago noticed that she could not turn right eye
outward, lately has had daily headaches.

Physical examination. — Mental condition good, facial expres-
sion good.

Vision, right eye 0.7; left eye 1.0. Pupils equal in size and
react to light.

Bilateral optic neuritis, choked disk, unable to close right eye
completely. Paresis marked of right abducens, slight weakness
of left abducens.

Head turns to left, face is inclined to left. Entire body in-
clines to left side. No tenderness of calvarium on percussion.
Paresis of right side of face. Tongue is protruded in median
line.

Xo disturbance of sensation anywhere.

Arms nonnal.

Legs, muscular power and reflexes are normal.

Marked static ataxia, cannot stand on right foot with closed
eyes, very difficult to stand on left foot. Staggers to left when
walking.

Dr. Ayres' examination. — Right eye, V = 0.7, left eye, V =
1.0.

Right ear loud tones 2 inches. Left ear hearing normal.
Loud tinnitus.

Right optic disk presents a rounded mass which extends
over and obscures the edge of disc. The veins are large, arter-
ies obscured by the swelling.

Left optic disk is enormously swollen, no hemorrhage into
the retina.

Patient was placed under treatment of iodide of potassium.
Returned home in January. 1893, and remained entirely well for
a year (see letter). She had an attack of fever in February, 1894.
In May. 1894. again became very ill with a headache and returned
to Cincinnati in June, 1894.

Examination, June. 1894.

Paralysis of external rectus of right eye. Vision, right eye
0.2, left eye 1.0. Marked choked disk both eyes.

Great difficulty in walking, cannot walk unassisted, staggers
and falls to the left.

Has severe pain in the left side of head and discharge from
the left ear. no evidences of mastoid disease.

Has severe pain in left occipital region.

In a letter dated March 9, 1906, patient writes that she has
recovered entirely. She is strong and well and capable of person-
ally doing the housework for her father. There remained only
some defect of vision of the right eye and a partial paralysis of

BRAIN TUMOR 101

the right external rectus. For the relief of the latter she had
performed a tenotomy in April, 1905, which was completely suc-
cessful, relieving the strabismus which had been present since
1894.

Viewing this case critically, in 1894 we have a history of
some cerebral process gradual in its onset, gradually increasing
in intensity, gradually compressing the cranial contents producing
headache, vertigo, vomiting, somnolence, choked disks as general
manifestations of a brain tumor and amblyopia of right eye,
paresis of right external rectus, paresis of left facial, typical stag-
gering gait, falling to left and static ataxia especially when stand-
ing on left foot.

A diagnosis of cerebellar tumor was certainly justified con-
sidering the slow gradual onset in a healthy robust girl, together
with the absence of any signs of tuberculosis anywhere, or any
focus of pus which might have produced a cerebellar abscess.
(The otorrhea did not develop until 5 years after onset of first
cerebral symptoms.)

Case III. Under observation 2 years, sent by Dr. B., George-
town, Ky. Examination August 22, 1904.

J. W. B., male, farmer, aet. 47, American, married, 4 children,
all healthy. Patient denies all venereal diseases. Has always
been well and worked hard. During past four or five years has
had stomach ache with frequent attacks of vomiting. Has not
been a drinker. Has had violent headaches for past four months,
occipital in character. He had two attacks of violent vertigo
in both of which he fell to the ground with momentary loss of
consciousness. Has double vision very often. Cannot recognize
objects one hundred feet off. Is unable to read ordinary print.
Vomits occasionally. Has occasional attacks of staggering, as if
he were drunk.

Examination. — Facial expression heavy, mental hebetude well
marked. Intellect good. Memory good.

Pupils equal in size and respond to light. Marked choked
disk in both eyes. External muscles of eyes normal. Reflexes
all normal. Examination in every other respect negative.

Resume : Headache, four months in duration, vomiting, violent
vertigo with attacks of momentary unconsciousness. Staggering
gait, double vision, great diminution of vision and bilateral choked
disk.

Diagnosis. — Probable cerebellar tumor.

Examination May 1, 1906 (has not been examined for twenty
months). Patient has gradually improved especially so in the
past eight weeks. But made no improvement at all until six
months ago. Headache has disappeared.

Has still occasional attacks of vertigo, slight staggering but
very mild compared to formerly. Double vision is still present,
objects being side by side. Can read large print.

102 HERMAN H. HOPPE

Examination. — Mental condition bright, considers himself
practically well. Has done some work this spring. Pupils equal
in size and react to light.

Slight atrophy of left optic nerve. Right seems normal.

Right patellar reflex diminished, left normal.

Examination in other respects negative.

This patient has been taking iodine in some form all this time.
There seems but little doubt that this case belongs in the same
category as the other two.

The diagnosis of brain tumor is based upon the presence
of certain symptoms and signs which point to a gradually
increasing local and general compression of the cranial
contents.

Of these the general signs and symptoms together with
choked disk are of greatest importance in making the diag-
nosis of the presence of a tumor. The chief factors in esti-
mating the value of these signs and symptoms are:

First — That of Time. Second — Compression.

As to the factor of time we must determine that from
slight and insignificant beginning the symptoms gradually
in the course of months grew in severity, duration and num-
ber, perhaps subject to periods of remissions and exacerba-
tions, but nevertheless steadily growing worse as time passed
by. The second point is equally important. All the symptoms
must be the result of a gradually increasing compression of
the cranial contents with localized destruction of brain tissue.
When those general and local symptoms occur in sufficient
number we can be reasonably certain of the presence of a
tumor, and ordinarily the diagnosis and localization are not
difficult. The only outcome of the brain tumor is relief by
surgery or death, and then the diagnosis is usually verified.
Leaving out of consideration possible errors of diagnosis which
are shown up by autopsy, when abscess, hydrocephalus or
some other gross lesion of the brain has simulated a brain
tumor ; there remain a few cases, as undoubtedly has happened
in the practice of us all, in which, after careful examination, when
all the signs and symptoms pointed to the presence of a brain
tumor, the patients either recovered with perhaps only a slight
defect or, death being caused by some other intercurrent dis-
ease, the autopsy revealed a negative condition of the brain.

BRAIN TUMOR

iQ3

Cases of this character are interesting enough, and of suffi-
cient importance to demand our attention. While every one
of us has undoubtedly seen them, the literature fc exceedingly
scanty. There are but two papers which deal extensively
with this subject. I refer to the articles of Nonne and Oppen-
heim. Nonne's article gives in detail 8 cases occuring in adults
and Oppenheim's deals with a similar condition in children.

It is needless to say that cases such as these cannot be
attributed to a functional derangement of the nervous system.
I may say that we can rule out hysteria at once. Such an
array of general and local symptoms can be due only to
some organic change either in the brain itself or in its mem-
branes, and this lesion must be capable of complete retrograde
change, restoring the brain to its original normal condition.

^ In considering the possible pathological condition under-
lying these cases we must divide them into two groups :

(a) Those cases in which death has occurred from some
accidental cause and in which the autopsy revealed no brain
lesion whatsoever.

(b) Those cases in which recovery occurred and the patients
are still alive or having died, no autopsy was held.

There are very few cases of the first group on record.
Nonne publishes three cases of this kind with autopsy in which
the brain examination, including microscopic and bacterio-
logical examination was entirely negative. Since Nonne's
publication (1890) I have found no others and I wish to put
my case with negative autopsy on record. While Nonne de-
clines to consider the possibility of hydrocephalus acquisitus
or serous meningitis, but inclines to the theory that some
unknown and hitherto undiscovered organic lesion which is
perfectly curable must be looked upon as the cause of the
trouble, it seems to me that we must consider one of the
following conditions as the underlying cause, I refer:

1. To serous meningitis producing acquired internal hydro-
cephalus, and

2. Hemorrhagic non-purulent encephalitis with serous
effusion.

3. Chlorosis.

4. Chronic cerebritis.

In the purely clinical cases, which have recovered after all

104 HERMAN H. HOPPE

the signs and symptoms of brain tumor were present, we must
consider in addition to the above condition, the possibility of

5. Brain tumors or tubercles which have either undergone
a retrograde metamorphosis or have become arrested in their
development and to which the brain has accommodated itself.

It has been shown that all of the above pathological con-
ditions except cerebritis, may produce a symptom-complex
not unlike that of brain tumor and terminate in recovery.

Let us take up internal hydrocephalus first. There can be
no doubt to-day, first, that internal hydrocephalus or serous
meningitis occurs quite frequently in the adult, and in the
second place it can hardly be doubted that although most of
these cases terminate fatally, recovery may and does take
place. Quite a number of acute mastoid inflammations are
associated with a meningitis which disappears in a day or two
after the operation, and which is in all probability serous in
character.

It is possible that the majority of cases with brain tumor-
symptom complex which terminate in recovery are really cases of
serous meningitis of a subacute or chronic character, leading to in-
ternal hydrocephalus. We know now, that acquired hydrocephalus
not only produces the general signs of a brain tumor, such as
headache, vomiting, vertigo .and choked disk, but also focal
signs,, such as staggering gait, hemiplegia, aphasia and
paralysis of the various cranial nerves.

Oppenheim calls attention to the fact, that it is difficult,
and often impossible, to differentiate between a tumor of the
occipital fossa and meningitis serosa, and that the latter con-
dition is the most frequent cause of a mistaken diagnosis
of a cerebellar tumor. He says further, that these cases usu-
ally occur in women who present the following symptom-
complex: Headache, vertigo, vomiting, choked disk, paresis
of the external recti muscles, more especially of the right eye,
nystagmus, more especially when the eyes are turned outward,
especially toward the paretic muscle, areflexie or hypo-
reflexie of the cornea, tinnitus and diminished hearing on the
same side, and cerebellar ataxia. He looks upon this symp-
tom-complex as typical, and says that whereas in the begin-
ning he always made the diagnosis of cerebellar tumor on the
affected side, he now knows that these are cases of acquired

BRAIN TUMOR

10;

internal hydrocephalus or serous meningitis. The apparently
focal signs of internal hydrocephalus are partly due to distal
pressure, and this would explain the paralytic signs on part
of the cranial nerves at the base of the brain. Oppenheim
says that a unilateral predominance of pressure in the laby-
rinth of one side may so affect the cochlearis and the nervus
vestibularis as to cause staggering to one side, tinnitus, as
well as the nystagmus, and the abnormal holding of the head.
As a rule, gross unilateral symptoms on part of the ex-
tremities are absent in acquired hydrocephalus, but they may
be present, as we know from reported cases, prominent among
which is the case of unilateral hydrocephalus reported by
Spiller. These, however, are the exceptions, and when they
do occur they are not progressive nor permanent (Oppen-
heim). The focal signs may also be explained by the fact
that serous meningitis may be complicated by a mild localized
encephalitis or, what may also happen, the encephalitis may
be the cause of the serous meningitis. Monoparesis, hemi-
paresis and hemianopsia are rare, still they have been observed
(Annuske, Quinke and Kupferberg).

Moreover, we may have attacks of convulsions with
periods of somnolence and coma, lasting perhaps a few days
and then disappearing, perhaps not to return in months. 1
have seen this in a case of hydrocephalus which was associated
with a brain tumor, and in which these attacks occurred six
or eight times in a period of two or three years. Remissions
are more common in hydrocephalus than in brain tumor.
Herzfeld calls attention to these attacks coming on with
almost apoplectic suddenness after long periods of compara-
tive well being. Oppenheim attributes these attacks to a
sudden increase of intraventricular pressure, or to a sudden
compression of the medulla or vasomotor centers caused by
a change in the position of the head.

We see, therefore, that there is a marked similarity not
only between acquired hydrocephalus and cerebellar tumors,
but also tumors of the brain in general. As a rule time will
clear up the diagnosis, and even during life we can say with
considerable certainty whether we have tumor or hydro-
cephalus. If the patient dies, then as a rule, the condition be-
comes certain. But what of those cases in which the autopsy

io6 HERMAN H. HOPFE

is entirely negative or in which the patients recover and remain
well? Nonne concludes that in the eight cases of brain tumor
complex with recovery which he reports in his article, there could
not have been an acquired internal hydrocephalus or miningitis
serosa, because of the absence of the etiological factors of the
latter condition, namely : alcoholism, physical or psychical
shock, insolation and infection.

It is possible, however, to have acquired hydrocephalus
without any cause known or discoverable during life, and I
personally am inclined to think that at least some of these
cases are due to acquired hydrocephalus taking its origin from
some cause unknown during life, which is either favorably
affected by the treatment or disappears spontaneously, the exuda-
tion being resorbed.

Let us consider briefly the etiology of acquired internal
hydrocephalus in regard to its pathology.

Spiller reports a case occurring in the service of Dr. Mills
in which during life the diagnosis of cerebellar tumor was
made. The autopsy however revealed an internal hydrocepha-
lus caused by closure of the aqueduct of Sylvius by prolifera-
tion of the neuroglia. Byrom Bramwell reports a similar
case caused by a closure of the foramen of Magendie. J. Parkes
Weber, reports a case of acquired hydrocephalus with marked
ependymitis of the fourth ventricles. He draws an analogy
between acquired hydrocephalus and serous pleurisy and peri-
tonitis. In both of these conditions we may have a large
serous effusion caused by a small local area of inflammation,
and he asks whether a large acquired hydrocephalus may not
be caused in the same way. This conclusion would seem to
be borne out by an autopsy which I recently made on a young
boy, in which a marked hydrocephalus complicated a case of
"brain tumor. The tumor, an endothelioma, grew in the thala-
mus and extended into the white matter. Covering the serous
surface of the lateral ventricle just over the tumor was a small
area of tough fibrous exudate about the size of a silver half
dollar which could be peeled off. In this case the symptoms
were typical for acquired internal hydrocephalus, and ante-
dated the focal signs of the brain tumor for years. It is not
improbable to conclude that this hydrocephalus may have had

BRAIN TUMOR I07

its origin from this small area of inflammation which was
found located over the tumor in the lateral ventricle.

We also know that autopsies do not always show a closure
of the various foramina in internal hydrocephalus.

From the reports of well examined cases we know that
acquired hydrocephalus may occur from an inflammation of
the tela choroidea, the choroid plexus, from pressure upon the
vena Galeni, or a localized inflammation around the opening
of the fourth ventricle. Any of these conditions might occur
during life, without our knowledge, and terminate in recovery.
Anton says that a frequent cause of chronic acquired internal
hydrocephalus is a localized meningitis at the base of the brain.
Quinke and Bonninghaus say that this meningitis spreads to
the tela choroidea and the choroid plexus, and in this way causes
internal hydrocephalus. Any localized swelling or inflamma-
tion around the foramen of Magendie or along the course of
the canal of Sylvius may lead to a closure of these passages
and thus cause an internal hydrocephalus. These various
localized inflammations may yield to treatment, or heal spon-
taneously. The passages may reopen and the accumulated
fluid become resorbed and the brain may return to a normal
condition.

I refer to Anton, Quinke, Gowers and Oppenheim as au-
thorities, that we may have recovery in typical cases of internal
hydrocephalus acquisitus. The symptom-complex which is at
times seen in myxedema of adults is probably due to a tempo-
rary meningitis serosa or internal hydrocephalus. Thus, I
kave a patient who has had myxedema for many years. She
is very intelligent and highly educated. For years she has
had attacks which begin with violent headache, vertigo, ir-
ritability, mental and emotional depression, marked stagger-
ing gait, delirium, mental confusion and, finally after some
days, inability to walk, terminating in great somnolence, apathy
and apparent dementia. These attacks may last from three to
five days, to as many weeks, and then terminate rather quickly
when the thyroid extract is pushed. She has had from one
to four attacks per year for the past five or six years, and I
look upon them as being due to an internal hydrocephalus
caused perhaps by the same toxin which causes the general
myxedema. I therefore feel that a large percentage of the

io8 HERMAN H. HOPPE

cases of so-called brain tumor ending in recovery are really
subacute cases of internal hydrocephalus which terminate
in resolution, I include among these, those cases in which death has
occurred and in which the autopsy has been negative.

Have we any means of making the positive differential
diagnosis between brain tumor and acquired hydrocephalus in
these doubtful cases. It is needless to say to-day that the
Quinke puncture, or the specific gravity of the fluid will not
clear up the differential diagnosis. The factor of time itself
will only enable us to say in the recovered cases, or in
cases with a negative autopsy, that we did not have a tumor
but may have had an internal hydrocephalus.

Polio-encephalitis hemorrhagica usually is acute in its on-
set and rapid in its course and does not ordinarily cause a
symptom-complex resembling brain tumor. But the reported
case of Schultze shows us how a polio-encephalitis superior may
simulate a tumor of the corpora quadrigemina especially if it is
complicated with an ependymitis with a secondary internal
hydrocephalus. Schultze's case had in addition to the focal
symptoms, somnolence and optic neuritis. Oppenheim reports
a similar case with recovery, and he states that he had had
a number of such cases, one in which he had even advised an
operation, and recovery occurred. He concludes that there was
present either a nonpurulent hemorrhagic encephalitis or some
hitherto unknown pathological process capable of complete
recovery.

Cases of completely cured polio-encephalitis, with perhaps
some slight defect, do undoubtedly occur and we have thus
another condition which may cause all the signs and symptoms
of a brain tumor and terminate in recovery. In these cases,
according to Oppenheim, the localized encephalitis is in or
near the cortex, which explains the occurrence of Jacksonian
epilepsy, monoplegia, aphasia, etc.

In this connection I also wish to refer to meningitis tuber-
culeuse en plaque which Oppenheim looks upon as the cause
of brain tumor symptom-complex occurring in a number of
children who recovered, and the author looks upon the local-
ized tubercular mieningitis as a curable affection.

Therefore, as far as encephalo-meningitis is concerned, we
can never be absolutely sure of the diagnosis, because we

BRAIN TUMOR 109

cannot rule out with certainty either localized tubercular or
localized syphilitic meningitis.

We know from the recorded cases of Crawford-Thompson,
Burton-Fanny, Jollye, Gowers, that chlorosis may produce
a symptom-complex which may temporarily simulate brain
tumor. We have in these cases pronounced headache, vomit-
ing, vertigo, together with optic neuritis. Oppenheim reports
a case of especial interest, in which the anemia was a com-
plication of carcinoma of the breast, and the headache, vomit-
ing, vertigo and optic neuritis simulated a metastatic cor-
cinoma of the brain. The importance of recognizing the fact
that anemia may produce a brain tumor symptom-complex
should render us more careful about vetoing the amputation
of a breast which otherwise might not only prolong the life
of the patient, but even end in recovery.

The consideration of pseudo-tumors of the brain, with
negative autopsy cannot be complete without taking into con-
sideration the subject of chronic cerebritis or cerebral hyper-
trophy. This condition is exceedingly rare, and occurs most
frequently in children, but may occur in adults. In adults
where the cranium cannot expand we may have all the signs
of intracranial pressure with irritation, resembling those of
brain tumor. The cases are acute in their course, but may be
subacute. The symptoms, according to Eulenberg, resemble
very much those of acute hydrocephalus, violent headache,
vomiting, slowness of the pulse, general convulsions, perhaps
optic neuritis.

Let me give you Rokitansky's description of this condition :
If we split open the dura mater we perceive immediately that
there is a swelling of the brain, so much so, that there is
great difficulty in putting back the calvarium. The various
membranes are remarkably thin, the dura mater is tender, pale
red in appearance, the pia mater is very close on the one side
to the dura, on the other to the cortex. They are abnormally
dry and their vessels small, flat and unusually free from blood,
the brain hemispheres appear at first sight unusually large,
the convolutions are pressed close together and flattened to
such an extent that the sulci are hard to recognize. The white
substance of the brain which has increased in volume is pale,
anemic, which differentiates this condition from hyperemic

no HERMAN H. HOPPE

turgescence which Rokitansky looks upon as due to an increase
in the neuroglia. Anton holds that we may have also a
parenchymatous hypertrophy of the brain. Rokitansky and
Eulenberg look upon the condition as due to a general increase
of the neuroglia.

Eulenberg says that the fatal termination is usually due
to a congestive hyperemia.

The literature on this subject is exceedingly scanty, but
if such a case should occur and we were on the lookout for a
tumor, especially if the brain were presented to us after the
removal from the calvarium, the condition might easily be
overlooked and the autopsy considered negative.

Anton asserts that there may be a partial cerebral hyper-
trophy, which if it did occur might produce even a more de-
cided brain-tumor symptom-complex. He gives, however, no
data to substantiate this assertion.

In the cases of recovery from brain-tumor we must bear
in mind that the patient may really have had a brain-tumor,
and that the latter disappeared, or the brain became accustomed
to its presence after it ceased to grow. Some of these cases,
however, are cases of brain-tumor with unusually long remis-
sions of the symptoms and not cases of real recovery, which
like Osier's case finally end fatally. Oppenheim, Gowers,
Bernhardt and Russel have reported similar cases. Psam-
momata, lipomata, cholesteatomata may attain a certain size
and then cease to grow. Cysticerci and echinococci may die
and shrink. The observations confirmed by autopsy are ex-
ceedingly rare. Xonne was able to find but four cases, those of
Bruns, Oppenheim and Simeon.

Aneurysms may cease to grow or become obliterated by
the formation of a clot and the brain accommodates itself to
the pressure (Oppenheim, Hutchinson, Hodgson and Hum-
ble). Solitary tubercles may undergo caseation calcification
and then become encapsulated causing no further damage
(Wernicke, Starr, Knapp, Gowers, Babinski and Sahlberg).
These observations are confirmed by the pathological obser-
vations of Simeon who reports an autopsy in which a calcified
tubercle was found which must have been in the brain for 30
years. Kirschberger's case shows how a tubercle may show
all the signs of a brain-tumor for a year and a half and the patient

BRAIN TUMOR m

recover and remain well for six and one-half years. The autopsy
in this case showed that the tubercle had become calcified. Gum-
mata may become absorbed and disappear.

Long remissions and even permanent disappearance of
symptoms may occur in brain-tumor as numerous cases on
record show. These cases, however, would hardly come under
the head of pseudo-tumors with a complete disappearance of
symptoms, because they had been regarded during life as cases
of epilepsy of many years' duration, and after death partly or
completely ossified tumors had been found as the cause of the
epilepsy.

That a pathological mass may be present in the cortex of
the brain for 40 years and cause no interference with the ordi-
nary daily life of an individual the following case will show:

Lately an individual, 60 years of age, died in my service
at the Cincinnati Hospital from acute meningitis. He states
that at the age of 21 his left arm became paralyzed, but that
it soon recovered. He has lived the life of a farmer and
teamster for the past 40 years. With the exception of some
weakness of the left arm and a constant headache he had al-
ways been well.

The autopsy revealed a mass, hard, indurated, cartilagen-
ous, about the size and shape of a peanut, situated in the
cortex, at the posterior end of the first frontal convolution of
the right side, pressing upon the ascending frontal convolution.
This mass was partly cortical and partly subcortical, was not
firmly adherent, and was surrounded by recent softening. On
splitting it open we find a very hard stony calcareous center
and a hard cartilagenous covering.

The practical conclusion of the consideration of this sub-
ject is, in the first place we should not be too pessimistic in our
prognosis of brain-tumors, especially in cerebellar cases, until
a considerable period of time has elapsed; and in the second
place we should not be too hasty in the recommendation of
surgical interference both in children and in adults, until
therapeutic measures have been given a long and complete
test.

BIBLIOGRAPHY.

*Nonne. D. Zeitsch. f. "Nervenheilkunde, Bd. 27, p. 169.

2H. Oppenheim. Berl. Klin. Woch., 1901, Nos. 12 and 13.

8H. Oppenheim. Nothnagel's Handb., der Spec. Path u. Therap., 1897.

ii2 HERMAN H. HOPPE

4W. G. Spiller. Am. Journ. Med. Sc., 1902, V. 124, p. 44.

5Spiller-Mills, loc. cit.

SF. Boenninghaus. Ueber Meningitis serosa Wiesbaden, 1897.

'Quincke. Volkmann's Samm. Klin. Vortrag. Inn. Med., 1893, No. 23.

"Annuske. von. Grafe's Arch. f. Ophth. Bed., 1873, Bd. 19, Pt. iii.

"Byrom Bramwell. Brain, Spring, 1899, V. 21, p. 66.

10F. Parks-Weber. Brain, 1902, V. 25, p. 140.

Anton. Handb. der Path. Anat. des Nervensystem., H. ii., pp. 398, 452.

Fr. Schultze. Nothnagel's Handb. der Spec. Path. u. Therap, 1901.

Gowers. Diseases of Nervous System, Vol. ii., p. 66.

A. Heidenheim. Berl. Klin. Woch., 1899, p. 1078.
15H. Oppenheim. Charite Annalen Jahrg., xv., 1890.
ieH. Oppenheim. Monatsschr. f. Psychiatrie u. Neurol., Bd. 18, H. ii.
"Rokitansky. Lehrb. der Path. Anat.
"Anton. Loc. cit.

"Eulenberg. Real Encyclopedic Chronic Cerebritis.
"Kirnberger. Inaug. Diss. Freiburg, i. Br., 1898.

vs

14

AFTER-CARE AND PROPHYLAXIS AND THE HOSPITAL

PHYSICIAN.*

By Adolf Meyer, M.D., LL.D.,

DIRECTOR OF THE PATHOLOGICAL INSTITUTE OF THE NEW YORK STATE HOS-
PITALS, AND PROFESSOR OF CLINICAL MEDICINE (PSYCHOPATHOLOGY)
CORNELL UNIVERSITY MEDICAL SCHOOL.

At the request of our President I have been induced to report
briefly on a movement which has been inaugurated in New York
State for the purpose of after-care of needy persons discharged
from hospitals for the insane. What Dr. Wise, Dr. Stedman, Dr.
Dercum, Dr. Dana, and Dr. Dewey had advocated since 1893,
has at last been realized and put in operation.

Largely through the efforts of Miss Louisa Lee Schuyler, the
Conference of Superintendents of the State Hospitals of New
York has requested the State Charities Aid Association to organ-
ize a system of after-care for the insane, and to put it into prac-
tical operation. It passed a resolution "That in the opinion of
this conference it is desirable that there shall be established in
this State, through private philanthropy, a system for providing
temporary assistance, and friendly aid and counsel for needy per-
sons discharged recovered, from State Hospitals for the Insane,
otherwise known as 'After-Care of the Insane.' "

This inaugurates a system of co-operation between the State
Hospitals and an organization of private philanthropy and makes
possible a co-operation of paid agents and of volunteers ; the
expenses to be paid by voluntary contribution, and with the utili-
zation of the allowance provided by the State of an amount
up to $25.00 for patients discharged and in need of help to
"defray his necessary expenses until he can reach relatives and
friends or find employment to earn a subsistence."

The State sub-committee on after-care consists of six members
from the State Charities Aid Association, and as organization
progresses, each hospital district will receive its special after-care
committee ; Manhattan State Hospital has a committee consisting
of five members of the State Charities Aid Association and two
members from the board of managers of the hospital, and the
superintendent. The Willard After-care Committee has seven

*Read at the meeting of the American Neurological Association, June
4 and 5, 1906.

114 ADOLF MEYER

members from the State Charities Aid Association, three mem-
bers of the board of managers, and the superintendent of the hos-
pital. There has already been an agent appointed to work in
connection with Manhattan State Hospital. The formal expenses
of salary, traveling and other after-care expenses are expected to
amount to about $2,500 annually, and in addition to the allowance
up to $25 assured by the State, private contributions will be
resorted to for practical assistance of individuals.

In the main the system of the English After-care Society
seems to have been the chief model of the movement inaugurated,
apart from the fact that more is made of a co-operation of the
hospitals with the local Committee, and that really a co-operation
between State and private philanthropy is assured. This special
fact is very gratifying. In a paper read by me at the conference
at which the State Charities Aid Association was authorized to
take up the co-operative work, I made a strong appeal in favoi
of as close as possible co-operation between the physicians who
have charge of the patients and any individuals who wish to
help the patients outside. The failure of the previous efforts
in such a movement in this country comes, to a large extent, from
a lack of conviction on the part of hospital physicians concerning
the efficiency and desirability of the ordinary type of charitable
movements. And I am also convinced that unless there is a hearty
co-operation between physicians and philanthropists, the move-
ment loses its greatest opportunity and its main spring which
would assure its life and its development into that which we
really need most of all, — namely, the breaking down of the hos-
pital walls, the extension of responsibility of the physician to the
prevention of relapses, and the responsibility of carrying useful
information gained in hospital practice to our intermediators
among the public — the physicians, and those who have the broader
sociological problems of the community at heart. This country
is fortunately not a region in which pauperism is an inevitable
doom of a certain portion of our population. Large cities may
offer numerous samples of destitution requiring monetary aid,
but as a rule our people are proud of supporting themselves ; they
like to make their own way, and wholly friendless individuals are
extremely rare. The main need is that of guidance to a field best
adapted to the qualification of the patient, and especially also
guidance of their environment in the direction of adequate help

AFTER-CARE AND PROPHYLAXIS 115

and strengthening of the healthy instincts in the struggle against
morbid tendencies.

In trying to do the work with the insane as conscientiously
as possible, and in interesting our colleagues in the service, cer-
tain needs have become evident which ultimately will have to be
taken up by the after-care associations.

In the first place, the desirability of encouraging and organiz-
ing in each community persons capable of spreading sound in-
formation concerning what the State can and will do for victims
of mental disorders.

2nd : The encouragement and organization of individuals who
will have enough interest in the cause to help the hospital phy-
sician get at the correct estimate of the conditions under which
the patient was wrecked, and to which the patient shall be dis-
charged, i. e., persons to be appealed to in obtaining direct infor-
mation.

3d : Persons who will be willing to relieve the tension between
the public and hospitals, usually based on misinformation.

4th: Persons who have a sufficiently wide acquaintance with
the opportunities of a locality for drawing a recovered patient
as rapidly as possible into a healthy and wholesome environment,
that is, persons who have contact with movements by no means
exclusively looking out for persons who have been insane. Much
help is obtained from churches, from charity organizations of
an independent character, from abstinent societies, and from all
those who are leaders of interests in the various strata of our
healthy population. The issue is to make all the possibilities
accessible.

In this whole movement we physicians can do a great amount
of good by helping in the co-ordination of all the individuals who
might be accessible to interests, — leaders among the various strata
of the healthy, physicians, schoolmen, leaders of social movements,
workers against alcoholic excesses, judges, clergymen ; to attract
their attention to the available reports, to organize some public
lectures on matters which seem to be specially in need of eluci-
dation in a community, to distribute such lectures, and to gradu-
ally replace the notions of half a century ago by the facts avail-
able at the present time.

The New York Psychiatrical Society aims to make a be-

n6 ADOLF MEYER

ginning in this direction, and it is hoped that other bodies will
follow.

In closing I should like to emphasize an appeal for harmonious
working, for a disinterested assistance to the hospital men, who
after all assume the greatest responsibility about the fate of the
patient, and well considered co-operation of any after-care and
prophylaxis movement in each community. But first of all, I
should urge the necessity of dropping the narrow-minded habit
of considering the restrictions under which hospital-physicians
work as inevitably those of sequestration. Let us help the hospital-
physician broaden his horizon and overcome the diffidence im-
posed on him by tradition and prejudice. He should be the center
of work for the patient, the collector of all the information and
therefore the one who will also be the central figure in the after-
care steps. Give the hospital-physician the chance and you will
see that the chief obstacle in the way of after-care is overcome.
Twelve years have elapsed since the committee's report. Since
then much has changed, inside the hospitals and outside. Civic
medicine has made much practical progress and has learned and
taught some good lessons in the duties and possibilities of popular
education, in social and personal hygiene and prevention. Let
us use what the tuberculosis struggle has taught us, and above
all, let us encourage those who more than ever try to rise from
the oppressed and artificially sequestrated positions of hospital-
phvsicians. Let us help those who have the patient under their
care for months or years ; let us widen their sphere of interest and
responsibility beyond the temporary mending; let us create links
between them and the public and the places to which the patients
return. Interest and responsibility grow with opportunity. If phy-
sicians in hospitals know that physicians and others outside will
profit from a knowledge of facts in a patient for the purpose of
directing local after-care work, a natural diffusion of information
will begin, much to the advantage of all concerned. With this
additional appeal I heartily endorse the recommendations made by
Dr. Stedman in his admirable presidential address.

THE INSANE COMMISSION OF THE ST. LOUIS CITY JAIL, AN

EXPERIMENT IN CIVIC MEDICINE*

By Sidney I. Schwab, M.D.,

OF ST. LOUIS.

The work which this paper attempts to outline is in the
nature of an experiment in the Grenzgebeit where the problems
concerning law and medicine are most frequently encountered.
The lamentable position which so-called expert medical testi-
mony has reached in the courts of the United States justifies
any logical attempt at improvement, and this Society furnishes
an admirable place before which to present such an attempt.
The special features of criminal procedure in the St. Louis
Criminal Courts give to this attempt a certain unique char-
acter, although the conditions elsewhere present largely the
same sort of problem. Mention should be made in this
place of the indebtedness which we feel to the efforts of Dr.
Stedman of Boston towards the improvement of the pro-
cedure in criminal cases in which the question of responsibility
is raised. Much of the inspiration to our modest efforts in
St. Louis is due to his work.

The main purposes underlying the organization of the com-
mission of which this paper treats were the cultivation of a
better standard of expert medical testimony in respect to
mental questions in the Criminal Courts of St. Louis, the
training of a group of experts in such questions for service
in the courts, and the collecting of such data as afterwards
might prove of value in respect to the problems that arise in
the relation of the criminal to nervous and mental diseases.

The central idea of this whole experiment is that all expert
testimony should be given on the question at issue and should
have nothing whatever to do with one side or the other in the
actual legal test of the case. In other words an expert exists
for the sole purpose of informing the court upon questions of the
proper interpretation of facts lying within the limits where ex-
pert knowledge is required.

A brief description of the organization of the criminal

*Read at the meeting of the American Neurological Society, June 4 and
5, 1006.

n8 SIDNEY I. SCHWAB

courts in St. Louis and the relation of the administration of
the City Jail and the Circuit Attorney to them might serve
to make clear the special problem which this commission had
to face.

There are nine circuit courts in St. Louis presided over
by nine elective circuit judges. Two of these in rotation sit
in the criminal division, thus forming two criminal courts.
In addition there is a third criminal court called the court of
criminal correction whose jurisdiction is more limited. This
latter court has its own prosecuting officer who is appointed
to that position. The circuit attorney of the city is the States'
representative in all criminal cases. The city jail contains all
prisoners who are awaiting trial or who have been sentenced,
and who for some reason are kept there until final decision
in their cases are reached. It is thus seen that the prosecuting
attorney determines the matter of prosecution, and it is clear
likewise that the question of responsibility concerns his office
first of all. By an ordinance of the city the chief dispensary
physician is likewise the chief physician of the jail, and before
the present commission became active he was the chief psy-
chiatric expert of the State in all such cases in which a plea
of insanity was brought forward, or in cases where insanity
was clearly present in the first instance. It is obvious that the
proper time to consider the question of mental responsibility
is before the trial takes place, and not at the trial where the
defense of insanity becomes not a medical question but par-
takes o*f the character of an ex parte appeal to the jury. It
became the first object of the commission to have the ques-
tion of a prisoner's sanity decided if possible before the formal
processes and trial took place.

For many years the most common defense in major crimi-
nal cases was that of insanity, and for the organization of
this defense the defendant hired such experts as the size of
his purse would allow to testify to his insanity; the State op-
posed to this the testimony of the jail physician who was
not at all trained in psychiatry nor even interested in its prob-
lems. As a result of this method expert testimony became
prejudiced, illogical, and was given not upon the question but
as a defense or prosecution argument. Nothing need be said
concerning the average quality of the expert testimony in

EXPERIMENTS IN CIVIC MEDICINE 119

regard to mental questions in the criminal courts, suffice to
say that neither judge, jury nor lawyers were impressed with
its weight. The idea of the present commission arose from
a knowledge of these conditions and the conviction that better
methods would in the long run help to create better standards
which could not be disregarded. The preliminary steps in
the organization of this commission will be omitted here,
mention merely being made of the valuable aid given to us
by the present chief dispensary physician, Dr. Scherck, whose
assistance and encouragement have made possible the expe-
riment of which this paper treats. A scheme for the improve-
ment of expert testimony and examination of prisoners sus-
pected of being insane was drawn up and presented to the two
judges then sitting on the criminal benches. This memorial
was as follows :

1. The Courts and jail physician should appoint a body
of three experts who are to be specialists on nervous and
mental diseases with knowledge and training sufficient to enable
them to speak with authority on these subjects. The jail physician
by virtue of his office and his interest in the charges under him
is to be the fourth member of this body.

2. One member of the body is to be appointed a chairman.
His duty will be to apportion the work to be done and to be
the representative of the body whenever such representation
shall be necessary.

3 Whenever in the opinion of the circuit attorney, the
jail physician, or the presiding judge there is committed to
the jail a prisoner in whose case there is any suspicion of
mental disease either past or present which has any bearing
on the case whatever, such a prisoner before coming to trial
should be examined by this body of experts either singly or
collectively, as the case demands, for the purpose of determin-
ing his responsibility, his irresponsibility, degree of irre-
sponsibility, and his final disposal if his irresponsibility is
established.

4. The decision of this body is to be submitted in writing
to the judge before whom the prisoner is to be tried. If the
decision is not unanimous a dissenting opinion can likewise
be submitted.

5. This body or any part of it will be at the service of the

120 SIDNEY I. SCHWAB

court to present their findings to the jury, or in any other way
to assist the court to arrive at a just opinion in regard to the
sanity or insanity of a prisoner.

6. Each member of this body will agree to serve without
compensation.

7. The jail physician or the court can add to this examining
body at any time physicians who, in their opinion, can aid
them in arriving at a decision. In this way no one can be
deprived of the services of experts who are not members of
this body. It is recommended, however, that if such additions
are made, only those who have the requisite knowledge should
be appointed.

8. A room is to be set apart in the jail building in which
prisoners under observation can be studied under the best
possible conditions.

9. A record of the work of this body is to be kept with great
care so that its services to the courts of justice and to the
community may be used as an argument in favor of the per-
manency of such a body, if this method of arriving at a just
solution of this part of criminal procedure should find favor
with those who can set about making this into a law.

As a result of this memorial the commission was created
embodying the provisions as set down, by the two presiding
judges in the criminal courts, with the consent and approval
of the circuit attorney. It is to be observed that this commis-
sion as at present constituted has no legal nor official position,
and exists merely as a matter of convenience to the court.
It is and remains an arm of the criminal courts in regard to
the elucidation of questions pertaining to the mental states
of prisoners in the jail awaiting trial. The commission con-
sists of four members, the jail physician being the ex-officio
member. The other members are Drs. Fry, Graves and the
writer. The method of procedure is as follows : Any prisoner
in the city jail before he is brought to trial and in some in-
stances before he is arraigned, in whom is found the slightest
evidence of mental abnormality is examined by the commis-
sion, and a written report of its findings is transmitted to the
circuit attorney. If the commission finds evidence of insanity
the prisoner is sent to an asylum either permanently or until
he has so far recovered as to be in a mental condition to stand

EXPERIMENTS IN CIVIC MEDICINE 12 1

trial. At that time then the question of his mental state at
the time the crime was committed is considered. If a defense
of insanity is made by the prisoner's lawyers, and if the com-
mission's report of sanity is not accepted by the defendant's
counsel, then the findings of the commission are taken to be
the State's attitude in the matter, and the members of the
commission are expected to present their testimony as ex-
perts at the trial which follows. Naturally, the defense has
its own experts, and the old method of ex parte testimony
must in the nature of things be made use of. The advantage
over the old system lies in the fact that the findings of the
commission have been arrived at from an absolutely unprej-
udiced standpoint and are based upon clinical evidence unin-
fluenced by the legal aspects of the case. If the prisoner is
found insane either the prosecution is allowed to cease and the
prisoner is sent to an insane asylum, or the prisoner is declared
to be insane by the jury before whom he was to have been
tried. Whatever the final conclusions of the commission might
be, its report being without bias or prejudice gains a certain
weight and dignity before the judge and jury.

In submitting- its reports, some of which were to be used,
in actual trials before the average juries such as are commonly
found in the criminal courts, the commission was confronted
with the fact that its reports must be as untechnical as possi-
ble and must avoid all complicated discussions which might
be concerned with the strictly scientific side of the subject,
and must show nevertheless that the important questions
which might be brought out at the trial were amply con-
sidered. For these reasons the reports were of two different
sorts, one contained a simple opinion without explanation, and
the other contained a short review of the case aiming to give
the jury a clear idea of the case from the standpoint of the
examining body. Of course if the case were once brought to
trial the report of the commission might not be accepted as
evidence, and in this instance the opinion of the commission
might be used to help the circuit attorney in his work of
prosecuting the case. A little experience in criminal trials
in which insanity is brought forward as a defense makes it
quite clear that the question really resolves itself into the
consideration of responsibility, not in the psychological sense,

122 SIDNEY L SCHWAB

but in the sense of which responsibility is used in the law.

Correct diagnosis is not so important as a careful consider-
ation of the criminal's ability to appreciate the nature of the
crime committed, its consequence to himself and society, and
his ability to distinguish right from wrong in the ordinary
sense. From the point of view of the psychiatrist this is un-
fortunate, but if he is to be of service to the State he must
find a way to reconcile these divergent points of view so that
he may approach as near as possible to that absolute justice
which the ideal of the law holds forward. The idea kept con-
stantly before us was to make our examinations with all pos-
sible care, and to use all ordinary means to arrive at a correct
clinical decision of the case, and from such data to consider
the individual from the standpoint of the law. In doing this
the avoidance of mooted points and the uselessness of long
discussion upon the complicated psychology likely to be
present in such cases was made necessary. It was a sur-
prising experience to us to find how simple our task became
when the limits of our problem were so plainly set down.
By starting out without previous opinion and by trying simply
to find out if a given individual is responsible for a deed com-
mitted, is not nearly so difficult a task as to be asked to aid
the defense or prosecution of the same individual on some
theory advanced by the lawyers of either side in regard to
the question of sanity.

In the course of the year we have had to consider a number
of cases of complicated mental disease, but in no single in-
stance did we fail to satisfy our conscience on the question
at issue. In one single instance we refused to intervene in a
case of murder when the individual was obviously a type of
degenerate criminal, for whom further examination would
have done little, since he was condemned to be hung and
had already been declared responsible by one jury. The rec-
ognition of our limitations and the feeling constantly before
us of the responsibility in each single case kept us always
within the bounds of logical inquiry, and prevented us from
yielding to the temptation of viewing our problem as merely
one of mental diagnosis. I need scarcely add that we always
availed ourselves of all the means of physical examination
at our disposal, the data derived from careful personal and

EXPERIMENTS IN CIVIC MEDICINE 123

family histories, and such other aids as are commonly used
in neurological and psychiatrical examination. Such data
naturally were rigorously excluded from the reports sub-
mitted to the circuit attorney.

The following two reports illustrate the foregoing remarks:
The first case refers to an alleged robbery with assult per-
formed by a nurse employed in a quack cancer cure establish-
ment. The nurse, one Blanche Somerset, when discovered
by the police was found tied with curtain ropes and con-
siderably scratched and cut by some blunt instrument. She
denied having any recollection whatsoever of the occurrences
which led up to the crime for which she was arrested. This
case had attracted considerable attention on account of a
diary belonging to the prisoner, and which the police gave
to the newspapers, and likewise because more than one of
the newspaper alienists had expressed the belief that the crime
was a result of some uncontrollable impulse. The report of
the commission is as follows: In accordance with the in-
structions contained in your letter we have examined into
the mental status of Blanche Somerset, a prisoner at the City
Jail, on charge of grand larcency.

Realizing the importance of the case, its publicity and the
fact that an opinion had already been expressed as to her
sanity, we felt that any decision that we might reach must
be based upon facts and deductions from them, and not upon
theories which any of us might hold in regard to the mooted
questions of psychology always present in cases of this kind.
Our opinion as given below is therefore based upon the fol-
lowing sources of information.

1. A complete serial history of the life of Blanche Somerset
for the five years preceding the commission of the crime,
relating to the chief events in her life. Data in regard to her
family history in respect especially to the question of mental
and nervous heredity.

2. A careful study by each one of us of a diary kept by
her and containing almost daily notes for three or four months
before the commission of the crime. The last note was made
the day before she was arrested. Clippings chiefly relating
to suicide and murders and note books on various subjects.
(These were kindly furnished by the police department).

124 SIDNEY I. SCHWAB

3. Interviews by one of us and examination made by the
whole commission.

4. A physical examination as complete as circumstances
would allow with especial reference to the nervous system.

A careful consideration of the facts so ascertained leads
us to the following opinion in regard to the mental state of
Blanche Somerset:

We find first of all that the prisoner has an absolutely
reasonable and normal conception of the nature of the crime
she is charged with. She is perfectly aware that such a crime
is punishable, and furthermore she is perfectly aware that
whatever her punishment may be, that it is the logical outcome
of her guilt. We find that the crime itself was deliberately
planned, and that there was a well defined motive or motives
for its performance, namely financial necessity and dislike
and jealousy of the individual robbed.

We find that at the present moment the prisoner shows
absolutely no trace of mental disease. She is logical, intelli-
gent and remarkably self-controlled and perfectly aware of
her surroundings and her part in their causation.

We find that for a period of three or four months immedi-
ately before the commission of the crime she was as normal
mentally as she is now.

We feel justified, therefore, in saying that for this period
before the robbery, and during the commission of the robbery,
and since that time there has been no evidence weighty enough
to cause us to question either the legal or the medical aspect
of her sanity.

We have carefully considered the possible influence of
functional diseases of the nervous system as bearing upon the
prisoner's responsibility. We have found, however, no suffi-
cient evidence for the diagnosis of either hysteria, neuras-
thenia or allied conditions. There have been at least two in-
stances of what may be considered imperative acts. The
addiction to the use of drugs, especially morphine and alcho-
hol, might be used to justify the assumption that this indi-
vidual was the subject of various uncontrollable actions. If,
however, these facts be carefully analyzed it will be found
that they have little or nothing to do with the question at

EXPERIMENTS IN CIVIC MEDICINE 125

issue. They cannot in any way be so interpreted that they
would weaken her responsibility before the law.

Our opinion, therefore, is that Blanche Somerset is not
insane, and that she is mentally responsible for her actions,
and that from a medical point of view she is responsible for
the crime which is charged against her.

The second report is concerned with the study of a young
man who ran amuck in the streets of St. Louis and cut a
number of women in the thigh and back, inflicting only
slight wounds in each case. This man was soon given the
name of Jack the Stabber and attained a great deal of news-
paper notoriety. The alienists who find the daily press their
best public, advanced a number of theories to explain the
acts of this man, and it was pretty well believed that his
crime was the act of an insane individual acting under the
influence of some mysterious power which the papers only
hinted at.

It can be seen from this that the report of the commission
would have to meet an opinion already created in the press by
the alienists, socalled, who made public their ideas before the
case had been seen by anyone. Inasmuch as our report would
not be accepted by the prisoner's lawyer we were forced to
render our decision in more technical language than usual.

The following is our opinion in regard to John Lawrence
Brady, a prisoner in the City Jail, charged with feloneous
wounding:

We find that John Lawrence Brady shows no evidence of
insanity at the present moment. He is to be considered as
mentally responsible within the meaning of the law, and he
is sufficiently intelligent to undergo trial for the offense he
has committed. Owing to the fact that his crime has no ap-
parent motive we suggest the following in explanation:

The crime may have been the result of one or a combina-
tion of these four conditions: 1. Sexual perversion; 2. Imperi-
tive act; 3. Epilepsy; 4. Alchoholic temporary excitement.

For the first there is not the necessary evidence. The
second seems to us insufficiently proven by the facts ob-
tained. There is absolutely no data upon which to base the
third. The fourth either alone or as a complicating factor in
the second opens the possibility of a reasonable explanation.

126 SIDNEY I. SCHWAB

We suggest, therefore that John Lawrence Brady be tried
as an individual mentally responsible, and that the possibility
of alchohol being the exciting factor be left to be determined
by the facts as elicited in the trial of the case.

These two reports are sufficient to illustrate the manner of
placing our opinion before the circuit attorney.

It is difficult to set down in a definite way the results of
the first year's activity of this commission, because it is highly
probable that its effect, if any, will lie in directions not at
present discernable. An effort like this has many ways of
making itself felt, and it cannot be determined just where and
how it will eventually work out. This much can be said with
perfect fairness. The judges and most of the lawyers whose
work brings them in contact with the criminal courts have
encouraged us to persevere in the work we have started. We
have not received any special encouragement from the legal
profession as a whole, or, at any rate, from such of them as
have been consulted about the matter. They see in the activity
of such a commission an infringement of the right which is
given them by law and custom of summoning such witnesses,
expert or otherwise, as may prove of strength to their side
of the case without reference to the strictly medical aspect.
To place the decison as to the defense of insanity altogether
in the hands of a group of unprejudiced experts belonging
to the court itself would be a serious infringement on the
pleader's prerogative.

In no single instance has the report of the commission
been rejected, and in those cases in which the defense has
refused to accept the judgment of the commission and have
brought the case to trial, the report or rather the opinion of
the commission has finally prevailed. I believe that this re-
sult has been obtained not through any remarkable work on
the part of the commission, but solely because the opinion
of the commission has impressed the jury and the judge as
being absolutely impartial, and as being concerned only with
the facts of the case as brought out in the examination of the
accused.

Omitting the advantages which each individual of this
commission has obtained in work of this nature, unhampered
as it is, the chief effect, I believe, so far obtained can be found

EXPERIMENTS IN CIVIC MEDICINE 127

in the better opinion which expert testimony on mental sub-
jects has been able to exert in the Criminal Courts. For the
first time they are in a position to hear testimony on the sub-
ject of insanity and allied questions which bears no relation
to the defense or prosecution, but is concerned only with the
question at issue. In this way perhaps a better standard has
been set which may afterwards bear fruit. The one tangible
result has been the establishment of a small observation ward
in the jail hospital for the use of the commission in the study
of cases suspected of insanity.

As was said before, the commission has no legal standing
as at present constituted, and it can be dissolved at a moment's
notice if the judge should refuse to consult with it or if the
circuit attorney should decline to respect its decision. Its
precarious existence has been the subject of some debate as
to the possibility of passing a State law establishing such a
commission legally with the proper standing before the courts.
We have up to this time opposed any such effort, for we fear
that if it becomes a State institution the question of politics
will enter into its activities, especially if its services are to
be adequately paid. We are content at present to let the work
it is doing effect in as large way as possible the procedure
of the courts in respect to the employment of expert testi-
mony, and leave the solution of the permanency of such a com-
mission to other hands.

In conclusion it may be said that the voluntary and unpaid
service to the State has appealed to us as being in line with
the larger view of civic responsibility which physicians feel bound
to share, and from which until of late there has been consider-
able shrinking. It is a part of a widespread movement which
is tending to remove the isolation which the profession has
held to the community of which it is a part.

CONSCIOUSNESS IN THE BRUTES.1
By George V. N. Dearborn, M.D., Ph.D.,

PROFESSOR OF PHYSIOLOGY, TUFTS MEDICAL SCHOOL, BOSTON.

(Continued from page 41.)
Such are some of the considerations which tend when taken
together to deprive the nervous system of its preeminence as the
representative of consciousness in animals, a supposition which
naturally arose from the former's peculiar function of being the
chief means of associating impulses passing between the really
active tissues of the body and between their parts. On the other
hand certain events in the realm of chemiphysics have recently
altered somewhat our view of matter itself and this alteration
bears in a sense on the basal relations or unity perhaps of mind
and body. Matter is proven in certain cases at least to be not
something fixed and immutable but rather centers of spontaneous
forces active despite all known conditions, and the tendency is
undoubtedly to place force where formerly matter stood. In
biology the same tendency has long been felt, for it is seen that
those reactions we summarily call vital are indiscriminately com-
posed of heat, movement, electricity, light, etc. But -now that
similar phenomena are seen to take place in inorganic substances
as well as in protoplasm, it is obvious that little is left of the
"substantial" part of matter. Just as a limited and rationally
forced pan-psychism is in the philosophical air, so this pan-ener-
gism or pan-kineticism (if I may be pardoned the rude terms) is
in the physical air. To the one view (the substantial rational
seeing of Idealism) nervous processes as well as mental processes
are psychical and the body itself is sentient experience. To the
becoming physical view, matter is something akin to a vortex of
kinetic energies and the brain, in the last analysis, becomes re-
duced to the powers of chemiphysical attraction and repulsion, of
heat, of electricity, of light, of chemism, modes of movement.
Both to physics and to epistemology protoplasm is a somewhat
whose chief characteristics are movement, change, indescribable
because unique but identical in terms of consciousness. Deny it

'Read before the American Philosophical Association in Philadelphia,
Dec. 29, 1904.

CONSCIOUSNESS IN BRUTES 129

as one may with wealth of dialectic, with statement heard so
often that "force and movement are not consciousness but force
and movement," still consciousness does seem more like these
various forces to which protoplasm bids fair to be reduced by
physics than like the lumps of white and greyish matter from out
the interior of a bony skull, and to this extent the becoming
view of physics and the liberal view of consciousness approach
each other. If consciousness is not a force still it has some of the
qualities of force as we know it, — and no matter what force is
as we don't know it ! Is this heresy to orthodox idealism, to claim
the forces of protoplasm and the thing we call consciousness alike
in some respects and to base on this similarity an increased claim
for the wider locus of consciousness? At any rate, the sole con-
tention is that the becoming conception of protoplasm including
nerve as made up of molecules or of clusters of molecules which
are, even physically, reducible to centers of chemic force, makes
it somewhat easier to conceive of some sort of correspondence be-
tween consciousness in animals and the mechanism of their life.
The difficulty is not to see this this way but rather to persist in
spite of basal resemblances in maintaining a contrast based alone
on a logical syllogism. Above, we urged the usefulness of this
very syllogism at the basis of idealism — at present we urge its
limitations when the basal paradox of our experience demands
that we should do so. A few years ago most physicists would
have claimed the doctrine of the conservation of energy infallible
in our experience; to-day he may see hints of phenomena which
relegate it perhaps to the limbo of other tottering theatrical idols !
If simple metals exhibit phenomena of this sort, surely we may
expect from a substance as highly elaborated as living protoplasm
relations at least as aberant from the supposed laws of matter.
And protoplasm finds only one of its forms, and that apparently
not the most active chemically, in the protoplasm of the nervous
system.

The structure of protoplasm, of late gradually made out
conjecturallv at least, offers a preemiently appropriate and ade-
quate seat or representative for consciousness. — its uniqueness
and the uniqueness of sentient experience correspond. Let us
glance at some of what are probably the salient features of this
substance bioplasm, biogen, or protoplasm, "life-stuff," "life-
bearer," "primal matter." Each year enlarges our knowledge of

i3o GEORGE V. N. DEARBORN

it as obtained through the microscope, and continually its general
chemiphysical nature becomes better known. Into the theories of
its morphology we need not go, for surely it is its basal chemic
constitution and not its physical structure which underlie its re-
lations to consciousness. If biochemistry has learned anything
surely about the structure of biogen it is that the group or cluster
corresponding to the molecule of inorganic matter is of unique
complexity and of a maximum instability. Among the consti-
tuents of this substance and probably of every cluster composing
it are three materials organic in nature and each of great com-
plexity. These three, of course, are proteid, fat, and carbohy-
drate, and proteid constitutes nearly the whole. Besides these
there are water and an unknown number and variety, very large,
of salts which elsewhere are termed "inorganic." here doubtless
part of the biomolecule, or life-unit. Of these five classes of
constituents of this vital unit every one is a compound and three
at least of them of great complexity, especially so the proteid.
No two analyses of the many forms of this substance are alike
and no one at all represents the original substance, for chemical
analysis inevitably kills it and its structure chemically depends
on its life. There is no doubt that all of the proteids contain
hundreds of "atoms" in their units and many of them thousands.
To account for the spatial arrangement of these thousands of
atoms the imagination must be actively employed, but the prob-
lem is simplified by considering the "atoms" stresses and strains,
forces, rather than as space-filling material bodies. The fats of
the vital molecule and the carbohydrates are also complicated in
molecular structure with scores of "atoms," and in instability only
secondary to the proteids, while the inorganic salts form combi-
nations with these in the life-unit group which are quite un-
known. All of these "atoms" are continually interchanging as
the vital unit anabolizes or katabolizes. and not only interchang-
ing with themselves but with other more or less similar complexes
brought to them as food. Of all the "molecules" known to chem-
istry, this one, probably, at the basis of protoplasm and of life is
the most complex in its ever-changing construction and probably
has as its essence a metabolism quite unique. This metabolism,
these most intricate chemical interactions within and between
these vital clusters making up protoplasm can be occasionally
imagined by the chemist who knows the nature of chemical reac-

CONSCIOUSNESS IN BRUTES 131

tions generally and the materials and end products of these vital
processes, but they cannot be described by him. From them are
set free motion, heat, light, electricity, power of various sorts,
phenomena we call forces. Nowhere else than in the living tis-
sues of animals are the causal or the effected conditions so com-
plex and inter-involved, and above all so capable of permanent
adjustment to varying relations. Such a uniqueness is fit con-
comitant for the uniqueness of consciousness. This intricacy of
forceful interaction would seem to supply the only apparent basis
for the intricate phenomena of the mental process. On the one
side a living body made up of events like these implied, almost
too complicated to be even suggested by other than a biochemist —
on the other side the indescribable experience consciousness. Only
these two of all finite things are reasonably adequate to mutually
represent each other it may be.

And there is at hand an illustration of this relation which is
more than rational fitness and probability. That protoplasm, bear-
ing no immediate relation whatever to any nerves, is capable
none the less of representing and of containing within its activity
at least latent psychical characteristics is seen by us all contin-
ually in the fact of the heredity of psychical characteristics —
or else consciousness is indeed the secretion of the brain and
La Mettrie was right and Leibniz and Spinoza, Plato and Hegel
quite beguiled. The extremely minute speck of protoplasm con-
stituting the male element in reproduction carries in its mole-
cular structure or activities not only the physical but also the
psychical peculiarities of the father of the new individual — or
else we must retire to materialism. Strength of will, tempera-
ment, affections of various sorts, even habits of thought (such, for
example, as those which lead to suicide in successive generations) ,
all are commonly transmitted, besides a host of characteristics as
much mental as bodily. Twins are often nearly alike not only in
psychophysical but in purely psychical respects. There must be
a basis for these aspects of consciousness ; no other basis is trans-
mitted than the speck of protoplasm ; hence this speck must be
the basis required — the climax of human mystery. The inter-
actions between the units and within them, kinetic relations in
the last resort perhaps, stand in the spermatozoan for psychical
events. If so many and so various determinants of consciousness
inhere in a male pronucleus, where nerve is not as yet, whv then

i32 GEORGE V. N. DEARBORN

not a portion of consciousness in the quite comparable proto-
plasm of the active tissues of a developed being? No theory of
heredity as yet suggested attempts to account for a relation of
this nature, just as no details of a doctrine of psychophysical par-
allelism will be expected when the consciousness of protoplasm
in general shall have become recognized as an element of its
vitality, basally inherent in it.

The phenomena of sleep and of its analogues strongly implies
that there is more in consciousness than the nervous system can
adequately represent. Unconsciousness is not to-day a scientific
any more than it is a metaphysic verity, for grant a nervous
break between the waking and the sleeping consciousness (in
sleep normal, in coma abnormal, in sleep easily bridged, in coma
seldom or never), and with exceptions the sleeping consciousness
has the extensity if not the intensity of the waking experience.
These exceptions are especially the senses of seeing and hearing,
which being in part closed off leaves us nearly the sleeping con-
sciousness. Sleep is particularly the resting of the nervous sys-
tem, as measurements show, while some of the bodily metabolism
is likewise decreased. When the nervous system rests the person
"loses consciousness," the mysterious break between the two
states gradually or suddenly occurring, yet no person is awak-
ened suddenly, unless too violently, without finding himself in
the midst of some sort or other of mental experience, often with
all the characters of the waking consciousness minus the over-
whelming experience of flooding daylight and of universal sound.
Such a mass of consciousness is not perhaps adequately repre-
sented by the metabolism of a few grams of grey nervous matter
in the cortex cerebri but only by a general bioplastic metabolism
in the mass of the body cells which know no rest corresponding
to the sleep of the individual. An increase in the metabolic
activity of any portion of the body-protoplasm is apt to at once
break into the sleeping consciousness, oftentimes with vigor suffi-
cient to recall the waking consciousness by stimulating the ner-
vous system out of its repose. In sleep the sub-conscious mass
of experience predominates, represented as it is perhaps by the
somatic or protoplasmic, as distinct from the nervous, portions
of metabolism.

We have now reviewed certain considerations which tend to
connect the activity of animal protoplasm in general with con-

CONSCIOUSNESS IN BRUTES 133

sciousness in general. In this vague relation is a "correspondence"
which is not subject to the close limitations of a supposed paral-
lelism between consciousness and neural tissue alone. If the cor-
respondence cannot be worked out in detail neither can the details
of the events themselves in either of the two correlatives con-
cerned, while on the other hand idealism supplies a logical hypo-
thesis of their relation if not one to satisfy psychophysiology.
Now all these complex protoplasmic conditions are found in
every sort of animal tissue in some degree or other, the degree
depending in general on the respective activity of any tissue in
an organism. Thus bone and connective tissue for example have
little epithelium and nerve and muscle much. It is of these va-
rious sorts of protoplasm that the bodies of all the animals we
know, brute as well as human, are composed. The protoplasm of
all, so far as we know, is of equal chemical complexity, and as
richly endowed with the interactions which form a reasonable
basis for a material fit for accompanying consciousness. Thus
for example the ameba, simplest of animals, lives on protoplasm
as its food, and the enzymes which digest it and the chemical
processes which make these enzymes are doubtless as complex
as those which make them in a human pancreas. Again in the
ciliary movements of many of the protozoa one can see (without
seeing a trace of nerves) as perfect coordination and adaptation
to a complex purpose as complete as is to be found anywhere
in man himself. Man but shows his egotism when he claims
himself superior on any biological standard to the simplest of
animals — the true measure is rather one of protoplasmic fitness,
or else one quite outside the range of biology, namely in ethics.
in the possession of a will free to do right or to do wrong.
Looked at broadly, unbiased by our human habits of thought,
what reason is there, if these statements are facts, to assume as
preliminary in every discussion of the consciousness of the brutes,
that the consciousness of each species and of each individual
even, corresponds to the complexity of its nervous system ? Back
of any possible correspondence between organic process and men-
tality is the unique complexity of chemic protoplasmic activities
and this is present in all animals so far as research has shown in
equal degree. It is a matter of the existence rather than of the
quality of consciousness in any form of life, the quality and the
intensity as well as the extensity of the mental processes depend-

i34 GEORGE V. N. DEARBORN

ing undeniably on the extent to which the division of bioplastic
labor has gone in any particular form or individual.

We have above offered a number of presumptions, but cer-
tainly there's more than a reasonable "presumption" of the exist-
ence of consciousness in the brutes, especially from considera-
tions like the following: Says Mill, "When two things resemble
each other in one or more respects and a certain proposition is
true of the one, it is probably therefore true of the other," and
all the whole world so far as rational at all works and lives on
this principle of analogy plus the calculus of probability. The
person skeptical of brute-consciousness knows himself conscious
and knows more or less of his own body's structure and the mode
of that structure's life. This is the "certain proposition" which
"is true of the one." Now here, instead of there being "one re-
spect," in which the analogues brute and man are similar there
are thousands of respects, there are almost as many scattered
up and down the animal series as there are known facts in the
physiology of animal life. The conclusion is logically, that is
to right common-sense, all but a syllogistic certainty. Outside
certain innate mathematic analogies there is hardly any proba-
bility greater than that the most evolved brutes are conscious,
man being so. Muscles, nerves, and glands, all are constructed
similarly, act on the one same plan, serve the same biologic pur-
poses — the muscles to achieve movements, actions, the nerves
correlation and adjustment, the glands bodily supply, the other
tissues for more mechanical service as groundwork of the rest.

The sceptic who admits his own consciousness but denies it
in the dog and elephant and lion has one resource which he is
bound to make use of continually. He can deny the principle of
continuity in organic evolution and claim that the protoplasm of
man is essentially different from that of all other animals, and
that the difference is such that consciousness may inhere in it
and not at all in the brutal organism, the consciousness accruing
to it suddenly as if out of Pandora's box. So arbitrary, however,
is this supposition, so gratuitous in the biology of protoplasm that
it may be disregarded, the burden of proof resting wholly on
its claimants. So far as every evidence goes, structural and func-
tional, the two classes of animals compared, brute and human, are
built on the one same plan, live in the light of the same con-
sciousness save probably for ratiocination which has perhaps de-

CONSCIOUSNESS IN BRUTES 135

veloped with the vast complicating of the connections of the
fibers of the brain and the consequent development of abstract
symbols into speech and language. The burden of proof in this
matter rests with the deniers of the analogic probability.

Now going along the multitude of animal forms toward the
simplest animal from the most human, where can a line be drawn
beyond which consciousness may be disclaimed? With wonder-
ful morphologic variety there is striking biologic uniformity, the
same use of the same mechanical principles and of chemical reac-
tions and assuredly of protoplasmic nature generally, so that
even in ameba, the simplest, indeed the logical limit of animal
structure, we find the same events in type and the same means
for producing these events -metabolism in irritable living proto-
plasm. Even in ameba is that same amazingly complex proto-
plasm whose chemiphysical interactions science is beginning only
to unravel. Coordination in ameba is poor and we find him some-
times trying to crawl in opposite directions for a brief space, for
of nervous matter there is of course nothing. For the same
reason the animal's adjustment to external conditions is imperfect,
although in the main protective of its life. But all the varied
metabolism is there, giving rise to the same sort of heat, motion,
and probably electricity, from the same protoplasmic life, sup-
plied by the same nutrients and giving off the same katabolic
waste as does a nerve cell or any other cell of a human body.
Without a single nerve-fibril the naked protoplasm conducts im-
pulses, as one may quickly see when the whole animal nearly
at once contracts after stimulation, and coordination and even
adjustments occur without anything which can be called nerve.
Without muscle contraction takes place. Without separate gland-
tissue secretion goes on. Without reproductive cells the marvel-
lous so-called simple division of the animal occurs whenever its
overgrowth demands, a process compared with which even mitosis
is easy to understand. In ameba then, the logical limit of animal
simplicity, a minute drop of uncolored streaming protoplasm, the
matter is organized as forces which interact and are mutually and
self-sustaining. The adjustment of relations which is its life is
nearly as perfect as in other animals and because the chemiphy-
sical process at the basis of this series of adjustments is perhaps
even more complex than elsewhere (since every function nearly

136 GEORGE V. N. DEARBORN

inheres in every part), a modicum, a trace, a sample of con-
sciousness must be supposed to be concerned.

What can be supposed as to the nature of this requisite con-
sciousness of ameba? Shall we imagine it like our own? Of
course not. Can we imagine it at all? Scarcely so, it must be
allowed, and yet, "the dim crawling life" is part and parcel of
a system of uniformities in which we ourselves and our own
consciousness partake and within these limits we can imagine
much. It is customary for descriptive psychology to say that
the most prominent aspects of mind as we know it are feeling,
will, and thought. The first, feeling, is based wholly on sensa-
tions, on modifications of consciousness which seem to have to do
with that protoplasm, which in man and his congeners is made
up as sense-organs. Ameba's protoplasm and that of other uni-
cells is universally sensitive to irritating stimuli, and its irrita-
tion causes reactions exactly comparable to those of protoplasm
elsewhere under the influences coming from sense-organs. A dim
and simple sensation-mass would seem then to be a reasonable
basis and substance of ameba's consciousness. Besides this there
are obviously elements of which we know as will or action and
this involves that something else, that "certain plusness," not
to be defined but representing perhaps in its last analysis the life
itself, action, active purposiveness that quality by which the
interactions of ameba's molecules exceed in complexity and in
self-adjustment those of other self-regulating materials — if in-
deed anv such besides bioplasm exists. Another word for will is
conscious spontaneity and possessing this the animal may still
be as much the slave of circumstance as you please for its de-
pendence on its environment is extreme. Sensation-mass and
will, conscious spontaneity, such we may imagine are present in
ameba's consciousness. In these nerves are unnecessary, and their
physical basis is adequately enough the universally complex,
irritable, and active protoplasm of which the whole bod); is com-
posed. So much for this logical type of animal, a speck of undif-
ferentiated bioplasm. In this form we are interested only for
these very reasons — that it is the logical type and it is undiffer-
entiated protoplasm only.

In the series of animals from ameba "up" (no scale save a
very indistinct one can be made out) , we find at once development
in the wav of a division of labor. Scarcely are we out of the

CONSCIOUSNESS IN BRUTES 13?

protozoa, the unicellular animals, before certain cells of the va-
rious organisms begin to take on distinctly the qualities and uses
of nervous tissue, the first form being cells with a new vigor and
promptness of reacting to stimulation, it being therefore the
sense-organ part of the nervous system which appears first in
the phylogenic development. In this simple plan these sensitive
cells are also means of defense. In animals a little more compli-
cated we find the rudiments of a nervous system entire, the first
form being a mere line or lines of fibrils, with the necessary nerve-
cells, connecting parts required to work in unison for some reason
or other, or where adjustment of any sort is necessary, functional
connection being the business of these fibers primarily and al-
ways. In forms of life more and more complicated, the nervous1
system's reticulum of fibers shows corresponding development,,
not only in actual intricacy, but in relative mass. Thus in a
way the nervous system comes to be a rough general index of
the complexity of any animal's life, of relations more and more
involved, not only between cells and organs within the limits of
the animal, but with numberless conditions outside the individual
yet part of its environment and in a biologic sense inseparable
from itself. Conduction, coordination, adjustment, appreciation,
become more and more complete as the vital conditions demand.
Small portions of the protoplasm develop into sense organs and
the corresponding sensation-mass of the animal we mav suppose
becomes "larger" and richer with inevitably a tinge of feeling
in its nature. In very simple forms muscular tissue of a simple
sovt has already developed, actions thereupon are made more
promptly and in a more perfectly adjusted way and therewith
the will has developed also in richness and in strength, as repre-
sented by what the various animals variously do.

As a glance backward over the literature on the will quickly
shows, the theories of its nature and of its relation to org-anism
on the basis of the phenomenal dualism are many and complicated,
for in this notion will or volition is involved the heart of the
question as to any sort of correspondence. If we think of will as
found in the brutes as spontaneous activity we cannot be far
wrong, but if we do so, we at once express the unification of
the mental and the bodily. "Will" at least, whatever "sensation"
and "thought" may mean, means nothing whatever unless within
it is included bodily activity. Here then is the empirical or scien-

138 GEORGE V. N. DEARBORN

tific corroboration of the epistemological viewpoint and for once
the two views are in fact unified, as well as logically. The scarcely
experienced "certain plusness" or fiat in the willing-process as
we describe it psychologically appears phenomenally as the ac-
tivity, kinetic, chemic, atomic, molecular, and molar, of the com-
ponents of protoplasm. In no other way is the fiat, the relation
of the two aspects, experienced, for all the rest of the volition
u's sensation arising from this activity.

In this way of thinking the sensation-mass of the brutal ex-
perience joins with an almost intelligible activity in the proto-
plasm and in the environment its sensations represent to consti-
tute the larger part of its consciousness. It is only by this free
and easy transition back and forth between physical and psychi-
cal, between protoplasmic activity and experienced will and sen-
sation, that any sort of explanation is forthcoming as to the
relations of body and soul. We must, really to explain, merge the
scientific and the epistemologic, the phenomena with the sentient
experience of the phenomena. To the dualist even this degree
of explanation seems forever forbidden.

But if sensation and volition constitute the by far larger part
of the brute's consciousness (as of man's) what of cognition, the
faculty of knowing, an analytically distinct aspect of the mental
continuum ? Scarcely yet have we escaped the exaggeration which
the associationists forced into psychology and man's pride is re-
luctant to admit how small the proportion of cognition and es-
peciallv of constructive conception in his mental process minute
by minute. Who can doubt that in the brutes the proportion of
conception is not much smaller still?

If cognition, understanding, thought, etc., be a comprehending
of relations ( and little else when the sensation of perception are
taken out), perhaps it is not extreme to suppose that on the
bodilv side this comprehending, or taking together, will imply
the proportional development of those organs which receive,
collect coordinate, compare, and adjust. No other organ or sys-
tem in animal bodies except the nervous system performs these
functions, the sense-organs the nerves and the nerve-cells.

Whether the relations comprehended be derived from stored
traces in the grey matter of the nervous system or be brought
in anew to it from without the process is one peculiar to nerve,
and only suggestions of the faculty exist in protoplasm itself,

CONSCIOUSNESS IN BRUTES 139

other than nerve. If ameba collects, coordinates, and adjusts,
it does these slowly and imperfectly as compared with more
evolved forms of possessing nervous systems. Whatever then our
compelled notion of ameba's consciousness must, we can think of
its cognition only as at the logical limit, the vanishing point of
reality. As the nervous system and its various sense organs, how-
ever, become more complicated, the comparing and coordinating
powers of the animal become more adequate. The fibrils making
up the system become general in the other tissues, ramify more
widely, gradually connect more universally, while their knots,
the nerves-cells, perhaps also distributing centers of nutrition,
probably become more complicated, although less numerous rel-
atively. The universal neural reticulum is connected not only
with more sense-organs but with more kinds of sense-organs
themselves always more and more complex as we look up the
series of animals. Becoming progressively greater in mass in
proportion to the grey matter, the conducting paths become also
more complex and their interconnections ever more involved,
thus representing more and more perfectly the consciousness
which so far as expression and conduct indicate becomes also
more and more complex. If the grey matter of the nervous sys-
tem represents the switching and adjustment of impulses, be-
sides nutrition, the white net of fibrils stands for the essential
coordination of bodily influences. In the simpler animals there
is neural simplicity in every way apparently, the complications
coming later being not only in connection but in structure — a
condition which neither use nor observation necessitates as true
as regards the body-protoplasm generally. Thus with developing
nervous systems, the animals up the animal series gradually
acquire the comprehension of associated relations which little
by little approaches the faculty we see evinced in the most know-
ing of our brute friends and victims. One sees well enough that
rabbits and sheep are less intelligent generally than are cats and
dogs, for example, and the ant's faculty of overcoming difficulties
far exceeds that of the cray fish. These differences have a physical
basis in the proportional quantity of grey matter of the nervous
systems and, as the physiologist knows, in the way the nervous
matter is arranged in the brain cortex and in the nerve trunks
sometimes. In general, in short, one can see a correspondence
between the complexity and mass of the nervous system, and
especially of its grey matter (the comparing part) and the cog-

i4o GEORGE V. N. DEARBORX

nitive processes of the animal. Knowing then corresponds to the
nervous system because reception of relations, and their coordina-
tion, comparison, and adjustment, are at once the basis of cog-
nition and the special function of this system alone.

But understanding and adjustment to simple new relations
such as we see in the most knowing of the brutes does not
mean necessarily conception and abstract thinking, and self-
consciousness arising therefrom. The recent work of Stumpf
and his colleagues on the calculating horse Hans shows these
relations well. Here is an animal which probably through an
unusually plastic or extensively ramifying nervous system has
developed a faculty of observation especially of its questioner's
face which seems to equal that of the most expert of human
physiognomists. Perception and recognition form the adequate
basis of this brute's unusual powers and the investigators could
find no trace of any appreciation of any numerical concept not uni-
fied with the percept of the questioner's face. The orang outang,
Joe, which visited this country seven or eight years ago left a quite
similar impression on the minds of many of his psychologic ob-
servers. No proof then of conceptualization in the brutes is to be
furnished either by the animals themselves or by their human
apologist. It is not enough to be able to see in the deep eyes of a
fine setter dog expressions sometimes like those of man under like
conditions, for these expressions arise rather in what one might
call an emotionally tinged simple cognition than in an abstract
conceptual experience. Indeed, if both theory and observation
may be trusted no sort of cognitional function beyond perception
rendered more useful by memory, and so going on to recognition
often with an affective tone is to be proven or evidenced by
any brute's expression or conduct.

It was from this sort of consciousness perhaps as a beginning
when speech had been acquired (perhaps by a Mendelian "chance"
variation in heredity), that man in the course of millions of vears
has developed special limited mental processes whch have made
invention and through that civilization possible. In the bound-
less multitude of the abstract notions humanity has thus acquired
one sees represented, very possibly, the size and complexity of
the hemispheres of man's brain. This difference in consciousness,
probably the greatest to be found in the whole range, is sufficiently
accounted for, it may be, by the development of language — but
even this blessing may be over-done !

periscope

Deutsche Zeitschrift fur Nervenheilkunde.
(Band 27, Heft 5 u. 6.)

17. Contribution to the Clinical Knowledge and Anatomy of Progressive

Facial Hemiatrophy. Loebel and Wiesel.

18. Studies Upon Oppenheim's Feeding Reflex and Some Other Reflexes.

Furnrohr.

19. Mikropsia and Related Conditions. Heilbronner.

20. Contribution to the Question of Bladder Disturbances of Spinal Origin.

Berger.

21. The Anatomical Findings in a Case Described as Hemorrhage Into

the Right Half of the Pons, Etc., from the "Ram. central, arter.
radicular u. facialis dextri." Wallenberg.

22. Investigations Upon the Nature of the Reflex Hyperesthesias Occur-

ring in Disease of the Organs. Petren and Carlstrom.

17. Progressive Facial Hemiatrophy. — Hitherto 170 cases of progres-
sive facial hemiatrophy have been published. Autopsies have been per-
formed on only six, and of these, five apparently indicated the existence
either of severe complications or of other conditions. The case reported
was that of a woman who, at the age of 14 years, had had a discharge
from the right ear. At the age of twenty-two she began to have pains
in the head, and the atrophy of the left side of the face began. Twelve
years before death Nothnagel demonstrated her as a case of progressive
facial hemiatrophy. The examination showed loss of fat and muscle, and
atrophy of the bones on the left side, with preservation of the hair, sensa-
tion and vision on that side. She also suffered from pulmonary tuber-
culosis, from which she died. The histological examination of the brain
and cord was negative. Aside from the atrophic tissues definite changes
were not found in the other organs. The left Gasserian ganglion showed
a variety of changes, particularly focal areas of round-cell infiltration, with
some proliferation of connective tissue. Changes indicating chronic
neuritis were also found in some of the branches of the fifth nerve. The
sympathetic nervous system was not abnormal. The muscles affected were
those supplied by the left motor root of the fifth nerve. The authors be-
lieve that in all likelihood pregnancy caused an autointoxication which
injured the fifth nerve on the left side.

18. Feeding Reflex. — Oppenheim's reflex consists of a rhythmical
tasting, sucking, chewing and swallowing movements, following irritation
of the lips and tongue in young children. Henneberg's hard palate reflex
consists of a powerful contraction of the orbicularis oris when several
vigorous strokes are made upon the hard palate. It occurs in cases of
bilateral focal disease of the brain, and occasionally in cases of hemiplegia
due to brain tumor. The buccal reflex of Toulouse and Vurpas consists
of a pursing of the lips when a blow is struck upon the upper lip with a
percussion hammer. It occurs in new-born children, in cases of anen-
cephalia, paretic dementia, chronic alcoholism, and in idiots. Oppenheim's
reflex was investigated upon a number of children. It apparently begins
to disappear in the eighth month. In older children it is observed in
cases of spastic diplegia, and twice in adults suffering from epileptic coma.
Furnrohr also reports some other interesting cases in which it was present
either typically or atypically. The reflex is probably the result of the
irritation of two special centres in the brain, one subcortical, which may
be described as the true reflex center, and one in the cortex, which has

142 PERISCOPE

merely an inhibitory action. In regard to Henneberg's reflex, Fiirnrohr
found it present seven times in 124 healthy children. In 138 cases of
nervous disease it was present 29 times in typical form, and 20 times
atypically. Of the 29 cases, 19 were hemiplegias variously complicated, and
the others presented epilepsy, multiple sclerosis, paretic dementia, encep-
halo-myelitis, Little's disease, infantile pseudo-bulbarparalysis, general tic,
psychopathic deterioration. The histories of a number of cases are given.
Frequently crossed reflex was present. Fiirnrohr does not agree with
Henneberg that this reflex is closely related to that of Oppenheim, but
believes that it is a mucous membrane reflex whose paths are in the
trigeminal and facial nerves, and is probably physiologically similar to the
anal reflex. The buccal reflex occurred in 12 of 20 children during the
first week of life, and of these 12 children the majority were less than five
days old. It was also present in all of 28 cases of paretic dementia. It
was also present in 60 of 70 cases of idiocy, or epilepsy associated with
dementia. It was likewise found in cases of alcoholism, hemiplegia,
pseudobulbar paralysis, Little's disease, acquired hydrocephalus, multiple
sclerosis, cerebral syphilis and neurasthenia. This reflex appears to be due
to some irritation of the cerebral cortex. It is probably not a true reflex
action, but appears as a result of the irritation of the peripheral nerves ;
therefore it cannot be regarded as a true reflex.

19. Mikropsia. — The patient, 27 years of age, had a subjective sensation
when reading that the book of paper moved away from him to an infinite
distance. The type, however, remained perfectly clear, and he could con-
tinue his reading. He also suffered from dizziness in all those situations
in which it is likely to occur. After a brief analysis of the case, and some
discussion of the nature of the dizziness, Heilbronner concludes that, in
addition to the subjective removal to a distance, with apparent diminution
in the size of the object (micropsia) there may also be a subjective
removal to a distance without diminution in the size of the object (por-
ropsia) ; that both these may be combined with disturbance of the apparent
position and movements of the object, and that they are probably due to
some diseased condition of the cortex. These forms are to be carefully
distinguished from those occurring in disturbance of accommodation. In
epilepsy they may replace the epileptic attack.

20. The Bladder in Spinal Diseases. — Berger reports two cases of men
who had received severe injuries to the spinal column, and who, as the
chief result thereof, suffered from involuntary dribbling of urine. In the
second case there were also attacks of forcible micturition. The sensation
of a full bladder was not present in either case. In regard to the nature
of the lesion, it seems unlikely that we can consider this symptom as due
to a traumatic neurosis. In the first case it seems likely that the fifth lum-
bar and the first sacral segments were involved, and possibly some of the
lower sacral segments. The absence of rectal disturbance indicates that
the fifth sacral segment at least was free. In the second case the lesion
probably involved the cauda equina, and affected not only the fibres to the
bladder, but also those to the sexual organs, but not the nerve fibres con-
trolling the rectum. These cases seem to controvert some of the theories
of Muller regarding the symptomatology of lesions of the lower portions
of the spinal cord.

21. Hemorrhage in Pons. — Wallenberg describes a case which
he diagnosed as hemorrhage from the central branch of the root artery of
the right facial nerve, which had caused destruction of the right half of
the pons between the sensory fifth nucleus, the trapezoid body, and the
root of the abducens nerve. Subsequently the patient died of pneumonia,
and a lesion was found in the right half of the pons which consisted of a
cyst, evidently the result of an old hemorrhage. Posteriorly this cyst was
attached to the under surface of the vermiform process of the cerebellum

PERISCOPE 143

which had been displaced to the right. On the ventral surface it extended
as far down as the inferior olive. Anteriorly extensions from the cyst
reached to the lingula cerebellae dorsi, and to just in front of the entrance
of the fifth nerve ventrally. Wallenberg gives a description in great detail
of the secondary degenerations which could be traced to this lesion, and a
most interesting table, much too long for reproduction, in which he com-
pares the symptoms during life with the supposed lesions which caused
them, and the lesions found at the autopsy. This shows how accurate his
topographical diagnosis was. He also gives for comparison the supposed
lesions and those actually found. Among the most interesting results are,
first, that the study of the sensory disturbance in the region of the fifth
nerve makes possible a diagnosis of the location and extent of the lesion.
Second, the sensation of touch does not seem to be disturbed if the spinal
root of the fifth nerve is destroyed. Third, complete destruction of the
motor root of the fifth nerve causes the tongue to be pushed obliquely
toward the opposite side. Fourth, disturbances of sensation in the opposite
side of the face suggest involvement of the formatio reticularis alba. If
the dorsal trapezeoid fibers going to the dorsal olive are destroyed there
is labyrinthine deafness. Fifth, loss of equilibrium after lesions of the
terminations of the vestibular nerves is not necessarily restricted to the
side of the lesion. Sixth, in spite of complete destruction of Deiter's
nucleus, the dorsal nucleus of the eighth nerve, and of the abducens
nucleus, there is not necessarily persistent conjugate deviation toward the
side of the lesion. The anatomical conclusions must be read in the original.
22. Reflex Hyperesthesia. — Petren and Carlstrom have investigated
seven cases of gastric disease with the algesimeter of Thunberg. They
found that hyperalgesia invariably occurred in the left upper quandrant of
the stomach, and over the lower ribs on the left side. The explanation of
this hyperalgesia is still indefinite, but it seems certain that it is not due
to any alteration in the sensory nerves of the skin in the affected region.
They suggest the theory, however, that the nerves from the skin, when
they come into contact with the centripetal sympathetic fibers, are either
rendered more irritable or else are distinctly inhibited. It is not known
where this action takes place, but they believe that it may be either in
the spinal ganglia, or in the corresponding segment of the spinal cord.
They then discuss the relative likelihood of these two hypotheses. In a
postscript they call attention to the great value of Thunberg's algesimeter
for the determination of slight defects of the pain sense.

Joseph Sailer (Philadelphia).

Journal de Neurologie

(Vol. XL, No. 9, 1906.)

1. Notes on a Case of Progressive Muscular Atrophy. De Buck and
Deroubaix.

1. Progressive Muscular Atrophy. — The authors call attention to the
fact that while the muscular atrophies have been divided into spinal, neural
and myogenic forms, 'facts brought out of recent years have pointed rather
to the essential pathological unity of these different forms. As a contri-
bution to the subject, they report a case very carefully studied both clini-
cally and anatomically. The patient, a man of middle age, had always
been of weak mind, and had had difficulty in using the muscles of legs
and arms, which difficulty had become more pronounced. The general
symptoms of the disease would place this case among the myopathies.
Death occurring from exhaustion, the pathological examination showed
decided changes in muscles, nerves, spinal ganglia, and in the posterior
columns and nerve cells of the anterior horns of the spinal cord. These
changes, which were of chronic degenerative character, are very carefully
described by the authors, and their bearing upon the pathology of the
muscular atrophies in general, is discussed at some length.

144 PERISCOPE

(Vol. XL, Nos. 10 and n, 1906.)
I. The Perverse. Marandon and de Montyel.

1. The Perverse. — The author emphasizes the distinction between the
criminal lunatic, the insane criminal and the perverse. The first commits his
crime on account of his insane condition, the second is criminal at the start,
and later becomes insane, wihile the third is not properly 'to be considered as
insane at all, his memory, reason and judgment being sound, his deficiency
presenting itself in the moral sphere alone. Each of these classes of cases
requires different treatment, and it is an injustice to each to keep them
together, as has been done heretofore, and is to a large extent still the
practice. To a discussion of the characteristics of the third class and
their management the author's paper is devoted. The perverse are the
terror of asylums. They know perfectly well their rights, that they are
not insane, and are only through an injustice confined along with the
insane, though they are ready enough to use the asylum as a place of
refuge and support, especially through the unpleasant season of the year.
By their egotism, their quarrelsomeness, their insubordination and ability
to evade the rules, to fashion keys and weapons, and by their bad in-
fluence over the other patients, they keep the institution in constant tur-
moil, and through the reckless carrying out of their schemes are a source
of danger, though their crimes do not so generally take the form of vio-
lence, as of swindling, malicious mischief, and mean or dirty tricks. They
are not mentally deficient and are capable of education, but the defect in
moral control is congenital and can rarely be overcome. Differing in all
particulars from the insane, criminal or otherwise, while the good of
the community demands that they should be sequestered, they should be
provided for in special institutions, winch should be constructed strongly
enough to prevent their escape, and in which there should prevail a dis-
cipline more rigid than in an ordinary asylum, and yet less strict than in
a prison. Here they should not only be cared for. but should be taught
trades of some sort, and given such moral training as possible. Tnto these
institutions they need not be committed for life, but in the interest of the
community; their discharge should be hedged about with such precautions
as to insure that their condition has sufficiently improved as to make it
unlikely that they will continue to be a danger to the public. The author
discusses at some length the general plan of suoh an institution, and the
legislation on the subject which he thinks is needed.

(Vol. XL. No. 12, 1006.)
I. Prophylaxis and Treatment of Habitual Criminals. Morel.

1. Habitual Criminals. — An earnest plea for the thorough and indivi-
dualized study, by trained psychiatrists of all cases of habitual criminals,
the great majority of whom are afflicted with mental defeot, more or less
pronounced. Also for the establishment of institutions for the medical
care and training of suoh individuals. The author insists upon the inutility
of punitive measures in oases of this character, and that better results are
to be expected by medico-pedagogical methods.

(Vol. XL, No. 13, 1906.)

1. Some Considerations on Mirror Writing. Boulenger.

2. Recent Work on the Ausculation of Muscles in Paralysis, Contrac-

tures and Reaction of Degeneration. Iotevko.
t. Mirror Writing. — Persistent involuntary mirror writing is always
pathological, and the sign of some mental disturbance characterized by
more or less disorientation. After quoting at some length from the writ-
ings of a number of authors, the author describes some cases of his own,
particularizing specially the methods employed by an experienced writing
teacher in instructing an imbecile who showed this defect, but in whom
some improvement was observed under the persistent and intelligent
efforts of the instructress in question. In cases of obstinate mirror writ-

PERISCOPE 145

ing the prognosis is unfavorable since it is most frequently observed in
idiots and imbeciles.

2. Auscultation of Muscles in Paralysis. — After quoting freely from
some previous works of her own, especially from one, "The Functional
Duality 0$ Muscle," the authoress considers the study of Link upon the
muscular sound. This is the sound which is heard when listening over a
contracted muscle -with the stethescope, or better with the phonendoscope.
This sound in the healthy muscle voluntarily contracted is found to cor-
respond to 22-24 vibrations per second. In complete flaccid paralyses this
sound cannot be produced, though when the paralysis is incomplete it is
heard more or less faintly, in proportion to the number of fibers capable
of functionating which are left. The sound is also more feeble in any
condition giving rise to impaired muscular force. It is heard in paralysis
agitans, in tremors, and is very intense in tetanus. On the contrary in
muscles having undergone contracture through nutritional causes (e. g.,
in contracture after hemiplegia) it is not heard. If the patient is able to
make any voluntary movement, however, it is immediately produced.

Normal muscle excited by the faradic current gives a note whose pitch is
dependent upon the number of interruptions per second of the apparatus.
In muscles showing complete reaction of degeneration neither the galvanic
nor the faradic current produces any sound. The authoress thinks that
these observations confirm the theory which she has put forward ; namely,
that the muscular contraction is composed of two elements, the contraction
of the anisotropic substance, which is intermittent and produces the
muscular sound, and that of the sarcoplasm which is continuous and silent.
She even suggests that we can take a step further in advance, assuming
that these two kinds of contraction are under the influence of innervations
from different points, that of the anisotropic substance coming from the
higher, the voluntary centers, in the brain, that of the sarcoplasm, from
the lower or medullary centers.

(Vol. XL, No. 15, 1906.)
1. A Rare Form of Pseudoesthesia. Mattirolo.

1. Pseudoesthesia. — By "pseudoesthesia" the author understands a false
though physiological mental perception of colors, sounds, odors, etc., which
are not real, but are nevertheless evoked by a real perception in the realm
of another sense. He narrates the case of a man of thirty years of age, in
good health, presenting no psychical anomaly, not neurasthenic, "in the
true sense of the word," though a little excitable, and easily depressed.
This man claims to have had since early childhood the following anomaly:
The hearing, or even the reproduction of the mental images of certain
words, are invariably accompanied by the sensations of the taste of certain
substances as of fruits, vegetables, meats, etc. ; for instance, the word
Russia calls up taste of pears ; admit, tomato sauce ; captain, roast fowl,
etc. The man is an Italian, but speaks French as well as be does his own
language, and knows German, though this he learned muoh later than
French. The corresponding French and Italian words equally arouse the
gustatory sensations, not so the German words. He has the idea that
words containing a number of labial and dental consonats give rise to
tastes which should be perceived on the anterior part of the tongue and
palate, while those in which gutturals abound cause tastes usually per-
ceived by the posterior part of the tongue and palate.

(Allen) Trenton.

Journal de Psychologie Normale et Pathologique

(Third Year, No. 3. May-June, 1906.)

1. The Sense of the Mysterious Among the Insane. G. R. D'Allonnes.

2. Modern Witchcraft. A. Marie and M. Viollet.

3. Some Time-Reactions Among the Insane. Cl. Charpentier.

I. The Sense of the Mysterious Among the Insane. — Among normal

146 PERISCOPE

individuals there is a sense of the mysterious. In accordance with the de-
gree of culture, it assumes the general features of an anxiety about the
unknown. Normal individuals, however, possess pre-eminently the power
of discerning the real, a perceptive power or faculty of drawing inferen-
ces which, if not entirely all that could be desired, is nevertheless suffi-
ciently practical for all human and earthly affairs. The explanation of
the unknown is the province of science and of philosophy; but it is in
metaphysics and the theoretical sciences especially that we confine the ex-
ercise of the sense of the mysterious. This leaves us free for the further-
ance of the positive sciences and the elaboration of the practical life.

It is abnormal for the sense of the mysterious not to be thus excluded
from the domain of the practical, but to manifest itself, as it were, in con-
nection with anything and everything in life. In the doubting mania
(folie de doute), for instance, question follows upon question; and as
long as the doubter remains engulfed in the sense of the mysterious he is
lost. The systematic psychopath organizes the mysterious and gradually
builds up a false conception of the world, of society, and of himself, suffi-
ciently strong to involve all of his utterances, his writings, his movements,
and even at times to lead him into terrific outbursts of violence.

Physiological disturbances, abnormalities in connection with the proper
knowledge of men and of things, and a vague consciousness of these
abnormal processes constitute the material out of which is evolved the
morbid sense of the mysterious ; the preservation of the reasoning faculty
is the active element in its evolution. According to the relative dominance
of one or the other of these different factors; namely, disorder of the
physio-psychological processes, confusion of the consciousness, vigor of the
reasoning faculty, the patient is more or less overwhelmed in an ocean of
confusion and flounders feebly about, or on the other hand reacts, inter-
prets and forms curious deductions while carving out of the chaos, in a
most summary way, certain frightful, amusing or even beautiful concep-
tions. And, if lie is able, he organizes them and creates a perfect dream-
world, elaborate in construction, monumental and absurd.

A total absence of intelligence at one end of the scale, and intact
lucidity of mentalization at the other are both incompatible with a morbid
sense of the mysterious. It is the mentally weak, the half-lucid, the mid-
dling-intelligent who, not fully comprehending the world or themselves, fail
to recognize their own incapacity while assuming to themselves a full and
perfect comprehension. If during the preoccupation of a mystic or of a
victim of the persecutory obsession one converses with him, one will be
struck with the fact that there is a constant intervention of the voluntary
reasoning faculty. This is the cardinal trait of this psychical abnormality.
The author illustrates his thesis with a detailed report of three pronounced
cases.

2. Modern Witchcraft. — Witchcraft, sorcery and incantation are all the
offspring of superstition. They are in existence to-day, though we are
prone to regard them as having vanished with the fallacies of the past.
The underlying cause and foundation of witchcraft are the same in ail
ages. In the past, as well as in the present day, it assumes various guises.
To-day it masks itself under the various forms of spiritism and assumes
the high-sounding name of occult science.

After presenting a brief but interesting account of ancient witchcraft
and an analysis of its basic religious and phychic constituents, Marie and
Viollet report in detail four striking cases. In all of them the mental
instability, hysteria, ignorance and superstition of the patients or of their
friends and relatives gave origin to the belief that the victims were be-
witched and could only be cured, or were cured, by the well-known
methods recorded in the history of mediaeval sorcery. The special danger
of those modern forms of witchcraft lurks in the degenerative psychas-
thenia which they are prone to awaken from a latent state. They excite
the predisposed and lead to disastrous results.

PERISCOPE 147

3. Some Time-Reactions Among the Insane. — According to the obser-
vations of Wundt, Hirsch, Exner, Waller, Auerbach, Binet and others the
reaction period for audition, in normal individuals, varies from twelve to
sixteen hundredths of a second. Buccola and Patrizzi have shown that
among patients whose powers of attention are deteriorated, fatigue ap-
pears and the graphic tracings incline more quickly than among normal
subjects. The general mean is more elevated, the oscillations are wider,
and the subject is slower to react. These same results are obtained under
general anesthesia. Janet has clearly established a characteristic re-
action curve for hysteria.

In the present essay Charpentier presents the tracings obtained by him
in a number of cases of mental trouble, such as mysticism, persecutory
insanity, mental debility, incipient general paralysis, athysoidea, dementia
precox, melancholia, alcholic general paralysis, maniacal excitement, etc.

He concludes that these reaction curves are of some interest, but that
they possess only an imperfect and approximate value. It would be an
exaggeration and wholly rash to affirm that each curve has a special
diagnostic value. On the other hand, when studied in conjunction with
the other symptoms, such as tracing may prove, useful in indicating the
patient's degree of attention. One can detect simulation and obtain thus
most useful objective criteria. A simulator of hysteria, for example, pro-
duced a reaction curve wholly inconsistent with the one Usually obtained
in cases of genuine hysteria.

From a physiological point of view, it is of interest to note that the
tracings obtained by the author are almost parallel with those obtained
with the aid of the dynanometer and the ergograph of Mosso. The
question is asked by the essayist, are we then to conclude that muscular
phenomena and attention are identical ? To answer this we need, he says,
to study with greater precision than heretofore the relationship of atten-
tion, not only to muscular force and the time of reaction, but also to
the circulation and the respiration in order to complete the psychophysical
and psychochemical basis of attention. Mettler (Chicago).

Miscellany

Dementia Precox. By W. A. White (Journal A. M. A., May 19).

Dr. White argues against the' theory advanced by some authors on the
basis of chemical studies, etc., that dementia prsecox is caused by an autoin-
toxication. The disease, he considers, is due to an original developmental
defect, and the physical symptoms suggesting autointoxication are the
result of the imperfect functioning of the nervous system.

Misleading Symptoms in Cerebral Disease. By J. A. Stucky (Journal
A. M. A., April 28).
The author reports a case of sarcoma involving the whole right temporo-
sphenoidal lobe, associated with and infected by chronic suppurative eth-
moiditis, and asks which was the primary lesion. No macroscopic evidence
existed of disease elsewhere in the brain. The local symptoms, pain and
bulging of the orbit, pointed to trouble in the right fronto-orbital region,
but there was aphasia (the patient was right-handed), spasm of the right
arm and hand, and the tongue deviated to the right. The author asks :
Could general intracranial pressure exist without motor symptoms refer-
able to right-sided pressure and also what would have been the result had
the sinus disease been eradicated months before?

Psychoses Resulting from Coal-Gas Asphyxiation. By Sanger Brown

(Journal A. M. A., April 28).

The author reports a case of asphyxiation from coal gas. When the

patient was found (Nov. 7) he was unconscious, his face was a deep purple

and the body was entirely flaccid. He was carried to bed, and after the use

i48 PERISCOPE

of restorative measures he regained consciousness at the end of three days,
and in about three weeks he was able to be up and about. His face con-
tinued to be purple, and his expression was dull and stolid. He had no
recollection of anything that transpired for from 36 to 48 hours prior to
the time he was found unconscious. He recognized his old acquaintances
and repeated their names and discussed correctly with them various
matters relating to a period prior to the asphyxiation. He repeated inci-
dents of early life and childhood usually well, but retained practically
nothing since the afternoon of Nov. 6. He could not remember what took
place from hour to hour, even the visit of an old friend whom he was very
glad to see. By dint of constant practice he finally remembered the name
of his nurse and his way to the toilet and dining rooms. He could read
and make simple computations in arithmetic. He realized his disability
and wanted to recover, but was not emotional or complaining. He would
read the newspaper, but could not discuss current topics. Though he re-
tained some few impressions in his memory enabling him to find his way
about the house and when out walking, there was no material improvement
while under observation, a period of fourteen weeks. On leaving the sani-
tarium he returned to the care of his family physician, who reported no
notable change in either the bodily or mental symptoms till about the
middle of December, two weeks before the man died. He suffered from
severe attacks of dyspnea so that he had to be under constant surveillance.
He was a little better for two days before his death, which occurred sud-
denly, soon after he retired and while he was alone in his room. Autopsy
showed no significant changes in the brain or spinal cord. The lungs
were markedly emphysematous, and the heart was considerably dilated.
There was a large cyst of the left suprarenal capsule. Dr. Brown says
that it may reasonably be assumed that some deleterious influence, not
demonstrable by present methods of examination, had been exerted on
certain cerebral neurones, so that they were no longer able to retain new
impressions. He also calls attention to the fact that the impressions made
on them some hours prior to the action of this influence were effaced by
it, while impressions of long standing were not affected.

Treatment of Idiopathic Epilepsy by Appendicostomy for Colonic
Irrigation. By S. LaPlace (Journal A. M. A., June 2).
Dr. LaPlace considers it probable that epilepsy is due to the manifesta-
tion of a toxin accumulated in the system as a result of the intoxication of
improper food or tissue metabolism and the locality of the production of
this poison is the colon. Consequently, he has resorted to appendicostomy
with subsequent irrigation of the colon through the fistula in one case with
excellent results. He concludes that the treatment is harmless, and is based
on sufficiently sound theoretical and scientific grounds; and even should
improvement of the epilepsy not result it cannot fail to do good from a
hygienic standpoint in affording general relief from constipation, to which
most sufferers from epilepsy are subject. The repeated flushings of the
colon keep it as nearly empty as possible, and almost eliminate its presence
as a reservoir for undigested and putrefying substances. Fear of a per-
manent artificial opening in the intestine should not be entertained. The
artificial fistula closes easily, and, after months of treatment, should one
desire to discontinue the flushings of the colon, the natural processes of
evacuation are resumed without difficulty. The method is not expected to
cure all cases of idiopathic epilepsy; but only those whose existence can
be traced to this particular cause. The procedure here advocated should
be accompanied by the proper dietetic measures.

Book IReviews

Histological Studies on the Localization of Cerebral Functions. By
Alfred W. Campbell, M.D., Pathologist to the Asylum Board of
the County of Lancaster. University Press, Cambridge.
This is a work that has been urgently needed for a long time. Ham-
marberg's work on "Idiocy," and isolated monographs here and there have
led up to the desire for a work in which one could find the chief histologi-
cal features of the entire cortex accurately and adequately presented. Dr.
Campbell has done this in his quarto of 360 pages. After discussing the
methods and material, and general remarks on cell lamination and the
arrangement of nerve fibers in the cerebral cortex, he takes up the several
areas of the brain substance. In Chapter III. the motor area is studied as
to its structure and function. The arrangements of cell and fibers are
given and comparisons drawn between the structure of the precentral area
of man and ape. Special attention to the giant Betz cells is given as well.
Functional studies on the changes in the cortex in amyotrophic lateral
sclerosis, post-amputative changes and the effects of lesions of this area
are given in this chapter as well. The post central area is then taken up
in the same exhaustive manner. Histological studies are followed by
physiological considerations. Chapters V. and VI. treat of the visuo-
sensory and visuo-psychic areas, and the temporal lobes and auditory area.
The limbic lobe, the parietal area, the intermediate precentral area, the
frontal and prefrontal areas and the island of Reil complete the main body
of the work. In an addendum the author presents further histological
studies on the localization of cerebral function, dealing particularly with
the comparisons of the brain of man and those of the lion, the dog and the

pig-

The more one reads the more is the impression deepened that we have

here a memorable volume which will serve as a new starting point in all

work on the brain, whether one is interested in neurological or psychiatric

problems. Campbell has set before himself the task of going over the

entire brain cortex, millimeter after millimeter, and here gives us, it might

be said, for the first time the complete story of the histology of the human

cortex. But he has done more, for in his hands histological investigation,

supplemented by embryological and pathological considerations has opened

up a well of suggestions concerning cerebral localizations which may well

be designated as fundamental. The work deserves the highest praise.

Jelliffe.

A Text Book of Psychiatry for Physicians and Students. By
Leonardo Bianchi, M. D., Professor of Psychiatry and Neuro-
pathology in the Royal University of Naples ; Minister of Public
Instruction in Italy; Medical Director of the Provincial Asylum
of Naples. Authorized translation by James H. Macdonald, M.B.,
Ch.B., Glascow, Senior Assistant Physician to the Goran District
Asylum. William Wood & Co., New York.
This text book, coming from one of the leading psychiatrists of Italy,
is of more than passing moment, for the works of Bianchi and Tanzi rep-
resent the leading trends in the Italian psychiatry of to-day. The latter is
strongly pervaded bv the influence of German psychiatry, particularly of
the Kraepelin school, while Bianchi represents Bianchi, a strongly in-
dividualistic writer and thinker.

The author introduces his work in the conventional manner by sum-
marizing the general facts of cerebral topography and minute anatomy,

150 BOOK REVIEWS

which is a scholarly and interesting presentation. The main principles of
mental evolution from the physiological point of view are there con-
sidered, special attention being given to the function of language.

In part II. the author discusses the psychological principles which
will serve as the framework of his symptomatology. The Psysio-path-
ology of Perception, of Attention, of Memory, of Ideation, of the Emo-
tions and Sentiments, of the Will and Consciousness, are the chapter head-
ings in this part of the work. Here the method of the author is made
manifest. He takes up in an easy manner the general phychological
scheme and elaborates it by copious references to contemporaneous litera-
ture. This is done, however, in an interesting, though in a very dis-
jointed, manner, yet the main facts of recent psychological research are
admirably presented. Illusions are defined by Bianchi as disorders of
perception by which the subject reproduces, in the object present, features
that do not correspond to the reality, but which are reawakened by an
altered associated mechanism and by an anomalous tension of certain
nervous apparatus. Such a representation necessitates the action of an
objective stimulus. Hallucinations are subjective perceptions according to
our author, and are closely related to illusions, if indeed they may not
be the same thing. These phenomena are elaborately and minutely illus-
trated by clinical examples and by a wealth of suggestive material.

Attention, Bianchi regards as a psychic fact, interposed between percep-
tion and the reaction which it tends to provoke. It is therefore one of
the higher reflex processes, such as conscious and voluntary movements,
and their inhibition. This chapter is a very fascinating one, and the fol-
lowing one on memory is no less so. In the chapter on Ideation the
phenomena of delirium are taken up. Delirium is a qualitative distur-
bance of ideation. The formative process of thought is altered by ex-
traneous associative relations between preformed images, drawn some-
times from the unconscious, or between already acquired ideas and the new-
comers, thus giving rise to a conclusion which does not correspond to
reality. The product of this abnormal process goes under the name of
delirium. Bianchi's attitude toward deliria is unusual. He says that the
"deliria" are always preformed mental products that have been eliminated
from consciousness at an early date; and he further speaks of the con-
sciousness offering less resistance to the invading power of these products.
His illustrations are striking, but the suggestion is too diagrammatic. Ac-
cording to the nature of the content he distinguishes deliria of grandeur,
of depression, of metamorphosis, of negation, of persecution, and of re-
ligion.

The chapter on the Emotions contains an excellent discussion of the
James-Lange theory, as well as much literature, old and new, and ranging
over an extensive field. It is surprising to an American reviewer to find
an author who has made so much use of the work of American psycholo-
gists. In fact, no worker of any significance is neglected, notwithstanding
the variations in speech.

The will is defined as "nothing more than the conscious resolution of
the motor tendencies of the intellectual-emotional synthesis," and we may
figure it to ourselves as the conscious motor potential tending to dis-
charge itself through circuits of various orders, from the lowest, which
must resemble the inferior and instinctive reflexes, to the highest, which
are represented in the actions of the heroes of humanity. That man is a
reflex animal even in his most complex intellectual acts is therefore the
attitude of our author.

The author has a repugnance to classifications of the psychopathies.
"Almost useless, incomplete and not vital" are his terms. He gets along
without one, therefore, but presents a series of groups. In the first group
he puts all those psychopathies developing on an evolutionary psycho-
cerebral defect; a second group consists of all the mental affectations of

BOOK REVIEWS 151

infective, autotoxic and toxic origin, developing in individuals regularly
evolved, and a third group includes all the affections with an organic sub-
stratum, localized or diffuse, in the central organ of mind.

In his first group he arranges phrenasthenia, paraphrenias, congenital
moral insanity, epilepsy, hysteria, developmental paranoia, fixed ideas,
developmental neurasthenia and the sexual psychopathies. In the second
group are arranged : Mania, lypemania, exalted-depressive insanity,
circular and periodic insanity, sensory insanity, mental confusion, acute
paranoia, late paranoia, neurasthenic insanity, choreic insanity, luetic
insanity, acute delirium, and the drug and infectious insanities. His third
group contains : Paralytic dementia, leutic dementia, senile dementia,
post hemiplegic dementia, aphasic dementia, traumatic dementia, and
dementia arising from tumors, scleroses, placques and other organic
diseases of the brain.

It is very evident that the ideas of prognosis so valuable in Kraepelin's
schemes are not taken into account by Bianchi, and furthermore it is
difficult to understand his attitude when he says that the secondary
dementias are always identical, whatever the clinical form from which
the particular symptoms are derived. If there is any large fact of
psychiatry that has been brought forth by the work of Kraepelin it is
that the secondary dementia group is far from being hemogeneous, and as
long as they were so considered little hope was offered in the unravelling
of the process that led to the dementia.

The descriptive portion is admirable, particularly so from the stand-
point of comparative psychiatry, although it is to be regretted that much
of the newer German symptomatology is conspicuous by its absence. As
a whole the work is one that in its present form should be read by
psychiatrists, who cannot help but profit in so doing. Jelliffe.

IRews arrt> note*

At a recent meeting of the New York Psychiatrical Society the follow-
ing memorial notice of the death of Dr. Alexander E. Macdonald was
presented by Drs. Charles F. MacDonald and William Mabon, a commit-
tee appointed for the purpose, was unanimously adopted and ordered to be
spread upon the minutes of the society and a copy of the same to be sent
to the family of the deceased :

Alexander E. Macdonald, L.L.B., M.D., a member of the New York
Psychiatrical Society, died Dec. 10, 1906.

For thirty-five years Dr. Macdonald had been intimately associated
with the insane. He commenced the study of medicine at Toronto Uni-
versity and graduated M. D., Medical Department, New York University,
1870; LL.B., Law School, New York University, 1881. Lecturer upon
Medical Jurisprudence in 1874; subsequently, Professor of Medical Juris-
prudence, Professor of Psychological Medicine and Medical Jurisprudence,
and was Emeritus Professor at the time of his death. House Physician
Hospital for Epileptics and Paralytics, Blackwell's Island, 1870; chief of
staff, Charity and Allied Hospitals, Bleckwell's Island, 1871. Resident
physician, New York City Asylum for the Insane, Ward's Island, 1874.
Medical superintendent of the same from 1874 to 1904, the title of the
asylum having been changed in the meantime to Manhattan State Hospital,
East, Ward's Island.

In 1901 he established the tent treatment of the tuberculous insane,
removing them from all communication with any unaffected patients. The

152 NEWS AND NOTES

principles underlying this undertaking are now universally accepted by
the medical profession here and abroad.

An article on this subject was published by the Charity Organization
of New York City and the National Association for the Study and Pre-
vention of Tuberculosis.

Dr. Macdonald was a delegate from the Ameircan Medico-Psychological
Association to the Fourteenth International Medical Congress at Madrid
in 1903; President of the American Medico-Psychological Association in
1904; delegate to the Congress of American Physicians and Surgeons, to
be held in Washington in 1907; honorary member of the Medico-Psy-
chological Association of Great Britain and Ireland, and of other continen-
tal medical associations.

His splendid administrative abilities made him familiar with every
detail in the care of the insane, seven thousand at one time being under
his direction. He possessed the rare gift of attracting to himself experi-
enced, trusty and loyal officers and friends.

Dr. Macdonald was one of the mos1 distinguished alienists of this
country, and a man of striking force of character. He had a hatred of
cant and pretense. His far-seeing powers, his unswerving integrity and
great executive ability qualified him in an extraordinary degree for his
responsibilities. At all prominent medical meetings his activities were
conspicuous. His commanding presence and lofty sense of duty will always
be remembered by those who had the privilege to be acquainted with him,
and his pupils in all parts of the country will pay many tributes to his
memory.

Dr. Macdonald was a cultured man of affairs, who wrote in a con-
vincing and agreeable style, and enjoyed a well-earned reputation as an
after-dinner speaker, lie was a member of the Lotus Club and a Mason
of Holland Lodge, New York City.

Our sincere condolences go out to the wife and children of our fellow-
member in their affliction

The Psychiatrical Society desires to spread upon the minutes this
tribute to the memory of their late associate.

C. Macfie Campbell, M.B., Secretary.

P. J. Mobius died in Leipsig, Jan. 8, 1907.

Vol. 34. March, joc;. No. 3

THE

Journal

OF

Nervous and Mental Disease

Original Hrticles

MIGRAINE AND HEMIANOPSIA.*

By John Jenks Thomas. A.M., M.D.,
of boston.

instructor in neurology, tufts college medical school; assistant
physician for diseases of the nervous system, boston city hospital,-
ass. neurologist, children's hospital/ member american neu-
ROLOGICAL association; American association pathologists
and bacteriologists; boston society of psychiatry
and neurology, etc

The literature of migraine is large, and few diseases have
been more carefully described, and there are few in which
more writers have described their own cases, many illustrious
physicians and neurologists having written of their own at-
tacks of this curious trouble. In one respect our knowledge
is singularly defective, as autopsies, except in cases where
some serious brain disease has coexisted, are rare. In conse-
quence, many theories have been advanced in explanation of
the symptoms, many of them more ingenious than probable.

The question broadly stated which I wish to discuss is
whether attacks of migraine, in the absence of disease of the
vessel walls, is capable of producing permanent changes in
the nervous structures. Moebius in his exhaustive mono-
graph on this subject in Nothnagel's Specielle Pathologic und
Therapie, published in 1894, speaking on this point, says that
the question whether hemorrhage or softening occurs, more
fully stated should be —

First: may it be possible that in time, because of the re-
peated attacks of migraine, degeneration of the vessel walls

*Read at the meeting of the American Neurological Association, June
4 and 5, 1906.

154 JOHN JENKS THOMAS

may occur so that some attack may occasion rupture or throm-
bosis of the vessel?

Second : may an attack of migraine itself, without previous
degeneration of the blood vessels, lead to destructive pro-
cesses?

To answer these questions with our present knowledge
of the subject is difficult, if not impossible. Moebius rightly
calls attention to the division of migraine into what may be
called the symptomatic, and the idiopathic forms. Both mi-
graine and degeneration of vessels are frequent conditions,
and may be simply coincident, especially in old persons, or
where syphilis is present. He concludes that the migraine
may be the exciting cause of the organic brain disease, and
this may be considered to be the case especially in instances
where the attacks, particularly the aura, are always uni-
lateral and the softening occurs on the same side. As he
says, the question is usually not whether a case is migraine,
but whether it is migraine alone or with something else.
Obviously this is a much more difficult question to decide.

In idiopathic migraine we have to do with a disease
which is most often hereditary. Kovalevsky in a recent mono-
graph collected no cases, in 70 of which there was a history
of heredity, and in 18 of these cases for three generations.
The disease generally begins in youth, and cases are to be
regarded as suspicious when it begin late in life, as well as
those where there is no history of migraine in the family.
The next characteristic of migraine is the intermittency. Then
the character of the headache must be considered, as headache
is an extremely common symptom. In neurasthenia the head-
ache is generally constant, and there is no vomiting. Head-
ache from disease of the nose is also without free intervals
and vomiting. Syphilitic headache does not occur in separate
attacks like migraine, and is apt to be worse at night. Head-
ache from malaria is somewhat questionable, while the pain
of glaucoma, anemia, and of supraorbital neuralgia can usu-
ally be easily distinguished. The headache of gross brain
disease, such as tumor and abscess, generally occasions no
difficulty in diagnosis, though some cases of symptomatic
migraine may be difficult to differentiate. Moebius thinks
the cases of migraine due to gout and malaria are altogether

MIGRAINE AND HEMIANOPSIA 155

doubtful, the latter disease in particular usually causing neu-
ralgias rather than migraine, and in the former case we prob-
ably have to do with alternations between the two diseases,
as is seen in other diseases. Migraine occurs as a symptom,
usually an early one, not uncommonly in tabes and paralytic
dementia, cases having been reported by Moebius and others,
but in these cases a careful examination should make the
nature of the case evident, and the same is true of the cases
due to tumor of the brain, though occasionally cases may
arise in which the diagnosis is extremely difficult, or even im-
possible, as in the case of aneurism of the basal artery reported
by Karplus.

A young woman, 29 years of age, all of whose nine broth-
ers and sisters had attacks of headache, had suffered from
youth with severe attacks of headache with eye symptoms
such as scotoma. She had no syphilis. She was suddenly taken
with a severe headache on the right side of the head. The
next day there was right ptosis, and roaring in the ears with
disturbance of hearing. She then improved, but three weeks
later the pain returned much more severely in the right fore-
head and temple with paralysis of the right third nerve, and
the patient died four days later. At the autopsy there was
found an aneurism of the right posterior communicating artery
which had burst, and adhesions of the right third nerve to
the aneurism.

Karplus thought there had been first a rupture of the
aneurism, and later a rupture of the spurious aneurism which
had formed, and thought that the migraine had aggravated
the disease of the vessels.

Moebius calls especial attention to the fact that in tumor
of the brain the vomiting is not followed by relief of the pain
as is usual in cases of migraine, that patients are not usually
free from symptoms in the interval, are often mentally dull,
and that the pain is not relieved by rest.

We should probably separate also the cases of recurrent
oculomotor paralysis from migraine. In the former disease
the intervals are usually longer than in migraine, and in the
intervals the patients are not free from all paralysis, at least
in the later course of the disease, and the headache is probably
often symtomatic only. There is usually no aura, or history

i56 JOHN JENKS THOMAS

of heredity, and the pain often lasts for weeks. While these
differences are observed in most cases this is by no means
always true. Cases of recurrent ophthalmoplegia have been
reported fairly frequently in which an aura was present, such
as a scintillating scotoma, where there was a distinct heredity,
where the intervals were short, and most important perhaps
where the disease began in youth, or migraine alternated with
attacks of ophthalmoplegia. Such cases have been reported
by Paderstein, Ballet, Seiffer, Suckling, Romano, Joachim,
Kollaritz, Chalbert, Lappersonne and others. So that while
in general a marked difference exists in these diseases there is a
close relationship, but the weight of authority seems to be with
Schmidt-Rimpler when he says that there is probably the same
cause for the pain and the paralysis, and as Karplus says the
cases form two separate groups, but in some there is a relation
between some anatomical alteration which is primary and
independent of the migraine, and is the cause, but which may
or may not be active in producing the attack ; while in the
hemicrania cases there is a local defect, but other independent
factors enter. Ballet thinks the ophthalmoplegia cases are
related to what the French call the migraine ophthalmique,
where there is a scotoma of some form, but not to the ordinary
cases.

Hemianopsia as an aura of migraine attacks is too common
a phenomenon to require more than mention. Occasionally
a transitory aphasia is seen, as in the cases of Determann,
Pick, Charcot and others. More rarely still disturbances of
sensation or of motion of one side of the body appear, and
sometimles aphasia with them, as in a case of Fere. A number
of cases are reported where symptoms appearing during the
attack similar to transitory ones in previous attacks have
become permanent. The French writers in particular are
incline to look upon these as the permanent effect of spasm
of the blood vessels in the brain, such is assumed to be the
cause of the transitory symptoms. In support of this theory
certain cases are repeatedly quoted, especially those reported
by Galezowski, Fere and Charcot, but a careful analysis of
these cases and others shows that in most, if not all of them>
we probably have a symptomatic migraine accompanying
organic brain disease, vascular or otherwise, coming in per-

MIGRAINE AND HEMIANOPSIA 157

sons, in some cases subject to migraine attacks, and in other
cases, even this much is doubtful.

Rossolimo's case of recurrent facial paralysis in migraine
if more than a coincidence is more closely allied to the re-
current ophthalmoplegias, as the attacks lasted several days,
and the intervals between the four attacks of paralysis varied
from two years, to three and a half years.

Galezowski's cases were:

1 st. A man, 67, who had had attacks every month to every
week for twenty years, in which he had hemianopsia and
scintillating scotoma for a few minutes, followed by pain in
one-half of the head lasting for two or three hours, had in one
attack a sudden loss of sight in one eye, from a thrombosis
of the central artery. The heart was negative.

2nd. A girl, 15, who had had migraine with scotoma of
flames and zigzag lines since the age of seven or eight, sud-
denly in an attack became blind in one eye, which blindness
was permanent in part. The field of vision was lost in its
whole lower half, the papilla pale and like the appearance seen
in embolism of the central artery, the fronto-temporal and the
fronto-nasal arteries were sclerosed, while Jthe heart was
normal.

3d. A woman, 29, who had had migraine without hemian-
opsia, but with zigzags of light and dark scotoma, nausea
and vomiting with the attacks, was found to have normal
vision in the right eye, while that of the left was much dimin-
ished, and there was paleness of the disc and diminution of
the size of the blood vessels, and a neuro-retinitis, with vessel
thrombosis.

4th. The patient, 52 years old, had had migraine with eye
symptoms for four years only, having had numerous attacks,
with hemianopsia in some and aphasia in some, of four or
five minutes' duration. There was an attack of migraine with
left hemianopsia, after which the vision of the right eye was
found normal, while that in the left was poor, without affec-
tion of the field of vision, but a neuro-retinitis with capillary
thrombosis.

In two of these cases we should suspect that arterial disease
was present, on account of the age of the patient, and the age
at which the headaches began, and they are probably to be

i58 JOHN JENKS THOMAS

considered cases of symptomatic migraine. The other two
cases prove pretty conclusively that thrombosis of the vessels
of the optic nerve may occur in an attack of migraine, and
are important as showing that this can occur in young persons.
Voss reports a similar case where sudden blindness came on
in a woman of forty-two during an attack of migraine to which
she had been subject since youth, where there was found
atrophy of the optic nerve from thrombosis of the central
artery or hemorrhage into the sheath.

Other cases are reported in which an aphasia, which was
permanent, came on in the course of a migraine attack. Many
of these were cases where there was disease of the vessel
walls, and the migraine was evidently a symptomatic one.
One of the earliest of the cases I have been able to find is
one reported by Fere in 1883.

A man, 53, whose father had suffered from migraine, and
who himself had had migraine fromj childhood, the attacks
coming about every eight days, accompanied by vomiting
and preceded by zigzag lines of light and a scotoma, had
an attack in which he developed a permanent aphasia with
partial paralysis of the right arm. Later he had trouble with
the left side also, and difficulty in swallowing, while later
still loss of consciousness came on, and he died evidently
from some vascular lesion of the brain.

Charcot mentions two cases of permanent aphasia coming
on during an attack of migraine, both occurring in old people.
Oppenheim's case, reported in 1890, is one of the few with
autopsy on record.

The case is that of a woman who had suffered from period-
ical headaches, probably from childhood, certainly for a long
time, which generally affected one side of the head only and
lasted from twelve to twenty-four hours with photophobia,
nausea, and sensitiveness to noise. She had had one healthy
child one year after marriage, but none since. Three years
after her marriage asphasia came on during a headache
which disappeared in twenty-four hours, and there were four
similar attacks. Twelve years later she suddenly lost her
speech but without loss of consciousness, and there was also
a right hemliplegia noticed as she lay in bed. She soon began
to speak, but after an hour this was again lost and remained

MIGRAINE AND HEMIANOPSIA 159

so. At first she was excited and sang. In five weeks she
could move the leg. There was no syphilis. Examination
showed aphasia, word deafness, and complete paralysis of the
right arm and partial of the right leg and face, with increased
knee jerks on both sides. Hemianopsia could not be made
out. The ophthalmoscopic examination was negative. The
prick of a pin could be felt on the right side. Some two months
later she was taken with vomiting and died, and at the autopsy
there was found a thrombosis of the left internal carotid
shortly before the giving off of the artery of the fossa of
Sylvius. There was also endocarditis and cicatrices of the
kidney.

This case again is evidently one of a combination of migraine
with vascular disease, though it is difficult to explain the re-
peated attacks of temporary aphasia, except as circulatory
disturbances after a small embolus in the neighborhood of
the speech areas.

Quairolo in 1893 reported a case of asphasia with paresis
of the right face and tongue, coming on suddenly, with dizzi-
ness, in a man of fifty, who had a diffuse arterio-sclerosis.
He thinks the transitory symptoms of migraine may become
permanent, and ascribes the disease to a spasm of the blood
vessels. The arterial disease in his case makes it unnecessary
to consider the migraine as more than an exiting factor for
what was probably a cerebral thrombosis.

Flatau in 1902 reported a case which seems to me to be
one where we have a migraine causing organic trouble in a
person whose age was favorable to disease of the vessels.

The man was forty-eight years of age, and there was a
history of heredity of migraine on both sides of his family.
His attacks had begun at the age of sixteen, and had occurred
every two to four weeks, accompanied by a scintillating
scotoma in one eye followed by the pain and vomiting. He
was well in the intervals. He also had paresthesia in the
fingers, face and tongue on the side opposite the headache,
accompanying the aura. He had typhoid and then smallpox,
and at the end of this aphasia appeared, with difficulty in
swallowing, but no weakness of the extremities. This lasted
between four to seven weeks and then passed away. The
attacks of migraine returned varying from one to ten a year.

160 JOHN JENKS THOMAS

In these attacks he had a peculiar feeling in the right hand,
face and half of the tongue, and a scotoma on the right, while
the headache was on the left. After one attack he found
agraphia, and some difficulty in getting the word he wanted
to use. This trouble lasted four days. With the next attacks
of headache he had no such symptoms. Later he had a similar
attack of agraphia, with aphasia, but no paralysis, which lasted
ten days.

The cases in which a permanent hemianopsia came on dur-
ing an attack of migraine are very similar to those in which
a permanent aphasia or paralysis occurred. That is, most of
them are in all probability cases in which arterial disease
existed. Fere in 1881 reported a number of cases of migraine
ophthalmique of which the ones that concern us are the fol-
lowing:

Case 6 — A woman, thirty-four years of age, with no history
of migraine in the family, and no previous illness, was taken
one day, three years before she was seen Fere with a sudden
pain in one half of the head, was stupid and then slept. Some days
later she was taken with a vertigo and feeling of pressure
in the head, which kept on until one month later she woke
one morning unable to move the fingers of the right hand.
The next day the arm was paralyzed. This passed off. Some
two weeks later the leg became weak in the same way. Three
weeks later she had an attack of vertigo and a convulsion
involving the right arm, while the head was turned to the
right and the mouth drawn to the right side, and she was
unable to speak. This lasted an hour, when the pain in the
head began, accompanied by nausea. In three months she was
well. Then for eighteen months she had no trouble, no head-
aches or other symptoms appearing. Then she was taken with
vertigo, lost consciousness, had pain in the head with a scintil-
lating scotoma, and vomited. The pain lasted five or six days,
and was worse on lying on the left side, and she had tinnitus
and fever every evening. Six weeks later there were con-
vulsive movements of the left arm, the mouth being drawn
to the left, and she could not move the left extremities, and
they were anesthetic. This lasted two hours, and was followed
by violent pain in the head, and there was diplopia during
the attack. Later the attacks became less frequent, and she

MIGRAINE AND HEMIANOPSIA 161

improved, but hemianopsia remained. Both sides showed
increased tendon reflexes especially the knee jerks. Three
months later there was another attack of headache with in-
crease of the hemianopsia.

In considering- this history with the absence of heredity,
the onset of the disease in adult life, the long intervals between
some of the attacks, the fact that convulsions were followed,
instead of proceeded by the pain, I think, any neurologist of
the present time would consider the case one of organic cere-
bral disease, and the pain purely symptomatic.

Fere's next case, case 9, was one of Charcot's. The his-
tory is given very briefly. The patient whose age is not given,
a year before in consequence of an attack of hereditary
migraine with temporary aphasia was left with a hemianopsia
which had not improved. The migraine attacks, however,
after this were less severe, and less frequent, but continued.
This case in the absence of further particulars we must con-
sider as a possible one of organic disease from migraine, but
we are without the means of judging of the condition of the
blood vessels.

Fere's third case, number 10 of his series, was also one of
Charcot's. It was that of a woman whose age was not stated,
who had suffered from intense migraine almost all her life,
sometimes on the right side, and at others on the left side
of the head. It could not be learned whether she had had
hemianopsia or scotoma during the attacks. Of late the at-
tacks had become less severe. Shortly before she was seen
she had an attack of migraine like her ordinary ones, only
with numbness of the fingers on the right and difficulty in
seeing the end of the line she was reading. She had no vomit-
ing as she usually did. She had remaining a right hemiparesis
of the face and tongue only, and aphasia and agraphia, but it
could not be determined whether hemianopsia was present or
not. There was no heart lesion or trouble with the stomach, and
there had been no vertigo.

This case, judging from the circumstances told, a woman
living alone, with no one to give information about her but
servants, the precautions urged upon the physicians not to
trouble her by many questions or much examination for fear
of alarming her, makes us suspect that it was an old woman,

162 JOHN JENKS THOMAS

where we probably have to do again with arterial disease.

Schroeder in 1884 reports a case, which is also open to
some doubt. A man of thirty had had for ten years scintil-
lating scotoma with migraine attacks, and after they had
lasted several years, had some attacks in which there was loss
of consciousness. Then he had attacks with numbness of the
left hand and weakness of the left leg. The headaches were
very severe, lasting a week. He had a symmetrical defect
of the left half of the field of vision, and diminished hearing
on the left. He had acquired syphilis four years before, but
after the appearance of the migraine, and after the appearance
of severe symptoms, so that Schroeder did not consider they
could have been caused by the syphilis. His second case of
visual defect coming on with migraine attacks, presented
a separation of the retina, and need not detain us.

Infeld in 1901 reported a case in a young woman twenty-
nine years of age whose mother had attacks of migraine about
once a month with vomiting, and one of whose brothers was
similarly affected, while she herself had had headaches since
she was twelve years old, coming about once a month, gener-
ally before the menstrual period, but not exclusively, lasting
one day, without aura or vomiting. There was no syphilis.
About seventeen months before she was seen she had one of
her headaches which had lasted several hours, when she was
frightened at some danger to one of her children, and while
bending over him she suddenly felt something like a tremor
in the left side of the head above the ear, and a sensation of
heat in the right side of the face and a sensation like a flash
of lightning in the right side of the body. She fell, but did not
lose consciousness. The right side of the body, including the
face, was paralyzed and without sensation, and there was loss
of sense of position of the right extremities and paresthesias,
while the mouth was drawn to the left. There was no diplopia
and the speech was not affected, but the right eye felt blind.
This condition passed off in about ten days. A month later
she had cramps in the right arm, but not in the leg. During
the period from this time till she was seen, she had few head-
aches which were milder than usual. On examination the
internal organs were normal, as were the blood vessels, and
there was no evidence of syphilis and the field of vision was

MIGRAINE AND HEMIANOPSIA 163

normal. The right extremities and the right side of the face
were still slightly weak, with very slight spasm, and some-
what increased reflexes, but no disturbance of sensation, or
sense of position and no astereognosis, but there were rather
quick athetoid movements on the right. During the next
nine months she had four more headaches.

Hoeflmayer in 1903 reported a case of a woman of fifty-
seven, who had had frequent attacks of migraine for forty
years, from which her father had also suffered. She had an
attack after much worry and severe long continued consti-
pation in which she became stuporous. It was difficult to
make her put out the tongue, and she could only repeat a
couple of words without sense, but she showed evidence of
pain. This condition lasted ten days, and then gradually
cleared up, but hemianopsia remained for a month, and then
gradually disappeared, at first the outline of objects being seen
dimly, and then more and more clearly. Hoeflmayer thought
the condition a toxic one, added to a neurasthenic exhaustion
and states that he could rule out hysteria.

To these cases of organic disease coming on during an
attack of migraine I am able to add three cases where a perma-
nent hemianopsia was observed. Two of these cases were
seen by me at the Boston City Hospital, and I am indebted
to the Physicians for Diseases of the Nervous System for per-
mission to report therm, while the third case was seen in con-
sultation with Dr. R. G. Loring of Boston, who has kindly
placed all his notes at my disposal.

The first case wa9 seen at the Boston City Hospital on March
28, 1894, and was that of a young woman (4630) thirty years
of age, single, a nurse at the hospital. The mother died of car-
diac trouble, and her father at the age of seventy-five, of some
brain trouble following an attack of the grippe, and he had had
an attack of apoplexy a year previously. Two brothers and two
sisters were living and well.

The history states that the patient had always been perfectly
well, but both Dr. Knapp and I recall that she afterwards stated
that she had suffered for some time from periodical headaches,
which had not been severe, and that also shortly before her ill-
ness, she had had a great deal of worry and mental strain from
the illness of her father. On February 2, 1894, she had been a
good deal excited at some occurrence, and had a severe headache,

164 JOHN JENKS THOMAS

during which she had a sudden attack of vertigo, accompanied by
loss of consciousness, but without paralysis or aphasia. The next
day there was violent frontal headache and a general numbness
of the entire left side of the body, and slight paresis of this side,
but no paralysis. For the first three weeks after the attack there
was complete amnesia, and after that she improved rapidly.
When examined at the Out Patient Department she complained
of numbness of the left side of the body, and of a sensation of
fulness in the head. There was still considerable mental dulness,
but no vertigo, headache or digestive disturbance. There was
some weakness of the left side, the grasp being 45 on the right,
and 20 on the left, and there was slight ataxia of the left hand,
but no muscular spasm. The knee jerks were increased, the
left more than the right, and there was no ankle clonus. Sen-
sation was normal except subjectively somewhat diminished on
the left. There was left hemianopsia. The left pupil was larger
than the right, but they reacted normally, and there was no
hemianopic reaction. Fundus oculi normal. Ocular muscles were
normal. Heart was normal except for a systolic pulmonary
souffle. There was slight swaying when standing with the eyes
closed, which soon disappeared. The hemianopsia was perma-
nent.

A letter of May 28, 1906. says that her health has been of
late much better than for the three or four years following this
illness, but she still has headaches almost constantly although not
severe, unless aggravated by excitement. With these headaches
she writes she has no vomiting, and never has had.

The second case was that of a single woman, twenty-seven
years of age, who was seen at the Boston City Hospital (5200)
on March 11, 1895. Her mother and one sister had migraine.
For ten years she had had attacks of headache always accom-
panied by vomiting, but she could not say whether one side of
the head was affected more than the other. These attacks usually
lasted three or four hours, and had not been growing more
severe. Excitement was apt to bring on an attack. In them she
had never lost consciousness, and neither the limbs nor the eye-
sight had ever been affected. She had never vomited except dur-
ing an attack of headache.

Four weeks before she was seen, a sister died and the patient
was much affected and had one of her ordinary attacks at this
time. Two weeks hte* while sewinsr she began to feel the onset
of one of her headaches. She vomited and felt faint, but there
was no loss of consciousness. Then she noticed a sensation of
pins and needles in the entire left side of the body with a par-
tial loss of power in the same side. This was accompanied by a
loss of sisrht in the left side of the field of vision of the left
eve. She regained power in the extremities in a short time, but
the trouble with the vision continued.

MIGRAINE AND HEMIANOPSIA 165

On examination there was left hemianopsia, and at the first
examination it was said that there was present the hemianopic
pupil sign, but at later examinations made by myself and others,
both sides of the retina, when illuminated, caused a reaction
of the pupils to light. The ocular muscles were normal, and sen-
sation was normal also. The strength was fairly good. The knee
jerks increased, but no ankle clonus. There was no evidence of
syphilis. The urine at this time had a specific gravity of 1.022
and contained sugar, but no albumin. On June 26, 1895, it was
1. 012, and contained no albumin, and no sugar. She had no head-
ache after this attack till August 18, 1895. The fundi were found
normal at repeated examinations, the last being on August 30,
1898, when the vision was found to be 2o/20ths, the same as at
the first examination.

On February 21, 1900. the sensation for touch, pain, and tern-

ADAPTED TO
270 SKEEL'5 SELFRECOHDING PERIMETER

J*ubtushe<£ t'ifEBJtet/rowitz.Xcw'thrk.

Fig. 1. Case 2.

perature was normal, and there was no astereognosis. The grasp
was 42 on the right, and 27 on the left. The chest was negative.
both heart and lungs being normal. Pulse 144. Complains of
slight headache, and of dyspnea on exertion. Menses every three
weeks, with some pain, and there is a retroversion. Headaches
are more on the left side of the head. Complains of passing
much urine, but the urine contains no sugar.

On March 6, 1900, she had had a headache during which she
had vomited, which had not occurred for a year after the loss
of vision. She was last seen on July 6, 1900, when the condition
remained the same.

The third case was that of a young woman, twentv-seven
years old, single, a dressmaker, who was first seen by me in
consultation with Dr. Loring on May 31, 1904. Her father.

i66

JOHN JENKS THOMAS

mother, seven sisters and four brothers were all living, and
healthy, with the exception of her father's trouble spoken of
later. One other sister had died at the age of three years, from
some unknown cause. There was no nervous disease, rheumatism,
tuberculosis, epilepsy or insanity in the family, except that the
father had been subject to periodical headaches, beginning in
youth, and continuing for many years, which were much more
severe than those of the patient, but similar in character. But
these had gradually become milder, and he had had none now for
several years. No other member of the family had had such
headaches.

The patient's headaches began at about the age of twelve
years, when menstruation was established, and came about once
a month, almost always about two weeks after the menses. The
pain was in both temples, but apt to be more severe on the left

SKCEL'S SELFRECOROING PERIMETER. ?70J

Publithe* hyE.ELMf*/rPwttz..S'mr'tork*

Fig. 2. Case 2.

side, and the left eye usually ached first. She had no scotoma.
The pain usually lasted about two hours, when she almost in-
variably vomited, after which she felt relieved. The headache
was throbbing in character, and was not associated with indis-
cretions in diet. She is pale during the attack. She had had no
illness since measles at ten years of age.

She went to Dr. Loring first on April 4, 1904. Shortly before
this she had had one of her headaches not very severe, and of
the usual character, and at the ordinary time, two weeks after
the menstrual period. She felt dizzy and had some pain, but no
vomiting. The pain lasted from eight in the morning till noon,
and then as it was no better she got up, when she noticed that
she was dizzy. The dizziness lasted three days, and after that
she felt well. She noticed no awkwardness in using the hands,

MIGRAINE AND HEMIANOPSIA 167

or weakness, nor numbness in the face or elsewhere. She did
notice some difficulty in seeing, but thought this was only in the
right eve, and finally went to the oculist, because she found that
she bumped into people on the street, and then realized she had
not seen them.

Dr. Loring found the fundus normal and a right hemianopsia
which had not changed.

There was no constant headache, no dizziness, and no palpita-
tion. Neither was there any vomiting, nor pain in the eyes. Sleep
was good. She did not have to rise at night to urinate, and there
was no dyspnea on exertion.

On examination the gait and station are normal. The grasp,
right and left is 18 kgm. Strength in the extremities equal and
normal. No disturbance of sensation for touch, pain, or tempera-
ture anywhere. No inco-ordination, or disturbance of the sense

270' SKEEL'S SELFRECOROING PERIMETER

Puhlnhf/ t>y E B AfP'/roWtU.XrHihrk.

Fig. 3. Case 3.

of position, or astereognosis. External ocular muscles are normal.
Pupils are equal, and respond normally to light and distance, both
sides of the retina causing the response to light equally. Right
hemianopsia. Triceps, biceps, and supinator reflexes equal and
normal. The knee jerks are normal, equal and reinforceable. The
ankle jerks are equal and normal, there being no ankle clonus, or
front tap contraction. The plantar reflex shows extension of the
outer toes, but no movement of the great toes, and is alike on the
two feet, and there is no Babinski's or Oppenheim's sign. The
abdominal and epigastric reflexes are equal and normal. The
heart is normal. Blood vessels not stiff. Hearing good in each
ear, and equal, air conduction being better than that by bone.
Reads normally. Writes normally, both spontaneously, copying

i68

JOHN JENKS THOMAS

and at dictation. No aphasia, paraphasia or other disturbance of
speech. No evidence of syphilis.

The patient was again examined by me on May 27, 1906,
when she said the headaches had come since the onset of the
hemianopsia just the same as before that, but that perhaps the
pain had not been quite as severe. The relation to the menses
had not been altered, and the vomiting had remained the same.
The last headache she had had at that time, had been on May 19,
1906. Examination showed the hemianopsia still existing. The
blood pressure was 120mm. of mercury. The urine 1.024 with-
out albumin or sugar. All the other details of examination re-
mained as at the previous examination.

SKEEL'S SELFRECOROING PERIMETER

Fig. 4. Case 3.

A consideration of these cases of permanent hemianopsia,
and cerebral paralyses, and aphasias reported by various
writers shows conclusively that such accidents occurring dur-
ing an attack of migraine are not exceedingly rare, and at least
indicate that migraine may be the exciting cause of a cerebral
thrombosis, or possibly a hemorrhage, but, as I have already
said, in most cases there is at least strong ground for believ-
ing that the cerebral lesion was due to arterial disease, the
migraine being at the most only an exciting cause and in some
cases the headache was probably symptomatic only, while in
other cases the presence of migraine at all, even as an inde-
pendent disease, seems very doubtful. Fere's case of aphasia,
reported in 1881, Oppenheim's, Queirolo's Flatau's, Fere's
case 10, Schroeder's and Hoeflmayer's were probably compli-

MIGRAINE AND HEMIANOPSIA 169

cated by vascular disease. In Fere's case 6, I should doubt
even the existence of migraine. Fere's case 9, though incom-
plete, and Infeld's form the only ones I have been able to find
in which it seemied even possible that the migraine attack
was responsible for the cerebral lesion in the absence of dis-
ease of the blood vessels.

Of the cases presented in this paper, the first one seems,
from the history, the absence of heredity, and the nature of
the attack itself, to have been due to arterial disease, and it
is probable that the migraine attack was no more than an
exciting cause for the vascular lesion, and possibly only a
symptomatic migraine. The second, and particularly the
third case seem to me to be clear cases where we can ascribe
the cerebral softening to nothing else than an attack of mi-
graine. In the second case the presence of sugar in the urine
was only temporary, it being absent in two later examinations,
and only present at the first examination, so that it was prob-
ably symptomatic only. In neither case was there any evi-
dence of kidney, heart, or arterial disease, or of syphilis.

The general opinion of writers upon migraine is that the
cause of the attacks is a vasomotor disturbance, probably
dependent upon some toxic cause of unknown origin, though
the former division into cases of vasoconstriction, and dila-
tation must undoubtedly be given up, if for no other reason
than that the condition of the superficial vessels, from which
the argument was drawn, often varies in the same person
at various stages during a single attack. Spitzer in 1901 ad-
vanced an ingenious theory to account for migraine. He
ascribes it to changes apparently supposed to be inflammatory
in character about the foramen of Monroe, which produce a
relative or absolute stenosis, then he also assumes a hyperemia
causing an increase of fluid in the ventricles, and so a pres-
sure which is greater upon the veins ; and hence there is added
a passive hyperemia, and he thinks often an actual tearing
of the tissues and hemorrhages. When the subdural spaces
are filled the headache begins, then the ventricles dilate, the
foramen opens, and the fluid passes off. This is of course pure
theory and I know of no recent theory of disease which is
founded upon fewer facts, and his view has found little favor
among other writers. Various objections have been uro-ed

170 JOHN JENKS THOMAS

to the theory, such as the "fact that all symptoms disappear
in the intervals between the attacks, which we should hardly
expect in the case of organic changes such as have been sup-
posed. Neither does such a theory explain the frequent uni-
lateral character of the headache, or its shifting from one side
of the head to the other during an attack, nor its heredity.

Moebius thinks that in migraine there are changes in the
cells in the brain. Oppenheim considers a vasomotor con-
striction of the vessels the most probable explanation. Stekel
and Meige and most other recent writers agree with this
opinion.

In considering the cases which I have collected in this
paper, I think we can conclude that attacks of migraine may
result in an area of softening in the brain, which shows itself
by a permanent paralysis, aphasia, or hemianopsia, and that
in most instances this is due to the attack favoring a vascular
lesion in persons who have already disease of the walls of the
blood vessels, but that in certain cases the vascular lesion may
occur in young persons whose blood vessels are in all prob-
ability in a normal condition. In all cases of organic disease
of the brain, coming on during an attack of migraine extreme
caution is necessary before ascribing even an exciting role to
the migraine, as it is much more common to find independent
organic disease of the blood vessels which would account for
the organic disturbance in persons who have suffered from
migraine, yet a few cases remain which can hardly be explained
in this way, and justify the statement made by Charcot and
■others that the transient hemianopsia or aphasia seen occa-
sionally in this disease may become permanent. Still this acci-
dent does not seem to be only, or even more common in the
cases having the temporary phenomena, then in those where
it has never appeared.

REFERENCES.

Ballet, G. La migraine ophthalmoplegique. La med. mod., 1896, vii.,
137 and 145. Rev. Neurolog., 1896, iv., 175.

Brasch und Levinsohn. Ein Fall von Migrane, mit Blntungen in die
Angenhole. wahrend des Anfalls. Berl. klin. Woch., 1898, xxxv., 1146.

Charcot. Migraine ophthalmique, et aphasie. Nonv. Inconogr. de la
Salpetriere, 1895, viii.. I.

Charcot. Lecons sur les Maladies de la Syst. nerveux. iii., 75.

Determann. Deut. Med. Woch., 1896.

Fere, C. Contrib. a l'etude de la migraine ophthalmique. Rev. de
med.. 1881. i.. 625. Rev. de med., 1883, iii., 194.

MIGRAINE AND HEMIANOPSIA 171

Fere, C. De la etat de mal migraineux. Rev de med., 1892, xii., 25.

Flatau. Ueber einen bemerkenswerten Fall von Hemikranie. Cen-
tralbl. f. Nerv. und Psych., 1902, xxv., 746.

Galezowski. Compt. rend. Soc. de Biologie, 1881, 75, iii., 335, and
Lancet, 1882, i. 176.

Hoerlmayer, L. Eine merkwiirdige Complication eines Migraneanfalles.
Neurolog. Centralbl., 1903, xxii., 102.

Infeld, M. Zur Kenntniss der bleibenden Folge des Migrane Anfalles.
\\ iener klin. Woch., 1901, xiv., 673.

Karplus, J. P. Zur Kentniss der Aneurismen an den basalen Hirnar-
tenen. Arbeit, aus d. neurolog. Inst, an d. Wien. Univer, 1902, viii. ; and
Schmidt's Jahrbuch., 1902, cclxxiii., 253.

Karplus, J. P. Migrane und Augenmuskellahmungen. Jahrbuch f.
Psych., 1902, xxii., 158.

Kollowitz, J. Ueber migraine ophthalmoplegique. Deut. Zeitsch. f.
Nervenheilk., 1904, xxvi., 128.

Koyalevsky. La Migraine et son traitement. Paris, 1902.

Meige, H. Migraine ophthal., hemianopsie, et aphasie transitoires, etc.
Rev. Neur., 1904, xii., 961.

Moebius. Die Migrane. Nothnagel Sp. Path. u. Therap., 1894. xii., 2.

Oppenheim, H. Casuistischer Beitrag zur Prognose der Hemikranie.
Charite-Annalen, 1890, xv., 298.

Paderstein, R. Beitrag zur Casuistik der ophthal. Migraine. Deut
Zeitschr. f. Nervenheilk., 1899. xv., 418.

Parinaud. Migrane ophthal. au debut d'une paralvsie generate
Archives de Neurol., 1883, v., 57.

Pick. Zur Symptom, der funct. Aphasien. nebst Bemarkungen zur
Migraine ophthalmique. Berl. Klin. Woch., 1894.

Queirolo. Emicrania oftalmica comitate endoarterite e trombosi cere-
brale. Cronica della clinica medica di Genova, 1894, No. 4; abstract Rev
Neurol., 1894, "•, 255 ; also Rev. Neurol., 1893, i., 422.

Romano. Gaz. degli Ospedali, 1896; quoted by Paderstein, loc cit , o
428. ' r

Rossolimo. Recidivirende Facialislahmung bei Migraine Neurol
Centralbl., 1901, xx., 744.

Saundby, R. A Case of Megrim with Paralvsis of the Third Nerve
Lancet. 1882, ii., 345.

Schmidt-Rimpler. Nothnagel. Path. u. Therap., 1898, xxi., 106 • also
Ann. Ophthal., St. Louis, iqoo, ix., 4. 214.

Schroeder. Ueber bleibende Folgeerscheinungen des Flimmerskotom
Klin Monatsbl f Augenheilk. 1884, xxii., 351; also Schmidt's Tahrb, 188=;
ccvn.. 285. D'

„ ?c,if!.er' W- , Ueber Migrane mit recidivirender Augenmuskellahmune.
Berl. khn. Woch., 1900, xxxvii., 657.

Spitzer. Ueber Migrane, 1901.

Stekel, W. Die mod. Path, und Therapie der Migrane Wien med
V\ och., 1897, xlvii., 2133 and 2186.

Suckling. Brain, 1887, x.. 241.

_ Thomayer. Migraine ophthalmique, abstr. in Revue Neurol i8qs
11., 508. ' ^"+'

Voss, G. Ueber die Diagnose des Kopfschmerzes. St Petersburg
med. Woch., 1901. n. f.. xviii., 96.

PERIPHERAL FACIAL DIPLEGIA AND PALATAL IN-
VOLVEMENT.*

By George W. Jacoby, M.D.,

OF NEW YORK.

Facial diplegia in its complete form has always excited the
interest of the observer, not only on account of the comparative
rarity of its occurrence, but also on account of the striking
clinical picture which it presents and of the distress and incon-
venience which it causes the patient.

Since Charles Bell, in 1836, first made known to us this
clinical picture, the subject has been studied in its entirety by
Davaine1, Wachsmuth2, Pierreson3, and Sainton4, while very
many other observers have given us reports of single instances.
Indeed so many single instances have been recorded and Sain-
ton has so recently given such a complete and excellent descrip-
tion, with full literary references, that it would be superfluous to
publish still more personal observations were it not for the fact
that observers still differ as to the presence or absence of cer-
tain symptoms. Nor would this alone induce me to report the
four cases which I have observed were it not for the fact that
in my opinion their study adds weight to our present position
in regard to the nerve supply of the soft palate.

In such a study we must bear in mind that facial diplegia
may occur in diseases of the pons and medulla oblongata, as
part of a multiple palsy of cerebral nerves (Rad5), in the course
of cephalic tetanus, as well as. and particularly in. the course of
a multiple neuritis (Pierreson, Eisenlohn, Striimpell6, Starr7,
and others), due to rheumatism (Romberg, Mott, Stintzings,

'Davaine, C. M. Gazette medicale de Paris, Nos. 46, 48, 50, 1852 ; Nos.

2, 3, 1853.

-Wachsmuth, Adolf. Monograph. Dorpat, 1864, Part II., pp. 81-114.

3Pierreson. Arch, generates de medecine, August, September, 1867,
Vol. X., pp. 159-296.

'Sainton, M. Paul. Gazette des hopitaux, 1901, p. 1265.

5Rad. C. Von. Zeitschrift f. Nervenheilkunde, Vol. XVII., 1900.

"Striimpell, Ad. 'Neurol. Centralblatt,_i88g, No. 21.

TStarr, M. Allen. Organic Nervous Diseases, 1902.

8Stintzing. Munehene med. Wochenschriit, January. 1893, Nos. I, 2.

*Read by title at the meeting of the American Neurological Association,
June 4 and 5, 1906.

PERIPHERAL FACIAL DIPLEGIA 173

Raymond), alcohol (Oppenheim9), influenza (Barkas10), or any
other toxic or infectious cause.

Only such cases as are certainly peripheral in their origin
are serviceable for casting any light upon the question, and of
these, only those in which clinically the dominant symptoms are
those of the facial diplegia. The supranuclear cases and the
nuclear, or bulbar ones, cannot be utilized in this connection.

The nerve supply of the palate has been the cause of much
discussion. In 1852 Davaine, writing upon facial diplegia, stated
that the majority of anatomists believed the nerve fibers to the
levator palati and azygos uvulae muscles to be derived from the
facial through the connection of its trunk with the Vidian by
the petrosal nerves. Debron11 had, about this time, by means
of galvanic experiments upon dogs, shown that the nerves to
the soft palate did not go from the seventh, but from the glosso-
pharyngeus directly, and Davaine, in order to explain this di-
vergence of views, endeavored to show that the fibers from the
glossopharyngeus should be looked upon as sensory and those
from the facial as motor fibers of the soft palate, and that
therefore paralysis of the palate, when it occurred, was actually
caused by affections of the facial.

From 1866, when Longet cast the weight of his authority
into the scales, it had been accepted as a fact that the facial
nerve governed the contraction of most of the muscles of the
soft palate and that this motor influence was effected in the
manner already mentioned.

The acceptance of this anatomical condition led to the clin-
ical agreement that when in peripheral facial palsy the lesion
was located above the geniculate ganglion there ought to be
paralysis of one side of the soft palate demonstrable by relaxa-
tion and inability to raise the palate upon the paralyzed side,
with a deviation of the uvula to the opposite one.

In 1873 Flint13 summarized the state of knowledge of that
time as follows : "In view of the pathological examples of par-
alysis of the palate and uvula in certain cases of facial palsy,

"Oppenheim, H. Lehrbuch der Nervenkrankheiten. 1905, Vol., p. 405.
10Barkas, W. G. Lancet, Jan. 26, 1896, p. 217.
"Debron. These de Paris, 1842.

I2Longet. Traite de physiologic 1866, Vol. I., p. 796.
"Flint. A.. Jr. The Physiology of Man, Vol. on the Nervous System,
N. Y., 1873, pp. 159 et seq.

174 GEORGE W. JACOBY

the frequent occurrence of contraction of the muscles of those
parts upon galvanization of the facial, and the reflex action
through the glossopharyngeal and the facial, there can be little
doubt that the muscles of the palate and uvula are animated
from filaments of the seventh nerve."

Later Erb, Seeligmuller, Leube, and Chevostek lent the
weight of their authority to the faciopalatal innervation theory,
and until 1893 this theory met with but scant opposition. In that
year Gowers14, writing of facial palsy, said: "It has been said
that the palate is sometimes paralyzed upon the same side as
the face from disease of the facial nerve," etc. * * * ''but the
opinion that the palate ever suffers from disease of the facial
nerve seems to be erroneous J The levator is supplied from the
spinal accessory and in more than a hundred cases of facial
paralysis due to disease of the nerve in various situations, care-
fully examined, I have never observed a corresponding defect
of movement in the palate."

Later Hughlings Jackson15, in connection with a case of par-
alysis of the face and palate which seemed to prove the associa-
tion between peripheral facial paralysis and palatal involvement,
but in which closer study demonstrated the cerebral origin of
the facial palsy, said: "The uninstructed might have mistaken
the case for one of Bell's palsy with paralysis of the palate, a
combination of symptoms which I (Jackson) have never met
with."

More recently Koester16, examining thirty-three cases of
facial palsy, could find no case with implication of the soft
palate, so that he also is a sceptic as to the existence of such
a combination.

Since then considerable has been written upon the subject,
the majority of authors taking a position in support of Gowers,
Jackson, Lermoyez17, and Koester, while others still maintain
that palatal involvement may form an integral part of the clin-
ical symptomatology of peripheral aflfection of the facial nerve.

"Gowers, William. Manual of Diseases of the Nervous System, Vol.
II., 1893, p. 236.

"Jackson, Hughlings. Lancet, April 2, 1887. p. 680.

"Koester, George. Deutsches Archiv fur klinische Medicin. 1900, Vol.
LXVIIL, pp. 343 and 505.

"Lermoyez. Presse medicale, May 7, 1898, No. 39.

PERIPHERAL FACIAL DIPLEGIA 175

Maum18, of Dresden, writing as late as 1904, deplores the ten-
dency to consider palatal palsy occurring in peripheral facial
paralysis as being due to vagoaccessory affections, and, publish-
ing four cases of such a combination due to acute middle ear
disease, stoutly maintains that both symptoms are dependent upon
an affection of one and the same nerve. He maintains that the
type of palatal palsy occurring in vagus affection differs clini-
cally from that due to facial nerve affection.

Others yet take a middle path and assert that, while palatal
involvement does occur (Tomke19) with more or less frequency
in peripheral facial palsy, it is never due to lesion of the facial,
but is a result of contemporaneous affection of other nerves (the
spinal accessory or its palatine branch). The arguments which
have been adduced on the one side or the other are as follows:

1. From the point of view of experiments in physiology.

a. Excitation of the facial. — Beclard20 (in 1866), Rad, De-
bron, and more recently Chauveau (experimenting on the
horse), Beevor and Horsley (from experiments on various ani-
mals), Vulpian22 (experimenting on the dog), and others are
agreed upon the fact that electrical excitation of the facial
muscles causes no movement whatsoever in the palate.

The experimental investigations of Rethi23 have shown that
the levator palati mollis is not supplied by the facial, but by the
vagus, and Koester, experimenting upon animals, was never
successful in observing a paralysis of the soft palate after de-
struction of the facial nerve as high up as the geniculate gang-
lion.

b. On the other hand, excitation of the tenth and eleventh
pairs produces energetic contraction of the palate.

All these experimental investigations and a case of trauma-
tism (stab wound in a man, Hoffmann24) show more and more
conclusively that the vagoaccessory carries the chief if not the
entire part of the innervation of the palate.

2. Clinical. Here the two questions must be answered.

"Maum, Max. Zeitschrift fur Ohrenheilkunde, Vol. XLVII., 1904, pp.
1 to 39-

Tomke. Archiv f. Ohrenheilkunde, Vol. XLIX., 1900.

Beclard. Traite de physiologie. 1866, p. 1010.

Beevor and Horsley. Proc. of the Royal Soc, May 16, 1888.

Vulpian. Acad, des sciences, Oct. 18, 1886.

Rethi. Wiener med. Presse. 1893, No. 50.

Hoffmann, J. D. Zeitschrift f. Nervenheilkunde, Vol. V., 1894, p. 72.

176 GEORGE W. JACOB}'

a. Do lesions of the vagoaccessory produce palatal paralysis?

b. Do lesions of the facial produce such paralysis?

The answers to a are unanimous and conclusive, viz., par-
alysis of the soft palate on one side and recurrent laryngeal par-
alysis upon the same side, without facial palsy, are of not in-
frequent occurrence. Cases are known in which paralysis of
the palate and larynx was accompanied by paralysis of the
sternocleidomastoid without being accompanied by facial palsy.

The answers to b are more divergent, being affirmative (for
competent observers have recorded cases of facial paralysis in
which the levator palati and azygos uvulae were more or less
completely paralyzed) as well as negative. An analysis of the
affirmative cases, however, shows that certain objections have
not been met by the reporters of these cases, viz. : A certain im-
mobility of the palate is physiologically not infrequent. Local
affections of the naso-pharynx which may give rise to partial
or complete paralysis of the palate have not always been ex-
cluded. Congenital asymmetry may be mistaken for unilateral
palsy. Sufficient care has not been taken to search for symp-
toms pointing to a vagoaccessory lesion in addition to the facial
one.

On the other hand, it must seem strange that the mere clini-
cal association of facial and palatal paralysis, leaving aside for
the nonce the physiological relationship, should have been so in-
frequently observed by certain clinicians, while others have been
able to note its occurrence repeatedly.

It has seemed to me that the explanation of these variations
of observation must be sought in the period of time at which
the cases have been examined, that cases examined very early
in their course will be the ones which may show a palatal in-
volvement, while those cases in which the facial paralysis has
existed for some time will certainly show none. We understand,
since Broadbent has explained it to us, that those muscles of
the body which are used only in conjunction with their fellows
of the opposite side have a bilateral cortical representation and
can be excited to action from either hemisphere.that these same
muscles are equally innervated, or nearly so. through the bul-
bospinal centers from each hemisphere, the impressions being
conveyed freelv in either direction through the commissures ;
and that destruction of the cerebral center of one hemisphere

PERIPHERAL FACIAL DIPLEGIA i77

does not cause paralysis of those muscles which are completely
bilateral in their actions.

This is well shown when the respiratory muscles, those of
phonation, and the muscles of the trunk or the abdominal muscles
are involved in consequence of unilateral lesion.

As I have shown elsewhere, this law applies in a way also
to peripheral palsies of the same muscles, only here there exists
in the beginning a complete paralysis, which in a comparatively
short period of time may be overcome by an interposition of the
unaffected contralateral hemisphere, so that a certain amount
of function or complete function is re-established at a time when
other muscles supplied by the affected nerve are still paralyzed
or paretic.

Synergic action of both palatal halves under all circum-
stances shows that they are excitable from either hemisphere,
and that therefore if one side of the palate is paralyzed, the
excitation could still take place from the opposite hemisphere
and the unilateral palsy thus be minimized or perhaps over-
come. It has therefore occurred to me that herein we perhaps
not only need the explanation of why paralysis of the palate
was infrequently or never found in facial paralysis, but also
why cases of diplegia facialis, both paths from the cortex being
involved, should show a persisting palatal involvement, one
which clinically would keep pace with the paralysis of the rest
of the muscles affected, provided the palatal muscles were in-
nervated by the facial nerve.

A study of the published cases of facial diplegia from the
point of view of palatal involvement is not very satisfactory, for
in many of the cases no reference is made to the condition of
the palate, and in others it is stated that speech was "nasal in
character" and that "no paralysis of the palate existed," two
statements which can be reconciled only with difficulty.

In a general way it is stated by Rosenthal26 that "speech is
nasal," by Grasset27 that "the voice is nasal, liquids pass through
the nose," and by Turner that "in complete bilateral facial palsy
there is no palatal movement on using the vowel sound "ah,"

k'Macoby, George W. Sign of the Obicularis, Etc. Journal of
Nervous and Mental Disease, October, 1903.

"Rosenthal, M. Lehrbuch der "Nervenkrankheiten. Erlangen. 1870,

i7Grasset. Maladies du systeme nerveux.

178 GEORGE W. J AC O BY

and the pronounciation of words requiring the closure of the
vaso-pharynx is rendered imperfect, so that "rub" is pronounced
"run" and "egg" "eng."

Davaine speaks of the "nasal tone and the paralysis of the
velum palati which causes it," and says, furthermore, "when
both facial nerves are paralyzed, the velum palati cannot be
moved, cannot be lifted, in consequence of which air passes into
the posterior nares and thus the nasal tone is produced, and
fluids and mucus easily find their way into the nasal passage.

On the other hand Sainton says that "in peripheral diplegia
the soft palate is usually intact," and, "of twenty cases collected
by Wachsmuth in 1864, in eighteen the palate was unaffected
while, of thirteen cases published by eleven different observers
since then, which I have analyzed, in only two was such paralysis
described."

This infrequent association of palatal palsy and facial diple-
gia, occurring only four times in thirty-three cases, certainly does
not lend support to the facial innervation theory. It is strange
that, of the following four cases which I have personally ob-
served, three should show palatal palsy, yet their careful study
evinces that here also this palsy is explicable in another way,
and that they therefore also speak against the above-mentioned
theory.

My cases were as follows::

Case I. — B. S., jet., nineteen, seamstress, came under obser-
vation October 28, 1901 ; she had been perfectly well until Octo-
ber 15 ; then complained of general malaise, had pains in the
extremities and especially in the right side of her face and in
front of the meatus of the right ear. This condition continued
until the 23d, when she noticed that she could not close the right
eye as well as the left, and when she arose the next morning
(the 24th) her face was drawn to the left side. This condition
remained unaltered during that day, but when she awoke on the
25th her face litis straight again, but she was unable to move
her mouth from side to side and she was told that her eyes did
not close. She also had some difficulty in swallowing and com-
plained of pain in front of the meatus of each ear. In contrast
to the distortion observed in cases of unilateral facial palsv, the
patient attracted attention on account of the marked smoothness
of the entire face and on account of its complete immobilitv and
mimic rigidity.

The cheeks and angles of the month were flattened and the

PERIPHERAL FACIAL DIPLEGIA 179

eyes could not be closed completely and showed the usual roll-
ing upward of the eyeball when closure of the lids was forcibly
attempted. She could not pucker up her mouth to whistle, nor
could she blow out a candle or retain fluids in the anterior part
of her mouth. She seemed to secrete a great deal of saliva, which
was constantly dribbling from her mouth. The lips were slightly
separated from each other and could not be approximated.

There was some difficulty in chewing (due to weakness of
the buccinator), but none in swallowing. Very noticeable was
the inability to pronounce any labial letter, b, p, m, v, and f
being supplanted by d, t, n, and th. Otherwise speech was in
nowise interfered with except that it was decidedly nasal in
tone. The tongue could be protruded perfectly straight.

Examination of the fauces showed the uvula to be relaxed
in the median line, with its point resting upon the base of the
tongue ; there was no asymmetry of the arcades of the palate,
but the velum palati hung relaxed and motionless and did not
move upon deep inspiration, upon intonation or upon tickling. At
the same time an almost complete insensitiveness of the palate was
noticeable, the patient saying that she felt no touch there ; very
striking was the ease with which she bore all pharyngeal examina-
tions ; the tonsils, the fauces, and the base of the tongue could be
freely touched without causing any retching or contraction. Her
hearing was good, there was supersensitiveness to noises, and
there was no disorder of taste. An electrical examination subse-
quently made showed reduction of electric excitability on both
sides, especially marked in parts innervated by the lower facial.
The palatal musculature was not tested.

The course of the case was the usual one of a facial palsy of
medium severity, the improvement being steady, but one side,
the right, always being somewhat in advance of the left. Ten
weeks after the onset complete recovery had taken place. The
palatal paralysis was noted at each examination until the fourth
week, when, the patient not having been seen for a week, the
palate was found to react perfectly upon phonation, but it did
not react reflexly and the entire fauces presented the same insen-
sitiveness to manipulation which has been described. During
the entire course of the trouble no other symptoms than those
noted were present — no aphonia, no palpitation, no respiratory
difficulty.

Remarks. — This case certainly seems to be one which could
be used in support of the faciopalatal innervation theory, as have
been those already referred to and published by other observers.

Now, leaving aside all purely anatomical considerations, with
the necessary deduction that this case is one with lesions of the
facial nerve at or above the geniculate ganglion, we note that
the patient presented certain sensory symptoms which persisted
and were still present after the palatal paralysis had passed

i8o GEORGE W. JACOBY

away. Sensory symptoms have been noted in cases published
by others (Stintzing28), and it is stated that the palate acted
upon phonation, but not reflexly. Whatever value such symp-
toms may possess from a diagnostic point of view, this value
certainly does not lie in the line of support of the faciopalatal
innervation theory. In view of our knowledge that sensory
fibers from the glossopharyngeus and trigeminus probably reach
the palate, and certainly do reach the tonsils, posterior pillars of
the fauces, and posterior parts of the tongue, while it is just
as certain that the facial takes no part in this sensory innerva-
tion, we must conclude that in this case there were symptoms
present which point to the involvement of other nerves than the
facial, and that therefore the vagoaccessory may also have been
involved and have been the cause of the palatal palsy.

Case II. — Mrs. K., jet., thirty, seen in consultation June 16,
1905. She had never been sick. She has four children, the last
born about ten days ago. The labor was a perfectly normal one
without rise of temperature. On the third day she complained
of pains in the right leg and of numbness in the great toe of
the right foot. On the following day the other toes of that foot
and the toes of the left one became numb. She then had pains
all over the body, and on the fifth day numbness of the fingers
and of the legs set in and the speech became nasal in character.

On the sixth day she was attacked with left-sided facial par-
alysis, and two days later the right side became similarly affected.
At this time she also complained of buzzing and roaring with
pain in both ears.

Examination shows a complete bilateral facial palsy. She
cannot close either eye completely, but closes the right eye bet-
ter than the left. She cannot wrinkle her brows or corrugate
the forehead, cannot pucker her mouth, whistle, or blow out a
light. The complete paralysis of the upper lip is apparent, and
she cannot pronounce a single labial letter, but Unguals are
pronounced perfectly. Her face is entirely expressionless and
gives no evidence of emotion. According to her statement she
is no longer able to cry, and lachrymation has ceased entirely
since the attack; no tears are secreted. Her laugh is merely an
inward grunt, and certainly here the words of Davatne are ap-
plicable, that "the face seems like a lifeless mask behind which
the patient laughs or cries." The masseters were not involved.

The tongue was protruded straight and was freely movable
in every direction. Taste was unaffected. The palate reacted but
imperfectly to direct (reflex) and to indirect (voluntary) stimu-
lation.

During the course of that day her speech became more de-
cidedly nasal in tone and fluids returned through her nose upon
attempts at swallowing. She also had paroxysmal attacks of pal-

"Stintzing. Miinchener med. Wochenschrift. January, 1893, pp. 1 and 2.

PERIPHERAL FACIAL DIPLEGIA 181

pitation. On the following day (the i/th) complete palatal par-
alysis zvas present.. Hearing was overacute in both ears, and she
was supersensitive to slight noises.

An electrical examination showed reaction of degeneration
in all the facial muscles ; mechanical excitability of these muscles
not increased. Marked tenderness existed in the arms all over
the nerve trunks ; she could not button her clothes easily, and
with her eyes covered she did not know whether she had dropped
objects from her hands or not. There was no muscular paralysis,
and there was no atrophy. Both knee jerks and both foot jerks
were absent, and an extensor paresis of both feet was observable.
This condition remained unaltered until the 24th, when she was
attacked with lobar pneumonia and died on the third day, with
complete consolidation of one lung.

Remarks. — This case is clearly one of multiple neuritis with
facial diplegia and palatal involvement. The attacks of palpita-
tion and the difficulty in swallowing indicate that the vagus was
involved. The clinical deduction that the paralysis of the soft
palate here was a vagoaccessory symptom has quite as much to
support it as the assumption that this symptom was due to af-
fection of the facial nerves.

Case III. — Seen in hospital service. Mr. S., aet., forty, No-
vember, 1896. There was a marked alcoholic history. The pa-
tient came into the hospital suffering from a multiple neuritis.
There was drop foot on each side, with tenderness over the
nerve trunks of both lower extremities, knee jerks, foot jerks,
and .sensory disturbances were absent in the legs. The upper
extremities showed no objective symptoms, but the patient com-
plained of paresthesia in the fingers of both hands.

In addition to these symptoms, persistent tachycardia was
present : the pulse never went below 108, and paroxvsmallv rose
to 180.

On the eighth day after his admission the patient had facial
palsy of the left side with disorder of taste ; two days later a
similar paralysis set in upon the right side. The face then was
perfectly smooth and almost devoid of wrinkles.

Chewing and swallowing were attended with difficulty, and
here also the characteristic symptom of facial diplegia, the in-
ability to utter any labial letter, was present.

On the following day his speech became nasal and he showed
unilateral palsy of the soft palate, the palate being relaxed and
immobile on phonation, but the relaxation and immobility being
confined to the right side; the uvula was distinctly turned toward
the paralyzed side. At the same time his voice became hoarse
and rough, stridor upon deep inspiration was present, and he
had slight difficulty in swallowing. Laryngoscopic examination
revealed the right vocal cord standing in the median position
and not taking any part in phonation and respiration.

i82 GEORGE W. JACOBY

The tongue could be protruded straight.

Ten days later, the clinical picture remaining about the same,
an electrical examination showed partial reaction of degenera-
tion in the lower facial territory of both sides and distinct re-
action of degeneration in the right side of the palate.

This patient was seen at intervals for about three months,
during which time all the symptoms, except the palatal palsy
and the vocal cord paralysis, disappeared. These later symp-
toms persisted at the time of his discharge from the hospital.

Remarks. — We are here dealing with a multiple neuritis of
alcoholic origin in which numerous symptoms of vagus involve-
ment are present. These symptoms are aphonia, palpitation, and
respiratory difficulty. Cases of palatal palsy with recurrent par-
alysis are not unknown, and a form of vagus neuritis limited to
one recurrens is occasionally encountered. In multiple neuritis,
especially the alcoholic form, bilateral facial palsy is not un-
usual (Starr), nor is vagus neuritis infrequently met with
(Mays).

The simultaneous occurrence of bilateral facial palsy and
unilateral recurrens paralysis has, so far as I know, not previously
been described ; that the palatal palsy here is also due to vagus
involvement is. I think, proved by the fact that it, as well as
the recurrens paralysis, is unilateral and both are upon one and
the same side, while the facial palsy is bilateral. Of interest
also is the degenerative change found on the right side of the
palate, showing that the vagus complication was also a neuritic
one.

Such electrical changes in the palate have been found by
Hill29.

Case IV. — Bilateral facial palsy without palatal involvement.
A woman, set. thirty-four, had pains in both ears for several
days, when, in October, 1904, she awoke with facial palsy of
the right side, especially noticeable on talking and chewing.
Three days later the left side became affected. There was a
marked affection of taste, but no dryness of the mouth ; taste
was lost on the anterior two-thirds of the tongue, the patient
being unable to distinguish salt from sugar or vinegar from
a solution of quinine. The ears were very sensitive to noises ;
sensation everywhere in the face was unaffected. There were
no changres of electric excitabilitv in the muscles or nerves.

Speech was not nasal in tone, but the interference with the
formation of labials was the same as in my other cases. The
palate responded perfectly to all forms of stimulation.

During sleep the lids, which otherwise could not be closed,
were gradually and completely approximated, so that the entire
eyeball became covered.

Recovery took place in about eight weeks.

'Hill. British Med. Journal, Feb. 2. 1899.

PERIPHERAL FACIAL DIPLEGIA 183

General remarks. — It has been stated that paralysis of the
dilatatores narium and the compressors narium renders the ala
flaccid, so that in breathing they move to and fro and close the
nostrils upon deep inspiration. Thus, in the case of Labadie
Lasrrave30 and Emile Boix it is stated that the alae nasi were
passive and, instead of dilating at each inspiration, had a ten-
dency to close the nares. This was especially noticeable in an
effort to smell anything, such as cologne.

Were this a fact, then another explanation than that of
weakness of the soft palate could hereby be given for the nasal
tone which at times accompanies bilateral facial palsy, but in
none of my cases could this statement be made, and the nostrils
were neither dilated nor contracted, but remained patent through-
out, being merely somewhat narrowed. It is indeed difficult to
believe that this could ever be otherwise, for the inner and outer
walls of each nostril are formed by lateral cartilages, so con-
nected to the upper cartilages and the front part of the carti-
lage of the septum, as well as with the nasal process of the
superior maxilla, that inactivity of the muscles which act upon
them can never cause them to collapse.

The nasal tone is therefore always due to weakness of the
velum palati, and when this symptom is present, and it has been
present when the palatal movements were not decidedly inter-
fered with during phonation, the conclusion is warranted that
paresis of the palate exists. This speech disorder due to palatal
weakness, being added to that caused by the labial paralysis,
greatly emphasizes the characteristic speech difficulty.

Reports differ as to the position of the uvula in unilateral
facial palsy, some observers saying that it is turned toward the
paralyzed, others that it is turned toward the sound side, so
that as far back as 1853 Debron looked upon the deviation of
the uvula as an accidental occurrence in health, having no con-
cern with the facial paralysis, and Bernhardt, in 1876, refused to
draw conclusions as to the involvement of the palate from such
deviations in posture. To-day the complete symptomatic insig-
nificance of such deviation is accepted.

So also in bilateral facial palsy it would be unwarranted to
infer palatal weakness from deviation of the uvula.

"Archives generates de med., 1896. Vol. I., p. 23.

184 GEORGE IV. JACOBY

In all of my cases the tongue could be protruded straight,
thus showing what has been demonstrated by Hitzing31 and
since accepted by every one, that the tongue does not deviate in
facial paralysis, but that the apparent deviation is due to crooked-
ness of the face and can be corrected by straightening the mouth.

In bilateral facial palsy, there being no distortion of the
mouth, the tongue is not protruded to one side.

In all of my cases the facial palsy of the two sides came on
at intervals, first one and then the other side being affected.
This has been so also in all reported cases, and in one of Hoff-
mann's32 the palsies came on a month apart.

The classical symptom of absolute inability to utter any
labial letter was present in all my cases, and in all of them it
was of interest to observe how little interference with such
pronunciation the unilateral palsy caused, and how marked it
became when the other side became paralyzed.

In conclusion, and referring again to palatal palsy as a con-
comitant of bilateral facial paralysis, I would call attention to
the necessity of seeking for symptoms which cannot be explained
by facial nerve involvement alone, such as palpitation, sensory
disturbances, hoarseness, etc. Whenever such symptoms are
found to be present persistently, the conclusion is warranted that
some other nerve than the facial has been implicated by the mor-
bid process and that the co-existent palatal palsy must be due
to such implication.

This conclusion agrees entirely with what we know of the
associated functions of the vocal apparatus, for, as Lermoyez33
and Rousseau34 have so well said : "Is it not more logical to admit
that the larynx and pharynx (the reed and the resonator), which
are after all but two parts of the same vocal apparatus, should
respond to the influence of one and the same nerve ? And would
it not be difficult to understand that the larynx and soft palate,
destined to live in accord, should receive their orders from two
nerves so foreign to each other as are the facial and the vago-
accessory ?"

31]

32 T

'Hitzing. Gesellschaft fur Psychiatric Nov. 14, 1892.

'Hoffman, J. Deutsche Zeitschrift fur Nervenheilkunde, Vol. V., 1894,
p. 72.

"Lermoyez, L. Presse med.. May 7, 1898. No. 30.

"Rousseau, L. These de Paris, No. 503 ; also Gaz. hebd. de med et de
chirurg.. 1898, p. 1009.

A STUDY OF THE SENSORY SYMPTOMS OF A CASE OF
POTT'S DISEASE OF THE CERVICAL SPINE.*

By Frank R. Fry, A.M., M.D.,

OF ST. LOUIS.

I have decided to present the following record because it well
illustrates the difficulties of sensory studies. I had started to say
some of the difficulties. But only those who are most used to
making- sensory examinations know best that they all present
difficulties. In this case I am not offering new sensory problems
nor attempting altogether new interpretations of old ones. On the
contrary I have selected a case where the problem will readily
appeal to those having only an ordinary knowledge of the anatomy,
physiology and disease of the spinal cord. By what is in one sense
a simple case I may gain the sympathy of a larger audience among
those whom we wish to impress with the necessity of careful
sensory work and its difficulties. In attempting to do this I shall
apply to this case, in as simple manner as possible, the most recent
data.

Dr. Henry Head, whose important contributions to sensory
studies have gained very wide recognition, has recently published
some observations, the result of a remarkable work both in its
amount and its scientific character. I shall briefly sketch certain
of his conclusions which are of assistance in a study of the kind
of a case now before us. The sense of touch may only be distinctly
tested by the lightest touch to the skin, which he makes by using
with great care little whists of "cotton wool." If this care is not
used "light touch" will be confused with pressure sensibility (deep
pressure sensibility), which is separate and distinct and presided
over by its own end organs and fibers, which latter travel with
the motor nerves. This distinction can be made clinically, and
when assured by the careful methods which he describes is at
times of much value. One may feel the lightest touch possible
to be made with the point of a blunt lead pencil, for example, and
yet be minus light touch sensibility, so delicate is the pressure
sensibility. This Head proved by destroying one kind' of nerves
and preserving the other kind of sensibility and vice versa.

In the same manner he proved that one kind of nerves and

*Read at the meeting of the American Neurological Association, at
Boston, Mass., June 4 and 5, igo6.

i86 FRAXK R. FRY

their end organs recognize only warm and cool temperatures,
and another kind hot and cold ones ; the first, for example, tem-
peratures between 20C and 35C, (or about these) the latter only
temperatures below 20C or above 50C (or about these). He
shows that spacing sensibility is also distinct in kind and intimately
connected with light touch. Although we may recognize by-
deep pressure sense when a certain part is touched, and locate
this sensation with a good deal of accuracy, we cannot recognize
with this kind of sensibility the two points of the dividers (es-
thesiometer) . This is only accomplished by the "spacing sensi-
bility" which may be absent in the presence of the pressure sense
and vice versa. Head divides the sensibilities which we may test
in the skin into three groups. In the first he places :

Sensibility to light touch.

Sensibility for spacing. Epicritic Sensibility.

Sensibility for warm and cool.

(Between 20C and 45C).

In the second group he place- :
Sensibility for pain.

Sensibility for hot and cold. Protopathic Sensibility.

( Below 20C and over 50C).

In the third group he places :
Sensibility to deep pressure.
(Located in muscles, tendons and joints).

When a nerve which has been severed has been sutured and
begins to heal, the second group of sensibilities begin to return
within seven or eight weeks and are rapidly restored. On the
other hand the sensibilities represented in the first group do not
show any sign of returning for 200 to 300 days and the full restor-
ation of them is proportionately slow. He therefore named the
second group "protopathic" sensibility ; and the first one repre-
senting a much higher kind of sensibility, he named "epicritic."
There is at least one advantage in these new terms, namely, they
facilitate description. There are several reasons, however, why
he has coined this new word '"protopathic". As we have just
stated the fibers which conduct this kind of sensibility are the
first to heal, and when repair of them has taken place to a certain
extent, trophic functions begin to return which were previously
absent. For example in a complete anesthesia of all kinds of

DISEASE OF THE SPINE in-

sensibility on the hand after severance of the ulnar, or another
similar nerve trunk, a certain skin area is apt to be hard and dry
and trophic ulcers apt to appear. With the return of the pro-
topathic sensibility this portion of skin regains its moisture and
the ulcers heal. This group of sensibilities is evidently closely
associated with the vasomotor and trophic functions. In a region
with disturbed protopathic sensibility there is also present what
is generally spoken of as hyperesthesia i. C, the prick of a pin
or the contact of heat or cold causes a suddenly diffused, badl\
located sensation, with an irresitible tendency for the subject to
wince c. g. to suddenly jerk the arm away when a protopathic
area upon it is irritated.

He claims, and I believe proves, that what have been taken for
different decrees of sensibility are actual differences in kind of
sensibility. It will readily be seen that it is more important in
almost any case to know the kinds of sensory disturbance than
merely the degree of the same.

It is very easy to show the advantages of these distinctions in
studying lesions of nerve trunks of various sizes. In this report
I have attempted to showr the advantage of keeping them in mind
when studying a spinal case. In our case the onset was gradual,
the pressure was very symmetrical, the subject in a hospital under
constant observation, and an exceptional good one for this kind
of examination.

Mrs. Chas. L. M., aged 25, married two years ago.; No
important items in family history, nor in the personal or
clinical history prior to the fall of 1904 (probably in the month
of September). At that time she had a recurring slight pain
in the back of the neck which was always (or nearly al-
ways) accompanied by a decided tingling paresthesia in the
left arm. She describes it as coming in the outer side of the
arm and very slightly in the fore-arm. About three months
later, December, 1904. her baby was born and she was then
much worse. In February, 1905. two months later, it was
very bad. The pain was almost constant and she had severe
paroxysms, during which the pain would radiate from the
back of the neck out to the shoulder tips and up behind the
ears and into the lower occiput. May 9th she went to Hot
Springs, Ark., and remained seven weeks with no material
benefit. During the summer months there was considerable
relief, but the neck was always stiff and she was subject to
frequent attacks during which the stiffness and helplessness

1 88 FRANK R. FRY

and pain were much increased. In the fall months she steadi-
ly got worse. I first examined, her December 21st, about
fifteen months after the first appearance of pain and stiffness.
For several weeks she had been getting very little sleep on
account of the pain. The head was carried in a fixed position
and she had to be very careful in her movements to prevent
pain paroxysms. It was almost impossible to get a position
on the pillows in bed that would relieve her. She indicated
the spines of the 2d and 3 C. vertebra as the centre or start-
ing point of the pain. From there it radiated into the
shoulder, especially the left and to the sides and back of
neck and up to the lower occiput and back of the ears. She
insisted that the pains had never crept high up on the back
of the head. At times she had felt considerable pain shoot-
ing down the left arm as far as the middle of the fore-arm,
but usually the sensation here had been a tingling paresthe-
sia. Rotation of the head was quite limited, but better than
extension and flexion, which were almost nil. Pressure over
the spines was not tolerated and there were many sensitive
places in the muscles of the back and sides of the neck, and a
generally rigid state. Xo objective sensory symptoms were
discovered at this time. The deep reflexes of the left arm
seemed greater than those of the right. The knee jerks were
plus and there was some ankle clonus on both sides. A week
later she returned to the city and was put to bed at St.
Luke's Hospital.

December 29, 1905, careful observations were begun.

As already stated the knee jerks and ankle jerks were ex-
aggerated on both sides and there was a slight ankle clonus,
but there was no Babinski nor Oppenheim. After sitting still
for some time her legs were often somewhat stiff, and slight-
ly spastic in starting to walk; but she could walk and ascend
stairs without marked fatigue. There had been no bladder
weakness at any time and she did not complain of her back
at any point below the level of the shoulders. She complained
of an extensive area of paresthesia, a numb feeling, not es-
pecially uncomfortable, on the anterior and external aspect
of the right thigh. (Very much like a meralgia paraesthetica).
Occasionallv she experienced somewhat the same feeling in
the toes and feet. She had a paresthesia similar to this in
the upper extremities, felt more distinctly in the right arm and
hand. She was never entirely free from this, but it was at times
more pronounced. Of this she did not complain so much as
she did of another sensation, namely, a feeling of arrestment
and lack of precision in the movements of the hands, arms
and shoulders. She found writing and sewing increasingly
difficult and. her hands and arms tired too soon, in holding a

DISEASE OF THE SPINE 189

book, for example. This condition was more pronounced on
the right side. And yet an. actual inco-ordination could hard-
ly be demonstrated. There were no localized atrophies. No
groups of muscles seemed especially weak.

The sensory examinations included tactile, spacing, local-
izing, position, pressure, temperature and pain tests, all con-
ducted with the precautions recently indicated by Head and
others. Control tests were at times made on nurses. We
were careful not to make the seances too long and to work
only when the conditions were conducive to reliable results.

The patient is intelligent, well educated and of a temper-
ament to make her an exceptionally good subject for this class
of work. Between December 29 and January 8 we had ex-
amined the skin carefully on all portions of the body. On
the left there was an area about the size of a silver dollar
which embraced the edge of the trapezius half way between
the acromion and the mastoid, where there was slight but
evident hyperesthesia to pin pricks and to hot and cold. When
this area was thus irritated to a certain extent she could not
resist a jerking or shrugging of the shoulders. She could
not here recognize warm and cool normally, only hot and
cold, and light touch (cotton wool test) was slighty reduced,
not lost in any portion of this small area. There was another
spot not so large, on the anterior aspect of the deltoid over
the head of the humerus where the conditions were similar.
These two areas were so small and the deviations so slight
that they could only have been established by the careful
kind of an examination which we made.

In attempting to know* the exact sensory state of an area
of this kind it is necessary to have some tangible and con-
ventional method of examination. I think it will readily be
seen how Head's distinctions may be here applied, and the
knowledge of them elucidates the description at once. But
we may go farther and make certain deductions from them.
We have here evidence that two classes of nerve fibers in the
cord are involved. The epicritic fibers do not resist pressure
as well as the protopathic. Here is an area which seems to
show that both kinds of fibers have been only slightly dis-
turbed, presumptively within the spinal canal, but so slight
that it may not be taken into consideration except in a nega-
tive way in determining the condition of the cord.

These were the only objective sensory deviations present
at this time. There were certain localities where there was
at times a question of hyperesthesia ; for example, at the bend
of the elbow (». c, the plexor side), in drawing a needle up-
wards or downwards, as it reached this region the patient
showed a tendency to flinch or slightly withdraw the arm.

igo FRANK R. FRY

But we found that this same condition obtained in normal
subjects to such extent that we could not pronounce it
abnormal in this case. It was the same on both sides.

The patient was kept in bed from the first, almost con-
stantly. Within a few days the pain in the neck was rapidly
diminishing, so that she was beginning to have restful nights.
When she entered she could lie only with the left side of her
head on the pillows and could rise from this position or change
it only with much difficulty. She soon was able to sleep on
the other side and turn from one side to the other with in-
creasing freedom and to sleep all night with no medicine. She
was also able to flex and extend the head with increasing
freedom. Her general condition was very good in all re-
spects. There was never any elevation of temperature. She
had a good appetite and was in good condition. The function of
the bladder was perfect. There was a constant constipation
which was somewhat difficult to manage at times. She had
all her life been of a constipated habit.

Between January 15th and 31st, routine examinations
were made sufficiently to keep track of the sensory conditions,
and no objective changes occurred. During this period
she complained continually of a paresthesia in both hands,
e. <f., she would say "things do not feel just natural," "I do
not feel them distinctly" especially with the right hand. At
the same time she could tell a penny from a dime with closed
eyes and no objective defects could be established anywhere.
By way of illustrating the manner in which the sensory tests
were followed up we may cite a note made on January 18th.
She was complaining of the paresthesia being most pro-
nounced on the palmer surface of the thumb, index and second
finger of the left hand. Tests were made as follows: light
touch (cotton), position, location, pain, temperature, the lat-
ter made by spoon handles lifted from hot and cold, warm
and cool water and dried before bringing them in contact
with the skin. Xo objective changes were found.

During this period there is recorded a good deal of com-
plaint of muscular startings in the right arm (brachial re-
gion) and right thigh. She also complained that the right
foot and leg were "shaky" and "jerky" in walking (spastic-
ity). There were at times between the 20th and 31st the
suspicion of a Babinski and occasionally of an Oppenheim
on this right side: none on the left side. The right knee jerk
and ankle jerk seemed slightly greater than those of the left.
February 6th we noticed for the first time that the spacing
sense at the tips of the fingers on both hands, and especially
the right index, was somewhat defective. Although very
slight this obtundity seemed greater in the thumbs and the

DISEASE OF THE SPINE 191

first two fingers than in other digits. There was no question
that the distal phalanx of the right index was most involved.
In all other respects sensation seemed objectively normal.
The strength of the right arm was less than that of the left,
e. g., in lifting a good sized pitcher of water she could manage
it better with the left than with the right hand. She
could not at this time detect any differences in the feeling
or in the strength of the lower extremities. On the 16th,
however, she called our attention to the fact that the right
leg was less reliable than the left and that there was a con-
stantly increasing paresthesia in the thigh of this side. The
knee jerks seemed equal. Sensory tests of all kinds were
made at frequent intervals especially over this area on the
front and external aspect of the thigh. We here estimated
light touch 75% as good as on the opposite thigh. (This
was with a most delicate cotton test.) There was only slight
loss of spacing sense and temperature seemed equal to the
opposite side. She noticed that the toes of this side were
objectively and subjectively cooler than the opposite side,
yet the temperature sensibility of them was so nearly that
of the opposite side that it would be very difficult if at all
possible to establish the fact of a difference.

Between the last of February and 10th of March we could
notice a very gradual falling off of the sensory acuteness of
the fingers, hands and fore-arms and to a less extent of the
feet and legs. This obtundity was slightly more pronounced
in the right hand, and in the index more than elsewhere.
Light touch and spacing sensibility were the most affected
in all localities on the hands at this time, and other kinds of
sensibility so slightly so that delicate tests were necessary
to make the conditions present evident. She could recognize
almost everywhere the difference between 30C and 40C and
sometimes even closer. The pain sense seemed perfectly
acute.

By the 20th of March there was a great deal of paresthe-
sia in the hands and feet (but no pain), and the paralysis
was rapidly increasing and all kinds of sensory losses were
evident. Although the sensory conditions still varied from
day to day it was now evident that light touch and spacing
sense were most affected and next to these position, and
temperature and pain still less. There were small, variable
but distinct areas of slight protopathic and epicritic- disturb-
ance all the way up the arms, especially on the right. The
anesthesia of all kinds in the hands was more pronounced in
the fingers and shaded off upwards, i. c, somewhat of the
glove character, being more pronounced on the radial sides,

192 FRANK R. FRY

however. The hands were sweating a great deal and often
cold and examinations were not easily made.

On the 26th of March she first experienced difficulty in
emptying the bladder. Within a few days the catheter was
constantly necessary. On April 1st the conditions were,
briefly stated, as follows : R. upper exteremity ; can flex and
extend digits feebly except the index which she cannot extend,
flexion and extension of wrist also very feeble. Pronation and
supination complete but very feeble. Flexion of fore-arm al-
most lost, very feeble. Abduction and aduction of arm well
preserved. The distribution of the paralysis was exactly the
same in the opposite extremity but it was a shade less in all
segments than that of the right.

The right foot, leg and thigh were all weaker than the
respective segments of the left, and the right was more spastic.
Babinski and Oppenhe'm reflexes could not be obtained on
the right but both obtainable on the left. In other words
they had disappeared from the right and appeared on the
left. This was possibly due to the lowered sensibility of the
right, or possibly to an increase spasticity which masked them.

At this time finer sensibility, i. c, light touch, spacing and
intermediate temperature sensibility were absent in the digits
and the greater portions of both hands, but to a less extent,
apparently, in the toes and feet. Position sense was lost in
the digits, but not at the wrists until a little later date. Deep
pressure, high and low temperature and pain sensibility were
never altogether lost at any time, although much obtunded.
A better idea of the conditions will be shown by the notes of
several examinations made about this time, taking the right
arm as an example : On the hypothenar margin an area two
inches long and one and a half inch wide was hyperesthetic
to heat, cold and pin pricks, sensitive to deep pressure, but in-
sensible to finer sensation. Areas that were particularly hy-
peresthetic to pricks, heat and cold, were found just above the
wrist, just below the. elbow, about half way up the arm and
just below the axilla on the ulnar side. Similar areas were
found on the radial side, especially over the belly of the
supinator longus and the belly of the deltoid. On both sides
of the arm all the way up, areas were found where light touch
was still well preserved. These areas were less difficult to
outline than the protopathic ones but there were more of them
over the size of a silver dollar. The same phenomena were
present in all the other extremities and upon the trunk. The
different kinds of areas were not disposed in the arms in a
perfectly symmetrical manner but nearly enough so to show
that they had a distinctly axial distribution, and were of
spinal cord origin.

DISEASE OF THE SIT Mi 193

In this case the pressure was evidently from the front
and so symmetrical and gradual that the different kinds of
tracts in the cord all felt the effects of it and almost equally
from before backwards. There were no symptoms pointing
to focal lesions in either the anterior or posterior gray mat-
ter, hence no confusion in either motor or sensory signs from
this source. There were no posterior root symptoms. The
pains in the early history of the case although severe were
not root pains. This is evident from the subsequent his-
tory. They were the kind of pains that have often been
described as cervical neuralgia and were of peripheral origin.

There were no pupillary changes, and there were no res-
piratory symptoms that could be assigned to involvement
of the phrenic nerves.

The uniform manner in which the distal portions of all
extremities were most affected is explained by the well-known
fact that the longest nerve fibers, or those which travel the
greatest distance from a lesion, are most affected.

An X-ray examination made soon after the patient entered
the hospital showed an absorption of the contiguous portions
of the bodies of the 26. and 3d C. vertebrae and a tilting up-
wards of the spine of the 2d. Since the last report herein
recorded there has been a gradual improvement, the patient
having been kept under continuous extension.

Two years ago I reported to the American Neurological
Association two cases of stiff neck with great pain, some par-
esthesia, with no paralysis but with deep jerks suspiciously
increased. In these cases I found no objective sensory signs.
The present case much resembled those cases when she first
came under my observation and I began at once the applica-
tion of these more recent tests, making a close personal study
of it. Dr. Philip Newcomb kindly assisted me by making
separate examinations for control and comparison.

I believe that after this kind of an examination we not
only know better the conditions present but we can more
definitely translate or express them. It is interesting to note
the length of time the paralytic or motor signs and the sub-
jective sensory symptoms preceeded the objective sensory signs,
and it is a source of satisfaction to reveal this fact in a more
precise way. The very gradual falling off of sensory function
which occurred in this case is recorded in terms that are
readily referred to for purposes of comparison and description.

HEMILINGUAL ATROPHY OF TRAUMATIC ORIGIN.*
By Smith Ely Jelliffe, M.D., Ph.D.,

ATTENDING NEUROLOGIST CITY HOSPITAL, CLINICAL ASSISTANT DEPARTMENT
OF NEUROLOGY, VANDERBILT CLINIC.

Instances of hemilingual atrophy are not common, and
in these the etiological element of trauma is rare. In Ascoli's1
able summary now some ten years old, in 79 instances trauma
was the cause in some 10 or 12 cases, and injury to the
hypoglossal at its e.xit from the skull due to an injury of the
cervical vertebrae was noted in about 4 instances.

The following history is reported as contributing another
instance to this form of affection originating in this rare
manner. I am indebted to Dr. J. Sherman Wight for the
privilege of reporting it at this time.-

History of Patient. — A. I!. \V.. 2J years of age (June I,
1905), a confectioner, telegrapher, nurse, by occupation. His
father, aged 62, and his mother, aged 52, were both healthy —
both living and in good health. It is asserted that father had
syphilis, but when, it is impossible to learn. One brother died
of diphtheria; one sister is living and well at the age of 15.

Personal History. — Patient lias worked since he was 12
years of age. He has had scarlet fever and measles and
denies syphilis. Was a strong, healthy man. Moderate
drinker. Not exposed to exogenous poisons.

History of Accident. — May 31, 1904, at 10 A. M., while a
passenger on a DeKalb Ave. car on Brooklyn Bridge, he was
thrown suddenly and forcibly backwards by reason of a rear
collision. He was not rendered unconscious but was able to
walk to a neighboring office of a patient who was about to
make arrangements to hire him as a nurse. He then went
home and went to bed. He called his family physician. Dr.
Hoag, who said his spine was injured.

He suffered from severe pains at the end of his spine and
also in the back of his head. He was shaky and tremulous.
Any movement of his head resulted in severe pain. He re-
mained in bed.

TI Policlinico, 1, 1894, PP- T4> 51, 159.

"A fuller report of this and other similar cases by Dr. Wight and my-
self is in preparation.

'Read by title at the meeting of the American Neurological Association,
June 4 and 5, 1906.

A1R0PHY OF TRAUMATIC ORIGIN

'95

On June 9, 1904. nine days after the accident, he was
examined by Dr. Sherman Wight in consultation with Dr.
Hoag. The patient was in bed. lie held his head rigid with

Hemiatrophy of Tongue.

his chin forward in the position typical of cervical vertebral
trauma. There was severe pain on the slightest movement
and attempts at forced movement were impossible. There were
no evidences of severe nerve injury at this time and patient's

ig6 SMITH ELY J BLUFF E

spine was strapped with adhesive plaster and a plaster jacket
was applied. No positive diagnosis could be made at the
time but absence of blood in the ear, or conjunctival ecchy-
moses or symptoms of involvements of cranial nerves seemed
to indicate that there was no fracture of the skull. The idea
was entertained that some severe injury to the cervical ver-
tebrae was present.

The patient remained in bed seven weeks and wore the
plaster jacket a period of six weeks, after which time it was re-
moved. He stated he was unable to work, but as the ac-
cident suit against the railroad had been begun this is not
unusual. He continued to complain of pain about the in-
jured parts, held his head forward and stiff and was unable
to rotate it as formerly.

From this time the history is not very distinct. The pa-
tient says that in about a month or so after the accident he
noted that he. did not speak as clearly as he had done pre-
viously. He thought his speech was becoming thicker, but
it did not inconvenience him very much. This became worse,
however, and he noted a change in his tongue, that it was
unsymmetrical and quivered a great deal.

I saw him first on June i. 1905, with Dr. Cecil MacCoy
of Brooklyn. He was a moderately muscular and well built
man. He carried his head forward in a stiff and strained
position. Attempts at forcible movement were painful, al-
though moderate, conscious motion was not attended with
much discomfort. The only anomaly was found in the tongue.
This as shown by the accompanying photograph is atrophied.
It was broadened, moist, thrown up with numerous furrows,
and there were very marked constant fibrillary contractions
sharply limited to the atrophic side. Pinching the tongue
showed a loss of muscular substance* The motion imparted
by the atrophied muscles was distinctly weaker than the
action of the well side.

Thus:on protrusion the tongue tip was forced to the atro-
phied side and a typical though slight bending of the lingual
raphe was observed. By strongly pulling the tongue within
the mouth a certain amount of bending in the opposite direc-
tion could be induced. The movements of the tongue, how-
ever, were not strongly interfered with. A slight but dis-
tinct slurring of speech could be detected for certain labials.

There were no detectable changes in taste perception.
Electrical tests were not satisfactory, as a typical reaction of
degeneration was not obtained.

There were no observable changes in the innervation of
the palatal muscles and none in the larynx. Slight vaso-
motor disturbances were noted. The patient usually had a

ATROPHY OF TRAUMATIC ORIGIN i97

flushed face and a slight inequality of the pupils (right di-
lated) was noted at my last examination. It had either been
overlooked or was not present at a previous examination.
The patient's general attitude was hopeful and his personality
was buoyant and inclined to be boastful. His intelligence
was of a medium grade only.

So far as we could ascertain no other exciting cause for
the atrophy was probable. It was not a congenital affair,
since it was definitely not present at the time of Dr. Wight's
first examination following the accident. Tabes and syringo-
myelia were definitely excluded. There were no indications
of either trouble. We believe that we can exclude syphilis,
both from his own statement as to his non-infection, and also
from the fact that as ordinarily observed the lesions incident
to syphilitic involvement, whether medullary, or extra-medul-
lary, are in the great majority of cases not so clearly confined
to the hypoglossal. Isolated nuclear involvement of syphilitic
origin has not yet been reported, so far as I have been
able to learn, and a syphilitic exudate either meningeal, or
occurring outside of the foramen, usually implicates other
nerve structures and thus gives rise to a more complex
syndrome.

There is ample justification for the view that a traumatic
luxation of the upper cervical vertebras may give rise to this
uncomplicated picture, and the case is presented as one of
simple hemilingual atrophy due to injury to the hypoglossal
nerve at its exit from the skull. A Roentgen photograph
shows a distinctly anomalous shadow in the region of the
third cervical vertebra. It is not distinct enough, however,
to be offered as conclusive evidence of the injury. In view
of the cases of TJhde, Hagemann and Boettger (Arch. f.
kl. Chirurgie 22, 1878, p. 217, Brasch, Arch. f. Psychiatric, 32
1899. P- 105. Morison Br. Med. Jl. 1, 1S88, p. 75/Parrv. Lan-
cet 1, 1900. p. 537, Trevelyan, Brain 13, 1900, p. 102), and
others quoted in Ascoli's1 list, the etiological factor is con-
sidered highly probable.

Society iproceeMngs

PHILADELPHIA NEUROLOGICAL SOCIETY.

October 23, 1906.

The President, Dr. D. J. McCarthy, in the Chair.

MOTOR PARALYSIS AS AN EARLY SYMPTOM OF TABES

DORSAL! S.
By Dr. C. D. Camp.

First Case: Male, 56 years old, history of syphilis thirty years before
and alcoholism for past three years. The first symptom was a unila-
teral paresis of the extensors of the foot. Examination showed loss of
the knee jerks and of the Achilles jerks, sensory symptoms, Romberg's
sign and myotic pupils with loss of the reaction to light. There was no
pain or tenderness over nerve trunks.

Second Case: Clerk, 65 years old, no history of syphilis or alco-
holism, but he had been a painter 20 years previous to the onset of
his symptoms. First symptoms sharp, shooting pains in the legs fol-
lowed by gastric and vesical crises, unilateral foot drop of recent de-
velopment and ataxia. Examination showed Westphal's sign, Rom-
berg's sign, ataxia of all four extremities, sensory changes, and optic
atrophy. Dr. Camp said that the motor nerves of the eyes are fre-
quently affected in the beginning of a case of tabes, but that other
motor nerves may be affected is not well recognized. The pathogenesis
is the same as in other cases of tabes, but the toxin acts more exten-
sively. The affection may be due to degeneration of the anterior horn
cells, owing to a default of the habitual excitations upon which the
vitality of the cells depend.

Dr. F. X. Dercum said that it is a well known fact that motor
involvement may occur in well advanced tabes, but it is not, as Dr.
Camp notes, a well known fact that these palsies may occur early in
tabes. It is a very common thing to see palsies in connection with the
eye muscles in tabes; there is nothing more common than a transient
diplopia, nothing more common than a ptosis. Sometimes these palsies
are temporary, at other times permanent and persistent. The speaker
said that one thought was suggested to him in both of Dr. Camp's
cases, namely, that the ordinary etiology of tabes was wanting. Both
syphilis and alcohol were present in one case, and the part possibly
played by alcohol had to be considered: in the second case there was
no history of specific disease. Dr. Dercum also called to mind the
palsies met with in primary neurotic atrophy, in which disease we may
also have organic changes in the cord, such for instance as degenera-
tion of the posterior columns of the cord. Dr. Dercum, however,
agreed with Dr. Camp that the cases shown were true tabes.

Dr. Alfred Gordon stated that a year and a half ago he reported
a case in American Medicine in which he discussed the pathogenesis of
lead intoxication. The patient presented during his life the picture of
tabes, but questioning closer he found the patient had been a painter.
He examined the peripheral nerves of all the extremities, also the
cord. He found posterior sclerosis as well as degeneration of the
nerve trunks.

Dr. J. Hendrie Lloyd thought it hardly fair to criticize these cases
after only a brief reference to the notes. He was skeptical about the
diagnosis of locomotor ataxia in the first case presented by Dr. Camp,
and considered it more suggestive of alcoholic neuritis. One point that
raised a doubt, however, was the condition of the eyes. Dr. Lloyd
stated that his ideas have been considerably enlarged and modified on
the subject of the possibility of the ravages of alcohol on the nervous
system. He had seen a number of cases in which the classical symp-
toms were not all present, but a clear and distinct history of alcohol

PHILADELPHIA NEUROLOGICAL SOCIETY

199

was obtained. Two years ago he had a young man under his care,
an undoubted case of alcoholic multiple neuritis, in which the symp-
toms were confined entirely to the lower extremities. In such a case
it might have been difficult for some observers to differentiate it from
a beginning case of locomotor ataxia. The patient made a good re-
covery.

The second case of Dr. Camp's he thought had a suspicious history
of exposure to lead, although he had not been thus exposed for a
good many years. One of the most marked cases of pseudo-tabes that
Dr. Lloyd had ever seen, was reported from his Blockley clinic ten
or twelve years ago. On making a careful microscopic examination he
found no trace of degenerative changes in the cord. The man had
followed painting for many years, but also had a history of alcoholism.
This he thinks is the only matter of doubt about such cases, and
raises a very interesting question. Another interesting question, is the
possibility of locomotor ataxia beginning as a multiple neuritis. -He
had seen cases which suggested this possibility. There is nothing in-
conceivable in it.

In closing Dr. Camp replied that in reference to the case in which
there was a history of alcoholism being one of alcoholic neuritis,
the patient had only been drinking for the last two or three years,'
and the symptoms dated back nine years.

As regards the etiology in the second case where there was no
history of syphilis nor alcoholism, there was only the one fact of
the man having been a painter 20 years before. That is a long time
to go back, but he supposed that if we have to theorize, there might
be some connection between the two. Lead intoxication has been con-
sidered to be one of the causes of tabes.

As to Dr. Spiller's reference to a statement of Cole's, that he
(Dr. Spdler) did not believe the posterior columns of the cord are
degenerated in every case of multiple neuritis, Cole's exact words are,
that he "could find no record of any case of multiple neuritis in which
the spinal cord was examined by the Marchi method, in which it was
stated that the posterior columns were free from degeneration."

TRAUMA PRECEDING PROBABLE SYRINGOMYELI \ AND

TABES.
Dr. S. D. Ludlum presented these cases:

Dr. Dercum thought one important point should be insisted on in
these cases: that is, the relation of trauma should be clearly defined
He did not think too much stress should be laid on the fact of trauma
in either of the cases presented by Dr. Ludlum. The relation of
trauma to tabes has been gone over a great many times and none has
ever been shown. He said that he understood that Dr. Ludlum dis-
claimed an etiological relationship with trauma in the cases presented

Dr. Gordon said that the cases did not impress him as in any way
extraordinary. Traumatic syringomyelia, as understood in its broadest
sense that is a hemorrhage or anything which involves in the spinal
cord Gowers tract, is a possibility. Dr. Gordon recalled that he pre-
sented before the Neurological Society a few years ago a woman who
had a distinct history of trauma and developed distinct syringomyelic
symptoms and atrophic disturbances. As far as the tabes is concermH
he thought this a question of some importance. At the last Congress

of the French Neurologists and Alienists the question of traumatic
paresis came up and observations were brought forward showing that
the symptoms of paresis developed immediately after trauma The
general opinion nevertheless was that the trauma was simply an acci-
dental cause. We know nothing of the previous condition of the patient
in regard to his knee jerks, his ocular symptoms, so it is difficult to
draw even the slightest inference as to trauma as a factor in the
causation of tabes.

Dr. Spiller said he did not believe trauma had been the cause in

200 PHILADELPHIA NEUROLOGICAL SOCIETY

either of the cases presented, and Dr. Ludlum was of the same opinion.
He did not believe that trauma is ever a cause of syringomyelia, unless
the trauma directly affects the spinal column and spinal cord. Many
writers have tried to show that trauma of the peripheral part of a limb,
i. c, the hand, as in the boy presented, may be the cause of syringomye-
lia. He thought the case of the boy very interesting from the fact
that his symptoms developed after the giving of a blow. He was not
injured by the blow although immediately after giving it his hand com-
menced to swell and continued swollen for two years. The boy prob-
ably had syringomyelia before the trauma occurred. He presented the
Brown-Sequard type of paralysis, i. e., he had disturbance of sensation in
the left lower limb and of motion in his right upper and lower limbs.

Dr. A. R. Allen stated that the boy had given him, upon question-
ing, a history of excessive work for two years prior to this condition,
carrying as much as a ton of coal a day in hods up to the third story
of a building. Dr. Allen mentioned this point as possibly having some-
thing to do with his condition.

\ CASE OF ADIPOSIS DOLOROSA.
By Dr. G. E. Price.

The patient was a female; white; widow; aged 54. She complained of
severe pain about the knees, rarely spontaneous, but induced by motion,
palpation, or by contact of her flesh with any object. She had marked
paresthesias (numbness, burning, tingling and crawling sensations), va-
riously distributed. Her flesh would bruise without adequate cause and
she manifested extreme fatigue upon slight exertion. The patient was
nervous, irritable and anxious. Weight 225 lbs. Symptoms developed
V/2. years ago. Previous history: married when 25. Had never been
pregnant, catarrhal jaundice when 37, syphilis when 39, sciatica. No
history of alcoholism.

Famiiy History — Father died of consumption. Rest negative.
Examination. — Nodular, lobulated masses of adipose tissue, very pain-
ful when palpated, about knees, elbows and back of arms, face, hands and
feet unaffected, and trunk but slightly involved.

Thyroid gland not palpable. No muscular atrophy about hands, but
had marked deformity of both little fingers and nodular deposits about
many of the joints. Large varicose veins were present upon both legs.
The skin was dry and the reflexes diminish

The eyes were negative except for hyperemia of the discs. A
few granular casts were found in the urine which was otherwise normal.
The patient had shown distinct improvement following V- ^ months'
treatment with thyroid extract. Attention was called to the common
history of antecedent syphilis or alcoholism in adiposis dolorosa.

Dr. Dercum thought the case a typical instance of adiposis dolorosa.
The pathology of this disease is an interesting matter. Unfortunately
it is one largely of speculation still, although in a number of cases at
autopsy changes have been found in the thyroid gland, pituitary body
and in the suprarenal capsules. There is probably some disturbance
of the internal secretions. It is not improbable that changes of the
thyroid secretion leads the way, and that the disturbances of the other
glands are probably secondary in character. However, whatever the
original cause is, cases are benefited by the use of the thyroid extract,
though Dr. Dercum thought it going too far to say they are cured.
He has seen several cases greatly and persistently relieved.

Dr. D. J. McCarthy called attention to the fact that the case of
adiposis dolorosa reported by Dr. Dercum and himself revealed later a
very marked hypertrophy of the suprarenal capsules. Lie also alluded
to an interesting case recently brought to post-mortem at the Phila-
delphia General Hospital. A German with multiple adipose tumors
scattered mainly over the upper extremities, although there were a few
over the lower, shortly before death had area« of painful swollen fat
in the legs with what appeared to be forming tumors. This was of

PHILADELPHIA XEUROLOGICAL SOCIETY 201

interest because the other tumors had not been painful. It may have
been that the previous tumors developed many years before as areas
of painful fat.

Another matter Dr. McCarthy mentioned was in connection with
syphilis where widespread changes in the lymphatic system occur as an
etiological factor in adiposis dolorosa. In the case studied by Dr.
Dercum and himself there were extensive hemolymph tissues, not only
scattered throughout the body, but in the adipose tumors, and he
thought perhaps it represented an attempt by nature at compensation
for disturbance of lymph tissue elsewhere in the body.

A CASE OF PROBABLE TUMOR OF THE BRAIN OF PARIETO-
OCCIPITAL LOCATION.
By Dr. J. W. McConnell.

H., aged 53 years, a plasterer, was admitted to the Philadelphia Gen-
eral Hospital, complaining of loss of power in the left side and staggering.

He gave a history of an attack of unconsciousness occurring seven
years ago, preceded by dizziness and an indescribable illness, accom-
panied by twitching of the left face and followed by transient loss of
power in the left upper and lower extremities and persistent numbness
of the left hand and forearm. At irregular intervals subsequently he
had twitching of the left face, up to one year ago when he had a
violent convulsive attack involving the left half of his body without
loss of consciousness and without modification of the symptoms
residual from the previous attack.

His family history was negative. His personal history contained
alcohol, tobacco and probably syphilis. He stated that he suffered for
a long time from headache, recently growing worse, especially after the
convulsive attacks, from dizziness and occasional nausea without ade-
quate gastric cause.

Examination shows a hemilateral ataxic gait, better brought out
by sudden turning. He sways some with eyes open and considerably
with eyes closed.

Mentality is excellent, memory good, both for past and recent
events. He has not aphasia, word, letter or number blindness, word
deafness or agraphia.

There is no difference in the pupils which respond to light, con-
vergence and accommodation. Extraocular muscles are normal. There
is no nystagmus, no loss of any associated movement. Examination of
vision shows left lateral homonymous hemianopsia without pupillary
inaction, with contracted fields, without optic neuritis or atrophy. The
motor fifth, the seventh, in fact all the cranial nerves seem to be
normal.

The movements of the left upper extremity are weaker than the
right, but are of good power, they are slow and ataxic. The reflexes are
increased. The movements of the left lower extremity are similar to
the upper. The reflexes are increased. Ankle clonus is not obtained.
Plantar stimulation gives no response.

The right upper and lower extremities are normal in all respects.
Plantar stimulation of the right foot gives plantar flexion.

A convulsive attack observed by the resident physician had for its
features a preceding numbness of the left arm. The left hand, arm, face
and leg in sequence were tonically convulsed and the patient asked to
be laid down. He became unconscious, and the convulsion drew the
head upward and to the left, the face was drawn to the left, eyes up
and to the left, the body in left pleurosthotonus. Later the convul-
sion became clonic and general.

Sensation: On the right side is normal to all forms of stimula-
tion. On the left side tactile sense is diminished over the arm and
leg, it being almost lost on the hand and forearm. Hypalgesia is found
in the same areas. Temperature sense is not disturbed. There is marked'
ataxia in all movements of the left upper and lower extremities. Pas-

202

PHILADELPHIA XEUR0L0GICAL SOCIETY

sive movement is not always recognized, especially is this true of the
fingers. There is loss of stereognostic conception in the left hand.

The general features of the case are those of a growth, probably
of specific origin, located in the parieto-occipital region of the right
brain. His previous improvement under treatment and his present bet-
terment under mercury and iodides both suggest the syphilitic nature
of the lesion.

ASTEREOGNOSIS WITHOUT MOTOR OR SENSORY INVOLVE-
MENT.

By Dr. T. H. Weisenburg.

The patient said he was under the care of Dr. R. S. Dorsett, of Phila-
delphia, with whom he was seen in consultation by Dr. Weisenburg, and
subsequently by Dr. Mills.

The man was thirty-two years old. with no history either of alco-
holism or syphilis, was perfectly well until three weeks before coming
under observation, when he awoke during the night with a pain in the
left side of the back of the head and in the same side of the neck, this
pain disappearing the following morning. Two days after this, he be-
gan to complain of a numb, dead feeling in his left arm, followed in a
day by similar sensations over the left chest and abdomen and the left
leg. These sensations have persisted. About two weeks after the onset
of these sensations he noticed that the grip in his left hand was not
as good as before when his attention and eyes were directed elsewhere
than to the object grasped. He has never had headache, nausea, vomit-
ing or any disturbance in his eyes.

When examined his eyes and cranial nerves were found to be in a
normal condition. The grip of the left hand, when his attention was
called away, was not as good as when he was looking directly at his
hand, in which case it was normal. The left leg, like the face and arm
showed no weakness. The reflexes were somewhat prompt, especially on
the left side, but no Babinski was present. Sensation for touch, pain and
temperature, and tone sensation were normal over the left side and
everywhere. The senses of position and movement were lost or greatly
impaired in the fingers of the left hand, the loss becoming less as the
thumb and forefinger were approached. To a less extent the sense
of location was disturbed, more so, as the radial side of the hand
was approached. The sense of pressure was normal. He could not rec-
ognize any object placed in or manipulated by his left hand, the as-
tereognosis being absolute. The hardness or softness of an object, or
its surface contour could, however, be recognized, but only by the
tips of his forefinger and thumb, especially the latter.

The patient was placed upon daily mercurial inunctions with in-
creasing doses of iodides. He seemed to improve almost immediately
and in the course of six weeks all of the symptoms above detailed dis-
appeared. The numbness of which the patient first complained disap-
peared first, and as the patient improved he was first able to recognize
objects placed between the thumb and forefinger, and later on in the
other fingers. At the present time, several months after the patient
was put upon treatment, no neurological symptoms of any sort can
be found.

Dr. Mills said that with regard to the case presented by
Dr. Weisenburg, which came under his observation, this man was
carefully studied by him. He had taken him into the lecture room and
demonstrated the facts spoken of by Dr. Weisenburg, namely, the
presence of astereognosis and the absence of motor paralysis and of
all sensory symptoms. He said that he had studied the patient on sev-
eral occasions and the condition remains the same, with the exception
that the astereognosis gradually receded until he now is practically nor-
mal. He thought the case important from the standpoint which Dr.
Weisenburg referred to, that which he had personally held and taught,
namely, that there were separate cortical centers for movements for
cutaneous and muscular sensibility and for stereognostic conception.

PHILADELPHIA NEUROLOGICAL SOCIETY 203

With regard to the first case, that presented by Dr. McConnell,
Dr. Mills stated that he had also lectured on this man at his clinic
at the Philadelphia General Hospital, having previously studied him in
the nervous wards. The man's symptoms when first seen by him were
much as they are now, with one possible slight exception. He believed
that the patient at first had some slight retention of tactile sense. He
now has loss of tactile and pain sense, not equally in the entire ex-
tremity, but with receding intensity as you pass from the distal to the
proximal portion of the limbs. The reverse, as is well known is fre-
quently seen in hysterical cases. He has no motor paralysis. (This
Dr. Mills showed in examining him before the Society). If you elimi-
nate the awkwardness which results from impairment of sensation, the
muscular sense and stereognosis there is slight if any true motor
weakness. The absence of motor paralysis is interesting in connection
with the fact that he has had typical Jacksonian spasms. He has lateral
homonymous hemianopsia. Dr. Mills thought it might be a case of
tumor of the parieto-temporo-occipital region. It might, however, be
a case of arterio-sclerosis with gradual necrosis of brain tissue. He
did not believe that the case could be explained as one of hysteria, pos-
sibly the patient had some hysterical epiphenomena. Hemianopsia in
Dr. Mills experience is extremely rare, if it ever occurred, in hysteria.

Dr. F. X. Dercum asked whether the sense of position of the
fingers had been tested. Astereognosis is made up of a great number
of factors— not only cutaneous impressions, but also muscle sense im-
pressions and impressions received from the joints. As Dr. Mills says,
there may be entire loss of the tactile sense, and notwithstanding preser-
vation of the stereognostic sense.

Dr. C. W. Burr thought it very difficult to determine in Dr. Mc-
Connell's case whether the inability to distinguish objects by handling
them as due to astereognosis or anesthesia. Thoug'h a man may be
able to recognize objects in the presence of slight tactile anesthesia, yet
if there be complete anesthesia to touch and deep pressure, he would
be unable to tell what he had in his hand. Dr. Burr also thought
that a distinction should be made between the inability to recognize
objects because of the loss of sensibility, whether it be of space sense
the sense of the position of the hand itself or any other sensory dis-
turbance, and inability on account of loss of memory of tactile sensa-
tions. This last condition, tactile amnesia, is comparable to word-deaf-
ness and mind-blindness.

Dr. Mills thought with regard to the relations between stereognostic
conception, sensation and movement, he believed that the first was an
independent function, although there is a sensory pseudo-astereognosis
and a motor pseudo-astereognosis. It is possible for a patient to have
entire loss of cutaneous sensibility (for touch, pain and temperature)
and yet retain stereognostic power; in other words, to retain the
ability to recognize objects by manipulation. This had been demon-
strated by himself and others in a well known case at the Philadelphia
ueneral Hospital.

Dr. McConnell, in closing, said that he had brought his patient
before the society more particularly for diagnosis. Upon the question
as to whether or not the case was originallv thrombosis or arterio-
sclerosis, these were matters on which he wanted the opinion of the
society. The man had an attack seven years ago, and he states that he
had loss of power following that attack. Whether what he took for
loss of power was ataxia or peculiar sensory disturbances which he
now has, is the question which comes to Dr. McConnell's mind The
fact that he has improved must be given due weight. He says he was
under treatment for a long time previous to coming into the hospital
Perhaps the treatment was the same as he is now obtaining Since his
last Jacksonian attack he has distinctly improved. He is still on mrr
cury and iodides.

Dr. Weisenburg thought all agreed that a man may have astereoe-
nosis without sensory or motor involvement. In regard to Dr Der-

204 PHILADELPHIA NEUROLOGICAL SOCIETY

cum's query as to sense of position: the patient had presented involve-
ment of sense of position, but less of the sense of localization. The
question arises whether one can have a case of pure astereognosis with-
out involvement of the senses of position, pressure, movement, and
localization. The fact that in this case there was involvement of all
of these senses seems to show that in astereognosis there is involve-
ment of the senses of position, movement, pressure and less so of
localization.

FACIAL DIPLEGIA ASSOCIATED WITH LABIO-GLOSSO-

LARYXGEAL PARALYSIS.

By Dr. Alfred Gordon.

The patient was exhibited, and Dr. Gordon stated that she had
bulbar palsy and presented some unusual features. In addition to the
involvement of the muscles of the power part of the face there was
complete paralysis of the muscles of the upper part and of the fore-
head with RD in the latter. The orbicularis palpebrarum, also the
external recti muscles were equally affected. This points to a probable
association of the nucleus of the upper facial nerve (which as is well
known is separate from the nucleus of the lower) with that of the
6th. Another interesting feature of the case is the total motor aphasia,
which is quite unusual for the classical bulbar palsy where dysarthria
or anarthria are only present. Finally, the patient presents a total
suppression of salivary functions: her mouth is unusually dry. The
most important point about the case is the involvement of both superior
facial nerves, as such an occurrence in association with the typical
bulbar palsy has been reported only in family bulbar palsy of children.
Dr. Spiller said he had seen several cases of palsy following diph-
theria. He had never seen a case of bulbar palsy occurring in an adult
with paralysis of the upper part of the face. Cases of muscular
dystrophy involving the muscles innervated from the medulla oblongata
and pons and cases of multiple cranial neuritis causing bulbar symp-
toms have been observed. This patient presented by Dr. Gordon has
the ability to lower her eyelids when she looks downward, but she
cannot close her lids when she tries to do so voluntarily.

Dr. Spiller thought the hypesthesia of the face and reaction of de-
generation a strong evidence of multiple neuritis. Another point of
importance was in regard to vision. The woman talked like a person
with bulbar palsy, and not like one with aphasia. He regarded the case
as one of multiple neuritis of cranial nerves.

Dr. McCarthy stated that two months ago he saw a case five weeks
after an attack of diphtheria. The symptom group of cranial nerve in-
volvement was rather irregular, the first symptoms were those follow-
ing usually an attack of diphtheria with paralysis of the soft palate,
with regurgitation of fluids through the nose, and followed after sev-
eral weeks by a paralysis of the 7th on one side and later both sixth
nerves, and later by involvement of the third nerve, and then paralysis
of the ninth and tenth with disturbance of the diaphragm and very
shallow respirations. The patient, however, finally recovered, but it
seemed to Dr. McCarthy that there was some latent or post-intoxication
indirectly connected with the previous attack of diphtheria. He thinks
the case Dr. Gordon presented would correspond in a way to the case
just narrated — some time after an attack of diphtheria or throat infec-
tion there has been involvement of the cranial nerves, multiple and
more or less bilateral.

Dr. Gordon, in closing, stated that the "yes" that she says is very
indistinct and the "no"' is absolutely indistinct. As to the lesion in
this case, he does not think it is of a cortical nature. He believes it is
a case of polioencephalitis; the nuclei involved are those of 6th, 7th,
9th, 10th and 12th nerves.

PHILADELPHIA NEUROLOGICAL SOCIETY 205

THE SECOND ANATOMICAL PROOF OF THE VALUE OF THE

PARADOXICAL REFLEX.
By Dr. Alfred Gordon.

He reviewed Dr. Dercum's communication made at the February meet-
ing concerning a patient with a hemorrhagic pachymeningitis who, during
life, presented the paradoxical reflex on the side opposite the lesion.
Dr. Gordon reported another case in which the paradoxical sign ex-
isted on one side without Babinski's or Oppenheim's sign. The opera-
tion was based exclusively upon the existence of this reflex and when
careful decompression was done, the reflex totally disappeared. The
patient recovered completely. This was verified by Drs. Mills and Der-
cum at the Jefferson Hospital where the patient was placed. Incidentally
Dr. Gordon mentioned another case of epilepsy which is now under
his care at the same hospital. Upon admission the patient presented
no abnormal reflexes. While in the hospital he developed convulsions.
Immediately after the knee jerk became increased and a distinct para-
doxical reflex appeared on both sides, Babinski's sign was slight on one
side, but there was no Oppenheim's sign. Six days after the seizure
all abnormal reflexes disappeared completely. Dr. Gordon draws the
conclusion that his reflex is a sign, to say the least, of cerebral irrita-
tion (motor area) or of a beginning lesion of the motor pathway, while
Babinski's is a sign of a well established lesion of the same tract.

Dr. Mills said he had seen the first case Dr. Gordon referred to,
and Dr. Gordon demonstrated before him the condition as stated in
his paper.

Dr. Mills further stated that it might be interesting to Dr. Gordon
to know that a few days ago in his office he had a case in which this
paradoxical reflex was present on one side when neither the Babinski
nor the Oppenheim phenomenon could be elicited. Curiously enough this
was a case of multiple neuritis of acute but not very severe type, the
woman was still able to walk and got to Dr. Mills' office with a mem-
ber of her family from somewhere out of town. She had not lost her
knee jerks. Dr. Mills expressed his pleasure in being able to testify to
the two cases. He has in many cases examined patients or had them
examined by his assistants in his presence for this paradoxical reflex,
at the same time that the Oppenheim and Babinski reflex were tested for.
He had never seen the paradoxical reflex demonstrable when the Oppen-
heim and Babinski reflexes were absent excepting in these two cases.
The great value of a sign of this kind is shown when you can elicit
it in the absence of other signs. If it can be elicited in the absence
of other signs it has certainly some value.

Dr. Dercum stated that he has seen Dr. Gordon's sign a number
of times independently. He demonstrated it in his clinic only a week
ago, in which it was the only symptom present, the Oppenheim and
Babinski both being absent, a case of mild hemiplegia, with slight ex-
aggeration of the knee jerk on the paralyzed side. Deep pressure upon
the gastrocnemius and soleus near the origin of their tendon gave
extension of the toe as a marked clean-cut reaction.

In regard to the first case Dr. Gordon spoke of, the man in whom
it occurred was an assistant in the clinic at Jefferson. Dr. Dercum had
studied him very carefully. He had a Gordon sign and no other sign
excepting plus knee jerk. The case was one of hemorrhagic pachymen-
ingitis. Dr. Keen operated upon the opposite side of the head, and as
soon as the skull was opened there was a tremendous gush of bloody
and serous fluid; immediately afterward the Gordon reflex disappeared.
A few days later the man became restless, and Dr. Dercum again
tested him for the Gordon reflex; it was again present. The wound
was reopened, retained discharges allowed to escape, and again the
Gordon reflex disappeared. To Dr. Dercum this was a clear demon-

206 PHILADELPHIA NEUROLOGICAL SOCIETY

stration of the value of this reflex. He regards this reflex as a dis-
tinct addition to our clinical knowledge. It will certainly often enable
us, in the absence of other signs, to determine the proper side in the case
of operation.

Dr. McCarthy stated that when Dr. Gordon brought his reflex to
the attention of the society some months since, he thought it was
identical with, or a modification of, the Oppenheim and the Babinski
signs. Since that time he has made extensive trials for it, and found it
in a case diagnosed as a prefrontal tumor transferred from the insane
wards to his service at the Philadelphia General Hospital. In this case
it was the only sign apart from some mental phenomena. He has found
the Babinski reflex present in several cases in which the Gordon reflex
was not present. If the condition is to be considered as a modification
of Oppenheim's reflex he is sorry to hear Dr. Mills give this case of
multiple neuritis as an example of the reflex. If there is anything in
the case, it lessens the value of Dr. Gordon's reflex as a symptom of
disease or disturbance of the central motor tract. At the same time
the case quoted by Dr. Dercum seemed to show that the reflex is cer-
tainly an addition to methods of clinical diagnosis. From all the in-
vestigations he has carried on, Dr. McCarthy is still confused as to
its exact value. The cases in which it occurs in which the Babinski
is also present, the cases in which it does not occur and the Babinski
occurs, these cases have not come to autopsy — or if they have, Dr.
McCarthy has not followed them; that is the difficulty with the work
at Blockley where the next service comes along, and in the absence
of the chief making the original observation, the cases are not followed
up. He thinks if a larger number were followed to autopsy they would
prove of much value in establishing this sign as a means of clinical
diagnosis.

Dr. Gordon, in closing, said concerning Dr. Mills' report he wished
to relate the following fact: A patient came to Jefferson Hospital with
a supposed sciatica on one side, he was examined as usual very care-
fully and Dr. Gordon found a distinct paradoxical reflex on the dis-
eased side, with an exaggerated knee jerk. A month later the patient
developed weakness on the opposite side, difficulty in micturition, and
finally the case turned out to be one of myelitis with difficulty in walk-
ing and paraplegic symptoms.

In regard to Dr. McCarthy's remarks, it is true that we do not
have many autopsies ; but what about Dr. Dercum's case reported in
the September issue of this journal, also what about Dr. Gordon's case
verified by Dr. Mills and Dr. Dercum, where we had not only before
the operation the reflex demonstrated in a clean-cut manner, but also
disappearance of it after the patient recovered from the immediate
effect? As to the reflex being a modification of the other two reflexes,
Dr. Gordon said he did not know. We cannot give the proper explana-
tion for any of these reflexes, but simply strong inferences.

Besides these two anatomical proofs, Dr. Gordon is in possession
of a number of clinical facts showing the value of this sign. As to
its exact significance he states that he can only repeat what he has
stated in his first clinical contribution, viz., the paradoxical reflex is
a delicate sign of an early stage of a lesion or only of irritation of
the motor tract. The latter particularly is seen from the case examined
by Dr. Mills and Dr. Dercum; Babinski's sign shows a definitely es-
tablished lesion of the motor system. Dr. Gordon stated that he has
examined two-hundred and fifty normal cases, and has never found the
paradoxical reflex present. It was always in conjunction with some
of the classical symptoms pointing to the involvement of the motor
tract. The demonstration of the reflex depends a great deal upon the
method. If the rules laid down by Dr. Gordon in his original contribu-
tion are adhered to, he believes the reflex will be demonstrated in a
larger number of cases.

U>ert0cope

Journal de Psychologie Normale et Pathologique
(Third Year, No. 4. July-August. 1906.)

1. Disorders of Voluntary Pantomime Among the Insane. Dromard.

2. Note Upon the Nature of the Subconscious and Unconscious Elements.

G. L. Duprat.

3. Attempted Suicide as a Result of Suggestion. A. Lemaitre (of Geneva).

1. Disorders of Voluntary Pantomime Among the Insane. — This is
the first of the essays promised by the author in his earlier article
(Journal Nervous and Mental Disease, October, 1006, p. 675), upon
the classification of the pantomimic manifestations of the insane. Herein
he studies the first of the two grand divisions into which he divides these
manifestations; namely, those of the voluntary or active expression (idea-
tive pantomimia in its relationship to the intellectual life). Theoretically,
these disturbances are the result of a rupture in the associations which, in
the normal state, connect thought with its appropriate motor exhibition.
There are three general types of these particular, abnormal manifestations;
namely, (a) those that result from a bad or vicious adaptation of the
gesture to the thought, (b) those that are the product of a conventional
adaptation, and (c) those that reveal a total absence of adaptation.

(a) The vicious adaptation of gesticulation to the thought is shown in
paramimic asemia and the various forms of mannerism. In asemia the
patients are incapable of portraying an idea by a corresponding motor
symbol ; hence the disorder is sometimes called asymbolia. The patients,
for example, open the mouth when told to close their eyes ; or they close
their eyes when told to put out their tongues. The trouble is observed
in cases of senile dementia, general paralysis, and many diseases with cir-
cumscribed or disseminated lesions of the brain. A kind of inverse
manifestation is seen sometimes in the exaggeration or multiplication of
the gesture, made to supply a deficiency of speech. This might be called a
hypermimia of supply. It is noticeable, especially in hysterical mutism.
This hypermimia of supply is to be contra-distinguished from paramimic
asemia by reason of the fact that in the former there is an ideo-pantomimic
hyperfunction complementary to the ideo-verbal, associational deficiency,
whereas in the latter there is an insufficiency of the ideo-pantomimic as-
sociations.

Mannerism is a form of paramimic manifestation which is characterized
chiefly by outlandishness and artificiality. It is outlandish because it is not
in consonance with the triviality, simplicity, and poverty of the thought
which it accompanies. At times it is inco-ordinate and void of all uni-
formity, whereas at other times it assumes a most systematized and pre-
determined character. It thus takes on at all times the appearance of
vulgar affectation, simpering childishness, or theatricality. Mannerism is
common among hysterics. The affectation so noticeable in the speech of
these patients is equally noticeable in their attitudes and gestures. A
mannerism of attitude is also observable among weak-minded people
generally. It is particularly so among the precocious dements. In the
latter the mannerisms are monotonous, whereas in hysteria they are
characterized by a high degree of richness and mobility. In a large num-
be of cases the mannerisms represent merely a survival of the motor ele-
ment in the psychic complexus handed down to the individual by his
ancestors. It is then a kind of atavistic stereomimia. Puerilism is a
form of mannerism, and usually represents, in most of the cases, an in-
fantile or atavistic regression. Pitres has indicated this symptom under

2o8 PERISCOPE

the name of ecmnesic delirium. The case of Gamier and Dupre, detailed
by the author, affords a most striking and interesting illustration; so also
do a couple of fully reported cases of his own.

(b) In the disorders manifesting a conventional adaptation and pan-
tomimic neologism, the adaptation of the gesture and facial expression to
the underlying thought is not, properly speaking, bad or vicious, but is
merely conventional, without any value except to the patient himself. The
ideo-motor association is, in a way, arbitrary and the significance of the
pantomimic expression is incomprehensible to the spectator who has not
been foretold of it. Degenerates, subject to obsessions, often attach
special importance to certain gestures and movements. They may regard
them as favorable or unfavorable, protective or antagonistic. Thus one
patient felt as if he were falling into a pit every time he closed his eyes;
while another, a victim of tic, always performed some particular move-
ments in order to prevent some worse or more annoying gesticulations.

Pantomimic neologism is analogous to verbal neologism and hiero-
glyphic writing. Cabalistic signs are often made by the persecutional insane
that resemble veritable formulae of exorcism, incantation, and conjuration.
For example, one patient made circles in the air with one hand while he
kept striking his abdomen with the other in order to rid himself of the
spirit of his brother who he thought was seeking to dwell in his body.
Among the pantomimic neologisms may be classed also certain gestures
which correspond to rudimentary representations in a backward brain.
Such exhibitions are not rare among idiots and agenesics generally. They
indicate, as a rule, an atavistic regression. The patient claps his hands,
sucks his lips, etc., which in the normal state indicate the sense of pleasure,
hunger, etc., but which in this condition are performed merely in a sense-
less, conventional manner.

(c) When the adaptation of the gesture and facial expression to the
underlying thought are zvholly at fault, the higher mind has lost all control
over the motor activities and the latter exhibit themselves automatically,
without reason or purpose. In normal individuals there is an automatism
of gesture, as, for instance, the extension of the hand unconsciously when
bidding a friend good-bye. In abnormal individuals this automatism shows
itself more particularly in stereomimia and echomimia.

Stereomimia is only a mode of stereotypy. In it the festures and play
of facial expression are repeated to the point of satiety, always in the
same manner, and without any real purpose in view. The manifestation
is pre-eminently characterized by its fixity and uselessness. The move-
ments are incongruous and are absolutely not in the least adapted to the
conditions actually present. They are intensely monotonous. In another
essay the author has studied this form of pantomime in detail (Journal
of 'Nervous and Mental Disease, January, 1906, p. 56). In a large num-
ber of cases, especially in the different varieties of dementia, and above
all, in insane dementia, this stereomimia is a form of secondary autom-
atism. The movements originally accompanied an idea, which idea has
gradually disappeared, leaving the movements as an acquired habit. In-
explicable at present, the movements are perfectly comprehensible in the
light of the past when they had their beginning. This secondary stere-
otypy of the gesture and facial expressions indicates an intellectual en-
feeblement, and up to a certain point measures the degree of that enfeeble-
ment.

In many other cases these stereotyped movements indicate a primary
automatism. Such are the istereomimic manifestations of the catatonics.
The preservation of fixed attitudes and the incessant repetition of the same
monotonous movements are but exaggerated manifestations and ultimate
witnesses of that mental state, of which the milder phases are seen in the
simple hesitancy of the psychomotor processes.

Stereotyped pantomimia is observed not only in cases of mental en-

PERISCOPE 209

feeblement, but also in cases of simple suspension of inhibition provoked by
a morbid process affecting directly but temporarily the psychomotor ap-
paratus. Here the phenomena represent an active process and not merely
a residental function. It is usually accompanied by catatonic traits such
as sluggishness, waxy flexibility and negativism; but it in no way indi-
cates what will be the outcome of the disease process causing it.

To agencies, such as imbeciles and idiots, also belong this primitive
automatism as seen in stereomimia. Their stereomimia should be care-
fully distinguished from that of the catatonics and dements on the ground
of its psychological mechanism. It is characterized by an imitative or
atavistic formalism, which is very often rhythmical in expression and con-
tains an emotional element based upon a hunger for activity with satisfac-
tion in its accomplishment. It ought not to be regarded as a mere crystal-
lized relique, so to speak, of a rich motor past, but rather as the im-
mediate manifestation of a congenitally miserable activity.

Echomimia consists of the impulsive imitation of the facial expressions,
and gestures of another ; an imitation which occurs immediately, brusquely,
and with the promptness of a reflex function, without the slightest pos-
sible inhibitory intervention on the part of the will. It is a particular form
of a much more general phenomenon ; namely, echokinesia. The author
has studied this symptom in an earlier article (Journal of Nervous and
Mental Disease, August, 1006, p. 546). Echomimia is devoid of any
emotional element, is involuntary and unconscious. It is the result of a
failure of inhibition. Like stereomimia, the echomimia of the demented
indicates an integral disintegration of the personality. It is not uncommon
in congenital weaklings, and it is pronounced in idiots. In the latter it is
not so perfectly autonomous and independent of the entire aggregation
of the personality as it is in the demented, but it is rather the direct
manifestation of a wretched personality which thus exhibits its activity as
well as it can.

Incontinence of the lower brain centers, these centers being set freeby
the dethronement or separation or absence of the higher directing faculties,
is in all cases of disorder of the voluntary pantomime the general sub-
stratum of the phenomena. By reason of the etiology, as herein explained
by the author, these psychomotor manifestations are seen to accompany
various psychic troubles which spring from the same general soil, and
which for the most part depend upon automatism.

2. The Nature of the Subconscious and Unconscious Elements. — Claude
Bernard. Durand (de Gros), Grasset, Janet and others attribute to the
subconscious or "inferior psychism" the same faculties or modes of psychic
action that are recognized as belonging to the conscious or "superior
psychism." As Grasset puts it. the inferior psychism is endowed with the
power of memory and of volition; is capable of perceiving, judging' and
reasoning; and is to all intents and purposes to be held as responsible.

Duprat thinks that certain psycho-physiological facts seem to show that
beneath the intellectual and representative psychic syntheses, involving
such objects as the ego and the external world (superior psychism), there
are certain unconscious psychic syntheses or elements which are only the
substitutes of the neuro-muscular phenomena of all sorts constituting
essentially the sensations, the emotions and various tendencies. The acts
of the inferior psychism are not intellectual operations ; they do not even
involve or comprehend the images of objects; they concern themselves
only with the "images" of the affective or sensorial states and states of
motricity. Between them and the phenomena of the clear, personal con-
sciousness take place the acts of the superior psychism, of which some are
not assigned by the individual to his own ego, but are perceived by him
merely while others are wholly subconscious. Hence Duprat recognizes
(1) certain unconscious psychic acts which are very close to mere physio-
logical states; and (2) certain acts that are (a) subconscious, (b) con-

210 PERISCOPE

scions, and (c) of the personal consciousness which alone is capable of
comprehending- or including in genuinety intellectual processes the per-
ception of objects, ideas, reasoning, and the formation of judgments.

3. Attempted Suicide as a Result of Suggestion. — Lemaitre reports the
interesting case of a young man having a weak, hysteroid temperament
who was so dominated by his intellectually stronger and more vicious com-
panion that upon two occasions he deliberately attempted self-destruction
for no other reason than that of the direct suggestion of the latter. The
case is not unique, and the moral of it is obvious. The p-wer of sug-
gestion employed by a criminal to secure the commission of a crime by
his dupe is and alwavs will be a question of much medicolegal importance.

(Third Year, No. 5. September-October, 1906.)

1. The Personality. W. Bechterew (St. Petersburg).

2. Attenuated Responsibility. J. Grasset (Montpellier).

1. The Personality. — This is not so much of a psychological or even
psycho-physiological study as it is a diffuse sociological and political
critique of the individual and communal personality observed in Russia
under present conditions, and of the adverse elements in the government
of that unfortunate country that are thwarting the growth of the nation
and its constituents.

2. Attenuated Responsibility. — Grasset, like all advanced students of
normal and abnormal psychology, recognizes that there are varying de-
grees of responsibility in human affairs depending upon many conditions
that involve individual mental capacity. Men are not, as the law too often
assumes, either responsible or irresponsible. There is such a thing as an
attenuated responsibility, which, however, must be distinguished from
mere partial responsibility. Hysterics and eoileptics furnish good ex-
amples of attenuated responsibility. In court the medical expert is often
taken to task by the legal fraternity for asserting this diminished respon-
sibility exists. Many of the highest legal authorities hold that it is both
irrational and harmful to society to regard a man as anything but re-
sponsible or irresponsible. Grasset has gathered together in this long
and interesting medico-legal paper some of these adverse judiciary opinions,
and in a clear, well-knit and forcible argument shows that the medical and
legal writers are concerning themselves with two separate and very dis-
tinct questions; namely, the condition of the patient mentally (medical
question) and the best interests of society (legal question). The practical
conclusions of the article are that in court the expert is justified most em-
phatically, legal opinion to the contrary notwithstanding, in maintaining
that there is such a thing as attenuated responsibility and that this sort
of responsibility should be taken into full consideration in the awarding
of punishment.

For the weakly responsible criminals. Grasset argues that corrective
infirmaries should be established, which infirmaries should not partake
wholly of the nature of prisons on the one hand nor hospitals upon the
other, but of the nature of sharp, training schools wherein the mind
diseased may be helped medically while the individual is made to feel at
the same time that he is undergoing punishment. In some countries such
institutions have already been established by law, but in France, Grasset
says, there is still a crying need for them. The improvement of the
criminal rather than his mere punishment is what society needs; hence such
institutions as above indicated will be most apt to foster harmony between
the medical and legal authorities anent this great question of responsibil-
ity, and in the end accomplish the highest aims of both medicine and law.

Mettler (Chicago).

PERISCOPE 211

Allgemeine Zeitschrift fiir Psychiatrie
(Vol. 63, 1906. Heft. 2.)

1. The Weight of the Cerebellum in Normal and Pathological Conditions.

M. Reichardt

2. A Case of General Paresis with Accumulated Convulsions, with Some

Observations on the Blood Pressure. W. Plaskuda.

3. Contributions to Clinical Knowledge of the Puerperal Psychoses. G.

Herzer.

4. Etiology and Symptomatology of Katatonia. Pfister.

5. Psychical Condition of Insane When Dying. W. Albrand.

6. Commitment on Account of Partial Insanity. H: Kornfeld.

1. Weight of the Cerebellum in Normal and Pathological Conditions. —
Reichardt gives a very complete account of his studies on the weight of the
cerebellum as found in 122 patients. From the weight of the cerebellum
alone, it cannot usually be stated whether it is atrophied or not. What is
wanted is the proportion which this weight bears to that of the cerebrum,
also the capacity of the skull. The highest and lowest cerebellar weights
found in the author's cases were respectively 185 and 80 grammes. They
usually ran from no to 150 grammes, averaging 130 grammes in normal
cases. The skull capacity was measured in most cases, making use of the
author's method of determining the quantity of water which the cranial
cavity would contain (already described in this journal). A brain was
considered normal, whose weight in grammes was from 10 to 16 per cent,
less than the capacity in cubic centimetres of the skull. The brain was
first weighed as a whole, then stripped of pia, the ventricles opened and
allowed to drain, and weighed again. The crura cerebri were next cut
through, the cerebellum separated, by cutting its peduncles close to their
entrance into it, the cerebral hemispheres separated, and each piece
weighed singly. The quotient obtained by dividing the weight of the
cerebrum by that of the cerebellum, was found to be normally from 7 to
8.5. Figures below 6.5 or above 9 should be regarded with suspicion, as
probably indicating a pathological condition. There is no absolute rela-
tion between brain weight and size of the body except that in general, large
people tend to have larger brains than small people. Neither does brain
weight as a rule diminish with emaciation of the body. The 122 cases are
arranged in twelve tables, in which the most important facts with regard
to each case are given. These tables are classified according to the cerebro-
cerebellar quotient normal or abnormal, as related to skull capacity, and
as found in functional psychoses, in general paresis and senile dementia
with and without brain atrophy, in microcephaly, in brain tumor, in cere-
bellar atrophy, and in congenital smallness of the cerebellum. As indicat-
ing that the cerebellum has to do with coordination of movements, it has
been found that at birth, the cerebro-cerebellar quotient is considerably
higher than in the adult, but since the cerebellum grows faster than the
cerebrum in the early months of life, at the end of the first year, the
quotient does not differ from that found in the adult. Also the author
found in a 25-year-old cretin, who could neither stand nor walk, a
quotient of 9.5. In the lower animals, those which immediately after birth
can run about readily, have at that time heavier cerebella than those
which are awkward and slow in their movements for some time, the dif-
ference being later equalized. In old age, low cerebellar weight is not
seldom found, and the author thinks that this may account for such symp-
toms as tremor and ataxia often observed in old people. As an appendix,
he discusses the relation between the cerebellum and sexual instinct, as-
serted by Gall, and to some extent supported by Moebius, though pretty
effectually demolished by Rieger. It happened that among his cases there
were two males, each of whom had lost a testicle, and one female aged 29
years, in whom the sexual organs had not developed beyond the infantile
stage. In none of these cases was there any change in the cerebellum,

212 PERISCOPE

whose weight and general appearance in each instance was normal. There
was no evidence of atrophy of the opposite half of the cerebellum in the
cases of lost testicle, such as according to Gall should occur.

2. General Paresis, Accumulated Convulsions and Blood Pressure. —
An account of a case of general paresis in which 568 convulsive attacks
occurred in twenty-two days, there being 100 attacks in one day alone.
Death at the end of this period, of exhaustion. Measurements of the blood
pressure by the Riva-Rocci sphygmomanometer during one series of at-
tacks showed a state of hypertension rising always during the convulsion,
though of course during this stage no accurate reading could be made.
The author exhibits his measurements in tabular form.

3. Puerperal Psychoses. — The author among 1896 patients admitted to
the Basel psychiatric clinic during the last twenty-five years found 221
cases of puerperal, or as he prefers to call them, "generation" psychoses.
He agrees with other authors that there is no special generation psychosis,
but he divides his cases — after Kraepelin's classification — as follows :
Dementia prsecox, 107 cases; manic-depressive insanity, 32 cases; hysteria,
18 cases; acute confusion (amentia), 15 cases; alcoholic insanity, 12 cases;
epilepsy, 11 cases; neurasthenia, 5 cases; general paresis, 4 cases; eclamp-
sia, 2 cases ; chorea imbecility, 2 cases ; diagnosis uncertain, 13 cases. Ac-
cording to time of appearance, the generation psychosis may be divided
into : (1) Those of pregnancy. (2) True puerperal cases (those coming
on at any time within the first two months after delivery), and the lacta-
tion psychoses. Of the 221 cases, 46 belonged to class 1, 102 to class 2,
6g to class 3, while in the remainder, the exact time of onset could not be
ascertained. He next takes up the cases according to clinical form, and
discusses their relation to hereditary predisposition, personal history, age,
whether occurring before or after delivery, the number of the pregnancy
in which they appeared, the nature of the labor and complications, with the
percentage of recoveries under each head, and after history as far as
could be learned. In general, recovery was more frequent in the older
patients, though of the primipara, those under twenty-five years more fre-
quently got well. The general percentage of recovery for the dementia
prsecox cases was fifty-seven, which is much better than that found in
dementia prsecox unassociated with reproduction. Heredity did not ap-
pear to influence recovery in these cases.

Among the manic-depressive cases, 81.2 per cent, had hereditary pre-
disposition, and 9 of the 32 patients had shown "traces of this psychosis
before marriage. All except two who died of intercurrent diseases re-
covered, but had other attacks sooner or later, four, however, not until
from eighteen to twenty-four years later. This psychosis seems to run
its course in the main, but slightly influenced by the act of reproduction as
does also hysteria. Ten of the eighteen cases of hysteria had shown
previous symptoms of this disease, and in 71.4 per cent, of the cases there
was hereditary predisposition. By acute confusion (or amentia) the
author understands the "exhaustion psychosis" of Kraepelin. Its frequency
has been much decreased by the placing of most of the cases formerly
diagnosed as such under the heads respectively of dementia prsecox, and
of manic-depressive insanity. Ten of the fifteen cases of this psychosis
were puerperal, five lactational. All were associated with difficult labor,
puerperal infection or some complication. All recovered usually within
three and a half months except one case, which was taken away after one
month, and was lost sight of. Five of these women bore one or more times
after recovery from a first attack without recurrence. Six of the epileptics
had their first attack in one or other period of the reproductive act. In
the other cases the influence of the child-beaing could hardly be considered
as more than helping along an existing trouble. In fact, it must be con-
sidered in the main, as chiefly an exciting cause acting upon an already
present predisposition.

4. Etiology and Symptomatology of Katatonia. — A male during his six-

PERISCOPE

213

teenth year suffered a severe injury to the head, causing fracture of the
skull with concussion of the brain, necessitating an operation for the re-
moval of depressed bone. From this there resulted alteration of character,
headaches, tremor of the hands, and later intolerance toward alcohol. Nine
years later, there began a mental disturbance characterized by hallucina-
tions, illusions and delusions of persecution, with later the characteristic
symptoms of negativism, verbigeration and stereotypy, which proceeded to
moderate dementia. Discussing this case as to its peculiarities, the author
discovers some features in the speech and handwriting with dermograph-
ism, etc., which suggests a traumatic neurosis, and makes him think that
there may be here a combination of this condition with dementia prscox.
He believes that trauma is never the sole cause of a neurosis or psychosis,
but always plays the role of an exciting cause acting upon an already pres-
ent predisposition. This he thinks well illustrated in this case, and while
he inclines to the view that dementia praecox in general is due to an auto-
intoxication of some sort, trauma, he suggests, may have an influence in
so disturbing the normal metabolism as to favor the production of harmful
substances.

5. Psychical Condition of the Insane When Dying. — Walter Albrand,
while making certain observations upon the iris movements in the dying, at
the Sachsenberg Asylum (already published in another journal), was led
at the same time to note the mental condition of his patients. After a
review of the subject, with some illustrative cases, he concludes that: In
insane persons the improvement in mental condition just before death over
that observed in the same individual in bodily health is inconsiderable as
a rule. People in general, upon the approach of somatic death, may con-
duct themselves differently, depending upon the nature of the death br'ng-
ing disease, but nevertheless their mental processes are apt to move more
or less in their formerly accustomed channels. The same thing is usually
to be found in the dying insane, the method of death, and the more or less
mobile mental condition having a similar effect upon the psychical state as
it would have in the sane. A complete alteration in the mental personality
of an insane person on his deathbed is never found, but a profound change
of mood, both on the approach of death and during severe bodily illness, "is
undoubtedly sometimes observed, though we can in no wav explain this
fact. Thatan insane person, just before death, occasionally abandons his
latest idea in favor of earlier ones, and begins, as it were, a new psychical
life, is also from time to time noted, but it is impossible to construct a
definite antemortal psychopathology. The author makes a digression to
discuss the influence of acute febrile diseases upon the mental condition
of the insane, and the proposal to utilize therapeuticallv the occasionally
observed curative effect of such processes. With regard to this last, how-
ever, he confesses great skepticism, and thinks that in general, infectious
diseases are more likely to have an unfavorable than a favorable influence
upon the mental condition.

6. Commitment on Account of Partial Insanitx. — Report of the judg-
ment of an Austrian upper court in a case of this character.

Allen (Trenton).

Brain

(Vol. 28. Parts 3 and 4.)

1. Cerebral Sclerosis. Alfred W. Campbell.

2. The Clinical History and Post-Mortem Examination of Five Cases of

Myasthenia Gravis. E. Farquhar Buzzard.

3. Ataxia in Childhood. Frederick E. Batten.

4. On the Metabolism and Action of "Nerve Ceils. F. H. Scott.

5. The Onset of Hemiplegia in Vascular Lesions. A. Ernest Jones.

1. Cerebral Sclerosis.— Dr. A. Campbell contributes a lengthy article on
the general pathological aspects of cerebral sclerosis. After some general

2i4 PERISCOPE

notes on neuroglia, its development and growth he takes up tuberose
sclerosis, megalocephaly, cerebral hemiagenesis and hemisclerosis, lobar
agenesis with sclerosis and microgyria, cerebral arteriosclerosis, giant cell
sclerosis and other forms of sclerosis in general paresis, senility, epilepsy,
idiocy and that following cerebral softening and syphilis.

He recognizes five neuroglia elements, (i) the large neuroglia cells of
Bevan Lewis, Kurzstrahler, of German writers ; (2) the stellate cell of
Golgi, small spider cell, Langstrahler ; (3) glia cells of Retzius ; (4) small
cell of Bevan Lewis, nucleus; (5) neuroglia cell of Ford Robertson. In
reference to the sclerotic processes he holds that for the commoner forms
of sclerosis they are brought about by the deposition and metamorphosis of
new elements and not by the proliferation of pre-existent cells. The most
important of these new cells is the large mononuclear leucocyte or
phagocyte. Speaking of tuberose sclerosis he notes that it is almost always
confined to idiots and imbeciles, and this suggests to him an intrauterine
origin for the cerebral disease which underlies it, which he believes is the
ultimate manifestation of some evolutionary aberration or disturbance.

Hypertrophy of the cerebrum is included although sclerosis is usually
accompanied by shrinkage. Here, however, there is expansion with marked
proliferation in neuroglia elements. The induration and enlargement are
general rather than local, and inasmuch as there is little evidence of irrita-
tive conditions the process is a unique one. Although comparatively rare, it
is common enough to have good material for comparison. There is also
a marked hereditary element in these cases, and Campbell inclines to the
view that the process leading to the hypertrophy probably was an active
one during intrauterine life. Its essential factors are not yet clear. The
increase in neuroglia is situated in the white tissues only, and probably
took place at the time of the neuronal development of the great systems.

Hemisclerosis, or hemiagenesis, is a rare affection. He believes it to be
due to an arrest of growth of one-half of the brain, and the histological
evidence tends to show the structures of a foetal brain. The cessation of
development probably took place just before or at the time of birth. The
elements subserving primary essential functions being developed persist,
while those elements subserving higher evolutionary functions, being only
partially developed, suffer decay, and hence the neuroglia proliferation
and sclerosis. Lobar agenesis is another rare condition, probably similar in
its origin, but not so widespread; moreover it is usually bilaterally situated.
The author makes a distinction between this process and that of the con-
traction and induration about an old patch of cerebral softening, and to
postmeningitic atrophy and sclerosis. Cerebral arteriosclerosis is next
discussed. He believes it not so common among the insane as heretofore
thought. He is speaking of gyral attenuation and sclerosis apart from
that attendant on gross lesions such as embolism and thrombosis. Gyral
arteriosclerosis, he concludes, with atrophy and pitting, is a disease chiefly
confined to aged dements with diseased arteries. It attacks the cortex in
patches, and apparently is the outcome of a discrete occlusion of cortical
arterioles. Colloid sclerosis is an affection of the blood vessels, with a
minor participation of glial proliferation. The colloidal material results,
the author believes, from a proliferation rather than degeneration. One
patient showed a giant cell sclerosis, or infiltration. It might properly be
termed a "glioma gangliocellular." Cerebral sclerosis in paresis, in senility,
in epilepsy, in hemorrhage, in syphilis, idiocy and multiple sclerosis are
briefly considered.

2. Myasthenia Gravis. — 'Buzzard contributes an illustrated paper on
this affection based on the pathological findings in five patients. He would
maintain from the clinical side that sensory disturbances may be present
in this disease, although heretofore they have been considered absent, and
he has had one patient with complicating mental symptoms. It is in all
probability a disease with a constant morbid anatomy consisting of widely
distributed cellular, and sometimes serous, exudations (lymphorrhages) in

PERISCOPE 215

the tissues and organs of the body. Slight muscle fiber changes are fre-
quent and severe, muscular atrophy is rare. Proliferative and degenera-
tive changes are frequently, but not constantly, met within the thymus
gland. The symptoms, he believes, are best explained on the basis of some
toxin having special influence in voluntary muscle and its relations to the
thymus are suggested.

3. Ataxia in Children. — Batten deals here with some irregular and little
known forms of ataxia not included in the well-known groups of Friedreich,
and tumor and lesions of the cerebellum and midbrain. He favors the term
cerebellar diplegia for his cases, grouping them in three series. (1) Case
in which ataxia has been noted early in life, and in which there is a ten-
dency to gradual improvement (congenital cerebellar ataxia). (2) Cases
in which ataxia has developed suddenly after some acute illness (acute
ataxia, encephalitis cerebelli). (3) Cases in which the child has been
healthy until a certain age and then has developed ataxia gradually. These
cases resemble Friedreich's, but differ in development (progressive cere-
bellar ataxia). Particular attention in differential diagnosis must be given
to multiple sclerosis, to quiescent cerebellar tumor and to past meningitis
and hydrocephalus.

4. Metabolism and Action of Nerve Cells. — In this paper Scott tries to
solve _ some of the problems of nerve function by trying to find similar
chemical substances in other organs of the body. He finds that a sub-
stance of the same nature as Nissl's substance occurs in the cells of the
pancreas and in the chief cells of the fundus glands of the stomach. The
neurosomes of Held, he holds, are morphologically homologous with the
zymogen granules of gland cells, and there is an interdependence between
the amount of Nissl substance and the number of neurosomes, exactly as
there is between the prozymogen of Macallum and the number of zymogen
granules. The nuclei of these three cells also resemble one another. There
is also much resemblance in the action of these three cells in that they all
are concerned in controlling the changes in proteids. On these similarities
the author frames the hypothesis that nerve cells also act by a kind of
proteolytic ferment.

_ 5. The Onset of Hemiplegia in Vascular Lesions. — The author con-
tributes an extremely interesting paper, which must be read in extenso.
Among those conclusions which seem to offer the greatest probability he
gives :

(1) Rest in bed, and especially sleep; protect to some extent against
cerebral hemorrhage. (2) Severe exertion and time of day appear to have
had too much stress laid on them in the past. Time of day is of interest
only when the habits of the patient's blood pressure at different hours are
known. (3) Consciousness is lost at the onset in half of the cases of
occluding lesions and three-quarters of hemorrhage lesions. (4) The im-
mediate prognosis is much graver when the onset is apoplectiform ; es-
pecially is this so in cases of hemorrhage. Contrariwise, cases of late
hemiplegia due to hemorrhage are less likely to have suffered from loss
of consciousness at the onset than hemorrhage cases taken as a whole, and
are therefore the more likely to be attributed to thrombosis. (5) Intra-
ventricular hemorrhage, which is nearly always secondary, may not cause
loss of consciousness. On the other hand, immediate loss of conscious-
ness as the initial symptom may be due to extraventricular hemorrhage.
The immediate prognosis is much graver in cases of hemorrhage than in
occluding lesions. In 828 cases of hemorrhage, 158 of thrombosis and 273
of embolism the results are as follows : Over 30 per cent, of the cases of
hemorrhage were fatal within twenty-four hours ; half as many of throm-
bosis and a quarter as many of embolism ; almost two-thirds of the
hemorrhage patients are dead in a week, and more than a third of the
patients with occluding lesions. Of twenty cases of each lesion four
hemorrhagic ones would survive a month ; five thrombosis ones and nine
embolism ones. Most of those that survive two years are patients with

216 PERISCOPE

thrombosis. (7) Of the patients in whom blood is found in the ventricles,
60 per cent, die in the first twenty-four hours and 90 per cent, in the first
week. It is not very rare, however, for such cases to live a few weeks.
(8) The mortality incident is heaviest on the first day amongst the younger
men ; in the next few weeks it is the aged women who are most likely to
die. (9) There is no indication that hemorrhage affects the right side of
the brain more often than the left. Occluding lesions may affect the left
side more than the right for all that is known to the contrary, but the
statements usually made are not warranted in the present state of our
knowledge. Jelliffe.

Psychiatrisch-Neurologische Wochenschrift
(Feb. 3, 1906.)
1. Simulation of dementia by Weakmindedness. — Bresler. The patient,
a woman, had been several times convicted of crime, but the last time she
was apprehended she was sent to the asylum. During her examination by
the magistrate, and afterward on her admission to the asylum she showed
marked mental symptoms, although all those that knew her testified that
she was an accomplished rogue. One of the principal features was her
marked memory defects. These defects, however, did not follow any
type and when she was observed and did not appreciate she was being
examined they largely disappeared. Her memory was still poor for recent
events though, and this the author thought evidence of weakmindedness, as
was also her great tendency to lie. In general her simulation was over-
done. The amount of mental defect was too great, as for example, at one
time she replied, "I don't know" to all questions.

(Feb. 10-17, 1906.)
1. Decisions of the Prussian Court in Regard to Caring for the Danger-
ous Insane. — Continued.

(Feb. 24, 1906.)

1. Delusion and Error. P. Nacke. (Continued.)

2. The Lack of Physicians in Asylums for the Insane and a Hitherto

Unobserved Cause for Same. H. Hoppe.

3. Decisions of the Prussian Court in Regard to Caring for the Dangerous

Insane. (Continued.)

1. Delusion and Error. — Will be abstracted when finished.

2. Lack of Physicians in Asylums. — Deals with local conditions only.

3. Decisions of Prussian Court. — Not of interest to American readers.

(March 3, 1906.)

1. The Question of the Psychiatric State Asylum. Dannemann.

2. Delusion and Error. P. 'Nacke.

1. Psychiatric State Asylum. — Continued.

2. Delusion and Error. — The article seems to be suggested by a recol-
lection of a fanatical Russian sect, the Duchoborzen, who started out to
find Jesus. They were a half clothed, ill-fed, poor, and more or less
alcoholic people easily influenced and led. Russia seems to be the land
above all others where all sort of possible and impossible sects thrive.
Lowenstimm mentions a sect that instead of seeking Jesus sought the
devil, and other sects are the Skopzen, Flagellants, Chlyster, Wanderers,
Deniers, etc. The belief in witches and demons is not yet dead. All these
ideas fixed by suggestion, delusions in the psychiatric sense, are errors
only. The distinction is by no means clear. It is said that delusion must
have its own special soil and error not, but epidemics of false ideas show
this often not to be the case. In both cases there is a special affect state,
mood, endogenous or exogenous, conditioned by the surroundings and the
time. The delusion develops gradually, the error often suddenly, when the
affect reaches a certain tension. The foundation of both may be quite
similar. Either may take its origin in the same way— from the Bible or

PERISCOPE 217

from a speech — a primary or secondary affect arises, then falsification of
memory and the border between delusion and error, already vague, is
still more encroached upon when hallucinations, illusions, and convulsions
occur as they frequently do in epidemics.

The author calls attention to the following distinctions. The delusion
is seldom single. Cases of hyperquantivalent ideas in the sense of Wer-
nicke, however, he thinks do occur. The delusion is usually fixed, cannot
be changed by argument, has a strong affect-tone and leads to action. In
delusional states the personality in its innermost parts is altered, while
in error this is not so. The individual remains the same. The delusion
grows and develops on a pathological foundation, the error on a founda-
tion of health. The idea in itself is characterized neither by delusion or by
error. We know how often the nucleus of the ideas in litigous insanity
may be true, and on the other hand how the most foolish ideas may be
held under certain conditions of time and surroundings. The author is of
the opinion that an error under favorable circumstances of soil and strong
outer influences may develop into a delusion, while an insane person may
have an erroneous belief which can be corrected without influencing the
delusional state. As to the alteration of the personality in error it may be
greatly altered by the radiation of the false ideas, while with single hyper-
quantivalent ideas there may be little change. Suggestion of long dura-
tion with unchanged surroundings and affects may lead gradually to a
falsification of the personality. Suggestibility may thus lead to true
insanity, while on the other hand the insane may become suggestible.

White.

Archiv fur Psychiatrie und Nervenkrankheiten
(Vol. 41, Part 1.)

1. Symptomatology of Epileptic Insanity, Especially Concerning the Re-

lationship Between Aphasia and Perseveration. Raecke.

2. On the History of Spasmodic Torticollis. Armix Steyerthal.

3. A Contribution to the Study of Myxedema. Frederich Heyn.

4. Symptomatology and Pathogenesis of Acquired Internal Hydrocephalus.

L. W. Weber.

5. Concerning Cortical Focal Symptoms in the Amnesic Phase of Poly-

neuritic Psychoses. Reihold Kuttner.

6. Contribution to the Normal Anatomy of the Ganglion Cell. Constan-

TINE J. ECONOMO.

7. The Operative Treatment of Brain Tumors. C. Furstxer.

8. The Neutral Cells of the Central Nervous System. P. Kroxthal.

9. Simulation and Mental Disorder. A. Schott.

10. Areas of Softening in the Medella Oblongata with Ascending Degener-

ation in the Pryamidal Tract and Fillet. O. Kolpix.

11. Hereditary and Predisposition or Degeneration in Progressive Par-

alysis of the Insane. P. Nacke.

1. Epileptic Insanity. — Raecke reports four cases in detail as a basis
of his discussion of epileptic insanity. The general result of his study is
that in the mental disturbances of epileptics aphasia and perseveration do
not stand in close causal relationship, and that the existence of one
cannot be assumed from the presence of the other. Amnesic aphasia
doubtless plays a large part in the symptomatology of epileptic insanity,
but cannot be regarded as an absolutely constant symptom. Certain details
are added regarding the somatic signs occurring in different stages of the
disease, as observed by the writer.

2. Spasmodic Torticollis. — In this paper the writer discusses from the
historical standpoint the condition of spasmodic torticollis, which he finds
described by many of the early investigators. Much of the article is a
reproduction of the original Latin in which the early descriptions were
made. As an addition to a previous article the author gives the subsequent

218 PERISCOPE

history and autopsy findings of certain cases previously reported. The
pathological anatomy of the condition remains unwritten.

3. Myxedema. — Heyn in this paper, on the basis of considerable per-
sonal experience of the disease, both clinically and anatomically, re-
views the general theories underlying the etiology of myxedema. The
treatment which has been found useful is in advanced cases, one of general
hygiene with an attempt to improve the nutrition. At the beginning of
treatment a milk diet with vegetables is used with benefit, although the
reason is not apparent. When improvement has begun iodide of potash is
given on general principles. Following this the specific thyroid treatment
is begun, which is administered in the form of thyroid tablets. A discus-
sion of the blood as studied in one of the cases concludes the article.
From autopsy findings the author concludes that the specific poison injures
the blood vessels to a high degree as shown by the changes in the heart,
aorta and coronary vessels.

4. Internal Hydrocephalus. — Weber offers a profusely illustrated and
elaborately detailed article on acquired internal hydrocephalus. The paper
is divided into four parts, which treat the subject respectively from the
point of view of clinical cases, from the standpoint of symptomatology,
followed by a discussion of the pathological anatomy and pathogenesis.
The concluding section summarizes the general results of the study and
their significance. As congenital hydrocephalus, are considered those
forms in which the cause is to be found in uterine life. It is maintained
that in the congenital form the mechanical prevention of the outflow of
cerebrospinal fluid is more significant, whereas the increase of the fluid is
less significant. As idopathic hydrocephalus only those cases are to be
considered in which the mechanical conditions cannot be explained by
pathological anatomical findings in the brain or its neighborhood. The
writer avoids the phrase "'hydrocephalus without anatomical basis." The
number of such cases is naturally diminishing as knowledge grows. The
increase in cerebrospinal fluid is often due to chronic inflammatory con-
ditions. A valuable discussion of the theories and the various conditions
under which hydrocephalus may occur concludes this significant contri-
bution.

5. Amnesic Polyneuritic Psychoses. — Attention is called to the fact
that in certain stages of the polyneuritic psychoses focal symptoms usually
of the aphasic type may supervene as somewhat temporary symptoms. As
more permanent symptoms are developed defects of intellect, loss of
memory for recent events, difficult concentration, confabulation and a
disturbance in writing, characterized by a marked difficulty in finding
proper letters, and in perseveration of components of words and sentences.
Cases are reported and literature bearing on the subject is cited. The
writer finally concludes that the aphasic or agraphic disturbance is due to
localized affection of the sensory area of speech, which represents an
increase of the diffuse brain process.

6. Ganglion Cell. — Economo offers a critical study of the recent nerve
cell histology, and draws attention to a particular intracellular structure
which he regards as an original observation. The article is illustrated by
fifty-three figures, and although not permitting detailed review on account
of its technical character, is worthy of close study by special students of
the subject.

7. Operation in Brain Tumor. — Fiirstner offers a clinical study of brain
tumors with comments on the operative treatment. In each of five cases
reported operation was performed, and the existence of tumor confirmed
by autopsy in three. Following an analysis of the cases from the clinical
standpoint, Fiirstner expresses himself in general as in favor of early
operation, not only in the hope of cure, but also as a relief of symptoms,
an opinion which is generally accepted by all who have given attention
to this subject. In general, Fiirstner would also not be in disagreement

PERISCOPE 219

with others in his statement that relatively small tumors in the central
convolutions alone offer favorable chances of extirpation, and that the
great majority lying in other parts of the brain are open rather to a
palliative than to a curative operation, and that in these latter cases opera-
tion should be done soon after the appearance of choked disc.

8. Neutral Cells. — Kronthal states that the simplicity of a proposition
is no criterion of its correctness. As an example of this truism, he argues
that the proposition that the peripheral nerve is a process of a nerve cell
is simple but wrong. He quotes the new fibrillar methods to substantiate
this claim. Kronthal has reached the conclusion on anatomical grounds
that the nerve cell is not an organism inasmuch as it is made up of small
cells. He uses the word "neutral"' cell to indicate cells which occur
sparingly in the white substance, but frequently in the gray, of varying
size, but usually small, with large nuclei and a small amount of protoplasm,
having ameboid characters and furnishing material both for glia and nerve
cells. The cells which wander into the central nervous system from blood
and lymph channels, Kronthal includes under the terminology "neutral
cells." The possibility is maintained that central nerve cells may result
from such so-called neutral cells, and an experimental method is sug-
gested of injecting into the circulation substances which may be taken up
by the cells and later recovered in the nerve cells which the wandering cells
have ultimately constituted. The hypothesis is of interest, but demands
further experimental classification.

9. Simulation of Insanity. — From a wide experience relative to simula-
tion and mental disorder Schott draws the following conclusions : That
it is questionable whether pure simulation of mental disorder ever occurs
in the mentally sound ; that the simulation of mental disturbance is most
frequent among degenerates, and is a consequence thereof; that the
acknowledgement of simulation as well as the unmasking of the simulant
proves nothing for the mental health of the individual, and that in such
cases the expert must bring proof of the mental health of the defendant ;
that all difficult cases of simulation should be under expert observation in
a clinic, even if it requires more than six weeks of such observation to
reach a conclusion ; that in consideration of the degree of simulation the
underlying degeneration must be variously interpreted ; that the simula-
tion of mental disturbance does not necessarily lead to actual insanity ;
that there is no absolute characteristic of simulation ; and finally that a
thorough study of male hysteria is extremely desirable, and promises
much aid in the solution of the question of simulation.

10. Retrograde Degeneration. — Kolpin presents an anatomical study of
secondary degeneration in the pyramidal tract, and in the fillet resulting
from areas of softening in the oblongata. The point to which he draws
particular attention is the retrograde degeneration of certain fiber tracts,
both motor and sensory.

11. Heredity and Paresis. — In the discussion of heredity and predis-
position in general paralysis of the insane, Nacke seeks to establish the
following propositions: First, that hereditary taint plays a large role in
the genesis of paralytic dementia, and in the second place that in general
paralysis an inherited, more seldom acquired, and very probably a specific
brain" constitution exists in such a way that the victim falls a prey to the
disease more easily in the presence of syphilis or other causes. If these
facts be true, general paralysis is brought into closer relations with other
psychoses than formerly supposed. Admission is made that cases of
general paralysis occur without hereditary -taint, and that there are also
exceptions to the existence of a recognizable predisposition or degenera-
tion. This paper is followed by a bibliography of 164 references covering
the mooted points in relation to the etiology of dementia paralytica.

E. W .Taylor (Boston).

220 PERISCOPE

Miscellany

Betrage z. Casuistik d. Myoclonie bei Epileptischen. G. Weiss (Kiel
Dissertation, 1905).

In this little pamphlet we find described no less than eight hitherto
unrecorded cases. That so large a number of cases of a rare disease is
reported by a beginner in medical practice is accounted for by the fact
that the eight cases were evidently from the material of the epileptic
colony at Bethel, near Bielefeld. As we know of no other cases reported
from the material of this colony, the latter may perhaps be assumed to
represent the total morbidity of this associated disease in this well-known
institution.

The cases in brief are as follows :

1. Male. 16, no bad inheritance, nursed normally, no teething convul-
sions. In his third year had encephalitis, and as a result suffered greatly
up to fourteenth year with headache (often severe enough to provoke
hallucinations), and enuresis. When nine years old developed epilepsy, the
first attack due to fright. Seizures reappeared about once in two weeks.
About two and a half years later the myoclonus appeared as a complica-
tion of epilepsy. The myoclonic contractions were of progressive and
great severity, and the epileptic seizures seemed correspondingly em-
phasized.

When examined patient seemed healthy in body and mind, aside from
the chorea-like twitchings affecting the voluntary muscles. During the
observation period two epileptic attacks were noted, at night. The fre-
quency of the epileptic attacks at this special period of observation was six
to eight monthly.

This case antagonizes Unverricht's teaching that in myoclonic epilepsy
the convulsions are nol synergistic, while in chorea this result is the case.
In this instance the convulsions were not only symmetrical, but the
lightning-like rapidity ascribed to choreic cases was present here.

2. Girl, 10. Diagnosis : Epilepsy due to intra-uterine trauma. Epileptic
attacks began when child was three or four months old. Father neurotic
and tuberculous ; otherwise no hereditary data.

When first seen the patient exhibited no marked stigmata, but had con-
tinuous myoclonic convulsions. She seemed to be below the normal in
intelligence.

There was a history of certain crises which were more than myoclonic,
which resembled epilepsy and which seemed to be followed closely by
myoclonic attacks of such severity that patient must lie abed. Under the
observation period patient had one or two attacks per month of epilepsy,
which increased the violence of the myoclonus.

3. Girl seen in 1899, then three years old. Diagnosis of epilepsy and
idiocy. But little history. Mother said to have died of puerperal fever,
and a brother died of convulsions.

Examination showed an idiotic child with extremities, head and face
in constant movement. Under observation patient was seen to have
myoclonic movements which led up to general convulsions and uncon-
sciousness. An attack of pneumonia temporarily checked both conditions.
which reappeared with renewed severity during convalescence.

4. Male. 10. Heredity normal, gestation normal. On second day of
life seemed to develop a case of trismus, which did not kill child, and
which became chronic. At age of nine months typical epilepsy set in, al-
though something like myoclonus or chorea had been in evidence soon
after birth. A sister had died under same circumstances. Close inspection
of patient showed evidences of mental weakness, while contractures of
many voluntary muscles seemed to represent the result of myoclonus.
Attempts to oppose these contractures led to clonic spasms, both flexors
and extensors. The progress of the case showed abundant myoclonic at-

PERISCOPE 221

tacks, especially of the "intention" order, following attempts to speak, etc.
Psychical excitement produced the same result. During the observation
period no epileptic attacks are mentioned, but the myoclonus showed a
periodicity and an intensity which suggested the latter. At an earlier
period in the history pronounced epileptic attacks seem to have occurred.

5. Boy aged six. The author finally placed this case under the caption
of chorea electrica, mentioning it only because of the doubt as to diagnosis.
The boy probably suffered from encephalitis at an early age, and as a
result was backward mentally. After his brain fever he had numerous
convulsions of presumably encephalic origin. These crises only partially
resembled epileptic seizures ; they were as a rule preceded by general
twitchings. The latter were in nowise due to external influences. The
author, despite Unverricht's criteria, is disposed to regard this case as
one of myoclonic epilepsy.

This patient died of intercurrent pneumonia, and no autopsy was per-
mitted.

6. Girl aged 16. No hereditary taint. At three years had encephalitis
and rachitis. Then epilepsy developed at intervals of fourteen days, four
weeks.

When seen at age of 14, child was found normal in most respects.
Had begun to menstruate. After this period various attacks had been
noted, in part typically epileptic and for the rest myoclonic. With further
progress the myoclonus appeared to precipitate the epileptic attacks. This
patient was left with this status quo.

7. Male. At age of one and a half years began to stammer as result
of convulsion. At the age of 14 the spasms still persist, in part as typical
epileptic seizures and for the rest severe myoclonic convulsions. This
patient's condition was so interesting that considerable space is devoted
to the different types of convulsions. The speech disturbances correspond
with those described by Unverricht.

8. Male, first came under observation at age of 26. Not much early
anamnesis obtainable. Head shows many scars. From age of 17 had had
both kinds of convulsions ; viz. : myoclonic and epileptic.

When examined denied being an epileptic, although gave credible ac-
counts of myoclonic seizures. While under observation had typical epileptic
seizures.

In analyzing these eight cases author states that all had true epilepsy.
As for precedence, epilepsy was surely primary in case first and secondary
in case fourth, also in case sixth. Others not considered. The author
appears to contradict himself, assuming at the outset that all the eight
patients had myoclonus, but he seems to have been undecided about Case 5,
which he once speaks of as electric chorea. He does not return to this
case in summing up, and further states that chorea is so rare in epilepsy
that not one case was recorded in 2.000 of epilepsy.

Under the head of pathologic anatomy he first gives the results of the
work of Clark and Prout. He mentions Apathy and Kronthal on the
histology of brain-cells, etc., and appears to think them not compatible
with findings of Clark and Prout, although he is obscure on this point.

Muni is also quoted on this point. In three autopsies he could find no
alterations in Rolandic regions. Unverricht and Bresler also deny that
any anatomical basis exists for epilepsy. A thesis in 1903 by Foerster, in-
spired by Bresler, makes a point that the muscular movements do not
correspond with definite muscular co-ordinating centres in the cortex.
The present author quotes about two pages more from Foerster's thesis.
He closes by stating from Unverricht that a spinal origin would explain
myoclonic movements much more than a cerebral one. Author states
that his eight cases reveal absolutely nothing as to the cause of the disease.

L. Pierce Clark.

Book IReviews

In the Thirteenth Annual Report of the Craig Colony for Epileptics
at Songea, N. V.. it is seen that the daily average census of the colony

has increased from ygj to 1,046. About 350 cases arc low grade epileptic-,
that should be cared for elsewhere, thus giving more room for hopeful
cases. The total number of epileptics in New York State is about 16,000,
and 2,000 of these are of low grade. The Superintendent, Dr. Spratling,
says the number of epileptics is not increasing out of proportion to the
increase of population; but he estimates a higher ratio in the community
than the textbook ratio of 1 to 500. As to curability he quotes Dr.
I luchzemcier that 5X7 epileptics at Bielefeld have been cured since 1867,
and states that 5 per cent, at Craig Colony is their record. He pleads
for earlier admissions as affording far greater hope. The death rate from
tuln.rculo.sis alone in this and four other institutions for epileptics averaged
_'4 per cent. The general death rate from tuberculosis in New York State
is t> per cent. One-third of the deaths at the colony are directly due to
epilepsy. Forty-five cases of status epilepticus occurred, of whom six died.
The Superintendent advocates checks on the perpetuation and in-
crease of the detective classes by laws preventing their marriage. He
also suggests as a way to help check insanity, epilepsy (and perhaps drunk-
enness), in their incipiency, that the State appoint eight psychiatrists, one
for each judicial district, whose duty it would be to visit and assist in
the early treatment of such cases, subject to the call of any physician, or
poor person, or overseer of the pour, and paid a salary by the State. The
money thus expended would also, he thinks, be an ultimate saving to the
State, presumably by shortening the time of maintenance of such cases
in public hospitals or elsewhere.

.The pathologist reviews the intoxication theory of epilepsy and agrees
that changes are found in the toxicity of the blood and urine in relation
to the attack, with changes in the substances excreted in the urine, also
related to the attack. He agrees that there is less (even no toxicity in
some cases), between attacks, and that an attack seems to be associated
with an "unloading of stored poisons;" that there is hypertoxicity of the
blood and urine preceding an attack; and that the true nature of the
poison is unknown.

The existence of an organic pathology of the cortex, he thinks, is not
yel proven. "The study of epilepsy as a disease of the metabolism, pos-
sibly spontaneous within the nerve cell and possibly due to the action of
an intoxicant formed elsewhere in the body, is the line of work planned
for the laboratory (at Craig Colony), and is one which lias always seemed
to promise the greatest results in the end." C. E. A.

Uf.cer Storuxgex df.s Handeln bei Gehirxkraxkex. Von- Prof. Dr.

H. Liepmaxx. Privatdozent an der Universitat Berlin, Assist-

enzarzt an der stadt. Irrenanstalt in Dalldorf-Berlin. S. Karger,

Berlin.

Licpmann here contributes a short but highly suggestive monograph on

disturbances of action as a result of brain disease, lie pays particular

attention to the subject of motor apraxia concerning which he has written

so extensively.

Summarizing his study he says that disturbances of action as local
signs following the destruction of definite portions of brain substance may
be referred. (1) To paralysis or paresis: Abolition of movement or loss
of strength of same. (2) To ataxia : Mistakes in the measure of the

BOOK REVIEWS 223

Strength of the excursion, etc., resulting from the loss of the peripheral
kinesthetic derivations. (3) To loss of the kinesthetic ideas: A condition
not sharply differentiable from cortical ataxia-soul paralysis. (4) To
Agnosia ("sensory" Assymboly-Apraxia in the old sense) : A loss of
perception or recognition by intact sensations. The identification of the
fresh impressions with the memory pictures ceases, either by reason of the
loss of the letter (Wernicke) or by reason of a delayed combination of
both (Lissauer). (5) An indirect cause of disturbed action is the
qualitative or eventually localized lapse of confined sensations : Cortical
blindness, etc. The corresponding lapse for the kinesthetic areas is in-
cluded under 2 (Ataxia).

Between 1, 2, 3, on the one hand, and 4 and 5 on the other there lies
still (6) a motor (innervated) apraxia : The movement is not in accord
with the ideatorv process ; the cortico-muscular apparatus functionates
well, but is not in the service of the entire psychical processes. Not caus-
ing true focal symptoms, but conditioned by diffuse processes, eventually
as general symptoms in large lesions is (7) ideatory apraxia: The move-
ment is in accordance with the ideational process, but this in the end, dis-
turbs the design of the movement series, by transposing the main goal
idea to a secondarv or partial goal idea. Ideatory apraxia is probably a
part of a general "ideational disturbance. (Memory, attention, etc), and
allies itself mostly with Agnosia, eventually only with an ideatory agnosia.
He makes a differentiation in this work between motor apraxia, ataxia and
soul pralysis, and also enters more deeply into the consideration of the
symptom'of perseveration. His main contribution consists in the separa-
tion of a motor and an ideatory apraxia.

The work is one of great originality— schematic in the Wernicke sense
— but no one can afford to overlook it. Jelliffe.

Christianity and Sex Problems. By Hugh Northcote, M. A. F. A.
Davis Co., Philadelphia.
The wide extension of the discussion of sexual matters betokens the
demand of a curious public, whose erotic sensibilities have been much
stimulated in recent vears bv the press, the pulpit and the stage. 'Northcote's
contribution contains much that is new and little that is untrue, and for
many readers it will prove interesting. It has the advantage of being
modest and non-prurient, and its honesty of motive is unassailable. This
much cannot be said for all such similar volumes. Its chief interest lies
in its analogies and commentaries drawn from the Hebrew writings con-
cerning the relations of the sexes. On the whole, it is an excellent work.

Jelliffe.

Studies in the Psychology of Sex. By Havelock Ellis. F. A. Davis
Co.. Philadelphia.

Ellis makes another contribution to his growing list of studies. He
here deals with Erotic Symbolism, The Unchanism of Detumescence and
The Psychic State of Pregnancy. This terminates his series of studies
on the usual phenomena of the sexual process, and he promises a conclud-
ing volume — one on the general problem in its social relations or the
psychology of sex as interpreted in the light of social hygiene.

He includes under erotic symbolism all of the aberrations of the sexual
instinct, although many of the phenomena have been already discussed by
him in other volumes.

Exhibitionism-fetichism and like phenomena make up the early portion
of the volume. Here are discussed a number of well known phenomena,
and attempts are made at general explanations.

The phenomena of detumescence are taken up for the male and female
in the second portion. The variations in detumescence are inadequately
vet for the purposes satisfactorily handled. The third portion is an ex-

224 BOOK REVIEWS

tremely interesting summary of the psychology of the female during child-
bearing. Here are collected a mass of the strange psychical phenomena
attendant on pregnancy. They are rich in suggestion, although not
critically presented. The volume is on a par with the author's previous
contributions, showing his zeal and discrimination and his scientific
training. Jelliffe.

The Second Biennial Report of the Parsons State Hospital for Epilep-
tics, at Parsons, Kan., claims for Kansas that it is the only State in the
Union which has entirely separated the epileptic and non-epileptic insane.
The total number of epileptics in Kansas in estimated at 3,000. The num-
ber cared for in the epileptic hospital has increased in two years from 170
to 355- Very young children, low grade imbeciles and idiots, are not
received. Insane epileptics are committed by the courts. "Sane" epileptics
are received on voluntary commitment ; the latter cannot be detained
against their will ; and the Superintendent comments that the form of
commitment is not always an index to the patient's mental condition. As
regards marriage of patients prior to admission, lie found that 30.7 per
cent, of the men and 42.8 per cent, of the women had been married, and
that 12.6 per cent, of the men and 25.7 per cent, of the women had
married after the development of epilepsy. The "most important causes
of epilepsy" as tabulated, were "bad heredity, infantile palsy, peripheral
irritation, head trauma and alcoholism." The most frequent causes of
death found were organic heart disease, exhaustion, pneumonia and status
epilepticus. C. E. A.

Physician's Visiting List, for 1907. P. Blakiston's Son & Co., Phila-
delphia.
The members of the medical profession — and they are many — who have
learned to look for the issue of this small volume about this time of year
will not be disappointed in its annual appearance. The completeness, com-
pactness and simplicity of arrangement which have been its boast in the
past are as conspicuous as ever, and it is in every respect strictly up to
date. The strong and dignified binding, the appropriate size for carrying
in the pocket, the pencil always ready for memoranda, and the secure
pocket for loose slips combine to make it a very desirable part of the physi-
cian's equipment. Goodale.

Ueber Robert Schumann's Krankheit. Von P. J. Mobius. Carl Mar-
hold, Halle. 1906.

Mobius contributes another to his many series of biographical sketches.
It was held by the physicians who treated Schumann and by those who
performed the autopsy that he died of paresis, but Mobius has reviewed
the entire history and shows with much wealth of detail that this is
probably an incorrect deduction, and that even the pathological findings —
not microscopically controlled, as is so necessary — are not conclusive.

He believes that Schumann suffered from dementia prjecox, and this
small monograph practically proves it. It is interesting reading.

Jelliffe.

Vol. 34. April, 1907. No. 4

THE

Journal

OF

Nervous and Mental Disease

Original Hrttcles

THE DIAGNOSTIC VALUE OF LUMBAR PUNCTURE IN PSY-
CHIATRY.*

By J. L. Pomeroy, M.D.,

OF WARD'S ISLAND, NEW YORK CITY.

Following the work of Widal, Ravaut and others, system-
atic observations have been made upon the diagnostic impor-
tance of the findings obtained by lumbar puncture, in doubtful
cases at the Manhattan State Hospital. We give here the
results of one year's experience, and while it is too early in
many cases to state positively whether or not our inferences
have been correct, still there are enough in which the
diagnosis now seems reasonably certain, to enable us to
draw some conclusions.

While a great deal of work has been done upon this sub-
ject abroad, it has received little practical application in psychi-
atric work in American institutions. At our own hospital there
existed a great deal of uncertainty among the members of the
staff as to the exact status of the whole subject. On account
of extravagant claims of the value of the method in the diagno-
sis of paresis, and opposing statements in many instances, as
well as the admission that under certain conditions alcoholism
also produced a lymphocytosis, the real value of the method
was a matter of great doubt; therefore, when this investiga-

*To the memory of the late Dr. E. C. Dent is due the acknowledg-
ment of kindly encouragement and stimulation given at the commence-
ment of this work. To the members of the staff at the Manhattan
State Hospital, Ward's Island, New York City, my sincere thanks
are also tendered. I specially acknowledge the opportunities given
by Dr. L. C. Pettit and the assistance of Drs. Karpas, Hamilton, Wash-
burn and Conzelman. This paper was read in part at the annual meet-
ing of the Eastern State Hospitals Association held at the Hudson
River State Hospital, Poughkeepsie, May 18, 1906.

226 J. L. POMEROY

tion was commenced, very little weight was placed upon the
presence or absence of a lymphocytosis. Other factors which
contributed to the uncertainty of the evidence furnished by
lumbar puncture were the lack of definite knowledge concern-
ing the histogenesis of the spinal fluid in various states, the
origin of the cellular elements, deficiencies in the technique
of examination, and finally most important of all, the absence
of a sufficient number of autopsy reports upon cases studied
with a view to determine the bearing of the spinal fluid exam-
ination. In view of these facts, we determined to compare
our results with observers abroad and gain a more definite
knowledge of the practical use of the procedure. It became
necessary to study the cellular content in the spinal fluid of
syphilitics. and we have to thank Dr. Follen Cabot for the
privilege of his wards at the City Hospital. Except for these
cases all of the material was under our direct observation.
Nothing has been added to the histogenesis, nor have we im-
proved upon Ravaut's technique, but it is hoped that these
clinical studies with the accompanying autopsy reports will be
acceptable as an endeavor to aid somewhat in the better under-
standing of the scope and limitations from a diagnostic stand-
point, of lumbar puncture. In such a field of medicine as
psychiatry, where of all others ordinary clinical methods more
often- fail to reveal a diagnosis, certainly it is our duty to test
with greatest care any method which promises to add addi-
tional diagnostic data.

Primarily, is the question of technique. We have fol-
lowed as closely as possible the method of Widal and Ravaut.
Concerning the operation itself the details are well known ;
after obtaining the fluid, usually from 3 to 5 cc, it is centri-
fuged for 15 to 30 minutes in a conical shaped tube having a
very fine point. This latter assists very materially in hold-
ing the sediment while the supernatant fluid is decanted. The
speed of the motor should be as near 3,000 revolutions per min-
ute as possible. Even then Xissl claims that he is not sure that
all the cells have been precipitated. In our work, this is found
to be a sufficient speed, and practically the decanted fluid has
been thoroughly decellularized. After inverting the tube it
should be allowed to drain in an upright position until only a
very small droplet remains in the tip. With the tube held in

LUMBAR PUNCTURE IN PSYCHIATRY 227

such a position, a previously prepared fine glass pipette is
passed up the center until by capillary action the drop is
withdrawn. Usually it rises in the pipette from 3 to 4 mm.
This material is carefully divided into 3 equal parts on cover
slips or glass slides, taking care not to spread the drops. The
slides can be fixed either in equal parts alcohol and ether or
absolute alcohol, and are then stained preferably with Unna's
polychrome. Excellent pictures were obtained quite rapidly
without fixation by using Nocht-Hastings' blood stain, such
preparations gave very clear chromatin and nuclear pictures.
Crystalline bodies frequently obscure the field, but may be in
a great part removed by gently washing the slide in normal
salt solution after fixation. The slides are mounted in the
usual way and the specimen examined at first under a low
power. This should always be done in order to see if there is
a uniform distribution of the cellular elements; this acts as a
control over the oil immersion. The counts should then be
made with an oil immersion lens, taking Ravaut's figures as a
basis, the findings are as follows, normal 2 to 3 cells ; 5 to 6,
a suggestive reaction; 6 to 20, a moderate increase; 20 to 150,
positive. In many instances the counts in the 3 slides will dif-
fer, and the method we have followed is to take the average
of 100 fields selected from all three preparations. Slides con-
taining blood are unsatisfactory, and in this report have been
rejected. Ordinarily, however, where the lymphocytosis is
unmistakable, and a second puncture cannot be obtained, I
see no reason why the evidence should not be admitted. The
fluid should never be changed from the original receptacle
before it is centrifuged. The pipettes should be prepared
shortly before using by oneself, and the same technique should
be observed each time.

The differentiation of the cells is an extremely difficult
procedure. Artefacts are common, one finds flattened, folded
and peculiarly shaped cells which sometimes stain deeply and
again faintly, together with distinct types of lymphocytes,
large and small apparently mononuclear elements, occasionally
polyneuclear cells of the neutrophile type. Nissl makes the
statement that in 100 cell elements in G. P., 80 to 90 are lym-
phocytes, 5 to 15 mononuclear, 5 to 10 neutrophilic leucocytes,
and claims that he has never seen granulations in these cells

228 J. L. POMEROY

which compare at all to those which occur in the blood. This
is certainly true in our experience, the discussion of these
points, however, is foreign to the purpose of this paper, al-
though it is hoped that with new methods the study of these
cellular variations will aid greatly in the better understanding
of our present difficulties. There are many things still to be
explained, such as the appearance of, in one case, marked
polyneucleosis without physical cause, such as fever, the pe-
culiar types of large lymphocytes met with in syphilis, etc. In
our own work, it appeared to us that the elements were poor-
ly fixed, and in a great many instances the cells were of a
transitional type. This part of the study needs further obser-
vation and work.

The albumin test should always be performed. It has been
pointed out that the highest readings occur in cases of G. P.,
although it is not as constant as the cellular increase. The
two findings are not always parallel. From a large number of
observations it is suggested at the present time that the albu-
min content may prove as an indicator when the cellular ele-
ments are absent; this has actually occurred in Nissl's experi-
ence. A case twice punctured showed a positive albumin con-
tent and a negative cellular, at the third puncture, lympho-
cytosis was found.

The technique is simple. Mix equal portions of spinal fluid
and saturated solution of magnesium sulphate in the cold and
filter, this removes the globulin which is present normally
in from two-tenths to one per cent. (Skoczinsky.) Now the
filtrate should be boiled and if normal it remains clear, the
appearance of opalescence indicates the presence of serum
albumin, which is abnormal. Quantitative tests were not
carried out systematically and in this report the varying de-
grees of opalescence only will be mentioned, following Nissl.
Tests for the copper reducing body, cholin, etc., are not in-
cluded in this report.

In consideration now of the causes of lymphocytosis in the
spinal fluid, we enter upon a very difficult phase of the sub-
ject. We recognize that inflammatory changes having a
known bacterial origin (meningitis, etc.) can be differentiated
with due care, and it is the slowly progressing changes of un-
certain causation that occupy our attention. Even concerning

LUMBAR PUNCTURE IN PSYCHIATRY 229

these, of a surety we cannot deny a bacterial origin ; as yet,
however, the character of cellular content does not enable us
to point out anything more than processes. Quincke is re-
sponsible for the statement that certain infectious diseases
such as typhus, scarlatina, pneumonia, sepsis, and many febrile
diseases, with manifestations of involvement of the central
nervous system, cause a high pressure and sometimes increase
cellular content. Gross changes are often absent, and the
fluid is of a pure serous appearance. Such conditions are ex-
plained by stating that there have been found in certain cases a
few bacteria of low virulence, but he admits in the majority
of cases the conditions are produced by the irritation of the
meninges and the central nervous system of a systemic chem-
ical toxin. The lymphocytosis which has been found in herpes
zoster, in chorea, heat stroke, multiple disseminated sclerosis
and mumps has not been sufficiently reported upon to enable
one to draw any conclusion. These conditions, however,
should be kept in mind, they are explained as mentioned upon
a bacterial basis or upon the theory of chemical irritation.
There is still another factor which is to be considered, name-
ly, pressure due to increased secretion. In cases of hydro-
cephalus, uremia, brain tumor, etc., a slight cellular increase
has been observed and attributed to pressure influences. It is
more than likely that there is a combination of causes.
Trauma to the skull or spinal column has also been found to
excite a lymphocytosis and without necessarily causing a
hemorrhagic discoloration. In certain cases of mental dis-
turbance resembling the early state of paresis where trauma
has recently occurred, such a lymphocytosis is extremely dif-
ficult to interpret, especially is this true where alcoholism has
been a factor. The absence of albumin increase and the degree
of cell content are of assistance, but further work upon these
cases is necessary. Finally, lymphocytosis bears a most direct
relation to syphilitic infection, and this of all other factors
plays the most important role. For a correct interpretation
then, it is necessary to consider the studies upon this subject.
The intimate relationship between syphilis and diseases of the
nervous system requires a most thorough investigation of this
disease and the spinal fluid.

230 /. L. P0MER0Y

SYPHILIS.

Observations have been made upon the spinal fluid in all
stages of the disease. Ravaut punctured 82 cases with active
secondary lesions. In 54 there was a cellular increase, in
28 the fluid was negative; in general, there was a slight albu-
min increase. In only 18 was the increase as large as occurs
in general paralysis. There was some cellular increase in 67
per cent. None of his cases showed besides headache, any
symptoms from the central nervous system. His conclusions
are that the lymphocytosis in secondary syphilis varies directly
with the intensity or persistence of the skin lesions. In other
skin eruptions unless there were complications in the nervous
system no changes in the spinal fluid were found.

Ravaut reports positive results in 26 cases of secondary
syphilis; in tertiary syphilis even when the skin lesions were
marked the fluid might be normal. In such cases he did not
find a lymphocytosis until symptoms of involvement of the
nervous system occurred.

Widal obtained negative results in 10 old syphilitic cases
in which there were no specific or nervous manifestations.
Fuchs and Rosenthal summarized their work in 1904 as fol-
lows : In 403 patients suffering from disease on a syphilitic
basis 94 per cent, gave a lymphocytosis. In 272 other cases
with nervous disease on a different basis only 6 per cent, gave
a positive result.

Le Maire examined 13 cases of suspected syphilitic hemi-
plegia, and 12 showed a lymphocytosis. The ordinary type of
apoplexy of a non-specific nature gave negative results. Chauf-
fard and Boidin confirm these views and also claim that they
are able to differentiate hemiplegia due to meningeal hemor-
rhage from that caused by central lesions, because of the pres-
ence in the former condition of discoloration and contamina-
tion of the spinal fluid with red blood cells.

Our findings in syphilitics are as follows: In 15 cases in
the City Hospital with well marked secondary lesions,
lymphocytosis was decided in 5, in 6 there was a moderate re-
action, in 1 a slight increase, while in 3 the results were nega-
tive. The 5 cases with positive reaction suffered intensely
with headache, but there were no other symptoms of involve-
ment of the nervous system. In 5 of the cases also, Dr. Flex-

LUMBAR PUNCTURE IN PSYCHIATRY 231

ner had demonstrated the Spirochitpe of Schaudin. The cases
were all under active mercurial treatment and presented
marked cutaneous symptoms. In 1 there was iritis. From this
small series then, the lymphocytes were increased in 80 per
cent. The 3 cases with negative findings showed well marked
secondaries and a faint trace of opalescence, but no lympho-
cytosis was found.

Of the tertiary lesions, 5 cases, all of whom had symptoms
of nervous involvement, were punctured ; there was a case of
facial paralysis, one of third nerve paralysis, another with a
gummatous basilar meningitis with choked disk, a case
of supposed svphilitic meningitis of the convexity of the brain,
and finally a patient who was supposed to be suffering from a
syphilitic endarteritis. All of these cases showed a marked
increase in pressure and lymphocytes, with a slight opales-
cence. Two of the cases are of special interest, one because of
the early nervous involvement and the second, because of a
critical autopsy review.

The first case, which I wish to report, was a man of some
thirty years, who entered the City Hospital with a syphilitic
secondary in May, 1905. During his treatment he developed
strangulation of a large hernia, and the latter part of May he
was operated upon for this condition. At that time he had a
fading secondary manifestation ; recovery from the operation
was prompt and he, remained in the hospital during conva-
lescence. During July he began to suffer with constant intense
headache, vertigo became marked, there was some ataxia, and
at times confused orientation. Later he had attacks of vomit-
ing. Examination of the eyes showed a right choked disk, the
right pupil dilated and irregular, but active, with equal and ex-
aggerated knee-jerks. The spinal fluid showed enormous pres-
sure, a very positive lymphocytosis and a trace of opalescence.
The early development of the symptoms following secondary
lesions1 brought up the possibility of a brain tumor. The find-
ing in the spinal fluid, however, was decisive for brain syphilis,
as was afterwards proven by the prompt recovery of the pa-
tient under thorough specific treatment.

In order to understand thoroughly the application of spinal
lymphocytosis, investigations should be carried on to deter-
mine how often lesions of a tertiary syphilitic nature involv-

232 /. L. POMEROY

ing tissues other than the nervous system are capable of pro-
ducing a lymphocytosis. We had one experience which
shows the necessity of further work upon this line. A patient
who was suffering from a gummatous syphilitic lesion of the
skin developed convulsions and coma, accompanied by symp-
toms which brought up the differential diagnosis of epilepsy,
uremia, spinal meningitis and cerebral syphilis. The pro-
found stupor and absence of previous attacks were against epi-
lepsy. The urinary findings, the absence of edema, made it
appear that the renal functions were active. The febrile symp-
toms being of a mild character and the absence of the diplo-
coccus in the spinal fluid were against spinal meningitis,
therefore, with the presence of a tertiary syphilitic infection
cerebral involvement was very probable. The spinal fluid
showed an enormous lymphocytosis and the patient was im-
proving under potassium iodide, when she died suddenly in
convulsions.

The microscopical examinations failed to demonstrate any
syphilitic changes in the vessels of the brain. Dr. Oertel,
pathologist at the City Hospital, found no changes of an infil-
trative nature in the meninges, and Dr. Rusk in the sections
examined found the brain and meninges normal. There was
marked chronic interstitial nephritis, edema of the lungs,
chronic valvular endocarditis and atrophy at the base of the
tongue. The anatomical cause of death was chronic nephritis
and edema of the lungs.

As the puncture was made for diagnostic purposes and
seemingly corroborated the suspicion of brain syphilis, the in-
ability to demonstrate changes in the meninges or brain sub-
stance, leads us to a consideration of the theories regarding
the causation and pathology of lymphocytosis. I am not ig-
noring the fact that in uremia lymphocytosis has been found
and attributed to pressure, but the increase in cells is usually
extremely discreet, while in this case it was enormous. In a
case of chronic hydrocephalus of long standing two punctures
were made. The first showing an average of 8 cells, the second
of 15. In such a case the observations of Quincke go to show
the presence of demonstrable chronic ependymitis. Thus
pressure is not the only producing factor. I am also aware
that infiltrative processes in the meninges are extremely easy

LUMBAR PUNCTURE IN PSYCHIATRY 233

'to overlook, as a prolonged search in one of Dr. Nissl's cases
revealed evidences of such which at first was not apparent,
nevertheless, a reasonable search was made and we must base
our conclusions upon the facts as they stand.

The French authors agree that lymphocytosis is to be taken
as a manifestation of meningeal irritation. By some, it is also
stated that, "Every meningeal irritation produces a lympho-
cytosis, and that by this symptom many otherwise clinically
unrecognizable meningeal changes can be diagnosed." Nissl
is of the opinion that such statements are merely proof of our
complete ignorance of the subject. Quincke, however, believes
that such cases as mentioned form the transition into actual
serous meningitis, which appears with pressure symptoms.
'Concerning the cases with symptoms of meningeal irritation
without anatomical evidences of inflammatory changes, he
regards these symptoms as resulting from a chemical toxin
acting directly upon the central nervous system.

Merzbacher has contributed some valuable observations

upon the question of meningeal changes. He investigated the

spinal fluid in 26 patients who were beyond doubt syphilitic,

but were suffering from psychoses upon a different basis. The

"history of infection with the manifestations is given in detail

with the mental diagnosis. In none of the cases were there

symptoms from the central nervous system which were not

'demonstrated as resulting from disease processes which are

Tiot productive of lymphocytosis. There were four such cases,

in three it was evident from the autopsy, and in one from

clinical examination the exact nature of the lesion.

He claimed that the French theories were entirely too
hypothetical, and his conclusions were as follows : He found
23 of the cases gave an absolutely positive result; in two it
was doubtful, in one only was it negative ; thus in 89 per cent,
an increase of lymphocytes was demonstrated. As a rule the
increase was far behind that observed in paresis, and very
noticeably albumin was present, in only one case.

The autopsy examinations were as follows : One case
showed marked arterial sclerotic changes in the brain. In
■one a large internal hemorrhage was present, while in the third
a deep-seated cerebral carcinoma was found. The meninges
"were carefully examined and were found to be perfectly nor-

234 /. L. POMEROY

mal. The following" is his conclusion : "In nearly all cases syph-
ilitic infection led to an increase in the cellular elements in the
spinal fluid, and this occurred when no clinical signs of
changes in the central nervous system or pathologically in the
brain coverings could be demonstrated." Therefore, as a gen-
eral chemical toxin syphilis is capable of producing a lympho-
cytosis.

Xissl endeavors to throw some light upon this part of the
subject in the following manner: "One of the most important
points in the whole question appears to me to be the knowl-
edge of the exudative meningeal processes on the one side,
and the hyperplastic conditions without cell exudate on the
other, and the relation these conditions bear to the cerebro-
spinal fluid. In circumscribed meningitis when the arachnoid
remains intact no changes in the spinal fluid occur."

Again, "In the hyperplastic form of meningitis with no
cellular exudate, no changes in the spinal fluid was observed.
Where a lymphocytosis has been present, prolonged search may
reveal changes of an exudative nature." He cites a case
which gave the general picture of acute nervous dis-
ease of a peculiar type — the diagnosis of tuberculous menin-
gitis being made but was not clear. At autopsy no
changes of an inflammatory nature were at first observed and
the lymphocytosis could not be accounted for. Later, marked
acute cortical cell changes were found microscopically. While
after prolonged search the soft coverings of the brain showed
exudative changes. On the other hand, in senile dementia,
where the pure hyperplastic type of meningeal changes are ob-
served, the spinal fluid is negative. Again, of no less import-
ance it appears to me to separate the inflammatory gummatous
exudative type of meningeal changes, and other circum-
scribed tumor formations from the non-inflammatory form of
brain syphilis. In the latter type we have a syphilitic disease
of the vessels at the base with results of a nature such as
softening and hemorrhage. At the same time meningeal
thickening of a hyperplastic type may occur.

According to Nissl's investigations, the inflammatory form
of brain syphilis shows the same cytologic and chemical
findings as most of the paralytics. Those singular cases of
non-inflammatory brain syphilis, however, show only a slight

LUMBAR PUNCTURE IN PSYCHIATRY 235

cellular increase and often no albumin. Whether this is cor-
rect, only a large experience with autopsy material will show.
The relatively few elements then speak more for the non-
inflammatory form of brain syphilis, but will not enable us to
differentiate those cases of general paralysis which show only
a slight cellular increase. The usual presence of large albu-
min content in general paralysis, however, is of value. Thus
we cannot be too cautious in interpreting small augmenta-
tions of cells, and in all cases the albumin content should be
recorded. Merzbacher also, is of the opinion that by such
means a quantitative differentiation is possible between brain
syphilis and general paralysis. Probably a further differential
study of the cells themselves may offer some help, and as yet
our technique does not permit us to do this very accurately.
(A persistent negative finding then is of more value for
diagnostic purposes than a suggestive or large increase.)

The following case illustrates the difficulty in differentiat-
ing between cerebral syphilis and general paralysis. The pa-
tient had one attack of an alcoholic psychosis in 1904, and at
that time presented the physical symptoms usually associ-
ated with acute alcoholism, besides these she suffered greatly
from headache and vertigo and her pupils were small, unequal
and irregular. An error in refraction was supposed to be the
cause of her pupillary signs. The patient gave evidences also
of a fairly recent syphilitic infection. She left the hospital in
January. 1905, as alcoholic psychosis, recovered.

She was readmitted in June, 1905, showing poor memory
for recent events with marked tendency to fabrication, and
marked depression. During the following four months she
developed progressively symptoms of involvement of the sev-
enth, the eighth and finally the third nerve on the right side;
her headache was most intense and she suffered greatly from
vertigo. Besides the physical symptoms mentioned, were
exaggerated knee-jerks, and slight tremor of the hands. The
patient improved under iodide of potassium, and paralyses dis-
appeared entirely save for a right internal ophthalmoplegia.

In June, when the case was first examined, and before the
onset of the cranial nerve symptoms, a spinal puncture showed
a positive result, and the case was regarded as one of very
probable paresis. However, there was no albumin increase in

226 J. L. POMEROY

the fluid. The further course of the case makes the diagnosis
of cerebral syphilis more probable. It is to be pointed out that
while the lymphocytosis gave evidence of the existing syphi-
litic disease, and coupled with the headaches and vertigo was
an indication of the developing cerebral involvement, it did not
enable us to exclude the possibility of paresis. Perhaps the
absence of albumin may serve as a differential point. Of this,
however, we are not sure.

We have had under observation also a remarkable case of
a very unusual type of cerebral syphilis, where the onset with
foolish purchases, memory defect and convulsive attacks,
made the diagnosis of paresis extremely plausible. The
•diagnosis of epileptic insanity was also considered for a time,
Decause of the rather typical convulsive symptoms. Early in
the development of the case was pronounced headache, while
physical examination showed exaggerated knee jerks and un-
equal pupils ; mentally were slight memory defect, uncertain
orientation and slight speech defect, with a persecutory trend
■of ideas ; spinal lymphocytosis was present, and the diagnosis
•of paresis was almost certain.

The patient developed, in the course of a few months,
marked aphasia and evidences of periostitis above the left
zygoma, and evidences of irritation of the motor area on the
left side; double optic neuritis was present. (The details of
this case will be published later and I give only the important
points from the standpoint of the lumbar puncture.)

On entrance into the hospital, the first puncture gave only a
■slight increase in cellular elements (5-6). A month later, with
the development of the aphasic symptoms and symptoms of in-
■creased cranial tension, a second puncture showed a marked
lymphocytosis (20-30). The patient was then placed on active
specific treatment and in a period of three weeks her im-
provement was most remarkable. A puncture some four weeks
after commencing treatment showed that the lymphocytosis
"had decreased (6 cells). The patient has since been dis-
charged from the hospital in a great measure perfectly recov-
ered. There is still a slight speech defect which may be resid-
ual from her lesion in Broca's center, and a slight reddening
of the left optic disc. There was practically no albumin in-
crease in this case, as in the previously mentioned patient. It

LUMBAR PUNCTURE IN PSYCHIATRY 237

is to be pointed out that unless this sign proves to be a con-
stant one, we have no way of differentiating from the spinal
fluid between paresis and cerebral syphilis. There seems to-
be, however, a not quite as great an increase of cellular ele-
ments in syphilis as in paresis. The diminution in cellular
content in this case, following specific treatment, is note-
worthy.

There is another class of difficult cases in which lumbar
puncture is of diagnostic assistance. I refer to those cases of
syphilis in early life with arrested development. In one case
the diagnosis of acute mania excitement in an imbecile had
been made. The further course of the disease, the develop-
ment of the physical signs, with rapid, tremendous mental de-
terioration, with a spinal lymphocytosis suggests strongly
the diagnosis of juvenile paresis.

In another instance, where the diagnosis of congenital in-
feriority was suggested, the presence of optic atrophy, loss of
hearing in the left ear, exaggerated knee-jerks, double ankle
clonus, right Babinski, tremor of the tongue and hands, with
defective speech, together with a spinal lymphocytosis,
showed that the underlying cause of the patient's condition
was syphilis of the nervous system.

I have yet to mention the results of spinal puncture in
several cases, with undoubted evidences of past syphilitic in-
fection. In two cases of manic depressive insanity we ob-
tained an absolutely clear history of syphilitic infection. One
seven years previously, and the other three years.

There were no symptoms of the involvement of the central
nervous system and the spinal puncture was negative in two
separate examinations.

In one case of psychosis of a senile type with an indefinite
hemiparesis of the face, sluggish pupils, coarse tremor of the
hands, with a certain amount of ataxia and speech defect, there
was absolute evidence of an old syphilitic infection. The
spinal puncture was twice negative. The condition then was

*This patient has since returned to hospital because of foolish con-
duct. Physical signs remained as when discharged, but patient now shows
very distinct gTandiose ideas and memory defect. Lumbar puncture
shows a large increase of cells and albumin. Case is regarded as belong-
ing to a rare combination of tertiary syphilitic brain lesions, along with
paretic changes.

238 /. L. POMEROY

of arteriosclerotic origin with syphilis merely as a passive
agent.

Still another patient presented a depression of a long dura-
tion with a certain amount of deterioration — tremor of the
hands and face and exaggerated knee jerks. There was an old
syphilitic necrosis of the frontal bone and a specific ozena.
The lumbar puncture was negative. The case has been classi-
fied as an alcoholic psychosis.

In another case of alcoholic history, there was a clear syph-
ilitic history of some 6 years previous. The patient presented
exaggerated knee jerks, tremor of the hands and tongue, with
marked emotional deterioration. There was a persecutory
trend, peculiar elation and active hallucinations. The lumbar
puncture was twice negative.

I mention these cases because of the fact that although
there had been undoubted syphilitic infection, yet lymphocy-
tosis was absent, and this demonstrates an exception to Merz-
bacher's conclusions and shows that there exist patients who
have suffered syphilitic lesions of tissues other than the nerv-
ous system, and still give normal reaction in the spinal fluid.
This is a point of some importance, since in the cases mentioned
a positive result would certainly have led us into the conclusion
that the central nervous system was syphilitically affected. An
autopsy has been held on one of these cases and showed no in-
volvement of a specific nature in the central nervous system.
A negative finding then in a case with a syphilitic history is
almost certain evidence that there is no involvement of the cen-
tral nervous tissue, and in cases where brain syphilis is clinical-
ly to be diagnosed, a persistent negative lumbar puncture
should make us look for some other etiologic factor.

Another case which has some bearing upon the question of
syphilitic disease of the non-nervous tissues is the following:

M. W., a woman of thirty-four, presented a psychosis com-
mencing with an inability to hold positions formerly occupied
satisfactorily, and four months ago had an attack of alcoholic
delirium, following which she showed a persistent indiffer-
ence, loss of memory and grasp. On entrance she showed
marked irritability of the emotional tone, imperfect orientation
and considerable paucity of thought. Physically there were
exaggerated knee jerks, fine tremor of the tongue and hands,

LUMBAR PUNCTURE IN PSYCHIATRY 239

slight jaw jerk ; pupils irregular but active ; old and recent
typical specific scars on the legs, several of which had become
chronically ulcerated.

There was a marked history of alcoholism ; the ulcerations
began seven years ago, and six years ago the patient had a
necrosis of the middle turbinated bones. The diagnosis was
obscure and the symptoms in favor of paresis not conclusive
because of the marked alcoholic history. The presence of an
old tertiary lesion also was confusing. The lumbar puncture
was entirely positive both to albumin, which was very marked
and cellular content. The mental deterioration and the phys-
ical signs with the results mentioned make the diagnosis of
paresis undoubted. It has not occurred in my experience to
obtain such a marked cellular and albumin increase in tertiary
skin lesions, and in this case with the presence of physical signs
I believe that we may interpret the findings as showing an
active deteriorating process in the nervous system.

In connection with syphilis, I would mention here, three
cases of hemiplegia. In one case there was acute apoplectic
symptoms, and on account of a severe chronic endocarditis,
embolism came into question. There was a suspicious history
of syphilis and considerable arteriosclerosis. A positive
lymphocytosis in this case points to syphilitic endarteritis. In
two other cases the hemiplegia was of some years' dura-
tion and had improved under potassium iodide. Both of these cases
gave positive results, these facts are of importance in enabling
us to differentiate these cases from certain purely senile
changes which are not directly due to syphilis. In senile de-
mentia and changes due to non-specific arterial lesions the
spinal fluid is negative. We have had several cases where this
point was of value. In one case the patient was about fifty
years old, of markedly alcoholic habits and following the com-
mencement of epileptiform attacks she developed the mental
deterioration with a motor aphasia. The duration of the condi-
tion at entrance was two years, her psychosis commencing
about two months after the onset of the convulsion. There
were no very definite neurological symptoms. It was stated, how-
ever, that she had before entrance weakness of the right side
of the body; the convulsions were quite general; pupils react-
ed fairly well; knee jerks- equally exaggerated; slight tremor

24o /. L. POMEROY

of the hands and slight Romberg. The diagnosis was to be
made between pachymeningitis interna, senile sclerotic
changes, paresis and a syphilitic arterial condition. The
presence of the recurrent convulsions and the aphasic state
with alcoholism as a factor were very much in favor of pachy-
meningitis. The spinal puncture showed a reaction of from
20 to 25 cells. The diagnosis remains in doubt, but certainly
we can be assured of a specific arterial change. Paresis, how-
ever, cannot be absolutely ruled out, as an autopsy on such a
case recently which was regarded as a senile psychosis re-
vealed a paretic brain. (G. Y. Rusk.) In reference also to*
the hemiplegic episodes, lumbar puncture is of value in dif-
ferentiating those cases of .deterioration following apoplexy
and the hemiplegic attacks which occur during the course of
paresis.

A case recently entered the hospital where the first symp-
tom of the paretic process presented two years ago with a right
hemiplegia which improved greatly in two months. It was a
question whether or not her psychosis could be the result of
an apoplexy. Physically, her age was forty, good nutrition,
weakness in the right arm and leg, tongue protruded toward
right; knee jerks much exaggerated; pupils unequal, react
slowly to light, right pupil larger than left, slight Romberg,,
tremor of the facial muscles; in walking drags her right leg.
No Babinski or ankle clonus.

The mental deterioration had not become advanced enough
to necessitate her commitment until a year and a half after the
stroke, and was not very general ; there was some loss in
grasp and knowledge ; the patient was dull and the memory
defective for recent events ; retention and orientation imper-
fect. There were no delusions or hallucinations. Such a pic-
ture is not uncommon in organic brain disease following hem-
orrhage or softening. The lumbar puncture showed a quite
marked positive result, 25 to 50 cells in a field with a marked
opalescence. With the presence of speech defect and hand
writing defect our diagnosis of paresis is clear. We cannot
rule out the arterial changes due to an active syphilitic pro-
cess, especially, because of the acute onset, but the slow prog-
ress of the disease, and particularly the speech and hand writ-
ing defect, with the marked albumin content, are points

LUMBAR PUNCTURE IN PSYCHIATRY 241

against a pseudo-paresis from tertiary syphilitic changes ; there
is nothing definite in the history of the patient regarding
syphilis.

Another instance which shows the importance of puncture
in these cases is the following. A woman of some seventy
years, who had previously been normal, developed delusions
of grandeur, became silly and childish in her talk and showed
poor memory and orientation. Alcoholism was denied; pa-
tient had had four miscarriages. Physical examination showed
a woman with marked symptoms of senile change; a fine
tremor of the hands and facial muscles ; spastic irregularity of
the pupils and absent knee jerks ; the knee joints were enlarged
and there was considerable exostosis on the inner condyle of
both femurs, on movement there was considerable grating
and the cartilages were relaxed. There was practically no
fluid accumulation and there was some external bowing.

The diagnosis of senile dementia was made as the most
probable condition on account of the physical signs, however,
a puncture was suggested. We were surprised to find a tre-
mendous cellular reaction (100 to 150) and a marked opales-
cence. We are forced to conclude that the most certain
diagnosis is that of tabes of long duration with final dementia
with the presence of Charcot joints.

In this next case the question of tabo-paresis, tuberculosis
of the spine and tumor of the spinal cord came into question.

An Italian woman of thirty-three presented an indefinite

*This patient has since come to the autopsy table and shows that our
conclusions were justified, at least, as to the nature of the process.

Sections examined from anterior and posterior central, first frontal
and angular regions and also from cerebellum show pial and perivascular
infiltration with lymphocytes and plasma cells and an occasional mast cell
is observed. The cerebellar pia is similar, but with infiltration of less
degree.

All the areas show a moderate increase of glia overgrowth, some few
of the cells presenting pigmentation ; the nerve cells themselves are not
excessively pigmented, but there is great pigment accumulation in the peri-
vascular sheaths and much evidence or phagocytosis in relation to the
pigment, in which process, however, the plasma cells appear to take no
part. There is general thickening of the walls of the arterioles with hya-
line degeneration and occasionally small foci of rarification of brain sub-
stance with the presence of compound granular corpuscles. In a few
areas in the frontal region there is an excessive number of vessels present.

Rod cells are to be seen in frontal and angular regions, especially.

Diagnosis — General paralysis with arterio-sclerosis of terminal vessels.
Note on Examination of Cortex, Autopsy 279. G. Y. Rusk, Pathologist

242 /. L. POMEROY

mental disturbance with a peculiar contracture of the adduc-
tors of the thigh, fine tremor of the hands and absent knee-
jerks. Insanity was present in the paternal side of the house,
form unknown. Husband gives suspicious history of syphilis
having had a sore eight years ago, no secondaries. Patient
has had one miscarriage and four normal children. She was ex-
tremely illiterate, had earned a living as a seamstress until
five vers ago. when she was married. Four years ago the pa-
tient bruised her left shin and it has been sore ever since. She
refused to use any medicine and during the past year has failed
in general health. Four months ago began to complain of
pain and stiffness in thighs and had difficulty in walking. A
month after this trouble commenced, she had one epileptiform
convulsion ; she took to the bed. became extremely talkative,
irritable, irrational, thought she was pregnant because of a
queer feeling in the abdomen, and was sent to the hospital.

P. S. C. A small, very thin Italian woman, showing pecul-
iar spastic gait, holding thighs stiffly, bringing feet down flat,
extension of thighs good, abduction limited and flexion on
abdomen can be accomplished only by much pressure and then
only about 120 degrees. On the left leg at middle third was a
large partly healed ulcer which consisted in three adjoining
indolent surfaces with thickened edges and much connective
tissue infiltration. The outlines were irregular and while the
lesion extended transversely across the middle third of the tibia
the ulcerated surface was quite small. The scar tissue was of
a bluish imperfectly formed material. At the lower third of the
thigh was a small (2x1 cm.) puckered scar just at the inner
margin of the quadriceps. The knee jerks were absent;
Achilles present. The hip joints were not tender to direct
insult: the adductors stood out stiff and taut; there was noth-
ing abnormal in the pelvis, the lower abdomen was prominent
and there was a little tenderness over the right iliac fossa.
Examination of the chest showed a little tenderness around
the right base and a few persistent moist rales. The muscles
of the calves were much wasted, but perfectly equal.

Mentally the patient was garrulous, irritable, and peevish,
again smiling and good-natured. Her memory was poor ; grasp
indifferent : orientation defective ; no delusions or hallucina-
tions.

LUMBAR PUNCTURE IN PSYCHIATRY 243

The diagnosis of a double psoas abscess of tuberculous origin
was considered. The leg condition and presence of the healed
sinus were very suggestive. The absence of temperature
changes, the inability to demonstrate any changes in the spinal
column, and the rarity of a perfectly symmetrical condition
from such a process make this diagnosis very improbable.

The symptoms could be explained on the basis of a tumor
of the spinal cord, but the absence of sensory symptoms and
the fact that the knee jerks were absent were against this con-
dition. Alcoholic neuritis was another possibility, but alcohol
was absolutely denied. The diagnosis of the tabetic type of
paresis was made because of the absence of the knee jerks, the
history of possible syphilis in the husband, the evident syphi-
litic infection in the patient, the occurrence of a convulsive
attack, tremor of the hands, static ataxia and mental deteriora-
tion. The pupils, however, were normal ; the ulceration ap-
peared to be more tuberculous in nature than specific, the
syphilitic infection in the husband was not established, and
the spasticity of the thighs occurring within four months from
the onset of the disease were facts which could not be entirely
explained on the basis of a tabetic process. The patient has
not had a repetition of the convulsive attack. The diagnosis,
however, could not be absolutely ruled out. The lumbar punc-
ture was now performed and the spinal fluid was perfectly
normal. With this additional evidence then we are certainly
justified in ruling out the diagnosis of paresis. The exact
status of the case still remains somewhat in doubt. Patient
has been under large doses of iodide of potassium for a long
time without much improvement.

Closely connected with these cases are the epileptic states.
In several cases where a positive result was found, Nissl was
able to demonstrate at autopsy, non-inflammatory brain syph-
ilis. The findings in epileptic cases are usually negative, and
this point is of great value since we meet many cases with
epileptiform attacks which render the diagnosis of paresis
extremely probable. In three cases of epileptic psychosis we
found two negative and one positive. In the latter case there
were exaggerated knee jerks, weakness upon the right side of
the face, and a history of syphilitic infection. The finding in
this case then is easily explained, and points to a syphilitic

244 /■ L. POMEROY

basis for the epileptic attacks. In several other doubtful case*
the question of epilepsy and general paralysis was difficult to
decide. A negative finding was of great value, in two punc-
tures in a patient of twenty-three, who had suffered convul-
sions for two years and showed besides a memory defect, slight
elation and unequal pupils. Similarly in a woman of forty,
who presented deterioration, with diminished cutaneous sensi-
bility, exaggerated knee jerks, general tremulousness, but nor-
mal pupils, with a history of suspicious miscarriages (also
scars on back), a negative finding which was twice obtained,
has given us the needed assurance that we were not dealing1
with paresis. An anamnesis recently obtained has developed
facts which make the diagnosis of dementia praecox the most
probable one.

Now to the consideration of the results of spinal puncture
in paresis. We punctured 30 clinically clear cases, and upon
22 of these the punctures have been repeated several times.
In every instance positive results were obtained. The albumin
content showed a marked opalescence in every examination,
and the highest amount was 5.2 by Nissl's tube. Micro-
scopically the fields in many instances were literally covered
with cells, many of which we were unable to classify. Differ-
ential counts were extremely unsatisfactory. The pressure in
all cases was quite marked, the fluid literally spurting from
the canal.

The Argyll-Robertson pupil was absent three times, once
in a tabo-paretic and twice in the cerebral type. Syphilis
could be proven absolutely in only nine cases, in seven it was
suspicious, while in fourteen the evidence was entirely nega-
tive; practically then 50 per cent, were syphilitic by the
records, while the results of the spinal puncture point to
syphilis in all.

Regarding this point we must naturally think of the trau-
matic origin of certain cases. Two cases gave a history of
trauma, in one, however, it was found that the psychosis de-
veloped before the fall ; in the other the patient did not develop
symptoms until one year after the accident. We cannot there-
fore conclude anything from these cases. But we should re-
member that trauma to the head or spine, if severe enough,
may produce a cellular increase in the spinal fluid.

LUMBAR PUNCTURE IN PSYCHIATRY 245

Lymphocytosis is one of the earliest and most constant
signs of paresis. It appears before the memory, eye and ataxic
symptoms (Jaffroy, Marie and Duflos). I have collected the
findings in 500 cases containing the results of 14 different ob-
servers. Of these 500 punctures only 18 give negative results.
Many of the cases (the latter) were punctured once only, in
two (Dana) the fluid was transferred from the test tube to
the centrifuge tube, and in three other cases although clinical-
ly they were considered as general paralysis, the autopsy
showed them to be chronic alcoholic. These five cases then
may be disregarded. The percentage then of negative results
which one might expect from our present technique is 2.6. If
we count the doubtful cases it is 3.5. Considering the individ-
ual equation as regards technique I believe that this percentage
is a remarkably low one.

The importance of repeated puncture is emphasized by
Achard, who had the following experience in a classical case
of paresis. The first two punctures were negative, a third
showed a slight cellular increase, and finally a fourth showed
a large number of lymphocytes. An interval of ten days was
allowed between punctures. Nissl had the following results in
a case of similar nature. In an otherwise clear case of paresis
a negative lymphocytosis was observed, but a marked opales-
cence was present. Twenty days later marked lymphocytosis
and opalescence were found. He points out then that in such
cases the albumin content should be recorded. Farrar makes
the explanation of the variation in the examination thus : "Spinal
lymphocytosis is simply the expression of a subacute or chronic
cerebro-spinal periarteritis and pia-arachnitis, and its intensity
doubtless stands in some relation to the degree of infiltration of the
meninges and of the adventitial sheaths of the blood vessels in
the central tissue itself. This adventitial infiltration in paresis
consisting of lymphocytes and plasma cells may show the
widest variation, at times subsiding or almost disappearing.
In the same manner the elements in the spinal fluid may be
present at times in greatly varying numbers ; on occasion even
practically disappearing." There is much hope that as the
different types of cells which occur in the spinal fluid must
have a different origin, with improvement of technique we
will be able from the variations in the types of cells to ascer-

246 /. L. POMEROY

tain something of a prognostic value. At the present time we
cannot here enter into a discussion of this point.

This brinsrs us to the study of results in alcoholism. Besides
syphilis and its various clinical pictures there is no more con-
fusing problem for diagnosis from general paralysis and tabes
than the various manifestations of alcohol upon the nervous
system. We must recognize that there are many different
types of alcoholic psychosis which closely simulate the pro-
tean pictures presented by paresis. Psychiatry holds no more
complex problem even for its best observers than the differen-
tiation between the paretic and alcoholic psychosis.

When we consider then that lymphocytosis has been shown
to present an early and constant sign of paresis and tabes we
realize that it should be of the greatest value in differentiating
these diseases from alcoholism, if it can be proven that this pe-
culiar sign does not occur in the latter group. I will now give
the data on this point.

Xissl collected from the literature and his own cases the
results of 30 observations. Twenty-three of these gave nega-
tive results, and seven were positive. Of these seven cases
autopsy has shown in two of them that general paralysis was
present and in three the clinical course since the puncture has
been that of paresis. In the remaining two cases the autopsy
showed the presence of chronic alcoholic conditions. The pos-
itive results in these two cases Xissl states must be traced
back to an old syphilitic infection, as there were no physical
signs of involvement of the nervous system. Recently Rehm
supports this latter view in an examination of nine clearly alco-
holic cases, where one only showed a positive result. In this
case previous syphilis was proven. Xo symptoms of involve-
ment of the nervous system were present. Joffroy has showrn
that acute alcoholic disturbances give negative results, in one
such case with a positive result general paralysis afterwards
developed. Dufour reports one such similar experience, but
makes the broad statement with Dupre that in an alcoholic if
the meninges are affected a positive result may be found. The
weight of opinion, however, points in these cases to previous
syphilitic infection. Regarding the meningeal complications
the opinion of several observers has been quoted. Very few
cases of Korsakoff's psychosis have been examined. In 12

LUMBAR PUNCTURE IN PSYCHIATRY 247

cases collected from the literature, including four of our own,
negative results have been found in all. E. Meyer, in two
cases where the Argyll-Robertson pupils were present, lays
great stress upon the negative puncture as a differential point
between these cases and tabes. The further course of his cases
have confirmed the assumption.

During the past 12 months 16 cases of clinically clear alco-
holic psychosis have been punctured. Fourteen gave negative
results, in two lymphocytosis was positive, but there was no
albumin increase. On entrance one of these cases showed an
acute hallucinosis with rapid improvement and perfect recov-
ery in four months. For a long time we were in doubt as to
the cause of the lymphocytosis. Since the patient's improve-
ment she gives the fact that in 1899 ner husband had a disease
which was undoubtedly syphilis. At that time sexual inter-
course was prohibited. Since then she has had three mis-
carriages.

The second case of alcoholism with a positive finding,
showed on admission moderate elation, with expressions of
the possession of great strength, with memory defect and ex-
aggerated knee jerks. At times she is quite elated and again
complains of intense headaches with vertigo and shows con-
fused orientation. Thus the diagnosis of paresis is very prob-
able.

In the following re-admissions the results of lumbar punc-
ture have been of decided value. A patient developed a psy-
chosis in January, 1900, was of marked alcoholic habit, had de-
lusions of grandeur, and physically showed tremor of tongue,
facial muscles and hands, defective speech, increased knee
jerks and variable pupillary reflexes. She was discharged ten
months after admission as paresis, improved. She remained
in civil life for six years and entered the hospital in January,
1906. She expressed exactly the same ideas that dominated
her six years before, and exhibited practically the same physical
signs. There was, however, no deterioration in the memory,
and she had good insight and was well oriented. Her hand
writing was unsteady and there was slight speech defect.
She had been drinking heavily. An undoubted specific papu-
lar rash of a mild type covered her entire body, and there were
condylomata about the vulva. The lumbar puncture was abso-

248 /. L. POMEROY

lutely negative and the question of paresis was certainly ruled
out. The puncture has been twice performed since the active
development of the syphilitic infection, and a slight lymphocy-
tosis has developed, but there has been no albumin increase.
The remarkable coincidence of the early secondary manifesta-
tions, just at the time of entrance, together with the fact that
in the three punctures we have had an opportunity to observe a
slight increase in the cellular elements due to this infection,
throws considerable light upon an otherwise doubtful case.

Similarly the diagnosis of dementia paralytica was made
in an alcoholic patient who was an inmate of M. S. H. eight
years ago for 16 months. There were marked physical signs
of alcoholism and somewhat sluggish pupils. On re-admis-
sion, in November, 1905, the patient showed fair memory save
for several periods during the past few years. Occasionally
she was elated and happy and emotionally variable, but there
was a strong persecutory trend extending over the entire
period of her psychosis. The physical signs, however, were
very suspicious of paresis, her pupils being unequal and slug-
gish, there was slight speech defect and increased knee jerks,
with some tremor of the hands. The spinal fluid has been
negative on three different punctures.

The following case is most striking because of the slow
progress of the disease and illustrates the similarity which ex-
ists between chronic alcoholism and paresis. A patient, D. D.,
a woman of some 37 years was admitted into the hospital in
1902, where the diagnosis of dementia paralytica was made.
She was markedly alcoholic : there were some memory defect,
apathy, confusion of personal identity, while physically there
were exaggerated knee jerks, unequal and dilated pupils with
static ataxia ; she had two convulsive attacks and developed
some smoothness of the left side of the face. She was dis-
charged after five months, much improved mentally. She
suffered greatly from a terrifying hallucinosis from right ear
only. On re-admission into hospital October, 1905, there was
a marked hallucinosis of a depressing character, with consider-
able memory defect, with poor grasp and retention, but good
orientation and preserved identity. Physically, the eyes were
normal, there was no speech defect, the knee jerks were in-
creased, there was only a slight tremor of the tongue and no-

LUMBAR PUNCTURE IN PSYCHIATRY 249

evidences of paralysis. The diagnosis was now made of
chronic alcoholic psychosis. Recently the case has again come
up for discussion and the patient now exhibits considerable
difficulty of an aphasic nature. Her enunciation is clear, but
she fails to name objects and frequently shows perseveration.
She shows mentally a mild deterioration, still the diagnosis of
alcoholic psychosis was upheld, but the case was deferred for
lumbar puncture. The spinal fluid showed an enormous reac-
tion, the cellular increase being 25 to 50, and there was marked
opalescence on testing for albumin ; with this evidence we must
admit the correctness of the diagnosis in 1902. (Very recent-
ly the patient has had convulsive attacks.)

Another illustration of the diagnostic difficulties is shown
in a case with a psychosis of a persecutory delusional content,
with physical signs suggestive of paresis, who entered the hos-
pital five years ago. She was discharged four months after
admission, having good insight, with no sign of a delusional
content and no deterioration. She has taken good care of her-
self during the past five years ; during the latter part of her
fifth year, her memory began to fail, she showed emotional
instability, and on examination, at entrance, there was fine
tremor of the hands and exaggerated knee jerks, but the pu-
pils were normal. The spinal puncture, twice performed, has
shown a positive lymphocytosis and a marked albumin in-
crease. The extremely slow development of this case, with
the very gradual deterioration, presented a somewhat unusual
type for diagnosis, and the lymphocytosis was of considerable
value.

We have the support of a recent autopsy on a case which
shows very typically the class in which the lumbar puncture
is of greatest value. This case entered the hospital with a
markedly alcoholic history, and was much confused in orienta-
tion and grasp. There was a history of two attacks in which
she suffered loss of consciousness for a few minutes, without
paralytic sequelae. These had occurred during the past six
months. There was mild elation, marked memory defect and
defect in judgment and comprehension. Physically there was
marked speech defect, tremor of the hands and face and un-
equal knee jerks, right greater than left. During the early
part of the her stay in the hospital the diagnosis of paresis was

250 /. L. P0MER0Y

very strongly suspected. But for the negative spinal fluid,
the diagnosis would have rested as such. The patient had two
convulsive seizures, one which was very transient and was
accompanied by twitchings of the right side of the body and
lasted only a few moments. Following this attack her speech
became markedly affected, yet there were no paralytic symp-
toms in the extremities. A few days ago, while the physical
examination for summary on this case was being made, and
the discussion of this work was being carried on, the patient
went into a convulsion and exhibited symptoms of paralysis
on the left side of the body and in a few moments died. At
autopsy, grossly, there were absolutely no evidences of paresis,
and on section of the brain a large hemorrhage was disclosed
involving the region of the internal capsule on the right side
and breaking into the lateral ventricle. On the left side, in a
symmetrical area, there was a small old focus of softening in-
volving the external capsule and claustrum, together with a
small acute hemorrhage at the level of the anterior tip of the
caudate nucleus. The findings in this case give lis much re-
assurance as to the accuracy of our assumptions in a very con-
fusing clinical picture.

I would mention here also in support of the accuracy of the
diagnostic inferences to be made from the results from lumbar
puncture, a second case in which we have recently performed
an autopsy. The clinical picture was extremely doubtful. The
mental symptoms were very meagre : the verv slight memory
defect, emotional instability, with slight elation, were not at
all characteristic. To further confuse the case, was the pres-
ence of chronic pulmonary tuberculosis. There was a delu-
sional content of a persecutory trend, and at staff meeting the
diagnosis of a paranoic condition with infective and exhaus-
tive psychosis was suggested. Physically there was slight
exaggeration of the right knee jerk, a rather uncertain tremor
of the hands and face, and occasionally she failed on test
phrases. The diagnosis of this case remained in doubt for
some time. The deterioration was very slight, her delusions
were poorly developed and her statements were extremely
variable : the memory defect was difficult to demonstrate.
Finally a lumbar puncture was performed and a positive
lypmphocytosis was obtained. This finding was practically

LUMBAR PUNCTURE IN PSYCHIATRY 251

the most significant symptom in the examination of the pa-
tient, and the diagnosis hinged upon this factor alone. Even
at autopsy, when the brain was removed and showed no symp-
toms of paresis in the gross, there were members of the staff
who still did not believe that the case was a paretic. Micro-
scopical examination, however, showed areas of typical degen-
eration. These areas, however, were quite small, but were
characteristic. (I am indebted to Dr. Karpas, of the M. S. H.,
for the notes in this case.)

In the differential diagnosis of Korsakoff's psychosis the
lumbar puncture has been of value. The absence of the
knee jerks, Romberg sign, slight nystagmus, memory defect,
with a certain amount of deterioration, in these cases is very
confusing; besides these symptoms, in one case there was a
history of convulsive attacks, and a negative finding was of
considerable help. Sluggish pupillary reactions in another
case brought up the question of tabes, and lumbar puncture,
twice performed, giving negative results, was of great assist-
ance. In several other cases the further course of the disease
has shown that our assumption based on a lumbar puncture,
was correct. In one case which was complicated by peculiar
aphasic conditions, besides a suspicious history of syphilis,
the negative punctures were of great help.

The following case resembles several readmissions already
described ; it is another example of the puzzling conditions
for diagnosis produced by chronic alcoholism. The patient
suffered a neuritic process in 1899, the details of which are not
known. She was brought to this hospital in 1901, remaining
18 months, recommitted in 1906. At her first commitment
she was in the hospital for three months. The records were
lost. In 1901 the diagnosis of general paralysis was made.
She presented memory defect, marked tremors, absent knee
jerks, irregular and sluggish pupils, defective orientation, had
delusions of persecution and had convulsive seizures on sev-
eral occasions. She was discharged as having greatly im-
proved. She remained out of the hospital for three years. At
the present writing the patient has reached the age of sixty.
Physically she presents marked tremors of the face and
tongue, little of the hands; slight Romberg and absent knee
jerks. The pupils are a little irregular and react within a;

2$2 J. L. POMEROY

very narrow range ; she shows slight nystagmus. Mentally
there is some memory defect for the period of her first and
part of her second attack, but not the general defect that one
finds in paresis. Orientation was correct ; emotionally there
is a little elation. There is some tendency to retrospective
falsification and fabrication. The speech is a little thick, but
not characteristic. No writing defect. How to classify this
case with the previous diagnosis, the history of the convulsive
attacks, and the mild degree of dementia present, was a very
difficult question. There were also certain scars about her
body which tended somewhat to support the diagnosis of
G. P. on the basis of specific infection. In spite of the patient's
age, the slow progress of the disease and the evident etiolog-
ical factor, alcohol, paresis could not be ruled out on the case
as it stood. The lumbar puncture has twice given negative
results both to cellular and albumin tests. With this data we
feel sure that the paient's condition is due to alcohol, but if it
were not for the negative puncture I do not think we would
he justified in assuming this.

(To be continued.)

REPORT OF A CASE OF HYSTERICAL MUTISM.*
By John K. Mitchell, M.D.,

OF PHILADELPHIA.

The following case of hysterical mutism, a disorder of
great rarity, is reported at length as a matter of record and
with the hope of eliciting histories of other similar instances.

G. C, aged 2,2. years, Kernersville, N. C, locomotive
fireman, was brought to me by Dr. Ashworth on June 5, 1905,
with complete loss of speech. The family history is with-
out any instance of positive nervous disease, although it is
said by the patient's physician that they are all neurotic in
temperament.

On August 24, 1904, while on top of a freight car, the pa-
tient ran against a live trolley wire which struck him on the
root of the nose, just below the right eyebrow. The "current
passed through him," according to his account. He was knock-
ed up 4 or 5 feet and fell on the car roof unconscious. He was
taken to hospital, where he stayed 5 days, being, according to
his account, unconscious the first 24 hours. When he awoke he
could not speak ; he could swallow, moved his tongue and
mouth well ; had much headache — frontal and over left side.
The eyesight was not affected. The right eyelid was some-
what burned and was, of course, sore. (Dr. Bahnson, Salem,
N. C, saw patient 10 minutes after accident and says he was
never unconscious, only dull and dazed, and that this con-
dition lasted 6-8 hours, not 24 as stated, and that the wound
was the merest brush-burn of a trifling character.) He had
the above mentioned headache almost continually from the
date of the injury ; it was less severe at times, seemingly chang-
ing without cause. He suffered from roaring and buzzing in his
left ear. Occasionally there were sharp shooting pains through
the arms, trunk and legs, sometimes very severe, and very con-
stant from the time of the accident up to the admis-
sion to the hospital in Philadelphia. Although he had perfect
memory and recognition of words and wanted to speak, it
seemed impossible for him to send the necessary motor im-
pulse. In his own phrase he "wanted to speak, but didn't
know how to go about it." His mother writes : "He spoke
three or four times (words) last fall (1904) in a clear, natural
voice, only he did not know it, though awake. The last time
was in November, and his sister occupying a room below

*Read by title at the meeting of the American Neurological Association,.
June 4 and 5, 1906.

^54 JOHN K. MITCHELL

his heard him talking in his sleep, loud and clear enough to
waken her."

The patient was admitted to the Infirmary for Nervous
Diseases June 6, 1905. Examination : Strong, healthy look-
ing, well-developed muscular young man. Heart and lungs
negative, sensation normal everywhere, externally; audition
perfect ; thinks clearly ; writes a definite and simple state-
ment of his feelings : C. says he cannot balance well when
walking in the dark. Appetite and bowels normal ; sleep poor,
3-4 hours at night ; dreams much ; he has headache almost con-
stantly : no nausea or vomiting. He has lost 25 pounds in
weight in the past nine or ten months. There is no cough or
expectoration.

Dr. Langdon examined his eyes June 24, 1905, and re-
ported them normal in every way except for complete rever-
sal of the red and green color-fields.

Kjs, active; no ankle clonus or Babinski; plantar reflex
normal ; sensation everywhere preserved. Other reflexes every-
where good. No disturbance of sphincters. Larynx mobile,
breathing easy. Smell and taste normal. Dyn. R 112-L no.
The electric reactions of pharynx, neck, tongue and external
laryngeal muscles are normal.

Treatment — House diet ; faradic brush to sides of neck
and over larynx. General massage: to walk out daily. Strych-
nia nitrate gr. 1/100 hypodermically into sides of neck daily,
alternating sides. On July 20th it was noted that there had
been no improvement. Dr. G. H. Makuen saw him early in
July and treated him regularly, but without benefit. His re-
port of the condition of the larynx and vocal cords is given
in full below. Dr. Eshner for some time hypnotized him daily,
attempting by suggestion to make him speak, without suc-
cess. Hypnosis never could be carried beyond the stage of
slight somnolence.

The patient was anesthetized June 15th and closely
watched, but beyond a few explosive noises made no distinct
vocal sound.

Dr. G. Hudson Makuen kindly saw the patient and re-
ported as follows :

"The aural condition seemed to be normal, and the patient
had always had good hearing.

"The septum was deviated toward the right, and on its
convex side there was a spur extending well back into the
nostril, and causing a considerable pressure upon the middle
turbinal bone. As a result of this structural irregularity
there was a slight catarrhal process in both the nasal and naso-
pharyngeal cavities. The spur was removed by Dr. W. J.
Freeman, leaving the nostrils entirely free and improving the

HYSTERICAL MUTISM 255

general condition, but having no effect whatever upon the
restoration of speech.

"The oral cavity was in good condition, the alveolar and
palatal arches regular in shape and the patient had good
voluntary control over the tongue for all purposes except
articulation.

"The faucial tonsils were slightly hypertrophied and they
contained some old contractions and adhesions, due to several
severe attacks of tonsilitis during the last few years.

"The pharynx was congested and there was some anes-
thesia of its mucous membrane.

"The larynx appeared to be normal, except that there was
a marked anesthesia of its mucous membrane. An applicator
passed beyond the epiglottis was easily tolerated without any
reflex muscular contraction.

"The laryngescope revealed nothing unusual except the
patient's inability to hold the cords in approximation and to
make them vibrate during an attempt at phonation. He
could easily approximate the cords, but they immediately
flew apart at the slightest attempt toward phonation. He
could give the so-called 'glottic clink' that is often practiced
by vocal teachers for the purpose of developing and strength-
ening the muscles of the larynx, and he could produce the
normal vocalized cough, but it always vanished into a faint
breath sound. He could not prolong the cough for any
appreciable length of time.

"It was found that he had lost the power not only of
phonation but of whispering as well. He could not make any
attempt to speak. He did not know how to begin. He was
both aphonic and mute. He lacked the mental conception of
articulative movements for vocalization and whispering. In
the hypnotic state, in which I appeared to have him at one
time, his attempts at vocalization were equally fruitless.

"All the known methods were used to try to bring back
the faculty of speech, but no vocalized laryngeal sound could
be elicited, and only very limited whispered sounds and ar-
ticulative movements could be developed."

Instruction under Dr. Makuen's direction was carried on
daily for several weeks with the result of the acquisition of
only a few short, partially whispered words, the kinesthetic
memories of which were lost almost immediately. He could
be taught to whisper a short monosyllabic word, but in a
few seconds he seemed not to know how to try to repeat it.

Discharged September 1, 1905, unimproved. There were
no changes.

C. returned and was readmitted November 4, 1905. There
had been no change of function during the two months since

256 JOHN K. MITCHELL

leaving, except that efforts at speech were clumsier than be-
fore. He could not count nor pronounce letters so well as
before. He could whistle and smile, though he could not
laugh; he coughed, but could not clear his throat (larynx).

On November 6th a small area on the head, approxi-
mately over the speech centre, was shaved and a strong fly-
blister applied. The blister had no effect whatever upon his
speech.

Especially noticeable was the fact that the reflexes of the
pharynx had been either lost or greatly impaired in the two
months' absence from the hospital. The condition seemed
like that of a voluntary inhibition of these reflexes, although
C. was blindfolded in order to prevent his peeping, which he
would do if he could. Of course he knew that attempts were
being made for some purpose, and on stimulation there seemed
some inhibition brought into play. No disorder of sensation
in the face could be discovered. An effort was made to sur-
prise him into speech by speaking to him in a low, firm tone
while asleep. He was slowly awakened, but only turned
over and then raised his head. He wrote next morning,
"What was wanted?" Attempts were made, too, to surprise
him into an involuntary reflex sound by a sudden blow on
epigastrium when passing him in the hall or ward, but to
no purpose. He complained of being frequently depressed
and had much headache.

In the fourth week of his second stay in the hospital, C.
suddenly recovered perfect control of his speech. The strug-
gle was witnessed by Dr. Peet, the resident physician, who
has given me the following account:

On November 26th, C. had complained of severe headache
with the previously mentioned recurring pains in his limbs.
He went to bed and possibly ate but little supper. He slept
until about 12.30 A. M., then awoke and found the pains in
the legs increased, and his head still aching. The nurse
stated that her attention was first attracted at 1 A. M. by his
moaning and great restlessness. She had the resident notified
immediately. When seen the patient was lying on his back
with head thrown far back and arms and legs in constant
motion; the jaw was chattering at a rate of 150-200 per min-
ute and the quickened respirations were each marked by an
expiratory groan that was caused by the larynx; there was a
little frothy saliva on his lips ; the eyes were closed, with
the pupils fixed in moderate dilation with no reaction to
candle, nor did his eyes follow the light. There was analgesia
(anesthesia?) to pin prick over entire body below neck except
genitals (not tried) and nipples. Over the neck and face, and
especially on the lips and nose, a pin prick caused motion and

HYSTERICAL MUTISM 257

a rather purposeless attempt at defense with the arms, by
moving arms and legs faster and then turning over as if to
escape. Limbs were spastic; Kj increased; no clonus; the eye-
lid reflex was present. All the fingers were fully extended.
The patient was altogether unconscious and could not be
roused by pin prick, voice, the application of ice to the face or
epigastrium, nor by pressure on the supraorbital nerve. Tick-
ling: the ribs roughly caused violent movements of the limbs
and ill-aimed blows, but no vocal sounds. These efforts at
rousing him intensified the movements and apparently his
headache became worse, as he groaned more deeply and held
his arms to his head, or buried his head in the pillow. To stop
the chattering, the lower jaw was depressed with the hand
and after some minutes the jaw grew quiet. The movements
then ceased and the limbs became relaxed and flaccid ; breath-
ing was easier. His pulse remained good throughout. Any
attempt to rouse him caused a return of the movements. He
was constantly addressed by name and questions as to pain
asked, without getting any response ; once, however, a sound
suspiciously like "O pshaw!" was made as he covered his
forehead with his arms, and another time he seemed indis-
tinctly to articulate "O Lord !" Pin pricks now caused no
movement unless stuck into the nipple or in the lips, nose,
forehead, or scratched across the neck. There was analgesia
over the rest of the body. Speaking was about despaired of.
However, as a last resort, he was asked if he wanted to take
ether and some aromatic spirits of ammonia was brought.
He was now lying quiet but still using his larynx in expira-
tory moans. A bit of gauze was saturated with the ammonia
and held near his nose ; he pulled his head away, the gauze
followed ; he coughed, then as if he had never ceased articu-
lating, he said in a firm voice, "Take the damn thing away, I
don't want to smell it." The gauze was still kept near, how-
ever, and he begged to have it removed and said so petulant-
ly. It was taken away and he was spoken to ; he answered
readily, but not always coherently; he was evidently not fully
awake. Some medicine was ordered and he was asked if he
would take it. He answered, "Yes." A small dose of bro-
mide and valerian was fetched. He raised his head well up,
smelled of the valerian, drank and swallowed it, snuggled on
his pillow under the bed clothing and to the query, "Are you
asleep?" said, "I will be soon, good-night." He was asked,
"Are you awake? Sure you are awake?" and replied, "Yes,
I'm awake." "Do you know me?" "Yes." "Sure?" "Yes."
"Well, good-bye." "Good-bye, doctor," he said, closed his
eyes and sank on the pillow. We went out and closed the
door ; we heard him get out of bed and then through the tran-

258 JOHX K. MITCHELL

som saw the light of the candle left on his table go out and
heard him get back in bed. To the nurse he now complained
of the light; said he would go to the roof garden, etc., that
he was perfectly conscious and found he could talk and
wanted to continue talking all night. He said his arms and
legs hurt and he was all tired out.

Finally he went to sleep at 3.30 A. M., and awoke per-
fectly clear and able to say anything, but headachy.

C. was apparently all right next morning ; he was most
happy and wanted to go home and was sure he was conscious
before the attack began and that he was conscious when he
took the medicine and knew then that he could speak and
especially when he said good-bye to the doctor. He talked
a great deal all day.

A week later the eyes were examined by Dr. G. E. de
Schweinitz who found that the reversal and contraction of
the color fields formerly noted had completely disappeared
and that the fields were normal in every respect. This sudden
and complete return to normal conditions of reversed color
fields is very unusual, reversal and contraction often being
found still present when all overt hysterical symptoms have
disappeared.

Summary. — Some degree of loss of speech is a common
hysterical manifestation and in marked cases a most intract-
able one, the patients seldom recovering full power of voice
after the aphonia has lasted some months. Now and then
an instance of moderate grade loss of voice is temporary and
passes off as the patient improves in general nutrition.

Judging from experience in aphonia cases I felt doubt-
ful after my first study of C. as to how the disability
would end. The hysterical origin of the trouble seemed
certain from the first. The physician who had seen him im-
mediately after the accident confirmed my suspicion of the
very slight character of the direct injury and of the utter
impossibility of the lad's having received the full current from
the electric wire he struck against, which would almost cer-
tainly have killed him, and added the suggestive point that
the patient's family all showed neurotic tendencies. The
final evidence needed came when the complete reversal of red
and green in the color fields was discovered. Surface anes-
thesia or analgesia, so common with reversed color fields, was
not found during C.'s first stay in hospital, but was noted as
present in the throat upon his second admission two months
later. This completes the picture, to which the final touch
is given by the dramatic manner in which speech was re-
covered. The patient went through a kind of parturition,

HYSTERICAL MUTISM 259

pains, groans, writhings, and at last brought forth articulate
speech, wholly unimpaired by its year of disuse.

Total loss of speech from purely psychic causes, followed
by sudden and complete recovery must be hysterical, and is
so rare that this is the only case I have seen. Dr. Weir
Mitchell, who saw the patient and studied him with interest,
has never previously observed an instance of absolute hyster-
ical mutism and I cannot find one recorded.

It is proper to record here my thanks for the great inter-
est taken by Dr. Makuen in this patient and the freedom with
which he spent time and trouble in studying the patient's
condition and in the endeavor to teach him to speak. His
careful and minute report of the laryngeal condition is a
valuable addition to the historv of a most unusual state.

SYMPTOMS SIMULATING BRAIN TUMOR DUE TO THE OB-
LITERATION OF THE LONGITUDINAL, LATERAL AND
OCCIPITAL SINUSES. A CLINICAL CASE.*

By C. Eugene Riggs, A.M., M. D.,

OF ST. PAUL.

The patient, Miss L., was referred to me by Dr. Strickler,
of Sleepy Eye, Minn., January 16, 1902. She was 22 years of age,
a teacher, father dead, one brother a confirmed epileptic, two
others had convulsions in infancy. Aside from the usual diseases
of childhood, patient was perfectly well until the present illness.
No syphilis, no tuberculosis. Two years before consulting- me
she was thrown out of a carriage striking upon the. top of her
head upon frozen ground. The only symptoms were vomiting
and severe headache immediately after the fall. She apparently
experienced no subsequent ill-effects until July, 1901, when she
complained of severe headaches which were regarded as neural-
gic. The pain was situated in the right frontal region. These
headaches were at first periodic, usually occurring each after-
noon although there would occasionally be an interval of as much
as three days between the attacks. During the headache the
face would be pale, there were dark circles beneath the eyes, and
the lids were edematous. Some three weeks after their first ap-
pearance the pain became so severe as to confine her to her bed
for a period of two weeks ; the severe pain was attended by
vomiting which lasted for two days. Afterward during her ill-
ness vomiting followed when the pain was very acute. She suf-
fered always more severely during the day. While under my
observation she was never entirely free from pain although she
was at times quite comfortable. When I first saw her, vision
was badly impaired and before her death it was almost entirely
lost. She could not distinguish between one and three fingers
held before the eyes. There was choked disc. The right knee
jerk was exaggerated, the left normal ; no ankle clonus, super-
ficial reflexes normal ; no Babinski ; stereognostic sense normal ;
dynamometer, right hand 19 deg., left 16 ; no inco-ordination,
pupils dilated but reacting to light and accommodation, no sen-
sory or vasomotor disturbances ; temperature normal ; pulse vary-
ing from 68 to 70 ; no leucocytosis ; urine normal ; intelligence
unimpaired.

On February 15, there was first observed a twitching of the
right side of the neck; it was confined to the sterno-cleido-mas-
toid and platysma myoides muscles. Sometimes the muscles of
both sides were simultaneously affected although it was very
much more frequent on the right and always more marked ;
never on the left alone. Accompanying this twitching on the

*Read by title at the meeting of the American Neurological Associa-
tion, June 4 and 5, 1906.

BRAIN TUMOR 261

right side there would occasionally occur a slight tremor of the
chin. February 16, along with a severe headache there was
twitching not only of the muscles just mentioned on the right
side, but also of the face and eyelid of the same side. This
twitching did not seem to have any of the characteristics of
cortical epilepsy and its appearance on both sides, although it
appeared more frequently on the right side, added materially to
the difficulty of making a diagnosis.

Miss L.'s condition became steadily worse and her suffering
was so great that an exploratory operation seemed justifiable
even though no definite localizing symptoms were present. Dr.
Archibald MacLaren of St. Paul operated at my request. The
result was negative aside from the fact that for several weeks
afterwards she was absolutely free from pain. This, however,
again appeared with a fiendish intensity and the second attempt
at relief was made during which death occurred.

I am indebted to the courtesy of Dr. Alexander Colvin for
the results of the post mortem findings.

There was no intercranial growth and the brain and cerebel-
lum presented a perfectly healthy appearance. The longitudinal
and two lateral sinuses were almost completely obliterated. The
adhesions between the sinus walls were old and inseparable. Here
and there in the course of the longitudinal sinus was found an
open space which marked the entrance of a vein; the torcular
Herophili was also obliterated. There were in some of the unob-
literated areas of the longitudinal sinus adherent shreds of a
brownish color which macroscopically had the appearance of
blood clots.

Thrombosis of the sinuses is supposed to occur more fre-
quently than any other form of venous thrombosis. This is due
to their peculiar construction for, according to Macewen, their
great width, the rigidity of their walls, their somewhat triangular
form, the trabecular that occasionally cross them, the peculiar
manner in which they are prevented from being emptied during
inspiration, and, in the case of the longitudinal sinus, the direc-
tion in which the blood from the cerebral veins enters at an
obtuse or right angle against the current, all tend to retard the
flow of the blood and thus to favor coagulation.

The usual etiological causes of adhesive thrombosis ^ were not
present. There was no phthisis, no Bright's, no cardiac weak-
ness, no exhausting diarrhea, no pneumonia, no carcinomatous
marasmus, no influenza, no appendicitis, no diseaseof the vascu-
lar walls, no septic or gangrenous areas, no direct injury of ves-
sels, and no middle ear disturbance. The symptoms were as
characteristically negative. There was no epistaxis, no delerium
or somnolence, no apparent edema, no distension of the veins of
the frontal and parietal regions of the scalp, no convulsions, no
temperature, no rapid or thready pulse; in fact the symptoma-

26a C. EUGENE RIGGS

tology of either marasmic or infective thrombosis was entirely
wanting-, and I am free to confess that I did not suspect its
presence.

The only significant symptom was the excessive hemorrhage
of venous blood occurring as soon as the incision of the scalp
was made.

Under favorable conditions the diagnosis of sinus thrombosis
is not an easy matter ; in fact "The clinical recognition of plastic
or adhesive thrombosis," says Fagge and Pye-Smith, "is rarely
possible."

I report this case because I should like to hear what the mem-
bers of this association have to say in regard to similar expe-
riences of their own.

Society proceedings

NEW YORK PSYCHIATRICAL SOCIETY.
Stated Meeting, Jan. 2, 1907.

The President, Dr. Adolf Meyer, in the Chair.

THE SYMPTOMATIC-PROGNOSTIC COMPLEX OF MANIC-
DEPRESSIVE INSANITY.

By Dr. George H. Kirby,

OF THE PATHOLOGICAL INSTITUTE OF THE STATE OF NEW YORK.

Dr. Kirby said: The field of psychiatry is too complex for us to ex-
pect absolute or clear-cut distinctions either in disease types or noso-
logical groups. Kraepelin did a great service by showing that most
of the previously made distinctions of types could be replaced by far
more valuable nosological groups if one considered the whole course
and outcome of mental disorders. From this point of view the great
bulk of the acute psychoses can be brought under two divisions, viz.,
those that pass into deterioration and those that end in recovery. It
was found that in cases which terminated in either of the above men-
tioned ways, one was able to identify certain characteristic symptom*
present from the beginning, and which thus acquired a distinct prog-
nostic value. Two large symptomatic-prognostic groups were thus
created — Dementia Praecox and Manic-depressive Insanity. At present
it seems best to consider the manic-depressive complex merely as a re-
action type and not a disease entity as Kraepelin proposes. It is rather
a type of response which may be elicited in various ways. In some cases
the' constitutional disposition may be most important, but in others the
exogenous causes are of great importance and give valuable hints as to
prophylaxis and probability of recurrence. This peculiar kind of re-
action in its pure form has the characteristics of a benign disorder and
thus a favorable prognosis is implied. Various additional elements may
enter to confuse the picture and the symptomatic and prognostic fea-
tures may seem to diverge at various times. There are many equiv-
alents difficult to recognize. In a few cases the principle seems to fail
through transitions to other forms.

A series of cases was reported which had offered difficulties for va-
rious reasons. Some patients were also presented. A recurrent de-
pression with retardation and prominent auditory hallucinations; an-
other case of depression with sensory-somatic complex and only slight
signs of difficulty in thinking. A third case illustrating the mixed forms
of manic-depressive insanity, the so-called "manic stupor," showing
inhibition and mutism with an exhilarated mood.

Dr. Charles L. Dana was inclined to think "prognostic principle" a
rather unfortunate term, inasmuch as this was not all that was used in
attempting to establish types. The consideration of the whole life his-
tory was the great principle to be used in making classifications, and he
did not think there could be any objection found to basing groups of
insanity upon this method. It was not new but the rational and accepted
one in other forms of disease. The case presented by Dr. Kirby in
which there was melancholia without retardation of thought was in-
teresting, but was a type not infrequently seen outside of asylums at
least, and often in connection with intense suicidal feelings. This sui-

264 NEW YORK PSYCHIATRICAL SOCIETY

cidal impulse was not always due to somatic feeling of inadequacy, but
was sometimes also a well reasoned out point of view. A woman of
intelligence, for example, realizing that she had had melancholia now
three times, that she would have it again, that she would be a bur-
den to her family, that she would never be right permanently, schemes
to kill herself, obeying in a way a logical conclusion as well as a mor-
bid impulse. Such patients did not have always retardation of thought,
but they often could not do their work easily or effectively. He did
not believe the first patient presented by Dr. Kirby would be able to do
her work. Such patients could not play games of skill as formerly, be-
coming tired quickly. Dr. Kirby had neglected to touch upon chronic
melancholia, melancholia of involution, a group which Dr. Dana be-
lieved to be represented in early life. He had records of cases of mel-
ancholia at the climateric who gave a history of depression earlier very
much like that of later life, so that there was a melancholia of early
life which did not belong to manic-depressive insanity.

Dr. L. Pierce Clark thought the symptom-complex of manic-depres-
sive insanity would be easier of analysis if the idea were borne in mind
that the complex was likely to partake of the nature of the physiologi-
cal epochs at which it occurred. The surgical impulse to which Dr. Dana
referred was well known to most alienists. Even in convalescence this
tendency was most marked.

Dr. August Hoch said it was usually claimed that it was impossible
to formulate any laws of prognosis about the different forms of manic-
depressive insanity. This was not quite correct. Dr. Kirby had shown
that a careful reasoning might do much in formulating a special prog-
nosis. Dr. Hoch wished to mention a few more general points of view
from which a prognosis might lit- made. He first referred to the de-
pressions. The symptoms of the entire depressive complex were re-
tardation, sadness, and the anxiety-unreality complex. In the typical
manic-depressive states there were only sadness and retardation. In
such cases the outlook was good. In the typical involution melancho-
lias there was, from the beginning, uneasiness, anxiety, to which were
often added later in the course symptoms of the anxiety-unreality com-
plex. In such cases the outlook was bad; such patients got into a state
of deterioration, characterized by a narrowing of the mental horizon.
But the anxiety-unreality complex might also be reached by way of the
manic-depressive states. This happened not infrequently in the manic-
depressive depressions, which occur at the involution period, sometimes
in those occurring earlier in life.. These cases might, therefore, begin
with a typical retardation or feeling of inadequacy and then develop an
anxiety-unreality complex. In such cases the prognosis was not so bad
as in the typical involution melancholias, but decidedly less good than
in the simple manic-depressive depressions.

The second point of view referred to the prognosis of the manic
states. All alienists knew that those cases which present the best prog-
nosis are cases of clean-cut manias of considerable intensity, manias
in which the exhilaration, the general excitement, and the flight of ideas
are all of about the same degree. The hypomanic states were much
less favorable prognostically. Dr. Hoch had always found that cases
in which the disorder of behavior was out of proportion compared with
the flight of ideas and the intellectual disorder in general, were prog-
nostically also more favorable. Such cases were apt to have long at-
tacks or many attacks. The prognosis in cases in which a delusional
element was strikingly out of proportion to the flight of ideas was also
more doubtful than in the simple classical mania. In other words, the
cases of mania in which there were strong discrepancies in the intensity
of the different symptoms were those which presented a less favorable
outlook than those in which there existed a certain harmony in the in-
tensity.

BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY.

October 18, 1906.

The President, Dr. Tuttle, in the Chair.

A CASE OF HYSTERIA.

By Dr. Henry C. Baldwin.

P. E., 9 years old, came to the Neurological Clinic of the Massachu-
setts General Hospital in November 1903. A few days earlier she fell
down stairs, but did not hurt herself. The next day she could not walk.

Physical examination shows normal knee jerks and plantars. Sen-
sation was normal. She walked on the toes of her right foot. The
diagnosis of hysteria was made, and the patient disappeared from ob-
servation.

She came to the Neurological Clinic of the Massachusetts General
Hospital a second time in July, 1906. She had constant spasm, especial-
ly of fhe muscles of the back, and when she was placed on the examin-
ing table on her back she assumed the position of opisthotonos. There
were no spasms or choreiform movements of the muscles of her face
or hands. She could walk, but her gait was very peculiar, and the right
leg was held rigid and not bent at the knees. There was no disturbance of
speech. The knee jerks, Achilles and plantars were normal. Sensation
was normal. During the three years that had elapsed since her first
visit to the hospital, she had been going to various hospitals in Boston
and New York. Scars about the right knee showed that operations had
been performed, and she stated that these operations were done at New
York hospitals, the hysterical nature of the trouble presumably not hav-
ing been recognized. The patient was given static electricity and sent
to the Zander room for daily treatment under which she improved.
This morning she walked almost naturally, putting both feet down
squarely on the ground and bending both knees. The movements of
the body have almost ceased.

Dr. Walton said that he had seen the case in the hospital when the
symptoms were those of paramyoclonus, that is, bilateral convulsive
movements limited to the larger muscles, particularly those of the trunk.
He had regarded the trouble as of hysterical origin, and looked on
paramyoclonus as generally allied to, if not a symptom of, hysteria.

Dr. Knapp said that Dr. Baldwin's patient occasionally visited the
City Hospital and efforts were made to take her into the hospital for
educational therapeutics, but the attempt to do so caused loud wails
and she remained only a day or two. When last seen she was unable
to sit in a chair, and, if placed there, would rotate until she faced the
back of the chair, resting on the contracted knee with the back strongly
arched backwards. Dr. Knapp thought that no one who saw her there
was disposed to make any other diagnosis than hysteria. She bears
the scars of a tenotomy under the knee, which was a very striking in-
stance of misplaced surgical interference.

Dr. Courtney also saw the case which Dr. Baldwin had presented,
many weeks ago at the Boston City Hospital, and at that time made
the same diagnosis as that made by Dr. Walton more recently, namely,
paramyoclonus multiplex. *»

FACIAL ATROPHY.
By Dr. Courtney.
The case is one of that rather rare disease known as idiopathic facial
atrophy, and makes the third of the sort that Dr. Courtney had the op-
portunity of showing before this Society. The patient, a schoolboy of 17,

266 BOSTON SOCIETY OF PSYCHIATRY

has nothing of significance in his family history. His personal history
prior to the actual onset of the present trouble has a certain bearing on
the case, and is, briefly, as follows : Patient is an only child. He is in
his third year in a suburban High School and is said to be a student.
He has had no bodily injuries of moment, has experienced no infection
of any sort, and does not drink or smoke. Four years ago he was treated
at the Massachusetts General Hospital for twitching or tremor of the
left hand, which recurred a year later. During these attacks he was
unable to hold things securely in the affected hand.

For the past year he has had sudden transitory attacks of numbness
of the left side of the body, of short duration. These attacks are said
to occur more particularly while the patient is studying. Six months
ago it was noticed that the right side of the nose was beginning to
shrink, and shrinkage was subsequently noted on the right side of the
forehead also. The wasting has been accompanied by more or less
pain limited to the right side of the face, and by headache confined to
the same side of the head. For four months patient has noticed a
dragging feeling in the right side of the nose and right half of the
forehead, and this feeling has been emphasized for the past month by
the simultaneous occurrence of transient vertigo accompanied by a
peculiar alteration of consciousness. During these vertiginous attacks
patient appears to know where he is and says he can speak, bjit hit
mind doesn't work normally. He becomes confused in his recitations
and has difficulty in grasping what the teacher says.

Physical examination shows a hemiatrophy sharply limited to the
tissues of the right side of the face. The line of demarcation is partic-
ularly noticable on the forehead. On the right side of the forehead is a
contracted scar of a dull white color. No other leucodermal mani-
festations are present. The right naso-labial fold is flattened some-
what; the brow wrinkles normally. The cartilaginous scaffolding of the
nose is markedly shrunken on the right, but smell is not affected. The
intrinsic muscles of the face are spared; likewise the masseters. The
tongue is tremulous and apparently slightly shrunken on the right half.
Taste is completely lost on the right half of the tongue, both anteriorly
and posteriorly. The palate and fauces are normal both sides. The
pupils are regular, equal and normal to tests of light and accommoda-
tion; the muscular movements of the eyeballs are normal. The eye-
lashes, eyebrows, and hair have neither changed color or fallen out.
There is diminished appreciation of heat and cold on the right side of
the face, but sensation is not otherwise disturbed. There is a fine trem-
or of both hands greatly increased on rotation. The muscles of trunk
and extremities are normal. The teeth and jaws are normal.

Dr. Courtney did not think that in this case the disease had attained
to its full development. He did not propose to say anything concern-
ing the pathology of the condition at this time, but hoped to show both
this and his other two cases again, after they had been subjected to the
paraffine treatment.

HYSTERICAL HYPERTHERMIA.
By Dr. G. L. Walton.
The case was one of high temperature of probable nervous origin.
A boy of eight (seen in consultation with Dr. Bush), unusually studious
and mentally active, became greatly excited over a coming exhibition.
He was also knocked down a week before by a larger boy who is said to
have sat upon the side of his head. This experience was followed by
headache, lasting a few days ; there were no further symptoms. During
the following week the temperature rose steadily to 1050 F. There was
no restlessness, no disturbance of consciousness, no retraction of the
head, no ocular or other cerebral symptom, no bleeding from the ear or
nose, and no subconjunctival hemorrhage. The urine was normal and

BOSTON SOCIETY OF PSYCHIATRY 267

there was no digestive or other general disturbance. There was history
of a similar experience a year ago but without quite so high a temperature.

Careful examination showed no disturbance of motor, sensory, reflex,
or other function. The skin was natural, warm ; the pupils were widely
dilated, but reacted perfectly to light. The boy was bright and intelligent
without restlessness or sign of discomfort. The blood pressure was 70.
The temperature, taken by the mouth under the direct observation of
the physicians, was 104.7° F. The conditions were unchanged for a week,
after which the temperature gradually lessened during several months.
The boy has been well since. The absence of constitutional symptoms rul«
out infection, and the nervous origin of the temperature was rendered
the more probable by the neurotic constitution of the child and the history
of a similar previous experience. Such a case can, however, be hardly
regarded as fever in the ordinary acceptation of the term, and the ques-
tion suggests itself whether the high temperature in such a case may not
represent a local hysterical manifestation rather than the general body
temperature.

Dr. Knapp recalled a case of hysteria which came under his observation
at the City Hospital nearly twenty-five years ago, which Dr. Edes doubtless
remembered. She had very profound right hemianesthesia involving the
special sense with right hemiplegia. At times she had a high temperature,
as high as 105° F, while at other times the temperature sank to 95°. Very
careful investigations were made and no source of the fever other than tht
hysteria could be found. Dr. Knapp thought that Dr. Walton's suggestion
of a local rise of temperature is somewhat fanciful, yet in this case there
was noted for a long time a difference of axillary temperature on the two
sides of from one to four degrees. For a time the temperature of the
anesthetic side was the lower, but later on the temperature of that side
was higher. Sphygmographic tracings on the two sides showed a differ-
ence, the pulse curve on the anesthetic side showing at times a greater
tension and at other times a lower tension and a more acute rise tharr
that on the other side.

Dr. Courtney, apropos of Dr. Walton's communication, wished to
mention a case which he had had under observation for a long time. It i»
that of a girl of about 18 years, who first came to the clinic complaining
of persistent headache. Physical examination revealed nothing to ac-
count either for the headache or for the fact that the patient's daily tem-
perature had been ioo° or 100.50 for a matter of three years. The patient
is an inveterate neuropath and has recently developed a form of myospasm
which strongly suggests paramyoclonus multiplex. He was inclined to
attribute the increased heat production in the case to nervous influencei
alone.

Dr. Mitchell said that he had made some observations upon the effect*
of exercise in healthy men that might be of indirect interest in connection
with this subject. Three healthy young men, on six different occasions,
had been given exercise for one hour playing baseball. The days were
warm and perspiration profuse. Rectal temperatures before the exercise
were never above 99.4°, and the rectal temperatures taken at the end of
exercise ranged as follows : The lowest of the eighteen temperatures was
102.20, and the highest 102.80 In each instance the temperature fell to
normal, following bath and rest, and there was never any sense of elevated
temperature.

GENERAL ENCEPHALOMACIA.
By Drs. Southard and Hodskins.
The speakers proposed to define a type of soft brain differing, on the
one hand, from encephalomalacia, due to plugging of vessels, and on tht
other hand from autolytic softening of post-mortem origin. They termed
the condition general encephalomalacia. The condition is characterized by
(1) Diffuse axonal reactions in many types of cell; (2) diffuse fatty de-

.268 BOSTON SOCIETY OF PSYCHIATRY

generation demonstrated by the Marchi method; (3) absence in increase
of weight (important in distinguishing grossly from edema) ; (4) absence
of exudative changes.

Epileptics are somewhat prone to exitus with soft brain. The condition
seems to be associated with a terminal exhaustion. The illustrative case
was that of an epileptic, dying at forty-two, was of importance in that it
showed the same histological changes in the midst of a sclerotic area, sis
■were shown by the remainder of the brain and cord. Thus the lysis, while
it appears to be a general histolysis, is actually a differential cytolysis or
axonolysis. Enlargements were shown from photomicrographs of axonal
reactions in various types of cell from the illustrative case.

DEMENTIA PRAECOX.
By Dr. Brownrigg.

Indications of beginning mental enfeeblement may be explained as
wholly dependent upon other bodily illnesses or irregularities and incipent
dementia praecox may be overlooked by general practitioners for weeks or
months before a threatened insanity is suggested. Many such cases are
recognized as nervous and put down under the general term, "neuras-
thenia" when close observation by experienced men cannot fail to detect
even quite early the probable essential trouble. Thus slight attacks of
dementia praecox may be recovered from at home without special treat-
ment, and only subsequently when an attack brings commitment to insane
hospital does the previous mild history disclose a former, but sufficiently,
well marked attack that ought to have been recognized as such and more
caution followed. These patients then follow the course of those that
have more violent attacks from the beginning and by degrees going down-
ward generally offer as poor a prognosis as those committed to asylums
at first.

From analysis of New Hampshire State Hospital records of the last
three years. 33 per cent, of dementia praecox patients "recovered" or were
very much improved so as to undertake their former work. Six per cent,
became perfectly normal as far as could be determined. Fifty-three per
cent, had not improved, or showed only sight improvement. But of those
that did not improve much, the duration of the illness previous to hospital
treatment was about two years, and of those that "recovered" or "much
improved" the duration before commitment was only two months.

From the past five years experience with psychasthenic cases that could
be classed as probably undoubted cases of incipient dementia praecox the
conclusion is drawn that such early cases under early treatment in private
hospitals where they could have careful control and individual attention
and separation from other more definitely insane cases, offered a much
more favorable prognosis as to both early and more complete recovery
than similar ones, that by habit and progress of the disease, had become
more damaged mentally. In fact dementia praecox has probably in a large
proportion of cases a more or less prolonged prodromal period with
"neurasthenic"' symptoms predominating, and in this period the disease is
not at all the hopeless affection that it becomes later when complete loss of
control has developed.

In treatment emphasis was laid on isolating the patient from friends
and customary surroundings and most of all on the need of judicious
moral treatment and control. To this end much personal time of the
physician and especially trained nurses are essential.

Dr. Folsom said Dr. Brownrigg's experience was somewhat in the
same line as his own. Looking up post-typhoid psychoses he found that
the prognosis of cases treated in the insane hospitals was reported as more
unfavorable than for cases treated outside the hospitals for the insane, and
he thought the same is probably true of dementia praecox. The explana-
tion is in part that the worst cases go to the hospital, but the hospital in-
-fluences, with its surroundings and associations, are bad for quite young

BOSTON SOCIETY OF PSYCHIATRY 269

people. The outlook is better for such patients out of the hospital. Dr.
Folsom's impression is that dementia praecox is not uncommon ; at least
the cases like dementia praecox that go on to complete dementia are not
unusual. The diagnosis is often overlooked, as Dr. Brownrigg says, as i*
especially true of mild cases in early stages. Some cases of dementia
praecox resemble chorea so far as the mental condition is concerned ; that
is, the limitation of intellectual capacity is the most prominent symptom.
Now and then in girls of 18 or 20 we find cases with very slight choreic
movements, but with marked impairment of intellectual power which pos-
sibly might be called either chorea or dementia praecox. In the case of a
girl, for instance, who was taking fencing lessons the fencing master was
the first to find that she could not co-ordinate the movements of her right
wrist. The subject of diagnosis is often open to doubt or dispute in
individual cases and requires a good deal of careful thought.

Dr. McDonald said that since Jan. 1, 1903, there have been discharged
from Butler Hospital 389 patients. Of these, 74 (19 per cent.) were diag-
nosed as cases of dementia praecox. In the hospital at the present time
are 75 cases of dementia praecox, so that we have 149 cases of dementia
praecox in which to consider the prognosis. This number does not in-
clude doubtful cases, but only those in which the diagnosis was made with
a reasonable degree of certainty. Fifty-seven were males, 92 females ; ». e.,
61.7 per cent, were women. These figures disagree somewhat with those
of Prof. Kraepelin, who says that the disease is approximately equally
divided in the two sexes. Of these cases, 6.6 per cent, have died ; 33.5 per
cent, proceeded to a very deep and apparently abiding state of dementia ;
i. e., deep apathy with neither depression or exhileration, combined with
various symptoms which have been characterized as diagnostic of dementia
praecox; i. c, negativism, catatonia, impulsive and foolish behavior, man-
nerisms, verbigeration, etc. 38.2 per cent, while not advancing to
this deep dementia, remained unimproved ; that is, with more or less acute
symptoms, such as hallucinations, delusions, foolish behavior, etc., with
more or less of the characteristics of mental defect. Four per cent, im-
proved slightly, but not sufficiently to permit a return to the home.
16.7 per cent, made a partial recovery; that is, improved to such
an extent that they were able to live at home without particular friction,
or would be able to live at home if the home conditions were not extremely
unfavorable. Many of these have taken up their old life to a considerable
extent. Some are capable of occupation and a number are earning their
own living. This 16.7 per cent, corresponds to those cases, which Krae-
pelin considers as recovered, though not necessarily without perceptible
defect. .6 per cent.; namely, one case (female) has apparently recovered
entirely so that not only the friends, but also physicians are unable to
detect evidence of even a minor degree of mental deterioration. We see,
therefore, that the prognosis of dementia praecox is extremely bad. The
class of cases giving the best prognosis and from which the largest num-
ber of recoveries were drawn, are the catatonics. We are warned, how-
ever, from this circumstance to regard with suspicion our diagnosis of
dementia praecox where catatonia is present to a marked degree in the
acute stages, particularly where there is a condition of catatonic stupor.
In these cases we have made many incorrect diagnoses in the past, and
expect to make still more in the future. A number of patients where this
diagnosis has been made, proved eventually to be probable cases of melan-
cholia-mania, and we are of the opinion that catatonic stupor is not
diagnostic of dementia praecox, though the condition, of course, occurs in
that disorder as well as in other mental disturbances.

Dr. F. H. Packard said that the diagnosis of dementia praecox is apt
to be difficult in many stages of the disease, and it is often especially so in
those very early stages of which Dr. Brownrigg has spoken. He thought
one should remember that there is, so to speak, often what might be called
a normal abnormality during the period of adolescence which fades away

270 BOSTON SOCIETY OF PSYCHIATRY

and does not lead to a dementia praecox. While it is usually or often at
this period that dementia praecox begins, one should bear in mind these
normally abnormal conditions, and be guarded about calling them re-
coveries from dementia praecox. What he wished to speak about more
particularly are those cases in a more advanced condition as usually seen
in the hospitals. From his experience with such cases he was rather scep-
tical when he heard people talking of recoveries from dementia precox,
and he suspected that in many such cases there was either a wrong
diagnosis made or that the patients were not followed carefully enough
or long enough. As to making a wrong diagnosis, he was quite sure this
is often done, especially in those cases of stupor where the previous
history is not well known and where the cases are not carefully analyzed.
Por a considerable time catalepsy has been considered by many as almost
a pathonomonic sign of dementia praecox, yet he had seen this phenomenon
in cases where the previous history showed that the way into the stupor
and cataleptic condition was typical of a manic-depressive condition, and
where the course and outcome of the case showed that without doubt it
was a case of manic-depressive insanity. What he wished to emphasize is
the necessity of considering more than the picture of the moment, as for
example, when one sees a cataleptic condition one must not say immedi-
ately that this is a dementia praecox. As to the second point, he was like-
wise quite certain that many of the so-called recoveries are not followed
carefully enough or long enough. Within a comparatively recent time
several cases have been observed at the McLean Hospital with such definite
symptoms of dementia praecox that there was no hesitation in making
such a diagnosis and giving a bad prognosis. Nevertheless, these patients
recovered sufficiently to go home and be pronounced cured by their rela-
tives. He might say that it was almost with pleasure that within the last
two months lie saw two such cases returned to the hospital, again show-
ing unmistakable symptoms of dementia praecox. One has progressed so
rapidly that there is no longer any question of recovery. The other one
likewise i^ in a very doubtful condition. Careful questioning showed that
ever since leaving the hospital one of these patients, called well, was
scarcely able to do more than simple thing's like feeding the chickens. He
would emphasize the necessity of more careful diagnosis and of more
careful and longer observation before speaking definitely about recoveries
from dementia praecox.

Dr. Mitchell said that the paper opened to discussion a very difficult
problem. The accurate differentiation of dementia praecox from other
psychoses was often uncertain, long after the patient had shown symptoms
necessitating hospital care, and this uncertainty must be even greater in the
diagnosis of early cases. He thought critical care should be exercised in
making the diagnosis of dementia praecox on neurasthenic or psychasthenic
symptoms, because in taking histories of hospital cases, diagnosed as
manic-depressive insanity, it was frequently found that the first attack was
regarded as neurasthenia or "nervous prostration," and that this condition
would be followed later by a well marked manic-depressive state. It is
also difficult to determine that a patient suffering from dementia praecox
has recovered, and this estimate could not be considered well founded
unless the patient displayed normal conduct and unimpaired intellect for
a long period. Hospital experience demonstrates that many patients who
show temporary improvement following the first outbreaks of this disease,
and who might at this period be considered as recovered, eventually show
progress of symptoms that either incapacitates them for leading useful
lives or ag"ain requires hospital restraint.

Dr. H. W. Miller agreed with what has been said relative to the diffi-
culty of diagnosticating in the early stages of dementia praecox. It is by
no means easy, and we are often led astray. This uncertainty often causes
one to question the diagnosis of dementia praecox when the patient makes
a good recovery. That some cases do recover seems unquestionable. We

BOSTON SOCIETY OF PSYCHIATRY 271

have little experience with very early cases in a public institution such at
Taunton Hospital is, and our recovery rate in this class is unfortunately
low ; the majority of the recoveries belong to those cases ushered in with
acute symptoms, chiefly the katatonic type. He felt that the tendency is to
use the term dementia precox too loosely, and that we are inclined to
group in this class cases which do not properly belong there because the
symptoms are ill-defined, and do not seem to fit satisfactorily into any other
group. He was interested in the discussion on this subject at the British
Medical Association meeting in Toronto, where criticism of the name
dementia precox was quite general among the British psychiatrists.

Dr. Folsom did not mean that cases should not have proper and in-
dividual treatment. If people have resources and suitable means for treat-
ment, young patients are, as a rule, better cared for outside of a hospital
for the insane, because they are at a very receptive age, and the suggestions
from hospital life are demoralizing to them. But if a hospital is necessary,
a small one like that at Nashua is preferable to a large one. Proper treat-
ment for the individual case is a necessity for the best results, and for
that the insane hospital may be the only available means, even if objection-
able, in some ways, except for the worst cases.

Dr. Knapp said that Dr. Folsom had rather anticipated what he was
about to say. Dr. Brownrig'g's cases illustrate the importance of early
treatment, which is of great importance. He thought that there are a good
many cases of sensory phrenosis that get entirely well and remain per-
manently well if they receive proper treatment early in the attack. In
many cases, however, asylum treatment is not the best thing in the way of
treatment, but proper treatment outside is usually a very expensive matter,
so expensive as to be beyond the means of many, and the prejudice against
asylums and the legal restraints that bar free admission often result in
fatal delay. He was glad to hear from Dr. Miller that our English
brethren have not succumbed to the perversions of the mother tongue
and object to the term "dementia precox." He had used Bianchi's term,
"sensory phrenosis," in preference. On Kraepelin's own showing, "de-
mentia precox" is often neither "dementia" nor "praecox."

Dr. Folsom said as regards the expense of which Dr. Knapp speaks he
did not think it need be great, if one is ready to run considerable risk as
to suicide, as he often did, for the better chance of recovery.

Dr. Brownrigg was in agreement for advanced cases of dementia
praecox, with those who are pessimistic about a possible complete recovery,
but he believed that in the early stages where no dementia is present the
affection seems essentially to be a curable one. Dementia symptoms come
later, and appear secondary to the progress of some underlying changes,
but before these have progressed far,, treatment seems more effectual
and the prognosis not at all bad.

I>eri0cope

The Journal of Mental Science
(Vol. LIL, No. 216, January, 1906.)

1. Amentia and Dementia; a Clinico-Pathological Study. Joseph Shaw

Bolton, M.D., M.R.C.P.

2. On Some Relations Between Aphasia and Mental Disease. Sydney J.

Cole, M.A.. M.D., Oxon.

3. Some Notes on the Study of Insanity. F. Graham Crookshank, M.D.,

London.

4. Multiple Lipomata in General Paralysis. Conolly Norman, F.R.C.P.I.

5. Some Clinical Notes Upon Urine-Testing and Results. Robert Jones,

M.D.

6. A Note on Psychiatric Terminology and Classification. Thomas

Drapes, M.B.

7. The David Lewis Manchester Epileptic Colony. Alan McDougall, M.D.

8. Notes Upon the Incidence of Tuberculosis in Asylums. George Green*,

M.A., M.B., Cantab.

9. The Necessity for State Interference on Behalf of the Imbecile. F. E.

Rainsford, M.D.

10. The Employment of Female Nurses in the Care of Insane Men ia

Asylums. George M. Robertson, M.B., F.R.C.P., Edinburgh.

1. Amentia and Dementia. — Continued article.

2. Relation Between Aphasia and Mental Disease. — The author calls
attention to the necessity of studying the aphasic disturbances in mental
disease, a view based upon the work of Wernicke, Pick and others. The
former was the first to emphasize this relation and laid stress upon the
significance of "Transcortical Sensory Aphasia" as a link between aphasia
and mental disease. The type of aphasia was thought by Lichtheim to be
produced by a supposed interruption of the path from the auditory word
center to a schematic center of concepts. The relation of these aphasic
symptoms and their occurrence in mental disease is then discussed, the
most important symptoms from the author's standpoint being echolalia.
This symptom he regards as aphasic, especially when it occurs in senile
dementia, epilepsy and general paralysis. In these cases echolalia is usually
accompanied by other aphasic symptoms. Such a value to echolalia may
also be given in other psychoses, including the katatonic form of dementia
prgecox. Echolalia may vary in degree from the slightest, the purposeful
repetition or giving back of a question (the "Echolalia in Frage form" of
Pick), to the severe grade — the "Automatic Echolalia" in which the
patient merely repeats mechanically what is said to him, words and even
sentences being thus repeated. In this series a relation between echolalia
and a defect for understanding spoken language can be demonstrated. The
author cites cases of Jacksonian epilepsy, and general paralysis in which
the above symptoms were present during periods of confusion following
seizures. Also in cases of acute insanity, confusional type. Ten cases
are abstracted from the literature, showing this combination of symptoms,
mostly in cases of senile dementia, organic dementia and general par-
alysis, a number of which came to autopsy and no focal lesions were found
to account for the symptoms. Certain cases, which the author thinks
might answer the description of dementia prgecox, have been observed, and
in the late stages echolalia was accompanied by aphasic disturbance and
dementia. A very interesting case is reported in detail and the admirable
manner in which it was examined, warrants its publication as well as our
attention and respect. He states that the case considered from a psychiatric

PERISCOPE 273

point of view is certainly dementia praecox, katatonic form, but also from
the result of the examination, is a case of sensory aphasia and the data
certainly warrants such a statement. Along* with mental impairment,
katatonic mannerisms, stereotyped movements, impulsive acts, echomimia,
good memory for certain things, and flight of ideas (rather word salad)
in a woman 54, who had been insane since the age of 20, occur also the
following aphasic symptoms ; extreme verbal paraphasia, agrammatism,
disorder of intonation with paraphasic logorrhea. and jargon ; serial and
imitative speech well retained, mild degree of alexia, understanding is
defective for spoken language, is lost for printed and written language,
voluntary writing is abolished and paragraphia is present. The fact of
these symptoms occurring in a case of dementia praecox is certainly
worthy of notice, but whether this paradigm will hold for other cases is
rather doubtful. The views regarding the causes and nature of echolalia
are unsatisfactory. While most authors hold that it is a disturbance of
the will, others, among whom is the author, claim that it is primarily a
speech defect and has nothing to do with the will. Various views are
cited, principally the dissolution of the inhibitory influence of the higher
association centers (Hughling Jackson). According to Pick, this inhibition
is accomplished by the auditory word center, but the author prefers the
schema of Lichtheim, who claims that the inhibition is exercised by the
center of concepts through the auditory word center. Whether these
theories explain echolalia or not, the author is satisfied to state that
echolalia and aphasic symptoms are closely related in mental diseases.
From a clinical and psychological standpoint, such a relation is surely ad-
missable, and such cases as the author produces tend to substantiate this
theory. To establish such hypotheses on an anatomical basis is infinitely
more difficult and even Wernicke could not demonstrate that such aphasic
symptoms depend upon known properties of certain regions of the brain
and their destruction by disease.

3. Notes on the Study of_ Insanity. — The author argties that in studying
insanity, psychical and physical series should be considered separately, that
physical causes are physical in the sense that physiological conditions are
physical. He would not consider "moral" or mental treatment except as
it applied to physical conditions. He also pleads for a systematic study of
insanity, based upon acceptance of elements of our actual knowledge.

Then he proposes the following "stages" as characterizing insanity, and
that these stages should be recognized as belonging to one process ; namely,
melancholia, mania and dementia, in the order named. This law is based
upon the following statements: 1. That the psychical phenomena of
insanity occur in the same order as sleep, delirium, intoxication and
senility. 2. That the order is the reverse of that which obtains in indivi-
dual and racial development. 3. That in recovery from insanity, the order
of psychical phenomena is that of individual and racial development. Ac-
cording to the author we are to abandon the treating of "mental disease"
as such, but we are to consider them as dissolutions of mind and nervous
system. From the confusing nomenclature and the idea that we are to
consider melancholia, mania and dementia as characterizing insanity and
the stages of one process, those engaged in the study of psychiatry may
find an easier method and a simpler label, but not much benefit could
come from such a usage.

4. Multiple Lipoma in General Paralysis.— A case of general paralysis
exhibiting multiple lipoma is considered sufficiently rare to report. The
author gleans from the literature that only one mention is made of this
occurrence in general paralysis, and another in tabes dorsalis. The
author's case was a tabetic paralytic with other unusual features. The
association of multiple lipoma and tabes and general paralysis would sug-
gest that it belonged to the tropho-neurotic conditions occurring in these
diseases, but the author regards this explanation as incomplete.

5. Not suitable for abstracting.

274 PERISCOPE

6. Psychiatric Terminology and Classification. — The author deplores
the present state of psychiatric terminology and classification and the fre-
quency of new classifications which distract the student of psychiatry. He
is much disturbed because there is as yet no universal classification and
lays the blame upon the fact that our knowledge on the subject is so im-
perfect, that the requisites for a proper classification are wanting, or that
there is an essential difference between psychiatry and other scientific de-
partments. He admits the great difficulties to be encountered. He leaves
the classification to psychologists, but unfortunately little that is practical
has come from such sources. He ignores the fact that what is needed is
a classification more suited for medical purposes. He disputes the idea
that we can have "so-called varieties of insanity" as dementia praecox, and
from a theoretical standpoint combats the use of "dementia" in both
dementia praecox and senile dementia. The stand taken that all other
forms of insanity, if not cut off by intercurrent illness, end in dementia
is difficult to comprehend. Also we can get little help from the proposed
method of classifying insanity according to duration and intensity. For
the former the terms "recent — sub-chronic — chronic" for periods of three,
six and twelve months, and for the latter "acute, sub-acute and mild" are
proposed.

7. Not suitable for abstracting.

8. Incidence of Tuberculosis in Asylums. — The author at the outset,
combats the prevalent idea that insane asylums are hot-beds for the growth
and spread of tuberculosis. From statistics it would seem that the pro-
portion of deaths by tuberculosis to deaths due to other diseases was lower
in asylums than in population outside. Poverty, unhealthy hygienic sur-
roundings and alcoholic excesses, factors potent in producing tuberculosis
in the general population, have no influence inside of hospitals.

Evidence deduced from post-mortem findings go to prove that the
tubercular bacillus is not spread in asylums. The symptoms of tuber-
culosis in the insane were different from those in other classes of patients.
Wasting, irritability at times coughing are present, but patients seldom
expectorate and seldom have hemoptysis. The author also states that
the physical signs in the insane are different to some extent from other
classes of patients and more difficult to recognize. In the discussion of this
paper which follows, many important points, such as ventilation and
general hygiene in insane hospitals were brought forward, special atten-
tion being given to segregation of the tuberculous insane.

9. Not suitable for abstracting.

10. Continued article.

Henry A. Cotton (Hathorne, Mass.).

Brain
(Vol. XXIX. No. 113, 1906.)

1. Upon the Orientation of Points in Space by the Muscular Arthrodial

and Tactile Senses of the Upper Limbs in Normal Individuals
and in Blind Persons. R. T. Slinger and Sir Victor Horsley.

2. Notes on the Taenia Pontis. Sir Victor Horsley.

3. The Mental Symptoms of Cerebral Tumor. Philip Coombs Knapp.

4. A Studv of the Minute Structure of the Olfactory Lobe and Cornu

Ammonis, as Revealed by the Pseudo-vital Methods (with re-
marks on the Plan of the "Nervous Structure of Vertebrates in
General. John Turner.

5. The Abdominal Reflex in Typhoid Fever. J. D. Rolleston.

6. A Family in which Some of the Signs of Friedreich's Ataxy Appeared

Discretely. Eric Gardner.

7. Note on Apparent Re-representation in the Cerebral Cortex of the

Types of Sensory Representation as it Exists in the Spinal Cord.
Colin K. Russel and Sir Victor Horsley.

PERISCOPE 275

1. Orientation of Points in Space. — This study comes to the con-
clusions that (1) the faculty of orientation in space, as determined by
the muscular and arthrodial sense, progressively diminishes from the
surface of the body outwards to the limits of the arm extended in any
direction, (2) orientation knowledge increases in passing from point
to point in the space around the body, beginning above the head, com-
ing down to the front of the body, and gradually approaching the cen-
tre of gravity of the whole body, (3) orientation knowledge also increases
in passing from point to point in the space around the body, beginning
laterally, e. g., in the plane of the shoulder, and approaching the mesial
sagittal plane of the body.

2. Note on the Tccnia Pontis. — It is first brought out that this
bundle of fibers is rarely symmetrical. This is particularly so in the
lower animals and the suggestion is hazarded that should this asym-
metry turn out to be universal in view of recent work that has been done
on the relation of asymmetry and the occurrence of rotatory courses
and movements in quadrupedal as well as bipedal animals. Horsley
believes it to be a constant structure. It is a ponto-cerebellar tract and
is a localized bundle of association fibers, uniting a portion of the front-
al border of the pontine gray matter with that of the cerebellum, ap-
parently the nucleus dentatus. The direction of the fibers is cerebello-
petal as demonstrated by degeneration methods.

3. Mental Symptoms of Cerebral Tumor, — Knapp presents an ex-
haustive and valuable study on this subject using as a basis, the clinical
histories of 104 patients in whom a growth of some nature was found on
autopsy. In 75 per cent, of the cases, mental symptoms were noted,
a rigid analysis however, made it imperative to revise this figure since
alcoholism, typhoid, or other complicating feature existed. Thus, in
64 cases considered as representing true tumor states, at least 90 per
cent, were found to show mental symptoms. Knapp believes his state-
ment of some fourteen years previous by "that in every case somt
change can be found" and "that there can be no gross lesion in tht
brain without some disturbance, greater or less, in the psychical func-
tions" receives further support by his later experience. As for the men-
tal changes noted Knapp agrees with Schuster. The largest number
31 in all, presented the recognized type of mental dulness and failure.
Languor, somnolence, dulness, apathy, mental torpor, failure of mem-
ory, and a general failure of all the mental functions, ending usually
in complete stupor and coma were exhibited. Seven patients showed
confusion and disorientation with failure of memory, irrelevancy in
speech, mild mental wandering, somnolence, stupidity and a dazed con-
dition. In 15 there was delirium often with hallucinations. Neuras-
thenic and hysterical states were occasionally noted in the earlier stages of
the disease, but nearly always developed more marked mental disturbances.
The mental symptoms showed themselves early in about one-half of the
cases. As to the relation of the symptoms to the site of the tumor
Knapp shows that five of the six cases of tumor of the frontal lobe,
or to speak more accurately, of the prefrontal portion thereof, exhibi-
ted signs of mental disturbance. In all cases this disturbance was
simple mental failure with marked dulness, but in only three of the
cases was it noted as being among the early symptoms. The only case
where no mental symptoms were noted was a sarcoma, the size of an
English walnut, at the foot of the left second frontal convolution near
the precentral sulcus. It is curious, he remarks, that this is the only
case of tumor of the prosencephalon or diencephalon in which no men-
tal symptoms were recorded, but mental dulness may readily have been
overlooked, as the patient was in bed for a number of weeks, com-
plaining' constantly of intense headache and therefore averse to any con-
versation. Of four tumors in the Rolandic region, two presented symp-
toms of mental dulness early in their course, a third later in the dis-

276 PERISCOPE

ease was noisy and delirious, and the fourth finally developed hallucina-
tions and delusions of persecution. One of the two parietal cases pre-
sented neurasthenic symptoms early in the disease; the other became
dull and stupid toward the close. There were six temporal tumors.
Two of these were mentally dull, two confused, one delirious, and one
presented a typical picture of general paralysis. One of the dull cases
did not show much change till late in the disease; in all the rest the
symptoms were of early occurrence. Every one of the three callosal
tumors showed mental symptoms early in the disease, and all became
confused, delirious, violent and demented. One case had hallucinations.
Seven out of nine cases of a growth in the optico-striate region were
mentally dull, but only two showed this symptom early. Two other
cases showed early mental symptoms and both became delirious, one
wildly maniacal. Two cases of tumor of the corpora quadrigemina be-
came dull early and the third also showed early mental impairment
with delusions of persecution. One of them manifested early various
neurasthenic symptoms, scrupulosity and a sense of unworthiness, later
growing demented. The other case of tumor was mentally dull. Five
out of seven cerebellar tumors were mentally dull, but only one showed
this mental failure early. The sixth was delirious; in the seventh case
no mental symptoms were noted, but she had headaches with intense
vertigo, aggravated by any effort, so that mental symptoms may well
have been overlooked. One tumor of the hypophysis showed mental
confusion early in the disease; the second was delirious toward the
close. Of seven tumors at the base of the brain, five were in the ante-
rior fossa. Of these, one became dull early, three showed mental con-
fusion later in the disease, and a fifth was delirious, showing mental
disturbance early. One patient with tumor in the middle fossa became
delirious later in the disease In only one case of a tumor in the poste-
rior fossa, a growth of the cerebellopontine angle, not involving the
brain deeply, there were no noteworthy mental symptoms.

Eleven tumors were classed as multiple, but two other cases might
fairly be regarded in this class, one a multiple growth in the opticostri-
ate region, the other a multiple growth in the pons. Three of the
eleven cases showed mental failure late in the disease. One was con-
fused early and three were delirious. One of them showed mental
disturbances early; one was mentally depressed. Of the three cases
where no mental symptoms were recorded, two were under observation
a very short time, one dying suddenly with cysticerci in the brain, the
other dying suddenly of surgical shock. A third case with multiple
gliomata in the basal ganglia has already been reported. In one other
case with mental failure the autopsy record of the findings in the brain
was lost, the only note being1 "glioma of the brain."

4. Minute Structure of Olfactory Lobe. — The author first details
the improvements in his technique which should be consulted in the
original. The structures of the bulb as stained by his method show con-
siderable similarities to the structures of the cerebellum and the hom-
ology of these organs is pointed out. In homologizing the cornu Am-
monis and the fascia dentata with the pallium, Turner speaks of the
stratum oriens corresponding to the fusiform or spindle cell layer; the
stratum pyramidulum and stratum radiatum to the large pyramidal
layer and the stratum lacunosum to the second or small pyramidal lay-
er. Turner believes in the neurofibril and its continuity and suggests
some features of the reflex arc integrations and the integrations of the
nerve system in general along the general hypothesis of the continuity of
the neurofibrils.

5. The Abdominal Reflex in Typhoid Fever. — Observations in 45 pa-
tients having typhoid fever, in 93.3 per cent, there were variations in the
abdominal reflex. It was completely lost in 68.8 per cent., impaired in
a greater or lesser degree in 22.2. Unaffected in three cases only. The

PERISCOPE 277

reflex resumes its activity as convalescence becomes established. The
author summarizes his result as follows: (1) The abdominal reflex is
affected in a very large number of cases of enteric fever, the percentage
of cases in which it is entirely lost exceeding those in which its nor-
mal activity is diminished only. (2) From its absence under 50 by being
confined to certain nervous diseases and acute abdominal disorders,
notably appendicitis and enteric fever, the absence of the abdominal
reflex in a given case of continued pyrexia in any patient below 50 is of
considerable diagnostic value. (3) The comparatively transient nature
of the affection of the abdominal reflex in enteric fever is a striking
contrast to the more chronic affection of the knee and ankle-jerks in
diseases associated with peripheral neuritis, e. g., diphtheria. (4) Re-
turn of a lost reflex, and a fortiori resumption of its normal activity,
are a valuable indication of commencing convalescence, and often cor-
respond with lysis and characteristic changes in the feces and urine.
(5) The objective sign of the return of the reflex is often associated
with the return of the subjective feeling of ticklishness normal to the
individual. (6) In re-appearance of pyrexia in convalescence, the con-
dition of the abdominal reflex is a valuable index of the nature of the
pyrexia. (7) No constant relation exists between the condition of the
abdominal reflex and that of the tendon reflex. (8) The frequency, de-
gree, and duration of impairment of the abdominal reflex are usually
in proportion to the age of the patient.

6. Friedreich's Ataxia. — The author gives an extensive literary sur-
vey of the cases of Friedreich's occurring' in more than one member of
the family and reports a new family. The mother showed nystagmus,
tremor, spasticity and increased knee-jerks. There were six daughters.
One showed spasticity, nystagmus, clubfoot, increased knee-jerks, and
changed speech; a second had scoliosis and absent knee-jerk, but is
otherwise normal; a third, child is normal, as is the fourth; the fifth
child, has no knee-jerk, pes cavus is present. The youngest child is
normal. He discusses the anomalous character of the illness, but pre-
fers to group them as a family disease showing some of the signs of
Friedreich's disease without specifying just where the present cases be-
long.

7. Sensory Re-representation in the Cortex. — The authors put for-
ward the thesis that the spinal representation of tactibility finds an
echo in the arrangement of that function in the sensory cerebral cortex.
They first review the three classes of views on sensory representation
in the pallium so far as they relate to the kinds of sensation represented,
i. e., (1) Representation of sensation of any kind in the pallial kines-
thetic area, (2) Representation of tactile sensation elsewhere in the pal-
lium as well as in the kinesthetic cortex, and (3) No representation of
sensation in the kinesthetic cortex. Evidence from the clinical side is
adduced which the authors say up to the present time has sustained the
views of Mills and Campbell that the post-central region is essentially
the seat of sensory (tactile?) representation, and that all the instances
of apparent lesion of the ascending frontal gyrus only are probably vitiated
by associated disorders of the ascending parietal convolution, and final-
ly that the corresponding "sensory" centers are arranged horizontally
behind the "motor" centers.

The authors proceed then to draw attention to an additional type ac-
cording to which tactility and topognosis appear to be also represented
in the cortex cerebri, viz.. a type which is apparently a re-representation
of that according to which tactility is represented in the spinal cord.
The representation of tactility in the spinal cord which is essentially a
metamerically-divided organ is readily mapped out, and the terminology
descriptive of the topographical mapping of tactility in at any rate the
hand and forearm was originally laid down by Ross from clinical ob-
servations and by Paterson from consideration of embryological an-

278 PERISCOPE

atomy, while since that preliminary epoch the subject of spinal sensory
representation has been exhaustively examined by Sherrington and by
Head, with the result that the topographical areas of the different spinal
roots are now well defined. The conclusion reached is that it is per-
fectly clear that what may properly be termed the mid-axial line and
region of the hand and forearm is as definitely represented in the cere-
bral pallium as it distinctly is in the spinal cord. It is perhaps natural
to expect that this should be so, because any contrast between the
post-axial and pre-axial portions of the limbs respectively, presupposes
an imaginary frontier line between them, and further, the cerebral mem-
orialisation of the transfer of the limb to and from the mesial plane of
the body demands that the cerebral pallium should have particularly
localized within it the orientation of the middle point of the limb which
is thus translated from or to the sagittal mesial plane. This further
proof of similarity between the sensory representation in the spinal cord
and cerebral pallium is confirmatorv of the other phenomena described.

Jelliffe

Deutsche Zeitschrift fur Nervenheilkunde.
(Band 28, Heft 1.)

1. The Symptomatology of Hemiplegia. Heilbroxxer.

2. The Status Hemiepilepticus Idiopathicus ; Eight Clinical and Anatomi-

cal Observations. Muller.

3. A New Algtesimeter, with a Critical Description of the Previous

Algesimetric Methods. THUNBERG.

4. Tumor of the Hypothesis Without Akromeg'alv. KOLLARITS.

1. Hemiplegia. — Upon the cadaver it may be observed that the outer
contour of the thighs is more convex than during life. The same appear-
ance may also be observed in the affected leg in cases of recent hemi-
plegia. A somewhat similar appearance may lie observed in the calf and
arm muscles. Hcilbronner calls this condition "the broad leg." It is not
present in sleep, nor in unconsciousness, nor in profound narcosis. It is
present in severe acute polyneuritis, but was not found in tabes, in chorea,
in Huntingdon's disease, or in hysterical flaccid hemiplegia. It is not cer-
tain that it will serve in the differential diagnosis of cerebral and spinal
hypotonia. The broad leg is not dependent upon the disappearance of the
patellar reflex, or even upon the return of voluntary movement; but if it
persists the contractibility of the quadriceps to percussion upon its tendon is
usually lost. After some discussion of the reflexes and muscle tone Heil-
bronner reaches the conclusion that in the course of recovery from
hemiplegia the following series of events occurs. First, return of active
motion; second, return of the contour-preserving tone; third, the return
of the reflex muscle tone. With reference to certain other clinical
phenomena he states his belief that the superior restoration of the func-
tion of the leg is merely apparent. He also discusses the hemiplegic gait,
and calls attention to the importance of educating hemiplegics how to
walk properly. He describes a curious form of rhythmical movements of
the arm during walking, which are entirely involuntary. They consist
of a flexion and lifting of the forearm, and may occur when apparently all
the symptoms of hemiplegia have disappeared.

2. Status Hemiepilepticus. — Although it is generally supposed that par-
tial or Jacksonian epilepsy is due to some focal lesion in the brain, a num-
ber of observations have been recorded in which such partial epilepsy has
existed although examination of the brain has been entirely negative.
Muller collects from the service of "Nonne eight cases of partial epilepsy.
The first, an alcoholic and leutic man of 26, who had had an injury to the
head. There was left-sided status epilepticus not relieved by trephining.
The macroscopical examination of the brain was negative ; apparently a
microscopical examination was not undertaken. The second case, a

PERISCOPE 279

chronic alcoholic, died in left-sided status epilepticus. At that autopsy
there were various lesions of the body, but the brain was microscopically
normal. The third case, a chronic epileptic, 38 years of age, had 306
attacks, involving' only the left side of the body. At the autopsy an area
of softening was found on the basilar surface of the right frontal lobe.
Elsewhere the brain appeared to be normal. The fourth case, a boy of
19, had symptoms of acute meningitis, then left-sided epileptic attacks and
death. There was a diffuse chronic meningitis in the base of the brain,
but no alteration in the substance of the brain. The fifth case, a woman
of 2>7, had epileptic attacks limited to the left side; there was a history of
injury to the brain. There was high fever, cyanosis, and loss of pupillary
reaction. The ophthalmic examination indicated disturbance of the optic
nerves. At the autopsy nothing abnormal was found, either in the brain
or body, and a microscopical examination of the former organ was nega-
tive also. The sixth case, a girl of 18, had albuminuria, and right-sided
epileptic attacks. The brain was normal ; the kidneys only slightly
affected. There was hypoplasia of the aorta. The seventh case, a man of
27, in the course of diabetes mellitus developed typical Jacksonian epilepsy.
At the autopsy the brain was normal, but there were changes in some of
the abdominal organs. The eighth case, a boy of 6, had general epileptic
attacks at the age of 4 years. Two years later he suffered from epileptic
attacks, limited at first to the right side, then to the left side of the
body, profound coma, gnashing of the teeth and trismus. Later he de-
veloped measles, and made a complete recovery. It seems wisest, in the
absence of more definite knowledge, to regard these cases as atypical forms
of general epilepsy.

3. Algesimeter. — Thunberg describes this algesimeter, which consists
essentially of a lever, to one end of which a needle is attached, and to the
other end a weighted screw, by which it can be brought into a state of
equilibrium. The arm to which the needle is attached is divided into ten
parts. The instrument is brought into a state of equilibrium and then
weights hung upon the arm. The position and size of the weight deter-
mines the amoifnt of pressure exerted. This pressure is increased until
the patient experiences pain. The paper is concluded with a valuable
critical description of the various instruments hitherto divised for the
purpose of measuring sensation.

4. Hypophysis Cerebri Without Akromegaly. — Kollarits tabulates a
series of cases in which there was tumor of the hypophysis cerebri, without
akromegaly. Among these he includes two cases of his own. Usually
these tumors occur in young persons, but Kollarits is of the opinion that
a careful consideration of the cases suggests that tumor of the hypophysis
is merely one of the symptoms, and not the cause of akromegaly.

J. Sailer (Philadelphia).

Miscellany

Tabes Dorsalis and Psychosis. M. Bornstein (Monatsschrift fur Psy-
chiatric and Neurologic Vol. 17, 1905).
Many authors claim that the psychical manifestations of tabes are
purely of a paretic nature. Bornstein discussed the many difficulties one
experiences in making a differential diagnosis between general paralysis
and other mental disorders. The author makes abundant reference to the
literature of tabes and psychosis, and among others he quotes the follow-
ing important neurologists and psychiatrists. Cassirer differentiates be-
tween the elementary psychopathic symptoms of tabes from a fully de-
veloped psychopathic state. The tabetics as a rule manifest extraordinary
quietness, even striking cheerfulness, which they exhibit in spite of the
pain they endure. Other authors are more reticent in generalizing their
observations. Leyden and Goldscheider assert that the emotional tone
in the tabetic is variable, as characteristic of all chronic diseases. Cassirer

280 PERISCOPE

maintains that the patients who suffer from tabes are cheerful, but other
authors disagree with him, and claim that the mood is changeable ; at times
they are elated, but oftentimes they are markedly depressed, even suicidal,
suffer with insomnia and become very nervous. However, in many cases
no such symptoms develop except an ordinary hypochondria. Simon
alleges that all tabetics present a peculiar mental symptom complex, which
he termed "Tabetic Dementia." Further study of Simon's patients showed
that the so-called tabetic dementias were nothing but ordinary cases of
paresis. Nageotte studied three cases of tabes which were devoid of
mental symptoms, but post-mortem examination disclosed a distinct
pathological process corresponding to that found in general paralysis. In
regard to the real psychosis in tabetics, Bornstein states that in almost all
cases of tabes, hallucinations of all senses play an important role in the
clinical picture. Kirsch and Pierret and their pupils regard such a
psychosis typical of tabes. According to Pierret, the fundamental symptom
in such a mental derangement is melancholia, which is founded on a
somatic basis. From such a state, sensory disturbances become marked
and exaggerated by patients. For instance, pain may be interpreted as an
imaginary foe and reduction of vision gives rise to optical false percep-
tions. Nageotte, Moebius and others disagree with Pierret. But Moebius,
however, admits that tabes dorsalis and paranoia may occur in the same
individual. Otto Meyer has made a study of 56 undoubted cases of tabes
with various mental aberrations. He groups his cases as follows: Paranoia
(chronic hallucinatory), 21 times; depressive psychosis (melancholia and
hypochondria), 14 times; circular psychosis, 4 times; acute hallucinatory
confusion (amentia), 2 times; maniacal excitement, 1 time; secondary de-
mentia (after paranoia), 1 time; paranoia dementia pnecox (Kraepelin), I
time ; primary dementia, 3 times ; psychosis with hallucinations of restless
character, 3 times ; severe periodical excitements, 1 time ; excitement in de-
fective mental development, 2 times ; dementia precox, 1 time.

Schultze described two cases of tabes, one of which was melancholic,
and the other a paranoic. The usual ratio of tabes between men and
women is 3 to 1 ; locomotor ataxia with psychosis, 1.6 to 1. This shows
that the relative frequency of psychical disturbance in female tabetics is
greater than in men. Functional insanity ( but not paresis) is more
common in those tabetics which show an affection of the optic nerve and
the nerves which regulate the pupillary accommodation ; and furthermore
in those patients who have marked consanguineous vesanity. Bornstein
describes a patient who developed a clinical picture of tabes with optic
involvement, who was subject to several attacks of mental disturbance.
The psychosis was essentially of an hallucinatory nature. The patient re-
acted to auditory, visual, haptic hallucinations, and was disoriented, ex-
cited, confused and irritable. These mental symptoms rapidly subsided
and the patient regained his normal equilibrium without insight. The
author's conclusions are briefly as follows: (1) There are no specific
foundations for a tabetic psychosis. (2) The most important symptoms of
all functional, mental disorders, occurring in tabes, are hallucinations of
all senses. (3) The psychical disturbance in tabes should not be con-
sidered as a complication of this disease process. (4) The frequent psy-
copathic symptoms in tabes usually arise from distinct somatic distur-
bances, as, for example, optic atrophy, paresthesia and other sensory
anomalies. (5) Patients without a predisposition for mental disorders may
have hallucinations without a true psychosis. On the other hand, those
patients who have a distinct vesanic taint may develop different forms of
psychoses, such as paranoia or depression.

F. J. Coxzelmann (New York).

The Neuritic Type of Progressive Muscular Atrophy. A Case with
Marked Heredity. By Archibald Church (Chicago Medical Re-
corder, November, 1906).
The writer reports a case of the true peroneal type — extending through

PERISCOPE 281

six, and probably eight, generations. According to the history the disease
successively became more extensive and severe with each generation. The
patient states that no females in the family were ever similarly affected,
but two maternal aunts had optic atrophy, and a sister weakness of the
ankles. J- E. Clark (New York).

True Sciatica and Diseases of the Posterior Urethra and Adnexa. By
G. S. Peterken (California State Journal of Medicine, August,

ioo6). . . . . .

The author differentiates (1) sciatica neuritis, or true sciatica, the
symptoms of which are those common to all inflamed nerves ; (2) sympto-
matic or false sciatica, the symptom of which is pain in or along the
sciatic nerve with absence of local objective symptoms usually accompany-
ing neuritis. In the opinion of the writer, false sciatica is frequently due
to a chronic inflammatory state of the posterior urethra and adnexa, and
the thorough examination of the male sexual organs is advocated in all
cases. J- E. Clark (New York).

Migraixic Psychoses. Alfred Gordon (Journal A. M. A., Jan. 5, 1907).
The author reports twelve cases of migraine associated with mental
symptoms, observed within the last four years, and all presenting similar
types of derangement ; namely, confusion, delirium, usually with hallucina-
tions, and stupor. The hallucinations were usually visual, though gustatory
and auditory hallucinations were also observed. The confusional stage
predominated in all, and was frequently accompanied with illusions of
identity, incoherence and disturbance of orientation. Some of the cases
suggested psychic epilepsy or procursive epilepsy. In the majority of cases
the mental symptoms occurred during the attacks, and in some they con-
tinued twenty-four hours after the subsidence of the migraine. In some
cases, however, they occurred either before or after, and they lasted in
some cases for twenty-four hours after the subsidence. He does not think
that he can explain these conditions as epileptic or hysterical, though in
some cases they suggested it. The special point is their association with
an autotoxic condition, which is the basis of migraine.

Landry's Paralysis. J. N. Hall and S. D. Hopkins (Journal A. M. A.,
Jan. 12, 1907). .

The authors report on five cases of acute ascending paralysis, all fatal
but one. and review and analyze other recent cases published, and discuss
the condition generally They conclude that not one bacterial species can
be credited with this intoxication, though there can be little doubt that it is
due to bacterial products. There is no apparent occupational factor,
though the predominance of the disease in males might suggest such a
possibilitv. Their analysis of carefully reported modern cases would seem
to show that sphincter" involvement is more frequent than is stated in the
text-books. As regards diagnosis, confusion is likely to arise with acute
ascending mvelitis, multiple neuritis and anterior poliomyelitis. In the
former the sensory involvement, trophic disturbances, wasting of muscles
and loss of faradic irritability should aid the diagnosis. In multiple neuri-
tis the sphincters are not involved. The paralysis is usually limited to
peripheral muscles, and there is marked pain, tenderness and sensory dis-
turbance. Anterior poliomvelitis is a limited paralysis of the extremities,
usually the lower extremities, with marked wasting, lacking sensory dis-
orders' and with tendencv to rapid improvement. The treatment of Lan-
dry's paralvsis is chiefly supportive. In the author's patient, who recov-
ered, benefit seemed to be derived from salicylates and iodid of potash,
followed later by strychnin, massage and electricity. Mercurial inunction
was also applied, though there was no specific history.

282 PERISCOPE

Head Trauma as a Cause of Insanity. C. W. Burr (Journal A. M. A.,
Jan. 5, i0o;).
The author asserts that, excluding traumatic epilepsy and hemiplegia
with their resulting mental disorder, injuries to the head will not cause
insanity unless some predisposition exists. His reasons for this belief are
that the vast majority of those suffering from brain injury do not become
insane unless there is such a loss of brain substance as to produce dementia
from that fact alone, and the rarity of mental disorder following extensive
operations on the brain in which lesion of the organ is much greater than
that of any ordinary trauma. That head injuries can be a directly exciting
cause when predisposition exists or in senility, or that they may aggravate
or revive an insane tendency is not to be denied. As regards the claim
that there is a characteristic form of post-traumatic insanity, he says it
can certainly be denied. The usual types are confusion, delusion, simple
dementia and epileptic insanity. He has never seen paranoia or true mel-
ancholia following a head injury. He excludes from consideration all
cases of post-traumatic delirium, transitory or rapidly followed by death
from exhaustion, and all cases in which the physical injury was so trifling
or the mental shock so slight that the trauma was a mere coincidence. The
only cases considered are those in which the relation of the time between
the injury and the onset of the insanity was so close as to make it reason-
able to assume that there was something more than mere coincidence. The
exact relation between early trauma and late insanity is difficult to ascer-
tain on account of the lapse of time and the usual vagueness of the his-
tories, but he has never seen a case in which other causes than the injury
could be excluded. A number of case summaries illustrating the author's
views are given in the article.

The Etiological Role of the Vasomotor Centers in Cardiac Neuroses.
R. Pollard (Zentralblatt fur Innere Medizin, Jan. 12. 1007).
Dr. Rudolf Pollard, after an interesting dissertation, gives us the fol-
lowing conclusions of his observations: (1) There is a group of diseases,
chiefly chronic, whose symptoms may be recognized by a preponderating
participation of the blood vessels, or rather the blood vessels of the nervous
system. To this group belong the heart neuroses, paroxysmal tachy-
cardia, Bassedom's disease, the angioneuroses of the skin, etc. (2) The
source of these disorders is an abnormally increased irritability of the
vasomotor centers in the medulla. ( 3 ) The resulting condition of the
heart and the vascular manifestations are in the way of a reflex which may
be elicited through peripheral as well as central (brain) irritation. (4)
Thereto, further, a reflex sensory tract is necessary ; the reflex processes
(probably on account of retarded influences at the surface of the brain)
may appear under circumstances at first, after the expiration of a certain
time (late reflex) and are not strictly confined to the location of the irrita-
tion. At wood (New York).

Paroxysmal Tachycardia. By John Hay (Edinburgh Medical Journal,
January, 1907).
Symptomatic tachycardia is caused most frequently by a diminution of
the normal inhibitory influences. Pyrexia, certain infective conditions,
alcohol, atropine and thyroid, may produce the condition, as well as direct
stimulation of the accelerator fibers or of the heart muscle. "Paroxysmal"
tachycardia, on the other hand, is doubtless of nervous origin, but "during
a paroxysm there is an essential and fundamental change in the mode of
cardiac contraction, the heart beats in a manner specifically different from
that normally found." Three cases are detailed, careful tracings of which
are reproduced and explained. The author suggests that "certain nervous
influences alter the condition of the heart muscle, and more especially the
fibers joining the auricles and ventricles, rendering them more excitable
and more capable "of stimulus production." Traumatism affecting the

PERISCOPE 283

heart, physical stress or strain is mentioned as the most exciting factor.
In Hay's first case the first paroxysm came on after a severe blow over th«
epigastrium and lower end of the sternum received in a game of football.
Some subsequent attacks in the same case followed physical stress, and
others seemed to have no assignable exciting cause. Paroxysms lasted
from some hours to eight days. The symptoms were usually severe and
distressing. The other cases were milder ; one was in a child of six and
the other in a man of forty-two. The author quotes that Hoffman believe!
that these attacks are of the nature of cardiac epilepsy, but that in thirteen
autopsies of such cases no lesion was discovered either in the central
nervous system nor in the vagus or sympathetic nerves. Hoffman agrees
that abnomal cardiac contraction is a distinct feature of the paroxysm.
Wenckebach is quoted as suggesting that the stimulation of the central
nervous system results in a great increase of the chrontropic and bath-
motropic influences playing on the heart. At wood ('New York).

Joint Affections in Nervous Disease. By L. F. Barker (Journal A. M.
A., Feb. 2, 1907).
Four types of joint disease in nervous affections are considered. The
first of these, the intermittent joint effusions, he considers closely related
to the angioneurotic edema of the skin and mucous membranes. The
danger is in these cases that a mistake in diagnosis may lead to need-
less and dangerous surgery or to tedious fixation and inactivity. The
sudden onset, absence of fever, short duration and periodic recurrence
make the diagnosis usually easy. What the patients require in treat-
ment is rest, encouragement and a flannel bandage. Aspiration of the
joint or injections are totally unnecessary. Hygienic measures will
often suffice to stop the attack. Angineurotic remedies may be advis-
able for the patient's general condition and arsenic has sometimes been
of service. The arthrooathies of tabes and paresis are treated of at
more length. The rarity of pain in these cases, the sudden firm swel-
ling, usually rapidly extending, are characteristic in most cases, though
rarely there may be pain and the swelling may be gradual. Sometimes
the swelling subsides, and the joint is left but little impaired, but more
frequently there is a breaking up of the joint and a mild case can be
converted into a severe one by neglect and overuse. The painless char-
acter of the affection tends to lead the patient to use the joint unless
strictly warned against it by the physician. Every joint of the body
is liable to be affected, but the larger ones more than the smaller. Two
special forms are mentioned; the tabetic foot, in which the bones of the
arch are particularly involved, and the tabetic spine, differing from the
other types of spondylitis deformans in its sudden onset and extensive
destruction of the parts as well as in its associated tabetic symptoms.
The joint lesions of syringomyelia are very similar to those of tabes,
but the common occurrence of pain, the predominance of involvement
of the upper extremities (80 per cent, of the cases) and the longer
course of the affection are notable differences. Its treatment is limited
to rest, orthopedic measures and the avoidance of trauma. Operative
measures are rarely advisable. As regards the theories of these spinal
arthropathies. Barker thinks that the neuritic explanation is plausible
for tabes, but insufficient for syringomyelia, and that similar objections
hold good in the case of the arthritis deformans theory. In conclu-
sion, the painless arthralgias of hysteria and the traumatic neuroses
are noticed, and the importance of differentiating them from cases of
organic disease, especially tubercular, is pointed out. In doubtful cases
the deep chloroform narcosis recommended by Charcot, should be em-
ployed for diagnosis. Isolation and psychotherapy are the sovereign'
remedies for this condition; hydrotherapy and electricity can be use-
ful adjuncts. Brief details of such treatment are given and its suprisingr
success is noted.

Book IRevtews

-A Treatise on the Motor Apparatus of the Eyes, Embracing an Ex-
position of the Anomalies of the Ocular Adjustments and
Their Treatment with the Anatomy and Physiology of the
Muscles and Their Accessories. George T. Stevens, M.D., Ph.
D. Illustrated with 184 engravings, some in colors. F. A. Davit
Company. Philadelphia, publishers, 1906.
Dr. Stevens may truly be said to have excited more comment about hit
work than any other American ophthalmologist; and this perhaps has
been in many quarters more unfavorable than favorable, for while there
can be apparently no doubts expressed regarding his knowledge of the
physiology of the ocular muscles, and of his skill in devising apparatus
and instruments to study the movements of the eyes, most ophthalmologist!
believe that his treatment of defects in the action of the eye muscles it
improper, and most neurologists and clinicians are convinced that his
claims that epilepsy and other neuroses may originate in eye-strain, are
erroneous. The book under review is a valuable one, and will surely be
so recognized by ophthalmologists, but amid all the scientific truths, de-
duced in a most admirable manner, by a logically thinking scientist, art
■conclusions regarding the effect of anomalous acting muscles so apparently
and flagrantly false that the reader grows to doubt after a time, if even
the scientific data upon which the premises are based are true.

As the work is largely concerned with the elucidation of optical prin-
ciples, neurologists will be interested only in the phases dealing with the
influence of imbalance of the ocular muscles upon the general system.
Among other observations bearing upon this subject, they will doubtless
be interested in the conclusion of the author that certain peculiarities in
the excursions of the eyes, in the vertical deviations especially, are as a
rule associated with certain types of crania, for he believes that as a
consequence of atypically shaped skulls, the axis of the orbit undergoes
variations, so that the visual planes change and are only adapted to a
normal working standard by compensatory adjustment of the head. Thus,
if the visual plane is elevated, the individual carries the head forward, so
as to depress the orbital axis, and the forehead is advanced beyond the
position to which it would otherwise come. On the other hand, if the
plane of vision is depressed, the head is thrown back for the most natural
pose. According to the author, bodily pose, gait and appearance are all
modified by the direction of the orbital axis. With this observation thert
will probably be no lack of accord by ophthalmologists, and the field for
further study and elaboration of his methods from which he obtained his
data will doubtless receive careful study. But agreement with some of his
clinical deductions is not so easy, and there will in all probability be but
few who will support him in his inferences that trachoma is rife among
subjects with tall or mesocephalic heads and that the peculiar carriage of
the head, the result of anomalies in the visual planes, is beyond question a
most important element in the predisposition to tuberculous disease of the
lungs. To fully appreciate the author's convictions upon the subject it is
perhaps only fair to quote his own words: "The bacillus of consumption
finds no rest and no encouragement to indefinite multiplication in the
chests of persons whose heads are habitually thrown backward, nor, indeed,
in the lungs of those whose heads are not habitually thrown too far
forward. The advantages of the so-called fresh air treatment and a great
■deal more beside can be secured by the proper carriage of the head which
follows at once on a successful correction of the declination or of the
anophoria." (By operation.) "In such corrections, important in them-

BOOK REVIEWS 285.

selves, are to be found the most effective means, not only of prevention,
but of relief from the most general single cause of destruction of human,
life. I am quite aware that these statements will be regarded as extreme
and as the outgrowth of too restricted attention to a single class of
phenomena. The statements are neither extreme nor the expression of
narrow views. They are well considered and based, not only on correct
principles, but upon carefully observed facts in a large experience con-
tinued through many years."

Equally questionable is the author's observation that strabismus exer-
cises a deleterious effect upon the health of the subjects. Thus, he says:
"That some strabismics who acquire the art of effectually suppressing the
mental appreciation of the image of the squinting eye remain in good
health until a somewhat advanced period in life, does not invalidate the
general rule that strabismus leads to early exhaustion of the powers of the
patient, and that but a small proportion of strabismic persons reach the
age known as middle life. Strabismic children are seen in much greater
numbers than adults who squint, and the difference is only in part due
to corrective operations."

The reviewer has not, nor as far as he is aware, has any other oph-
thalmologist, practiced as yet the form of operation which the author
describes in his book for the correction of muscle errors, but from a
knowledge of the difficulties attending operations upon the muscles of the
eye, it would appear inadequate in cases of pronounced deviation of the
ocular axes. While all ophthalmologists are in hearty accord with the
author's assertion that the great principle which should guide in all
surgical treatment of the muscles of the eyes is that all of the functions
of movement should be made more perfect and more harmonious after
the treatment than before, the realization of this ideal is difficult of attain-
ment. The author's wholesale condemnation of tenotomies and advance-
ments is surely improper, for every ophthalmologist of experience can
relate many instances where these procedures have been of greatest ad-
vantage.

Notwithstanding its weaknesses, however, Dr. Stevens' book should
be ready by every ophthalmologist, for his methods and instruments for
examination deserve careful study and invite further elaboration. It must
not be forgotten that ophthalmology is gTeatly indebted to Dr. Stevens for
calling attention to the existence of anomalies in the ocular muscles, which
had escaped detection by others, and that it owes to him in large measure
the means of detecting quickly and accurately the degree of such varia-
tions. The neurologist will probably gain but little by its perusal, for in
the opinion of the reviewer the deduction as to the importance played by
various types of crania in the production of systemic disease is unsub-
stantiated and erroneous. William Campbell Posey.

Affektivitat, Suggestibilitat, Paranoia. Von E. Bleuler, Professor der
Psychiatrie in Zurich. Carl Marhold, Halle.

This is a short monograph of 144 pages, in which the author in an
inimical manner discusses certain aspects of the "feelings," applying his
analysis in part to the elucidation of the paranoia problem.

Feelings, Bleuler tells us, are distinctly various and a sharp differentia-
tion should be made between the groups if we are to arrive at more
fundamental conceptions. He says that at least four groups stand out
more or less sharply differentiated: (1) Those due to mass of centripetal
processes, of sensations, perceptions (thus the feeling of warmth — of bodily
sensation) ; (2) those conditioned by intracentral perceptional processes
related (a) to that which happens without (feeling of certainty, of prob-
ability), and (b) that which happens within us (feeling of sadness, of
blindness, etc.) ; (3) those arising from indefinite and hazy recognition, be
it a direct perception or a conclusion which is uncertain and unknown in
its elements ; and, finally, (4) feelings of pleasure and pain. For the first

.^86 BOOK REVIEWS

three g'roups, he countenances the term "intellectual processes," and he
says they have nothing to do with what he wishes us to understand by
"affectivity." The feelings in the last group are closely allied with "affec-
tivity," they are mixtures of intellectual and affective processes and contain
a sensation and a feeling produced or determined by it. The intellectual
processes in his series have no control over the psyche — this is only
moved when an affect is added.

In order to arrive at a physiological idea of affectivity, he cites an
illustration of the ameba. "The irritation of a grain of food stuff acts
upon it at a given place. The portion lying in close contact sends out a
pseudopod, and engulfs the spoil, digests, and throws away that which is
undigested, and the individual returns to its normal shape. This whole
process Bleuler designates as a localized, objective, intellectual process.
By it, however, the entire amoeba must have been altered in its nourish-
ment tone and in its entirety. During the taking in of the nourishment
other portions of the body dare not flow too much in other directions;
such streamings must be retarded. The reception of the nourishment
works for the good of the entire body; it becomes stronger, is more in-
clined to divide or carry on its other functions. This general action, he
says, may be arranged by the side of the affects. The affect renders a
reaction general, or as he puts it. ///.' affect is a generalized reaction. And
affectivity is the condition determining the conduct, the pushing element
in our actions; reinforcing the reaction if in the line of the affect, retard-
ing it if opposed. A prick of a pin causes one to draw the hand back. If
one is shocked by it the entire body draws "away: if one reacts in anger
the entire body passes on to an attack. The affect further has the interest-
ing quality that it persists longer than the experience. Affectivity is for
him the mainspring of responsiveness and activity which is not due to
purely mechanical reflexes.

Blueler then takes up the subject of suggestion, which he believes is an
affective process. Thus it can and does control the action of the glands,
of the intestines, the beating of the heart, and can disrupt the ideas, modify
judgment and even be the means of bringing about hallucinatory states.
Suggestibility is more than mere imitation, it starts the affective processes,
and thus can influence not only the actions of the individual, but even
move an entire community.

Paranoia is then discussed at length in relation to its being an affective
process as has been held by many, notably Specht. The initial experiences
in most paranoics are common to all. especially the suspicions and the mis-
trusts. Their incorrioible fixation is the pathological element — not the
ideas, since so many normally constituted individuals have them. The
feature that renders them dominant and incorrigible is perhaps primarily
the make-up or dispositi' n so well known to exist in some individuals, to
which is added predisposing chains of events. Further than this he does
not seem to go. He concludes that paranoia is not an affective psychosis.

The reviewer finds it difficult, even with the help of Meyers masterly
summary (Psychological Bulletin, Aug. 15, 1006), to follow the author
throughout the argument taken up in the latter part so largely with a
criticism of Specht's views of paranoia as an affective psychosis. His
illustrative cases are interesting, and the whole book is highly stimulating.

Jelliffe.

Emotional Variability in Epileptics. Prof. Dr. Gustav. Aschaffenburg.

Aschaffenburg's monograph on emotional variability of epileptics is an
important contribution to the literature of psychopathology. The gist of
his brochure mav thus be briefly stated :

Hoffman, in "1862, was the first to describe epileptic equivalents. Ac-
cording to this writer epileptic convulsions and coma may be substituted
by delirium, confusion and hallucinations. Aschaffenburg studied fifty
cases of epilepsy ; forty-eight of whom were delirious and confused ; twenty-

BOOK REVIEWS 287

eight had convulsive seizures; twelve were subject to fainting spells; fifteen
had petit mal and vertigo. The author asserts that the variability of mood
in epilepsy is an important psychical manifestation, and as he expresses it:
"Upon the ground of all these observations, I maintain that the fluctuation
of emotional tone is a specific symptom of epilepsy ; it is a symptom be-
cause of its frequency of occurrence, and the difficulty of comprehension
of epilepsy, it is by all means very significant." Mood was variable; some
patients were depressed, worried a great deal, and showed suicidal ten-
dencies. Others were apprehensive and reacted to auditory hallucinations
of a depressive character. Many patients complained in a verbose manner
(not flighty) about their situation, confinement, and protested against
former injustices which were done to them. With the disappearance of
the emotional disturbance they became content and attended to their work
as usual. Delusions of persecution were rare; yet one patient had
marked auditory hallucinations of a threatening nature, but these dis-
appeared in a few days. As a rule patients showed fugitive tendencies;
attempts were made to escape from hospitals, opposed detention, indulged
in purposeless walking, marched and travelled till they became exhausted.
Especially they complained of being homesick (Heimweh). Ofttimes these
attacks were either followed or preceded by a convulsive seizure. A
marked clouding of consciousness was not noticed ; but a feeling of in-
sufficiency was experienced. Most of these patients showed great intoler-
ance for alcohol, no matter how small the quantity was. Soon after tak-
ing liquor they became confused, delirious, expressed fantastic delusions
and manifested impulsive and assaultive acts. The intelligence of the
epileptics was divided into three classes : First, patients who showed good
knowledge and sound judgment. Second, patients who showed_ meagre
intelligence and deficient knowledge. Third, patients who exhibited evi-
dences of intellectual reduction. During the attacks physical disturbances
were manifested by the following symptoms : Headache, cardio-vascular
functional irregularities, perspiration, dilated pupils ; many other re-
actionary conditions of the central nervous system. These peculiar emo-
tional disturbances bore a strong resemblance to periodic alcoholic intoxi-
cations. The attacks usually lasted from a few hours to several days. He
classifies his cases into two tables: (1) Twenty-one criminal epileptics
with convulsions; all but one showed emotional variability. (2) Twenty-
nine epileptics in whom no convulsive attacks were noticed, although they
could not be positively excluded.

The following is a brief summary of the fifty cases of epilepsy :

■3 Character of emotional tone.

Accom-
panying
Depres- Irrita- Change- somatic
sion. bility. ability, symptoms.
15 2 3 13

861 7

23 8 4 20

100 24 42 58 44 74 28 36 18 54 70 46 16 8 40

Differential diagnoses between epilepsy and hysteria and epilepsy and
imbecility are discussed in detail. It is worthy of note that Aschaffenburg
in 1895 advanced his views on the variability, of mood of the epileptics,
but, unfortunately, the neurological world did not consider him very
seriously. It is to be hoped that the painstaking labors of the renowned
German investigator will give a sufficient stimulus for further research in
this particular line. Morris J. Karpas (New York).

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Dr. William Clexdenin Pickett. — The readers of the Journal will
learn with much regret of the death of Dr. William C. Pickett, which oc-
curred at his home, at Aldan, of ulcerative endocarditis, on Feb. 5, 1007.
Dr. Pickett was born at Meadville, Pa., on Nov. l6, 1870. and was edu-
cated at the Meadville High School and Allegheny College, receiving the
degree of A. M. from the latter institution in 1804. He graduated from
the Jefferson Medical College in 1895. Subsequently he served as surgeon
in the schoolship Saratoga, and in July, 1898, was appointed assistant chief
physician of the Philadelphia Hospital, a position which placed him in
charge of the male department of the insane. He resigned this position in
1890, but retained official connection with the hospital as registrar. Later
in 1902, he was elected examiner of the insane at the Philadelphia Hospital,
and in 1904 was made a member of the Neurological Staff. For a num-
ber of years he was demonstrator of neuropathology and instructor in
insanity in the Jefferson Medical College. On Oct. 7, 1904, he was elected
Professor of Nervous and Mental Disease in the Medico-Chirurgical Col-
lege of Philadelphia. In January, 1907, he was elected President of the
Philadelphia 'Neurological Society, but unfortunately was already confined
to his home by illness.

Dr. Pickett took an active part in the meetings of the Philadelphia
Neurological Society and of the American Neurological Association. Sev-
eral of his papers attracted much attention. Two of them especially
should be mentioned ; they were based upon statistical studies of the rich
material in the insane department of the Philadelphia Hospital. One
upon "Dementia Praecox," and another upon "Senile Dementia." He also,
it will be remembered, made a detailed study of the von Bechterew reflex,
and one of his latest studies was on pupillary reflexes in cases of extirpa-
tion of the Gasserian ganglion.

Dr. Pickett was filled with earnestness and enthusiasm, and his personal
qualities were such as to make his loss seriously felt in the circle in
which he moved.

The ninth biennial report of the Delaware State Hospital expresses
satisfaction with the new law permitting the Board of Trustees of the
hospital to appoint two physicians to pass on all patients seeking admission
from the city of Wilmington, and suggests that a similar law should cover
the State. Alcoholic cases and mild senile dements, it is claimed, have
been weeded out in this way. and much needed space preserved for other
cases. This law is, perhaps, unique in the United States. The two physi-
cians must be of different schools and reside in Wilmington. They hold
office for three years, and may be removed by the trustees at any time for
cause. The physicians are not compensated for these examinations except
for commitments. Since appointment they have certified 129 persons and
refused certification to 30 persons, most of the rejected being alcoholics.

The thirty-third annual meeting of the American Neurological Asso-
ciation will be held in Washington, D. C, in conjunction with the Con-
gress of American Physicians and Surgeons, on May 7, 8, and 9. 1907.
There will be one session daily, held from 9.30 A.M. to 1 P.M.. in the New
Willard Hotel, which is to be the headquarters of the Association. The
annual dinner will be held on Tuesday evening. May 7. The Council an-
nounces that the dues for 1907 will be five dollars, and calls the attention
of members who intend to contribute papers to the following regulations :
That the reading of the paper shall not exceed twenty minutes, and that
no one shall consume more than five minutes in the discussion of a paper ;
that if possible a verbal abstract of a paper should be presented, instead
of a reading in full ; that no title may be printed in the program unless ac-
companied by an abstract; and that titles and abstracts must be sent to
the Secretary at least six weeks before the meeting.

Vol. 34 May. tooj. No. 5

THE

Journal

OF

Nervous and Mental Disease

Original Hrttcles

A CASE OF EPILEPSY ASSOCIATED WITH ACROMEGALY.
By William T. Shanahan, M.D.,

FIRST ASSISTANT PHYSICIAN, THE CRAIG COLONY FOR EPILEPTICS, SONVEA, N. Y.

As the number of cases of acromegaly associated with epi-
lepsy reported has been so small, I wish to add the following
one which recently came under my observation.

L. S., thirty-one years of age, married, housekeeper.
Father living and well. Mother died at age of twenty-four
years, two weeks after birth of patient, assigned cause being
some complication of confinement. History of grandparents
negative as is also that of remainder of family. Patient was a
puny infant, weighing but three pounds at birth. Had swollen
cervical glands during infancy and diphtheria at seven years.
Married at twenty years of age. About two years later first
symptoms of acromegaly appeared. At age of twenty-six
years she had her first epileptic seizure. This seizure was
apparently grand mal in type. Seizures then varied in fre-
quencv. from one in two days to one in three weeks. No
aura. " She would not know she had had a seizure but for her
lacerated tongue. Left side first involved in some seizures.

When admitted to the Colony she was well-nourished,
weight being 168 pounds. Temperature, pulse, and respira-
tion" normal/ Occipito-frontal circumference of head 54 cm.
General massiveness of face, especially nose and inferior
maxilla. Circumference neck 36 cm. Marked spacing of
teeth in inferior maxilla. Tonsils moderately enlarged. Some
macroglossia, patient complaining that speech is thick be-
cause of this condition. Prominent transverse rugae on an-
terior portion of hard palate. Fingers are very broad. She
does not know size of gloves formerly worn, but states that
she is now unable to place wedding-ring on little finger of
left hand, whereas said ring was at first too large for ring
finger of that hand. She formerly wore No. 3>4 shoes, but

2oo WILLIAM T. SHANAHAN

now wears the largest she can buy ; she wore No. 6 when ad-
mitted. Very marked kyphosis in cervico-dorsal region,
slight scoliosis also present. Circumference of chest one
meter.

Skin is of a brownish tinge, especially on face and neck.
No flushing, cyanosis or change in hair or nails, except latter
are somewhat broadened. Mucous membranes slightly pale.
Blood count and percentage of hemoglobin normal.

Fig. i. Taken two years before onset of acromegaly.

Slight enlargement of postcervical glands, no tibial nodes
or other evidence of syphilis. Thyroid not palpable.

Moderate exophthalmos present. Pupils normal. Patient
states that at times she is much annoyed by an involuntary
twitching of eyelids. Examination of fundus shows no abnor-
mality. Patient can readily read ordinary newspaper print.
No hemianopsia, strabismus or nystagmus, except slight lat-
eral when she looks to extreme right or left. She has never
worn glasses.

EPILEPSY

291

At times during- the last few months she has had a buzzing

ihm lew iiioiiuks mil iui> imu a im^ziii^
sound in ears, especially right. She says it resembles the
sound of machinery

Hearing apparently normal as tested
with voice and watch. Taste normal : smell somewhat im-
paired on both sides.

Breathing is mostly costal in type. Diminished expansion,

Fig. 2. Taken shortly after admission to the colony in 1906.

otherwise respiration is normal. No dullness over site of
thymus.

Cardiac dullness slightly increased to left of mid-clavicular
line. Blood pressure normal. Some accentuation of second
pulmonic sound.

Tongue coated, some gingivitis in inferior maxilla. No
increase in appetite or thirst. Bowels usually constipated.
Examination of abdomen negative.

Urine normal ; no polyuria, but as patient sometimes

292 WILLIAM T. SHANAHAN

urinates involuntarily, it is difficult to measure amount ac-
curately.

Breasts atrophied: uterus very small. Menstruation be-
gan at age of twelve years, and was regular until onset of
acromegaly, at which time it ceased, and has not reappeared.

Several years ago she had severe occipital headache, also
a bursting sensation in eyeballs. At present, and for some
time past, lias had no headache. Indefinite history of having
had vertigo at about the same time headaches occurred.

Voice moderately hoarse.

Cutaneous sensibility normal : considerable increase in
perspiration with some fetid odor accompanying it. Reflexes
moderately active. Xo paralysis of any part. Musculature
good ; dynamometer registers more than the average for her
sex. Patient herself claims she is not as strong as formerly.
Co-ordination and sense of position normal. She has diffi-
culty in assuming an erect posture because she says it "hurts
her backbone." Gait is normal except for slight awkwardness.

Mental condition is good for one in her station in life.
Can write without difficult}-.

Since admission she has had frequent petit mal seizures,
which begin in left hand as if sin- were trying to approximate
finger tips. Moderate dilatation of pupils, involuntary urina-
tion, marked automatism. Duration of seizure about one min-
ute. Patient has no recollection of having; had seizures. Xo
distinctive convulsive movements observed during these seiz-
ures.- A few grand mal seizures have occurred, but under
such circumstances as to preclude their being satisfactorily
observed.

A somewhat extended review of the literature on the sub-
ject brings to light the following cases, in which a definite
history of convulsions accompanies that of acromegaly.

Grinker1 reports a man of 45 years of age, who, eight
years before, had some "psychic traumatism." Had sensa-
tions as in petit mal seizures, then after a year somnolence
and marked weakness. Then screaming attacks with trem-
bling of the legs and crying. Two years later is said to have
had his first epileptic attack. He now had marked enlarge-
ment of the nose, eyebrows, inferior maxilla, hands, and feet.
Xo disorder of the eye muscles or of the optic nerves. Larynx
not enlarged. Xo other nervous abnormalities. Mental
weakness present. This case was said to belong to the
chronic form, which lasts from eight to thirty years.

Farnarier2 reports a typical case of acromegaly associated

EPILEPSY 293

with epilepsy and a condition approaching dementia.

Hinsdale11 quotes from Raymond and Souques, who describe
a case of acromegaly, of many years' standing, in a man of
fifty-four years, who in the last three years developed Jack-
sonian epilepsy.

Hinsdale also quotes from Marinesco, who describes a
woman aged thirty-two years who had epilepsy beginning at
twenty-two years, the attacks occurring three or four times
a week. At the age of twenty-five years she had an attack of
giddiness in which she fell from a second floor. Six months
later she noticed that her feet were enlarged, and later her
hands, face, and abdomen. Menses ceased. Strabismus,
polyuria, and weakness supervened. Sensibility preserved in
all forms except vision. Examination revealed bitemporal
hemianopsia. Glycosuria present.

A. Napier4 reports a case of acromegaly in a woman, with
onset at twenty-five years. Later she had an epileptic seiz-
ure with albuminuria.

Hutchings3 reports a man aged forty-four years, who had
epilepsy since puberty. Acromegaly at thirty-six years. De-
mentia present.

In the discussion3 is mentioned a case of acromegaly with
epilepsy in a young man of twenty-eight years.

Oestreich and Slavyk0 — acromegaly in a boy of four
years. Convulsions present. Autopsy showed cystic
psammo-sarcoma of pineal gland. Pituitary normal.

Jolly7 mentions a case of acromegaly having petit mal
seizures.

Gatt8 reports a woman aged fifty-six years who had
acromegaly for more than ten years. This w^as preceded by
insomnia and headache for several years. Two years before
report she had convulsive attacks. Autopsy revealed sarco-
ma in the sella turcica and adjoining bone. Colloid cysts in
thyroid.

De Blasio* reports an acromegalic skull in an epileptic
who had syphilic hepatitis.

Graves10 reports a case of myoclonus epilepsy which de-
veloped acromegaly.

M. F. Moutier11 reports a man aged 36 years. At twenty-
three vears of age, during militarv service, he had measles and

294. WILLIAM T. SHAN AH AN

typhoid, also some indefinite genital trouble. Since then he
has become fat, lost strength, and has had violent headaches.
His military service was interrupted by blindness of the left
eye, preceded by severe pain in eye and marked vomiting. It
could not be ascertained when the acromegalic deformities
commenced. The patient remembered that when seven or
eight years of age he attracted attention because of his large
hands and feet. Xow has characteristic appearance of acro-
megaly. Indefinite lancinating pains in legs and jaw. A s*1
vere parieto-frontal headache, which was unrelieved by reme-
dies. Complete left optic atrophy. Mental condition failed
considerably since 1893, especially memory for recent events.
Became morose.

The convulsive phenomena appeared first in 1901. These
appeared every day for eighteen months, then became less
frequent, but have again become very frequent, occurring two
or three times daily. At present psychic equivalents appear
often. No aura. Convulsive seizures are apparently grand
mal in type. Psychic equivalents were first observed in 1905
He had short spells oi vertigo before this time.

Moutier says epileptiform crises are more frequently ob-
served in this class of cases than are the mental changes.
During the intervals between seizures the patient is intelli-
gent; He is inclined to believe that the cause of the condition
is some cerebral tumor, hypophyseal or otherwise.

He states that these phenomena of automatism are excep-
tional and does not see how to indicate as analogous any but
the case of Devic and Gauthier, in which there was a glioma
of the frontal lobes and left sphenoidal lobes. Their patient,
a woman of fifty-two years of age, had presented a slight
tendency toward ambulatory automatism.

The question naturally arises as to how many of these
cases have been merely symptomatic Jacksonian types and
how many had typical grand mal or petit mal seizures, asso-
ciated with mental symptoms characteristic of epilepsy. It
would appear that some of the cases had epileptiform convul-
sions accompanying brain tumor.

The weight of opinion seems to indicate that acromegaly
is due to an affection of the essential substance of the pituitary
gland. This may be caused by some malignant growth, viz.,

EPILEPSY 295

sarcoma, which either involves the gland substance or else
causes atrophy or change in function by pressure. Again it
may be caused by a benign growth which slowly brings about
changes in the gland.

A large number of cases of tumor of the pituitary gland
and surrounding structures have been reported in which there
have been no symptoms of acromegaly. In these cases, it was
deemed very probable that the pituitary structure was not in-
volved or at least only partially, as in many of these cases there
is no mention made of a careful microscopical examination of
the pituitary body.

Kollarits thinks that tumor of the hypophysis is not the
fundamental cause of acromegaly, but rather one of the symp-
toms, as he reports 53 cases in which there was tumor of the
hypophysis without acromegaly.

Many of these hypophyseal tumors are thought to ordinate
in the infundibulum.

F. Farnarier thinks that degenerative states are favorable
for the development of acromegaly and that certain changes
in the hypophysis react on the nervous system already in a
state of instability by the hereditary influences.

Boettiger considers a toxemia as the cause of acromegaly.
The pituitary gland is thought by some authors to have an im-
portant trophic influence on the central nervous system. In-
terference with this function or complete ablation of the gland
would bring about a state of toxemia, and so convulsions of
various types. In order that convulsions may occur it seems
reasonable to think that there must necessarily be a lack of
stability in the cortical cells in such acromegalics. This would
lead one to consider the pituitary changes as one of the many
exciting causes of convulsions or other symptoms of epilepsv.

If a tumor of the pituitary is present, it is but reasonable
to believe that the epileptoid symptoms may be produced by
direct pressure on the cortical substance, by increase in the
size of the tumor, or else by general increased intracranial
tension and so bring about convulsive movements.

Various nervous phenomena may be due to the defective
nutrition or the accumulation of toxic substances in the body.
Brooks claims that if there is no glycosuria or hemianopsia

296 WILLIAM T. SHANAHAN

it is questionable as to the involvement of the pituitary body.

Heersman's theory is that the hypophysis neutralizes
through its products in the blood the secretion of other blood
glands. It regulates the vascular system and hinders the
growth of bone. Through lack of this secretion acromegaly
develops. This is the result of a tumor of the pituitary or of
a secondary alteration through a chronic alteration of the
blood.

Cushing states as follows: "A disturbance of the menstrual
function may be one of the earliest symptoms of some intra-
cranial tumors. Growths in most diverse situations, or indeed
an increase of intracranial tension has been known to affect
the regularity or even completely interrupt for long periods,
previously normal catamenia. These cases may be divided
into two groups: one, those in which amenorrhea accom-
panies tumors of the hypophysis or tumors affecting the gland
by direct compression. The other, those in which the men-
strual disturbance is a symptom of tumors situated elsewhere.

The occurrence of diabetes, mental disorders, epilepsy, etc.,
with acromegaly may be the result of a perverted pituitary
secretion on unstable tissues, or such a secretion or an entire
lack of secretion may produce this instability and so allow
other toxins to bring about such conditions.

The case now under observation will be followed carefully
so as to ascertain further eye changes and if death occur, to pro-
cure an autopsy.

REFERENT ES.

'Acromegaly with Epilepsy. Grinker. Chicago Medical Examiner,
December, 1903, Abstracted in Neurol. Centrlblatt, 1004.

'Abstract in Journal Nervous and Mental Disease, Vol. 27, p. 456.
Acromegaly and Mental Degeneracy.

'Acromegaly-Syringomyelia. Guy Hinsdale.

'Glasgow Med. Journal, Vol. 49. Jahresbericht. 1S98.
Archives of Neurology and Psychopathology, Vol. 1, No. 4.

'Jahresbericht Neurologie und Psychiatric 1899.

'Idem, 1899.

"Idem, 1902.

"Idem, 1903.

10Idem. 1904.

"Rev. Neurologique, Nov. 30. 1906. J. Kollarits. Abstract in American
Medicine, Nov. n, 1905. Britisli Medical Journal, 1899. Vol. 1. p. 850.
Harvey Cushing. Sexual Infantilism with Optic Atrophy in Cases of
Tumor Affecting the Hypophysis Cerebri. Journal Nervous and Mental
Disease, November, 1906. Burr and Riesman. Idem. January, 1899.
Sidney Kuh. Idem. Vol. 28. p. 419. Idem. Vol. 31, p. 54. Abstract of
Article by Lannois and Roy. Acromegaly and Diabetic Gout. H.
Brooks. Archives of Neurology and Psychopathology. Vol. 1.

GLIOMATOSIS OF THE PIA AND METASTASIS OF GLIOMA.*

By William G. Spiller, M.D.,

OF PHILADELPHIA.

PROFESSOR OF NEUROPATHOLOGY AND ASSOCIATE PROFESSOR OF NEUROLOGY IK
THE UNIVERSITY OF PENNSYLVANIA.

Various forms of malignant tumor may implicate the pia
of the spinal cord and brain diffusely. The sarcomatous in-
filtration is the best recognized. The first case of this kind
reported in America, so far as I know, is that of George K.
Weaver,1 in 1898. In 1903 P reported two cases, one in asso-
ciation with W. F. Hendrickson, and the present communica-
tion is made in relation to one of these. Since then two
•cases have been recorded by F. X. Dercum.3 The German
literature contains the largest number of cases and a few may
also be found in the British journals.

Sarcomatous infiltration, however, is not the only form of
diffuse tumor formation of the pia. The carcinoma and glioma
have been known to appear in this manner. An important
paper in regard to gliomatosis of the pia has recently been
published by Grund.4 This author says that the earliest men-
tion of glia proliferation in the pia is by Klebs, who found glia
in the pia near a glioma of the brain. He cites Alzheimer as
authority for the statement that glia proliferation in the pia is
common in paretic dementia. Schlesinger and Saxer have
seen proliferation of glia in the pia in syringomyelia.
Schlesinger, in his monograph on tumors of the spinal cord,
makes no mention of diffuse glioma in the pia arising from
the neuroglia, but since the publication of his monograph four
cases have been reported (Leusden, Frankel and Benda,
Fischer, Roux and Paviot) and Grund adds one more, but does

'Weaver. Journal of Experimental Medicine, 1898. Vol. III., No. 6.

'Spiller and Hendrickson. American Journal of the Medical Sciences,
July, 1903.

'Dercum. Philadelphia Hospital Reports, Vol. V, 1903, and Journal
of Nervous and Mental Disease, March, 1906, p. 169.

4Grund. Deutsche Zeitschrift fur Nervenheilkunde, Vol. XXXI., Nos.
3 and 4, p. 283.

♦Read before the Pathological Society of Philadelphia, Feb. 14, 1907.

2Q8 WILLIAM G. SPILLER

not refer to my case, so that at the present time six cases of
gliomatosis of the pia are on record.

The glioma, unlike the sarcoma, carcinoma, endothelioma
or perithelioma, is not a sharply defined tumor of the nervous
system, but infiltrates into the surrounding tissue, and it is
owing to this fact that its surgical removal is so difficult. In-
deed, P have advocated leaving the tumor untouched if at the
operation it can be shown to be a glioma. In the striking
language of Walton and Paul.6 one might as well attempt to
remove the decayed spot from a fruit in order to arrest the
process of destruction as attempt to remove a glioma in order
to arrest the tumor formation. It may be possible, however,
when the glioma is very minute, to remove surgically suffi-
ciently surrounding brain tissue to prevent further progress
of the growth.

Unlike sarcoma, glioma seldom extends into the mem-
branes of the brain or cord, and never breaks through beyond
the membranes. Glioma, unless very cellular and closely re-
sembling sarcoma, grows very slowly. Max Borst,' in his
work on tumors, has a very interesting chapter on glioma, and
according to him cavities in a glioma lined with cylindrical
cells are rare, but in this finding the embryonal relation of
the glia cells to the ependyma may be recognized. (Ilia
cells as derivatives of ependymal cells may have the power to
return to the type of epithelium of the primary neural canal, 'li-
the cylindrical cells in the glioma may be regarded as separa-
tions from the ependymal cells of the ventricles from which
the glia cells of the tumor are derived. Both conditions are
possible.

The term gliosarcoma has fallen into some disrepute, as it
implies an origin from both mesoblastic and epiblastic tissues,
but Borst employs the term for the mixed tumor and calls
the glioma rich in cells glioma sarcomatodes. The distinctions
between glioma and sarcoma may be difficult to make.
The presence of glia fibers does not make a tumor a glioma,
especially if the fibers are near the border of the tumor, as

"Spiller and Frazier. University of Penna. Med. Bui., September. 1906.
'Walton and Paul. Journal of Nervous and .Mental Disease,
August, 1905, p. 481.

7Borst. Die Lelire von den Geschwiilsten, Vol. 1.

GLIOMATOSIS AND METASTASIS

299

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Fig. i. Diffuse tumor formation of the pia of the spinal cord with rows
of ependymal cells inclosing space-.

.300 WILLIAM G. SPILLER

they may be the remains of neuroglia caught within the tumor,
and glia fibers, Borst states, occur in almost every growing
tumor of the central nervous system. Sometimes what are
supposed to be glia fibers are really fibrin fibers, and these
may closely resemble the glia fibers, and they have no connec-
tion with the glia cells. Borst even goes so far as to say that
it is uncertain whether a glioma may not be composed entirely
of cells, i. c, may be without fibers, and he implies that such a
form of glioma may occur, the differentiation of such a tumor
from a sarcoma might therefore be impossible.

In a case reported by me in 1903, to which reference al-
ready has been made, very many minute tumors and tumor
infiltration were found in the pia of the spinal cord. The
structure of this tumor infiltration of the pia was so extraor-
dinary that I hardly knew what name to give to it. It re-
sembled closely tumor arising from the ependyma, (See fig. 1.)
but 1 could find no record at that time of gliomatous infiltration of
the pia, and none of the eminent pathologists I consulted had
ever heard of such an occurrence. I recorded the findings as
follows :

"The tumors everywhere have much the same structure.
They consist of round or somewhat elongated cells, and even
by Mallory's neuroglia stain contain verv little intercellular
tissue. In some places the cells are distinctly columnar and
resemble those of the ependyma. The columnar cells are
arranged in long rows and have a large nucleus situated at
one end of the cell. These rows of cells are found especially
about the blood vessels, but also where there are no blood
vessels. There is unquestionably a close resemblance between
these cells and those of the ependyma. and the temptation,
therefore, is to call the tumor an ependymoma, but it seems
remarkable that an ependymoma, being a form of glioma,
should give extensive metastasis to the pia of the spinal cord,
which is of mesodermic origin. This, and the absence of glia
fibers between the cells, and the distinct tendency to the for-
mation of rows of cells about the blood vessels, seem to justify
the classification of the tumors under the sarcomata, possibly
endotheliomata or peritheliomata ; and yet the close resem-
blance of some of these cells to those of the ependyma may
permit us to regard the growth as a mixed one, and as being

GLIOMATOSIS AND METASTASIS

301

Fig. 2. Tumor filling the fourth ventricle. The proliferation of the
ependymal lining is clearly shown.

302 WILLIAM G. SPILLER

partly a sarcoma and partly an ependymoma. The ependyma
is known to proliferate in cases of syringomyelia when the
cavity extends to the central canal and to cover in part the
wall of the cavity. It is not unreasonable to suppose that
a sarcoma growing from the pia may extend to the fourth
ventricle, and by irritation of the ependyma lead to its prolif-
eration, and cause in this way a mixed tumor." I referred to
the fact that the tumors of the pia in this case had a resem-
blance to the neoplasms described by Rosenthal, Frankel
and Benda.

Since the publication of this paper the possibility of dif-
fuse gliomatosis has been in my mind, and I have been wait-
ing for further evidence of its occurrence, and this is now
given in Grund's paper. I am now inclined to regard the sar-
comatous nature of the tumor infiltration in my case as doubt-
ful, and I look upon the growth as multiple gliomatosis. A
section from the medulla oblongata shows a tumor filling the
posterior part of the fourth ventricle, and the proliferation
of the ependymal cells lining this ventricle is so pronounced
that the ependymal origin of the diffuse process seems fully
demonstrated. (See fig. 2.) These cylindrical cells no longer
form a row lining the ventricle, but occur in long rows, or
bordering papillomatous processes, clearly arising from the
ependyma, and extending outward into the tumor.

In another case, reported by me8 briefly from a clinical
aspect and with scarcely any reference to the pathological
findings, a tumor filled the posterior part of the fourth ventri-
cle and extended downward upon the cord as low as the
sixth cervical segment. This tumor also contained rows of
cells resembling those of the ependyma, and forming the
lining of large irregular spaces. It was an ependymoma.
Another, but smaller tumor, having the same structure, was
found upon the lower part of the thoracic region of the cord
and was probably a metastatic growth, and therefore exceed-
ingly interesting. Borst says that metastasis of glioma is ex-
ceedingly rare, and that Stroebe in one case saw regionary
metastasis, i. c, near the original tumor. Multiple gliomata.
according to Borst, have not positively been observed.

"Spiller, Musser and Martin. University of Penna. Med. Bui., March
and April, 1903.

IS EPILEPSY A DISEASE OF METABOLISM? A REVIEW OF

THE LITERATURE*

By J. F. Munson, M.D.,

LABORATORY OF THE CRAIG COLONY FOR EPILEPTICS, SONYEA, N. Y.

It has been and is the hope of all that by an exact study of
the vital processes of epileptics during life and of their tissues
after death, some light might be thrown on the nature of the
disease. Patient and accurate pathological work has yielded
no changes which can be found in cases of every form and
duration, and many believe that the primary nature of the
changes which have been reported is open to doubt. The
cause of the disease, if there be one in an organic sense, is
still to be discovered. I do not wish to be understood as deny-
ing the possibility of an organic lesion. There must be such a
lesion. I do, however, most seriously doubt, whether this
lesion is one which can be made visible by the methods of
the pathologist. I believe that the epileptogenous change af-
fects the chemical structure of the cell — whether this change
is visible or invisible, seems to me immaterial.

The common idea of the cell is a morphological one. I
wish, however, to direct your attention to a chemical concep-
tion of the cell and its activities. I believe with Vaughn (under
whom I had the privilege of working) that "the cell is a chem-
ical compound of very complex, but of definite structure." This
theory differs from others in the emphasis placed oh the defi-
nite chemical nature of the cells. Thus function is the result of
change in the chemical structure of the cell, brought about in
accordance with the laws governing chemical action. Dis-
ease being a change or failure of normal function, it follows
that disease is the result of interference with the normal chem-
ical processes of the cell, either from inherent tendencies or
by the action of external agents.

Such a conception of the cell and of disease, authorizes the
application of chemical methods to problems which have hith-
erto been the exclusive province of the pathological anatomist.

Even could we point out a visible lesion in epilepsy we

*Read before National Association for Study of Epilepsy, etc., New
Haven, Conn., Nov. 8, 1906.

304 /. F. MUNSOX

should be but little nearer an understanding of the disease.
We should still have to ask how this particular lesion pro-
duced the disease, and, more important yet, we should have to
seek the cause of the lesion. If the activities of the cell are
carried out as I have indicated, by chemical means, bio-chem-
ical methods can be logically applied, and offer, from their
searching and accurate nature, great hope of light in what is
now darkness.

The absence of a visible lesion led to the assumption that
endogenous poisons or metabolic disturbances were the cause
of the disease. Clinical analogies to other autointoxications
have led some to accept this view, but such analogies, while
presenting contributory evidence, are not direct proof, — a
poison or a disturbance in metabolism must be demonstrated
experimentally.

The urine being the most easily obtained of the fluids of
the body, has received the most attention. While the old idea
that the attack was always followed by the voiding of urine
has been found wrong, it is generally stated that the epileptic
is given to polyuria, especially following the attack. Krainsky
reports daily amounts of two to three liters, and states that
four arc not unusual. Rabow, and Vbisin and Petit report an
increased volume after the attack. Fere speaks of crises of
polyuria. Bleile and Ferrannini find no change, and A,lessi and
Pierri report the urine scanty. An increased specific gravity
is reported, especially after the attacks, and this, with the in-
creased volume, would seem to indicate an increase of excre-
tory products at the time of the attacks.

Albumin in the post-paroxysmal urine was first noted by
Seyfert, in 1854. Others, Rabow, Furstner, Otto, Fiori, Halla-
ger, and Kleudgen, report its presence as rare and inconstant,
and in this opinion Binswanger agrees. Voisin, however, finds
it in about half the cases and other authors are in practical
agreement with him. Huppert and Dewitt find that the
amount of albumin depends on the time elapsed after the seiz-
ure and on the severity of the seizure. Brunninghausen finds
it in the greater number of cases, but of irregular occurrence
in the same case. Galenti found 0.05 to 2.0 per cent. Lanois
and Mairet found it 29 times out of 50, and Klein 14 times
of 23.

EPILEPSY AND METABOLISM 305

Albumin in the post-paroxysmal urine would appear to be
of more than rare appearance. We must consider, however,
the possibility of concurrent renal disease and of errors in the
recognition of albumin. The fact that it is found only in the
early hours after the attack, may explain some of the negative
findings. The whole ground must be gone over again, using
methods of unquestioned accuracy and studying a large num-
ber of cases.

Sugar has been found in epileptic urine, but the general
opinion seems to be that its occurrence is not an epileptic
phenomenon.

Of the inorganic constituents of the urine, the chlorides
and the phosphates have been most studied. Vires finds the
former increased, while Mairet and Bosc report them decreased
and Agostini does not find them increased. Krainsky finds no
relation of chlorine to the attack.

The phosphorus metabolism has been more extensively
studied. Gibson, Ecchevera and Mendel, Voisin, Mairet,
Krainsky, Agostini, Lepin, Egremont, Aubert, and Mairet
and Bosc find phosphoric acid increased after the seizure.
Lepin and Jaquin, and Mairet and Vires find an increase of
the earthy phosphates relative to the alkaline, which may even
be decreased. Fere and Herbert cannot substantiate this.
Adenine and Bonelli find the earthy phosphates decreased in
both urine and feces and report excellent results from the ad-
ministration of calcium. Mairet associates the earthy phos-
phates with brain activity. Lepin, Egremont, and Aubert find
an increase of organic phosphorus. This is also reported in
degenerative nervous diseases by Symers. If this can be con-
firmed, and the phosphorus shown to be present as compounds
other than neucleo-albumins, we shall have an important fact,
for organic phosphorus is an important constituent of nerve
tissue.

Agostini, Dide and Strenuit, Xelson Peter, Vires, Voisin,
Mairet and Bosc, and Rabow report an increase of urea. Teeter
finds it variable. Krainsky and Bleile find no constant rela-
tion to. and Alessi and Pierri, and Rabow find a decrease after,
the attack. We must take into consideration the imperfect
methods for the estimation of urea generally used. That the

3o6 J. F. MUNSON

majority agree on an increase is to some extent a check on the
accuracy of their work.

Haig- brings forward uric acid as the cause of the attack,
having found a retention before and an increased excretion
after, the attack. Caro, Guidi, and Krainsky confirm his re-
sults. The latter does not believe that uric acid is the actual
poison but that some antecedent substance, readily transformed
into uric acid, by changes in the body fluids, is responsible.
Bleile, Herter and Smith, Putnam and PfafF, and Mainzer do
not get results favorable to Krainsky's view. Paraxanthin
was found in relation to some epilepsies by Rachford.

Galenti and Savini find the etherial sulphates increased and
Galenti and Herter and Smith find indican increased. These
results are in cases with indigestion.

Acetone has been found by Hoppe in 8.5 per -cent, of 325
cases, but never after single attacks. Rivano found it after
attacks in 30 per cent, of his cases. Hoppe observes that
acetone is generally found in cases where the taking of food
was interfered with; this probably accounts for its occurrence.

Benedicenti and Galdi and Tarugi find an increase of
urinary acidity.

The toxicity of the urine has been much studied to deter-
mine if there was a retention or an increased excfetion of poi-
sonous matters in relation to the attack. Normal urine has a
certain degree of toxicity. Deny and Chouppe, Ferrannini,
Voison and Peron. Tramonti and Obriga find the interval and
ante-paroxysmal urine less toxic than normal urine or the
urine from after the attack. Mariet and Bosc, Fere, Agostini,
Galdi and Tarugi find the post-paroxysmal urine less toxic
than that of other times. All except Heboid and Bratz find
an increase in toxicity in relation to the time of the attack, but
differ as to the exact time of maximum and minimum toxicity.
The method is probably responsible for this difference of opin-
ion. The saline concentration and the reaction of the urine, the
rate of injection and the susceptibility of the experimental
animal into which the intravenous injection is made are all
variable factors. The method is at best a crude one.

The cause of the toxicity of normal and epileptic urines
appears to be the same, the symptoms from both being alike.
Osmotic action, the toxic potassium ions, the coloring

EPILEPSY AND METABOLISM 307

matters, uric acid perhaps, and, according- to some, alkaloidal
bodies, all play an important part. The toxicity is not due to
one substance, but is the sum of all.

Cabitto found the sweat of epileptics more toxic just before
the attacks ; the toxicity afterward and during the interval is
normal. Mairet and Ardin-Delteil find the highest toxicity
during or after the attack. Mavrojannis finds no change. The
method used is the same as that used with urine.

Belisari, Agostini, and Leubuscher report the hydrochloric
acid of the gastric juice increased by the attack. Agostini
finds the toxicity of the gastric juice increased just before the
attack, corresponding to the transitory dyspepsia.

As regards the cellular composition of the blood no changes
have been established as peculiar to the epileptic. Claus and
Van Der Stricht report the density of the blood lowered, and
Lui, Charon and P.riche, and Pugh find the alkalinity dimin-
ished before the attack, to rise afterward.

Chiaruttini and Cololian found the toxicity of the blood
greater at the time of the attack. Mairet and Vires found the
blood hypotoxic in the interval. Herter found no special tox-
icitv. Krainsky, injecting blood taken just before an attack,
produced both immediate and repeated seizures in a rabbit,
and Pearce and Boston performing a similar experiment on a
case of pernicious anemia, got a similar result. Geni finds
the blood of epileptics more teratogenic than normal blood.
He also reports that the blood during the exacerbations of the
disease is much more toxic than during the intervals.

Ceni's work on the serum treatment of epilepsy, if it can be
confirmed, will give us absolute evidence of a toxin for the
disease. But before it can be accepted, it must be verified un-
der the most rigorous conditions, with careful controls of the
hygiene and medication employed. Longer periods of obser-
vation and larger series of cases must be employed, and the
theoretical side carefully studied.

Comberali and Bue and Voisin have reported staphylococci
in epileptic blood. Bra found the "nenrococcus" in the blood
of a large proportion of the epileptics he examined, but could
find it only at the time of the attacks. This fact he uses to ex-
plain previous failures. Besta. Tirelli and Bossa cannot du-
plicate his work, and it is quite possible that he was dealing

308 /. F. MUNSON

with a skin contamination. It is interesting to note, however,
that Tirelli reports increased bacteriocidal power of epileptic
blood against staphylococci.

Mott and Halliburton and Donath have found cholin in the
cerebro-spinal fluid of degenerative nervous diseases and of
epilepsy, and Donath believes it to be the cause of the con-
vulsion. The presence of cholin has been doubted by several
authors, and, again, others have confirmed its finding. The
question centers around the accuracy of the separation and
identification of cholin, those who doubt its presence claiming
that the product obtained is an ammonia or potassium com-
pound and not cholin. Its presence could be easily under-
stood as it is a product of the cleavage of myelin, and it has
been shown that after death there is an enzyme which can
bring about this cleavage. One can imagine that under favor-
able conditions this enzyme could become active during life.
Injected into the circulation, cholin is not convulsive, but ac-
cording to Donath, its direct application to the brain does pro-
duce convulsions. The mechanical effect is to be taken into
consideration, however. Even though cholin is not ordinarily
a convulsive poison, it is to be remembered that the epileptic
brain is inherently sensitive, and it responds actively to irri-
tants which would have no action on the normallv constituted
brain.

While this review of the literature is an exceedingly
meager one. it will be seen that there are changes in the meta-
bolism of the epileptic and in the toxicity of his body fluids.
Just what these changes are and their time of occurrence is
doubtful because of contradictory findings. The fact that
some variation from the normal is almost always reported,
makes one hopeful that further work along bio-chemical
lines, conducted with the greatest care, using the most exact
mehods. carefully controlling every possible factor, and using
a goodly number of cases, will in the end bring a solution of
the problem.

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EPILEPSY AND METABOLISM 311

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THE DIAGNOSTIC VALUE OF LUMBAR PUNCTURE IN PSY-
CHIATRY.

By J. L. Pomeroy, M.D.,

OF WARD'S ISLAND. NEW YORK CITY.

(Continued from page 252.)

Abstract from Report of Pathological Institute.

dr. a. meyer.

In discussion of the cases of Korsakoff's syndrome the
following observation is of note. "While all the cases showed
% fairly typical delirium, only two had a frank polyneuritis, in
some of our cases the polyneuritis appeared to be very mild
or to have disappeared entirely before the patient came under
observation. Such cases may offer considerable difficulty in
differentiation from general paralysis, the difficulties in diagno-
sis are further increased by the frequent occurrence of pupil-
lary abnormalities, jerky tremors and speech defect, the writ-
ing frequently showed poor spelling and omissions, but we
have not observed the characteristic transposition of the par-
alytic. We have observed in practically all of our cases a
nystagmus-like twitching of the eyeball which may be slight
or very well marked. Lumbar puncture has been of consider-
able aid in the diagnosis. In none of our cases have we found
distinct lymphocytosis. Five cases, two of which were very
probably syphilitic, one giving a positive history, the other
presenting scars, were examined and negative results ob-
tained."

Again, we wish to quote from the report, the results of
lumbar punctures in 11 cases of G. P. In nine cases there was
a marked lymphocytosis ; in the other two there was a distinct,
but less pronounced reaction.

Lumbar puncture was also of aid in differentiating G. P.
from central neuritis. "The patient, a woman thirty-nine years old,
had complained of attacks of dizziness and weakness for a few
months, and had shown some change in disposition. Three
weeks after a fracture of a bone in the hand she suddenly be-
came delirious and was brought to the hospital. She then
showed an intense episodic agitation with fear, talked delir-

LUMBAR PUNCTURE IN 1'SYCIUATRY 313

0

iously, yet remained relatively clear as to her whereabouts.
At this time bilateral ankle clonus was observed with some
muscular twitching in the arms. The delirious episodes sub-
sided in a month ; then for a period she was averse to examina-
tion, and seemed to have a generally hazy grasp on the past
and claimed to know nothing about the injury to her hand.
Her mood and behavior gradually became more normal, but
she was simple in manner and lacking in initiative, yet, without
evidence of G. P. The ankle clonus continued and later she
began to have attacks of weakness in which she would fall
over. Diarrhea developed, accompanied by progressive ema-
ciation. She became again delirious; general rigidity appear-
ed with strong muscular twitchings, and episodes of jactita-
tion of the arms. There was indistinct articulation and the
speech was finally reduced to an almost unintelligible sound.
The L. P. showed no decided lymphocytosis. The patient died
from exhaustion, but no autopsy was permitted. This case is
classified as central neuritis."

We have examined a number of cases where the question
of dementia praecox and dementia paralytica were under dis-
cussion. First in the case of a negress, who was discharged
in 1902, as dementia paralytica, improved. At that time there
were Increased knee jerks, tremor of the tongue and hands and
facial muscles, with slight static ataxia ; the pupils, however,
were normal ; there was defective judgment, active hallucina-
tions and some deterioration in memory. In 1904 she was re-
admitted. She has deteriorated in all fields, but the physical
signs are very difficult to elicit, the pupils are normal and the
spinal fluid has been twice negative. Early in the develop-
ment of the case were hallucinations of hearing and smell and
somatic-psychic delusions, but to further confuse the picture, were
several epileptiform seizures. Regarding these, however, an in-
vestigation of the subject has shown that convulsions are not
infrequent in dementia praecox, and we are of the opinion that
this is the correct diagnosis.

In this next case dementia praecox, paresis and alcoholism
came into discussion. In favor of dementia praecox were a
gradual decreasing efficiency for work, delusions of somatic
origin, marked emotional instability and hallucinations of
sight and hearing. In favor of paresis were unequal and slug-

314 /. L. POMEROY

gish pupils, marked tremor of the hands, face and tongue, and
absent knee-jerks. For alcoholism there was a memory defect
for recent events, a tendency to fabrication, delusions of a
persecutory trend, confused orientation, misinterpretations
and hallucinations of sight and hearing. To further make the
picture unclear the patient gave a history of convulsive at-
tacks commencing about a year before admission. The patient
had been markedly alcoholic, but at staff meeting the case
was viewed with great doubt. The lumbar puncture was
called upon to decide, and on the grounds of two negative re-
sults we ruled out the diagnosis of paresis and classified her
as an alcoholic. At this time, five months since the puncture,
the patient's condition shows the correctness of our diagnosis.

Tn another case of diagnosis of paresis was made some four
years ago, and on re-admission in October, [905, there were
many symptoms such as active hallucinations, rather fantastic
delusions and variable emotional tone which were in favor of
dementia pnecox. The physical signs particularly were not
conclusive. A positive finding in this case pointed out that
the previous diagnosis was correct.

We have had several cases where the question of a purely
functional basis for the psychosis had to be differentiated from
certain organic conditions. In one case there were marked
tremors and exaggerated knee jerks, with a peculiar unstable
emotional condition. The diagnosis at staff meeting of paresis
was made. The fact that there is good memory and that the patient
has developed delusions of a persecutory trend, coupled with
the negative lumbar puncture, make the diagnosis of paresis
extremely doubtful. With a history of alcoholism this would
seem to be the more fitting classification. In several cases of
hysterical manifestations, such as variable anesthesias, to-
gether with exaggerated knee jerks, with a certain amount of
memory defect, the differential diagnosis from paresis has
been extremely difficult. In one case a positive lymphocytosis
has shown the correct diagnosis. In two others negative find-
ings have guided our observation. In this same group one
meets certain cases of an anxiety type, occurring in alcoholic
women about the involution period, who present serious prob-
lems for diagnosis. In two such cases, besides the appearance
of extreme anxiety, there was in one, a history of convulsive at-

LUMBAR PUNCTURE IN PSYCHIATRY 315

tacks, marked tremors of the hands and face, unequal pupils
and a peculiar speech defect. The lumbar puncture gave neg-
ative results, and the patients have since improved greatly;
the tremors having entirely disappeared. In the other case
there were delusions of grandeur, elation, mild deterioration
with tremor of the hands, fibrillary twitchings about the
mouth, and irregular pupils, but on the other hand there was
considerable anxiety and agitation, with ideas o'f self-reproach
which, with her age and coincidence of the menopause, made
the diagnosis of involution psychosis very probable ; at the
same time the presence of memory defect and ideas of wealth
were strongly in favor of paresis. The spinal puncture has
shown absolutely negative results on two examinations, and
the patient has improved somewhat. The eve condition has
been explained by the presence of an error in refraction and a
choroiditis.

There are certain cases of paranoic condition where the
presence of grandiose ideas with certain physical signs are
difficult to differentiate from the early stage of paresis. The
presence of a megalomania with elated expression, tremor of
the tongue and hands, with exaggerated knee jerks in a woman
of forty-three years, presented a very confusing picture. The
duration was three years. (Inset following death of husband,
became extravagant and forgetful, gave away $11,000 to var-
ious churches because of the peculiar delusional content ; she
imagined that the Pope would make her queen of a certain
city in Germany provided she followed a certain charitable
course. A pin which had been sent her from a sister in Eu-
rope came from His Holiness. Symbolic coloring was placed
on all natural events. She received communications from the
man in the moon and various air ships, and she developed a
strong persecutory trend against a certain bishop who had ob-
tained possession of the magic pin. Her orientation was cor-
rect. She adapted herself rapidly to her surroundings and our
examination failed to reveal any defect in memory or grasp.
She had hallucinations of sight and hearing. In this case there
was no alcoholic factor. On the symptoms one could not rule
out the diagnosis of paresis. The lumbar puncture was now
called upon to decide and the examination of the spinal fluid
showed an absolutely normal condition. The patient's conduct

Ji6 /. L. I'UMEROY

since that time has sustained our diagnosis of paranoic con-
dition.

Finally I would mention a case which at first showed
marked symptoms of a manic type, but presented also promi-
nent ideas concerning money, with marked elation, exagger-
ated knee jerks and tremors of the hands. There was typical
flight and word association. The lumbar puncture in this case
gave us quite a surprise, as the finding was positive. The pa-
tient has since shown evidences of deterioration, and our
diagnosis of paresis is sustained. We have punctured one case
of brain tumor which, for a time, was suspected as being a
paretic; the negative result ruled this out. In another case
where the symptoms were similar to paresis in development,
the spinal fluid was negative, and the repeated convulsive at-
tacks with the development of a peculiar aphasia have made
the diagnosis of internal pachymeningitis the most probable
one.

I feel that I have shown the scope and character of the
cases in which the results of lumbar puncture are of value. I
would like now to speak briefly of the dangers connected with
the operation. Andre Maystre collected from a large litera-
ture 18 deaths following lumbar puncture, 14 of these were
punctured for therapeutic purposes, and the large quantity
of fluid withdrawn, 25 to 90 cc. was responsible for the fatal
issue. Two of the cases can be discarded because death did not
occur until several days following the operation. Of the four
remaining cases the puncture was made in the course of dis-
eases leading to certain death, and Maystre could not estab-
lish any connection because death occurred two days follow-
ing the puncture. Also 20 cc. of fluid were removed. In the
last case tuberculous disease in the spinal meninges was found
and at autopsy an organized hemorrhagic clot was present in
the cauda equina.

Nissl, in a large experience, knows of no fatal case follow-
ing lumbar puncture which has been made for diagnostic pur-
poses when only from 3 to 5 cc. of fluid have been withdrawn.
The operation is contraindicated in cerebellar tumor. Quincke
does not admit of even this exception, stating that if carefully
done the low pressure in such cases is a valuable diagnostic

LUMBAR PUNCTURE IX PSYCHIATRY 317

point, and he has punctured a case six times during six weeks,
causing an amelioration of symptoms and disappearnce of the
choked disc. Nissl's conclusions after a study of the results
in the normal and in the insane are: the patient should not be
punctured unless he can be immediately put to bed. Symptoms
as a rule do not appear until 8 to 12 hours after the puncture.
At that time headache, nausea and sometimes vomiting may
occur, as a rule there is complete incapacity for work. The
symptoms are made worse, but sometimes not felt at all, ex-
cept on movement. They may last from 1 to 8 days. The pa-
tient may feel perfectly well, get up, and the rapidly-appearing
headache causes them to seek their bed again. So long as
they remain quiet in bed they are comfortable.

Upon the insane. 48 patients out of 112 punctures had
marked symptoms, the duration was usually from one to two
days, several cases lasted ten days. It must be mentioned
here that in 62 of his cases ether was used as an anesthetic,
and he does not mention what effect this might have had. It
is noteworthy that no symptoms followed puncture in gen-
eral paralysis. At the time of puncture a few patients com-
plain of transitory stinging pain in the legs. I have not used
any anesthetic save a few drops of a four per cent, cocaine
solution in the skin, and this was only necessary in certain
cases. Chauffaurd and Boidin, in 223 punctures, report no
bad results, in three cases there was vomiting-, in a few others
headache. In our own series of 150 punctures, I have ob-
served mild headache, vertigo and nausea in 15. Three cases
of secondary syphilis suffered from vertigo for eight days, but
they would not remain quiet. In the brain tumor case death
occurred three days after the puncture. The patient had been
suffering from marked pressure symptoms for some time, only
3 cc. of fluid were removed, and at autopsy there was a hemor-
rhagic focus of softening in the pons. Xo connection between
the puncture and the patient's death can be proven. In eight
alcoholic cases headache and vomiting were quite severe, but
perfect rest in bed for a few days was all that was necessary.
In the majority of the cases the symptoms were of a fleeting
nature and if only small quantities of fluid are removed and the
patient placed in bed little discomfort follows the operation.

3i8 /. L. POMEROY

CONCLUSIONS.

1. Patients should not be punctured unless they can be
put to bed.

2. To be of definite value the puncture must be repeated
two or more times, at an interval of at least ten days.

3. Ai constant negative finding is of more value than a pos-
itive one, for it rules out the presence of brain syphilis and
parasyphilitic conditions.

4. In general paralysis the lymphocytosis is a constant
and early sign and is usually associated with a heightened al-
bumin content. The same can be said for tabes.

5. Lymphocytosis may occur in secondary and tertiary
syphilis without clinical evidences of involvement of the nerv-
ous system, also it may occur in patients who give evidences
from scars or other signs of old syphilitic infection. As a rule
the cellular increase in such cases is far behind that observed
in paresis and there is very slight albumin increase. Where
inflammatory brain syphilis exists albumin increase may also
appear.

6. In arteriosclerotic insanity a positive finding points to a
syphilitic process, such as softened foci following specific ar-
terial disease. In brain tumors a negative finding is the rule.
If a positive finding occurs, a syphilitic basis for the process
can be taken for granted.

7. Epilepsy shows negative findings ; if otherwise the sus-
picion of brain syphilis is justified.

8. Alcoholism in all its varieties gives negative results, if
the finding is positive and there are no signs of nervous in-
volvement an old syphilitic infection is to be taken for granted.
Where symptoms of involvement of the nervous system are
present general paralysis or brain syphilis is to be suspected.
It is questionable in some cases even when symptoms of in-
volvement of the nervous system are not present, in a positive
finding with albumin increase, whether we are not dealing with
an early paresis.

9. A differential diagnosis is to be made between brain
abscess and meningitis by the presence in the latter of in*
creased cellular material.

10. It cannot be enough emphasized that the lymphocyto-
sis presents a singular disease sign, and only after consideration

LUMBAR PUNCTURE IN PSYCHIATRY 319

of all other clinical symptoms of the disease, should it be
used to construe the case. When the findings are con-
sidered with due care to the possibilities, the results ob-
tained from lumbar puncture are an important and ofttimes an
invaluable aid to the diagnosis of obscure nervous and mental
diseases. It is of especial importance in differentiating alco-
holism, general paralysis, dementia pnecox, epilepsy, brain
tumor and finally brain syphilis. With the advancement of
our knowledge of the occurrence of lymphocytosis in syphilis
of tissues other than the nervous system, with further autopsy
reports, and improvement in technique, we can look forward
to the solution of many, at present, doubtful phases of the
subject.

TABLE.

No. of

Diag. Cases. Pos. Mkd.Mod. S. I. Neg. Syph.

Gen. Par 30 30 o o o 16

Doubtful Cases 33 14 1 6 u 4 Pos.

20 Neg.
9 Susp.

Ale. Clear •• 16 2 o o 14 1 Pos.

including 1 Susp.

Korsakoff •• 5 ° ° o 5

Syphilis :

Secondary 15 5 6 1 3 15

Tertiary •• 5 5 o o o 5

Ter. C. Psy. & N. Sym 10 7 o o 3 10

Ter. with Psy. & no N. Sym .. . 400134

Epilepsy 3 1 o o 2 I

Deni. Prse 600060

Brain Tumor 1 o o o 1 o

Pachymeningitis 1 o o o 1 o

Psy. fol. C. S. M.* •• 1 1 o o o o

Hydrocephalus 1 o 1 o o o

Senile Dem 500050

131 65 8 8 50 66

* Cerebrospinal meningitis.

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JOINT MEETING

OF THE

NEW YORK NEUROLOGICAL SOCIETY

AND THE

PHILADELPHIA NEUROLOGICAL SOCIETY.

Held in Philadelphia, Nov. 24, 1906.

The President of the Philadelphia Neurological Society, Dr. D. J.

McCarthy, in the Chair.

A CASE OF AMNESIA.
By C. W. Burr, M.D.

A man, 55 years old, was found by the police, confused, in the street, in
November, 1900. He was taken to the Philadelphia General Hospital,
where he had an attack of excitement and violence lasting a couple of
days. Since then he has had no recollection of his past life for some
years previous, and cannot remember anything that happens now even
for a few minutes. The events of his childhood, youth and early man-
hood and the tilings that he learned at school he remembers fairly well.
He knows that he has been married, but does not know whether his wife
is living or dead, and says he has forgotten entirely what she looks like.
When he is spoken to about his wife he becomes emotional, but in a few
minutes forgets all about it. He knows who he is and has never had any
alteration in personality. He is neat and clean in his habits, quiet in
manner and shows no moral defect. He knows that he has lost his
memory and knows that it is on account of disease. His intellectual
judgment is much better than is usually found in senile or presenile
dementia. His loss of memory is so great that if he reads (and he reads
well) a paragraph in a newspaper he forgets the first sentence before he
has read the last. Though he has been told many times that he is in
the Philadelphia General Hospital he can never remember it. When in
(he ward he can reason out that he is in a hospital on account of the
number of beds and the presence of people manifestly sick. When he is
in the hospital office, however, he reasons out that he must be in some
business house on account of the number of desks and clerks. He cannot
tell five minutes after a meal whether he has had a meal or not, but
reasons that since he is not hungry he must have been fed. He does not
know the year, the month or the season of the year. He remembers the
year of his birth, but does not know how old he is because, as he says, "I
do not know what year this is." In the last few months a few things have
made some impression on him, for he now vaguely realizes all the time
that he is being treated in a hospital for his sickness.

Dr. B. Sachs said the condition was an extremely interesting one, and
the only cases that he has seen that have been equally puzzling have been
cases entirely different from the one presented. Two years ago he saw a
man who developed an amnesia which was as complete as that of the
patient presented, and even more complete. He lost memory of his own
personality. He developed this amnesia as an early symptom of general
paresis. A few weeks later he developed general paresis with very
characteristic symptoms and passed more than a year as an inmate of an

PHILADELPHIA NEUROLOGICAL SOCIETY 323

asylum. Dr. Burr's case has lasted so long that there is no question of
this sort. The difficulty in the class of cases Dr. Sachs spoke of and in
the one he cited as an example was to decide whether the man was
simulating. In his case there was a law suit pending and he thought the
patient had good reason for forgetting his personality and for simulating,
but the later developments proved that he was not shamming at all. He
is now very near the final stage.

Dr. Morton Prince called attention to the fact that there were two
types of continuous amnesia, one the functional form and the other the
organic. Charcot was the first to call attention to the functional variety in
the famous case of Madame D., who as a result of an emotional shock
was found to continuously lose all memory of every experience as fast as
it occurred. It was found, however, that the memories were not abso-
lutely lost, but only dissociated, for the memories of her life were re-
hearsed in her dreams and were completely recovered in hypnosis.

In the organic type, that is in continuous amnesia depending on organic
disease, the memories seem to be completely lost, or at least it has not
been shown that they were simply dissociated and could be recovered.
This form of amnesia has been frequently observed in Korsakoff's psy-
chosis and in alcoholic neuritis. The speaker had observed one very
extreme case following what was believed' to be from the history of the
latter disease, and also in a case that clinically appeared to be one of
multiple sclerosis. As to the pathology of this organic form of continuous'
amnesia we know practically nothing. It is curious to note how a person
with a marked continuous amnesia can get along without being markedly
incommoded and without allowing it to be suspected. The case of
multiple sclerosis, for example, had attended the hospital clinic for three
months without the amnesia being suspected.

A CASE OF COMBINED POSTERIOR AND LATERAL SCLEROSIS,
WITH INVOLVEMENT OF THE CELLS OF THE
ANTERIOR HORN.

By J. W. McConnell, M. D.

Dr. Joseph Collins said he did not know whether it was the intention
of Dr. McConnell to present this case as a new type of disease, but, if so,
he was loth to accept it as such. Sufficient had been said about its occur-
rence and about the character of the disease to make it clear that it was a
manifestation of diffuse syphilitic disease of the cord analogous to that
Nonne had described in his last contribution. He could not say at the
moment whether he had seen more than two or three cases similar to this
or not, but he was quite sure he had seen that number. He understood
that there were some sensory disturbances in Dr. McConnell's case.
There must have been widespread, more or less disseminated, lesions
throughout the spinal cord which entitled it to be classed as a dissemi-
nated syphilitic lesion.

Dr. C. E. Atwood saw one case of subacute combined sclerosis when
an assistant of Gowers, and it corresponded very closely to this, but it
was not so far advanced. It had similar paresthesia in various parts of
the body, especially about the anus and genitalia and in the extremities.
The age of the patient was about the same and there was, as in this
case, a good deal of anemia. He believed that in these cases one of the
earliest symptoms is a very pronounced anemia. There was in his case a
condition of spastic paraplegia with anesthesia, girdle sensation, increased

324 PHILADELPHIA NEUROLOGICAL SOCIETY

knee jerks, Babinski, and inability to walk, as the disease advanced, from
weakness and marked spasticity. The disease runs a rapid course and on
autopsy marked wasting of the white matter in the cord is found. The
disease may be due to some chemical toxic substance in the blood.

Dr. McConnell, closing, said he had not stated that these patients had
cranial symptoms. One of the patients showed Argyll-Robertson pupil.
He had not intended to describe any new clinical type, but it had occurred
to him often that the appellation cerebro-spinal syphilis is such an in-
definite one that we should have a better term. Other scleroses were
spoken of as posterior sclerosis, combined sclerosis, lateral sclerosis. Why
not give a clinical pathological diagnosis to our cerebrospinal syphilitics?

A CASE OF TABES IN A NEGRESS.
By John K. Mitchell, M.D.

Dr. Mitchell said he was sorry to say that he had just learned that the
patient whom he had hoped to show had at the last moment refused to
come to the College of Physicians, and he would therefore say only a very
few words about her.

The only unusual features of the case and the reason why he wanted
to exhibit her lay in the rarity of the occurrence of locomotor ataxia in
a black of pure blood. In spite of the frequency of occurrence of syphilis
among the blacks, ataxia is so rare in his experience as to be almost
unknown, except in those who obviously have a greater or less share of
white blood. It is probable, of course, that there are not a gTeat many
negroes in the country who have not some percentage of white blood, but
so far as one can judge by appearance this ought to be one of the cer-
tainties, and the woman herself is entirely ignorant of any trace of
Caucasian in her pedigree.

She has a Charcot joint in both knees and in one ankle. She has
been under Dr. Mitchell's observation with the disease for three or four
years. She is pretty nearly at a standstill and presents no symptoms of
any peculiar interest.

Dr. S. Weir Mitchell regretted very much that his son could not
present the case. There were three disorders of the nervous system which
the negro escapes. This was certainly one. He thought chorea, again, was
another. Chorea among pure black children was practically unknown in
this country and Cuba, and he has had occasion recently to find from
inquiries sent out that this was probably the case as concerns exophthalmic
goiter. He found to his surprise that in Cuba it is exceptional and rare
among the negroes. Physicians wrote him from Cuba that it is scarcely
heard of among the pure-blooded blacks. These were things which the
negro escapes.

Dr. J. A. Booth had seen six cases of tabes in the colored race, and
they were all patients in the Colored Home in New York City. Among
the six there was no question of four of them being of the pure colored
race. He had also seen one case of chorea in the Colored Home.

Dr. L. Pierce Clark said he had reported in his second thesis on
myoclonus-epilepsy a full-blooded negro patient who died of myoclonus-
epilepsy. The case had been first diagnosticated as choreic epilepsy be-
fore admission to the Craig Colony for Epileptics, but the movements
were typical of myoclonus as seen in the association disease. In an
analysis of two thousand cases of idiopathic epilepsy in his service at
the colony there were at least six full-blooded negro patients, about the

PHILADELPHIA NEUROLOGICAL SOCIETY 325

normal ratio existing between the races in the general population of the

State.

Dr. H. M. Thomas said that in Baltimore were seen a considerable
number of cases of tabes in black people, but he found it very hard to
prove that they were pure-blooded blacks. He was sorry his statistics
were not perfectly accurate on that account. Any person who had any
negro blood was classed as black, and they came in among these cases.
Many of them did not know their parentage and he had to judge by looks.

Dr. J. K. Mitchell said that it was difficult to be sure in any given case
of negro that he had no white blood. He supposed there were few
negroes in this country without any taint of white blood. This woman
looked as if she had none, and when asked she said : "Oh, Gawd, I don't
think so, both my grandmothers was mos' 'spectable women." Consider-
ing the frequency of syphilis among the blacks, the rarity of tabes must
be very great. There are 70,000 negroes of varying degrees of darkness
in Philadelphia alone, it was remarkable that no more cases should turn
up at the nervous clinics, the case under discussion being absolutely the
unique instance known to Dr. Mitchell of ataxia in a negro of presum-
ably undiluted African blood.

A CASE OF PROBABLE APRAXIA.
By John H. W. Rhein, M.D.

Dr. Rhein stated that the man was fifty-five years of age and had
been admitted to the Philadelphia Home for Incurables on July, 1906,
complaining of loss of vision. The family history, as well as the- previous
history, was practically negative. Three years ago he began to lose his
eyesight, and this loss progressed gradually until at the end of two years
he was unable to read. At present he is unable to see anything but a
bright light, and is not always sure of this. He has entirely lost his ability
to recognize the position- of his body and limbs. He cannot tell whether
he is standing or sitting', or what position his arms or legs are in. He
has lost entirely his sense of localization. He recognizes a light touch
in certain places, but cannot locate it. When asked to place his right
hand upon his nose or ear he places his hand upon his knees or his chest,
stating at the same time that he is touching his ear or nose. When he is
asked to squeeze the hand of the examiner with his left hand, he grasps
his right leg with his right hand and squeezes, believing that he is squeez-
ing the examiner's hand with his left hand. At the same time he does not
move the fingers of his left hand whatever. When a watch is placed in
his right hand, and he is told to place it to his ear, he does it frequently
correctly, but some times puts it to his mouth. He does not recognize
the ticking of a watch, but when asked if he knows what the object is he
replies: "Yes, it is a watch." He states that he knows this because his
reason tells him that the watch would be the object which the examiner
would place to his ear to test his hearing. The tactile sense in his left
hand appears to be lost ; in the rig'ht hand it is present. Tests of the
pain sense were rather unsatisfactory because they irritated the patient
very much, and obscured the accuracy of the observations. It is prob-
able that this sense is retained in both hands. He is unable to distin-
guish between light and deep pressure. He recognizes the difference
between heat and cold in the right hand, but does not always recognize the
difference in the left hand.

Dr. "Neman, the resident, found the thermal sense markedly impaired

326 PHILADELPHIA NEUROLOGICAL SOCIETY

all over the body. The stereognostic conception is impaired; he does not
recognize the nature of objects placed in his hands. His gait is "patter-
ing," he takes small steps, first with the right foot, and usually toward
the right.

In a brightly lighted room, if a hand is placed before his eyes, while
he is walking, he turns away from the hand without recognizing that an
object is placed before his eyes. He does not recognize objects in a
brightly lighted room, and will frequently bump into a table or the wall
in walking alone. Both arms and legs are rigid, especially on the left
side, although not truly spastic. The knee jerks are increased; there is
no clonus or Babinski. The arm jerk is present on both sides. The
station with the feet together is good. The grasp is good and equal on
both sides. The tongue is protruded straight in the median line, and is
tremulous and tooth-indented. The taste sense is markedly altered, while
the olfactory sense seems practically unimpaired. He cannot write his
name, and in making this effort makes a scrawl, writing from the right
to the left.

Examination of the eyes by Dr. W. C. Posey revealed the early
changes of simple atrophy of the optic nerves. There was no Wernicke's
pupillary inaction and no palsy of the extraocular muscles. The pupils
reacted to light. Dr. W. G. B. Harland reported that there was nothing
in the examination of the ears that would not be found in an old man
with mild middle-ear disease.

The patient is intelligent, answers questions promptly, and his memory
appears to be good. He is well nourished, his appetite is good, his diges-
tion unimpaired, and his bowels regular. He complains of nothing ex-
cepting his blindness. He has a quick temper, and becomes frantic when
the examination is pushed beyond a certain point.

The case bears some resemblance to those cases of apraxia which
have been reported. However, a further study of the case must be made
before a diagnosis can be ventured upon. At present this much can be
said, that bilateral lesions involving the occipital and parietal lobes would
explain most of the symptoms which this patient presents.

Dr. A. Fraenkel, of Haiden, Switzerland, said that he imagined the
case might have been one of functional disease, but as he saw the patient
coming in, he was sure it was not functional, but that it was a sort of
bulbar disease, and that it interested us to know whether he had any
ophthalmological history. Dr. Rhein stated that he had very early stages
of optic atrophy. This would not explain his blindness. There might be
a double lesion in the occiput with symptoms of apraxia.

Dr. Joseph Collins said that those who attended the American Neuro-
logical Association would recall the type of disease which he had attempted
to portray as a clinical entity, a discussion of which had appeared in The
Journal of Nervous and Mental Disease. They would recall that the
most striking characteristic of the disease was the alteration of the
patient's appearance. The individual became transformed from a person
expressing grace in movement, and relaxation in repose into an immobile,
inanimate replica of the normal person. The second was that the cases
first impress one as being paralysis agitans, and that when you came
to dissect and analyze the one symptom above all was the immobility.
There was no motorial function of the body which might display the
disorder. This immobolization gives a characteristic attitude and gait,
and to a lesser degree a characteristic physiognomy. The gait is the most
remarkable feature of the patient. The stride is short, oftentimes only a

PHILADELPHIA NEUROLOGICAL SOCIETY 327

few inches, the feet slightly lifted, the rhythm generally slow, occasionally
rapid. One case he had complained of impaired vision. The disease was
clean-cut in its delineation, quite as much so as Parkinson's disease. He
has had several autopsies, and has had six or seven brains which show
the distinctive lesions. What the lesion is it was imposible to describe in
three or four minutes. Some changes were confined to the motor areas
and others were distributed throughout the entire brain. The disease was
that which Charcot probably had in mind when he described abasia
trepidant ; afterward an attempt was made by a Polish clinician Bieganski
to describe it. In hospitals where many patients were undiagnosticated it
had been forced upon him that there was a type of disease of which
this man is the best exemplification he had ever seen, that has a definite
clinical type and which must at the present time be called a definite form
of general cerebral arteriosclerosis with special symptoms. The patient
now exhibited seemed to him to be a fairly typical example of the disease.

Dr. Joseph Fraenkel said that the cases he had seen did not fully co-
incide with the description given by Dr. Collins. Those described origin-
ally by Charcot under the name of "gait stuttering and stammering" which
manifested a condition like the patient presented, he had never seen
except once. He thought the same patient was presented in New York.
They did not make a diagnosis of his condition then.

Dr. Rhein said that he had not yet had an opportunity of looking
into the literature exhaustively, but that there were three cases recorded
which were in many respects similar to the one exhibited. One was a
case reported by Dr. S. Weir Mitchell, a woman giving a history
of gradually increasing blindness, together with loss of the stereognostic
sense. She died under Dr. Pershing's care in Chicago, and an autopsy
revealed the presence of cysts situated in both occipital regions, and general
sclerosis of the cortex. Another case was reported by Dr. Charles W.
Burr, without autopsy, in which the patient had progressive blindness
and tactile amnesia.

The third case was described by Liepmann under the title of "Unilateral
Amnesia." In his case there was degeneration of the occipital and parietal
regions, together with portions of the corpus callosum.

Dr. Rhein thought that, as far as he had gone into the study of the
case, the idea suggested by Dr. Fraenkel that the lesion was in the
occipital lobes, was in part, at least, the best explanation of the case,
although he himself inclines to the view that the parietal, as well as the
occipital lobes, are involved.

A CASE OF PROBABLE PARALYSIS AGITANS IN A BOY OF

TWELVE.

By T. H. Weisenburg, M.D.

The speaker stated that the family history and the past social history
of the patient were uninteresting. The boy had the ordinary diseases of
childhood, and up to a year ago was considered normal. At this time,
while going to school, his teacher noticed that the boy became somewhat
stupid and slow mentally, and that he was not as rapid in learning as he
had been. The teacher also noticed that his speech became more or less
monotonous and indistinct. About the same time the boy began to have
a shuffling gait, and every once in awhile would trip over slight objects.
The boy at present has a stiff attitude, he holds his body rigidly, head bent
over, arms held to his side. When he walks the body is inclined forward,

328 PHILADELPHIA NEUROLOGICAL SOCIETY

the steps are short, shuffling, and he has a tendency to slip over the
slightest object. His face is mask-like, suggesting strongly the
facies of paralysis agitans. His speech is slow and monotonous and hard
to understand. He has dribbling of saliva almost constantly. He smiles
very rarely and he hardly ever cries. His mental condition is slow ; he
responds to questions fairly well, but it is evident that as compared to a
boy of his years and opportunity for education he is undeveloped mentally.
There is no apparent coarse tremor, although he has fine tremor of the
upper limbs and sometimes of his head. He holds his hands in flexion
and somewhat in the position of a case of paralysis agitans, but there is
no pill-rolling movement. Any sudden push forward or backward will
cause him to fall. There is no festination, although others have observed
a tendency to it. The reflexes are increased generally, and sensation is
normal.

The patient, from appearance, attitude, facies, tendency to shuffling
gait and falling forwards and backwards suggests paralysis agitans. It is
rather difficult to say at this early date and in such a young person
whether the case is a true one of this character or whether it is a fore-
runner of some other disease as multiplesclerosis. There is no denying the
fact, however, that it strongly suggests paralysis agitans.

Dr. Charles Dana said that about fifteen years ago a boy came into
his hands with symptoms very like this case. The boy was about this age
when he first came and was finally transferred to the Montefiore Home.
He thought the picture had gradually changed to multiple sclerosis. It
seemed to him that this was precisely what this boy's condition would be
ten years from now.

Dr. Joseph Fraenkel stated that he and Dr. Sachs had had a case of
paralysis agitans in which the diagnosis had been made by the children
with whom the child played, long before they had made it. The boy's
mother had told Dr. Fraenkel that his schoolmates called him "false face."
He presented for a number of years the most characteristic picture of
paralysis agitans that he had ever seen. The only feature not charac-
teristic of paralysis agitans was nystagmus. Later the patient began to
show evidences of disease of the pyramidal tracts ; markedly exaggerated
tendon reflexes and ankle clonus. Three years ago Dr. Turner, of
London, suggested to the speaker the possibility that cases of this kind
were some type of Little's disease — cerebral diplegia.

Dr. Sachs said that the case resembled that which Dr. Fraenkel re-
ferred to very strongly, but he felt great hesitation in arriving at a diagnosis
in a case he had seen for only a few minutes. He thought he was one
of the first to see the case that Dr. Fraenkel referred to. and suggested
that it was a peculiar fact that when a condition resembling paralysis
agitans occurred in a younger individual it should assume the form of
multiple sclerosis. Paralysis agitans was much more common in the later
periods of life than in the early. All the symptoms here suggested
paralysis agitans. It would be interesting as years go on to follow de-
velopments in this case. In the boy's face there was a suggestion of
scleroderma, but on examination of the hands he thought there was noth-
ing of the sort. We should be careful about establishing new types. It
was interesting to note what an unusual number of atypical cases occur
which it is not easy to label one way or another.

PHILADELPHIA NEUROLOGICAL SOCIETY 329

A CASE OF HEMIATROPHY OF THE FACE.
By A. Gordon, M. D.

The gradual wasting of the muscles followed an attack of two days'
duration of neuralgic pain in the infraorbital region on the right side.
Now, eight years after the onset, the atrophy is complete and the reaction
of degeneration is distinct. At no time were there vasomotor disturbances
on the affected side, and the pupils are equal, a fact which militates against
the sympathetic origin of the disease in the present case. Dr. Gordon
reviewed other theories, criticizing them, and concluded that facial hemi-
atrophy may be caused by involvement of the lower sympathetic ganglion,
by the fifth nerve, by the seventh, by the Gasserian ganglion, finally by
a cerebral lesion.

Dr. M. Allen Starr asked if any one present had ever noticed any
facial hemiatrophy following operations on the Gasserian ganglion. He
had never seen one. In only one case of hemiatrophy had he seen neural-
gia symptoms referable to the fifth. He had considered the advisability
of exsecting the ganglion in hemiatrophy, but unless it is proven that the
fifth ganglion has a relation to hemiatrophy he thought it would be a
rather risky operation.

Dr. Spiller, in replying to a question from Dr. Starr, said he had
never seen a case of atrophy resulting from operation on the Gasserian
ganglion.

Dr. Dana said that this was a typical case of hemifacial atrophy. The
atrophy was very slight. It was progressive : that several of the cases
he had seen had been associated with scleroderma and this patient's face
suggested it. He had observed a number of cases where the Gasserian
ganglion had been removed for a long time without any effect upon the
trophic condition of the face.

Dr. Morton Prince said that an alternative hypothesis must be con-
sidered ; namely, whether it was not rather a case of muscular dystrophy
rather than of so-called ganglionic hemiatrophy. In most of the cases of
hemiatrophy reported the bones and other tissues were involved. In this
case this did not seem to be the fact, but the atrophy was limited entirely
to the facial muscles which were paretic. He believed therefore that the
theory of muscular dystrophy must be entertained, or possibly the case
was one of simple facial paralysis.

Dr. Knapp said that his own experience coincided with that of the
other gentlemen who have spoken ; that he had not found hemiatrophy
following lesions of the cervical sympathetic or operations on the fifth
nerve. The patients which he had seen had had no paresthesia. This
case seemed to him rather peculiar on account of its general diffuse
character. In the early stages of hemifacial atrophy he had noted, as
others had, the involvement of bone. In one case in particular the trouble
began with a marked wasting of the tissues in the forehead and bone as
a depressed band right down the forehead close to the medium line with
a diffuse wasting of the rest of the face. A general diffuse wasting like
this without bony involvement he had not seen in a case of hemiatrophy.

Dr. Sachs said that he was impressed with the fact that this might
belong rather to the class of cases spoken of as pseudo-hemiatrophy.
There were marked sensory changes in this case, not of syringomyelic
type. This case seemed parallel with two or three cases he had observed
closely for years in private practice which began with very marked pain
within the trigeminal area ; they suggested syringomyelic disorder. In

330 PHILADELPHIA XEUR0L0GICAL SOCIETY

one the marked trigeminal symptoms had been followed by atrophy just
as was seen in this case, an atrophy which was muscular rather than an
atrophy that involved the subcutaneous tissues, the bone and so on, as
was the case in progressive hemiatrophy. These cases he referred to he
had no: been able to label properly. He rememberd that Dr. Jacoby
some years ago thought that they might be incipient cases of tabes, but up
to the present time no symptom of tabes had developed. They were
surely cases of trigeminal disease no other symptoms following.

Dr. Adolf Meyer asked if there had been any electric reaction of
degeneration in the facial nerve.

Dr. Gordon, in closing, replied that Dr. Prince's remark concerning
the possibility of a muscular dystrophy cannot be accepted in this case
for the reason that the duration of the disease has been eight years and
further, the disease is confined to the face. His arms and the muscles
of the neck are absolutely intact. The reaction of degeneration i- very
pronounced. Therefore the duration of the disease for eight years and
the lesion being confined exclusively to the face throw out the diagnosis
of muscular dystrophy.

As to another possible origin of the disease, Brissaud suggested the
possibility of syringomyelia of the medulla. The patient does not present
sensory symptoms corresponding with that. There is no vasomotor dis-
turbance so as to make us think of the sympathetic system. As to the
question of operation. Dr. Gordon did not see what operation could ac-
complish under these circumstances.

(To be continued. )

NEW YORK NEUROLOGICAL SOCIETY.

October 2. 1906.

The President pro tern. Dr. Adolf Meyer, in the Chair.

A CASE OF SUBCORTICAL TUMOR.

By Richard Weil. M.D.

The patient was a man. forty-two years old, a Russian, who. three
months before he came under observation complained of severe headaches
from which he could obtain no relief. About the same time, some impair-
ment of the mental faculties was noticed, and there was impairment of
vision which rapidly progressed to total blindne —

During the first two months of his illness he also had two convulsions.
According to the history given by his wife, he would wake up in the night,
complaining that his left arm was shaking. From the arm. the movements
would progress to the corresponding leg, and finally the entire left side
would become involved, and unconsciousness would supervene.

When the man entered the hospital, the optic nerves showed a secondary at-
rophy. The physical examination revealed very slight impairment of the
motor functions. On the left side, the reflexes were slightly increased : there
was no clonus in the patella nor ankle. Power was unimpaired ; no ataxia ;
no Babinski. He had perfect thermal sensibility, and the pain sense was un-
impaired. There was only one pronounced symptom, namely, astereogno-
■-is. which persisted up to the time of operation, and he was unable to

NEW YORK NEUROLOGICAL SOCIETY 331

distinguish the form or character of any body that was placed in his left
hand. This symptom was constant, invariable and very pronounced. The
exact condition of the muscular sense could not be determined.

Upon the strength of the above symptoms, a diagnosis of cortical
brain tumor was made, and localized, according to .Mills, in the right su-
perior parietal, and the skull opened in the region indicated. The result
was absolutely negative. No tumor was found, and the man died two days
later of shock. At the autopsy, a subcortical tumor, situated at a con-
siderable depth, was found. It was a glioma, originating in the posterior
part of the lateral ventricle. The white fibers were scarcely involved at
all, and the tumor was nowhere near the cortex.

Dr. Weil said this was the only case he knew of in which a tumor
situated as deeply as was this one had given rise to astereognosis ; it was
also remarkable inasmuch as this was the only symptom of localization.

Dr. B. Sachs said the case reported by Dr. Weil was particularly in-
teresting on account of the diagnosis. The symptoms that were present
would certainly have induced anyone to make the diagnosis of a localized
cortical tumor. In addition to the astereognosis. the occurrence of con-
vulsive seizures would point to cortical irritation ; in fact, all the symp-
toms were those generally associated with cortical tumor. In view of
the autopsy findings, Dr. Sachs said that the most plausible explanation
of the cortical manifestations was that they were the result of the pressure
exerted by the subcortical tumor upon the adjacent parts, thus interfering
with the fibers that ordinarily conducted the stereognostic impressions from
the gray centers.

The Chairman. Dr. Meyer, said that judging from a rather hurried in-
spection of the specimen shown by Dr. Weil, he inferred that the tumor
evidently was in close proximity to the cortex on the mesial side of the
hemisphere, and to the corpus callosum.

Dr. Weil, in reply to a question, said that an in<-;<;()n wa^ made into
the cortex at the time of operation, but nothing could be felt. In reply to
Dr. Meyer he said that the corpus callosum overlaid the tumor and did
not seem to be involved. There was certainly a considerable distance
between the tumor and the cortex. The tumor originated in the lining
epithelium of the ventricle, and destroyed only a small area of white.
The most interesting feature of the case was that its effects should have
been limited to the area giving rise to stereognosis. There was probably
some interference with the fibers conducting the stereognostic sense, as
suggested by 'Dr. Sachs: that explanation was more likely than to attribute
the symptoms to cortical compression. On the other hand, the JacksOnian
attacks certainly pointed to a cortical irritation; but the fact that the irri-
tative motor symptoms were completely absent from the picture except for
the two epileptiform explosions seems to point rather to sudden and pass-
ing changes in the relation of the tumor to the brain, as by a ^ndden in-
crease in size through edema.

FUNDAMENTAL CONCEPTIONS OF DEMENTIA PR.ECOX.

By Adolf Meyer, M.D.

In this paper, the author gave an outline of the main facts of demen-
tia praecox, which showed the fundamental importance of a consideration
of the mental factors, the habits and ways of thinking of a patient, for an
understanding of the disorder and prophylaxis and treatment. While

332 NEW YORK NEUROLOGICAL SOCIETY

Kraepelin seemed to despair of such an explanation, and simply created
a disease-entity on the ground of some final symptoms, such as negativism,
mannerisms and stereotypes and disorders of volition, and appealed to the
concept of autointoxication, he missed many factors which furnished a
more intelligible and natural picture of the condition. As soon as we
abandon the schematic use of conventional psychology and observe the
actual experience and modes of mental activity of the patients, we see that
most of the symptoms appear as perfectly natural results, not of abstract
and so far undemonstrated auto-intoxications, or supported merely by frag-
ments of histological knowledge, but of habits of function and mental activity
which may in part open a chance for correction and should be pushed to the
front, so that that danger could be recognized in time. As long as consump-
tion was the leading concept of the dreaded condition of tuberculosis, its rec-
ognition very often came too late to make therapeutics tell ; if a few symp-
toms and the outcome in dementia are the leading concept of a disorder, the
physician will not think of it until dementia is established, and a declaration
of bankruptcy drives him to fatalism. To-day, the physician thinks in terms
of tuberculous infection, in terms of what favors its development or sup-
pression, and long before "cohsumption" comes to one's mind, the right
principle of action is at hand ; the change of habits, of breathing poor air,
of physical and mental ventilation, etc. In the same way, a knowledge of
the working factors in dementia praecox will put us into a position of
action, of habit-training, and of regulation of mental and physical hygiene,
as long as the possible "mental consumption" is merely a perspective, and
not an accomplished fact. To be sure, the conditions are not as simple as
with an infectious process. The balancing of mental metabolism and its
influence on the vegetative mechanisms can miscarry in many ways. The
general principle is that many individuals cannot afford to count on un-
limited elasticity in the habitual use of certain habits of adjustment ; that
instincts will be undermined by persistent misapplication, and the delicate
balance of mental adjustment and of its material substratum must largely
depend on a maintenance of sound instinct and reaction-type.

In the antecedents of cases of dementia praecox, one invariably finds
where the facts are sufficiently well known, that the individual had abnor-
mal ways of dealing with the situations of life, an inability to get square
with events, and a tendency towards false adjustments. At first, perhaps,
there is merely an excess of substitutive reactions, such as occur also in
the normal, a shirking and scattered and distracted slurring over of the
difficulties, secretiveness. instead of a frank ventilation and correction by
joining the activities of the normal, a habit of excusing carelessness and
lack of determination by hypocondriacal complaints or fault-finding with
others, or the habit of passing over difficulties by imaginative thoughts, or
mere praying, or pondering, or other expedients which as a rule help
successively over an individual disappointment; or we find much more
serious reactions, such as blind tantrums, or hysteroid outbreaks, or a
mechanism of partial suppression, brought out so well by the studies of
Breuer and Freud, and by the Zurich school; the creation of undercurrents
•of uncorrected false lingering attitudes, which form the foundation for the
more serious developments which are almost pathognomonic of a disorder
which marks the over-stepping of the elasticity; a disruption of judgment
only insufficiently accounted for by any special mental or physical upset (t. e.,
without any evidence of intoxication or other delirium, or without the manic-
depressive thinking disorder, or the foundation of the hysterical or epileptic

NEW YORK NEUROLOGICAL SOCIETY 333

disorder), discrepancies between the mood and the general reaction,
peculiar attention disorders and feeling of interference with thinking and
deterioration in matters which are largely dependent on sound instinct,
such as differentiation of the real and unreal, and the critique or imagina-
tive material; all this in the face of relative clearness, so that we are
forced to think of a fundamental deterioration or defect as the only means
to account for so much perversion of instinct and reasoning. In connec-
tion with this, there appear a number of symptom-pictures, also met with
occasionally as more or less adequate excusable and corrigible reactions,
such as states of puzzle, of religious and mystic fascination, of automatic
and stuporous states such as can be in part obtained by hypnotic sugges-
tion, or such as arise as psychasthenic and hysterical reactions (as we
call them when they appear on sufficient and characteristic foundation).
The insufficiency of the provoking factor, and the oddity and incongruity,
rather than the mere excess of what might be the result of a sufficient
cause in an average person constitutes one of the most important criteria
for the estimation of the seriousness of the process.

It is striking how, in well observed cases, all the symptoms and events
stand out as necessary results of small beginnings, the knowledge of which
is more important to the physician than the mere recognition of irrepar-
able end results. As long as physicians are satisfied with such terms as
dementia praecox ; that is, a mere statement of an end result like consump-
tion, and as long as they disregard the factors and conditions which work
towards this final result, they miss their opportunities for action, and
merely satisfy their empty desire to have a name for a disorder which is
to be handed over to the asylums in a spirit of fatalism. The name is un-
essential and only preliminary, and will have to be substituted by terms
which designate specific mechanisms of work — the hysteroid reaction, the
abnormal habit reaction, the type of attention-defect and of judgment-
defect. The term dementia praecox will then become unnecessary, or will
indicate merely the perspective, that which is likely to come about, but by
no means necessarily so. Etiologically, the constitutional make-up counts
for a great deal; but not in the vague sense of heredity and degeneracy
merely. There is much more to be had in the study of deterioration of
the habits and undermining of instincts and their somatic components.

Dr. Meyer warns against elusive hopes in histological explanations, in
auto-intoxication guesses and the tendency of the physician to ozw-correct
common-sense, to rule out mental reactions from the domain of legitimate
study, and reduce all mental diseases to the paradigma of general paralysis.
If he continued to believe that the only condition of mental health lies
with the proper amount of indican and the ideal status of the parathyroid
and a few other glands which lack of knowledge makes a home for a
wealth of theories, he misses his chance with the great percentage of
simple dementias. Mind, like every other function, can demoralize and
undermine itself and its organ and the entire biological economy, and to
study the laws of the miscarriage of its function and life, is one of the
conditions for any true advancement in psychopathology.

Dr. B. Sachs said that a few years ago he had placed on record his
opinion regarding Kraepelin's concept on dementia praecox, and he had
since then seen nothing to disabuse him of the views held at that time ; on
the contrary, they had rather been confirmed.

In regard to what should be implied by the diagnosis of a disease, to
which Dr. Meyer had referred, Dr. Sachs thought the term should neces-
sarily cover only two factors ; namely, the morbid process and the clinical

334 NEW YORK NEUROLOGICAL SOCIETY

entity. Those two factors had to be included in every diagnosis ; otherwise
it could not be properly considered.

The speaker said the only objection he could raise to the diagnosis of
dementia praecox, aside from the fact that the term was unfortunate and
implied altogether too much, was that while deterioration was the central
figure in a certain proportion of these cases, it was not so by all means in
all of them. Kraepelin himself admitted that there was no dementia in
iy per cent, of the cases in which he made the diagnosis of dementia
prsecox. A serious objection to the term was the inevitable ease with
which the diagnosis was made, and the presumption that the symptoms in a
typical case necessarily implied a great dread of chronic and serious
deterioration of the mind. This was the one feature of the entire sub-
ject that had always struck him most forcibly, and he could not admit
that the term dementia was justified in a considerable number of the
cases now tabulated under the title of dementia • praecox. Still, he was
willing to admit that a great stride in advance had been made through
the influence of Kracpclin's studies, and that it was far better to accept
this one general clinical term, and to recognize a certain relationship be-
tween a great many different disorders, which was formerly not properly
recognized.

Dr. William B. 'Noyes said that the paper of Dr. Meyer was worth
most careful consideration, and was. the first discussion of a mental disease
before the Neurological Society, where the purely psychological side of
the subject had been given due weight. In New York and in America in
general, neurologists and alienists have not given adequate attention to
psychology. He thought that the confusion that existed in our under-
standing of dementia precox was due to the fact that even while some
attention had been paid to normal psychology, developmental psychology,
which included a study of many defectives, queer children, etc., has been
largely ignored, and it was among these that Dr. Meyer is demonstrating
that dementia praecox has its inception. In the asylums, on the other
hand, we had to deal with terminal cases, in whom the diagnosis was well
established. In order to get a proper conception on the subject, the cases
had to be studied from the beginning.

There are certain terms that serve as a catch-all for a large number of
cases. Some years ago the word degenerate was used in medical and
general scientific literature to include a large class of abnormal types. Out
of this class of degenerates may be recognized a large class of special
cases that if we know the outcome, are to be eventually called dementia
praecox. It is of paramount importance to recognize these early.

Five years ago. Dr. Noyes said, he thought he had a fairly clear idea
of what was meant by dementia praecox. Now he was much more un-
certain in regard to the class of cases in which that diagnosis should be
made. It seemed that these cases differed widely in their etiology and
outcome, as well as in their clinical manifestations. The diagnosis was a
very broad one, and could only be properly comprehended by a study built
upon normal and abnormal psychology.

Dr. Smith Ely Jelliffe said that there were two phases of Dr. Meyer's
paper which appealed to him as being of more than usual interest, and in
which he heartily concurred with the presentation of the evening. These
concerned themselves with Dr. Meyer's remarks on diagnosis and on
prophylaxis. So far as diagnosis was concerned, he was in sympathy with
Dr. Meyer's standpoint, which was philosophical, and quite apart from a
mere academic presentation of the subject. Just what constitutes a

NEW YORK NEUROLOGICAL SOCIETY 335

diagnosis from a biological point of view in dementia praecox was by no
means a simple matter to answer off-hand. In the shifting lights of
psychological tendencies, it was difficult to pick out stable features which
permit of the construction of a disease entity, and those who had studied
what Kraepelin has termed dementia praecox from many points of view
had emphasized this difficulty. He felt that more attention could be
centered on the question of what constitutes a diagnosis with advantage.

The objection that Dr. Sachs had raised to the term dementia praecox,
because, according to one author, the cases temporarily classified thus did
not show dementia in 17 per cent, he felt was of little weight. While it
is desirable to have as good names as possible, even for shadowy entities,
discussion of the name rather than the essence of the thing was fruitless.
Some so-called fevers run their course without fever, but one symptom
in a complex being absent in some individuals surely ought not to modify
the abstract idea of the complex, as embodied in the word used for the
diagnosis, or temporary grouping.

Dr. Jelliffe thought that Dr. Meyers analogy to the prophylaxis of
tuberculosis, and its detection in an early stage, if rational therapy was to
be -instituted, was a crucial point. He had hoped that if possible, Dr.
Meyer might present some psychological foundations, if such had been ob-
served, whereby the pre-dementia precox stages might be recognized.
Were there mental types which reacted disastrously to their environment,
types that might be classified by any of the newer modes of investigation
of mental character? Were there certain memory types, certain reaction
types, certain association types, which in line with Dr. Meyer's idea of a
habit psychosis might offer a clue as to the very early stages of a
deteriorating process?

Dr. Joseph Collins said that if he had understood the speaker aright,
what he desired to impress upon us was that there was great incumbency
on the part of the physician to interpret small signs indicative of the future
occurrence of dementia praecox, occurring' remotely anterior to the appar-
ent beginning of that disease, to weigh with care and to place in proper
perspective each particle of evidence that might be construed to indicate
the disordered mind, and, especially to estimate it from the psychological
point of view. We probably need to have this constantly brought before
us. but for his part he would say that these patients are almost invariably
seen by the general practitioner, who cannot possibly have the training,
even though he have the inclination, nor the perspicacity either to detect
these signs, or to estimate their importance. If. when such patients dis-
playing trifling aberrance of act or conduct which parents construe as
evidences of misbehavior, are brought to the alienist or to the student of
psychological medicine, then no doubt many of these cases would be
detected very much earlier than they are to-day; and. moreover, the fore-
shadowing of the disease which we call dementia praecox and its early
manifestations might become much more familiar. The speaker said that
he did not understand that the validity of the term of dementia praecox
was under discussion; despite this he said that he had a succinct objection
to the use of the term, not based upon any academic discussion upon what
the word diagnosis meant or should mean, but upon the significance of
the term in the minds of physicians and the laity. It is now generally ad-
mitted that dementia praecox occurs in some cases without recognizable
dementia, and that dementia praecox recovers in a very considerable pro-
portion of cases, but despite this it is, he believed, the conviction of the
general practitioner and of the laity that the disease carries with it the

336 NEW YORK NEUROLOGICAL SOCIETY

stigma of mental impotency which the victim will carry to his grave, and
that it is in general an incurable disease. Aside from this, he saw no
particular objection to the term dementia prcecox. Likewise, he saw no
particular advantage of it over the term which was supplanted ; viz.,
hebephrenia, and especially when the latter was used without a qualifying
adjective to describe its attributed origin from factors which we now
know were symptoms and not etiological factors of the disease.

Dr. Henry Rafel asked Dr. Meyer to illustrate by examples what he
meant by "bad judgment," "improper reaction to life," and the other
general qualities which, according to Dr. Meyer, render possible an early
recognition of the disease or of the certainty or probability of its occurring
later. Cases of dissolute conduct are often diagnosed as dementia praecox,
but juries will not agree, as men of the world allow as normal a much
greater latitude of conduct tha/i closet-students.

Dr. Meyer, in closing the discussion, said that whether we called this
condition dementia prnecox or something else was of comparatively second-
ary importance. The important feature was the utilization of the psycho-
logical events that led to the formation of this group of cases. Kraepelin
was very wise in starting from terminal dementia in shaping his general
picture of dementia prsecox. But our task is to study the group with
more reference to etiology and to the mechanism which leads to the end
result of dementia. If the term appears unsatisfactory, we can explain
to the public that every physician sees a certain percentage of the cases
recover, and our duty as physicians is to learn to distinguish in the in-
dividual case whether it is one doomed to dementia or one with chances
of recovery ; moreover, we must not allow the achievement of the diagnosis
to stand in our way of establishing these facts, modification and correc-
tion of which brings the chance of recovery. We thus remove the pessi-
mism and fatalism, and push to the front that which is to help to the
practitioner and an inspiration for progressive work. A brief reference
to a case pointed to the necessity of paying attention to matters usually
overlooked, but the only means of prophylaxis and of avoidance of
relapse that is at present available to our knowledge.

THE PSYCHIATRIC CLINIC AT MUNICH, WITH NOTES ON.'
SOME CLINICAL PSYCHOLOGICAL METHODS.

By G. H. Kirby, M.D.

The writer gave first a brief description of Prof. Kraepelin's new clinic,
and the organization of the medical work. In the wards, one is impressed
with the prevailing quietness and good conduct of the patients ; this Prof.
Kraepelin ascribes entirely to the methods of treatment in vogue, especially
to the dormitory plan for observation, the rest in bed for all new cases, and
the use of continuous baths to quiet excitement. Many voluntary patients
are admitted to the clinic, and a legal process for detention is resorted to
only when necessary.

Each physician on the staff, besides looking after his service, carries on
some definite line of investigation, he has moreover, three months in each
year to devote entirely to research work.

The value of "secondary light reaction" as a pupillary sign in general
paralysis was mentioned. Some of the recent work in lumbar puncture
was reviewed. By the addition of formalin to the fresh cerebro-spinal
fluid before centrifuging, preparations are obtained which allow a more

NEW YORK NEUROLOGICAL SOCIETY 337

satisfactory differential cell count. Fischer has reported twenty cases in
which the findings in the fluid during life were compared with the condi-
tion of the meninges post-mortem. When a lymphocytosis predominates
in the fluid, so can a lymphocytic infiltration of the membranes be demon-
strated; if the fluid is rich in plasma cells, then this type of cell pre-
dominates in the meninges.

Kraepelin was the first investigator to apply the methods of experi-
mental psychology to the study of mental diseases. There are a few
methods in use which can be applied easily and quickly enough to be
practicable in any insane hospital.

As a measure of the amount of mental work which an individual is
capable of doing, the method of continuous addition has been developed by
Kraepelin and his pupils. With this method, we have a simple yet prob-
ably the best way of estimating fatigue and at the same time we are able
to study the influence of practice, and determine the restorative action of
a pause during the work. Specht studied the traumatic neuroses with this
method, and thought the absence of improvement with practice was in-
dicative of dissimulation.

Apprehension and retention are studied with an apparatus having a
shutter arrangement, and by means of which a number of letters are ex-
posed to view for a known space of time. The "writing balance" of Krae-
pelin has been used in the study of certain symptoms, especially inhibition
and retardation ; e. g., in katatonia and manic-depressive insanity.

The association tests offer one of the most important aids which we
have to-day in the analysis of certain mental states. Jung has especially
developed this method, and has shown how it can be used to discover
undercurrents of thought or hidden complexes existing in the patient's
stream of mental activity, especially in hysteria and dementia praecox.

Dr. Pearce Bailey said that he had had the good fortune to spend a,
few months at Munich during the past spring. He had found Prof. Krae-
pelin extremely cordial and accommodating. In addition to the weekly
visit to the wards of the hospital, which gave the visitors an opportunity
to examine and discuss the various cases, Kraepelin gave regular clinics
on psychiatric and medico-legal subjects. Among the cases observed there,
those classified as dementia praecox were in the majority. There were
also many cases of manic depressive -insanity and general paresis, as well
as the alcoholic forms of insanity. Other types of mental disease were
not particularly frequent. Dr. Bailey said he saw no cases of involution
melancholia, and only one which was pronounced paranoia. The speaker
said he was struck by Kraepelin's views in regard to hysteria, to .which
group he gave a very much larger scope than we were accustomed to do
in this country. For example, he ascribed the commission of many petty
crimes to the trance states of hysteria.

In referring to the statement made by Dr. Kirby that the patients under
Kraepelin's care were unusually docile and quiet, Dr. Bailey said he was
inclined to partially attribute that to their low order of mentality, their
intelligence having been stunted by generations of beer drinking; and also
to the fact that centuries of strict military regime among the people,
especially in Bavaria, have taught them to heed authority. This, he
thought, rendered the patients much easier to handle than those in our
country. He said that what the student in psychiatry missed in Kraepelin's
clinic were the borderland cases — those cases in which it was difficult to
say whether the individual was insane or not.

338 NEW YORK NEUROLOGICAL SOCIETY

Dr. Jelliffe spoke of the pleasure he had had at the Munich clinic,
especially with reference to the unexcelled opportunities for laboratory
work. The Munich clinic had at least four times as much proportionate
floor space devoted to research laboratories as any other psychiatric clinic.
The equipment was particularly ample. In addition to the features men-
tioned by Drs. Kirby, Bailey and Gregory, he had been interested in the
cinematograph in use for registering psycho-motor manifestations, and also
Dr. \Veiler"s excellent cinematographs of pupillary reactions. He also
spoke of the Eglfing Asylum outside of Munich, and called attention to
the system of exchange of assistants between Prof. Kraepelin's clinic and
the Eglfing Asylum. He also commented on the sensible plan of allowing
a clinic assistant a three months" respite from ward duty in order to carry
on special research.

Dr. M. S. Gregory said he considered Kraepelin's clinic one of the
best in Europe. In other parts of Germany he did not think the institu-
tions for the insane were as good as those in our own country, so far as
the care of the patients was concerned. In scientific work, however, there
was no doubt that both in Munich and in some institutions in other parts
of Germany they were far in advance of this country.

Dr. Kirby, in closing, said he did not think the docility of the patients
in Kraepelin's clinic could be altogether explained on the grounds ad-
vanced by Dr. Bailey, they certainly would not hold good in the case
of the female patients.

jpertscope

Archiv fiir Psychiatrie und Nervenkrankheiten

(Vol. 41, No. 2.)

15. Atypical Alcohol Psychoses. F. Chotzen.

:6. Psychical Disturbances in Multiple Sclerosis. Raecke.

17. Inanition in the Course of Mental Diseases and Their Cause. G. Drxy-

FUS.

18. Unilateral Disturbances in Genuine Epilepsy. Emil Redlich.

19. Pathological Anatomical Alterations of the Brain in Leprosy, Leprosy

Bacilli in the Gasserian Ganglion and the Anatomy and Pathology
of Nerve Cells of the Brain in General. Hugo Stahlberg.

20. Amyotrophic Lateral Sclerosis Combined with Multiple Brain Cysti-

cerci. E. Meyer.

31. Agrammatism and Disturbances of Internal Speech. Karl Heilbron-
ner.

J2. A Contribution to the Opium-Bromide Treatment of Epilepsy follow-
ing Flechsig (Ziehen's Modification). P. Schirbach.

33. The Korsakow's Symptom Complex in Brain Syphilis. L. Roemheld.

24. An Hitherto Apparently Undescribed Malformation of the Spinal Cord.

A. Westphal.

25. Syphilitic Disturbances of Sensibility on the Trunk. Knapp.

26. Description of a Dermograph with a Report of Results of an Investi-

gation Made with It on School Children. P. Prengowski.

15. Atypical Alcohol Psychoses. — Chotzen, after a detailed analysis
of psychoses associated with alcoholic excess, together with the report
of a large number of illustrative cases, reaches in part the following
conclusions: In the present state of our knowledge of psychoses dif-
ferential diagnosis is often difficult to make. To attribute chronic
paranoid psychoses to alcohol is difficult because they cannot be dis-
tinguished from the psychoses of abstainers. The same is true of var-
ious conditions of alcohol hallucinosis. In Kraepelin's description of
the hallucinatory conditions in drinkers various disease processes may
be included whose clinical identity is not assured. The so-called Kor-
sakow's symptom complex is frequently not typical, but from the out-
set difficult of interpretation. To distinguish also the psychoses oc-
curring in acute and chronic infectious diseases from those occurring in
chronic alcoholism is frequently a matter of much difficulty. Many details
of similarities and dissimilarities are discussed at length in this paper
to which space does not permit us to allude.

16. Psychical Disturbances in Multiple Sclerosis. — On the basis of
three carefully studied cases Raecke draws attention to the often dis-
cussed psychical disorders observed in multiple sclerosis. He gives the
opinions of various writers on the subject and adds comparatively
little to the conclusions already reached by other writers. The possi-
ble association of multiple sclerosis with dementia paralytica is dis-
cussed and in general regarded as too unusual to merit consideration
in spite of the fact that the mental disturbances often simulate those
of general paralysis. Usually grandiose ideas in sclerosis develop late

340 PERISCOPE

in the course of the disease, leaving ultimately a condition of mental
enfeeblement. In the special cases studied it was noteworthy that the
, patients maintained for a long time interest in their surroundings; that
they showed relatively little dulness, and preserved their capacity for
orientation. Finally it was observed that the dementia occurred only
after long persistence of the signs of somatic disease.

17. Inanition in Mental Diseases. — Dreyfus writes an exhaustive arti-
cle on the causes of inanition in the course of mental diseases, and
brings to his aid in this research the histories of sixteen cases. The
paper is much too detailed for intelligent review in a brief abstract.

18. Unilateral Disturbances in Genuine Epilepsy. — Redlich discusses
in detail the hemiplegic conditions which come on in the course of gen-
uine epilepsy in certain instances. As a result of this careful clinical
investigation the general conclusion is reached that the hemiparetic
symptoms under discussion most frequently are manifest only after the
attacks, and in other cases are more conspicuous after attacks than at
other periods. From this it is apparent that these conditions are to be
ascribed in part at least to exhaustion. This, however, is not a wholly
satisfactory explanation, since one hemisphere is evidently involved
more than the other, and the suggestion is made that there is pre-
sumably an anatomical lesion as the basis of the condition. An elab-
orate discussion of the theories and opinions of other investigators is
included in the article. Redlich is in general of the opinion that hemi-
plegic signs point to a certain local alteration in the brain or to an
accentuation of diffuse alterations in definite areas. The question of
differential diagnosis between hysteria and epilepsy also receives brief
mention.

19. Anatomical Alterations of the Brain in Leprosy. — Continued article.

20. Amyotrophic Lateral Sclerosis with Multiple Brain Cysticerci. —
Meyer reports a case chiefly interesting on the pathological side of
amyotrophic lateral sclerosis combined with multiple brain cysts. The
histological elements of the case are discussed in detail, and the paper
is of value as a curious combination of disease processes. The writer
regards the special peculiarity of his case to lie in the fact that there
was found an adventitial infiltration of plasma cells and lymphocytes
in cord, oblongata and pons which were regarded as the indication
of a chronic inflammatory process.

21. Agrammatism and Disturbances of Internal Speech. — This paper
is an exhaustive study of a case of aphasia with special relation to the
so-called motor type. Certain of the conclusions which the writer
reaches are as follows: Agrammatism may occur as the consequence
of an otherwise slight motor speech disturbance; it may remain station-
ary for years; it is not associated with mental weakness; it is a pri-
mary defect and not secondary to the difficulty in motor speech. Con-
siderable degrees of agrammatism may be associated with slight or
even no difficulties in understanding parts of sentences and consecutive
speech. Several other deductions are also drawn from this study.

22. Opium-Bromide Treatment of Epilepsy. — Schirbach after clinical
trials of the opium-bromide treatment of epilepsy concludes that the
method may bring useful results in carefully selected cases in which
bromide alone is inefficacious. A further use of the method is alto-
gether justified, and the dangers may be reduced to a minimum by

PERISCOPE 341

treatment in a hospital under suitable hydrotherapeutic and dietetic
rules.

23. The Korsakoiv Symptom Complex in Cerebral Syphilis. — In this
case of unquestioned syphilitic character all the symptoms of the Kor-
sakow syndrome were present. Three possible explanations of this re-
lation are given: First, that the mental symptoms may have been due
to a diffuse disease of the vessel walls; second, that a possible gumma of
the left hemisphere may, through increased intracranial pressure, have
produced the psychical disturbance, and, finally, that the symptoms may
have been produced through a syphilitic intoxication.

24. Malformation of the Spinal Cord.— Westphal publishes with
many illustrations a report of a unique case of malformation of the
spinal cord, in which a doubling took place at its lower end, associa-
ted with certain pathological alterations which finally led to the death
of the patient. The illustrations demonstrate well the exceptional
conditions which were found.

25. Syphilitic Disturbances of Sensibility.— On the basis of two cases
Knapp draws attention to certain unusual distributions of skin sensibility
in syphilis, which he regards as peculiar to that disease. He discusses
at length the anatomical relations of the branches of the intercostal nerves.

26. Investigations with a Dermograph.—Prengowski has under-
taken a study of the so-called dermographic phenomenon by means of
a special instrument. His investigation was made in school children
and he has carefully summarized the dermographic reaction, its inten-
sity, its method of production, the time of its appearance after irritation,
and other details of interest. E. W. Taylor (Boston).

Neurologisches Centralblatt
(Vol. 25, May 16, 1906, No. 10.)

1. Toxic Polyneuritis in a Case of Phthisis. W. Salomonson.

2. Hysteria in Animals. J. Mainzes.

3. Isolated Traumatic Paralysis of the Subcapularis and of the Musculo-

cutaneous Nerves. F. Tirchler.

1. Phthisical Polyneuritis. — The author describes two cases of phthisis,
in the course of which multiple neuritis appeared. He does not be-
lieve that this was due to the disease, but believes that it was the
result of the ingestion of creosote.

2. Hysteria in Animals. — The author comments upon the rarity of
these observations, and describes three cases occurring in dogs. The
symptomatology is open to doubt.

3. Isolated Paralysis of the Subcapularis and Musculocutaneous
Nerves.— In the first instance the paralysis was brought on by a for-
ward stretching of the arm, the lesion occurring between the beginning
of the plexus and the entrance of the nerve into the supraspinal
muscle. Only fourteen similar cases are recorded. The musculo-
cutaneous paralysis was also traumatic in origin, and only eleven similar
cases are known.

(Vol. 25, No. 11, June 1, 1906.)

1. Concerning Hyperesthesia of the Peripheral Visual Fields. A. Pick.

2. The Bulbar Syndrome: Dissociation of Sensation with Cerebellar

Ataxic Disturbances. S. E. Henschen.

3. Sexual Anomalies in Animals. S. Lomer.

342 PERISCOPE

i. Hyperesthesia of the Visual Fields. — Cases of hypesthesia of
the visual fields are more or less common, but the opposite condition
has not been described. Pick describes a woman in a functional mental
state who, when sewing for example, if anyone would pass by would
be compelled against her will to look in that direction. Any visual
irritation of the peripheral fields would bring on these movements of
the eyeballs. The movements were either lateral or downwards and
never upward in direction. The cause is difficult to ascertain, but Pick
is inclined to believe it cerebral.

2. A Bulbar Syndrome. — Henschner, following the report of Babin-
ski, Nageotte and Rossolimo, reports a very interesting clinical case
of what appears to be a unilateral specific lesion of the bulb, giving
the symptoms of involvement of the sensory fifth, sixth and ninth,
and of involvement of pain and temperature sense of the right limbs.
There were also present bulbar symptoms plus ataxia. In another
clinical case, as a result of contracoup of the skull, there resulted an
abducens paralysis, plus pain and temperature disturbances and ataxia
of one lower limb.

(Vol. 25, June 16, 1906, No. 12.)

1. The Descending Connections of the Thalamus. V. v. Bechterew.

2. The Course of the Central Fibers in the Medulla. S. Sergi.

1. The Thalamus and Its Descending Connections. — Bechterew calls
attention to the fact that in 1898 he described a tract of fibers coming
from the optic thalamus which connected with the red nucleus, and
thought that these fibers were a central connection with the so-called
v. Monakow's bundle in the extra-pyramidal tracts. He calls attention
to the work of Ernst, done in his laboratory, in which in experimental
injury to the optic thalamus there were found two distinct sets of fibers
coming from the thalamus and connecting with the nucleus articularis
and the nucleus of the formatioreticularis respectively. Both of these
tracts Bechterew had also described previously. In the experiments
of Ernst no degeneration was found traceable to Monakow's bundle,
but a tract was found which connected with a red nucleus of the same
side. It can also be assumed that there is a connection between the
thalamus and the opposite red nucleus, in opposition to Probst. De-
generation was also traced by Ernst which terminated in the anterior
corpora quadrigemina.

2. The Central Tract of the Hypoglossus. — In a case of porencepha-
ly with right-sided spasticity and atrophy, at necropsy was found an
atrophy of the left lower* central gyri with thinning of the upper pos-
terior gyrus and of the supramarginal gyrus. Accompanying the
usual degeneration of the pyramidal tracts there was found atrophy
of the distal portions of the hypoglossal nucleus. The cell degenera-
tions were not limited to particular groups. The afferent fibers of
the same side were thinner and seemed underdeveloped. The nuclei of
the hypoglossus in the proximal portions were not affected, and its cor-
responding afferent fibers seemed also normal, but the fibrse rectas
of the raphe on the opposite side were atrophic. The author con-
cludes that the cortico bulbar hypoglossus fibers in man follow the
pyramidal tracts to the bulb, where they are to be found in the
fibra; rectae of the raphe after which they cross over by means of the
dorsal fibrae efferentes to the hypoglossus nucleus.

PERISCOPE 343

Graphic Kinesthetic Hallucinations. — Margulies returns to a de-
scription of these sensory phenomena now occupying so important a
field in psychiatry, particularly in the study of dementia praecox and
of hysteria. He gives in full detail the history of a hysterical psychosis
in an eighteen-year-old student, in which motor graphic hallucination
played an important genetic part. They entered consciousness with
great suddenness, were perceived to be foreign and of external origin.
The patient had no doubts about their reality, and believed them to be
the word of God. The hallucinations in many instances were analo-
gous to the "hearing one's thoughts spoken out loud" type of hallu-
cinations, at times they were written in the consciousness of the patient,
where they had an imperative character. In following the commands
the patient sprang into the water and was saved from drowning with
difficulty. The psychosis persisted seven days and full insight into
the whole history was gained.

Neurasthenia and Sea Climate. — The author is in favor of a sea
climate in the treatment of neurasthenics, especially if accompanied by
the accessories of sanitarium regulations.

(Vol. 25, No. 13, July 1, 1906.)

1. Tumor in the Substance of the Motor Zone (Arm Area). The Dif-
ferential Diagnosis of Cortical and Sub-Cortical Lesions. C. T.

Van Valkenburg.

1. Cortical and Sub-Cortical Lesions. — Valkenburg records a case of
a sub-cortical sarcoma of the motor area which gave the usual symp-
toms, and he attempts to differentiate cortical from sub-cortical tu-
mors for the study of his case and others. The important differential
diagnosis seems to be in the study of the type of Jacksonian convul-
sions. In cortical cases the convulsion always starts in the same part
of the same limb, whereas in sub-cortical cases, although the con-
vulsion is limited to the involved limb, the movements may start in
different muscle groups. This is really an important differential point,
and one not often recognized.

(Vol. 25, No. 14, July 16, 1906.)

1. The Prognosis of Tetany in the Mature Individual. L. V. Fiankl-

HOCKWART.

2. Graphic-Kinesthetic Hallucinations. A. Margulies.

3. The Treatment of Neurasthenia by Sea Climate. Dr. Ide.

1. Tetany. — Continued article.

(Vol. 25, No. 15, August 1, 1906.)

1. Sensory Disturbances in Incipient Progressive Paralysis. J. Peltz.

2. The Prognosis of Tetany. L. V. Frankl-Hockwart.

1. Sensory Changse in Paresis. — Peltz, in a study of sensory changes
in paresis, found that there was a diminution of the pain sensation of
the skin — a hypalgesia or analgesia — of the whole body, with the ex-
ception of an area around the neck and of an area in the buttock and
the upper posterior portion of the thigh. He also found an increase of
tactile sensation in the buttock and the inferior parts of the back.

2. Prognosis of Tetany. — Frankl-Hockwart, in an extensive study of
a large number of cases of tetany, comes to the conclusion that cases of
tetany recurring in epidermic-endemic form in workmen, and in the period

344 PERISCOPE

of maternity are not as hopeful of recovery as previously thought. The
paper should be carefully read.

(Vol. 25, No. 16, August 16, 1906.)

1. Epilepsy with Unilateral Appearances. Dr. Boetz.

2. A Case of Acute Loss of Consciousness of Alcoholic Origin. Dr.

JULIUSBERGER.

3. Acute Encephalitis and Apoplectic Lesion of the Cerebellum. F. Wrrrx.

4. The Etiology of Progressive Spinal Muscular Atrophy. V. Vitek.

1. Unilateral Epilepsy. — Bratz records a case of genuine epilepsy
with unilateral manifestations. He places the lesion in Amnion's horn.

2. Acute Disturbance Due to Alcohol. — A unique case of dissocia-
tion due to alcohol giving the picture of a phase of dementia praecox at
elucidated by Stransky.

3. Acute Encephalitis of the Cerebellum. — On the seat of an old
hemorrhage due to an arteriosclerosis an acute encephalitic process de-
veloped. The author considers this due to the pneumococcus. The
lesion caused a stagnation of the blood supply, which gave the coccus
an opportunity to cause the inflammation.

4. Progressive Spinal Muscular Atrophy. — Vitek records a case of
an old acute poliomyelitis which came on in infancy, and in which
twenty years later there appeared the changes of a progressive degen-
eration of the anterior horn cells in other portions of the cord. (Vitek
refers to the German authors, but fails to mention the excellent paper and
complete review of this subject by Potts in the March number of the
University of Pennsylvania Medical Bulletin. 1903).

(Vol. 25, No. 17, September 1, 1906.)

1. A Further Contribution to Autogenetic Regeneration of Nerve Fibers.

E. Lugaro.

2. Organic Weights and Idiots. H. Vogt.

3. Bilateral Athetosis. S. Klempner.

1. Autogenetic Nerve Regeneration. — Lugaro in some further ex-
perimental work reasserts his previous conviction that no autogenetic
regeneration can occur in peripheral nerves in which the associated
parts of the spinal cord and ganglia have been removed. Raimann re-
cently contested this statement, but there was no certainty in his work
that the ganglia had been removed. In the recent work of Lugaro no
precaution was spared, and in those cases in which both spinal cord and
ganglia were removed there was complete degeneration of the periph-
eral fibers, both by the osmic acid and Cajal methods. The few re-
maining axis cylinders which can only be demonstrated by the Cajal
method belong to the amyelogenetic fibers, and belong to the sympa-
thetic system.

2. Idiots' Organs. — An interesting article showing that other organs
than the brain are deficient in idiots.

3. Bilateral Athetosis. — Klempner attempts to differentiate under
the title of double athetosis a form of movement different from that
usually understood by that term. This is not original with him. By it
he describes bilateral movements of varying intensity which are cho-
reic in character and are characterized by remissions. Disturbances
of intelligence, convulsions, paralyses and spasms are not found in
this disease, or are very little in evidence. In these cases the eating

PERISCOPE 345

Teflex of Oppenheim is found. This is obtained by touching the buccal
surface of the lips or the tongue, chewing, sucking or swallowing move-
ments resulting in pathology as given. It is rather doubtful if such a
clinical classification can be made; at least the author has failed to
establish his point. Weisenburg (Philadelphia).

Centralblatt fur Nervenheilkunde und Psychiatrie

(30, Jan. 1, 1907.)
I. Contribution to Study of Chronic Alcoholic Hallucinosis. F. Chotzen.
Chotzen agrees with Wernicke that hallucinosis alcoholica acuta
may culminate in a chronic form. He describes one case. His patient,
thirty-four years of age, free from neurotic and vasanic taint, indulged
in alcoholic excesses, developed a typical toxic delirium, later neu-
ritic signs occurred, and with the subsidence of the acute symptoms,
chronic hallucinosis supervened. The patient presented- no evidences
of defective retention or memory, and no deterioration could be de-
monstrated. The diagnosis was carefully considered; Dementia Pre-
cox, Korsakoff's Psychosis, Paranoia, and Kraepelin's Hallucinator-
ischen Schwachsinn der Trinker, were eliminated because the clinical
picture showed no characteristic features of those diseases. The au-
thor claims that chronic alcoholic psychosis may be precipitated by the
following conditions: (1) Direct injury to the brain through disturbed
metabolism; the latter caused by alcohol; (2) Poisonous action of al-
cohol upon the other organs of the body; (3) Nutritional disturbances
due to alcohol; (4) Auto-intoxication superimposed by alcohol; (5)
Affection of brain tissue and cerebral arterio-sclerosis, especially in
the senile and involution periods, brought about by alcohol; (6) Con-
•tituticmal psychopathic state. The last condition could not be consid-
ered in the patient in question because his family history showed no
neuropathic or psychopathic traits.

(30. Jan. 15, 1907.)

1. Psychoanalytic Method of Freud. Sadger.— Contains no new ma-
terial.

(30, Feb. 1, 1007.)
I. Organic Contraction in Progressive Paralysis.—' T. S. Herman \.

The author briefly discusses the motor symptoms of general paraly-
sis. He claims that flexor contractures associated with immobility
of the spinal column are of a rare occurrence. This condition is us-
ually developed in the last stage of paresis. The contractures are so
marked that the gait becomes affected. Passive motion in. contractures
of long duration is impossible. In some cases decubitus may originate.
Contractures may develop in upper and lower extremities; more fre-
quently in the latter. He reports six classical pictures of general par-
alysis. Three of them showed contractures of the lower limbs and in
the other three both upper and lower extremities were involved. All
of them disclosed muscular atrophy and fixation of the spinal col-
umn. In regard to the pathological anatomy, the author agrees with
Berger that the lesion is situated in the cells of the anterior horn.
Brief reference is made to Bechterew and Hoche. According to the
former the pia-mater of the spinal cord and cord substance are dis-

346 PERISCOPE

cased; but the latter maintains that the anterior roots are affected.
The following are his conclusions: (i) Contractures in paresis are in
the last stage of the disease process and are associated with profound
dementia and paralysis. (2) The contractures are of a flexor nature
and occur in the lower extremities — in 50 per cent, of his cases botli upper
and lower extremities were involved. (3) Muscular atrophy and wast-
ing accompany contractures. (4) All his cases were attended with
rigidity of the spinal column.

M. J. Karpas (Ward's Island).

Journal de Psychologic Normale et Pathologique
(Vol. 3, No. 6, Nov. -Dec, 1906.)

1. Variations in the Structure of the Cerebrum. P. Girard.

2. Hysterical Laughter. J. Ingegnieros.

1. Variations in tlie Structure of the Cerebrum. — Anthropologists
have long imagined that, as a result of some measurement, weight, or
other mode of calculation, a mathematical index might be established
to indicate the relative intellectual status of any one given individual.
So far their hopes have not been realized. In the present essay Girard
attacks the problem in a somewhat different way, a way which provoker!
much brilliant and heated discussion along about the middle of the
last century. Granting that two factors, the one somatic, represent-
ing the organic mass, and the other intellectual or psychic, represent-
ing the coefficient of cephalization. determine the volume and weight of
the encephalon, the problem is to solve the manner and extent to
which one or the other of these factors influences the form and inti-
mate structure of the encephalon, especially the cerebrum. After re-
viewing the history of the earlier attempts to answer this question and
after detailing some of his own experimental work, the author pre-
sents certain general conclusions. He says that in chemical analysis,
and not in mere morphological observation, must the proper answer to
the question be sought. He compares the white matter with the
gray, and in their relative and comparative chemical composition he
discovers a more or less definite index of the individual's intellectual
status. In its general features the problem is solved thus: Taking into
account the superiority of the size of the animal, the superiority of
the intelligence, using the word in its broadest and fullest physiologi-
cal sense, implies a particular structure of the brain corresponding to
a certain proportional development of the gray substance and of the
white.

2. Hysterical Laughter. — There is very little literature upon the nerv-
ous and mental pathology and pathogenesis of laughter, though the
studies are numerous that relate to its physiology and psychology. In-
gegnieros quotes some definitions from these studies and then takes
up the pathology of laughter, particularly hysterical laughter, illus-
trating by case reports. He says that in ordinary laughter three fac-
tors are to be distinguished, namely, the pantomimic element, the emo-
tional element, and the intellectual element. The phenomenon is thus a
complex one and these various elements may associate and dissociate
among themselves in numerous ways. There exists, therefore, a path-
ology of laughter that is purely pantomimic, one that is purely emo-
tional, and one that is purely intellectual. These the author elaborates,
differentiates and studies in great detail. The pathological pantomimic

PERISCOPE 347

laughter is seen in some of the spasmodic manifestations of hemiplegia,
lateral sclerosis, bulbar lesions, etc.; in the exhibitions of imitative
laughter occurring in idiots, dements, etc., and in the classical laughter
in ore stultorum; in the tics with the manifestation of rictus; and in
the convulsive movements of the muscular groups normally con-
cerned in laughter, as for instance, in hysteria. In pathological emo-
tional laughter, we meet with dissociation between the emotional state
and its pantomimic expression. For example, the laughter accom-
panies a painful feeling. Sometimes there is a disproportion between
the emotional state and its pantomimic manifestation. This is seen
in the intense and irresistible laughter accompanying a really inade-
quate motive (fool laughter). It is also observed in the emotion of
pleasure, with corresponding pantomimic manifestation, revealed by
certain born criminals when relating the details of their crimes.
Among the cases of pathological intellectual laughter are to be in-
cluded those in which the laughter is provoked by a morbid process of
reasoning (delirious laughter), by morbid perceptions (hallucinatory
laughter), by obsessions, by false representative processes, etc. The
erotomaniac, the victim of hallucinations, and the reasoning fool who
find pleasure, for instance, in their illogical ideas, are all illustrations
of this third form of morbid laughter. After discussing thus the gen-
eral subject of the pathology of laughter, the author devotes the rest
of his long article to hysterical laughter, taking up in detail its classi-
fication, its origin, its differential diagnosis, its paroxysmal manifes-
tations, and its treatment by hypnotic suggestion. As these are all
portrayed from long case reports rather than discussed in a set schol-
astic manner, the author's article is not one easily abstracted, though
it is highly interesting and instructive.

(Vol. 4, No. i, Jan. -Feb., 1907.)

1. Disorders of Emotional Pantomime among the Insane. Dromard.

2. Contribution to the Physiology of the After-sensations of Taste. Poli-

MANTI.

3. The "Call of God." Benezech.

1. Disorders of Emotional Pantomime among the Insane. — In a pre-
ceding paper (Journal of Nervous and Mental Disease, March. 1907, p.
207) Dromard discussed the disorders of voluntary pantomime ob-
served among the feeble-minded. The present paper is the second of
the series and is a study of the disorders of involuntary or passive pan-
tomime among the insa'ne. Of these involuntary, passive, emotional
pantomimic disorders, some exhibit themselves as real disturbances of
adaptation and seem to take their origin from a perturbation of the
ideo-affective associations; while others appear to be mere disturb-
ances of function resulting from an alteration in the apparatus which
is specially set apart for the organization of the emotional manifesta-
tions, namely, the thalamus and its dependencies. In the disorders of
adaptation there is detected an incongruity between the manifestations
of the emotion and the emotional quality of the situation. In the dis-
turbances of function, the performance of the pantomimic movements
themselves is profoundly affected, whether that be by failure of inhibi-
tion or by defective dynamogeny. Each of these three forms of dis-

348 PERISCOPE

turbed emotional pantomimia the author discusses in detail and illus-
trates by case reports, (i) Of the first, paramimia, he concludes as fol-
lows: In certain patients there is a dissociation between the ideational
activity and the affective activity. The emotion is not in consonance
with the idea. It happens, therefore, that the pantomimic manifesta-
tions do not accord strictly with the accompanying speech. Indeed,
paramimia is not so much an indication of a discrepancy between the
pantomimic expression and the thymopsychic activity of which it is
the portrayal, as it is an evidence of a discrepancy between this thymo-
psychic or affective activity and the noopsychic or intellectual activity
which ought to be normally fully commensurate with it. This is equiv-
alent to saying that the phenomena now under consideration are not
due to a break in the ideo-pantomimic connections, but to a break in
the ideo-affective associations. And, if we admit that there is an indis-
solubility between the emotional life and the pantomimic activity, we
will recognize the fact that here the pantomimic manifestations pre-
serve their normal attributes, qualities, or fundamental mental rela-
tionships. This psychological observation proves that paramimia, prop-
erly speaking, is not a psycho-pantomimic disorder. Many writers give
a broader definition to the term paramimia and make it include a num-
ber of disorders which Dromard speaks of under the respective heads
of spasmodic pantomimia and dissociated pantomimia. Dromard be-
lieves that it is of special practical value not to classify these disorders
according to their mere external characteristics or objective traits
when one is studying them from the standpoint of psychology. (2)
The disorders of emotional pantomime from failure of inhibition
have their origin in a disturbance of the ideo-affective associations re-
sulting from the thalamus being directly excited by an irritative lesion
or, better still, from the loss of its cortical connections through a de-
structive lesion of the corona radiata, the cerebrum being thus pre-
vented from exercising its proper inhibitory control. The motor dis-
charges are therefore somewhat automatic in character and assume
the form of a spasmodic pantomimic manifestation, which is always
involuntary if not always unconscious. This spasmodic pantomimia is
observed in patients who possess old organic lesions (hemorrhage or
softening). It is not rare where the lesion is diffuse or disseminated.
It has been studied in cases of cerebral syphilis and general paralysis.
It is frequent in senile dementia. In the psychoneuroses, notably hys-
teria and epilepsy, it occurs: sometimes as remarkable exhibitions of
automatic laughing and weeping. It is not uncommon in the psychoses,
as for instance, catatonia and dementia prsecox. (3) In contradistinc-
tion to the preceding type of emotional pantomimia is that in which
there is a defective dynamogeny by reason of the thalamus not exer-
cising over the lower executive centers the coordinating authority that
it should, and in this way throwing the neuro-muscular apparatus and
all its dependencies into a condition of nullity and clumsiness. In gen-
eral these disorders are revealed in a dissociation and discordance of
the pantomimic movements. So important are these the author pro-
poses to devote a separate paper to their discussion.

2. Physiology of the After-Sensations of Taste. — This is a physio-
logical study wherein Polimanti criticizes some earlier theories con-
cocted to explain the modifications in the taste of certain substances
when other substances are applied to the tongue. He concludes that
the after-sensations of taste thus engendered are due to a modification,

PERISCOPE 349

physico-chemical in nature, of the membrane which incloses the gusta-
tory papillae.

3. The "Call of God." — Benezech reports the case of a scientific in-
vestigator who had a distinct auditory hallucination in which he clearly
heard the voice of God calling to him to go out and labor in the mis-
sionary field. He gave up his scientific work and obeyed the call. The
case is reported as a sort of sequel to Binet-Sangle's study of the
prophet Samuel, who was looked upon as a cerebral degenerate.

Mettler (Chicago).

Miscellany

Cases Simulating Cerebellar Disease. A. A. Eshner (Journal A. M. A.,
March 23, 1907).
The author reports two cases suggestive of cerebellar disease. In
one there was a reeling gait, unilateral weakness, impaired hearing and
tinnitus, but the lack of objective symptoms and the fact that the dis-
orders followed rather closely a mental shock, suggested hysteria, and
treatment directed on this theory effected a speedy cure. The other case
commenced with headache, vomiting, vertigo and ataxia, followed later by.
left hemiparesis and increase of reflexes, drowsiness, etc. There were no
mental symptoms or ophthalmic or other cranial nerve symptoms, and
the course of the disorder was afebrile. There was no specific history,
but the patient gradually improved under treatment with iodids and
mercury. The drowsiness, which seemed hardly to be accounted for by
the bromids given for the intense headache, suggested meningeal or
arterial disease.

The Physiologic Conception of Disease in 'Neurology. L. Harrison
Mettler (Journal A. M. A., February 23, 1007).
The author considers that the anatomic or organic conception of
disease, the accounting for disorders by the structural changes found,
though still dominant in clinical medicine, is passing, and that the idea
that disease is an abnormal physiologic process is coming more to the
front. In practical scientific medicine it is the abnormal physiology,
the disturbed functions, that is the desired goal of study. This is the
physiologic conception of disease, and while not opposed to the ana-
tomic, on which it in part rests, it is a higher and more accurate con-
ception than the latter. It has, nevertheless, been slow in acceptance,
«ind while recognized by the most advanced leaders of medical thought,
it is still inadequately presented in the teaching of the day. It is in
neurology, he thinks, that the physiologic principle is the interpreta-
tion of disease, and its symptomatology is more conspicuous than in
any other department of medicine. The neurone theory, which Mettler
considers as essentially valid in spite of the modifications necessitated
by recent discoveries, has given us one unit and that a physiologic one.
In the nervous system it has given us a physiologic conception of its
diseases, which renders the usual anatomic classifications of the text-
books confusing to the average student and practitioner. He gives a
summarized explanation of his own tentative physiologic classification
of nervous diseases, into those of the neuronic or functionating tissues
and those of the supporting or nutritional ones, the former being
characterized by degenerative, the latter by inflammatory processes,

350 PERISCOPE

and these again being subdivided. This classification was published
several months before the appearance of Grasset's more radical and
elaborate presentation of a physiologic classification, but Mettler thinks
that perhaps at the present time, when the pathology and neurologic
status of some diseases are still in dispute, a less radical change from
the older classifications may have its advantages.

Multiple Neuritis Simulating Progressive Muscular Atrophy. J.
Grinker (Journal A. M. A., March 9, 1907).
Three cases, one of alcoholic polyneuritis, one of lead paralysis and
one of progressive muscular atrophy, illustrating the futility of at-
tempting to differentiate these conditions by objective symptoms alone,
without study of the etiology and course of the disease are reported by
the writer, who holds, nevertheless, to the advisability of clinically sep-
arating the cornual from the peripheral lower neurone disorders. His
conclusions are given as follows: 1. Clinically, multiple neuritis may
simulate a spinal atrophy as regards distribution of parlysis, absence of
sensory symptoms and protracted course. 2. Progressive spinal muscular
atrophy may resemble neuritis in the presence of pain, remission of symp-
toms and subacute course. 3. Etiology and course are still the best
guides in the clinical diagnosis of the various muscle atrophies.

Surgery of the Spinal Cord. J. B. Murphy (Journal A. M. A., Mar.
2, 1907).
The surgical diseases and lesions of the spinal cord, contusions,
concussions, punctured wounds, hemorrhag'.'. fractures and disloca-
tions, gunshot wounds, spina bifida, syring miyelia. etc , and their
management, are reviewed by the author. He holds that when the
axons and ganglion cells that make up the substance of the cord
above the cauda are destroyed, regeneration is impossible, and, there-
fore, in gunshot or stab wounds with immediate paralysis, operation
is useless as regards hope of repair, except in the caudal zone, where
the possibilities are the same as in the case of wounds of peripheral
nerves. Hemorrhage, concussion and contusion without laceration
may give rise to the same immediate symptoms as division, and a
positive differential diagnosis is impracticable. The time and order
of appearance of symptoms may be the only guides; there is no
direct relation between the severity of the trauma and the degree of
injury to the cord. Absence of immediate paralytic symptoms is not
a guide — they may appear after days or weeks. Early spinal punc-
ture may relieve paralysis due to hemorrhage which in some cases
may be as complete as that due to division of the cord. Most patients
with incomplete paralysis following fractures recover without opera-
tion, and when the displacement is not great the physician is justified
in assuming that the cord is not suffering continuous compression and
in refraining from operation. The special indications as regards opera-
tion in the various conditions above enumerated are pointed out and
the technic of laminectomy is described. The danger of delay in
conditions calling for operation, especially in non-malignant tumor,
tuberculoma, etc., is emphasized. Late operations after necrosis in
the cord has taken place are worthless. Surgery of the spinal cord,
like surgery elsewhere, must be timely, i.e., before the pathologic con-
dition has passed the possibility of repair.

Book tReviewe

A Treatise ox Diagnostic Methods of Examination. By Prof. Dr. H.
SahlIj of Bern. Edited, with additions, by Francis P. Kinni-
cutt, M.D., Professor of Clinical Medicine, Columbia Univer-
sity, N. Y.; and Nath'l Bowditch Potter, M.D.. Visiting Physi-
cian to the City Hospital and to the French Hospital. W. B.
Saunders & Company, 1905, Philadelphia and London.
Sahli's work on diagnosis has been a German classic for years and
in its new fourth edition in the original it represents the best work of
its kind in any language. The English translation from this last edi-
tion is a veritable storehouse of material and will be appreciated by
the American physician.

It is preeminently a clinical work, maintaining at the same time its
qualities as a technical manual. This quality of combining laboratory
and clinical methods of investigation is that which gives the stamp of
preeminence to the volume under consideration.

New features have been added, including a chapter on the clinical
investigation of blood pressure by Theodore C. Janeway and newer chem-
ical and physico-chemical studies on the urine included. The publishers
deserve special praise for their part in making this a high class work.

Brown.

Bew0 anfc mote*

An International Congress on Psychiatry, Neurology. Psyschology
and the Nursing of Lunatics will be held at Amsterdam, Holland,
September 2 to 7, 1907, under the auspices of the Netherlands Psy-
chiatry and Neurology Society. The congress will be organized along
the lines of previous congresses at Brussels and Paris, with the im-
portant addition of a section for psychology introduced in recogni-
tion of the influence of that science upon modern conceptions and
methods of treatment of nervous and mental diseases. The work of
the congress will be divided into two parts: the General Sessions, at
which the larger questions of general bearing will be taken up, and
the Meetings of Sections for discussion of special questions. There
are four sections: (1) Psychiatry and Neurology, (2) Psychology and
Psycho-physics, (3) Nursing of Lunatics and (4) Exhibition. The
section on nursing of lunatics will be of the same practical character
which made it so valuable a feature of the congresses of Antwerp and
Milan. French, German and English will be the languages used.

Every American whose interests lie in the field of psychiatry,
neurology, psychology and the care of lunatics is invited to become a
member of this congress. The only necessary formality is registra-
tion with the General Secretary, Dr. G. A. M. van Wayenburg, Prin-_
lengracht 717, Amsterdam, together with the payment cf the congress'
fee of $5.00. Contributions on special subjects will be welcomed, and
those intending to make them are requested to send in synopsis before

352 NEWS AND NOTES

May i. The Secretary will see to the printing and translation of all
articles, and will distribute copies among the members of the congress.
A more detailed program will be issued shortly, and any questions
as to the organization and work of the congress will be gladly an-
swered by the Secretary.

The Pathological Society of Philadelphia, which is one of the oldest,
if not the oldest society, of its kind on this continent, will celebrate its
semi-Centennial in May, 1907. Instituted at a time when pathology scarcely
had a foothold in this country, it has kept pace with the tremendous de-
velopment of that science, and has had a share, not only in giving Phila-
delphia its eminence as a medical center, but also in fostering the scien-
tific spirit in America.

The celebration, which may rightly be considered an event of national
importance, will extend over two days, Friday, May 10, and Saturday,
May 11. On the first day addresses will be delivered by Dr. Frederick
G. Novy, of Ann Arbor, Mich., on "The Role of Protozoa in Pathology;"
by Dr. Simon Flexner, of the Rockefeller Institute, New York, on "The
'Newer Pathology," and by Dr. A. E. Taylor, of the University of Cali-
fornia, on "The Dynamic Point of View in Pathology."

In the afternoon, at four o'clock, a commemorative meeting will be
held in the Pennsylvania Hospital, where the first meetings of the Society,
in 1857, took place. At this meeting, Dr. William Osier, Regius Professor
of Medicine, Oxford University, will deliver an address on "Pathology
and Practice."

At a dinner in the evening, prominent men from all parts of the country

will respond to toasts.

An exhibition meeting of interest to pathologists, clinicians, and sur-
geons will be held on Saturday, May 11.

The date of the celebration will enable those to be present who have
been in attendance upon the Congress in Washington, and those who are
coming East a little in advance of the meeting of the American Medical
Association.

Vol. 34 June, 1907. ', No. 6

THE

Journal

OF

Nervous and Mental Disease

CDrtainal Article*

AMBULATORY AUTOMATISM.*
By Hugh T. Patrick, M.D.,

CLINICAL PROFESSOR OF NERVOUS AND MENTAL DISEASES, NORTHWESTERN

UNIVERSITY MEDICAL SCHOOL,* PROFESSOR OF NERVOUS AND MENTAL

DISEASES, CHICAGO POLICLINIC, CHICAGO.

"By the term ambulatory automatism is understood a patho-
logical syndrome appearing in the form of intermittent attacks
during which the patient, carried away by an irresistible impulse,
leaves his home and makes an excursion or journey justified by no
reasonable motive. The attack ended, the subject unexpectedly
finds himself on an unknown road or in a strange town. Swearing
by all the gods never again to quit his penates, he returns home but
sooner or later a new attack provokes a new escapade." This ex-
planatory definition of Pitres1 is fairly good. We might add that
while the patient may not act exactly like himself during his er-
ratic trip, usually there is nothing obviously pathological in his
conduct ; and that on returning to normal consciousness, no knowl-
edge remains of what transpired during the ambulatory period.

In its widest sense the disturbance occurs as a manifestation of
quite diverse diseases. It has been observed as a post-traumatic
state, in the disturbed consciousness of alcoholism, as a post-epi-
leptic phenomenon or epileptic equivalent and as one of the voic-
ings of hysteria. Some cases, I believe, are scarcely to be included
in any of these categories, but seem to present the syndrome as a
mora or less isolated, or particularly striking manifestation of
psychic instability or of that condition of vague definition called
degeneracy.

Ambulatory automatism is not to be confused with the con-

*President's address before the thirty-third annual meeting of the
American Neurological Association, held at Washington, May 7, 1907.

354 HUGH T. PATRICK

scious or semi-conscious flights of the insane, such as general
paretics,2 senile or precocious dements,3 paranoiacs, melancholiacs,
etc.

Then certain neuropaths are simply inveterate wanderers ;4 vic-
tims of an almost constant ambulatory or travelling obsession.
Indeed, many persons have the ambulatory instinct or habit. The
persistent pioneer of early days ever on the move ahead of civili-
zation ; the wandering "journeyman" who inconstantly works at
his trade and never for long in the same town ; the restless travel-
ler for pleasure or health ; the professional tramp, are familiar ex-
amples. Not to be definitely separated from these is a class of
unstable, more or less defective individuals who mean to be stable
and stationary but are unable to carry out their good intentions.
Such a one, apparently settled for good, yields to a sudden impulse
and starts for elsewhere. The impulse is based on fear, anger,
weariness of occupation or environment, desire to see another
locality or other persons ; in short, on any of the ordinary motives
of travel or removal but on a motive utterly inadequate in degree
to move a normal person. Oftentimes such a patient is himself
scarcely able to recognize the motive back of the impulse and is
apt to attribute his running away to "just a sudden notion." This
vagrancy of defectives often begins in childhood."'

Between all these groups of conscious errants and the ambula-
tory automaton there is some sort of relationship. The same
individual may be first a conscious and then an unconscious
wanderer. Such a disposition or habit of mind plus misty con-
sciousness or secondary consciousness is quite apt to result in am-
bulatory automatism. Naturally, a recently acquired but intense
mental impression or desire may play the same role as the crystal-
ized habit.

As every neurologist has observed, some persons are seized
at irregular intervals with a feeling of unrest, of "nameless long-
ing," of discontent, and I believe this may be the determining ele-
ment of an automatic flight. As Kraepelin.n Aschaffenburg7 and
Gaupps have shown, such periodic fluctuations of spirit may reach
a marked pathological degree, and these authors have correlated
them with epilepsy and the inebriety of the periodic drinker or
dipsomaniac. The question of this relationship I shall touch later,
but there can be no doubt of the intimate relation of such transient
affective states to ambulatorv automatism.

AMBULATORY AUTOMATISM 355

A consideration of my own and of published cases has im-
pressed me with the frequency of another element in the deter-
mination of these so-called fugues or flights. This is the inherent
tendency of the patient to run away from trouble. Some persons
are natural fighters, others are inclined to "grin and bear it,"
still others suffer in dumb though sullen submission, while a cer-
tain proportion of us prefer neither to combat nor to submit ; we
run away, consciously or unconsciously.

Tissie9 lays great stress upon dreams as an exciting agent of
the impulsion to start and Raymond10 calls attention to the same
thing but I think the importance of this influence has been exag-
gerated. It seems more reasonable to suppose that the subject
dreams of running away or of visiting a certain place because the
idea has been in his mind, than it is to assume that the dream
originated the conception. In other words, both dream and fugue
are the result of the frame of mind.

To the study of this, as of many other neurological questions,
Charcot seems to have given the first effective impulse, although
Hughlings Jackson and others had previously given it careful at-
tention. In 1888 Charcot11 published a typical case and the
following year12 further discussed the same patient. This case
was reported as an epileptic one and clearly has had undue in-
fluence on subsequent writers, many later cases having been
called epileptic, which were really hysterical or degenerative
simply because the writers blindly followed Charcot's lead. In
later years his case was restudied by Sous13 who threw grave
doubts upon its epileptic nature, adducing evidence tending to
show that it was hysterical.14

In this country the subject has received little systematic at-
tention. Of the forty-one bibliographic references in the critical
review of Rene Semelaigne15 twenty-seven are French, six Italian,
five English, one German and two American16. Th following
cases, therefore, seem to merit brief report and comment.

Case I. — On a Monday afternoon, July 27, 1896, a young
woman brought her husband to the Chicago Policlinic with the
statement that he had suddenly become deaf and dumb. After a
little cross-examination it was learned that on the previous morn-
ing before breakfast they had had a difference and she, obviously
the dominant one, had soundly slapped his face or boxed his ears.
He took what she gave and a few minutes later went out for a

356 HUGH T. PATRICK

morning paper. She did not see him again until after ten o'clock
that evening, when he returned without power of speech or hear-
ing. His statement, made in writing when first seen and later
verbally, was to the effect that not seeing a newsboy he had stop-
ped for a single glass of beer and then started down the street
to buy a paper. With one exception he remembered nothing from
this time until he found himself at about ten o'clock in the even-
ing in the business part of town, not knowing just where he was
nor how he got there. He recalled having seen a street car pass
a crossing and having noted that he heard no gong. He also
remembered remarking that the streets seemed unusually quiet.
When he regained consciousness he was weary, footsore and
hungry. Stopping the first passerby he attempted to ask his way,
and found that he could neither speak nor hear. In a small book
he wrote the question, "How can I get to the Rush Street bridge?"
knowing that once there he could easily find his way home. The
gentleman pointed the way and although the patient was within a
few blocks of his home he did not rind the place readily, but passed
the house and had to come back to it.

Speech and hearing aside, results of examination were quite
negative, except that the tongue, especially the anterior half,
seemed to be rather anesthetic. Nothing in the history indicated
any form of epilepsy. I may add that the wife was agitated by
the liveliest concern. Fear that her assault was responsible for an
awful calamity evidently possessed her. These facts, together
with the general demeanor of the patient, especially his lack of
great concern over his condition, pointed to hysterical deaf-mutism
and hysterical ambulatory automatism.

In writing, I told the patient that we would bring back his
speech first and attend to the hearing later. Forthwith I passed
a very strong faradic current transversely through the neck, in-
forming him that in a moment he would be able to say ah. In a
few seconds a feeble "ah" was heard, and we went through the
vowels.

After about three treatments given within a week, speech was
normal and three more restored the hearing, when the couple
promptly disappeared. The result of treatment verified the diag-
nosis as far as the deaf-mutism was concerned, and under the cir-
cumstances I think it is only fair to suppose that the automatism
was of the same nature. True, simulation cannot be excluded

AMBULATORY AUTOMATISM 357

with absolute certainty but I was able to satisfy myself that the
case was one of disease and not of deviltry.

This, then, was a frankly hysterical case, relatively simple and
of short duration. Because of its simplicity it serves well to typify
one sort of ambulatory automatism. It is to be regarded as an ex-
ample of vigil ambulism or hysterical somnambulism, Charcot's so-
called second state. Given an inpressionable, unstable individual
and a violent emotional shock, an hysterical attack is nothing out
of the ordinary. Hysterical deafness from a blow on the ear is
no great curiosity. Hysterical mutism from mental perturbation
is nothing new. That this patient should at once have passed into
a state of somnambulism instead of having a hysterical spasm may
be regarded as a matter of disposition or of the personal equation.
A young man of about the same age whom I saw some years ago,
when castigated by his mistress had a fit of violent tremor or gen-
eral clonus with extreme tachypnea. In the case under consider-
ation I think we must assume that there was within his conscious-
ness, and based upon his certain timidity, a wish to get away or
to go somewhere for relief, possibly to go off until his spouse
should be sorry for her treatment. This mental element it was
which made the case ambulatory or wandering rather than con-
vulsive, cataleptic or lamentative.

This impulsion to ambulation must pertain to every case, what-
ever its nature. Of the origin or nature of the impulsion we
sometimes know but little and in the epileptic cases, I believe we
know nothing at all of it. Doubtless something approaching reason
or desire is always present, but a clearly defined raison d' ctre is
seldom obtainable. In most instances the nearest approach to
reasoning seems to be a process of auto-suggestion. Obviously,
however, there can be no such thing as auto-suggestion ab initio.
There must be some process of reason, some mental conclusion or
some desire ; at least some inclination or whim to be gratified, and
each of these psychic states or processes must originally spring
from something outside of the ego. It must go back to something
in the shape of experience.

In the following case evidence of this inherent or pre-existing
impulse to abandon his penates is easily traced.

Case II. — A real estate clerk, forty-five years old, referred to
me by Dr. Webster of Evanston, was first seen October 1, 1902.

358 HUGH T. PATRICK

What he complained of was severe recurrent pain about the right
ear and over the right side of the face.

At nine years of age he had had scarlet fever complicated by
double suppurative otitis and by "dropsy."' For seven years there-
after aural discharge had been frequent and until the present
time the patient had suffered with recurrent earache. Concern-
ing the recent attacks of pain I could get no satisfactory history.
His statements were too vague to allow of definite conclusions,
but from his description, his manner and the almost negative re-
sult of examination I concluded that it was an hysterical pain or,
at least, an ordinary earache enormously exaggerated by hysteria.
He stated that the pain had been very severe, enough to "drive
him crazy" for seven or eight weeks until, a week before his
visit to me, he had been out all night in a rainstorm when the
pain had suddenly stopped for some days. In an attempt to get
the details of this somewhat peculiar happening, I elicited the
following bit of history. On a Monday morning, after doing some
work about the house (in Evanston, twelve miles north of Chica-
go) he had gone upstairs to change his "garden suit" for his
office clothes but soon came down in the old clothes and went out
of the back door without speaking to anyone. The last thing he
remembered was starting upstairs. When consciousness returned
it was night, he was sitting on the ground under a hedge, wet to
the skin, cold, dead tired and footsore. He got to his feet and
started to investigate his whereabouts but fell into a ditch and
concluded to wait for daylight. After about two hours he made
his way to a farmhouse and learned that it was Thursday morn-
ing and that he was no miles south of Chicago. Of what had
transpired in the interval he knew absolutely nothing.

With this phase of the case I did nothing for several days. A
few applications of strong faradism to the right ear and surround-
ing parts rapidly removed all pain and tenderness. Having by
that time gained the patient's confidence and believing that his
unconscious wandering was of hysterical origin, I hypnotized him
and had no difficulty whatever in getting from him the following
statement, which he repeated a few weeks later before the Chicago
Neurological Society. During the recital he frequently stopped
but promptly resumed when told to go on. Several times I inter-
rupted with questions. Consequently, the written statement is

AMBULATORY AUTOMATISM 359

more consecutive than was his oral one but it is practically in his
own language.

''I walked on Asbury Avenue and then across the prairie to
Western Avenue, walked on Western Avenue to the Chicago
River, where the car starts. Took the street car to 63d Street, on
63d Street car to Madison Avenue and then the surburban car to
Whiting, Indiana. Walked a little way on Illinois Central Rail-
way tracks to a railway crossing; when a freight train stopped
I got on and it took me to Niles, Michigan. There a brakeman
found me and put me off. Walked to South Bend, Indiana, four-
five-six hours 'till it was getting dark. Went to sleep on the
river bank. Wakened up at daylight, went to eat in a little rest-
aurant with a sign "Open all night," then walked on past the big
wagon works. Asked a man which way to go to get to Illinois.
He told me to keep on south and then west. Walked on all day
to another railroad and walked, and walked, and walked, going
west. I see a freight train stop at a crossing and get into an
empty car. I ride on train through a number of towns and after
a time I see that we are coming to a larger town. As the train
passes the station I see that it is Kankakee. We go through Kan-
kakee across the river where the train stops and the watchman
puts me off and drives me out of the freight yard. I am lost and
don't know where I am going. I am walking, walking, always
walking ; it gets daylight. After a long time I meet a man and ask
him where I am and he says twenty-five miles south of Kankakee.
Forgot to ask him which way to go and so keep on. Went to
a farmhouse for something to eat and the lady said she had only
bread, and I said I would be very glad to get it. Walk, and walk,
and walk. It got dark and I lay down along the road ; feet tired,
hurt awful bad, raining now, hard, I am getting wet, I must get
up, I am so tired." (Began to whimper and stopped.)

I asked him if that was all and he said "Yes, that is all."

Evidently, at this point he awakened to find himself under the
hedge. The location of the towns mentioned, the railway lines
and the distances harmonize with the patient's tale.

He denied the occurrence of anything similar in his past but
later I learned from others some facts in his history that certainly
are important. About twenty-one years ago, before his marriage,
having taken part in some rather questionable business trans-
actions, he found it expedient to go west. Here, instead of set-

360 HUGH T. PATRICK

tling down, he led a sort of nomadic existence, travelling on a
pony over a large part of Colorado and New Mexico. The whole
occurrence evidences a tendency to abscond or an inherent instabil-
ity which voiced itself as ambulatory unrest. What seems to have
been his first fugue (or unconscious flight) occurred soon after
his marriage twenty years ago. One Sunday, on his way home
from church, he stopped for a shave and nothing was seen or
heard of him for a week or two, when he returned and asserted
that he didn't know where he had been. Again, fourteen or fifteen
years ago, on the occasion of some domestic disagreement, he left
home and was gone for a week, but this is said to have been a
conscious absenting of himself. Nevertheless, it shows a willing-
ness to escape trouble by flight.

Furthermore, I have learned that for some time prior to his
visit to me he had been involved in financial trouble ; trouble con-
nected with alleged irregularities on his part. Five months after
my examination he one day failed to keep a business appointment
and nothing was seen or heard of him for several days, when his
wife received by mail a power of attorney. The document had
been executed in Chicago, the envelope was postmarked Denver
and the address was poorly written ; not in the usual hand of the
patient. Since then nothing has been heard of him. In addition
to the foregoing it must be said that from childhood on this pa-
tient had shown evidence of imperfections of makeup. Probably
some would call him a degenerate. At any rate, he was to a limited
extent a defective. As a school boy he did not take kindly to
educational methods ; showed an inapitude for study, an aptitude
to play truant. He was unreliable in word and deed. In later
years the same traits persisted. One occupation after another was
tried and abandoned. Good advice and assistance were alike un-
availing and his early infractions finally culminated in the first
running away to Colorado already mentioned.

The relation of the face pain to his fugue is of some interest.
In the literature I have found a good many cases in which before
their flight the patients complained of more or less intense head-
ache. In some instances this headache was not especially severe,
probably only a part of the preautomatic nervousness and
distress. In other cases it was intense and, I believe, a determin-
ing factor of the attack. For pain to occasion a hysterical out-
break is commonplace. As already indicated, whether this out-

AMBULATORY AUTOMATISM 361

break shall be convulsive, delirious or ambulatory will depend up-
on the personal equation or upon casualties. Here, as elsewhere,
the pathological may be not much more than an exaggeration of
the physiological. How many quite normal individuals when in
distress of body or spirit must pace up and down or tramp rest-
lessly from one place to another? How many others when un-
well or worried instinctively seek change of scene, make a shorter
or longer journey, for some ostensible reason or another?

Case III. — Is quite similar to the foregoing one but the motive
or driving influence initiating the deambulation is decidedly dif-
ferent. A. C, colored, laborer, forty-three years old, came to the
dispensary of the Northwestern University Medical School, Jan-
uary 3, 1907. He has been married sixteen years, has four healthy
children and his habits are good.

Twenty-five years ago he suffered a fracture of two ribs,
twenty years ago had a venereal sore with suppurating bubo, at
about the same time malaria, and eighteen years ago, influenza.
In 1902 his home was washed away by a freshet and he lost all
of his worldly goods. About a month later his leg was injured
in the rolling mill where he worked as a skilled operator, and he
-was laid up for a month. Only a week after his return to work
the mill shut down and he was thrown out of employment. He
was now in debt, instead of having money ahead, everything
seemed to go wrong, and he has not been so prosperous since.
The reverses have greatly worried and distressed him. Two years
ago in a railway accident, his head was badly bruised, some teeth
knocked loose and he thinks he sustained "internal injuries." He
was unconscious for about an hour. One year ago he was sand-
bagged and beaten into unconsciousness. In the history there is
nothing to indicate either epilepsy or hysteria except that once he
came home with ten dollars, gave them all to one of the children
and then laughed and "carried on" like a child. Results of physi-
cal examination were negative.

His first fugue occurred about two weeks after the accident
of two years ago. Since that time he has had fifteen or twenty.
Ordinarily an attack begins with worry about the circumstances
of his family and his poor earning power. This brings on head-
ache and backache, he becomes restless, depressed, soon leaves the
house and remains away for from one to five days. He has al-
wavs returned of his own accord and when asked where he has

362 HUGH T. PATRICK

been responds "looking for work." Generally he has no idea that
he has been gone for more than a few hours. Sometimes he
can vaguely recall an incident or two of his wanderings. The
rest is a blank. On his return he is restless, often somewhat
dazed or confused and always wants to start right off again. Even
when he has a job it is the same. He wants to hunt a better one ;
says he must have more money.

His wife has learned never to ask him for money and has for-
bidden the children to ask him for anything, because if he cannot
gratify them he at once begins to fret and soon disappears. Evi-
dently the occasion of his last wandering was his inability to buy
Christmas presents for his family.

For purposes of diagnosis I tried hypnotism. Satisfactory
hypnosis having been attained in the third sitting I obtained from
him the following statement of his last trip.

"I left home Christmas morning and went to the West side
where I had been working, to finish up the work, a temporary job.
After I got through there I started out to hunt work and went
first to the Boston Store. This was Christmas night. There I
saw a man named Liller, foreman of the digging gang. The
store was about to build an addition and they were excavating. He
said he could not put me to work then but he might be able to
the next morning. I then started home but came back and .thought
I would wait around until midnight, when there would be a change
of shift. At midnight he could not put me to work so I again
started home but came back and waited around until eight o'clock
in the morning, the next change of shift. As I was then unable
to go on I went over to the West side to look for work. The
first person I remember seeing was an acquaintance named Camp-
bell whom I met on the street. He asked me where I was going
and I answered that I was looking for work. He gave me some
lunch. After a while I met my cousin and went home with him.
I said I was sleepy and he said "Well, you can sleep here," and
his wife fixed up a bed for me. This was in the evening and I
slept all that night and the next day until evening. Then I got up
and went back to the Boston Store, but found no work. I waited
around there all night and the next morning went over to the
North side where I had been told they unloaded a lot of coal cars
at a factory. To get there I crossed the Robey Street bridge and
then walked up the Northwestern railroad tracks. This was in

.AMBULATORY AUTOMATISM 363

the morning. I waited there a while and then went to sleep. I
don't know how long I was there. When I wakened the men
were eating lunch and asked me if I was hungry. I said I didn't
care for anything to eat. They told me I had slept ten or twelve
hours. I asked them about the cars to be unloaded and where I
would find the foreman and what his name was. I finally learned,
the name of the foreman, which was Thompson, but could not
find him and after a while started back home. I came down on
the West side and on out to 18th Street, where I stopped and
rested a while on the street. I then started east on 18th Street
where I met a man with whom I had formerly worked. I do not
know his name. He asked me what I was doing over there and
I told him I was looking for work. He said "there is no work
over here." He asked me what I was doing with the shovel and
the rubber boots. I had borrowed these the morning I left home
from a friend who lives near the corner of 20th and State Streets
and had had them with me all the time. This acquaintance re-
marked that I looked tired and advised me to go home. This was
at about two o'clock in the morning. I have seen this acquaint-
ance once since and he told me that it was about that time. I con-
tinued east on 18th Street to State Street and then south on State
to 35th and went home. I rang the bell and my wife came to the
door. I gave her the boots, told her to take care of them and
that I would be back in a few minutes. She asked me where I
was going and I told her I was going over to see Al. Hamill and
see if he could not get me a job at scrubbing. She made me come
into the house and told me that I should not go out. The boy
got up and made a fire and my wife warmed some water. I
washed and went to bed."

Ten days later he was hypnotized before the class and re-
peated the account. It varied a little from the first recital but not
essentially. On March 26, I again put him to sleep and received
substantially the same statement.

About February first he secured employment as a railway
porter and I did not see him for a month. He had had an accident,
sustaining a fracture of the left wrist and a dislocation of the
right elbow. Again I hypnotized him and received the following
account of the trip before the last.

"Next to the last time I went away from home was long about
the last of November. I left home in the morning to go to work

364 HUGH T. PATRICK

at the dock of the Anchor Line. I went to the warehouse on Kin-
zie Street and waited there for orders until nearly night. Then
I got word to come back at seven o'clock in the morning, when
a boat would be in to be unloaded. I started for home and got
as far as 18th Street, when someone said the orders were to re-
port at six o'clock the next morning instead of at seven as I had
supposed, so I went back to see whether this was true. When I
got back I found that one of the boys named Lee Hill had made
a fire and some of the others were standing around it. They told
me to wait and see the steward. I fell asleep and slept until about
eleven o'clock. By that time the vessel was in and I saw the
mate and said I would go home. I walked south to Polk Street
and then went over to State to take a car for home, but in some
way I got a car going north instead of south. When I discovered
that, I thought I might as well go back to the warehouse, which
I did and sat there by the fire until seven o'clock, when I went
to work. After about an hour I didn't feel very well and so I
quit work. I must have worked an hour as I received an hour's
pay. I then started for home ; walked to 18th Street and west on
l8th Street to the railway tracks in the 18th Street yard. There
I met a porter named Hainey and talked to him. He said he was
going to stay in the car that day and all night as he had had a
poor trip and staying in the car would save expenses. I lay down
there, went to sleep and slept until nearly ten o'clock that night.
When I woke up I said "Lou, why didn't you call me?" He said
he thought I needed the rest, and besides, having me there was
company for him and so he thought he would let me sleep. I then
went home and my wife said, 'where have you been?' I told her
I had been to work. She said 'why didn't you eat your lunch ?' It
seems I had not eaten my lunch which I still had in the pail."

Although hypnosis was used primarily as a diagnostic aid, I
also have tried to influence the patient by suggestion, apparently
with good results. He declares that he no longer is nervous and
that the head distress which had driven him into his "spells" has
entirely disappeared. He also says that his head is clearer, the
sense of confusion gone and that he can better understand and
remember the printed instructions to railway employes. He has
received no medicine.

Scattered through the literature are plenty of cases similar to
these three. Raymond17 reports one of them. The patient was a

AMBULATORY AUTOMATISM 365

man thirty years old, a resident of Nancy in eastern France, of
neuropathic family and himself a neurotic. At seventeen years
he joined an expedition to South America, was wounded but re-
turned to duty as soon as well and soon thereafter went to Africa.
Some years later, after the death of his wife, he was with difficulty
dissuaded from going off to Africa again. His fugue followed a
period of continuous overwork and strain causing a number of
neurasthenic symptoms and great increase of emotivity. One
evening after several drinks with some friends in a cafe, he felt
a severe pain in the head and started for home. The next thing he
remembered was finding himself lying in the snow on the bank of
a stream near a city. It was night and he was sore and weary. A
street car took him to a railway station where he learned that he
was in Brussels and the date eight days later than his last evening

in Nancy.

This patient had a strong aversion to hypnotism and it was
found impossible to hypnotize him, but by degrees he succeeded
in recalling the principal events of his fugue. Prior to the flight he
had been subjected to great emotional disturbances such as would
not only tend to induce a hysterical attack but would also suggest
the advisability of flight. Indeed, he had been threatened with an
exposure to the police. All of these facts and the entire absence
of any evidence of epilepsy, easily place the case in the hysterical
category.

Proust18 relates the case of a young lawyer in Paris, "an in-
veterate hysteric," who, after an altercation with his father-in-law
left home and on coming to himself three weeks later was stupe-
fied to learn that he had gone travelling through the department
of Haute-Marne, had got into debt and had been convicted of
swindling. In hypnosis he was able to recount all of his doings
during the three weeks.

In this case, as in my Case II, there was evidence of previous
instability and lack of ethical sense. Indeed, there had been in-
fraction of the legal code. The extent to which this nervous and
moral unreliability runs through the histories of these patients is
very striking. Early in a study of the cases the questions are
thrust upon one: To what extent are these flights voluntary?
To what extent, if at all, are they unconscious ? To what extent
is the assertion of ignorance on the part of the subject simply a
falsehood? I believe that there is an imperceptible gradation to

366 HUGH T. PATRICK

be traced from perfectly conscious, voluntary, rational (if unwise)
flights with perfect memory for all their events, to perfectly in-
voluntary, unconscious19 flights with complete amnesia. Further,
as already stated, the same patient may have conscious as well as
automatic flights. He may begin as a voluntary traveller or fugi-
tive and end in being an involuntary one.

Of all the published cases of hysterical ambulatory automa-
tism, one of those recorded by Tissie20 and by Pitres21 of Bor-
deaux is probably the most remarkable. The history reads like
a fantastic tale from fiction. The patient's first trip or attack oc-
curred at the age of twelve, when he left his native town and
walked to another twenty miles distant. Here his elder brother
found him going about with a peddler. Touching him on the
shoulder the brother asked "what are you doing here?" The boy
seemed to waken as from a dream and was astonished to learn
where he was and what had transpired. A month later he found
himself in a town forty miles away. Some time after this he was
sent out with ioo francs to pay a bill. The next day he came to
himself in a railway train with a ticket for Paris in his pocket.
In that city he was given fifteen days in prison as a vagrant and
then, as his family declined to send money, he walked back to
Bordeaux, two-thirds of the way across France. From this time
on his wanderings were frequent and various. All the principal
cities of France, Algiers, the Rhine country from Dusseldorf to
Darmstadt and Frankfort, then Wurzburg, Nuremberg, Lintz
and Vienna were included in his itineraries. Later he went over
much the same route and later still visited Prague, Leipzig, Berlin,
Posen, Varsovie and [Moscow. Conducted by the Russian police
to the frontier he wandered to Constantinople, then to Vienna,
where a comrade put the idea of Switzerland into his head. He
tramped by a round about way through southern Germany and
visited the Swiss cities. During this time he had enlisted and
twice deserted, but at Basle his impulsion sent him back to France
and he surrendered to the police at Delle. After serving out his
punishment at hard labor in the military camps of Africa he re-
turned to Bordeaux, settled down to work, after some months be-
lieved himself cured and became engaged to be married. On the
wedding eve he disappeared and came to, three months later, at
Verdun, without knowing how he got there or what had tran-
spired in the interval. Soon after this he came under medical

AMBULATORY AUTOMATISM 367

treatment and his escapades became less frequent and less ex-
tensive but they did not cease.

This case was at first supposed to be one of epileptic equivalent
of the ambulatory type, like the ones described by Falret22, Char-
cot23 and others, but Tissie and Pitres plainly showed it to be one
of hysterical equivalent or prolonged hysterical somnambulism.
Examination revealed complete hemianalgesia and concentric con-
traction of the visual fields with some dyschromatopsia. More
■conclusive still, it was found that in the hypnotic state the patient
could recount, what was otherwise unknown to him, the various
incidents of his several flights. In 1894 I saw this patient in the
service of Ballet at St. Antoine, and when hypnotized the minute
exactness with which he related details of some of his long tramps
of years before was truly surprising.

But a study of this man's numerous wanderings shows that
they were by no means always automatic. Many a time he moved
on like any other tramp just because the spirit moved him. Some-
times a fugue started unconsciously but when he came to himself,
instead of going home he stayed where he was or wandered fur-
ther. This indifference to or love of absence is noticeable in a
number of other cases and, I think, is of assistance in determining
their nature.

Among the earliest hysterical cases reported are those of Jules
Voisin24 and his pupil Saint-Aubin,23 (eight cases) since which
time many have been published.26

My fourth case is a more difficult affair than the preceding
ones. It illustrates not only the severity which the syndrome may
attain but the psychologic complexity of some cases: a complex-
ity of etiology and of manifestation. Although the observation is
far from complete, I think it presents evidence that some cases are
neither epileptic nor hysterical.

Case IV. — The patient, a man twenty-two years old, was seen
July 5, 1902, through the courtesy of Dr. J. H. Hoelscher. The
expressed wish of himself, his young wife and his friends was that
I should facilitate his commitment to a state institution for the
insane. The history obtained was, in brief, as follows :

Both parents, now dead, were nervous and both were, so the
patient stated, inebriates. A brother and sister had died of ne-
phritis following scarlet fever. The mother's only sister was
very nervous. The patient had begun at an early age to mastur-

368 HUGH T. PATRICK

bate, smoke cigarettes and indulge in alcoholics — all excessively.
As a child he had received no systematic training, his habits had
been irregular and without due restraint. He ran about much as
he pleased but says he was bright in school.

His first escapade in the way of fugue or flight occurred at
the age of eighteen when he was attending a college in Indiana
although, naturally, he had played truant in the ordinary way a
great many times. He was walking through the campus when
he saw passing the grounds a livery carriage on its customary trip
to the railway station. At once he was seized with the idea of going
somewhere. He called to the driver, was driven to the station
and took the next train going west. As he had no ticket the con-
ductor asked him where he was going, so as to collect cash fare.
Up to that moment a definite destination had not occurred to him,
but at the question Kansas City came to his mind and so he said
"Kansas City." On the advice of the conductor he paid his fare
to Chicago and thinks that there he purchased a ticket for Kansas
City. Arrived at the latter place he realized that he had no busi-
ness there, found his funds exhausted and wired for money. One
of the professors went for him and he returned to the college.
That this journey began as a mere whim and that his destination
was determined by a stray thought are clear in his memory. I
believe this to be important as illuminating the nature of the
trouble. Most of the occurrences during this first flight are also
remembered. Evidently the escapade was more the freak of an
ill-balanced boy than a manifestation of disease. Certainly any-
thing like epilepsy was out of the question.

From this time his fugues followed each other in rapid suc-
cession. Some were partially conscious. Some were begun con-
sciously but ended unconsciously and the tendency was for them
to become more frequent, more prolonged and more purely auto-
matic. For instance, at about six o'clock one afternoon he found
himself sitting in a restaurant, evidently having just finished
dinner. From the general appearance of the place he concluded
he was in the Bismarck restaurant of Chicago and asked the waiter
something about trains on a certain railway to the suburb where
he lived. As the waiter knew neither suburb nor road, he con-
cluded that he was not in Chicago. Going into the street he
bought a paper and learned that he was in Kansas City. In his
pocket he found sleeping car receipts showing that he had gone

AMBULATORY ANTOMATISM 369

from Chicago to Omaha, from Omaha to Salt Lake City and
thence to Kanses City, a total distance of nearly 3,000 miles. On
several occasions he returned to Chicago with a number of part-
ly used railway tickets, indicating that he had started for a distant
city and had broken the journey at some intermediate point to
go off in another direction, only again to change his destination
midway of the trip. One morning he telephoned a friend to come
to him at a certain hotel. The friend found him dirty, unkempt
and quite used up. He was just back from a fugue and said
"Lord only knows where I've been." He had partly used tickets
for Denver, Cheyenne (Wyoming), Salt Lake City and Galves-
ton, Texas.

The impulse to start generally came suddenly ; and in spite of
his disgust with himself after the termination of a flight, when
the impulse came he followed it. As before noted, ordinarily he
was perfectly conscious of the impulse. He said "something
pushes me." On one occasion when he had reached home tired,
hungry and penitent after an absence of some days, his wife went
to a nearby shop for refreshments, only to find on her return that
he had disappeared. Another time while sitting apparently con-
tentedly at home he made some flimsy excuse and stepped out.
Being fearful that it was the beginning of an escapade, the wife
telephoned to her brother and they hurried to a certain railway
station. Something the patient had said within a day or two led
the wife to expect that he would leave by that road. A few min-
utes before the departure of a through train for the far west, the
patient appeared, with a new travelling bag wherein was newly
purchased clothing, and went aboard the train. He had a preoc-
cupied air, recognized neither wife nor brother-in-law, and when
they attempted to persuade him to leave the train was irritable and
rebellious. Finally, they got him out of the car and into a carriage
where his wife broke down and sobbed. Her grief seemed to
waken him, he suddenly became like himself, tenderly inquired
what was the matter and apparently knew nothing of what had
gone before.

Pursuant to his wish, he was committed to an insane asvlum
but, naturally, soon tired of it and made his escape. This was a
conscious flight. He was arrested as a possible car thief but quick-
ly explained who he was and whence he had escaped. He was

370 HUGH T. PATRICK

returned to the asylum but procured his release by process of law
and I have lost sight of him.

In this case I had no opportunity to attempt hypnosis but I
doubt if his fugues were hysterical. On the other hand, I believe
they were not epileptic, though I have no doubt some authors
would have classed them as such. In the spring of 1901, a year
before I saw him and three years after his flight, he had a "faint-
ing spell." Since then he had had one every few weeks or months.
From his description it was impossible to determine their nature
but he was positive that they bore no relation to the fugues. There
were no hysterical stigmata.

In addition to what he himself told me, I learned that he was
unstable, unreasonable, extravagant, impulsive and foolish in
many ways. More than this, I was informed that he had indulged
in many dishonesties, some petty, others of graver magnitude. Not
only would he raise money for his fugues by deception and illegal
means, sometimes with considerable cunning, but at other times
in a perfectly conscious and deliberate way would perpetrate
swindling operations. In short, what this man did during his auto-
matic periods was not very different from what he did in the, for
him, normal state.

I must admit that I have no cogent reasons for not calling this
an hysterical case. Quite possibly the whole trouble may be hy-
steria developed on a basis of degeneracy. Certainly in many re-
spects it is similar to my Case II, to the celebrated case of Tissie
and to many others surely hysterical. But the very complexity of
the case puts a doubt into my mind. The gradual passage of per-
fectly conscious voluntary truancy into automatic fugues is scarce-
ly characteristic of hysterical attacks. Sometimes it seemed a toss
up whether this patient would spend a sum for one of his fugues
or for some other form of debauch. It was not only in the way of
journeys that he yielded to sudden impulse and gratified it by hook
or by crook. Once he was taken with the idea of giving his wife a
handsome ring. Instantly he proceeded to swindle a jeweller out of
one. On a Saturday, he missed a train which was to bring him home
for Sunday. He was furious and immediately spent his last dollar
to charter an engine. On another occasion he started to row a
boat a certain distance up a stream but encountered shallows and
other difficulties. He became quite beside himself, swore he would
get there if it killed him and finally did accomplish the job, hav-

AMBULATORY ANTOMATISM 371

ing lost half of his clothes, ruined what he had left and exhausted
himself to the point of illness. At times such as these he was not
unconscious at all but "besides himself" to the degree of absolute
indifference to surroundings and consequences. Afterwards, too,
memory for the details was hazy. This same odd mixture of the
conscious with the unconscious, of known whim with indefinite
impulsion and slightly hazy memory with total amnesia is seen in
many of the recorded cases.

Until more definite tests are applied to individual patients, un-
til the cases are more carefully studied and perhaps until we know
more of so-called secondary states of consciousness, no final classi-
fication of ambulatory automatism can be made. But arbitrarily
to force a case like the preceding one into the rubric of either
epilepsy or hysteria seems to be acting prematurely. Such are the
cases I prefer to call degenerative. Degenerative they certainly
are. A more definite, a more desirable designation must be for
the future. We know so little of the nature of these secondary
states, so little of consciousness and so little of memory that it is
presumptious to say that all automatic wanderings must be trauma-
tic, toxic, epileptic or hysterical. Numbers of writers have de-
scribed the patients, called by Tissie27 captives, who are conscious-
ly in the grip of an imperative impulse ; some have adopted the
term determinisme ambulatoire of Duponchel,28 which indicates
the same thing ; many, as I have said, have written of patients par-
tially conscious and with only partial amnesia and have classified
them in various ways, but all seem to be agreed that as soon as a
flight is purely automatic with complete amnesia it must be epilep-
tic or hysterical if it be not traumatic or toxic and the patient be
not the victim of a well defined psychosis. To this I am not pre-
pared to agree. The more the cases are studied, not as examples
of ambulatory automatism but as individuals, the more re-
semblance one sees in many of them to other defective, unstable
or degenerate folk. Particularly suggestive is their similarity to
the peripatetic myth makers so well described by Dupre,29 Kraepe-
lin30 and others. For such a case of morbid personality to be-
come one of ambulatory automatism nothing is needed but the
addition of some amnesia or periodic alterations of consciousness.
Who shall say that such secondary consciousness or amnesia must
be either epileptic or hysterical? The difficulty of definitely
placing each case is well illustrated by the following.

372 HUGH T. PATRICK

Case V. — L. C, a clerk, twenty-eight years old, of good family
history but himself always nervous, married two years, was re-
ferred to me June 17, 1904, by Dr. Ouales. At thirteen he is
said to have had a sunstroke and has had a good deal of headache
ever since. During the last year he had had half a dozen attacks
of intermittent pain in the right lumbar region and right flank,
each attack lasting a couple of days. They were very annoying
but never kept him from work. He worried considerably about
them. Four months before he had begun to have "neuralgic"
pains all over the body, worst in the neck. His physician made a
diagnosis of muscular rheumatism. He had had none of these for
six weeks.

Until about a year before he had been a man of exemplary
habits and a consistant church member. At that time he began to
drink some and to gamble. Soon he was in debt, tried to recoup
his losses and lost more. Likewise he drank more but never
heavily ; never enough to interfere with his work and never so that
his wife noticed it. Naturally, he lied to his young wife, deceived
his parents and his pastor. The whole thing worried him greatly
and constantly. Three or four weeks prior to my examination he
had begun to have severe headaches. These also worried him
and he decided to consult a well known physician.

On Sunday evening, June 5, he had a bad headache and after
retiring was very nervous and could not sleep. On Monday he
received his pay, about $55.00, quit work earlier than usual, took
several drinks and went down town to consult the physician he
had determined upon, but too late to see him. His memory is
misty for events after the start for down town. He does not re-
member where he got off the street car but does recall passing a
certain populous corner. When he came to himself he was sitting
in a railway train which was standing at a station. In his hand was
a railway ticket and upon it he read "Suspension Bridge to New
York." He thought "What do I want in New York? I'll get off
here." He did so and learned that he was at Niagara Falls, (over
500 miles from Chicago). For a time he walked around "trying
to collect his thoughts" and then went to a hotel. He had only
$5.00 in his pockets. The fare from Chicago to New York is
about $25.00. He does not know whether it was Tuesday or
Wednesday but thinks it was Tuesday. He disavows having had
any intention or idea of running away but when he realized where

AMBULATORY ANTOMATISM 373

he was, he was afraid to go home, afraid something would happen
and frightened by the severe headache he was having. He feared
he would lose his mind or do something rash. For about two days
he wandered about the place in a somewhat dazed condition. On
Thursday he wrote for his wife. He thought of sending a tele-
gram and then it "skipped his mind." After writing he seems to
have lost track of events again. By Sunday, the 12th, he was out
of money and about to apply to the police when his wife arrived.
When he saw her he burst into tears and clung to her. He wept
frequently through the day. In appearance he was pale, haggard
and unkempt. He was quiet, talked little and slowly, walked
slowly, and appeared to be ill. The following day they left for
home, reaching Chicago the day after, June 14, three days before
I saw him. After arrival at home he was entirely rational but
slept poorly, felt tired and weak and complained of headache.

Results of examination were very meagre. The patient seemed
listless and was not communicative but answered all questions
promptly and to the point. I saw him first in the morning when
the pulse was 108 and the temperature 100. At five-thirty in the
afternoon after three doses of phenacetin, jy2 grains each, pulse
was 108, temperature 994. Pulse and temperature remained about
the same until June 22 when he went to the country. On his re-
turn July 2, the temperature was normal and remained so but the
pulse continued high.

The most careful inquiry failed to elicit any evidence of epil-
epsy except that on several occasions shortly before his fugue his
wife noticed that he was absent-minded. The most flagrant in-
stance was that he took the baby carriage out of the house and
soon afterward asked her where he could find it.

I saw this patient again March 24, 1907. He has had no fur-
ther attacks of ambulatory automatism, has worked hard and
steadily in the same position, his habits have been correct and he
has saved money. No treatment has been used. When he is very
tired he is apt to be quiet and occasionally his wife notices that
he is absent-minded or forgetful. As nearly as I can ascertain he
has exhibited absolutely nothing which could be construed as in-
dicating any form of epilepsy. Nor has he shown signs of hysteria.
Except for the one year of backsliding he has always been an ex-
emplary man and since his escapade has been as steady as a clock.
For sixteen years he has been with the same firm and they never

374 HUGH T. PATRICK

have complained of him as an employe. To call him a degenerate
is impossible. Never having been really intoxicated his fugue
scarcely could have been alcoholic. For the few days that he was
under observation, conditions seemed to me to be unpropitious for
hypnotism and later I had no opportunity.

There is the same difficulty in placing the case of Bregman.31
His patient was a lad of fourteen in whom the wander instinct
seems to have been almost congenital. At four years of age he
showed a strong predilection for hiding himself and his fugues
began at seven years. The first time he left home was to visit the
grave of a recently deceased brother of whom he had been ex-
tremely fond. From that time his flights were numerous and of
gradually increasing length. Many of them simply those of a
juvenile tramp ; others were partly automatic. At least there were
lacunae in his memory of them and these lacunae he tried to fill by
fantastic inventions. The boy was not an epileptic, apparently
not hysterical, nor was he an imbecile. To the ordinary tests he was
normal morally and mentally. If to his inherent topographical in-
stability, a little more change of consciousness had been added, he
would have been a perfect automatic wanderer. The question
waiting for an answer is, to what transitory alterations of con-
sciousness short of a known psychosis, is such a subject liable.

As an example of the germ from which the degenerative form
of ambulatory automatism may spring I may cite the case of a man
now thirty-two years of age, son of a nervous mother but level-
headed father. As a schoolboy he was most unsatisfactory, could
not apply himself, learned little and played a good deal. Later
he was sent to business college with small profit. He was tried in
every department of his father's manufacturing establishment, was
always inefficient and stuck to nothing. At twenty-five he married,
soon disagreed with his wife and her people and within five
months ran away, because he feared bodily violence at the hands
of his brother-in-law. For three or four days he wandered about
the streets without going to bed and when found could not give
a complete account of where he had been and what he had done.
Then began a series of longer or shorter absences. Sometimes
they seemed to happen in the most casual way. He would go out
for the evening, carelessly stay too late, be ashamed to go home,
make a night of it, be more ashamed in the morning and remain
away, generally wandering aimlessly about. Sometimes he seemed

AMBULATORY ANTOMATISM 375

to go away in obedience to an impulse or impulsion and later a de-
sire for alcoholics seemed to have an influence, not only in starting
him, but also in keeping him away and in contributing to the am-
nesia. Various positions were procured for him ; he could hold
none of them. Finally, he was sent to a city 500 miles away to do
clerical work. One night after working over hours he was sud-
denly seized with an idea that he would go home. On the instant
he started, walked half of the way and for the other half stole his
way on freight trains. The principal events of this journey he
remembered but the details were decidedly misty.

It is of interest to know that since a course of treatment for
alcoholism four years ago and the definite settlement of his con-
jugal troubles, this man has not had a fugue and has done toler-
ably well in a small business way. Had the element of fear not
been eliminated, had not life been made easy for him and his en-
vironment attractive he was in a fair way to become worse. And
he needed only the addition of more obscured consciousness to
have presented typical ambulatory automatism. Just what it is
that obscures the consciousness in such cases and induces the am-
nesia: just what the nature of this obscuration or "disintegra-
tion" is, I cannot surmise. But I cannot admit that it is epileptic
and I believe that it is not always hysterical.

After noting the frequence with which attacks of ambulatory
automatism are preceded by a desire or longing or fear tending to
start the patient on a trip, it is not surprising to learn that many
cases have been reported by military men.32 Especially is the
trouble frequent in countries of compulsory military service. In-
deed, many of the German and French cases reported by civilians
relate to desertion or absence without leave. The military cases
do not differ from others except in their special forensic bearing.
In the reports there is the same confusion as to nature and, con-
sequently, the same disagreement as to classification found in other
publications. But, to my mind, the pregnant facts are the great
relative frequency of fugues in the army and the circumstance
that what the young soldier perpetrates as an unconscious or
automatic fugue is exactly what he would have liked to do con-
sciously. This point I shall mention again.

The relation of fugues to alcoholism is interesting but still
needs much elucidation. One thing is clear. A distinction must
be made between fugues in an alcoholic and alcoholic fugues. An

376 HUGH T. PATRICK

alcoholic may be a degenerate, a hysteric or an epileptic and may
have any of the various kinds of flights pertaining to these sub-
jects. A good example is the case of Souques33 which was one of
conscious deambulation due to an overwhelming impulsion ; what
Regis has called dromomania. Each flight followed a drinking
bout but started the first thing in the morning when the patient
was not intoxicated. There was simply the impulsion to tramp
straight away without a conscious object. The flights lasted
twenty-four to forty hours and the patient had normal remem-
brance of all that transpired. The attack terminated in a nervous
attack of trembling and weeping. Fully conscious of all he was
doing and clearly realizing the unreasonableness of his actions,
this patient cannot be said to have been a victim of automatism,
but in my opinion such a case does not differ radically from those
in which consciousness and memory are partially obscured, nor
these latter from some of those with perfect automatism and am-
nesia. What seems to have been an alcoholic flight with peculiar
amnesia, in a dcscquilibrc, was that of a patient seen in 1902.34

Case VI. — At about noon a man, apparently forty-years of
age, accosted a policeman, saying that he could not remember his
name nor where he belonged. The officer brought him to the
Passavant Hospital. On admission he was not intoxicated, no
evidence of trauma was found and results of physical examina-
tion were negative. He talked fluently, correctly and rationally
but knew neither his name nor residence, whence he had come nor
his destination nor names of relatives. He was quiet and entirely
amenable, perfectly clear as to surroundings but distressed by his
loss of memory. Appetite and sleep were good. By evening he
began to have a misty recollection of having driven about in a
cab with a couple of women, of having visited a theatre and sev-
eral resorts and having had a number of drinks. It appeared to
him that the cab man had put him out. He recalled having awak-
ened or come to on the street at dawn and having walked about
until he spoke to the policeman. The next morning he remember-
ed that he had come to Chicago from New York and had gone to
a hotel near the station, but of the start and the journey he knew
nothing. Later he recalled that he had been attending the yacht
races in New York and had drank much champagne, but he could
not remember the names of his friends. Soon he began to recall
scenes of his childhood and soon after this recalled his sister's

AMBULATORY ANTOMATISM 377

married name and also that of his mother who had married a
second time. About a day later he joyfully told the interne that
his name was Reese Williamson and that he had friends in Chi-
cago. By degrees he recalled the names of these friends but when
they were communicatd with, they disavowed knowledge of any
such person. After the patient had been in the hospital about a
week he asked the interne again to mention to some acquaintance
certain doings in which they had participated. The interne re-
turned with the message that the occurrences were correctly
stated but that they related to a certain Mr. A. B. Whereupon
the patient suddenly sat up in bed and exclaimed "Why I am A.
B.," and this proved to be the case. Other events came back to
him rapidly but the thing he could not remember, or said he could
not, though he was in the hospital a month, was that he was then
a deserter from the United States Army.

In this case, as in many others, investigation showed that the
patient had been for many years a man of bad habits, reliable only
in his unreliability, swayed by every desire or whim, a moral cow-
ard, given to evasion and duplicity. Finally, as a last resort, his
friends had got him into the Army, from which he had deserted.
He asserted that he never had had anything like the fugue which
brought him to the hospital, but this statement I had no opportu-
nity to confirm. An item of interest is that he had been in the habit
of assuming the name Reese Williamson when (voluntarily)
going out on disreputable escapades.

One of Heilbronner's35 cases is quite similar to this except that
his patient had repeated attacks. He had been a bad boy, twice
expelled from school and frequently out all night. During his
military service he had deserted without apparent cause. He
never started on a flight unless he had been drinking and always
drank excessively during the attack.

What the relative frequency of the hysterical, epileptic and
degenerative cases may be I would not attempt to estimate. That
many are hysterical is clear. When one comes to select the epil-
eptic cases from the literature he is at once confronted by the
problem of deciding what the criteria of epilepsy really are. To
acquire for one's self a fairly definite working opinion is not very
easy ; to formulate in set terms what is and is not epilepsy is ex-
ceedingly difficult ; to harmonize the opinions of only the most
distinguished writers is impossible.36 For some a so-call-

378 HUGH T. PATRICK

ed, psychic equivalent must be marked by some sort of
a fit, great or small. Christian's dictum was "There
is no epilepsy if there be not this sudden, complete,
absolute loss of consciousness.37 For the diagnosis of any
epileptic disturbance, Rsecke3S demands two data: I. Clinic-
ally, the mental disorder must bear the stamp of epilepsy. 2. The
existence of genuine epilepsy must be established.

Binswanger39 in speaking of abortive attacks says that the
diagnosis is certain only when undoubted epileptic (i. e., convul-
sive) siezures are observed in addition to the anomalous attacks
and that the same holds good for the marked psychic forms. In
another place40 he protests against the tendency of some writers
(Lombroso) to attribute to epilepsy, even when other indications
of the disease are lacking, all such sudden and violent outbursts
as epileptics are prone to exhibit.

On the other hand, writers who recognize the psychic equiva-
lent as itself being an epileptic fit, naturally are willing to make this
diagnosis when all the ordinary signs of epilepsy are wanting.
They even dispense with loss of consciousness and amnesia. For
instance, in the diagnosis of epileptic insanity Samt41 simply
eliminated the ordinary signs of epilepsy and Kraepelin follows
him when he says "The diagnosis of epilepsy can just as clearly
rest upon a well-marked dreamy state (Dammerzustand) as upon
a typical convulsive seizure."42

Following the lead of Kraepelin, Aschaffenburg,43 after dwell-
ing upon the moodiness of epileptics proceeds to elaborate the
thesis that the moodiness is of itself an epileptic equivalent, even
when the patient shows no other signs of the disease. A full dis-
cussion of the question would take too much space, but I beg to
remark that because a prisoner (his patients were criminals) has
unaccountable and indescribable periods of depression with a feel-
ing of apprehension, or unrest, or longing, or homesickness, or in-
ternal irritability, one is scarcely justified in making a diagnosis
of epilepsy. As regards epileptic fugues this author further states
that he has seen all stages of transition from the purely auto-
matic attack with complete amnesia to a simple purposeless
wandering about, with complete consciousness and unimpaired
memory of the entire time. He even puts into the epileptic class
one patient who regularly went home to sleep every night after
tramping about all day.

AMBULATORY ANTOMATISM 379

The extent to which the epileptic conception of imperative
deambulation is sometimes, I might almost say habitually, stretch-
ed is well exemplified in a paper by Donah44 who reports three
cases. First, he not only contends that loss of consciousness is
no necessary part of an epileptic seizure, but makes the same con-
tention even when a so-called attack extends over months and the
patient during that time lives a fairly normal life. Nor is his
faith in the epileptic nature of the fugue shaken by the fact that
there is no amnesia whatsoever of the fugue period.

His first patient, a man thirty-eight years old, had had a fall
upon the head at the age of seven. Ever after, at the same time
of the year, he had become possessed by an imperious inner long-
ing (Zwang) to wander or travel. At first his wanderings lasted
only a few days, later weeks and finally up to five months. Be-
fore one of these long trips he begged, borrowed and stole, until
he got a goodly sum together. Having thus deliberately prepared
for a journey, he left on horseback, sold the horse, travelled by
train to Budapest, Vienna, Hamburg and there took ship for New
York. Finally, he tired of America and returned to Hungary. He
came to this country because a scamp of a chance travelling com-
panion persuaded him into it. He remembered perfectly all the
details of the entire trip and expressed great penitence for his
misdeeds. To call such an escapade epilepsy, it seems to me, is
to burlesque pathology. We might almost as well say that the
ordinary vagabond tramp who winters in the poorhouse and starts
out in the spring, automatically abstracts the hen from the roost
and epileptically slips on into the next township. I may add that
the patient was an irresponsible loafer and drinker who abused
his wife ; that during the examination he burst into a fit of sobbing
and the only "seizure" he ever had was one his wife observed
at night, when he threw himself about in bed and scratched his
face and chest.

In some respects Donath's second case resembles my second ;
in other respects my fourth. The patient was a man aged forty-
nine who, as a fourteen year old boy had wandered all about
Hungary, though he easily could have had a steady position. The
pathological flights he had had for three years ; at first only once
a vear for two or three days, later two or three in a year lasting
a week or ten days. It is to be noted that at first there always
was an ascertained exciting cause ; that is, some cause for run-

380 HUGH T. PATRICK

ning away such as fraud, theft, gambling debts. Several times
he left because of excruciating headache and said himself that
the headache compelled him to go. During his observation in the
hospital he had one of these headaches and remarked that if he
were outside he certainly would start on one of his journeys.
Fancy an epileptic saying "If I were outside now I'd have a fit!"
Frequently for twenty-four hours before running away he had
tinnitus or a sense of roaring in the head. Donath considered
this to be an epileptic aura. But a twenty-four hour aura seems
to me altogether extraordinary. Further, this patient, by good
means or bad, always provided himself with funds before leaving,
and on his last escapade was constantly writing to his wife for
money. I confess my inabilities to conceive of an epileptic making
elaborate preparations and when he is ready having his seizure.

Donath's third case was a young man of nineteen, who seems
to have been a rather ordinary, unstable, moderate defective. He
was dishonest, untruthful and lacking in sense of shame. Caught
stealing he strenuously denied it and afterward confessed. There
was no amnesia, no loss of consciousness and never a convulsion.
Unless one assumes, as the author apparently does, that a fugue,
even though voluntary and conscious, is itself evidence of epilepsy,
I can see no reason whatsoever for invoking this disease to explain
such cases. The author's definition of epilepsy, supposed to cover
attacks of any form or origin, is surely broad enough and loose
enough. He says it is "a pathological excitation (Erregung) of
the cerebral cortex which suddenly appears, periodically returns,
typically runs its course and quickly subsides." Verily, to borrow
an expression of Binswanger, this is shoving the boundaries of
epilepsy into the dim distance, but even this definition could scarce-
ly cover several days' preparation, a twenty-four hour aura and
a fit lasting five months. In none of Donath's cases was hypno-
tism tried.

To be sure, the cases and the position of Donath are rather
extreme but not very exceptionally so. So good a man as Schultze45
in reporting three cases seems to assume that in the absence of a
definite psychosis, ambulatory automatism means epilepsy. His
cases are very similar to those of Donath. There is the same
inherent instability, the same emotional variability, the same lack
of ethical sense, the history showing the same ingrained tendency
to run away, to travel or wander. Especially do they show be-

AMBULATORY ANTOMATISM 381

fore and during the attacks an extreme suggestibility as to when,
where and how to go. His cases likewise show the same lack of
evidence of epilepsy, aside from the fugues themselves, and many
positive signs pointing to hysteria or a similar state. There was
the same conscious impulse to go and generally memory of the

trip.

In a later paper Schultze46 takes a less positive stand on the
epileptic question. Obviously, he has been influenced by the paper
of Heilbronner, presently to be mentioned, but he still contends
that the cases of the former paper were epileptic. In this second
contribution he reports nine cases of various kinds but says he
has never seen an hysterical one. It is rather interesting to note
that while he is quite ready to make a diagnosis of epileptic fugue
in the absence of characteristic fits, he is unable to make a diagno-
sis of hysteria without the classical stigmata. He never tried
hypnotism. One of his cases, as he admits, is very difficult to
classify. Like many others it indicates to me that a new class or
new classes of automatic wandering will have to be recognized

and defined.

In a quite recent paper Donath47 reports three more cases and
reiterates his former opinions but it is rather obvious that he, too,
has had his confidence somewhat shaken by Heilbronner's paper.
Of these three cases not one is certainly epileptic, though the first
may have been, and the third one the author himself admits was

not epileptic.

Sous48 reports one personal case and nine from the literature.
His thesis is strongly tinctured with the influence of Legrand du
Saulle and Charcot and consequently hysteria is not seriously con-
sidered. He says that hysterical ambulatory attacks are generally
preceded and followed by violent hysterical convulsions and that
in the absence of such demonstrations, the diagnosis of a hysteri-
cal fugue cannot be made. Now we know better. Nor, without
more evidence than he has given us, can I accept as epileptic the
celebrated case of Legrand du Saulle.19 When this patient came
to, he was aboard ship just entering a harbor. On inquiry he
learned that the city was Bombay. He had gone from Paris to
Havre and thence to Bombay without in the least attracting at-
tention and could remember nothing of the trip. That an epilep-
tic fugue could be so tranquil and so prolonged may not be im-

382 HUGH T. PATRICK

possible, but it needs something more convincing than assumption
or assertion to establish its epileptic character.

It seems strange that Charcot and his pupils did not hit upon
hysteria as an explanation for some fugues, for they were very
near it many times. This is notably true of the clear-headed
Gamier50 who recognized his patient as hysterical and explained
a momentary memory of the fugue events by supposing a mo-
mentary and casual lapse by the patient into his secondary con-
sciousness ; but apparently the author never thought of trying to
induce this secondary state by hypnosis and thus to obtain details
of doings in the automatic period.51

No less interesting than this unusual oversight of the Paris
school, is the manner of the discovery of hysterical ambulatory
automatism. The remarkable patient of Tissie had been observed
for years and carefully studied in hospitals. The diagnosis always
was epileptic automatism and as such the case had been lectured
upon in clinics. Tissie himself had studied and treated him for
months when, apparently more haphazard than with definite de-
sign, he hypnotized him and learned that in hypnosis the subject
could tell the story of his unconscious flights.

But long since the time of Tissie, as I have tried to emphasize,
many writers, good ones too, have gone on in the epileptic rut
for no obvious reason. The case of Fere52 is strongly suspicious
of hysteria. Binswanger53 in reporting two cases hardly requires
of himself in the way of diagnostic criteria what he demands of
others. He remarks, too, that the patients act "exactly like one
hypnotized," actuated by a "strong psychic impulsion." The an-
alogy certainly is more indicative of hysteria than of epilepsy. The
cases of Gerstacker54 and Burgl55 are not at all convincing. The
latter considers a dreamy state (Dammerzustand) itself as con-
clusive of epilepsy. This would exclude the possibility of hysteri-
cal cases. Of those who have taken a broader view Heilbronner58
is particularly to be mentioned. His painstaking paper is too long
to be abstracted but I may state that he reports thirteen cases and
comes to the conclusion that the epileptic ones are relatively in-
frequent. He has tabulated forty-five cases, twenty-eight of which
were considered by the reporters to have been epileptic. But
Heilbronner shows that only fourten of the twenty-eight present-
ed any symptoms of epilepsy and of these fourteen, many showed
positive signs of hysteria. Quite properly he cautions against

AMBULATORY ANTOMATISM 383

attributing to epilepsy every abnormal manifestation in an epilep-
tic. One of his own patients, a lad of sixteen, was probably an
epileptic but there was nothing to indicate that his escapades were
caused by epilepsy. The same may be said of some of the cases
of Schultze. Colman57 reports a case supposed to be due to epilep-
sy. Though the patient never had shown signs of the disease,
there was epilepsy in his family. The fugue itself was almost ex-
actly like that of my second case. In the absence of evidence
why assume that it was epileptic rather than hysterical or of some
other origin ?

In an excellent paper containing a fine psychologic analysis
Woltar5S reports a case which formerly would surely have been
considered as epileptic and which would now be so regarded by
many had not the patient been hypnotized. In the history there
was nothing to indicate hysteria and on examination no stigmata
were found and yet in hypnosis the patient was able to recount
all the details of the amnesic fugue period. This case is further
of special interest because the patient was under observation for
several days of the secondary consciousness period without this
fact being suspected. It was thought that this period had passed
before his admission to hospital, so natural was the patient's
demeanor.

I do not wish to be understood as doubting the existence of
epileptic wandering. Unequivocal cases are sufficiently numer-
ous in the literature. But I do insist that this diagnosis has been
made too often. Study of reported cases and observation of my
own has impressed upon me the frequency of several traits militat-
ing against epilepsy.

As I have already noted, the great majority of well-marked
cases have been conscious of a strong impulse to start off; not
only conscious but so acutely so that the feeling equaled an
emotional strain not to be controlled: an inward pushing or long-
ing not to be overcome. This has absolutely no analogy in any
form of epilepsy. More than this, yielding to the impulse often
carries with it a certain gratification, like satisfying an appetite,
akin to the relief afforded by a hysterical explosion after repres-
sion and something like the solace experienced by the confirmed
tiqueur when, after a period of suppression, he "lets go." Need-
less to say, this is utterly foreign to epilepsy.

Related to this impulsion must be the longing of many young

384 HUGH T. PATRICK

military recruits to go home, to see the loved ones or to free them-
selves from army restraints. But that this inward pressure in-
duces an automatic flight is decidedly against its epileptic nature.
An epileptic does not have procursive epilepsy, petit nal, epileptic
mania or epileptic automatism in accord with his previous dis-
position or desires but according to the unaccountable dictates of
his unaccountable disease. The mere fact of the relative fre-
quence of ambulatory automatism during the period of compul-
sory military service speaks against its epileptic nature.

Several times I have alluded to the patient's preparation for
a fugue. Supposing that such a wandering, once begun, were
an epileptic equivalent, the procedure might be likened to a con-
vulsive epileptic removing his clothing, inserting a gag, wrapping
himself in a feather bed and then having his fit.

Quite noteworthy is the fact that the patients are not more con-
cerned about themselves. Ordinarily if a man found himself ly-
ing in the snow, like Raymond's patient, or sitting under a hedge
125 miles from home, like my second case, or in Moscow like
the case of Tissie, he would be seriously alarmed. A great many
of these patients have no fright at the time and no great worry
about it afterward. More than that, many of them instead of
hurrving home, stay where they find themselves or voluntarily
wander farther. Schultze has noted this point and attributes it
to the low grade of mentality of the patients. His explanation I
believe to be good for some of the degenerate cases but the fact
is also entirely in accord with the traits of hysteria; it cannot be
harmonized with epilepsy.

What appears to me extraordinary is that in a number of cases
reported as epileptic, the patient has expressed repentance for his
flight and even has promised not to do it again.

Early in my investigations I was struck by the enormous pre-
ponderance of men. In the very considerable number of reported
cases, I have found only two women. Their fugues were hysteri-
cal and not long continued. But one other writer (Heilbronner),
so far as I know, has particularly noted this point. It seems to
me to be strong evidence, not proof, against the frequency of epil-
eptic fugues. An epileptic fit is not adjusted to the personal dis-
position, temperament and inclinations of the patient nor
to his surroundings ; a hysterical attack frequently, nay generally,
is. The erratic doings of degenerates or unstable individuals are

AMBULATORY AN TOM ATI SM 385

more or less in accordance with custom and environment. The
incidence of epilepsy is about equal in the two sexes and the fits of
women do not differ from those of men. Then why no ambula-
tory automatism in women? On the other hand, it is quite natural
that a hysterical woman should not go off on a long- and compli-
cated journey but, for her attack, should have one of the "regular"
manifestations of the disease.

In any given case epilepsy could not be excluded because bro-
mide gives no relief but it is a striking fact that instances of ambu-
latory automatism surely stopped by this drug are scarcely to be
found. If the disorder were frequently epileptic, instances of
marked relief should not be rare.

Finally, the frequence with which automatism fugues are
started by casual conditions is distinctly against their epileptic
nature. That a man should have an epileptic seizure when he
gets into debt, or quarrels with his wife; when he is threatened
with arrest or tires of his job ; when he has a bad headache or
wants to get more money, might occur, but as a coincidence only ;
not as a regular thing.

Turning now to some of the recognized traits of epilepsy we
cannot evade the almost invariable rule of sudden onset, disorder-
ed (not necessarily violent) action, short duration, loss of or
greatly impaired consciousness and amnesia of the fit period. Even
the so-called dreamy states of epilepsy comply with these condi-
tions. The actions of epilepsy are without motive. Rarely are
they purposive and when so they are of short duration. To all
of these rules there are exceptions but I am unable to reconcile
our knowledge of epilepsy with attacks covering a period of many
days or weeks, during which the patient leads a lucid, not obvious-
ly unreasonable life with no signs of a seizure. And the more
the cases of extended fugue are studied the more inconsistencies
with epilepsy are found. Spratling59 has published a conclusive
case lasting twenty-eight days but during this time the patient
had several ordinary epileptic seizures and the whole period of
automatism seems to have been made up of a number of shorter
periods succeeding each other.

The evidence seems to show conclusively that attacks of psych-
ic epilepsy may occur without the accompaniment of a big or little
fit. Especially is this true of a single attack. If, on the other
hand, the patient with psychic epilepsy be observed for any con-

386 HUGH T. TAT RICK

siderable period, additional evidence of the disease is pretty sure
to show itself. In not one of forty-five cases of epileptic transi-
tory disorder of consciousness observed by Siemerling60 did he
fail to detect other epileptic or epileptoid seizures.

ADDENDUM.

Case vi. Since the foregoing was sent to the printer I have
seen another case which again shows a divergence from what
might be called the classical type of ambulatory automatism.

The patient was a gentleman fifty-nine years old, of a nervous
family and himself somewhat eccentric and quite impressionable.
Until a recent date his habits had been very good. About twenty
years ago he had what was called nervous prostration for about
a year, during which time he had many inconstant physical dis-
comforts, insomnia and sundry phobias. He suffered greatly from
a sense of chill along the back whenever he lay down to sleep so
that he had a horror of going to bed. Finally he made a complete
recovery.

For a number of months before the fugue presently to be men-
tioned, the patient had been struggling with grave business
troubles and had got into the habit of taking more alcohol than
was his wont, sometimes to excess. Finally, after much hard
work, he believed that he had arranged a deal which would re-
lieve him of all trouble and embarrassment, when one morning he
learned that he had been tricked and that he was financially ruined.
He was absolutely crushed ; saw no hope and felt that the only
escape was suicide.

Leaving the office where he had received the aforementioned
information, he started out with no definite object but an ill-
defined purpose to end his troubles by putting himself out of the
way. Finding that he had but sixty cents in his pocket he thought
he would go to the bank for money but this idea then passed out
of his mind and the next thing he remembers was meeting an
acquaintance in a distant part of the city, far from his home and
almost equally far from the business district. The friend re-
marked that he was "off his beaten track," to which he replied
that his factory was not far away. The next thing he recalls was
passing a certain well-known building on the out-skirts of the
city, at least twelve or fourteen miles from where he had spoken
to his acquaintance. At this time it was growing dark, he was

AMBULATORY ANTOMATISM 387

footsore and weary and he has an impression that he would have
taken a car for home had he had any money. But he found that
he had spent the sixty cents with which he had started and so con-
tinued walking. He next remembers walking through a suburb
and finally seeing a larger house than the others where there was
a light. He went to this building, recognized it as a hotel, and
walked in. In the clerk of the hotel he recognized a former em-
ployee and found that it was about twelve-thirty a.m.

He was put to bed but did not sleep well and remained in bed
or about the hotel all of the following day. That night he slept
somewhat better and by the next morning felt more like himself
and telephoned for a friend who at once went for him.

It is probable that he had walked the entire time from about
ten o'clock in the morning until after midnight, as the feet of his
socks were entirely worn away and he was completely exhausted.
Physically the patient is unusually strong and active for his age
and a great walker. Frequently he walks ten miles for pleasure.

During the day spent at the hotel there was not only great
physical fatigue but also what we may suppose was great mental
exhaustion. Lassitude was very pronounced and though the
patient was quite conscious and perfectly rational, both present
and past events were hazy. When his friend appeared the patient
broke down and sobbed freely. After return to his home nothing
abnormal was noticed except that he seemed very quiet and not
disposed to meet people. I saw him four days after his return,
just one week from the beginning of his fugue, and it was then
evident that he was worried about the occurrence, that he did not
like to talk about it and that he feared it meant a return of the
nervous breakdown of twenty years ago.

Examination revealed none of the so-called stigmata of hys-
teria, there was nothing either in the history or examination to in-
dicate epilepsy, and the physical examination revealed nothing ex-
cept a slightly hypertrophied heart and a suspicion of sugar in
the urine. Blood pressure taken in the recumbent position with a
Stanton instrument was 130. Two days after my first visit I made
an attempt to hypnotize the patient and again on the following
day but did not succeed, though he became slightly drowsy. He
then left the city, v

It seems perfectly clear that this could not have been an
epileptic case and I see no sufficient reason for calling it hysteri-

388 HUGH T. PATRICK

cal. Neither is it reasonable to suppose that it was alcoholic as
the patient had not sufficient funds to procure intoxication. It
was simply a case of disturbed consciousness due to severe mental
shock in an overwrought, nervously exhausted and naturally
somewhat unstable person. The additional element necessary
for the production of ambulatory automatism was his feeling that
there was no practical way out of his difficulties, and he did in his
disturbed consciousness what many a person does during perfect
consciousness ; namely, wander about in a rather aimless way
preparatory to a projected more or less indefinitely determined
upon suicidal attempt.61

BIBLIOGRAPHY.

'Lecons cliniques sur l'hysterie et l'hypnotisme, Paris, 1891, Vol. 2, p.
268.

2Des fugues dans la paralysie generate. Arch. clin. de Bordeaux,
January, 1894. Berger. Neurolog. Centralblatt, 1895, p. 1143.

3Ducoste. Les fugues dans les psychoses et les demences. Archives
de Neurologie, 1907, p. 38.

4Meige. Le juif errant a la Salpetriere. Nouvelle Iconographie de la
Salpetriere, 1893, pp. 191, 277. 333-

6Maurice. Les fugues chez les enfants. These de Paris, 1900.

"Psychiatric Vol. II., p. 630, p. 657 et seq.

7Ueber gewisse Formen der Epilepsie. Arch, fur Psych. Vol. XX.,
p. 955 and Ueber die Stimmungsschwankungen der Epileptiker. Halle,
1906.

9Die Dipsomanie. Jena, 1901.

"Les Reves. Paris 1898.

10Legons sur les maladies du systeme nerveux, 1894-95.

"Lemons du Mardi, Vol. I., p. 113.

"Ibid. Vol. II., p. 303.

1SG. Sous. De l'automatisme comitial ambulatoire. These de Paris,
1890.

"Undoubtedly Charcot was influenced by the previous graphic writings
of Legrand du Saulle. Etudes medico-legales sur les epileptiques, 1877.

"Annales Medico-psychologiques, 1894, p. 71.

"I have not made a painstaking search of the American literature.
Doubtless many cases have been observed and a considerable number
published under various titles. Punton (Kansas City Medical Index,
May 1893) reports as "hysterical aphonia" a case quite like my case I,
except of longer duration. But it was mutism and not aphonia. And
when my paper was all but finished I received a reprint of Dr. Angell's
paper, "A Case of Double Consciousness," etc., (Journal of Abnormal
Psychology, Oct., 1906.) McCarthy (Jour, of Nervous and Mental Dis-
ease, 1900, p. 143), has also published a case, but the flights were so short
as scarcely to fall within the category of those under consideration.

"Legons sur les maladies du systeme nerveux, 1894-5, P- 529-

"Bulletin Medical, 1890, p. 107.

"This word is here used loosely as meaning another or greatly altered
consciousness. Of course a person who walks about and does things,
must have some degree and sort of consciousness.

20Tissie. Les alienes voyageurs. These de Bordeaux, 1887. Ibid.
Les Reves, Paris, 1890.

AMBULATORY ANT OM AT ISM 389

"Legons cliniques sur l'hysterie et l'hypnotisme. Paris, 1891 Vol.
II., p. 268.

"Elat mental des epileptiques. Arch. de. Med., 1861, p. 431.

^Legons du Mardi. Vol. I., p. 112, and Vol. II., p. 303.

"Semaine Medicale, Aug. 10, 1889.

Annales Medico-Psych., 1889, Vol. X.

25Des fugues inconscientes hysteriques. These de Paris, 1890.

"Colin. Essai sur l'etat mental des hysteriques. These de Paris,
1890, and Gazette des Hop., 1890, pp. 852 and 794.

Boeteau. Automatisme somnambulique avec dedoublement de la
personality Annales Medico-Psych., 1892, Vol. XV, p. 63.

Alcindor et Morat. Gazette des Hop., 1889, p. 253.

Chantemesse. Societe Med. des Hop., June 27, 1890.

"Les Alienes Voyageurs.

MDes impulsions morbids a la deambulation. Annales d'hyg. oub €t
de med leg., 1888, Vol. XX., p. 5.

wLa Mythomanie. Paris, 1905.

""Clinical Psychiatry. New York, 1904, p. 289.

"Neurolog. Centralblatt, 1899, p. 776. One of the cases of Pitres is
very like this one. Loc. cit, p. 507.

32Ewald, Stier. Fahnendlucht und unerlaubte Entfernung. Halle, 1905.
With good bibliography. Duponchel. Des Impulsions Morbides a la
Deambulation, observers chez, des militaires. Annales d'hygiene publique
et de med. legale, 1888, Vol. 20, p. 5. Janchen. Beitrag zur Kentniss
epileptoider Zustande. Wiener medic. Wochensch, 1887, p. 499. Conlonjou.
Automatisme ambulatoire au cours de service militaire. Annales Medico-
Chirurg du Centre, March 18, 1906.

33Automatisme ambulatoire chez un dipsomane. Arch, de Neurol.,
Vol. 24, p. 61.

^Unfortunately the hospital record cannot be found and I must report
from memory.

3iTJeber Fugues, und fugueahnliche Zustande. Jahrbiicher fur Psych.
u. Neurol., 1903, Vol. 23, p. 107.

36These different opinions are pretty fully given in the monograph of
Ardin-Delteil, L'Epilepsie Psychique, Paris, 1898.

3'Folie Epileptique. Epilepsie, Paris, 1890.

38Die transitorischen Bewustseinsstorungen der Epileptiker. Halle,
1903

39Nothnagel's specielle Pathologic Die Epilepsie, Vienna, 1899, P 337-

40P. 273.

"Archiv fiir Psychiatrie, Vols. 5 and 6.

"Quoted by Siemerling, Berlin, klin. Wochens, 1895, pp. 909 and 938.

"Ueber die Stimmungsschwankungen der Epileptiker, Halle, 1906.

"Der epileptische Wandertrieb (Poriomanie). Arch, fiir Psychiatrie,
1899, P. 335-

4oBeitrag zur Lehre von dem pathologischen Bewustseinsstorungen
Allgem. Zeitsch fiir Psych., Vol. 55, p. 748. Discussion, p. 807.

46Ueber krankhaften Wandertrieb. Allgem. Zeitsch. fiir Psych., 1903,
Vol. 60, p. 795.

"Weitere Beitriige zur Poriomanie. Arch, fiir Psych, u. Nerv., XLII.,
1907, P- 752.

MDe l'automatisme comitial ambulatoire. These de Paris, 1890.

49Loc. cit., p. 11.

^L'automatisme somnambulique devant les tribunaux. Annales
d'hygiene pub. et de med. leg., 1887, Vol. 17, p. 334.

MSee also Fajnkind (Feinkind) Du Somnambulisme dit maturel
(noctambulisme). Ses rapports avec l'hysterie et l'attaque hysterique a
forme somnambulique. These de Paris, 1893.

390 HUGH T. PATRICK

"2Les Epilepsies et les Epileptiques. Paris, 1890, p. 332.

MLoc. cit., p. 284, et seq.

MEin Fall von psychischer Epilepsie. Allgem. Zeitsch. fur Psych.,

1888, Vol. 45, P- 364.

"Eine Reise in die Schweiz im Epileptischen Dammerzustand, etc.
Miinch. med. Wochens., Sept. 11, 1900, p. 1270.

""Ueber Fugues und fugueahnliche Zustande. Jahrbiicher fur Psych.
und Neurol., 1903, Vol. 23, p. 107.

07W. S. Colman. A Case of Automatic Wandering Lasting Five Days.
The Lancet, Aug. 29, 1903, p. 593-

""Ueber den Bewusstseinszustand wiihrend der Fugue. Jahrbiicher f.
Psych, u. Neurol., XXVII., 1906, p. 125.

"'Epilepsy in Its Relation to Crime. Journal of Nervous and Mental
Disease, 1902, Vol. 29, p. 481.

""Berlin, klin. Wochens., 1895, pp. 909 and 938.

nIn addition to the foregoing bibliography the following may be
mentioned :

Kran. Ein Fall von Epileptischem Wandertrieb. Psychiatr. Wochens.,
1900, p. 149.

Voigtel. Vier Falle von Krankhaftem Wandertrieb. Deutsche mihtar.
Zeitung, 1900, p. 594.

C. v. Leupoldt. Zur klin. Bewerthung patholog. Wanderzustande.
Allg. Zeitsch. f. Psych., 1905, p. 303.

TWO CASES OF DISLOCATION OF THE EYE-BALL THROUGH
THE PALPEBRAL FISSURE.

By Beverley R. Tucker, M.D.,

CLINICAL ASSISTANT AT THE PHILADELPHIA ORTHOPEDIC HOSPITAL AND IN-
FIRMARY FOR NERVOUS DISEASES.

The first case is one of cerebral gumma with exophthalmus
so great as to cause a complete dislocation of the eye-ball.

This case is reported because of the many extraordinary
symptoms which made the diagnosis difficult, among which
was the extreme exophthalmus; and because of the patient's
satisfactory recovery. The following notes are abstracted
partly from the records of the Pennsylvania Hospital from the
service of Dr. Morris J. Lewis and mainly from the records of
the Orthopedic Hospital and Infirmary for Nervous Diseases
also in the service of Dr. Lewis, to whose kindness I am in-
debted for the privilege of reporting the case.

The patient, S. L., age forty years, white, married, occupa-
tion housework, gives the following history :

Family History. — Father paralyzed at the age of sixty
years and later died of pneumonia. Mother paralyzed at the
age of forty-five years, and later died of diabetes. Balance of
family history negative.

Past History. — She had the usual exanthemata as a child.
In 1901 had rheumatism and intermittently since. In 1903
had a discharge from her left ear, the ear has discharged at
times since and she has been somewhat deaf. In 1903 also, she
had what she calls ''water pox," probably poison ivy, and says
her sister's children had it at the same time. A year later she
had some "throat trouble."

She has been married 20 years, having no children born
but one self-induced abortion. She will not admit specific in-
fection.

On November 12, 1903, she came to Dr. J. K. Mitchell's
clinic at the Orthopedic Hospital with a left facial palsy be-
ginning six days before. Ten days previous she had caught
cold after being overheated. The palsy got worse for three
days, and then began to improve. At the clinic an effort to
protrude the tongue was ineffectual and the tongue inclined
to the left in the mouth. Food was collected on the right side
of the mouth. She was treated and greatly improved.

In the year 1903 she states that she had a forward and
backward tremor of the head, which soon cleared up, but she
has had a recurrence since.

392 BEVERLEY R. TUCKER

In April, 1905, she had what she calls a "stroke," involv-
ing the face only. The right side she states was first paralyzed
and then the left.

July 12, 1905, she was admitted to the service of Dr. Lewis
at the Pennsylvania Hospital. She came to the hospital in
the ambulance complaining of pain in the back of the neck
and inability to walk because of weakness. Her eyes were no-
ticed to be prominent, and she stated that they had been some-
what so all of her life. She described attacks resembling petit
mal, which came on suddenly with no aura. She uttered a
cry, became set and rigid, her head twitched and she thinks
she lost sight during attack, which would last only a few mo-
ments. She did not remember occurrences during this time,
and would come out of them crying. Did not fall nor bite
tongue. Had not had one of these attacks for over a year.

Nine weeks before admission into the Pennsylvania Hos-
pital, she had pain starting at the crown of head and passing
down neck. Was sewing at a machine when this pain first
came on. These seizures of pain came with increasing fre-
quency, since which her eyes have been more prominent and
her deafness increased.

She has also had four or five chills during the nine weeks
before admission.

The tongue protruded straight. Heart, lungs and abdo-
men practically negative.

The patient was nervous.

The case was diagnosed at this time as "Exophthalmus
of unknown origin and brain tumor" followed by an inter-
rogation mark.

While in the hospital her eyes became very prominent and
on one occasion her left eye protruded to such an extent that
it became dislocated from the orbit through the palpebral fis-
sure. This occurred while a nurse was looking at her. The
lids contracted behind the eye-ball.

Dr. Harlan was sent for and replaced the ball and stitched
the lids together over it. After some weeks the exophthalmus
was less and the stitches were removed. Never again was the
exophthalmus so great as to cause this startling phenomenon.
The attack came on so soon after the admission, that no
ophthalmoscopic examination was made at the time.

On August 5, 1905, she was discharged from the hospital
very much improved. She was in the hospital a little over
three weeks. The treatment consisted mainly of sodium iodide
and rest in bed.

Ten days after her discharge she was readmitted. The
pain in her head had returned and her nervous symptoms had
increased. Her neck was stiff, and her head drawn back. Her
eyes were thought to be somewhat less prominent.

DISLOCATION OF THE EYE-BALL

393

She was found to have anesthesia to touch, heat and cold
on the right side of the face from a horizontal line through
the center of the nose nearly to the vertex.

Her jaws opened with difficulty and the muscles of masti-
cation seemed rigid. Her tongue protruded with difficulty and
turned slightly to the right. Her knee jerks were plus. Her
ear discharged — she fainted once while in the hospital.

She improved greatly in a few weeks. When discharged
she had less anesthesia and less protrusion of the eyes. The
rigidity of the neck disappeared. The treatment was strych-
nine in moderate doses and potassium iodide in large doses.
Diagnosis same as former admission.

About two months later, on November I, 1905, she came
to the clinic of Dr. Lewis, at the Orthopedic Hospital and In-
firmary for Nervous Diseases, complaining of severe pain in
the jaw. She says the jaw appears to dislocate at times. Her
mouth opens poorly and she frequently bites her tongue while
talking. Has difficulty in chewing and swallowing and com-
plains of general depression and weakness.

She is poorly nourished and has a cyanotic, asymmetrical
face. Her eyes are very markedly prominent especially the
left. She can close the lids over them upon attempt.

Her thyroid is moderately enlarged. Her pulse weak and
102 beats to the minute. Heart action regular. Temperature
101 2-5 deg. F. Respiration 22.

Knee jerks: Right exaggerated and left more so. There
is no clonus. Dynamometer R. 20., L. 15.

With each wink of the eye there is a simultaneous fleeting,
muscular contraction of the right angle of the mouth and right
side of the chin.

The mouth is somewhat drawn to the right.

The cervical and upper six dorsal vertebrae are tender and
painful. Pressure on the side of neck causes cyanosis and
weakness.

She was admitted the next day, November 2, 1905, to the
wards, and put to bed. A soft fluctuating swelling was found
upon the scalp in the upper left occipital region. This was ten-
der to pressure. It was opened two days later and found to
contain pus. It healed promptly and temperature became nor-
mal. Pressure over the atlas and axis causes intense agony
and the head is thrown back because of retraction of the neck,
she is very nervous. Knee jerks found to vary in intensity
but always present.

There is some tenderness over the liver. Diffuse enlarge-
ments are found on the upper right tibia, on the middle of the
left tibia and on the inner one-third of the left clavicle Bend-
ing the head back and forth causes tremor and pain.

There is "pins and needles" sensation on the upper lip.

394 BEVERLEY R. TUCKER

Over an area from a line horizontal through the center of
the nose to the vertex on the left side all sensation is dimin-
ished, but not absent, below it is hyperesthetic or normal.

On the right side of the face, and on both sides of the up-
per lip are hyperesthesia and hyperalgesia. There is a reflex
movement of the muscles of both sides of the face upon strok-
ing the upper lip.

There are spots of loss of heat and cold sense on both
sides of the face. The jaw jerk is absent.

The next day, November 3, 1905, improvement was
marked. The patient was brighter and more cheerful. Move-
ment of the facial muscles was freer. Discharge from the
ear ceased. Areas of disordered sensation have disappeared.

November 4 to December 13, 1905, she improved some-
what.

December 13, 1905. While sitting in a chair she fell for-
ward in an 'apparent faint. She was perfectly unconscious
for a few moments and recovered suddenly and cried. She
had no bad after-effects from this attack. She said that she
had had these "spells" before.

December 22, 1905. She went home looking well and like
another woman. She had fattened 16 pounds, and her eyes
were much less prominent. Her treatment in the hospital
consisted mainly of rest, potassium iodide in increasing doses
up to 200 grains daily, and small doses of Fowler's solution.
She is to come to clinic.

The following special examinations were made while she
was in the hospital.

Dr. Freeman examined her ears and found pus in the left
middle ear and believed the ethmoid also involved. A few
days later, November 7, he found the aural canal practically
closed. On December 7, he found the canal more open, and
the membranes dry and posterior superior wall in the proper
position.

Dr. de Schweinitz made the following eye examination.

Vision. O. D. and O. S. 6 — 6. Edges of disk normal, no
vessel change. Hyperopia of one D. No spots in fundi nor
swelling of disks. Bilateral exophthalmus, no diplopia. Ab-
duction causes nystagmoid movements in each outward effort.
Convergence is normal. No von Graefe nor Dalrymple sign,
no Mobius sign. No dislocation of the lids.

Her blood and urine were examined several times without
finding any pathogenic change except that the hemoglobin on
November 6 was 55 per cent.

She came to the clinic from time to time and showed steady
improvement. On December 5, 1906, she was seen at her
home by me. Her ears have not discharged for months. Her
eyes are still less prominent. There are no nystagmoid move-

DISLOCATION OF THE EYE-BALL 395

ments. Convergence is good. There is no disturbance of sen-
sation of any sort. Her thyroid is full but not noticeably en-
larged. Muscle movements are better on the whole right side
of the face. Knee jerks are slightly diminished, but present.

She states for the first time that during 1903 or 1904 after
she had had the left facial palsy, she fell on the ice and struck
the back of her head hard enough to make her vomit.

The case presents many features of diagnostic interest.
Three years ago she undoubtedly had a 7th nerve peripheral
palsy which has gotten completely well. The forward and
backward tremor of the head, which occurred also during this
year (1903) and which returned for a while a year or so later
may have been a precursor of her more serious troubles of
1905.

The so-called stroke she describes in April, 1905, as par-
alyzing first the right and then the left side of the face, and
only the face, we can only ascribe to cerebral syphilis. She
never admitted this infection, but the gummatous nodules and
the effect of antisyphilitic treatment proved it. Her hypal-
gesia and hyperesthetic areas were peculiar and can only be
explained by the multiple specific lesions.

The condition of her eyes would lead one naturally to think
of exophthalmic goiter, but she hardly had enough other symp-
toms of Graves' disease to justify the diagnosis.

Her unconscious attacks were not epilepsy as there was no
froth at the mouth, no tongue biting, no true movements, and
no history of their occurrence previous or later. They
somewhat resembled hysteria and if they were hysterical
this condition was superadded and could not account for
her other symptoms. There were reasons for not thinking
these attacks simple fainting spells, as for instance, her rigid-
ity. Atypical Jacksonian epilepsy must be considered, which
in the writer's opinion, they probably were.

The scalp abscess was probably an infection through a
hair follicle from her discharging ear. This abscess could not
however account for the intense pain in the back of the neck,
for this occurred before the abscess and continued after it had
healed.

The great pain, the increased knee jerks and the retrac-
tion of the neck and stiff muscles, lead us rather to the conclu-
sion of a specific meningitis.

There are indeed many points of interest in this case, the
discussion of which would add too greatly to the length of this
paper.

In conclusion it is fair to state that the woman is appar-
ently well, performing her daily duties with comfort.

The second case is one of exophthalmic goiter in which

396 BEVERLEY R. TUCKER

the eye-balls were dislocated through the palpebral fissure.

This case occurred in the service of Dr. Morris J. Lewis
at the Orthopedic Hospital and Infirmary for Nervous Dis-
eases, Philadelphia. I am indebted to Dr. Lewis for permis-
sion to report the case.

The patient, Miss E. C. B., aged twenty-six years, came to
Dr. Lewis's clinic April 25, 1906.

Family history. Father alive, but "nervous." Mother alive
but in delicate health. One brother well, and one has "spasms."
Five sisters well though one had chorea as a child.

Past illness. The patient had the usual exanthemata. Had
typhoid when ten years of age, and again when seventeen
years of age. She had convulsions once when a child, lasting
three days. Menses never troublesome. When nineteen years
of age she noticed that her eyes were becoming prominent.
Her ears discharged at this time also. About six months after
this she noticed some enlargement of the neck. She has had
difficulty in respiration, but less trouble now.

At present her pulse is 96. Her neck just below the chin
is 12^4 inches, and at the greatest part 14J4 inches. She
states that her neck was larger and that she was given Fowl-
er's solution two years ago and again six months ago, which
seemed to reduce its circumference. Her thyroid is markedly
enlarged. She states that at times the exophthalmus has been
so great that each eye-ball has protruded from its socket about
six times, sometimes without known external cause and some-
times when wiping them with a handkerchief, etc. She re-
duced them to their proper position herself. Dr. Lewis at
clinic touched gently the lower lid of the left eye, and to the
surprise of all present the globe protruded beyond the palpe-
bral fissure, which contracted behind it. Dr. Langdon imme-
diately replaced the eyeball by manipulation, and makes the
following report as to her eye conditions.

"Marked exophthalmus and eyes equally prominent. Pal-
pebral fissures wide. Motions full and convergence good.
Pupils equal and normal in reaction. Media clear and fundi
normal. Von Graefe's sign present at intervals. Hyperopia
O. D. 2 D. O. S. sy2 D.

She was admitted to the hospital April 29, 1906. Auscul-
tation of her heart showed accentuation of the 2nd pulmon-
ary sound, and the 1st pulmonary booming in character, other-
wise negative. Her pulse while in bed ranged from 60 to 80
beats per minute. Her urine was normal. May 3, 1906, he*
hemoglobin was 90 per cent., red cells 4,940,000, white cells
9,000. June 6, 1906, she became hoarse, then almost lost her
voice, also her ears were discharging. Dr. Freeman was called,
he found the right ear drum almost gone and the left perfor-
ated. She had an acute trachitis and her right vocal cord was

DISLOCATION OF THE EYE-BALL 397

inflamed. Dyspnea was marked. Turpentine stupes to throat
and inhalation of tr. benzoin co., menthol and creosote
frequently administered, relieved her. She was quite ill for
some ten days. Her temperature ranged from 98 to 100 deg.
only. After this time her improvement was steady, and she
was discharged August 25, 1906. Her thyroid had become
smaller and her neck measured May 20, 1906, in its greatest
circumference 13% inches. About this time a mass of granu-
lations was removed from her right ear and her hearing im-
proved.

When she left her eyes were much less prominent and
they never became dislocated again. She gained 13 lbs. in
weight and her nervous system was much quieted.

August 29, 1906. She returned to the clinic still improv-
ing. She was given potassium iodide gr. ten. She is to be
glassed at the University of Pennsylvania.

December 1, 1906. She writes that she has been working
since October 5. Her neck measures in its greatest circumfer-
ence 14 inches. Her eyes have been getting better all the time,
and she concludes by saying "Everyone that has known my
condition for the last eight years is astonished at my improve-
ment."

Society procceMngs

THE BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY.

Nov. 15, 1006.
The President, Dr. Tuttle, in the Chair.

A CASE OF CHLORAL DELIRIUM.
By Dr. Mitchell.

The resemblance to alcoholic delirium was emphasized. A shoemaker
of sixty-two began to take chloral sixteen years ago for insomnia ; and it
became his habit to take gr. 15-30 for many years every night. Also he
used alcohol moderately up to ten years ago.

Four years ago his family first noticed he was more restless and he
took more chloral. At night he fancied he heard horns and bands of
music, and later voices. He would be irritable and unreasonable in re-
action to hallucinations, which would appear irregularly for a time, and
then he would seem as well as usual for some months, only to have a re-
currence. Three years ago he took a large dose of chloral, with suicidal
intent. Afterwards he increased his daily average allowance to 75 gr.

Nine months ago he formed delusions explanatory of his hallucina-
tions; his neighbors were conspiring against him, and he bought a re-
volver to protect himself against incendiaries. He lost weight, became
tremulous, and had a delirious attack lasting weeks ; he saw strange
animals and men, and heard abusive epithets ; he was restless and dis-
orderly. This acute attack subsided rapidly, but he soon resumed chloral
with a recurrence of delirium; and he was committed to the Danvers'
Hospital.

He was poorly nourished and his face cyanotic. His gait was feeble
and unsteady; pronounced Romberg; fine fibrillary tremor of the facial
muscles; tremulous and husky voice; general tremulous incoordination;
reflexes generally lively ; pupils reacted normally ; and considerable blunt-
ing of tactile sensibilities existed.

Mentally he was disoriented ; his attention could not be held in con-
versation; restless and disorderly, moving his bed about, throwing his
bedding around, trying to climb out of the window and keeping constantly
in motion. He had visual and auditory hallucinations ; he was apprehensive.

In a week he had improved and was able to sleep without drugs. At
the end of four months he was practically well and had gained in weight
so that he left the hospital, able to sleep better than for years and without
drugs.

Dr. Dewey said he saw recently a case of what he considered delirium
due to the salicylates. A man who formerly used liquor quite freely, but
who had drank none for several months, was taken suddenly with a severe
pain in his hip, but without fever. His physician, thinking that the pain
was rheumatic, gave him large and frequent doses of salicylates which
relieved the pain. On the fourth day he had ringing in his ears and be-
came delirious. He saw beautiful scenery on the ceiling. Later he saw

BOSTON SOCIETY OF PSYCHIATRY 399

Jong needles in the bed clothes and heard his wife taking medicine in her
mouth, the glass syringe striking her teeth.

When seen this condition had lasted three days. He then recognized
that the first hallucinations were not real, but believed that his wife had
been taking' medicine and that the physician who had just examined him
had put some medicine on his chest with his stethoscope. He was well
oriented.

His physician reported that in three days he was practically well.

t
LATE EPILEPSY IN A WOMAN OVER SIXTY YEARS OF AGE.

By Dr. Southard.

The subject showed a general arteriosclerosis. The vessels at the
base of the brain showed a trivial degree of diffuse thickening. The
tissues in general showed involution changes.

The reader called attention to the fact that although numerous sections
from various parts of the nervous system were examined, a progressive
Marchi reaction could be demonstrated in one focus alone; viz., about a
small cyst of softening of the left hemisphere of the cerebellum. Minute
dissection of the remainder of the nervous system revealed no other focal
lesion. Microscopically no characteristic lesions were found, except focal
perivascular gliosis in the interior of the spinal cord and in various parts
of the cortex. None of these perivascular glioses appeared to be accom-
panied by a Marchi reaction. There was a characteristic pigmentation of
the cells of the fusiform layer in numerous regions.

The case must be counted one of late epilepsy developing upon an
organic basis.

TUMOR OF THE RIGHT FRONTAL LOBE.
By Dr. H. W. Miller.

The specimens presented show a tumor in right frontal region which
is* of interest from the size of the growth, the duration, and the complex
of symptoms manifested at various times during the course.

The clinical history in brief is as follows: A male, sixty-four years
of age, upon admission to the Taunton Insane Hospital in January, 1894;
excessive alcoholism; onset with insomnia, pain in the head, irritability,
some memory disorder, and convulsions (nature and number not ascer-
tained) for three months before admission.

At the time of admission physically well nourished, but pale, with
motor symptoms suggestive of a peripheral sensory motor neuritis. Pupils
unequal, right dilated, left contracted; sluggish reaction to light and ac-
commodation; knee jerks absent; edema of the lower extremities; tremor
of tongue, lips and facial muscles. He had at no time convulsions in the
hospital, nor was there any vomiting until his final illness.

In three months he recovered from the motor disturbance so that he
was given parole and did outside work. He frequently complained of
frontal headache, a feeling of dizziness, and pain in his legs, which he
spoke of as rheumatic.

At first he was mentally much confused, disoriented, elaborated very
poorly; in brief, was in a somnolent, semi-stuporous condition. These
symptoms subsided with the physical improvement so that five months
after admission it was stated that he showed only a mild degree of gen-
eral intellectual impairment. His condition remained stable till June,
1896, when he was discharged as much improved.

400 BOSTON SOCIETY OF PSYCHIATRY

One year later he was recommitted. In the interim he had indulged
freely in alcoholic drinks; had a few (?) convulsive attacks. Shortly
before his return he became despondent, restless ; complained of a feeling
as if the upper part of his skull was falling off; often held on to his
head ; said that he was dizzy ; and he screamed frequently at night.
Physically at this time he showed some Romberg, equal but sluggish
pupils, absent knee jerks, and by no means persistent headache.

The more acute mental symptoms rapidly passed off, and following
that time he showed only slight irritability, temporary attacks of depres-
sion, restlessness, rare hallucinatory episodes, and a distinct moral de-
terioration of the nature of sexual perversion.

The above in brief characterizes his condition up to the present year.
On April 6, 1906, twelve years after his first admission, he had a fainting
spell with vomiting; became bewildered and stupid, passed into a coma-
tose condition, and died five days later. The fatal termination was appar-
ently due to the rupture of some of the vessels belonging to the new
growth.

The tumor was located in the right frontal lobe, commencing anteriorly
I cm. from the tip, 6 mm. from the medial surface. Its greatest diameter
was in a position 5 cm. from the tip where it measures 5^2 cm. From
this location backwards it decreased in size. The posterior extremity
was found 11 cm. from the tip of the frontal. This extremity involved
the anterior third and the anterior second of the anterior capsule and a
small portion of the inner part of the lenticular nucleus. The lower, inner
involved the gray cortex.

The degenerative changes are well shown in the specimens. The pro-
trusion into the longitudinal sinus left a depression on the inner side of
the left frontal lobe into which the ends of two fingers could easily sink.
The septum lucidum was pushed to the left, its walls thickened, and the
cavity of the fifth ventricle almost obliterated. The optic commissure was
not interfered with; the optic nerves of normal size, and the right had
a few bands of adhesions to the tumor mass ; the right olfactory atrophied.

Histologically the growth was a glioma, very vascular, with a pre-
dominence of fibrils, but also with many neuroglia cells. Remnants of
nerve cells and nerve fibers were found well within the tumor mass.

A CASE OF FRONTAL TUMOR.
By Dr. Walton.

The tumor so far simulated cerebellar tumor that operation in the
latter region was concurred in by most of the neurologists who saw the
case. The patient was a young woman, referred into the wards of the
Massachusetts General Hospital by Dr. Taylor, and seen while there
by Drs. Putnam, Paul and Waterman, as well as by Dr. Walton.

The early complaints were pain over the right eye and down the right
side of the face and neck, loss of vision and vomiting, commencing some-
what over a year ago. During the past two months there had been severe
and constant pain in the occipital region, and back of the neck, with
drawing of the head backward, and to the left shoulder, the pain ex-
tending to the arm with subjective numbness. There had been hysterical
attacks with screaming. There was unsteadiness on standing with possibly
a tendency toward the right. There was double optic neuritis with marked
projection of the disc on the left. The right pupil was larger than the
left, both reacting to light. The patient answered questions in a fretful

BOSTON SOCIETY OF PSYCHIATRY 401

manner, indicating a change of disposition, which should perhaps have
suggested frontal tumor, but which is by no means pathognomonic of
such tumor. There was no asynergia, but decided diadikokanesia in the
left arm in which she was unable to make rolling movements; for ex-
ample, with the facility shown on the right.

Primary operation in the sub-occipital region by Dr. Beach showed
tense and bulging dura. The patient died before the secondary operation
could be undertaken.

Autopsy by Dr. Wright showed rounded tumor-mass projecting into
the cavity of both lateral ventricles on each side of the septum lucidum
and just anterior to each caudate nucleus. These masses appeared con-
tinuous with one another beneath the septum lucidum and just anterior
to the pillars of the fornix. The right frontal lobe was largely occupied
by dark, soft, spongy, finely reticulated tissue extensively infiltrated with
clear fluid (g'lioma).

Dr. H. C. Baldwin asked the reader if there had been any complaint
of pain or rigidity in the back of the neck.

Dr. Baldwin stated that rigidity of the muscles of the neck was men-
tioned as one of the symptoms of tumor in the frontal lobes of the brain.
No case of tumor of the frontal lobe with this symptom had ever come
under his observation ; but during his service in the Massachusetts Gen-
eral Hospital this last summer a patient was admitted to the surgical
wards suffering from a bullet wound which involved both frontal lobes.
The patient made a perfect recovery and had no symptoms except pain
and rigidity of the muscles of the neck.

THE RELATION OF PSYCHOGENIC DISORDERS TO DETER-
IORATION.

By Dr. Adolf Meyer.

After a brief statement of the position taken in his "Fundamental
Conceptions of Dementia Prsecox" offered as part of a discussion at the
meeting of the British Medical Association at Toronto, August, 1006,
Dr. Meyer reported two cases which showed the importance of a con-
structive conception of the disease for the purpose of an adequate sizing
up and adequate therapeutic measures. The first patient had three periods
of classical hysteria preceding the outbreak of the final broader psychosis,
which at first could hardly be distinguished from a hysterical disturbance,
but in the course of a number of aggravations and relapses, took the
shape of an outspoken catatonic deterioration. In this psychosis the same
conditions which had before fed the hysterical episodes reappeared with
the characteristic reaction type of a deterioration process, and as rela-
tively easily traceable unbalanced and unbalancing substitutive reactions.
The patient is now in a state of catatonic dementia. Non-recognition of
these factors appears to have been a serious element of almost every
aggravation in the process. The therapeutic efforts all tended to sub-
merge the psychogenic issues in more or less drastic somatic measures.
The perfectly glaring lack of penetration into the mental difficulties of
the patient led to a series of disastrous blunders. A readjustment of
the management of the patient with due attention to the psychogenic con-
stellation has brought about a certain practical change, though, of course,
no radical alteration in the undoubted defect which has now existed for
a number of years.

The second patient is one in whom a certain constitutional peculiarity

402 BOSTON SOCIETY OF PSYCHIATRY

and several short episodes of hysterical emotional outbreaks preceded a
typical fantastic catatonic development remarkably clearly traceable to
definite material of experience. A comparison of the stereotyped mode
of presentation by the routinist with that obtained in the full history and
observation of the case, formed the foundation of a discussion of the
therapeutic needs of such situations. The main purpose of the communi-
cation was to show the lines along which to utilize the reconstructive
conceptions of disease. The excellent helps furnished by Kraepelin's
prognostic nosology should not be taken for more than a place where we
can take a new breath and from which to go forth for more fundamental
work. The exclusion of deterioration from practical nosological entities
such as psychasthenia and hysterical states has a certain justification, but
as the studies of Janet show, the hysterical and psychasthenic mechanism
may continue to form an essential part of super-added unfavorable con-
stellations, and although from a prognostic point of view these psychas-
thenic and hysterical factors may then be subordinated, from a therapeutic
point of view they may be the very points which must be kept in evi-
dence in any plan of arresting the disorder and in providing the patient
with material for a sound reconstruction. Grasset's recent sketch in the
Revue de Psychiatrie, and the many valuable contributions to psycho-
therapy by members of the Boston Society of Neurology and Psychiatry,
tend greatly to systematize what undoubtedly every physician must have
tried in such cases unless he was wholly under the dogma of prematurely
rigid disease-conceptions. The aim of modern psychopathology is not
merely the dogmatic diagnosis, but such a knowledge of the facts and their
working together that they can be used for therapeutic and prophylactic
work.

Dr. Knapp said that Dr. Meyer's paper has emphasized one point
which is perhaps a common truism in all neurological work, but which
should be the rule in every department of clinical medicine. The prognosis
and the treatment must vary with the individual and not be dependent
solely upon the diagnostic label we put upon the individual's condition.
Even when we recognize that the patient is the victim of an incurable
disease we should not sit down hopelessly and do nothing. We all
recognize, for example, when we make the diagnosis of tabes, that in
some cases the prognosis is comparatively benign and the patient may go
on for years with little discomfort, and that our treatment is absolutely
different according as the patient is ataxic, or suffers pain. In dealing
with the few diseases of the brain which are miscalled "mental diseases" —
although every disease of the brain presents "mental" symptoms — we must
not be too prone to make a diagnosis of a given disease from the existence
of certain symptoms such as negativism, katatonia or mental retardation.
In these, as in other brain diseases, we must recognize the fact, which is
generally recognized in regard to such symptoms as aphasia or paralysis,
that a lesion in a given locality always gives rise to the same symptoms
no matter what the pathological process may be. This law is too often
ignored by the alienist, although it has been emphasized by Wernicke,
whose treatise on psychiatry, however, was based upon the solid founda-
tion acquired in the preparation of his masterly treatise upon brain
diseases. We are told to beware of the man of one book. If the alienists
were less disposed to swear to the words of their single master, Kraepelin,
they would perhaps recognize more frequently that his nosology was not
final. What we lack, however, are more definite clinical methods in the

BOSTON SOCIETY OF PSYCHIATRY 403

study of brain disease. If we had them we could determine more accu-
rately whether we were dealing with compulsion, stupor and apathy or
whether the morbid process had gone on to complete cell destruction and
to incurable dementia. If we had these methods the difference to which
Dr. Stedman has alluded would disappear. Dr. Knapp said he could not,
however, so readily give up the elder belief that "dementia" is a secondary
state of an incurable nature. He believed that the so-called "primary"
cases go through a phase of stuporous confusion first, from which they
may recover, but, if not, that they finally pass into a state of incurable
dementia. In some cases it is possible clinically to distinguish between
these two states.

Dr. Folsom said with regard to psycho-therapeutics there was more
done fifty years ago than until quite recently. Isaac Ray and Dr. Bell
were masters in it. Prof. Tyler was appointed to the Medical School
nearly fifty years ago, and some of us can remember his careful analysis
of symptoms and what was mis-called "moral treatment." It is a pleasure
to see psycho-therapeutics coming in vogue again after Virchow's cellular
pathology has had its swing. It is a singular fact that Tyler's course of
instruction was entirely omitted in the history of the Harvard Medical
School recently published.

Dr. E. E. Southard raised objections to the use of the term psychogenic
on general grounds. He maintained that the term might lead us too
far when used in connection with various acute psychoses. Whereas it
must be conceded that the histopathologists have scarcely made out a
convincing brief for dementia praecox as related with structural alterations,
nevertheless it is equally going too far in the opposite direction to insist
that these cases have a psychical basis. This question should be held
open until more facts are produced. It seemed equally apposite to main-
tain that various psychoses are patrogenic or metrogenic or hetairogenic
as to say that they are psychogenic.

Moreover, philosophically speaking, it might be alleged that a strictly
theoretical use of the term psychogenic would commit one to the inter-
action hypothesis. With respect to the interaction hypothesis, we are still
in the position of waiting for more facts. In brief, though it seems
absurd to speak of the anatomical origin of many mental diseases, it is
equally true that the burden of proof rests with one who insists on the
psychical origin of various mental diseases.

Dr. Walton said the work of Kraepelin, which has brought order out
of chaos, should not be judged by so unimportant a question as whether
the choice of the term dementia praecox is a happy one. Dr. Meyer's sug-
gestions are most timely that the task is not completed when the diagnosis
is made. The one characteristic underlying the "psychogenic" disorders
is the obsessive temperament, of which Dr. Meyer's cases give evidence in
the doubts, fears, scruples and anxieties antedating alienation. That
the mental' balance of the obsessive may be to a greater or less extent
restored by training there is no question, and even in such cases as
deserve the title and the prognosis "dementia," the collapse may be at
least postponed bv efforts in this direction. _

Dr Cotton said as he understood Dr. Meyer's interesting and instruc-
tive paper, he hardly saw where he repudiates Kraepelin's work or dis-
credits what Kraepelin has done for psychiatry, and he should like to be
clear upon that point. It seemed to him that our zeal in working for
diagnoses under this classification has not been misdirected, but that the

404 BOSTON SOCIETY OF PSYCHIATRY

very act of probing deeply into the details of our cases, in order to
establish a diagnosis, has made Dr. Meyer's paper a possibility. It has
certainly given us a clearer idea in regard to symptomatology and
has brought us to a point where causal factors can, or should be
recognized. And that having reached this point we should not be satisfied
merely with making diagnosis, but should now be able to go further
and derive some benefit from our work, and utilize the facts obtained
by following Kraepelin's methods.

In closing the discussion Dr. Meyer explained first in what sense he
used the conception of "psychogenic" factors. In this respect the con-
trast of psychogenous disorders to general paralysis proves most instruc-
tive. The main factors of the disturbances in the cases of "dementia
prsecox" belong to the sphere of mental reactions, or better, of reactions
which could not be thought of as other than "mental." An attempt to
express them in terms of nerve physiology would eliminate many funda-
mental facts which we only know in terms of psychological experiences.
In general paralysis the development of the disease depends on the inter-
communication of syphilitic infection. In psychogenic disorders we deal
with the inability of the individual to adjust himself to certain vital
constellations, and certain uncorrected and inadequate mental factors
remain the directing element of dynamic processes. The transformation
of the symptomatology of general paralysis and also the disappearance of
the text-book description of raving mania since the diminution of drastic
measures and kindred modes of dealing with patients, shows, of course,
the importance of mental constellations in any disease, even those not
plainly precipitated by ill-digested and upsetting mental experiences or
mental reactions. But certainly the radical management of psychogenic
disorders could not be thought of without due attention to their psychic
mechanism which in individuals with inadequate defenses can become
part of a process of deterioration. In this respect Kraepelin has given
us excellent help towards arriving at a position of order replacing the
former bewildering confusion. But, after the preliminary survey with
his principles, we must venture into the fundamental work of a recon-
structive study, but not without a warning against losing one's self in
pondering. Nissl's arraignment of psychologizing interpretations would
only be justified if imaginative construction took the place of rigid ob-
servation of fact; what the speaker advocated is the orderly use of the
facts at hand and the throwing off of the dogmatic routine which seems
to make of a diagnosis a protective against the reproach of medical im-
potence in difficult but not necessarily fundamentally ill-fated cases, rather
than a natural and helpful sign-post in the material for the orthopedics
of habits and physical and mental life of the patient. In this respect
the moral treatment of the excellent physicians of the past had decided
shortcomings because it worked with a conventional moralizing psy-
chology, whereas to-day we have an adequate knowledge of the role of
substitutive reactions and automatisms and a more adequate sizing up
not only of the odds, but also of the constructive possibilities required for
adequate reaction. In all this, we could not value enough the great
help derived from the studies of Janet and others, and the growing ten-
dency to peal out dynamic principles which cannot fail to become of im-
portance in every nosological and therapeutic activity.

That psychogenic factors are to be considered in a disease or are
possibly at the bottom of it, does, of course, not make the disease any

NEW YORK NEUROLOGICAL SOCIETY 405

less real and serious ; but the recognition of the factors is one of the
essential avenues for help and will alone free the patient from the sad
faith in routine bred in many hospitals. It is certainly absolutely essen-
tial for non-institutional care of mental disorders.

NEW YORK NEUROLOGICAL SOCIETY.

Nov. 28, 1906.

The President, Dr. Joseph Fraenkel, in the Chair.

THE MECHANICAL TREATMENT OF NERVOUS DISEASES.

By Dr. H. S. Frenkel, of Heiden, Switzerland.

By the mechanical treatment of nervous diseases was understood a
treatment which did not deal with drugs nor physical means, such as
hydrotherapy, electricity, etc., but one wherein the therapeutic factors
depended upon the functions of the muscles themselves, and might con-
sist in active or passive movements, or in changes of nutrition and assimi-
lation, as was supposed to be produced by massage of the muscles. The
mechanical treatment was not much appreciated by the scientific world
until the results of the re-educational treatment suddenly suggested the
possibility of improvement or cure in organic disease. One of the most
important diseases in which the mechanical treatment had been tried,
following the good results of the educational treatment of locomotor
ataxia, was hemiplegia. To improve the power of standing and walking
in the hemiplegics, Dr. Frenkel laid a great deal of stress on exercising
the healthy side in order to make it compensate in a certain degree the
function of the paralyzed side. The system of "Bahnender and Mermen-
der Therapy" had been recommended also in the chronic spastic spinal
cord diseases, for instance, lateral sclerosis and multiple sclerosis, but Dr.
Frenkel had never seen any improvement in these cases ; on the contrary,
he had observed a more rapid course of the disease. A special point of
interest was that those cases of multiple sclerosis with intentional tremor
of the hands, and unaccompanied by muscular weakness, could be im-
proved by exercises graduated similarly to those of tabetic ataxia of the
upper extremities.

ORTHOPEDIC TREATMENT IN NERVOUS DISEASES.

By Dr. Frenkel.
One of the diseases in which one saw excellent results from orthopedic
procedures was a spastic paraplegia due to spondylitis. Dr. Frenkel had
himself seen some cases of total paraplegia with all the signs of spasticity
disappear completely by extension continued for a long time. In a special
form of pseudo-muscular hypertrophy in which the afophy of the soleus
muscle was combined with a slow retraction of the tendon, he could
improve the act of walking by an orthopedic apparatus which fixed the
foot at a right angle, so that in walking the toes did not touch the ground
first. He cautioned against ever allowing tenotomy in organic nervous
diseases where there was muscular weakness. In poliomyelitis anterior
improvement would not follow any exercise, but good orthopedic measures
could greatly benefit the patient. In multiple neuritis in the acute

406 NEW YORK NEUROLOGICAL SOCIETY

stage, mechanical treatment should be absolutely avoided. In chronic
alcoholic multiple neuritis convalescence in many cases would be short-
ened by the use of moderate massage and passive movements. In paralysis
agitans, where the other muscles were in a good condition, by carefully
suggested active innervation one could make these patients walk normally
again for a time.

From what he had said before, one could conclude that the optimistic
idea which prevailed at least in Europe among the practicing physicians
and also amongst the neurologists who did not occupy themselves with
this question, was not well founded, in so far as the degenerative motor
lesions of the brain and spinal cord were concerned. There was danger
that neurology, through this optimism, would be set aside from the ways
that were successfully pursued by internal medicine, and which might
bring us to the knowledge of the course of disease, and thus to a causal
instead of symptomatic treatment. He meant by this the biological
methods of investigation which were so closely connected with bacterio-
logical and chemical methods, such as the investigation of organic poisons
and their antidotes. There was a field for experimental investigation in
the central nervous system. If the nature of the different forms of
degeneration of the nerves, of sclerosis, etc., could be recognized as being
produced by certain poisons, it would not be Utopian to say that anti-
toxins would be found. In short, neurology should not content itself
with dazzling installations of mechanical and electrical appliances for
symptomatic treatment, but it should take an important part in the re-
search of the causes of the diseases with which it had to deal. If
neurology did not apply itself more to the casual researches than it had
hitherto, it was certain that internal medicine would replace it in this
most important part. For this reason, he was proud to say that the
newly built nervous clinic in Berlin, with which he was connected had
gotten recently the most perfect installations for chemical, experimental
bacteriological and biological investigations.

Dr. M. Allen Starr said he was very much interested in Dr. Frenkel's
paper, particularly as he had covered such a large ground and had pointed
out to them lines of therapeutics in a great many different directions.
Personally, he was familiar with Dr. Frenkel's written works upon tabes
and its treatment, and had been wonderfully impressed and surprised
at the success he had had in the treatment of several of his own private
patients that he had sent to him on the other side. Dr. Starr supposed
that a good deal of this mechanical treatment was limited to the treatment
of tabes dorsalis. It had not occurred to him that there were so many
various types of nervous disease which were open to this method of
education of the muscles. For this reason, he said he was impressed with
what had been read, which opened up a very hopeful view. It seemed
to him that if this mechanical treatment, when carried out in tabes, could
be applied to other diseases, it was our duty to apply it. Dr. Starr said
that after a careful study of the method, he would adopt it. He believed
that particularly in hemiplegia, decided benefit would accrue to the
patients from proper training of the muscles. He was impressed with
the statements made regarding paralysis agitans, because he was con-
vinced from his own experience in the treatment of that disease that
benefit could be had from the proper education of the muscles. He had
had several cases of paralysis ag*itans where material benefit followed
massage given by Swedish masseurs who had educated the muscles. He

NEW YORK NEUROLOGICAL SOCIETY 407

was convinced that the method had a very wide application. He believed
they were much indebted to Dr. Frenkel for bringing this subject before
them, and showing the wide application of the method.

Dr. B. Sachs said he was indeed very much interested in Dr. Frenkel's
conservative views, and he thought it was safe to say that his opinion re-
garding the limited application of the mechanical treatment in organic
nervous diseases were shared by the larger number of American neurol-
ogists, and perhaps by the orthopedic surgeons as well. But there were
one or two points in which his conservatism exceeded the views held by
some here. If he understood Dr. Frenkel correctly, he stated that he did
not think the mechanical treatment aided very materially in those con-
ditions in which the limbs were paralyzed from organic lesions. Dr.
Sachs was not disposed to agree with him on this point. There was one
period, for instance, in the treatment of hemiplegias, in which he thought
the spastic contractions might be benefited. In his own experience with
patients recovering from apoplexy and hemiplegia, if the patient possesses
a certain amount of motion, if you ask him to try and move the limb
more and more, you would find that by such encouragement, movements
will be made by the muscles of the affected side, and the patients would
ultimately succeed better than if this effort was not directed to those
parts. While it was difficult to force a path through sclerotic tissues he
believed motor impulses could be forced through, if the tissues were not
wholly destroyed. Following these apoplectic seizures, he believed more
could be done than Dr. Frenkel implied, although in the main he was
disposed to agree with him. There was another form of organic disease
successfully treated in this country, and Dr. Sachs' experience with it
dated back to an early association with Dr. Gibney, and that was in post-
hemiplegic athetosis and in post-hemiplegic contractures ; here, the ap-
plication of suitable splints to the paralyzed limbs for weeks and months
would result in some relaxation of the contractures, and this relaxation
offered some possibility of education by the method advised by Dr.
Frenkel. Personally, he was thoroughly convinced of the possibility of
improvement by this mechanical restraint, and he adopted it as a routine
measure in the hospital in most cases of hemiplegic contractures.

Dr. Virgil P. Gibney apologized for not having posted himself on the
treatment of tabes, as practiced by Dr. Frenkel ; his only apology was
that he regarded the disease itself, from his own standpoint, as a noli me
tangere. He had never seen anything in orthopedics which would help
in tabes except after resolution of the disease itself. He believed there
were a great many convalescents improved by mechanical appliances.
He had been assured by neurological friends associated with him that
the muscular power could be restored by this method. He was not quite
sure whether he understood Dr. Frenkel correctly when he said that in
the contractures of poliomyelitis division of the tendons resulted fre-
quently in loss of power. He was inclined to believe that he misunder-
stood the doctor. If there was anything' of which Dr. Gibney was firmly
convinced in his mind it was that lengthening the tendons in polio-
myelitis by tenotomy did not impair their function. This was almost self-
evident, after long observation of these cases. He knew that this impres-
sion prevailed among the laity, and also among certain physicians. He
believed that often the neurologists would be very glad to have the
tendons divided in order that the foot might be brought to a right angle
with the leg, and so get a useful limb. Such a division does bring about

«o8 NEW YORK NEUROLOGICAL SOCIETY

the desired result, and in the same way does division of the muscles
about the hip and leg. Dr. Gibney said that he could imagine that a
very free division of the sartorius, the adductors and other muscles
about the hip, might result in a dangling leg', thus making the patient
worse. But when one found the muscles shortened, making it almost
impossible for the patient to stand erect because of an extreme lordosis,
he sometimes questioned whether it would not be better for the patient
to have a dangling limb rather than a hideous deformity. He had failed
to see good in these cases result from massage or manual traction.

Regarding atrophy of muscles caused by steel bands or other re-
straining appliances, he said he had seen many cases where illy-con-
structed appliances to palsied limbs had caused atrophy of the muscles;
yet it was hardly fair to call such apparatus orthopedic appliances ; they
were the appliances of the shops. The ordinary orthopedic surgeon ap-
plied an apparatus for the relief of a dangle limb, the result of a polio-
myelitis, aimed to get the points of support away from the muscles. The
orthopedic surgeon's idea was to limit the motion in such joints as the
hip, knee and ankle; it was believed that such a strain on the joints, by
distortion of the limbs, and by hideous positions on the floor or on the
bed, retarded repair and frequently rendered the patient more helpless.
Thus the hip muscles stretched over night, while the patient slept with
the limbs hyperextended, so that the heels touched the buttocks. The
ligaments of the knee were likewise strained, and what little power re-
maind in those muscles was exhausted. Direct relief is not claimed for
such an apparatus; it does not per se, develop the muscles, but it does
enable the patient to assume the upright position, thus improving the cir-
culation in the limbs, and preventing those fibres not wholly destroyed
by the disease from overstrain. It also helps the masseuse and medical
gymnasts to carry on their work better, and the neurologist to better
reorganize power in muscles when relieved of tension.

Dr. George W. Jacoby said he was very much interested in the final
remarks of Dr. Frenkel that neurologists would lose their occupation
unless they gave up the systematic treatment of disease and paid more
attention to experimental, bacteriological, and biological investigations, ask-
ing them to first take up the causal relationship in nervous diseases.
Much attention has been given and is being bestowed the world over upon
the etiology of nervous diseases ; bacteriology and biology are special
subjects for which the neurologist will find little time, considering the
demands already made upon him. Neurology is by no means barren of
practical results, and he had no fear that it would be absorbed by
general medicine. Dr. Jacoby thought that Dr. Frenkel's attitude towards
the mechanical treatment of nervous diseases had perhaps been too skep-
tical, except in his attitude toward the treatment of ataxia in tabes, about
which he is very enthusiastic, and with cause.

In the mechanical treatment of nervous diseases, it seemed to Dr.
Jacoby that two distinct lines could be drawn on the treatment of affec-
tions of the peripheral neurone ; i. e., in affections of the peripheral
nerves, of the muscles, and of the anterior horns we were able to accom-
plish most by mechanical means. If we waited until the acute process
had passed, we were able to make the muscular fibers yet existing do
double work, making them take the place of the complete muscles in
certain groups, and thus causing marked functional improvement in
certain patients. He also believed that in the early stages of poliomyelitis,

NEW YORK NEUROLOGICAL SOCIETY 409

by placing the limbs in a certain position, so as to cause a relaxation of
the antagonists, we could prevent the contraction of these antagonists,
a condition which is the cause of so much trouble.

When, on the other hand, we were dealing with disease of the motor
tracts, we confronted an entirely different question. Here, excepting in
those muscles which were bilaterally innervated, we could do nothing.
If they were bilaterally innervated, nature could be aided and the
opposite centres could be made to do the work of the two.

In the treatment of tabic ataxia the question too was entirely different;
here it was not a question of the treatment of motor impulses, but a
question of treatment of sensory defects. So long as the limb has a mini-
mum of sensibility, Dr. Frenkel can re-educate the muscles, by means
of this remaining amount of sensibility, and he could by this means
convey to the central organs the knowledge of the position of the limbs.
He made the minimum sensibility do the work of the entire amount that
previously existed. This whole question Dr. Jacoby said was a very in-
teresting one.

DISTURBANCES OF VISION IN A HYSTERICAL PATIENT,
PRODUCED BY EXAGGERATION OF BINOCULAR

ASSOCIATION.
By Prof. Pierre Janet, of Paris.

Dr. E. Gruening said that it gave him gTeat pleasure to open a
discussion on Dr. Janet's paper, because we should then have an oppor-
tunity to hear him speak again in closing the discussion. He said he was
especially indebted to the Neurological Society for the invitation to be
present to hear the classic and plastic recital of this remarkable case of
hysteria. The eye is a favorite arena of functional disturbances due to
hysteria, whether they present an exaggeration, or what Dr. Janet calls
a deficit of function. Every oculist is more or less familiar with various
phases of hysterical manifestations in the organ of sight. Thus we may
observe complete blindness of one or both eyes, without anatomical sub-
stratum, diplopia, homonymous or heteronymous, due to fleeting paralysis
or contraction of the one or the other ocular muscle, narrowing of the
visual field to such a degree that only central vision remains, and the
patient may read the finest print, yet be unable to find his way about.
The manifestations are of so protean a character, and so impossible of
explanation on physiological grounds that psychology has been called into
service to supply working hypotheses. In hysteria, as in a fairy-tale,
everything is possible, and the "nil admirari" on the part of the physician
is nowhere more applicable than in its manifestations. Dr. Gruening said
it would have been interesting to have had a chart of the visual field of
that particular patient. Dr. Janet had not mentioned whether or not the
field had been taken. The theory that the patient did not see with her
good eye, because she hungered for binocular vision, and for this reason
could not make use of her monocular sight was interesting, but not borne
out in practice. People who lose one eye, have, as a rule, no difficulty
in adjusting the remaining eye to the demands of their occupations. This,
of course, does not apply to a case of hysteria, because almost anything
can happen in this fourth dimension of medicine.

Dr. Gruening, in concluding his remarks, said he wished to state
that to hear Dr. Janet present a case was a rare literary treat.

Dr. Pearce Bailey said that the history of the case reported by Prof.

410 NEW YORK NEUROLOGICAL SOCIETY

Janet illustrated well the new lines of work being done abroad and in this
country. Namely, the case of a woman with atrophy of the optic nerve
of one side, the other side being normal who nevertheless was unable to
see. Sight was restored after a careful analysis of all the psychological
conditions which could account for its loss of vision, and applying appro-
priate means to counteract them. We are much indebted to Dr. Janet
for analyzing functional cases hitherto unobserved and unstudied, show-
ing the necessity for a careful analysis and study of every psychic symp-
tom, and after a complete study of the case, applying the correct psychic
remedy. The case reported by Dr. Janet was a good example of his
work, and Dr. Bailey emphasized strongly the value of this work, which
he had done for years in the Salpetriere.

Dr. B. Onuf related a case which, although not of the same character
as the one reported by Dr. Janet, seemed to belong to the same class.
It illustrated how in a hysterical patient a group of physiological functions
normally under conscious control may by habit hypertrophy detach itself
from conscious guidance as to almost form an automatism of its own.

The case was one of a girl, with hysterical stigmata, such as con-
traction of the visual fields and analgesias and thcrmo-hypesthesias of a
regional character, who on the basis of a slight refractional error (viz.,
a myopic astigmatism of one-half diopter of both eyes, combined in one
eye with a myopia of one-quarter diopter), developed a spasm of the
apparatus of fixation, i. e., convergent squint, contraction of the pupils and
spasm of accommodation. When seen, she had, in addition to this, a
marked blepharospasm. The latter was regarded as grafted on the spasm
of the apparatus of fixation through the habitual contraction of the pupils,
which formed part of the spasm. This habitual smallness of the pupils
made the retinas over-sensitive to light. When in the course of the
disease the wearing of glasses, correcting the refractional error, had led
to a subsidence of the spasm of fixation, and with it to a dilatation of
the pupils, the increased influx of light thus resulting gave rise to an
exaggerated form of the reaction normally following such increased ex-
posure of the retina to light ; namely, a blepharospasm.

Dr. Adolf Meyer said that the two guests of the night, who came
from abroad, had brought reports in a field of neurology which, fifteen
years ago, would have received but little thought and probably would
have met with little hope; namely, the field of the functional consideration
of neurology. So much had to be and could be done in the anatomical
sphere and in localization that naturally study went in that direction.
While it was not so very long ago that it was stated that neurology had
about reached its limits, Dr. Meyer thought that they were beginning to
see a widening' horizon, even though there were limitations to the anatomi-
cal consideration. We must learn to study functions, as a condition for
further function. Both Dr. Frenkel and Prof. Janet had shown clearly
along what principles these studies must be made and how they were to be
applied. This did not only pertain to the fields they had touched on; it
held as well in the domain of psychiatry. Dr. Meyer commented on the
brilliant presentation of Dr. Janet on how necessary it was to enter
patiently upon the details of the individual's reactions, in order to reach
the disturbing factors, and what is needed to build with, and how we
should not mind merging in the use of hypotheses, etc.

JOINT MEETING

OF THE

NEW YORK NEUROLOGICAL SOCIETY

AND THE

PHILADELPHIA NEUROLOGICAL SOCIETY.

Held in Philadelphia, Nov. 24, 1906.

The President of the Philadelphia Neurological Society, Dr. D. J.

McCarthy, in the Chair.
(Continued from page 330.)

PSYCHASTHENIC ATTACKS SIMULATING EPILEPSY.
By William G. Spiller, M.D.

In the Journal fiir Psychologie und Neurologie, Vol. 6, 1905-1906,
Oppenheim discusses peculiar attacks under the title of Psychasthenic
Convulsions. Although he has spoken briefly of this condition previously,
he g*ives in this recent paper a full presentation of his views. Convulsions
may occur in certain forms of neurasthenia, in cases which are not
hysteria nor epilepsy nor organic. The first contribution to this subject
was made by Westphal in 1872 (Archiv fiir Psychiatrie, Vol. 3), in his
paper on agoraphobia, and according to this author the occurrence of
convulsions with agoraphobia is not uncommon, and they may be seen
as frequent signs of various psychopathic and neuropathic conditions.
Oppenheim refers to the fact that Westphal's views have not received
general acceptance.

As Oppenheim presents the subject, the individuals are intensely
neurotic or psychopathic from birth, and show the first sysptoms of this
diathesis in childhood. The neurasthenia is of the grave type which
has been regarded by French writers, especially Janet and Raymond, on
account of mental abnormalities as psychasthenia. The tics, states of
anxiety, phobias, obsessions and vasomotor disturbances predominate.
On such a foundation, with, however, some immediate cause, such as
emotional disturbance, mental or physical overwork, alcoholic indulgence,
especially by one unaccustomed to it, sleeplessness or a period of anxiety,
the attack develops.

This may be only deep unconsciousness with involuntary defecation
and micturition, or there may be also convulsions, biting of the tongue
and rigidity of the pupils.

Usually only a few of these attacks occur, interspersed with periods
of vertigo, anxiety, etc., and the tendency may disappear under proper
hygienic treatment.

These attacks are not hysterical, every hysterical stigma is wanting,
and the attacks themselves are not hysterical in character. Oppenheim
dismisses the question of any resemblance to hysteria in a few lines. The
differentiation from epilepsy is more difficult.

(1) The attack in itself cannot be distinguished from that occurring
in epilepsy. The patient is not an epileptic, he has not had such attacks
in childhood or early youth, he is always neurasthenic or psychasthenic,
and always periods of anxiety, phobias, tics or vasomotor disturbances
have preceded the convulsions.

412 PHILADELPHIA NEUROLOGICAL SOQIETY

(2) A special cause for the convulsive attack is always necessary, such
as overexertion, mental or physical, anxiety, vertigo, etc.

(3) The condition is merely an episode in the course of the psychas-
thenia, the attacks are few, or there may be only one during the life of
the individual.

(4) The attack may resemble fully the epileptic, but on the other hand
there may be variations, thus profound unconsciousness may occur with-
out convulsions, or the convulsions may be limited to a few muscles, or
they may persist after consciousness has returned. The condition may
Tesemble petit mal.

(5) Intelligence and memory do not become impaired even though the
attacks may be numerous.

(6) The treatment should be mental, bromides are of little value.
Acquired neurasthenia probably never causes these convulsions. Op-

penheim prefers the name of "psychasthenic convulsions," even though
convulsions are not always present; "psychasthenic attacks" he regards as
too comprehensive.

Mistakes of diagnosis may be made easily, indeed, Oppenheim himself
has made them, as in one of his cases an organic condition was present,
and Dr. Spiller is inclined to think that the danger of mistake is especially
great as regards the dreamy state of epilepsy described by Hughlings
Jackson under the name of uncinate group of fits. Dr. Spiller said he
had not been able to find any reply to Oppenheim's views, and as yet
they seem to have received little attention. The subject is, however, one
of importance, because of the resemblance of these conditions to epilepsy,
The word epilepsy conveys much dread to the patient and his relatives,
but far more important is the fact that not only the diagnosis, but also the
treatment and prognosis of the psychasthenic attacks are essentially
different.

Dr. Spiller reported two cases.

Case I. — C. twenty-one years old, consulted him about five or six
years ago. at which time the following notes were made :

A maternal uncle died in an insane ayslum. No convulsions had
occurred in the family of either parent. The mother of the patient is
very irritable, easily excited, and somewhat quarrelsome.

The patient has had five brothers, but no sisters. His father has shown
great artistic talent. The first son is a sculptor and is irritable. The
second son does not appear to be neurotic. The third son was very eccen-
tric. He tried to commit suicide two or three times while at home, and
finally succeeded. He at times became very much depressed and occasion-
ally when he had these attacks he would wander away and stay away over
night. Once he was absent two days. Before he wandered away his
expression would become peculiar so that his relatives would know he
was about to leave home. In one attack he went a distance of several
hundred miles.

The fourth son seems to be normal. The fifth son is the patient. The
sixth son is sixteen years old and is afraid to go into the dark.

C, the patient, has never had convulsions. When he was seventeen
years old he had his first visual hallucination. He was in church. He
heard the minister begin his sermon and then as he looked across the
church he noticed that a certain man was looking at him. At first he
liked the face, and something in it reminded him of a boy of whom he
had been very fond, and whom he had not seen for about two years.

PHILADELPHIA NEUROLOGICAL SOCIETY 413

This boy had taught him masturbation. In this first attack he did not
know what occurred about him, he got up and came out of the church after
the service was over, and the money he had intended to put in the plate
he had still in his hand. Whether this was unconsciousness or not is un-
certain. He did not speak during the attack. After this first attack he
began to hate and fear the face, and always had a warning before seeing
it, "a sort of spasm would go through his whole body," or if he were
holding a book his hand would tremble violently, and then if he looked
across the church the "face" would be looking at him. It was always the
same face and had always the same sneering expression. Except on one
occasion the man was always in the same part of the church. He was
not motionless, but was not seen by the patient to walk out of the church
except on one occasion, when he followed the patient. During the first
year the man was observed always in the same church, then he was seen
in another church, and later was seen repeatedly on the street. The whole
figure of the man was visible, but the patient spoke of the hallucination
as "the face."

If the patient fixed his eyes upon the wall be could bring the figure
of the man before him, but it did not seem real to him, and did not
"satisfy him," as he expressed it.

The attacks occurred every Sunday during the first year, but not so
frequently during the second year, and during the third year not more
than four times. The patient believes the face is real. The attacks have
been frequent proportionately as masturbation has been frequent.

He can always tell the day in advance that he will see the face. His
eyes seem to be out of focus, he cannot keep them focused upon the model
he is copying, and if he tries to do so he gtts a bad headache, then becomes
sleepy for the rest of the day. The aura usually occurs about four P.
M. He has always had a bad taste in his mouth during the aura, "like
cheese after you have eaten it the night before" or a "musty taste." If
he falls asleep after the aura he has very vivid dreams, on one occasion
he saw a comet coming toward him and exploding, and on another he
saw clearly the face of his brother, who a few days later committed
suicide. He has had the aura without seeing the face the following day,
but has never seen the face without having had the warning the day before.

Within about fifteen minutes after the visual hallucination he gets
sleepy and stupid, and does not know what is going on about him. The
vision is followed by fullness of the head and palpitation of the heart.
He has formed the habit of taking a back pew in church so he can hide
behind the people and from the vision, and support himself against the
wall. Only on one occasion he saw two children with the man. Each
time he has had the vision his "eyes have gotten out of focus" and objects
seem to move to and fro. He then has had a sick feeling and had to sit
down. He has the same taste in his mouth during the hallucination that
he has during the aura. Immediately after seeing the man his "ears
ring like bells and insects all singing together." He has had occasionally
aural hallucinations without other disturbances ; i. e., he has heard his
mother calling him or bells ringing.

The young man is very intelligent. He has never wet his clothing
during an attack nor cried out, nor bitten his tongue. When he feels he
is about to have the vision and resists it, his face flushes, he gets cold and
hot alternately, and all objects appear queer.

Dr. Spiller said he had seen this patient again within the past few

414 PHILADELPHIA NEUROLOGICAL SOCIETY

months. He is in excellent health. The visual hallucinations lasted one
or two years after he was first seen, and then ceased entirely. They gave
place to a difficulty in swallowing. The man believed he could not
swallow and was depriving himself of food. An examination showed
nothing abnormal to explain the dysphagia. This condition lasted about a
year and a half and then disappeared.

Interesting in this report are: The neurotic family history; the at-
tacks of wandering in one brother ; the aura always preceding by one day
the visual hallucination and associated with a bad taste in the mouth,
suggesting Hughling* Jackson's uncinate group of fits, and associated also
with ocular disturbances and followed by drowsiness ; the occurrence of
the hallucination at first always in one place, a church, and therefore in a
crowd, but later in other places and on the street ; the resemblance of the
face seen to that of a boy who had taught him masturbation ; the frequency
of the attacks proportionate to the frequency of masturbation ; the bad taste
in his mouth and sick sensation during the attack ; the possible uncon-
sciousness in only one attack; the drowsiness, fullness of head and pal-
pitation of the heart following an attack, and the absence of all convul-
sions.

Case II. — A. B., thirty-six years of age, consulted Dr. Spiller Sept. 10,
1906. He was a patient of Dr. Radcliffe Cheston, and at the head of a
large business. He comes of a neurotic stock. His father had nervous
prostration, and now is tormented by unreasonable doubts as to the
manner in which he conducts his business.

The patient is a hard worker. Some years ago he undertook to study
a profession, but as he was engaged all day he was obliged to study at
night. After passing his examinations he "went all to pieces," as he
expressed it. He would sign a letter and after a few minutes would tear
the envelope open to see whether he had signed the paper. On one oc-
casion he visited his sister, and wandered about the house in a dazed
condition. He was very irritable. Two or three years ago he went
away for complete rest for fourteen weeks, and since then he says he
has "felt his nerves" more. He had difficulty in fixing his mind on his
work, and has frequently repeated his actions in order to be sure he had
done his work properly, and often would read a paper without being able
to fix his attention upon it. He took exercise in the same energetic
manner in which he carried on his business.

He is the father of three healthy children, two of whom are "high-
strung'." He gives no history of sexual irregularity. He had never had
any attacks of any kind before July 4, 1006. In the early part of the
summer of 1906 he went to Europe, and took an automobile trip from
Paris lasting two days. He travelled about two hundred miles each day.
The weather was not very warm, but he was much tired by the trip.
After the second day's journey, in the evening while talking to some one
he fell and was said to be unconscious. His face was a little flushed, and
his eyes had a vacant look. He was "perfectly limp" about ten minutes,
then he became rigid in his feet, and had involuntary movements of the
upper limbs of a purposive character. He was put to bed and had
what he called a chill; he shook all over, his teeth chattered, he became
red in the face and cold in the feet, but the thermometer showed no rise
of temperature.

After this first attack he had weak spells in which he would sit with
a vacant expression. These attacks occurred once or twice a day and

PHILADELPHIA NEUROLOGICAL SOCIETY 415

nearly every day. He was not unconscious in these attacks, although he
seemed to be '"wandering in mind."

The second severe attack occurred July 13, and in this he fainted.
Other attacks occurred July 17 and 21. In the latter he had a vacant
expression, became limp, then got up and tried to walk and fell after he
had gone upstairs. He then became unconscious and was rigid in his entire
body, but had no convulsive movements. After this attack was over he
got up and went to bed, and had a chill and headache in bed.

Attacks occurred on July 24, 26 and 2j. After the first two or three
attacks he had a warning in a general weakness and sensation as if he
were "charged with electricity." His memory began to be impaired. The
attacks continued every few days until he got on a steamer, Aug. 29, on
his return journey. He had two attacks on board the steamer. In all, he
had twenty-five major attacks. The last attack was on Sept. 3. In one
attack, when walking alone he fell and became covered with mud.

Before taking the steamer he had an attack in which he was uncon-
scious one hour, and in this his body was more rigid than in the other
attacks. In two attacks the face twitched, but convulsive movements were
confined to the face.

He had taken a drink of whiskey or beer daily, occasionally some
claret, and had smoked about twenty cigarettes daily. He had also been
much worried about his wife's condition, as she had been in a hospital
three times.

Before leaving America he had been having headache since April, 1906,
more on the right side and in the parietal region or over the mastoid pro-
cess, but this pain disappeared. There was no mastoid disease.

This was the history as obtained from the patient and his wife at the
first interview. A further study of the patient by himself revealed some
interesting facts. He said that sometimes when he was supposed to be
unconscious he was not so, and the so-called rigidity was often purely
voluntary on his part and was the result of an attempt to get the numb-
ness out of his forearms and ankles. While he was on the ocean on his
way to Europe he kept control of himself, but when he reached Paris he
did not care and gave way to his feelings. He did not care whether
he fainted or not, as it was a temporary relief to do so, and if he felt
like sitting still and looking at a spot upon the wall he did not make a
mental effort to avoid it. He would become weak after dinner and he
began to dread this period, and if he could have been fooled regarding
the time of day he believed he would not have fainted. He does not know
why he fell.

The man presented no hysterical stigmata nor signs of organic disease.
The treatment was psychotherapy.

He was seen again on Oct. 19, 1906. by Dr. Spiller. He had been weak
twice, and had had constant slight headache. On one occasion he felt
an attack was coming' on. his wife urged him to resist it, but he pleaded
with her to be allowed to fall, pushed her from him and said she must
let him fall. His attacks have usually occurred when his wife was present.
At this time he was again on a vacation with no business to occupy his
mind, and he felt that he need not control himself. He said that if he
were asked any time in the day whether he had headache he would reply
yes, and yet usually he was not aware that he had headache. It was not
real pain that he experienced, but as he expressed it, it was "conscious-
ness that he had a head." He said if he had known that falling would
have injured him he would never have fallen.

416 PHILADELPHIA NEUROLOGICAL SOCIETY

Dr. Morton Prince said that he thought pathologically these cases
were to be regarded as types of hysteria, though the statement needed
some explanation. We must make a distinction between a clinical and a
pathological classification of disease. As he viewed the matter, hysteria
from a nosological point of view is a clinical conception. That is to say,
in practice it is customary to classify cases as hysteria purely on grounds
of clinical symptom-complexes. That being the case it is purely arbitrary
how extensive we shall make our symptom-complex.

On the other hand, we can make our classification on psychopathological
grounds ; in which case we might include under hysteria cases which
clinically would exhibit diverse clinical manifestations. The question is
therefore comparable to that of clinical and pathological diphtheria. We
may limit clinical diphtheria entirely to membranous inflammation, but
pathological diphtheria would include all cases in which the specific bacillus
was found, irrespective of the clinical manifestations.

In an analogous fashion, if we can find a psycho-pathological basis for
hysteria, we might include many cases in such a pathological conception'
which clinically appeared to have little resemblance.

*Now recent researches seem to have shown that hysteria can be re-
ferred to a psycho-pathological basis, which is functional dissociation on
the one hand and motor, sensory or ideational automatisms on the other.
For instance, anesthesia, amnesia and paralysis are due to dissociation,
while contractures, tics, hallucinations, hystero-epileptic attacks to automa-
tisms. Either dissociation or automatisms may predominate and un-
doubtedly our knowledge of these alterations needs to be further worked
out, and we are only on the threshold of a complete knowledge of them.
But a classification based upon pathology must give us a far better con-
ception of the disease than a mere clinical differentiation. The only ques-
tion is whether our pathological conception is correct.

It is for the above reason that Sidis drops the word hysteria entirely
and uses such words as psycho-pathic dissociation, psycho-pathic auto-
matisms, etc.

Dr. Prince realized that such cases as Dr. Spiller reported are not
those which ordinarily are clinically classified as hysteria, but he believed
that fundamentally it would be found, if they were subjected to a search-
ing analysis, that psycho-pathic dissociation and automatism was the
underlying pathology ; therefore he called them hysteria.

He also thought that Janet was too precise in making such a sharp
difference between hysteria and psychasthenia. That writer's conception
of hysteria necessitates a dissociation of consciousness producing a sub-
consciousness of which the subject is not aware. The question then of
awareness of the obsessing ideas with him is a test of dissociation, but
plainly we may have dissociations of which the subject is perfectly aware,
as for example, dreams, hynotic states, automatic writing and speech, etc.,
etc. The obsessions of psychasthenia differ only from those of Janet's
hysterics in that the subject is aware of the former and not of the
latter. He did not believe this was a sound distinction, although he would
not class all so-called psychasthenics as hysterics.

Dr. Spiller's first case, that of C, reminded the speaker of the case of

M 11, which he had reported with Dr. Sidis. The main difference being

that the automatism in Dr. Spiller's case was purely visual, while in the

M 11 case it was both visual and motor. The vision which M 11

experienced was that of his employer, whom he always saw in a dream at

PHILADELPHIA NEUROLOGICAL SOCIETY 417

the beginning of his attack. Dr. Prince thought that if Dr. Spiller's case

C. had been hypnotized, as was M 11, we would have found various

sub-conscious phenomena which would have thrown light upon the attacks
and would have placed it in the pathological category of hysteria, if we
accept the above pathology of hysteria. He admitted that there were
cases which are difficult with our present knowledge to bring within
the above pathological conception of hysteria, and it may be that as Dr.
Spiller claimed, we shall have to make a third division to be called
strictly psycho-epilepsy. We should then have epilepsy, hysterical-epil-
epsy and psycho-epilepsy. The clinical problem would then remain, into
which division to place any given case. This perhaps seemed to be tak-
ing a back track, but he should want to see the pathology of hysteria
thoroughly worked out before making a third group of distinct pathology.

To illustrate his views, Dr. Prince described a couple of cases which
he had seen. The first case was that of a woman who, a short time ago,
had appeared at the clinic of the Boston City Hospital, complaining of
epileptiform spasms, from which she had suffered for the past six months.
The spasms occurred daily, sometimes several attacks taking place during
a day. While the patient was being examined an attack occurred, appar-
ently so far as one could see without ostensible cause, though, as it after-
wards appeared, an unsuspected emotional cause was really present. The
attack as witnessed was of the following character:

The patient remarked that an attack was coming on. She was stand-
ing at the time and described, on request, her sensation as they developed.
There was first a sort of aura consisting of a feeling of being "gripped"
in the region of the sternum. At the same time she experienced a strong
beating sensation as of the heart in the same region ; then she began to
feel faint and was obliged to sit down. At this moment there developed
a feeling in the lower abdomen as if it was being strongly drawn up-
wards ; then followed a succession of spasmodic movements of the ab-
dominal muscles, while at the same time there were clonic spasms of the
diaphragm causing a series of inspiratory movements. Finally the muscles
of the larynx and neck were thrown into strong clonic spasms. At this
point she made an effort to speak, but though she moved her lips and
tongue no sound was produced. From later investigations it appeared
probable that this aphonia was due to tonic spasms of the laryngeal
apparatus. (She knew what she was trying to say; namely, to describe
her sensations.) The attack then passed off, leaving her for a few
moments weak and with a severe headache. The whole attack from the
beginning of the aura to the end of the spasms lasted perhaps two
minutes, while the weakness and headache lasted a few minutes more.

The attack had all the appearance of Jacksonian epilepsy, for which
for the moment it was mistaken. It was soon learned, however, that the
attack could be brought on by a blow upon any part of the body; by this
method, for the purposes of study, the "attacks were brought on as often
as desired. Further study and analysis revealed the fact that the attacks
originated in an emotional shock and fright which she had received some
six months previously and developed out of a delirious condition into
which she fell as a result of the fright, and in which she imagined that
she had epilepsy, or the same disease from which her mother suffered.
This fear still persisted and brought on the attacks. It was very easy
by suggestions to completely cure her.

The second case to which he referred was one which he had already

418 PHILADELPHIA NEUROLOGICAL SOCIETY

reported with Dr. Sidis. The subject, a young man, for five years had
suffered from a series of attacks extending1 over a whole week, and
which when superficially observed appeared to be Jacksonian epilepsy.
During this week a condition representing status cpilepticus developed.
Through hypnosis it had been possible to show that the convulsions were
due to subsconscious ideas originating in a fright which he had received
five years before. The memory of the circumstances attending this fright
had recurred periodically, but sub-consciously ever since. A cure was
also brought about in this case.

Since this discussion, Dr. Prince has seen a case which in 1804 had
been diagnosed by himself and one of his colleagues as petit mal, but
which now in the light of a more searching analysis is plainly seen to
be one of some form of psycho-epilepsy, and is made up of functional
dissociation and automatism, call it by what name you will.

These cases illustrated the principle on which in his opinion such
cases should be pathologically classified as hysteria, though clinically the
manifestations might be very different from those which we are accus-
tomed to group under this name.

Dr. L. F. Barker said that the subject of psychasthenia and its relation
to other psychoneuroses was interesting them in Baltimore, and he, to-
gether with Dr. H. M. Thomas, the neurologist to the Johns Hopkins
Hospital, had been studying a number of cases recently in the light of
the more recent literature. They had come to the conclusion that a sharp
differential diagnosis was often difficult, and that the boundaries of the
individual psychoneuroses are as yet not very well defined. He was glad
to hear Dr. Spiller's interpretation of the cases he had studied. The loss
of consciousness in the attacks would seem to separate the cases from
typical psychasthenia, at any rate if we accept Janet's definition of the
syndrome. According to this French investigator the relation of psychas-
thenia to epilepsy is a very close one. He believes that in both diseases
there are remarkable oscillations of the psychologic tension. He attributes
both diseases to lowering of the psychologic tension. In epilepsy, how-
ever, the lowering is great and sudden and results in complete loss of
consciousness for a brief time, after which the tension again rises, he
thinks, so much that the patient feels very well, and does not even com-
plain of the sensations of incompleteness which are so characteristic in
psychasthenia. In some of the so-called epileptic deliria the true psy-
chasthenic states are more nearly approached. Indeed, psychasthenia, ac-
cording to Janet, may be regarded as a very attenuated chronic epilepsy
in which the lowering of psychologic tension is continuous, and yet is
never so gr.eat as to lead to complete loss of consciousness. If these
conceptions are right, the cases described by Oppenheim, and to-night by
Dr. Spiller, would have to be grouped as cases of psychasthenia with
epilepsy. It is obvious that the place of such cases in nosology will depend
entirely upon the definitions we give to the terms psychasthenia and
epilepsy. The case Dr. Prince describes would, he thought, undoubtedly
fall among true hysterical cases rather than in the psychasthenic group.

It seemed to him that the psychasthenic state may occur, perhaps, in
a whole group of diseases of different etiology, just as the old typhoid
state is now known to be a condition which may be manifest in infectious
diseases of different origin. We must study our cases at present very
objectively; later when we have collected sufficient data, a more specific
differentiation will be possible.

PHILADELPHIA NEUROLOGICAL SOCIETY 419

Dr. C. K. Russell, of Montreal, Canada, said that one of Dr. Spiller's
cases reminded him very much of a case observed at Queen's Square. It
was a girl of about twenty-two, who had been in the hospital fourteen
months previously with a condition very similar to what Dr. Spiller de-
scribed. She had attacks starting with great fear, and thought she saw
girls working in a room. She had never seen the girls or room before.
In later attacks she saw rooms with golden pillars, then she saw some
animals ; but her attacks were all of the same nature and over a certain
period were very similar. She was looked upon as having a hysterical
condition. She left the hospital, but was kept under observation. She
came back when he was there last year, and with these same attacks.
Althoug'h her eyes were examined regularly there was nothing ever
found until she had been in the hospital two or three days when she
developed optic neuritis, which increased rapidly, and when they were
discussing operation she suddenly died. At autopsy there was found a
large tumor invading the temporo-sphenoidal lobe.

Dr. Dana said he was much interested in the description of these
seizures because he had been studying and trying to classify them himself
for some time. A year ago he had read a paper before the Academy of
Medicine upon a condition which he called "para-epilepsy," in which he
described a number of forms of sensory seizures which he thought could
not be classed with hysteria or epilepsy and had ventured to suggest that
they should be grouped together as a special periodical neurosis. The
paper was only provisional and had never been published. There was
such a difference of views as to what was psychasthenia and what was
hysteria that it seemed difficult to him to come to conclusions about the
nature of these attacks unless we agreed as to what we mean by the terms.
There was a group of morbid mental conditions which were characterized
by morbid fears, doubting mania, abulia, fixed ideas. These had been
classed under the different names of degenerative insanity, neurasthenic
insanity, psychasthenias, etc. He did not think the word psychasthenia
exactly included this type now. But he thought all neurologists recognized
the type as a special and easily recognized one. The sufferers from this
condition which he had called "phrenasthenia" were subject to periodical
seizures of various kinds. Some of them like that which Dr. Spiller
described, though he had seen extremely few of them — only two. In
most of the cases the seizures were slight in character and might be
called the petit mal of phrenasthenia. In many of these patients their
trouble began with an attack. For example, a patient he saw recently,
after studying hard for two years, was sitting one evening smoking a
strong cigar, when he suddenly felt a tremendous sensation of the nature
of a general paresthesia come over him as if it were a douche. It began
in the head, passed down like an aura from head to feet. He fell back
and went into a condition of partial unconsciousness, with shakings and
tremblings. In the course of an hour or so revived. After that he had
a number of attacks coming several times a week in greater or less
violence. His fear of the return of these seizures gave him agoraphobia.
Many morbid fears are largely based on the fear that the patient will
have one of his seizures. This class of attacks should be put with the
seizures of psychasthenics.

{To be continued.)

Dertacope

Brain

(Vol. 29, No. 114, 1906.)

1. An Address on Mendelian Heredity and Its Application to Man. W.

Bateson.

2. A Contribution to the Study of Amaurotic Family Idiocy. F. J.

Poynton, J. H. Parsons and Gordon Holmes.

3. A Case of Orbital Encephalocele, with Unique Malformations of the

Brain and Eye. J. H. Parsons and George Coats.

4. A Study of the Various Changes which Occur in the Tissues in Acute

Diphtheritic Toxemia, More Especially in Reference to Acute
Cardiac Failure. Leonard S. Dudgeon.

1. Mendelian Heredity in Man. — Bateson presents a brief sketch of the
Mendelian hypothesis of heredity in its applications to some of the dis-
eases of mankind, notably color blindness, congenital cataract, etc. He
urges the study of hereditary diseases in the light of the Mendelian
hypothesis. The paper does not permit of an abstract.

2. Amaurotic Family Idiocy. — The authors, from an examination of
three cases of this affection, show that: (1) There is strong evidence
that it is a primary disease of the nervous elements. These are affected
not only throughout the whole nervous system, but also in the dorsal root
ganglia and in the retina, and so universally that not a single normal cell
can be found. The changes which have been described, and all the evi-
dence that could be obtained on the mode of their development, prove that
the disease is not due to a primary affection of the neuroglia, but that the
proliferation of the latter has only followed the degeneration of the
nervous elements. Further, there is no evidence to suggest that the changes
of the nervous elements resulted from any vascular condition, there was
no visible disease of the vessels and no signs of either old or recent in-
flammation. (2) Though they employed different methods for the demon-
stration and estimation of pathological changes in the different parts of
the neurone, it can be asserted that the nerve cells are relatively more
affected than the fibres. In many systems, as in the direct cerebellar
tracts, the dorsal and ventral spinal roots, and the optic system, there
may be no visible change in the fibres though the cells from which they
spring are severely altered. From this fact it may be concluded that the
affection is a primary cell disease, and that the alterations visible in nerve
fibres are only secondary to this. (3) The condition of the nerve cells as
demonstrated by the elective stains (Nissl's, Bielschowsky's), for their
component parts, shows that the interfibrillar protoplasm is very much
more severely affected than are the neurofibrils, and suggests that the
primary change is disease of the interfibrillar protoplasm, and that to this
the alterations in the neurofibrils are secondary.

Certain conclusions can also be drawn on the etiology of the disease
from its morbid anatomy in conjunction with its clinical symptomatology:
(1) It is not due to arrested development. If it were so, the clinical symp-
toms of the disease would be probably evident from birth which has not
been so in any of the cases observed ; and there is no reason why a mere

PERISCOPE 42i

arrest of development should produce a progressive and invariably fatal
disease. There is also little anatomical evidence of mal-development, and
the appearance on which Sachs lays so much emphasis can be explained by
the wasting the cerebral convolutions must undergo as a result of the
disease. Further, the most easily-obtained evidence of the completed
development of the nervous system, myelinisation of the brain, proves that
the final development of the different parts of the brain is completed at
different periods in a fairly long space of time, and is not completed till
a few months after birth. But the examination of these brains does not
indicate greater abnormalities in the regions which develop late than
in those where development is completed early in intra-uterine life; e. g.,
the visual cortex, which is myelinated early, is quite as severely affected
as the prefrontal region where the myelinated fibres appear late. If,
however, the disease dates from the earlier months of extra-uterine life,
the development of the fibres which myelinate late may be checked owing
to deficiency of trophic influence from the diseased cells. (2) The nega-
tive results of the bacteriological examination and the entire absence of
such reactions in the vascular and lymphatic systems as frequently ac-
company bacteriological infections suggest that the disease is not due to
bacterial toxins. The clinical facts also argue against this theory; its
family nature, its occurrence only in the Jewish race all militate against
this view. (3) The final conclusion possible, which is supported by the
microscopical investigation, is that the disease is due to some inherent bio-
chemical property of the cells, as a result of which it undergoes certain
changes which result in its degeneration, and, consecutively, in degenera-
tion of the parts of the neurone (neurofibrils, axis-cylinders and myelin
sheaths), the normal existence of which is dependent upon it. The cell
changes have not the characters of a simple atrophy; in fact they seem
to be due to an excessive growth of the protoplasm which later undergoes
degenerative changes. This fact is not in favor of Sachs' hypothesis that
the pathology of the disease can be described by the term abiotrophy (a
term suggested by Gowers to represent an inherent defective vitality in
the cell), or of Schaffer's suggestion that it may be explained by Edinger's
"Ersatz-theorie," which assumes that elements are inherently feeble and
undergo degeneration when exposed to the strain of life to which they
are not normally resistant.

3. Orbital Encephalocele. — The authors present a detailed report of an
extremely rare congenital abnormality of the eye, and an apparently unique
malformation of the brain. Three congenital abnormalities of the globe
were present: (1) Coloboma of the choroid, (2) Coloboma of the optic
nerve entrance: the ectasia had taken place to the inner side of the inter-
vaginal space, and the latter has not been displaced with the nerve, but
has retained its normal position, (3) A central or macular coloboma. The
globe abnormalities were probably due in large part to the orbital en-
cephalocele. An isolated mass of brain substance had probably been
snared off at an early period of foetal life and had interfered with the
proper budding of the primary optic vesicle. It seemed probable to the
writers that this alone would not explain the anomaly. Since there was
no defect below, either in the nerve or in the retina, it seemed evident that
a secondary optic vesicle was formed and closed in a similar manner, and
that the defects in the globe were caused by the pressure of the brain

423 PERISCOPE

masses on the growing secondary optic vesicle. The macular coloboma
remains inexplicable.

4. Changes Due to Diphtheria Toxemia. — Dudgeon contributes a
lengthy, well-illustrated and detailed morphological study of the tissue
changes in acute diphtheritic toxemia, paying particular attention to the
changes thought to be responsible for acute cardiac failure. Sixteen cases
served as a basis of the examinations in conjunction with extensive ex-
perimental work. The changes found in the tissues coincide with those
with which pathologists are already familiar. He concludes, however, (a)
That the most important lesion in the acute cases is a fatty change of
the heart muscle and diaphragm, which is due to a direct action of the
toxins on those tissues, (b) That similar fatty changes may be found in
certain of the important viscera, especially the adrenal gland and liver, (c)
That the expression "cardiac paralysis" in acute diphtheritic toxemia
should be abolished and replaced by "acute cardiac failure," (d) That
the changes found in the nervous system are secondary factors and not
the primary cause of cardiac failure, (e) That the antitoxin, if given in
sufficient quantity and within the first forty-eight hours, may prevent or
considerably diminish the possibility of death from cardiac failure.

Jelliffe.

Miscellany

Fractures of Base of Skull. (Annal. of Surg., December, 1906.) — Drs.
L. R. G. Crandon and Louis T. Wilson analyze 530 cases of fracture of the
base of the skull. The mortality was 44 per cent. Alcoholic intoxication
was present in 32 per cent., of whom 38 per cent. died. Many of these
developed delirium tremens, which could not be wholly differentiated
from symptoms of laceration or meningitis. Forty-four per cent, were
unconscious at first examination, and fully half the conscious ones were
dazed or stupid. Fifty-eight per cent, of the unconscious died, against 33
per cent, of the conscious. Early delirium was usually due to alcoholism,
but when late, infection was the cause. Hemorrhage from at least one
cranial orifice was present in 74 per cent., the order of frequency in this
series being the ear 281, nose 168, subconjunctival 53, two ears 47, mouth
44. In practically all cases of aural hemorrhage the drum was ruptured.
Where pharyngeal bleeding occurs the mortality is very high. Respiration
as a symptom is unimportant except in primary shock and toward a fatal
termination, and the quality of the pulse is of greater significance than its
rate. In 117 cases presenting stertorous breathing' 106 died. A subnormal
temperature seems to indicate shock or alcoholism. Nearly all those with
high initial temperature died. The escape of cerebrospinal fluid was noted
in only 27 cases of this series. The most striking result of the study
of pupillary change was that in 142 cases without reaction 131 died. Of
these 530 cases 59 were operated, with a mortality of 53 per cent. The
writers conclude that only those cases should be trephined where either
hemorrhage seems the most important part of the clinical picture or the
course is considered one of continuous and progressive intracranial com-
pression. Patients with non-reacting pupils, or unconscious with stertorous
respiration are nearly always bleeding deep in the brain substance, and are
hopeless. It is urged that in suspected basal fracture that rest in bed for
three full weeks be enjoined. Cowles (New York).

Cerebrospinal Meningitis. By J. S. Billings, Jr. (Journal A. M. A.,
June 2).
Dr. Billings gives a history of the epidemic of cerebrospinal meningitis
in New York City in 1904-05, with the methods employed to meet it. It

PERISCOPE 423

began in the early part of 1904, and continued through 1905. During 1904
there was a total of 1,083 deaths and a death rate of 4.6; during 1905, 1,511
deaths and a death rate of 6.3. Fifty-five per cent, of the cases were males
and 45 per cent, females. The cases occurred mostly in children, only 19
per cent, being adults and only 1 per cent, over 50 years of age. Italians
seemed particularly susceptible and negroes the least. The great majority
of the patients were evidently of the poorer class, 76 per cent, residents of
tenement houses and often living under insanitary conditions. In only 6
per cent, had there been any direct exposure to other cases of the disease
and in only a small number was there evidence of direct transmission. In
the majority the attack began without antecedents; only 6 per cent, were
in bad health. The onset was sudden in all but 5 per cent. Stiffness of the
neck was the most common symptom and closely following it came vomiting,
headache and convulsions. Eruption was present in 30 per cent, of the
cases; it was petechial in 19 per cent., and herpetic in 11 per cent. "Nasal
discharge was noted in only 13 per cent. Of complications, those of the
eye were most frequent, next came muscular paralyses, then otitis. In 33
per cent, of the cases, lumbar puncture was performed to confirm the
diagnosis and the meningococcus was found in 82 per cent. In the re-
mainder the diagnosis was by clinical signs only. Death usually was
due to coma and exhaustion. About 7 per cent, of the patients died on the
first day, less than 34 per cent, during the first five days and 39 per cent,
after ten days. Recovery was complete in 84 per cent, of the recoveries.
Diphtheria antitoxin was employed in 313 cases, with a mortality of 69
per cent. Large doses were no more effective than small ones. While
its harmlessness was demonstrated, no credit is given it as a curative agent.
In conclusion, Billings says that little light has been thrown on the mode
of transmission of the disease, nor has any effectual treatment been dis-
covered. It is to the laboratory that we must look for further light. One
imortant fact brought out is that, in all probability, the disease is much
the most infectious during the first two weeks. The Department of
Health acted on this knowledge, enforcing quarantine, etc.. during the
first two weeks and insuring disinfection of rooms and bedding. As a
possible consequence of this the number of deaths reported for the first
six weeks of 1906 have been 102, as compared with 170 for the same period
in 1905.

Uniocular Optic Neuritis and Retinitis. By A. A. Hubbell (Journal
A. M. A., July 7).
The author remarks that the ophthalmologic text-books are compara-
tively silent on the subject of unilateral inflammation of the optic nerve
and retina. After a number of references to the literature, which, he says,
is also comparatively scanty, he reports and analyzes eighteen cases of his
own observation within the past fifteen years. It is difficult, he finds, to
fix any definite etiologic relations of the conditions. One-sided nephritis
existed in one case; there was more or less arteriosclerosis in five patients,
two of whom also had albuminuria; valvular disease of the heart, together
with previous cerebral hemorrhage, was found in one patient, while the
remainder were classed as healthy and without cerebral, vascular or kidney
disease. In a quarter century's experience in ophthalmologic practice, he
has never seen a case of optic neuritis that was not uniocular except when
there was syphilis or brain tumor. He has never seen a case of neurore-
tinitis or retinitis that was not uniocular, except when there was double
orbital cellulitis, Bright's disease, diabetes mellitus or syphilis. He does not
claim, however, that this must have been the experience also of others. The
treatment he has employed has been almost invariably the administration
of iodid of potassium, which he thinks has been of benefit in some cases.
In others it seemed ineffective. Hubbell considers the condition more
common than is indicated in ophthalmologic literature.

Booft "Reviews

The Dissociation of a Personality. By Morton Prince. London, 1906.

Miss Beauchamp is a person in whom several personalities have
become developed; these follow in regular succession, often changing
from hour to hour. The self with which she was born may change
to any one of the other selves, each of which has a different character.
Two of the selves have no knowledge of each other or the third;
when one of these is replaced by another there is a blank in memory;
when it reappears it finds itself of what it has said or done just before.
Miss Beauchamp is an actual case of Stevenson's Jekyll and Hyde.

Many cases of such multiple personality have already been reported
in considerable detail. Dr. Prince makes an exhaustive study of this
one. It would be hopeless to present in brief form the mass of details
that he has collected. Portions of the book make very interesting
reading, although there is a lack of systematic presentation making it
very often confusing. Scripture.

The Management of a Nerve Patient. By Alfred T. Schofield, M.D.
P. Blakiston Sons & Co., Philadelphia, Pa.

The book represents the author's ideas of psychic treatment of functional
nervous disorders and goes over the ground of ethics to be practiced be-
tween the consultant and the consulting.

The idea is strongly brought out that the fascination quackery has for
people is mainly by the means of suggestion, and that the only way to
overcome the evil is that physicians learn the value of suggestion and use
it, thus obviating the necessity of irregular practitioners.

The essential traits in the physician are shown to be sympathy, patience,
perseverance and attention to details. The author is resourceful in sug-
gestions regarding the management of a case.

He takes as a premise that matter is governed by mind, and the latter
not always being in the same vigor there are consequent deviations in the
organic processes, the first aim is to get the patient's confidence, change
the outlook on life and influence the unconscious mind so as to energise
it for good; suggestions to be made indirectly to the unconscious mind by
environment and treatment and changing the course of thought.

The value of hypnotism is doubted, emphasis is laid on a change of
environment during sickness and afterward, and that the recovered health
must never be used above its limit.

The general ideas are broad in scope, there is perhaps too much
entreaty for the ideas advanced, instead of a bold slash at the principles
involved.

It is not a book so much for the specialist as it is for the newly-
graduated student. S. D. Ludlum.

Jahresbericht ueber die Leistungen und Fortschritte AUF DEM
Gebiete der Neurologie und Psychiatrie. Herausgegeben von
Dr. E. Flatau und Dr. S. Bendix; Redegiert von Prof. Dr. E.
Mendel und Privatdozent Dr. L. Jacobsohn. IX. Jahrgang. Be-
richt iiber das Jahr, 1005. S. Karger, Berlin.
The ninth volume of this masterly review has appeared. It is arranged
in the same complete and thorough manner as its predecessors. It is un-
qualifiedly the most valuable general reference book that we possess, and
no active worker in neurology or psychiatry can afford to be without it.

Jelliff*.

Vol. 34. JULY, 1907. No. 7

THE

Journal

OF

Nervous and Mental Disease

©risinal Hrtfcles

UNILATERAL PARALYSIS AGITANS OCCURRING AFTER

HEMIPLEGIA.

By Joseph Sailer, M.D.,

OF PHILADELPHIA.

Unilateral paralysis agitans, so-called, is not an uncommon
condition. Two distinct forms can be recognized: that in which
the more obvious symptoms of the disease appear first on one
side, or are at least more pronounced upon one side, and that in
which the paralysis agitans has developed equally, but subse-
quently has, in consequence of hemiplegia, ceased, either tempo-
rarily or permanently, upon the paralyzed side. I have been un-
able to discover the record of any case in which, some years after
an attack of hemiplegia, paralysis agitans has developed and re-
mained restricted to the healthy side. The following instance
of this condition, therefore, seems worth reporting.

Mrs. D., now 76 years of age, had, at the age of 69, a stroke
of apoplexy, causing paralysis of the right side. Speech was
affected ; the mouth was drawn to the right, and the leg and arm
were paralyzed, but apparently incompletely. The speech soon
became normal again, and there was a considerable return of
power in the right arm and leg. At the age of J$ — four years
after her attack — she began to notice shaking in the left arm
and hand, which has continued to the present time, apparently
increasing very moderately in severity.

Owing to the somewhat imperfect memory of the patient, the
family history is untrustworthy, and the early previous history,
possibly for the same reason, appears to be unimportant. The
present condition is as follows:

She is very stout ; the legs are edematous ; the peripheral
arteries are in a state of advanced sclerosis ; there is a loud sys-
tolic murmur, heard best at the aortic cartilage, and transmitted
clearly into the vessels of the neck. Speech is apparently normal,

426 JOSEPH SAILER

although the patient claims that she cannot speak as well as she
did a year or two ago. The pupils are equal, and react to light,
but she states that her eyesight has failed recently. The ex-
pression is mask-like. In the left hand there is a persistent tremor.
At the wrist this consists in movements of extension and flexion ;
the thumb is in a position of apposition, and, with the fingers,
exhibits the characteristic pillroller's tremor. When the patient
attempts a voluntary movement the tremor stops completely, and
may remain absent for as long as two minutes, but if the move-
ment continues for a longer time the tremor reappears, at first
faintlv, but soon becoming more violent than during rest. There
is no tremor whatever of the right arm or hand during either
rest or movement. There is moderate impairment of power in
both arms and hands, apparently about equal in degree, but the
movements of the right arm appear to be more limited than those
of the left. The patient states that within a year the left arm was
considerably stronger than' the right. There is a tremor in both
feet at the ankle, resembling the oscillations of clonus. This
tremor disappears if the feet are forcibly flexed dorsally. The
tendon reflexes of the arms and legs are absent. Distracting the
patient's attention by asking her to count or look at the ceiling
does not cause them to appear, and Jendrassik's method cannot
be tried. The Babinski reflex is not present on either side. Walk-
ing is impossible, probably in part due to weakness, to the severe
edema of both legs, and to the excessive weight. While sitting
in her chair there is no sign of either propulsion or retropulsion.
There is distinct rigidity to passive movement of the left arm.

To summarize the case briefly : Seven years ago a woman of
69 developed right hemiplegia, from which she made a partial
recovery. Four years later she first noticed tremor in the arm
and hand of the opposite side, which has continued until the
present time. There is now the typical symptom-complex of
paralysis agitans in the left arm, with paresis of the left arm,
and tremors in both feet. In short, there is an incomplete
Parkinsonian hemiplegia, and some traces of an old organic
hemiplegia.

The first observation of a case of unilateral paralysis agitans
is credited to Marshall Hall, but as the tremor in his case (a
young man) developed only upon voluntary motion, then becom-
ing violent, and as there were also curious movements of the eyes,
and disturbances of speech, it is fair, I think, to conclude that his
patient was suffering from multiple sclerosis. Later observers,
however, have generally united in believing that paralysis agitans,

UNILATERAL PARALYSIS AC IT ASS 427

at least in its incipiency, is nearly always unilateral, although they
all state that in the course of a few years it becomes generalized.
(Brissaud, Eulenberg, Erb, Berbez, Wollenberg, Williamson, and
Gowers.) Fuerstner is the only author who states positively that
the disease may be limited to one side throughout its entire course.
Dutil records a case of 2 years' duration, atypical in some respects,
in which the tremor had remained limited to the left side. The
other symptoms were general in character. Berbez, in 28
cases examined in Charcot's clinic, found 3 cases in which the
tremor was unilateral, and 7 in which it was more pronounced
on one side than on the other. The three unilateral cases were in
the early stage, and there was no reason to believe that extension
might not ultimately take place.

Regarding the arrest of the tremor by hemiplegia, there seems
to be very little definite information in the literature. Eulenberg
and Lamy, both of whom have written comprehensive articles on
the subject for systemic works, have failed to mention it at all.
On the other hand, Gowers, Wollenberg, and Williamson speak
of it as a well-known fact. Gowers states that, if the paralysis
is not complete and permanent, the tremor may return, and Wil-
liamson states that the arrest of the tremor after cerebral hemi-
plegia is usually transient. Williamson makes the assertion that
there are two cases on record in which the arrest of the tremor
was permanent. Examination of the literature cited in the
monographs of Wollenberg and Williamson has failed to show
upon which actually recorded cases their statements were based.

The practical value of observations of unilateral Parkinson's
disease, and the effects of hemiplegia upon the tremor, consists of
its aid in the determination of the localization of the lesion. This
localization has been made in every part of the motor tract, from
the cerebral cortex to the muscular fibers.

The results of histological examination and investigations
have been contradictory. Changes have been found in the spinal
cord similar to those found in the cords of old persons suffering
from general arteriosclerosis, but these changes are by no means
constant, observations by competent neuro-pathologists having
failed to reveal any changes at all. (Fuerstner.) No characteristic
changes whatever have hitherto been found in the cerebral cortex,
although th$ majority of neurologists now believe that the lesion
is situated there. A few, basing their opinion upon some of the

428 JOSEPH SAILER

symptoms, and the fact that occasionally tumors of the peduncle
have caused symptoms resembling paralysis agitans, believe that
it is in the basal ganglia. Blocq and Marinesco believe that the
lesion affects chiefly the motor tract in the lower portions of the
brain.

It seems hardly worth while to repeat the various arguments
in favor of the cerebral localization. That based upon the uni-
lateral occurrence of the disease is not entirely satisfactory be-
cause, in disseminated sclerosis, even when the cord is chiefly
involved, the symptoms may be preponderant upon one side, and
the fact that paralysis agitans almost invariably invades the other
side, would be rather in favor of a general brain disease, or at
least a disease affecting the brain bilaterally, even if unequally,
than a disease affecting one hemisphere. It is easy to understand
how diffuse lesions of the pons or medulla might, under ex-
ceptional circumstances, produce tremor only upon one side of
the body. In practically all recorded cases there have always been
symptoms that show that the opposite side was sharing in the
disease. Neither does it seem to me that the cessation of the
tremor, after hemiplegia, necessarily indicates a cortical situation.
It merely suggests strongly that the cause of the tremor affects
the central motor neurones, not the peripheral neurones. And
this view is supported by the frequent reappearance of the
tremor with the restoration of power, which means a recovery of
the central motor neurones. It is of somewhat more significance
that the moderate injury of these central neurones may serve to
check the subsequent development of the tremor in the injured
side.

There is no question that, in a part that has been subject
to a tremor, it can be more readily produced than in a part in
which tremor has never occurred. In the same way, the
tremor of paralysis agitans, if inhibited for a time by a sud-
den injury to the central motor mechanism, may be apparently
easily re-established ; but if the central motor mechanism has
never learned to produce a tremor, then it is unable to acquire it
after a moderate degree of injury.

Of course, in the present case, although the time that has
elapsed since the onset of the tremor in the left arm is rather
longer than usually occurs without the development of a tremor
in the right arm, no definite statements can be made as yet. It

UNILATERAL PARALYSIS AGITAKS 429

is still possible that bilateral tremor will occur, just as, seemingly,
it has already occurred in the feet ; but even if it should subse-
quently occur, it will be justifiable to ascribe the long delay to the
hemiplegia.

LITERATURE.

Berbez. Gazette hebdom. de med. et de chir., 1889, p. 383.

Blocq and Marinesco. Compt. rend, de la Soc. Biol., 1893, May 27.

Brissaud. Legons sur les malad. nerv., 1894, Vol. 1, p. 469-

Dutil. Nouvelle Iconograph. de Saltpetriere, 1889, p. 165.

Erb. Deut. Klinik am Eingch., Vol. 6, p. 31.

Eulenberg. Ziemssen's Cyclopedia, etc., Vol. 12, Part II., p. 375-

Fuerstner. Arch. f. Psychiatrie, Vol. 30, p. 1. m

Gowers. "Manual of Diseases of the Nervous System, Second Edition,
Philadelphia, 96, p. 649. ..„„.« n ,r 1

Grasset and Ranvier. Traite de Med. (Bernardel & Gilbert), Vol.
8, 1902.

Marshall Hall. "On the Diseases and Derangements of the Nervous
System," London, 1841, p. 320. ,

Lam}'. Traite de Med., by Brissaud & Bouchard, Second Edition,
Vol. 10, p. 529.

Williamson, R. T. "On Paralysis Agitans," etc., Manchester, 1901.

Wollenberg. Nothnagel's System, 1899, Vol. 12.

•

A STUDY OF REFLEXES OF THE LOWER EXTREMITIES IN

SIXTY CASES OF PARESIS, WITH A SPECIAL REFERENCE

TO THE PARADOXICAL REFLEX.*

By Alfred Gordon, M.D.,

ASSOCIATE IN NERVOUS AND MENTAL DISEASES, JEFFERSON MEDICAL COLLEGE;
EXAMINED <3F THE INSANE AT THE PHILADELPHIA HOSPITAL, ETC

A systematic study of cutaneous and deep reflexes in pare-
tic dementia has been made by very few observers, and that
of Babinski's sign particularly only by a few isolated writers.
The consensus of opinion is that the "phenomene des orteils"
in paresis is an exception. Very recently Robert and Four-
nial (Revue Neurologique, No. 21, 1906) studied 66 cases and
found Babinski's sign present only in one case. The reason of
this rarity it is apparently difficult to explain, as on one hand
involvement of the motor tract in paresis is the rule, and on the
other Babinski's reflex is unquestionably a sign of an involve-
ment of the motor pathway in its central or terminal ends.

An ensemble study of all the reflexes well known to be
the expression of disease of the motor tract appeared to me to
be of some scientific interest.

As I have shown from my first clinical studies (Journ. OP
Nerv. and Ment. Dis., July, 1906), and subsequently from
the anatomo-clinical observations that the paradoxical reflex
is "a sign of irritation or early stage of a lesion of the motor
tract," it occurred to me that a study of this sign in a disease
in which Babinski against all expectations is absent, may be
of some pathogenetic value.

Anglade in 1898 (Arch, de Neurologie), Wyruboff in 1900
(Revue Neurol.), have shown on a very large number of path-
ological specimens that the participation of the cord in paresis
is a constant fact, and while the posterior columns are very
markedly affected, the pyramidal tracts are to a lesser de-
gree, but nevertheless invariably involved. WyrubofFs study
shows that all paretic cases from the anatomo-clinical stand-
point can be divided into three groups.

(1) First concerns cases characterized by markedly ex-

*Read at the meeting of the American Neurological Association, May 7,
8 and 9, 1907.

STUDY OF REFLEXES 431

aggerated knee-jerks and anatomically by a degeneration of
the posterior columns in the thoracic region and a recent de-
generation of the pyramidal bundles.

(2) In the second group the knee-jerks are abolished,
which corresponds to a considerable degeneration of the pos-
terior columns in the lumbar regions and some degeneration
of the pyramidal tracts.

(3) In the third group there is a marked degeneration of
the posterior columns through the entire cord and again some
changes in the pyramidal bundles.

Klippel, who made extensive studies of paresis, is also of
the opinion that a degeneration of the motor neurone in gen-
eral and of its portion in the cord particularly is a constant
phenomenon in paretic dementia.

The conclusion at which one can arrive from these studies
is that while the motor pathway is always involved, neverthe-
less it is only to a very slight degree in the majority of cases.
As Babinski's sign is usually the clinical expression of a well-
defined degenerative lesion of the motor tract, the very mod-
erate degree of pyramidal involvement will perhaps satisfac-
torily explain the rarity of the "phenomene des orteils" in
paresis.

On the other hand the study of the paradoxical reflex in
organic nervous diseases suggests very strongly that it is the
expression of a slight or early involvement of the motor tract.
This is proven beyond any doubt, I believe, by the anatomical
cases reported: one by Dercum (Journ. Nerv. and Ment.
Dis., Sept., 1906, p. 593), and the other by myself (Revue
Neurol., No. 22, 1906).

The presence of this reflex in a large number of paretic
cases and the comparatively slight involvement of the pyram-
idal tracts are therefore highly interesting and logically must
be considered more than a simple coincidence. In the study
of 60 well developed cases of paresis I found the paradoxical
reflex present in 42 instances : in 35 cases on both sides and
in 7 only on one side.

The reflex was present in 39 cases together with increased
knee-jerks and in 3 cases with absent knee-jerks. The latter
fact is quite remarkable for this reason, that in all my previous
studies the paradoxical reflex was always found to be asso-

432 ALFRED GORDON

dated with exaggerated patellar tendon reflex.

This anomaly is only apparent. The pathological studies
of the above writers show that even in cases of paresis of
tabetic type with loss of knee-jerks, alongside of total degen-
eration of the posterior columns, there is invariably also some
involvement of the pyramidal fibers. .

In two cases with increased knee-jerks the paradoxical re-
flex was absent. In one case with normal knee-jerks the para-
doxical was also absent.

In the seven cases with one-sided paradoxical reflex, the
latter corresponded to an exaggerated knee-jerk which was
present on the same side and absent on the other.

Babinski's sign was present only in 3 cases on both sides
and one side in 4 cases. It coincided with spasticity and
markedly exaggerated knee-jerks.

The antagonistic relation of Babinski's and paradoxical re-
flexes observed by me in my previous studies is fully corrob-
orated also in my present investigation. In all cases except
two where Babinski was present, the paradoxical was absent,
and vice versa.

Oppenheim's reflex deserves special mention. Some neu-
rologists expressed the opinion at the time of my first com-
munication that the paradoxical reflex is perhaps a modifica-
tion of Oppenheim's. In my second series of organic cases
reported to the Philadelphia" Neurological Society in December,
1905 (Journ. of Nerv. and Ment. Dis., July, 1906), Oppen-
heim's reflex was absent in 41 instances out of 58; only in 5
cases it was present together with the Babinski and paradoxical
reflexes. In the two pathological cases mentioned above the
paradoxical reflex was conspicuous, all others, except increased
knee-jerks, were absent, and operative procedures were decided
upon because of the exclusive presence of the paradoxical re-
flex. One case was seen by Keen, Dercum and myself, the
other by Mills, Dercum, Da Costa and myself. In my pres-
ent study of paresis I laid special stress upon the relation of
the paradoxical reflex to Oppenheim's, and the result was this,
that while the former was present in 42 cases, Oppenheim's
only in 8 cases, in 4 of which it was bilateral and in 4 uni-
lateral.

STUDY OF REFLEXES 433

Ankle-clonus was present only in n cases, in most of
which it was slight, and only in one case pronounced.

CONCLUSIONS

The present study appears to me to be of certain import-
ance for the following reasons :

The old triad of reflex phenomena, viz., exaggerated knee-
jerks, ankle-clonus and Babinski's sign, which we are accus-
tomed to find in hemiplegia or in any other organic disease
with a distinct degenerative lesion in the motor pathway, is
here markedly dissociated. While the first is present in the
majority of my cases, the other two are rare. Of the two more
recently described reflexes, Oppenheim's is also rare, while
the paradoxical is frequent.

In view of the fact that the pathological studies of compe-
tent observers show a constant presence of motor fibers' le-
sion, and that the latter is in the majority of cases only very
slight, — the rarity of Babinski's and Oppenheim's reflex, also
of ankle-clonus, and the frequency of the paradoxical phenomenon
acquire I believe for this reason a valuable clinical signifi-
cance.

These observations were made in the presence of Drs.
H. M. Stewart and B. Robinson, internes at the Philadelphia
Hospital. I am indebted to Dr. Hawke for the courtesy ex-
tended to me.

SENSORY AND MOTOR DISTURBANCES IN PARTS ABOVE

THE DISTRIBUTION INVOLVED BY DEFINITE ORGANIC

LESIONS OF THE SPINAL CORD.*

By T. H. Weisenburg, M.D.,

OF PHILADELPHIA, PA.

FKOM THE DEPARTMENT OF NEUROLOGY AND LABORATORY OF NEUROPATHOLOGY
OF THE UNIVERSITY OF PENNSYLVANIA.

The object of this paper is to call attention, first, to the
gradual extension of the areas of disturbed sensation above
the peripheral distribution related to definite lesions of the
spinal cord, and secondly, to the marked increase in the ten-
don and skin reflexes in the same parts, and in parts above.
These facts have not, heretofore, been noted.

These observations are based upon three cases, one with
necropsy. In all, the lesions were of long standing, being 35,
29 and 4 years in duration, and the sensory phenomena were
carefully studied and noted at varying intervals. The lesions
were of traumatic origin, and the symptoms were of such
clearness that it was possible in each case to make a clear-cut
diagnosis in definite localities of the spinal cord.

The cases are as follows:

Case 1. Morgan. Was admitted to the nervous wards of
the Philadelphia Hospital June 13, 1899, where he still is. His
past and family history are of no importance, has never used
alcohol or tobacco ; and has never had syphilis.

When 27 years of age he was struck across the lumbar
spine by a piece of iron and rendered unconscious. When he
recovered, he was unable to use his lower limbs, and has never
had more than slight use of them since. He has never had
any bladder or rectal disturbances, or bed sores. Consider-
able pain was present in his lower limbs for some years after
the injury, and girdle sense has always been present.

Notes by Dr. Van Epps made in January, 1900, state that
the patient had from January 1 to 14 herpetic eruptions ac-
companied by much pain in the left side of the body extending
from mid to mid line laterally and from costal margin to iliac
crest posteriorly, and the pubic line anteriorly. The vesicles
gradually disappeared but the pain continued for some time.

Examination on November, 1900, 28 years after the injury,

*Read at the meeting of the American Neurological Association, May
7, 8 and g, 1907.

SEXSORY DISTURBANCES

435

by me, denoted almost total loss of power in the lower limbs.
They were considerably wasted and spastic, more so the right.
The cremasteric, patellar and plantar reflexes were present
and prompter than normal ; ankle clonus was present on each
side, but the Babinski reflex could not be obtained.

Sensation for all forms was absent to a line corresponding

Fig.

Fig", i. Fig. 2.

I. The shaded areas represent disturbed sensation in 1900.

Fig. 2. The shaded areas represent disturbed sensation in 1907.

with the umbilicus. Above this point pin prick was appreci-
ated, but touch and temperature sensations were not normally
recognized until two inches above the umbilical line; just above
this line there was a zone of hyperesthesia and the patient com-
plained here of a girdle sense.

Examination by me on February, 1907, seven years after
the last examination and thirty-five years after the injury,

436 T. H. WEI SEN BURG

showed practically the same condition as to his motor power
in the lower limbs. He could only slightly move the toes
and knees. The cremasteric and patellar reflexes were still
increased, but ankle clonus could not be obtained; the Achil-
les jerks were present. Plantar irritation produced flexion of
all the toes. The bladder and rectum were normal.

The state of the sensation altered considerably. In my
first examination of this year, he was unable to recognize
touch, pain and temperature sensations over the lower limbs
and abdomen up to the line of the nipples, and sensation did
not really become normally appreciated until about the first
intercostal space. Subsequent examinations have confirmed
this, with the exception that pin prick was occasionally inter-
preted correctly below the nipple, but never more than two
inches above the line of the umbilicus. (Fig. 2.) Bone sen-
sation as tested by the tuning fork was diminished in the
lower ribs, but was gradually better appreciated as the upper
ribs were approached, and was normal about the second rib.

Power in the upper limbs was normal, and there was no
apparent atrophy present. In the finger to nose test some
ataxia was noticeable, but this was not marked. There was
some hypotonia in the elbow joints. The sense of position
was about normal, but on one occasion when absolute relax-
ation was obtained, it was demonstrated to some extent in the
fingers, wrist and elbow joints. The biceps, triceps and wrist
reflexes were prompter than normal, more so in the right side.
On tapping with the percussion hammer over the chest and
shoulder prompt contraction could be obtained in the cor-
responding muscles, so that practically reflexes could be ob-
tained wherever desired.

X-ray examination made by Dr. Leonard D. Frescoln
showed an inflammatory thickening (probably periostitis)
around 10th to 12th thoracic and 1st lumbar vertebrae.

Summary. A man of 27 years, as a result of a severe blow
to the 10th, nth and 12th thoracic and first lumbar vertebrae
sustained complete paralysis of the lower limbs. There must
have been an almost complete transverse myelitis of the 9th,
10th, nth and 12th thoracic spinal segments. An. examina-
tion made by me 28 years after the injury denoted a spastic
paralysis of the lower limbs with increased tendon reflexes,
and disturbed sensation up to a line 2 inches above the um-
bilicus. The bladder and rectal functions were at no time in-
volved. Examination made also by me 7 years later and 35
years after the injury showed the same condition as to motor
power in his lower limbs, but sensation was disturbed to the
first intercostal space. The tendon and skin reflexes in the
upper limbs and in the reflex arcs of the chest and shoulder
muscles were markedly exaggerated.

SEXSORY DISTURBANCES

437

Case 2. Egan. Was admitted to the nervous wards of the
Philadelphia General Hospital, May n, 1892. His family
and past history were of no importance and there was no his-
tory of alcoholism or syphilis. In 1884, at the age of 35, the
patient lost his balance while on a running freight car, and
fell to the track, striking his lumbar spine. He then lost

Fig. 3-

Fig. 3. The shaded areas represent disturbed sensation in 1899.
Fig. 4. The shaded areas represent disturbed sensation in 1907.

almost all power in his lower limbs and control of his blad-
der and rectum.

Notes made in June, 1899, I5 years after the injury, by Dr.
G. E. Pfahler, state that the patient had loss of power in the
lower limbs with the exception of some ability in flexing the
right thigh on the abdomen. Bladder and rectal functions
were completely lost. Sensation was lost as indicated in
chart No. 3.

438

T. H. WEISEKBURG

Examination by me in February of this year (1907), 23
years after the injury and eight years since the last examina-
tion, showed almost the same condition as regards the motor
power of the lower limbs. The only movement possible was
that of slight flexion of the right thigh on the abdomen. The
toes were extremely hyperfiexed and cyanotic. All of the ten-
don reflexes in the lower limbs were lost. Plantar irritation
produced no movement of the toes. Bladder, rectal and sex-
ual functions were totally lost.

Sensation for all forms was totally lost in the lower limbs
and buttocks, with exception of a small area just in the inner
surface of both thighs, and over the lower parts of the abdo-
men, to an irregular line about two inches below the um-
bilicus. From this line to a line drawn about 1 to 1/2 inches
above the umbilicus, sensation became gradually better appre-
ciated, being normal at the above point. (Chart No. 4.)

Power and movement was normal in the upper limbs. The
biceps and triceps tendon reflexes were very prompt, more so
on the left side. On tapping with a percussion hammer over
the chest and shoulders prompt contraction could be obtained
in the corresponding reflex arcs. The abdominal reflexes were
lost on both sides, as were also the cremasteric. In the finger
to nose test, some ataxia was present, more so in the left limb.
Sensation was normal in the upper limbs.

The X-ray examination denoted caries of the body of the
third lumbar vertebra, especially towards the left side.

Summary. A man of 35, as a result of a fall, became com-
pletely paralyzed in the lower limbs with total loss of bladder
and rectal functions. There must have been a complete trans-
verse myelitis of all portions of the cord below the 2nd and 3rd
lumbar segments. An examination made 15 years after the
injury denoted almost a complete flaccid paralysis of the
lower limbs with the exception of a slight ability to flex the
right thigh on the abdomen. The bladder and rectal functions
as well as all of the tendon reflexes were totally lost. Sensa-
tion was disturbed over both lower limbs, buttocks and
perineum with the exception of a tringular area over the front
of the thighs. An examination made 8 years later and 23 years
after the injury showed the same condition as to the motor
power in the lower limbs, but sensation is now disturbed to a
line about iy2 inches above the umbilicus. The tendon and
skin reflexes in the upper limbs and over the chest and shoul-
der are markedly increased. There is some ataxia in the upper
limbs.

The third case, a brief history of which is only given, does
not illustrate the sensory and motor changes which are the
subject of this paper, but is used because it was a case of trau-
matic myelitis in which a careful microscopic examination

SENSORY DISTURBANCES 439

was made, and in which the pathological findings are illus-
trative of the changes which probably have occurred in the
two similar clinical cases here recorded.

Case 3. This case was recorded by Dr. Spiller and myself
in the Review of Neurology and Psychiatry, October^ 1904. A
young man, because of an injury to the back, sustained com-
plete paralysis of both lower limbs and of the bladder and
rectum. All of the tendon reflexes of the lower limbs were
lost. When examined by me one year after the injury, sensa-
tion was lost to a line corresponding about 2 inches below the
umbilicus, and further examination made 3 years later and 4
years after the injury denoted absence of all sensation to a line
drawn about 1 inch below the umbilicus.

A careful microscopic examination of sections taken from
the upper part of each segment of the spinal cord from the
10th thoracic to the upper part of the cervical enlargement
showed that as high as the upper part of the 10th thoracic
segment, the cord was completely destroyed. Many normal
fibers entered the cord in the posterior roots of the 9th thoracic
segment.

Examination of the sections above the 9th thoracic seg-
ment stained by the Weigert hematoxylin method showed
that the posterior root entrance zones, and the columns of Bur-
dach and Goll were much better and more deeply stained than
the other portions of the cord. A marked thickening was also
found in the walls of the arteries, besides the usual ascending
secondary degenerations.

We have here, therefore, two cases of definite lesions of the
spinal cord; one involving the 9th to the 12th thoracic seg-
ments; and in the other the spinal cord below the 2nd or 3d
lumbar segments. In both the lesions were of long duration,
being 35 and 23 years, and the sensory symptoms were studied
and noted at intervals of 7 and 8 years respectively. The
areas of sensory disturbances increased in the period of 7 years
in the first case from a line drawn 2 inches above the umbili-
cus to the 1st intercostal space, and in the second case from
irregular areas over the thighs to a line drawn about iy2
inches above the umbilicus. In these areas of increased sen-
sory phenomena, sensation was lost absolutely only about
2 or 3 inches, and above these parts there was a gradual shad-
ing off of disturbed sensation. The important point is that
the areas of disturbed sensation have markedly increased
above the limits previously found.

440 T. H. WEI SEN BURG

What are the causes of this increase in the sensory dis-
turbances? The first answer which naturally presents itself,
is an extension of the myelitic process, and secondly, the pos-
sible influence of the secondary ascending degenerations.

Let us consider first the possibilities of the occurrence of
an ascending myelitis. It is well known that whenever the
spinal cord is injured, even in a restricted portion, that the
parts both above and below the point of injury may have small
areas of hemorrhage or of softening. In fact the whole extent
of the spinal cord may be so involved. In most instances after
the subsidence of the acute process, these areas of softening
and myelitis disappear and no trace of them is to be found,
and clinically no symptoms appear. It is more than probable,
however, that they are replaced by neurogliar tissue and we
may have here the origin of a future sclerotic process.

The spinal cord receives its blood supply from the anterior
and posterior spinal arteries, both of which arise from the ver-
tebral, and from the intercostal branches. These intercostals
have ascending and descending branches, which anastomose
freely with one another and with the anterior and posterior
spinal arteries, making an arterial network about the spinal
cord, from which numerous small branches penetrate the sur-
face. The gray matter receives its blood supply principally
from the anterior spinal arteries, and it is to be noted that this
supply is largely from different branches than that of the
white matter. It is also to be remembered that the arteries
which enter the cord are terminal. Considering this, it can
be readily understood how a destruction of a number of spinal
segments would cause interference with the blood supply, first
of the whole cord, and after the acute symptoms have sub-
sided, especially of the contiguous parts. This arterial oblit-
erative process in common with all degenerations has a ten-
dency to increase, and if the patient lives long enough, would
involve considerable portions of the spinal cord.

In the case with necropsy (Case 3) the arterial degeneration
is evident. Sections of all parts of the cord show marked
endarteritis and this seems to be much more apparent in the
lower parts of the cord near the lesion, and especially so in the
periphery and in the lateral columns. The vessels in the gray
matter seem less sclerosed, the reason for this greater endar-

SENSORY DISTURBANCES 44*

teritis in the white matter of the cord being the more ready
involvement of the arterial supply. This has only recently
been called attention to by Allen.1

It is probable that a similar arteritic process is present in
the clinical cases here recorded, but of much greater intensity
as the lesions are of 35 and 23 years' duration as compared
with 4 years in the case with pathological findings. This en-
darteritis causes impairment in the nutrition of the parts;
this resulting in a gradual necrobiosis and impairment of func-
tion. In this is to be found the probable explanation of the
increase in the sensory disturbances.

What influence, if any, do the secondary degenerations
have? This question has long been in dispute, from the time
that Charcot first explained the occurrence of the contractures
in hemiplegia as the result of secondary degeneration of the
motor columns. Take, for instance, in the case with necropsy.
Here as a result of a myelitis in the 9th thoracic segment,,
marked secondary degenerations are to be found in the cervi-
cal cord. In studying such sections stained by the Weigert
hematoxylin method it seems as if these extensive degenera-
tions must have some influence, if not upon the neighboring
fibers, at least upon the fibers which mingle with them.

Let us try to analyze this. In a lesion of one internal cap-
sule interrupting the motor columns, secondary degeneration
results throughout the whole extent of the pyramidal tract.
Such degeneration will, at first, only be apparent by the Mar-
chi and later by the Weigert hematoxylin method.

The question is whether this has any influence upon the
structures which are associated with it. We assume that there
is a connection between the cells of the anterior horns of the
spinal cord and the motor columns, and if this is true, as we
have every reason to believe, a degeneration of the motor col-
umns should have influence upon these cells, and yet patho-
logically this has never been satisfactorily demonstrated. That
is no argument, however, that this does not actually occur.
Clinical evidence shows sufficiently that in hemiplegia there
are atrophy and vasomotor disturbance ; these have never been
satisfactorily explained, but are probably due to a loss of

'A. R. Allen, University of Pennsylvania Medical Bulletin, 1905.

443 T. H. WEISENBURG

tone of the whole motor system of which the motor nuclei in
the anterior horns of the cord play a prominent part.

When a paralysis occurs, as for instance, because of a cap-
sular lesion, how is loss of power produced? There is as a
result of this lesion, immediate disturbance of physiological
relation between the cortical motor cells, the pyramidal tracts,
the cells of the anterior horns, the anterior spinal roots, the
peripheral nerves, and the muscles, tendons and fascia these
supply. More than this, there must be some disturbance of
the normal relation with the sensory arc.

This disturbance of physiological relation, or "diaschisis,"
as Von Monakow has termed it, is, of course, immediate, and
will become permanent in varying degree ; this depending
upon the extent of the original lesion. And how is this dis-
turbance of relation manifested? Clinically by loss of power
and pathologically by degeneration of fibers. This degenera-
tion, which is called secondary, is progressive as shown by the
reaction to the Marchi and Weigert stains. So far our micro-
scopic methods have failed to demonstrate any changes in the
cells of the anterior horns, and in the nerves and muscles.
This, however, is mainly because of the recuperative power
possessed by the motor cells on account of the innervation re-
ceived from other sources, and the independent trophic action
which they possess. We see then that what is termed sec-
ondary degeneration is really nothing more than the physio-
logical or mechanical death of a part.

What action, if any, then, has this secondary degeneration
or physiological death of a part? Evidently none, for what-
ever has produced this, has at the same time produced loss of
function in the related parts. Secondary degeneration, how-
ever, does produce from the very nature of its slow death,
some physiological disturbance. Take for instance the motor
columns. Even though there is a complete destruction of
these as a result of a capsular lesion, other motor fibers, the
so-called extra-pyramidal bundles, join the motor columns in
their course downwards. Whether these bundles intermingle
freely with the motor columns in the pons and medulla, or
whether they are independent in their course, has not been
fully determined; but it is known that they ultimately join
the motor columns in the spinal cord and probably mingle

SENSORY DISTURBANCES 443

with them. We can readily imagine that the degenerated or
dead fibers must have some detrimental action upon the
healthy fibers.

This can be better demonstrated in the so-called ascending
or sensory degenerations. Take, for instance, in Case 3, in
which because of a lesion in the 9th thoracic segment, the
secondary degenerations are marked. As we go higher and
higher, newer fibers enter by means of the posterior roots, and
join either the posterior columns or the columns of Gowers
and the direct cerebellar tracts. These newer fibers intermin-
gle, or at least, accompany the degenerated fibers.

This influence is probably the result of a vascular change.
The blood vessels that supply or are in association with a de-
generating or degenerated tract must share somewhat in the
sclerotic process, and it is conceivable that as a result of this
obliterative arteritis, some degeneration is produced in the
contiguous or intermingling healthy fibers.

In the case with necropsy a careful examination of sec-
tions of the spinal cord above the lesion showed that the fibers
in the posterior columns and in the entrance root zones were
much better or more deeply stained than the fibers in the
other parts. The pallor in the centripetal columns can be ex-
plained as the result of secondary degenerations, but this does
not explain the apparent degeneration in the motor columns.
Retrograde atrophy of the pyramidal tracts has been de-
scribed, and it occurs in the motor columns above destructive
lesions of the spinal cord. This is as we should expect, for
when physiological relations are disturbed, as they would be
in such case, there must be some disturbance of function in
the whole motor system as has been indicated above. This
disturbance is manifested pathologically by a downward de-
generation of the motor columns below the point of lesion, but
is not apparent in most instances in the parts above, at least,
by our pathological methods. This is because these fibers still
retain their trophic cortical innervation. Reasoning from this
then, retrograde atrophy must occur in every case, in the mo-
tor as well as the sensory tracts.

The increase in the sensory phenomena in the parts above
the peripheral distribution related to definite lesions of the
cord, has an important practical bearing. Most of our obser-

444 T. H. WEISENBURG

vations upon sensory areas are based on definite lesions of the
spinal cord, in which no attention has been paid to a possible
increase of the sensory phenomena, as is pointed out in this
paper. Manifestly then such observations in which the lesions
are of long duration cannot be as accurate as those which are
the result of lesions of a shorter time. In this is to be found
one explanation of the great variance in the sensory dia-
grams.

The second part of this paper is to again call attention to
the increase of reflexes in the parts above definite lesions of
the spinal cord. This clinical fact was first called attention to
by me in 1904. ("Clinical Report of Three Cases of Injury
to the Lower Spinal Cord and Cauda Equina."2) In this paper
I called attention to the increase of patellar jerks in a lesion
of the cauda equina. As this subject is an important one
and as no other writer has contributed to it, some of the re-
marks then made pertaining to the subject will be quoted.

"I have been unable to find any reference to this condition
in the literature at my command, except in Thorburn's3 con-
tribution to the surgery of the spinal cord. This author men-
tions the following cases with increase of the patellar reflexes,
but pays no special attention to this subject. One case I have
found also reported by Franz Volhard.4

"First case, cited by Thorburn from Kirchoff; backward
crushing of the first lumbar vertebra causing a degeneration
of the fourth and fifth sacral segments, the only symptoms
being paralysis of the bladder and rectum and increased patel-
lar reflexes. Sexual and sensory changes are not mentioned.

"Second case: a partial compression of the cauda equina
about the level of the last lumbar vertebra, causing severe
neuralgic pains in the sciatic and pudic distributions, a weak-
ness of some of the muscles of the lower limbs, but no com-
plete paralysis and no anesthesia of the limbs. The bladder
and rectal functions were paralyzed. The patellar reflexes were
slightly exaggerated, but there was no ankle clonus.

"The third case is cited by Thorburn from Oppenheim, and
was one of fracture of the first lumbar vertebra, causing a my-

*The American Journal of the Medical Sciences, May, 1904.
•Philadelphia, Blakiston & Son, 1899.
'Deutsche med. Wochen., 1902, No. 33.

SENSORY DISTURBANCES 445

•elitis of the conus medullaris. There was a slight weakness
of the calf muscles, otherwise no loss of power or atrophy.
Anesthesia was limited to the peroneal region and buttocks.
There was paralysis of bladder and rectum. Here also the
knee-jerks were exaggerated, but there was no ankle clonus.

"The fourth case, by Volhard, of a tumor of the cauda
equina, as proved by necropsy, with motor and sensory symp-
toms, absent Achilles jerks, and weakness of the plantar re-
flexes, but both the patellar reflexes and the cremasteric re-
flexes were exaggerated.

"In all four of these cases, therefore, the exaggeration of
the patellar reflexes was probably caused by lesions below the
reflex arc."

In the two clinical cases now recorded, the tendon reflexes
in the upper limbs, that is, the biceps and triceps, were very
prompt and the skin reflexes over the shoulders and chest were
exceedingly exaggerated. Tapping over any portion of the
chest, shoulders or back produced prompt and marked con-
traction in the corresponding reflex arcs. How is this to be
explained? Quoting again :

"It is difficult to find a satisfactory explanation for such a
phenomenon as this, but evidently the reflex arcs are in some
way thrown into a state of excitation in these cases. No
writer has made this a subject of careful study, and it seems
therefore important to emphasize the fact that a reflex may be
increased by a lesion in the spinal cord below the portion in
which the reflex arc is represented. Considerable evidence is
offered that in the nervous system there are both depressomo-
tor and excitomotor fibers for the different reflexes, these hav-
ing their origin in the brain ; and it may be that other excito-
motor fibers arise. We know that spinal roots on entering
the spinal cord give off descending branches that pass down-
ward in the posterior columns; the function of these fibers is
entirely unknown, but we must assume that in some way they
affect the function of the lower segments. It is probable that
in a similar manner the lower spinal segments exert some in-
fluence over higher segments, and there is no doubt whatever
that in the antero-lateral columns degeneration of short fi-
bers occurs upward. It is presumable that these fibers exert
some control over higher segments than those in which they

446 T. H. WEISENBURG

arise, and in this way possibly cause an exaggeration of ten-
don reflexes."

It is also probable, as has been shown in the present paper,
that the disturbance in the arterial supply in the parts above
definite lesions of the cord, produces a disturbance in the func-
tions in the motor columns, this being further influenced by
the retrograde atrophy. As has been shown by Rothmann, the
only constant symptom of a lesion of the motor column is an
exaggeration of the reflexes. Here, then, is to be found the
explanation of the reflexes in the parts above lesions of the
spinal cord.

The following conclusions can be drawn from the study
of this paper:

First: An injury to the spinal cord will cause at first in-
terference with the blood supply of the whole cord. If, as a
result of such an injury, there should be produced a limited
lesion of the spinal cord, there will be interference with the
blood supply of the contiguous areas. This interference will
be progressive, thus causing arterial obliteration and necrosis
in the contiguous parts.

Second : This progressive degeneration will cause disturb-
ance of function, it being manifested clinically by a gradual
extension of the areas of disturbed sensation, and by increase
in the tendon and skin reflexes.

Third : A lesion in any portion of the spinal cord will
cause disturbance of physiological relations in the associated
parts. This disturbance is greatest directly after the injury,
and becomes less in the course of time.

Fourth : Secondary degenerations "per se" do not produce
any direct symptoms, for whatever has produced secondary de-
generations, has at the same time caused loss of function in the
related parts. Secondary degenerations, however, cause some
physiological disturbance. Every degenerating or degenerated
tract has healthy fibers from other sources mingling with it.
The arterial degeneration present in the involved tract will
cause degeneration in these healthy fibers, and of the imme-
diate fibers surrounding the degenerating tract.

KORSAKOFF'S PSYCHOSIS SUPERIMPOSED UPON MELAN-
CHOLIA.*

By John W. Stevens, M.D.,

ASSISTANT PHYSICIAN, LONG ISLAND HOME, AMITYVILLE, L. I.

In April 1906 issue of the Journal of Nervous and Mental
Disease, there appears an article by Dr. Wm. A. White, in which
he sets forth the theory that there is no reason for believing that
a patient already suffering from one form of mental disease may
not develop another during the course of the primary disorder, or
as he expressed it at one point in his article: "Thatbecause aperson
has manic-depressive insanity is no reason he should be immune
from the ordinary diseases that affect the brain and impair the
mind. He further lays particular stress upon the fact that the
clinical picture of a given psychosis may be greatly modified by
episodic intoxication and infection processes, resulting in what
would be confusing and anomalous symptoms did we not recog-
nize the possibility of such a combination. To his very able and
clear exposition of this theory I can add nothing, and would refer
you to his original communication, but this belief appeals to me
as a very sound and tenable one, and I wish to present for con-
sideration the report of a case which seems to have very clearly
shown the co-existence of the characteristic symptoms of melan-
cholia of involution and Korsakoff's psychosis.

As a matter of fact, the question has been raised as to whether
the group of symptoms described as constituting Korsakoff's psy-
chosis is merely a syndrome, or a definite clinical entity ; but the
considerable majority of investigators have accepted the latter
view.

The following is a report of the case in question :
A. C, female, white, single, aet, 44, American, occupation
none. One of four children, the other three being quite normal.
She comes from a very refined, and intellectual family. No un-
favorable hereditary history. The patient has, however, since
childhood shown signs of constitutional degeneracy. At school
she was one-sided and erratic in her accomplishments. Notably
brilliant in certain subjects, she was greatly deficient in others,
particularly the exact sciences. As she grew into young woman-
hood, she manifested many very noticeable peculiarities of conduct.

♦Read before the Brooklyn Society for Neurology, Oct. 25, 1906.

448 JOHN W. STEVENS

She was seclusive, could never be particularly interested in any-
thing, lacked initiative, and failed to show the ''get up and hustle"
of the average American woman of her intellectual attainments.
Though not of robust health, she had never had any serious or
prolonged illness previous to the present one. She never used
drugs or alcohol in any form. Signs of the menopause presented
some months previous to the onset of her illness, and she has not
menstruated since December 1905.

She has masturbated for many years, and at intervals greatly
to excess. This latter was the case during the autumn of 1905.

In the spring of 1905 she began to manifest undue emotional
depression, which increased, and according to the account of her
family physician, gradually evolved into the clinical picture of
melancholia — painful emotional depression, ideas of self-unworth-
iness, and then distinct delusions of self-accusation.

She was sent away to the country for a time, and was then
taken back home for a few months, remaining there until Decem-
ber last. It is to be carefully noted that the family physician,
whom I consider quite competent to judge, states positively that
up to this time she had not presented the amnesia and disturbance
of orientation that subsequently became so marked for a time.

In December there came on suddenly an attack of severe pain
in the head, face, and arms, lasting about 48 hours. It was looked
upon at the time as neuralgia, and there were no physical sequelae
after the abatement of the pain to indicate that it was anything
else. This, however, I do not consider as absolutely proven.
Mentally, she did show a distinct change for the worse, and as
her brother expressed it, "completely went to pieces." He then
sent her to the sanitarium, (Dec. 21,) which however, is not an
institution for the insane, and hence the reports that I have been
able to get as to her mental condition while there are far from
being as minute as I would wish. However, they indicate that
she was much depressed emotionally, had marked self-accusatory
delusions, thought her soul eternally lost, etc. At times became
exceedingly agitated, and begged persistently for poison, "be-
cause she could not and would not live any longer." Once she
tried to put her head in the fire, and at another time talked about
jumping out of the window. They were uncertain as to the con-
dition of her memory, but stated that orientation was impaired.
There were no local evidences of neuritis. Her deep reflexes were
increased, and her pupils dilated. Pulse rate tended to be high,
particularly in her periods of excitement, when it reached 105-120.
Her family physician states that normally her pulse rate is 75-80.

She was admitted to the Long Island Home, Feb. 13, 1906.

She was that morning brought from the other sanitarium to
New York on a private car, and from thence to Amityville by
special train, accompanied by her brother and a nurse.

MELANCHOLIA 449

The initial examination showed that she was in a rather poor
physical condition, badly nourished, very weak, so that she walked
unsteadily, skin was muddy, tongue was coated, pulse 120, tem-
perature normal, pupils normal, patellar reflexes greatly exagger-
ated, superficial reflexes normal, no disturbance of sensation dem-
onstrable. Her facies was dull and indicative of mental torpor.

She understood what was said to her, and her answers as a
rule were relevant, though occasionally she interjected a question
or remark whose relation to the subject under discussion was not
apparent. There was very little mental activity present, and it
was frequently necessary to urge her in order to secure a reply to
questions. There really seemed to be a question as to whether
apprehension was entirely clear, for she was unable to clearly
grasp the full meaning of any other than short questions.

She possessed no true insight, though she said that she had
been ill, and that her physician had ordered her to bed.

It was in the field of memory and ojientation that the most
startling revelations were made. She had but the most vague and
indefinite recollection of having been on the train with her brother
that morning, and was absolutely unable to give any details of the
trip here, though she did know that she had been in New York
City that morning. She at first said that she came to the Home
that morning in company with her brother and sister (it was real-
ly her brother and a nurse), but a short while afterward she de-
clared that she was still at the other sanitarium (which I will
designate as X), that she had been here 5 or 6 weeks, and had
never been on Long Island. She said she went to X in June, but
did not know of what year — thought it might be 1904. At first
she said she did not know the present month, but finally said it
was June, though she still adhered to her statement that she came
here (to X) in June, and that she had been here five or six weeks.
She was unable to see the inconsistency in this. She was unable
to tell what she had had at the previous meal, and had no recol-
lection of certain statements that she had made to her nurse that
morning. Fifteen minutes after this visit she had but the most
vague and indefinite recollection of ever having seen the examiner
before, and had forgotten all about the visit.
Feb. 14, 1906.

Passed a sleepless though not very restless night. Talked a
great deal about suicide, and her wish to commit the act. Very
difficult to induce her to take sufficient food. There is very much
more mental activity to-day, so that she answered my questions
readily, and spontaneously entered into conversation.

Her whole thought seems dominated by the idea that her
family have deserted and repudiated her and left her to her own
resources. She relates quite in detail, repeating the exact words
used, a conversation supposed to have occurred between her and

450 JOHN W. STEVENS

her brother when he visited her here (at X) three or four days
ago. He told her that he had discovered certain things, and that
now he is done with her, that she could provide for herself in the
future, that he would no longer pay her board here, would no-
longer furnish her with clothing, etc., because she had grossly
deceived him. As a matter of fact, no such conversation ever did
occur, nor did she see her brother at all on the date she states.
She becomes reticent when questioned as to the details of why he
had spoken to her so, but admits that it was because of her wrong-
doings, "about which she does not care to pray."

In all of this, to which she constantly reverts, and assures me
over and over again is true, she gives no evidence of acute emo-
tional depression, but on the contrary, there seems to be rather
a lack of emotional feeling of any kind, so that her emotions seem
to remain at an uniform level, with neither tears nor smiles.

The same disturbance of orientation and memory continues.
She has been here five or six weeks, came Dec. 21, 1905, and it is
now June 8, 1906. Is unable to see the inconsistency. She has no
recollection of my visit and examination of yesterday. She thinks
she has seen me several times, but don't know just when. Could
not tell what she had had for breakfast. Only after very pointed
suggestions from me did she recall having been on the train at all
recently, entirely denying it at first. She still insists that she is
at X, and will not accept my statements to the contrary, and has
forgotten that I explained to her yesterday her present location
and how she got here. Her appreciation of the passage of time
is much impaired, and she says it has been three or four days
since she saw her brother who was here with her yesterday.

She is ready to bridge over the past with ready explanations,
though she does not glaringly fabricate spontaneously. However,
she does make certain highly improbable statements about occur-
rences at X, such as that one of the buildings there fell down, that
another one burned etc. (I have subsequently learned that these
statements are without foundation in fact).

Given two numbers to remember, she was unable to repeat
them ten minutes later. This amnesia occurs in the presence of
clear apprehension.

Pulse remains very rapid.

Feb. 16, 1906.

She was very depressed and agitated yesterday evening be-
cause her family had deserted her, etc. Her family has suffered
great wrongs and calamities on her account, her brother has lost
all of his property and his son died from grief, all caused by her
wickedness. She wished she was dead, felt that she ought to be
in hell, and begged the nurse for chloroform. This morning, how-
ever, she is fairly cheerful and ready to smile on occasion, though

MELANCHOLIA 45 1

she still holds the same delusions. No evidence of acute mental
pain arising therefrom.

Her mental processes are active, apprehension is unimpaired,
and her answers to direct questions are usually relevant, though
a peculiar condition is to be noted, when in the midst of a sentence
she breaks off into another on an entirely irrelevant line.

Hallucinations of hearing are present.

When questioned she says her brother did not bring her here
to this place, but that she cannot remember the name of the place
he did take her to. "He took me to the place where the fire oc-
curred. They are all Presbyterians there, and the fire destroyed
that beautiful stone porte cochere."

Q. "What place is this?

A. "You said it was some place on Long Island."

Q. "Would you have known that had I not told you so?"

A. "No."

Q. "Do you remember being on the train with your brother

on the trip here?"

A. "No. My brother has never been here. Just before the
fire he went to New York with me."

Q. "How long ago was that ?"

A. "Six or seven weeks."

She says she does not remember anything about how she got

here. ff

Q. "Where were you before you came here?

A. "I don't know 'that either. Was it not at Dr. Weis's that
the sanitarium broke down ? I give it up. The large things I re-
member perfectlv, but the little things I forget."

Q. "When did vou go to X?"

A. "Ah, that's the place. I went there in December."

Q. "Of what vear?"

A. "Of this vear."

Q. "Well what year is this ?"

A. "1907, is it not?"

Q. "What month is this ?"

A. "February."

Q. "How long have you known me?"

A. "Three or four days."

She cannot remember the number that I gave her yesterday
to repeat to me this morning.

February 18, 1906.

She has been exceedingly anxious and depressed during the
last two davs in response to her depressing delusions. She also
believes that her friends are seeking her, and that she must go
away with them. To this end she fights and struggles with her
nurse to the last ounce of her strength. She says she hears her
brother's voice in the next room.

-453 JOHN W. STEVENS

Last night she was much distressed because the ship was sink-
ing and she could not escape. Ten minutes later she wanted to
borrow fifty cents with which to get away from here. Apprehen-
sion and comprehension of what was said to her were perfectly
■ clear throughout this.

Amnesia as previously noted.

February 24, 1906.

Continues very anxious and restless much of the time, but par-
ticularly at night. Many self-accusations. Says she has been here
seven or eight weeks. That she has been two weeks in the room
to which she was removed four or five days ago. Gave the correct
date yesterday, and said that she was at Amity ville.

February 27, 1906.

She remembers that I yesterday told her that my name was
Stevens, but I could not convince her that such is true. Yester-
day she told me that she was very sorry for Dr. Stevens, whom
she had caused so much trouble. She would not believe that I
was Dr. Stevens. She forgets her nurse's name from day to day

Q. "How long have you been here?"

A. "I do not know. I thought this was the end of March,
but the nurse tells me that it is the end of February."

Q. "How many weeks have you been here?"

A. "I don't know. I haven't the least idea, and cannot reckon
it. I was at two or three other places before I came here, and I
don't know anything about how I got here."

Q. "Well, approximately how long do you think you have
"been here?"

A. "I should say about five weeks." (2 weeks).

Q. "Do you remember anything about a trip on the train
with your brother?"

A. "I simply remember starting from X with my brother, a
nurse and Dr. Shyro. I don't remember having seen them since.
I don't think my brother did come here with me. I don't remem-
ber. I am confused."

Q. Can you tell me the year and month ?"

A. "1905, I guess. The nurse said it was the end of Febru-
ary. I supposed it was later."

She does not know the name of the institution, but says it is in
Amityville. She has been told the name of the institution many
times. Sne makes many mistakes in relating what she had for
the previous meal, and altogether her memory for passing events
is very defective.

She is quite depressed, despondent, and self-accusatory, and
wishes to kill herself.

She has improved very much physically, sleeps fairly well, and
-appetite is good. Pulse remains very rapid, much of the time as

MELANCHOLIA 453.

high as' 130. Patellar reflexes remain greatly exaggerated. Cu-
taneous sensibility normal.

March 15, 1906.

Recently painful emotional depression has been more promi-
nent, and much of the time she is in an exceedingly agitated state,
begging most persistently for poison, and trying to injure herself
by every means in her power. This is because she thinks she has
been so wicked and has caused her family so much trouble. She
thinks she is going to be turned out in the cold without any cloth-
ing, or that she is to be deserted by every one and left here alone.
Memory and orientation practically unchanged. Pulse is not quite
so rapid — about 100. This pulse has throughout been unaccom-
panied by any elevation of temperature, and is not due to agita-
tion, for it continues so in her periods of quiet. Hallucinations of
hearing active. Improved physically ; sleeping 5 to 8 hours night-
ly without hypnotics.

April 8, 1906.

Continues in the same agitated and distressed condition pre-
viously noted. Hallucinations of hearing still present, but less
active.

Since the last note a very marked improvement has occurred
in the field of memory and orientation, so that now no glaring de-
fects of either would be noted on a superficial examination. Some
defect does, however yet remain, so that she cannot give an ac-
curate account of what she had for the previous meal, and makes
mistakes with reference to the time elapsing between events. She
does not know definitely how long she has been here, usually say-
ing six or seven weeks. While she always knows the year, and
generally gives the month correctly, yet she is not perfectly cer-
tain about this or what time in the month it is, so that it would
be very easy to deceive her in this regard.

Is in fairly good physical condition.

April 17, 1906.

To-day the clinical picture is clearly and purely that of mel-
ancholia of involution. She is greatly depressed with the most
painful delusions of self-accusations. She becomes very agitated
in reaction to these at times, and is always very anxious for death,
for she knows she can never be forgiven for her sins. Her de-
pression and distress have been more acute during the last few
weeks than at any time since her admission.

Her memory for both old and recent events, and orientation
are now normal.

Hallucinations of hearing have been absent for two or three
weeks. She now has a fairly good disease insight into what her
condition has been during the past few months, realizes that she
has had hallucinations of hearing, that her memory has been im-

454 JOHN W. STEVENS

paired, and speaks of the condition of confusion that she was in.
Patellar reflexes remain very much exaggerated. Pulse ioo.

From this time until about the middle of June her condition
showed little change. She then developed a line of nihilistic de-
lusions in connection with her ideas of self-accusation, and has
held them with little variation until the present, (Sept. 20).

There is no such place as New York City, and never was.
There is not nor ever was any America, or world. She is on one
little piece of land, and this is crumbling away into nothingness,
with every thing that is upon it. She sees imaginary persons,
wagons and horses going about, but these are imaginary only, and
soon vanish. All these things, her former belief in the existence
of her father, mother, of the world, God, etc., really existed only
in her imagination, and now since she has had her eyes opened,
she sees it all in its true light. The people about her are spirits,
reembodied for the moment, but when they leave her they return
to the beautiful spirit world, and her constant cry is that she may
be allowed to return to that beautiful land with us. She declares
that she has committed sins which she knows have eternally shut
her out from that paradise, but she pleads that she may be for-
given, and feels that she is now suffering the most awful torture
in being thus excluded. On this account she is greatly agitated
and distressed all the time. Is perfectly oriented, and memory for
passing events is very good indeed.

She has not menstruated since last December.

I cannot pass it by without briefly directing attention to that
very interesting condition present in connection with her nihilistic
delusions, viz., a feeling that a change has taken place in herself,
the changed way the past seems to her in retrospect, and a feeling
that her surroundings are strange, unnatural, and different from
what they once were. This symptom, usually spoken of as the
"feeling of unreality," has attracted some attention recently,
articles on the subject having been published by various writers.
Packard1 has reviewed some of this literature and defines the con-
dition, that is, the sensation, as one arising from "a disorder of
apperception, which in turn is due to an association difficulty of
some kind." The associational defect — a disharmonious and mor-
bid interaction of the higher associational processes — would seem
to be the main cause in this patient. Grossly, I think we must
consider it a disturbance of consciousness.

This is not the place to enter into a long discussion of this
symptom, however, so I will simply detail that part of an examina-
tion made Oct. 13, 1906, which brings out this symptom. More
than that would be to diverge from the main object of this paper,
which is to show the presence at the same time of two forms of
mental disease in the same patient.

'Packard. Jour, of Abnormal Psychology, June, 1906.

MELANCHOLIA 455

"Paradise is all around, but we can not see it with human eyes,
and I am afraid I will never see again except with human eyes.
My mind has been made a blank so that I can only see dirty city
streets. I don't see what brought me here. It was all a horrible
dream. (She hears music down stairs). Instead of the beauti-
ful music of paradise I have my head all full of the most horrible
stuff. I don't understand it at all. I don't know what the spirits
do. All I see now is steam and smoke." (She does not mean
this literally I am sure.) "I have nothing but visions of rows and
blocks of stupid houses. I know there is some land and some
water, but I know there is not the world I thought there was.
There is something called {he sun."

Q. "Why do you not believe in the existence of these things?"

A. "Why? Because I am not a fool. It is because I have
had my eyes opened. — I was made to dream there was a city,
world, etc., after I lost my place in Paradise, and now I know
from what I see outside and what they say that it isn't so."

Q. "Now what is it you have seen and heard that makes you
believe or feel as you do?"

A. "Lots of things. How things grow and how they don't
grow, but oh Doctor, you know all about it. I am no fool. I only
wish now that spirits could die. Miss M., told me I have paid
dearly for my folly."

Q. "What did she mean by that?"

A. "For having had evil thoughts before I came here."

Q. "What change have you noticed in the way things grow

etc?"

A. "Well, one tree will have cherries one time, and then have
pears, and you know that can't be."

Q. "Where did you see such a thing?"

A. "Why, over by the cottage there is a tree which had a few
cherries on it, and then pears." (As a matter of fact, there is a
pear tree and a cherry tree at the place she mentions).

"I have seen trees move their positions. When I came here
those clumps of green trees were close together, and now they are
far apart."

Q. "Do you feel that you are physically different?"

A. "No, but I have not thought much about it. I know that
I still have a headache once in a while, that my knee still gives me
some trouble."

Q. "Do you feel that any change has occurred in you since
ten years ago ?"

A. "I was not alive ten years ago. Up until about a year ago
I was a spirit."

Q. "Did you, or could you suffer pain then?"

A. "No. That is only the imagination of the last ten months.
Every one that has been here has simply been a good spirit play-

456 JOHN W. STEVENS

ing a part. I cannot understand how I got here. By that I mean:
I cannot understand how I ever lost my place in Paradise."

To sum up briefly, then, what have we? First, a defective
constitutional basis, with psychic stigmata of degeneracy. Then
at the age of 44, or the involutional period, there developed a
mental disorder which has continued already for more than eight-
een months. This psychic disorder was characterized first by
painful emotional depression, delusions of self-accusation with a
strong religious coloring, and later, suicidal tendencies. Seven
or eight months after the onset of this condition occurs the epi-
sode of headache and pains in the arms of 48 hours' duration,
followed by an accentuation of her symtoms. If not immediately,
at any rate within the next six weeks, there is superimposed a con-
dition of disorientation for time and place, an extreme amnesia for
passing events, great disturbance of the time element in memory,
fabrications, dreamy delusions, and hallucinations of hearing,
underlying which is the original state of emotional depression,
with certain modifications, and self-accusatory delusions. This
amnesia, disorientation, etc., continues for some six or seven
weeks, and then rather rapidly disappears, her memory becomes
excellent, fabrications cease, orientation becomes perfect, and hal-
lucinations disappear, leaving her in the original state of severe
emotional depression, painful self-accusatory delusions, despond-
ency and utter hopelessness, and a wish for death, and still later,
nihilistic delusions.

Now this is not the clinical picture of melancholia of involu-
tion, pure and uncomplicated. Such it evidently was during the
first five or six months of its existence, and undoubtedly is now.
Such a delirium does not occur in that disease. Undoubtedly we
do see cases of melancholia where the patient, because of his in-
tense mental agony, is so dominated by his damning delusions and
is so agitated in his reaction thereto, that he may fail to take ma-
terial note of extraneous happenings transpiring during this agi-
tation, and at which times it is impossible to get him to co-operate
with the examiner and tell of those things which he really does
know and remember ; but such was not the case with this patient.
At the times my examinations were conducted she was quiet and
composed, and frequently not particularly depressed. Her appre-
hension and comprehension for the moment were clear, as it had

MELANCHOLIA 457

been at the time of the occurrence of those matters with reference
to which her memory was tested. To-day, when her memory is as
accurate as is that of an average normal individual, she is even
more depressed and distressed than she was at the time this am-
nesia was noted. Further, to-day in her most agitated states, she
does not present any such disturbance.

What I have said in reference to the connection between agita-
tion and memorial co-operation may also be applied to the state
of orientation. Disorders of orientation do occur in melancholia,
without question, but in such cases of melancholia there would
seem to be present a much more marked degree of clouding of
consciousness to be associated with such a degree of disorienta-
tion as was present in this case.

The special significance that I would be disposed to attribute
to the hallucinations occurring in this case is due to the fact that
they seem to have set in with the disorientation and amnesia, and
to have disappeared with the same. Aside from this coincidence,
they would have attracted no special attention, since hallucinosis
is a comparatively common symptom of melancholia.

The emotional attitude of this patient, during the stage under
consideration, was not uniformly that usually characteristic of
melancholia. A part of each day, and particularly at night, she
was much distressed and showed an acute emotional reaction to
her delusions, while at other times she seemed almost devoid of
mental pain and talked readily about her self-accusatory delusions
without any appearance of mental suffering therefrom. In fact,
at times her attitude and conduct were such as to strongly suggest
a state of advanced emotional deterioration. This and the variable
nature of her reaction to her delusions, constituted her departure,
in an emotional way, from the usual picture of melancholia. She
does not show this emotional dullness now, but is always keenly
depressed.

I think we may say very positively that she did present definite
fabrications, which is another symptom not characteristic of mel-
ancholia.

Such are the features that raise the question as to whether or
not it is an uncomplicated case of melancholia, and would seem to
me to justify a negative answer, and a belief that here we have a
case primarily one of melancholia, upon which has been engrafted

458 JOHN W. STEVENS

a secondary symptom complex, viz., Korsakoff's syndrome or
psychosis.

The amnesia and its peculiar features — exceeding* defect of
memory for events of a few minutes or hours before, in the pres-
ence of practically clear apprehension, and the great disturbance
of the time element — , the disorientation, the fabrications, all of
which were so very marked, go to make up quite clearly the clini-
cal picture of Korsakoff's psychosis. Then, too, the episodic na-
ture of the appearance and disappearance of these symptoms
would speak for their consideration as a superimposed condition,
since we have the patient in a given condition previous to their on-
set, and in a similar condition after their disappearance.

Furthermore, I believe that we may look upon the very rapid
pulse rate as a point in favor of the belief in the presence of Kor-
sakoff's disease, and that it is an expression of the toxemia present
with a special reaction upon the cardiac nerve supply, or of a neu-
ritis affecting the pneumogastric. Mills, Lloyd, Sharkey, and others
report cases of alcoholic multiple neuritis with marked tachycar-
dia, sudden death from heart failure, etc. Tachycardia was a
very prominent symptom in an unquestionable case of Korsakoff's
that we had recently under treatment. It began at the initiation
of the disease and continued, though diminished, for three months
after the subsidence of all active symptoms, both mental and phys-
ical. In A. C. it was present on admission, and not until five
months afterwards did her pulse rate drop down to its normal
average of 80.

Of course the weak point in my claim that Korsakoff's psycho-
sis was co-existent here, is the fact that we have no evidence of
the occurrence of a definite neuritic process, unless such was the
nature of the pains in the head and arms. When I saw her there
were no sequellae other than the rapid pulse and a certain degree
of muscular weakness, that would warrant the assumption that
a neuritis had occurred. We are told, however, by those who have
made a particular study of Korsakoff's psychosis, that the occur-
rence of a neuritis, per se, is not necessary, for the toxines may
effect the cortex cerebri alone, so that the only symptoms produced
are in the psychic field ; and a number of such cases have been
reported. In others, the neuritic symptoms have been so slight as
to escape attention.

Certainly we had here presented the Korsakoff's syndrome.

Society proceedings

JOINT MEETING

OF THE

NEW YORK NEUROLOGICAL SOCIETY

AND THE

PHILADELPHIA NEUROLOGICAL SOCIETY.
Held in Philadelphia, Nov. 24, 1906.

The President of the Philadelphia Neurological Society, Dr. D. J.

McCarthy, in the Chair.

(Continued from page 419.)

DISCUSSION ON APHASIA, ESPECIALLY WITH REFERENCE
TO THE VIEWS OF MARIE.

Dr. Charles K. Mills said that neurologists owe some gratitude to
Pierre Marie for reviving interest in the study of aphasia and for show-
ing that some of the classical views about cerebral disorders of speech
are worthy of re-examination, if not of revision. Marie has already found
some supporters for his view, and has awakened the attention or opposi-
tion of distinguished neurologists like Dejerine and von Monakow.

The task assigned to Dr. Mills was simply that of opening a discussion
which it is hoped will bring out new data and a full expression of opinion
from the members of our two societies. After a glance at the views of
Marie and the manner in which these have been opposed by Dejerine, he
would content himself with a rather dogmatic presentation of personal
views.

The most important of Marie's assertions are: that auditory, visual
and motor speech centers do not exist; that aphasic phenomena are not
due to interference with auditory, visual, or other images, but to intellec-
tual deficit, this deficit causing difficulty in the comprehension of speech
and interfering with numerous didactic processes ; and that Broca's con-
volution takes no part in the function of speech and its lesions in the pro-
duction of aphasia. Considering how universal has been the opposite of
this last Opinion about Broca's convolution, this is perhaps the most start-
ling of his assertions. Marie admits that Wernicke's aphasia, Broca's
aphasia, and anarthria are clinical facts, but explains these facts, especially
as regards Broca's aphasia, very differently from his predecessors, — assert-
ing that Broca's aphasia is nothing but Wernicke's aphasia complicated
with anarthria, or anarthria complicated with Wernicke's aphasia. Anar-
thria, as he understands the term, is due to lesion of the lenticula and its
environment. According to Marie, the regions, lesions of which produce
aphasia, are all included in Wernicke's zone, which he defines as com-
posed of the supramarginal (inferior parietal) and inframarginal gyres
and the posterior extremities of the first two temporal convolutions, — in
other words that cortical region composed of the gyral masses which curve
around the extremities of the Sylvian and the parallel fissures.

460 PHILADELPHIA NEUROLOGICAL SOCIETY

In his replies to Marie, Dejerine maintains the classical or at least
the usually accepted views regarding aphasia, holding with reference to
sensory aphasia that the long accepted theory of centers for sensorial
images cannot be successfully attacked, and that the diminution of intelli-
gence sometimes exhibited by aphasics is dependent upon disruption or
disturbance of the cerebral mechanism of speech rather than the aphasia
upon the intellectual loss or deficit. He stoutly maintains that Broca's
convolution plays an important part as a speech centre, explaining the
cases in which it is involved and aphasia does not result by the compensa-
tory action of the opposite hemisphere, and cases of Broca's aphasia with-
out lesion of Broca's convolution by the fact that the motor speech zone
includes other parts, as the anterior insula and the foot of the second
frontal gyre. He adheres to his theory of sub-cortical motor aphasia due
to lesion of the fibers entering and leaving Broca's convolution. He holds
that the existence of the real or the apparent sensory aphasia in motor
aphasics is usually only temporary, and in any case is not to be explained
in the way that Marie suggests. Anarthria or dysarthria, according to
Dejerine, is due to lesion of the motor projection fibers and is different
from cortical or subcortical motor aphasia. He contends also that the
cases with numerous or extensive lesions described by Marie are cases
of total aphasia, the lesions involving all or a large part of the speech zone ;
also that Marie fails to recognize cases in which Wernicke's zone and
the lenticula are not involved and yet the Broca syndrome is present.
Dejerine believes that a purely unilateral lesion of the lenticula does not
produce anarthria.

Dr. Mills' views regarding the questions in dispute between Marie and
Dejerine are largely those of the latter, differing in some particulars
which will appear in the course of the discussion. He summarized these
views as follows :

1. The centers concerned with speech may in a general way be desig-
nated as sensory and motor.

2. Under sensory should be included lower and higher sensory centers,
the lower being places of storage for the auditory and visual memories
of words, letters and all else which take part in language on its recipient
side. The higher sensory areas have sometimes been termed the concept
areas ; they are regions in which names become associated with the ideas
of objects named, and in which probably other somewhat evolved and
complex sensory processes take place.

3. The lower and higher sensory areas for speech and their associated
structures are all included in the posterior association area of Flechsig,
the concrete concept or concrete memory field of the writer. They do not
belong to the cerebral primordial or projection fields, but have been evolved
out of these, — a fact important to remember when considering the ques-
tion of intellectual deficit in aphasics.

4. For the purposes of this discussion all the sensory centers for
speech, — auditory and visual, — may be regarded as included in Wernicke's
zone as defined by Marie, with the addition of some portion of the third
temporal convolution. It needs only to be remembered when speaking of
the supramarginal convolution as a part of Wernicke's zone that only the
caudal or posterior half of this convolution is to be taken into account.

5. The cortical motor center for speech is situated in the insula and
in the hinder part of the left third frontal convolution.

PHILADELPHIA NEUROLOGICAL SOCIETY 461

6. In the lower third of the precentral convolution are situated the
cortical motor centers, concerned with phonation, articulation, and facial
expression, — in short with all movements which take part in spoken
language. These motor centers taken together constitute an utterance or
executive speech center, and are of necessity connected with Broca's con-
volution.

7. The motor center for speech is not connected by projection fibers
directly with the bulbar nuclei, but indirectly through the motor cortex.
Whether the cortical speech centers proper are connected directly with the
lenticula or other basal centers not bulbar, is not yet positively determined,
but probably the cortical executive center is connected with the lenticula
and thalamus.

8. The lenticula has motor functions, and like the precentral cortex is
subdivided into centers for movements of different parts of the body, as
for the leg, arm, and face, necessarily therefore having within its borders
motor centers of some sort concerned with articulate speech. The part
played by the lenticula in motor speech, however, is different from that
which is performed either by the motor center included in the insula and
Broca's convolution, or in the cortical center for movements of the face
and tongue.

With regard to the cerebral zone of speech, and also other regions of
the brain, we are not much beyond the threshold of our knowledge of
the subdivision of function.

In some quarters a tendency to rebel against the extreme differentiation
of the brain into areas and subareas and centers is exhibited, but close
attention to the facts, particularly those which are being obtained through
clinico-pathological observation, would seem to show that this differentia-
tion is even much greater than has been supposed by the most ardent be-
liever in localization.

Sensory aphasia, according to Marie, is the only real aphasia. He
would have us believe that all our slowly and patiently acquired views
with regard to memorial images, auditory, visual and for all the senses,
so far at least as the discussion of aphasia and the cerebral phenomena of
speech are concerned, should be cast aside; that in Wernicke's zone, as
already defined, are not the long recognized auditory and visual centers
and their elaborate connections, but that this zone is an intellectual area
or center and that the aphasia of Wernicke is due, not to disturbance of
auditory and visual processes, lower and higher, variously combined, but
to intellectual disintegration.

The centers, visual and auditory, concerned with speech are, as Dr.
Mills has already stated, part of the great concrete memory field, or
posterior association area of Flechsig. It must be admitted that this is a
region concerned with thinking, with concrete ideas, but these very forms
of mental activity have for their bases sensorial images and their correla-
tion with each other and with other cerebral processes. The posterior
association area is a psychic zone, higher in grade than the fields of pro-
jection and lower than the prefrontal psychic zone concerned with abstract
conception and the highest intellectual functions. The intellectual deficit
described by Marie and observed by all students of aphasia, is conditioned
by destruction and disturbance of the sensorial cerebral centers, and of
the structures connecting these with other parts of the brain. When
Marie admits, as he does, that Wernicke's aphasia is a clinical type with

462 PHILADELPHIA NEUROLOGICAL SOCIETY

the characteristics described by Wernicke and others, he largely admits
all that is asserted by those who hold to the more commonly accepted
views regarding auditory and visual aphasias. One may, if he so choose,
regard the two sets of convolutions which curve around the extremities
of the Sylvian and of the parallel fissure, as an audito-visual "intellectual"
center — a center composed of auditory and visual subcenters with cor-
relating intrinsic and extrinsic structures.

One might ask Marie in this connection some questions of such sim-
plicity as to scarcely appear to have scientific value. What for example
does he regard as the basis of the intellectual activity of his psychic center?
Is he going back to the ancient mythical and metaphysical ideas of some
spirit dwelling in this or that part of the brain? Is intelligence with
him some indefinite essence separated into different parts, each dwelling
in some particular region of the cerebrum? If he recognizes higher and
lower grades of intelligence or intellectuality, does he regard them as
dependent upon some subdivided entity which he calls the intellect, or does
he believe that they are in some way correlated to sensation and motion
and to physiological processes of perception and apperception which have
their anatomical substrata in different regions of the brain? In brief,
what is his exact definition of an intellectual center, disturbance or dis-
integration of which gives rise for instance to the intellectual deficiency
which is present in his aphasia?

It seemed to Dr. Mills that Dejerine has the best of the argument as
regards the question of intellectual deficit depending upon interference
with sensorial processes, and not these processes upon intellectual impair-
ment. It must be said, however, that Dejerine, in common with others
from which list Dr. Mills could not exclude himself, may have spoken at
times without due consideration of aphasics having no impairment of
intelligence, just as at other times too great stress may have been laid
npon intellectual impairment. If the cases are closely studied, it is true,
as Marie asserts, that such impairment of intelligence will be found in
varying degree.

Too much emphasis cannot be placed in this connection upon the
individual capacities, natural and acquired. Aphasic patients like those
seen at the Bicetre, the Salpetriere, and at the Philadelphia General Hos-
pital, are most frequently individuals of no great natural endowment and
sometimes of little or no education. Lesions which interfere with the
cerebral zone of speech either on its sensory or motor side will cause in
such persons an impairment of ability to carry out mental processes to a
greater degree than in those of a higher order of intelligence. Dr. Mills
had again and again noted striking differences in the ability of aphasics
to understand and carry out directions or to act for themselves along lines
requiring intelligence, such patients presumably from their symptoms suf-
fering from lesions of the brain of similar extent and location.

In discussing the part played by sensorial images, attention should be
more strongly fixed upon the fact that it is not alone destruction or dis-
turbance of sensory centers concerned with interior speech that causes
aphasic phenomena and interference with intellectual processes, but that
these sensory centers are of various grades of simplicity and complexity
according as they administer to lower or higher sensory concepts, and also
that the disruption or disturbance of the associations between sensory
centers for the different senses, and for lower and higher conceptual pro-

PHILADELPHIA NEUROLOGICAL SOCIETY 463

cesses are the agents in causing aphasia as much as the assaults which are
made upon isolated sensorial centers. Moreover, the breaking of associa-
tion between the audito-visual portion of the cerebral zone of speech with
all its intricate associations and correlations and the motor portion of
the speech zone and the projection system add both to the aphasia re-
garded simply as a speech disorder, and as due to deranged or diminished
intelligence, but that the loss of interference with memorial images is the
main cause of the aphasia, is fundamental.

The references of Dejerine to insanity are interesting in the support
which they give to his views. He refers for instance to the fact that
hallucinations among the insane support the idea of sensorial images. He
does not perhaps lay sufficient stress upon the fact that such hallucinations
and illusions are more dependent upon the disruption of associations be-
tween centers than they are upon the interference or destruction of the
centers themselves. The writer gave some attention to this subject in a
paper recently presented to the section on psychology of the British
Medical Association at the meeting held in Toronto, September, 1906.
As shown in that paper the study of the hallucinations of the insane is in
a large and proper sense a study of an interesting phase in cerebral locali-
zation, a view which has been supported in the past by many alienists and
neurologists. Dejerine's reference to general paretics is one which must
appeal to every alienist. How often do we observe cases of general
paresis with more or less advanced dementia still showing no true aphasia,
either sensory or motor, notwithstanding the fact that because of the
nature and site of some of the lesions, anarthric or dysarthric affections
of speech may be present?

The symptomatology of disease of Wernicke's zone will differ ac-
cording to the size and extension of the lesion. If the lesion be, as it
usually is, of considerable extent, the main symptoms will be word deaf-
ness (sometimes nearly complete, although more often partial), word
dumbness more or less pronounced, dyslexia, paralexia or alexia, slow-
ness or difficulty in word speaking (paraphasia), repetition of the same
words and phrases, and at times abnormally rapid paraphasic speech or
logorrhea. The sensory aphasic, whatever may be the limitations or the
extent of the lesion producing his symptoms, if such lesion is confined to
Wernicke's zone, is not deprived of the power of speech, like the motor
aphasic suffering1 from a lesion of the cortex or subcortex, or cortex and
subcortex of the insula and Broca's convolution.

Dr. Mills did not give much space to the consideration of the clinico-
pathological evidence favoring the existence of centers for word seeing,
word hearing and other forms of memorial imagery, and also of tracts
in the audito-visual zone connecting these centers with each other and
with other parts of the brain. Such evidence is to be found in the well-
known works and articles on aphasia, and to a certain extent it has been
marshalled by Dejerine in his part of the interesting discussion now under
way. Dr. Mills had from time to time recorded cases with such symptoms
as word blindness, word deafness, word dumbness, object blindness, alexia,
paralexia, paraphasia and the like; and believed that most of these will at
least stand the test involved in referring them to lesions of a true audito-
visual zone.

It needs to be said that word deafness and word blindness are rarely
monosymptomatic, although Marie admits that the latter may be : and

464 PHILADELPHIA NEUROLOGICAL SOCIETY

that cerebral lesions are only in very rare instances either purely cortical
or purely subcortical.

Probably one of Dr. Mills' own cases, now well known in the literature
of the subject, approached as nearly as any recorded case to an illustra-
tion of word deafness due to an isolated and limited lesion.

This case was first recorded by him in 1891. The two cerebral hemis-
pheres are still in his possession and have been brought here this evening.
The patient, fifteen years before her death, had an apoplectic attack, pre-
vious to this time not having had any known affection of hearing, sight, or
speech. As the result of this attack she became word deaf, and had a
marked form of paraphasia, although she continued to read, and to some
extent to write. She was described, however, as having mixed up her
words in writing. She could hear and appreciate musical and ordinary
sounds, like a bell, a knock, or the tick of a clock. Six years before her
death, she had a second apoplectic attack and soon after became totally
deaf, or nearly so, as to sounds as well as to words. She was also, as a
result of this second seizure, partially hemiplegic on the left side. At the
necropsy in this case, even before the membranes were removed, it was
noticed that the first temporal convolution was smaller and thinner than
usual, and that at the posterior extremity of this convolution about op-
posite the upward turn of the posterior extremity of the Sylvian fissure,
was a depression which included also a part of the adjoining second tem-
poral convolution, the depression being about seven-eighths of an inch in
diameter. This depression, as was proved subsequently, was the result
of an old embolic or hemorrhagic cyst. On the right side was an old and
very extensive hemorrhagic cyst which had completely destroyed the first,
and almost completely the second, temporal gyre, the island of Reil, the
retroinsular gyres, the lower extremities of the central gyres, and to a
large extent, but exactly how much was not determined, the ganglia and
capsules. The first temporal, retroinsular, and subfrontal (Broca's con-
volution) gyres were greatly wasted.

We can have a motor aphasia which is distinct in its symptomatology
from a sensory or sensorimotor aphasia or from a dysarthria or anarthria,
the dysarthria and anarthria being used in the commonly accepted sense
of impossibility or difficulty in articulating, enunciating and vocalizing
words or expressions. Motor aphasia due to lesion of the cortex and it9
immediate subcortex may be complete or partial, according to the degree
of destruction of the cortex and subcortex. In complete motor aphasia
the patient is unable to speak at all, although as is well known, in cases
almost complete he sometimes retains a single or a few recurring utter-
ances. If the case is one of absolutely pure motor aphasia, the patient
may have no paresis of the organs concerned with speech. He is unable
to recall words which describe objects or which are used in the formation
of phrases or sentences. Apparently he cannot arrange language for
utterance. One of his difficulties might be expressed as Broadbent so
long ago expressed it, as "inability to propositionize" ; and indeed this
fault or loss has been expressed in various ways, none of them entirely
satisfactory. The patient is word dumb, but more than this. It is said
that the psychomotor memories concerned with language are lost, but this
does not make the matter much clearer. Again, it is sometimes said that
the motor aphasic cannot build words, phrases, or sentences. Not a few
cases of motor aphasia as seen in practice are partial at first and become

PHILADELPHIA NEUROLOGICAL SOCIETY 465

complete as in a case of advancing tumor. Sometimes the motor aphasia
is complete or nearly so for a time, but disappears and reappears, these
varying conditions of motor speech disturbance being due to variations
in the condition of the lesion and in the physiological activities of the
parts associated with the centers affected by it.

The motor aphasic may exhibit some dysarthria or anarthria, this being
especially noticeable with regard to certain sounds as those made by den-
tals and labials. It may be a question whether the dysarthria or anarthria
of a motor aphasic is due to the influence of the lesion on the true motor
speech center, or on adjoining or connected parts, as the centers at the
foot of the precentral convolution or perhaps those in the lenticula.

Motor aphasics may have trouble both in reading and in comprehend-
ing spoken words, but these defects are not the same in degree and prob-
ably not the same in kind as in the case of sensory aphasics. Troubles of
this kind present early in a case of motor aphasia due to a severe lesion
may disappear entirely and not be a part of the residual syndrome. They
are doubtless due either to the effects produced by the edema and other
temporary states or to the diaschysis of von Monakow — that is, to inter-
ference with the physiological actions of the parts with which the center
attacked is anatomically and physiologically connected. Von Monakow, in
expounding diaschysis diagrammatically, indicates a lesion placed in some
portion of the cortex. Coming to and going from this place of lesion are
association fibers to other portions of the cortex, and also commissural
connection through the callosum to the other hemisphere, and presum-
ably, from the other hemisphere through the callosum; also fibers going
from the cortex to the bulbar nuclei, etc. A certain physiological inter-
change of function takes place between the different but correlated areas,
so that destruction of one area necessarily causes a change in the
physiological state of other centers or areas with which it is correlated.

Von Monakow calls attention to the importance of giving more heed
to negative cases ; also to the fact that much still remains to be learned
with regard to many phases of the subject of aphasia, Marie for this
reason deserving the thanks of neurologists for the interest which he has
excited in the subject.*

The difficulty in understanding spoken language sometimes exhibited
by motor aphasics is so little marked as to need considerable study for its
detection. The amount of this difficulty is conditioned to a certain extent
by the original intelligence, education and training of the aphasic.

In a correct sense the cerebral zone of speech is a single great mechan-
ism, but it has many parts. If the machinery in one part is interfered
with, the effects of such interference may extend to all parts.

One case recorded by Dr. Mills has helped to convince him of the part
played by Broca's convolution and the insula in the function of speech.
This patient was long an inmate of the insane department of the Phila-
delphia General Hospital. Dr. Mills saw him first about nine years after
an apoplectic attack which left him aphasic. His language was very re-
stricted. He could speak only a very few words or phrases, or one or two
very short sentences. Word dumbness was a marked feature of the case,
although he learned by training to name objects like a watch, a pencil or
This reference to von Monakow was introduced since the discussion
at the meeting of the two societies, his paper having appeared about that
time.

466 PHILADELPHIA NEUROLOGICAL SOCIETY

a knife, with some facility. The expressions he made use of were such as
"very pretty," "thank you," etc. He had a curious recurring utterance
which he made use of when he attempted to read aloud. It was, "England,
oh, my soul, England, oh, my soul!" He would read, apparently under-
standing what he was reading, and then make use of this expression in a
loud and rather oratorical tone. He was apparently able to read, although
with difficulty. He was tested as regards this matter, for instance, by
asking him to select words from different parts of the page which he was
reading, and which he would do correctly, although taking some time.
What he said was said with distinctness and clearness. No paralysis of
the muscles of articulation, enunciation or phonation was present. He
had no anarthria or dysarthria in the usual sense in which these words
are employed, but was a true motor aphasic. He could understand what
was said to him. The patient was able to recognize objects by touch,
hearing, taste and smell, but as a rule was not able to name the object.
The case was clearly one of marked, although not absolutely complete,
motor aphasia. The patient could write many single words or short com-
binations of words correctly, holding his pen or pencil with ease and
firmness.

In some of the cases in which motor aphasia has been present, the
convolution of Broca apparently remaining intact, lesions have been pres-
ent in both the external capsule and the anterior part of the internal
capsule, parts which are closely related to the insula and the convolution
of Broca.

In the cases cited by Marie in which so-called motor aphasia was
present, and in which the lenticular nucleus was implicated in a destruc-
tive lesion, parts neighboring on this ganglion were also nearly always
involved. These parts included the insula and the external capsule. The
insula and its subjacent cortex, by many as by the writer, have been in-
cluded with Broca's convolution and its subcortex in the so-called motor
center for speech; and the probabilities are that in the large lesions to
which Marie refers the subcortex of at least part of the motor speech
center is involved.

The fact that atrophy or involution of Broca's convolution sometimes
takes place after destructive lesion involving Wernicke's zone on one or
both sides is an argument in favor of the view that Broca's convolution
is an integral part of the zone of speech. In the personal case of sensory
aphasia to which Dr. Mills had referred, that of a patient who had suf-
fered from word deafness and paraphasia because of a lesion limited to a
small area at the junction of the hinder portions of the first and second
temporal convolutions, and who afterwards became totally deaf from a
destructive lesion attacking the temporal and central convolutions and
other parts of the opposite side, the post-mortem examination showed
that Broca's convolution among other parts was greatly atrophied. The
attack, causing the word deafness, it will be remembered, occurred fifteen
years before death, and that which brought about complete cerebral deaf-
ness, nine years before death.

While sensorial and motor aphasia are separate and independent clinical
syndromes, many of the cases of aphasia observed in practice are, because
of the nature and especially because of the extent of the lesions causing
them, sensorimotor, or as they are sometimes called, mixed or total
aphasias. The lesions in these cases often involve, as is well known, such

PHILADELPHIA NEUROLOGICAL SOCIETY 467

parts as the superior temporal convolution, the insula, Broca's convolution
and its subcortex, the central and the supramarginal convolutions, the
lenticula and the external and internal capsules. They are instances of
widespread destruction of all parts irrigated by the middle cerebral artery.
In other instances the cerebral regions supplied by this artery are involved
in varying degree, giving a more or less confusing smyptomatology made
up of a combination of sensory and motor speech phenomena with other
symptoms.

Marie's views would seem to be largely built up upon the record of
cases of these so-called total aphasias.

What is necessary in this discussion is in the first place to marshal tha
symptomatology of cases in which the lesions have been confined to the
audito-visual (Wernicke's) zone; secondly, that of cases with lesions
limited to Broca's convolution or the insula and its immediate subcortex;
and thirdly, that of cases in which the lesions were confined to the lenti-
cula. Cases of each of these descriptions are on record and give a particu-
lar symptomatology.

Much stress is laid by Dejerine upon the distinction between cortical
and subcortical motor aphasia. Such a distinction can no doubt at times
be made; at least isolated cases of subcortical motor aphasia have been
recorded, their symptomatology differing somewhat from that of the cor-
tical forms of Broca's aphasia. For reasons, however, which must be
Tery clear to every practical neuropathologist the lesions causing the
aphasia, in fact massive lesions of all sorts, are very rarely purely cortical.
The vessel which closes or which is broken has its branches both in gray
and white matter, and hence the softened area or the hemorrhagic cyst
usually involves both. It is probable, as Dejerine says, that a subcortical
motor aphasia, if of pure type, will leave certain powers or capacities of the
patient, — as that of writing, — intact, or but little affected, but such a case
will be of rare occurrence. The usual symptom picture, whether the
lesion be in Broca's convolution or the insula or in both, or in whatever
part of the cerebral zone of speech, is one that is due to a lesion which is
jointly cortical and subcortical. Dr. Mills excluded here those cases of
lesion of the internal capsule and corona radiata, sometimes observed, in
which no portion of the gray matter, either cortical or central, is
diseased; but even in capsular lesions and in lesions of the corona outside
of the usually accepted cerebral zone of speech the gray matter is often
involved.

Motor aphasia, according to Marie, is simply Wernicke's aphasia plus
anarthria. Dr. Mills did not see how this definition is to be accepted
unless we give a new meaning to anarthria, which indeed Marie seems to
have done. The generally accepted definition of anarthria is that it is a
defect or difficulty in speech, especially connected with articulation. Even
if we expand this definition as Marie has suggested, so as to include
defects of the expiratory, phonatory and articulatory mechanism, it is
still clear that such an anarthria does not constitute motor aphasia in the
accepted sense. Many of the motor aphasics whom Dr. Mills had studied
have presented no anarthria or dysarthria. Some partial motor aphasics
are dysarthrics ; some monoplegics or hemiplegics have anarthria or dysar-
thria which is regarded by careless observers as motor aphasia, but anarth-
ria and motor aphasia are quite distinct, although the two may be com-
bined in the same case. Add to the well recognized phenomena of sensory

468 PHILADELPHIA NEUROLOGICAL SOCIETY

aphasia such as partial word deafness, paraphasia, etc., an anarthric de-
fect of speech, and the resultant will not be a true motor aphasia. Defec-
tive vocalization and articulation will be added to the sensorial phenomena,
and yet the patient may be able to speak, although in a stumbling manner.

To what is anarthria or dysarthria due when present from a cerebral
lesion, — from a lesion above the bulb? In some cases it is undoubtedly
due, as is now well known, to lesions usually bilateral of the internal
capsule ; in others to lesions of the subcortex of the facial and orolingual
region, and in others to lesions of the orolingual cortex itself.

Dejerine believes that anarthria producing the pseudo-bulbar syndrome
never occurs from a unilateral lesion, either cortical or capsular, the cases
observed by him having always been instances of bilateral lesions. He
believes that the centers which come into play in the mechanism of speech
have in reality a bilateral cortical representation.

The question of the correctness of Marie's views with regard to the
part played by lesions of the lenticula in the production of motor aphasia
necessarily involves the discussion of the entire question of the functions
of this body. Dr. Mills had the opportunity of making personal observations
on several cases with necropsies in which destructive disease of the lenti-
cula was present. The lesions, however, were rarely strictly confined to
the lenticula. In the laboratory of neuropathology of the University of
Pennsylvania, Dr. William G. Spiller has the specimens from some of
these cases, with others collected by himself. One or two of these speci-
mens have been brought here for the inspection of those taking part in
this discussion. Later it is the intention of Dr. Spiller and the writer to
take up the question of the functions of the lenticula largely from the
point of view of personal clinicopathological studies.

Probably the work of Mingazzini on the symptomatology of lesions
of the lenticular nucleus is the most valuable contribution to our knowl-
edge of this subject. As the result of carefully made personal observations
and of a study of cases recorded by others he concludes that a focal
lesion, even if of small size, which involves only the lenticular nucleus
never fails to manifest itself with motor disturbances, these motor symp-
toms showing themselves as dissociated or generalized paralysis or paresis
to which are sometimes added irritative symptoms.

Mingazzini discusses the speech disorders which he, in common with
Nothnagel and others who preceded him, believe result from destructive
lesions of the lenticula. These are particularly described as dysarthrias,
and Mingazzini holds that they would appear to result only from lesions
of the left lenticula. He gives cases with necropsies demonstrating the
fact that lesions of the right lenticula do not, while those of the left if
peculiarly situated do, cause dysarthric affections.

BIBLIOGRAPHY.

Marie, Pierre. Semaine Medicale, May 23, 1906.

Marie, Pierre. Semaine Medicale, Oct. 17, 1906.

Dejerine, J. La Presse Medicale, July 11, 1906.

Dejerine, J. La Presse Medicale, July 18, 1906.

Mills, Charles K. University Medical Magazine, November, 1891 ; also
American Journal of the Medical Sciences. September, 1904.

Von Monakow. Neurologisches Centralblatt, No. 22, 1906.

Mingazzini, Giovanni. Sulla sintomatologia delle lesioni del nucleo
lenticolare. 1002.

PHILADELPHIA NEUROLOGICAL SOCIETY 469

Dr. James Hendrie Lloyd said that Marie's paper on aphasia is more
important for what it indicates than for what it really says. As a pro-
nouncement on the subject of aphasia it is noteworthy chiefly for attempt-
ing to tear down all the work that has been done by others, and to erect
instead an edifice which is largely theoretical and purely Marie's. Viewed
in this light it does not seem to be deserving of all the attention it is
receiving; and Dr. Lloyd failed to see that it marks an epoch.

But from the standpoint of what it indicates — as showing, for instance,
a tendency — Marie's paper is of some significance. It is a protest, or a
reaction against the extreme academic school which has long been para-
mount. This academic, or diagrammatic school has elaborated this subject
of aphasia beyond all reason. A recent author gives twenty-eight varieties
of aphasia. There is hardly a monograph in which this excessive sub-
division is not more or less in evidence. We see the nicest analyses made,
and the whole subject partitioned out, each variety being assigned to a
limited area of the brain cortex. Dr. Lloyd did not hesitate to say that
these fine-spun schemes are not so much in accord with bedside observa-
tion as they are mere evidences of a burning of the midnight oil. We
even hear it said that there are special and distinct centers for the gram-
matical parts of speech, as nouns and names, but for his part Dr. Lloyd
had never been able to subscribe to those extreme views, and he believed
he was within bounds when he said that it is impossible at the bedside to
verify all this theoretical psychology.

His own doubts on this subject have been growing greater and graver
for some years. Bedside observations, very faithfully made and in large
hospital clinics with ample material, have not enabled him to make many
of the fine distinctions which are so popular. In most cases that he saw
the phenomena are mixed. Thus with motor aphasia there is some audi-
tory aphasia and word blindness, especially in bad cases, and in the early
stages even of mild cases. There is also, as Marie points out, some failure
of intelligence, or mental confusion, so that it is most difficult to say just
how much is aphasia properly so-called, and how much is due to mental
defect. He had been in the habit for some years at Blockley of calling
these cases sensori-motor aphasia, as indicating that both the sensory and
motor elements of speech are involved. He knew that the criticism is
brought against these views that those who hold them are lacking in the
power of precise observation. But that criticism is the worst kind of a
begging of the question. Precise observation is not a monopoly, even of
those who can discern twenty-eight varieties of aphasia.

In a recent case at Blockley there was complete motor aphasia, with
some degree of word deafness and word blindness; also very evident
mental dullness; but the brain cortex on gross inspection, after hardening
in formaline, was not involved, and the lesion was confined to the internal
capsule and lenticular region. Dr. Lloyd has now two cases of right-sided
hemiplegia under his care in the Methodist Episcopal Hospital in neither
of which is there the slightest evidence of aphasia of any kind. He did
not agree with Marie that the cortex must necessarily be involved in order
that there should be aphasia proper, for he had certainly seen genuine
aphasia in cases of purely lenticular lesions. He said this, however, with
due appreciation of the fact that we have no right on mere naked eye in-
spection to say that the cortex is not involved when there are large
underlying capsular lesions. Even a microscopic examination might not
suffice to determine whether the brain cells in life had been able to

470 PHILADELPHIA NEUROLOGICAL SOCIETY

functionate in cases in which the circulation had been so seriously ob-
structed as by large underlying hemorrhages or softenings.

This led him to say a word about the difficulty of interpreting patholog-
ical changes. We have in many of these cases great ripping lesions, tearing
up large areas of the brain substance. Even in one or two of Marie's
pictures it looks as though large parts of the side of the brain had been
torn out. In such cases precise conclusions are often unwarranted. The
damage even in small lesions is often much more extensive than it seems
to the naked eye. He had seen a minute but fatal hemorrhage in the
spinal cord which seemed to be confined to the anterior parts of the
posterior columns, but under the microscope the damage was seen to be
much more extensive, acting in fact like a total transverse lesion. So in
the brain, a seemingly small lesion may be responsible for much greater
and more widespread damage than it is credited with. Observation in
some of these cases can hardly be exact; and as some of them are re-
ported and described no proper attempt is made to delimit the lesion. We
are totally deprived of all opportunity to experiment in order to prove
anything in aphasia, for of course the anthropoid apes are of no value for
such a purpose, and we cannot experiment on the human subject under
ether. Dr. Lloyd often feels like protesting against the dogmatic state-
ments that are based on improperly observed pathological changes. Will
the time ever come when some enthusiast will have the temerity to excise
carefully the so-called auditory speech center or the angular gyrus in a
normal human brain? He should not like to be either the excisor or the
excisee.

Marie asserts that in every aphasic there is trouble to comprehend
spoken language, but that the tests ordinarily used are not adapted to
bring this defect out. Dr. Lloyd thinks this is a criticism that should be
taken to heart and put to the test by some of the advocates of pure motor
aphasia. It will doubtless be found in many cases if the demands made
of the patients are a little complicated (not merely an order to "put out
your tongue," or "hold up your hand") that Marie is right in this respect
He knew that he had often found it to be so.

Another most important point is Marie's statement that in every case
there is some loss of intelligence. It is surprising how commonly it is
assumed that intelligence is intact in aphasia ; that there is nothing the
matter with the mind but a speech defect; although it should be evident
that because of this very speech defect the difficulty of determining the
integrity of the mental processes is almost unsurmountable. Dr. Lloyd
would not tarry here to attempt to discuss the vast question of the de-
pendence of thought upon the faculty of language; it is enough to point
out that this dependence is very close, and that those persons who calmly
assume that in aphasia there is no mental defect, take much more for
granted than either the facts or the science warrants. Upon this important
subject Marie's criticism ought to do some good, and should invite to a
less superficial view of these cases. If the attempt is made to induce an
aphasic to use his mind for abstract thinking, it is usually soon evident
that he is out of his depth. He can "put out his tongue," and "hold up
his left hand," but he cannot sustain any complex train of thought, and
the mere attempt soon worries and exhausts him. This raises the im-
portant medico-legal question of the will-making power of aphasics, at
in the celebrated Parrish case.

The emotional life is usually well preserved in aphasics, as Marie says,

PHILADELPHIA NEUROLOGICAL SOCIETY 471

and this gives a superficial appearance of preserved intelligence. But the
emotions are easily excited, even in the weak-minded, and are a very poor
gauge of the extent of the intelligence.

Marie asserts that Broca's motor aphasia and Wernicke's sensory
aphasia are very analogous, with the capital exception that in Broca's
aphasia the patient cannot talk. This inability to talk is merely an
anarthria, which is a sort of pseudo-bulbar palsy due to a lesion of the
internal capsule. His scheme is a very simple one. The seat of all true
aphasia is in a comparatively limited area of the brain cortex, and in-
cludes the supramarginal convolution, the angular gyrus, and the posterior
ends of the two upper temporal gyres. When the capsule is involved, ther«
is added an anarthria. Broca's classic convolution is thrown out entirely,
as having nothing to do with aphasia. As has been already said, Dr. Lloyd
thinks this cheme of Marie's is entirely too theoretical and dogmatic, and
is open to the same criticism that can be brought against that of other
schemers. But in some details, to which Dr. Lloyd had already referred,
he believed Marie's criticism is based on just grounds, especially his claim
that the superfine analysis of aphasia into many varieties is largely acade-
mic. Yet he would not go quite so far as Marie. In a large and genera!
way he believed aphasia can be subdivided into a few types. In one type
the motor defects predominate, and this can be called the motor type. In
another, the sensory element is more conspicuous, and this can be called
the sensory type. But he believed it is a mistake to go much beyond this)
simple plan in our present knowledge of aphasia. As for the localization
of these defects in the brain cortex, he believed that the zone of speech is
much more extended than the area which Marie has mapped out.

Dr. F. X. Dercum briefly stated Marie's position with regard to aphasia ;
namely, that aphasia is an intellectual deficit; that it is a unit; that it is
not made up of sensory aphasia on the one hand and motor aphasia on
the other, but that by lesion of the zone of Wernicke there is established
an intellectual deficit for the comprehension of spoken language; that in
so-called sensory aphasia the lesion involves the zone of Wernicke, that in
so-called motor aphasia there is, in addition, an involvement of the region
of the lenticular zone. Lesion of the lenticular zone gives rise to anarthria.
Therefore in so-called motor aphasia, we have merely ordinary Wernicke
aphasia plus anarthria. Dr. Dercum then detailed the results of his studies
of fourteen cases of aphasia according to the method of Marie, for the
determination of the presence of intellectual deficit. Some aphasics can-
not comprehend a single word. More frequently they comprehend things
that are relatively simple. As a rule they can execute simple instructions,
but not complicated ones. Some aphasics have great trouble in executing
a single act; others are embarrassed by a direction to perform two con-
secutive acts, and others fail when three or four are attempted. In all of
his fourteen aphasics, Dr. Dercum found an unquestionable deficit. Four
were unable to carry out any instructions, no matter how simple; two
invariably failed when an instruction containing two factors was given;
one was able to perform one instruction fairly well, but usually failed when
the instruction contained two factors. Four were able to execute instruc-
tions containing two factors, but always failed when they contained three.
Three could execute instructions containing three factors, but usually
failed when this number was exceeded.

Similar facts were elicited when the attempt was made to have the

4/2 PHILADELPHIA NEUROLOGICAL SOCIETY

patient carry out written instructions. Seven of the fourteen could read;
that is, they could read single words, written or printed. Thus one patient
could read the word "hand" and would correctly indicate the object upon
his own person by raising" and exhibiting his own hand. He could read
the word "head" and indicated this portion of the body. A short sentence
embodying these two objects; namely, "hand" and "head," was now placed
in writing before him, thus, "Put your hand on your head." He failed
absolutely to comply. He evidently could not comprehend the sentence
and was as helpless in the presence of a written instruction as he had been
in the presence of the verbal instruction. Other interesting illustrations
were given.

Dr. Dercum contended that the intellectual deficit maintained by Marie
must be unhesitatingly admitted. He pointed out that this deficit is special
in character. It differs, of course, from the deficit seen in arrested develop-
ment on the one hand and in dementia on the other. The deficit is
lacunar, involving one function or a closely related group of functions.

Dr. Dercum was unable to classify his aphasics into motor and sensory.
He failed also when he attempted to arrange them into groups according
to the presence or absence of anarthria. The motor speech difficulty ap-
peared in each case as something added to the essential symptoms of the
aphasia ; an anarthria added to the failure to comprehend words or.
sentences.

Dr. Dercum's clinical studies were confirmatory of the results obtained
by Marie. Further, Marie's contention that motor phenomena may be
produced by involvement of the longitudinal bundle and by the isthmus
which connects the zone of Wernicke with the region of the basal ganglia,
bears a strong probability of truth, but it is only the confirmation of
pathological observations which will definitely determine the question.

Regarding the third left frontal convolution, the occurrence of isolated
lesions of this region in right-handed persons without producing aphasia
must be extremely significant. Certainly such instances entitle us to the
legitimate doubt as to the real function of the third left frontal.

Dr. E. D. Fisher said that what we understood by an intellectual defect
must be in regard to speech or in regard to writing. He had a patient
who illustrates this. He attends to his business regularly. He is a
hemiplegic and not an aphasic. He could not calculate in figures and yet
his mind as a mind was as active as it ever was in business relations. He
thinks there are many aphasics who are not intellectually aphasic in any
way.

Dr. Starr said he had read these papers by Marie very carfully and given
them a great deal of thought. As a lecturer on aphasia it was very interesting
to draw diagrams, as Dr. Dercum said, and show what we thought ought to
be the beautiful varieties of this disease, but, unfortunately, if you had to
show the patients whom you thought illustrated the lecture it was some-
times hard to bring harmony between theory and fact. It had often been
very difficult to find a case which corresponded exactly to the distinctions
which were laid down in regard to motor and sensory aphasia. He be-
lieved Marie was right in calling attention to the fact that the majority of
aphasics are doubly aphasic, that there was a sensory and a motor element
combined in the majority of aphasics. He thought, on the other hand,
that Marie had taken a decided step backward in trying to enforce this
idea as applicable to every aphasic. He thought everyone who had studied

PHILADELPHIA NEUROLOGICAL SOCIETY 473

a large number of aphasics could put his finger here and there on a case
which was decidedly and distinctly motor, or entirely sensory, and if
cases of this kind existed, it overthrew Marie's contention absolutely and
brought us back to Dejerine's point. It seemed they were both right in
part; that as Marie said aphasics were often both motor and sensory, but
that Dejerine was also right in that there are cases of very limited lesion
with purely motor or purely sensory symptoms. He had seen examples of
both kinds. Exner was the first to figure it out in his wonderful diagrams
'way back in 1881, limited lesions causing pure types of aphasia, in Wer-
nicke's region sensory aphasia and in Broca's motor aphasia. We have
been acting upon this localization in brain surgery in the removal of
tumors and abscesses from the different speech areas of the brain with
success, and he therefore was not prepared to give up the idea of separate
aphasic areas.

Dr. Joseph Fraenkel said that there are undoubtedly cases of pure
sensory and pure motor aphasia occurring. It is true, of course, that such
pure types are rare. Some years ago Dr. Onuf and he analyzed the
clinical and autopsy findings of all cases of motor aphasia thoroughly re-
ported in the literature. Out of a total of about no cases they found only
about nine cases in which the speech disturbance was the result of a
strictly localized lesion in Broca's center. Out of this number, only three
showed the aphasic disturbances to be permanent. In the other cases
there was a more or less marked recovery of the speech faculty in spite
of the permanence of the lesion. Most of the other cases showed widely
distributd lesions, so that it is impossible to conceive that these lesion*
should give rise to a clearly defined clinical picture.

periscope

Deutsche Zeitschrift fur Nervenheilkunde.
(Band 28, Heft 2-4.)

5. Osteoacusia and Its Relations to the Sensation of Vibration. Neutra.

6. Contribution to the Study of Spondylose Rhizomelique. Mingazzini.

7. Acute Multiple Gangrene of the Skin, with Investigations Upon the

Necroses Produced by Pure Hydrochloric Acid. Zieler.

6. Contribution to the Knowledge of Congenital Muscular Defects.
Steche.

p. A Case of Defect in the Muscles of the Shoulder-Girdle and Their Com-
pensation. Capelle.

10. Communications Concerning Hysteria. 1. Hysterical Mutismus in
Combination with Hysterical Asthma After an Accident.
Stintzing.

IX. Hysterical Somnolence with Choreatic Movements. Grober.

12. Complete Cutaneous and Sensorial Anesthesia in a Case of Traumatic

Hysteria. Seifert.

13. Contribution to the Origin of Brain Pressure by Brain Tumors, and

Other Diseases of the Brain, and a Peculiar Form of Swelling of
the Brain that May Be Observed in These Conditions. Reichardt.

5. Osteoacusia. — Neutra, after a very exhaustive discussion of bone
•conduction, reaches a series of conclusions of which the following is an
abstract. Hearing of a tuning-fork placed upon any peripheral portion of
the body depends upon bone or cartilage conduction. This behaves in all
respects as the conduction of vibrations through the cranial bones. If
the external ear is closed during this conduction, the sound's intensity, and
usually also its duration, are increased. This may possibly be due to
psychical as well as physical causes. Osteoacusia is most distinct in those
cases in which the bones are subcutaneous. It is affected by various
diseases of the skeleton, and is not affected by organic sensory disturbances.
If the tuning-fork is placed upon the spinal column it is found that kyphosis
increases the duration of the sound, lordosis diminishes it. Osteoacusis
is entirely independent of the sensation of vibration. Slight changes of
the latter cannot be determined. The bones play only the part of reflec-
tors, the sensation being perceived in the pressure nerves of the soft parts.
In addition to the bones, firm connective tissue, and even contracted
-muscles may act as reflectors. Therefore, the sense of vibration must be
Tegarded as a modified pressure sense. For these tests tuning-forks having
from 100 to 200 oscillations per second are the best. The absence of either
osteoacusia or the sensation of vibration upon a place where they are
normally present is, with certain precautions, a definite sign of either
hysteria or simulation.

6. Spondylose Rhizomelique. — A man of twenty-nine, began, at the age
of 19, to have pain in the lumbosacral region, and in the legs. Later, dur-
ing his military service, he had pain in the left thigh which terminated
in ankylosis at the hip. From this, however, he made a partial recovery.
Subsequently when examined by Mingazzini the patient was found to have
marked limitation of movements in the knee and hip joint, which disappeared

PERISCOPE 475

-under spinal anesthesia, and were evidently due to pain. There was also
pain in the muscles of the neck. The spinal column gradually became
more and more deformed until the upper portion was at right angles to
the lower portion. Radiographs of the hip showed alterations in the
bones. Mingazzini regards the deformity of the spinal column as due
directly to the alteration in the anterior vertebral articulations, and not
to the effect of gravity.

7. Skin Necroses and Hydrochloric Acid. — A girl of twenty-two had
for about half a year suffered from a curious eruption of the skin. First
■there was a hyperemic area upon which welts appeared with white, shining
centres, and a circular erythema. In the course of a week either a super-
ficial scale separated, leaving normal skin beneath, or there was a very
superficial area of gangrene. There were no general symptoms. Later
some small blisters were occasionally seen around the eruption, and still
later larger blisters appeared. The mucous membranes were not involved,
and keloids never formed. There were no disturbances of sensation. The
histological examination of one of the lesions showed hyperemia and
edema of the cutaneous and papillary bodies, with slight round-cell in-
vasion around the capillary bodies. As the lesions resembled very closely
those produced by dropping raw HC1 upon the skin, such artificial lesions
were examined microscopically, and indicated a distinct necrosis proceed-
ing from the surface, entirely different from that of the hysterical lesions.

8. Muscular Defects.— The first patient, a boy of twenty, had complete
defect of the left serratus. There was high position and hypoplasia of
the left shoulder blade. The second case, a boy of eight years, lacked on
the left side the pectoral muscles, and the latissimus dorsi, and there was
imperfect development and weakness of the serratus. Anomalies of the
skeleton consisted of shortening of the clavicle and rudimentary develop-
ment of the left hand. A fold of skin extended between the thorax and
the upper arm. There were also some developmental disturbances of the
skin of the left breast, the mammary gland on that side being entirely
absent, and the skin abnormally thin. The third case, a man of twenty-
six, had on the left side defect of a portion of the pectoralis major, and
of the whole of the pectoralis minor. There were some defects in the
ribs, deformity of the left hand, and a fold of skin between the left arm
and the chest. The skin on the left side was thin, and the mammary
gland was absent. The fourth case, a man of twenty-four had almost
complete loss of the left trapezius muscle, without any other conditions.
The fifth case, a man of twenty-two, had absence of the deltoid, but the
disturbance in function in this case was exceedingly slight. The sixth
case, a man of fifty-two, had congenital absence of several muscles in the
"ball of the thumb on both sides. There were practically no functional
disturbances, and no congenital anomalies otherwise. Steche calls atten-
tion to a combination of a group of conditions associated with defect of
the pectoral muscles, which includes, in addition to disturbances of the
skeleton, the skin and mammary gland. The loss is always unilateral, and
is never hereditary. He collects cases recorded in the literature, and
tabulates them, and explains the inability of determining any cause, and
in conclusion reports a case in which the mother of a patient suffering
from muscular dystrophy, presented this uniateral defect in the pectoral
muscles, which the autopsy indicated, was congenital.

9. Shoulder Girdle Defects. — Capelle describes a case with congenital

476 PERISCOPE

absence of the latissimus dorsi on the left side. He discusses very fully
the functional disability that results from this, and also the method by
which it is in part compensated. In addition to the latissimus, examination
also showed absence of the pectoralis minor, and of the lower portion of
the serratus.

10. Hysterical Mutismus. — A man of twenty-nine suddenly experienced
severe pain while at work. He subsequently became weak, had some
vomiting and severe asthma, as a result of which he was unable to work.
Later he became unable to speak, even to whisper, although his under-
standing of spoken speech was perfect. The movements of the vocal
cords were not impaired. The reflexes were all increased, but not
pathological. A diagnosis of hysteria was made, and the patient re-
covered rapidly under psychic treatment. The condition correspond*
exactly to that described by Charcot.

ii. Hysterical Somnambulism and Chorea. — A child of three and a half
years of age had several attacks, probably hysterical in nature, and then
became lethargic. The diagnosis was doubtful ; meningitis, possibly tuber-
culous, was suspected, but never conclusively proven to be present. After
three months of the lethargic state he recovered consciousness, but was
dumb, and had a functional stiffness of the right wrist. Subsequently
there were several brief attacks, typically hysterical in nature, followed
by complete recovery.

12. Traumatic Hysteria. — A man of thirty-eight fell violently upon the
ground, striking his head and left arm. Subsequently he developed a
condition diagnosed as traumatic hysteria, in which he emaciated, became
pale, was melancholic, had profuse sweating during investigation, and
had numerous tender points. There were also some cutaneous anesthesia,
but no disturbance of the special senses, or of motion. The reflexes were
normal. Later he had an attack of confusion lasting two days, followed
by total blindness in the left eye, unilateral loss of cutaneous sensation qn
the left side, and loss of hearing, taste and smell on the same side. There
was concentric contraction in the visual field in the left eye, and the
general condition grew worse. Still later, after a slight infection, he
developed hysterical mutism. Another confusional attack was followed
by partial anesthesia in the right hand. If, during this period, the right
eye and ear were closed he went into a somnolent condition. Later he
lost the hearing in both ears, was unable to speak for a prolonged period,
and finally developed hysterical paresis of the left arm. During the course
of the disease the patient repeatedly expectorated blood. Lasegue's test,,
substituting for visual control the sensation of the skin in order to obtain
movement in the anesthetic hand, was not successful, but if the anesthetic
hand was laid upon a sensitive portion of the skin, and either touched
with the sensitive right hand, or first observed with the right eye, thtf
fingers could be freely moved. Some other very interesting experiments
are also described. These cases of extensive distribution of the hysterical
symptoms are rare.

13. Brain Tumor and Pressure. — Reichardt calls attention to the im-
portance of the position of the tumor for the production of intracranial
pressure. This also occurs in simple hypertrophy of the brain. He re-
ports a number of cases of brain tumor, and studies in each the cause
of the pressure. In the first case a huge tumor, causing increase in the
pressure purely by its bulk, was found. In the second case an extra-

PERISCOPE 477

•cerebral tumor, weighing 162 gm. produced very little pressure because
there was an atrophic area in the brain in which it was accommodated. In
the third case a huge glioma of the left hemisphere had produced severe
internal hydrocephalus. The brain, however, was distinctly atrophic, and
this served to explain the very mild symptoms of intracranial pressure
that were present during life. In the fourth case a small tumor containing
about 100 cc. of clear viscid fluid and pressing upon the right frontal
lobe, caused symptoms of severe intracranial pressure. In this cyst a
small glioma was found. An histological examination of the brain re-
vealed the presence of a productive gliosis. The patient was young, which
•probably accounts for the increased resisting power of the brain, and the
symptoms of pressure. In the sixth case (cholesteatoma) were symptoms
suggesting multiple sclerosis. The brain showed distinct indications of
increased intracranial pressure due to a swelling, not the result of edema,
but of a severe hyperemia, probably to be brought into relation to the
action of the tumor. The seventh case was one of periodic dementia, there
were evidences, at the autopsy, of severe intracranial pressure (evidently
■of acute origin) shortly before death. The brain was swollen, but no
cause for this could be found. The ninth case was practically the same.
Reichardt insists upon the necessity of a better comprehension of the term
"swelling of the brain." There are varieties of this, and possibly they
may serve to explain why sometimes a small tumor will cause a high
grade of intracranial pressure and a large tumor will not do so. His
studies have been based upon a comparison of the relation of the capacity
of the skull to the weight of the brain, and he believes that such studies
-are important. He also believes that the choked disc must be regarded
not as a indication of the size of the tumor, but of the intensity of the
intracranial pressure, and — to a certain extent — of the resistance or re-
action of the brain to the irritant.

(Band 28. Heft 5-6.)

15. Investigations Upon the Idiomuscular Hyper-Irritation (The Idio-

Muscular Contraction of Schiffs). Curschmann.

16. The Relations of Congenital Weakness of the Ectodermal Germinal

Layer to the Development of Tabes Dorsalis. Bittorf.

17. The Syphilogenic Diseases of the Central Nervous System, and the

Question of "Syphilis a virus nerveux," with Introductory Re-
marks by W. Erb. Fischler.

18. Brief Communication. Further Remarks on My Article, "Studies

Upon Oppenheim's Feeding Reflex, and Some Other Reflexes."

Furnrohr.
15. Idiomuscular Hyper-Irritation. — Curschmann, after a careful re-
view of the literature of the idiomuscular contraction, proposed to him-
self a study of its nature and duration, and also of the wave-like contrac-
tions. At the same time he made a careful examination of the irritability
of the muscle examined, and of the general muscular system, as well as
the mechanical and electrical irritability of the motor nerve and the
muscle. Furthermore he studied the relation of the tendon reflexes, the
vasomotor irritability, and finally, the occurrence of the spontaneous
movements of the muscles. These results are carefully tabulated, although
the tables are not reproduced in extenso. Curschmann summarizes them

478 PERISCOPE

as follows. Idiomuscular super-irritability and SchifFs waves occur
exclusively as a result of mechanical irritation, and pre-eminently in the
presence of pathological emaciation. They may be absent under favorable
circumstances in women, young children, and in uncomplicated senile
emaciation. They do not, however, represent a symptom of wasting, but
are the expression of a specific irritability of the muscle. This phenomenon
is not the product of the degeneration and death of the muscle ; at least,
not in the functioning muscles of persons suffering from disease. It may
be that deficient water in the tissue is of some significance. At any rate,
the fundamental cause resides in the muscular tissue, and is probably
due to the action of various toxic materials upon the contractile sub-
stance. Disturbances of the central or peripheral motor neurones has no
influence upon the occurrence of the idiomuscular tumor formation. In-
deed, the latter seems to require at least the essential features of co-
ordination and central trophic influence. There is no relation between it
and the tendon reflexes. The degree of idiomuscular contraction is
directly proportional to the general muscular irritability. This is also true
of SchifFs waves, and therefore, both are probably the expression of an
alteration in the irritability. Almost invariably there is found in the more
extreme cases of idiomuscular super-irritability a similar increase in the
mechanical, and probably the electrical, irritability of the nerves. This
must not be regarded as of etiological significance for the muscular phe-
nomena, but probably as an expression of a simultaneous change in the
irritability produced by the same poisons. Whether the idiomuscular
super-irritability bears any relation to the involuntary fibrillary twitchings
of the muscles, or involuntary movements as a whole of muscle groups, i»
doubtful. But it is certain that those diseases which produce secondary
tetany also give rise to the idiomuscular super-irritability, SchifFs waves,
and the most extreme type of super-irritability of the nerves. There is
no relation, however, to vasomotor super-irritability.

16. Tabes and the Ectoderm. — Bittorf has made a careful study of the
literature of tabes dorsalis, in order to determine whether there is not
some congenital anomaly or vice of construction in the nervous system
which is the basis of its development. He regards as sufficient proof for
this the discovery that the patient has a neuropathic heredity, because
this indicates a diminished resistance of the central nervous system. Among
the most important factors in the ancestry are alcoholism, suicide, mental
and nervous disease, and epilepsy. The statistics are obtained from sixteen
men and fifteen women. Of these thirteen of the men and twelve of the
women showed in their ancestry mental disease. This can be compared
with five of eighteen men with neuropathic heredity, and two of fourteen
women. He concludes with a study of the physical signs of degeneration
in his cases. Eight men and seven women had less than five of these
signs; eight men and eight women had more than five. Of the cases for
comparison 25 per cent, had three of the signs and none had one.

17. Latent Syphilis. — The causation of tabes and paresis is still a sub-
ject for investigation. It is not clearly understood how the infantile
forms occur, nor what is the nature of the congenital forms. Further,
there are records of groups of persons infected with syphilis from the
same source in whom a large percentage have developed one or the other
of these diseases. These observations have given rise to the suggestion of
a peculiar form of "syphilis a virus nerveux," or, to the hypothesis of

PERISCOPE 479

Hitzig that there is an additional infectious substance usually conveyed at
the same time as the other infection. In an effort to answer these ques-
tions Fischler, upon Erb's suggestion, has undertaken an analysis of the
cases found in the literature. The first group includes the cases of
juvenile tabes and paralysis. It appears that the disease has not yet
been recognized in the first years of life, and therefore, probably does not
occur until later. Moreover, even in hereditary syphilis it may not occur
until after puberty. From among these children it is possible to exclude
the so-called accessory factors: Tobacco, alcohol, excesses, struggle for
existence, etc.; indeed, in some it is expressly stated that, being sickly
from birth, they were especially shielded. In the majority of cases con-
genital syphilis could be determined. In a few cases syphilis acquired in
infancy, chiefly from the wet-nurse, appeared to be the cause. In some of
the latter cases anti-syphilitic treatment was energetically employed, but
nevertheless, paresis subsequently developed. The senses appeared to be
about equally effected, a pronounced difference from the conditions occur-
ring in adults. In many cases there is a hereditary neurotic tendency.

In the second group of cases is included a series of cases in which both
husband and wife suffered from tabes, tabo-paresis, or from tabes or
paralysis in combination with other syphilogenic disturbances. A study
of the material indicates that syphilis is the chief cause, and that he-
reditary family influences have little to do with it. Nor does it appear
that a similarity in the manner of life is of much influence. Another series
of factors, such as the excessive use of tobacco, etc., can also be partially
or completely excluded. Certain cases in which other persons than the
husband and wife have been infected from the same source and developed
the disease seem to render the etiological relation of syphilis more direct.
Fischler admits the frequency with which paresis or tabes occurs in only
one member, but also calls attention to the frequency with which syphilis
has reached the non-communicable stage by the time marriage is under-
taken.

The third group includes various combinations of tabes, paresis and
the syphilogenic diseases of the central nervous system. The number of
cases is large, and in the great majority it is possible to determine the
existence of a distinct syphilitic infection. It is remarkable how fre-
quently in these cases both parents, as well as the children, are affected, in
nearly" 50 per cent. These cases support the view that in certain cases of
syphilis there is a marked tendency to the production of diseases of the
central nervous system. _

The fourth group includes an interesting series of cases in which
several persons not in any way related were infected from the same
source, the majority of them in some instances, and sometimes all, de-
veloping tabes, paresis or syphilis of the central nervous system. The
number of these instances is necessarily small, in all probability chiefly
because it is so difficult to determine a common source of infection in a
number of unrelated people. If they are related, as in families, it appears
that such groups may be frequently recognized. Fischler believes that
everything in these studies speaks for the existence of a lues nervosa.

18. Feeding Reflex.— Fiirnrohr calls attention to the fact that Goltz, in
some experiments upon dogs, observed a reflex closely analogous to that
of Oppenheim. Sailer (Philadelphia).

48o PERISCOPE

Centralblatt fiir Nervenheilkunde und Psychiatrie

(XXX., 1907, Feb. 15.)

1. Ideas of Reference. M. Rosenfield.

2. Number of Syphilitic Cases in Copenhagen and the Number of Paretic

Dementias in Skt. Hans Hospital. P. Heiberg.

3. Trional Cure. Wolff.

1. Ideas of Reference. — The author reports three cases, the clinical pic-
ture of which, in addition to retardation, depression, and general in-
activity, were dominated by delusions of persecution with ideas of ref-
erence. The patients did not react to hallucinations, showed no evidence
of katatonic symptoms, expressed no hypochondriacal ideas, and intelli-
gence was intact. The recoveries were rapid, complete, and without any
defect in the psychical sphere. In regard to diagnosis Rosenfield does not
regard these disease pictures as acute abortive paranoia, but classifies them,
according to Kraepelin, as manic depressive insanity (depressed form).

2. Syphilitic Cases in Kopenhagen and Paresis in Skt. Hans Hospital.—
Heiberg maintains that there is a causal relation between the total number
of syphilitics of Kopenhagen and the paretics of Skt. Hans Hospital.
Two and a half per cent, of all syphilitics in Kopenhagen develop paresis.
He draws his deductions from the following table :

Number of Syphilitic Cases Death from Paresis in Skt. Hans

in Kopenhagen. Hospital (15 years later).

Year. No. of Syphilitics. Year. Number of deaths.

1864-1880 13,500 1879-1885 321

1881-1890 13,500 1896-1905 321

1891-1905 20,000 1906- 1920 500 (to be expected.)

3. Trional Cure. — Dr. Wolff claims that trional shortens the duration
of excitement in certain mental diseases. In his 12 cases (5 cases were
reported in Centralblatt, 1901, and 7 cases are reported in the present
number), 7 were manic depressive insanity, 4 belonged to the infective ex-
haustive groups, and 1 was an anxiety psychosis, trional cure was applied
with success. His treatment is outlined in the following manner : For
fourteen days patients received trional from 2 gm. to 3 gm. daily, later
the drug was reduced to 0.5 or 1 gm. In most of his4 cases the drug was
administered through a stomach tube. On the second week patients' sleep
much improved, psychomotor unrest diminished in frequency and inten-
sity, and excitement soon subsided. Trional was used also with advan-
tage in allaying the excitement in two patients who suffered from dementia
praecox, paranoid form and katatonia, respectively. In the trional cure
no injurious or unpleasant after-effects were observed, except one case
showed marked evidences of intoxication, but patient soon recovered. The
author, however, fails to call attention to the fact that urine should be
frequently examined for hematoporphyrin. It is to be remembered that
"when trional is taken in full dose for several weeks, it produces very
distinct alterations in the blood, which are manifested by hemotoporphy-
rinuria— a state in which the urine is dark red and almost blood. The
drug should be stopped at once when the urine begins to be red and
saline purgatives must be used freely (Hare)."

Morris J. Karpas (Ward's Island.)

PERISCOPE 481

Review of Neurology and Psychiatry

(Vol. V. 'No. 1.)

:i. A Plea for the Study of the Intermedio-Lateral Cell- System of th«

Spinal Cord. A. Bruce and J. H. H. Pirie.
a. A Report of Two Cases of General Paresis with Focal Symptoms. A.
Hoch.

I. Intermedio-Lateral Tract. — It is known that division of the connect-
ing fine medullated fibres between the sympathetic and the spinal roots
causes a reaction a distance in the cells of the intermedio-lateral tract;
also that division of the cervical sympathetic produces similar cell-changes
in the corresponding intermedio-lateral tract and not beyond it. The
analogy of the relationships of the splanchnics to the cord suggests for
them a similar origin. Bruce and Pirie, in their interesting article, report
two cases, with autopsy, in which there was involvement of the sym-
pathetic system and lesions of the intermedio-lateral tract adequate to
have produced the symptoms in question. In one case loss of sweating
in the lower extremities had developed during the course of an acute
atrophic paralysis in an adult. The other case was one of acute ex-
• ophthalmic goitre, in which death took place during an access of hyper-
thyroidism. In the first case, there was complete flaccid paralysis of the
muscles of the abdomen and of both lower extremities. The case had a
sudden onset, and during the four months of its duration there was an
intermittent temperature of hectic type from Q9°-ioi°, and later ioi°-i02°;
once as high as 1060. With many of the accessions of temperature there
was profuse perspiration above the level of the sixth intercostal nerve,
while below a sinuous line two and a half inches above Poupart's ligament
there was absolute loss of sweating except over a small area on the inner
side of both thighs. Abdomen perspired in irregular patches. On autopsy
of this case a congestive and hemorrhagic condition was found in the
lumbar and sacral and lower dorsal segments, with partial thrombosis of
the anterior spinal vein and in some of the arteries of the posterior roots
and in a few of the lateral coronary branches passing towards the inter-
medio-lateral tract. Motor cells were degenerated, both of the anterior
horn and the intermedio-lateral tract. The direct cerebellar tract and
Clarke's column were only slightly affected. The writers conclude that
there is a special area for sweat secretion in the lower limb, and suggest
a special examination of this area, in suitable cases, in the intermedio-
lateral tract.

In the case of exophthalmic goitre reported, the nerve-cell changes
were limited to those cells contained in the intermedio-lateral tract. They
were most pronounced in the 3 D. and 4 D. segments, less in the 2 D. and
5. D., and slight in the I D. and 6 D. segments.

The only deductions to be drawn are, apparently, that it is in the
intermedio-lateral tract of the segments involved that we should look for
the nervous lesion of this disease, inasmuch as it is these segments which
give origin to the roots, stimulation of which produces retraction of the
upper eye-lid, protrusion of the eye-ball, acceleration of the heart, and
sweating and vaso-regulation of the upper part of the body. The writers
are not prepared to say that this nervous lesion is the primary one in
exophthalmic goitre.

2. Two Cases of General Paresis. — Dr. Hoch presents careful histories

48,2 PERISCOPE

and post-mortem findings showing, in the first case, intense processes,
more marked on the left side, which had given rise to apoplectiform attacks
with subsequent focal symptoms. The patient had exhibited sensory
aphasia, explained by changes in the first temporal convolution ; and a
peculiar visual disorder due to changes in both calcarine fissures. The
visual disorder was bilateral. The patient was not blind, but bumped into
objects on either side. His attention on the right side could not be
attracted by movements or objects, and on the left side only to about 500,
and this with difficulty and to a limited degree.

In the second case similar intense processes gave rise to convulsions,
followed by transient paralysis in one leg and aphasia; later, twitchings
and loss of power in right arm and again aphasia. The right arm pre-
sented at first ataxia; then, after a slight apoplectiform attack, athetosis.
The latter ceased after renewed attacks and gave place to twitching, while
the arm became more helpless and the reflexes of that side increased. The
aphasia was characterized by an almost total inability to speak or write,
but there was also marked dementia. On autopsy there was found a
marked general paralytic process with greater involvement of the left
side, and special involvement of the anterior central and first temporal
convolutions and the angular gyrus. The motor tracts were degenerated,
left more than right. The third frontal convolution was not involved in
this case.

(Vol. V. No. 2.)

1. Circumscribed Hemorrhagic Cortical Encephalitis, with the Report of a

Case in which the Lesion was Limited to the Motor Zone, the
Chief Clinical Manifestations Being Jacksonian Epilepsy. C. K.
Mills.

2. Eight Cases of Hereditary Spastic Paraplegia. E. Jones.

3. An Investigation Into the Arrangement of the Achromatic Substance

of Nerve Cells, and of the Changes Which It Undergoes in
Various Forms of Mental Diseases. W. M. Smith.
1. Cortical Encephalitis. — Mills reports a case clinically and pathologi-
cally. The patient was an old woman of eighty-three. Jacksonian attacks
occurred over a period of about a week before death, and involved the left
face and left hand. During attacks the left eye was closed, brow wrinkled,
left nostril dilated and the platysma contracted; there was no frowning
or movement of the jaws or eye-balls. The movement of the hand was
confined to the deep extensors of the fingers and thumb and group of
ulnar extensors. Between convulsions there was great weakness of the
lower left face and left arm with wrist-drop. Upper arm and shoulder
girdle movements were possible, but were also weak. Tongue protruded
to the left. Left conjunctiva greatly inflamed. Sensation and reflexes
normal. There was almost complete loss of convergence and of move-
ment of eyes to left and of associated upward eye movements, the latter
being more marked on right side. Necropsy showed an enlarged soft
heart and patches of sclerosis, and ulceration of the aorta. There was a
limited area of softening of the cortex cerebri anterior to the bottom of
the central fissure due to hemorrhage and a hemorrhage of recent origin,
in the outer portion of the right occipital lobe. Dr. Spiller's microscopical
report was, briefly, that there were numerous hemorrhages within the
cortex and a very few in the subjacent white matter. They were limited

PERISCOPE 483-.

in extent, the transition from the normal to the hemorrhagic cortex being
quite sharp. The adjacent pia was hemorrhagic and contained numerous
fatty granular cells and round cells. The affected cortex contained con-
siderable black granular pigment. There was slight round cell infiltration
about the small vessels of the peduncles.

2. Hereditary Spastic Paraplegia. — Jones' eight cases were of a single
childship. Symptoms were the same in all the cases with slight variations.
There were in each case spasticity of the lower limbs, talipes equino-varus
tnd changes in the reflexes indicative of an organic affection in the
pyramidal tracts. Paresis was slight. The inequality in degree of the
cardinal signs was not proportional to the age of the patients. The arm
jerks in all were increased. The jaw jerk was obtained only in the two
worst cases. In no case were pseudo-bulbar symptoms present. All cases
affected were boys, the ninth child of the family, a girl, escaping. No
assignable cause was found. All cases showed first evidences when be-
ginning to walk, between ages of one and two years. All the cases ran a
similar progressive course, never reaching total incapacity. "No cases were
found in the ancestry going back 150 years.

3. Nerve Cells in Mental Diseases. — Two methods were employed ; viz.,
Bethe's original and Lugaro's colloidal silver method. The former to
show the achromatin arranged as fibrils streaming through the cell and
indicating nerve-cell relationship and conduction ; the latter to show the
substance arranged as an interlacing meshwork in the cells and greater
detail of structure. Ramon-y-Cajal's No. 3 method and the pyridin methods
of Donaggio were also tried. Brain tissue from healthy animals were
used for comparative purposes. After a review of some theories of others
of the intracellular fibrillary arrangement the pericellular network, anas-
tomosis, development of cells, etc., the author gives his own investiga-
tions on normal material from the ox, sheep, pig, and cat, and then states
the pathological changes in the neurofibrillar elements of nerve-cells which
he claims to have met with in thirty cases of insanity. The precentral
convolution was always examined, and in many cases parts of the medulla,
cord and cerebellum also. Several interesting drawings accompany the
descriptions. Space will not permit report of the changes found except
to say that the achromatic structure of the cells as described is profoundly
affected in mental diseases, and that the changes differ in degree rather
than in kind in the various conditions. Six cases of general paresis, six
of chronic brain atrophy, two of epileptic dementia, three of chronic
mania, one of diabetes mellitus with melancholia, and the others of de-
mentia, were studied.

Chas. E. Atwood (New York).

Miscellany

Family Care of the Insane and Feeble- Minded. Alfred Petren (Hy-
giea, 1905).
This is a paper which describes the author's travels in Germany,
undertaken for the purpose of determining the status of this subject
in the latter country. As a purely personal narrative it loses some value
from the fact that a number of German psychiatrists had already gone
upon record on the subject of family care of mental maladies; so far
at least as their personal experience is concerned. (Alt, Wahrendorff,

.484 PERISCOPE

Nawratski, Falkenberg and others.) The author appears to hare ris-
ked chiefly such medical centres as had been already made the subject
of public description of family care, etc.; so that his narrative seemt
designed to do no more than convey the testimony of an eye-witnesi
to his colleagues in Sweden.

The pamphlet as it stands is not adapted for reviewing. The style
is not only cursory, but there is a total absence of schematic arrange-
ment, statistics, summaries, etc. It might be classed as a piece of
medical feuilleton, or as an ordinary medical letter of a traveler — a
so-called Reisebericht or Reise-brief, which is a common feature in
all medical journalism.

As for the subject-matter, it may be found in a more acceptable
form in the original articles upon this subject, one of the latest and
best being that of Alt: "Die familiare Verplegung der Kranksinnigen
in Deutschland," 1903.

Degeneracy. P. C. Smith (Edinburgh Medical Journal. New Series,
Vol. XXI, No. 2).

The writer treats the subject as an entity, investigating the mode
•of its transmission, and giving an account of its pathology, etiology,
•ymptoms, complications, diagnosis, prophylaxis, and treatment. De-
generacy he defines as a state of imperfect development, originating
probably in malnutrition on the part of an ancestor, or of the indi-
Tidual during the period of growth, affecting many or all of the bodily
systems and functions, and always involving a dissolution of heredity.
The symptoms, he states, consists of defects, structural or functional,
present at birth or shown during development. The psychical symp-
toms he classifies into idiocy, imbecility, moral insanity, criminality
(some forms), volitional insanity, sexual perversions, and "neuras-
thenia minor" (neurotions). Anatomical stigmata, he thinks, are not
shown to so great an extent in infancy as later. In the slighter forms
of degeneracy, the changes in the nervous and glandular systems are
as yet unknown. There may be irritable weakness of the nervous sys-
tem, defective metabolism, diminution of sexual power, hyperplasia
or hypoplasia of muscles, bones, ligaments, blood vessels, skin or
connective tissue, or one or more gross anatomical abnormalities;
but the chemical and histological changes in the nervous and glandu-
lar systems are unknown. Degeneracy is found among all civilized
nations, in all ranks of society, and in both town and country. Its
causes at any one epoch should be looked for in the conditions of a
generation or two previously. As regards neurasthenia, the writer
holds that where there is much neurasthenia there is a good deal of
degeneracy. Degenerates, he says, are more liable than sound per-
sons to attacks of indigestion, to rickets, infantile scurvy, catarrhs,
infections and relapses in infective diseases, to local syncope, local
asphyxia, and local gangrene, and to the various neuroses and psy-
choses. They furnish also a disproportionally large number of cases
of arteriosclerosis, Bright's disease, consumption, tabes, and perhaps heart
disease. The great majority of the insane, he thinks, are degenerates.
Tabes and may be other organic nervous diseases affect the neurotic by
preference.

In the diagnosis between insanity and degeneracy, from the medico-
legal point of view, lawyers might admit a condition of "diminished

PERISCOPE 485;

responsibility" in those who, as the result of developmental defect,
have stronger impulses and weaker resisting influences (instinct, in-
grained habits, will) than normal persons.

The writer contends that degeneracy may be eradicated from the
race chiefly by the regulation of marriages and by mental and physical
education from birth; celibacy is inculcated; the monastery is sug-
gested for some neurotics; and it is urged that the subject of degen-
eracy should be studied by schoolmasters, jurists and criminal lawyers.

C. E. Atwood.

Cerebro- Spinal Fever. Wm. Osler (The Edinburgh Medical Journal,
New Series, Vol. XXI, No. 3).

Osier points out several interesting features. Sporadic cases are
always with us, but epidemics have occurred in periods of 10 or 15
years since the recognition of the disease in 1805. The first known out-
break began in America and prevailed also in some parts of Europe
for eight or ten years. The second, also in America and Europe, oc-
curred in 1837. The third in 1850, and lasted all through our Civil
War. A fourth epidemic began in 1871, and a fifth in 1901. In New
York in the past two years there have been nearly 4,000 cases with 3,000
deaths. At present the disease is causing alarm in Belfast and Glas-
gow. A second peculiarity of the disease is that epidemics occur in
very widely separated areas, in which it prevails severely, but
does not spread widely. It is never pandemic, like influenza. Some
of our severest epidemics were in the mountains of West Virginia,
and in the mining regions of Pennsylvania, and last year one of the
worst epidemics on record was among the Silesian miners. Another
peculiarity is that the mortality ranks very high, for an acute infection,,
perhaps next to the plague. Its mortality is from 50 to 75 per cent.
Lastly, among the infections, it is the most virulent. Death has oc-
curred from it within six or eight hours. Other cases may be ex-
ceedingly mild and transient.

The specific germ of the disease is the diplococcus intracellulars
meningitidis. It is found in the exudate in the brain and cord, and
in the secretion in the back part of the nose and throat. Osterman
last year found it in the throats of 17 out of 24 persons attending upon
patients, but who had not the disease. A certain type of meningitis,
the posterior basic, is due to the same organism, so that in reality
cerebro-spinal fever, while not occurring as an epidemic, does exist
in this sporadic variety all over the country. There are also sporadic
forms of pneumococcus mengitis which occur in house-epidemics.

Cerebro-spinal fever has probably the same low degree of conta-
giousness that we see in pneumonia. It is much more a spinal affec-
tion than any other form of meningitis. We have as special symptoms
the stiffness of the neck, the muscular rigidity, and the cutaneous
sensitiveness. All forms of meningitis the author considers fatal ex-
cept the cerebro-spinal which gives us from 20 to 40 per cent, of re-
coveries. The skin eruptions vary in different epidemics. Arthritis
may occur, or early deafness, dumbness or blindness. The meningo-
coccus should be sought for, by lumbar puncture, early in the disease,
ts at the end of a week or ten days it may not be present. The disease
does not often prevail beyond the winter season. Where the disease is
prevalent the nose and throat of attendants and others near by should

486 PERISCOPE

be examined bacteriologically and carefully treated. The hot bath, fre-
quent lumbar puncture, the serum of Wassermann and of Flexner are
mentioned in treatment. C. E. Atwood.

Ok Insanity, with Special Reference to Heredity and Prognosis. A
R. Urquhart (The Edinburgh Medical Journal, N. S. Vol.
XXI, No. 3). Lecture I — Prolegomena.
In this, his first Morison Lecture on the subject, Dr. Urquhart
fives an interesting historical review of the methods of study and in-
vestigation of insanity from the time of Hippocrates down, and dis-
cusses some of the modern opinions. Acknowledging himself to have
been a follower of Sankey, whose generalization that all insanities
begin with melancholia and tend to pass through mania and dementia
unless interrupted by recovery (or death), he now recognizes later in-
fluences and lauds especially the work of Bruce and Robertson; that
Bruce has finally brought insanity into the category of other somatic
diseases through his clinical studies into the toxic nature of insanity;
»nd that Robertson's conclusions in reference to general paralysis, the
failure of the organism to protect itself against bacterial invasion, he
thinks may be extended to forms of ordinary insanity which hitherto
have evaded the skill of the pathologist; and finally states that it is
necessary to revise the opinions of yesterday and recognize that the
physical conditions are the more important considerations which ren-
der insanity an affair of medicine. In compiling statistics, the neuro-
pathic heredity should be more carefully studied. Want of mental bal-
ance, eccentricity, alcoholism, paralysis, should be especially inquired
into. It is his custom, so far as possible, to construct graphic charts
of each family under observation. From these it appears that the in-
cidence bears heaviest upon the eldest members of the families in fra-
ternity, and that there is a fairly constant diminution of frequency
as the families increase in size.

C. E. Atwood.

Plasma Cells in Normal Gasserian Ganglia. E. Meyer (Anat. Anzeiger
XXVIII, Bd. 3, 4).
This article as reviewed by Dr. Goldstein of Konigsberg (Central-
blatt f. Nervenheilkunde, January 1, 1907), says that Meyer was able
to demonstrate plasma cells in all human Gasserian ganglia. The
cells were situated within the capsule and they were either singly or
in groups. His observations are of great interest inasmuch as plasma
cells are usually found in pathological conditions of brain and spinal
cord. Morris J. Karpas (Ward's Island).

Tumor of the Hypophysis Without Akromegaly. Kollarits (Deutsche
Zeitschrift f. Nervenheilkunde, Band 28, Heft. I.)
Kollarits tabulates a series of cases in which there was tumor of
the hypophysis cerebri, without akromegaly. Among these he includes
two cases of his own. Usually these tumors occur in young persons,
but Kollarits is of the opinion that a careful consideration of the cases
suggests that tumor of the hypophysis is merely one of the symptoms,
:and not the cause of akromegaly.

J. Sailer.

PERISCOPE 487

A New Algesimeter, with a Critical Description of the Previous Alge-
simetric Methods. Thumberg (Deutsche Zeitschrift. f. Nerven-
heilkunde, Band 28, Heft 1).
Thunberg describes his algesimeter, which consists essentially of a
lever to one end of which a needle is attached, and to the other end a
weighted screw, by which it can be brought into a state of equilibrium.
The arm to which the needle is attached is divided into ten parts.
The instrument is brought into a state of equilibrium and then
weights hung upon the arm. The position and size of the weight de-
termines the amount of pressure exerted. This pressure is increased
until the patient experiences pain. The paper is concluded with a
valuable critical description of the various instruments hitherto de-
vised for the purpose of measuring sensation. J. Sailer.

The Symtomatoloqv of Hemiplegia. Heilbronner (Deutsche Zeit-
schrift f. Nervenheilkunde, Band 28, Heft 1).
Upon the cadaver it may be observed that the outer contour of
the thighs is more convex than during life. The same appearance may
also be observed in the affected leg in cases of recent hemiplegia. A
somewhat similar appearance may be observed in the calf and arm
muscles. Heilbronner calls this condition "the broad leg." It is not
present in sleep, nor in unconsciousness, nor in profound narcosis.
It is present in severe acute polyneuritis, but was not found in tabes,
in chorea, in Huntingdon's disease, or in hysterical flaccid hemiplegia.
It is not certain that it will serve in the differential diagnosis of cere-
bral and spinal hypotonia. The broad leg is not dependent upon the
disappearance of the patellar reflex, or even upon the return of volun-
tary movement; but if it persists the contractility of the quadriceps to
percussion upon its tendon is usually lost. After some discussion of
the reflexes and muscle tone Heilbronner reaches the conclusion that
in the course of recovery from hemiplegia the following series of events
occurs : First, return of active motion ; second, return of the contour-
preserving tone; third, the return of the reflex muscle tone. With
reference to certain other clinical phenomena he states his belief that
the superior restoration of the function of the leg is merely apparent.
He also discusses the hemiplegic gait, and calls attention to the im-
portance of educating hemiplegics how to walk properly. He de-
scribes a curious form of rhythmical movements of the arm during
walking, which are entirely involuntary. They consist of a flexion and
lifting of the forearm, and may occur when apparently all the symp-
toms of hemiplegia have disappeared. J. Sailer

The Status Hemiepilepticus Idiopathicus; Eight Clinical and Ana-
tomical Observations. Muller (Deutsche Zeitschrift. f. Nerven-
heilkunde, Band 28, Heft 1).
Although it is generally supposed that partial or Jacksonian epi-
lepsy is due to some focal lesion in the brain, a number of observa-
tions have been recorded in which such partial epilepsy has existed
although examination of the brain has been entirely negative. Muller
collects from the service of Nonne eight cases of partial epilepsy. The
first, an alcoholic and luetic man of 26, who had had an injury to the
head. There was left sided status epilepticus not relieved by trephining.
The macroscopical examination of the brain was negative; apparently

488 PERISCOPE

a miscroscopical examination was not undertaken. The second case, a.-.
chronic alcoholic, died in left-sided status epilepticus. At that autopsy
there were various lesions of the body, but the brain was macroscop-
ically normal. The third case, a chronic epileptic thirty-eight years of
age, had 306 attacks involving only the left side of the body. At the
autopsy an area of softening was found on the basilar surface of the
right frontal lobe. Elsewhere the brain appeared to be normal. The
fourth case, a boy of nineteen, had symptoms of acute meningitis,
then left-sided epileptic attacks and death. There was a diffuse chronic
meningitis in the base of the brain, but no alteration in the substance
of the brain. The fifth case, a woman of thirty-seven, had epileptic
attacks limited to the left side; there was a history of injury to the
brain. There was high fever, cyanosis, and loss of pupillary reaction.
The ophthalmic examination indicated disturbance of the optic nerves.
At the autopsy nothing abnormal was found either in the brain or
body, and a microscopical examination of the former organ was nega-
tive also. The sixth case, a girl of eighteen, had albuminuria, and
right-sided epileptic attacks. The brain was normal; the kidneys only
slightly affected. There was hypoplasia of the aorta. The seventh
case, a man of thirty-seven, in the course of diabetes mellitus, de-
veloped typical Jacksonian epilepsy. At the autopsy the brain was nor-
mal, but there were changes in some of the abdominal organs. The
eight case, a boy of six, had general epileptic attacks at the age of four
years. Two years later he suffered from epileptic attacks, limited at first
to the right side, then to the left side of the body, profound coma,
gnashing of the teeth, and trismus. Later he developed measles, and
made a complete recovery. It seems wisest, in the absence of more
definite knowledge, to regard these cases as atypical forms of general
epilepsy. J. Sailer.

Vol. 34. AUGUST, 1907. "No. 8

THE

Journal

OF

Nervous and Mental Disease

©rtgtnal Hrttcles

THE CLASSIFICATION OF PSYCHO-NEUROTICS, AND THE
OBSESSIONAL ELEMENT IN THEIR SYMPTOMS.*

By George L. Walton, M.D.,

OF BOSTON.

PHYSICIAN TO THE NEUROLOGICAL DEPARTMENT, MASSACHUSETTS GENERAL

HOSPITAL.

The present trend in psychiatrical circles seems in favor of
simplifying the classification of the psychoses, of looking into
their nature, and of grouping together cases representing varia-
tions of a common faulty tendency.

The object of this communication is to emphasize the in-
fluence of the obsessive tendency in the psychoses and to suggest
grouping together those cases which present variations of this
tendency.

Among the neuroses, psychoses, or psychoneuroses with
marked obsessive element and amenable in greater or less degree
to psychotherapeutics, may be mentioned tic cowuulsif, (or more
appropriately, tic obsessif) , habit chorea, hypochondria, neu-
rasthenia (psychasthenia), hysteria minor, and manic-depressive
tendencies in mild form ; folic du doutc may be mentioned to re-
mind us that some of those conditions are already merged under
more general diagnoses.

Certain cases offer sufficiently distinctive characteristics to
warrant their separate classification. Analysis, however, shows
that they are all variations of a common tendency, and experience
reveals that many cases present, in various degrees, symptoms
of all these classes. The latter cases it is not only useless but
misleading to classify other than under some such general term
as psychoneurosis, or still more appropriately, obsessive psychosis.

*Read at the thirty-third annual meeting of the American Neurological
Association, May 7, 8 and 9, 1907.

490 GEORGE L. WALTON

All sufferers from these varied forms of mental disorders are
ideo-obsessive, and it takes no great stretch of the imagination
to trace in all these morbid manifestations the obsessive tendency,
the modification of which by educational therapy is the important
practical consideration.

The movements of tic convulsif, however automatic they may
appear, originate in the compelling impulse, and further study
of the case will disclose the ideo-obsessive constitution.

Folie du doute results from an obsession to satisfy the doubt.
If the victim of chronic indecision doubts which of two tasks
first to take up, it is because of an overscrupulous insistence that
he take up the right one first. This habit of mind once fixed,
the indecision extends to the most trivial questions, but the habit
of mind is the same as if the question lay between two actions
involving a principle of right or wrong, justice or injustice, ad-
vantage or disadvantage.

In this form of disorder, training, especially self-training,
under competent supervision, is often effective, whether directed
toward the important or the unimportant matters. In fact, such
training, directed first against unimportant obsessions, may
gradually extend to the more important. I have known more
than one doubter who finally learned to say even in important
matters, "Others make mistakes, why should not I? It is better
that I decide this question wrong than that I allow my mind to
become unbalanced by chronic indecision."

Hypochondria results from the obsession to be well, to feel
comfortable, and to be safe. The hypochondriac is obsessed to
have his every sensation correspond to an ideal firmly established
in his mind, an obsession unshaken by argument, ridicule or re-
proach. The sexual hypochondriac is the victim of an obsession
that his organs shall convey to him a certain sensation, and shall
perform their functions in a certain way. If they fail to satisfy
these requirements he is in distress. If the heart-beat of the
hypochondriac varies from an ideal rhythm and character estab-
lished in his mind as the result of an obsession, his alarm be-
comes acute, the blood rushes to his head, his mind becomes con-
fused and he is unable to proceed with his duties. Such a
patient, after systematic training, may so far alter his ideals as
to free his mind from these fears and to comfort himself in these
matters like a normal individual.

PSYCHO-NEUROTICS 491

The phobias, closely allied to the hypochondriacal fears, re-
sult from an obsession to be always perfectly safe, as well as
perfectly comfortable and perfectly well. More than one victim
of this form of disorder has been restored to normal mental
balance by persistent practice in relaxing mentally and physically,
and learning to say to himself, "The worst that can happen to
me is nothing compared to losing my mind. It is better that I
should break a bone and be laid up for months than that I should
be imprisoned for life by hypochondriacal compulsions."

Neurasthenia, a term including the most varied clinical pic-
tures, is generally attributed to overwork or other stress of cir-
cumstance. In point of fact, the ranks of neurasthenia are
recruited largely, if not entirely, from the ideo-obsessive. In
the majority of cases it is not the overwork or the overstrain
which has produced the breakdown, but the mental constitution
of the individual which makes all work disastrous. The business
or professional man who breaks down with neurasthenia will be
found generally to have succumbed under a burden no greater
than is carried successfully by competitors and associates, whose
methods are more reasonable and whose mental poise is more
equable. The embryo neurasthenic is opposed to leaving any
detail of his business to his subordinates, carries his work into
the night hours, takes no vacation, and will not sleep until all
the tangles of his life, past, present and future are straightened.
If advised to take a vacation before his breakdown, he declines
to do so on the ground that he is too busy and that he does not
enjoy himself anywhere except at his work. He presents ill-
directed mental activity rather than the feebleness implied by
the word asthenia. Nor has material gain been made by sub-
stituting phrenasthenia or psychasthenia. Asthenia is a mis-
leading word to apply to one who is ready and willing to walk
miles to satisfy a doubt, or to ascend a dozen flights of stairs
to avoid an elevator. The symptoms precipitated by stress are
daily matched by those developed in idleness. Neurasthenics
carry their stress with them.

I have seen more than one individual of this sort completely
alter his ideals, devote himself so assiduously to an avocation as
to forget his business while in its pursuit, and to bring himself
to say, "No matter if I do not enjoy the vacation, I shall enjoy
my work the better for having stayed away from the office fojr

492 GEORGE L. WALTON

a definite period." One professional man learned to surrender
the details and much of the responsibility of his work to sub-
ordinates by saying to himself, "I can better afford that they
make mistakes, than that I break down and have to go to a
sanitarium for an indefinite period, or perhaps abandon my
work entirely."

The fatigue following simple excessive work without faulty
mental tendency is physiological, not pathological, and in this
event some such term as the "brain fag" of Tuke is preferable
to either neurasthenia, phrenasthenia or psychasthenia.

While manic-depressive insanity in its extreme form is little
amenable to treatment, a moderate tendency thereto may be
lessened, and even rendered inert, by training and exercise in
the direction of establishing a healthy emotional poise. It re-
quires no great stretch of imagination to assume that the ex-
hibition of manic-depressive tendency may result, in part at
least, from an obsession to give way to and externalize the emo-
tions. Here is an example of flight of ideas I recently took down.

"Are you blue ?"

"Blue, true blue, red, white and blue, one country, one king,
no, not one king, one president, we are going to have a new
president — President Hearst, cursed, the worst." Who does not
recognize the modest prototype of this elaborate rigmarole
chasing itself through his brain as he walks the street in jaunty
mood? And who has not moments in which his feelings ap-
proach those of the depressive form of this disorder. There can
be no question that an inherent tendency to manic-depressive in-
sanity may be lessened by persistent training from childhood in
the direction of resisting the obsession to give way to and ex-
ternalize the emotions, of preserving the emotional poise and of
pursuing the even tenor of one's way. While marked cases of
this disorder may well be separately grouped, there are many
at present thus classified, which partake so far of the other faulty
mental habits of the obsessive that it seems forcing a point to
classify them more closely than under the term psychosis, or
obsessive psychosis.

There is unnecessary insistence on the part of clinical ob-
servers to place every psychopathic individual in some one definite
class, according to the prevailing mental faults.

Mav I cite the case of a woman of middle life whose parents

PSYCHO-NEUROTICS 493

were long-lived but invalids ; one uncle was an invalid, and one
relative is in a insane hospital. Her own mental trouble dates
back several years. After caring for her mother, and settling
her estate, she became nervous, complained of inability to do
things, preferring to remain unoccupied. She has been back
and forth between a sanitarium and home, improving somewhat
at the former, but at the latter unable to take care of herself,
physically strong but uneasy and restless, fearing she would lose
her mind, spending most of the time in a rocking-chair, prac-
tically never in definite employment, unable to decide upon or
carry out any line of conduct. Her mental horizon is limited to
insisting upon her weakness of body and going over arguments
to fortify this idea. She expects to die every night and says
they have broken her body at the hospital. Talks at night and
says she should be allowed to do so as she is at, the point of death.
Questioned regarding her symptoms she states she is too tired to
talk, but once started becomes voluble upon the subject of her
sufferings.

This case partakes of the characteristics of so-called neu-
rasthenia, manic-depressive and hypochondria. Is it necessary
to place her definitely in either class?

I have an athletic friend, the picture of physical health, a man
of exceptional ability, who bid fair at one time to abandon his
profession on account of mental tribulations. He feared to travel
alone and he feared to stay at home ; he dreaded his work but
feared to leave it off. He spent hours pondering and discussing
the question whether he should go to a sanitarium, just what he
would do when he was there, and what its effect would be upon
him. He would conjure up and worry over every conceivable
comment that this step would occasion. He dreaded to be away
from home lest something happen to his family ; he dreaded to
go home lest his wife learn of his fears and not understand them.
In his depressed mood his heart was the main object of his
solicitude. I have examined this organ again and again as have
various other physicians without being able to convince him of
its absolute soundness.

After years of mental torment during which efforts were
made on the part of several physicians (apparently at the time
unsuccessful, but doubtless useful as sowing the seed) he broke
down completely and agreed to go to a sanitarium. There he

494 GEORGE L. WALTON

came under the immediate care of a physician of peculiarly-
happy method, who devoted himself to training out his obsessions
by a judicious combination of stimulation and neglect. At the
end of three months he returned, laughing at his own fears. He
resumed the same work under which he had previously broken
down, and has continued it for months without exhaustion. He
takes the chances others do and comports himself in every way
like a normal individual.

Should this case be classed as hypochondria, neurasthenia or
manic-depressive? It partakes of the characteristics of all, and
so in many of these cases, however we may focus our attention
upon one or another mental peculiarity, careful examination of
the intellectual and emotional life history will develop a similar
combination.

In the Neurological Department of the Massachusetts General
Hospital the tendency has increased to class such cases under the
psychoneuroses, at the expense particularly of neurasthenia. Dur-
ing the year 1906 the diagnosis psychoneurosis was made 91
times; the diagnosis neurasthenia was made only three times,
whereas it was made during the same time in the medical depart-
ment 127 times.

This change of classification does not signify a waning ability
on the part of the neurologists to distinguish the different forms
of psvchoses ; it results rather from a growing conviction that we
were wasting time in trying to make these combination cases con-
form to a single type, time better employed in the attempt to
modify by psychotherapy the faulty mental tendencies. To the
comment that nothing has been gained by substituting one om-
nium gatherum for another, the obvious answer is that it is
better to use the word psychoneurosis correctly, than the word
neurasthenia incorrectly.

It is no more necessary or accurate to subdivide these com-
plex cases according to their besetting faults than it would be to
insist that the tortoise-shell cat shall be classified as either yellow,
black or white, according to the prevalence of either of these
colors in her coat.

In a certain number of cases, it is true, the symptoms are so
well-defined that it is advisable to place them in a definite sub-
class. This applies to a certain extent to hypochondria, to a
greater extent to hysteria, and to a still greater to manic-depres-

PSYCHO-NEUROTICS 495

sive. We have come to recognize certain symptoms as distinctly
hysterical, such for example are aphonia, anesthesia (particularly
hemianesthesia), and the paralyses, hyperesthesia, the con-
tractures and the convulsive attacks and the angio-neurotic
edemas. Cases exhibiting such definite signs may well be classed
as hysteria. Such cases, though doubtless presenting other signs
of mental deviation, cannot be traced directly to the obsession,
except in so far as the insistent desire from childhood to have
one's way, and to be an object of sympathy (a desire which doubt-
less often aids in the development of the symptoms) may be re-
garded an obsession.

Babinski1 has recently proposed to define hysteria as the neu-
rosis constituted by all the disturbances which are susceptible of
being cured by persuasion, direct or indirect. He proposes to
call it pithiatism, from peitho, persuasion, and iatos, curable. He
says hysteria is the only affection susceptible of being cured by
psychotherapy. I should take issue with this conclusion and with
this classification.

Many more cases are appropriately classed as manic-depres-
sive. Doubtless, however, a large number of cases are at present
so classed at the expense of straining a point. Take the follow-
ing case.

Case. A bright young woman engaged in clerical work. Her
father is in an insane hospital. She has been for some time tor-
mented by fears, scruples and self-reproach. She has never re-
covered from the effect of a certain letter conveying a reproach
upon a member of her family. She fears she has sinned irrepar-
ably. She not only regards it her duty to help support her father
but contributes from her wages toward the support of another
relative. After the death of this relative, who left enough funds
for the support of her father, her mental state is not in the least
relieved by the lessening of her burdens. She writes that she
fears she exaggerated some statement in her former visit, but still
feels that her sins are heavy. She is now cast down because she
has not the proper degree of affection for her father, and says it
were better she had never been born. During the past year she
has been torn by doubts whether to marry. She has insistent
ideas regarding air in the room. She is inclined to think others
do not want her around. She is physically strong and can walk

tribune medicale, Sept. 22-29. 1906. Abstracted in Jour. Amer. Med.
Ass'n, Feb. 2, 1907, Vol. XLVIIL, No. 5.

496 GEORGE L. WALT OX

miles. She performs her work with accuracy and despatch.

Whether this case be classed under manic-depressive, neu-
rasthenia, or elsewhere (surely not as dementia prsecox in view
of her work), the underlying characteristic seems to me that she
is constitutionally ideo-obsessive and that her case is another in-
stance of obsessive psychosis.

Since writing the above I have received a communication from
the patient stating that what I told her about putting herself
through rigid mental training has been a great help to her. "My
distress of mind is passed. — it all seems like a wretched night-
mare, wherein I greatly exaggerated, and very unjustly blamed
myself. Life once more looks worth living, and I would thank
you for all the time you spent so carefully consulting with me."

It is. of course, too early to say whether this frame of mind
will be lasting, or whether it is merely a phase of manic depressive
tendency. Such cases can be multiplied indefinitely.

Conclusions.

Many psychoneurotics offer a combination of the symptoms
classed under neurasthenia, hypochondria, folic du doute, tic con-
vulsif, habit chorea, manic-depressive and hysteria minor. Many,
if not most, of their morbid mental and physical tendencies may
be traced to the obsession.

In these cases the treatment is more important than the exact
classification ; unless the symptoms of one or the other disorder
are definitely preponderant it lends more to clearness to include
the general term psycho-neurosis, or still better, obsessive
psychosis, than to insist upon a more distinctive classification.

The result of simple fatigue, without obsessive or other mor-
bid mental tendency, is physiological, not pathological. In such
cases, therefore, the term "brain fag" of Tuke would answer
every purpose and be less misleading than neurasthenia or even
phrenasthenia or psychasthenia.

The term neurasthenia, though convenient, like "nervous pros-
tration," for popular use, is inaccurate, misleading and unsatis-
factory, and can be discarded so far as scientific records are con-
cerned. Nor has any material gain been made by substituting
psychasthenia or phrenasthenia. The majority of the cases thus
classed partake so far of the various morbid mental states peculiar
to the ideo-obsessive, that they are best included under the general
designation, psychoneurosis or obsessive psychosis.

THE USE OF SOCIAL INTERCOURSE AS A THERAPEUTIC

AGENT IN THE PSYCHONEUROSES, A CONTRIBUTION

TO THE ART OF PSYCHOTHERAPY.*

By Sidney I. Schwab, M.D.,

OF ST. LOUIS.

Abstract. Meaning of the terms Psychotherapy and Social
Intercourse as used in this paper. Etiological factors open to
treatment. Treatment directed to the change or removal of the
known indirect and contributing causes as opposed to the treat-
ment of the unknown direct or fundamental causes. Problem in
Psychotherapy largely the former. Re-education and develop-
ment of a personality. Use of selected individuals as the founda-
tion of a new social life. Methods, difficulties and limitations. Re-
sults and conclusions.

In this paper I plan to outline briefly an experiment in psycho-
therapy based upon the realization that an individual whether
normal or abnormal reacts favorably or the reverse to the various
people and circumstances among which his lot happens to be cast.
I wish to suggest further that in certain instances these factors
can be to some degree influenced by forces external to them, and
that this influence can be consciously exerted in that direction or
in those directions which may seem to be most favorable to the
individual. I hope likewise to be able to prove that an effort of
this kind falls within the scope of a neurologist's therapeutic
activity.

The object of this therapeutic experiment is a case of hysteria
in a woman with the usual complicating factor of neurasthenia.
Thus the attempt both in respect to the psychical disease and to
the treatment made use of may well come within the meaning of
the term psychotherapy.

Probably the most striking phenomenon in neurology to-day
is the sudden interest manifested in the subject of psychotherapy.
In the past three or four years the literature has been plentifully
supplied with papers, monographs and books dealing with this
subject. The better of them reflect the spirit of a widening
grasp of the power inherent in the action of one mentality upon
another. There runs through some of them a desire, scarcely
more than indicated, directed towards the development of some

*Read at the thirty-third annual meeting of the American Neurological
Association, May 7, 8 and 9. 1907.

498 SIDNEY I. SCHWAB

tangible technique or method by which these forces subtle though
they are, may be set most economically in action. The chief
obstacle to a wider use of psychotherapy is found in the lack of
an analysis of the force implied in the term, a means by which it
can be applied and a measure of its utility. Freud's various papers
dealing with psycho-analysis may be said to be the most definite
attempt at a systematized technique that has as yet appeared. Its
complexity and difficulty of application, to say nothing of the
etiological factor which is a necessary complement of the method
speak most surely against the hope of anything approaching a
general use of this system. Perhaps in no better way can the
truth be emphasized that psychotherapy is largely an individual
therapeutic art than the utter failure of psycho-analysis to meet
the average neurologist's requirements.

It is therefore evident that the most that can be done at
present is to note such individual instances of the use of psycho-
therapy as they appear and to attempt to see in them such general
principles as seem to be demonstrated. In such a manner very
gradually some kind of a generalized technique may be built up
out of which each individual may obtain the procedures or the
suggestion of them which will be useful in his special need.

The term psychotherapeutics as used in this paper implies
the use of all forces outside of drugs, manipulative and so-called
physiological methods which can be directed toward curing or
making better an individual the subject of functional disease of
the nervous system. The definition is sufficiently broadly devised
in order that the attempt to be outlined in this paper may be
covered. It assumes likewise that the influence inherent in the
personality of the therapeutist may be considered fairly a factor
and that this does not necessarily detract from whatever thera-
peutic proof there may be in the efficacy of the experiment.

It is the author's belief that the neurological therapeutist in
common with others of a less restricted field has the right to re-
gard as possible curative agents any factor found in the social
life of his patient or further any factors which he may choose
to inject into that social life. By the term social life is naturally
meant the sum of all the activities which arise from the relation
of an individual with others of his kind. This relationship may
be organized or unorganized, complicated or simple as the case
may be.

SOCIAL INTERCOURSE AS AN AGENT 499

It is apparent that an effective therapy in hysteria must be
based upon a sound conception of what hysteria is and to what
hysteria is due. These are fundamental necessities for the per-
manent solution of any problem in therapy. It is just as apparent
that at the present moment we are in no position to satisfy either
of these demands and we are consequently forced to admit that
hysteria exists largely in the person of an individual who has
what we are accustomed to regard as hysterical symptoms. In
other words our therapy is compelled to busy itself not with the
attempt to remove or touch the cause but to moderate the effects.
That is, the indirect factors which are present in determining the
persistence of hysterical phenomena are the only ones that are
really open to treatment. Not-only must this be admitted but it
must be acknowledged that the genesis of the hysterical symp-
toms is not understood.

In spite of a vast amount of work of which special mention
might be made of Freud, Janet, Sidis and Prince and others we
are in no position to say where nor how the hysterical phenomena
plav their part, that is in a psychical sense. If for example we
are prepared to regard them as products of sub-conscious activity
we are met with a divergence of opinion not only on this score
but likewise on the question of the existence of such a thing as
the sub-conscious. Whichever way we turn we are face to face
with the fact that hysteria offers no certain field for the exercise
of a therapy aimed to remove or remedy first causes. On the
other hand there is an increasing lot of data which has to do with
the indirect or secondary causes. These influence the progress,
the degree and the persistence of hysteria in a very definite and
tangible way. It is these causes which appeal to me to be the
legitimate object of psychotherapy and this paper is concerned
with an account of how such causes were attacked in an individual
instance of hysteria.

The Case. From a purely clinical point of view the case
offers nothing of interest. A woman 35 years old coming from
a marked neuropathic family has for the last seven or eight years
been the subject of a group of symptoms which are commonly
found in hysteria. In addition there exists side by side with them
a group of symptoms depending upon an abnormal degree of
fatigue and irritability. These point to neurasthenia. In other
words this patient presents the not uncommon neurasthenia hys-

5oo SIDNEY I. SCHWAB

teria symptom-complex. It might be of interest to state that in
addition to the purely mental symptoms of hysteria there were
present objective indications of the disease such as sharply limited
areas of hyperesthesia, hyperesthesia over the ovarian region,
hemihypesthesia, increase in the deep reflexes, conjunctival an-
esthesia, etc. The data of the past history that the limits of this
paper permit to be mentioned are, an unhappy marriage ending in
divorce, the husband disappearing four years ago, two gyneco-
logical operations, one induced abortion on account of hyper-
emesis gravidorum. There were no other notable illnesses and
no other etiological factors that could be definitely placed. The
patient has one child now about fourteen years old. It might be
mentioned here for the purpose of making clear certain points
afterwards to be alluded to that Mrs. J. came to St. Louis from
Massachusetts knowing no one and having so social opportunities.
During this time she lived with a brother and son, keeping house
for them. In this limited circle, with no amusement, no oppor-
tunity for social intercourse, no deviation from the household
regime, three years were passed. She came under my care a
completely hopeless and discouraged woman, one that had run to
seed mentally, physically and it might be said morally.

The case from the very outset appealed to me as one that
offered an unique opportunity for an experiment in psycho-
therapy in its widest application. Here was a woman physically
normal, well educated, with a latent talent for minor literary
activities, a sufficient idealist, gifted with imagination, no ac-
quaintanceship, and a consistent and eager desire to get well. This
latter tendency was based upon two factors which in cases of this
kind are of importance. First an instinctive love for the physically
healthy and normal, and a keen desire to lessen the burden resting
upon the shoulders of her brother.

I wish to preface the account of the therapeutic attempt by the
remark that no mystery was allowed to exist in this case at all.
Every step taken was carefully explained to the patient and her
co-operation demanded. The group of symptoms were taken as
existing and no attempt was made to investigate them further
than to be aware of their presence. No insistence was made con-
cerning the importance of their disappearance in respect to the
favorable progress of the case. I mean that their origin was left
unexplained and the conditions which were present and which

SOCIAL INTERCOURSE AS AN AGENT 501

seemed to act towards their continuance were attacked. As soon
as a thorough understanding was reached a scheme of treatment
was planned which was to last for a long time. I emphasized this
because I believe that one of the causes of failure in psychothera-
peutics lies in the fact that no definite and consistent plan is
either considered or carefully followed. In some mysterious
way the mind is supposed to be influenced by the persuasive or
suggestive power of another mind and the result achieved is often
as much of a mystery as the manner in which it was brought
about. In fact to many of us psychotherapeutics is a sort of
negative process, the chief distinction about it being that drugs
are not given. It is this careful planning that marks, I believe,
the first step towards the building up of a technique.

Briefly, the therapy was planned to meet the following funda-
mental needs :

1. Need of a social existence in which the patient might feel
a constantly growing activity and importance.

2. The necessity for the development of some serious business
in life in which the patient could regard herself as fulfilling some
purpose and further as giving her the chance to feel herself gain
in mastering over whatever this employment might be.

3. The need for the creation and the development of an ideal
of living apart from the mental and physical sufferings to which
this woman had been so long accustomed. The mechanism by
which the first was accomplished was in outline as follows :

Certain friends and patients of mine and some who were
neither, were considered solely from the point of view of their
possible personal influence upon this patient. In other words a
rather bold attempt was made to create de novo a social life, the
nucleus of which was formed by a group of individuals selected
largely with a view to their favorable social reaction upon the
patient. That this is very artificial the writer is willing to admit,
and that it is more or less blameworthy to use individuals as social
pawns he confesses to likewise, but there seemed to be little
danger and the fascination of the game proved sufficiently strong
to hide the defects of the system. Sometimes these people were
led to meet the patient through the ordinary conventional means,
more often not. Complicated schemes were devised through
which meetings were arranged which on the surface appeared
accidental. After the pivotal units were gotten together, the rest

502 SIDXEY I. SCHWAB

followed even more rapidly than at times was altogether desir-
able. In this way very slowly a small group of people was formed
of which the patient was an active and congenial factor. Among
those who were selected were one or two whose robust person-
ality and sane views told with great force upon the patient's
weakened grip on the tangible business of life. She saw in them
the positive evidence of the new viewpoint which it was the part
of her physician to attempt to develop for her theoretically. The
second part of the therapeutic scheme was accomplished with
very little difficulty. The patient had a talent for verse which had
enabled her to have published in some of the better magazines
some of her work. The Atlantic Monthly, Scribner's, and the
Century had printed some verse of hers, and one or two of them
had attracted the attention of the editors. Some of you have very
possibly seen specimens of her verse. These poems are very ana-
lytic and rather somber and they are of a kind that would never
attract popular attention. When she came under my care, she had
given this thing up for three years or more. It was part of the plan
to make this activity the central part of her life in its larger rela-
tions. This was never lost sight of for one moment. Its im-
portance was perhaps exaggerated from the very beginning. She
was encouraged to attempt newer forms of activity in a literary
way. Short stories, drama, sketches, a novel, etc. The physician
in this instance established himself as her literary critic and con-
fidant and at times supplied plots for the short stories. Through
her published work a certain amount of recognition was obtained
which was more effective than any other one thing in strengthen-
ing her growing feeling of importance and the lessening the
tendency towards self-minimization which was so much in
evidence before. This patient became somewhat sought after,
that is, in a minor sort of way, and her sense of being somebody
with a place created by her own effort seemed to act in the \vay
a tonic ought to but never does. I might mention here the effect
on the patient of a series of imaginary characters for one of the
shorter stories and the effect on a writer of the mental diversion
produced by following their necessary fate. I mean as an agency
for directing the attention from the thought of the neurasthenic
symptoms this can be made remarkably effective. The last part of
the plan was fulfilled mainly through carefully planned talks at
frequent enough intervals so that the thread of the thought might
be continued. This is difficult to describe, but it consisted largely

SOCIAL INTERCOURSE AS AN AGENT 503

in an effort to dissect former erroneous ideas and hopes and to
substitute a saner conception and a more definite appreciation of
the whole scheme of existence. Especial attention was directed
to the creation of the objective attitude to happenings of daily
experience. No description of this part of the plan is necessary.
Everyone has had his to do. I wish to insist again, however, that
to be of any service an effort of this kind must be carefully
planned and consistently carried out and yet with enought tact
that the patient is not aware that she is the object of a series of
didactic lectures on her shortcomings.

The result. After a year and a half the patient, whose con-
dition I have outlined in the begining of this paper, is a very much
changed person. She herself confesses to a totally different
feeling about herself. The fatigue symptom has almost disap-
peared. The hopelessness and morbidity are no longer in evi-
dence. The patient is active, busy and fairly happy and reason-
ably contented. The testimony of her brother supports this view.
At the last examination the objective hysterical symptoms had
very nearly vanished — the subjective completely. As a thera-
peutic result I should consider this case an exceedingly favorable
example of treatment. That she still has hysteria I am willing
to admit, but as a member of society she does very well in spite
of the neurasthenia and hysteria.

The limitations of the method outlined in this paper must be
sufficiently obvious. It is only in rare instances, I believe, that
such a combination of circumstances is met with as was con-
stantly present in this case. For this very reason it is not a suffi-
cient experiment to warrant any conclusions. It might be said,
however, that experiments in therapeutics are usually made on
the extreme instances of disease and that afterwards the more
common varieties are the subjects of treatment. In this way per-
haps this experiment in psychotherapeutics may be regarded. It
establishes, I trust, the right of the neurologist to broaden the
field of his therapeutic endeavor, and it implies the existence at
least, of forces to be used in a curative way. that were not thought
within the province of the physician. Above all it suggests that
the technique or system of psychotherapeutics must in the long
run be made up of the accumulated wisdom of many such ex-
periments in each of which some definite thing might be found.
To contribute something to this end has been the chief purpose
of this paper.

MYOCLONUS-EPILEPSY WITH A REPORT OF TWO ADDI-
TIONAL CASES.*

By William T. Shaxahan, M.D.,

FIRST ASSISTANT PHYSICIAN, THE CRAIG COLONY FOR EPILEPTICS, SONYEA, N. Y.

This condition is one of the numerous forms of the epilepsies
of which there has been but a small number of cases reported.

A review of 2150 cases of epilepsy admitted to the Craig
Colony for Epileptics, since its opening in February 1896, shows
but seven cases of myoclonus-epilepsy. The first of these was
reported by L. Pierce Clark in Archives of Neurology mvd
Psychiatry, Vol. II, 1899. Three of these were reported by L.
Pierce Clark and T. P. Prout in their excellent paper in the
Journal of Insanity in 1902 ; the fifth by L. Pierce Clark and my-
self, the last two being now reported for the first time.

The first case on record of paramyoclonus multiplex reported
was that by Friedreich in 1 88 1. A search through the earlier
literature shows histories of cases which were undoubtedly the
same condition. He describes a patient, aged 50 years, who
developed quick clonic contractions of symmetrical muscles of
extremities. These contractions resembling those produced by
an electric current, ceased during sleep ; increased by periph-
eral mechanical stimuli. They were diminished or entirely in-
hibited by voluntary movement. Muscles of trunk and face
escaped. Nutrition and mechanical and electrical irritability un-
altered. Increased knee jerks, no affection of sensation. No in-
terference with motor power or coordination of involved muscles.

His case was a result of a severe shock, and the spasms, after
lasting several years, rapidly ceased, recurring later and con-
tinued until death.

Many variations from this description have been seen in cases
reported later. In some there is considerable locomotor effect,
in others little or none.

Face and trunk muscles are frequently involved. Voluntary
movements often increase the myoclonic movements instead of
diminishing them. Knee jerks may be normal or diminished in-
stead of increased.

It attacks groups of muscles which cannot be thrown into

*Read before the Rochester Pathological Society, May 2, 1907.

MYOCLONUS-EPILEPSY 505

contraction voluntarily and movements show no coordination as
occurs in movements produced at will. In the majority of cases
the proximal segments of the limbs are most affected.

Mental excitement and physical fatigue often provoke the
movements. Excess of indican has been present in some cases
when the myoclonic movements were most marked. In other
cases it was absent. The movements are of a type that cannot
be produced voluntarily.

Some of the phenomena of hysteria may be present in myo-
clonus epilepsy as in ordinary epilepsy.

Clark in his article in The American Journal of Insanity in
1902 has compiled a list of 57 cases of myoclonus epilepsy re-
ported up to that ttime. Since then several cases have been re-
ported in the literature. The most recent being eight cases
reported from the Colony for Epileptics at Bielefeld in a popula-
tion of 2000 epileptics.

Aldren Turner in his recent work on Epilepsy reports but two
cases of myoclonus epilepsy in one thousand cases of epilepsy
that came under his observation.

Many of these cases have been confused with motor aura and
incomplete seizures.

Unverricht in 1891 in his monograph, "Die Myoclonic,"' de-
scribes several cases of a family type.

Etiology. — The same causes which predispose to epilepsy, in-
sanity, imbecility, etc., are found in these cases, viz., alcoholism,
insanity, tuberculosis, epilepsy and other signs of family de-
generacy. These patients themselves show many signs of de-
generation.

The exciting cause, if one is given, is frequently one which
has little or no bearing on the condition in question. In one of
the two cases reported in this paper no cause is assigned except
that patient was always "nervous." In the other jerkings ap-
peared a short time after patient had measles.

Sex. — Males seem to predominate. In those at Bielefeld 5
were males, 3 were females. In the 57 collected by Clark in 1902
the ratio was 5 males, 3 females. In the seven at the Colony, 4
were males, 3 were females.

Most of the cases develop before adult life although some do
occur later, one reported in this paper claiming that the myoclonic
movements did not appear until she was over 30 years of age.

506 WILLIAM T. SHAN AH AN

Turner's two cases were women and in them the myoclonus
was present for many years before the first epileptic seizure.

Pathology. — Friedreich and Unverricht believed the disease
to be due to excitation of the motor ganglia of the cord. Un-
verricht also considered an additional involvement of the cortical
motor ganglia. Others have described the condition to lesions in
the medulla oblongata, cerebellum, corpus striatum, optic thalamus
and cerebral cortex. As has been frequently stated, it would seem
if the lesion was in the spinal ganglia we would have trophic
changes in the muscles.

Clark and Prout conclude that the lesions appear to be in the
cerebral cortex involving the nucleus and the intra-nuclear net-
work of cells of both sensory and motor types. Its pathogenesis
appears to be an intoxication or an auto-intoxication of these
cortical cells, probably brought about by a faulty chemotaxis of
these same cells because of an inherent organic anomaly.

Clark reports a case from the Craig Colony in which an
autopsy was made and a microscopical examination of the brain
showed the following condition: General chromatolysis, absence
of nuclear membrane and granular (often swollen) nucleus in
every portion examined (Sections taken from both motor and
frontal areas). He lays stress on the fact that the large pyra-
midal cells of the third layer are especially involved.

J. Ramsey Hunt believes that there is a coexisting degenera-
tive affection of the cerebro-spinal axis, the epilepsy referable to
the upper, the myoclonus to the lower centres. He found a
marked hypertrophy of the muscle fibers in a case of myoclonus
multiplex.

J.. Risien Russell's hypothesis is that according to the phe-
nomena, the motor neurones of both the brain and spinal cord
may be affected, and that the neuroclonic state existing in the
neurones of the anterior horns of the spinal cord or their homo-
logues in the medulla oblongata and pons, may give rise to myo-
clonic spasms, whereas an altered state in the neurones of the cere-
bral cortex may be subsequently and secondarily induced, giving
rise to epileptic seizures. Or again the altered condition of the
cerebral cortex, and the consequent epilepsy, may be primary, and
the neuroclonic state of the neurones of the spinal cord may ap-
pear subsequently.

This hypothesis of Russell's appears to be very reasonable

MYOCLOX US-EPILEPSY 507

when the symptoms are given careful consideration.

Diagnosis. — This condition is confused at times with pseudo-
myoclonic contractions (which the patients themselves char-
acterize as "jerks"); isolated tics of epilepsy; post-hemiplegic
choreic movements associated with epilepsy ; choreic epilepsy ;
hysteria ; and myoclonia in general paresis.

The characteristic grand mal seizure and movements which
could not be produced voluntarily should be sufficient to ex-
clude hysteria.

The pseudo-myoclonic movements, "jerks" are bilateral flexure
movements of the upper extremities although cases are seen in
which these premonitory "jerks" involve the lower extremities.
Some are on the border line between epilepsy and myoclonus
epilepsy.

Various tics in epilepsy are confined to the face ; are not co-
ordinate and usually voluntary or reflex emotional acts,
acts whose general character continues unchanged although
exaggerated by emotions.

One case admitted to the Craig Colony showed multiple
tics involving especially face and right arm. These movements
were constantly present to a greater or lesser degree but in-
creased markedly 24 to 28 hours before seizures. Patient had a
marked neuropathic family history.

In choreic paresis and in infantile spasmodic hemiplegia
(without palsy) the convulsions begin and involve most fre-
quently parts once paralzed. The choreiform movements are
rhythmical and unilateral. Unilateral atrophy also occurs.

In general paresis the mental state, speech, pupils, etc., should
make the diagnosis clear.

The diagnosis is made on the presence in an epileptic of bi-
lateral, electrical shock-like convulsions occurring in paroxysms
and involving no impairment of consciousness and at intervals
the occurrence of grand mal seizures, epileptic in nature.

It may appear as a pre-epileptic or post-epileptic phenom-
enon or as a condition independent of the distinct epileptic
seizure. In the latter case it is sometimes considered as an
equivalent of the seizure.

Prognosis — Periods of freedom from myoclonic movements
of variable length occur but there is no permanent cessation.
The mental condition may change but little. Death may oc-

508 WILLIAM T. SHAN AH AN

cur in status myoclonus or from intercurrent disease as pneu-
monia.

Treatment — This must be along general lines tending to
place a patient in the best possible physical condition.

Chloral hydrate and amylene hydrate have a marked effect
in controlling myoclonic movements. Bromides have an ex-
cellent effect in some cases.

Report of two new cases follows :

E. C. B., age 39 years. Single. Common school educa-
tion.

Family History — Father living, aged 71 years. He is an
alcoholic and has been frequently intoxicated during the past
twenty-four years. Said to be a worthless character. No def-
inite history of syphilis can be obtained but as he was an old
alcoholic soldier and his wife had several miscarriages it
would seem probable that he had syphilis.

Mother was a nervous woman who had frequent head-
aches, fainting spells and attacks of vertigo, but no fits or
movements similar to those patient has. She died at age of
39 years. Assigned cause of death was confinement and
Bright's disease.

Maternal grandmother died at age of 87 years. She enjoyed
good health until late in life, when she developed some ner-
vous trouble.

Patient eldest in family of five children. One brother died
at 19 years from pulmonary tuberculosis. One sister was sickly
and died at age of two years from some intestinal trouble.
Two sisters married, both of whom are in poor health, exact
condition unknown. One has no children, the other has had
several who have been sickly and died young. She has one
daughter living and well. One of the children who died, a
son, had convulsions during his last illness at five years of
age. He is said to have been a bright boy but frequently cried
without apparent cause.

Two maternal aunts are troubled with some gastrointes-
tinal disorder, the exact nature of which cannot be ascertained.

Personal History — Patient was born at full term. Nursed
by mother. Nothing can be ascertained as to delivery or early
infancy of patient. No history of any traumatism. No his-
tory of difficulty in learning to walk. Had measles at six
years. She is said to have been ill for three months with
scarlet fever at age of nine years. During the period of this
illness she had convulsions and was totally blind for an un-
known period.

Patient claims that her first seizure, resembling a fainting
spell, occurred when she was eighteen years of age. She

MYOCLOX US-EPILEPSY 509

was at that time working as a clerk in a store and had to give
up her position. The seizures recurred and became more se-
vere until she had a general convulsion at age of twenty-two
years. During this seizure she fell against radiator burning
her right hand. Usually has no aura, but at times has a ting-
ling in her fingers. Previous to her admission to the Colony
she is said to have had seizures at intervals of from one week
to two or three months. They occurred usually in series and
were followed by a marked prostration and stupor. The first
seizures in the series were severe and the later ones mild.
Face and hands said to have been affected first. She had bit-
ten lips and tongue during seizures, and received many injur-
ies by falling at those times, viz., burns, fracture of nose, con-
tusions about head and arms.

Patient complained of a pain and a "drawn feeling" in the
head after seizures. At age of thirty-six she had a slight para-
lysis of left hand following seizures. This disappeared after two
months. She has had as many as eight seizures in twenty-four
hours. Is said to have been jealous, stubborn, depressed and at
times hysterical.

Physical examination on admission to the Craig Colony,
June 15, 1905. Brunette of spare build. Height 4 ft. iol/2 in.
Weight 71 y2 lbs. Has an anxious expression. Ears have ad-
herent lobules. Small inferior maxilla. Palate has a nar-
row and moderately high arch. Moderate scoliosis. Slight
facial asymmetry. Thyroid not enlarged. Skin and mucous
membranes pale. Xo evidence of syphilis. Slight cyanosis of
feet. Eves — Xo ptosis, exophthalmus. nystagmus or strabis-
mus. Twitching of eyelids. Cornea and conjuctiva are mark-
edly sensitive. Vision — right eye. 20 — 40: left eye, 20 — 50.

Complains of an occasional tinnitus aurium. Gustatory
sense normal. Olfactory sense impaired on both sides.

Chest negative. Has alwavs been troubled with constipa-
tion. Appetite poor. Some pyrosis and distress of epigas-
trium after eatine. Considerable orominence of abdomen in
general, apparentlv due to accnmulation of gas in intestines.

Breasts atrophied. At age of 27 years she had both ovaries
removed as she was told this would cause her seizures to stop.
Menstruation be^an at id years and was irregular no to time
of operation. Comolains of almost constant vertigo, sub-
occipital headache and pain in vertex. General feeling of
weakness and exhaustion.

Tactile, pain, temperature, localization and stereognostic
senses normal. Dermatographia absent. No anesthesia of
ulnar nerve.

Slight abdominal and eois-astric reflexes. Verv active pa-
tellar ierks. Plantar is of lively flexion type. Active wrist
and elbow jerks.

5io

WILLIAM T. SHAXAHAX

Patient right handed. Dynamometer shows no inequality
between two sides. Handgrasp only moderately strong for
her general physique.

Fig. i.

E. C. B. Holding inferior maxilla with right hand and left hand

grasping clothing tightly., in an effort to control myoclonic movements.

No signs of paralysis except that in showing her teeth mus-
cles on right are more active than on left. General muscula-
ture is poor. Sense of position normal. Because of presence

UYOCLONUS-EPILEPSY 511

of myoclonic movements patient could not walk without as-
sistance. Mentality fair. Speech interrupted but slightly by
movements.

Shortly after her admission to the Craig Colony, she had a
series of grand mal seizures which was followed by a state of
mental confusion accompanied by illusions and hallucinations
of sight and hearing. Disoriented. Very lachrymose and
then would suddenly change and laugh in a meaningless way.
She dressed herself and went to the table for her meals. At
another time she had marked myoclonic movements following
grand mal seizures. Seizures are usually grand mal in type
and occur at intervals of several weeks.

Following is a brief description of a myoclonic period:
Patient appears slightly agitated, is lachrymose. When walk-
ing with support there is a marked extension of right leg at
knee from time to time. Very unstable equilibrium, especial-
ly when weight is borne on left leg. Bilateral clonic nodding
movements, at times muscles on right side of neck draw-
ing head to that side, occasionally similar movement of head
to left. Smacking, tasting and munching movements of jaws.
To and fro movements of tongue when mouth is open. Fre-
quent marked clonic movements of muscles of mastication
causing lower jaw to be depressed and then elevated. Patient
holds inferior maxilla with her hand endeavoring to control
movements. (See photograph.) Swallowing movements fre-
quent. When mouth is closed there is a lifting of chin and
compression of lips at frequent intervals.

Muscles of eyelids and forehead occasionally involved.
Drank water without difficulty when glass was held to lips by
nurse. No ejection of food from mouth. Active involvement
of temporal muscles but only occasionally of occipito-frontalis.
Complains of a "drawn sensation" in temporal and occipital
regions.

When sitting or walking the muscles of back and back of
neck are markedly involved in lightning-like jerks. No tremor of
tongue. No nystagmus.

Can walk about room by balancing against walls, chairs,
beds, etc., or having some assistance from nurse.

When lying on abdomen there is an occasional myoclonic
movement of erector spinse. Lying on back there is a marked
myoclonic flexion of lower extremities, especially right. Right
upper extremity, then left markedly involved. Flexors more
than extensors.

Knee jerks exaggerated. Patellar clonus on right side.
No ankle clonus or Babinski reflex. No increase in reflexes of
upper extremities.

Abdomen prominent, walls are not rigid nor apparently in-
volved in myoclonic movements. Peristaltic movements ap-
parent in lower abdomen. No borborygmus.

512 WILLIAM T. SHANAHAN

Passive movements of extremities resisted. (Patient said
she was endeavoring to exert some control over movement.)

No diaphragmatic grunt. No hiccough. Patient says she
feels worn out and discouraged during myoclonic periods.

When not spoken to and allowed to lie quietly in bed, the
movements are somewhat less frequent, but when spoken
to become exaggerated.

She says she often has a sensation of tingling formica-
tion, followed by a feeling of coldness over entire body, but
more in left arm and leg, especially former. Feels better
when sitting up sewing, although when working at latter,
she frequently sticks needles or scissors' points in fingers and
has great difficulty in threading needle.

Urine examined during myoclonic periods shows no in-
crease in indican. Sometimes urinates involuntarily during
myoclonic periods. No impairment or loss of consciousness.
Complains frequently of anorexia and insomnia.

Patient states that previous to her first seizure at age of
eighteen years she was nervous, could not stand any excite-
ment and had frequent crying spells. No myoclonic move-
ments until she was about 34 years old. They first appeared
in hands and feet, later in head. Movements have gradually
become more severe and frequent. Movements are frequently
more marked following seizures than preceding them. Marked
vertigo accompanies periods.

She says the weather has no influence on the movements
and this has been corroborated since her residence here. Elec-
trical reaction normal.

This patient has not been entirely free from the movements
at any time since her admission to the Colony.

E. J. W. Age 15 years. No occupation.

Patient is second child in family of three children (two
boys and one girl, all of whom are living).

His brother, aged 11 years, has jerkings and has had "two or
three fits."

Father died at 29 years from typhoid fever and is said to
have had nervous prostration. Mother died at 23 years from
tuberculosis. She had convulsions when a child. On his
mother's side there has been a number of cousins who have
had convulsions. Mother's people were "nervous." Father
or mother was not intemperate. Maternal grandfather died
at 40 years from tetanus. Otherwise grandparents negative.

Patient born at full term. Labor "quick and normal." De-
livery natural. No injury during delivery. Weighed eight
pounds at birth and was a strong baby. Had no spasms di-
rectly after birth nor was he paralvzed. Nursed by mother.
No indigestion nor prolonged crying in infancy. Dentition
began at four months and was not accompanied by convul-

MYOCLONUS-EPILEPSY 513

sions. No pavor nocturnus. Began to walk without difficulty
at age of fourteen months. Did not show any swollen
glands or signs of rickets. No epistaxis. No injury in early
life. Had pertussis at nine years and measles at ten ; both
ran ordinary course.

Patient says he started to school when he was ten years
old, could not go earlier because he lived so far away from
school.

First attack occurred when he was eleven years of age. He
was driving a horse when it fell down and broke the harness
and shafts. That night he had first convulsion just before go-
ing to bed. Supposed cause was fright. Second attack oc-
curred three days after first. Attacks have occurred nearly
every night during the last two years. Has had a few attacks
in day time. Attacks are not as bad as formerly, but are more
frequent. One attack is described, "He screeched and shook
for about ten minutes." Feels badly in head after each at-
tack. Xo aura. Vary in severity. Sometimes he says his right
and sometimes his left side has a pain in it after a fit, more
often the right. Patient is conscious in light attacks. No
paralysis or aphasia following seizures. Has had seven at-
tacks in 24 hours. Rather small eater. Patient says that for
about a year preceding his fright he had what he called
"jerkings." They began a short time after he had the measles.

Physical Examination — Rather slight. Hair brown and
abundant. Poor musculature. Height, 3 ft. gl/> in. Weight,
74 lbs. Head well shaped. Palate high, some lordosis. Is
flatfooted. Scapulae stand far apart. No eruptions, scars or
bruises. Skin and mucous membranes pale. No evidence of
syphilis. Thyroid not enlarged. Eyes negative as also ears.
Taste and smell normal. Chest somewhat flattened. Lungs
and heart normal. Digestive organs normal.

Patient says he is not as strong as formerly. No vertigo
except after seizures. Seldom has a headache. Following
some attacks he has a pain on right side just below costal
border. Tactile sense, slow in responding, seems diminished
in all parts of body. Pain sense diminished. Temperature
sense normal. Stereognostic sense poor. Reflexes negative.
No evidence of any paralysis. Co-ordination and muscular
sense normal. Has frequent jerkings of upper extremities,
chiefly on right side, sometimes head jerked also. These move-
ments occur frequently and are apparently more frequent
when he closes his eyes. Slight tremor of tongue. Mental
state fair.

November 1, 1905 — Flexor muscles of leg are most often
affected in convulsive movements. At times they are almost
continuous changing from one group to another. No loss of
consciousness. At times has great trouble in dressing and
walking.

514 WILLIAM T. SHANAHAN

July i, 1906 — Continues to have much jerkings of his mus-
cles, chiefly in arms, legs, head and lips. More on right
than on left. They are worse in early morning, at which
time he is quite helpless.

October 1, 1906 — Movements are present much of the time,
although some days he is entirely free. They are absent dur-
ing sleep. All muscles seem involved with no distinct order
of invasion. Sometimes upper extremities and sometimes
lower. At times neck muscles. Always worse in morning.

January, 1907— Pale and anemic.

February 16, 1907 — Myoclonic movements continue. At
frequent intervals, especially in morning, although at times
they are present during entire day. Recently received a se-
vere contusion of tissues about left eye by falling during a
seizure. Myoclonic movements involve trunk extremities
and facial muscles. To-day, directly following a grand mal
seizure, he had loss of plantar, patellar, wrist and elbow re-
flexes. Wets bed every night. Ordered strontium bromide
grs. x, sodium bromide grs. v, chloretone grs. iii, t.i.d.

February 27, 1907 — Is in a semi-stuporous state. Occa-
sional myoclonic movements on right side. Chloretone
stopped.

March 13. 1907 — Cold, rainy day. Myoclonic movements
are very marked. (They were practically absent for past two
weeks.) They are general and involve principally the flexors.
Muscles of abdominal wall markedly involved. No nystag-
mus. Pupils widely dilated and react but slightly to light.
Some spasm of eyelids but not much of facial muscles. No
impairment of consciousness. Reflexes not exaggerated, ex-
cept plantar which is toe flexion in type. No ankle clonus.
Flexors of toes are first involved, then foot, then entire ex-
tremity on each side. No apparent involvement of muscles
of back. Movements increased when talking.

March 15, 1907 — Marked myoclonic movements during
early morning and up to 10 a.m., when he had a grand mal
seizure which was followed by marked perspiration and com-
plete cessation of myoclonic spasms for several hours, after
which they reappeared and were very severe, but again ceased
when patient was given chloral hydrate grs. x, potass, bromide
grs. xv. Developed difficulty in swallowing and seemed to
have a spasm of laryngeal muscles producing difficulty in res-
piratory act. Occasional loud grunt.

March 16, 1907 — Abdomen is now negative. Patient had
no myoclonic movements for several hours after yesterday's
grand mal seizure. They returned late in afternoon and be-
came more severe.

He developed difficulty in swallowing and seemed to have
inspiratory difficulty. Auscultation over chest, negative. Grunt

MY0CL0NUS-EP1LEPSY

515

heard occasionally as though respiratory muscles were in-
volved in myoclonic movements.

March 28, 1907 — Pupils well dilated. Wrist jerks exag-
gerated on both sides. No difficulty in swallowing fluids.
Myoclonic movements involving sterno-cleido-mastoid, trape-
zius, deltoid and flexors of forearm and hand on both sides
but not synchronously. Spasm of both eyelids is synchronous
and bilateral.

No exaggeration of elbow jerks or knee jerks. No ankle
clonus or Babinski reflex.

x

■

■■\^<-

•^t/V

1 y^x^X I

w-

u*

Fig. 2. Sample of writing of E. J. W., showing inability to control

myoclonic movements.

Some borborygmus. No hippus.

March 29, 1907 — Marked myoclonic movements to-day
which involve muscles of back, abdominal wall, occipito-fron-
talis, right face, eyelids, flexors of lower extremities and all
muscles of upper extremities. Right upper extremity affected
much more than is left, arm being raised from side. Head
turned toward left but not held rigidly.

Occasional grunt accompanies severe myoclonic move-
ments. Facial muscles are not as markedly involved as are
muscles of right arm. Some difficulty in speaking. Reflexes
not exaggerated. Swallows without trouble.

Tapping muscles, excitement, etc., increases movements.
Pupils normal.

Si6 WILLIAM T. SHANAHAN

General convulsion occurred about 10 a.m. Head turned
markedly to left, pupils widely dilated, no cry before, but did
occur after seizure (at time of cry patient appeared to have
an atypical seizure as pupils dilated and there were some clonic
movements of upper part of body). All parts of body in-
volved. Saliva blown from mouth. Slight stertor and very
brief period of cyanosis. Reflexes, tested immediately after
cessation of clonic movements, were absent except for slight
plantar flexion.

Flatus passed but no fecal matter or urine. Pupils returned
to usual size directly after convulsive movements ceased.
Moderate increase in pulse rate. Two minutes later reflexes
were active but not exaggerated.

April 3, 1907 — Myoclonic movements marked since 6 a.m.
Mild seizure at 7.40 a.m. Thirty minutes after taking amylene
hydrate by mouth all movements ceased and patient was able
to sit up in bed and read.

April 5 — Jerkings slight until 5 p.m., when they became
very marked and he had a grand mal seizure at 5:15 p.m., after
which he perspired very freely for several hours and was very
restless. Myoclonic movements returned at 7 p.m.

April 6 — Myoclonic movements continued very severe all
night so that patient could not sleep.

April g — Dark, rainy day. Marked myoclonic movements
involving especially flexors of extremities both distal and prox-
imal positions. Increased cremasteric reflexes. Diaphrag-
matic grunt. Slight lateral movement of eyeballs in some
movements. Back muscles involved markedly also. Fibril-
lary twitching observed in posterior aspect of thighs. Con-
sciousness unimpaired.

Seizures, both grand mal and abortive or atypical types,
vary in frequency. Grand mal occurring from two to twenty-
two times per month, the abortive form more frequently.
Electrical reaction of muscles normal. At no time has there
been an increase of indican in the urine.

BIBLIOGRAPHY.

Clark and Prout. "The Nature and Pathology of Myoclonus-Epilepsy."
American Journal of Insanity, Vol. 59, p. 185. 1902. M

Dana, Charles L. "Myoclonus Multiplex and the Myoclonias." Jour-
nal of Nerv. and Ment. Dis., Vol. 30. p. 449.

Hunt. Ramsay J. "Pathology of Paramyoclonus Multiplex." Ibid, p.
408, July, 1903.

Neff, Irwin H. "Four Cases of Myoclonus and One of Myoclonus-
Epilepsy. American Journal of Insanity. Vol. 60, p. 467.

Allbut. "System of Medicine." J. S. Risien Russell, Vol. 7.

Spratling. "Epilepsy and Its Treatment."

Turner, Aldren. "Epilepsy."

Weiss, G. (Review.) "Beitrage z Casuistik d. Myoclonic bei Epilepep-
tischen." Journal of "Nervous and Mental Disease. March, 1907.

Excellent biographies are appended to articles of Clark. Hunt. Dana
and Russell.

Society proccc&mfid

NEW YORK NEUROLOGICAL SOCIETY.

Dec. 4, 1906.

The President, Dr. Joseph Fraenkel, in the Chair.

A CASE OF SYRINGOMYELIA.
By Dr. William B. Noyes.

The patient was a young man of twenty-three, a straw-maker by oc-
cupation, whose mother died of some rheumatic complaint, and his father
of some obscure complication of medical conditions. There was no
history of syphilis.

Four years ago the patient first noticed a heavy feeling in the arms
and legs, accompanied by weakness, which gradually became more marked.
About two years ago he also began to develop pain in his legs. When
Dr. Noyes first saw him, five months ago, an examination revealed marked
atrophy of certain muscles of the upper extremities, notably the supra-
spinal and trapezius. The patient complained of very severe pain along
the course of the spine and around the abdomen, which has been quite
constant. There were certain well marked areas of anesthesia and
analgesia and of thermal anesthesia over the back, chest and upper
extremities, although these areas of loss of sensibility to pain and to
heat and cold did not entirely coincide with each other. In certain areas
over the back and arms he could not distinguish between heat and cold.
Fibrillary twitchings were well marked over the atrophied muscles. The
knee jerks were increased. There was ankle clonus. There were no symp-
toms referable to the special senses ; no bulbar symptoms. Babinski re-
flex was present. Arm reflexes were absent. He had an unexhaustible
ankle clonus on the left side. His abdominal reflexes were normal. His
eyes were normal, and there was no symptom of disease of any of the
cranial nerves.

Dr. Noyes said he regarded the case as one of syringomyelia, although
there was a possibility that it was one of meningeal tumor pressing on
the nerve roots. The only reason for even suggesting any other diagnosis
than syringomyelia is the uncertainty of the true value of failure to dis-
tinguish between heat and cold, where anesthesia and analgesia are
present over the same areas. In this case there were undoubted areas
demonstrated before the Society where thermo-anesthesia alone was
present.

Dr. J. Arthur Booth said that from the symptoms presented by the
patient shown by Dr. Noyes he thought there was no question of the
correctness of the diagnosis of syringomyelia. The symptoms were those
of an anterior and posterior poliomyelitis from a gliosis of the cord in the
cervico-dorsal segment. The patient also shows a difficulty in walking,
which had not been noted before.

518 NEW YORK NEUROLOGICAL SOCIETY

A CASE OF DEMENTIA PARALYTICA IN A BOY 15 YEARS OLD.

Dr. M. S. Gregory.

This patient had been referred to the psychopathic ward of Bellevue
Hospital for examination from the New York Juvenile Asylum with the
statement that he was developing imbecility. The boy's present, as well
as his antecedent history, had been furnished by his mother, who was a
well developed, well nourished woman, about thirty-eight years of age.
She was somewhat emotional, and readily became suspicious and irritable
without provocation.

According to her statement, the family history had been negative, with
the exception of one brother, a maternal uncle of the patient, who had
been an inmate of the Manhattan State Hospital for the past six years,
suffering from a mental disease of a paranoid type, with prominent religi-
ous ideas and hallucinations of hearing. The patient's father had been
addicted to the use of liquor for many years ; he had kept late hours, and,
it was believed, dissipated and associated with women of low character.
It was not known whether or not he had had syphilis. The mother had
had ten children in all — nine by the patient's father, and one by her
second husband. She had had two full term still-births, one between the
second and third child, and one between the fourth and fifth child; the
latter was said to have had a "water-head."

The patient was born on July 17, 1891. He was the seventh child, and
two healthy children had been born since his birth. He was a healthy and
well-developed infant, and the delivery was a normal one. The mother
denied his having snuffles, coryza, skin lesions, etc. He walked at fifteen
months, learned to talk at the usual age, and as a child was healthy and
well. He entered school at the age of seven, and left at thirteen, making
fairly good progress in his studies, and acquiring an average knowledge
of the elementary branches. He was not considered backward in his
class. At seven years of age, while at play, he was struck on the center
of the forehead, and was unconscious for two hours following the injury.
He had a small scalp wound, which healed promptly. He suffered from
no headaches nor inconvenience after the injury.

At thirteen he left school and entered a box factory, where he worked
for six months, giving satisfaction, as far as was known. He afterwards
became a messenger boy in a theatrical agent's office, where he remained
for four months. Later, he was employed in a bookbinding establishment,
where he remained until the time of his commitment to the New York
Juvenile Asylum, May 9, 1906, at the age of fifteen. During the time
that he remained at home, his mother was certain that he showed no
peculiar traits, being fairly obedient and industrious until three or four
months prior to his commitment. Between the ages of thirteen and
fifteen years he smoked cigarettes to excess, averaging from two to three
boxes of Turkish cigarettes a day, and inhaling them. About April 1
he became unruly, indolent and frequently failed to come home at night.
He also stayed away over Sundays, and did not give his earnings to his
mother as he had previously done. He admitted having spent the money
for cigarettes. About this time his step-father precipitated a quarrel
which resulted in the commitment of the boy to the New York Juvenile
Asylum for disorderly children.

At the asylum he was employed mostly out of doors, weeding the
garden, mowing the grass, etc.; he did his work fairly well, but seemed
to take little interest in it. About Aug. 1, 1906, while working in the

NEW YORK NEUROLOGICAL SOCIETY 519

garden, he had a "sunstroke," followed by a convulsion and a stupor last-
ing twenty-four hours, and on the following day it was observed for the
first time that he had some difficulty in speech. He "stuttered," hesitated
in talking, and became irritable when he could not express himself. Dur-
ing the following month it was noticed by the attendant that he was
unsteady on his feet and was unable, on account of his shaking, to do the
work he had previously done. Finally, it was noticed by his mother that
he showed marked tremor in writing home, and talked with much diffi-
culty when she visited him.

On admission to the psychopathic ward on Oct. 16, 1006, a physical
examination showed a well-developed and well-nourished boy; complexion
fair; features regular; slight tendency to continual arching of the right
brow, but no loss of power in the facial muscles ; bridge of nose broad ;
teeth show some irregular ridging, but are not of the Hutchinson type;
no glandular enlargement. The skin showed a peculiar condition; it
was smooth and waxy in appearance, and there was an absence of hair
over the entire body surface. The left pupil was slightly larger than the
right, and both reacted slightly, if at all, to light. Both reacted to ac-
commodation. The movements of the eyes were apparently normal. The
patient complained of imperfect vision, but rough tests showed little
impairment. There was no hemianopsia, and an examination made by
Dr. Reese, of the Cornell University, showed the eye grounds to be nor-
mal. The elbow, wrist and knee jerks were slightly exaggerated, but
equally on both sides ; front cap and Achilles reflexes were present and
lively. The superficial reflexes were about normal ; no Babinski. There
was no distinct impairment of power in any muscle group, so far as could
be determined. The right forehead was more deeply corrugated than the
left, but both sides were wrinkled equally well on examination.

There was some fumbling when attempts were made to touch the
nose with the finger-tips with the eyes closed. There was pronounced
lateral tremor of the extended fingers, and a fine tremor of the tongue,
which was extended in a jerky fashion. Marked flicker of the muscles
about the mouth was present on showing the teeth. Speech showed a
well marked defect, and enunciation and articulation were indistinct and
ataxic. Heart and lungs normal. An examination of the spinal fluid
made by Dr. Hastings, of Cornell University, showed marked lymphocy-
tosis.

Mental examination : The patient was quiet, composed and well be-
haved. His mood, as a rule, was mildly exhilerated, with occasional quick
changes to irritability on insufficient grounds. At such times, however,
he could be easily pacified. He felt contented and happy in a childish
way, showing very little appreciation of his condition and situation. He
had no expansive ideas nor well defined delusions. Memory showed slight
impairment, and judgment was quite defective.

This case was presented, Dr. Gregory said, as one of interest mainly
because of the age of the patient, he being the youngest of about 1,500
cases of dementia paralytica that had been admitted to the psychopathic
wards of Bellevue Hospital during the past five years. The next youngest
case was that of a girl of seventeen who had contracted syphilis when
thirteen, and the third youngest a man of twenty-one whose father and
mother were both syphilitic. The former had dementia paralytica and
the latter tabes. Another point of interest was that, although very

520 NEW YORK NEUROLOGICAL SOCIETY

young, the patient presented fairly typical somatic as well as mental signs
of dementia paralytica.

In the consideration of the etiological factors in this case, the most
stricking feature, perhaps, was the absence of the positive history of
syphilis. However, the dissipated life of the father, as given in the
history; the peculiar condition of the skin, which had been suggested by
Dr. Collins as being a form of syphilitic cachexia, together with the
presence of marked lymphocytosis in the cerebrospinal fluid might suggest
the existence of specific infection. It was also worthy of consideration
what part the head injury and cigarette smoking might have had, if any,
in the causation and development of the disease.

Dr. Edward D. Fisher said the case was a good illustration of the
type of general paresis in which the patient is in a fatuous, contented,
happy condition ; it was not an example of the expansive type.

Dr. L. Pierce Clark said that some four or five years ago, Dr. Mott,
of Claybury, England, collected all cases of juvenile paresis on record, and
the number at that time amounted to about 97. He considered it rather
a rare type, and called attention to the fact that these cases commonly
developed soon after puberty. The case shown by Dr. Gregory, Dr. Clark
said, could not be counted as an instance of a particularly early case of
the juvenile type. There seems to be no doubt but that the case is one
of juvenile paresis and not an early development of the ordinary adult
paresis, as Dr. Gregory appears to imply.

Dr. Charles L. Dana inquired if the boy had not some bad sexual
habits, and he suggested the possibility of acquired syphilis.

Dr. Gregory said that they had found no positive evidences of acquired
syphilis. Sexually, the patient was not as well developed as a boy of his
age should be.

The President. Dr. Fraenkel, said that Dr. Sachs and himself have seen
what was perhaps the youngest case of dementia paralytica on record.
The patient was a girl of ten years, whose mother came to the clinic
complaining of tabetic pains. At that time it was noticed that her little
girl, who was then attending school, presented the same somatic picture
as the mother; i. e., unequal, stiff pupils and exaggerated reflexes; and six
months later the child was admitted to the Montefiore Home with well
marked symptoms of general paresis, which rapidly progressed to a fatal
issue. The post-mortem examination corroborated the diagnosis. Patient
was ten years old when she was admitted to the home.

Dr. Gregory said that he had seen a case of dementia paralytica in a
child of seven years at Dr. Kraepelin's clinic in Munich last summer.
That case, however, was of a different type from this boy, who presented
many of the symptoms present in the adult type of the disease, which
perhaps was due to the fact that his age closely approached the limit of
the juvenile period. One of the interesting features of the case to which
he had already called attention was the peculiar waxy condition of the
skin, and the entire absence of hair on the body. He was uncertain as to
whether this was indicative of syphilitic disease.

Dr. Fraenkel said that this type of velvety skin was usually looked
upon as a form of trophic disturbance of the skin, and was not infre-
quently observed in tabes, either in a localized or generalized form. It
was regarded as a tabetic or post-syphilitic dystrophy of the skin.

Dr. William M. Leszynsky said he did not think the absence of hair
was an unusual manifestation of syphilis. He recently saw a man of

NEW YORK NEUROLOGICAL SOCIETY 521

fifty who was in the tertiary stage of syphilis, and whose body, with the
exception of his head, was entirely denuded of hair.

SARCOMA OF THE SPINE; PROBABLY EXTRADURAL.

By Dr. I. Abrahamson.

The patient was a male, thirty years old; married; a native of Russia
and a painter by occupation. His family history was negative. The
patient had pneumonia ten years ago. He denied venereal disease; there
was no history of lead intoxication; he used alcohol and tobacco in
moderation.

Seven years ago a mass was noticed in the spine, in the sacro-lumbar
region. It had increased in size during the past two years. His present
illness dated back two years, and was assigned to a fall from a scaffold,
striking on his right shoulder and head. Four weeks after the injury
he complained of a pain in the right lower ribs, posteriorly, burning in
character ; this was followed a week later by pain in the left lumbar region,
in the axillary line ; pains then occurred in the ball of the left foot, and
soon afterwards in the ball of the right foot. He began to suffer from
constipation and increasing difficulty in urination ; i. c, delay and inter-
rupted flow ; then a girdle sensation around the abdomen below the
umbilicus, at first on the left side; at about the same time there was
weakness and stiffness in the left lower extremity, together with numb-
ness and a "dead" feeling over the same extremity; there was also-
diminished potency. He complained of no symptoms above the waist
line excepting occasional dizzy spells, with blurred vision simulating
diplopia. About this time the mass on the back began to increase in
size, and the patient ascribed his symptoms to it. He remained in the
hospital three months, and during that period his symptoms improved
somewhat, his pain being less severe.

Examination showed the head, chest and upper extremities normal.
There was no lead line on the gums. The pupils and reflexes of the
upper extremities were normal. The abdominal reflexes were present,
but the left lower abdominal reflex was much diminished. There was no
clonus. The patient dragged the left lower extremity somewhat, and
the foot was turned outward. Motor power was somewhat diminished.
Tactile sensibility was normal. There was a belt of hyperalgesia on the
right side from the umbilicus to the ribs anteriorly, and from the buttocks
to the ribs posteriorly. There was hypoalgesia on the right side from the
umbilicus to the groin, and sensibility was still more diminished over the
right thigh, especially its outer surface. There was analgesia over the
right upper outer leg and foot. On the left side there was hyperalgesia
from the umbilicus to the groin. There was tenderness to percussion over
the ninth dorsal spine, and upon moving the upper body from side to
side the girdle sensation was increased. The electrical reactions were
normal.

The mass over the spine was removed, and a microscopical examina-
tion showed it to be a spindle and giant celled sarcoma. The patient was
given hypodermic injections of salicylate of mercury and increasing
doses of iodide of potash, with very little improvement.

A study of this case, Dr. Abrahamson said, indicated the presence of
a lesion of the spine involving from the tenth to the twelfth dorsal seg-
ments, mainly on the left side, probably posterior, and of extra-medullary
nature. The likelihood was that the lesion was either extra-dural, and

522 NEW YORK NEUROLOGICAL SOCIETY

large and flat, or else of the dura itself. It was sarcomatous. The case
was of particular interest en account of the marked sensory symptoms,
the Brown-Sequardian tendency and the minimum motor symptoms.

Dr. B. Sachs said that in view of the anatomical and pathological find-
ings in this case, there could be very little doubt about the nature of the
condition. He thought Dr. Abrahamson was right in suspecting a rather
diffuse sarcomatosis rather than a small, localized tumor, on account of
the extensive character of the motor and sensory involvement.

Dr. Sachs said there were a number of cases of spinal tumor on record
in which pain was the most pronounced and for weeks and months the
only symptom. The speaker said he was particularly interested in this
subject, as he had within the past few years seen a number of cases of
spinal cord neoplasm secondary to malignant disease elsewhere in the
body. Within the past few months he saw two cases of carcinomatosis
of the spinal cord which developed in a remarkably short period of time
after radical operations for mammary carcinoma. In one instance, the
spinal involvement occurred eight weeks, and in the other four months
after the removal of a cancer of the breast.

Dr. Adolf Meyer thought it was questionable that a diffuse sarcoma-
tosis, as the term is understood by Redlich and others, could produce such
well-marked sensory disorders of so one-sided a character. Of course, it
was probable that we had to deal with a tumor of fairly good size, but h«
could scarcely coincide with the view that the condition was a diffuse
sarcomatosis.

Dr. B. Sachs said that by the term diffuse sarcomatosis he meant one
or more flat tumors, and not a single compact one. A growth of the
latter kind in the limited space of the spinal canal would doubtless by
this time have given rise to very marked paralytic disturbances and of a
more localized character than were shown in the case reported by Dr.
Abrahamson. From that point of view the speaker said he would argue
that the tumor was widespread in character and not limited, say, to one
segment of the cord.

Dr. Edward D. Fisher said the symptoms in Dr. Abrahamson's case
were rather characteristic of pressure on the spinal nerves, rather than
on the cord itself. He did not see how such unilateral motor and sensory
symptoms could be caused by pressure on the cord.

Dr. L. Pierce Clark asked Dr. Abrahamson how frequently tumors
outside of the cord and extradural growths that had produced the Brown-
Sequard syndrome were met with in literature. He understood that it
was an extremely rare occurrence.

Dr. William M. Leszkynsky said that if the growth in this case was
extradural, there might be some chance for its successful removal. -

Dr. Charles L. Dana said that the immediate outlook for surgical
intervention in extradural tumors of the cord was very hopeful. Quite
recently he had had a growth removed from almost the exact region of
that in the case reported by Dr. Abrahamson, and the result was very
successful.

Dr. Abrahamson, in closing the discussion, said that as a rule, the
extradural conditions did not give rise to the Brown-Sequard syndrome.
The case he had shown was also particularly interesting on account of
the comparatively little motor and the very marked sensory symptoms.
The objective sensory symptoms were far in excess of the motor, and

NEJV YORK NEUROLOGICAL SOCIETY 523

indicated that the lesion was essentially one-sided, that it was most
probably extradural, and rather diffuse.

A CASE FOR DIAGNOSIS; POSSIBLY SYRINGOMYELIA.
By Dr. Edwin G. Zabriskie.

The patient was a boy of nineteen, a native of Silesia, and a baker by
occupation. No satisfactory family history was obtainable, but he had
apparently enjoyed good health up to the time of his present illness. He
used tobacco and beer moderately. About a year ago he fell on the side-
walk, striking his left elbow and causing a fracture of the olecranon.
Shortly afterwards, his left hand became emaciated and weak, beginning
in the middle finger and extending across the hand to the thumb, the
condition taking about two months to develop. Since then the hand
had been growing progressively weaker, and a month ago the right hand
became similarly affected. The electrical reactions showed complete loss
of response to both galvanic and faradic stimulation. The reflexes were
present in the biceps and triceps, but the wrist reflex could not be elicited
unless the muscle was struck directly. The knee jerks were unequal,
the left being1 greater than the right. There was a well-defined Babinski.
The patient had a pronounced scoliosis. There was decided analgesia
and thermo-anesthesia in a well-defined area about the elbows, and the
temperature sense over the rest of the body was also impaired. There
was no vesical nor rectal disturbance. The speaker said he was inclined
to regard the case as one of syringomyelia.

Dr. L. Pierce Clark said he thought the case was undoubtedly one of
syringomyelia. He thought the speaker was trying to involve the periph-
eral trauma as a cause of the syringomyelia, which he considered un-
likely to be the case, although not a few neurologists held that view.

Dr. Fraenkel said that some years ago he saw a patient with marked
chronic degenerative disease of the cord. The symptoms were reported
to have come on about three weeks after an accident. The speaker was
at that time already able to make a diagnosis of amyotrophic lateral
sclerosis. Subsequently, the case came to court, the patient claiming that
his disease was the result of the injury he had sustained. Dr. Fraenkel
said that he did not coincide with that view, and testified to that effect,
but other physicians testified to the contrary, and the jury took their view
of the case.

Dr. Noyes said that last spring he showed a case of amyotrophic
lateral sclerosis in which the symptoms developed two months after the
patient had sustained an electric shock from a third rail, which severely
burned his hand. There was a possibility, however, that the symptoms
might have been the result of lead poisoning, though no symptoms of
lead poisoning were obtained, and the patient gave an indefinite history
of weakness of the muscles supplied by the posterior interosseous nerve
prior to the accident. There was a scar of an old stab wound inflicted
many years before directly over the nerve, and there had been no in-
crease of the paralysis before the electric shock. The symptoms had
grown progressively worse quite rapidly, the muscles of the legs and
neck now being affected, together with some symptoms of bulbar paralysis.
Dr. Noyes said he was still inclined to believe that the electric shock was
the cause of the symptoms in this case.

Dr. Zabriskie, in closing, said that while he was inclined to look upon

524 NEW YORK NEUROLOGICAL SOCIETY

the case as one of syringomyelia, the relation of the symptoms to the
accident was very significant. He had found several cases on record
where a very definite connection was traced between an injury and the
onset of syringomyelia.

REMARKS ON MYOCLONUS EPILEPSY, WITH REPORT OF A

CASE.

By Dr. L. Pierce. Clark.

The case reported was of the family type, and was briefly as follows :
The patient was a woman, fifty-two years old, single, who was admitted
to the Craig Colony for Epileptics on Sept. 30, 1904. Her paternal grand-
mother had always suffered from headaches. A paternal uncle had three
children, one boy and two girls, all of whom suffered from myoclonus-
epilepsy similar to that of this patient. The disease was known in the
family as St. Vitus' dance and fits. Whether the epilepsy or myoclonus
developed first in the cousins was not certain. The eldest of the myo-
clonus-epileptic cousins (female) married and had one child, who lived
to an adult age and showed no signs of the disease or other nervous
affection. The mother died of an unknown disease at fifty years of age.
The two male myoclonus-epileptic cousins died of unknown diseases at
the ages of twenty-five and thirty, respectively. A maternal granduncle
was insane and had several children who were insane; one grandson
(second cousin to the patient) died of paresis. Several maternal rela-
tives had tuberculosis. The father and mother of our patient were first
cousins. Both suffered from chronic rheumatism. The father was still
living and was a fairly healthy man of seventy-five years.

The patient was a strong child. She had an ordinary attack of typhoid
fever at ten years of age. She began school at five years of age and
made the average progress of her grades until thirteen years of age, when
she had a typical grand mal epileptic fit at night, without obvious cause.
The myoclonus, which either immediately preceded or followed the fit,
began in the arms first. Although it was more or less constant after its
inception, its paroxysmal intensity at stated periods was certain. On the
bad days, the myoclonus often interfered with her piano practice. It
was interesting to note that the patient saw her myoclonic cousins a few
months prior to the onset of her own disease, and she was much affected
by the sight. The fits were rather severe in her fourteenth year, and on
one occasion she had seven severe fits in one night. From fifteen to
forty-two years of age the attacks were less frequent, averaging' one a
month. She was now having eight attacks a year ; four grand mal and
four petit mal, equally divided between day and night attacks. An aura
of a cramp-like sensation in the right wrist was invariably present
formerly, but it was now absent. For several years after the onset of her
association disease she had increasing vertigo and myoclonic movements
for two or three weeks before the genuine fits occurred, after which she
was perfectly free from myoclonus for two or three days. The myoclonus-
never interfered with nor did it occur during sleep. Bromide and chloral,
particularly the latter, improved her condition considerably during the
thirteen years of their use, from the onset of the disease. She was now
a Christian Scientist, and had taken no medicine for several years. Coffee
had some quieting effect on the myoclonic movements. The patient had
nocturnal enuresis until she was thirty-one years of age ; this stopped with-

NEW YORK NEUROLOGICAL SOCIETY 5^5

out treatment. Involuntary urination never occurred during the myo-
clonic or epileptic attacks.

Dr. Clark said that the epileptic attacks in this case were so classic in
detail that they did not deserve mention. They had produced little or
no mental enfeeblement. Some myoclonus was now present every day.
The movements ranged in degree from slight fibrillary twitchings in in-
dividual muscles to that of universal involvement of all voluntary muscles.
Extremes of heat and cold, mental stress and emotion excited the myo-
clonus. At first, the myoclonus often interfered with swallowing1, and
occasionally now, at the height of paroxysmal myoclonic days, foods and
fluids were forcibly ejected at meals. She had broken her nose and re-
ceived many disfigurements about the face due to her myoclonic attacks.
At the present time the myoclonic movements might be observed to
rapidly succeed each other in a series of brisk, shock-like muscular con-
tractions typical of myoclonus. All the muscles of the trunk and ex-
tremities were involved in this play of spasm movement, bewildering to
describe. The large proximal muscles of the extremities were most
involved, together with those of the trunk proper. The movements of
the muscles of the two sides were a little asynchronous, the body and
head being hurled to the right frequently at the end of the complex move-
ment. In the extreme paroxysm all the muscles of the face were markedly
affected, and the diaphragm and respiratory muscles were commonly
involved. At times, when standing, she was thrown from her feet by the
shock -like contractions ; if she remained in bed she was almost hurled
from it by the violent contractions. There was never loss of conscious-
ness during any myoclonic movements. Speech was commonly interrupted
thereby by the violence of respiratory involvement, but continuity of
thought was never broken. The great flexors of the trunk were most
involved, and the contractions of the rectus abdominis were often painful.
For several days following these severe periods of myoclonus a feeling of
general exhaustion and muscle soreness existed. The nervous system
showed no other abnormality, nor was there any hysterical stigma.

Dr. Charles L. Dana said that Dr. Clark was so familiar with the sub-
ject of myoclonic epilepsy, and had presented it so fully, that he hesitated
to make any criticism or offer a different point of view. The speaker
said that from an observation of several cases that had come under his
care he was inclined to regard the myoclonic manifestations as a serious4
progressive motor disorder, finally involving the whole body, so that for
protracted periods many of the muscles were in a state of almost con-
tinual tonic contraction. In addition to the twitching of the muscles, there
were, at the same time, certain irregular movements which were entirely
similar to those observed in chorea. That fact had led him to look upon
the disease as a degenerative myoclonus, and one that was closely related
to the degenerative tics. When associated with epilepsy, the latter might
be regarded as a terminal condition or an accidental occurrence, or the
combination perhaps represented those forms which had a particularly
serious family character. At all events, he was inclined to recognize a
form of degenerative myoclonus which was distinct from the epileptic type.

Twenty years ago, Dr. Dana said, he reported a case of this character
under the title of choreic tics. The term myoclonus epilepsy was then
unknown. The onset of the disease in that case was very similar to that
observed in Sydenham's chorea, the movements first being limited to one
arm and gradually involving the entire body. There were also intercurrent

526 PHILADELPHIA NEUROLOGICAL SOCIETY

epileptic attacks, which were regarded as accidental. The patient died,
and an autopsy showed changes in the cortical cells.

Dr. C. E. Atwood said he had seen two cases of myoclonus associated
with epilepsy, and one of myoclonus without epilepsy. The latter patient
was an inmate of a hospital in London, and was regarded by the physi-
cians there as a case of multiple tic. The movements which involved the
muscles of the trunk and extremities were violent and lightning-like in
character, and the case corresponded very closely to the disease that had
since then been so well described by Dr. Clark under the name of myo-
clonus.

Dr. Clark, in closing, said that in the near future he expected to show
some biographic pictures which were taken of a well-marked case of myo-
clonus epilepsy, and these, he felt assured, would clearly differentiate this
type of case from the condition known as multiple tic. The character
of the movements in the two conditions was entirely distinct.

PHILADELPHIA NEUROLOGICAL SOCIETY.

December 21, 1906.
The President, Dr. D. J. McCarthy, in the Chair.

A CASE OF INCOMPLETE BROWN SEQUARD PARALYSIS.

By Dr. G. E. Price.

J. G., Italian laborer, aged 46, from the Philadelphia Hospital.

Eight years ago he had been stabbed in the neck by a fellow-country-
man, the wound being followed by immediate loss of power in the left
arm and leg, the right side of the body being unaffected. Movement
of the shoulder was regained within a few days, and some motion of the
fingers in a month. He was in bed 17 days and could walk in about
one year from the time of the injury. Upon examination a linear scar
three-quarters of an inch in length is seen, almost horizontal, and di-
rectly across the median line of the neck between the spinus processes of
the sixth and seventh cervical vertebrae. The pupils are unequal, the
right being the larger ; both react to light and accommodation ; there are
no external ocular palsies. The patient has no motor or sensory involve-
ment of the face, and no difficulty in swallowing; the tongue is protruded
in the median line. His gait shows a stiffness and dragging of the left
leg, the station is normal.

Of the upper extremities, the movements and reflexes of the right
arm are normal, the left arm presents no weakness of the muscles about
the shoulder, of the biceps or triceps, but the grip is distinctly weak.
All reflexes of the left arm are plus ; there is no inco-ordination of either
extremity.

The trunk presents no signs of muscular weakness, the cremasteric
and abdominal reflexes are preserved on both sides, the sphincters are un-
affected.

In the lower extremities there is no muscular weakness or rigidity of
the right leg, the left leg is distinctly weak and stiff. The knee-jerks and
Achilles jerks are increased on both sides, especially on the left, ankle
clonus is absent on the right side and present on the left; there is no
Babinski or Gordon reflex on either side and no inco-ordination.

Sensation : Tactile sense, pressure sense and muscle sense are pre-

PHILADELPHIA XEUROLOGICAL SOCIETY 527

served over the entire body. Pain and temperature senses are, preserved
upon the left side, but lost over the entire right lower extremity and over
the trunk as high as the costal margin anteriorly and two finger's breadths
below the angle of the scapula posteriorly. The loss is distinctly defined
at the median line of the body and includes the right half of the penis,
and the right testicle. There is no astereognosis.

The patient also presents symptoms of a sharply defined localized
sweating on the left half of the trunk, extending to a little below the hip
and including the left shoulder, arm, forearm, and hand, though much less
marked in the forearm and hand than in the other parts affected.

There is no evidence of muscular wasting in any part of the body.

A skiagraph taken by Dr. Kassabian revealed no abnormality of the
bony structure.

Dr. F. X. Dercum asked whether the pupil on the side of the lesion
was smaller. Dr. Price replied that it was.

Dr. Dercum said that it was rather an interesting fact that the pa-
tient's myosis was present on the side of the lesion or wound. Of course,
the symptom itself could be explained only in a speculative way. Perhaps
as has been attempted in the myosis of tabes, lesion of the posterior col-
umns interferes with impressions coming from the general body surface
which have a dilator action on the pupils. The absence of such dila-
tor stimuli would, of course, result in a small or myotic pupil on the same
side as the lesion in the cord.

Dr. Alfred Gordon thought the case very interesting. It reminded us
clearly of Brown-Sequard's experiment when he produced line sections
of the spinal cord and produced symptoms almost identical with those
of the present case, excepting the areas of anesthesias and hyperesthesias
which are usually present above the level of sensory disturbances. In hear-
ing Dr. Price recite the case, some thoughts of medico-legal nature sug-
gested themselves to Dr. Gordon. For instance, in cases of a stab wound
in the back, the patient may present a paralysis of one side and sensory
disturbances on the other. Acute disturbances of the function of the
cord are usually looked upon very seriously. The great improvement the
patient presents with an evident lesion of the cord, points to the great
practical importance of the fact that patients of this character, in spite
of distinct cord lesion might improve considerably.

A CASE PRESENTING SYMPTOMS OF CEREBRAL TUMOR,

WITH RECOVERY.
By Dr. A. A. Eshner.
The patient was a man, 30 years old, suffering from vomiting, an-
orexia, bad taste, headache and vertigo. Gait and station were ataxic,
and the man was unable to attend to his business. Pulse and tempera-
ture were normal. The man was a large eater, but he had not indulged
excessively in alcohol or tobacco, and he denied venereal infection. Under
observation, weakness of the extremities on the left side of the body de-
veloped, with increase in the reflexes. There was no change in the eye-
grounds. Under treatment with increasing doses of iodid and mercu-
rials, improvement gradually took place, leaving only a slight degree of
weakness on the left side, not sufficient, however, to interfere with the
pursuit of the man's usual avocation. The early symptoms in this case,
namely: vomiting, headache, vertigo and ataxia, suggested the possibility
of a new-growth involving the cerebellum. The subsequent development

528 PHILADELPHIA XEUROLOGICAL SOCIETY

of the left hemiparesis, with increase in the reflexes on the affected side,
bespoke invasion of the motor tract on the right side. The absence of con-
vulsions, of perturbation of consciousness, of sensory disturbance, of as-
tereognosis, of mental derangement, pointed to freedom of the cerebral
cortex, while the absence of changes in the eyegrounds and of palsy of
ocular muscles and the escape of other cranial nerves indicated that the
lesion must have been one of small dimensions. The afebrile course of
the illness seemed to exclude an inflammatory process. The results of
treatment raised the question of a possible syphilitic infection, while
drowsiness pointed in the direction of meningitis or arterial disease.

A CASE OF HYSTERIA PRESENTING SYMPTOMS OF CERE-
BELLAR DISEASE.
By Dr. A. A. Eshner.

The patient was a tailor, 42 years old, who had difficulty in walking
after the removal of several teeth, in conjunction also with fright from
having remained alone for a short time in a house in which a close friend
had died. The man walked like a drunken person, witli .1 tendency to fall
to the right. The right chest felt as if grasped in a vise, and there was
pain on the right side of the head. There was tinnitus in the right ear,
with impairment of hearing. Sensibility was less acute on the entire
right side of the body than on the left. The visual apparatus was normal,
and there was no lesion of the fundus. There was no sign of inflammatory
disturbances in either ear. The muscular apparatus was normal. A lax-
ative containing aloin. cascara. and asafetida was prescribed and hypnotic
suggestion was practised, and recovery ensued in the course of three
weeks. The disorder of gait, in conjunction with the feeling of unilateral
weakness, suggested the existence of cerebellar disease, and the tinnitus
and impaired hearing an aural origin. The suspicion of hysteria was
strengthened by the absence of organic disease and it was established by
the results of treatment.

Dr. W. G. Spiller said that the absence of early changes in the eye-
grounds in the case with cerebellar symptoms should make one very cau-
tious in diagnosticating tumor of the cerebellum. Among the earliest signs
of cerebellar tumor is choked disc. Tumor in the motor region may exist
a long time without any change in the eyegrounds, but a tumor in the
basal ganglia, the pons, or the cerebellum is likely to cause early choked
discs. Dr. Spiller stated that he had had two cases within the past few
years which simulated tumor of the brain very closely. He was called
to see a young woman about three years ago who had intense ataxia, vio-
lent headache, vertigo and other symptoms of brain disease. The symptom-
complex, after careful study, seemed like hysteria, therefore she was
placed in a private room at the University Hospital with a trained nurse,
and under treatment by suggestion all the very grave symptoms of brain
tumor disappeared in a few weeks, and the woman became perfectly well.
The notes of this case had been given to Dr. YYeisenburg and had been
reported by him.

Last summer Dr. Spiller had a patient brought to him from a distance
who was said to have symptoms of brain tumor, viz., optic neuritis,
convulsions on the right side, weakness on the right side, and complete
blindness in the left eye, and sensory disturbances which aroused his sus-
picions of hysteria. She had the history of having been struck on the left
side of the head by a piece of iron which had fallen some distance. The

PHILADELPHIA NEUROLOGICAL SOCIETY 529

physician who brought her stated he had operated and found the bone of
the skull exceedingly thick, he had cut through the dura and the parts
seemed to him abnormal. It was possibly a case of hysteria added to or-
ganic disease. Dr. A. C. Wood operated and found the bone exceedingly
hard and three-fourths of an inch thick over the parietal region.

Dr. Shumway had examined the eyes previously and had found no
evidence of neuritis. Immediately after the operation the blindness of the
left eye and hemianesthesia disappeared, and the patient improved rapidly
and g'ot almost entirely well. The brain was found protruding very slightly
through the dura. Extreme care must be taken in diagnosticating such
cases. Dr. Spiller said he had been called to a case within the past few
days in which it was almost impossible to decide how much was hysteria
and how much was organic, the man having been in a trolley car accident.
He had symptoms which were largely hysterical, and yet probably some
of his symptoms were due. to an organic lesion.

A ease in which the symptoms of Paralysis Agitans developed in the
unparalysed side of a hemiplegic. — By Dr. Joseph Sailer. (See this
journal, page 425.)

Dr. Spiller said that the question of the effect of hemiplegia on tremor
which Dr. Sailer brought up was one of importance. It interested him
some years ago very greatly, and he studied at that time the literature on
the subject. Paralysis agitans is not uncommonly unilateral. A case of
this character is at present in the Philadelphia General Hospital. The ef-
fect of paralysis on tremor has been observed sufficiently often to show
that a relation exists. Dr. Spiller said that in a case of malaria of the
nervous system he had reported which had been under the care of
Dr. Dercum, the tremor was exactly like the intentional tremor of dis-
seminated sclerosis, and was only on one side. The malarial parasites
were found in the blood vessels of the brain and spinal cord, and it was
hard to understand how an irritation so general could produce a strictly
unilateral tremor. One of the pyramidal tracts was slightly degenerated.
Dr. Spiller explained the condition on the supposition that the slight de-
generation of the pyramidal tract prevented the impulses caused by irri-
tation from passing downward on the degenerated side to the degree that
they did on the normal side and therefore these abnormal movements oc-
curred on one side only. On looking up the literature he found that Dr.
Sinkler had reported a case of disseminated sclerosis in which hemiplegia
caused cessation of tremor on the paralyzed side. Mannaberg' had reported
a case in which there was hemiplegia and the patient had tremor during
a malaria chill only on the non-paralyzed side.

Dr. T. H. Weisenburg said that some years ago in a clinical study of
hemiplegia, he had examined 300 cases for skin eruptions. In those in which
there was a general skin eruption, it was remarked that this was limited to the
unparalyzed side. In one patient who had been paralyzed for many years,
the patient himself remarked that he would tan only on the healthy side,
and that the other would look paler than it should. Dr. Weisenburg had
also observed that in many cases of peripheral facial palsy hardly any
eruptions would occur on the paralyzed side in cases where acne was com-
mon. All of these observations seem to point to the fact that the patients
are not as well nourished on the paralyzed side as they are in the other
side, and in spite of this when any general skin disease appears, the par-

530 PHILADELPHIA XEUR0L0GICAL SOCIETY

alyzed portions of the body seem to escape. This is rather a curious con-
clusion and opposite to what we should expect.

Dr. Sailer agreed that the point brought forward by Dr. Spiller was
similar to the one that he had suggested for his case. He believes that
paralysis agitans is a diffuse disease affecting all the superior neurones,
not necessarily equally, and perhaps at first those on one side more than
those on the other. In nearly all recorded cases in which disturbing fac-
tors have been absent, ultimately the disease has become general, and
there appears to be no record of a case without at least bilateral rigidity.
In the case reported he believed that he had not sufficiently emphasized
the fact that the residual symptoms of the hemiplegia on the left side
were exceedingly slight. Practically the only symptom was slight difficulty
in carrying out complicated movements with the right arm.

A CASE OF APPERCEPTION.
■ By Dr. W. W. Hawke.

Apperception may be defined as sense-perception (of objective things)
as influenced by subjective factors, especially by attention, association
and memory. One reason for the title of the paper is that the case here
presented shows phenomena regarding which there is room for question
as to whether the hallucinations are of the real or pseudo type.

The patient is a single woman twenty-four years of age, born in Bos-
ton of Irish parents. Family history shows no evidence of mental or
nervous disease in near or distant relatives. Patient started school at five
years and completed grammar school at sixteen, then left school to go to
work. Was employed in a mill for some years, but gave up her position
last September on account of slackness of work, because she was less in
need of employment than some of her companions. A week later she
left home without notice to her relatives and came to Philadelphia, at-
tracted to this city by newspaper accounts of the progress along educational
lines, the ability of the surgeons, and especially the work of the Society
to Protect Children from Cruelty. On reaching the city she secured do-
mestic employment, but could not get along with her mistress, and after
two weeks gave up the position. She felt helpless and confused, and went
to the rooms of the Society to Protect Children from Cruelty to ask
advice. She was referred to the Organized Charities of Philadelphia, and
was sent to the Philadelphia Hospital. After her admission she worried
because she was unable to pay for prolonged treatment, and worried also
about the condition of the patients, feeling it to be her duty to help
them as much as possible, and depressed because there was so little that
she could do.

Patient stated that she had always been extremely fond of reading,
and that she seemed to see the historical and fictitious characters about
whom she had read, and to hear their voices. She dreamed as much dur-
ing the day as at night, and heard voices of all those amongst whom she
had been, especially if they were complaining in any way. It was a sort
of repetition, and she heard them most when she was farthest away from
them. She could also hear historical persons telling her what they had
suffered. Stated that she had heard these voices for some years, usually
at night, but sometimes in the day. When asked whether it was real
or imaginary she replied. "It is real to me ; I see it with my variations,
I suppose someone el-e see- it with other variations." The vividness of
her mental pictures, as she described them, seemed at first to indicate that

PHILADELPHIA NEUROLOGICAL SOCIETY 531

they were real hallucinations, but further questioning showed that she did
not attribute objective reality to them. At one interview she stated that
her power of imagination was not so strong as formerly, and she was
afraid she was losing it. At another time she said that she could call up
images at any time, and could make them seem as real as life, but did not
allow herself to do it very often. "It's a pleasant pastime, and I used to
do it a good deal ; but I was afraid I might get to seeing things too much,
so I stopped doing it except once in a while, and then I was careful to be
sure what was real and what was imaginary. It's terrible to think they
are real, as some of the patients do."

The patient was given Titchener's questionary upon types of mental
imagery, and her answers show a wealth of images in all departments of
sense, especially visual and auditory. When asked if she believed others
could call up images as vivid as hers she replied, "Oh, yes, I think a
great many people can, but not everybody; I think there are some who
cannot." She believed that she could write magazine stories if only she
had a quiet place where she could think, and once gave a brief outline of
her favorite production. Her most noticeable sensory delusion is the
tendency to see beauty in everything. She has many intellectual delusions,
mostly of the expansive type.

Dr. Gordon thought the case exceedingly interesting from several
standpoints, particularly from the standpoints of psychology and psychi-
atry. He had an opportunity to see the patient on many occasions. The
first day she arrived in Philadelphia she went to the Society for the
Protection of Children from Cruelty, which society referred the case to
him for examination. He talked with her for about three-quarters of an
hour. He thought at first she was an hysterical patient. She told him
that she had read a number of books and that she acted in accordance
with what she read. She came to Philadelphia because she read about the
great work of the society. There was a great element of auto-suggestion,
every act of others she thought was referable to herself and if she read
anything she presented in her mind that she participated in the acts de-
scribed. He found a number of hysterical stigmata at that time. He
arrived at the conclusion that the case was probably one of hysteria with
hallucinations in which auto-suggestion played the most prominent part.
He saw her a second time and made a second examination and elicited
in addition to the above symptoms also delusions of persecution, vague in
character. He saw her several times in the Detention Ward of the Phil-
adelphia Hospital. After a thorough study of the case he arrived at the
conclusion that it was very probably a case of the paranoid form of de-
mentia paranoides.

Dr. Dercum said that he saw the patient in a rather cursory way
on one of his visits to the Insane Department at the Philadel-
phia General Hospital, and that he was very much interested in
her case. He said that the members were indebted to Dr. Hawke for
bringing her down and making so elaborate a report of her symptoms. The
case was also interesting from the standpoint of classification He thought
the case unquestionably one of dementia paranoides. It was a case with
expansive and mystic ideas and it was a case, too, which closely approxi-
mated true paranoia ; paranoia simplex, or the paranoia to which Kraepelin
limits the term paranoia. In paranoia simplex there are no hallucinations
whatever. The entire superstructure of the delusive beliefs is built upon
other matter than hallucinations, either from actual observation or from

532 PHILADELPHIA NEUROLOGICAL SOCIETY

vivid mental pictures which could hardly be called hallucinations. The
case was further interesting in proving that the sharp differentiations made
in the whole degenerative group cannot stand ; that there are transitional
cases. This is a transitional case, it is not an ordinary case of paranoid
dementia or of paranoia hallucinatoria. On the other hand, it is not a
paranoia simplex, but occupies a position between paranoia simplex and
paranoia hallucinatoria.

Dr. Hawke, in closing, said he thought the members had determined
by their line of questioning what he meant by pseudo-hallucinations.

A CASE OF POLIOENCEPHALITIS IN A BOY OF EIGHT YEARS

ENDING IN RECOVERY.
By Dr. David Riesman.

Dr. Riesman showed a boy of eight years, who had recovered from
what had seemed to be an attack of polioencephalitis. Except for migraine
in the father and brother, the family history was excellent. There had
been no serious prior illness and only a few trivial falls that were without
consequences.

On the morning of August 13, 1906, he awoke with double vision. On
the 14th he was dizzy and staggered ; felt a little nauseated, but did not
vomit ; perspired profusely ; had a bad taste in his mouth ; and spat a good
deal of saliva. On the 15th, although able to play, he would often run to
his mother and say he was dizzy and afraid he would fall ; and twice he
did fall. About this time left-sided ptosis appeared, and the gait became
staggering. A neurologist who saw him made a diagnosis of brain tumor.

On August 24, when he first came under the care of Dr. Riesman, his
condition was pitiable. He was almost helpless, and usually had to be
carried. The face had a sleepy, expressionless look. The eyebrows and
forehead were contracted : the left eye nearly closed by ptosis. The eye-
balls themselves were fixed, owing to a complete external ophthalmoplegia.
The head was bent forward and tilted to the right. There was risus
sardonicus, especially when he tried to laugh. One could not then tell
whether he was crying or laughing. He could not whistle, and speech
was indistinct. He would begin a sentence fairly well, but as he pro-
gressed the words would become more and more slurred, until they ceased
to be intelligible. There was some difficulty in swallowing, and liquids
regurgitated through the nose. He staggered on walking, and was in-
clined to fall toward the right. After attempting to walk a few steps, which
he did out of doors, he would soon tire and ask to be carried. About the
end of August a paresis of the left arm set in — dynamometer left 10. right
35. There were no sensory disturbances, except astereognosis of the left
hand. The knee-jerks were somewhat variable, as a rule not exaggerated;
ankle clonus and Babinski reflexes were present, more marked on the
left side. There was slight headache, and occasionally some tenderness
on percussion just to the left of the occiput. No trouble with the sphinc-
ters ; heart-sounds normal ; pulse irregular — 84 to 102 ; respirations 24 to
29; no fever at any time; lungs normal; abdomen soft; bowels obstinate-
ly constipated ; appetite poor ; vomiting occurred a few times, seemingly in-
duced by food or medicine; was not projectile, and was preceded by nau-
sea. Occasionally there were attacks of diarrhea with cramps, which
were probably caused by the medicine he was taking — hydriodic acid. An
eyeground examination made about the middle of August had shown no
changes in the fundus ; on a second examination, a slight congestion-

PHILADELPHIA NEUROLOGICAL SOCIETY 533

edema was found. The diplopia, which had lasted only one day — August
13 — returned on September 8.

Early in September improvement began, first shown by a tendency to
hold the head erect. The risus sardonicus became less pronounced, and
finally disappeared ; movement returned in the eyeballs, first in the up-
ward, then in the inward direction. The external recti remained paretic.

At the time the boy was shown, he seemed to be entirely well, except
for diplopia, which was due to persistent weakness of the abducens.*

The diagnosis of the case was attended with difficulty. A number
of neurologists had seen him and had diagnosticated tumor. Dr. Ries-
man's first impression was that the case was one of myasthenia gravis,
but more careful reflection led him to consider it polioencephalitis superior
(Wernicke). The involvement of the left arm indicated that the process
had also extended to the cord. The rapid and almost complete recovery
seemed to be ag"ainst the existence of a serious organic lesion and made
the propriety of the word encephalitis somewhat doubtful.

As to the pathogenesis, nothing was known ; it was easy to assume,
but difficult to prove the existence of some toxic agent.

Dr. Gordon said he did not know how soon after his examination
of this case Dr. Riesman made the examination. He was requested to
make an examination and gave an opinion on the case last summer. When
he examined the patient he had Dr. Perkins' negative report concerning
the eyes. When Dr. Gordon examined the child he found that the patient
walked with zigzag movements, with a tendency to walk always towards
the right ; he had distinct nystagmus, he had paresis of the external recti ;
when he examined him for station he presented a distinct Romberg sign,
he had also ataxia of the upper extremities. He found distinct Babinski
on the left with exaggerated knee-jerk, the knee-jerk on the right side
was distinctly diminished. At that period of the case he did not have
any marked difficulty in swallowing, but the relations told him that the
child would have at times some difficulty. However, he ate his food.
They gave Dr. Gordon a history of a fall with headache, vomiting, which
he understood was not connected with the food. Having that picture be-
fore him, he concluded after excluding everything else that it was proba-
bly a cerebellar condition. He did not say tumor. Since then Dr. Gordon
had not seen the case. At present the patient presents still some difficulty
in walking, he has still a tendency to walk towards the right; the knee-
jerk on the left side is different from the right; he has distinct Babinski
on the left and edema of the disc with diplopia. The case presents un-
doubtedly some obscurity, but to say that it was a case of myasthenia gravis
Dr. Gordon could not agree; he is more inclined to believe that the condi-
tion is organic.

Dr. C. K. Mills said that when he saw the case first it was to him
as it has been to others, difficult of diagnosis. He thought, however, it
was not clearly, in spite of the symptoms which pointed in that direction,
a case of cerebellar tumor. Dr. Riesman and Dr. Mills at the time dis-
cussed the question of myasthenia gravis or bulbo-spinal paralysis, to which
diagnosis Dr. Riesman was inclined and Dr. Mills thought with good reason ;
it seemed to him, at least, that it was the probable diagnosis. The case
might be one of somewhat widely distributed polioencephalitis. If the pa-
tient's symptoms were due to a polioencephalitis he would probably have

*This weakness is gradually disappearing.

534 PHILADELPHIA NEUROLOGICAL SOCIETY

fared worse than in the outcome as now seen. After all we do not know
exactly what myasthenia gravis is etiologically, and it is possible that a
toxemia of some sort had to do with the origin of this case. It is well
known that there are cases of myasthenia gravis lasting a comparatively
short time, cases fatal after recurrences of attacks, cases of recovery and
others of partial recover}'.

Dr. Potts thought the symptoms described in this patient resembled
very much the symptoms that were present in a patient he had in the
Philadelphia Hospital a couple of years ago, and in which he made a
diagnosis of polioencephalitis. Dr. Dercum agreed with this diagnosis.
Typhoid fever was followed by ocular palsies, intense bulbar symptoms, in
co-ordination of the extremities, weakness of the legs, increased knee-
jerks, ankle clonus and the Babinski phenomenon. This patient
afterwards died, but an autopsy was not obtained. The existence
of permanent symptoms in Dr. Riesman's patient was certainly against
myasthenia gravis as was also the existence of the ankle clonus and the
Babinski reflex. He did not think that the symptoms coincided with the
usual idea of myasthenia gravis. He was inclined himself to think of en-
cephalitis in this case. It would have been of some interest and some value
if a careful electrical examination of the muscles had been made.

Dr. Perkins stated that at the time be saw the boy his vision was
absolutely perfect, but his general condition was so grave that it was im-
possible to estimate accurately the presence of a paralysis of the right
rectus. There were no abnormal fauces conditions present. The case
having come to him not by being referred by a physician, but because he
had treated some members of the family, he was- absolutely in the dark
as to previous medical history. The boy had a hypermetropia of moder-
ately high grade.

Dr. Dercum stated that we must bear in mind that the knee-jerks are
unequal, that the left is exaggerated as compared with the right and that
there is a distinct Babinski of the left side. These symptoms are not in
keeping with myasthenia gravis. It is not improbable that some toxin
acting upon the nuclei, and giving rise to polioencephalitis, also acted upon
other nervous centers and in turn gave rise to the other general and local
symptoms found in this case.

Dr. Spiller thought that because of the constancy of the symptoms in
this case without periods of amelioration or exacerbation and without in-
crease in intensity of symptoms after fatigue, the condition was unlike
myasthenia gravis and that probably the case was one of basal encephalitis.
He reported a case with Dr. Buckman, of Wilbesbarre, of myasthenia
gravis confined to the ocular muscles, which showed exhaustion paralysis
when an object was fixed. Dr. Buchman had written that complete re-
covery had occurred. Dr. Spiller did not believe that the Babinski reflex
would exclude myasthenia gravis. Babinski had not said that his reflex
was always the result of an organic change, but had spoken of perturba-
tion of the pyramidal tract. Dr. Spiller believed that a functional dis-
turbance of this tract sufficient to cause marked paralysis as in myasthe-
nia gravis might produce the Babinski reflex.

Dr. Eshner said that at the time he saw the boy he thought the symp-
toms were unmistakably those of organic disease and he thought probably
involved the cerebellum. He believed that there was a growth gummatous
or gliomatous in character. The improvement that the boy showed was
simply amazing. It would be interesting if Dr. Riesman would state the

PHILADELPHIA NEUROLOGICAL S0CIE1 V 535

1

treatment the boy had been given, how much iodide and mercury, if these
were used.

Dr. Gordon said as far as the result of treatment was concerned, he
could cite a case he had had for four or five years. A case of cerebellar
tumor, the child is still living, in which large doses of the iodides had
been given, up to 115 grains three times a day. The ataxia, headache, and
the vomiting disappeared; the improvement under Dr. Riesman's treat-
ment is not surprising to him if there is an organic condition.

Dr. S. F. Gilpin stated that in listening to the history of the case and
the history of the recovery, he would like to suggest the diagnosis of mul-
tiple neuritis, even though the knee-jerks were plus and the Babinski re-
flex present.

Dr. Riesman, in closing, said that seeing how difficult it was at this
time to make a diagnosis, it was not surprising that there should have
been a great diversity of opinion at the outset. The case had come to
him labeled with a variety of diagnoses that had been made by different
members of the Neurological Society. The majority were on the side of
brain tumor, the hopelessness of which condition had been explained to
the parents, who in consequence were in the greatest mental distress.
Dr. Riesman did not think it was brain tumor when he saw the case, be-
cause of the absence of headache, of vomiting, and of choked disc, one, or
all of which could, with reason, have been expected to be present in a
case showing such profound focal disturbance of the nervous system. His
first impression of the case was that it was one of myasthenia gravis be-
cause the symptoms had come on in gradual sequence, and some of them
had seemed to be aggravated as, for instance, the difficulty in walking and
speaking, by effort. The first symptom had been ptosis, then had come
drooping of the head, then ophthalmoplegia and paresis of the face, then
paresis of the arm. In that diagnosis he had the approving counsel of
Dr. Mills, who could not convince himself of the existence of brain tu-
mor, and was inclined to attribute the symptoms to some toxic agent. At
the height of the boy's illness, when his life seemed in peril, no one could
have predicted the outcome of the paralysis in case of survival. The ex-
ternal ophthalmoplegia had been complete. At the present time the ex-
ternal rectus was still paralyzed ; but Dr. Riesman questioned whether
that would be permanent. Dr. de Schweinitz was of the opinion that the
right external rectus was probably congenitally weak, but that there was
a definite paralysis of the one on the left side. The vomiting had not
been projectile, but had always been due to some discoverable cause. The
speech had been decidedly a fatigue speech, as had been observed by the
mother and the nurse. With regard to the Babinski reflex. Dr. Riesman
did not think its presence could be used as a point against myasthenia
gravis ; the strongest argument against such a diagnosis was, aside from
the incomplete character of the fatigue phenomena, the persistence of
the ocular palsy. An affection of such a pronounced character as myas-
thenia could easily produce disturbances of the reflexes resembling those
of organic disease. Although myasthenia was considered as not dependent
upon an anatomic lesion, he could not conceive of a disease going1 from
bad to worse and frequently ending in death, as having no organic basis.
Neither the changes in the muscles that had been found, nor those in the
thymus gland, could in themselves explain the condition. It seemed to
him to be a toxic process, which produced some structural change of such
a fine character that up to the present time it had not been possible to dis-

536 PHILADELPHIA NEUROLOGICAL SOCIETY

cover it. Returning to the subject of diagnosis, Dr. Riesman said that he
had come to the conclusion that the case was one of polioencephalitis for
the reasons already indicated. The treatment had been simple ; the boy
had been put at rest in the charge of a trained nurse, and had received
cascara for the bowels and increasing doses of syrup of hydriodic acid.
He had gained weight and seemed as well and bright as he has ever been,
except for persisting double vision due to the abducens palsy.

Note. — There has been a decided improvement in the condition of the
eyes since the foregoing remarks were made.

A CASE OF TABES DORSALIS WITH INVOLVEMENT OF MANY

CRANIAL NERVES.
By Dr. T. H. Weisenburg.

This patient was seen with Dr. Wm. Zentmayer in the Wills Eye Hos-
pital. The patient was 51 years of age, with no medical history of any
importance and no specific history. His trouble begun two years before he
came under observation with a diplopia. Soon after this he had drooping
of the left upper lid. These symptoms subsided in the course of two
months and gradually disappeared. About the same time he began to
have a twitching-like sensation in his right face. This sensation termi-
nated with a pain in the right eye, and came on gradually. He was ap-
parently well otherwise until two months ago, when he was taken to a
hospital for involvement of the bladder and rectum. About the same
time he developed a drooping in the right upper eyelid. He has had in-
creasing girdle sense and numbness in both legs, and about the same time
he began to stagger, especially in the dark or with his eyes closed.

Examination shows complete paralysis of both oculomotor' nerves and
also paralysis of the right fourth nerve. The ptosis on the left side is not
complete. The motor fifth nerve is normal, but the sensory portion of
the fifth nerve, however, is involved. Touch and pain sense as well as taste
are disturbed in the anterior two-thirds of the right side of the tongue.
Teeth can be pulled out on the right side of the jaw without any difficulty,
not so in the left. The seventh nerve is partially weak, the other cranial
nerves are normal. ± The pupils are partially dilated and react only to
strong light stimulus. Both optic nerves are red gray. The fields are
functionally normal for form, and slightly contracted for color. Power in
both upper and lower limbs is about normal. Ataxia, especially with eyes
closed, is very marked in all of the limbs. All of the tendon reflexes are
lost. Sensation has disappeared over the front of the chest and soles of
the feet. There is considerable hypotonia present in all of the joints.

The case is evidently one of tabes dorsalis, with disease of the right
second, third, fourth, fifth and seventh nerves and of the second and third
nerves on the left side. Ordinarily without the involvement of the cranial
nerves there would be no question about the diagnosis of tabes dorsalis.
With this rather unusual affection of the cranial nerves, the question arises
whether this case is really one of tabes or of syphilis. All of the cranial
nerves which are diseased in the present instance may be involved indi-
vidually in tabes, and there is no reason why a diagnosis of syphilis should
be made even though as many cranial nerves are diseased as happens in
this instance.

AMERICAS NEUROLOGICAL ASSOCIATION 537

AMERICAN NEUROLOGICAL ASSOCIATION.

Held in Washington, May 7, 8 and 9, 1907.
The President, Dr. Hugh T. Patrick, in the Chair.

Presidential address: Ambulatory Automatism. By Dr. Hugh T.
Patrick. (See this journal, page 353.)

The Study of Reflexes of the Lower Extremities in Sixty Cases of
Paresis, with a Special Reference to the Paradoxical Reflex. By Dr.
Alfred Gordon. (See this journal, page 430.)

Dr. F. X. Dercum said he believed the paradoxical reflex has a dis-
tinct practical value. One of the cases in which he was able to study it in
connection with pathological findings has, as Dr. Gordon has said, been
already placed on record, but it was so important a case that a brief state-
ment of the facts is still of value. The gentleman was a medical man
who had been a member of Dr. Dercum's own staff at the Jefferson
Hospital. He had had what proved to be an effusion or a hemorrhage
in the membranes upon the right side. He had no distinguishing features
so far as his reflexes were concerned to enable them to localize any
lesion (the effusion was very slight in degree) except the presence of this
paradoxical reflex, and it was distinct. Dr. Keen operated upon the right
side, and a considerable amount of bloody serous fluid was evacuated.
Immediately after the operation, as soon as the patient had recovered from
the ether, he was tested as to the paradoxical reflex and it had disappeared.
Some days subsequently the drainage became obstructed and the para-
doxical reflex again appeared. There was no other guide at this time as
to the localization of the lesion. Both knee jerks were somewhat exag-
gerated ; there was no ankle clonus upon either side. The patient was
operated upon again, at least the wound was opened and freely drained,
and again the paradoxical reflex disappeared. It seemed to Dr. Dercum
that the paradoxical reflex is one which obtains when the interference
with the motor pathway is very slight. It may be lost or masked when
the lesion is gross. In his judgment it is a very valuable sign.

Dr. Morton Prince said he was unable to add anything in regard to
the clinical value of the contraction spoken of by Dr. Gordon, but he
would like to say a few words upon our interpretation of this sign. It
would seem to bear some relation to, if it is not identical with, Westphal's
"paradoxic" contraction. If they are different it is unfortunate that Dr.
Gordon should have adopted the same name, '"paradoxic." Westphal
included extension (dorsally) of the ankle, as well as of the toes. Dr.
Gordon only describes the toe movement. This may possibly be due to
the mechanical interference with the foot from the position adopted in
testing. It has been forgotten that Erlenmeyer in 1880 maintained that
Westphal's contraction was due to excitation of the calf muscles caused
by stretching; Charcot and Richet (1885) held the same view and pointed
out that in hysterical subjects dorsal flexion of the foot under certain ex-
perimental conditions could be induced by massage of the calf muscles.
They concluded that when a muscle is stimulated its antagonist is simul-
taneously excited, the latter having thus a regulating function, and under
certain conditions its action may become predominant. This spasm of
the antagonist has been found in other muscles than the extensors of the
foot and toes ; e. g., in the flexors of the knee and in the arm muscles.

538 AMERICAN NEUROLOGICAL ASSOCIATION

In 1889 the speaker had become interested in this phenomenon and pub-
lished some observations (with cases) upon it (Boston City Hospital Re-
ports, 1889), but at that time had considered, perhaps erroneously with
Charcot and Richet, the "paradoxical contraction" and that resulting from
massage of the calf muscles as identical. He had given it the name
"antagonistic contraction." There were other ways, besides those men-
tioned, of producing the contraction. It is possible that two different
reflexes have been included under Westphal's ; viz. : that following dorsal
flexion of the foot and that from massage of the calf muscles. The
former, the speaker had shown, was only an exaggeration of a normal
phenomenon ; the latter may be identical with Dr. Gordon's reflex. And
yet it is significant that Dr. Gordon had not found this reflex in hysteria
and functional diseases, while Charcot, Dr. Prince and others had found
it in hysteria. Westphal had found his reflex in tabes with motor weakness,
atypical multiple sclerosis (?) and paralysis agitans, while Dr. Gordon
had not found his reflex unless the motor tract was involved. Dr. Prince
had found "Westphal's" contraction in multiple sclerosis and functional
troubles. The relation to one another of these different contractions, in-
cluding Oppenheim's and Babinski's, elicited by different methods, needed
further investigation.

Dr. P. C. Knapp said that in spite of Dr. Gordon's kindness in demon-
strating the technique of his paradoxical reflex to him, he had to con-
fess that he had often failed to obtain it, even in cases where the Oppen-
heim or the Babinski reflex was well marked. He cannot therefore speak
absolutely pertinently with reference to this question of the prevalence
of the paradoxical reflex in general paralysis, but he has seen a con-
siderable number of cases in which the relations between the exaggeration
of the knee jerk and the Babinski and Oppenheim reflexes were not con-
sistent. Of course we all agree that those reflexes are indicative of
change in the motor tract, just as the exaggeration of the reflex is often
indicative of such a change, especially if the exaggeration amount to a
true clonus. But the two do not seem to hold the same relation. In
general paralysis, for example. Dr. Knapp had seen a case in which
there was a complete absence of knee jerk. It was impossible to obtain
the knee jerk in any way, even by reinforcement, and yet there was on
one side a distinct Babinski reflex and Oppenheim reflex. In hemiplegia
he had sometimes noted upon the paralyzed side a diminution in the knee
jerk, often a knee jerk which could be obtained only by reinforcement,
although there was a fair knee jerk upon the unparalyzed side, and yet
in the paralyzed leg there were the Babinski and Oppenheim reflexes. It
is perhaps unfair to include in this, as an example of this discrepancy, the
existence of the Babinski and Oppenheim reflexes in cases of fracture of
the spine where the knee jerk is lost, because there is a possibility that the
reflex arc for the knee jerk is higher than that for the plantar reflex.
There may have been a lesion there, although in one case. Dr. Knapp re-
called that the fracture was much above the reflex center for the knee jerk.
There are certainly a considerable number of cases in which the Babinski
and Oppenheim reflexes are not in harmony with the knee jerk. Of
course, in paresis it is quite rare to get a sufficient exaggeration of the
tendor reflexes in general to amount to a true ankle or patellar clonus. It
is worth while to bear in mind certain other methods of eliciting the knee
jerk which often have a decided significance, especially in cases of
unilateral lesion where it is desirable to determine any difference in the

AMERICAN NEUROLOGICAL ASSOCIATION 539

reflexes on the two sides. The knee jerk obtained by striking above the
patella instead of below it, the so-called tibial reflex obtained by striking
upon the periosteum of the broad head of the tibia, the patellar twitch
obtained by drawing down the patella with the fingers as in testing for
patellar clonus and striking the fing'er a sharp blow, and the front- *ap
contraction, are forms of the knee jerk, and these methods should be
employed. Dr. Knapp had very often found them to be of use in showing
differences in the tendon reflexes where the ordinary test for the reflex
was not significant.

Dr. H. M. Thomas said he had only one or two remarks to make, deal-
ing particularly with the definition of the reflex. He feels strongly about
giving names to signs and not describing them. As he understands the
discussion by Dr. Prince of Dr. Gordon's paper, it was simply brought
about by the lack of definition. Dr. Gordon gave no definition at this
meeting. He has done so before. It seemed to Dr. Thomas that if we
are going to use the term paradoxical reflex for contraction of the tibialis
anticus, according to the method of getting the ankle clonus, it is ex-
tremely important to define what we mean. Dr. Knapp describes four or
five methods of getting the knee jerk. Dr. Gordon did not say anything
about the ankle reflex that Dr. Thomas heard ; he said ankle clonus. Dr.
Thomas does not know whether Dr. Gordon's cases had exaggerated ankle
reflex or not; he supposes they had, and that it was not clonus.

Dr. P. C. Knapp asked to be permitted one word in response to Dr.
Thomas's criticism. Giving the different grades of exaggeration there is
first the simple knee jerk, as obtained by striking the tendon below the
patella; in a slighter degree of exaggeration there is the knee jerk ob-
tained by striking above the patella; in a third degree of exaggeration the
patellar twitch obtained by pulling down the patella with the finger and
striking it a sharp blow with the percussion hammer ; the fourth degree
would be the front-tap described by Gowers ; the fifth would be the so-
called tibial reflex, the kick forward in striking the broad head of the
tibia, and the sixth would be the true ankle and patellar clonus.

Dr. F. X. Dercum wished to be allowed to say that he believed Dr.
Gordon's reflex is an entirely new thing in itself, a new discovery. It has
nothing to do with what was formerly known as the paradoxical reflex.

Dr. A. Gordon said in reference to Dr. Knapp's remark that in a
number of instances gentlemen who wished to exhibit the reflex and
have failed to do so called him to help them, and he obtained the reflex
with the greatest facility. It is consequently a question of the exactness
of the method. The patient is placed on a chair, and his feet (not the
legs) are placed on another chair. The patient is told to relax his muscles,
to make himself perfectly comfortable. The feet should be thrown
slightly out, not forcibly, and the operator should place himself outside
of the legs, place the soft part of the hand on the tibia in order to avoid
irritation of the extensors. The tips of the fingers are placed on the
middle of the gastrocnemius muscle. Then pressure should be made
upon the middle of the soft part of the calf of the leg. Sometimes the
examiner has to pass his fingers up and down (frequently he does not
have to do that) ; and at the moment the reflex is present the toes will
come up, particularly the big toe. The same can be obtained when the
patient is in bed.

In regard to the explanation of the phenomenon. Dr. Gordon said he
wished to answer Dr. Prince that at present he has on record 357 normal

540 AM ERIC AX NEUROLOGICAL ASSOCIATION

cases without the slightest ailment, especially ailment of the nervous
system, in which he has not been able to elicit the reflex of which he is
speaking. In these cases pressure of the calf muscles of the legs gives no
response at all or flexion, but in the cases where the motor tract is sup-
posed to be involved, he very frequently has found this phenomenon.

He said he wished to emphasize one more point in regard to the value
of this sign. As far as the relation of this reflex to Oppenheim's is
concerned it is not an Oppenheim reflex at all or a modification of it.
Dr. McCarthy, who at first expressed the opinion that it was perhaps a
modification of Oppenheim's reflex has since retracted that opinion. It
is a decided sign of involvement of the motor tract. He said he wanted
to refer to another anatomical and clinical case. A boy entered the Jef-
ferson Hospital with injury to his right temporal region; he had head-
ache and was stuporous. He was put to bed, and on the opposite leg in-
creased knee jerk was found, but no Babinski, no ankle clonus and no
Oppenheim. Dr. Mills and Dr. Dercum examined the case and they saw
that while all the other reflexes were absent, this reflex was present. Dr.
Da Costa operated upon the right side of the skull and found marked
pressure. After the operation the reflex disappeared, and Dr. Gordon
has examined the patient many times since and has never been able to
discover the paradoxical reflex.

(This case was reported before the Philadelphia Neurological Society
and is to be published in the American Journal of the Medical Sciences.)

THE SENSORY SYMPTOMS AND THE SENSORY AFFECTIONS

OF THE FACIAL NERVE.
By Dr. J. Ramsay Hunt.
The facial nerve like the trifacial is a mixed nerve ; consisting of a
motor root, a sensory root and ganglion.

In this communication the symptomatology of the sensory mechanism
of the seventh cranial nerve is discussed, with the practical importance
of this group of symptoms to clinical neurology and otology.

1. Preliminary remarks on the embryology and anatomy of the facial
nerve.

2. Pain and sensory disturbances in facial palsies (Fallopian neuritis).

3. Herpetic inflammations of the geniculate ganglion.

4. Primary otalgia (neuralgia of the facial nerve).

5. Secondary otalgia (tabetic ear pains).

6. Reflex facial twitchings and spasms.

Dr. P. C. Knapp said he had had the opportunity lately of seeing two
or three cases of facial paralysis very early in the onset of the disease.
In them he found just for a day or two a very slight diminution of
sensibility. It could only be obtained, as Dr. Hunt has suggested, by the
comparative method of testing the two sides, and sometimes only by the
comparison of exceedingly slight stimulus such as Frey's esthesiometer, and
in a day or two even that difference had disappeared. He thought that
if we could see the cases very early and test by the comparative method
we should find sensory disturbance in facial paralysis more often.

Dr. H. H. Hoppe said he would like to ask Dr. Hunt whether he
came across many cases of pain in the eyeball. Only a few days ago he
(Dr. Hoppe) saw a patient who had been paralyzed some years before.
The history was that the onset of the facial paralysis was accompanied by
acute pain in the eyeball.

AMERICAN NEUROLOGICAL ASSOCIATION 541

Dr. T. H. Weisenburg said that he always had thought that the
facial nerve had also a sensory function. For many years he had fol-
lowed a case of facial palsy in which he noticed that whenever the patient
developed an ordinary coryza there would not be as much secretion from
the paralyzed side as from the other. This he had observed in many
similar cases of peripheral facial palsy. He had also observed that when,
for instance, a general eruption like an acne would appear upon the body
the paralyzed side of the face would escape. This freedom from general
manifestations is also true of other so-called motor palsies. He had one
patient, a hemiplegic, who would tan only upon the paralyzed side. It
seemed to Dr. Weisenburg that the terms motor and sensory palsies were
purely relative. Thus in a case with pure motor lesion there will always
be some sensory symptoms. For instance, in hemiplegia there will
always be loss of vasomotor tone, and this in a broad sense is a sensory
manifestation. On the other hand, in cases of pure sensory lesion there
are always some motor symptoms. As for instance, in a case of pure
sensory involvement of the fifth nerve there will always be some difficulty
in moving the muscles of the face on the involved side. In tabes, in
which the lesions are almost wholly sensory, there will be some difficulty
in movement, the so-called incoordinate movement of tabes.

Dr. L. P. Clark said that in the last two or three years he has been
interested in the neurological surgery of the seventh nerve. He has
noticed in a number of very old cases of facial palsy, even when by very
careful sensory test no difference in the herpetic zoster zone is capable
of detection, yet subjectively the patients state that there is alteration in
the sensibility in that side. Heretofore he has supposed that the patients
having the palsy would naturally think they ought to have a sensory de-
fect also, but Dr. Hunt's explanation would be a complete justification of
their contention.

Dr. S. I. Schwab said he would like to ask Dr. Hunt whether he in-
cludes deafness as a part of the syndrome in his cases. Dr. Schwab had
an opportunity of observing a patient who had the herpes, deafness,
-vertigo and facial paralysis on one side, and the deafness was very distinct.

Dr. Hunt said in regard to Dr. Schwab's remarks, he of course in-
cludes deafness as a very important symptom in this syndrome. The
simplest expression is the herpetic pain and the zoster, in the other clinical
types there is facial palsy alone or in conjunction with auditory symptoms.
These may be vestibular or cochlear or both. They are so marked in some
cases the thought has occurred to Dr. Hunt that perhaps the sensory
ganglia of the acoustic nerve may have to be brought into the realm of
herpes zoster also, but he has explained these cases in his paper by an
extension of the inflammation from the geniculate ganglion through the
sheaths of the nerves.

In regard to the other questions, the tympanum canal, the auditory canal,
the concha and the auricle have a very complex and a very varied innerva-
tion. This is from the auricular branches of the trigeminus and of the
cervical and of the vagus nerves, and, lie thinks also, from auricular
branches of the facial. These all converge and innervate a very small
area. As the auricular area of the facial nerve is small and the additional
innervation so extensive, anesthesia probably would be of very short
duration or very slight. There are also certain difficulties in examining
the sensation of a canal like the auditory canal. Personally, he has never
found a distinct anesthesia in the concha or the canal. He has, however,

542 AMERICAN NEUROLOGICAL ASSOCIATION

only expected to find it in the early stage of severe facial palsy. Gowers,
however, says distinctly that he has observed it in a number of cases, and
Dr. Cushing says he has found in some cases a hypesthesia. There is no
question as to the subjective sensation in the ear in these cases of facial
palsy. If inquiry is made very definitely the patients say the ear seems full
or there is something in it, which may be interpreted as a paresthesia.

In regard to Dr. Hoppe's case with pain in the eye, of course in cases
of facial palsy or neuritis it is not infrequent to find pains in the tri-
geminal area, just as in affections of the trigeminal area it is very fre-
quent to find a pain in the sensory area of the facial nerve. The anatomi-
cal connections of the two sensory systems he thinks afford a sufficient
explanation.

ON THE SPLITTING OF AFFERENT FIBERS IN PERIPHERAL

NERVES.

(Observations of Dr. Elizabeth H. Dunn.)

Reported by Dr. H. H. Donaldson.

In a frog, the ventral roots of the spinal nerves supplying the leg were
cut within the spinal canal. This left the limb supplied only by the
afferent fibers derived from the dorsal nerve roots. A study of the
supply to the skin and muscles showed that the muscles were abundantly
innervated with afferent fibers. A study of the numerical relations showed
also that the afferent fibers must split in their course, in such a way that
each division of the split fiber passed to a different segment of the limb.
It could not be determined, however, whether any of the splitting fibers
were so distributed that one division went to the skin, and the other to a
muscle.

We do not know whether this splitting is more developed in the frog
or in man, but if it occurs in the frog, it probably occurs in man also, and
is an anatomical fact to be taken into consideration in cases of disturbed
sensation, and possibly also has a bearing on the phenomena of "referred"
pain.

Dr. Langdon said it seemed to him that this subject has a practical
bearing of clinical import. For instance, in the question of the origin of
referred pain. He wished to ask Dr. Donaldson if he will give us his
individual opinion as to whether this splitting of fibers, so-called, is really
a histological splitting of a neurone process, or perhaps more likely a re-
arrangement of the fibrillae ; in other words, does a new structure arise
at that point of splitting or is it simply a separation of pre-existing paths?

Dr. Bullard asked how much of what Dr. Donaldson had said applies
to man and how much to the frog and lower animals.

In answer to the first question, Dr. Donaldson said he should hesitate
to introduce a discussion of the fibrilla hypothesis at this stage.

As to the second point, there are no direct observations showing that
this observation does apply to man. There are some indirect observations
based on the size of the nerve trunks both in the limbs and in the nerve
roots, which seem to favor this, but he said he was careful to emphasize
the fact that his observations had been made upon the frog. There is,
however, at each turn a high degree of similarity in the arrangement of
the nerves even between the frog and the higher vertebrates, and he feels
very strongly that we shall be able to corroborate these relations in
mammals and in man.

(To be continued.)

periscope

Miscellany

Internal Hydrocephalus. W. G. Spiller and A. R. Allen (Journal A. M.
A., April 13).
The authors discuss the causes of internal hydrocephalus, reviewing
the literature, and remark that while the occlusion of the aqueduct of
Sylvius is not infrequently mentioned as an etiologic factor in the text-
books, it is rare to find references to actual cases of such occurence. They
take the opportunity, therefore, to report a case in which the condition
was induced by a probably congenital, almost total occlusion of the aque-
duct. The subject was an elderly woman who was supposed to have been,
born hydrocephalic, but in spite of this and of an epilepsy that had lasted
for years she had lived to the advanced age of 62, and retained her facul-
ties fairly well developed. The aqueduct, while almost entirely occluded,
was well lined throughout by a layer of ependymal cells which would not
be the case had its occlusion been due to neuroglia proliferation, as in
a previous case reported by Spiller. This, and the long continuance of the
condition through the patient's whole life, indicates the congenital nature
of the obstruction.

Cerebral Localization and the Study of Psychiatry, with Especial
Reference to the Mechanism of Hallucinations and Illu-
sions and the Classification of the Forms of Insanity. Chas.
K. Mills, M.D. (The British Medical Journal, Sept. 29, 1906).
Coarse cerebral lesions when diffuse are effective in the production of
hallucinations and illusions, but not if strictly focal, and it is evident there-
fore that the part played by the associative mechanism of the brain is
most important in the symptomatology of insanity. The author's classi-
fication of insanities is into the teratological or abiotrophic and the path-
ological or acquired. Under the first would be classed congenital idiocy
and imbecility, dementia pnecox, dementia choreica and other presenile
insanities, and senile dementia ; also those less in degree, such as the
melancholia-mania group, paranoia, hysteria, epilepsy and psychasthenia.
The pathological insanities would include those due to diffuse destructive
organic disease, as the forms of imbecility or mental defect due to post-
natal causes, general paresis, syphilitic insanity, and traumatic insanity;
also the insanities due to toxemias and exhaustion. C. D. Camp.

Paralysis of the Eye Muscles Following Spinal Anesthesia. Alvin.
Ach, M.D. (Muench. med. Woch., March 26, 1907).
The etiology of the paralysis of the eye muscles, following spinal
anesthesia is still obscure. Adam, who observed the first case of paresis
of the muscles, thought the manifestations were due to hemorrhage in the
nucleus of the sixth nerve. Loeser considered it to be due to the toxic
action of the drug on the nucleus or nerve involved. He points out the
affinity and selective action that some poisons have for certain nerves and
nerve centers, as lues, alcohol, diphtheria and leal. Landow agrees with
Loeser. Lang thoug'ht it to be perpipheral neuritis, whereas Baisch, in his
case of double-sided abducens paralysis, was under the impression that it
was an apoplectic insult. Ach is of the opinion that it is not due to the

544 PEKISCOPE

toxic action of the drug on the nucleus in the floor of the fourth ventricle,
and the anatomical relations make it nearly impossible for any solution to
enter the fourth ventricle from below. His view is that the poisons act
directly on the nerves. Paralysis of the eye muscles occured from four
to eleven days after the operation and lasted from six to forty-three days
in the case observed by him. He gives the following rules for spinal
anesthesia: (i) The most harmless drug should be used. (2) Tropa-
cocaine is better than stovain as the latter has a marked influence on the
motor nerves. Use small doses. (3) Do not use concentrated solution.
(4) Rest of patient after operation, with head and shoulders raised.

F. J. Conzelmann ( U. S. Army).

The Pathology of Paralysis Agitans. C. D. Camp (Journal A. M. A.,
April 13).
Camp, after giving a review of the literature of the pathologic findings
in the nervous system in paralysis agitans, reports the results of his ex-
amination of fourteen cases, in eight of which he was able to study the
peripheral nerves and muscles, and in two the ductless glands also. The
most constant lesion in the nerve centers was a fibrosis of the capillary
blood vessel of the spinal cord, which by rendering them more prominent,
caused them to appear more numerous. The posterior and lateral column
region^ seemed most involved. There was no degeneration of nerve fibers
of the cord in any case, and in only two cases was this observed in the
peripheral nerves with the Weigert hematoxylin stain ; in two others there
was a swelling of the myelin sheaths, accompanied in one case by swelling
of the axis cylinders. There was considerable pigmentation of the Betz
cells in the paracentral lobule, but in only two cases were distinctly degen-
erated cells observed. He discusses the various theories of the disease,
and thinks that many of the pathologic conditions found, and to which
the disorder has been attributed, are only coincident senile changes. The
muscular theories are also discussed, and in nine cases in which he ex-
amined the muscles, one of them during life, he found pathologic changes.
There was swelling of the muscle fibers, which were round in cross-section
instead of polygonal, multiplication of nuclei, etc., his findings agreeing
in the main with those of Schwenn, Schiefferdecker and Idelsohn, indica-
ting, he is inclined to believe, a specific change in the muscles in paralysis
agitans, though he admits that this is not yet definitely proven. Camp, in
considering the pathogenesis of the affection, finds most reason to believe
that it is due to a toxemia, and that this is connected with disordered
parathyroid function. In the two cases in which he was able to examine
the ductless glands he found the parathyroids in a decidedly pathologic
condition ; in both there was a peculiar fatty infiltration, especially in re-
lation to the blood vessels. Such a finding, in connection with the experi-
mental evidence as to the effect of parathyroidectomy and the therapeutic
results of Berkley in the treatment of paralysis agitans with parathyroid
•extract, furnish, he thinks, strong proof that the parathyroids play an im-
portant part in the pathogenesis of paralysis agitans. His conclusions are
given as follows: (1) Paralysis agitans is not a neurosis nor is it
senility. (2) The anatomic basis of the symptoms, muscular rigidity,
tremor and the symptoms dependant on them lies in the affection of the
•muscles. (3) The disease is probably a general toxemia, and there is
evidence that it is due to alteration in the secretion of the parathyroid
glands. The case histories of the patients of which Camp made the
pathologic studies are appended to his article.

PERISCOPE 545

The Delimitation of General Paralysis of the Insane. Julius Mickle
(The British Medical Journal, Sept. 29, 1906).
In the delimitation of general paralysis with relation to degeneracy
and mental degenerates, as regard symptoms the author divides the
relevant cases into four groups. Degenerates with deliria, but not marked
physical signs, simulating G. P. I. Recurrently alcoholized and deliriant
degenerates simulating both the mental and physical signs of G. P. I.
Original paranoiac degenerates simulating both the mental and physical
states of G. P. I. Degenerates becoming true G. P. I.'s. Cases of
general paralysis of the insane may be arrested in their course, the patient
remaining a chronic mental defective. This is a fixed mental state and
not a long remission, and is one of the terminations of progressive gen-
eral paralysis of the insane though the descriptive term, progressive, does
not apply. Camp (Philadelphia).

The Pre-Insane Stage of Acute Mental Disease. Campbell Meyers,
M.D. (The British Medical Journal, Oct. 20, 1906).
The stage referred to is "the weeks or months" which "often elapse
between the time when any competent observer can notice the deviation
from normal mental health and the time when the boundary line of in-
sanity is reached in the onward progress of the disease." The symptoms
are : Difficulty in sustaining intellectual effort and concentrating the
attention, loss of will power and energy, morbid sensitiveness, emotional-
ism, morbid introspection, mental depression, loss of affection for friends
or relatives, senseless fears, insomnia, and peculiarities in speech and hand-
writing. The author favors calling the condition "cerebrasthenia" and ad-
vocates its treatment in special wards in all general hospitals believing
that such care would prevent many cases of insanity.

C. D. Camp (Philadelphia).

Trephining as a Palliative Measure in Tumors of the Brain. Herbert
A. Bruce (Annal. of Surg., April, 1907).
Five cases are reported to show that the classical symptoms of brain
tumor — optic neuritis, headache and vomiting — can be relieved or entirely
removed by freely opening the skull and dura. As regards vision im-
provement depends upon the condition of the optic discs. Where second-
ary changes have set in improvement in proportion to the changes only
can be expected. Where loss of vision is due to simple swelling of the
discs the sight is not only saved, but improved.

Cowles (New York).

Experiences in Cerebral Surgery. Frank Hartley and James H. Kenyon
(Annal. of Surg., April. 1907).
After a review of the lack of adaptability of instruments generally em-
ployed in brain surgery, Drs. Hartley and Kenyon describe a new hand
motor from which power is derived for drilling bone and cutting osseous
flaps by means of drills, burrs and disc saws. The advantage claimed for
this device are safety, ease of manipulation, shortening the time of opera-
tion, lessening of operative shock, and making it possible to cut a clean
beveled edge, which last brings autoplasty in cerebral surgery to its high-
est utility. The most striking point, however, is the fact that they can
easily expose any cerebral area through an autoplastic flap having for its
base the temporal fossa, the thinnest portion of the skull. This also

546 PERISCOPE

insures an abundant blood supply to the flap through the temporal or
occipital arteries.

Cowles (New York).

Occupation in the Treatment of the Insane. T. J. Moher (Journal
A. M. A., May 18).

The author calls attention to the need of a more systematic use of em-
ployment in the treatment of insanity. The percentage of patients who
will not be benefited by occupation of some kind is very small, and if we
exclude the physically disabled and the very advanced demented cases it is
practically negligible. Acute maniacs in some stages and some exalted
paretics are temporarily unable to work, but the duration of this condition
can be very much shortened by careful and systematic effort. Some few
patients absolutely refuse to work, arid can not be made to by any effort.
Occupation should be simple at the outset and the patient's temperament
and predispositions should be studied in every case. It is not wise to restrict
a patient to any one class of work, and his previous occupation and social
condition should not be the only determining factor in the choice, though
some can not be induced to undertake anything to which they have not
been accustomed. Another thing not to be forgotten is to avoid asking
certain patients to perform some of the more menial work that has to be
done. The objections of friends can usually be successfully met by patient
explanations, and the patients themselves are generally easily influenced
by surroundings, and the facts that they are never asked to overwork and
that the occupation is made pleasant for them induces even the indolently
inclined to fall into line and accept willingly the tasks asked of them. If
the fact that occupation is an important remedy is impressed on intelli-
gent attendants and they are instructed how to apply this method of treat-
ment in a skilful and systematic way, there will be little difficulty, Moher
says, in keeping patients employed. His experience has taught him that
it is unwise to offer any pecuniary reward for patients' work. They
should not be allowed to get the idea that they are employed for the ad-
vantage of the institution rather than for their own good. In some cases
it may be advisable to encourage patients to learn a trade with a view to
their self-support after discharge. It is not always easy to say how oc-
cupation effects a cure. Besides the exercising and calling into action of
disused brain centers in some cases, it acts by improving the physical
condition. As a result of suitable outdoor employment we find that
patients are less restless, sleep better, improve in appetite and become
more normal in their secretions. While employed in the wards also, they
become less noisy, less quarrelsome or destructive and better behaved gen-
erally. Mental improvement is often directly coincident with improvement
in physical health. It is important that members of the medical staff
regularly visit and observe the patients at their work, with a view of study-
ing the effects in individual cases. But while admitting that the cure in
many cases can be rightly credited to occupation, Mohr believes that its
greatest good is conferred on the incurable cases by delaying dementia and
adding to the comfort, happiness and general well-being of the chronic
insane. Agricultural pursuits and caring for the grounds appear to be the
ideal labor for the great majority of male patients, while female patients
can be employed with advantage in the vegetable and fruit garden, weed-
ing, picking berries, etc., in addition to the work performed in the day
rooms, dormitories and dining rooms. They should also do fancy work,
do all the mending, and assist in the industrial department in making of
mats, mattresses, etc.

Book 1?e\>iew0

Ananlyse von 200 Selbstmordfallen nebst Beitrag zur Prognostik der
mit Selbstmordgedanken verknupften Psychosen. Von Dr.
Helenefriederike Stelzner. Mit einem Vorwort von Professor
Dr. Th. Ziehen. S. Karger, Berlin. 4 marks.

This is not only an interesting contribution to the subject of suicide,
but it contains some important features usually overlooked in studies of
this nature. Most older observations on the subject are taken up in the
larger part of their pages with considerations of age, of sex, of race, etc.,
whereas the present volume very wisely discusses the whole problem
from the standpoint of the underlying psychoses. Statistical inquiries are
silent on this point.

From a careful analysis of 200 cases of attempted or successful suicide,
the author has clearly brought out those mental disorders which are
most likely to lead to suicide, in Berlin, at least. It is quite conceivable
that other cities and other nationalities may present some variations.

The depressive psychoses — melancholia, in Ziehen's sense — show the
greatest incidence of suicide. Of the 200, 65 were suffering from one of
the forms of melancholia, climacteric, hallucinatory, hypochondriacal and
periodic, as outlined by the chief of Berlin's psychiatric clinic.

The degenerative mental states, hysteria and the psychopathic constitu-
tion, contributed the next largest number of suicides ; 32 in the group of
200. Other psychoses contribute but smaller numbers of suicides in the
present study.

Thus in the lists there were 11 cases suffering from acute paranoia
(Ziehen), including this same author's amentia; 24 cases were in chronic
paranoiacs, 4 in senile dements. Dementia paralytica contributed 6, while
dementia praecox is credited with 7. Suicide was attempted by 11 epilep-
tics, by 3 imbeciles and alcoholism was responsible for 6 cases. In 31
there was no history of a distinct psychosis.

The author further attempts, by her clear and careful analysis, to
show what may be the determining features leading to suicide in the
varying psychoses. Thus, in acute paranoia (Ziehen), the extreme anxiety
due to being followed or oppressed by the hallucinations is the given
cause. In chronic paranoid psychoses suicide is sought as a relief from
the persecutory delusions. In dementia praecox, simple pathological im-
pulsiveness seems to be the cause in the majority of the cases. As a rule,
a logical reason for the attempt at suicide is rarely given by the patient
suffering from dementia praecox.

Very superficial motives come to the fore in the study of attempts
committed by imbeciles — simple quarrels with relatives and neighbors be-
ing sufficient. In hysteria and other psychopathic inferior states, a com-
mon cause of the attempt is largely dependent on some emotional shock,
and is very frequently accompanied by a general theatrical mode of
operation.

The study, notwithstanding its many excellent features, is incomplete
in that only women were studied, and the cases were only those brought
to a psychiatric clinic. Thus, wide generalizations are impossible to be

548 BOOK REVIEWS

drawn from the material at hand. In spite of the drawbacks, however, the
book is one of the best that have appeared in years. It is well worth
reading. Jelliffe.

Areeiten aus dem Neurologischen Institute an der Weiner Uni-

versitat. Herausgegteben von Prof. Dr. Heinrich Obersteiner.

Band XIII. Franz Deuticke. Leipzig und Wien, 1906.

Vol. 13 of Obersteiner's Arbeiten comes with its usual rich collection

of thorough and stimulating studies. We can but enumerate some of the

more complete and noteworthy. Of the purely anatomical papers, E.

Zuckerkandl contributes two extensive dissertations, one on the Anatomy

of the Calcarine Fissure, and another upon the Gyrus Transitivus ; M.

Grossman has a study on the Intrabulbar Connections of the Trigeminus

with the Vagus; E. Hulles one on the Sensory Roots of the Medulla, and

P. Biach, a Study on the Comparative Anatomy of the Central Canal in

Mammals.

Of pathological studies there are Cytological Chang'es Observed in Puer-
peral Eclampsia, by E. Pollak ; Changes in the Spinal Ganglion Cells
After Amputation of the Upper Extremities, by K. Orzechowski ; one or
two on Senile Changes in the Brain, and an extensive study by Marburg
on Hypertrophy, Hyperplasia, and Pseudohypertrophy of the Brain.
The collection is thoroughly representative and praiseworthy.

Jelliffe.

Annual Report of the Central State Hospital of Virginia (for the
Insane).
The old clinical classification is still maintained at this hospital, al-
though the records are said to be arranged after Kraepelin. The superin-
tendent recommends that each year one of the medical staff be sent to
some medical center for a month for instruction in the most modern prac-
tice. He also suggests joint meetings, once or twice a year, of directors,
superintendents, assistant physicians and other officers of Virginia State
hospitals, at which papers should be presented and discussed.

The Thirty-Third Annual Report of the Cincinnati Sanitarium.

An epitome of the medical results of the year shows the total number
treated during the past year to be 302. Of these, 88 were under treatment
at the beginning of the year, and 214 were new admissions. The daily
average for the year was 93.15. Eighty-one patients were discharged re-
covered (2>7.2,7%) ; 73 as improved; 38 as unimproved. The mortality was
18 (5.96%). The medical administration has been strengthened by the
addition of a pathologist and hematologist. A series of research observa-
tions on the relations of the Bacillus paralyticans of Robertson to paresis
has been conducted in the clinical laboratory, and is made the subject
of a separate illustrated paper accompanying the report proper. This re-
search work is especially creditable to a private institution, which receives
no State aid of any kind ; and is an evidence of progressive methods, which
merit the approval and continued confidence of the profession generally.

Atwood (New York).

Primer of Psychology and Mental Disease. C. B. Burr, M.D. Third

Edition. F. A. Davis Co., Philadelphia, 1906.

In every hospital for the insane there is a need of a book that will

give the nurses and attendants an idea of the real state of such patients

as they are thrown in contact with. It is only by means of understanding

BOOK REVIEWS 549

the nature of a mental change that the persons intrusted to their care be-
come interesting and subjects of their sympathy and thoug'htfulness, and
are not only interesting because they do and say curious things.

Dr. Burr's book fulfills these wants to a marked degree. His chapter
on psychology is good ; it is not perhaps based on principles which meet
the approval of all psychologists, but that is not a possible task.

The chapter on insanities is founded on the newer teaching, embraces
dementia praecox and manic depressions, insanities, etc.

It is difficult in a small book to present such intricate diseases so as
to be recognizable by nurses, but sufficient is given for developing their
powers of observation and making them a valuable aid to the physician in
studying the cases.

The chapter on the management of cases is sufficient as an outline of
what should be accomplished in conditions of alienation, and the author's
advice on the diplomacy of action with the insane is most creditable.

S. D. Ludlum.

Collected Studies on Immunity. By Professor Paul Ehrlich. Trans-
lated by Dr. Charles Bolduan. John Wiley & Sons, 'New York.

This neat volume of 586 pages, well printed and well bound, contains
the greater portion of the studies on immunity published in late years
by Professor Ehrlich and his collaborators. They are here made avail-
able to the English reading public for the first time.

As the leading worker in this sing*ularly complex and intricate field —
that of cellular metabolism — Ehrlich's views constitute at the same time
the foundation and the superstructure. His ideas, as is well known, have
developed along chemical lines of thought, and in the study of the funda-
mental biological phenomena the significance attached to chemical inter-
pretations, rather than those founded on morphological considerations, is
manifest. With this view modern science is in accord.

The lectures and studies here presented are invaluable, and should find
a place in every student's library. To review them more in detail would
be a work of supererogation. Howard (New York).

Beitrag zu Lehre von den psychischen Epidemien. Von W. Wyegandt.
Carl Marhold, Halle a. S.

In this short, practical monograph of 100 pages, Weygandt discusses
some of the important and striking phases of psychic infection. He first
gives in considerable detail the life histories of a few carefully observed
cases in which mental contagion was a prominent etiological factor.
Using these few cases as illustrations he further elaborates his theme, and
endeavors to show how such contagion may spread from simple foci, as
outlined, to at first a few friends, and then to larger masses of people, and
thus give rise to widespread epidemic conditions. That such widespread
epidemics have been frequent in various communities the history of the
middle ages amply verifies. Even in our own time, similar epidemics are
not rare.

A most interesting portion of the monograph deals with the interpreta-
tion of the psychoses as seen in the histories studied. His second case he
speaks of as one showing the signs, in classical fashion, of being "possessed."
She would certainly have been in the middle ages an applicant for trial
as a witch. In another, an involution or senile melancholia would have
been interpreted in the same light.

In speaking further of those mental disturbances which seem to bear

550 BOOK REVIEWS

•

most the stamp of a more or less defined psychosis, Weygandt states that
for the most part they are best arranged under the groups of paranoid
states, hysteria, and in a few instances the communicated type bears the
ear-marks of a manic depressive psychosis. Naturally, in the case of
twins, of members of the same family or in close relation a certain
"anlage" may be posited to explain the tendency to similarity in the ob-
served disturbance, but further one must bear in mind in the case of twins
or members of the same family that what appears as a contagion may be
simply the onset of a psychosis in a predisposed individual, not set up at
all by reason of the contact with a similar affection in a near relative.

The monograph is not only interesting, but highly suggestive, and
affords a glimpse at a mode of attack on the study of the psychology of the
masses. Jelliffe.

UnTERSUCHUNGEN UND STUDIEN UBER DIE INNERVATION DES PERITONEUM

der vorderen Bauchwand. M. Ramstrom. J. F. Bergmann,

Wiesbaden.
The peritoneal nerves arise partly as small branches of the intercostal
and lumbar nerves which enter the lateral portions of the peritoneum, and
partly by the joining of adjacent intercostal or lumbar nerves which enter
in the neighborhood of the lateral borders of the recti muscles. The nerves
form plexuses in the serosa and subserosa, and end in perivascular net-
works, in a network of non-myelinated fibers between the vessels of the
serosa and subserosa, in end-bulbs and other lamellated nerve structures
similar to the Vater-Pacinian bodies. This investigation shows that the
phrenic nerve has nothing to do with the innervation of the peritoneum of
the abdominal wall. The work is beautifully illustrated in colors.

C. D. Camp (Philadelphia).

Physiology of the Nervous System. By J. P. Morat, Professor of
Physiology of the University of Lyon. Authorized English Edi-
tion. Translated and Edited by H. W. Syers, M.A., M.D. W. T.
Keener & Co., Chicago.
We cannot attempt to do full justice to this large work of 676 pages
in review form. All that can be done is to outline the function of the
volume, to state wherein it differs from similar volumes, and how effec-
tively the author's task has been performed.

To answer this last inquiry first, the work is an excellent one, of
superior merit and integral worth. No recent modern writer has pre-
sented so lucidly and so well the current doctrines regarding innervation
and its physiological consequences as has Morat. This means that, for
the most part, the work differs from preceding ones of its kind, largely by
reason of its newness and freshness, but further, a difference in looking
at the problems is manifest. Morat's physiology is of gTeat service to
students of clinical problems of nervous and mental disorders. Stimulation
or destruction of brain or cord areas is viewed in the light of the re-
sulting physiological conditions, and treated in a simple and effective liter-
ary manner. It is an extremely useful volume. Jelliffe.

The Prophylaxis and Treatment of Internal Diseases. Designed for
the Use of Practitioners and of Advanced Students of Medicine.
By F. Forchheimer, M.D., Professor of Theory and Practice of
Medicine, Medical College of Ohio, Department of Medicine of
the University of Cincinnati, etc. D. Appleton & Co., New York.
"In order to get the best therapeutic results," says Dr. Forchheimer, in

BOOK REVIEWS 551

concluding his introduction, "the physician should be both scientist and
practitioner." This sentence epitomizes the spirit of Dr. Forchheimer's
book, in which one recognizes the voice of a master in the art of thera-
peutics, who is quick to recognize and use every aid which science has to
offer. This work admirably fulfils its aim in presenting to the practitioner
a working system which he can apply in private practice, leaving the con-
sideration of such measures as require hospital treatment to other works.

In this systematic consideration of internal diseases, prophylaxis re-
ceives the same broad treatment that is bestowed upon the curative meas-
ures. The important hygienic measures which apply to, the prevention of
specific diseases in the community are outlined, and the subject 01 personal
prophylaxis is considered in some detail. That "to the bacterial cause
(of disease) we must add the chemical, physical and biological causes" is
not lost sight of in the treatment of this most important subject.

In describing the treatment of each disease, Dr. Forchheimer first
outlines the method which has proved most serviceable in his own hands,
and then describes other measures which may be found of value, giving
considerable attention to measures other than drugs, such as diet, hydro-
therapy, exercise, etc. Complications and sequelse are fully considered,
and the care of the patient during convalescence is most satisfactorily de-
scribed— a subject which is largely neglected in the great majority of text-
books on medicine. The author has made free use of the best literature,
particularly in reference to those subjects which are new or which are
still under discussion.

The convenient arrangement and full index make this work a very
handy reference book, and in referring to it the reader may feel that he
is appealing to very high authority. We know of few books which will
prove as valuable to the advanced student of medicine or the practitioner
as "The Prophylaxis and Treatment of Internal Diseases."

Howard (New York).

Epilepsy. William Aldren Turner, M.D., London, England. 267 pages.
The Macmillan Company, Limited, London and New York.

"Epilepsy — a Study of the Idiopathic Disease," by Turner, is based
largely on Dr. Turner's experience as physician to out-patients at the
National Hospital for Paralyzed and Epileptic, and as visiting physician
to the Colony for Epileptics at Chalfont, St. Peter's. It is divided into
twelve chapters in addition to appendices and an index.

Chapter I. deals with a definition, general considerations, inheritance,
conditions underlying convulsions, and speaks of epilepsy as "an organic
disease." Turner's definition of epilepsy embraces ninety words and
seems unnecessarily cumbersome and to contain features that have no
place in what purports to be a definition only. Turner defines epilepsy as
"A chronic, progressive disease of the brain characterized by periodic oc-
currence of seizures in which loss of consciousness is an esential feature,
commonly associated with convulsions and frequently accompanied by
psychical phenomena of a well defined type ; occurring generally in per-
sons with a hereditary neuropathic history which shows itself in signs or
stigmata of degeneration ; running its course uninterruptedly or with
remissions over a number of years, and terminating either in a cure, in
the establishment of the confirmed disease, in delusional insanity or in
dementia." The last lines seem to encroach decidedly upon prognosis and
to have no bearing upon definition.

Chapters II. and III. deal with the etiology of epilepsy, the general

552 BOOK REVIEWS

prevalence of the disease, its relative frequency in the sexes, and the age
at onset.

Chapters IV. and V. take up the clinical side of epileptic fits ; and here
Turner seems to follow Binswanger in the classification of types. Much
may be noted in this chapter similar to the writings of Gowers.

Chapter VI. deals with the mental states found in epilepsy, the epileptic
temperament, and the various psychoses that precede, accompany or fol-
low epileptic convulsions.

Chapter VII. deals with the miscellaneous phenomena of epilepsy, in-
cluding its neuropathic associations, such as paroxysmal headache, chorea,
the tics, myoclonus epilepsy and chronic nervous diseases ; accidents due
to epileptic fits, conditions that have been fully described in other works
on this disease.

Chapter VIII. deals with pathology. A careful study reveals nothing
that is strikingly new ; yet the chapter is well and conservatively written,
and seems up to date in all respects. "Changes resulting from epileptic
attacks" are found in this chapter. Turner states the brain of an epileptic
is "unusually bulky, its convolutions simple and its membranes to the
naked eye are clear and not apparently thickened; they are not adherent
to the cortex and are congested only in cases which die in the status
epileplicus." The statement that the brain of an epileptic is "unusually
bulky" and its "convolutions simple" does not seem to us to be borne out
by facts observed in dead-houses in this country, where hundreds of epilep-
tic brains have been studied.

Chapter X. takes up the diagnosis of epileptic convulsions, points the
way in which they are to be distinguished from hysterical fits, from
epileptiform convulsions and from aural vertigo.

In Chapter XL, prognosis and curability are well discussed. It is
evident that Turner takes a more generally optimistic view of the cur-
ability of epilepsy than do most neurologists in this country. He gives
the percentage of cures at ten to twelve, and states that no case is to be
regarded cured until the attacks have been arrested for at least nine
years. Just why Turner fixes upon this seemingly arbitrary period of nine
years we do not quite understand.

The last chapter deals with treatment, taking up the bromids, the
methods of their administration, as well as numerous other remedies.
Prophylaxis is not overlooked.

Appendix "A" deals with incidence and mortality of epilepsy among
European troops, native troops and prisoners in India for the years 1S99,
1900, 1901, 1902 and 1903.. So far as we have the data are new and are of
more than passing interest.

Appendix "B" gives a list of "quack remedies" for epilepsy. We have
known for more than fifteen years that substantially all quack remedies
advertised as sure cures for epilepsy contained the bromid of potassium
in some form and variously disguised. The prescriptions given by Turner
of quack remedies fully bear out this assumption.

Appendix "C" comprises a list of the common foodstuffs according to
their purin value.

Appendix "D" deals with epileptic colonies, describing the essential
features of such communities.

Altogether Turner has written a very excellent book on epilepsy, re-
stricted as it is to the idiopathic disease, and the volume is a welcome
addition to the increasingly frequent literature on epilepsy. It contains
numerous charts and illustrations. W. P. Spratling (Sonyea).

VOL. 35. SEPTEMBER, 1007. No. 9.

THE

Journal

OF

Nervous and Mental Disease

©riotnal articles

HAVE THE FORMS OF GENERAL PARESIS ALTERED?*
By L. Pierce Clark, M.D.,

OF NEW YORK.
AND

Charles E. Atwood, B.S., M.D.,

OF NEW YORK.

There has been considerable speculation in recent years re-
garding the variations of the forms of paresis. Many neu-
rologists and alienists believe that the disease has undergone
great modifications in types and in their proportionate frequency.
Thus Paton, for example, believes that until recently the ex-
pansive form included the majority of the cases, but that now
only one-tenth to one-fifth are of the expansive type ; while the
depressed type forms the majority of all cases, and the increase
of the demented type is apparent only. Unfortunately Paton's
generalization is based upon comparatively few cases.

Paresis with excitant and exalted delusions is considered by
Brower and Bannister, on the other hand, as still the typical
form of paresis, a statement to which most clinicians readily
subscribe. The megalomanic type is held by Diefendorf (who
also quotes Kraepelin to the same effect) as becoming much less
prominent, until now it is encountered in the disease in less than
one-fourth of the cases. The dementing form is also held by
Kraepelin to be the prevailing type, forming two-fifths of all
cases ; while the depressed form exists in more than one-fourth

*Read at the thirty-third annual meeting of the American Neurological
Association, May 7, 8 and 9, 1907.

554 CLARK AND ATWOOD

of the cases of paresis. One gains not a little insight to our
subject in Kraepelin's statement that the neurologist sees more
dementing forms of paresis than the alienist on account of the
absence of the grave mental symptoms which necessitate asylum
care.

As a representative of the English view one notes with in-
terest that Clouston holds that one-third of paresis belongs to
the dementing form and that all the older physicians in asylums
believe the type is increasing at the expense of the grandiose
type. However, it is interesting to note that not a few English
writers fail to diagnosticate paresis in the absence of euphoria
during some stage of the disease, a view largely dependent upon
Mickle's teaching two decades ago.

Italian, French and Russian alienists make no extended com-
ment upon the modern views of variations of type in paresis.
Indeed, it may be said that not many writers of to-day in any
country even, make anything like a genuine attempt to differen
tiate types or forms of paresis, hence our task of a wide
geographical interpretation must be somewhat imperfect. Our
own experience in hospital, dispensary and private practice led
us at first to believe an affirmative answer should be returned
to the query title of this paper.

On account of the varying opinions respecting the types of
paresis and their proportional frequency, we have endeavored
to dispel the present confusion of the subject and bring the whole
subject up for general discussion here by making a careful ana-
lysis of 3,000 cases of paresis covering the period of the last
three decades. The material under immediate study was drawn
from the asylums of the New York Metropolitan district at
Ward's Island and Central Islip Hospitals. Only male cases
were considered in the study.

We have found it practicable to subdivide paresis in but three
forms : grandiose, depressed and simple dementing. The gran-
diose form embraces all cases in which euphoria and expansive
delusions obtained, whether attended by motor restlessness or not.
The depressed includes all cases that have exhibited depression
and excessive emotional element, depressive delusions or hypochon
dria throughout the major part of the disease. The simple de-
menting form includes those cases that show primary progressive
deterioration without further mental symptoms the existence of

GENERAL PARESIS 555

which would permit their being placed in either of the other
two types.

Our analysis naturally possesses the advantage of covering
the entire course of the disease, as all the cases were under
asylum care and the histories were very complete, and the diag-
nosis was confirmed by death in the majority of cases. One
appreciates the advantage of viewing the whole course of the
disease in classifying types of paresis, inasmuch as the grandiose
complex is not infrequently established late in the course of
the disease. It often suffers a preliminary cloaking of hypo-
chondriacal depression. Again, etiological factors other than
syphilis, such as alcohol, very often tinge the prodromes of the
disease, giving rise to persecutory ideas, ideas of marital in-
fidelity, etc.

The gradual increase of the simple dementing form during
the last few years shows that some cases of cerebral lues are
finding their way into this class. Many simple dementing pare-
tics of earlier years were, moreover, lost in the former classifica-
tion of terminal dementia. Not a few cases in old records show
that acute melancholia terminating in dementia should have been
classed as the depressive type of paresis. All these facts explain
the natural numerical advance of this form of paresis.

The same explanation can not, however, be urged of the acute
maniacal phases of insanity, as the agitated types of paresis, for
which they might be mistaken, usually present the wildest ex-
travagance of euphoria.

In considering our analysis by year periods one finds no dis-
tinctive feature in the curve-charts. Although there is consider-
able variability from year to year in the thirty-year period we
have analyzed, there is no constant law deducible. If one groups
the data in five-year periods, however, there appears to be a
fairly constant ratio between the total admission, the total paretic
class and the total grandiose type ; in other words, the ratio is
constant between the cardinal features of the disease study.
This fact alone teaches us that the grandiose element in paresis
is the true disease complex. The principle may be considered
so firmly established that no immediate change in it may be
looked for in the future. (Time may be saved if the charts are
allowed in the main to speak for themselves.)

We found the euphoric syndrome in recent years less extrava-

556 CLARK AND ATWOOD

gant, less grotesquely exalted. Patients in the last decade spoke
of possessing, or hoping to possess, a few thousand dollars, in-
stead of having billions of trillions as formerly. The frequent
persecutory ideas of the grandiose state have a curious exalted
trend and are strangely mixed with true euphoric concepts, even
in the same sentence.

A percentage analysis of the grandiose type by five-year
periods shows that there was a steady increase from 1877 to
1896, from which date there has been a gradual decrease to
date. Fully 70 per cent, of paretics are of the grandiose type
to-day. Even in mild euphoria the manner of grandiose reason-
ing in paresis is as characteristic as that encountered in the
persecution of paranoia.

On the whole one may say that the depressed type of paresis
has steadily decreased in frequency since the first five-year period
(1877-81), at which time it was 15 per cent, of the total paretic
class. It reached its minimum frequency in 1892-96. when it
was about 10 per cent. It has increased slightly in the last ten
years. During the last five years it has stood at about 12 per
cent, of the total paretic data.

It is interesting to note in passing that while Bayle in 1822
first recognized paresis as a morbid entity characterized by am-
bitious delusions which he believed to be pathognomonic, it re-
mained for Baillarger of Paris, nearly forty years after, to show
that the depressive syndrome might exist in certain forms of
paresis. The French school exemplifying the old adage, still
persists to-day in making no provision for these cases in paretic
classifications. There is often a strangely enlarged view even
in the depressive phase of paresis. Patients believe they have
murdered all the people in the world, have killed all the numer-
ous members and relatives of their family, etc.

The greatest period of frequency for the simple deteriorating
class of paresis was in the first five-year period of our analysis
(36 per cent.), since which time there was a steady decrease
until during the last ten years it has remained constant at about
17 per cent. As the type runs a rapid course, without remis-
sions, and almost invariably ends in convulsions, the majority
of the cases remain outside of asylums until late in the disease.
Indeed, the greater part of the disease course is an extra-asylum
state. This fact accounts somewhat for the opinion among neu-

GENERAL PARESIS 557

rologists that the simple dementing form is gaining in frequency
at the expense of the grandiose type. Difficulties in diagnosis
here, as elsewhere in paresis, are largely removed if one depends
more on the somatic signs than on any mental criteria.

In conclusion it may be said but three types are needed for
analysis of paresis, and variations between types of late years
are less great than formerly held.

The true explanation of the occurrence of a considerable num-
ber of depressed and simple dementing types of paresis rests
upon a more exact analysis of cases and a recruiting of these
two classes from the melancholias and dementias of former years.
The real but slight variations in types are due to a better system
of treatment and earlier diagnosis. Moreover, the specific treat-
ment of syphilis, in paresis, has largely been discarded for more
rational principles of hydrotherapy, dietetics and hygienic sur-
roundings, both in and outside of asylums. The more prompt
detection of the disease has made paresis a younger disease;
more cases occur between 20 and 30 than formerly and fewer
occur over the age of 50. In whatever light paresis is viewed
we can hope for but little variation in the disease, inasmuch as
the fixed and definite causes of paresis are syphilis, alcohol, sexual
excesses and mental stress. We believe the relative percentage
of the various types should be more generally expressed in text-
books, in order that readier comparisons and deductions may

"be made.

The whole subject under study here is far from being merely
academic. The different types of paresis have a widely dissimilar
prognosis. The determination of the true syndrome of the dis-
ease and its atypical forms is, therefore, a very practical and
timely issue.

Finally, from our study of 3,000 cases we deduce that paresis
is essentially a disease in which the grandiose type predominates
in about 70 per cent, of all cases, the dementing form occurs tiext
in frequency of 20 per cent., while the depressive form is found
in but about 10 per cent.

THE SYMPTOMATOLOGY OF LESIONS OF THE LENTICULAR
ZONE WITH SOME DISCUSSION OF THE PATHOLOGY

OF APHASIA.*

By Charles K. Mills, M.D.,

PROFESSOR OF NEUROLOGY IN THE UNIVERSITY OF PENNSYLVANIA; NEUROLO-
GIST TO THE PHILADELPHIA GENERAL HOSPITAL.

AND

William G. Spiller, M.D.,

PROFESSOR OF NEUROPATHOLOGY AND ASSOCIATE PROFESSOR OF NEUROLOGY IN
THE UNIVERSITY OF PENNSYLVANIA J NEUROLOGIST TO THE PHILA-
DELPHIA GENERAL HOSPITAL.

INTRODUCTION.

The views on aphasia recently advanced by Marie have served,
among other things, to concentrate the attention of physiologists
and neurologists upon the functions of the lenticular nucleus, to
which body Marie has given an unusual role in the production of
motor aphasia. It is a noteworthy fact that, in spite of the neu-
rological activity all over the scientific world during the last three
or four decades, the functions of the basal ganglia still remain
largely undecided. Many speculations have been advanced re-
garding the functions of the thalamus, caudatum and lenticula ;
and many facts, anatomical, physiological and clinicopatholo-
gical, have been contributed regarding these organs ; but the
comparative certainty of our knowledge as to the functions of the
cerebellum, most of the cortical fields and centers, and many
of the encephalic tracts of projection and association, is lacking
with regard to these ganglia. The reasons for this state of affairs
are not hard to see. Owing to the deeply seated position of the
basal ganglia, it is difficult to experiment on them without in-
volving or injuring other parts ; and the lesions which are ob-
served by the clinicopathologist are rarely absolutely limited to
any one of these organs. Microscopical investigations of degener-
ations of these ganglia and of their incoming and outgoing tracts
have not led to as clear inferences as in other regions of the brain.

Our paper is based in the first place upon a study of eleven
cases with necropsies, in ten of which the lesion involved the

*Read at the meeting1 of the American Neurological Association, May
7, 8 and 9, 1907.

LESIONS OF LENTICULAR ZONE 559

lenticular zone. In six of these cases the lenticula itself was in-
volved. Other parts of the lenticular zone were variously impli-
cated in the ten cases. It was possible, however, at least in some
of the cases, in which regions other than the lenticula were in-
volved, to arrive at an idea as to the part played by this body
in the symptomatology presented by the patients.

For several years the writers of the paper have been collecting
cases with necropsies in which lesions of the basal ganglia have
been present. Most of the specimens from these cases are to be
found in the Laboratory of Neuropathology of the University of
Pennsylvania. In not a few instances papers have been pub-
lished in which references have been made to some of these cases,
and some use will be made of these published but personal data.
In going over the specimens of cases, clinical and pathological
studies of which have not yet been made, the writers found that
they had in their possession more than twice as many specimens
of cases as have been used in this paper, but owing to the im-
perfections of the clinical data, or because of the confusing char-
acter of the lesions, only eleven of these cases could be used with
any advantage.

OLDER VIEWS REGARDING THE FUNCTIONS OF THE LENTICULA.

We shall first note briefly the views regarding the functions
of the basal ganglia held by some of the older physiological and
neurological teachers.

Fifty years ago one of the most relied-upon general works in
physiology was that of Carpenter.1

An old view which is discussed but antagonized by him was
that the thalami in some way were centers for movements of
the upper extremity, and the striata for the lower. Carpenter
also opposes the idea of Magendie that removal of the striata
causes an irresistible tendency to forward progress, whilst the di-
vision of the peduncles of the cerebellum occasions the reverse
movement.

Discussing the functions of the striatum, Carpenter says that,
"According to Longet, Schiff and Lafargue, the results of re-

'"Principles of Human Physiology," by William G. Carpenter, M.D.,
F.R.S., F.G.S., Examiner in Physiology and Comparative Anatomy in the
University of London, etc., fifth American from the fourth and enlarged
London edition, Philadelphia, 1853.

560 MILLS AND SPILLER

moval of the corpora striata with the anterior upper part of the
cerebral hemispheres, are for the most part negative ; for the
animal usually remains in a state of perfect stupor, although still
retaining the erect position ; and it is only when irritated by
pinching or pricking that it will execute any rapid movements.
No mechanical irritation of the corpora striata produces either
sense of pain or muscular movements. No distinct evidences re-
garding the special functions of either of these ganglionic masses
can be gained from pathological phenomena. So far as is yet
known extensive disease of either the thalami optici or the corpora
striata of one side, produces hemiplegia or paralysis both of
sensation and motion on the opposite side. The same result very
commonly follows an apoplectic effusion into the substance of
either."

Broadbent,2 writing in 1876. voiced the views which were
held by many about the time and shortly after the time when the
study of cerebral localization received its greatest impetus through
the suggestions of Hughlings Jackson (1864) and the researches
of Hitzig, Fritsch, Ferrier and others (1870-1875).

Discussing the position of the thalamus and striate bodies,
with reference to the crusta and tegmentum, after indicating the
existence of connections between these ganglia and the other
parts of the nervous system, both lower and higher, he ex-
presses the opinion that the striatum is a motor and the thalamus
a sensory ganglion for the entire opposite half of the body. With
regard to the striatum, like all the earlier writers not separating
in his discussion the caudatum and the lenticula, Broadbent holds
that this ganglion translates volitions into actions and puts into
execution the commands of the intellect. "It selects, so to speak,
the motor nerve nuclei in the medulla and cord appropriate for
the performance of the desired action, and sends down the im-
pulses which set them in motion. These impulses are trans-
mitted through fibers, and the fibers must start from cell processes
in the corpus striatum. A given movement, therefore, must be
represented in the corpus striatum by a group or groups of cells
giving off downward processes, which become fibers of the motor
tract of the cord." When the movement is simple the cell group
will be small and the fibers few ; when complex the cell group

=Broadbent, Wm. H. British Medical Journal, April 1, 1876.

LESIONS OF LENTICULAR ZONE 561

will be large and well denned and the descending fibers numer-

ous.

"Words," says Broadbent, "which require for their utterance
the simultaneous co-operation of the muscles of the chest, larynx,
tongue, lips, etc., and the exquisite and rapid adjustment of their
movements concerned in phonation and articulation, must be
represented in the corpus striatum by very large groups of cells,
and not in that of one side only but in both."

According to Ferrier3 it is evident that destruction of the
striatum produces a much more complete and enduring paralysis
than destruction of the cortical motor centers alone, or of the
pyramidal tracts which proceed from them.

He summarizes his views with regard to the corpora striata
as follows: "It appears from these facts that the corpora striata
proper are centers of innervation of the same movements as are
differentiated in the cortical motor centers, but of a lower grade
•of specialization. The innervation of the limbs in all that relates
to their employment of instruments of consciously discriminated
acts is dependent on the cortical centers, while for all other pur-
poses involving mere strength or automatism, primary or second-
ary, the corpora striata with the lower ganglia are sufficient.
In man almost every movement has to be elaborately acquired by
conscious effort through the agency of the cortical centers, and
continues to involve the activity of these centers to a greater or
less extent throughout. Hence the destruction of the ganglia of
the corpora striata adds little if anything to the completeness of
the paralysis which results from destruction of the cortical motor
•centers alone."

Ross4 has contributed something to our more exact knowledge
of the motor functions of the lenticula in a paper on what is now
commonly designated as pseudo-bulbar paralysis, the title of his
•contribution, however, being labio-glosso-pharyngeal paralysis of
cerebral origin. He cites a case from Oulmont5 with the typical
symptoms of pseudo-bulbar paralysis in which the motor and
speech phenomena were apparently due to bilateral lesion of the
lenticula.

"The Functions of the Brain," by David Ferrier, M.D., second edition,
rewritten and enlarged. New York, 1886.

4Ross. James. Brain, Julv. 1882.

"Oulmont. Cited by Leoine. R. Mensuelle de Medecine et de Chi-
rurgie. Vol. 1, 1877.

562 MILLS AND SPILLER

"An old hemorrhagic focus was found in the right hemisphere
occupying the third or external segment, and a smaller focus
situated in the second segment of the lenticular nucleus. Similar
foci were found in the third and second segments of the lenticular
nucleus of the left hemisphere. The internal capsule was not in-
volved in either hemisphere. The medulla oblongata and pons
were free from disease."

Ross cites a case of Eisenlohr6 in which lesions were found in
both striata (the lenticular nuclei?) and in the thalami.

Ross also cites the case of Kirchhoff,7 published in 1881, in
which lesions of both the caudatum and lenticula were found,
but as the capsule also seems to have been involved in this case,
it is not of as much value for our purposes as other cases in which
the lenticula alone seems to have been implicated.

One of the most important cases of labio-glosso-pharyngeal
paralysis or pseudo-bulbar paralysis from disease of the lenticula
which has as yet been described is that reported by Ross him-
self. In this case the lesions described were as follows :

"The lenticular nucleus of each hemisphere was found post-
mortem replaced by a well-defined cystic cavity, containing a
clear, straw-colored fluid, the internal capsules being apparently
uninjured. Microscopic examination failed to detect any evi-
dence of disease in the nerve nuclei of the medulla oblongata, or
descending changes in the pyramidal tracts in any part of their
course."

In another case recorded by Ross the lesions present were
described as follows :

"The anterior part of the lenticular nucleus of the left hemi-
sphere presented two small cyst-like cavities, containing clear
fluid. These cavities occupied the second and third segments of
the nucleus, and one of them appeared to encroach to some extent
on the knee of the internal capsule. The right hemisphere was
preserved in spirit, and was not examined until a fortnight later,
when a small cavity was found in the lenticular nucleus of this
hemisphere also. This cavity occupied the anterior part of the
nucleus, but did not appear to encroach upon the internal capsule."
Some descending degeneration, probably due to lesion in the
internal capsule, was present in this case.

'Eisenlohr, C. Archiv. fiir Psychiatric Vol. IX, 1878, p. 43.
7Kirchhoff. Archiv. fiir Psychiatrie, Vol. XI., 1881, p. 132.

LESIONS OF LENTICULAR ZONE 563

In a third case recorded by Ross a small cystic cavity was
found in the left lenticular nucleus close to the border of the genu
of the internal capsule. No secondary degeneration detectable by
the naked eye was in the crura. A careful microscopical ex-
amination of successive sections of the crura, pons, and medulla
oblongata, failed to detect any secondary degeneration of the
pyramidal tracts. The bulbar nuclei were healthy. This case,
which was complicated with disease of the spinal cord, presented
typical pseudo-bulbar paralytic symptoms.

Ross held that his cases did not prove that the lenticula is an
independent center for the regulation of all movements of arti-
culation and deglutition. He was also inclined to negative the
view that the lenticula is a ganglion of interruption between the
cortex and the parts below, and looked with favor on the idea
that in the cases of labio-glosso-pharyngeal paralysis recorded
by him the symptoms were due to lesions interfering with the
paths of conduction from the cortex, although at least twTo of his
three cases seem to have been instances of lesions isolated to the
lenticula, these causing disorders of speech and some paresis of
the face and upper extremity. His view would appear to be in a
general way that of Dejerine that the cases of pseudo-bulbar
paralysis attributed to lesions of the lenticula, either unilateral or
bilateral, are probably dependent upon undetected lesions of the
pyramidal tracts or cortex.

THE VIEWS OF DEJERINE.

In his Anatomy of the Central Nervous System8 Dejerine in
several places goes rather fully into the question of the functions
of the lenticula, but his results would seem to be included in the
assertion that this ganglion plays only a negative part. He is
mostly concerned with denying its connection with the motor and
other portions of the cortex by projection fibers, appearing to
hold that the lenticula plays no part in the control of movement
or in the function of speech. In order that his views with regard
to the functions of the striate bodies may be understood, it will
be necessary to include a reference to his opinions as to the an-
terior limb of the internal capsule. Lesions of the anterior seg-

"Dejerine, J. "Anatomie des centres nerveux," Vol. II., fasc. 1, Paris,
1001.

564 MILLS AND SPILLER

ment of the internal capsule, says Dejerine, are not manifested
by any appreciable motor disturbances when they occupy only
the anterior half or three-quarters of this segment. These fibers
are, he believes, frontothalamic projection fibers. He says that
as soon as the knee of the capsule is reached, a distinct symp-
tomatology appears, — that of paralytic phenomena on the oppo-
site side of the body. Secondary degeneration of this part of the
capsule is also seen following cortical lesions of the Rolandic
zone. Dejerine has shown that the area of degeneration in the
anterior portion of the posterior limb of the capsule is correspond-
ingly more posterior, according as the lesion is higher and higher
in the Rolandic cortex, his own observations confirming in this
respect the physiological observations of Horsley and Beevor on
the internal capsule of the monkey.

When the knee and the adjacent portion of the posterior limb
of the internal capsule are involved in a lesion, a paralysis of the
inferior facial nerve and of the half of the tongue on the opposite
side is observed. The fibers arising from the frontal operculum
and Rolandic operculum pass through the knee and the adjacent
portion of the posterior segment of the capsule. Facial paral-
ysis of capsular origin presents the same features as that of cor-
tical origin, the superior facial is not entirely intact.

When the lesion is bilateral and symmetrical, the clinical pic-
ture will be that of pseudo-bulbar palsy. The anatomical locali-
zation of the paralysis has been and still is differently interpreted.
It is known that this may be of cortical origin (bilateral lesion of
the Rolandic operculum), subcortical, capsular, pontile, or bulbar,
situated in the course of fibers arising in the motor zone which
control the nuclei of the motor cranial nerves. Dejerine does
not accept the localization of those who have their views based
upon cases in which the lesions were supposed to be limited to
the lenticula. In one place he says emphatically that the lenticular
nucleus does not send fibers into the foot of the cerebral peduncle
and does not receive any from the cortex. Further on in the
same work, however, he modifies this statement by saying that
the putamcn does not receive any fibers from the cortex, but that
the globus nallidus may do so. The lenticular fibers of projec-
tion, he holds, belong to the system of strio-thalamic and sub-
thalamic radiations.

Dejerine states that symmetrical lesions (hemorrhage, soften-

LESIONS OF LENTICULAR ZONE 565

ing, either in the putamen or in the lenticular nucleus as a whole)
are frequently observed in the necropsies of the aged, who have
not presented any symptoms of pseudo-bulbar paralysis during
life. He recalls the fact that Oppenheim and Siemerling had
shown in 1886 that when they observed a bulbar palsy during life
in these cases of symmetrical lesions of the lenticula, there were
always also foci of softening in the pons and oblongata. Accord-
ing to Dejerine in all the cases in which there was absence of all
pontile or bulbar lesions appreciable by the microscope, the
pseudo-bulbar palsy seems to have resulted not from the localiza-
tion described as lenticular by some ; but when these cases are
studied by the method of serial microscopical sections, the bi-
lateral and symmetrical lesions of the lenticula are found always
to have involved the knee and a portion of the posterior limb of
the internal capsule.

He speaks of tracing clearly in the retro-lenticular portion of
the internal capsule fibers which traverse the globus pallidus. He
says that these may appear to be cortico-lenticular fibers, but
suggests that inasmuch as they cannot be followed in the corona
radiata, except immediately above the retro-lenticular segment,
they may rather be lenticulo-caudate fibers, that is caudate fibers
of projection or termination.

Dejerine asserts that in cortical lesions, either extensive or
confined to small areas, when the material is treated by the
method of Weigert and Pal, the globus pallidus does not appear
to undergo any modification, either in the form of atrophy or dis-
appearance of fibers, similar to that which is seen in the thalamus
in the same case. He acknowledges, however, that we cannot
assert that the globus pallidus possesses in such cases as many
radiating fibers, or as dense a network of fibers as in the normal
state.

It is further stated by him that in two cases of recent cerebral
disease, in one of which the lesion was extensive and in the other
limited, examined by the method of Marchi, the globus pallidus
and the corpus Luys both received fibers of projection from the
cerebral cortex.

In still another place Dejerine states that the striatum, es-
pecially the caudate nucleus and the putamen, at least in man.
do not receive direct cortico-striate fibers ; that they receive onlv
cortical fibers of projection traversing them on their way to the

566 ] MILLS AND SPILLER

internal capsule (corticothalamic, cortico-pontile, cortico-bulbar,
cortico-spinal fibers). It seems to be well demonstrated, accord-
ing to Dejerine, that cortical lesions, whatever may be their situa-
tion, their extent, and their duration, do not affect the caudatum
and the putamen as they do the thalamus. This contrast existing
between the striatum and the thalamus, says Dejerine, was well
recognized by Gudden in 1872 as the result of experimental ob-
servations. Other well known investigators cited by him have
observed atrophy of the striatum following cortical ablation ex-
periments, but this atrophy results probably from the degenera-
tion of fibers of passage and collaterals or injured cortical neu-
rones, and is not comparable with the atrophy, even extreme, in
the thalamus under the same circumstances. The very slight
diminution in size of the striatum sometimes seen in man follow-
ing old lesions of early childhood is, in Dejerine's opinion, the
analogue of the diminution in volume seen in all these cases in
the anterior corresponding half of the encephalon, in the anterior
horn of the opposite side of the cord, and in the opposite cere-
bellar hemisphere. It results as much from degeneration of the
collaterals which the system of cortical projection fibers sends
to the striatum and the region of the tegmentum, as from the
functional inactivity of this region. Dejerine9 has expressed his
views regarding the lenticula also in a recent paper.

Some others, (Schwalbe, Edinger, Sachs, Bechterew, Mari-
nesco). Dejerine remarks, deny the existence of cortico-striate
fibers of projection, but depending on the homology of develop-
ment of the striatum and of the cerebral cortex established by
Wernicke, attempt to prove the existence of a cortico-striate
fasciculus of association, and as such describe the occipito-frontal
fasciculus and collosal fasciculus of Muratoff.

THE VIEWS OF MINGAZZINI.

In the appendix to his monograph, Mingazzini10 discusser
and antagonizes the opinions of Dejerine.

The arguments of Dejerine, says Mingazzini, appear far from
decisively proving that the lenticular nucleus does not possess

'Dejerine J. L'Encephale, No. 5, May, 1907.

10Mingazzini, Giovanni. "Sulla sintomatologia delle lesioni del nucleo
lenticolare." 1902.

LESIONS OF LENTICULAR ZONE 567

motor fibers, and that therefore a lesion of the same is incapable
of producing paralytic disturbance. The argument that the
secondary degenerations show that the lenticula does not send
fibers into the foot of the cerebral peduncle and does not receive
any from the cortex, and its fibers of projection must belong only
to the system of the strio-thalamic and sub-thalamic radiations,
according to Mingazzini, has little value, since he (Mingazzini)
believes that he has shown in the beginning of his monograph
that lesions of the lenticula, according to the points at which
they occur, seem to give rise to a diverse symptomatology.

Mingazzini believes that it is not true that in every case in
which lesion of the lenticula produces permanent disturbances^
there must be existing concealed destruction of the internal cap-
sule. He believes that the arguments of Dejerine might just as
well be turned around ; in other words, it is just as likely that
lesions of the lenticula might be present and escape detection in
those cases in which capsular lesions are discovered as the re-
verse. The arguments of Dejerine that because lesions of the
pons and bulb are frequently found in pseudo-bulbar paralysis,
therefore these are probably present and the real cause of the
paralytic phenomena in cases apparently due to lesions of the len-
ticula, is easily overcome, according to Mingazzini, if we remem-
ber that the symptomatology of cerebro-pontile pseudo-bulbar
paralysis is much richer than pseudo-bulbar paralysis of pure
cerebral origin ; in other words the picture of the two diseases is
different.

Mingazzini insists on the point that only certain parts of the
lenticula transmit motor and sensory fibers or have motor or sen-
sory functions, and it is therefore easy to understand how lesions
may sometimes be found in these ganglia in the old or in others
without motor symptoms.

Mingazzini does not accept the opinion of Dejerine with re-
gard to the cases collected from different authors, in which
atrophy of the lenticula occurred after lesions or arrests of the
cerebral lobes or convolutions, but believes that these cases show
that anatomical and physiological connection exists between some
part of the cortex and the lenticula. Mingazzini lays particulai
stress upon the researches of Dejerine, already referred to in our
analysis of Dejerine's views, in which he found degenerated fibers
in the globus pallidus as the result of cortical lesions, since Min-

568 MILLS AND SPILLER

gazzini sa\s it shows that these ganglia receive fibers of projec
tion from the cerebral cortex.

Leaving his criticisms of Dejerine, let us turn now to Min-
gazzini's positive statements of his own views based upon per-
sonal clinico-pathological observations, his pathological findings
being both gross and microscopic. In his monograph he first
calls attention to the manner in which the question of the func-
tion of the lenticula has been largely passed by, or has been al-
together slighted by writers on neuropathology and clinical neu-
rology. He refers particularly in this connection to well known
authors like Gowers, Oppenheim, von Monakow, and Brissaud.
Unlike Dejerine, who attacks the problem of the functions of the
lenticula in his great work on the anatomy of the nervous system,
with the result of negativing its functional importance, the other
authors referred to by Mingazzini have contented themselves
with slight or imperfect allusions to the problem of lenticular
disease.

Mingazzini, in this monograph, gives details of nine cases of
lenticular lesion with necropsies observed by him, and refers to
other cases in a preceding publication. We have gone carefully
over the notes of these cases, and also the table in which the
topography of the lesion and the disorders of articulation and
of motility in the face and limbs are summarized. These cases
would seem to leave little doubt of the correctness of the con-
clusions drawn by Mingazzini. One criticism is worth mention-
ing, however, regarding some of them. Several of these patients
were quite advanced in years ; some over seventy and others be-
tween sixty and seventy. In several of them also abnormal con-
ditions of the meninges and cortex or subcortex were present, as
opacities of the membranes, adhesions with decortications, shrink-
age of the convolutions, and in one or two instances, actual
softening. Making, however, due allowance for these findings
and their possible bearing upon the symptoms in limbs, face and
speech, we believe that the most important of Mingazzini's con-
clusions are to be accepted. We shall give these somewhat at
length, translating and summarizing his remarks, omitting quota-
tions, as in order to save space we shall not follow his language
consecutively and with exactness.

A focus of disease, even of small size, involving only the
lenticular nucleus, according to Mingazzini, never fails to mani-

LESIONS OF LENTICULAR ZONE 569

fest itself with motor disturbances. Usually these are dissociated
or total paralyses, to which are sometimes added irritative symp-
toms.

Facial paralysis is very rarely of lenticular origin. Mingazzini
has not observed any case of it. He refers to the one recorded
by Ross, to which we have already directed attention. Cases of
unilateral facio-lingual paralysis and of bilateral facio-lingual
paralysis such as is frequently seen in pseudo-bulbar paralysis
without involvement of the limbs are also rare. Mingazzini gives
three instances of what he regards as facio-iingual paralysis of
lenticular origin. In the first the putamen on the left and in the
second the putamen on the right in the neighborhood of the genu
was softened ; in a third a focus of softening was present in the
globus pallidus. Mingazzini refers in this connection to the cases
of Lepine and Halipre11 which with others have been criticised
by Dejerine.

Mingazzini refers to a form of paralysis intermediate between,
the pure facial and the brachio-facial paralysis which he had pre-
viously reported. The patient presenting this symptom-complex,
besides having paralysis of the inferior portion of the right facial,.
was affected with athetoid movement of both hands. Many la-
cunar foci were found in the left putamen.

A single example of pure brachio-facial paralysis is recorded..
The case was that of a patient affected with paresis of the seventh
nerve and of the superior limb of the right side following soften-
ing of the anterior portion of the left lenticula.

Facio-crural paresis is very rare indeed. Mingazzini says
that he has never seen a pure case of this dissociated paralysis,
but refers to a case previously recorded by him in which was
present oscillatory tremor of the left superior limb with paresis
of the left inferior facial distribution and the left lower extremity.
Two foci of loss of substance as large as a millet seed were
found ; one in the external part of the right putamen and the
other in the external member of the globus pallidus. In two
cases Mingazzini has observed an irritative paretic disorder of
the upper extremity from partial destruction of the lenticular
nucleus on the opposite side. In one of these cases the limb
affected was spastic ; in the other it was the seat of clonic move-

'Lepine, R. Op. cit.

570 MILLS AND SPILLER

ments. In another case in which softening was found in the
middle part of the left putamen, the patient was seized occasion-
ally with clonic movements of the hand and the forearm of the
opposite side.

While the forms of hemiplegia, with or without irritative
phenomena, are sometimes present in lesions limited to the lenti-
■cula, the more frequent syndrome, according to Mingazzini, is
motor paresis of the entire half of the body. He records five
such cases in the monograph we are analyzing and refers to
others previously recorded. The paralytic disturbances often
pass without being observed by the patient, says Mingazzini. They
apply to the physician complaining of paresthesia, he continues,
or of pain along the paretic limbs, or else of vertiginous condi-
tions, or weakness of memory, symptoms evidently due to a
diffuse cerebral arterial sclerosis. It is only a minute objective
examination, he says, which will reveal certain hemiparesis.
While the attack of paralysis may be ushered in by an apoplectic
stroke with unconsciousness, the symptoms accompanying this
are not so severe and persistent as in ordinary cerebral hemorr-
hage. The patients are often syphilitic, and probably because of
this the attacks are frequently preceded by headache and febrile
symptoms. As indicated, much of the paralysis disappears, but a
residue can always be found by a careful examination. The pare-
sis or paralysis of the facial is almost always limited to the in-
ferior distribution of the nerve. The superior extremity assumes
peculiar attitudes. The forearm tends to bend on the arm, and
the hand on the forearm, but these conditions or attitudes are
only rarely spastic in character, as is observed in capsular lesions.
This point seems an important diagnostic one to the writers who
have observed cases presumably of lenticular lesion in which the
non-spastic limbs assumed special attitudes, simulating those
seen in spastic hemiplegia. The three portions of the upper ex-
tremity are usually about equally affected with the impairment of
power. Gross oscillatory tremors may result from attempts to
use the limb. In the lower limb, as in the upper, the paresis is
usually about equally distributed in its three parts. It is rarely,
if ever, a complete paralysis. The patient feels as if his paretic
leg would give way ; sometimes he can walk and sometimes not ;
when he walks his steps are slow and short. The leg of the
paretic side is a little flexed on the thigh, the foot striking the

LESIONS OF LENTICULAR ZONE 571

ground, without, however, performing the classic movement
peculiar to capsular lesions.

Mingazzini lays stress upon the fact that the majority of his
cases with the syndrome of hemiparesis could be referred to
softening of the putamen, situated near, and in correspondence
with, the anterior limb of the internal capsule and not with the
posterior portion. The lesions being somewhat removed from
the pyramidal tracts, therefore their effects when these lesions are
hemorrhagic cysts cannot be attributed to pressure upon these
tracts. In addition, Mingazzini points out that in most of his
cases the lesions were foci of softening which did not exercise
pressure on neighboring parts. A still further point in favor of
the paralytic disorders being due to lenticular lesions and not. to
pressure exerted upon the capsule is the fact that these affections,
even if they are not marked, are persistent and continue until
death. Although partial paralyses, they are not transitory.

The motor function of the lenticula, says Mingazzini, de-
serves to be called supplementary if it is borne in mind that the
motor disturbances in comparison to those produced by the
destruction of the pyramidal region of the internal capsule are
very mild. Mingazzini does not attempt to decide whether the
motor fibers which originate in the lenticula join with those of
the internal capsule ; whether the neurones of which they are
part originate in the motor cortex or in the lenticula itself; and
whether if they originate in the lenticula they come in contact
with neurones derived from the cortex. These are matters for
future research to determine, especially by the studies of experi-
mental and other degenerations. His claim is simply that the
lenticula is a motor organ of some sort ; that it possesses real
motor function. He refers to Johansen's faradic excitation of the
lenticula as confirming his own results and views.

Disturbances of speech, according to Mingazzini, are often
associated with lesions of the lenticula. He says with some re-
serve that he believes the dysarthric disturbances dependent on
lenticular lesions arise only when these lesions are situated on the
left side. He has recorded cases in which the dysarthric disturb-
ances were absent even when the lenticula was injured on both
sides. His explanation of such observations is that the fibers
destined for the movements concerned in speech run in circum-
scribed zones, as it is true that the fiber s destined for the face, the

572 MILLS AND SP1LLER

upper and lower limbs, run also in circumscribed zones ; in other
•words, that the motor zone of the lenticula is subdivided as is the
cortical motor zone.

Discussing in detail some of his observations regarding
speech, Mingazzini says that disturbances cf articulation under
the form of elisions, initial pricking and bad pronunciation of the
dentals were signalized in one case in which tbe external mem-
ber of the globus pallidus on the left was destroyed ; and in an-
other case in which there was a softening of the left putamen.
But it was impossible to find any disorder of speech in still an-
other case in which there was a hemorrhagic focus on the ex-
ternal margin of the right putamen. Disturbances of articulation
were found in a case in which there was a loss of substance which
occupied the more external limit of the left putamen, on a level
with the middle part of the colliculus caudatus ; and these were
not found in another case in which the hemorrhagic focus occu-
pied the medial and inferior part of the globus pallidus of the
left ; and not in still another case in which the lesion was in the
base of the putamen and in the middle part of the external cap-
sule of the left. These results demonstrate again that the lesions
of the right lenticular nucleus have no effect on speech, and that
those of the left lenticular nucleus give rise to disturbances of
articulation only if situated at fixed points.

VIEWS OF SCHAFER, VOX MONAKOW AND OTHERS.

Coming to one of the most recent physiological works, the
views of Schafer,1- regarding the functions of the striatum (len-
ticula and caudatum) are stated in the following manner:

"Cajal describes axones of many of the pyramidal cells of
the frontal lobe as passing to the corpus striatum. After destruc-
tion of the frontal lobe in dogs and monkeys, Marinesco found
numerous degenerated fibers in the corpus striatum and especially
in the caudate nucleus. On the other hand, the corpus striatum
receives numerous fibers from the thalamus and the sub-thalamic
region, and probably sends out centrifugal fibers downwards,
along the motor tract ; but these have not hitherto been satisfac-
torily traced ; some appear to go to the substantia nigra. The

12"Text Book of Physiology," edited by E. A. Schafer, LL.D, F.R.S.,
Vol. II., Edinburgh and London, 1900.

LESIONS OF LENTICULAR ZONE 573

corpus striatum is generally believed to act as a center for the
higher reflex movements, and to be in close association with the
Rolandic area, but the experimental grounds for this belief are
still lacking. Morphologically, the corpus striatum is regarded
as a part of the cortex."

Von Monakow13 says that a lesion taking in almost the entire
caudate nucleus, leaving the internal capsule free, or even the
lenticular nucleus, does not of necessity cause a persistent hemi-
plegia. He continues that Reichel14 has shown that a symmetrical
softening of both lenticular nuclei may occur without clinical
manifestations. As a rule, hemiplegia with the involvement of
the facial and hypoglossal occurs in extensive lesions of the cau-
date and lenticular nuclei. It is seldom complete and only per-
sistent when the internal capsule, that is the premedial portion
of it, is implicated. Some areas of softening, either in the lenti-
cula or in the caudatum, usually are latent. Irritating foci, for
example tubercles, cause occasionally early hemiplegic contrac-
tion. Aside from the hemiplegia, — though together with this in
connection with lesion of the caudate and lenticular nuclei — oc-
casionally occur hemianesthesia, tremor, forced laughter, chorei-
form movements, vasomotor disturbances (elevated temperature,
reddening of the skin, etc.) and central pain in the opposite half
of the body, especially in the arm. But all these phenomena, as
a rapid glance through the literature on focal diseases shows,
may occur without direct lesions of the ganglia of the forebrain.
Occasionally they appear following lesions in the neighborhood
of the posterior internal capsule, in the posterior portions of the
thalamus, and in the tegmental region. Nothnagel, for instance,
says von Monakow, attributes vasomotor disturbances accom-
panying hemiplegia to involvement of the posterior internal cap-
sule. Numerous observations speak, however, for the closer rela-
tion between elevation of temperature in the paretic extremities of
one half of the body and disease of the caudate nucleus in the
opposite half brain. Experimental investigations also are favor-
able to this view. We know that irritation of the caudate nucleus
in animals may be accompanied by pronounced, though transitory,
elevation of temperature. Various investigators have observed
similar elevations of temperature on the opposite side to the foci

"Von Monakow, C. "Gehirnpathologie," second edition, Wien, 1905.
"Reichel. Wiener Medicinischer Presse, 1898. "Diseases of the Cau-
date Nucleus and Lenticular Nucleus." Cited by von Monakow.

574 MILLS AND SPILLER

of disease in man. In such cases edema of the skin was also
present in the extremities. In all these cass th lesion, even
microscopically, was not limited strictly to the caudatum.

Choreiform movements, says von Monakow, were years ago
associated occasionally by this or that investigator with disease
processes in the caudate or the lenticular nucleus. Ellischer,
Flechsig and others have seen in those who have been affected
with chorea and have died, peculiar, strongly refractive, often
mulberry-shaped, bodies in the lymph sheaths of the vessels in
the portions of the brain mentioned. YYollenberg found similar
formations in the lenticula of persons who had not suffered from
chorea, and therefore disputes the causal relation between chorea
and these bodies. Hebolt observed tremor in the extremities in
a case of lesion of the putamen. Such isolated observations, ac-
cording to von Monakow, are of little value so long as they re-
late to the chance occurrence of focal disease. At all events, he
says, a uniform relation has not yet been established between
choreiform movements and disease processes limited to the cau-
date or lenticular nucleus.

Deroubaix,15 in a paper on spasmodic laughing and weeping,
reports one case with necropsy which is of great interest in con-
nection with the pathology of this emotive syndrome, and with
the general discussion of lesions of the lenticula. The patient
was a man thirty-eight years old who had had a stroke causing
left hemiplegia, but without any aphasia or dysarthria. He ex-
hibited spasmodic laughter followed by weeping and accompanied
bv associated movements in the paralyzed left arm. Death was
from a second stroke. Necropsy showed a large area of soften-
ing which had destroyed the lenticular nucleus, the anterior limb
of the internal capsule, and all the white matter of the frontal
lobe and of the central region, to the cortex on the right side.
The thalamus, genu and posterior limb of the internal capsule
were not affected.

Some of the conclusions drawn by Deroubaix are as follows:
That the fibers concerned with the function of emotive expression
probably pass outside of the pyramidal fibers like those concerned
with the function of coordination and tonus ; that the thalamus is
the seat of the automatic movements of emotive expression, es-

"Deroubaix. M. A. Journal de Neurologie, Vol. XL, No. 5, 1906.

LESIONS OF LENTICULAR ZONE 575

pecially of laughing and crying ; that laughing and weeping are
under the control of the cortex ; that the corticothalamic fibers
pass in front of the knee of the internal capsule, probably by the
lenticular nucleus. Deroubaix therefore did not attribute the
spasmodic laughing and weeping in his case to destruction of
centers in the lenticula, but of fibers passing from the cortex
through the lenticula to the thalamus. He speaks especially of
the facio-thalamic bundle.

With regard to this explanation it is not altogether acceptable,
as Mingazzini believes he has shown and as facts supplied by
others indicate, that the lenticula is a motor organ and has dis-
tributed through it zones and centers of particular kind for move-
ments of various parts of the body, including the movements con-
nected with the expression of emotion. This being the case,
destruction of such centers, especially if on both sides, would
give rise to such a lack of control of the movements of expression
as to cause the involuntary or spasmodic laughing and weeping.

In one or two of our cases of lenticular lesion involuntary
emotion was present.

In connection with the question of speech disorder from len-
ticular lesion it will be observed in the case of Deroubaix that
the lesion was right sided.

Pagano,10 by injecting solutions of curare into the caudate
nucleus has concluded that :

(1) Excitation of the anterior third and of the middle third
of this nucleus provokes in dogs something very like the emotion
of fear. This effect is best brought out when the injections reach
the internal half of the organ. All the characteristics of this
emotion are present, the gesticulations, the play of the physiog-
nomy, the cardiac and respiratory phenomena, the actions of the
intestines, and of the bladder, the state of the pupil, and the
effect of threats and noises all go to form conclusive evidence of
this emotion.

(2) The excitation of these points, but especially of the
middle third, provokes a strong erection of the penis which ap-
pears immediately after the injection and persists until death.

(3) The excitation of the anterior extremity of the nucleus

"Pagano. Riv dipatol. nerv. e. Ment., July, 1906. Reviewed by W. W.
Ireland in the Journ. of Mental Science, January, 1907, p. 175.

576 MILLS AND SPILLER

produces an agitation which presents the appearance of fear
modified with anger.

(4) The excitation of the posterior third of the nucleus pro-
vokes a series of manifestations of anger ; the grinning and bark-
ing, the readiness to attack and bite, and the whole attitude leave
no doubt as to the nature of the emotion.

(5) The excitation of the outer part of the anterior third of
the nucleus, besides some emotional disturbance, provokes in a
greater degree intestinal and vesical phenomena.

The nucleus caudatus according to these experiments is a
center of some of the emotions.

Pagano has shown the existence of distinct motor centers in
the cerebellum by the same method.

THE NUMBER AND CHARACTER OF THE CASES STUDIED BY THE

WRITERS.

The cases which follow are a few out of a considerable num-
ber which have come under the observation of the writers, in
which lesion of the lenticular nucleus was found at necropsy. In
the majority of these cases the lesion, usually a hemorrhagic cyst
or an old area of softening, has not been confined to the lenticula ;
indeed, in most of them several parts of known functional im-
portance, and others whose functions are still in obscurity, were
involved in the destructive area of disease. The reason of this
is of course easy to recognize, and resides in the fact that the
blood supply to the great basal ganglia is from branches of the
middle cerebral artery, which also sends branches to various
regions both of the cortex and of the interior of the brain. The
writers have realized the same difficulty that has been realized
by others in reaching conclusions regarding the functions of the
striate bodies, because of the infrequency of lesions isolated to
them. Even in the cases chosen to illustrate some of the points
of this paper, the lesions present were scarcely in a single one
absolutely limited to the lenticula. In two or three, however,
this was so nearly the case that they have felt justified in draw-
ing some inferences regarding lenticular function.

The points which the writers have attempted to elucidate or
at least on which they have tried to obtain some light through
the study of their cases, circle around the subject of the mechan-
ism of cerebral speech and that of the representation of m6tility.'

LESIONS OF LENTICULAR ZONE $77

Case i. Apoplectic Attack Causing Right Hemiplegia and
Loss of Speech — Partial Recovery of Motility and Speed; — Som?

Mental Slowness and Confusion — Dysarthria — Partial Word
Dumbness — Word Deafness Present but only Slightly Marked —
Hemorrhagic Cyst involving the entire Lenticula, {he white mat-
ter of the Insula and the anterior part of the First Temporal
Convolution, and slightly the Posterior Limb of the Internal
Capsule.

M. S.. aged forty-eight years, white, born in Ireland, was
admitted to the men's nervous wards of the Philadelphia General
Hospital August 21, 1903.

On admission the patient complained of headache and also of
more or less weakness and helplessness in his right leg and at
times in his right arm.

No family history and no history of important illness previous
to that producing his condition on admission could be obtained.

The patient made a statement that he had had hts after an
injury to his head, after which he had also developed some diffi-
culty of speech.

He also said that three months ago he came home feeling in
his usual health, and after supper became dizzy and fell on his
face. He said that he did not know anything for two weeks,
but when he recovered his mind, he found that he could not use
his right leg or arm and could not speak at all. He remained
unable to speak for about two months, since which time his power
of speech had gradually returned, but he still spoke with difficulty.

The patient was a hearty, robust-looking man. His tongue
was moist, slightly coated ; pulse of good quality. His heart
action was irregular. The lungs showed good expansion.

The pupils were equal, reacted well to light, but slowly to
accommodation.

Examination made September 16, 1903, showed but little loss
of power in the right arm or leg ; the grip on the right side was,
however, slightly impaired. Station was good and gait steady.
The reflexes were normal. No note as to sensation was recorded.

On February 24, 1904, a note was made by one of the phy-
sicians in attendance which stated that in his last apoplectiform
attack he had some spasm in the right arm and leg ; and also
that he had sensory aphasia ; and although he did not miss any
words he occasionally missed a syllable.

On February 25, 1904, the record stated that his gait was
fairly good, but slightly stiff : that he dragged the right foot
slightly. The knee-jerks were spoken of as "spastic" with slight
attempts at clonus on both sides ; station was good with the eyes
open or closed ; the pupils responded to light and accommodation ;
no palsies of ocular muscles were present ; the tongue protruded
to the right ; the naso-labial fold was slightly deeper on the right

578

MILLS AND SP1LLER

side. The grip was now said to be better on the right than on
the left side.

The patient's mentality was noted as "slow" ; he required
more time to comprehend questions. He could not read nor
write because of lack of education. He appreciated the purposes
and uses of objects. He recognized a book and named it as
"book." He called a gold watch a "dollar." When pointed to
the time, which was 12.20. he said it was "after two"; he could
not specify the minutes, lie could say the days of the week
slowly. When told to close his eyes lie grasped his hand; when
asked to point to a chair, he picked up his hat. lie easily con-
fuse'! the name of one object with that of another, lie recog-
nized what spectacles were and said that he needed them him-
self ; he could not. however, name them. Me could not name

Fig. I. Cyst of the Left Lenticular Nucleus and External Capsule.
Motor Aphasia Incomplete (Case I).

a lead pencil. He recognized a pen, could not name it at first
but after a little effort was able to name it. He was also asked
to name various other objects, as a key, a ring, and gloves, but
failed to do so ; but he named some objects of wearing apparel
correctly.

Astereognosis was not present.

On December 21. 1905, he was found in a state of collapse
and the following facts were noted : His eyes were turned up-
wards and oscillated slightly from right to left ; the face was
drawn slightly towards the left side. The right arm and leg
dropped lifeless when raised. There was some spasticity in the
right arm. The reflexes were exaggerated. On December 22,
1905, the patient was conscious again and seemed to understand
all that was said to him .and a note said "were it not for his
partial aphasia would be able to answer intelligently."

The heart sounds were very good, the second sound being
exaggerated, especially the aortic. Pulse at the wrist was strong,

LESIONS OF LENTICULAR ZONE 579

of rather high tension and moderately rapid. The patient did
not respond to pin pricks. Upon catheterization only one half
ounce of urine was obtained.

On December 2$, 1905, the patient was in fairly good con-
dition at 10 A.M. At 11. 15 he was found rigid, with legs ex-
tended and arms held close to the body, the forearm being flexed
on the arm. His face was markedly cyanosed. The jaw was
rigid, respirations had ceased and the pulse could not be felt at
the wrist. The heart sounds could not be heard. A minute
or so later the patient relaxed and was dead.

A section made at the level of the upper part of the basal
ganglia revealed a cyst in the left hemisphere, which had impli-
cated the middle and posterior part of the left lenticular nucleus,
and extended to. but did not involve, the cortex ai the island of
Reil. It extended ventrally to 0.5 cm. (1-5 in.) from the an-
terior limit of the lenticula. It extended to, or possiblv slightly
involved, the posterior limb of the internal capsule. At a level
0.5 cm. (1-5 in.) lower the cyst extended from its posterior end
into the anterior part of the white matter of the first temporal
convolution, but did not involve the cortex, nor the posterior half
of the first temporal convolution.

The temporary right hemiplegia with residual very moderate
hemiparesis was probably due to the lenticular lesion, although
it is possible it may have depended on the slight involvement of
the internal capsule. The temporary, somewhat complete, aphasia,
was probably due to the effects of this lesion on neighboring parts,
some of the motor defect in speech being, however, probably due
to the lenticular lesion. The partial word dumbness could not
have been due to lesion of Wernicke's zone, as only the anterior
part of the first temporal convolution was involved. As the
posterior part of this convolution is considerably higher than the
anterior part, the fibers from the former could not have been
greatly involved by the extension of the cyst at a low level
into the anterior part of the first temporal convolution. It is
more probable that some of the symptoms are to be attributed
to injury of fibers in the external and extreme capsules which
stand in relation to the posterior part of the first and second
temporal convolutions.

Case 2. Apoplectic Attack causing Right Hemiplegia and
alost complete aphasia — Only a fczv Recurring Utterances
retained — Marked Word Deafness at First — Probably some
Word Blindness which soon Disappeared — Pozver of Humming
Melodies retained — Continuous Improvement under Systematic
Training — Spontaneous Language largely regained — Ability
to write Ziith unparalyzcd arm acquired — Mentality practically
unaffected — Death after four years from Thrombosis of Su-
perior Mesenteric Artery — Dura thickened and adherent —

580 MILLS AND SPILLER

Cyst destructively involving the Insula, the Lenticula, the Anterior
and Posterior Limbs of the Internal Capsule, the External part of
the Thalamus, and the White Matter of the Anterior Half of the
First Temporal Convolution at a little distance from the Cortex —
The Area of Broca and Subjacent White Matter and Wernicke's
Zone not involved.

This case is one, the clinical details of which were in part
given by one of us, Dr. Mills,17 in a paper on the treatment of
aphasia by training, published nearly two years before the death
of the patient. A contribution giving some facts regarding his
condition and attempts made at training him for his aphasia be-
fore he was seen by Dr. Mills has also been published by Mrs.
Kate Herman.18

In the account which follows the writers have summarized
the most important facts bearing upon his aphasia and hemi-
plegia from the papers just referred to, and also from communica-
tions received from the patient's former secretary, Miss Dorothy
C. Falk, and his former professional and business associate, Dr. H.
C. Hays. As this contribution is intended to deal more especially
with the functions of the lenticula and the symptomatology result-
ing from a lesion of this ganglion, the writers have thought it bet-
tei to concentrate attention upon the facts demonstrating his type
of aphasia, rather than upon the efforts at re-education of his lan-
guage and the results of these efforts. The case is unusually valu-
able because of the fulness of the history obtained from the differ-
ent sources to which reference is made, and also because of the
intelligence and education of the patient which allowed a more
complete record of his speech defects.

The patient was a physician, forty-five years old, residing in
one of the western states. In July, 1902, he had an attack of
right hemiplegia with almost complete aphasia. He was first
under the instruction of Mrs. Kate Herman from June 15, 1903,
to July 15, 1903. At the beginning of this period his vocabulary
consisted of only four expressions, namely "yes," "no," "but,"
and "O God." "Yes" and "no" were commonly used correctly.
He sometimes added the word "but" to "yes" or "no" ap-
parently when the "yes" or "no" did not seem to him to
express his meaning, or in order to give some force to what
he was trying to say. At other times he would use the expression
"O God." He often used pantomime in an unmistakable man-
ner. When he got possession of a few useful words and phrases
he discontinued this expletive. Dr. Mills does not recall his

"Mills, Chas. K. "The Treatment of Aphasia by Training." Journ.
of the Amer. Med. Association, Dec. 24, 1904.

"Herman, Mrs. Kate S. "Heilung der Aphasie durch den Artikulations-
unterricht." "Eos." Vierteljahrschrift fur die Erkenntniss und Behand-
lung jugendlicher Abnormer, Heft 3, 1906.

LESIONS OF LENTICULAR ZONE 581

having used it when he was under his care. His memory for
persons, places and occurrences was good. He was often very
insistent in his efforts to make himself understood. His instruc-
tor was soon convinced that his periods of concentration should
be short and his exercises for improving his language varied.
Word deafness was quite marked at this time, but was not com-
plete. He seemed at times to be partially word blind, but this
defect was probably comparatively slight if it really existed, as
even early in the efforts to train him he was much helped by
seeing the words which were used in training him either in
script or printing. It was noted that he could assist himself in
understanding what was read from a newspaper by tracing the
words with a pencil as the paper was being read.

When he heard music which he knew, he would hum the
melody and occasionally articulate some of the words of the song.
One day when he was trying to relate an historical occurrence
he could not pronounce the word "Maryland" intelligibly until
it fortunately occurred to him to murmur the song, "Maryland,
my Maryland."

His voice was not impaired, — a rather interesting fact in con-
nection with the functions of the lenticula. He was trained sys-
tematically after the manner used with dumb children. The
formations and combinations which he found most difficult were
those with which such children struggle most, namely, k, g, and
ng; tli also gave trouble. He was made to repeat the names of
objects in his environment, and his teacher states that the patient
would succeed one day in using such words as house, cow, tree,
bird, etc. and at another time would be unable to recall these, un-
less helped a little at the beginning. Gradually verbs were taken
up and longer and longer sentences tried. With his first in-
structor, as later with Dr. Mills, it was found that he experienced
his greatest difficulty with adjectives, pronouns and articles, and
words generally which expressed no mental image.

He was taught to write with his left hand, making continuous
and notable progress. He repeated aloud what his instructor
wrote for him.

When he first consulted Dr. Mills in October, 1903, his right-
sided paralysis, though still marked, was much improved. No
loss of sensation and no affection of the bladder or bowels were
present. The face was the seat of a moderate right-sided paresis,
the tongue not deviating to either side. The deep and super-
ficial reflexes were of the usual type found in cerebral hemiplegia
— exaggerated knee-jerk with front tap and ankle clonus and the
Babinski response being present on the right side.

When tested with Wyllie's physiologic alphabet, it was found
that he could repeat the vowels a, c, /, o and u well, having been
previously trained in their pronunciation, but he could not re-
member them from day to day. In like manner he could repeat

582 MILLS AND SPILLER

the consonants of the alphabet, but could not recall them spon-
taneously. He was partially word deaf, having regained word
hearing to a considerable extent by time and training. He could
understand most familiar expressions, but if a strange or unusual
word were used he did not understand it. He was also apparently
partially word blind, having relearned to read considerably before
coming under observation. With his left hand he could write
the words that he was able to read. He could not understand
the meaning of such prepositions as of, to, and for, if pronounced
or read. He could not spontaneously write these words when
asked, but could copy them.

In connection with a study of his reacquisition of language,
particular attention was paid to the degree in which he regained
different parts of speech. It was noticeable that in his efforts
to talk he chiefly used his nouns and verbs, occasionally employ-
ing a pronoun. The words which expressed the qualities of
things, which join and relate things to each other and to ac-
tions,— in other words, adjectives, adverbs, conjunctions and
prepositions, — were still almost entirely eliminated from his
vocabulary. Auxiliary verbs like to have, and to be, in all their
modes and tenses, were apparently without any meaning to him.
The word is or was occurring in a sentence seemed to worry him.
In brief, this patient was a hemiplegic aphasic, the motor aphasia
having at first been almost complete ; the sensory aphasia partial.
An appreciable degree of recovery from his aphasia had occurred
from the first under the method of training by repetition and by
efforts at spelling, reading and writing.

Persistent efforts at training were made. The measures em-
ployed were the facial and other gymnastic methods used with
the deaf and dumb, the method of repetition from dictation, of
copying, the use of Wyllie's physiologic alphabet, of a phonetic
reader, a language primer and grammar. An interesting point
in the history of the attempts at this man's re-education in speech
was the fact that he made much use of a small dictionary. He
made considerable advance by looking up the definitions of words,
and when he found words and expressions in the definition which
he could not comprehend, these in their turn were looked up in
the appropriate places.

After the patient's return home communications were received
from time to time regarding him. He steadily improved, al-
though at first his progress was comparatively slow. In a short
time he was reading his newspapers and magazines and under-
standing fully what was in them. Six months after he left Dr.
Mills word was received that he wTas acquiring more voluntary
expressions every week. A noticeable feature now was that when
he was told to say anything instead of repeating it verbatim, he
would express the idea in his own words. He read much and
played whist and other games, and had just finished transacting

LESIONS OF LENTICULAR ZONE 583

some business for the institution, the first which he had done of
any importance since his illness. A little later, in describing his
improvement, the physician associated with him in his work, said
that his use of words to express an idea was much more general
than had been the case heretofore. He now expressed in his own
words answers to questions in the form of a sentence rather than
a single word, and it was noticeable that he was able to use a
different word to express the same idea. At times he made sen-
tences of considerable length, using nouns, verbs, adjectives, pre-
positions, etc. Thorough and systematic training with the as-
sistance of his instructors and members of his family was kept
up. the patient helping the work very much bv his own de-
termination and originality in methods. He continued to use his
dictionary. His teaching was much along the line of both what
is known as the word method and also that of spelling bv usinr
each letter as in the older method.

Many of the details of the methods used to improve his
language, and of the time spent in these efforts will be better
reserved for an additional paper. With regard to the re-educa-
tion in language this case is the most interesting that has ever
come under our observation. Nearly four vears elapsed between
the time of the apoplectic attack causing his hemiplegia anci
aphasia, and his death. During much of that time with interrup-
tions sometimes extending over a few weeks, or even months
the earnest, formal retraining of his speech was carried on and
even when this systematic instruction was not resorted to the
patient, a man of much originality and energy, was always trying
to re-educate himself in the use of language'. His former secre-
tary calculated that during the four years he was given about
one and one half years of training. As a rule only one to two
hours daily were given to formal instruction.
m It is interesting to note in connection with the question of
intellectual deficit in aphasics, which has become so prominent
through the views of Marie, that this patient retained through-
out his mental vigor and general capacity. His deficiencies
seemed to be entirely those conditioned bv his defects of speech
meaning by this, of course, his word deafness, his early slight
or moderate word blindness, and his difficulty in correlating con-
crete concepts with each other as well as his very pronounced
motor aphasia. About nine months after his attack the sani-
tarium, of which he was the proprietor and chief physician
burned down. Measures were at once taken to rebuild 'it and
as bearing on his mental condition, his secretary wrote Dr Mills
that he was always able to figure on any proposition just the same
as before his illness but he could not speak it, ail his figuring for
his sanitarium being done in a very accurate and clearsighted
manner. &

584

MILLS A XD SPILLER

The improvement in his speech was continuous up to the time
of his last illness.

He had no second apoplectic attack. He had. however, three
distinct epileptiform seizures, at long intervals, during the last
two or three years before his death. No increase either of his
paralysis or of his aphasia occurred as the result of these attacks.

His general mental state was good. At times there were in-
dications of moroseness, some irritability of temper and im-
patience when he was not immediately understood, and occasion-

Fig. 2. A case of marked motor and sensory aphasia. The area' of
Broca is intact and the subcortical white matter was not in-
volved in the primary lesion (Case 2).

ally when much discouraged, he spoke of suicide. He showed no
marked change in disposition which could be noted as altogether
different from his former self. His general physical health re-
mained good.

The conditions and symptoms preceding his death could in
no way be attributed to the cerebral lesion causing his aphasia
and hemiplegia, although the changes found in the aorta and the
superior mesenteric artery might have some relation to the al-
terations in the vessels of the brain which were present at the
time of the cerebral attack. He died about four years after the
onset of his aphasia and hemiplegia, from thrombosis of the
superior mesenteric artery, as determined at the post-mortem

LESIONS OF LENTICULAR ZONE

585

examination. His symptoms were those of shock and great ab-
dominal pain.

The necropsy was made by Dr. Philip Hillkowitz of Denver,
Colorado, at which place the patient was at the time of his death.
We are much indebted to Dr. Hillkowitz for the account of the
gross findings. The body was well nourished, with considerable
adipose tissue ; muscular development good ; the heart showed

Fig. 3. The lenticular nucleus and the island of Reil were destroyed.

The sclerosis extended anteriorly to the white matter of Broca's

area, and posteriorly to the posterior extremity of the

island of Reil (Case 2).

slight thickening of the mitral
were found on the aorta, above
ing of the coronary arteries,
around the opening of the right
of the left lung was strongly
diaphragm. The left kidney was
face. A slight scar was found on

valve ; numerous small plaques
the valves and around the open-
Marked hyperemia was present
coronary artery. The lower lobe
adherent to the chest wall and
very much puckered on its sur-
the external border, about 1 cm.

586 MILLS AND SPILLER

(2-5 of an in.) in diameter, extending into the interior. The cor-
tex was slightly diminished and was pale in color ; the right kidney
was similar to the left with the exception of the scar. The in-
testines showed a dark purple color extending all over both the
large and small intestines. The superior mesenteric artery showed
a thrombosis which could be followed in the branches of the
vessel.

The dura was much thickened and adherent in many places
to the membranes beneath. The membranes over the occipital
lobe were largely congested. An elliptical cavity 5 x 2.5 cm.
(2 x 1 in.) was found in the left cerebral hemisphere. The
description of the parts destroyed by this lesion is given in the
following paragraph after careful study of the specimen by Dr.
Spiller. the brain having been forwarded, after hardening in
iormalin, to the Laboratory of Neuropathology of the University
of Pennsylvania by Dr. Hillkowitz, who however had made an
examination at the time of the necropsy. The description of the
position and extent of the lesion differs in only one particular
from that furnished by Dr. Hillkowitz, although this is one of
some importance. Dr. Hillkowitz speaks of the lesion as in-
volving a portion of the inferior frontal convolution (presumably
meaning by this the third frontal). Although the cyst extended
close to the third frontal it did not involve the cortex of this con-
volution.

A large cyst was found in the left cerebral hemisphere. In
a horizontal section through the lateral ventricle and upper part
of the basal ganglia, the sclerosis was found to extend to 1.5 cm.
(3-5 in.) from the cortex of the convolution posterior to the
ascending limb of the fissure of Sylvius. The area of Broca and
subjacent white matter were intact, although fibers passing to or
from the foot of this area were probably implicated. The cyst
had destroyed the island of Reil, the whole of the lenticula, the
anterior and posterior limbs of the internal capsule and the ex-
ternal part of the thalamus. The head of the caudate nucleus
was very slightly affected. The gray matter of the first temporal
convolution was not involved, although the white matter was in-
volved at a little distance from the cortex.

The part of the first temporal convolution destroyed was the
white matter of its anterior half. To be exact, the posterior
border extended to the beginning of the innermost part of the
middle portion of the first temporal convolution, in a section made
through the upper part of the basal ganglia.

This case, although one of great value in connection with
the discussion of the subject of aphasia, loses some of its im-
portance as regards the functions and symptomatology of the
lenticula, because of the fact that not only was this ganglion
destroyed, but so many other functionally important regions. Any
speech or paralytic disorder if dependent upon the lenticular

LESIONS OF LENTICULAR ZONE 587

lesion, was probably covered by the effects of destruction of other
parts. Broca's convolution was not involved, as was not the
Rolandic operculum.

THE LENTICULAR ZONE OF MARIE AND MOTOR APHASIA.

Some light is thrown on several of the points of great inter-
est in connection with the current discussion of the subject of
aphasia, springing out of the somewhat revolutionary contribu-
tions of Marie, by the clinical and pathological facts observed
in the case just described. Marie has laid much stress upon
the lenticular zone. In defending himself against those who have
charged him with giving too much importance to the lenticula
in his theories of the pathogenesis of motor aphasia, he insists
that the lesions producing the train of symptoms to which he has
called attention are not due to isolated lesions of the lenticula,
but to it and to those portions of its environment which he
includes in this lenticular zone. It is important, therefore, to
know just how he defines this zone.

In a horizontal section of the brain, he says, a transverse line
drawn from the anterior angle of the insula to a corresponding
point of the lateral ventricle will give its anterior border, while
a line from the posterior angle of the insula to a corresponding
point of the lateral ventricle will give its posterior limit. Thus
he includes within this zone more than half of the thalamus,
both limbs of the internal capsule, the greater part of the caudate
nucleus (all except a part of the tail), the lenticular nucleus, and
the island of Reil with the subjacent white matter. Marie does
not attempt to distinguish between the symptoms of lesions of
the striatum and of the white matter and cortex of the island of
Reil. He defines his position concisely as follows:

A lesion implicating only the zone of Wernicke causes the
aphasia of Wernicke ;

A lesion of the lenticular zone causes anarthria, which is
merely the pure motor aphasia of the writers, believed by them
to result from a lesion of the white matter beneath Broca's area
with the cortex intact. Articulate speech alone is affected, inter-
nal speech is preserved ; the patient reads and writes and under-
stands without difficult}- spoken speech.

A lesion implicating the zone of Wernicke together with the
lenticular zone causes the aphasia of Broca (great impairment

588 MILLS AND SPILLER

or loss of spontaneous speech, of reading and writing, and more
or less impairment of the comprehension of spoken language).

The case just given fulfills these requirements for the aphasia
of Broca. The patient was motor aphasic and agraphic in large
measure and had great impairment of the power of reading,
According to widely accepted opinion, the case should have exhib-
ited also pure word dumbness and pure word deafness, because
the lesion did not extend to the cortex either in Broca's area or
Wernicke's zone.19

"Marie, Pierre. Revue de Philosophic 1907.

{To be continued. |

Society proceedings

AMERICAN NEUROLOGICAL ASSOCIATION, HELD IN
WASHINGTON, MAY 7, 8 AND 9. 1907.

The President, Dr. Hugh T. Patrick, in the Chair.

(Continued from page 542.)

INTRADURAL RESECTION OF THE POSTERIOR ROOTS OF A

NUMBER OF SPINAL NERVES. FOR THE RELIEF

OF INTRACTABLE PAIN.

By Dr. George W. Jacoby.

Historical. General belief that the operation is dangerous is erroneous.
Questions of technique which are of neurological interest. Tabulated
cases. Indications for operation. Report of a successful case in which
all the roots which .go to make up the brachial plexus were resected.
Sensory change after operation. Head's observations. Conclusions.

Dr. P. C. Knapp said that in spite of Dr. Jacoby' s paper his own ex-
perience has forced him to look with considerable hesitancy upon this oper-
ation for the division of the nerve roots. He had reported two cases of
division of the roots before this Association several years ago. In one
case death occurred upon the table. The patient was a very stout and
muscular man in good physical condition at the time of the operation.
Much blood was lost in getting into the spinal canal. In the second case,
also for amputation neuralgia, the operation proved temporarily successful
for the relief of the neuralgia, but although four or five nerve roots were
divided there was no special loss of sensibility which could be made out
in the stump, the stump being close to the elbow, so that there were the
areas of a number of nerve roots there which could be tested. The man
at the time the case was reported had developed a spastic paraplegia which
came on rather gradually after the operation. After the case was re-
ported another operation was done, the laminectomy wound opened, and
there was found no indication of any hemorrhage or any special pressure
upon the cord. The pain had returned, though never to the same extent
in the stump. Further roots were divided, but nothing was found which
could be relieved, and the man was in a most deplorable condition, still
suffering from pain in the stump in the one arm, and with a most extreme
grade of spastic paraplegia of the legs. There was considerable disturb
ance of sensibility in the legs, but it was about equal on the two sides.
His statements in regard to the degree of sensibility, however, were rather
untrustworthy, so that it could not be very exactly mapped out, but his
condition was distinctly deplorable. In view of these two cases and of Dr.
Prince's, which Dr. Prince will probably speak of, Dr. Knapp said they
felt in Boston considerable hesitancy about recommending division of
the posterior roots for the relief of intractable pain.

Dr. H. H. Hoppe said the experience he had had of resection of the
posterior roots is limited to one case, but that case was an especially dis-
astrous one. The woman had suffered from intractable pains in both legs
for three or four years, and a tentative diagnosis of extradural tumor was
made. It was decided that at the operation if no extradural tumor was
found the posterior nerve roots were to be cut off. Laminectomy was
performed and the posterior roots were divided on both sides of the spinal
cord. After the operation there was absolute loss of sensibility in both

590 AMERICAN NEUROLOGICAL ASSOCIATION

legs, the reflexes were abolished and the pain continued. During the
operation the cord seemed to be entirely normal. There was no swelling
in the cord, in spite of the fact that all of the pain was concentrated and
localized in both lower extremities. The operation was followed by com-
plete paralysis of both lower extremities, which at the time seemed to con-
firm Sherrington's opinion that complete loss of sensation in all of its
qualities leads to loss of motor power. Twenty-four hours after the
operation this woman developed acute trophic sores on the heels and died
seventy-two hours after the operation. No autopsy could be obtained, but
the fact was very striking that this woman's pains were not relieved by
the division of all the posterior roots on both sides.

Dr. Morton Prince said he has always felt that in suitable cases this
operation is one which he should not hesitate to recommend, but he
thought the case must be a justifiable one. By this he meant that the pain
must be of such a severe character as to justify the risk, which his own
experience showed was considerable. In his case (one of brachial neuritis)
which had just been referred to by Dr. Knapp and was included in the
statislics of the reader there was as a result of the operation complete
relief of the pain in the arm. This was fine, but that was not the end
of the patient's troubles. After the operation there developed a Brown-
Sequard paralysis attended by most shocking pain in the leg. The cause
of this secondary paralysis can only be inferred to have been caused by
pressure of some kind, while the pain may have been due to an ascending
neuritis. The patient's troubles and trials were so great that as a final
result of the operation he shot himself; so that it cannot be said that so
far as the ultimate results were concerned the operation was a success
in this case.

Dr. Prince said there was another point which he thought must be
borne in mind, and that is, that when the pain has persisted for a long
period of time there is a tendency for the patient to become hysterical
and develop hysterical pains. Dr. Weir Mitchell, it will be remembered,
called attention to this fact in his work on the injuries of nerves. The
patient becomes worn out mentally and physically with suffering, and the
pain after a while spreads and becomes both in degree and extent far out
of proportion to the injury. Dr. Prince thought that in the case Dr.
Knapp spoke of a very intense hysterical condition developed, creating
pain beyond that which could be accounted for by the affection of the
nerve. The persistence of pain after the resection of the nerves may
often be explained in that way. He thought that this tendency must be
taken into account to explain the failure of this operation to relieve pain.
If the nerve roots are cut there must be cessation of pain in that district
unless the pain is of an hysterical character, or unless an ascending central
neuritis has developed.

Dr. P. Zenner said he merely wished to mention a case never reported
which he had under observation several years ago. This was a case of
tumor involving all of the brachial plexus. The tumor was shown post-
mortem. The man had intractable pain. He had had symptoms probably
for eight months before Dr. Zenner saw him; pain, then anesthesia in
the ulnar region, and paralysis of all the muscles below the elbow. He
had become addicted to morphia on account of his intense suffering. In
this case after a preliminary operation seeking for the tumor, which was
not found, laminectomy was performed and the roots of only three nerves,
the first dorsal and the last two cervical roots were resected. For a little
while the patient had complete relief from pain, so that one might suppose

AMERICAX NEUROLOGICAL ASSOCIATION 59i

that all the nerves related to the affected area had been resected, but soon
his pain returned, and he said his suffering was as great as ever. This
was doubted. He lived six months or longer, and finally died of a fatty
heart. The operation appeared to have done no harm in this case. It
did not impair his general health, excepting that he always said he was
disabled, that he could not hold his head as well, etc. But the operation
seemed to have done no harm to the man, and while it was supposed that
his pain might be explained in the way Dr. Prince has just spoken of, still
it is more probable that the pain returned or was as severe as ever because
not sufficient roots had been resected.

Dr. F. R. Fry said that Dr. Mudd had recently operated for him on a
case where the relief from pain was marked. The patient had a large
sarcoma in his left thigh. The right thigh also contained considerable
amount of the growth. The distribution of some of the pain regions led
him to believe that the cord might also be involved. The operation was
done for the purpose of severing all the sacral and lower lumbar sensory
roots. Owing to the unusual amount of fluid in the wound and the general
condition of the patient the lowest roots were missed. Three days later
the patient was again placed on the table ; the field was dry ; the patient's
condition good and these roots were readily recognized and cut. The
patient was entirely relieved from the severe pains which morphine was
failing to control. He died two months later from exhaustion. Dr. Fry
thought there would be an advantage in a two stage operation in some
cases of this kind.

Dr. H. T. Patrick said the crucial points in this question are the surgeon
and his technique. He has seen a few of these operations performed, and
it makes every difference who does the operation and how it is done. He
was quite impressed with the technique of Sir Victor Horsley a year ago.
This surgeon had gone so far as to have special spectacles made; strong
convex lenses combined with prisms, so that the strain of convergence
would not be too great. By this means he could readily see the small
vessels supplying the posterior roots, and Dr. Patrick thinks it is rea-
sonable to believe that Sir Victor Horsley was right in supposing that
cutting these small vessels going into the cord had a great deal to do
with the seriousness of the operation from the surgical standpoint.

Dr. G. W. Jacoby said he was glad the paper had brought out much
discussion. It seemed to him the stand Oppenheim takes in the last edi-
tion of his text-book should not be allowed to go unchallenged. Natur-
ally the cases must be selected. The indications for the operation must
be precisely drawn. The source of pain must be in the nerve roots or in
the ganglia. Then, having drawn the specific indication for operation,
Dr. Jacoby agrees with Dr. Patrick absolutely that it is a question of the
surgical technique. If the technique is beyond criticism, then from what
Dr. Jacoby has seen he does not believe the danger of these cases is any
greater than it is in an ordinary laminectomy. He does not believe that
the section of the nerve roots themselves adds to the danger of the opera-
tion. The small sensory defect after the section of a large number of
roots in other cases than his own will bear a great deal of discussion.
The fact that a number of cases have not been relieved at all is, he thinks,
explicable by what Dr. Prince has said. The majority of these cases are
morphinists, and whether they have not been relieved of their pain be-
cause of the craving for morphia, or whether you would call it a persist-
ence of hysterical pain, is a question upon which he cannot enter now.

Sensorv and Motor Disturbances in Parts Above the Distribution In-

592 AMERICAN NEUROLOGICAL ASSOCIATION

volved by Definite Organic Lesions of the Spinal Cord. By Dr. T. H.
Weisenburg. (See this journal, page 434-)

Dr. F. R. Fry said he would like to ask Dr. Weisenburg what import-
ance he attached to certain predisposing factors in these and similar
cases ; for instance, syphilis and other infectious diseases, arteriosclerosis,
etc.

Dr. C. K. Mills said this paper of Dr. Weisenburg's interests him par-
ticularly with regard to the question of the occurrence in stages of certain
symptoms as the result of a co-terminus necrosis due to arterial oblitera-
tion, which seems to him to be one of the points of the paper. It is of
considerable clinical and pathological importance in connection with that
general but often vaguely considered subject of arteriosclerosis. He be-
lieves it is true, as Dr. Weisenburg has stated, that in an old case of
transverse myelitis, especially if it is complete (that is, completely trans-
verse), or when it is not quite complete, there is a tendency, for what-
ever reason, to the very slow obliteration of blood vessels near the point
where the original necrosis or where the acute myelitis resulting in de-
struction has taken place. There is a distinct clinical type of arteriosclero-
tic disease which has not, Dr. Mills thinks, been well and systematically
presented, although he could certainly not say that it has not been con-
sidered, and this is the type of disease in which we have both cerebral
and spinal symptom-complexes which simulate others which may be due
to tumor or to some other lesion, as to syphilitic inflammation. There is a
clinical type of disease in which, for instance, we have a definite form of
hemiparesis with or without hemianopsia and with or without other cere-
bral symptoms lasting for a definite time, and then remaining for a time in
statu quo so far as the symptoms are concerned ; next in a period of two
or thiee months increasing by steps rather than by insidious progression.
Undoubtedly the increase is due to a peculiar form of obliteration of
neighboring vessels. Dr. Mills said he had had several of these cases;
three operation cases of this kind, one of which was studied microscopi-
cally after the operation by Dr. Spiller. These cases should be regarded
not as myelitis or encephalitis, but rather as a peculiar form of necrosis
occurring in successive stages.

Dr. W. G. Spiller said he was rather inclined to doubt whether this
ascending form of disturbed sensation will be found in every case, and
only further investigations will determine that. Dr. Weisenburg spoke of
lesions occurring in various parts of the cord and of the vascular changes
resulting therefrom. In early life the cord has a remarkable recuperative
power, and fewer fibers and nerve cells may perform the function usually
performed by a larger number, and it is possible for recovery of function
to take place ; later, as years pass by, the vitality of the cord is lessened
and the fibers and nerve cells can no longer perform the function so per-
fectly, and there is a progression of the symptoms in that way, as seen in
certain cases of poliomyelitis, etc.

Dr. Weisenburg in closing said in answer to Dr. Frey's question as to
what influence syphilis has, he was careful to select cases for his paper
in which such disease was excluded, but he thought that syphilis, as well
as alcohol, if present, would cause the disease process to be more
marked.

As regards Dr. Mills' comment. Dr. Weisenburg stated that he had
taken up the question of secondary degeneration in this paper because it
had a direct bearing upon the subject. He thought that the questions re-
lating to it were very important, and should be further investigated.

NEW YORK NEUROLOGICAL SOCIETY.

Jan. 8, 1907.

The President, Dr. Joseph Fraenkel, in the Chair

DEMONSTRATION OF THE RESULTS OF THE RE-EDUCA-
TIONAL TREATMENT OF TABES DORSALIS.

By Dr. H. S. Frenkel, of Heiden, Switzerland.

Dr. Frenkel said that in order to complete his theoretical explanations
of the re-educational treatment in tabes dorsalis, he had tried to get
some demonstrable results by starting the treatment in a few hospital
cases of different stages of ataxia. Through the kindness of the President
of the New York Neurological Society, Dr. Joseph Fraenkel, he was able
to show three different cases of tabic ataxia treated in the Montefiore
Home, with the most attentive and intelligent assistance of Dr. E. A.
Fruchthandler, the assistant physician of the Home. While the results in
these three cases were perhaps not striking, on account of the short dura-
tion of the treatment and the nature of the cases, they demonstrated very
well some important improvements, and also the lines to be followed in
the further treatment.

The first patient was a man, sixty-two years old, whose present illness
began seven and a half years ago, when he noticed pain of gradually in-
creasing severity and of a shooting character in both legs. This was
diagnosed as sciatica. At the end of two years he could not walk in the
dark, and for the past two and a half years he could not walk without a
cane. The interest in this case, Dr. Frenkel said, lay in the marked hypo-
tonia, which was almost limited to the left knee. An examination showed
that the difficulty of the gait was due not so much to the ataxia as to the
hypotonia, and its unequal development in the knees. This change ren-
dered these patients especially unfit to balance the weight of the body. In
unilateral hypotonia the act of walking was rendered more harmful than
in a case of equal knee-hypotonia, as in the former condition the patient
was inclined to rest the weight of the body on the hypotonic side. By
doing this, the concavity grew more and more, and the re-educational treat-
ment, as ordinarily applied, not only failed in its purpose, but was directly
dangerous and actually contra-indicated. The proper procedure in these
cases was to have a special appliance made before the re-educational treat-
ment was instituted. The principle of the appliance was very simple, but
its execution was rather difficult. A marked improvement in the gait of
this patient was noticed when he wore the appliance.

The second patient showed by Dr. Frenkel was a man, forty-three years
old, who showed all the classical symptoms of tabes dorsalis. His history
dated back six years. In 1004 he was first unable to walk in the dark, and
since then he had been compelled to use a cane. His gait had improved
markedly under the re-educational method of treatment. He was able
to walk without the aid of a cane, and in the course of four or six weeks,
the speaker said, he would probably be able to walk in the dark.

The third case shown by Dr. Frenkel was a man, forty-nine years old,
who had suffered from tabes since 1900, and for the past five years he had
been confined either to bed or to a chair. On 'Nov. 10, 1906, when Dr.

594 NEW YORK XEUROLOGICAL SOCIETY

Frenkel first saw him, the ataxia was very marked. In order to raise him
from his chair it required the assistance of two nurses, and when he at-
tempted to remain on his feet his knees would give way under him and he
would fall to the ground. Treatment was begun on the following day.
At first, the patient was able to stand only for a second or two ; then the
period gradually lengthened, and on Dec. n. he stood without assistance
for two minutes and ten seconds. Three days later he arose from his
chair without assistance, and balanced himself for a few seconds without
falling. On Dec. 25, he was able to lift his foot and put it down without
falling. He was now able to take a few steps, and there was a slow but
gradual improvement in his condition.

In conclusion, Dr. Frenkel again emphasized the fact that this method
of re-education applied without a thorough knowledge of its principles
and dangers was criminal.

Dr. George W. Jacoby said that in connection with the appliance -hown
by Dr. Frenkel he wished to call attention to the fact that within the past
few years a relative of the orthopedist Hessing had settled in this country,
and the high standard of the work he turned out was worthy of the ap-
preciation of the profession. For example, in order to obtain an exact fit,
it was his plan to build his apparatus upon a model of the part.

Dr. Jacoby said he could not let this opportunity pass without ex-
pressing his appreciation of the work done by Dr. Frenkel since his arrival
in this country. While the progress made by the patients shown at this
meeting was apparently not very startling, they certainly showed marked
improvement, which could be appreciated by those who had been able to
watch these cases from the time when treatment was first commenced

Dr. Frenkel, in closing, said that while Hessing made some very won-
derful appliances, they were intended for orthopedic rather than for
neurological conditions.

In reply to a question as to whether these exercises increased the tabetic
pains, the speaker said that on the contrary, some of the patients took
them in order to relieve the pains.

Dr. Frenkel said that he agreed with Dr. Jacoby that while the im-
provement in the cases he had shown was not startling, still they fur-
nished a good example of what might be expected from this re-educational
method of treatment. In the third case, for example, the patient had not
been able to stand for five years, and now. within a period of less than
two months, he was able to stand and even to lift his foot. Standing was
the first essential in these cases ; the treatment of walking was secondary.
People who could learn to stand could always learn to walk, but you could
not teach a man to walk who was unable to stand. A far advanced case
of this kind, therefore, was a more instructive object lesson than it would
be to show a score of milder cases whose locomotion had been improved
by this method.

A CASE OF SUBCORTICAL CYST : OPERATION AND RESULT.

By Dr. William M. Leszynsky.
The patient was a school girl, twelve years old, who was referred to
him on April 24, 1905, by Dr. Francis Todd, of Paterson, N. J., with the
following history: For the previous five months she had often stumbled
while walking, and had occasional jerking of the left hand and arm, fre-
quently dropping things held in that hand. She was supposed to have
chorea. Two months ago, when she came under Dr. Todd's care, she
complained of occasional general headache and twitching of the fingers

NEW YORK NEUROLOGICAL SOCIETY 595

of the left hand, and of the facial muscles on the same side. Twice or
thrice daily the left thumb would suddenly become flexed and adducted,
the left eyelids twitching' simultaneously. These attacks usually lasted a
few moments, and were at once followed by weakness of the hand, which
remained useless for about five minutes. Subsequently, the left arm be-
came paralyzed, and later the left leg, and the spasmodic attacks ceased.
A month later, the headaches became more intense and were accompanied
by vomiting. Diplopia began five weeks ago, and still continued. During
the last few weeks the headache had been more severe, and was attended
with vertigo and mental confusion. She was in constant tear of falling.
She had never had a general convulsion nor lost consciousness. She
vomited four or five times daily, and her symptoms were getting pro-
gressively worse. She slept well ; her memory was good ; appetite normal ;
bowels constipated. She had never menstruated.

The patient was born normally at full term, of healthy parents, and
up to the time of the present illness she had been in good health, ex-
cepting chicken-pox in the sixth year and occasional attacks of "nig'ht-
terrors." There was no history of a fall or injury of the head. Her father
and mother were living and had seven healthy children. Three others
died in convulsions during infancy. There was no family history of
tuberculosis, cancer, epilepsy, syphilis or rheumatism.

The diagnosis was made of a subcortical tumor in the Rolandic area
on the right side, and an early operation was advised. Iodide of potas-
sium was being administered, and its use was continued. When Dr.
Leszynsky first saw her, her gait was hemiplepic, and she dragged the left
leg in walking. The pupils were equal, reactions normal ; paresis of the
right external rectus and homonymous diplopia ; bilateral optic neuritis
of four diopters, with numerous retinal hemorrhages. About three months
later, when he again saw her, he was informed that the headache, vomiting
and vertigo had entirely subsided. Recently, there had been occasional
tonic spasm of the left upper and lower extremities, and one general con-
vulsion followed by coma. Her mental condition was good, and she was
increasing in weight. Both pupils were dilated and she was totally blind.
The facial paralysis had disappeared; the left upper extremity was in the
same condition as at the first examination. In the left lower extremity there
had been added loss of muscular sense, pseudo-clonus, and Babinski plan-
tar reflex.

On July 22, 1005, the skull was opened by Dr. John C. McCoy at the
Paterson General Hospital, and a large subcortical cyst was found in the
right Rolandic area. The cyst was evacuated and drained. She left the
hospital nine weeks after the operation, and her improvement was pro-
gressive.

The operation was performed seventeen months ago, and resulted in
complete relief from the headache, vomiting and convulsions, and a sub-
sidence of the hemiplegia. Her general health was excellent. At the seat
of the operation there was a pulsating hernia1 cerebri, one by two inches,
projecting with the bone flap over two inches above the level of the skull.
She still dragged the left leg, but was able to walk without assistance.
There was no rigidity. The knee jerk was exaggerated and ankle clonus
and Babinski were unchanged. Had the operation been performed at the
proper time, blindness would have been prevented. In all probability, the
cyst was of gliomatous origin, and from the history of recent local con-
vulsive attacks, a gradual recurrence of the previous symptoms might be
expected.

596 NEW YORK NEUROLOGICAL SOCIETY

Dr. Charles L. Dana said the results obtained by the evacuation of
the cyst in the case presented by Dr. Leszynsky were very similar to those
reported by Dr. Gushing after the decompression operation. In those
cases there was a subsidence of the symptoms for a year or more, and
the operation was not followed by the production of a hernia cerebri, as
in this case.

Dr. Leszynsky said that one of the marked features of this case was
the complete flaccid paralysis of the left arm, from which the patient had
entirely recovered. In the operation done by Dr. McCoy the cyst was not
only evacuated, but it was drained for some time. The operation was
certainly more radical than the decompression operation of Cushing, to
which Dr. Dana had referred.

A CASE OF ENCHONDROMA OF THE SELLA TURCICA.
By Dr. L. Pierce Clark.

The patient was a boy, seventeen years old, the eldest in a family of
two. His family and personal history were negative. When he was four
years old a growth appeared on the sixth rib, at the juncture of the rib
and sternum. It grew slowly, without pain, and five years thereafter it
was removed by Dr. Charles McBurney at the Roosevelt Hospital. Dr.
Eugene Hodenpyl, who examined the specimen, found the growth to be
a typical enchondroma. A second, third, fourth and fifth growth appeared,
several months apart, on the left wrist, at the end of the radius, on the
upper end of both tibia, and on the costal ends of all the ribs on the left
side. Similar tumors were now to be found on all the long bones of the
body. They ranged in size from a very small to a fair-sized orange.
The patient and his relatives expressed the belief that the tumors come
and go, disappearing spontaneously after a certain size is obtained, and in
proof of this statement the patient showed several sites which were appar-
ently formerly occupied by growths that had disappeared, and which still
showed the remnants of ruins of former tumor formation.

During the past two years the patient had been gradually growing stiff
and weak, and a progressive spastic quadriplegia was now fairly developed.
The spastic palsy began in the right side. For the past four months the
feet often fell asleep at night. There were no sensory defects. During
the past few months the patient had had paroxysmal frontal headache.
The left hand and foot had steadily enlarged during the past year in an
acromegalic manner.

An eye examination, made by Dr. Henry H. Tyson, showed that there
was a blurring of the nasal half of the optic discs, with hyperemia and
slight swelling of the discs, and that the veins were enlarged and slightly
tortuous. The field of vision was contracted on the temporal side for
form and color.

The diagnosis in this case, Dr. Clark said, was multiple enchondroma,
one of which was at present growing from the sella turcica, causing pres-
sure on the pituitary body, the chiasm and the crura.

Dr. I. Abrahamson said an interesting feature of this case was the
absence of myxedema and infantilism. With a destructive lesion of
the pituitary body we should expect symptoms of either myxedema or
infantilism.

A CASE OF PERONEAL MUSCULAR DYSTROPHY.

By Dr. Clark.
The patient was a boy, ten years old, whose paternal grandfather had

NEW YORK NEUROLOGICAL SOCIETY 597

asthma, and whose paternal grandmother died of diabetes. His maternal
grandfather died of cancer. No member of his family ever had any form
of dystrophy. The boy's past history was unimportant, with the exception
of the fact that dentition was delayed and accompanied by fever. He was
a vigorous child and learned to walk at one year of age; he then stopped
walking for several months without apparent cause. Between the ages
of three and seven years he suffered from measles, pneumonia, diphtheria
and scarlet fever, and from all of these he had apparently made an un-
eventful recovery.

Nothing abnormal was noticed in the patient's muscles until eight
months ago, when he began to turn the left foot out and drag it in walk-
ing, and walked flat-footed with the right. This condition slowly pro-
gressed. Six months ago he began to experience difficulty in going up-
stairs, and this had steadily increased. The patient now presented a
marked degree of left club foot of the varus type. The right foot showed
a slight grade of talipes valgus. The peronei on the left side were weak
and atrophic, as was the outer part of the soleus ; on the right side these
muscles were hypertrophic, but weak in contractile power. The left
quadriceps was much weaker than the right, although both were deficient.
The knee jerks were absent, and all the affected muscles showed dimin-
ished sensibility to both currents. There was. however, distinct R. D. in
the left peronei. There was a moderate degree of lordosis. The entire
musculature of the shoulder girdle was slightly affected with hypertrophy,
weakness, fibrillation or fasciculation, and the right infraspinatus was
especially prominent in enlargement. The muscular fasciculation induced
a sort of choreiform movement in the hands and fingers. There was an
extreme hypotonia in the fingers, showing advanced disease in the small
muscles of the hands.

This case, Dr. Clark said, was an example of the Charcot-Marie-Tooth
type of peroneal dystrophy and progressive muscular atrophy — a transition
case embracing the pseudo-hypertrophic, the neuritic and central degen-
erative symptoms of the mixed type. It presented symptoms of the three
affections, but was nearest to the peroneal dystrophy type.

Dr. J. F. Terriberry, in speaking of muscular dystrophies, said that
for the past eighteen months he had had under his observation a child,
about four years old, in whom the muscles of the face and upper extremi-
ties were very much atrophied, while those of the lower extremities were
hypertrophied. The electrical reactions were all changed ; still they main-
tained the normal formula. The mother stated that the child had been
weak from birth, and it was now unable to stand or to raise the arms
above the head. Its cry was very feeble, showing that the body muscles
were also probably involved.

This case demonstrates that all of the so-called types of muscular
dystrophy may be found in the same child at the same time.

Dr. Clark said the case referred to by Dr. Terriberry was possibly a
combination of the pseudo-hypertrophic type and the Erb juvenile atrophic
type. The speaker said the case he had shown was quite distinct from
any of the seven types of juvenile atrophy described by Erb. Among1 the
many thousand cases of muscular disorders that had been seen at the
Vanderbilt clinic during the past ten years, this was only the second case
of this particular type. The speaker said he wished to call special atten-
tion to the central and neuritic features of the case, in contradistinction to.
the pseudo-hypertrophic picture that was also presented.

598 NEW YORK NEUROLOGICAL SOCIETY

A CASE OF CHRONIC PROGRESSIVE OPHTHALMOPLEGIA.

By Dr. Isador Abrahamson.

The patient was a man, twenty-seven years of age ; single ; a butcher by
occupation, and a native of Germany. His family history was negative,
with the exception of the fact that his mother had been paralyzed for
years. The patient was anemic as a child, and had diphtheria when he
was twelve years old. He smoked much, and drank beer excessively in
iormer years. Eight months ago he had a small ulcer on the penis, which
left no scar. He had no secondary symptoms of syphilis. His eyes were
apparently normal up to six months ago, the date of the onset of his
present illness. At that time he complained of pain in the left knee, like
rheumatic pains. There was also general formication, and he was easily
fatigued. Soon afterwards, there was pain in the left upper extremity, and
immobility of the eyes. He could not rotate them, and the eyelids could
not be raised. His speech was slightly altered and he felt tired when he
spoke for a time, although his voice remained unchanged in pitch, etc.
There was slight difficulty in swallowing. He also complained of delay in
urination, with diminished potency, and constipation.

A physical examination showed a ptosis of both eyes ; the pupils were
equal, and reacted normally. The ocular movements were very much
limited from side to side; also upwards, and to a lesser extent down-
wards. Convergence was preserved ; divergence was considerably dimin-
ished. The superior oblique muscle seemed to be least involved. The
lines on the right side of the face were flattened, and there was some
weakness on that side. The mouth was drawn somewhat to the left, and
hearing and bone conduction were diminished on the right side. There
was weakness of the pharyngeal musculature. The tongue was protruded
straight ; there was no tremor ; motor power in the upper and lower ex-
tremities was normal. There were no fibrillary twitchings; Romberg ab-
sent; knee jerks lively; Achilles lively; no clonus; sensibility normal;
electrical examination negative. The disease was rather sudden in its
onset, but made very little progress. Specific treatment and little or no
influence up to the present time.

Clinically, Dr. Abrahamson said, the condition was a progressive
chronic ophthalmoplegia. Whether it was of luetic nature, or indicated the
early stages of a high tabes the future could only decide, yet the integrity
of the pupils in spite of the extensive involvement of the ocular muscles
seemed to negative the latter.

A CASE OF CONGENITAL MYOTONIA (THOMSEN'S DISEASE)
ASSOCIATED WITH OPHTHALMIC MIGRAINE.

By Dr. Charles E. Atwood.

The patient was a Scotchman, twenty-three years old ; single ; a book-
keeper by occupation. He complained of left-sided headache, with left
ptosis ; also stiffness and weakness of the voluntary muscles, especially
after rest, and becoming better with use. One sister, aged thirty-five, has
had the same muscular disorder since childhood, but to a less marked de-
gree than the patient. His oldest brother, when about ten years old,
"could not start quicklv to run." Otherwise, the family history was nega-
tive.

The patient, as a child, had pneumonia and incontinence of urine. At

NEW YORK NEUROLOGICAL SOCIETY 599

nine years he had little strength to stand, and the wind from a passing
football knocked him down. At the age of eleven or twelve he noticed
that he went upstairs slowly, and could not lift heavy thing's. He also
began to suffer from attacks of migraine on the left side, with vomiting,
etc., occurring every six or eight weeks. He was also very constipated.
At seventeen, the left eyelid began to droop during these attacks. When at
play, he noticed that after resting it would be hard for him to start again,
and he began to fear to go into a crowd because he could not move quickly
enough to protect himself. These symptoms had persisted since, the mi-
graine occurring intermittently for a week at a time about every six
weeks, and when the patient was first seen at the Vanderbilt clinic he was
suffering from one of these attacks of migraine, associated with paresis
of the left third nerve, which disappeared in a few days. Other cranial
nerves were free. The eye muscles affected were the lavator palpebral,
the left superior and inferior recti, and the inferior oblique.

The patient was well formed, and showed excellent development of
muscles, without local hypertrophies or other external defects, the strength
not being proportionately great. After rest, the voluntary muscles showed
stiffness and rigidity or spasticity, both flexors and extensors and other
groups being affected. The condition gradually wore off with exercise
of the various muscle groups, only to recur again after a period of rest.
There were no sensory changes to heat, cold, pain or touch. The right
knee jerk was normal; the left diminished. He showed plainly the well-
known myotonic (persisting) reaction of muscles to percussion and also
the Erb (persisting) reaction after prolonged faradic stimulation and re-
moval of the electrodes. Co-ordination and position and muscle sense
were apparently unaffected. There was no Romberg; no astereognosis.
There was no ankle clonus or Babinski. The patient was not paralyzed at
all, but there was a feeling of resistance or persistent contraction which
he had to overcome in performing any act. Mental excitement exag-
gerated the stiffness of the muscles. Ergograph tracings by Dr. Scripture
showed an incomplete relaxation of both flexors and extensors at the
initial of the muscle movement. Electric stimulation of the abductor in-
dicis showed the same thing.

Dr. George W. Jacoby said he believed he was the first one in this
country to demonstrate a case of congenital myotonia, and in connection
with that disorder he thought it well to emphasize a little more strongly
the myotonic reaction, because after all the diagnosis would. depend upon
that. In the case shown by Dr. Atwood, there was apparently no question
in regard to the correctness of the diagnosis, although the history was a
complicated one and contained some reference to a cerebral trouble. The
case would probably have to be classed in Erb's second group, in which it
was questionable whether the muscular disorder was primary or secondary.

In a typical case of myotonia, the three cardinal signs upon which
to base the diagnosis and which constituted the myotonic reaction, were
the persistence of the muscular contractions to the faradic stimuli, the
same persistence to mechanical excitation, and the persistent contracted
state of muscular groups after voluntary action.

Dr. Clark said that in looking over the literature of myotonia, he was
surprised to see that hypertrophy was so little dwelt upon by Hale White.
Thomsen and others. Writers agreed that at most the muscle state could
easily be embraced in calling it the athletic type.

The possibility that the case shown by Dr. Atwood was not of the

6oo NEW YORK NEUROLOGICAL SOCIETY

congenital type was worthy of considerable attention, in view of the fact
that the patient had suffered from paroxysmal migraine and constipation
for many years. Possibly, the muscle state here was of toxic origin, which
also had some bearing on typical Thomsen's disease, as had been demon-
strated by Goldflam and others for family periodic paralysis.

Dr. Terriberry said he had reported two cases of myotonia occurring:
in the same family, both girls. In neither of them was there noticeable
hypertrophy of the muscles. He was inclined to think that hypertrophy in
these cases was a less marked feature in females than in males.

ANTERIOR POLIOMYELITIS WITH INCREASED KNEE JERK.

By Dr. Atwood.

The patient was a girl, three years old, who had enjoyed good health
and had been able to walk at the age of two years. Last June. i. e., six
months ago, she had an attack of fever lasting two days, following which
she has limped slightly in the right leg. The muscles permanently affected
are the posterior tibial. In these there is reaction of degeneration. The
knee jerk of the affected limb is greater than that of the left and the case
is interesting on this account.

A CASE OF ACUTE POLIOMYELITIS IN AN ADULT.

By Dr. Atwood.

The patient was a man, thirty-three years old; a college student. His
family and previous history were negative.

In August, 1906, nearly five months ago, he had a fever of several days'
duration, accompanied by certain subjective symptoms, and the gradual on-
set of paralysis in his right arm, beginning in the shoulder and upper arm
and culminating in the hand and finger muscles after thirty hours. An
examination showed that sensation to heat and ''old. pin prick and cotton
were preserved. There was marked wasting of the right upper arm,
shoulder and extensor surface of the forearm ; also slight wasting of the
right anterior tibial. The hand and affected portions of the arm were
cooler than the left arm to the touch. The position of the hand was
peculiar, on account of the extensor paresis. The muscles affected were
the pectoralis major (upper portion), the supra and infra-spinatus, the
deltoid and . coraco-brachialis, the biceps, triceps, the extensors of th»*
wrist and the Ions extensors of the fingers. There was also weakness
of the pronators and supinators, and of the abductor pollicis.

This case, Dr. Atwood said, was thought to be of some interest on ac-
count of the comparative rarity of acute anterior poliomyelitis in the
adult, and of the clearness of the subjective symptoms. In connection
with the treatment of this case, the speaker inquired regarding the ad-
visability of nerve transplantation.

Dr. Leszynsky, in discussing Dr. Atwood's first case of poliomyelitis,
with increased knee jerks, said he had seen a number of cases in children
where in the early stage of the disease the knee jerk was entirely absent
on the affected side, but gradually returned and remained active, while the
peroneal group of muscles was paralyzed and remained so.

Dr. Clark said it had occurred to him that we had a very simple ex-
planation for the exaggeration of the knee jerks in certain types of
poliomyelitis: 1. e., those affecting the lower posterior group of muscles

NEW YORK NEUROLOGICAL SOCIETY 601

of the leg. As was well known, these muscles were represented in
groups of anterior horn cells at the side of the anterior horn. and. as
was also well known, the central branch of the anterior spinal artery sup-
plied more than the gray substance of the cord ; in fact, it supplied nearly
all of the lateral limiting layer that was situated between the gray sub-
stance and the lateral pyramidal tract. Injury to the fibers of the lateral
limiting layer destroyed the controlling connection between the first and
second segments of the motor system, and then, as in hemiplegia, we
might expect to find an unrestrained reflex center in the anterior horn,
giving rise to an exaggerated reflex. That the injury outside the gray
matter was confined to the lateral limiting layer was evidenced in that
the exaggerated reflex in these cases did not bring the Babinski sign
with it, or other definite symptoms of serious injury to the pyramidal
tract.

Dr. Clark believed that a sharp distinction should be drawn between the
ordinary cases of poliomyelitis, in which the reflexes returned in the
repair process, as cited by Dr. Leszynsky, and the type Dr. Atwood
showed. The latter had been very carefully studied from their very in-
ception, and had presented the unique reflex exaggeration from the first
stroke of the disease.

Dr. Terriberry, in reply *o Dr. Atwood's query as to the advisabilitv
of nerve transplantation in these cases, said that although some excellent
results had been obtained in nerve grafting, he believed that in suitable
cases much more p-ompt and efficient repair to loss of muscle balance
could be obtained b_, muscle transplanting; he instanced a case of sub-
stitution of the sartorius for a useless quadriceps extensor which he
had seen recently, with a most happy result, and this was but one of many
very excellent results of attempts at muscle balancing that he had seen at
the Hospital for Ruptured and Crippled Children in this city.

The following officers were elected for the ensuing year : President,
Dr. Charles L. Dana; First Vice-President, Dr. B. Sachs; Second Vice-
President, Dr. L. Pierce Clark; Corresponding Secretary, Dr. Hallock :
Recording Secretary, Dr. E. G. Zabriskie; Treasurer, Dr. Graeme M.
Hammond.

NEW YORK NEUROLOGICAL SOCIETY

February 5. 1907,

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

DISCUSSION OF APHASIA, WITH PRESENTATION OF CASES

By Dr. B. Sachs

The subject of aphasia is of extreme interest at the present moment,
•owing chiefly to the articles that had appeared recently from the pen of
Marie, which, at least in some important respects, threatened to revo-
lutionize our past conception of speech disorders. For the past half
•century we had accepted the dictum that motor aphasia was due to a lesion
•of the third frontal convolution. Marie had shown that that dictum
was based on the slimmest possible evidence; he questioned the exist-
ence of a pure motor aphasia, and the possibility of differentiating ana-
tomically between various forms of aphasia. He doubted whether there
were any cases of pure motor aphasia, and also, whether in so-called
sensory aphasia there was really a loss of the true perception of words,
or whether it was more or less an intellectual defect. It was very diffi-
cult, Dr. Sachs said, to make out exactly what Marie meant by the
term "intellectual defect" ; whether he meant a defect in single or col-
lective concepts, or in general intellectuality.

In connection with this subject, Dr. Sachs showed a woman, 39
years old, who he said represented the most complete example of loss of
motor speech that he had met with in many years. The case was not
one of pure motor aphasia, as there was just as marked a defect on
the sensory side as on the motor, and although the woman had a most
complete loss of language, she retained her musical sense to a remark-
able degree. The history of the case was that about four months ago
she had sustained a right hemiplegia, which was clearly due to embolism.
At the same time, she suddenly developed this complete motor aphasia,
combined with sensory aphasia. It was impossible to determine wheth-
er there was also word blindness or agraphia, as no reliable information
could be obtained concerning the woman's mental attainments prior to
her illness. She was very emotional, and while her speech was limited
to jargon, it was easy to demonstrate that her musical sense was very
good. There was no hemianopsia nor hemianesthesia; no apraxia.

Dr. Sachs said he was impressed with the fact that sensory aphasia,
pure and simple, was of extremely rare occurrence. This had particu-
larly impressed him in connection with otitic temporal abscess, where
we should expect to find sensory aphasia, pure and simple, according to
Wernicke's theory. As a matter of fact, the speaker said he had never
seen a case of temporal abscess in which sensory aphasia was not also
associated with some form of motor speech disturbance.

A CASE OF PRE-SENILE DEMENTIA WITH APHASIC SYMP-
TOMS
Presented by Dr. Leslie Meacham for Dr. Dana.

The patient was a man, 61 years old; a court photographer by pro-
fession, who was first seen at the Cornell University Medical College

NEW YORK NEUROLOGICAL SOCIETY 603

Dispensary on February 1, of the present year. His father had died of
apoplexy at the age of 64: his mother had died of tuberculosis. Four
brothers and sisters were alive and well; one had died from nephritis
and five from various diseases. The patient was the father of eight chil-
dren; six of these had died at or soon after birth, and his wife had had
one miscarriage.

The patient had pneumonia ten or twelve years ago. He denied
all venereal history, and had been very temperate in his habits. For
some time he had been troubled with shortness of breath, and about
three years ago he had an attack of dizziness. He did not fall nor
become unconscious, but for several days afterwards his speech was
thick, and for six or eight weeks he had much difficulty using his left
hand and arm. There was also some difficulty in walking, and the left
hand had remained permanently weak. He had suffered much from in-
digestion, and had practiced gastric lavage, but had discontinued it after
this seizure.

In September, 1905, he awakened one night about midnight with very
severe pains in his head. He also had severe pains in his stomach, which
continued for two or three days, and for the relief of which he was given
codeine by his physician. Since that time he had had much trouble with
speech, and had been unable to write any letters, but he was still able
to read. He had become timid about going out alone, fearing he might
become lost. He had continued to direct his business, but had been un-
able to use the camera in the preparation of legal exhibits. He had
also become unable to get correct scales, and was uncertain about the
use of the chemicals employed in the development of photographs. Dur-
ing the summer of 1906 he engaged in active exercise in order to reduce
his weight and relieve his shortness of breath. In September, 1906,
after certain exercises, he complained of feeling dizzy, and this persisted
for about two weeks. After this he found that he was no longer able to
read, as he would frequently lose his place, and could not grasp the
meaning of what he read. His speech became more difficult, and he
had some trouble in understanding what was said to him. He was even
unable to read his prayers, which he had read daily during his entire
life. He was still able to give instructions as to the proper conduct of
his business, but could not converse with customers. At times, he had
outbursts of laughter or tears, and became irritable when he could not
make himself understood.

Examination showed that the facial innervation was unequal, prob-
ably as the result of his old hemiplegia. There was some drooling from
the left corner of the mouth. Gait and station were normal, with the
exception of slight uncertainness and some vertigo. The pupils were
equal, and reacted to light and accommodation. There was no hemi-
anopsia; no atrophy nor tremor of the tongue. Taste and smell were
normal, but he showed some hesitancy in being unable to recall the names
of substances. Hearing was apparently dulled, but was equal on both
sides, and he understood names of objects producing sounds. The
palate reflex was present. The deep reflexes were active; the superficial
ones were present, but the left plantar was diminished and sluggish.
There was a systolic heart murmur, with accentuation of the second
sound, and some cardiac irregularity. The patient's voice was rather
low-pitched and somewhat monotonous. He hesitated, then spoke a few
words rapidly, followed by another hesitation, and stated he was afraid

604 NEW YORK NEUROLOGICAL SOCIETY

that he would forget what he wished to say. His wife asserted that he
had always had some trouble in speaking. He could not picture words.
He could spell, but could not tell the number of letters in words of even
three letters without counting on his fingers. He could repeat the
Lord's prayer correctly, but brokenly and hurriedly. Repetition was
much affected; voluntary writing was bad and copying even worse. He
had a clear understanding of the use of articles, and there was no as-
tereognosis. He could carry out simple instructions, and could usually
do two things, but never three. For many years he had been a member

»f a number of secret orders, but he could no longer recall the pass-
words. His urine contained a trace of albumin and some mucus and

quamous epithelium; no casts; no sugar; it was acid, with a specific
gravity of 1,010. He habitually drank large quantities of water.

The president, Dr. Dana, said the case shown by Dr. Meacham was

lot presented as one of distinct aphasia, but rather as one of pre-senile
dementia, although the patient lacked many of the characteristic symp-
toms of dementia, while on the other hand he showed many of the
characteristics of mixed aphasia. He regarded the case as a form of
aphasia associated with senile dementia. The symptoms of dementia
were apparently limited to the language zone. The case was certainly
rather unique, especially in connection with the recent dictum of Marie
that aphasia was associated with an intellectual deficit.

A CASE OF APHASIA.
By Dr. C. L. Dana and Dr. J. Ramsay Hunt.

The patient was a man, 45 years old, who was brought to Bellevue
Hospital on November 26, 1906. He was suffering from complete motor
aphasia, together with a moderate degree of right hemiplegia. He was
unable to express himself or answer the most simple questions. Upon
admission, the light reactions of the pupils were somewhat stiff, and it
was thought for a time that the case might be one of aphasia associated
with early paresis. In the course of a few days, however, his speech
disturbance began to clear up; he was able to say a few words and then
a few sentences, and this improvement has been progressive. There were
some sensory disturbances on the right side, which still persist in a mod-
erate degree, and he has also evidence of a right hemianopsia. On ad-
mission, he could understand and was able to carry out single direc-
tions, such as those to close the eyes, etc.

From a friend who visited the patient at the hospital it was learned
that the latter, for several weeks prior to the onset of his attack, had
complained of headaches and a distinct weakness in the right leg. The
patient was now able to speak fairly fluently; he was still unable to
make himself understood or to name certain objects. He has alexia and
agraphia. The case was regarded as one of occlusion of the posterior
cerebral artery, probably syphilitic in origin. (There were large pig-
mented scars along the tibia in both legs, and a somewhat doubtful his-
tory of a primary lesion.)

Dr. Dana said that while this patient had fairly good voluntary
speech, and while his general intelligence was excellent, there was a jar-
gon of sentences which made his speech unintelligible. He was unable
to write. He understood words and sentences, and did what he was told.
His worst defect, apparently, was the anomia, which applied not only

NEW YORK NEUROLOGICAL SOCIETY 605

to objects seen, but also to objects felt and heard. His ability to read
was absolutely gone. The case was one of pure sensory aphasia, with
anomia as its dominant feature, and with it was associated agraphia,
and, as was usually the case, alexia. The lesion in this case was re-
garded as a thrombosis, or perhaps a small hemorrhage.

In considering this general subject of aphasia, Dr. Dana said he
was inclined to believe that the new theory of Marie regarding the lo-
calization of these speech disorders was really much nearer correct than
the views that had been accepted by the profession for half a century or
more. While these disorders were the result of a lesion in the so-called
aphasic area, he believed it would be wise to either cut out the Broca
convolution from the zone of language, or else regard the latter as only
more or less distantly associated with the real aphasic area, and of minor
importance in that connection. The frontal lobe governed, apparently,
the centers for memory of the movements of articulation rather than tne
true centers of speech. It controlled, apparently, certain forms of dis-
turbance of speech, such as stuttering, but was not intimately asso-
ciated with the higher speech centers.

Dr. Joseph Collins said that the views of Marie seem at first sight to
be more revolutionary than they are in reality. The most far reaching
effects of Marie's conception are in the psychological conceptions of the
development of speech and its production. There is no doubt that the
schematic or diagrammatic representation of the speech areas has been
carried too far, and the definiteness with which verbal memories and
visual memories, and memories of movements of the spoken and
written words have been allotted to certain small areas has been over-
done, but this does not justify the overthrow nor the attempt at over-
throw of that which has been definitely proven in regard to the locali-
zation of the different forms of memories, the awakening of which con-
stitutes the initiation of articulate speech. Marie's views are sufficiently
definite and his position in the scientific world sufficiently firm to de-
mand that his claims be verified or denied. This verification or denial
cannot be through expression of personal opinion, but by study of pa-
tients and of the lesions which are found in their brains after death.
Much that Marie claims is by no means new. For instance, everyone
who has much to do with aphasia will agree with him that there is in
all aphasic individuals a diminution of intellectual capacity which
amounts to real enfeeblement. Anyone who would claim the contrary
could scarcely have an adequate conception of the enormous structural
lesions that are at the basis of the particular lesion that gives rise to the
aphasia. In the vast majority of cases of aphasia there is widespread
arteriosclerosis, and the nutrition of the brain and its dependent psy-
chological functions are proportionately disordered.

Although Marie has brought forward much evidence to show that
many cases of so-called motor aphasia, i.e., aphasia due principally to the
loss of memories of articulation, is dependent upon a lesion of the pos-
terior areas, i.e., of the first temporal and the inferior parietal convo-
lutions, plus anarthria; although Dr. Collins for one, was willing to
admit that in some instances this condition is the one that exists and
which accounts for the symptoms, still there are cases on record in which
the lesion is closely limited and confined to the allotted seat of mem-
ories of articulation, viz., to Broca's convolution, and in these cases
the symptoms that occurred were typical of motor aphasia. Dr. Collins

6o6 NEW YORK NEUROLOGICAL SOCIETY

referred particularly to the cases of Ladanie and of Bernheim. One
such case as either of these is as good as one hundred to demonstrate
that motor aphasia may be the result of a lesion so situated.

Finally, a word in regard to Marie's conception of anarthria. First,
it must be admitted that Broea's convolution sends no projecting fibers
directly into the motor tract, and that therefore a lesion of Broea's area
does not cause anarthria. Second, Marie's idea of anarthria and its rela-
tion to destruction of the lenticular area is not materially different from
Dejerine's idea of subcortical motor aphasia, or pure motor aphasia, as
he calls it. Finally the only way of settling this question is not academ-
ically, but at the bedside and at the post-mortem table, and that work
we are called upon to do.

Dr. B. Onuf said that frequently, in cases of aphasia, the autopsy
showed very extensive lesions, making the cases unfit for differential
diagnosis, inasmuch as such lesions caused the involvement of so
many functions that it was difficult to determine which part of the
lesion had impaired this function or the other. As proof of this state-
ment Dr. Onuf adduced three cases (two of aphasia and one of dysarth-
ria) which had been clinically observed by Dr. Fraenkel and himself,
and examined post-mortem in several sections. In all three of these cases
the lesions had been very extensive, destroying a large part of the hemi-
sphere.

The question of the role of the third frontal convolution, which
Marie denied had any relation to the function of speech, had been care-
fully investigated by Drs. Fraenkel and Onuf, and embraced the study
of 104 cases of aphasia, with autopsies, collected from the literature. This
had shown on what a remarkably small number of clear-cut cases the
view of the speech functions of Broea's region was based. Only five of
the 104 cases showed a lesion confined to Broea's area, while in two
cases there was a slight encroachment on adjoining regions. In all the
other cases, Broea's region was either not involved, or there were
marked additional lesions of other cortical regions or of the sub-cortex.
Of the seven cases first referred to, only two showed clearly a lasting
aphasia, while in the others it was either only temporary or not suffi-
ciently long observed to say whether it was temporary or permanent.
Nevertheless, the fact that all of these seven did show aphasic dis-
turbances, whether temporary or permanent, was in confirmation of the
importance of Broea's center for the function of speech.

To elicit further evidence regarding the function of Broea's center,
Drs. Fraenkel and Onuf tabulated, graphically, all the cases of purely
cortical lesions in their collection, according to the scheme of Nau-
nym, which consisted in having the surface of the brain divided up into
squares of equal size, and registering the lesions on that diagram in the
following manner: Whatever squares were covered by the lesion in a
particular case received one dot. If a given square fell within the do-
main of the lesion of a second case, that square received a second dot,
and so forth, so that the squares showing the greatest number of dots
indicated the greatest number of cases in which those particular regions
had been affected. The result of this registration showed such a marked
accumulation of dots in the region of the foot of the third frontal con-
volution that the view of the important role of that region for the func-
tion of speech was amply confirmed.

Marie's views regarding aphasia, as set forth in his first article, ex-

NEW YORK NEUROLOGICAL SOCIETY 607

perienced a considerable elaboration, modification and crystallization in
his second article, making some things clear which did not appear so
in the first article. The exact meaning, for instance, of the word "an-
arthria" was by no means clear from the first article, but was distinctly
defined in the second one. It appeared that some of his differences of
view from those of other writers were partly in name only. Anarthria,
for instance, was substituted for the term aphasia motrice pure of other
authors, and was acknowledged clinically but given another anatomical
basis by Marie. That basis was a lesion of the so-called lenticular zone,
i. c, of the zone consisting of the white substance situated between the
cortical convolutions of the insula and the lenticular nucleus, and ot
the outer layers of the lenticular nucleus itself. Marie gave no definite
explanation why such lesions should cause anarthria.

The researches of Drs. Fraenkel and Onuf, on the other hand, endeav-
ored not only to find an anatomical basis for the aphasia motrice pure,
but also to explain the mechanism of the lesion. Their results spoke
against the existence of a direct speech pathway leading from Broca's
area of the internal capsule, inasmuch as lesions of the internal capsule
were relatively very rare in sub-cortical cases of aphasia in the 104 cases
they had collected. On the other hand, the lesion mostly met with in
those cases was one of the medullary layer of the third frontal convolu-
tion, and next in frequency the region around the upper margin of the
lenticular nucleus in its anterior part was involved. This strongly con-
firmed their theoretical considerations that these two regions formed
part of an association pathway connecting Broca's area with those cen-
ters situated at the base of the central convolution which innervated the
muscles concerned in the function of speech ; i. e., the muscles of the
tongue, larynx, pharynx, lips, etc.; briefly, the articulo-motor muscles.
They confirmed their view that Broca's center was a higher co-ordina-
tory center, presiding over the articulo-motor centers just mentioned,
grouping those innervations of the latter which were necessary for the
purpose of articulation.

Dr. Joseph Fraenkel said that by accepting Marie's views we gave up
a great deal of what we had for years thought to be the best established
truths of neuro-physiology. Personally, he did not hesitate to say that
Dr. Onuf and himself had done a great deal of work in connection with
aphasia, and for some reason that work had received no notice. Dur-
ing his residence at the Montefiore Home he had seen and thoroughly
studied a goodly number of all forms of aphasia, and had witnessed the
autopsies of a considerable proportion of them. As a result of this he
believed:

1. That we must clearly know and define the terms we are using,
and appreciate the fact that aphasias are all disturbances of speech
resulting from an interference with the psychic mechanism of speech,
and that anarthrias are all disturbances of speech which are the re-
sult of interference with the somatic or mechanical mechanism of
speech.

2. That there undoubtedly exist — rarely, to be sure— forms of pure
motor aphasia, cortical and sub-cortical.

3. That rarely would the lesions producing these forms of aphasia be
so strictly localized as not to encroach upon neighboring territories, and
even so, the underlying disease would to an extent interfere with the
other functions of the brain, thus producing some intellectual impair-

608 NEW YORK NEUROLOGICAL SOCIETY

merit, which would appear in every case at some time or other.

4. That their investigations had shown the existence of the lenticu-
lar association zone, which in their belief was the sub-cortical speech
path, and which led, when diseased, to what they called sub-cortical mo-
tor aphasia, and what Marie called anarthria.

In connection with Dr. Sachs' case, the speaker said he wished to
mention that Edgren had shown that the musical concepts and pic-
tures were stored in the second left temporal convolution, and that there-
fore the preservation of this faculty in the patient presented by Dr.
Sachs was not surprising.

Dr. L. Pierce Clark said if Marie's theory that an intellectual deficit
was always associated with aphasia should be proven, it might have an
important bearing from a medico-legal aspect, particularly regarding the
will-making capacity of apoplectics.

Dr. Sachs, in speaking of the case of aphasia he had shown, said that
a'f Dr. Collins had been present at the time, he could not possibly have
made the statement that the patient did not have sensory aphasia, or
that it was simply a case of motor aphasia.

This general subject of aphasia, Dr. Sachs said, was one of the ut-
most importance, and in spite of the statement made by Dr. Collins, and
the quotation from Marie's recent article, the reference made by that
writer to an intellectual defect in aphasics was not very clear, partic-
ularly from a psychological point of view. Personally, he believed Marie
meant that the defect was entirely in the conception and perception of
speech, and did not necessarily imply a distinct mental defect. Mental
deterioration could be safely denied in a large number of cases of
aphasia, and the speaker cited such a case that was at present under
his observation at Mt. Sinai Hospital. The case was one of motor apha-
sia, puTe and simple, in a man of considerable intelligence, and there was
not a single indication of any mental deterioration.

In a close analysis of cases of motor aphasia, Dr. Sachs believed that
the chief difficulty was not connected with the concept movements, but
was simply a difficulty in directing the movements of speech. He
thought there were very few cases in which the actual conception of
movements that were necessary to effect articulation was absent; the
difficulty was simply an inability to use the organs of speech. He was
perfectly willing to substitute the word anarthria for the French term
aphasia motrice pure, and if that was to be the outcome of Marie's
doctrine, he considered it a distinct step in advance. It was unfortu-
nate, he thought, that the work of Onuf and Fraenkel in connection with
aphasia had not received more general attention.

Dr. Dana said that this subject of aphasia would probably come up
before the Society for discussion again at some future period, and that
at present it was impossible to arrive at any absolute conclusion re-
garding it. The entire question should be taken up in a receptive mood,
and carefully re-studied. In the course of his teaching. Dr. Dana said,
he had at times been somewhat embarrassed by the practical inutility of
the older methods of presenting the subject of aphasia, and he had never
been quite able to n^ake the text-book descriptions of these speech disor-
ders tally with his clinical findings. He was inclined to agree with those
who believed that the entire subject should be studied from a< little differ-
ent point of view, which implied, essentially, that the cases should be
studied as we saw them. We practically never saw cases of either pure

NEW YORK NEUROLOGICAL SOCIETY 609

motor or pure sensory aphasia, and it was very difficult to explain this
difference to students.

Dr. Dana said he agreed essentially with the views expressed by Dr.
Sachs that the Broca convolution was not in the same class as the rest
of the zone language; that it was of a lower type, and while cortical
disease in that region might cause aphasia, it was a loss of articula-
tion and not of the concept of language. He did not like the term an-
arthria.

ADDRESS OF THE RETIRING PRESIDENT.
By Dr. Joseph Fraenkel.
The retiring President, in a brief address, thanked the members of
the Society for their support during the past year. He said that the
gloomy views that had been held out in regard to neurology in recent
years had not been realized: on the contrary, the outlook in this branch
of medical science was brighter than ever, particularly in connection with
the clinical investigation and study of function, a field that had been
too much neglected in the past.

ADDRESS OF THE INCOMING PRESIDENT.
By Dr. Charles L. Dana.

Dr. Dana said that since his first experience in that office there had
been many intensely interesting phases in the evolution of modern neu-
rology. The finer anatomy of the nervous system was then a matter of
active discussion, because it was just being unfolded. The exploitation of
the neurone theory, the localization of the cortical and spinal func-
tions, the changed views of neuro-pathology, the better descriptions
of the various nervous diseases, the new diagnostic methods and
signs and the portrayal of new types furnished a constant succession
of interesting themes and topics for discussion. There was now a
feeling that all of this was more or less completed, at least in its
larger outlines, and to a certain extent this was true, but it was no
more true than for other specialties, or even for internal medicine.

Dr. Dana said that all over the world where neurological societies
existed he had found that the main body of the work was in the
clinical presentation and study of cases, and this was the line along
which the New York Neurological Society would have to continue.
We could not tell at what moment the deeper knowledge^of physical
forces, of chemistry, radio-activity, etc., would evolve new problems
and rich illumination. The time had come when the neurologist had
to keep in closer touch than ever before, perhaps, with the laboratory,
especially in the solution of functional neuroses and psychoses.

Among other topics touched upon by Dr. Dana in his address
was the duty of the neurologist in relation to public economic ques-
tions; the great necessity for a hospital for nervous diseases in New
York City, especially for the middle classes; a study of the nervous
and mental diseases incident to our American mode of life; nervous
diseases and diseases in general in relation to the occupations of
the poor; and the proper enlightenment of the public in regard to
the evils of the various forms of faith cure and charlatanry. The
speaker said he looked upon the psychic side of neurology as still quite
a fresh field. There was a whole world of subjective complaints that
had heretofore been dismissed with impatience, but which really deserved

610 NEW YORK NEUROLOGICAL SOCIETY

study and classification. The neurologist had also been silent on the
subject of alcoholism as a social evil and cause of neuroses. In
short, the neurological conscience needed quickening, and the time
had come when neurologists had to take a more important part in the
world as physicians. Otherwise, they would sink into insignificance
as mere technical experts in the occasional correct diagnosis of tumors
and obscure organic lesions that they could only point out and not
cure.

REMARKS ON THE CURABILITY OF A RARE FORM OF
NOCTURNAL PETIT MAL EPILEPSY BY USE OF LARGE
DOSES OF BROMIDE. WITH NOTES OF FOUR CASES.
By Dr. L. Pierce Clark.

Dr. Clark stated that rapidly recurring nocturnal petit mal was a
rare form of sleep epilepsy which occurred both independent of and
in connection with grand mal seizures. The general exhibition of
the type was the same, whether associated with grand mal or not.
Herpin called this type "intractable" epilepsy, ■ defying all medica-
tion. No writer had made extended comment on the condition. Bro-
mides, as ordinarily administered, invariably increased the attacks.
That fact had caused many observers to diagnosticate the state as
a form of hysteria, a disorder of sleep such as pavor nocturnus, som-
nambulism and the like.

Dr. Clark said he had seen but four cases of this type of epilepsy
in a material of several thousand. Aside from the peculiarity of the
attack, the epilepsy in which the seizure occurred did not differ in
causation or course from idiopathic grand mal. However, its termi-
nation under the specific treatment was quite different. The attacks
of nocturnal petit mal invariably occurred while the patient slept,
either by day or night. It usually began as soon as he fell asleep.
There might be as many as 300 separate and distinct attacks in a
single night. The patient usually awoke from a deep sleep, the eyes
widely open, the pupils dilated and irresponsive to light, the head
moving from side to side. There was an anxious and furtive look in
the face, which might be either congested or very pale. In a few
seconds after the onset, the patient executed some incredibly rapid
movements of the hands or feet, but with no clear intent or purpose
such as was seen in somnambulistic states. For instance, the patient
might drum on the bed, kick aimlessly into space, or beat his head,
thigh or chest in a senseless way. He might spring into the air or
turn somersaults rapidly. Sometimes, the patients exhibited attention
when spoken to, but they made no coherent reply. Unless disturbed,
the patient soon passed into normal sleep at the end of the attack.

Dr. Clark then reported in detail four cases of nocturnal petit
mal, all of which were relieved by large doses of bromides. In one
case where 60 to 120 grains of the drug daily were not only ineffectual
in controlling the attacks, but actually increased the number threefold,
the attacks ceased entirely after a daily dosage of 400 grains, con-
tinued for five days. The dose was then gradually decreased to 230
grains daily, at which amount the medication was sustained for sev-
eral months. The patient had no more awakenings nor epileptic mani-
festations whatever, and he was now in excellent mental and phys-
ical health, which was in marked contrast to his former hopeless state

NEW YORK NEUROLOGICAL SOCIETY 611

Dr. Clark said the principle of high dosage of bromide might be
stated as a form of hyperbromidism, bromide intoxication or poison-
ing. The drug was given in a steadily -increasing dose, as was the
iodide in specific disease. The patients received a high rectal irriga-
tion once or twice daily to reduce the amount of congestive catarrh,
eliminate toxins, and for its diuretic effect. They were also given
prolonged hot packs and baths at night for diaphoretic effect, and
cold douches, sprays and cold drip sheet treatment in the morning.
Vigorous deep massage was steadily maintained to cleanse the muscle
circulation. Incipient heart failure might be gauged by the second
pulmonic sound and the degree of splitting of the second tone; the
latter was easily controlled by strychnia and digitalis. Diet was care-
fully regulated, and no meats were allowed. In brief, the object aimed
at was extreme impregnation of the cortex, while the somatic effect
of the bromide was reduced to a minimum.

The speaker said that while it was highly gratifying that this peculiar
and rare type of sleep epilepsy was most amenable to amelioration
or cure by extreme bromide medication, the care and attention that
such cases must necessarily be given during the course of the treatment
could not be too thoroughly insisted upon.

Dr. B. Sachs said that under a recent ruling, the State Commission
in Lunacy took the ground that insane persons could not be harbored
in any home or clinic that was not regularly licensed. By this ruling,
Dr. Sachs said, an injustice might be done in many instances not only
to the physician, but to the patient. He thereupon moved that a com-
mittee be appointed to communicate with the State Commission in
Lunacy in regard to the matter. This motion was carried, and a com-
mittee of three was appointed by the President to investigate the
matter and report at the next meeting of the Society.

i ■

periscope

Revue Neurologique
(Vol. XV. No.. i. Jan. 15, 1907.)

1. Crises of Petit Mai, with a Paramnesic Aura. Illusion of False Recol-

lection. J. Seglas.

2. True Tactile Aphasia. Ernest Jones.

1. Paramnesic Aura in Petit Mai. — There were sudden attacks in
which the patient had the impression that he had been exactly in the same
circumstances before. These false recollections in this case were an aura
to an epileptic petit mal attack, pallid face, eyes fixed and staring, etc. On
gradually recovering from this state there was an amnesia, more or less
complete, for the entire period of the crises, including the period of the
false recollection.

2. Tactile Aphasia. — Raymond and Egger showed before the Neurologi-
cal Society of Paris a patient who was unable to recognize objects placed
in his hand. Raymond named this condition "tactile aphasia." Claparede
suggested for this condition the name of "tactile asymbolia," reserving the
name "tactile aphasia" for a condition where there is only an inability to
name the object. He considered the occurrence of such a case would be
very improbable inasmuch as our memory of words is much more con-
nected with the other senses such as vision, audition, etc. The author re-
ports a case of true tactile aphasia, the first reported. The patient had
traumatic hysteria with anesthesia. In the progress of recovery he passed
through four stages ; first, complete anesthesia ; second, he could feel the
objects in the hand, but had lost the sense of localization and could not
tell their form; third, could perceive the form of objects and name their
attributes, but he did not know what the object was ; for instance, a piece
of money was "a piece of metal, round and flat, but he did not know what
it was," this phase corresponds to the "tactile asmbolia;" fourth, he
recognized the object and knew its use, but simply could not name it, true
tactile aphasia.

(XV. No. 2. Jan. 30, 1907.)

1. The Lesions of the Spinal Roots, the Root Ganglia and Nerves in a
Case of Friedreich's Disease. Studied by the Method of Ramon
y Cajal. J. Dejerine and Andre Thomas.

1. Friedreich's Disease. — A typical case of Friedreich's disease of
22 years duration. The authors calls especial attention to the pres-
ervation of all forms of sensation in -the limbs up to a short time before
death. Macroscopically the spinal cord showed a general diminution in
size, a gray color of the posterior columns and of the lateral columns in
the region of the crossed pyramidal tracts extending from the sacral re-
gion to the medulla. There was a marked grayness of the posterior roots
which was in marked contrast to the anterior roots and the pia was thick-
ened and irregular on the posterior surface of the cord, particularly in
the lumbar region. Examination by the osmic acid method showed normal
anterior roots, but marked atrophy of the posterior roots; there was
nothing, however, to indicate an active process of degeneration. The
atrophy was present in the fibers of the posterior root ganglia, and distally

PERISCOPE 613

to the junction of the anterior roots. In the cervical region the atrophy
of the fibers proximal to the ganglia was more marked than in those distal
to the ganglia, but in the lumbar region the process was about equal on
each side of the ganglia. Lesions of the peripheral nerves were similar to
those in the posterior roots and were more marked in the cutaneous than
in the muscular nerves. Studies of the spinal cord by the method of
Ramon y Cajal showed that axis cylinders had completely disappeared
from the posterior columns except in the cornu-commissural and posterior
radicular zones.

(XV. No. 3. Feb. 15, 1907.)

1. Paralytic Ptosis in Hysteria. Ch. Sauvineau.

2. Paralysis of the Abducens Nerve and the Cerebral Arachnoid Space.

F. Levy and A. Baudouin.

1. Ptosis in Hysteria. — The first observation was in a child of eleven
years who after punishment developed a bilateral ptosis. There was no
sig"n of blepharospasm. She was cured by one treatment with a slightly
painful faradic current. A recurrence was cured by massage of the lids
and suggestion. In the second case, in a child thirteen years old, there
was a phlyctenular conjuctivitis. On the left side there was blepharo-
spasm, on the right a paralytic ptosis with no signs of blepharospasm. The
ptosis was cured in one seance by suggestion, but the blepharospasm per-
sisted.

2. External Motor Ocular Paralysis. — A transitory paralysis of the ab-
ducent nerve may follow spinal anesthesia. The author reports two in-
stances of a similar occurrence following the deep mjection of cocaine
for the relief of facial neuralgia.

(XV. No. 4. Feb. 28, 1907.)

1. Two Clinical Observations of Pseudobulbar Palsy Without Paralysis

of the Limbs. Henri Lamy.

2. The Pathogenesis of Mercurial Tremor. Guillain and Laroche.

1. Pseudobulbar Palsy. — A man, aged sixty-two, developed a sudden
dysarthria and paralysis of the lower portion of the right side of the face.
There was also a remarkable anesthesia of the mucous membrane of the
pharyngo-palatine region. The tongue protruded slightly to the right
side. There was no psychic trouble, no difficulty in deglutition and no
paralysis of the limbs. There was spasmodic laughter. The second case
was very similar. The author thinks that the lesion in each case was in
the external portion of the right lenticular nucleus. The facts suggest a
lesion in a territory which presides over the function of articulation of
words and phonation.

2. Mercurial Tremor. — The author concludes that the tremor produced
by mercurial intoxication is not hysterical, and may endure a long time
after the cessation of the exciting cause. The symptoms would indicate
a lesion of the cerebellum or of the cerebellar tracts.

A. R. Allen (Philadelphia).

614 PERISCOPE

Brain

(Vol. 29. No. 115.)

1. On Some of the Nervous Complications of the Specific Fevers. Sm

Thomas Barlow.

2. The Development of the Vertebrate Nerve Cell : A Cytological Study

of the Neuroblast Nucleus. John Cameron.

3. Miner's Nystagmus. A. Christie Reid.

1. Nervous Complications of Specific Fevers. — This is pre-eminently
a clinical paper, and one, though discursive, filled with much wealth of ex-
perience. Speaking of diphtheritic neuritis, Barlow reports instances of
similar nature occurring after measles. Acute ascending paralysis due to
measles he also reports, as well as hemiplagic and disseminated sclerosis
syndrome pictures. The specific infectious organism in anterior poliomye-
litis is unknown. Barlow suggests that there is little doubt that measles,
scarlet fever, typhoid and even chicken pox are to be reckoned with.
Disseminated encephalomyelitis as a complication of the specific fevers is
mentioned and stress laid upon transverse myelitis in the same connection,
Multiple neuritis and hemiplegia are also discussed as secondary to the
infectious fevers.

2. Development of Vertebrate Nerve Cell. — An extensive and detailed
embryological paper copiously illustrated, from which the author's sum-
mary may be quoted in full: (1) The scanty cytoplastic investment which
the neuroblasts possess during the early development stages takes little
part in producing the abundant cytoplasm of adult nerve cells. (2) The
latter is to be regarded partly as a product of the metabolic activity of the
neuroblastnuclei during metabolic life. (3) One of the earliest indica-
tions of this metabolic activity is shown in the lower vertebrates (e. g.,
fishes and amphibians) by an ingestion of yolk particles at one definite
pole of the nuclear wall. For this the title of assimilative pole has been
adopted. (4) The ingested yolk is elaborated within the nucleus and
stored up as chromatic material which first shows near this pole. (5) The
ingestion of the yolk is further evidenced by a progressive increase in the
size of the nuclei, which occurs during the period when the absorptive pro-
cess is going on. (6) The rudiment of the axis-cylinder process arises in
the form of successive extrusions of nuclear achromatic substance from
the assimilative pole of the neuroblast nucleus. This pole thus becomes the
axon pole. (7) It is to be clearly understood that the term achromatic is
applied throughout to a fluid substance which is nuclear in origin, and is
in the nascent condition strongly resistent to the action of all coloring
agents. This term is therefore applied in contradistinction to the chroma-
tic or staining elements of the nucleus. It is possible that several distinct
substances may be included under this title of achromatin ; but from its
very nature it has as yet defied attempts at learning its composition by
means of microchemistry. (8) The assimilative or axon pole of the
neuroblast nucleus has always a definite direction. Thus it looks towards
the ventricular cavity in the cerebral hemispheres, and forwards as well
as outwards in the anterior cornua of the spinal cord. (9) Not only
the axon rudiment, but also a gTeat part of the cytoplasm of the future
nerve cell is produced from the neuroblast nucleus, owing to the continued
exercise of the achromatin function. (10) The nuclear metabolic product
is extruded mainly from the axon pole. This would account both for its
gradual accumulation in this region and also for the eccentric position of
the nucleus in the embryonic nerve cell. (11) The material which is

PERISCOPE 615

given off from the neuroblast nucleus is achromatic only in the nascent
condition. It very soon, however, undergoes a characteristic process of re-
chromatization which affects the extruded perinuclear substance in a
definite manner and gives rise to the neuro-fibrillary network and the
Nissl bodies. (12) The neuroblast nuclei exhibit structural changes as
evidence of their metabolic activity. The most striking is a disappearance
of the accumulated chromatic material from the axon pole, which occurs
during the period that the axon rudiment is being given off. The chroma-
tic element is thus re-transformed into nascent achromatic element, in
which condition it is discharged from the nucleus. (13) In some regions,
the retina, cerebral hemispheres and ganglion habenulae, of lower verte-
brates, the neuroblasts exhibit in addition a marked reduction in size
during the period that this achromatic element is being discharged. (14)
Three types of neuroblasts may be recognized. For these the names of A.
B., and V-neuroblasts have been adopted. (15) The a-neuroblasts retain
their embryonic character more or less. They probably form a reserve of
young nerve cells. (16) The b-neuroblasts become invested by a very
scanty envelope, their process thus appearing to pass directly from the
nuclei. (17) The v-neuroblasts become transformed into actively func-
tioning nerve cells, and become endowed with an abundant investment
which forms the adult cell-cytoplasm. (18) It is important to note that
the nerve cells begin their life history as an a-type of neuroblast, and
pass successively through the b and v-types. (19) Several observers have
shown that the cytoplasm of nerve cells is rich in nuclein compounds.
This seems to suggest that a part of it at least is derived from the nu-
cleus as shown in this research. (20) The nucleus not only gives part
origin to the protoplasm of the nerve cell, but also furnishes a fresh
supply of material to replenish the latter, when occasion demands,
throughout the life history of the individual. The nucleus is thus the
nutritive center for the nerve cell. (21) It is thus obvious that a mod-
ification in our present acceptation of the Wallerian law of degenera-
tion will be necessary. The latter ought therefore to read somewhat
as follows: An axon when cut off from its nutritive center, the nucleus
of the nerve cell, soon exhibits degenerative changes.

3. Miner's Nystagmus.— The author puts forward a new hypothesis to
account for this disturbance. He terms it the equilibration disturbance
theory. His conclusions may be summarized as follows : The etiology is
complex, the factors of most importance are (1) Conditions tending to do
away with yellow spot fixation; e. g., feeble light; (2) Conditions tending
to d;sturb the equilibrium of the body; (3) Conditions in which some more
or less rythmical series of movements is performed by the head and body,
the eyes remaining fixed; (4) The onset is hastened by debilitating in-
fluences ; i. e., alcoholism, influenza, accident. Jelliffe.

Hews anfc flote*

In the death of E. Mendel neurology has lost another striking figure.
He died on the 23rd of June from chronic nephritis. Mendel was born
in Schlesia and took his first university studies at Breslau. He finished in
Berlin and Vienna, taking his examination in 1861. He soon built up a
large general practice in Pankow, a suburb of Berlin. After the Franco-
Prussian war, in which he served, and was wounded, he founded a private
sanitarium for nervous and mental diseases at Pankow, from which
material he contributed important studies on the Early Diagnosis of
Paresis, 1880 and Mania, 1881. In 1882 he founded the Neurologisches
Centralblatt. and in 1884 was made Extraordinary Professor. His lectures
were so well attended that a special auditorium was built for him. He
built up a large consultation practice, being particularly aided by the fact
of his great teaching ability and because Westphal, who held the chair, was
more or less of an invalid. His was an optimistic and good-humored per-
sonality. He was genial r.nd stimulating, and his loss will be felt.

Post-Graduate Courses in the Psychiatric Clinic in Munich. From
No. 2. 4-24. 1007. as follows:

1. Alzheimer: Normal and pathological anatomy of the brain cortex;
2~ lectures.

2. Gudden : Anatomy of the central nervous system ; 6 lectures.

3. Kattwinkel : Neurological demonstrations ; 9 lectures.

4. Kraepelin : Clinical and forensic demonstrations ; 28 lectures.

5. Nitsche: Methods for clinical examination of patients; 5 lectures.

6. Plant : Research in sero-diagno«is ; 3 lectures.

7. Rehm : Cyto-diagnosis from examination of the cerebrospinal fluid;
3 lectures.

8. Riidin : Facts and problems of degeneration ; 6 lectures.

9. Specht: Experimental psychology, clinically considered; 8 lectures.

10. Specht: Criminal psychology; 8 lectures.

11. Weiler: Physical methods of clinical examination; 5 lectures.

12. Visits to institutions.

The courses will be given daily from 8 to 12 A. M., and 4 to 6 P. M.
Cards are issued for the entire group at 60 marks. Application before
Sept. 1.

The International Congress of Physio-Therapye. — The Committee
of the Congress to be held in Rome next October for the consideration of
physical remedies in the treatment of diseases have arranged special transit
facilities for members of the Congress and their families with the follow-
ing companies :

Societa veneziana di navigazione a vapone.

La Veloce.

Lloyd Italiano.

Navigazione generale Italiano.

The last named have agreed to a reduction of 30 to 50 per cent. The
advantages proffered by the other companies can be learned through any
transportation agency. The Committee have also concluded an especially
favorable tariff for their visitors at the best hotels in Rome and other
Italian cities to which excursions will be made at very reduced rates. The
Secretary of the Congress is Prof. Colombo, Via Plinio, Rome.

VOL. 35. OCTOBER, 1907. No. 10.

THE

Journal

OF

Nervous and Mental Disease

©rtglnal Hrttclee

LOSS OF COMPREHENSION OF PROPER NAMES*
By Frank R. Fry, M.D.,

OF ST. LOUIS.

On April 27th, 1906 (one year ago) I examined with Dr. J.
W. Dreyfus of Louisiana, Mr. A. B., a gentleman 40 years
of age. Seven days previously he had spent the evening rolling
ten pins and attending an informal banquet. He had drunk "a
good deal." Late at night four of his friends accompanied him
to his home, leaving him at the front door. He was found in bed
the following morning in a dazed state with most of his clothing
unremoved. Dr. Dreyfus was sent for. The patient although
confused and stupid was able to respond to questions with some
intelligence. He was complaining of pain, and soreness on the
left side of his head and face. A large area of the scalp above
the ear was swollen and tender. There were blood stains on the
pillows, which were traced to a hemorrhage from the right ear
(the side opposite to the trauma). On the front steps of his
residence there was quite a pool of blood which is supposed to
have come from the same source. The ear was irrigated and
there was no subsequent escape of blood or any other kind of
fluid.

The patient cleared up rapidly within the next few hours and
it was then evident that he could recall only to a limited extent
the events of the evening of his injury. (These were learned
subsequently from the companions who escorted him home and

♦Read at the thirty-third annual meeting of the American Neurological
Association, May 7, 8 and 9, 1907.

618 FRANK R. FRY

from others). What was still more noticeable, and especially dis-
tressing to the patient, he could not recall the names of the mem-
bers of his family and most intimate associates.

I had obtained the above account, in greater detail, before I
began my examination, one week after the injury; hence from
the start I was alert to discover the character of his speech defect
and to use due care in preserving a record of the examination,
etc. When I was introduced he repeated my name, greeting me
with a few courteous words spoken cordially and freely. I re-
marked to him that he did not have the appearance of being ill.
He replied (almost verbatim) : "I guess I am not very sick but
I have been through a little experience in the last few days that
is not very clear to me. To-day I am feeling stronger and better
than any day yet and I feel that my head has cleared up a great
deal, but I cannot yet remember all that happened to me the other
night, which the doctor has no doubt told you about, and I can-
not remember names at all. I cannot remember the names of
any of the boys down at the bank (his place of business)." After
what I had been told concerning him I was quite surprised to
hear him speak at this length with none of the usual aphasic diffi-
culties. Carrying the conversation farther I found that he not
only spoke with fluency but very intelligently, and I soon noticed
that he was deliberately avoiding the necessity of employing
proper names in his conversation. When there was urgent neces-
sity of one he appealed to those about him for it. I also noticed
that when a name was supplied to him he accepted it on faith,
as it were. It was quite evident that he was not positive about
any proper name. At the time I saw him he was just beginning
to venture on the given names of three or four persons and the
manner in which he used them showed that he was never sure
of any of them. I finally made some tests of which the following
dialogue is a sample :

"Who was George Washington?" He smiled blankly and re-
marked: "Anything along that line gets me, Doctor, I cannot
tell anything about it."

"Who was the first president of the United States ?"

"Of course I should know, but I can only say you under-
stand how to catch me."

"Where is Washington, D. C?"

"No, I cannot tell."

LOSS OF COMPREHENSION 619

"What is the capitol of the United States?"
"No, I cannot get anything along that line."
He was then tested in a similar manner with a number of
names of familiar persons and places. In each instance when
asked to repeat the name he always did so with no difficulty. And
what was quite surprising, he wrote names to dictations ac-
curately and without hesitation and did not gain any comprehen-
sion of them by so doing. When asked to write his own name
he did so, and explained that he had recently re-acquired the
ability to do so.

This peculiar disability lasted for about three weeks ; at least
at the end of that time names were coming back rapidly enough
to give him an assurance that he would recover.

The above description hardly conveys the picture that this case
presented to the observer, that of an alert, intelligent, fine ap-
pearing young gentleman conversing fluently, hardly hesitating
or tripping on a word, and yet with as little conception of proper
names almost as though he had never known any.

The loss of substantives, and especially the proper names is
conspicuous in all aphasic cases but I never before have seen it
so completely and strikingly limited to the one class, and I felt
that this instance was rare enough to merit recording.

In attempting to at least partially consider the condition
present in B.'s case it is necessary to keep in mind the distinction
between memory and recollection.1 B. had not lost the memory
of proper names, for when he wrote, by dictation, names like
"Chicago" and "Mississippi," promptly and accurately, the mem-
ory pictured in some form must still have persisted. The diffi-
culty was, according to our modern theories, that by none of the
intercortical connections or associations could the conceptions
be recollected. In the case of proper names these associations
are necessarily complicated. It is a trite observation that those
who readily recall persons' names have an enviable gift. In
some, as we know, it is a gift comparable almost to an unusual
musical or mathematical faculty. In the majority of individuals,
however, the recollection of proper names is a relatively difficult
matter, and in some of us is only accomplished by multiple as-
sociative processes or ideas as numerous and almost as varied
as the multitude of physiognomies which we would undertake
to label with their respective baptismal stamps. And especially

620 FRANK R. FRY

as we grow older our efforts to retain a respectable cognominai
vocabulary become a source of amusement, as well as chagrin,
to ourselves and to others. These well-known facts, however,
cannot altogether explain the total loss that was present in this
case. And for that matter, the whole literature of aphasia reminds
one of the difficulty of explaining some of the unusual patho-
logical defects of the language faculty which now and then ap-
pears. These irregular phenomena cannot be taken care of by
the usual diagrams and theories. On this point Oppenheim re-
marks : "In constructing these diagrams originally the question
of individual variations was not thought of. One person uses
his visual memory pictures in speech more than another ; another,
his auditory, speaking, reading and writing through the sound
images ; and a third the motor. According as one or the other
of these predominates does the effect of the disease vary : the loss
of a certain center will cause a hardly noticeable defect in one
and a severe and persistent disturbance in another."

The history of this subject, like that of all difficult ones, well
illustrates the usual tendency to elaborate hypotheses on insuffi-
cient data and misinterpreted phenomena ; theories which are
not only entertaining but instructive, and yet not to be taken too
seriously, for we may at any time be called on to abandon them
for something more convincing. In fact we are just now con-
fronted with a proposition of this kind from a most eminent
source. I refer to the recent observations of Marie.2 They are,
to say the least, quite revolutionary, yet they must of necessity
influence our views of aphasia for some time to come.2

The singular loss of one class of conceptions in our case is
somewhat comparable to certain authentic cases where patients
quite word-blind are still able to recall mathematical characters
and to do mathematical calculations ; or to other instances of
patients who having a command of two languages lose entirely
the recollection of one of them and retain the other. If the loss
had not been confined entirely to the one class of conceptions we
could readily classify the case as one of "intercortical sensory
aphasia."3 and conceive of a temporary difnculcv in conduction so
slight as to permit the stronger class of stimuli to carry, but fail-
ing for a time to convev the feebler or less insistent ones. An-
other suggestion is to be thought of ; namely, that this was not
a case of aphasia at all, but merely a transient psychic or so-called

LOSS OF COMPREHENSION 621

hysterical condition. There were, however, no other symptoms
that would tend to support this view.

On physical examination I found a large area of the scalp
above the ear quite tender to pressure and boggy to the touch,
evidently the site of a contusion which was rapidly subsiding.
There was no abrasion of the skin. He had been having a great
deal of pain in this locality, but at the time of my examination
he was only feeling occasionally a slight headache on this side of
which he complained very little. He also confessed to a slight
vertiginous sensation at times. For several days following the
injury the vertigo had been pronounced. The supraorbital nerves
were not tender (the left possibly slightly so). The pupils were
equal and responded to light and accommodation. There were no
visual disturbances. There was a suspicion that the right side
of the face was a shade smoother than the left, but a paresis of
none of the muscles could be demonstrated. The deep and super-
ficial reflexes of the body were everywhere symmetrical. There
were no subjective or objective sensory symptoms. The sensi-
bility of the fauces was normal. The pulse was from 62 to 70.
There had been no elevation of temperature after the first day
or so.

His occupation has been, for a number of years, cashier of a
bank. He has had a good education, leaving school when about
twenty-one, and has since been actively, engaged in business, of
which he has made a very good success. In recent years he has
been drinking, in a convivial way, too much and too often, but
he could not be considered an "alcoholic" ; nor has he been one
at any time. He is a person of fine appearance, showing no signs
of dissipation, and has an active and alert mind.

Within the last few weeks I wrote him asking him to answer
a number of questions. He replied (in part) as follows: "I am
glad to report that my health at the present time is very good.
While I still have some trouble in the memory of proper names,
it is limited. My greatest trouble as a result of my accident last
spring seems to me to be a shortened vocabulary. Very often in
dictation or in conversation I am halted by an inability to bring
to mind a word (the most common word) I wish to use,"

He further states, in answer to one of my questions, that be-
fore the accident he had had no especial difficulty in remembering
proper names. He also states that at no period of his life had he

622 FRANK R. FRY

been required to write proper names to any great extent, but
simply to the extent demanded in the usual routine of business.

REFERENCES.

(i) My attention was recently called to some well expressed
sentences covering this point by Dr. Charles W. Burr, as follows :

"It is well not to use the words memory and recollection
synonymously but to distinguish clearly between them, using the
former to mean the storing up of sensations or ideas in the brain
but not in consciousness. In the diseased states in which for a
time power of recollection is lost, but later recovered, memory
is not really at fault, the 'imprints upon the brain' of the original
sensations or ideas have been retained, but the ability to bring
them into consciousness, power of recollection, has been tem-
porarily suspended." ("A Case of Loss of Memory" by Charles
W. Burr, American Journal of Insanity, January 19th, 1907).

(2) Marie maintains that Broca's convolution — the third in-
ferior frontal — plays no special part in the function of speech.
Careful and very extensive pathological and clinical observation
leads him to deny the existence of a special word-hearing center
in the first temporal convolution, and to reject the current ex-
planation of word-deafness. He regards the different aphasias
as different degrees of the same disease. The essential difference
between the motor aphasia of Broca and the sensory aphasia of
Wernicke, according to Marie, is that in the first the patient is
unable to speak, whilst in the latter he can speak, more or less
badly. In other words, Broca's aphasia is simply Wernicke's
aphasia minus the power of speech. The essential fact of aphasia,
of whatever variety, is insufficient comprehension of speech. When
to this is superadded anarthria, due to a lesion in the neighbor-
hood of the lenticular nucleus, we have Broca's aphasia. The
intellectual processes of speech are usually localized in the left
hemisphere, whilst anarthria may be produced by a lesion of
either lenticular nucleus. (The International Medical Annual,
1907).

(3) When the association fibers between the memories of sight
and the memories of sound are severed a condition of aphasia re-
sults which is characterized by an inability to recall the name of
a thing seen and to picture to the mind the appearance of a thing
named. Yet the name is recognized when heard and the object
is recognized when seen. This condition has been described under

LOSS OF COMPREHENSION 623

different names by different observers. Freund named it optical
aphasia or transcortical aphasia, and these terms are used by the
Germans. I prefer the term intercortical sensory aphasia as less
obscure and misleading. A patient suffering from this type of
aphasia has not lost his memory pictures, for he is able to recog-
nize anything once heard or seen. He can, therefore, hear, under-
stand, and read ; but if he is asked to call to his mind some place
or person whose name is given e. g.} Lake George, Lake Como,
President McKinley — he cannot do so. The impulse started from
the word-hearing center cannot reach and arouse the visual mem-
ories ; nor can the association be made in the opposite direction,
for if he is shown an object or a person — a watch, a chain, or
some familiar face — he cannot recall the name, though he recog-
nizes it when heard. {"Organic Nervous Diseases," M. Allen
Starr, M.D., etc., 1907).

THE SYMPTOMATOLOGY OF LESIONS OF THE LENTICU-
LAR ZONE WITH SOME DISCUSSION OF THE
PATHOLOGY OF APHASIA.

By Charles K. Mills, M.D.,

PROFESSOR OF NEUROLOGY IN THE UNIVERSITY OF PENNSYLVANIA; NEUROLO-
GIST TO THE PHILADELPHIA GENERAL HOSPITAL.

AND

William G. Spiller, M.D.,

PROFESSOR OF NEUROPATHOLOGY AND ASSOCIATE PROFESSOR OF NEUROLOGY IN
THE UNIVERSITY OF PENNSYLVANIA; NEUROLOGIST TO THE PHILA-
DELPHIA GENERAL HOSPITAL.

(Continued from page 588.)

THE ROLE PLAYED IN THE PRODUCTION OF APHASIA BY LESIONS OF
DIFFERENT PARTS OF THE FIRST TEMPORAL CONVOLUTION.

In the discussion of the effects of lesions of the lenticular zone
and the zone of Wernicke* in the production of aphasia, the im-
portance of each portion of these zones must be carefully consid-
ered. It is only in this way that we can arrive at reliable conclu-
sions on the mooted questions of the localization of the represen-
tation of the different elements of cerebral speech. The first
and second temporal convolutions necessarily hold a prominent
place in this discussion. It has been usually held that the higher
auditory area, the so-called center for word hearing, is situated
in the posterior portion of the left first temporal convolution, or
of the first and second temporal convolutions, the focus of repre-
sentation being about opposite the posterior upward turning of
the horizontal branch of the Sylvian fissure. As a rule more
stress has been laid upon lesions of the cortex than of the sub-
cortex in the causation of word deafness, although of course the
pure word deafness of Lic'htheim and Dejerine has been attrib-
In the two cases, the histories of which have just been given,

*It might be well to give here Marie's definition of this zone. Accord-
ing to him it consists of the supramarginal and angular gyri and the feet
of the first two temporal convolutions. Its limitations cannot be accurately
determined, and it is impossible to say whether the symptoms accompany-
ing a lesion of this zone are caused by the alteration of the cortex or the
subjacent white matter; Marie inclines toward the importance of the whit*
matter.

LESIONS OF LENTICULAR ZONE 625

utable to injury of subcortical tracts proceeding to the cortical
center from the basal centers and the auditory periphery,
word deafness was undoubtedly present and somewhat persistent,
although not permanent. In both of these cases the zone of
Wernicke, as described by Marie, was not involved in the destruc-
tive lesion, this being confined to the white matter of the anterior
portion of the first temporal convolution.

It is not necessary to call into service the theory of diaschisis
of von Monakow to explain the word deafness in these cases.
When word deafness is a symptom, the subcortex of the anterior
portion of the first temporal convolution being diseased, while the
cortex and subcortex of the posterior halves of the first and sec-
ond temporal convolutions escape, the aphasic phenomenon finds
its explanation in destruction of the paths of transmission
to and through the external and extreme capsules to the insula
and the center of Broca. One of the writers, Dr. Mills,20 has
reported a case, now well known in the literature of the subject,
which shows that word deafness may result from a lesion limited
to the posterior portion of the first or of the first and second
temporal convolutions, chiefly to their cortex, and reference will
next be made to two cases previously recorded by Dr. Spiller.21

Case 3. Fracture of the Skull in the Temporal Region — Con-
tusion and Disintegration of the Inframarginal and Supra/mar-
ginal Regions — Hemiplegia, Hemianesthesia and Aphasia Nearly
Total at First — The Disappearance of Paralysis and Improvement
in Motor Aphasia. Marked Word Deafness and Paraphasia Per-
sistent— Operation with Improvement — Relapse — Auditory and
Visual Hallucinations — Persecutory Delusions — Necropsy Show-
ing Destructive Lesion Chiefly Invoking the Zone of Wernicke
(the Supramarginat and the Posterior Portions of the First and
Second Temporal Convolutions).

The patient, a man twenty-nine years old, had suffered from
a fracture of the skull which left him at first completely hemi-
plegic and hemianesthetic on the right side and almost totally
aphasic. He recovered largely from the paralysis and to some
extent from the speech disturbance, but word deafness and para-
phasia were pronounced. He was probably word blind.

An operation revealed a stellate fracture with contusion and

"Mills, Chas. K. "Lesions of the Superior Temporal Convolutions Ac-
curately Locating the Auditory Center." University Medical Magazine,
Vol. 4, November, 1801.

"Spiller, William G. "Lesions of the Left First Temporal Convolution
in Relation to Sensory Aphasia." Review of Neurology and Psychiatry,
May, 1006.

626

MILLS AND SPILLER

disintegration of brain substance, probably of the first and second
temporal convolutions. Word deafness persisted, and later the
patient became insane with auditory and visual hallucinations and
delusions of persecution. The patient died in the insane depart-
ment of the hospital and necropsy showed an area of sclerosis
involving the posterior part of the first and second left temporal
convolutions, and also part of the parietal lobe. It extended to the
posterior part of the insula and to the optic radiations.

The necropsy showed the reverse picture of the lesions ill
cases i and 2 so far as the temporal lobe was concerned, the sub-

Fig. 4. Complete destruction of the first temporal convolution, with
marked sensory aphasia. The lesion extends to the lenticular zone. (Case
3.)

cortex of the anterior halves of the first temporal convolutions
being destroyed in these cases. Word deafness was pronounced
but not complete. It would seem, therefore, from these three
cases that either a destruction of fibers passing from the posterior
part of the left first temporal convolution by way of the external
capsule, or of these fibers plus a lesion of the cortex of the pos-
terior part of the left first temporal convolution may cause word
deafness. In the first two of these cases the word deafness was
less persistent. It is to be noted that the sclerosis in case 3
involved the upper part of the middle portion of the left second
temporal convolution.

Case 4. Apoplectic Attack twenty-three years before death
causing Hemiparesis and Disorder of Speech — A Second Apo-

LESIONS OF LENTICULAR ZONE

627

plectic Seizure fifteen years later — Slight Paraphasia and Para-
graphia (Occasional Omission or Misuse of Words in Talking
or Writing) — Word Deafness not present for several years
before his death — No Facts as to Word Hearing at the Time
and immediately after his aplo plectic attack — No Word Blind-
ness or Letter Blindness — No Mental Impairment except some
Defect of Memory — Was Ataxic and had other symptoms of

Fig. 5. Complete and long-standing destruction of the left first tem-
poral convolution without marked persistent sensory aphasia. The de-
struction extends to Marie's lenticular zone. (Case 4.)

Tabes — The Microscopic Findings of Tabes — Destruction of the
Entire Left First Temporal Convolution except in the Angular
Region — Destruction of the Insula except at its anterior pole —
No Involvement of the Lenticula.

A man, abrut sixty-one years of age at the time of his death,
twenty-three years before this time had an apoplectic attack. He
was left with some disorders of speech and impairment of power
in the right half of the body. About eight years before his death
he had a second seizure. He became partly aphasic, could not
write without making mistakes, walked with difficulty, and at
times had difficulty in swallowing and in urination. He also
had spells of hiccough and vomiting. He had cramps or twitch-
ings in the right leg.

628 MILLS AND SPILLER

The patient, at least in a late period in the history of his case,
had no difficulty in understanding words. He was sometimes at
a loss for a word, although he could talk with comparative ease.
He was liable to misuse words in writing, sometimes misspelling,
but these defects were but little marked. He was sound mentally,
except that his memory had failed somewhat. He was right-
handed. He read constantly, evidently not being word or letter
blind. He was ataxic and had other symptoms of tabes.

The left first temporal convolution was destroyed in its entire
length except at the angular and supramarginal gyri. The scle-
rosis extended to the posterior horn of the lateral ventricle. It
destroyed the cortex of the island of Reil and the white matter
immediately subjacent except in the extreme anterior end of
the island. It did not involve the lenticular nucleus. The lesion
was very similar to that in the brain of the patient in case 3,
except that it extended a little more inwards and considerably
further forward, but left the supramarginal and left second tem-
poral convolution intact. It did not cause persistent word deaf-
ness, at least the patient was not word deaf at the time his case
was studied. About his condition as to word hearing at the time
of his attack and in the earlier years after it, no record was
made.

In the original report of this case, one of us. Dr. Spiller, has
suggested that the only explanations for the preservation of
word hearing in this case are that the center for this function
was largely in the posterior part of the left second temporal con-
volution, or that the right first temporal convolution had been
unusually well developed during the patient's entire life, and was
capable of assuming the function of the destroyed left first tem-
poral convolution. It seems improbable that the small portion of
the angular and supramarginal gyri preserved could explain the
retention of word hearing.

The preservation of mentality in this case, as in case 2, is of
interest in connection with Marie's views as to intellectual deficit
caused by lesion of Wernicke's zone. The history of the case
emphasizes the fact, to which attention has been directed by one
of us22 in a recent paper, that the degree of intellectual deficit
in cases of lesion of this zone is largely conditioned by the intel-
ligence and general capacity of the patient before the attack caus-
ing the aphasia.

THE INSULA AS A DISTINCT AND IMPORTANT FUNCTIONAL AREA.

One of the results of the acceptance of the views of Marie
is to underrate the importance of the insula as a functional area
or as a portion of a functional area concerned with speech. The

"Mills, Chas. K. The Journ. of Nerv. axd Ment. Dis., Vol. 34, July,
1907.

LESIONS OF LENTICULAR ZONE 629

effort should in the first place be made to distinguish between the
functions of the insula and those of the lenticula.

Some of the contributors to our knowledge of aphasia, and
especially some of the earlier writers of the period beginning
with Broca's discovery in 1861, have gone so far as to regard
the insula as the sole cortical motor center for speech, a view
which must fix our attention in connection with some of the find-
ings given in this paper, although we are inclined to the opinion
that it is only a part, but it may be a large part, of this corti-
cal motor center. The numerous cases of lesion of Broca's
convolution with motor aphasia, even if the lesion in many of
these cases was not confined to this convolution, cannot be set
aside. In one of our own cases (case 5) the lesion causing the
motor aphasia was nearly equally distributed between the insula
and Broca's convolution, Wernicke's zone, the lenticula and the
capsules not being involved.

For the literature of the insula in its relations to speech we
must refer our readers to such well-known works as those of
Bateman, Wyllie, Dejerine, and others.

Dr. E. A. Spitzka23 has contributed something of interest in
this connection from the standpoint of the anatomist and morphol-
ogist. He has directed attention to the redundancy of the pre-
insula in the brains of highly educated men, — men with great
capacity for language both as a means of verbal expression and
of reasoning.

The island of Reil is embryologically very different from the
striatum. The latter rises from the base of the brain and is sep-
arated by a fissure, as Edinger says,24 from the mantle or pallium,
whose wall becomes thickened relatively late. Thle striatum
develops in all vertebrates, but it is only in the higher that the
pallium has a development of importance. The pallium later con-
tains the cortex, on which depends all mental processes. In a
figure of a frontal section through the brain of a human embryo
at the age of two and one-half months, given by Edinger, the
striatum rises free from the base of the brain, distinctly sep-
arated by a fissure from the external wall of the lateral ven-
tricle. At a later embryological period (about the fourth month)

""Spitzka, E. A. Amer. Anthropologist, N. S., Vol. 5, October-Decem-
ber, 1903.

"Edinger, L. "Vorlesungen tiber den Bau der nervosen Centralorgane."

630 MILLS AND SPILLER

it is divided into the caudate and lenticular nuclei by the fibers of
the internal capsule growing through it. The caudate nucleus
projects free into the lateral ventricle, as does the lenticular
nucleus also ; but in later embryonal life the small fissure between
the latter and the wall of the cerebral hemisphere becomes so
narrowed as to be invisible ; but even in adults the wall of the
hemisphere can be separated from the outer part of the len-
ticular nucleus without tearing of fibers. This region of the
early fissure is sometimes of importance in the fully developed
brain. Hemorrhage occurs here very readily, and the blood, if
not too great in quantity, fills the space between the wall of the
cerebral hemisphere and the outer division of the lenticular
nucleus. Edinger believes that the striatum has some of its fibers
in the anterior limb of the internal capsule.

These remarks of Edinger explain why the external capsule
is so often the area occupied by a hemorrhage or a cyst. In one
of our cases (case 6) a cyst was found in each external capsule
which was a locus minoris resistentia.

In another case studied by us, — not included formally in the
<:ases given in this paper, — in which the lenticula was in an early
stage of red softening, no separation of the lenticula from the
island of Reil was seen when the brain was first opened, but dur-
ing the process of hardening the putamen contracted from the
white matter of the island, leaving a fissure in the external
capsule.

The blood supply of the lenticula and of the insula and its
subcortex seems to be distinct. We have preparations from a
case (case 7) in which occlusion of the middle cerebral artery
occurred after the supply to the basal ganglia had been given
off. The point of thrombus formation is clearly demonstrated.
The softening implicates the island of Reil and subjacent white
matter, but leaves the lenticula intact. The patient could not
speak during three weeks, but seemed to understand.

From these facts we may conclude that the function of the
island and its white matter is distinct from that of the lenticula,
and cases in which both structures are implicated may be wrongly
interpreted.

Case 5. Apoplectic Seizure causing Aphasia without Par-
alysis of Face or Limbs — Aphasia of Motor Type — A Few Re-
curring Utterances — Marked Paralexia — Some Retention of

LESIONS OF LENTICULAR ZONE 6,?i

Writing — No Impairment of Articulation or Vocalization —
An Old Cyst Involving only the Cortex and Subcortex of the
Caudal Portion of the Left Third Frontal Convolution and the
Insula.

Alt'hought the following case has been used by one of us, Dr.
Mills,25 in a previous article, and has also been referred to by
Gordinier,26 it has so much value on the negative side of the dis-
cussion of the functions of the lenticula, as this ganglion was not
involved in the lesion, and also so much on the positive side of
the consideration of the functions of the insula and Broca's con-
volution, both of which were destructively implicated, that we
have thought it important to reproduce it in connection with our
present series of cases. There is scarcely to be found in the lit-
erature of aphasia a more instructive case. Neither Wernicke's
zone, the lenticula, nor the internal capsule was involved, and
yet the patient showed motor aphasia of typical form with the
retention of some power of writing and with the retention (or
reacquirement, as the case was not seen at an early period after
the apoplectic attack) of the power of reading silently.

The third frontal gyre and the insula were neatly involved in
the same circumscribed lesion, the second frontal convolution, the
internal capsule, the basal ganglia, and all other portions of the
brain not being the seat of any old lesion.

The following citation and summary are taken from the paper
in the American Journal of the Medical Sciences:

"This patient, after an apoplectic seizure, developed aphasia,
apparently without preceding paralysis or any other symptoms of
focal lesion like visual blindness and hemianopsia. When exam-
ined about nine years after the onset of the aphasia, he had almost
complete inability to name persons and objects which 'he was
able to recognize through all his special senses. He had also
a marked form of paralexia. When he attempted to read, although
he understood what he was reading, he repeated an absurd for-
mula of a few phrases. He had limited spontaneous speech, even
using short sentences without concrete nouns correctly. He could
write many single words correctly, sometimes misspelling, how-
ever. He held his pen or pencil correctly and wrote with ease
and firmness."

Many examinations of this patient were made. The case was
clearly one of aphasia with marked verbal amnesia and general
disorganization of language on its dynamic side. Grammatical
expressions and combinations were lost. The patient could speak
only in single words, or in short phrases, or very short sentences.
What he said, however, he articulated and enunciated clearly.

"Mills, Chas. K. Amer. Journ. of Medical Sciences, September, 1904.
"Gordinier, C. H. Idem, 1903.

632

MILLS AND SPILLLK

He had no paresis of the organs of articulation, enunciation or
vocalization.

The only lesion to be seen in the lateral aspect of the left
hemicerebrum was confined to the hinder part of the third fron-
tal convolution. The lesion was probably part of an old hemorr-
hagic cyst. When the brain was sectioned at the level of the
insula the insula was found to be largely destroyed by a lesion
which was continuous with that in the caudal part of the left
subfrontal gyre. Other parts were not involved, as shown by

Fig. 6. Case of motor aphasia without hemiplegia. The primary lesion
involves the left third frontal convolution and the insula. (Case 5.)

this section and also a subsequent one made a little lower than the
first.

It is worth while to refer in this connection to one of the
most recent and valuable contributions on the pathology of aphasia
— a paper which forms a part of the general discussion which has
arisen since the promulgation of the views of Marie. In this
paper, in addition to many important considerations regarding

LESIONS OF LENTICULAR ZONE 633

focal lesions and the pathology of aphasia, Dejerine27 gives the
details of two previously unrecorded cases studied both macros-
copically and in microscopical serial sections. In these cases the
primitive lesions causing the aphasia were confined to the cortex
and subcortex of Broca's convolution and to the second frontal
convolution with a slight involvement of the insula and extreme
capsule in one case. The zone of Wernicke, the lenticula and
the capsules, except as mentioned concerning the extreme cap-
sule, were not implicated if we exclude processes of secondary
degeneration.*

The first of the two cases reported by Dejerine in this paper
was one of motor aphasia, at first very marked, the patient retain-
ing only "yes'' and "no" and interjections. Any evidences of sen-
sorial aphasia were very temporary. No paralysis, orolingual,
facial or of the limbs, was present. The patient was motor
aphasic without being dysarthric. Writing could not be tested,
as the patient had lost his right arm by amputation and had not
learned to write with his left hand. As time progressed, and
before his death two years after the apoplectic attack, he had
regained largely the power of speech.

The necropsy showed a lesion similar in some respects in its
limitations to case 5 of our series, the insula, however, not being
nearly so much involved. In Dejerine's first case the lesion de-
structively involved about two-thirds of Broca's convolution and
to a very moderate degree the anterior portion of the insula and
the related segment of the extreme capsule. The caudate and len-
ticular nuclei were not attacked by the primary lesion, as were
not the Rolandic operculum and the external and internal cap-
sules. Serial microscopic sections showed some involvement of
the second frontal and of the corona radiata, with a considerable
portion of the frontal lobe anterior to the precentral convolution.
Degeneration was distinctly marked in the knee of the callosum.
The temporal lobe was nowhere diseased. Softening was ob-
served in the first and second frontal convolutions of the right
hemisphere. The degeneration involved the anterior segment
of the internal capsule, the fibers of passage through the striatum,
and the occipito-frontal bundle. Degeneration of the anterior

"Dejerine. J. L'Aphasie Motrice et sa Localisation Corticale. L'En-
cephale, No. 5, May, 1907.

*We understand by Broca's area, which has been described differently
by writers on aphasia, that corticosubcortical area which surrounds the
ascending branch of the Sylvian fissure, including its bifurcations. This
makes Broca's convolution include what Dejerine calls the orbital portion,
the cap and the foot of the convolution. The foot of this convolution is
the part situated between the precentral convolution and the horizontal
and ascending branch of the Sylvian fissure.

634 MILLS AND SPILLER

fibers of the extreme and external capsules was also present.

In the second case of Dejerine, the patient, a woman seventy
years old, had a left hemiplegia and some years later an attack
causing motor aphasia. This motor aphasia as described was
typical and persisted. The patient retained only a few expres-
sions, such as "yes," "no," and "good day." She was not word
deaf, word blind or letter blind, or if word blind at all only to
a limited extent. She understood all that was said to her, even
when she was spoken to rapidly. She could read what was
placed before her, but had difficulty if the sentences were long or
complex. She could not write, except her name, although she held
the pen correctly. She could, however, copy and transfer print
into script.

We shall omit the lesions found in the right hemisphere in
this case, except to say that they were such as to account for her
left hemiplegia and perhaps some other phenomena. In the left
hemisphere a yellow plaque was found, so situated as to destruc-
tively involve the cap of Broca's convolution, and also in part
the second frontal convolution. Serial microscopical sections
showed that this primitive lesion did not involve the insula, the
external or internal capsules or the basal ganglia. The white
matter of the third and second frontal convolutions was consid-
erably diseased. Degenerations were present much as in the first
case, involving, for example, the anterior segment of the internal
capsule, the radiate fibers to the thalamus and the knee of the
callosum. The zone of Wernicke and all other parts of the left
hemisphere were intact.

This case clearly shows that Broca's aphasia (motor aphasia
of persistent form) may be due to a lesion involving the third
and second frontal convolutions and the subjacent white matter in
the primitive lesion, all other parts escaping.

The first of the two cases is of similar import, although the
insula and extreme capsule were to a slight extent included in
the lesion, and the patient recovered largely from his motor
aphasia. This recovery may have been due to the restoration of
the parts of Broca's convolution and the insula not included in the
lesion, or as Dejerine suggests, the fact that the patient had lost
his right upper extremity some twelve years before his death
may have had something to do with the unusual facility with
which the convolutional areas of the right hemisphere, homolo-
gous to those of Broca in the left, assumed the representation of
motor speech.

Case 6. Right Hemiplegia with Exaggerated Reflexes on the
Paralyzed Side — Attacks of Vertigo — Linear Cyst in the Exter-
nal Capsule of Each Hemisphere — Area of Sclerosis in the Middle
of the Foot of the Left Cerebral Peduncle — Right Pyramidal
Tract in Cervical Region Degenerated.

LESIONS OF LENTICULAR ZONE

635

The notes of the following case were meager.

E. D., aged fifty-seven years, white, German, was admitted
to the Nervous Wards of the Philadelphia General Hospital No-
vember 14, 1902. He had been a strong man and had worked as
a sailor.

When admitted to the hospital he stated that he was paralyzed
on the right side six years ago. He said that he had had attacks
of vertigo every day for the last six months, in some of which
he fell to the floor. The eyes reacted normally to light and in ac-
commodation. On the right (paralyzed) side knee-jerk was ex-
cessive, slight on the well side. Xo ankle clonus could be
obtained, but a slight Babinski response was present on each side.

The next notes in this case were not made until September

Fig. 7. A symmetrical cyst is present in each external capsule in the
region of least resistance. (Case 6.)

11, 1903, when the records state that the patient was in a stu-
porous condition, unable to answer any questions and he did not
seem to understand anything that was said to him. He had
great difficulty in swallowing.

On September 15, 1903, the notes stated: He became weaker
this evening and was no longer able to be out of bed. Inconti-
nence of urine and feces was present. He died September 20th.
The fresh spinal cord seemed to show sclerosis of both right and
left pyramidal tracts. The brain showed some areas of soften-
ing of the right caudatum.

A horizontal section through the cerebral hemispheres nearly

636 MILLS AND SPILLER

at the upper border of the lateral ventricles showed a small
hemorrhagic scar in the right hemisphere probably cutting some
of the fibeers that form the knee of the right internal capsule.
This may have developed shortly before death. A linear cyst
was found in the external capsule of each hemisphere in a section
made through the upper part of the thalamus and lenticula. The
cyst on the right side to the naked eye measured 2.5 cm. in length
and 0.5 cm. in its widest portion (1 in. in length by 1-5 in. in
width). It did not extend into the cortex of the island of Reil
and encroached very slightly on the lenticula. Its anterior end
was 0.5 cm. (1-5 in.) behind the anterior end of the lenticula.
Its posterior end reached very nearly to the posterior end of the
lenticula. The cyst on the left side was smaller than that on the
right side. It was in exactly a corresponding position except that
its anterior end was 1.5 cm. (3-5 in.) behind the anterior end of
the lenticula. Its posterior end extended to the posterior end of
the lenticula. It also encroached very little on the lenticula. Nei-
ther cyst extended into the capsule, and neither extended down-
wards as far as the level in which the cerebral peduncles appeared
distinctly formed, nor did they change their relative positions. No
cause was detected for the right hemiplegia.

Sections of the cerebral peduncles and of the cervical region
of the spinal cord made by Dr. T. H. Weisenburg showed a small
area of sclerosis in the middle of the foot of the left cerebral
peduncle. The right crossed pyramidal tract of the cervical
region of the cord was degenerated. The lesion producing this
degeneration has not been found, unless it was the cyst in the
external capsule, which was doubtful.

The history in this case is very meager, but we have retained
it in this series because the notes record that the patient stated
that he had been paralyzed in the right side six years previously,
and made other assertions. He therefore probably was not motor
aphasic, though we could not assert that his speech was normal.
An old lesion, a cyst, was found confined to each external cap-
sule and claustrum, and yet persistent or complete aphasia seems
to have been wanting. The right hemiplegia might be attributed
to this cyst in the left external capsule, but inasmuch as a small
area of degeneration was found in the middle of the foot of the
left cerebral peduncle, it seems possible that some other lesion
in the left cerebral hemisphere has been overlooked. The lenticula
on each side, to the naked eye, seems to have escaped.

This case, after all, is of chief importance as illustrating the
points made when discussing the views of Edinger and others
as' to the embryonal, and even later, separations of the insula and
its subcortex from the basal ganglia, the inference being that they
are functionally, anatomically and morphologically distinct.

Case 7. Right Hemiplegia with Aphasia — Deep Reflexes but

LESIONS OF LENTICULAR ZONE 637

little changed — Some Hypesthesia — Stereognosis not studied
—Aphasia of Motor Type— No Word Deafness— Thrombus of
Left Middle Cerebral Artery just above the place where the Ves-
sels to the Basal Ganglia are given off — Softening invoking
the Cortex and Subcortex of the Insula, the Foot of the Pre-
central and Postcentral Convolutions, the Entire Parietal Lobe,
the Fibers to the Lower Part of the Callosum, the Optic Radia-
tions to a small extent — The Lcnticula and the Temporal Lobe
were not implicated in the Lesion.

A. H., sixty years old, colored, was admitted to the Phila-
delphia General Hospital December 15, 1904, and died December
29, 1904. The only history that was obtainable was that she
had not spoken for five days and since that time had been paral-
yzed in the right half of the body.

On examination t'he patient was found lying in bed with her
eyes closed, making no attempt to move or talk. The face was
drawn to the left over one-half of its extent. There was marked
over-action of the occipito-frontalis of the left, while on the
right movement of this muscle was verv slight.

The eyes were directed anteriorly without deviation ; t'he right
pupil was contracted, and apparently immobile. She could not
be made to accommodate ; the left pupil was fixed ; the media of
both eyes were very clouded, especially on the left, which seemed
to show a cataract. Arcus senilis was marked. She could not be
made to move her eyes in any direction when told to do so,
although she evidently understood the command, as she made an
effort to obey by a slight turning of the head.

The tongue could not be protruded. She opened her mouth
when asked to put out her tongue, which was pushed to the left
and was slightly tremulous and somewhat coated.

The right arm was apparently completely paralvzed and fell
helplessly when raised. The response was verv feeble on tap-
ping the triceps and biceps tendons. The right leg, which was
paralyzed, gave a slight knee-jerk but no ankle clonus, although
there was a suggestion of dorsal flexion of the great toe on
plantar stimulation.

She slightly moved her paralyzed foot and leg occasionally
when stuck by a pin. Attempts to elicit ankle clonus occasion-
ally resulted in a flexion of the thigh on the pelvis. The left leg
gave a very slight knee-jerk. No ankle clonus and no Babinski
response were determined. This limb was moved somewhat more
when stuck by a pin than was its fellow. There was no positive
result on either side to stimulation by the Oppenheim method.

Under date of December 18, 1904, the clinical notes stated that
there was no change in the patient's condition. She understood
what was said to her, but could not answer. Her bladder and
bowels were incontinent. Her pulse was very irregular and she

638 MILLS AND SPILLER

slept most of the time. She was mentally dull. Temperature at
this date was still down, but respiration was up to 50; pulse
was at 150. The right chest gave bronchial breathing and
great impairment about its middle in the midscapular
line. Both sides were full of large bubbling and smaller sized
rales. She could be aroused by vigorous questioning, but could
not answer, although she tried. She was very weak. She died
December 29, 1904.

At the necropsy the following pathological conditions were
found in the various organs :

Congestion of the lungs ; chronic interstitial myocarditis ;
chronic congestion and interstitial splenitis ; chronic congestion
and interstitial nephritis with infarction and hemorrhagic and
healed infarct of the kidney ; chronic congestion and fatty fibrosis
of the liver and general arteriosclerosis. The brain and spinal
cord were removed for hardening and further investigation.

Later this investigation showed a thrombus occluding the left
middle cerebral artery just above where the arteries to the basal
ganglia are given off, so that the latter arterial supply was intact.
A large area of softening was found which implicated the cor-
tex and white matter of the island of Reil, leaving a narrow mar-
gin of white matter intact on the lateral aspect of the lenticula ;
the latter ganglion was not affected. The foot of the precentral
and postcentral convolutions were softened, but the extreme an-
terior part of the island of Reil escaped. The softening extended
very close to and probably slightly involved the optic radiations.

At a higher level and just above the lenticula the softening
extended inwards so as to involve slightly the fibers going to
form the lower part of the callosum.

The precentral convolution was softened only in its lower
part, but the postcentral was more involved together with almost
the entire parietal lobe. The temporal lobe was intact.

This case therefore showed very clearly that the arterial sup-
ply of the island of Reil is distinct from that of the lenticular
nucleus, and that the lenticule may escape although aphasia is
pronounced.

Cast 8. Apoplectic Attack causing Right Hemiplegia and
Loss of Speech — Tongue protruded to the right — Right Hemi-
anesthesia— Memory poor — Partial Recovery of Speech — Aphasia
Motor in Type — Reflexes exaggerated on the paralyzed side —
Linear Hemorrhagic Scar in the Left External Capsule — Lesion
Involving also the Insula and Anterior Limb of Internal Cap-
sule, the Lenticula and Posterior Limb of the Internal Capsule.

E. J., fifty years old, colored, born in Virginia, an expressman,
was admitted to the nervous ward of the Philadelphia General
Hospital in the service of Dr. Charles S. Potts, on June 12, 1903.

LESIONS OF LENTICULAR ZONE 639

No family history or previous history of importance was ob-
tainable. The patient denied having had syphilis.

Several weeks before admission he fell unconscious in his
wagon and remained unconscious for three days. It was
then found that the entire right half of his body was paralyzed.
At first he was unable to make his wants known by talking, but
speech gradually improved. His wife stated that for several
weeks before the paralytic attack he had complained of headache.

On June 14th, two days after admission, it was noted that he
could not move his right arm and leg, that his speech was slow
and his memory apparently poor. In general appearance the pa-
tient was lean and weak. The pupils were equal ; the light
reaction was normal, the accommodation reaction poor. The
pulse was intermittent, the chest normal, the abdomen tympanitic.

Under date of June 17th notes were made that he was anes-
thetic on the entire right side, the anesthesia extending about one
inch beyond the median line on the left side. The conjunctiva
on the right side was anesthetic. The patient was so stupid that
it was difficult to get from him satisfactory answers. He could
not see a quarter of a dollar when it was brought toward him
from the right, but he recognized it at once when brought from
the left, or when it was held in front of either eye. Dr. Howard
F. Hansell, one of the ophthalmologists of the hospital, how-
ever, reported no hemianopsia. On the right side he could rec-
ognize cold, but invariably called hot "cold." He could not dis-
tinguish any difference between two test tubes containing hot and
cold water when they were placed on the right side, but could at
once when they were placed on the left side. He complained of
much pain when the right arm or leg was moved, but these limbs
could be pressed or touched with impunity and he did not com-
plain of pain in these parts while they were at rest.

He had use of all parts of the left arm, although power in it
was somewhat impaired. He could also move the left leg prop-
erly, but with some diminution of power.

Further examination showed absence of sensation in the right
side to above the costal margin, except on stroking with a sharp
point. Sensation was also absent in the right arm and upper
part of the body, except on very deep sharp pressure. Sensation
was present on the left side. The knee-jerk was increased on
the right side and still more increased and spastic on the left.
The biceps jerk was increased on each side. The tongue, which
was tremulous, was protruded slowly and to the right.

On June 226. examination showed that hemianopsia was ab-
sent. The Babinski reflex was present on the right ; the plantar
reflex was present on the left. No ankle clonus was present on
either side. The tongue protruded decidedly to the right, with
tremor. The naso-labial fold was lessened on the right; the

640 MILLS AND SPILLER

mouth was very slightly drawn to the left. The pupils were
equal, contracted to light and very slightly to accommodation.

Arcus senilis was present. The arteries were thickened and
tortuous, the right radial being somewhat beaded. The pulse was
intermittent, its tension moderate. The heart was irregular in
action, the second sound being accentuated, the first sound clear
but not proportionately loud. Considerable atrophy and con-
tracture were present in the right hand ; the patient complained
of pain in moving his right leg. He had frequent micturition
and had control of bladder and rectum.

He apparently understood all that was said to him, but was
not always able to find words to answer. When the proper an-
swer was repeated to him, he recognized it. There was there-
fore apparently some motor aphasia.

On July 15th he called the hot test tube "cold" on both sides,
and still had complete absence of power in the right arm and leg.

On July 25th it was noted that he had made some improvement
during the preceding five days, but on this afternoon he became
very suddenly prostrate, dyspnea became marked, and the pulse
weak and rapid. He died during this day at a time not mentioned
in the clinical record.

Xecropsy showed the dura and pia normal. The upper aspect
of the right cerebellar lobe was edematous, grayish yellow in color
with distinct loss of substance. Inspection of the ventricles was
negative. The vessels at the base of the brain were sclerotic.
The specimen was removed for hardening and further examina-
tion.

Other pathological conditions present were : Fatty degenera-
tion of the liver and myocardium, thrombosis of the pulmonary
arteries, chronic pleuritis, edema and congestion of the lungs,
chronic nephritis, slight prostatic enlargement, fatty degeneration
of the kidneys, especially of the right, deformity of the right foot,
and ulcer on the right ankle.

A horizontal section made through the cerebral hemisphere at
the level of the upper part of the basal ganglia showed a linear
hemorrhagic scar in the left hemisphere in the external capsule.
It extended forward as far as the anterior limit of the island
of Reil but not beyond, its forks sending off a branch cutting
the anterior limb of the internal capsule. It implicated the
greater part of the left lenticula, and extended very near to the
posterior limb of the internal capsule, although apparently it did
not implicate this limb at this level. The cortex of the island of
Reil was not involved. The lesion extended downward in the
same relative position about 1 cm. (2-5 in.) from this level. The
.upper part of the scar, in a section from a higher level, involved
the posterior limb of the internal capsule, and as the island of

LESIONS OF LENTICULAR ZONE

641

Reil is very short at this level the scar extended forward here
beyond the anterior end of the island.

It will be noted that the lesions in this case involved both
the external capsule, the anterior limb of the interior capsule,
the lenticula, and to some extent the posterior limb of the internal
capsule ; also slightly the island of Reil. It is therefore difficult
to draw any positive inferences with regard to the lenticula;
the motor aphasia may have been due to lesion of the external
capsule and the island, or to the lenticular lesion.

This man, several weeks after the beginning of his right hemi-
plegia, had slow speech ; he apparently understood all that was
said to him, but was not always able to find words to answer.

Fig. 8. A hemorrhagic cyst is present in the left lenticular nucleus.
Some motor aphasia persisted. (Case 8.)

When the proper answer was repeated to him, he recognized it.
There was apparently some motor aphasia, but it was by no means
complete, and yet a large part of the putamen was destroyed.

The occurrence of the hemorrhage into the external capsule
of one side is interesting in connection with what has been said
of lesions thus located and of the anatomical and functional sep-
aration of the basal ganglia from the insula.

Case 9. Left Facial Paresis — Deviation of Tongue to the
Right — Spasticity of Right Upper Limb and of the Lower Limbs
■ — Babinski Response on Both Sides — Spasticity Present and Deep
Reflxes Exaggerated on the Left — Incontinence of Urine and
Feces — Involuntary Laughing and Weeping — Mentality Dull — ■
Speech Indistinct but no true Motor Aphasia Present — A Small
Cyst in the Left Putamen extending into the White Matter of
the Insula.

R. S., sixty-two years old, white. German, was admitted to

642 MILLS AND SPILLER

the nervous wards of the Philadelphia General Hospital October
24, 1905.

Examination showed the left naso-labial fold to be less marked
than the right. The tongue protruded to the right. The brow
was wrinkled equally well on the two sides. The pupils were
unequal, the left being larger than the right. The ocular move-
ments seemed to be preserved, but the patient's mental condition
rendered the examination of these movements a somewhat un-
certain matter. On attempting to close the eyes, the left was not
so well closed as the right, the edges of the left being separated
by quite a little distance as compared with the right. The pu-
pils reacted to light and in accommodation.

The patient seemed to have considerable strength in both
upper extremities, all movements being preserved. A suggestion
of spasticity was present on tbe rigbt side. The reflexes of the
right upper limb were increased ; the left were not increased.
The patient had lost control over the bladder and bowels. Move-
ments of the legs were restricted and appeared to be spastic, but
it was here again, as with the ocular movements, difficult to
sav how much was paralysis and how much failure to understand.
Both knee-jerks were plus and the Babinski response was ob-
tained on each side. The ankle jerk was also much increased on
each side. The biceps jerks were present on both sides.

Under date of December 18th additional notes were made as
follows: The right knee-jerk was plus ; the left plus, plus; the
ankle jerk was plus on the right side and also on the left ; (lowers'
front tap was present on the left side and absent on the right;
ankle clonus was absent on both the right and the left sides.

Stimulating the sole of the foot gave very uncertain results.
On the right side at times extension of the toes appeared to be
present, and at other times, flexion. On the left side the tendency
seemed to be towards the extension or Babinski response.

Power in both upper limbs was much diminished. Move-
ments were much better performed with the right upper extrem-
ity than with the left. Fine movements were very poorly and
clumsily performed. Movements were very ataxic, especially
those of the right side. Marked tremor was present when the
fingers of each hand were extended. The limbs on the right side
were spastic, and contractures were present. The patient could
move the right leg, but not nearly so well as the left. Sensation
to touch, pain and temperature seemed to be undisturbed.

On December 27th further notes were made. The patient's
condition was not so good as it had been. The nurse stated that
the patient had occasional spells of laughing and crying ;
her mentality was not clear ; speech was not distinct, and it was
only with difficultv that she could be understood. She had no
trouble with chewing or swallowing; she had no dribbling of

LESIONS OF LENTICULAR ZONE

643

saliva. The pupils were unequal, both being larger than normal,
the left larger than the right. Extraocular movements were
normal. It was impossible to tell the condition of the light
reflex and accommodation and convergence. Apparently the
seventh nerve on each side was not involved. Apparently ptosis of
the right upper lid was present. The other conditions were as
noted in the preceding observations.

The bedside notes contain a statement without date made by
Dr. Spiller that the patient's speech was very indistinct, but that
she was not aphasic.

Fig. 9. A small cyst is present in the left external capsule, extending
into the lenticular nucleus. The speech was indistinct, but not aphasic.
(Case 9.)

On February 4, 1906, while eating her dinner, she suddenly
turned to the attendant who was feeding her and said that she
had enough. Immediately after this she gasped for breath, be-
came cyanosed and fell over dead.

At the necropsy the pathological findings showed the presence
of hypertrophy of the heart ; chronic passive congestion of the
spleen ; chronic interstitial nephritis ; passive congestion and fatty
infiltration of the liver and s:eneral arteriosclerosis. The skull
appeared to be thicker than normal. The brain and spinal cord
were retained for subsequent investigation.

The gross lesion found was a small cyst 0.5 x 0.5 cm.
(1-5x1-5 in.) in the middle of the left putamen in a horizontal
section through the upper part of the basal ganglia. This cyst

644 MILLS AND SPILLER

did not extend into the cortex of the island of Reil, but impli-
cated the white matter in the middle of the island.

It would seem in this case that the anarthric or dysarthric
affection of speech and the impairment of power and spasticity
and exaggerated reflexes on the right side might be fairly attrib-
utable to the lenticular and subcortical lesion. The speech disor-
der in particular is similar to that which seems to have been ob-
served in other cases of limited lesion of the putamen — not a
true motor aphasia, but a speech disturbance more nearly allied
to that which is seen in pseudobulbar paralysis from capsular
lesions. The woman was sixty-two. and some of the symptoms
may have been caused by senile changes in the brain, but this
finding is important, viz., a small cyst interrupting the fibers
in the left external and extreme capsules, and extending into the
putamen in about its middle portion.

Case 10. Apoplectiform Attack without Unconsciousness —
Speech Lost for Two Hours, then Recovered — Heniiparesis of
Right Lower Face — Deviation of Tongue to Right — Paralysis
of Right Upper and Lower Extremities — Reflexes increased on
right — Sensation not impaired — Destructive Lesion involving
fiie Left Lenticula and both the .Interior and Posterior Limbs
of the Internal Capsule — Absence of Persistent Motor Aphasia.

A. YV.. white, thirty-six years old. was admitted to the ner-
vous wards of the Philadelphia General Hospital December 27,
1898. The family and previous history of the patient contained
no fact of importance, except that her mother died of dropsy at
the age of forty-two. The patient used alcohol moderately.

Five weeks before admission the patient had an attack of influ-
enza from which she recovered. Three weeks before admission
she was taken with weakness while on the street and felt three
times. While unable in these spells to stand or walk, she re-
mained perfectly conscious. Her speech was affected for two
hours, during which time she was unable to talk. On attempting
to move the right arm or leg she was unable to do so.

Examination showed a fairly well nourished adult. The pu-
pils were equal ; the irides reacted to light, and in accommodation
and convergence. The extraocular muscles and the eyelids were
not paralyzed. The muscles of the right side of the face appeared
to be partially paralyzed, this being especially noticeable in the
lower part of the face. The tongue deviated to the right on
protrusion.

The right arm and leg were completely paralyzed, but there
was no limitation of movement in the left extremities. The bi-
ceps and triceps jerks were increased on the right side and absent
on the left ; both knee-jerks were increased. Slight patellar clonus
was present on the right side ; ankle clonus was absent. The

LESIONS OF LENTICULAR ZONE 645

plantar reflexes were increased on the right side. Sensation was
nowhere impaired.

The pulse was frequent, small, and fairly strong. The heart
sounds were normal; the second sound was accentuated.

Examination of the lungs showed nothing on palpation and
percussion, but on auscultation at the right apex was heard a
slight prolongation of expiration, especially noticeable at the mid-
dle lobe posteriorly.

An occasional note regarding this patient was made between
her admission and November 17, 1903, simply showing that the
patient was a right hemiplegic. On November 17, 1903, examina-
tion showed that the woman was weak and her breathing shallow,
but that she was conscious. Both the right upper and lower ex-
tremities were completely paralyzed. Knee-jerks were present on
both sides, prompt on the right; the Babinski response could be
elicited on the right, but was absent on, the left; neither ankle
clonus nor patellar clonus was present. The tongue protruded
slightly to the right. No old contractures were present on either
side. Sensation was not impaired.

Notes were made at this date that the patient had not slept
well. She was constantly muttering and picking at the bed-
clothes. She could, however, be aroused and made to answer
questions intelligently. Respiration was increased, but not la-
bored. The tongue was heavily coated. Examination of the
urine was negative. Resonance was impaired over portions of
the middle and lower lobes of the lungs on the right side ; breath-
ing was distinctly tubular over an area of the middle lobe. On
November 18th the patient developed edema of the lungs ; the
heart became very rapid and weak. She died November 19, 1903.

The following conditions were found post mortem : Croupous
pneumonia with red hepatization and right-sided slight hydro-
thorax ; slight chronic diffuse nephritis and acute parenchymatous
nephritis ; also chronic passive congestion of liver ; slight fatty
degeneration of liver ; slight chronic thickening of the pia arach-
noid ; atheroma of thoracic and abdominal aorta.

A horizontal section was made through the left cerebral hemi-
sphere, just at the upper border of the head of the caudatum
and thalamus, so as not to remove any of these structures. At
this level a cyst was found occupying the entire area of the len-
ticula and encroaching upon the anterior . and posterior limbs
of the internal capsule and the white matter of the island of Reil.
The cortex of the latter region was intact. The head of the cau-
datum and the thalamus, so far as could be determined by the
naked eye, were not implicated. The cyst did not extend forward
or posteriorly beyond the limits of the lenticula. It measured 3.5
cm. in length and 1.5 cm. in width (1 2-5x3-5 in.).

A horizontal section made through the cerebral hemisphere

646 MILLS AND SPILLER

1 cm. (2-5 in.) below t'he previous section showed the lower
termination of this cyst. It was directly beneath the center of
the cyst as shown in the previous section and measured 1.5 cm.
long by 1 cm. wide (3-5x2-5 in.). Sections of the spinal cord
made by Dr. Weisenburg showed intense degeneration of the right
crossed and left direct pyramidal tracts.

Tiie lesion present in this case, although in large part in the
lenticula, was not confined to it, extending both into the anterior

Fig. 10. Complete destruction of the left lenticular nucleus and anterior
and posterior limbs of the left internal capsule, without persistent motor
aphasia. (Case 10.)

and. posterior limbs of the internal capsule. We cannot there-
fore draw any positive conclusions as to the part played by the
lenticular lesion in the production of the hemiplegia. The case
is chiefly of value in throwing some light upon the effect of so
large a lenticular lesion on the function of speech. Speech, while
affected at first, was soon recovered, and the patient continued to
speak intelligently. She was not a motor aphasic.

This in connection with the first case of this paper shows that
complete destruction of t'he left lenticula does not necessarily
cause complete and persistent motor aphasia. While the notes on
the condition of speech in this case are not as complete as might be
desired, they indicate very clearly a recovery, in part at least,
of the motor speech function, and we have the statement from Dr.
T. H. Weisenburg that when a resident in the hospital he fre-
quently conversed with the patient, and that she was able to speak.
We cannot conclude, however, that speech was normal.

Case 11. Aploplectic Attack causing Complete Right Hemi-

LESIONS OF LENTICULAR ZONE 647

plcgia with Hemianesthesia and Complete Aphasia— Disappear-
ance in large part of Speech Affection and Hemiplegia — Per-
sistence of Hemianesthesia — Right Lateral Anopsia — Dyslexia —
Partial Word Deafness and Partial Word Blindness — Deviation
of Tongue to the Right — Right-sided Spasticity and Contract-
ures and Exaggerated Reflexes — Large Cyst involving Left Ex-
treme Capsule, Claustrum and External Capsule and Destroy-
ing the Left Lenticula and Carrefour Sensitif, also involving
Optic Radiations — The Anterior Half of the Posterior Limb of
the External Capsule and the Anterior Limb of the Internal Cap-
sule not involved.

A case which was first recorded by one of us, Dr. Mills,28
in a paper which was written in collaboration with Dr. G. E.
de Schweinitz, is of some value in connection with the study of
the motor and speech functions and the question as to the sen-
sory functions of the lenticula. This patient died in the wards of
Dr. F. X. Dercum, in the Philadelphia General Hospital, and the
case was made the subject of a paper by Drs. Dercum and
Spiller,29 on permanent hemianesthesia resulting from de-
struction of the carrefour sensitif and the lenticula without impli-
cation of the thalamus, the case appearing to demonstrate that
the cerebral sensory fibers are located chiefly, if not altogether,
in the area of the carrefour sensitif, or it may be that some sen-
sory fibers pass through the lenticular nucleus, as held by Edin-
ger. The writers define the carrefour sensitif, following Verger,
as comprising the last third of the posterior limb of the internal
capsule in the most anterior portion of the opto-striate region.

The hemorrhagic apoplectic attack which left the cyst found
at necropsy occurred many years before the death of the patient.
Immediately after the attack the man was completely paralyzed
in the right arm and leg, and also completely aphasic and hemi-
anesthetic. He recovered his speech very largely in about two
months and the motor paralysis largely disappeared in about
three months. The hemianesthesia remained and was extremely
marked up to the time of the patient's death. The man was par-
alyzed in 1892. Four years later, in 1896, when the clinical
report of Dr. Mills and Dr. de Schweinitz was made, he had
right lateral quadrant anopsia ; absence of Wernicke's symptom ;
dyslexia ; right hemiparesis ; partial right hemianesthesia ;
and partial word deafness and word blindness. His tongue
was slightly tremulous on protrusion and deviated a little
to the right. With regard to his aphasia, the patient stated at

^Mills, Chas. K., and de Schweinitz, Geo. E. The Philadelphia Hos-
pital Reports, Vol. III., 1896.

29Dercum, F. X., and Spiller, William G. The Amer. Journ. of the
Med. Sciences, N. S., 123, March, 1902.

648

MILLS AND SPILLER

this time (1896) that from the first he knew what he wanted
to say, but could not put it into such words as would be under-
stood by his hearers. He could recognize objects, but could not
pronounce their names. He could not read writing or print, be-
cause everything ran together ; he recognized the letters, but
could not pronounce them. He understood sentences, but could
not read them. In 1896 he had almost completely recovered from
his aphasia, although his voice was a little thick and difficult to
understand.

In 1899 there was present a spastic hemiplegia of the right

Fig*. II. A. Portion of the lenticular nucleus not destroyed. B.
Anterior limb of the internal capsule. C. Head of the caudate nucleus.
D. Posterior limb of the internal capsule. E. Carrefour sensitif. F. Cyst
in the lenticular nucleus. (Case 11.)

side, moderate in severity, with a moderate degree of contracture
of the right arm and spastic rigidity and exaggeration of the
knee-jerk on the right side. The right side of the face was only
slightly involved. The hemianesthesia appeared to be every-
where complete, and was associated with right-sided homo-
nymous hemianopsia.

"A cavity, probably resulting from an old hemorrhage, 2.8 cm.

depth from above downward, and 2.5 cm. in its longest

m

diameter, (1 1-8 in. x 1 in.), was found in the extreme

LESIONS OF LENTICULAR ZONE 649

capsule, claustrum and external capsule of the left side. The
left lenticula appeared to be almost destroyed and the extreme
posterior part of the posterior limb of the internal capsule
and the optic radiations were involved in the destructive lesion.
The anterior half of the posterior limb of the internal capsule
was not implicated in the cyst. The anterior limb of the inter-
nal capsule was entirely normal. The thalamus was not impli-
cated at all in the cyst, and the external medullary lamina
of the thalamus was distinct and normal in appearance. The
external nucleus seemed to be of about normal size. A
transverse cut passing through the hypothalamic region showed
the anterior half of the posterior limb of the internal capsule
apparently normal. The lenticular nucleus, except in its extreme
ventral portion, was destroyed.

"The portion of the thalamus that showed atrophic change was
the pulvinar, and this alteration was the result of the destruc-
tion of the optic radiations."

In addition to the macroscopical examinataion of the speecimen
in this case, careful microscopical investigation by serial sections
was also made, this confirming the fact that the anterior half
of the posterior limb of the external capsule and the entire
thalamus were not involved in the lesion, while the carrefour
sensitif and the lenticula, with the exception of its most ventral
portion, were destroyed.

It would seem fair in this case to refer the moderate spastic
hemiparesis which persisted until the death of the patient partly
to the lenticular lesion, as the motor subdivision of the pos-
terior limb of the internal capsule was only a little involved.
The early aphasia which disappeared in two months was prob-
ably due to compression or partial destruction of some part of
the lenticula concerned in speech phenomena, which must be the
anterior portion, the compression of the neighboring speech
areas in the temporal lobe and to the destruction of the insula.
We are inclined to refer the permanent hemianesthesia chiefly to
destruction of the carrefour sensitif, although we do not deny
that sensory fibers may pass through the lenticula. The dis-
turbance of both phonation and articulation which is referred
to in the statement that his voice was thick and difficult to un-
derstand, was probably dependent upon the lenticular lesion,,
as the genu and anterior half of the posterior limb of the inter-
nal capsule were not destroyed.

Both from our study of the literature of the subject and from
the analysis of the personal cases given in this paper, we find
is somewhat difficult to form positive conclusions as to the symp-
tomatology of lesions of the lenticular zone.

650 MILLS AND Sl'ILLER

We believe, however, that a few general conclusions may be
drawn :

1. Lesions restricted to the lenticula apparently do not cause
sensory symptoms ;

2. Motor, symptoms probably result from lesions situated
in certain parts of the lenticula; speaking generally, the lenticula
may he regarded as a motor organ :

3. Anarthric or dysarthric speech disorders result from lesions
of some portion of the left lenticula, which probably contains
centers which are concerned with the movements which make
speech possible ;

4. Destructive lesions of certain portions of the lenticula
probably cause a paresis of the limbs or face ;

5. The paresis or paralysis caused by destructive lesions of
the lenticula differs from that produced by capsular lesions, the
impairment of power not being so severe and not being so char-
acteristic in the former as in the latter case ;

6. The paresis or paralysis which is caused by lenticular
lesion- differs from thai produced by cortical lesions in that it is
less likely to be dissociated ; although dissociated lenticular paresis
may occur :

7. While the loss of power which results from a destructive
lenticular lesion is permanent, it is usually not intense ;

8. Persistent true motor aphasia, as this form of speech dis-
order is generally understood, is not caused by a lesion restricted
to the lenticula, no matter what its size or destructiveness ;

9. The insula, cortex and subcortex play an important part in
speech phenomena, one entirely different from that played by
the lenticula and the internal capsule :

10. The insula is a part of the cortical motor center for speech,
Broca's convolution probably forming with the insula the entire
cortical motor center for speech ;

11. Motor aphasia may be present without a lesion of the left
third frontal convolution ;

12. The lenticula forms too large a portion of the cerebral
hemisphere to be regarded merely as a vestigial organ.

HAVE THE TYPES OF GENERAL PARESIS ALTERED?

By L. Pierce Clark, M.D.,

OF NEW YORK.
AND

Charles E. Atwood, B.S., M.D.

OF NEW YORK.

(Continued from page 557.)
Charts omitted from article published under above caption in last
issue, September, 1907, in which 3,000 cases of general paresis were
analyzed by types.

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Analysis of 3,000 paretics by yearly periods. The foremost (dotted)
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simply dementing type. The lowest (light continuous) line, the number
of paretics of depressed type.

652

CLARK AND AT WOOD

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#odet\> proceedings

AMERICAN NEUROLOGICAL ASSOCIATION.

Held in Washington, May 7, 8 and 9, 1907.
The President, Dr. Hugh T. Patrick, in the Chair.

(Continued from page 592.)

SOME FORMS OF ACRO-CYANOSIS AND THE RELATION OF

ACROCYANOSIS TO RAYNAUD'S DISEASE, ERYTHRO-

MELALGIA, OSLER'S DISEASE AND OTHER

CONDITIONS.
By Dr. Lewellys F. Barker and Dr. T. J. Sladen.

The paper reports a case of chronic anesthetic acrocyanosis with
gangrene of the end of two toes in one foot and malum perforans of the
great toe of the other foot. Instances of acrocyanosis in connection with
the other syndromes mentioned are given, and the relations of allied
symptom-complexes are discussed. (The paper will be published in this
journal.)

Dr. A. Gordon said that two or three weeks ago he exhibited before
the Philadelphia County Medical Society a case almost identical in
its clinical manifestations to that of Dr. Barker and Dr. Sladen's, and his
conclusions were almost identical with those of these gentlemen. It was
a case of a young man of twenty-two, who had a redness of both hands.
He was a carpenter by occupation. There was no alcoholic history what-
ever. He noticed about five weeks prior to his coming to Dr. Gordon
gradual on-coming redness of the hands, limited just at the level of the
wrists Of course the first thought was that of erythromelalgia, but the
patient presented a number of little ulcers or scars which were the result
of old ulcerations. Dr. Gordon thought of Mitchell's disease and of Ray-
naud's disease. However, a close examination showed that while ap-
parently the case presented some features of erythromelalgia, on the other
hand it presented signs which were antagonistic to Mitchell's disease. Dr.
Gordon concluded that the case could not be classified as either of the two
forms. It is allied to these two types, and it goes to show that the two
extreme types of erythromelalgia and Raynaud's disease are not always
present. There are many cases of so-called intermediary types.

Dr. E. Riggs said he was very much interested in Dr. Barker's paper
because of a recent experience of his own. A man of forty-seven years of
age had had. for several years what he supposed were rheumatic pains in
the feet. When lie came under Dr. Riggs' observation there was a larg<e
ulcer of the left big toe, a slight congestion of the foot, and a cyanosis of
the little toe. Dr. Riggs did not know how to classify the case. He did
not regard it as one of Mitchell's disease: he could not regard it as typical
of Raynaud's condition. However, the toe amputated itself, the pain dis-
appeared (Dr. Riggs forgot to say that the pain was atrocious), and the
marl made an apparent recovery.

654 AMERICAN NEUROLOGICAL ASSOCIATION

Dr. A. R. Allen said that in a case which Dr. J. K. Mitchell and he had
reported before the American Association of Physicians last year the
symptoms were very much like those in Dr. Barker's case, but they found
over 20,000 white blood cells, with a distinct destruction of red blood
cells, and 13 per cent, eosinophiles. There was intense itching, which was
rather paroxysmal, coming in in the night. The urine showed a large
amount of urobilin. During the hours of itching Dr. Allen examined the
blood at intervals, and also examined it during the daytime, but tnere was
no difference. He said he would like very much to know what the blood
picture in Dr. Barker's case was.

Dr. H. H. Hoppe said he arose briefly to refer to a case of symmetrical
erythromelalgia which he saw in a child four or five years of age, which
was not typical. Both hands and both feet were affected, congested, red
and swollen, with a formation of blebs ; these blebs varied from the size
of a split pea to the size of a ten cent piece. The special feature in this
case was a subjective sense of pain and great heat, so that the child carried
a small bucket of water around to put her hands in. The peculiar feature
of the case is that the child recovered after six weeks under iodide of
potassium.

Dr. P. C. Knapp said Ik- wished to -peak of a case <>i a young woman
who had been under his care a year previously, who presented a very
marked cyanosis of both hands, gradually diminishing on the arms, al-
though there was a distinct congestion as high as the elbow, with the for-
mation of very small ulcerations upon the tips of the fingers which were
slow in healing. In this case there was no pain and very little sensory
disturbance. There was one method in treatment tried at the suggestion
of Dr. Cushing; namely, the putting an Ksmarch bandage and tourniquet
on the arm for a number of minutes each day and then letting it out in
order to flush out the artery. The method, however, gave practically no
relief.

Dr. W. G. Spiller said lie had been forced to very much the same
conclusion that Dr. Barker had reached, that these cases shade into one
another more or less. In a case of erythromelalgia reported by Dr. Weir
Mitchell and himself a number of years ago the blood vessels and the
nerves of the big toe. which was amputated, were very much diseased.
In another case of erythromelalgia that was under the care of Dr.
Spiller, the big toe was amputated and the blood vessels and the nerves
were very distinctly diseased. It is very important to determine how the
nerves are examined. Degeneration if slight may entirely escape detec-
tion. _ Dr. Spiller believes that if the examination is properly made the
peripheral nerves will in every case of erythromelalgia be found diseased
in the limbs that are affected.

Dr. Spiller cautioned against operations on the feet of persons affected
with vasomotor trophic neuroses. In the case which Dr. Mitchell and he
had reported the big toe was amputated, and it looked as though the
wound would never heal. In the other case to which he had referred it
looked also as though the wound would not heal. He said that in the
past two or three weeks he had seen still another case in which an opera-
tion on the foot had proved disastrous. The treatment which he thought
would give most relief where pain in the foot was intense was either a re-
section of the nerve at the lower part of the leg or possibly stretching,
but he would orefer the former.

Dr. J. J. Putnam said he thought it was very extraordinary, as Dr.

AMERICAN NEUROLOGICAL ASSOCIATION 655

Barker had said, how many of these affections there are and how they run
into each other, and yet on the whole, although the types are numerous,
they are nevertheless types. The cases run pretty true in their own line.
Each individual case remains as it was in the beginning, lie said they had
recently received at the hospital two cases in children which must be in-
cluded in this general group— more especially as they are Hebrew children
— where both arms were red almost up to the -elbows, intensely red, the
color fading slowly away, but there was no pain or sensory disturbance.
Dr. Putnam's experience with the tourniquet had been a little more
favorable than Dr. Knapp's. He had one patient with an ulcer on the side
of his foot whose case belonged in this category, where the tourniquet was
applied and he was put to bed. It was not possible to say whether the re-
lief which followed was due to the tourniquet or to the rest in bed or to
both, but it did seem as though the tourniquet was beneficial. His ex-
perience had been like Dr. Spiller's with regard to amputation. Frequently
after amputation the wound does not do well.

Dr. Putnam said he would like to say a single word about the subject
of acroparesthesia, of which he had seen a large number of cases. In the
first description of this disorder, which he had written twenty years or
more ago, he had suggested that there was perhaps a vascular change
which involved the circulatory supply of the nerve endings, and this
hypothesis still seemed to him admissible. It is certain that the skin
sometimes changes color and that the muscles become stiff, so that vaso-
motor phenomena must be reckoned with. Yet these signs are not con-
stant. The only constant feature is the paresthesia itself, but this could
also be referred to a vasomotor change, if it could be shown that the nerve
or nerve-endings have an independent circulation. This is possible, al-
though the proof is lacking.

Dr. J. R. Hunt said he had seen several examples of the class of case
that Dr. Spiller referred to, in which there was a gTeat deal of pain and a
great deal of redness in the extremities, more particularly in the toe, es-
pecially the big toe, and these cases were very often called erythromelalgia,
and they do present many of the symptoms of erythromelalgia. In the
cases he had seen, however, there was very marked defect in the pulsa-
tion of the pedal arteries, and he had regarded them as belonging to
that very unusual type of endarteritis occurring in young adults of obscure
origin. In these cases the changes in the peripheral arteries are so marked
that any amputation near the site of the gangrene would be absolutely
inadequate and healing delayed or impossible, and surgeons in such cases
usually go above the ankle or the middle of the thigh ; in fact they often
do the' operation without checking the hemorrhage, and they g<o on operat-
ing until they get a certain flow of blood which will presuppose the healing
of the flap. These cases it seemed to him should be somewhat separated
from the type Dr. Barker has described, particularly from the acrocyanosis
and acroparesthesia and pure types of Raynaud's disease. He had seen
one case which would come more particularly into this group, the case of
a very young girl with marked scleroderma. She had repeated attacks of
acrocyanosis, paroxysmal crises in the tips of her fingers and toes, as well
as in' the tip of her tongue, and on several occasions there was distinct
substance loss. Just before her death she lost one or two fingers and he
thought a toe.

Dr. F. X. Dercum said he did not think that the cases of sclerodactyly
belong to these purely vascular or peripheral nervous cases, as would ap-

656 AMERICAN NEUROLOGICAL ASSOCIATION

pear to be the case with erythromelalgia and allied states. Sclerodactyly
is only a phase of scleroderma. It has distinct relations with morphea, it
seems to be primarily neurotic, and he thought it important, while admit-
ting relations between the various forms of peripheral dystrophies to keep
them well defined.

Dr. L. F. Barker said he thought he should emphasize again the entire
absence of pain in their case. The part was not at all painful ; it was
anesthetic.

As to the blood count, when the patient came to the hospital he was
suffering from bronchitis, and had a sligtit polymorphonuclear leucocytosis,
but after the bronchitis disappeared the blood findings were normal.

With regard to the Esmarch bandage for treatment he had had no
experience, but he said he would like to point out the value of the Esmarch
in diagnosis. If we have, for instance, in diabetes a gangrenous toe, we
all know how useless it is to amputate the toe, at any rate until we have
watched it for some time. Von Eiselsberg in these cases puts on an
Esmarch from the toe up to the thigh, leaves it on ten or fifteen minutes
and then removes it, and usually finds that while the blood returns very
quickly to the whole upper thigh, the leg below the popliteal space remains
pale. In that case if he amputates at all he does so above the knee; in
other words, the application of the Esmarch and watching what happens
afterwards gives, he believes, a clue to the seat of the arteriosclerotic
disease. Dr. Barker said they had confirmed this in diabetic cases in the
Johns Hopkins Hospital.

{To be continued. )

PHILADELPHIA NEUROLOGICAL SOCIETY.

January 22, 1907.

The Vice-President, Dr. J. W. McConxell. in the Chair.

BULBAR PALSY IN MULTIPLE SCLEROSIS.

By Dr. T. J. Orbison.

Dr. Dana and Dr. Spiller first called attention to the rarity of the
disease in this country. In Starr's experience it occurs once in about
370 cases. The case exhibited is from Dr. Spiller's Polyclinic Hospital
service. The ordinary type of the disease begins with numbness and
increasing weakness of the legs. The gait is wabbly, rather than ataxic.
The feet seem to wander about as in drunkenness. Oppenheim describes
it as "vacillation." It is due to an irregular contraction of the mus-
cles of the trunk, and the entire body sways in the attempt at locomo-
tion. Tendon reflexes are increased and there may be a Babinski reflex
on either side or on both. There is tremor in the hands, so much so, at
times that a glass of water held to the mouth will be so shaken that
its contents will be spilled. Bulbar symptoms often appear early, the
speech is scanning rather than mumbled. The tongue may not be atro-
phied. Scanning is due to ataxia or intention tremor of the muscles
of speech production. There are certain mental symptoms suggesting
paresis that are often noted. All of the above symptoms, except the
Babinski reflex, are seen in the case exhibited.

Dr. F. X. Dercum said that unequal involvement of the two hands
and wrists is, of course, not uncommon. Sometimes the inequality is
very decided, but he had never seen a case limited absolutely to one
side. He recalleG one patient where the difference between the two sides

PHILADELPHIA NEUROLOGICAL SOCIETY 657

was very great, and in this instance the patient gave a history that one
side was distinctly paralyzed for a period of weeks before the other
side was involved. Dr. Dercum did not, however, see him during thii
time. He thought it probable that palsy begins on one side and per-
sists more frequently as a one-sided palsy for a time than we are in the
habit of noting.

PROLONGED STUPOR RESULTING FROM ALCOHOLISM.
FOLLOWED BY AMNESIA AND CONVALESCENCE.
By Dr. A. C. Buckley.
Male, age thirty-six, clerk. Excessive user of alcohol for fifteen
years. Two years ago, after an over-indulgence, suddenly developed
delusions of persecution and self-accusation, after which he passed
into a state of excitement followed by stupor. He remained in bed
in a state of absolute passiveness for about nine months, during which
time he occasionally roused to say a few words and again would re-
lapse into his former state. For several months there followed a state
in which was complete absence of volitional action, while reflex phys-
ical response to stimulation was present. The latter state abruptly ter-
minated by the patient suddenly beginning to talk; the following day
he began to perform volitional acts, talked some, but speech was
limited on account of a total amnesia for all past events. Later, he was
able to recall what was said to him, also all that was told him about
himself, his family and his surroundings, but could not by association
recall any event of his previous life. His memory of recent events
is good. His present knowledge is solely the result of experiences
since his awakening. Objects the uses of which were at one time
familiar to him, he recognizes as seeming familiar, but he does not know
why they should be familiar. He is now in process of re-education; he
has difficulty at times in remembering new facts which he has learned.
He is able to write his name, which he has been taught to do: he can
copy with difficulty.

UNILATERAL WRIST-DROP FROM LEAD.
By Dr. W. G. Spiller.

A man who was not alcoholic, and who had worked as a painter
four years, developed in October, 1906, weakness of the extensor
muscles of the right fingers, the palsy beginning in the forefinger.
The extensors of the wrist were not affected. At the present time all
extensor power in the right fingers is lost. Four or five weeks ago
the extension of the first finger of the left hand became impaired.
This finger is the only portion of the hand affected. Sensation is
intact. Unilateral wrist-drop from lead is of very unusual occurrence.

Dr. Potts said that his recollection of a case mentioned by Dr.
McConnell was that while the patient was under his observation only
one side was affected. While he thought the trouble was due to lead,
he had hesitated to make a positive diagnosis, because there was also
a history of alcoholism. A point in favor of lead was that the supin-
ator longus muscle reacted well to the faradic current, while the
extensor muscles showed reaction of degeneration. The man as a
house painter had been, of course, exposed to lead. The fact that the
other arm became affected after he came later in Dr. McConnell's
charge would seem to settle the diagnosis in favor of lead.

658 PHILADELPHIA NEUROLOGICAL SOCIETY

SPINAL CORD CHANGES FOLLOWING A SECONDARY GEN-
ERAL ANEMIA WITH RECOVERY.
By Dr. J. W. McConnell.

A young man of about^forty years had a sudden gastric hemorrhage.
A few days afterward he began to have diminution of vision and be-
came totally blind in a few days. Soon after he had numbness in his
limbs, this being followed by weakness. Within a short time he
presented symptoms of a postero-lateral sclerosis. Blood examination
then showed the changes of a grave anemia, with first an optic neuritis
followed later by an optic atrophy. In the course of several years,
during which time he was under constant observation, all of the scle-
rotic symptoms disappeared, leaving only the optic atrophy.

Dr. Spiller stated that he was much interested in the patient, as
the man had been in his service at the Philadelphia General Hospital
at the time the symptoms were very grave. He was paralyzed
in his lower limbs especially, so that he was unable to stand. The
case was interesting in other particulars. The man said he had vom-
ited about a quart of blood and had passed blood by the bowel, out
he really did not know how much blood he had lost. Such a case
as this seems to show that the spinal cord changes may be the result
of anemia. This man was healthy until the loss of blood occurred. He
could not have had much degeneration of the spina! cord, or he would
not have recovered as he had done. Dr. Spiller thought the optic
neuritis might be the result of severe anemia, as it occurs also in
chlorosis, although he was not aware that it had been observed in anemia.
Certain mild forms of optic neuritis are hard to distinguish from atrophy.

Dr. Dercum thought it questionable whether the fluid that fills
the vessels after such a severe anemia is not it-elf toxic. It seems
difficult to explain the optic neuritis by a mere anemia. It is also
interesting to note that this man had a Babinski reflex, which has since
disappeared.

Dr. C. W. Burr asked if the patient had paralysis of bladder and
rectum on admission.

Dr. Burr called attention to the fact that there had been some
instances of women becoming paralyzed after bleeding in childbirth in
precisely that way. He had never heard of a real optic neuritis fol-
lowing hemorrhage.

Dr. Weisenburg stated that he knew this case very, well, as the
patient was admitted while he was on duty. He did not believe that
he had seen a case of spinal cord change as a result of pernicious
anemia recover, and that there were few, if any such instances in the
literature. In the present case the blood changes were those of a grave
anemia and not of the pernicious type. The occurrence of an optic neu-
ritis is extremely rare. Only recently Dr. Weisenburg had written
upon this subject and had found no similar instances in the literature.
Optic atrophy, a result of hemorrhages, is not an infrequent occurrence,
and is not difficult to explain. The only reference that he had been
able to find in the literature regarding optic neuritis was in Norris and
Oliver's book. These authors mentioned the fact that sometimes in the
course of a pernicious anemia there appears what seems to be an albu-
minuric retinitis. It may be that in this present instance the optic neu-
ritis may have been a forerunner of the above condition. Another

PHILADELPHIA NEUROLOGICAL SOCIETY 659

possibility is that of a coincident optic neuritis as a result of another

cause.

Dr. Potts thought that the relation of an anemia to optic
neuritis had been shown, at least in the form of anemia known as
chlorosis. A number of cases had been reported, among others by
Patrick, in which the eye symptoms were such that for a time it was
doubtful if the patients did not have a brain tumor. To be sure chlo-
rosis is not a simple anemia, but it is one of the forms of that condi-
tion.

Dr. Burr called attention to the fact that this man did not have
chlorosis. He had a sudden large hemorrhage and immediately after
the loss of a great deal of blood he became paralyzed in both legs.

UNILATERAL OPHTHALMOPLEGIA WITH PARESIS OF

VOLUNTARY UPWARD ASSOCIATED

OCULAR MOVEMENT.

By Dr. J. T. Krall.

The patient was white, male, age forty, occupation fireman. He said
he had a chancre seven years ago. His vision was good until six
months ago, when during the night he was suddenly seized with severe
pain in the head, as though something had burst. He could move his
arms and legs, and there was no loss of sensation or motion in any of
the extremities, and he was. not unconscious. After this the right upper
lid drooped and he could not move his eyes. He* also had diplopia, diz-
ziness and a feeling of dullness in the head. When examined, on June
12, 1901 :

O. D., external appearance negative. O. S., ptosis of upper lid, not
complete, he could forcibly lift the eyeball 3 mm. It could be moved
a little down and out, but not inward and beyond the median line. Upper
motion lost entirely, either alone or in association with O. D. Sec-
ondary deviation of O. D. outward. Cornea clear; pupil dilated, reg-
ular, round, 6 mm., did not react to light, accommodation or converg-
ence.

Ophthalmoscopic Examination: O. d. ; media hazy, nerve outlines in-
distinct, red in color. Perivascular neuroretinitis. O. S.: Cornea clear,
media hazy; hyalitis. Nerve red in color; hazy: outlines veiled; ves-
sels slightly congested and tortuous. Retina smooth, woolly, neuroretin-
itis. Some whitish plaques to outer side of nerve. O. D. V.=6/9 ??.
O. S. V. =6/12 (by holding lid open). The sight of neither eye was
improved with lenses.

Accommodation: O. D.+4.25 D. O. D.— 325 D. Fields were con-
centrically contracted for form and color in both eyes about one-half
the normal.

When examined on December 3, 1906, Dr. Krail noticed that the pa-
tient had a peculiar, fixed, stary, expressionless countenance. Head
was thrown well back and upper lids forced open as far as possible.
Examination showed O. D. normal. Excursions possible in all direc-
tions, pupil reaction normal. O. S.: The excursions were good except
a trifle limited upward and inward, but in association with O. D. neither
eye moved upward beyond the horizontal. All other associated move-
ments normal. Voluntary associated movements upward not so good

66o PHILADELPHIA NEUROLOGICAL SOCIETY

as when following an object. On attempting to follow a moving
object upward O. D. moved further than O. S. by a series of lateral
motions. The von Graefe test was negative, there being no move-
ment of the eyeballs either upon inserting prisms or removing them.

Ophthalmoscopic examination showed a decided improvement in the
condition of both eyes. The neuroretinitis had subsided. Media clear. Ac-
commodation: O. D.— 3.50 D. O. S. =3.25 D. (about normal for age,
forty-five). O. D. ¥.=5/7.5. S. myd.-f-.25 C. ax. oo°— 5/5. O. S. V.=
5/7.5. S. myd.-j-.25 D. S.X—5 C. ax. 90°=5/5. The vision had im-
proved as is shown, and with a low correcting lens gave full vision.
Fields for form were normal in both eyes. Slightly contracted for color.
Music balance at 5m.r=exophoria 8° and L. H. i°. Muscle balance at
33 cm. = exophoria 140 and L. H. 1°.

Dr. Weisenburg said that he had examined the patient with Dr.
Krall. The case was a very interesting one and it was rather difficult
to understand why after a number of years following a unilateral
ophthalmoplegia the other eye should be involved. Two possible ex-
planations can be given: one that the nucleus of the oculomotor nerve
has become diseased; the other, that we have here symptoms which are
due to disuse, the latter being probably the case. This is also borne
out by the fact that the movements of the eye are much better in so-
called involuntary action than in voluntary movement.

Dr. Dercum asked why the affection could not have been a polioence-
phalitis superior. Polioencephalitis does distinctly begin on one side
and at times is even limited to one side. Tt is not necessary to fall
back on a theory of hemorrhage in a case of this kind.

AN UNUSUAL SYMPTOM IN CHOREA.
By Dr. G. E. Price.
A report of three cases of chorea from the Neurological Dispensary
of St. Christopher's Hospital, presenting marked hypersecretion of saliva
with more or less constant dribbling. Two of the cases were in girls and
one in a boy; the ages being six, twelve and fourteen years respect-
ively. All three cases had one prior attack of chorea, the intervals be-
tween the attacks being from one to three years. In each instance the
choreiform movements were general, the tongue and muscles of masti-
cation being especially affected. There were speech involvement and
some degree of mental disturbance in all, but no history of fright, rheu-
matism or scarlet fever could be obtained in any of the cases. Two of
the patients had systolic murmurs at the cardiac apex; in one case
the heart sounds were normal. One child was poorly nourished and
anemic, two were in fair general physical condition. None of the
cases presented hysterical stigmata. One of the patients was included
in the series through the courtesy of Dr. Luther C. Peter, the case oc-
curring in his service.

THE CLINICAL RESEMBLANCE OF CEREBROSPINAL SYPH-
ILIS TO DISSEMINATED SCLEROSIS.
By Dr. William G. Spiller and Dr. Carl D. Camp.
The case reported illustrated the difficulty in diagnosis which may
exist. A young man, positively denying during several years, syphilitic
infection, presented marked ataxia of gait, intention tremor of the limbs,
and a month or two before death, of the muscles of the face; scanning

PHILADELPHIA NEUROLOGICAL SOCIETY 661

speech, at first normal pupillary reactions, later Argyll-Robertson pupils,
unequal pupils and pallor of the temporal side of the right optic nerve.
Remissions did not occur during the years he was in the hospital.
Nystagmus was not observed. The lesions found were those of men-
ingo-encephalo-myelitis, consisting chiefly of round cell infiltration, and
degeneration of the posterior columns of the cord. It may be that
some cases of multiple sclerosis are overlooked by superficial examina-
tion, but on the other hand there seems at present a danger that much
will be called multiple sclerosis that in reality is some other disease.

THE NEURASTHENIA OF AUTOINTOXICATION.
By Dr. T. J. Orbison.

On the one hand is Oppenheim with those with him who explicitly
deny that neurasthenia may be due to autointoxication. On the other
hand are Bouchard and those who actively support the affirmative side
of the question. There is a middle ground occupied by Osier and Musser,
teachers who do not deny the possibility of this cause, but who do not
teach it in their books. This paper supports the affirmative side of
the argument and gives cases in support. The intestinal tract is an
ideal laboratory for the manufacture of poisons; the mucous membrane
is a secreting one; the bile and urine have been proven to be active
poisons; the blood itself is a carrier of poisons. Given an excess in
the poisons or a decrease in the expulsion of them, it is reasonable to
suppose symptoms may arise that are truly neurasthenic in character.

Dr. Guy Hinsdale said that as we saw cases of the graver type of
mental disturbances due to autointoxication he saw no reason why
we should not have cases of neurasthenia due to the same cause.

THE PHILADELPHIA NEUROLOGICAL SOCIETY.

February 26. 1907.

The Vice-President, Dr. J. W. McConnell, in the Chair.

PARALYSIS OF THE SIXTH NERVE. COMING ON DURING
AN ATTACK OF TYPHOID FEVER.
By Dr. J. H. Lloyd.
Dr. J. H. Lloyd showed this patient, a negro woman, a school
teacher, aged twenty-nine years, who had been admitted to his wards
in the Methodist Episcopal Hospital in January, suffering with ty-
phoid fever. When admitted she was about at the end of the second
week of the disease. The fever pursued a regular, uncomplicated
course until the twenty-seventh day, after which her temperature re-
mained practically normal. For a part of the time the patient received
the Brand treatment, having in all ten tubbings during a period of four
days. For the remainder of the time she was sponged. There was only
slight delirium, and not much diarrhea. The urine for a while presented
some albumin and a few casts. There were no nervous symptoms of
special importance, except a little headache when the patient was ad-
mitted, and later the slight confusional delirium just mentioned. The
Widal reaction was positive. The patient first noticed diplopia when
she came out of her delirium, that is, before the fever ended; hence

662 PHILADELPHIA NEUROLOGICAL SOCIETY

in about the third or fourth week. She was then observed to have
internal strabismus of the left eye, caused by paralysis of the left
external rectus muscle. There were no cerebral symptoms, no head-
ache nor any other paralysis, no rigidity nor signs of meningeal involve-
ment.

Dr. Veasey examined the patient later and reported paralysis of the
left sixth nerve. The patient saw double images on following the mov-
ing object to the left beyond, or a little beyond, the middle line, and
the images tended to get further apart. There was no paralysis of
accommodation, nor of any outer muscles of the eye. The fundus was
normal. This patient had been under treatment for her eyes at the
dispensary of the hospital before her typhoid fever, but at that time
had no paralysis of her sixth nerve; so the onset of the trouble during
the typhoid fever is quite clear. Since leaving the hospital, about ten
days ago, the paralysis has decreased, and while still apparent it is not
so noticeable as it was formerly. This, of course, is of good augury,
and shows that the prognosis is favorable, just as in cases of diphther-
itic paralysis, and that the patient will probably make a satisfactory
recovery. Such cases must be very rare. This is the only one of the kind
Dr. Lloyd had ever seen, and the literature is scanty. He had found
only one reference to a somewhat similar case, but associated with
double ptosis. Dr. de Schweinitz has stated that paralysis of accom-
modation after typhoid fever is not uncommon, but that other ocular
palsies are very rare. The analogy of this case to some cases of post-
diphtheritic paralysis will probably strike everybody, but in post-diph-
theritic paralysis there is usually paralysis of accommodation, as well
as nasal speech, dysphagia and loss of power in some of the extremities
with abolition of the knee-jerks, none of which symptoms have been
present in this patient. Besides, in this patient, who was under careful
observation during most of her fever, there was no evidence of a diph-
theritic process. Neither had there been any polyuria, as is seen in some
cases of sixth nerve paralysis. Nor was it possible to make out a spe-
cific history.

NEW CLINICAL SYMPTOMS IN HEMIPLEGIA AND TABES

DORSALIS.

By Drs. T. H. Weisenburg and C. C. Manger.

In a series of hemiplegias it was noted that the palpebral fissure on
the hemiplegic side was larger than on the sound side. This symptom
was looked for in about ninety cases and found in about eighty. It
is probable that this was due to the drooping of the lower lid. This
sign has not heretofore been noted, and is of some importance in the
instant recognition of paralysis. It is, of course, also present in per-
ipheral facial palsy.

For some time Dr. Weisenburg has noticed that patients with tabes
dorsalis have a remarkable similarity of facial expression. So much
so that it has been possible in many instances to recognize patients
with this disease on sight. The composite picture shows this very
easily. There is a paleness of the face and puckering of the brow
and drooping of the upper lid and the corners of the mouth, and a
peculiar expression around the eyes which is rather difficult to describe
but easy to recognize. Besides, in a series of thirty-five cases, all
men, the eyes had been found to be either blue or gray. This does

PHILADELPHIA NEUROLOGICAL SOCIETY 663

not hold true in women. The occurrence of blue or gray eyes in such
a large percentage of cases examined is rather important and while
this number is very small, still it is suggestive.

Dr. Charles W. Burr said any study of a possible relation between
the color of the eyes and the occurrence of tabes to be of any value
would have to include a very large number of patients. It was neces-
sary also that the race of the patients and not merely their place of
birth should be considered. Dark-eyed people were not as common at
Blockley as light-eyed.

Dr. W. G. Spiller said that the widening of the palpebral fissure in
hemiplegia, to which Dr. Weisenburg alluded, brought up the interesting
question of paresis in the upper branch of the facial nerve distribution
in hemiplegia. When Dr. Spiller was in Vienna in 1893 the paresis
of the upper part of the face in hemiplegia was well recognized. In
almost every case of hemiplegia where the face is implicated there is
at first some involvement in the distribution of the upper branch of
the seventh nerve. It is usually of transitory duration. The widening
of the palpebral fissure to which Dr. Weisenburg alluded, probably de-
pends on paresis of the orbicularis palpebrarum muscle.

Dr. Sailer called attention to the value of composite photographs for
the purpose of determining the physiognomy of disease. The oppor-
tunities at Blockley for making such photographs are excellent, and they
might be of great service in the conditions under discussion, that is,
tabes dorsalis and hemiplegia. In the latter the difference in the palpe-
bral fissure would probably be more accentuated in such a photograph
than in any individual case.

Dr. D. J. McCarthy thought the involvement of the lids was due to
secondary contracture pulling down the inferior lid. Dr. McCarthy also
said that cases of tabes in the negro had been frequently reported to the
Society. In all these cases, of course, the eyes were dark.

Dr. Spiller said in regard to the patients presented, they were old,
and it is common to find in the aged a little drooping of the lower
lid in paresis of the upper branch of the facial because of the loss of the
elasticity of the skin.

Dr. Weisenburg in closing agreed with Dr. Burr that 35 cases of
tabes in which blue eyes constantly occurred did not demonstrate much,
but he thought that the fact that it occurred in so many cases was rather
interesting. In the study of these cases, the race of the patients was con-
sidered, but there was no definite relation found. Dr. Weisenburg's main
object in bringing this matter before the Society was. if possible, to ob-
tain further information upon the subject, and also to stimulate further
observations in the color of the eyes in tabetic cases.

Dr. Weisenburg did not agree with Dr. Spiller that the widening of
the palpebral fissure was the result of the paresis in the upper part of the
face, but thought that it was due to the paresis of the lower eyelid. He
did not agree with Dr. McCarthy that this sign is due to secondary con-
tracture as in secondary contracture we should have the opposite con-
dition, that is lessening in the width of the palpebral fissure.

INCIPIENT TABES WITH SEVERE PAINS IN THE NECK.

By Dr. W. G. Spiller.

The patient was a male, 55 years of age. He had ataxia of gait, Rom-
berg sign, difficulty at times in urination, numbness of the hands, very

664 PHILADELPHIA NEUROLOGICAL SOCIETY

feeble reaction to light, and gray degeneration of the optic nerves. The
patellar reflexes were not diminished, possibly were a little prompter
than normal; this is unusual in tabes but has been known to occur when
the reflex collaterals in the lumbar region are not implicated. The pain
in the shoulder was very striking, it occurred in severe attacks every
few minutes, extended up the back of the head about as far as the ear
on the left side and over the front and back of the upper part of the
trunk on the left side. Sensation was diminished in this area. Spinal
syphilis might be thought of, but Babinski's sign was not obtained. The
pains in the left side of the neck resembled the shooting pains of tabes.

Dr. McCarthy thought these attacks of pain suggested the pain of
cervical pachymeningitis. He asked if it was present from day to day.

Dr. Spiller replied that the patient had it constantly with exacerba-
tions at times.

Dr. McCarthy reiterated that the type of pain was suggestive of the
early stage of cervical pachymeningitis, but the great degeneration of
the optic nerves and the ataxia of the lower limbs he had never seen in
any cases of pachymeningitis he had examined. He had watched the
crises of tabetics but they were not continuous as he understood the use
of the term. They came and exhausted themselves and were not of the
continuous type of neuralgic tic like Dr. Spiller's patient presented.

Dr. C. K. Mills said he had seen this man when he first came to the
hospital and lectured on him on one occasion. He thought the case one
of so-called high tabes. He had seen a considerable number of cases
of this sort. He had also seen some cases of cervical hypertrophic
pachymeningitis and forms of syphilitic meningitis in the cervical region.
Confirming the diagnosis of high tabes were such symptoms as the
ataxia, the condition of the pupils, and the atrophy of the optic nerves.
Cases of high tabes vary considerably in their symptomatology. He had
seen a case a week previously in a young man, a private patient, who had
pains somewhat similar to the pains suffered by this man, but not simi-
lar in their continuance. The pains occurred at intervals but not almost
daily. The patient had pains about the chest; he had lost the knee jerks
and Achilles jerks and had dilated pupil on one side. It was a question
in all these cases of the intensity, and above all of the peculiar distri-
bution of the lesions. He had seen all sorts of commingling of phen-
omena in connection with dominating cervical tabes. He could recall
io or 12 other cases; some with knee jerks lost, and Achilles jerks
retained, others with knee jerks and Achilles jerks present, and so on
through a considerable list of similarities and differences.

Dr. Sailer said he remembered some years ago seeing a commercial
traveler passing through the city, who came into his hands suffering
from tonsilitis. He discovered that he also had tabes dorsalis. The
patient had continuous severe pain in the right arm, so severe that it
practically disabled the arm unless he took huge doses of potassium
iodide. There were no gross motor disturbances in the arm, no ataxia
nor any sensory disturbances, simply the pain which compelled him to
keep the arm quiet.

He remembered another case he saw with Dr. Musser a good many
years ago, a man with tabes dorsalis evidently of the superior type. He
had laryngeal crises, diplopia, ptosis of one eyelid, and Argyll-Robertson
pupil. The case was typical, excepting that the knee jerks and the

PHILADELPHIA NEUROLOGICAL SOCIETY 665

Achilles tendon jerks were more lively than normal. There was, how-
ever, no ankle clonus.

LESION OF THE CAUDA EQUINA PROBABLY UNILATERAL.

By Dr. W. G. Spiller.

H. C, a male, thirty-one years old, was injured eighteen months
previously by a bale of cotton falling against the abdomen. He was
unable to work for about three weeks, but then returned to heavy work,
feeling not quite so well as formerly. About a month after returning
to his occupation, while lifting a bale of cotton, he felt something give
way in the right inguinal region, and at the same time he heard a tear-
ing sound. He immediately felt weak and limped on the right lower
limb, but walked home, a distance of about two blocks, and went to
bed. After one day he got out of bed but remained at home about a
week. He then returned to heavy work, but he has not been so strong
as he was before the injury.

After the accident he lost control of the bladder, so that when he
coughed or exerted himself, the urine would escape. This condition
gradually became worse until now he has no control of his bladder and
has been wearing an urinal about a year. Sexual desire is not weak-
ened, but only the dribbling of urine prevents the sexual act. During
the past two months he has noticed that the rectal sphincter function-
ates feebly and that when there is a call to stool it is urgent His gait
and station are good. The lower limbs are well developed but the man
thinks he is weaker than he was before the accident. The left side of the
scrotum, left side of the perineum, and the left buttock near the anus
have fully normal sensation to touch and pin-prick, whereas the right
side of the scrotum except the upper outer portion, the right buttock
in a small area near the anus, and to a less degree the right side of the
perineum, show diminution of sensation to touch and pin-prick. The
right side of the penis also is less sensitive than the left side. The sen-
sation of the testicles is normal. The patellar reflexes are prompt, but
the Achilles reflexes are slight. Babinski's sign is not present. The
tipper portion of the body is not affected. The lesion must be in the
lower sacral roots, and probably confined to one side because of the
unilaterality of the disturbance of sensation in the supply of these roots.
This unilaterality also is contrary to a lesion of the conus. It is a ques-
tion whether the vesical and rectal incontinence can be caused by an
unilateral Ies>ion but it seems probable. The cause of the symptoms
was probably stretching of the lower sacral roots *of one side by ex-
cessive straining, as has been seen also in lesions of the sciatic nerve.

Dr. Mills thought this a very interesting case. The only thing that
suggested itself was as to how this stretching could occur in a case of
this kind without other injury. That is, what were the exact mechanics
of the process. It was difficult to understand how, with the nerves of
the cauda equina, in the absence of accident locally interfering with
them in some way, this stretching could be brought about.

Dr. McCarthy referred to a case he saw three or four years ago in
Dr. Spiller's clinic of a man lifting a heavy weight, the case later com-
ing to autopsy, in which there was a lesion of the cauda equina. It was
bilateral. There was paralysis of the rectum and bladder (the rectum.
afterwards recovered). There was distinct sensory disturbance
around the anus and scrotum. Dr. McCarthy's own impression was that

666 PHILADELPHIA NFA R0L0G1CAL SOCIETY

it was not due so much to stretching as to a localized hemorrhage either
within or around the cord, without any special grounds for such an
opinion. In that case there was no pain as he remembered it.

Dr. Spiller said he did not think we could accept a diagnosis of
hemorrhage of the conns in this case, for the reason that the lesion
was chiefly unilateral. If a hemorrhage is in the conus it must cause
bilateral symptoms, as the conns is very small. It is also improbable
that the hemorrhage is in the roots of the cauda equina, because we
could hardly suppose that a hemorrhage around the roots would be
confined to one side. The cauda equina roots are anchored as they pass
through the dura, and if there is a forcible over-stretching of the back
with the feet firmly planted one can readily believe there might be
stretching of these roots. Dr. Spiller said he had found in the Berliner
Klinische Wochenschrift a few weeks ago, a description of a man who
was striking with a heavy instrument: he missed the object and the blow
went farther than he intended and caused paralysis of the sciatic nerve
from the stretching of the nerve. It did not seem necessary to assume
that there was hemorrhage here.

Dr. Spiller also said that the paralysis of the bladder in the case
with unilateral symptoms was not complete at first. He was able to
retain urine excepting when he coughed or was under unusual exer-
tion. It was an interesting question as to whether the bladder could
be paralyzed from an unilateral lesion. The rectum had not been abso-
lutely paralyzed but its action was very imperfect. To establish the
unilateral involvement he depended more upon the area of sensation.
We must assume that the bladder and rectum are innervated from the
lower sacral roots, and we know that the area of anesthesia which this
man had was in the distribution of probably the fourth and fifth sacral
roots.

A CASE OF INTERMITTENT CLAUDICATION.
By Dr. D. Riesman.

T. W., married; 40 years of age; native of Russia; occupation, potter.
For a year and a half typical attacks of intermittent claudication charac-
terized by cramp-like pains coming on after walking a short distance and
compelling him to sit down; after a few minutes' rest is able to pro-
ceed, but walking is again interrupted as before by cramp in the calf
muscles. No pain at night; occasionally cramp in the toes and sensa-
tion of burning on inside of leg and in soles, with pain under toe nails;
at times pains in back, arm, and wrists; changes in weather have no
influence. Huge varicose veins, which in patient's opinion have no-
thing to do with present trouble; slight degree of flat foot. Tendon
reflexes normal; no Babinski reflex; no ankle clonus; plantar reflex
feeble; tactile sensation not disturbed; pupils unequal; react to light.
Absence of pulsation in dorsalis pedis and posterior tibial arteries.
Comments upon this case and upon arteriosclerotic ischemias in gen-
eral.

Dr. McCarthy said that in respect to the cerebral type of exhaus-
tion paralysis, two or three years ago, he discussed before the College
of Physicians a condition which he called intermittent exhaustion par-
alysis of cortical origin. This was before the recent discussion on the
senile type of intermittent claudication was published. Last year he

PHILADELPHIA NEUROLOGICAL SOCIETY 667

presented the subject more in detail before the American Neurological
Association without publishing it. At that time he called attention to
a syndrome which differed considerably from the intermittent peri-
pheral paralysis with spasm, and called attention to the condition of
intermittent hemiplegia occurring in cases of marked cerebral arterio-
sclerosis, these cases going to autopsy, diagnosed as uremic, although
they could not be explained on that ground. His attention was first
called to this condition in a case of migraine in which there was exten-
sive arteriosclerosis without kidney involvement. In this just as in
the peripheral cases, there is a condition of deficient nutrition to brain
centers due to a very marked condition of arteriosclerosis. This con-
dition he tried to explain in this discussion must be distinctly differ-
entiated from cases with uremic symptoms, on the one hand, and the
sclerotic cases in which the pons or basic centers are involved. In these
cases the symptoms are much more prolonged. In the condition of
which he was speaking they may last 24 hours. His own feeling about
these cases of peripheral intermittent claudication was that they could
not be altogether explained on the deficiency of the blood supply. There
was some change in the muscles. A damming back of the blood with
increased total blood supply in the extremity was a much more potent
factor than the deficient blood supply. In the Phipps Institute the leg
muscles had been examined in practically every case autopsied. Very
often they came across extensive grades of arteriosclerosis, and in one
case only, of intermittent claudication. We must consider whether a
parenchymatous change in the lower extremities rather than a deficient
supply from the vessels is responsible; i.e., a pathological change in the
whole extremity in the arteries, veins, muscles and to a certain extent
in the tissues.

Dr. Spiller stated that he understood Dr. Riesman to say that the
only important differential feature in this central claudication accord-
ing to Dejerine, is the condition of the pulse. Dr. Spiller stated that
Dejerine emphasized the fact that in the central type of claudication
the reflexes may be exaggerated after exhaustion and lost at other
times; there may be a Babinski sign after exhaustion. He thought
hardly anyone who had studied the subject of intermittent claudication
believed it due solely to the arteriosclerosis. Erb stated that there must
be something in addition to the arteriosclerosis. Arteriosclerosis often
occurs without intermittent claudication.

Dr. Spiller said transitory hemiplegia from arteriosclerosis is well
known. He had spoken of it himself repeatedly during many years.

A CASE OF ALTERNATING UNILATERAL EPILEPTIFORM

CONVULSIONS ASSOCIATED WITH CORTICAL

CEREBRAL DEGENERATION.

By Drs. Charles W. Burr and Carl D. Camp.

An elderly man suddenly fell unconscious in a right-sided con-
vulsion. For the remainder of his life, a few weeks, he continued un-
conscious and had recurring epileptiform convulsions, sometimes
confined to one side, sometimes to the other, and occasionally passing
over slightly to the other side. The immediate cause of death was lobar
pneumonia. At autopsy the calvarium and dura mater were found to
be entirely normal. The pia over the Rolandic region and anterior

668 PHILADELPHIA NEUROLOGICAL SOCIETY

thereto was much thickened and milky in appearance. The anterior
horns of the lateral ventricles were contracted and showed numerous-
adherent bands. The rloor of the lateral ventricle was distinctly thick-
ened. There was no softening or hemorrhage anywhere within the brain.
The superior longitudinal sinus contained an ante-mortem clot. The
pons, medulla and spinal cord were normal. The thickening of the pia
was due to an overgrowth of the connective tissue without round cell
infiltration. Many of the Betz cells of the cortex were markedly de-
generated. The case is interesting on account of che occurrence of the
convulsions due to primary disease of the cortical cells. It is also-
interesting on account of the nature of the convulsions themselves, some-
times occurring on one side, sometimes on the other.

Dr. Spiller stated that some years ago he had a case similar to this.
The man had unilateral convulsions first on one side of the body and
then on the other caused by an extradural hemorrhage in the occipital
region. The patient was operated upon and the hemorrhage removed.
There seemed to be irritation first on one side of the brain and then
on the other.

NEW YORK PSYCHIATRICAL SOCIETY.

March 6, 1907.

Dr. Allan McLane Hamilton in the Chair.

THE PSYCHOGENETIC FACTORS IN SOME PARANOIC CONDI-
TIONS. WITH SUGGESTIONS FOR PROPHYLAXIS AND

TREATMENT.

By Dr. August Hoch.

Dr. Hoch pointed out that among the paranoic states there were cases,
and that they probably represented a large proportion, in which the
psychogenesis could be clearly traced, when the facts of the cases were
really accessible. The theory of the development of paranoic states Dr.
Hoch summarized briefly as follows, stating that besides basing his ideas
upon facts of his own studies he had been influenced by the work of
Adolf Meyer, Freund, Bleuler and Jung :

Every person has certain points on which he is especially sensitive. He
has ideas or complexes of ideas which are associated with very strong
feelings. These complexes refer either to personal defects, shortcomings,
limitations, or to feelings of guilt, remorse, shame; on the other hand to
certain longings and desires. We may, therefore, generally speaking, say
that they belong either to the realm of self-assertion or to the sexual
sphere, in the broadest sense of the term. Now most people are able to
get square with such things, partly because their nature is such that these
feeling's never reach anything like a great intensity, or partly because
they have a healthy way of dealing with these matters.

Other people do not get square with such difficulties. They do not
acquire balancing, healthy habits, such as a healthy turning away from
one's difficulties to outside interests, or a habit of unburdening or a cer-
tain aggressiveness and the like. While then such undercurrents, as we
may call these complexes, when they are of any intensity have themselves

NEW YORK PSYCHIATRICAL SOCIETY 669

a tendency to set narrower and narrower limits to the interest and to
create a certain fascination, they often become a menace to the sanity of
mind, also because they are not balanced sufficiently by sound mental
tendencies. In this way there develops a growing disharmony which
gradually, or sometimes under the influence of acute causes, physical or
mental, may suddenly lead to an unbalancing of the mind, when, finally
the undercurrents break through to the surface.

But the mind, even in the cases in which the undercurrents are not
handled properly, makes certain miscarried attempts at readjustment.
Thus, the feelings of defect and the longings do not come to the surface
as such, but are transformed ; the former give rise to a general suspicious-
ness and delusions of persecution, probably for the same reason that we
are inclined to blame everyone else except ourselves, when anything
which we do goes wrong1; the latter give rise to ideas that the innermost
longings are fulfilled. And there are still other forms of such miscarried
adjustments.

We see then that we have two things, the undercurrents and the ab-
normal manner of dealing with these undercurrents, upon which we should
lay stress as important in the causation of these paranoic states. To a
certain extent this division is of course artificial and the two principles
often enough overlap greatly. Then again, it is difficult often to find a
correct or definite formula for that which we have called abnormal mental
habits, or difficult to pick out from among the complex fabric of mental
reactions, those which are disastrous or estimate the dangers of certain
combinations, or to correctly guage the value of saving traits. Naturally
it will often be a combination of traits rather than single traits which we
have to consider, and while we speak of some reactions as dangerous
mental habits they may exist in certain combinations in which they are
sufficiently safeguarded.

It is also very evident that other causes than an unhealthy manner of
dealing with the undercurrents may enter into the causal constellation as
well — such as influences which increase the strength of the undercurrents
or influences, which, in other ways than those indicated, lessen the resist-
ance, such as the action of alcohol, the menopause, and the like.

These principles were demonstrated by means of careful analysis of
four cases and certain indications for treatment were discussed.

Dr. H. R. Stedman, of Boston, was inclined to lay more stress on the
influence of heredity in affecting the progress of genuine paranoia than
did Dr. Hoch. "Numbers of cases of the disorder were seen in patients
who had been sensibly brought up and who were treated affectionately by
their families, nothing being left undone to make their surroundings con-
genial and their lives smooth and happy, yet in spite of it all they de-
veloped paranoia. Little could be hoped for, he believed, in the way of
materially modifying the psycho-genetic factors so as to make any real im-
pression on these cases of typical paranoia, a disease arising on a defec-
tive constitutional basis and gradually and logically developing into an
inflexible system of delusional thought and conduct.

He thought, however, that after the disease had developed, when
family, friends, and a normal environment had proved powerless to in-
fluence the disease and the patient was sent to the hospital, his condition
was more susceptible of improvement than is generally thought to be
possible. He had not infrequently found the paranoiac to be rendered

670 XEW YORK PSYCHIATRICAL SOCIETY

decidedly more manageable and his life made far more comfortable by
regular friendly and explanatory talks, answering his questions, making
the endeavor to set him right, and satisfying such of his minor demands
as were not wholly unreasonable. The fact that many of them are hope-
less and cannot be reached at all by such means — in fact only become
worse in consequence — accounted, he thought, for the tendency that exists
to pay them as a class little or no systematic attention, such as Dr. Hoch
adopts with his cases. Dr. Stedman questioned if the reader had not
chiefly in mind the paranoid state rather than the paranoic, that sym-
ptomatic, persecut )ry. condition so often found in dementia praecox. If
so, he was wholly in accord with his view that much might be done in
the way of prophylaxis. Dr. Hoclrs masterly analysis of the psychogene-
tic conditions in his cases showed this plainly and he believed it to be due
to the fact that the morbid direction of their thought had become less im-
paired than in the true paranoiac. Dr. Stedman felt the same confidence
that he had expressed at length several years ago, that not a few cases of
this kind when recognized early by the psychiatrist while yet the patient
is comparatively comfortable, may be saved from an attack by well-
directed medical oversight and guidance and regulation of his habits and
surroundings. He attached little importance to the menopause as a
special causative factor in insanity, as individual experience and statistics
seem to show quite conclusively that paranoia develops to the same ex-
tent in both sexes during the period of life in which the menopause occurs.
Dr. Charles L. Dana had been interested in Dr. Hoch's analysis, which
was instructive as showing that in a certain group of cases of paranoia con-
ditions might be improved by careful therapeutic effort. He had not been
in a position to carry out this method oi treatment, which could not be
very successfully employed by those not connected with institutions. He
agreed with Dr. Stedman as to the importance of hereditary taint in all
these cases, and that a goodly proportion of paranoiacs develop in spite
of careful bringing up. Few of these patients could be influenced unless
they were taken in hand very early. He had been much interested in two
or three cases of paranoia which illustrated that the undercurrent does not
always break through in a way that particularly disturbs the mental make-
up or general Hfe of the patient. Such a case was a woman, about fifty
years of age. now under his care, who was first seen by him when she
was forty years old. She was married and the mother of two healthy
children. About fifteen years before he first saw her she had developed
delusions of a certain kind of persecution — that when she went out on the
streets people made remarks about her, trying to annoy her and to injure
her. She had these delusions throughout her married life and during her
pregnancies. She was a good mother, however, and to most people who
knew her she remained a good, kindly woman, about whose mental con-
dition no one had suspicions except her husband, some members of her
familv, and Dr. Dana. She was probably preserved from a general
paranoic state by the fact that she was able to stay in the house and keep
away from sources of irritation. He had had under observation also a
man. now forty years old, who had been engaged in business all his life.
For fifteen or twenty years this patient had had similar delusions of
persecution — that the police and detectives were after him and that at-
tempts were being made to watch him. But this undercurrent delusion
never broke through except in one little spot in his brain. One or two of
his children developed dementia praecox at the age of sixteen. Such

NEW YORK PSYCHIATRICAL SOCIETY 671

very limited types of paranoia certainly lent themselves to treatment by
instruction and by careful selection of environment, which was all essential.
As to the general correctness of Dr. Hoch's analysis there could be no
question

Dr. Maurice C. Ashley, of Middletown, N. Y.. agreed with Dr. Hoch in
the main, but he questioned whether the therapeutic talks with paranoiacs
would accomplish very much as a curative measure. In his experience
there had been no such beneficial results. He recalled one paranoiac
who, for ten years, had believed that he had been giving him poison. At
first the patient was inclined to retaliate, he threatened, and made definite
efforts to take the life of the doctor's children. The man had some somatic
symptoms which he himself attributed to the poison which he thought
had been given him. He still has the delusions, but no longer attempts
to execute his threats. Another patient, a woman, for eight years had
believed that he had been turning an electric current upon her for the
purpose of annoying her. Every argument had been used to convince her
that this was impossible, but without effect. As the disease progresses the
reason of such patients becomes enfeebled and less active, and while they
continue to have their delusions they become accustomed to them and
cease to react much to them.

Dr. William Hirsch thought that in forming a definite opinion con-
cerning the cases analyzed by Dr. Hoch it must first be determined
whether one had to deal with genuine paranoia, or with a paranoiacal
state of another disease. Genuine paranoia is always a congenital and
not an acquired disease, although the true paranoiacal symptoms often
do not manifest themselves during the earlier part of life. But there is
always a cong'enital condition, a constellation of mental factors, which
not only predisposes to. but which necessarily develops, at some time of
life, such a combination as to produce that mental condition known as
paranoia. When such a point in any given case would be reached cannot
be determined in advance, but we are, in most cases, able to predict the
development of a true paranoia. Various conditions, such as environment,
worry, etc., might have something to do with it, at least with a premature
manifestation of the condition. He did not believe, however, that in any
given case anything could be done to prevent the manifestation of the
paranoiacal condition, even though it were recognized that the develop-
ment of such a condition existed. This opinion was not based merely on
theory. In his practice he had had children brought to him whose parents
realized that they were a little peculiar, nothing more, but whom he
recognized as abnormal individuals who in later life would become para-
noiacs. In such of these cases as he had been able to follow ten or fifteen
years he had found that they developed genuine paranoia in spite of all
the precautions which had been taken. He had warned the mother not to
let the child have any impressions which would stimulate the imagination
or fancy of the child, not to let it read any fiction, to g'uard it against any
undue emotions ; all this was carried out with the greatest care. But at
some time in life, generally after an unusual emotion, such as falling in
love, slig'ht business troubles — something which otherwise would be of no
importance — would develop a true paranoia. A normal individual, normal
from the start, would never develop paranoia. A normal individual might
develop melancholia, or some other acu*e disease, but never paranoia.
When he said one must differentiate between types he meant cases in
which there was genuine paranoia and those in which there was a para-

672 NEW YORK PSYCHIATRICAL SOCIETY

noiacal state. The paranoiacal state might occur in a great many psy-
choses. He had seen such a case lately. A man of sixty years of age, a
good business man, perfectly normal all his life, suddenly developed a
paranoiacal condition ; he had delusions and hallucinations, imagined there
was a conspiracy against him, that his neighbors tried to kill him, etc.
After remaining in this condition for nine months he gradually became
demented. He is still living, and is suffering from a condition of general
arteriosclerosis. The case could be denned as dementia senilis, but not as
paranoia.

Dr. P. C. Knapp, of Boston, thought it a mistake always to regard de-
lusions of persecution, with hallucinations of one form or another, as
constituting paranoia, and that we should be guarded in speaking of such
conditions as paranoiac states. He agreed entirely with Dr. Hirsch's
opinion that true paranoia, while not a congenital condition, is dependent
upon a congenital condition, is dependent upon a congenital mal-arrange-
ment, so to speak, of the brain Tanzi had taken the same position, viz. :
that, whereas other forms of mental disease might be spoken of as true
diseases, paranoia was not a disease, but a morbid congenital state which,
later in life, under the influence of various factors, might develop into
typical paranoia with hallucinations and delusions. He thought that the
"under-current" did not always "break through." In this connection he
cited the case of a woman who for years had had a limited type of de-
lusion. She had lived a secluded, narrow life in one of the smaller New
England cities ; for many years she had been active in the care of her
household and family and in church work ; she had been trained in the old
New England habit of keen theological discussion and argument, and for
many years she had had the very definite idea that she had been excom-
municated from the church. In the main the idea had been suppressed,
many of her church associates did not know of it, and those who did kept
it secret. The idea existed for many years without going on to any real
mental disturbance. Cases were not uncommon in which the delusions
occupied a limited field in the consciousness and affected but little the
conduct. With a true paranoiac, however, he questioned very much the
real importance of any emotional stress, or of any psychical ideas as in-
fluencing materially the genesis of the disorder. They might influence the
development in so far as changes in modern belief influence the character
of delusions. As Dr. Hirsch had suggested, it was impossible to protect
these patients from all influences that might give rise to the condition.
Not infrequently delusions of persecution developed in normal individuals
in connection with hallucinatory conditions having a distinctly physical
basis. He had recently seen such a case, a man with well systematized
delusions on an alcoholic basis, derived largely from tactile disturbances,
which proved to arise from the paresthesias of a very mild alcoholic
neuritis.

Dr. L. Pierce Clark was of the opinion that the cases cited by Dr.
Hoch might be called paranoid states rather than typical or true paranoia.
The therapeutic suggestions outlined would be of undoubted value in
these paranoid states. During the past three years he had been treating
several cases by analyses and talks and the method had been very ad-
vantageous. He thought the method was of little use in true paranoia as
the mental state was too fixed ; his experience in asylum service had proved
this fact to his entire satisfaction.

Dr. Swepson J. Brooks, of Harrison. N. Y., was very glad to know of

NEW YORK PSYCHIATRICAL SOCIETY 673

the success Dr. Hoch had had with therapeutic talks. He had tried this
plan and found it productive of results in many cases, but the patients
would relapse into the old condition after being released from institutions.
He presumed that Dr. Hoch had reference in his paper to simple paranoid
states. The question of paranoia was a hard one to go into, and sometimes
one almost concluded that paranoia and paranoid states were the same,
only differing in degree. The forcing of patients to do things, as sug-
gested by Dr. Hoch, was often neglected. He had in mind two cases in
which it certainly had a very salutary effect. One case was a woman,
forty-five years of age, who had delusions of persecution. She was put
in a very quiet hall. She complained that she was merely brought to the
place to be put in jail, that there were no sick people there, and that she
would like to see some sick people. She was allowed to see some sick
patients ; the next morning she was convinced, and she got well. That
was four years ago, and she had remained well since. The other case
was of the manic-depressive type. The patient confessed after her re-
covery that her family physician had had to force her to take medicine,
that he would stand her up against the wall and knock her head against
it if she did not take the medicine, and that she believed his method did
good.

Dr. Smith Ely Jelliffe said that Dr. Hoch's paper had offered glimpses
into a large and but partly explored territory. To him four different
trends of thought were suggested, all of which were the subjects of much
investigation. In the first place, the importance of the study of the mental
development of the child was emphasized. The work of Weygandt, on
abnormal children ; of Koch, on pathological inferiority ; of Hall, in
his masterly work on adolescence ; and of Sommer, on character and per-
sonality, were instances in point as to the activity of these lines of in-
vestigation. As to the psychogenic origin of certain types of delusions,
Dr. Jelliffe was in accord with Dr. Hoch. He spoke of the help that
might come from the literary side, as evidenced by the stories of Henry
James, "The Turning of the Screw," and the "Two Magics;" Weir Mit-
chell's "Constance Trescott," and.Ansty's "Statement of Stella Maberly."
In all these this type of delusion formation is beautifully brought out, with
great literary charm, if not with scientific pedantry. Therapeutically, he
deemed Dr. Hoch's paper as stimulating, and he himself regarded certain
phases of the subject with optimism. Paranoia, he said, was too large a
term to use in a general blanket manner. While it is true that little can
be accomplished by the most tactful of psychotherapeutic conversations in
chronic lunatics who have been in the asylums for years, yet the important
factor in the whole problem is to recognize the beginning stages, before
the delusional ideas have become too firmly crystallized. Greater success
had not been attained because the psychogenic origin of many delusional
states had not been sufficiently understood. It required a rare tact to
work on these patients, and the outlines given by Dubois, Dejerine and
Oppenheim were but the beginnings of a scientific psychotherapy which
for some time had been grasped at by pseudo-scientists. Dr. Jelliffe de-
sired to rank himself with those who saw a hopeful outlook for the
amelioration, if not cure, of certain cases of dementia praecox, and of the
paranoid states, by early and intelligent psychotherapy.

Dr. George H. Kirby had been interested of late in the management
of paranoic states along the lines suggested by Dr. Hoch, and thought that
much could be accomplished in this way toward the correction of morbid

6-4 NEW YORK PSYCHIATRICAL SOCIETY

trends. Dr. Hoch's work was particularly important in regard to the
study of delusions in general. Such a method of analysis opened the way
to an understanding of certain mechanisms which heretofore had heen
practically inaccessible.

Dr. Hoch, in closing the discussion, stated once more than what he
wished to bring out was the fact that certain paranoic states were pro-
duced by purely mental causes ; i. e., by conflicts and unhygienic ways of
dealing with them, and that they were more <>r Less amenable to treat-
ment early in the course, but that naturally he did not mean to claim that
old cases of paranoia could thus be influenced. It was necessary in order
to help such cases that one should still get at the root of things and ex-
plain to the patient the genesis of his delusions and train him to healthy
mental habits. The criticism that his cases were not cases of typical
paranoia, he could not quite understand, because he was unable to see
where the line could be drawn between cases such as his and cases of so-
called typical paranoia. Again, to say that paranoia was caused by heredity
was an exceedingly unsatisfactory way of stating the situation becuse it
did not mean enough. He had claimed that some paranoic states were
due to an unhealthy dealing with conflicts. Such an unhealthy dealing
may be due to tendencies which were more or less inherited, but it was
time to make an attempt at determining what these tendencies were, be-
cause the mere statement of heredity was absolutely barren, that the same
may be said about the statement which lias been made that paranoia was
due to a congenital mal-arrangement. If Dr. Ilirsch said that a normal
individual would not develop paranoia, this was doubtless true, if, by
normal individual was meant one who had perfectly healthy mental habits.

periscope

Deutsche Zeitschrift fur Nervenheilkunde.

(Band 29. Heft. 1-2.)

1. Experimental Investigations Upon the Anatomy of Traumatic Degener-

ation and Regeneration of the Spinal Cord. Fickler.

2. Investigations Upon the Sense of Vibration, and Its Clinical Significance.

Sterling.

3. Paralysis of the Abdominal Muscles in Anterior Acute Poliomyelitis in

Childhood. Ibrahim and Hermann.

4. The Differential Diagnosis Between Tumors of the Cerebellum and

Chronic Hydrocephalus, with a Contribution to the Knowledge of
Angioma of the Central Nervous System. Finkelnburg.

5. Intermittent Claudication of One Arm, the Tongue and the Lungs

(Dyskinesia intermittens angiosclerotica). Determann.

6. Contribution to the Clinical Manifestations of Tumors of the Corpus

Callosum. Bregman.
1. Regeneration Spinal Cord. — As a result of six experiments, five
of which were performed upon cats, and which consisted of exposing the
spinal cord and then striking a single blow upon it with sounds whose
heads were of various shapes, Fickler classifies the changes as follows :
First, contusion, sub-divided into (a) without simultaneous injury of the
spinal column; (b) with injury of the spinal column. Second, injurywith
alteration of the external form ; and third, the post-traumatic lesions. In
the first form there is disseminated insular degeneration of the nervous
parenchyma. This may lead to a spinal paralysis without injury of the
spinal column, hemorrhage, or cavity formation. Fickler gives a theoreti-
cal explanation for the occurrence of this condition, which depends upon
the fact that the wave of the spinal cord is somewhat slower than the wave
of the spinal canal, and he believes that experiments which he made upon
a decapitated calf confirm this view. The injury is, of course, caused by
the violent blow of the wave in the spinal cord against the surrounding
bones. The experiments showed that the injuries in these cases were
greatest at the position of the contre coup. In a second group, in which
direct injury is present, it is found that the changes are greatest in the
direction of the blow, although there is a certain degree of reflection from
the commissure. The lesion is produced chiefly as a result of compres-
sion, and varies of course in proportion to the distance from the seat of
injury, and the resistance of the different tissues, the nervous tissue being
the least resistant, and the blood vessels the most resistant. Only in case
the central canal is torn is there a sufficient extravasation of lymph to
cause much destruction. Central hemorrhages never occur unless there
is injury of the nervous tissue, and only when the central veins are in
direct line with the injury. Thrombosis is of very little significance, and
the changes in the blood vessels seem to be capable of producing a late
spinal apoplexy. An interesting feature of these experiments was the ap-
pearance in some of the spinal cords examined of undoubted evidences of

676 PERISCOPE

regeneration. This occurs only in the nerve fibers, never in the ganglion
cells. If the ganglion cells controlling the nerve fibers are destroyed by
pressure or any other cause, regeneration does not occur. The commonest
source from which regeneration proceeds is the spinal ganglion nearest to
the focal lesion. The fibers always require a conducting path, usually
provided by the blood vessels, particularly their perivascular lymph spaces.
Experiments seems to indicate that regeneration only occurs in sensory
fibers from the spinal g&nglia, and in the fibers uniting various segments
of the spinal cord. Consequently, the number of fibers capable of regenera-
tion is not very large. When these regenerated fibers reach the gray sub-
stance they may travel upward for a considerable distance, and even come
into relation with the dendritic processes of the ganglion cells of the gray
substance. The fibers of Clarke's column, however, do not appear to be
capable of reaching the central neurones, and the functional result at-
tained by regeneration is probably insignificant.

Z. Sense of Vibration. — Sterling has made a large number of investiga-
tions upon the perception of vibration, according to the method of Gra-
denigo, which consists of the determination of the point at which the
vibrations cease to be felt in any particular part of the body, by means of
an ingenious optical arrangement attached to the vibrating forks. In
eighteen cases of tabes dorsalis he found, without exception, that this
sensation was more disturbed than any other. In twenty-nine cases of
other forms of nervous disease he found that, in a gToup involving the
spinal column without affecting the spinal cord, there was no disturbance
in the vibratory sense, but that in the cases of paresis with some pain, but
without disturbance of touch, pain, or temperature sense, and in cases of
distinct paralysis and disturbance of sensation, the perception of vibration
was seriously impaired. In seven cases of disease of the peripheral nerves
it was found that the disturbance of the vibration sense was limited to the
territory controlled by the affected nerve. Sterling then discusses the
various theories regarding this form of sensation, and finally states that
personally he believes that the perception of vibration is common to all
tissues in which the terminations of sensory nerves are found. The
physical qualities of tissues have influence in so far that the denser tissues
transmit better the vibrations. The skin is not inferior in this perception
to the other tissues. He calls attention to the two conditions suggested by
Goldscheider; first, disturbance of the sensation of touch in the skin. with-
out loss of the perception of vibration ; and second, the preservation of the
sense of touch, with loss of the perception of vibration. Goldscheider ex-
plains this by the preservation of the vibratory sense in the deeper layers
in the first instance, and its loss, in the second, but Sterling quotes some
cases in which these conditions obviously did not exist. He does not be-
lieve, therefore, that we are capable by this method of determining directly
the condition of the deep sensation. Although the subject is at present
not clear, he believes firmly in the clinical value of the investigation of
the vibratory perceptive phenomena.

3. Abdominal Paralysis in Anterior Poliomyelitis. — Ibrahim and Her-
mann report four cases of undoubted anterio-poliomyelitis. In all of them
there was paralysis of the muscles of the abdomen ; in two unilateral, and
in two bilateral, but unequal. As in similar cases, the muscles of the back
were also affected, in addition to muscles of the limbs. In all the children
the rectus abdominalis appeared to be practically intact, the oblique muscles

PERISCOPE 677

being the ones chiefly affected. The symptoms consist in the bulging of
the abdomen at the site of the paralysis. There is no deviation of the
umbilicus toward the sound side. The abdominal reflex was usually, but
not invariably, lost in all three segments. In two of the cases there were
distinct signs of spontaneous improvement. In conclusion they report a
case of spina bifida, and meningo-myelocele in which there was also
paresis of the muscles.

4. Tumors of Cerebellum and Hydrocephalus. — Finkelnburg* reports
three cases of intracranial disease, the first in a child of fourteen, who had
had symptoms for 2% years. They commenced with headache, then ver-
tigo, staggering gait, diplopia, difficulty in urination, paresthesia in the
back, hallucinations of sensation in the extremities, and finally, impairment
of memory, state of excitement, and pains in the back of the head and
neck. There were choked disc, left-sided paralysis of the abducens. The
reflexes were normal. At the autopsy a moderate hydrocephalus was
found. The infundibulum had been forced forward, and pressed upon the
trigeminal nerves and the abducens. The fourth ventricle was not dis-
tended, but in the floor was found a cavernous angioma. There were
other changes of similar character, including chronic inflammation of the
choroid plexus. The second case, a child of seven years, had symptoms for
seven months. There were vomiting, frontal headache, staggering gait,
and loss of vision. There were also choked disc, tenderness over the left
posterior portion of the head, ataxia of the right arm and leg, incontinence
of urine and feces ; the reflexes were normal. The patient finally became
blind; was unable to walk or stand; the patellar reflex was diminished; and
there was an indication of Babinski. Trephining was of no avail. At the
autopsy there was found a small and moderate hydrocephalus, thrusting
forward the infundibulum ; the meninges and the choroid plexus were
normal microscopically and macroscopically. The third case, a woman of
thirty-six, began with headache in the parietal region, vomiting, staggering
gait, attacks of vertigo and diminution in vision. There was choked disc,
particularly on the left side ; tenderness to percussion in the parietal
region ; the tendon reflexes were active ; and Schmidt's symptom was posi-
tive ; that is to say, evidence of increase in the intracranial pressure by
change of position. The patient died suddenly, after discharging a con-
siderable amount of fluid from the nose. A diagnosis of cerebellar tumor
was made, but at the autopsy a small circumscribed tumor was found in
the right corpus striatum, projecting into the third ventricle, where it had
produced a moderate degree of hydrocephalus. The essential features of
these cases, according to Finkelnburg, are, first, that the cerebellar gait
may be present in chronic hydrocephalus, and in tumors of the central
ganglion, even in their early stages. Second, that a normal reflex activity,
or even a diminished reflex activity, is not against chronic hydrocephalus.
Third, that Schmidt's symptom is not characteristic for tumors of the
cerebellum, but may also occur in tumors of the cerebrum. Fourth, cir-
cumscribed pressure and percussion tenderness of the skull may occur in
chronic hydrocephalus, and therefore have only slight value as a local
symptom. Fifth, predominant development of the choked disc upon one
side is not a certain indication for the homolateral position of the tumor.
5. Intermittent Claudication. — A man of fifty-one had had for ten years
evidence of passive congestion with pain in the left great toe. This was
finally amputated with only partial relief. For some time he had suffered'

678 PERISCOPE

also from partial intermittent claudication, involving both legs, and a some-
what similar condition in the tongue and right arm. If the patient talked
for a long time the tongue became gradually stiffer and stirrer, until further
conversation was impossible. From ten to fifteen minutes work with the
arm caused it to become impotent, not so much on account of pain, as on
account of an uncomfortable feeling of weight. Power in the right arm
was less than in the left. The pulse in the dorsal arteries of the foot
could not be felt. The pulse in the right arm was slightly weaker than on
the left side. The pulse in the lingual arteries was weak on both sides.
There was no atheroma of the peripheral arteries, but the second aortic
tone was accentuated; the heart was moderately dilated; and on two oc-
casions albumin was found in the urine. Determann discusses the few
cases of intermittent claudication of the arm hitherto recorded. In the
case he reports there was a family tendency to arteriosclerosis, and the
patient smoked cigarettes habitually to excess.

6. Tumors of Corpus Callosum. — A man of thirty-eight, developed
headache, pain and stiffness in the neck, frequently vomited, and occasion-
ally had convulsions. Finally, there was paralysis of the left arm, and
some diminution in vision. When examined the pupils reacted to light;
the left lower facial muscle was weak ; vision was impaired. All the other
cranial nerves were normal. There was marked paresis of the left leg.
The patellar reflex was diminished on both sides, but particularly on the
left ; there was no Babinski. The left upper extremity was almost com-
pletely paralysed, and there was distinct ataxia. The tendon reflexes were
diminished. The abdominal and cremasteric reflexes were more active on
the left. The pulse was 64 and regular. The internal organs were regular.
The patient seemed to be exceedingly confused, and was usually apathetic.
He died in an epileptic attack. A tumor involving the anterior and middle
portions of the corpus callosum and the adjacent portions of the hemis-
phere, was found, which miscroscopically proved to be a spindle-celled
sarcoma. J. Sailer (Philadelphia).

Book *Kevtew0

The Nervous System of Vertebrates. J. B. Johnston, Ph. D., Professor
of Zoology in West Virginia University. P. Blakiston's Sons &
Co., Philadelphia.
In such a book as the one of Johnston's there is a good deal to be said
in way of satisfaction by the reader. It brings to our minds in a clear
way the sum of the work which has been done upon the nervous system
of the lower forms of vertebrates. The system of the nervous mechanism
is shown in its simpler forms of life and the relationship displayed as an
organism rises in the scale, which is an aid in the clinical work of the
physician. An instance of which is the recent statement that in man there
are sensory fibers in the seventh nerve. This observation can be supported
by the fact that In a lower vertebrate with gill slits the seventh nerve sub-
serves a considerable sensory function. Also in these lower forms it
-seems pretty definitely shown that afferent visceral sensory fibers go into
the cord by way of the posterior root and end in the region of Clarke's
column. This fact is presupposed in human anatomy but not proven,
yet to find it so in the low forms is an aid and guide in research.

It is an aid in the proper understanding of the relationship and function
of the medullary nuclei and of the sympathetic system with the central
nervous system. It is the bringing together of the work on vertebrates in
a manner easily referred to that makes the book of value to the medical
man. S. D. Ludlum.

La Melancolie. Etude medicale et psychologique. Par Rene Masselon
Medicin-adjoint de i/asile de Clermont de l'Oise. Felix Alcan,
Paris. «

This is a small monograph of some 284 pages, partly descriptive, partly
■experimental, which is pleasing, inviting, and possesses a number of fea-
tures of real value. The author's desire is to elucidate the melancholic
syndrome, by which he does not mean the older conception of the term
melancholia, nor yet is he prepared to accept the more limited application
put upon it by the followers of Kraepelin. For him there is no definite
melancholia — there are a number of melancholic states which may be
found in different nosological groups. Of these he would select one
which is, he believes, fairly clearly outlined — one in which the melancholic
state dominates the entire picture, but concerning the etiology and path-
ology of which we are as yet much in the dark. The analysis of this, to
"him a clearly delimited syndrome, is the author's task.

This analysis is largely psychological and the author depends in large
part for his conclusions upon the study of the mental associations of his
patients. He divides his cases into three groups, saying as he does so that
it is for purposes of convenience only, and that his simple, delusional and
stuporous melancholia groups are not to be interpreted in any sense as
disease groups. To this broad basis he adheres throughout. It is impos-
sible to give a complete idea of this work without outlining at considerabla
length the residts of the author's researches. It contains much very ex-
cellent material, and is a very commendable and thoughtful modern pres-
entation of a difficult problem. Jelliffe.

Views ant) note*

Eighth Annual Meeting of the National Association for the Study
of Epilepsy.

The eighth annual meeting of the National Association for the Study
of Epilepsy will be held at the Jefferson Hotel, Richmond, Va., Oct. 24-
25 next.

Addresses will be given at the first session by the Governor of Virginia,
the Mayor of Richmond and the President of the Medical Association of
the State of Virginia. Responses to these addresses will be made by Dr.
Everett Flood, President of the Association, and by Dr. William P.
Spratling, of The Craig Colony for Epileptics, Sonyea, N. Y.

Reports from all States in this country which are now caring for
epileptics will be made by the Secretary.

Dr. H. M. Weeks, of Skillman, N. J., will read a paper on "The Utili-
zation of Epileptic Labor."

Rev. J. Duncan MacNair, resident Chaplain of The Craig Colony at
Sonyea, N. Y., will read a paper on "Colony Life of an Epileptic — Social
and Religious."

Dr. James F. Munson, Sonyea, N. Y., "Sewage Disposal — the Con-
struction and Work Done by the Filter Beds at Sonyea, 'N. Y."

Dr. J. S. De Jarnette, Staunton, Va., "Epilepsy : Its Definition, Treat-
ment, etc."

Dr. Thomas C. FitzSimmons, Wilkesbarre, Pa., "Alcohol as a Primary
and Exciting Cause of Epilepsy."

Dr. M. B. Hodskins, Palmer, Mass., "The Etiology of Epilepsy."

Dr. William P. Spratling, Sonyea, N. Y., "The Systematic Treatment
of Epilepsy Versus Its Treatment by an Occasional Consultation and Pre-
scription."

Dr. J. Allison Hodges, Richmond, Va., "The Value of Elimination in
the Treatment of Epilepsy."

Dr. William T. Shanahan, Sonyea, N. Y., "Pulmonary Edema as a
Complication of Epileptic Seizures."

Dr. Matthew Woods, Philadelphia, Pa., "Surgery as a Therapeutic
Measure in the Cure of Epilepsy."

Dr. H. H. Levy, Richmond, Va., "Surgical Intervention in the Treat-
ment of Epilepsy."

Dr. A. V. Cooper, Palmer, Mass., "Injuries to Epileptics."

Dr. Edward A. Kennedy, Palmer, Mass., "Myclonus Epilepsy."

Dr. L. Pierce Clark, New York City, "Cranial Nerve Fits."

Dr. D. D. Wilcox, Richmond, Va.,""The Relation of Eye Defects to
Epilepsy."

Dr. G. Kirby Collier, Sonyea, N. Y., "Some Features of the Epileptic
Aura."

Dr. James F. Munson, Sonyea, N. Y., "The Heart's Action Preceding
the Seizure."

All persons interested in the study of epilepsy, the care and treatment
of epileptics, are cordially invited to attend the meetings of the Associa-
tion. The day following the meeting in Richmond the Association will
hold a session at the "Innside Inn" at Jamestown.

Persons desiring to join the Association should write Dr. James F.
Munson, Secretary-Treasurer, Sonyea, N. Y., or Dr. William F. Drewry,
Chairman Executive Committee, State Hospital, Petersburg, Va.

Vol. 35 NOVEMBER, 1907. No. 11

THE

Journal

OF

Nervous and Mental Disease

©rtQtnal articles

A CASE OF APHASIA, BOTH "MOTOR" AND "SENSORY," WITH
INTEGRITY OF THE LEFT THIRD FRONTAL CONVOLU-
TION: LESION IN THE LENTICULAR ZONE AND
INFERIOR LONGITUDINAL FASCICULUS.*

By F. X. Dercum, M.D.,

PROFESSOR OF NERVOUS AND MENTAL DISEASE, JEFFERSON MEDICAL COLLEGE J
NEUROLOGIST TO THE PHILADELPHIA HOSPITAL.

A new and all-absorbing interest 'has been given to the sub-
ject of aphasia by the views lately advanced by Pierre Marie.
As revealed in his recent publications, Marie maintains that
aphasia has been fundamentally misinterpreted and that this has
resulted from purely theoretical considerations. Many writers
indeed have taken as their point of departure complicated dia-
grams and schemes and have drawn from these long series of
deductions. The results are just what might have been antici-
pated, for the prevailing view of aphasia is a doctrine essen-
tially theoretical and schematic and which has been carried to
such extremes as to find itself totally at variance with observed
facts. To Marie the problem presented by aphasia is that of a
disturbance of the intelligence, a disturbance which constitutes
a special defect for the comprehension of language. Marie's
views are absolutely opposed to the classical doctrine of aphasia.
He denies that there exists in the left hemisphere an auditory
verbal center in the foot or posterior half of the left first tem-
poral convolution ; he denies that there exists a visual verbal
center in the left angular gyrus ; he denies that there exists a

*Read at the meeting of the American Neurological Association, May
7, 8 and 9, 1907.

682 F. X. DERCUM

center for writing in the foot of the left second frontal convo-
lution : he denies that there exists in the foot of the left third
frontal a motor verbal center. He insists that such an inter-
pretation is merely schematic and theoretical and in no way
justified by the facts. The theory of so-called word-deafness
which is usually interpreted as a lesion in which auditory images
are destroyed and in which the patient is no longer able to receive
words in his auditory center and no longer capable of com-
paring new impressions with the auditory images already amassed
and catalogued, he pronounces absolutely erroneous.

He points out that except in the rare cases in which non-
comprehension of language is absolute, the patient can compre-
hend isolated words, short phrases, simple instructions, but in
proportion as the phrases become lengthened, as the number of
words becomes augmented and as the instructions become com-
plicated, the comprehension of the patient fails. If, however,
in testing such a patient we pronounce anew and separately each
word, if we dissect the phrase into its elementary parts, if we
decompose the instruction into its separate and distinct factors,
we discover that the patient is again able to comprehend them.
In short, that which disables or confuses the patient the most
is the factor of complexity of language. Marie does not con-
sider the zone of Wernicke as an auditory center — a so-called
psycho-sensorial center — but as an intellectual center, and he
insists upon the inevitable intellectual deficit which ensues when
this center is destroyed. At the joint meeting of the Phila-
delphia and New York Neurological Societies, held in Phila-
delphia November 24th, 1906, in the discussion upon aphasia, I
detailed the results of my studies of fourteen cases based upon
the method of Marie. In all of these patients there was present
an intellectual deficit. All revealed in a more or less pronounced
degree an inability to carry out any but very simple instructions.
Some failed absolutely, others complied, provided the instruc-
tions did not embrace more than two or possibly three factors.
Onlv one or two could carry out instructions embracing four
factors and always failed when this number was exceeded. How
profound the intellectual disturbance is can readily be demon-
strated when an ap'hasic is requested to do simple sums in arith-
metic. Usually the additions are grossly incorrect and not infre-

A CASE OF APHASIA 683

quently the patient will begin his additions with the left-hand
column, absolutely unconscious of the gross incongruity. Some-
times the intellectual deficit is glaringly revealed when the pa-
tient is instructed to perform some act with which 'he is long
familiar and in the performance of which he has at one time
been especially skillful. Thus Marie cites the case of one of
his aphasics who, though sufficiently intelligent to mingle daily
with his fellows and who, though formerly a chef de cuisine,
proved to be utterly incapable of preparing so simple a dish as
a fried egg. The patient having been taken to the kitchen and
placed before the stove, was handed the necessary articles, a pan,
an egg, butter, pepper and salt and was told what to do. The
man hesitated for a moment and then commenced by breaking
the egg very awkwardly. He emptied it into the pan without
any precaution to avoid breaking the yolk, then he put some
butter on top of the egg, sprinkled it with salt and pepper and
then put the whole thing in the oven. Neither this gross blun-
der, nor the fact that the dish was absolutely unpresentable, dis-
turbed the patient in the least.

As Marie clearly points out, the intellectual deficit in aphasia
does not involve the intelligence as a whole. In general intel-
lectual deficit may manifest itself in one of three ways: first, in
the form observed in arrested cerebral development ; secondly,
in the form observed in dementia, as in paresis ; and thirdly, in
the special form seen in aphasia. Here the deficit instead of
being generalized, involves merely one function or related group
of functions. In other words, the deficit in aphasia is a special
deficit dealing especially as Marie puts it, "with the stock of
things acquired by didactic processes." Marie, it will be remem-
bered, holds that aphasia is a unit, that it is not made up of
sensory aphasia on the one hand or motor aphasia on the other,
but that by lesion of the zone of Wernicke there is established
an intellectual deficit for the comprehension of spoken language ;
that in so-called sensory aphasia or aphasia of Wernicke the
lesion involves the zone of Wernicke (i. e., the supramarginal
gyrus, the angular gyrus and the posterior portions of the two
first temporal convolutions) ; that in so-called motor aphasia
there is in addition to a lesion of this zone of Wernicke, also
an involvement of the region of the lenticular nucleus. Lesion

684 F. X. DERCUM

of the lenticular nucleus gives rise to anarthria, therefore in so-
called motor aphasia, or Broca's aphasia, we have merely ordinary
Wernicke aphasia plus anarthria.

How frequently aphasia is due to softening, the result of
embolism or thrombosis, it is not necessary to point out, and
Marie calls attention to the difference obtaining between cortical
softening on the one hand and deep softening on the other. In
cortical softening- the extent of territory involved depends upon
the point at which the middle cerebral artery has become ob-
structed. If the obstruction has occurred at or in advance of the
point at which the branch or branches supplying the third frontal
convolution are given off, the third frontal is of necessity in-
cluded, but such involvement is by no means necessary to the
production of aphasia. Not a small number of cases have been
reported in which the third frontal alone has been involved in
the softening without the slightest speech disturbance, as note
the recent cases reported by Souques, and by Marie and Mou-
tier. Again cases are not wanting in which the third frontal
escaped involvement and in which notwithstanding motor aphasia
was present. Such a case has only recently been placed on
record by Marie and Moutier.

More interesting still are the facts in regard to the aphasia
resulting from deep softening in which the cortex escapes and
in which the lenticular zone and the white matter alone are
involved. The case of aphasia that I here place on record belongs
to this group. The case was as follows :

The patient was a man who was admitted to the nervous
ward of the Philadelphia Hospital August 20th, 1903. His age
was estimated at sixty-five. The diagnosis upon admission was
that of aphasia with right hemiplegia. At the time it was learned
that he had had an apoplectic seizure in the year 1902, after
having previously suffered from attacks of dizziness, and that an-
other attack of dizziness, followed by impairment of speech, had
occurred in 1903. Owing to the fact that the patient could
neither speak nor understand spoken language and that he could
not understand writing, it was subsequently impossible to obtain
either a family history and past medical history or a history of
the present disease from him. It was noted that the right arm
was more affected than the leg. He had great difficulty in articu-
lation and enunciation. He had a very marked anarthria. When

A CASE OF APHASIA

685

he attempted pantomime with the unparalyzed arm, his move-
ments were confused.

Examined August 22nd, 1903, the diagnosis of right hemi-
plegia with aphasia was confirmed. The right upper limb was
paralyzed and contractured, the forearm was flexed on the arm
and the hand on the forearm. The right leg was paralyzed but

Fig. 1. Showing involvement of left lenticular nucleus and posterior
longitudinal fasciculus; freedom of third . frontal. Also extensive basal
lesion on right side which immediately preceded death.

not completely. The right foot and toes were contractured.
There was also present a paresis of the lower half of the right
side of the face. The patient could wrinkle his forehead well
and equally on both sides, but he could not draw up the right
angle of the mouth as well as the left. He closed both eyelids
well, but did not close the right eye quite as well as the left. The

686

F. X. DERCUM

biceps, triceps and wrist reflexes were exaggerated upon the right
side. They were about normal upon the left. The patellar re-
flex was exaggerated upon both sides. Ankle clonus was not
elicited upon either side ; this was also true of the tendo-Achillis
jerk. The Babinski reflex was not positive upon either side.
No sensory losses could be determined. The pupils were equal
and contracted to light. Dr. Spiller, from whose record the

Fig. 2. Showing involvement of left lenticular nucleus and posterior
longitudinal fasciculus ; freedom of third frontal. Also extensive basal
lesion on right side which immediately preceded death.

above facts are abstracted, also noted that the patient had com-
plete motor aphasia and that he was probably at least par-
tially word deaf. He seemed to be able to give merely his name.
The patient remained in the wards enjoying comparative
health and remained for some years in about the same
condition. Early in November, 1906, he was repeatedly

A CASE OF APHASIA

687

Fig

Parallel Case of Marie.

Fig. 10. Horizontal sectiou of the left hemisphere of Per . . . The
softening met with here is of the type of deep softening * * * * It is
represented by the black line which extends from R. to K\ it occupies the ex-
ternal capsule and the base of the white substance of the convolutions of the
island of Reil. At R' a line of softening bifurcates and is directed forward
and inward toward the internal capsule; posteriorly the softening traverses the
temporoparietal isthmus and extends into the white substance of the temporo-
occipital lobe R" where it occupies the neighborhood of the external wall of
the posterior horn of the lateral ventricle and follows faithfully its contour;
it abandons this wall altogether posteriorly and terminates in the white sub-
stance of the occipital lobe. This patient was one of the most beautiful
aphasics of Broca which it has been given me to observe. Here the aphasia of
Broea has been produced because the lesion R R' has given rise to the an-
arthria and the lesion R' R" to the aphasia. 1 Pierre Marie. 1

688 F. X. DERCUM

examined bv myself. He presented, of course, as before a
right-sided hemiplegia with contractures, together with aphasia.
It was clearly demonstrated that he was unable to understand
what was said to 'him, tbat he was unable to comprehend or to
carry out the simplest instruction unless this instruction was
accompanied by gestures and' pantomime on my part. Without
such aid be failed utterly to comprehend what was desired of
him. When told "raise your left hand," he failed utterly. If,
however, the command were accompanied by my own gesture, he
would at once comply. Under such instruction he would raise
bis band, place it upon his head or other portions of his body, but
in no instance could he perform such an act when instructed ver-
bally. I le was with great difficulty able to give bis name, though
the sounds were barely intelligible, lie could also say "yes" and
"no."' though be substituted a "d" for the "n" in the "no." Upon
one occasion during my tests be repeated after me the word
"pencil."' though very imperfectly, llis anarthria was very pro-
nounced. There was present also complete alexia ; neither could
he write or form letters with his left or unparalyzed hand ; nor
could 'he copy letters, though the tests were limited to his own
name. Tbere was also present apraxia. Pantomime was im-
perfectly preserved.

On December 5th, 1906. the patient was in his usual good
health, but during the night suffered from a fresh apoplectic
seizure, this time affecting the left side. The left arm and left
leg became completely paralyzed and flaccid. There was con-
jugate deviation of the eyes and of the head to the right. The
other and usual symptoms of an apoplectic seizure were present ;
the patient was comatose, presented stertorous breathing and a
rapid pulse of rather high tension. There was little change in
his condition subsequently. The deviation of the head and eyes
to the right became somewhat less pronounced and he became
somewhat weaker. Congestion and edema of the lungs grad-
ually made their appearance and the patient died on December
10th at 10 p. m.

Autopsy. — The results of the general pathological examination
need not detain us here. They consisted in brief of adherent
pericardium, hypertrophy and dilatation of the heart, fibroid
myocarditis, congestion of the lungs and interstitial nephritis. Ex-
amination of the brain proved to be of great interest. There was
no gross lesion of any convolution. A horizontal section passing
through the basal ganglia at the level of the foot of the left
third frontal convolution revealed two extensive lesions. First
an old lesion upon the left side of the brain involving the lentic-
ular zone and the inferior longitudinal fasciculus ; secondly, a
recent and very extensive softening upon the right side involving
the basal ganglia and capsule. The lesion upon the right side
was of course the one which immediately preceded death ; it is the

./ CASE OF APHASIA 689

old lesion upon the left side which concerns us here. As just
stated, the lesion upon the left side involves the lenticular nucleus,
the adjacent portion of the internal capsule and can also be
traced far back along' the inferior longitudinal fasciculus. The
third frontal convolution is absolutely intact, as is also its sub-
jacent white matter. This is also true of the convolutions of the
regions of Wernicke' and of the angular gyrus. This interesting
case is almost an exact parallel of the case described by Marie
in his article in the Scmaine Medicate, May 23rd, 1906, and illus-
trated by Figure 10. This figure is here reproduced. Marie
says of his case that the patient presented one of the most beau-
tiful aphasias of Broca — motor aphasia — which it had ever
been given him to observe.

The question arises, how can such a lesion as is here described
give rise to aphasia — to motor aphasia or the anarthria of Marie
upon the one hand and to sensory aphasia or aphasia of Wer-
nicke on the other? The lesion of the lenticular zone readily ex-
plains according to Marie's view the anarthria. It would seem
further that the degeneration of the posterior longitudinal fasci-
culus produces sensory or Wernicke aphasia by isolating the
zone of Wernicke and secondly the degeneration of this fasci-
culus also produces alexia because it cuts off all communication
between the zone of Wernicke and the visual centers. To me
this case has been one of great interest for it is most suggestive.
We know very little of the function of the striated body. It is
a structure which is persistent throughout all the vertebrate forms
and in the lower vertebrates, as is well known, it constitutes all
of the cerebrum. Even when we ascend the scale as far as birds
we find that in them the pallium, — the part corresponding to our
cortex, — is still very rudimentary and that the striated bodies must
carry on the cerebral function. In man the striated body has
retained so great a size that it cannot possibly be regarded as
a rudimentary or vestigial organ. In spite of the enormous de-
velopment of the pallium, this organ has persisted in the
higher vertebrates to such a degree as to necessitate the inference
that it has most important functions. That the striated body
should be concerned in speech presents nothing inherently im-
probable. While I do not mean to compare the speech of the par-
rot' with the speech of man, the facts justify the inference that
the parrot talks with his striated body ; this view has also been
expressed by Kalischer. Unfortunately physiologists have thus

6go F. X. DERCL'M

far given us but little information as to the function of the stri-
ated body : it is possible that the propulsive movements of Ma j en-
die, the circus movements of Nothnagel have something to do
with movements of co-ordination. However, the facts of the
special disturbances claimed by Majendie and by Nothnagel have
been questioned and denied and we are of necessity forced to draw
our inferences from pathological and clinical evidence.

The function performed by the lenticular nucleus appears
to be one of co-ordination of complex muscular movements,
and motor speech is pre-eminently a function requiring the co-
ordination of complex movements ; e. g., the movements of the
tongue, palate, lips, larynx and of the muscles concerned in
expiration. A derangement of this intricate co-ordination means
of necessity anarthria, means of necessity the .impossibility of
speech enunciation. Just in proportion as the substance of the
lenticula is destroyed, so must there be an absence of motor
speech ; just in proportion as the function of the lenticula is
deranged, so must there be present an anarthria.

REFERENCES.

Pierre, Marie. La Semaine Medicale. May 23, 1906. Ibidem, Oct. 17,
1906.

Pierre Marie. La Semaine Medicale, Nov. 28, 1906.

Pierre Marie et Francois Moutier. Bulletins et Memoires de la Societe
Medicale des Hopitaux de Paris, Decembre 14th, 1906.

Pierre Marie et Francois Moutier. Bulletins et Memoires de la Societe
Medicale des Hopitaux de Paris. Fevrier, 15th. 1907.

Pierre Marie. La Revue de Philosophic, 1907.

Pierre Marie. La Presse Medicale, No. 4, 12 Janvier, 1907.

Souques. La Presse Medicale, October 24th, 1906, p. 683.

Souques. Bulletin et Memoires de la Societe Medicale des Hopitaux
de Paris, 19 Octobre, 1906.

Souques. Bulletins et Memoires de la Societe Medicale des Hopitaux
de Paris, 1 Mars, 1907.

DISPENSARY WORK IN NERVOUS AND MENTAL DISEASES.1 *
By Smith Ely Jelliffe, M.D., Ph.D.,

VISITING NEUROLOGIST CITY HOSPITAL, NEW YORK; CLINICAL ASSISTANT, DE-
PARTMENT OF NEUROLOGY, VANDERBILT CLINIC, NEW YORK; CLINICAL
PROFESSOR OF PSYCHIATRY, FORDHAM UNIVERSITY.

A yearly statistical resume of the work of the Department of
Nevous Diseases of the Vanderbilt Clinic presents a number of
interesting features. These reports have now been prepared for
the years 1902, 1903, 1904, 1905 and 1906, and already the facts
brought together are of value in generalization.

The social economic side of disease has yet to be studied. It
has been attempted in only a sporadic fashion. In addition to
the purely medical aspects of the question, these statistics are of
service from the social economic point of view — a standpoint
which was emphasized in a previous resume.

During the year 1906 the patients seeking help in the nervous
department were 2,308. Of these 2,141 were examined and
their histories recorded in the case books. The number of pa-
tients was practically the same as for 1905.

The entire Vanderbilt Clinic population as given me by Mr.
J. V. Colgan, in charge, is as follows :

New Visits

patients. made.

Nervous

Orthopedic 1,256 7,442

Surgical 4,564 21 .886

Medical and applied therapeutics 14,620 44,305

Gynecological 2,813 10,064

Pediatric .• 4,233 11,362

Ophthalmological 5,oi8 15,848

'Report of Clinic of Nervous and Mental Diseases of Professor M.
Allen Starr for the year 1906. Fifth Annual Report. For previous reports
see Journal of Nervous and Mental Disease, 1903, 1904, 1905 and 1906.

'Members of Clinic Staff, 1906: Richard H. Cunningham, Chief of
Clinic; Chas. E. Atwood, B. E. Krystall. Smith Ely Jelliffe, S. P. Good-
hardt, E. L. Hunt. L. P. Clark, L. S. Manson, H. R. Humphries, J. M.
McEntee. Thos. P. Prout. Geo. W. Todd, J. E. Clark and Chas. D.
Qeghorn.

692 SMITH ELY JELLIFFE

Otological 1 .766 6,574

Nose and throat 4-771 1 3.063

Dermatological 3.959 1 1,775

Genito-urinary 2.633 10,882

47,941 163,733

During the past year the visits per person remained, as in
times past, about 5.

Of the 2,141 patients whose histories are recorded in the
case books, it was found that 134 ( ~2 men and 62 women) were
not suffering from any nervous disorder, while for 128 cases
(67 men and 61 women) the diagnosis is not recorded, and the
facts stated do not permit of the drawing of an inferential diag-
nosis. The present statistical presentation is limited then to the
consideration of 1.879 cases of disorder of the nervous system.

The incidence of disorder of the nervous system when com-
pared with the entire clinic population remains at about 5 per
cent., a point which has been fairly constant since 1902.

Tn view of the fact that mental disturbances are not seen in
anything like their true proportion in the population, the figure is
undoubtedly below the general average of involvement of the
nervous system. Of the 1,879 cases under review, 827 were men
and 1 .0^2 women.

Mental Disorders.— The statistics of 1906 bear out the gen-
eral facts already noted in our previous inquiries. (See partic-
ularly Report IV. for 1905, Journal of Nervous and Mental
Disease, April, 1906.) The number of patients who seek relief
is far below the number who need it. We here retain for the
time being the subdivisions of our previous reports, and the psy-
choneuroses in the broad sense as used by Dubois are classified
with the nervous disorders. Only 173 cases (9.2 per cent.) are in-
cluded here under the mental rubric — 85 men and 88 women.
This is a slightly lower number than in 1905 — 95 and 99.

As in previous years the defective developmental patients
preponderate. Thus, under Idiocy, were classed 4 boys and 1
girl ; under Imbecility, 35 boys and 37 girls. The line of de-
marcation is not sharply drawn in our histories and it were
better perhaps to classify them simply as Defectives. Many
more of this class appear in the general clinic statistics as a num-

DISPENSARY WORK 693

ber are observed in the pediatric department. This is true par-
ticularly for the higher grade imbeciles.

Of the insanities per se, in their milder grades, for only the
mild grades come to an out-patient department such as t'his, there
is little to offer. The facilities of our out-patient department are
too crowded to permit of a satisfactory detailed examination of
these mental cases. This is one reason perhaps why they do not
come.

No recognizable cases of Toxic or Exhaustive psychotic
states were recorded.

The Dementia Precox Syndrome was diagnosed in 24
cases, 16 men and 8 women. This number represents about
13.8 per cent, of the mental cases of the clinic. The cases would
all fall in the hebephrenic group.

Paranoid States,, allied to Dementia Prsecox, or appearing
as post manic-depressive delusional developments, or associated
with other psychoses, are reported for 1 man and 3 women.

Manic-Depressive States were diagnosed in 6 men and in 13
women, while Symptomatic Depression was noted in 5 \romen.
Involution Melancholia was noted in 1 male.

General Paresis was diagnosed in 23 instances (13.3 per
cent.). Of this number 19 were men and 4 women. There
were no special features in any of the patients observed.

Record is made of 12 cases of Menopause Psychoneuroses.
These are probably best considered as mild anxious and de-
pressed conditions, allied, in general, with the involution and
presenile melancholic states. Most of them were of compara-
tively mild grade, and hardly merit being termed psychoses.

Senile Dementia is recorded once in a man.

Nervous and queer children are recorded in 5 instances, 4
girls and 1 boy.

Nervous Diseases. — Seventeen hundred and six patients, or
91.8 per cent, come under this group. The custom of previ-
ous years in the division of our patients will be followed here,
although it is well recognized that hard and fast lines of demar-
cation between the classes are inadmissable. This is particularly
true of the groups of Neurasthenia and Hysteria of the present
and of previous reports. Although it is believed that the more
general term Psychoneuroses is more advisable for this general

694 SMITH ELY JELLIFFE

group, the arbitrary division of neurasthenia and hysteria is re-
tained.

Neurasthenia is represented in the case books of 1906 in
370 instances — 200 men and 170 women. The preponderance of
the foreign population remains one of the striking features in this
annual resume. As in former years the neurasthenia histories
are but fragmentary, as far as the records show. These patients
are those who always complain of their little ailments. Inasmuch
as they are recruited for the most part from the latest arrivals,
particularly from the Jewish race, the influence of underfeeding,
bad hygiene and strangeness should not be overlooked. Some
of these patients are very ill, and are in need of hospital, rather
than ambulator}' treatment, but our facilities for taking care of
the functional cases are grossly inadequate. The time may
soon come when these very cases may receive that which many
of them should receive — namely, hospital treatment — and then a
large economic saving may be brought about. The present am-
bulatory treatment of many of this class of patients is, from some
points of view, a farce, but it seems to be a necessary one with our
specially developed type of institutions.3

Hysteria was diagnosed in 95 instances (5 per cent.) — 12
men and 87 women. A more detailed and systematic study of
the hysteria cases is very desirable. True hysteria, we are con-
vinced, is a comparatively rare affection in the clinic population.
Hysterical manifestations of various grades are very frequent.
The basis of the majority of the hysteria diagnoses is that of
one or more hysterical manifestations. The severer grades of
hysteria were few in the year's analysis. The crowding inci-
dent to the physical construction of the clinic makes it difficult to
treat this class of patients. A quiet room is needed where help-
ful psychotherapy may be carried on. This is impossible in the
present state of the clinic's rooms.

Epilepsy still figures largely in the yearly resume. There
were 87 males and 79 females suffering from this disorder (8.8
per cent.). The general average remains as in previous years.
Provision is made for the transfer of many of these patients to
Craig Colony.

8An excellent analysis of 6.000 cases of neurasthenia from the case
records has been made by Dr. Cleghorn. Medical Record, March 7, 1907.

DISPENSARY WORK 695

Sydenham's Corea was diagnosed for 152 patients, 57
males and 95 females. The marked preponderance of girls is
still striking in this, as in the figures of other years. I have been
unable thus far to obtain reliable data respecting the infantile
rheumatisms and the relation they bear to chorea. The query
is one that I believe would prove of value to decide.

Two instances of well defined unilateral chorea were of spe-
cial interest in the records. The percentage of chorea to the
general nervous population for 1906 is 8.2.

Tics of one type or another were recorded as follows: Fa-
cial tics, 3 males, 6 females ; spasmodic torticollis, 3 males, I
female : habit spasms, 2 males, 6 females.

Paralysis Agitans was present in 1 1 men and 9 women,
or 20 cases in all.

Paramyoclonus Multiplex was diagnosed in one instance
in a male.

Thomsen's Disease was found in one patient, complicated
with an ophthalmoplegic migraine.4

. . .Peripheral Nerves. — The peripheral nerve affections were
numerous in the statistics of 1906. Combining the peripheral
neuralgias, neuritides, and neuroparalyses there were 324 pa-
tients— 204 men and 104 women. This number coincides exactly
with the admissions in 1905. The women are much fewer in
this year's summary.

The line of separation between neuralgias and neuritides is
difficult to draw. As in previous years, it has been made here
in a general way only.

Neuralgias. — These were present in 158 patients, distributed
as follows:

Male. Female.

General and non-localized 6 6

Cervico-occipital 8 5

Supra orbital 8 8

Trigeminal 23 40

Deltoid-Brachial o 6

Intercostal 3 o

Lumbar 5 o

*N. Y. Med. Jour., July 20, 1907.

696 SMITH ELY JELL1FFE

Sciatic 32 6

Anterio-crural I o

Plantar o 1

Neuritis in 1906 was diagnosed in 61 instances:

Male. Female.

Unknown causation 4 3

Alcoholic 11 1

Anterior Tibial 5 o

Ant. crural 2 o

Brachial o 2

Lead 10 1

Median 2 o

Musculo-Spiral o 3

Ulnar 15 o

Pressure o 2

The Peripheral Palsies were observed in 112 patients, 6
per cent., 69 men, 43 women. It is highly probable that some
of the palsies noted as peripheral were in reality central in
origin, but it is at times difficult to establish a differential. As
in 1905 the traumatic element causes the marked preponderance
in males.

These palsies were distributed as follows:

Male. Female.

Erbs (birth palsy) 2 6

Brachial (mostly alcoholic and pressure) 13 9

Circumflex 5 o

Deltoid 1 o

Facial (Bell's) 23 23

Facial (nuclear) o 1

Median 4 o

Musculo-Spiral 21 2

Ulnar o 1

Third nerve O I

The central nervous system w-as primarily implicated in 235
patients (12.5 per cent.). In these the spinal cord was the chief
organ involved in 96 instances. These were distributed as fol-
lows : Acute Anterior Poliomyelitis was present in 30 males
and 21 females. Chronic Anterior Poliomyelitis was diag-
noses in 3 males. Bulbar involvements were not observed dur-

DISPENSARY WORK 697

ing the year. Amyotrophic Lateral Sclerosis was present in 2
men and 1 woman. Tabes was present in 35 men and in 1
woman. Friedreich's Disease was diagnosed in 1 boy and in
3 girls. Combined Scleroses were found in 1 woman. Mul-
tiple Sclerosis was diagnosed in 10 patients5 — 5 males and 5
females.

The Myelitis syndrome was obtained in 14 — 11 meji and 3
women. Of these, syphilitic myelitis was diagnosed in 2 men,
traumatic or compression myelitis in 2 men and 2 women,
caisson myelitis in 1 man, meningomyelitis in 1 man ; 3 cases
were of undeterminate character, while in 2 men and 1 woman
ataxic paraplegia is recorded, and in 1 male spastic paraplegia
without fuller details.

Hematomyelia was present in 2 men. Syringomyelia in 2
men and Spinal Cord Tumor was present in 1 man.

Brain. — This was involved in 139 patients (7.4 per cent.).
Epidemic Cerebro-Spinal Meningitis presented itself only in
2 males and 2 females.

Meningoencephalitis was diagnosed in 1 woman, and
Pachymeningitis was thought to be present in 1 woman. Post-
otitic Meningitis was diagnosed in 1 male.

Generalized Cerebro-Spinal Syphilis was diagnosed in 12
men.

Meningeal Hemorrhage from trauma was present in 1
woman.

The Hemiplegic Syndrome was present in 63 patients — 43
men and 20 women. In 50 instances there was a right hemi-
plegia, in 13 it was on the left side. The localizing signs were
not recorded. Infantile Cerebral Palsy was present in 2
males and 6 females. Cerebral Tumor was diagnosed in 2
males and 5 females. Cerebellar tumor in 2 males. A cerebel-
lar ataxia was diagnosed in 2 females.

Hemianopsia was recorded in 1 male and optic nerve atrophy
in 1 female.

.Concussion was diagnosed 8 times, Arterio-Sclerosis 23 and
Senility once.

Trophoneuroses. — Of the Trophic Disorders the following are

"Nos. 2805, 2815, 3017, 3633, 3665 in male and 3742, 3928, 4500, 4828,
5018 in female record book of 1906.

698 SMITH ELY JELLIFFE

recorded: Erythromelalgia, i ; Muscular Dystrophy, 4; Ex-
ophthalmic Goiter, 2 males, 17 females; Arthritis Deform-
ans, 2.

Miscellany. — Acroparesthesia, 6 men, 4 women; Alco-
holism, 29 men, 6 women ; Flatfoot, i ; Headache, 29 men, 55
women ; Hyperidrosis, 7 ; Fracture Skull, i ; Incontinence
of Urine, v; Insolation, i ; Insomnia, 9 men 7 women; Mer-
curial Poisoning, i ; Night Terrors, i ; Stammerers, 9 men,
9 women ; Trauma to Spine, 2 ; Vertigo, 2 men and 4 women.

TRAUMATIC LESION OF THE PONS AND TEGMENTUM WITH

DIRECT AND RETROGRADE DEGENERATION OF THE

MEDIAN FILLET AND PYRAMID, AND OF THE

HOMOLATERAL OLIVE.*

By Adolf Meyer, M.D.,

OF NEW YORK.
DIRECTOR PATHOLOGICAL INSTITUTE.

Looking back on my own training in anatomy of the nervous
system, I remember keenly the frequent feeling of discourage-
ment over the discrepancy between the schematic presentation and
the actual material, which more than the schemes, is the real
salvation in case of doubt and the real field for experience and
work.

One of the most disastrous consequences of schematic teaching
is that the student does not learn how to deal open-mindedly and
with equanimity, with the many unanalyzed parts, the unclassi-
fied residuum, which after all is material worth the greatest res-
pect as the ground on which the help from discrepancies and un-
certainties is bound to come. He ignores it, or fumbles with it,
but refuses to meet it calmly for what it is worth.

It is my conviction that a method obviating this difficulty is
furnished by a combination of accurate drawings and glass re-
constructions, with a system of interpretations by colors. In this
manner, that which is plain and simple stands out excellently and
yet there will be no need of suppressing that which is the hope of
the future. We can give a loud interpretation to the matters
which appear safe, and a more tentative one to those which are
tentative. The method is one of great advantage to the worker
and its results do not have to be modified to become perfectly
acceptable to students.

I beg to show the successive stages of presentation with the
help of A. T. Thompson's Projection-reflectoscope, in connection
with a communication of a rather interesting case of lesion of
the pons.

The patient was an Italian who was stabbed in the left side

*Read at the thirty-third annual meeting of the American Neurological
Association, May 7, 8 and 9, 1007.

700 ADOLF MEYER

of the neck in March. 1900, and evidently sustained a fracture of
the skull. He remained unconscious for weeks, passed through
a period with loss of speech, inability to swallow . paralysis of the
right arm and leg and partial loss of sensation. He was admitted
to Manhattan State Hospital July, 1901, on account of depression
and threats of revenge, etc. ; the tongue protruded to the right ;
he could walk unassisted. No accurate status was given. The
patient died December 13, 1903, with chronic enteritis, and I
owe to the Manhattan State Hospital the opportunity to have
the case worked up in the laboratory of the Institute.

The study of the whole brain and of serial sections showed a
rather sharply outlined cutting out of nearly the entire left half
of the pons. Only the deepest transverse layers are preserved.
The pyramid is completely destroyed and about section 421 the
tissue-defect involves the mesial fillet which was evidently cut
through as well and brought to degeneration, with the exception
of about one-half of the mesial fourth and a few bundles near
the bend into the lateral fillet. The most posterior actual tissue-
defect is seen in section 461, in the center of the left middle
cerebellar arm, the most anterior in 190, i. c, in the most an-
terior part of the pons.

The anatomical interest of the case lies in the secondary
degeneration of the left mesial fillet, the so-called retrograde de-
generation of the left pyramid, the degeneration of the left olive
and its fleece, and the isolation of a number of bundles which are
usually covered up. The series shows further a distinct defect
of the left T4 and a marked reduction of the marrow of the left
temporal lobe (with remarkable integrity of the callosal radia-
tion) and hardly any reduction of the anterior commissure.

In the glass-models many details are not entered on account
of the small enlargements ; but in a large model it will be pos-
sible to render the individual smaller tracts without danger of
confusion. Furthermore, it is desirable, in order to avoid con-
fusion, that a uniform color scheme be agreed upon for the dem-
onstration of fiber tracts.

Society proceedings

AMERICAN NEUROLOGICAL ASSOCIATION.

Held in Washington, May 7, 8 and 9, 1907.

The President, Dr. Hugh T. Patrick, in the Chair.

(Continued from page 656.)

TUMORS OF THE CAUDA EQUINA AND LOWER VERTEBRAE.

By Dr. William G. Spiller.

The paper is based on the observation of nine cases of tumor of this
region, seven of which were with necropsy and three with operation. The
differential diagnosis is discussed between tumors of these parts and
hysteria, multiple neuritis confined to the lower limbs, intrapelvic tumor,
caries of the lumbar vertebras and sacrum, lesions within the vertebral
canal but external to the dura, and lesions of the conus medullaris. The
few cases of tumor of the cauda equina with necropsy reported in the
literature and the question of operation are considered. Tumors of this
region seem to be much more serious for surgical intervention than are
those higher in the vertebral column.

Dr. Starr said this paper had interested him very much. He thought
these cases were extremely rare. The case Dr. Spiller referred to as
under his (Dr. Starr's) care was the only one he had ever seen. It was
successfully operated on and the patient recovered entirely, and used to
come to the clinic for the purpose of being shown. Dr. Starr said a picture
of this case was in his book, one leg being totally paralyzed and the other
normal. He thought that in a later report the statement was made that
he was entirely cured. Dr. Starr said he felt that one of the most im-
portant things in the diagnosis of these conditions is the very careful ex-
amination for the areas of anesthesia. When they exist they are really
of more importance in the localization of the lesion than almost anything
else. With regard to the possibility of the return of power of the blad-
der and rectum after lesions of the conus, he was rather inclined to think
that such a recovery might occur, although it was in his experience ex-
ceedingly rare. One case he had on record of distinct history of injury
and hemorrhage into the cauda equina with total and distinct anesthesia
in the destroyed area up to the level of the second sacral segment and
loss of bladder and rectal control ; in that case after a time the girl ap-
peared to recover to a considerable extent the control of the bladder and
rectum, even though the anesthesia and the slight paralysis in the muscles
of the feet, especially the long peronei remained. He said it is of course
a very important thing to be able to make this diagnosis early. The pain
in the sacrum seems to him to be one of the most valuable of the diagnos-
tic points, referred to the periphery in part, but also occurring in and

7Q2 AMERICAN NEUROLOGICAL ASSOCIATION

around the sacrum, and he thought that without such a sacral pain it
would be rather perilous to attempt operation.

Dr. C. L. Dana said with reference to the question of surgical operation
in these cases he would like to put on record some rather better experi-
ence, perhaps, than Dr. Spiller would lead one to think likely. Last winter
Dr. Woolsey operated on two cases of tumor which were not, strictly
speaking, of the cauda equina, but of that region. One was a tumor be-
ginning in the root of one of the lower sacral nerves, not originally a
conus or cord tumor, although it did eventually press upon it. and it had
all the beginning symptomatology of cauda tumor with the exception that
there was involvement of the bladder. Dr. Woolsey cut down and re-
moved the tumor, and it had to be dissected out from the lower part of
the cord. The patient was an old man, but he made a good recovery so
far as life was concerned, and he was relieved of his horrible pain and
has continued relieved at the end of eight or ten months. Dr. Dana said
they had another case of tumor which seemed to be caudal ; it had caudal
symptoms, but they were not sure whether it was that or a bony tumor
pressing upon the nerve. Tt turned out at the operation by Dr. Woolsey
that it was a sarcoma of tbe sacrum which had pressed upon the sacral
nerves. The patient had a distinct area of anesthesia which was very
characteristic and some weakness and atrophy of one leg. In this case
operation was successful.

Dr. C. K. Mills said that it was true as Dr. Starr had said that tumors
in the cauda equina are comparatively rare, yet he thought he had seen
at least eight or ten of these if he included several clearly defined clinical
cases with four or five cases in which necropsy or operation or both proved
the presence of tumor. The most interesting and the most difficult diag-
noses to make are in the very earliest stage from sciatica; and at any
stage, except the very late stages, from intrapelvic tumor. Dr. Mills said
he has notes of some half dozen cases of intrapelvic tumor which he ex-
pects some time to publish. In these for a long time (in one case for
fourteen years after the onset of the symptoms) the diagnosis was ex-
tremely difficult. In each of these cases the diagnosis of spinal or cauda
equinal or other organic disease, or hysteria had been made. The dif-
ferentiation between these intrapelvic tumors, especially if they are soft
tumors, is difficult. The intrapelvic nerves are often robust enough te
function through the tumor masses, even if these are of considerable size.
It is for this reason that the diagnosis remains difficult and that the symp-
toms, although the growth involves many nerves, are referable sometimes
to one or two. He said he thought the length of time of development
of the growth, the commonly (though not always) unilateral character of
the symptoms and the dissociation and diffusion, rather than the concentra-
tion of the symptoms, are the most helpful points, but of course an ac-
curate statement of the diagnosis cannot be given in a few words.

Dr. J. J. Putnam referred to the apparent tenderness or pain evoked by
pressing upon the nerves in one of Dr. Spiller's cases. This he believed to
be due to mental association. A patient whom he had seen, with spinal
tumor, used to suffer exquisite pain in the back if she turned her head
very slightly, or even if she gaped. Such slight movements as these could
not be supposed to drag on the ninth thoracic nerve, where the tumor
lay, and the only reasonable explanation was that in order to turn the
head it was necessary to set slightly the muscles of the back, and that this
recalled, by association, the stronger action of these same muscles which

AMERICAN NEUROLOGICAL ASSOCIATION 703

had so often been a real direct cause of motion and of pain. The excit-
ability of the nerve centers related to the affected part may be so great
that anything which even suggests a stimulus which had previously caused
pain is enough to reproduce it.

Dr. Pierce Bailey said that in speaking of the differential diagnosis of
these cases Dr. Spiller had stated that in multiple neuritis the muscles sup-
plied by the peroneal nerves are often most affected. Dr. Bailey said he
had seen a case recently with Dr. Jelliffe in which there was an unusual
distribution of the paralysis. The man had a history of long and ex-
cessive use of alcohol. He had the loss of knee jerks, pains, etc., but the
palsy, instead of being most pronounced in the peroneal nerves, was much
more pronounced in the muscles around the hip. When the man was
taken out of bed to walk he could grasp the floor with his toes, but the
muscles above the knee were absolutely powerless. So that in this case
there was a great increase in paralysis in the flexors of the thigh and the
flexors of the leg with only partial paralysis in the muscles below the knee.
If the etiology had been any less distinct in this case Dr. Bailey would
have questioned very much the alcoholic neuritis origin.

Dr. Patrick said he had seen two cases of multiple neuritis affecting
particularly the pelvo-femoral group of muscles. Both cases presented the
characteristic symptoms of neuritis, and both patients recovered in what
would ordinarily be considered a proper time for recovery from multiple
neuritis.

( To be continued.)

. JOINT MEETING OF THE
NEW YORK 'NEUROLOGICAL SOCIETY,

AND THE

PHILADELPHIA NEUROLOGICAL SOCIETY

Held at the Academy of Medicine, New York, March 16, 1907.

The President of the New York Neurological Society, Dr. Charles L.

Daxa, in the Chair.

A CASE OF MYOCLONUS.

By Dr. L. Pierce Clark.

The patient was a Jewish boy, 15 years old; the third of a family of
five children. His family and personal history was good with the ex-
ception of myoclonus in the patient's sister, which occurred when she was
sixteen years old. After a severe attack of grippe, eight weeks ago, the
patient noticed some fibrillary twitching in the rectus abdominis, and in
the course of two or three days he developed a diaphragmatic spasm
(inspiratory grunt). Lightning like fibrillary and fascicular muscle spasm
was now seen in all trunk and proximal muscles of the extremities. Cold,
emotional excitation and depression made the myoclonus worse, and the

704 NEW YORK NEUROLOGICAL SOCIETY

same was true when efforts were made to control it. The muscles es-
pecially involved were the diaphragm, trapezii, the sternocleidomastoid,
the pectorals, the latissimus dorsi, the triceps, the rectus abdominis and
the sartorius. The muscle spasm was asynchronous and asymmetrical on
the two sides of the body, and was outside the control of the will. Oc-
casionally, the muscles about the angle of the mouth and eye participated
in the spasm. The myoclonic movements occurred twenty to thirty times
a minute. There were no hysterical stigmata.

Dr. Pearce Bailey said he had expected to show a case of paramyo-
clonus of the Friedreich type, but the patient was unable to be present. It
was the case of a young man, twenty-one years old, who was thrown out
of a wagon, sustaining a fracture of one collar bone and of three ribs on
the opposite side. As a result of this injury, he developed a traumatic
pneumonia and pericarditis, and about six months later, paramyoclonus
was first observed. The muscular movements were of two kinds : One, a
general fibrillation involving the masseters, the muscles of the upper ex-
tremity, the trunk and thigh; the other variety was a contraction of in-
dividual bundles of muscles. There was also an increased peripheral re-
flex excitability. The movements were entirely inco-ordinate, and the
picture presented was that of typical paramyoclonus, as described by
Friedreich, and apparently the result of the thoracic inflammation which
in turn was the direct result of the injury.

In the case shown to the Society, Dr. Bailey said, the picture presented
was an entirely different one and was presented as a distinct clinical con-
trast. The movements, which had followed an attack of grippe some
weeks ago, were confined to the muscles of the chest and diaphragm, and
from their co-ordinate and distinctly associated character he was in-
clined to look upon the case as one of multiple tic rather than of para-
myoclonus. An interesting feature of this case was that one sister had
been similarly affected.

Dr. F. X. Dercum, in discussing Dr. Clark's case, said he certainly did
not regard it as a typical one of paramyoclonus, and as Dr. Bailey had
suggested, it seemed more closely allied to the multiple tics.

Dr. Wharton Sinkler coincided with Dr. Dercum that the case re-
sembled one of habit spasm or convulsive tic more than one of myoclonus
multiplex.

Dr. Alfred Gordon thought the case represented a mixed form of
muscular twitchings, and that the picture did not agree entirely with
that of paramyoclonus. The patient presented contractions not only of
the myoclonic type, but also of electric chorea of the Bergeron-Henoch
type ; also those of myokymia of Kny-Schultze's type.

TUMOR IN THE ANTERIOR PORTION OF THE BRAIN
STIMULATING GROWTH IN' THE POSTERIOR FOSSA.

By Dr. William Leszynsky.

The patient was a girl, 19 years old; single; a native of Russia, and
a cigarette-roller by occupation, who was admitted to the Lebano»
Hospital on April 16, 1906.

She stated that she had enjoyed good health until about six months
ago, when she fell down stairs, striking her head in the right occipital
region. She remained unconscious about five minutes. Severe frontal
headache soon followed, and persisted, with acute exacerbations, for

NEW YORK NEUROLOGICAL SOCIETY 70s

several months. The headache then extended to both parietal regions,
and there was occasional vomiting. Subsequently, she had severe ver-
tigo lasting three days. Vision then began to fail, and at the end of
two weeks she was blind.

Six months after the injury she was admitted to the hospital in the
following condition. Examination showed a well-nourished, healthy-
looking girl, weighing 130 pounds. The pupils were equal, slightly
dilated, reacting slowly to light and in attempts at convergence; paresis
of the left externus; vision of both eyes equal shadows at eight inches;
bilateral choked disks of four diopters; no retinal hemorrhages. Slight
asymmetry of the muscles of expression, with weakness on the right
side: tongue protruded well, slightly tremulous and coated; speech
normal; slight rigidity of the post-cervical muscles, accompanied by
pain on movement of the head. Pain and tenderness on pressure and
percussion over the temporal and suboccipital regions on both sides.
No enlarged lymphatics. The watch was heard at eighteen inches on
the left side, and at six inches on the right. Tests for smell and taste
proved unreliable. The grasp was equal on both sides, but there was
slight weakness of the flexors and extensors in the left upper extremity;
also uncertainty in volitional movements of both hands in the finger-
to-nose test, but no distinct ataxia nor loss of muscular sense. In either
hand she could recognize a pocket-knife and a half-dollar coin, but
she could not correctly distinguish smaller coins or keys. There was
some uncertainty and unsteadiness in gait, but no titubation. No
static ataxia. In both lower extremities the muscular power and re-
sistance were preserved, but there was occasional extensor rigidity on
the left side when the limb was manipulated. Both knee jerks were
weak and obtained only with re-enforcement. There was spurious
ankle clonus on both sides; plantar reflex was feeble, but of normal
type. No objective sensory disturbances. Thoracic and abdominal or-
gans presented no evidences of disease. Urine normal; blood, hema-
globin, 80 to 90 per cent.; 9,200 white blood cells. There was no his-
tory of syphilis.

The patient soon became totally blind, and during the following
month she frequently complained of frontal headache and sharp, shoot-
ing pains beginning in the sub-occipital region and radiating through
b««th upper extremities to the finger-tips. The knee jerks became more
active, the partial astereognosis had disappeared, and the hearing be-
came normal. Subsequently, there were frequent attacks of intense
occipital headache and vomiting, with cervical rigidity and retraction
of the head, and pain radiating through the arms. Tenderness and
pain on pressure over the suboccipital region persisted; paresis of both
external recti muscles and spontaneous horizontal nystagmus devel-
oped; the jaw jerk was well marked. Both hands and feet were cold
and cyanotic; there was rigidity of the flexors and pronators in both
upper extremities, more pronounced on the right side, with slightly
exaggerated elbow jerks and increased mechanical and faradic irrita-
bility of muscles. Muscular power was unimpaired, and her gait and
station remained normal. Passive movement of the lower extremities
produced extensor and adductor rigidity. Kernig's sign was present
on both sides, and paresis of the right posterior thigh group was ob-
served. The knee jerks were equally exaggerated: right ankle clonus

;o6 NEW YORK NEUROLOGICAL SOCIETY

well marked; spurious clonus and increased Achilles reflex on the left
side, and normal plantar reflex.

In August. 1906, the patient's condition was practically unchanged,
although the symptoms varied in degree from time to time. The optic
neuritis receded, and atrophy developed. The cerebrospinal fluid was
found normal, and the withdrawal of 30 c.c. was followed by intensified
headache lasting several hours. The patient's condition became grad-
ually worse. The diagnosis was made of brain tumor, probably located
in the posterior fossa.

Operation: Bilateral occipital craniectomy was performed, and four
days later the dura was opened and the posterior fossa explored, but
no tumor formation was discovered. Death from exhaustion occurred
on the eighth day, without any indications of infection.

Autopsy: For obvious reasons, the brain was removed through the
surgical opening. A glioma about two centimeters in diameter was
found in the median line in the anterior portion of the brain, origin-
ating in the cerebral substance in front of the anterior horns of the
lateral ventricles, and extending posteriorly to the anterior pillars of
the fornix, destroying the septum pellucidum and pressing upon the
foramen of Munro. It was attached laterally to the caudate nuclei, and
inferiorly just in front of the optic chiasm. The lateral ventricles were
much distended with serous fluid. There was no growth in the posterior
fossa.

In conclusion. Dr. Leszynsky, after discussing the indications and
symptoms which led to the diagnosis of a tumor probably located in the
posterior fossa, with pressure upon or involvement of the upper cervi-
cal nerves, said that in view of the autopsy findings, in all probability
the pains in the arms were due to the forcing downward of the cere-
bellum and medulla into the foramen magnum as a result of prolonged
intracranial pressure, as had recently been described by Collier.

Dr. Charles K. Mills said that some years ago he had a patient
operated on by Dr. Frazier for a tumor which was supposed to be
located in the prefrontal region. No tumor was revealed by the opera-
tion, but after death one was found in the cerebellar pontile angle.
This patient was not seen until a very late stage of the disease, after
terminal conditions had clouded the true diagnosis.

In speaking of the paralysis that occurred in the case reported by
Dr. Leszynsky. Dr. Mills said that the explanation offered for this
condition by Collier was probably the correct one.

Dr. William G. Spider said the statement made by Dr. Leszynsky
that the posterior horns of the lateral ventricles were very much dilated
perhaps offered another explanation for the cerebellar symptoms. With
such dilatation there was pressure upon the cerebellum. Dr. Spiller had
reported a case in which the symptoms of cerebellar tumor had been
caused by dilatation of the posterior horns of the lateral ventricles.

He was much in doubt as to the significance of pain in the upper
limbs in cases of brain tumor. He could recall two such cases. In one
of them, which came to autopsy, the tumor extended down on the cord
several segments. In the other case, the patient was still alive.

Dr. Dercum. in discussing Dr. Leszynsky's case, referred to a case
of supposed cerebral tumor in which operation was performed and

NEW YORK NEUROLOGICAL SOCIETY 707

nothing was found. At the autopsy, a large tumor was found in the
cerebellum.

A CASE OF LANDOUZY-DEJERINE FORM OF MYOPATHY.

By Dr. Charles E. Atwood.

The patient was a boy, five years old, who came under observation
in February, 1907. The family history was as follows: The boy's father,
a salesman, had rheumatism ; one paternal aunt was insane ; the mater-
nal grandmother had asthma. The patient was the second birth; the
first was a miscarriage, and the third a bright and healthy girl. None
of the child's relatives, so far as could be ascertained, suffered from
dystrophy. The birth was reported to have been a shoulder presenta-
tion. In infancy, he was unable to suckle properly from the beginning,
although he had swallowing movements, and nourishment was supplied
to him from a bottle in the nipple of which a large hole was cut so
that the milk could flow more readily. He had had whooping cough,
chicken-pox, summer complaint and tonsillitis; he also had adenoids
and was tongue-tied, and operations were performed on the tongue
and to remove the tonsils and adenoids.

Dr. Atwood said the nature of the child's disease gave it an appear-
ance of mental deficiency, which was, however, probably apparent only.
He was very timid, and it had been rather difficult to examine him.
There seemed to be no disturbance of the special senses or of general
sensibility, excepting that hearing was somewhat diminished. All the
cranial nerves were intact. The muscles of the eyeball were somewhat
affected (exophoria, etc.), but not those of mastication or deglutition,
nor the laryngeal muscles. The boy began to walk at the age of four-
teen months and made the ordinary movements of all the limbs, but
the mother had never noticed any movements of the facial muscles
excepting lately. There was very little involvement of the tongue. He
could make the associated lip movements sufficient to permit "trough-
ing'' of the tongue. There was no fibrillation to be found anywhere;
also no pain; no vasomotor disturbance; no skin or bone trophic dis-
order; the sphincters were normal. The mechanical irritability in the
affected muscles was less than normal, and their faradic and galvanic
excitability, as far as they could be tested, seemed to be diminished,
but there appeared to be no R.D. The knee jerks were absent.

The chief facial muscles effected were the zygomatics, as shown
by the loss of the labiofacial fold; the risorii, levator menti arid orbi-
cularis oris, the patient being unable to whistle, to change expression,
as in crying, or to articulate clearly labials and Unguals; the buccin-
ators were unable to draw back the corners of the mouth in smiling;
the orbicularis palpebrarum closed the eyes incompletely, and the cor-
rugator supercilii and the occipito-frontalis were inactive. There was
no movement to puff out the cheeks, but there was some ability to
compress them. The appearance of the face was somewhat analogous
to that observed in myasthenia, but the muscles in which there was
some activity did not become quickly exhausted. Wasting in the facial
muscles was not at present demonstrable. The supra and infraspinati
on each side were noticeably atrophied, and there appeared to be a
slight weakness of the right sterno-cleido-mastoid and omohvoid, and

70S NEW YORK NEUROLOGICAL SOCIETY

of most of the shoulder girdle muscles. The left anterior tibial and
peroneal muscle groups were slightly atrophied. The left foot was in a
moderate degree of varus.

The case was of interest on account of the early development of
the symptoms, as shown by the lack of facial expression and inability
to suckle, apparently starting as a primary congenital defect.

Dr. E. W. Scripture, who had examined Dr. Atwood's case, de-
scribed in detail the delects of articulation, which were confined chiefly
to the labials and Unguals.

Dr. Spiller said he had seen several cases of myopathy of the Lan-
douzy-Dejerine type in Paris, but he had never met with a very pro-
nounced case in this country, or in Germany, or Austria. Where the
paralysis is intense, the condition of the face resembles that of double
facial palsy, although the differential diagnosis is not difficult to make.

Dr. Gordon in discussing Dr. Atwood's case, said that it did not
impress him as being a muscular affection of Landouzy-Dejerine type.
The patient also presents some features of the pseudo-hypertrophic
variety of myopathy, as can be seen from his gait and his manner of
rising from the floor. Moreover, in the facio-scapulo-humeral type the
upper part of the face is usually not involved at all, at least to the
extent seen in the patient. It appears to be a case of general myopathy
with predominance of muscular atrophy in certain portions of the body.

Dr. John K. Mitchell criticised Dr. Gordon's statement that the
patient rose from a recumbent posture in a typical manner, and said
that he did not "climb up his thighs," but simply touched one hand to
one thigh tor a moment, after he was nearly erect.

Dr. Mitchell did not think the patient walked in an unusual manner,
but only like a person not accustomed to going barefoot.

Dr. J. F. Terriberry, in discussing Dr. Atwood's case of Landouzy-
Dejerine myopathy, said the case resembled in some respects a case
of congenital myopathy which he had had under observation for some
time, and a photograph of which he exhibited. It illustrated the three
so-called types of Landouzy-Dejerine, Erb, and the leg or Leyden-
Mobius type, and in addition there was weakness of the lower arm
muscles and the internal rectus of the left and possibly of the right
eye.

The child was born of Austrian parents who were healthy, was of
good habits and free from hereditary and other shortcomings. The
mother had had three pregnancies and had three living children. The
patient was the youngest, the other two being healthy. The child's
gestation and birth were normal. It was three years old, and had had
no illness other than the present one. The mother stated that the child
was very feeble and helpless at birth; it moved its extremities very
little, and could not raise its head; its cry was feeble. It was breast-
fed. As it grew, it gradually became stronger, and was now able to
stand for a short time, but it could not walk nor raise its arms above
its head.

Examination showed that the muscles of the shoulder girdle were
markedly atrophied, while those of the lower leg were symmetrically
hypertrophied; the forearm and thigh muscles seemed enlarged; the
face was flattened; the angles of the mouth were raised but little when
the child cried: the mouth was open and the lower lip everted. There
was external deviation of the left and possibly of the right eye; the

NEW YORK NEUROLOGICAL SOCIETY 709

pupils were normal. The knee and ankle jerks were absent. The elec-
trical reactions were reduced, with some qualitative change, particularly
in the hypertrophied muscles. There seemed to be no trouble of the
special senses, and the child's mentality was apparently normal.

Dr. Terriberry said that these cases probably belong to the cate-
gory of hereditary muscle disease or weakness which usually did not
appear for some time after birth, the profundity of the hereditary
shortcoming probably causing the early appearance of the myopathy,
this early appearance being undoubtedly exceedingly rare.

A CASE OF HERPETIC INFLAMMATION OF THE GENICU-
LATE GANGLION. WITH FACIAL PALSY AND
ACOUSTIC SYMPTOMS.

By Dr. J. Ramsay Hunt.

The speaker said that at a meeting of the American Neurological
Association held in Boston, June 4, 1906, he presented a new syndrome
dependent upon a herpetic inflammation of the geniculate ganglion of
the facial nerve. (Posterior poliomyelitis of Head and Campbell.)

The immediate proximity of this ganglion to the facial and the
auditory nerves in the depths of the internal auditory canal, and their
common sheath, would explain the frequency of facial and auditory
symptoms in this group of cases, the inflammatory process extending
to the facial and in some instances to the auditory and its terminations.

The syndrome resolved itself into three clinical groups: 1. Herpes
auricularis. 2. Herpes auricularis and facial palsy. 3. Herpes auricu-
laris, facial palsy and auditory symptoms.

The zoster zone for the geniculate was situated in the interior of the
auricle (concha, external auditory canal and the tympanum). The gen-
iculate zone was therefore intercalated between the Gasserian zone in
front and that of the second and third cervical ganglia behind.

The following case was a typical one of this affection: The patient
was a man, 30 years old, an upholsterer. On Saturday evening, February
16, 1907, he was seized with sharp, shooting pains in and behind the
left ear. On Sunday the pains were more severe; on Monday and Tues-
day the pains were very severe, and so intense at night as to prevent
sleep. They were tearing and shooting in character, chiefly in the ex-
ternal auditory canal, but also in the occipital, temporal, and facial
distributions. The throat and ear were examined on Tuesday, with
negative results. About this time the auricle became somewhat swollen
and reddened, and looked as if frost-bitten. It was tender, and he was
unable to sleep on that side. He kept the whole left side of the face
protected by a dressing, as any draught brought on an attack of pain.
On the 19th of February the face was noticed to be paralyzed on the
left side, and about the same time his wife noticed a few groups of
white vesicles in the interior of the auricle. He had no tinnitus aurium,
no vomiting or disturbance of equilibrium, and the diminution of hear-
ing was not observed by the patient until special tests were carried out.

Status Prsesens: On February 27, 1907, there was complete palsy
of the 7th nerve, in all its branches, with sagging and drooping of the
parts, and the patient was unable to close the left eyelid. For a few
days after the onset he had an overflow of the tears (epiphoria), but

7io NEW YORK NEUROLOGICAL SOCIETY

this had not been present during the past week. Taste was lost over
the anterior two-thirds of the tongue on the left side.

Sensation: All sensations were preserved over the left side of the
face, the left ear and in the region of the occiput and neck. On com-
paring the sensations on the two sides, a slight diminution was demon-
strable on the left side of the entire cephalic extremity, face, head and
neck, including the mucous membranes, sharply demarcated in the
middle line. The corneal and conjunctival reflexes were present, but
diminished on the left. The aural reflex was diminished on the left.
There was no tenderness over the points of exit of the trigeminal or
occipital nerves.

Herpetic symptoms: The vesicles had coalesced and formed two
plaques, each situated on a reddened base and exuding serum. The
smaller of these plaques was situated on the inferior border of the
external auditory meatus at its entrance; the other was concealed be-
neath the fold of the anthelix in its superior portion. The canal and the
tympanum were free. The orifice of the canal was still slightly swollen,
and smaller than the right No evidence of herpes was noted else-
where about the face or neck. The aural examination was made by Dr.
McAuliffe. In the left ear, the hearing was diminished one-half, as
compared with the right side. The partial deafness was of the central
type (nerve deafness). No tinnitus; drum membrane normal. The tear
sensation tested on March 8, 1907 (oil of mustard) was normal, and
equal on the two sides. The examination of the other cranial nerves,
and the neurological examination in general, namely, reflexes, motility,
sensation, etc., were negative, as were the internal organs, urine and
blood.

Electrical examination. March 7, 1907: The indirect reactions of the
left facial showed a slight quantitative increase to both currents. Di-
rectly applied, the responses were somewhat diminished. No qualitative
changes.

Notes on the course of the disease: On March 15, 1907, the pains
had gradually diminished in intensity and had practically disappeared.
The most troublesome were those shooting into the external auditory
canal. The 7th palsy improved very rapidly and by March 15th only
a trace of it remained. (This was one month from the time of onset.)
The sense of taste was completely restored. The hearing on March 8
showed only a diminution of one-quarter as compared with the normal
right side, and on the 15th, hearing was equal on the two sides. Two
small depressed scars marked the seat of the herpetic manifestations.

Remarks: Dr. Hunt said this group of cases was characterized by
the severity and intense neuralgic character of the pains. (Pre-herpetic
and post-herpetic neuralgia.) Also by the occurrence of the herpes
zoster. While the pain in rheumatic facial palsy might endure for a
fortnight or more, it never reached the same degree of intensity as in
these cases. In many cases the zone was in the trifacial or in the occi-
pito-cervical distribution, and not in the geniculate area.

Dr. Dercum said Dr. Hunt had so clearly analyzed these cases, and
had placed the matter in so definite and unmistakable a light, that he
thought there was very little to be said on the subject. Dr. Hunt had
certainly established a new medical group, and one that was most
suggestive.

NEW YORK NEUROLOGICAL SOCIETY 711

Dr. Sinkler said the nearest approach he had ever seen to the con-
dition described by Dr. Hunt was a case of facial palsy slightly preceded
by a herpetic eruption, or rather a discrete eruption of a vesicular char-
acter on the scalp and about the auricle, and with pain in the auricle.

Dr. Gordon expressed his admiration for Dr. Hunt's new syndrome,
which he thought might properly be termed "Hunt's disease."

DEMONSTRATION OF GLASS MODELS OF BRAIN LESIONS.

By Dr. Adolf Meyer.

The speaker said that one of the chief aims of a central plant, such
as the Pathological Institute of the New York State Hospitals, must
be to conduct research work in such a manner as to make it a help and
a stimulous to the hospital physicians in their actual work, as much as
an achievement in the field of disputed points, or satisfaction along the
lines of more personal problems; every problem of investigation was,
of course, something like an individual query, but the results would not
answer their purpose unless we got them into such form that they pass
readily into the fund of practical resources which our hospital phy-
sicians need in order to outgrow the routine in which they might too
readily lose the best opportunities. This was by no means an easy task
in that one of its fields of work which he wished to demonstrate briefly
to-night. Brain anatomy has at best a verbal interest with most phy-
sicians. It becomes, therefore, especially necessary to devise means of
presentation which will make the facts easy of grasp and telling, and an
improvement on the ponderous volumes out of which we ourselves had
to dig our knowledge of the work of the past.

The glass-models represented an idea which had occurred to many
(they are, for instance, used by geologists), but which had not to his
knowledge been used in brain anatomy as systematically before. In
purely morphological work, with its interest in surfaces, the wax-plates
have their special field; but to topographical work with its many inter-
lacing fiber tracts, the glass-model method is, so far unrivaled.

The color schemes used were more or less accidental, and determined
by what Higgins' inks offered. The choice happened to coincide to quite
an extent with Barker's, and with the recent work of Johnston. It was
indeed attempted to come to an agreement, and to propose a scheme of
colors to facilitate a certain uniformity in the presentation for students.

In the study of the brain-stem of a case of traumatic destruction of
one-half of the pons, the segmental efferent or motor nerves are to be
found in brick-red; the pyramids in carmine; the segmental afferent or
sensory nerves in blue tinges (Higgins' true blue for V, cochlear, IX,
X; indigo for the vestibular); the cerebral afferent paths, green for the
mesial fillet (destroyed on one side), and violet for the trapezium and
lateral fillet. The cerebellar systems appear in yellow, orange and
browns ; the central tegmental bundle of vermilion, etc.

In the forebrain a kindred color-scheme was used, as was shown in
the two cases of reconstruction of occipital lobes, in which the geniculo-
calcarine tract appears in blue, the geniculo-temporal in violet; the
occipito-temporal afferent paths in vermilion, the callosum in violet, the
lenticular complex in indigo, etc.

The original drawings were, of course, hard work; but together with

-12 NEW YORK NEUROLOGICAL SOCIETY

the series of sections and the models, they were infinitely better than
long-winded descriptions for which physicians generally had neither
time nor patience. The drawings were open to entries and corrections
and the best field of registration of observations. There was, of course,
no loop-hole for the haziness with which so many errors pass under
the cover of words. One's interpretations show here their natural and
indelible color.

Dr. Meyer wished to express his sincere thanks for the increasing
care and accuracy with which his colleagues in the State Hospitals
furnish both the brain material and the records, and trusted that the
return which the Institute was able to give would be a still further
stimulus; he also hoped that one or the other of the neurologists present
might take an interest in these methods of brain-study and enter into
co-operation with the Institute. Well defined, small enough lesions in
the Marchi period, i.e., from 3-6 weeks after the onset, were so rare, and
the result of their study so dependent on well organized technique, that
the material should pass into skilled hands as often and as rapidly as
possible, especially since a delay of more than two weeks makes a Marchi
reaction with formalin specimens questionable.

DEMONSTRATION OF A NEW METHOD OF BRAIN RECON-
STRUCTION.

By Dr. B. Onuf.

The method made it possible to reconstruct fiber tracts and study
them in their relation to the surface or other parts of the brain. Par-
ticular advantages were offered for studying the Island of Reil, which
could be fully demonstrated in its relation to the surface "of the brain.
It was possible, furthermore, by means of this method, to reconstruct
from a series of brain sections of a given direction, say sagittal, for in-
stance, sections in other planes, such as horizontal and vertical ones.
Thus from one and the same brain, horizontal, vertical and sagittal
sections from any desired level could be obtained. The results of the
method could be utilized for publication when desired, which was a dis-
tinct advantage of the procedure.

Dr. Alfred Reginald Allen said the beauty and value of Dr. Meyer's
work was apparent. The only suggestion he had to make was that if a
whiter quality of glass were used, a glass which would not possess quite
so much the property of a light filter, these wonderfully instructive
preparations could be made the subject of stereoscopic photography,
and in that way used as illustrations.

SOME CLINICAL OBSERVATIONS ON THE TREATMENT OF

GRAVES' DISEASE.

By Dr. J. Arthur Booth.

The author offered the following conclusions:

1. Although Graves's disease is recognized by the prominence of
four symptoms, namely, tachycardia, exophthalmos, goitre and tremor,
this symptom-complex may be incomplete in the developmental stage
of the disease, and here the other symptoms are sufficient for the diag-
nosis.

NEW YORK NEUROLOGICAL SOCIETY 713

2. At the time of the first examination, the degree of thyroid intoxi-
cation should be noted, and the patient then placed, if possible, under
one of the three clinical groups.

3. The prognosis depends upon heredity, the social position of the
individual, the type of the disease and its early recognition. All these
conditions being favorable, with good care and perseverance, there is
a fair chance of recovery in those patients classed in the first group.
The more advanced cases stand a better chance of recovery by opera-
tion, but this must not be delayed too long, lest organic changes have
already set in.

4. Recent clinical and experimental data still further emphasizes
the general belief that over-activity of the thyroid gland is quite suffic-
ient to explain the appearance of the symptoms of Graves' disease, and
their disappearance after operation.

5. Thyroidectomy should be the operation of choice, as giving the
best results.

6. The cause of death following operation is shock and the use of
a general anesthetic; therefore, this should be placed in only expert
hands, and local anesthesia should be employed when possible.

7. The introduction of cytotoxic serum marks an important advance
in the treatment of the disease, and perhaps may ultimately prove to
be the only rational therapeutic method.

Dr. Gordon said he was astonished to hear the speaker reporting
such brilliant results from thyroid treatment. He had treated quite a
number of cases of exophthalmic goitre with thyroid extract, and
while the patients improved for a time, the final result was disappoint-
ing. As to the question of the pathogenesis of the disease, he wished
to mention that about two years ago, he had shown at a meeting of
the Philadelphia Neurological Society a woman who, while apparently
in perfect health, developed ptosis, which was soon followed by an in-
ternal strabismus; three or four days later she noticed a bulging of
the eyes, tachycardia and enlargement of the thyroid gland. He had
in mind also another in which a goitre was associated with paralysis '
agitans. The literature contains abundant examples of Graves' disease
developed in the course of organic nervous affections.

Dr. Gordon said he regarded it as a mistake to hold the thyroid
gland responsible for all the symptoms of Graves' disease. As a matter
of fact, he looked upon the changes and degeneration in the thyroid
as secondary, and that the primary focus of the disease was in the me-
dulla. Dr. Booth, in his paper, made no reference to the work of
Jonnesco and others, who operated on a number of these cases, remov-
ing the cervical sympathetic ganglia and the latter was followed by
total disappearance of Graves' syndrome. The nervous origin of the
disease is therefore also evident from the therapeutic results.

Dr. Sinkler said he had had practically no experience with the
operative or serum treatment of exophthalmic goitre. He could recall
a number of cases in which recovery took place under absolutely no
form of therapeutics. It was a fact that a much larger percentage of
those patients recovered than was generally supposed.

Dr. Allen said that apropos of the last picture shown on the screen
by Dr. Booth he wished to call attention to the fact that three years
ago, when he was sent to investigate the Goitre Colony in Indiana

;i4 XEIV YORK NEUROLOGICAL SOCIETY

County, Perm., out of seventy odd cases of goitre that he had exam-
ined, he had found only one among them that showed any of the usual
symptoms of Graves' disease.

Dr. Booth, in closing, said the changes in the medulla to which Dr.
Gordon had referred, were doublless secondary, as are also similar
changes found in other tissues of the body. Besides, no such changes
are found in the earlier stages of the disease, while on the other hand
there has been no death recorded without involvement of the thyroid
gland.

The speaker said he had used the anti-thyroid serum in seven cases.
One of these was cured, two were improved, and in the others no
results had been noticed.

TOBACCO AS A CAUSE OF NERVOUS DISEASE— EXPERI-
MENTAL OBSERVATIONS.
By Dr. L. Pierce Clark,
i. It is fairly proven that tobacco is primarily a cardio-vascular
poison.

2. Its acute toxic effects on the neuro-muscular apparatus are first
as an excitant and mild convulsant; second, as a motor nerve depress-
ant; and, finally, a paralyzant of the central and peripheral nerves of
the heart and lungs.

3. Its chronic toxic effect on the nervous system (as yet so inac-
curately studied), is to induce toxic congestion of the brain, spinal
cord and peripheral nerves, inducing finally, in the latter, a mild type
•of degenerative neuritis.

4. The toxic coefficient, even in animals, under strict test, is so very
variable as to vitiate many of the attempts to derive any definite con-
clusions of its' effects on the nervous system in man.

[' CLINICAL OBSERVATIONS.

1 By Dr. B. Sachs.

In discussing this phase of the influence of tobacco on the nervous
system, the speaker said the chief points which he hoped to establish
were that tobacco did exert a most pernicious influence on the heart
and the circulatory organs, and that it was a very important factor in
the production of functional nervous disease, but that it did not play
any sort of role in the causation of organic diseases of the nervous
system, and that many of the disturbances of the nervous system were
due, not to the direct influence of the tobacco upon it, but that the
changes and morbid conditions were brought about indirectly through
the effect that tobacco had upon the various parts of the circulatory
system. Even the question as to which was the toxic element produc-
ing the harm done by smoking was not easily settled. Most of us would
off-hand claim that it was due to nicotine, the alkaloid contained in
the tobacco leaf, but Nessler had shown that Syrian tobacco, which
was said to have a strong toxic effect, contained no nicotine whatever.
Havana tobacco, the tobacco imported from Porto Rico, contained
only 1.6 to 1.2 per cent, of nicotine, whereas some of the German to-
bacco, which was supposed to be as mild as any, contained 3.36 per
cent.

In the causation of purely functional derangement, the excessive

XE1F YORK NEUROLOGICAL SOCIETY

/ o

use of tobacco was unquestionably an important factor. In neuras-
thenia and hypochondriasis its influence was a powerful one, although
Dr. Sachs said he believed that even here the deleterious effect of to-
bacco was brought about in an indirect way. He had not, in his experi-
ence, seen a single case of chronic psychosis which he could conscien-
tiously attribute to tobacco and tobacco only. If we allowed that
neurasthenia, with its accompanying symptoms of insomnia, tachycardia,
gastro-intestinal disturbance and occasional fainting spells may be
put down as being due to the excessive use of tobacco, we have brought
the heaviest charge against the pernicious use of the weed. In closing,
Dr. Sachs referred to the statement that had been made that the ex-
cessive smoker not infrequently became impotent.

Dr. Dercum said that almost invariably those who used tobacco
were also addicted to the use of alcohol, and he did not think it was
possible to differentiate the symptoms due to the use of one from
those due to the use of the other. For example, vasomotor changes,
which unquestionably resulted from the use of tobacco, also resulted
from the use of alcohol. The same was true of amblyopia.

Personally, Dr. Dercum said he did not believe that tobacco did
very much harm in the way it was used by a large majority of people;
the harm arose when it was used to excess.

Dr. J. K. Mitchell said that he had had occasion to observe a great
many employees in snuff factories — persons who lived in a perfect
atmosphere of tobacco, much more so than in cigar factories, where
there is more or less dampness, and among that class of workmen he
never saw any nervous disorders or any form of neuritis that he could
fairly attribute to tobacco poisoning.

In regard to the anaphrodisiac properties of tobacco, to which Dr.
Sachs had referred. Dr. Mitchell said that there is at least an estab-
lished belief that it is to that end sailors affect it during their absence
from port.

Dr. Spiller said he had seen a number of cases of neurasthenia in
young women who were employed in tobacco factories, but he had
never been able to prove that they were tobacco smokers. They were,
however, in the habit of biting off the ends of the tobacco, and moist-
ening the ends of the leaf with their lips, and occasionally they swal-
lowed pieces of tobacco.

Dr. W. W. Hawke referred to the occurrence of convulsive tic affect-
ing usually the upper face among tobacco smokers. He also mentioned
the observation of Professor Millet, of the University of Virginia, that
cigarette smoking was harmless unless the smoke was inhaled.

Dr. G. E. Price said that in case of nervous disorders which were
commonly attributed to the use of tobacco, the possibility of a neurotic
predisposition or heredity should not be lost sight of.

Dr. Gordon said that tobacco, in its effect, apparently had a special
predilection for the acoustic nerve, as was seen from the researches
of Delie (Congres Intern. d'Otologie, 1904). Its influence on the sexual
function had long been known, and a number of such cases were
reported by Segrais, (Arch. gen. de Med., 1902). Experimental re-
searches have demonstrated this depressant action of tobacco on the
generative organs: atrophy and sclerosis of the testicles and ovaries
were observed in chronic intoxication.

716 PHILADELPHIA NEUROLOGICAL SOCIETY

Dr. Gordon also referred to the experiments of Ballet and Faure
in 1899, who had shown that subcutaneous injections of maceration of
tobacco produced epileptiform convulsions, and the speaker said he
could recall a case of epilepsy in his own practice where convulsions
would follow the use of tobacco. The patient was an inveterate smoker.
He was forbidden to chew or smoke: every time he would resume
his old habit, the convulsive attacks would increase in frequency and
intensity. Renon, in 1905, reported an important case of intermittent
claudication, at the autopsy of which was found a thrombosis of the
abdominal aorta. The patient was neither alcoholic nor syphilitic, but
used tobacco very excessively. The reporter compares tobacco to
adrenalin, which is a vaso-constrictor, and both produce arterial hy-
pertension. In arthritic individuals, who usually smoked excessively,
ii is not impossible that tobacco plays a role in the production of their
arterial sclerosis. Erb observed this influence of tobacco in 38 cases
out of 45 of intermittent claudication.

The President, Dr. Dana, referred to the deleterious effects of the
inhalation habit among boys who had become addicted to the use of
cigarettes.

PHILADELPHIA NEUROLOGICAL SOCIETY.

March 26, 1907.

The President. Dr. Alfred Gordon, in the Chair.

A CASE OF ABSCESS OF THE BRAIN OF TUBERCULAR

ORIGIN IN A BABOON.
By Dr. J. H. W. Rhein and Dr. Herbert Fox.

The following is a preliminary report upon a case of tuberculous
abscess of the brain in a baboon, whose symptoms were studied three
days before death. A future report will be made which will be in the
nature of a comparative anatomical study. The brain, in large part,
has been cut in serial sections, and, as the study of these sections is
not quite complete, only a brief reference to the pathological anatomy
will be made. The baboon appeared to be perfectly well until October
18, 1906, when some lameness in the upper and lower extremities on th«
right side was observed. This gradually increased, and was associated
with twitching of the muscles of the left side. On November 30,
1906, Dr. Rhein examined him, and found the following con-
dition. The right upper and lower extremities were weaker than
those on the left side. The power in the left upper and lower extremi-
ties seemed to be fair. He was able to hold on to an iron bar with the
fingers of the upper and lower extremities on the right side, but in
withdrawing the bar it was not difficult to overcome his grasp, and the
power on this side was distinctly less than that on the left. The move-
ments of the right arm were somewhat ataxic, as observed when he
made efforts to grasp the iron bar with which the examination was
made. The knee jerks were increased on both sides, and appeared to
be equally so. There was no evidence of facial palsy. He moved both
sides of the face equally well at those times at which he expressed anger

PHILADELPHIA NEUROLOGICAL SOCIETY 717

or fear in the facial expression. The tongue seemed to be retracted
equally well on both sides. Tests for hemianopsia were, of course,
unsatisfactory, but he seemed to recognize readily the approach of the
iron bar from both sides. There was no disturbance of the rectal or
bladder functions, although at the autopsy the bladder was full. At
the autopsy the brain and spinal cord, with the other organs, were
examined. The dura was adherent to the left side of the brain, in the
prefontal region, in the upper third, and when the brain was removed
it was observed that an area of softening lay beneath this point. A
small caseous mass was also observed at the base of the right lung,
and beneath the diaphragm on the right side was a large abscess, partly
involving the liver. The tubercle bacillus was found in the pus removed
from the area of softening beneath the left cortex. A study of the
brain revealed the presence of three foci of softening. The largest one
was situated in the left hemisphere in the prefontal region, and ex-
tended from just beneath the cortex in the upper third of the prefontal
region, downward almost to the base of the brain. This area was cyl-
indrical in shape, and measured 2.5 centimeters in its greatest diameter.
The area of softening consisted of caseated material and pus, in which
the tubercle bacillus was found present. A second area of softening
was found on the right side of the brain, much smaller in extent, and
measuring about 1.5 centimeters in diameter. There was no pus present
in this area, but it consisted of a circumscribed mass of caseous ma-
terial. The apex of this area of softening was just beneath the cortex
in the prefrontal region. On the right side, and in the removal of the
brain the cortex was torn just above this area of caseation. This point
was .5 of a centimeter in front of the central fissure, and about 1 centi-
meter below the superior surface of the brain.

A third area of softening was observed posteriorly in the white
substance, in the parieto-occipital region, and meamred about 6 milli-
meters in diameter. A study of the sections of the brain shows beauti-
fully the extent of the destruction of the brain tissue. The optic
thalamus, the lenticular nucleus, and the posterior limb of the internal
capsule on the left side, are destroyed in part. The anterior limb of the
internal capsule, in one section, is preserved, notwithstanding the fact
that the optic thalamus on the same side has been, in large part,
destroyed. And in spite of the fact that the posterior limb of the in-
ternal capsule has been destroyed at some levels, it is interesting to
note that the degeneration in the pyramidal tract of the pons and me-
dulla, and the crossed pyramidal tract of the spinal cord on the opposite
side is not intense — although distinct. It is also very interest-
ing to note that, in view of the severe insult to the posterior
limb of the internal capsule on the left side, there was no more paraly-
sis, for it will be remembered that there was considerable power of
prehension in the right upper and lower extremities. The smallness
of the frontal lobes, and the unusual development of the temporal lobes,
should be noted. In looking at the illustration it will be observed that
the development of the cerebral convolutions is much better than in the
usual picture of the brain of the circopithecida?. and the accompany-
ing drawing of the ordinary brain of the circopithecid?e will serve to
confirm this observation. Dr. Rhein was not prepared to discuss the
question of tuberculous abscesses of the brain, either in the baboon or

718 PHILADELPHIA NEUROLOGICAL SOCIETY

in man. It is well known that tuberculous infiltrations occur in the
brain substance, which may undergo cheesy degeneration. Although
he had not had an opportunity, thus far, of studying the literature of the
subject, his impression was that tuberculous abscesses of the brain
substance itself are comparatively rare in men.

Dr. Herbert Fox said:

In addition, sections made through the brain tissue in the neighbor-
hood of the large abscesses, showed small foci of lcucocytic and epi-
thelioid infiltration, in which areas the tubercle bacillus could be
demonstrated by stain. The same sections, stained by Gram Weigert
method, showed the presence of some bodies at the margins of these
small collections, but those could not be identified positively as con-
taining bacteria. This brain came from an adult in the Zoological
Gardens, on October 14, 1905. which was kept in the laboratory until
March 31, 1006, having been injected twice during that interval with
tuberculin, and the last injection which was given on the 10th of March,
1906, was followed by a typical reaction of a healthy monkey. In the
Monkey House it was perfectly well until October 18. 1906. when it
began to show lameness in the upper and lower extremities on the right
side. The animal was returned to the laboratory on November 23rd,
and while there showed progressive lameness, with progressive twitch-
ings of the right side, but no convulsive seizures. It died on Dec. 2, 1006.

Dr. D. J. McCarthy thought that tuberculous abscess of the brain
of lower animals was a decided rarity. Tuberculosis of the brain,
however, apart from tuberculous abscess is not a very exceptional
condition. In a good deal of the experimental work that has been done
on the lower animals, especially cows and heifers, tuberculous menin-
gitis has not infrequently been met with as a complication. The type
of tuberculosis in the lower animals is not as it is in the human being
which undergoes liquefaction necrosis; and as a result of the tendency
to break down in the human being an abscess of the brain of tubercu-
lous origin is not a very infrequent condition. The tendency is for the
development of a distinct granulomatous process or a fibrinous process,
the latter much less frequent. In the lower animals there is a general
tendency toward a condition of fibrosis. In the monkey there is more
frequency of the disease in the spleen and liver than in the brain. Dr.
McCarthy came across a tuberculous tumor in a heifer which developed
spontaneously, in which the general structure of the tumor at the first
glance and in the microscopic section was one which could easily be
mistaken for endothelioma. Here again the tendency was for final
organization rather than breaking down. Microscopic sections, and sec-
tions stained for presence of tubercle bacillus made the diagnosis in
that particular case. Another very interesting case of tuberculosis which
has a distinct bearing upon certain types of tuberculous meningitis,
was a case Dr. McCarthy studied a few months ago. the brain of a
cow which had received inoculations of tubercle bacillus with the idea
of developing antituberculous serum. While under observation she
calved, or rather miscarried, and following was septic infection of the.
uterus and she died of tuberculous meningitis of the septic plastic type
seen in the human being. There was infection not only with the tub-
ercle bacillus, but with the staphylococcus and streptococcus. Dr. Mc-
Carthy has noticed that in tuberculous proliferation types in the human,

PHILADELPHIA NEUROLOGICAL SOCIETY 719

being in the same case where there is miliary tuberculosis but mixed
septic plastic type, in those cases they complicate the abscess type of
advanced pulmonary tuberculosis and that this condition is due to a
mixed infection. He considers this case of Dr. Rhein's so far as the
rarity is concerned, not only in the monkey but the lower animals in
general, notable.

FAT CRYSTALS IN THE SPINAL CORD.
By Dr. Alfred Reginald Allen.

The spinal cord in question was removed from a young man who
had suffered a crushing injury of the spinal column in the neighbor-
hood of the ninth thoracic vertebra. There was evidently an incom-
plete solution of continuity at the point of injury and the patient lived
over a year during which time laminectomy was performed with very
poor result. The osmic acid preparations of sections above the injury
show numerous crystals stained intensely black. The form is either
aciciAar or irregular plates suggesting a parallelogram in shape. There
was not found the feathery variety reported by McCarthy ("Contribu-
tions from Win. Pepper Laboratory of Clinical Medicine." Vol. 6,
1003).

Dr. McCarthy said that as far as these crystals are concerned, they
are apparently of the same type of crystals, excepting a little bit larger
than those in the case he described. Like Dr. Allen's case the crystals
were found only in the posterior columns and the degeneration was
secondary to a tuberculous caseating tumor of the lower dorsal region
(as far as he can remember). The degeneration of the posterior col-
umns was distinctly yellow in color, or rather uniquely yellow, as far as
any gross color changes he has seen in the nervous system: one might
have surmised some fatty change by the reaction. There were a large
number of acicular crystals superimposed upon them in more or less ro-
sette shapes, giving the feathery appearance. That was due to the fact
that the sections were not cut very thin, as in Dr. Allen's case, and Dr.
McCarthy thought that would account for the difference in form. The
only reference he could find was in F.ichhorst. in which it was stated
that in the neighborhood of certain areas of focal softening in the nerv-
ous system Eichhorst occasionally saw these fat crystals and concluded
that they were a combination of fatty acids and magnesium. With the
two types the causes were different. Dr. McCarthy's case was a slowly
forming degeneration due to a slowly growing tuberculous tumor of
the dorsal cord, whereas Dr. Allen's was a rapidly developing case.
There must be chemical factors which determine the formation of these
fatty crystals. The disappearance of the fat crystals in Dr. Allen's case
was probably due to a different chemical combination.

Dr. W. G. Spiller said he had seen Dr. McCarthy's specimens and
Dr. Allen's. He thinks it is very singular that these fat crystals should
be so rare. He has never found them, though he has been on the look-
out for them, and has examined a great many specimens of the spinal
cord. The fact that they disappear so readily is suggestive of arte-
facts, and there may be something unknown at present which produces
this crystallization after death.

Dr. McCarthy said he agreed with Dr. Spiller that the crystals
probably were not present before death. Both of these specimens were
hardened in Midler's solution.

720 PHILADELPHIA NEUROLOGICAL SOCIETY

STUDIES ON THE CHOROID PLEXUS.
By Dr. Henry H. Donaldson.

The studies reported were made l>y Dr. Meek at the University of
Chicago, under the immediate direction of Dr. Hatai. The choroid
plexus of the lateral ventricles was examined, and attention directed
especially to the epithelium covering the vascular leaf, which constitutes
the plexus. This epithelium is continuous with the ependyma. The
impulse to the present investigation was given by the incidental obser-
vation that in the albino rat before birth, the nuclei of the epithelial
cells were located near the apex, whereas in the mature plexus, they
were found at the middle or towards the base of the cells. It was
determined that this shift in position occurred between the second and
seventh clay after birth. The general morphology of the choroid plexus
varies in the animal scale. 1 he plexus is always much folded, but in
some forms is also studded with villous like projections. During growth,
there is comparatively little change in the size *of the already formed
cells, although they generally spread so that each cell at maturity
covers about twice the surface which it covers at birth. In the rabbit,
large globules of fat are often present in these cells. This fat is ex-
truded from the cell, but the process does not appear to destroy the cell
itself. Mr. Meek has corroborated the observations of other investigat-
ors, which show that drugs which stimulate secretion, modify the shape
and structure of the choroid cells. It is inferred from this, as well as
from direct observation on the How of the cerebro-spinal fluid under
the action of drugs, that these cells contribute to the formation of the
cerebro-spinal fluid.

Dr. F. X. Dercum asked whether the other ependyma] cells have
been studied in a similar way.

Dr. Spiller stated that Mr. Hutchison, a fourth year student at the
University of Pennsylvania, had made a very interesting study of a case
of syringomyelia with hydrocephalus, and in the choroid plexus found
vacuoles in the cells like those Dr. Donaldson described as occurring
in the rabbit. Within the past week Dr. Spiller had an opportunity
to study a very curious tumor. It had the structure of the choroid
plexus, and was probably an epithelial growth.

Dr. McCarthy stated that two years ago he reported a very exten-
sive tumor of the choroid plexus of a horse. He has sections from
nearly two hundred choroid plexuses and has noticed these changes
looking like vaculoes in the cells of the choroid plexus, and changes in
the shape of choroid plexuses.

Dr. McCarthy thought Dr. Donaldson's study a very interesting
and valuable one He has worked with specimens from persons dying
of hydrocephalus, or tuberculosis of the choroid plexus, of which he
has reported eight or ten cases already. In his own work he has taken
not only the plexus of the lateral ventricles but also the plexus of the
fourth ventricle. He has seen no difference in structure between those
from the fourth and those from the lateral, especially as concerns the
ependyma.

Dr. Spiller said Dr. Donaldson had mentioned the well known fact
that the structure of the cells lining the choroid plexus is different
from that of the cells lining the walls of the ventricles. In the latter
the type is cylindrical. Dr. Spiller had found that in tumors growing

PHILADELPHIA NEUROLOGICAL SOCIETY 721

from the ependyma, the cells preserve their cylindrical form, whereas
in tumors growing from the choroid plexus the cells are more
cuboidal.

Dr. Donaldson said he thought the general opinion was that secret-
ing cells are only those which cover the choroid proper. Dr. Donaldson
said that the gentlemen had spoken of the work as his, but he wished
to emphasize the fact, that it is the work of Dr. ^leek, done under Dr.
Hatai in Dr. Donaldson's laboratory.

DEVELOPMENT OF THE CORPUS CALLOSUM.

By Dr. G. L. Streeter.

A description of five models reconstructed from human embryos 80,
95 and 150 mm. long, showing the morphology of the corpus callosum,
fornix, and anterior callosum. In the youngest stage the corpus callo-
sum and commissure of the fornix form together a round bundle of
fibers crossing in the lamina terminalis, dorsal to the fibers of the an-
terior commissure, as a result of the caudal migration of the fornix
commissure, the corpus callosum becomes gradually separated from it
and maintains its position so that its center remains dorsal to the an-
terior commissure. The two originally are nearly equal in bulk, but the
fornix commissure early comes to a standstill in growth, while the
corpus callosum continues to increase in number of fibers until it
reaches the proportion formed in the adult. This transportation occurs
in what may be considered as modified lamina terminalis and the so-
called fifth ventricle develops as a cavity of the lamina terminalis.

PHILADELPHIA NEUROLOGICAL SOCIETY.

April 23, 1907.

The President, Dr. Alfred Gordon, in the Chair.

A CASE OF STAB WOUND OF THE NECK.
By Drs. John Mulrenan and Cyrus Fridy.

The patient, J. D. L.. a boy of 17, was admitted to the Howard
Hospital, in the service of Dr. John H. W. Rhein, on December 2,
1006. He came with a history that he had just been stabbed with a
stiletto on the left side of his neck. He had been drinking, but was not
intoxicated.

Examination revealed the presence of a small stab-wound on the
left side of the neck, just above the clavicle, at about the junction of the
outer and middle thirds. Shortly after his admission he was seized
with a convulsion, which was limited to the left side. The eyes twitched
during the entire convulsion, and there was an internal squint of the
left eye. The head was drawn to the left. He remained partially uncon-
scious after the convulsion, until the following day when he could be
partially aroused.

722 I'll II. JDELPH1 A \ EURO LOGICAL SOCIETY

Upon examination there seemed to be some weakness of the left
arm at this time. He moved both legs freely. The tongue was pro-
truded in a straight line. There was no asymmetry of the face, and the
muscles of both sides of the face were moved equally well. He made
no effort to grasp the hand of the examiner with his left hand, and did
so feebly with the right hand. He was hyperesthetic on the right side
of his chest and right, arm, but completely analgesic in the left arm.
His respirations were 32 to the minute.

On December 5th, 4 days after his admission, the mental condition
had improved very much, and he was quite rational. Efforts to raise
the left arm were entirely unsuccessful, but the grasp of the left hand
was fairly good. There seemed to be no diminution in the power of
either leg. There was marked weakness of the pectoral and bid i>-
muscles. There seemed to be an anesthesia of the conjunctiva of the
left eye. There was some disturbance of sensation in the left arm as
well, but this could not be positively determined on account of the
mental condition of the patient.

The eyelids were kept closed, and when forcibly opened by the
examiner the eyeballs wire Found to be turned to the left. The left
pupil was slightly larger than the right, and did not respond to light.

The right knee jerk was present, and about normal: the left-knee
jerk was very slight. The plantar reflexes were active. Babinski's
sign was not developed.

During this examination there was a repetition of the convulsive
sei/.ures, of which he had had several since his admission. There was
an irregular clonic spasm of the muscles of the left arm and leg and
of the face. The eyelids were firmly closed and there was a tendency
to opisthotonos. He was apparently unconscious during the convul-
sion. Some of these convulsive seizures, observed later, began with
spasmodic twitchings of the left side of the face, and of the muscles
of the shoulder girdle on the left side, becoming general. After sev-
eral of the convulsions the twitchings of the left side of the face and
the left shoulder-girdle muscles, persisted off and on for some hour-.

On December 15th. 12 days after his admission, he had a general
marked convulsion, after the introduction of the catheter, lasting for
an hour and three-quarters. This began on the left side of the face,
and spread rapidly, becoming general, and was tonic and clonic alter-
nately.

On December 17th, 15 day= after his admission, his grasp was equal
and good on each side. He extended his left arm with almost as much
power as the right. The power in the biceps muscle, however, was
feeble, and he had scarcely any power in the left deltoid.

Pronation and supination of the forearm were weak, and there was
hypalgesia of the left arm and of the conjunctiva of the left eye. The
deltoid, the biceps, the supra and infra-spinati muscles, the pectoral
group, and the latissimus dorsi. appeared weaker on the left side than
on the right.

Examination of the color fields, form fields, and optic nerves was
normal. The ocular movements were normal (Dr. W. C. Posey).

An irregular fever was present tor the first 9 days of his sojourn
in the hospital.

PHILADELPHIA NEUROLOGICAL SOCIETY 723

Lumbar puncture was made on the fourth day, with negative re-
sults.

The patient left the hospital in a few days, his condition remaining
unchanged.

He was again examined on April 23, 1007, in the Out-Clinic, when
he stated that there had been no recurrence of the convulsive seizures,
and that he had returned to work some weeks back. On this date it was
found that the left biceps muscle was markedly wasted and weak. The
deltoid was also weak, but did not show much, if any, wasting. There
was distinct wasting of the supra and infra-spinati muscles of the left
side. In other respects the muscles of the shoulder-girdle and arm
appeared to be normal.

There was a slight hypalgesia over the left deltoid.

The scar was situated just above the clavicle, and four and a quarter
inches behind the sternoclavicular articulation, and measured about
13-16 of an inch in length.

An electrical examination at this time showed the presence of re-
actions of degeneration in the left biceps muscle, and in the infra-
spinatus muscle. The muscles of the remainder of the arm, shoulder,
and chest responded normally.

At first the stuporous state, convulsive seizures, the rise of tempera-
ture, and paralysis of the left arm led to the suspicion that the stiletto
had entered the vertebral canal, injuring the meninges and possibly the
cord. The disappearance of the convulsions, and rapid clearing up of
the mental condition, with the paralysis limited to the biceps, deltoid,
supra and infraspinati, pectoral and latissimus dorsi muscles on the
left side, were all sufficient to change the diagnosis in a few days.

The convulsions were believed to be hysterical in origin, and the
cause of the paralysis, an injury to the brachial plexus.

A study of the brachial plexus shows that a single lesion, to pro-
duce paralysis of the muscles described in this case, must be at the
portion of the fifth cervical nerve just before it joins the brachial
plexus.

Paralysis of the upper roots of the brachial plexus arises chiefly
from fracture of the clavicle, difficulties at birth, injuries about the
shoulder, infantile paralyses, and wounds of the neck and shoulder.

The muscles affected in injuries of the upper roots of the brachial
plexus are the deltoid, supra and infraspinatus, biceps, pectoral mus-
cles, brachialis anticus, and the supinator longus. with wasting of the
muscles, and reactions of degeneration. There is loss of power at the
main joints, with inability to abduct the shoulder, and to flex the fore-
arms. There is likewise a loss of cutaneous sensation in the areas
supplied by the circumflex and certain branches of the musculo-spiral
nerve.

Penetrating wounds in this region, with injury to the nerve roots
forming the brachial plexus, are comparatively rare. One other case,
reported by Harris of England, was that of a young girl stabbed in
the neck, the blade entering at the fourth cervical spine and taking a
course to the posterior border of the sternocleidomastoid muscle.
Subsequently, at operation, the root of the fifth cervical nerve was
found to be completely severed. There was, in this case, complete par-
alysis, of .the muscles abducting the shoulder, and inability to flex the

724 PHILADELPHIA NEUROLOGICAL SOCIETY j ijRfii

forearm, with wasting of the muscles, and complete reactions of de-
generation.

In this connection it is interesting to read the statistics of Strauch
{W'cin. med. Woch., Nov. 7. 1003, p. 2131 ) who classified stab-wounds
in the spinal region as follows:

"Those from before backward, in which the weapon may go through
— (1) the intervertebral disks; (2) through the body of the vertebrae,
destroying them; (3) through the intervertebral foramens; (4) through
the transverse foramen of one spine into the intervertebral
foramen between this and that of the one below, and finally, into the
spinal canal. Stab-wounds from below upward, in which the weapon
may pass — (1) through the intercrural spaces; (2) between the spinous
processes; (3) through the trigonum arterise vertebralis. The size of the
wound depends upon the sex. age, and bony structure. The size of the
wound between the vertebra? differs in different individuals of the same
age. and on the right and left sides of the same individual. It is rare
that stab-wounds of the anterior cervical region into the spinal canal
are associated with injury to the large vessels of the neck. In these
last injuries it is possible — (1) not to injure the membranes of the
cord; (2) to involve the membranes; (3) to penetrate the membranes
and injure the cord; (4) to injure the membranes, the roots, or root-
fibers of the same side, but not to affect the spinal cord; (5) to injure
the membranes and the roots of the other side, but not to involve the
spinal cord. In neck wounds from before, in the direction of the spinal
canal, it i> possible for the weapon to glide along the anterior side of
the spinal column on the prevertebral fascia, and to injure a nerve on
the opposite side. The spinal cord becomes frequently injured in stab-
wound-- of the back in the thoracic region, in such a way that the
external wound, and the spinal cord lesion are on opposite sides. It is
possible to demonstrate the direction taken by the weapon from the
appearance of the external wound."

Dr. Rhein said that this case had been admitted into the wards of
the Howard Hospital in his service, and presented at first some very
confusing symptoms. The patient was at first in a semi-conscious con-
dition, and while being examined he developed a convulsion which
began with twitching of the left side of the face, extending to the left
shoulder muscles, and finally becoming general. During the few days
after his admission he had several convulsions of this sort, and also
some attacks in which only the left side of the face and the muscles
of the left shoulder were involved. He was also anesthetic in the left
conjunctiva, in the cervical region, and in the left arm. There was rise
of temperature extending over a few days.

At first it occurred to Dr. Rhein that the knife had entered the
spinal canal and injured the meninges, and possibly the spinal cord,
and that the convulsive seizures were due to irritation of the meninges
or cord, but the rapid return to a normal mental state, associated with
anesthesia of the conjunctiva of the left eye, of the left arm and shoul-
der, not limited to any particular nerve distribution, and the irregu-
larity of the convulsive seizures, justified him in the diagnosis of hys-
teria, added to an injury of the brachial plexus. Dr. Rhein thought
that the diagnosis presented by Drs. Mulrenan and Fridy — namely,
that the fifth cervical nerve was injured. — was the probable explanation
of the symptoms presented by this patient.

PHILADELPHIA NEUROLOGICAL S0CIE1 Y

/-.->

PARALYSIS OF THE LOWER EXTREMITIES FOLLOWING
A GYNECOLOGICAL OPERATION.

By Dr. J. Hendrie Lloyd.

The patient, a young white woman, had had a pelvic abscess caused
by a self-produced abortion. The abscess was behind the uterus and
extended up above the true pelvis far enough to produce a mass which
could be felt through the abdominal walls. Dr. Salada had operated
by a laparotomy, with counter-drainage through the vagina. The pa-
tient had been very ill for three months, during part of which time she
had had a slight confusional delirium. There was no history of alco-
holism. Before the abscess healed the patient became paralyzed. This
paralysis was confined almost entirely to the muscles below the knees
on both sides. Both extensors • and flexors were involved; there was
foot drop; lost knee jerks, and wasting of the muscles. There was also
a very intense causalgia of both soles, with vaso-motor paresis, caus-
ing a contact erythema of the parts. This area was extremely sensi-
tive, the slightest pressure causing the patient to cry out. No
anesthesia. The reactions of degeneration were present in the calf and
peronei muscles. There was no involvement of the bladder, nor any
symptoms in trunk, arms, neck, face or eyes. Dr. Lloyd explained the
case as due to a septic infection of the sacral plexus on both sides
caused by extension of the inflammation from the abscess to the nerve-
sheaths.

Dr. Spiller said he did nor know what the difficulties of diagnosis
had been, but the case seemed at present to be one of multiple neu-
ritis. The reaction of degeneration, pain on pressure over the soles of
the feet, and double foot drop are typical of multiple neuritis.

A CASE OF POST-DIPHTHERITIC MULTIPLE NEURITIS
WITH VESICAL INVOLVEMENT.

By Dr. C. D. CAMP.

The speaker said the involvement of the auditory nerve and of the
urinary bladder are both very rare in multiple neuritis, and he thanked
Dr. W. G. Spiller for the privilege of reporting a case in which these
symptoms were both present. The patient is twenty years of age. He
had typhoid fever in January, 1007, and when convalescent from this
was taken to the Municipal Hospital with diphtheria. At the time of
leaving the Municipal Hospital he first noticed that his hearing was
impaired, that his voice was changed, and that fluids regurgitated
through his nose. About a week later he noticed that his hands and
legs felt numb and weak, and at the same time he had incontinence of
urine, "could not hold his water," soiling his clothes and his bed. An
examination by Dr. Walter Roberts showed deafness of one ear to be
of nerve origin. On April 1st, 1907, the voice was still weak but fluids
no longer regurgitated through his nose. His gait was uncertain, ataxic,
and there was a bilateral foot drop which was worse on the left side.
There was a marked Romberg's sign. There was no paralysis of the
face, tongue or extra-ocular muscles. There was a hypesthesia in the
ulnar distribution of the left hand and the grip of both hands was weak.
The knee jerks and Achilles jerks were absent and there was no Bab-
inski reflex. There was tenderness on pressure in the muscles of the

-26 PHILADELPHIA NEUROLOGICAL SOCIETY

arm and over the peroneal nerves, also on pressing the calf muscles.
Examination on April 22nd showed that the deafness due to nerve
involvement had remained about the same. His gait had improved
slightly and the foot drop was not quite so marked. There was a par-
alysis of accommodation, ordinary print becoming blurred at a nearer
point than twelve inches.

HERPETIC INFLAMMATION OF THE CERVICAL AND

THORACIC NERVES.

By Dr. T. II. Weisenburg.

A young man of twenty-six with an excellent family history, played
a rather hard game of golf. The following day he felt a little pain in
the wrist of the right arm, this pain resembling that of rheumatism.
About six days after this the whole hand and arm felt numb and dead,
and at the same time there appeared herpetic eruption over the right
shoulder and upper arm. Examination about eight days after the ex-
posure showed that power was practically normal with the exception
that he could not lift his shoulder as quickly as lie should. He had
also pain in the back of his head and over the right side of the face
and in the right arm. The herpetic eruption extended from the shoulder

ng the upper border of the whole arm, this including the thumb and
the first two fingers, being limited to the distribution of the fifth cervi-
cal segment. He had besides a hypesthesia for touch and pain over the
whole right side of the face, right ear, the whole right side of the head
and neck, this extending to a point about six inches below the angle
of the scapula and in front of the chest on the nipple line, then to the
middle of the chest and then to the face. The arm was wholly hypes-
thetic, this being more so in the distribution of the fifth cervical seg-
ment. In the course of a week the herpetic eruption disappeared and
the area of hypesthesia gradually receded and in about three weeks
after the appearance of the symptoms the patient was well. It is evident
that the area of first inflammation was in the distribution of the fifth
cervical ganglion, and the roots, both above and below, were involved.
No herpetic eruptions were present excepting at the point of initial
irritation. The case is rather interesting because of the large extent of
sensation involved, this area including the fifth cranial nerve, all of the
cervical nerves and the first six thoracic nerves, all of these being on
the right side. It is also rather interesting to note that the hearing
was not in any way diminished.

Dr. Lloyd asked whether Dr. Weisenburg made a puncture.

Dr. Weisenburg replied that the man got well too quickly.

ABNORMAL RESPONSE TO AN IRRITATION OF THE MO-
TOR AREA OF THE BRAIN.

By Dr. Alfred Gordon.

Abstract: A boy of 16 had been suffering from facial epilepsy affect-
ing left arm. face and neck. An operation was decided upon. An
osteoplastic flap uncovered the entire motor area on the right side.
A very carefully applied faradic electrode (unipolar method) gave
invariably a response on the right side of the body and not for one
moment on the left side.

PHILADELPHIA NEUROLOGICAL SOCIETY 727

Dr. Lloyd said he thought this was really a very extraordinary
observation. He has seen a good deal of faradization of the cortex and
he has never seen anything like it. He thought the only explanation
was that there was non-decussation of the pyramids. Such a thing is
extremely rare. He asked whether there was any possibility of fara-
dization of the membranes by which the current could have been trans-
mitted to the opposite hemisphere. He would also like to know where
the indifferent electrode was placed. Dr. Lloyd said he wished to say
one word as to the technique. It seems to be the idea that it is better
to faradize the ascending parietal convolution first. Dr. Lloyd does
not have that idea. He has faradized the human cortex a number of
times, and he inclines to the view that according to the theory of
Grtinbaum and Sherrington, the ascending parietal convolution exer-
cises a reinforcing action, that is to say, if you put a rather strong
current on this convolution you may get a little motor response. That
is perfectly conceivable, the current may follow through the neurones.
He thought under these circumstances it is better to apply the current
to the ascending frontal convolution first. If you want to demonstrate
that the motor neurones are entirely in front of the Rolandic fissure
it is better to faradize them first. Then with an equal strength of cur-
rent faradize the ascending parietal, when it will be evident that this
latter convolution does not give a motor response. But if, at the very
first, you use a very strong current, and faradize indiscriminately the
various convolutions, you obtain overflow effects, and the results are
confusing and valueless.

Dr. Spiller said that complete failure in decussation of the pyramidal
tract is so uncommon that great caution should be observed in attribut-
ing symptoms to this condition.

Dr. Gordon said he had not mentioned in his talk everything he
had written in the paper. He simply wanted to report an unusual re-
sponse of the motor area to faradization. In answer to Dr. Lloyd's
remark about first faradizing the precentral convolution and then the
posterior convolution, this is entirely opposite to what Dr. Mills ad-
vises. Dr. Gordon compared very carefully the original notes of Dr.
Mills and Dr. Lloyd, and Dr. Mills also advises to begin with the
posterior convolution, first because he says the precentral convolution
is absolutely certain to be motor, but if you start from the anterior
convolution and then go to the posterior convolution, you may get
some contractions in faradization of the posterior convolution, when
no response would have been, perhaps, obtained had the electrode
been applied first to this convolution. Dr. Lloyd, however, believes
in the opposite. In regard to Dr. Spiller's query, Dr. Gordon said that
in his experiments, which embrace two cases, one a normal case and
this apparently abnormal case reported, he found certainly very dis-
tinct contractions in the opposite side by faradizing the precentral
convolution and the sulcus, he also found them present in faradizing
the postcentral convolutions, but less marked than in faradization
of the precentral convolution. In regard to the possible explanation
of the convolutions and the responses on the same side as the faradized
side, he is really at sea to explain this occurrence. All possible precau-
tions were taken. In his other case he found normal responses, which
means faradization on one side, convulsions on the other side. At no

728 PHILADELPHIA NEUROLOGICAL SOCIETY

moment did he observe in his rirst case even the slightest indication
of contraction or twitching on the opposite side. When the area was
exposed. Dr. Da Costa found on the side exposed some blood vessels
which resembled very much angiomatous veins, but the cortex itself
was intact. There was no autopsy in the case, no microscopical examina-
tion, no examination of the medulla, but Dr. Gordon did not see how
otherwise could be explained the response on the same side than by
want of decussation. Dr. Gordon stated that he had put the indifferent
pole on the chest and before he transferred the electrode to the brain
he tested the strength of the current with his hands, and he obtained
a slight tingling sensation and only this current he employed for the
experiment. There were extremely slight movements of the fingers.
The same strength of current was used in the second case where the
patient had normal contractions.

Dr. J. W. McConnell asked if Dr. Gordon had ever taken notice
how much less this current is perceived when it is tested on the hand
than when it is tested on some more sensitive part, for instance the lip.
In many of the University Hospital cases of Dr. Mills they tested on
the lip. and a current that was just perceptible to the lip was the cur-
rent used.

PRESERVATION OF THE SENSATION OF PRESSURE IN
THE FACE AFTER DESTRUCTION OF THE TRIGEM-
INAL NERVE.

By Messrs. R. H. Ivy and L. W. Johnson.

This paper is concerned with the conduction of sensory impulses
from the face to the sensorium. and especially the conduction of deep
pressure sensibility as contrasted with that of cutaneous sensibility to
light touch, temperature, and pain sense. Up to a comparatively recent
period it was considered that all sensory impulses of the face were
carried by way of the fifth nerve, while the seventh nerve was con-
cerned solely in the motor supply of the muscles to which it runs. Re-
cently, however, the opinion has been gaining ground that while the
fifth nerve conveys impulses of light touch, pain, and temperature sen-
sations from the skin of the areas of its distribution, deep or pressure
sensibility is conveyed by afferent fibers running in the motor nerve to
the muscles, viz., the seventh nerve, except in the case of those muscles
supplied with motor fibers by the fifth nerve. To support this view two
cases studied by the writers and one case by the writers in association
with Dr. Spiller. are reported, in which pressure sensibility was re-
tained in the trigeminal area of the face after lesions completely destroy-
ing the Gasserian ganglion. These investigations have an important
bearing upon the surgery of the fifth nerve. It has been noticed that
after operation on the Gasserian or the sensory root of the fifth nerve,
some sensation has been retained in the side of the face supplied by
the nerve operated upon, at times giving rise to the assumption that
the operation was imperfect. The subject is important also, because
after surgical intervention on the fifth nerve a certain form of sensation
may be preserved, so that there is not complete anesthesia, even with
complete destruction of the fifth nerve.

Conclusions: The fifth nerve conveys sensibility to light touch, pain

PHILADELPHIA NEUROLOGICAL SOCIETY 729

and changes in temperature from those parts generally recognized as
being within the area of distribution of the said nerve. The seventh
nerve contains fibers of deep or pressure sensibility running from the
muscles which it supplies with motor fibers. The muscles of mastica-
tion which derive their motor supply from the fifth nerve, probably are
also furnished with fibers of deep sensation by that nerve.

Dr. Spiller said he thought Drs. Ivy and Johnson deserved much
credit for the work they had done. During one of his lectures he had
invited the students of the Fourth Year Class to report this case and
Drs. Ivy and Johnson had responded.

Dr. Spiller remarked that the deep sensation of the facial nerve may
be temporarily interfered with by operation on the trigeminal nerve.
Twisting out peripheral branches of the latter causes much swelling
of the face, and probably thereby, some impairment of function of the
facial nerve. Excision of the Gasserian ganglion causes swelling of
the axis cylinders and meduallary sheaths of the peripheral branches
of the trigeminal nerve, and if these are intimately associated with
branches of the facial nerve, this swelling also may interfere tempor-
arily with the function of the latter. Destruction of the sensory root
of the trigeminal nerve by a tumor affords better opportunity for test-
ing the sensation of the face, than does destruction of some part of
this nerve by operation, at least in the period immediately following
operation.

periscope

Psychiatrisch-Neurologische Wochenschrift
( March 31, 1906.)

Some Somatic Characteristics of Idiocy. HEINRICH Vogt.

The autlior calls attention to the fact that in general idiots are smaller,
■weigh less, and die young'er than normal persons. They show the signs
of senescence earlier and the several organs weigh less, the most im-
portant organ to weigh less being, of course, the brain,

( April 7. 1906.)
The Treatment of Alcoholic Delinquents. Otto Juuusbruger.

Ilii author calls attention to the fact that, in general, idiots are
-mailer. Society has a right to protect itself from this anti-social being,
bul should subject him to curative rattier than correctional measures.

( April 15. IQ06.)

EglUng. — An account of this institution with a picture of the lay out.

( April _>_>. [906. )
Course of Medical Psychology in Relation to the Treatment and Edu-
cation of the Born Defectives. Dannemann.

A short account of some of the work that is being done along these
lines as set forth at a meeting of those interested in this work at Giessen,
April 2 to 7.

( April _>X. 1000. )

The Case of Brcmke. 11. Si hai-er.
A detailed account of a case of only local interest.
Proponal. Bresler.

Researches with New Hypnotics. Shecke.

Proponal is a colorless, crystalline solid, melting at 145°, dissolving in
70 parts boiling water and 1,640 parts water at 200. It has a somewhat
bitter taste. The formula is given as:

C2 U- CO— NH

C CO.

C3 H7 CO— NH

The hypnotics discussed in the second article are veronal, viferral,
hypnal, proponal. Nothing new occurs in the article. The author cites
an old text that holds that the existence of a great many drugs for a
special purpose indicate that none are of much value and counsels trying
them all carefully and holding to the best.

(May 12, 1906.)
Oswald Alving. Boege. (Continued.)

(May 19. 1906.)
Ten Years of Family Care in the Province of Saxony. Conrad Alt.
■Oswald Alving. Boege. (Concluded.)

Family Care. — This article shows that the increase in the number of

PERISCOPE 73i

patients cared for in families in Saxony has been from two in 1896 to
475 in 1906.

Oswald Alving. — A psychopathological study of the character of Os-
wald Alving in Ibsen's "Ghosts."

(May 26, 1906.)
The Opening of Roderbirken. Ernst Beyer. (Continued.)

(June 2, 1006.)
The Opening of Roderbirken. Ernst Beyer. (Concluded.)
An account of the new sanitarium for nervous diseases. While its
sister sanitaria, Hans Schonow and the Provincial Sanitarium at Han-
over, provide for both sexes and classes, this is for women only and for
one class. It contains 145 beds.

(June 9, 1006.)

Petition of the Moravian Hospital Physicians for a Bettering of Their
Conditions. — Of local interest only.

White.

Revue de Psychiatrie et de Psychologie Experimentale

(June, 1906.)

1. Conditions of Surgical Intervention in Hypochondria. Picque.

2. Eroticism in Hysteria. Buvat.

1. Surgieal Intervention and Hypochondria. — The author of this article
is a surgeon, and while he does not pretend to be able to solve the problem
of hypochondria from a psychiatric standpoint he believes that clinically
we must recognize that there are two forms of disease, an essential
hypochondria which is entirely mental in origin, and a symptomatic which
depends upon physical lesions. From the point of view of the indications
for surgdcal intervention, however, he would classify the hypochondriacal
syndrome under two captions. In the first class of cases the hypochondria
is merely an episode in the course of a well defined psychosis, such as
general paralysis, or associated with constitutional psychopathy, toxic-
infectious psychoses or neurasthenia. In these cases surgical intervention
is useless. In the second class of cases the hypochondria constitutes the
entire delirium. It is a veritable morbid entity justifying the name hypo-
chondria. In these cases we find the syndrome with a legitimate somatic
basis. Surgical intervention in these cases is not only justifiable, but may
produce excellent results. He considers this state under the following
headings : (1) The co-existence of a somatic lesion, with the hypochon-
driacal idea. (2) The conditions in which a lesion can produce the
hypochondriacal idea. (3) Consideration of the facts which prove the
simultaneous disappearance of the lesion, and the idea.

The Lesion : It is very difficult to tell in a given case whether there
is any etiological relation between the pathological condition and the
hypochondriacal idea. It is important, however, to make this determina-
tion before operating, because it not infrequently happens that operations
do no good, but actually aggravate the mental disease. The author in a
very few words and superficially gives his method of determining this
connection upon the basis of what he calls "the dose of subjective trouble"
and the "knowledge of the organic state of the patient." In prolapsus of
the uterus, for example, we may ask whether the mental depression is the

,'32 PERISCOPE

result of displacement of the organ, or on the contrary, if it is exaggerated,
or invented out of whole cloth, or held as due to no cause. The author has
shown that contrary to current opinion some of these patients exaggerate
or invent symptoms in order to be subjected to operation, others merely
attach their trouble to a physical lesion which they discovered themselves
or which their physician called their attention to. The author insists on
the necessity of seeing that the cause in the functional disease is pro-
portionate to the lesion. Any disproportion ought at once to engage the
attention of the surgeon. When the apparent lesion cannot be considered
as the origin of the depression, which is at the base of the hypochondriacal
idea, one should look for the existence of latent visceral disturbances
which may explain it.

Formation and Evolution of the Idea: For the promotion of the
hypochondriacal idea the author states that it is necessary to have a par-
ticular psychic constitution, a hypochondriacal temperament, as Roy says.
Given this character he believes that with a clearly defined lesion when the
pre-occupations of the patient are en rapport with the gravity it presents
and the degree of its evolution, and when it does not effect the form of
obsession with anguish, it imposes itself imperiously on the mind and
can no longer be replaced by reason. From the simple condition of hypo-
chondria minor there is a characteristic evolution to hypochondria major
in which the patient is incurable and surgical treatment is powerless. In
the most marked cases of this condition we find the delirium of negation.
In regard to the evolution of the hypochondriacal idea he calls attention
to cases where there are some lesions which could not possibly produce
the hypochondria, as for example a displacement of the uterus with no dis-
turbance of the adnexa and also cases where the patient believes in a
lesion which does not exist in order to explain his mental condition. It
would, of course, be a mistake to operate in these cases, and he has re-
ported cases of operation for false appendicitis which in one case occurred
as an epidemic, the result of mental contagion.

Results of Surgical Treatment : In certain classes of cases, for in-
stance in metrorrhagia, where the condition is associated with infection and
exhaustion, there is no question about the indication for operation. In
certain other cases, however, where the operation is plastic or orthopedic
we have learned to fear the aggravation of a pre-existing mental state,
and operation could only be performed in accordance with the rules pre-
viously laid down. The author reports several such occurrences as a re-
sult of operation. He appreciates, however, that the fundamental psycho-
pathic state will remain, and that the case may relapse under a new physi-
cal and mental stress.

2. Eroticism in Hysteria. — The author calls attention to the fact that
modern writers on hysteria have contradicted the opinions of the older
writers to the effect that hysteria was an erotic neurosis. As a result of
a study of seventeen cases, however, which are briefly reported, he says in
conclusion that he believes eroticism to be a pathognomonic symptom of
the disease.

(July, 1006.)

1. Examination of Some Questions Touching Responsibility. Toulouse

and Crinon.

2. Some Particular Cases of Mental Disorder of Paranoid and Melan-

cholic Character. Soukanoff.

PERISCOPE 733

1. Questions of Responsibility. — The authors support the thesis that
between the normal man and the completely irresponsible there are all
sorts of gradations of persons who come under the review of the penal
law ; that the ill-balanced, the semi-lucid seem to have temporarily partial
deliria. The question of these cases should be carefuly considered, not
simply from the medico-legal standpoint, but from the point of view of
the psychologist and the pathologist.

The author starts in by a short discussion of the question of free will
and comes to the general conclusion that there is such a thing as penal
responsibility, although there are psycho-physiological antecedents to voli-
tion, which in a sense determine it, there does not seem to be any place
for the capricious will. He divides acts into instinctive, spontaneous and
reflective, the first two of which belong to Grasset's inferior psychism.
as alcohol, only in a more marked degree. The well-known effects of
alcohol in retarding the reaction time to sight and sound stimuli is dis-
cussed, also the impairment of the muscular sense produced by the same
agent. These conclusions do not F.gree with the subjective sensations, as
those under investigation always imagined they were reacting with custom-
ary rapidity, or even in excess of their usual speed. From statistical in-
quiry Cto which he gives fair warning regarding their flexibility), he comes
to the conclusion that responsibility varies within three degrees.
The measure of culpability varies with these three degrees. In the in-
stinctive acts the individual is entirely irresponsible, in the spontaneous
acts there is a small degree of culpability, while in the reflective acts
there is complete responsibility. Responsibility is based on the clearness
of consciousness and the capacity of voluntary effort of the subject which
varies much both in the normal and the abnormal. Punishment, which is
actually correction, should also, in order to satisfy our desire for justice,
have the same gradation. Irresponsibility is not thus always a matter of
disease. The question of responsibility is a question to be decided in
each individual case by the most careful examination, the ordinary methods
of examination by psychiaters being entirely insufficient.

He concludes that the examination of delinquents is a matter of psy-
chology and not one of medical diagnosis simply, and that the preparation
of the medical expert should be along lines of psychological laboratory
work, and that this is the only preparation. It follows thus that all
criminals should be considered side by side, and not be classed in categories
of vicious and insane, since the characteristic of irresponsibility is not a
question of pathology. "Nothing is more artificial than this division. All
alleged criminals should be examined by an expert. The prison would
become then a hospital where the delinquents could be treated whether
they were insane or not. After a period of observation sufficiently long
a final disposition of the cases would be urged, the incorrigibles would be
put to work and submitted to appropriate discipline, society would thus be
protected from them. The corrigibles following treatment would as soon
as possible be discharged, and the insane taken care of in special asylums.

2. Paranoid and Melancholic Cases. — The author, after citing several
cases, reaches the following conclusions: (i) The symptomatological
signification of the delirium of obsession by animals (serpents, monkeys,
etc.), in its pure form seems more often found with reasoning paranoia
(chronic), and the delirium of obsession by the devil is more often found
in relation with the grave state of melancholia or with special troubles
producing hysteria. (2) Often enough one encounters psychoses having

734 PERISCOPE

a paranoid character along with changing delirious ideas and hallucinations
of the different sensory organs and delirium of obsession by some animal,
in the representation of which (ordinarily among women), the patient
associates the ideas with demons. ( 3 ) The absurd ideas of possession by
some animal or by the devil are observed oftentimes in different states of
dementia, for example in the primary dementia of adult- and in paresis.
(4) In certain complex cases the delirium of obsession by some animal
and delirium of obsession by the devil are combined with the delirium of
transformation into some definite animal or into a demon. (5) In certain
cases of melancholia the emotional state of anguish i- as-ociated in a very
intimate manner with painful and unpleasant sensations localized in the
region which has suffered from a traumatism at the same time of the
emotional shock. W. A. White (Washington).

Centralblatt fur Nervenheilkunde und Psychiatrie

( No. XX. March 1 and 15. 1907.)

1. Contribution to the Knowledge of Motor Apraxia Upon the Grounds
of One Case of One-Sided Apraxia. K. Abrahams.
Abrahams classifies apraxia, according to Heilbronner, in three classes :

1. Cortical: This form is characterized by an impairment of con-
ductivity of the sense-motor paths and by the preponderance of para-
kinetic manifestations in all movement-.

2. Subcortical : By the intactness of the conductivity and the resulting
parakinetic complicating voluntary movement-.

3. Conducting apraxia : Through well regulated interchange of move-
ment-, often in the sense of perseveration, likewise due to the absence of
parakenetic manifestations.

He places his case in the third class. He attributes the disorder of
apraxia not to receptive faculty, but regards it as purely reactionary.
Much importance is assigned by him to the psychical component which
enters in the mechanism of apraxia. In Leipman's case of right-sided
apraxia the lesion was demonstrated in the superior parietal lobe and
supramarginal gyru-. Abrahams does not localize the lesion of apraxia
in any particular region, but explains this abnormal phenomenon on the
theory of diaschisis, formulated by v. Monakow. "which implies that when
a region in the cerebral cortex, the integrity of which is associated with
certain functions, is diseased, the specific functions of this area are not
the only ones impaired. Xo region is independent by itself, but each stands
with others in union, corresponding' to the infinite and manifold relations
of the cerebral cortex. A diseased area will, therefore, bring about not
only local but also associative disturbances ; the process of separation of
a diseased region from others is designated by v. Monakow as Dias-
chisis."

The author's case is exhaustively treated. The following is only a
brief resume of the important features of the clinical picture. The patient
was sixty-one years of age. fairly intelligent, and a prosperous business
man. From May 27, 1900. till Dec. 5. 1905 (the day of his death), he was
subject to many attacks of apoplexy, which at each time were accom-
panied by peculiar manifestation, the latter soon disappeared with the
return of consciousness. After the attacks patient was observant, ex-
hibited interest in the examination, and showed no abnormal irritability.

PERISCOPE 735

The disturbance was sensory aphasia which usually lasted for about four-
teen days. Then speech remained ungrammatical, patient was able to
understand spoken language and had no difficulty in finding words. Only
in the later stages of the disease did the amnestic aphasia become promi-
nent and persistent. The capacity for repeating words was not markedly
affected. After each apoplectic attack patient showed inability to read
and understand what lie read, but soon rapid improvement was noticed.
At first complete agraphia was present, but he was soon able to write well.
Later right-sided hemianopsia was demonstrated which often showed a
slow and incomplete remission. After each attack of apoplexy a tempor-
ary paresis of the right side of the body was demonstrable. With the
improvement of the paralysis a disturbance of purposeful execution of
movements of the right upper and lower extremities was observed. For
instance, patient made an attempt to put on a sock ; after long manipula-
tion he was not able to find the opening. However, he was successful
when he used the left hand only. He took a handkerchief in the left hand
and wiped his forehead correctly ; he was asked to do the same thing
with the right hand ; he took the handkerchief between the third and
fourth fingers, then in the first, but did not wipe the forehead. At last
he threw it on the floor and wiped the forehead with the bare hand. He
made false movements with the right leg in putting on trousers, etc. Such
disturbances were occasionally seen on the left side, but they were only
transient and not permanent. Remissions occurred on the right side, but
they never completely disappeared. Impressions from external world were
correctly conveyed. Stereognostic sense was at first slightly but later
considerably affected.

The post-mortem examination 'if the brain revealed the following:
Dura was adherent to the skull; marked cerebral arteriosclerosis, es-
pecially of the basilar arteries and arteria foss;e sylvii; the pia over
the convexity was more adherent on the left than on the right ^iflr : no
hemorrhagic areas could be demonstrated; the sulci of the left frontal lobe
were widened, and the gyri were much reduced in volume : the left
ascending' parietal convolution, parietal and occipital lobe underwent great
changes ; also their convexities were rough and covered with a brownish
membrane; the convexity of the left superior parietal lobe was affected
and its superior convolution was narrowed; all the convolutions of the left
occipital lobe were reduced in volume ; the superior temporal gyrus of
left temporal lobe was narrow, and also diminished in size and the surface
was nodulated. The pathological condition of the encephalon is explained
on the basis of arteriosclerosis

M. J. Karpas (Ward's Island).

The Journal of Mental Science
(Vol. LI I. No. 217. April, 1006.)

1. Alcoholism, Crime and Insanity. W. Bevan Lewis.

2. Amentia and Dementia : A Clinico-Pathological Study. Joseph Shaw

Bolton.

3. The Morison Lectures for 1906. The Pathology of General Paralysis

of the Insane. W. Ford Robertson.

4. The Prognosis in Dementia Paralytica. George Greene.

73$ PERISCOPE

5. Mental (or Asylum-Trained) Nurses; Their Status and Registration.

T. Outterson Wood.
5. The Nursing Staff at the Metropolitan Asylum, Leavesden ; Notes

Upon a Scheme of Promotion. Frank Ashby Elkins.
7. On the Etiology of Asylum Dysentery. W. Bernard Knobei..

1. Alcohol, Crime and Insanity — The author prefaces his remarks upon
the relation of alcohol to crime and insanity, by a cursory review of the
physiological effects of alcohol upon heat formation, deduced from animal
experimentation, and the effects of alcohol upon the reaction time and
muscular sense. He concludes that thermogenesis is modified in two ways
by this agent; at first, there is a decreased thermogenesis due to the
stimulating effect of the alcohol on the vaso-motor centers ; this is fol-
lowed by an increased heat production and radiation due to a paresis of
these centers. He found, also, that chloral exhibited the same phenomenon
to the conclusion that the incidence of alcoholism does not coincide with
that of insanity, 5ut does coincide with crime. These conclusions, which
are somewhat at variance with other investigators, are based upon the
statistics of different counties in England, where the social and racial con-
ditions differ greatly and hence can be used for comparison. However, he
does not belittle the influence of alcohol in the causation of insanity, not
directly only, but through heredity. A very good exposition of the so-
called laws of heredity is given. He doubts that alcoholic tendencies, as
such, are inherited, but he is convinced that alcohol, like other toxic
agencies in the parents, have a detrimental effect on the germ plasm. He
deplores the loose term of "heredity" in cases of alcoholism, as well as in
cases of toxemia — such, for example, as syphilis. Here a mother gives
birth to a syphilitic child and the congenital syphilis may be the result of
a simultaneous infection. That such conditions should be considered as
the result of direct transmission rather than a hereditary influence, is a
point that is well taken. The author goes even further into the analysis
of the effects of these toxic agents on the germ plasm. He reasons from
certain biological facts that there is a distinct difference between paternal
and maternal forms of transmission to the embryo. The arrest of de-
velopment, as shown in congenital mental weakness, idiocy and imbecility,
he believes is the result of maternal toxemia, while convulsive neuroses,
epilepsy, chorea, hysteria and like affections, are the legacy from the
paternal side. This fact of alcoholism in the parents, especially at the time
of conception, producing detrimental changes in the embryonic structures,
has been considered by other authors, and is of considerable importance,
and its relation to race hygiene should not be underestimated.

2. Amentia and Dementia. — Continued article.

3. The Pathology of General Paralysis. — This article is an abstract of
the Morison Lectures, for 1906, published elsewhere, and gives the author's
recent work upon the bacterial nature of general paralysis, and the relation
of the diphtheroid bacillus, or bacillus paralyticans, as termed by him and
his associates, to this disease. Various criticisms and reviews of the work
have appeared, usually unfavorable to the view that general paralysis is
caused by the diphtheroid bacillus. The criticism of Ferrier, in the Lum-
leian Lectures for 1006 (Royal College of Physicians, London), seems to
be a fair and just estimate of this work by one of the author's own country-
men. While he considers the views of Ford Robertson interesting, he finds
that there are many difficulties in the way of their general acceptance as

PERISCOPE 7*7

a satisfactory pathogeny of tabes, cerebral and spinal. Other investigators
(Eyre and Flashman) found this bacillus in the throats of a large num-
ber of patients, suffering from different forms of insanity, as well as in
the tissues of a considerable number of cases post-mortem, and there was
no evidence that this bacillus was more common in the throats of general
paralytics than of other insane patients. They were unable to trace any
causal relation between diphtheroid bacilli and general paralysis. When
competent bacteriologists review this subject, then the weak points of the
theory are easily exposed. Dr. Bullock (quoted by Ferrier) states that
the diphtheroid organism may be found in the intestines, genito-urinary
tract, throat, and in the nasal secretions and elsewhere in perfectly normal
individuals, as well as in catarrhal conditions of the respiratory tracts. He
also states that the characters given this bacillus by Ford Robertson are
not sufficient to differentiate it from other forms of diphtheroid organisms.
If diphtheroid bacilli exist in the blood and cerebrospinal fluid of general
paralytics, they should be capable of cultivation at once without waiting
for the cessation of any supposed bactericidal action of these fluids, for
no lysogenic action of the serum for bacilli of this group has been proved
to exist. From specimens of cerebrospinal fluid, blood, and urine of
several cases of tabes, and general paralysis, absolutely sterile cultures
were obtained by competent bacteriologists for Ferrier, and he comes to
the conclusion that it is not improbable that the bacilli found by Ford
Robertson, so largely diffused throughout the tissues in general paralysis,
are the result of a terminal invasion. This view seems perfectly justifiable.
He also claims that it has not been shown that symptoms and post-mortem
appearances of general paralysis can be produced by toxines prepared
from these bacilli. It is difficult to see why it is necessary to have such a
severe disease as syphilis in order to cause an impairment of the resistive
power of the various tracts and thus allow the bacillus paralyticans to
gain an entrance to the system ; such an impairment could certainly be
produced by a large number of conditions, and it seems unnecessary to
bring syphilis into the etiology at all.

4. The Prognosis in Dementia Paralytica. — The conclusions of the
author are based upon the analysis of 500 cases of general paralysis, and
are interesting as showing what factors tend to limit or prolong the
course of the disease. Among the factors that favor a long course are :
Youth, from the age of 25 to 35, the duration of the disease steadily
diminishes, and from the age of 35 to 40 the acutest form of the disease
appears. (2) Females live nearly twice as long as males. (3) Recently
acquired alcoholism has a tendency toward prolonging the course of the
disease. He found the early onset of dementia a very unfavorable
symptom, and that melancholic subjects rarely survive a year. In another
paragraph, however, he states that melancholic types tend to remissions.
Maniacal exalted types run a variable course. Systematized and fixed de-
lusions indicate that the course of the disease will be protracted. Pupils
inactive to light, sluggish reaction to light, rapidly alternating pupils are
unfavorable signs. It is interesting to see that epileptiform convulsions
have little or no general bearing on the course of the disease, and that
the degenerate types live longer than the more highly developed subjects.
The disease in juvenile subjects pursues a long and chronic course, and
finally the association of early tabes with early general paralysis is an
indication that the course of the latter disease is likely to be lengthened.

738 PERISCOPE

5. Trained Nurses. — Not suitable for abstracting.

6. Nursing Staff. — Not suitable for abstracting'.

7. On the Etiology of Asylum Dysentery. — The author has endeavored
by a thorough investigation to ascertain the cause for the prevalence of
this disease in the English asylums. From the reports it would seem that
dysentery is much more prevalent in the English asylums than in this
country where happily it is rather rare. Scattered cases may occur with
us, but never in such numbers as reported by English writers. He comes
to the following conclusions: That dysentery in England is mainly con-
fined to insane asylums, and does not occur except rarely in other large
institutions, such as prisons and workhouses; that the increased precau
lions that have been taken during the past few years have made no appre-
ciable difference to the incidence of or the mortality from this disease ;
that there is strong evidence in favor of the view that not one, but many
micro-organisms, either singly or as a mixed infection, can give rise to
dysentery. From the fact that dysentery develops after a disturbance of
the subsoil in the neighborhood of an asylum, he argues that there must
be some relation between this disturbance and the disease. That the evi-
dence deduced from the relation between the inhalation of sewage effluvia
and dysentery supports the theory that asylum dysentery can be caused
by some microorganism which normally inhabits the colon and becomes
pathogenic when the resisting power of the tissue is sufficiently reduced.
That the occurrence of dysentery in members of the staff of an asylum is
probably due either to infection by a virulent form of some universal
organism, or to some normal colon organism becoming pathogenic, owing
to the reduction of immunity caused by the frequent breathing of an at-
mosphere permeated by a fecal odor. That there is strong evidence to
support the theory that, in the insane, the vitality and the resisting power
of all tissues to infection i- reduced, owing to the impairment of their
trophic nerve supply. That dysentery is particularly apt to occur in the
insane owing to the deterioration of nerve cells affecting the trophic nerve
supply to the colon. That it is far less apt to occur in congenital cases
of insanity or those in whom the mental disease is stationary. That the
statistical evidence is entirely against the view that dysentery is spread by
the transfer of recovered cases from ward to ward. He calls especial
attention to the fact that it is hardly possible that the disease is com-
municated from one person to another, thereby disagreeing with Mott,
who, in an earlier article on the subject, claimed the spread of dysentery
was due to imperfect precautions against infection, but with the best
possible means of precaution in Claybury Asylum had failed to lessen
the mortality of the disease. H. H. Cotton (Hathorne, Mass.").

Review of Neurology and Psychiatry *
(Vol. V. No. 3, 1907.)

1. Tabetic Atrophy of the Auditory Nerve. Cowers.

2. Alcoholic Psychoses : A Study of Their Mechanism and of Their Re-

lation to Other Mental Disorders. C. W. Chapin.

3. Dementia Pnecox. J. MacPhersox.

1. Tabetic Atrophy of the Auditory Nerve. — Gowers suggests that a
progressive reduction of hearing from above and below, analogous to

PERISCOPE 739

concentric restriction of the fields of vision; and a loss in the centre of
the range, analogous to a central scotoma in vision, make the diagnosis
probable of labyrinthine deafness due to atrophy of the auditory nerve :
and the significance of such deafness occurring in tabes is especially ^reat
«f the deafness accompany optic nerve atrophy.

2. Alcoholic Psychoses. — Chapin (of Ward's Island) mentions the
fundamental symptom elements of alcoholic insanity as apprehensiveness
and defective grasp.

Alcoholic insanity, lie thinks, is analogous in its mechanism to senile
psychoses, to the polyneuritic psychosis when due to other causes, and
to certain traumatic pychoses, but is fundamentally different from manic-
depressive insanity and dementia praecox.

3. Dementia Prcccox. — MacPherson presents an interpretation of
Kraepelin's conception of dementia praecox, quoting Kraepelin's observa-
tions on development, physical disturbances, etc., and analyzing the basic
symptoms of the disease. He considers that the great importance of Krae-
pelin's presentation of dementia praecox lies in the essential advance he
has attained in the prognosis of a hitherto unclassified group of cases.
His explanation of Kraepelin's 8 per cent, of recovery in dementia praecox
is that our knowledge is not sufficiently advanced to enable us to distin-
guish allied types which are not really cases of progressive dementia from
those which are. C. E. Atwood (New York).

Miscellany

The Bearing of Philosophy ox Psychiatry, with Special Referexce
to the Treatment of Psychasthenia. James J. Putnam (The
British Medical Journal, Oct. 20, 1906) .
There are two reasons why psychiatrists should study philosophy : It
helps to a better understanding of the origin of mental symptoms, and it
helps to dispel the mystery which surrounds the relationship between con-
sciousness and the material world. By philosophy a man is studied in his
relations to the community. Insanity in most of its characteristics is a
social concept : the general paralytic is usually detected as offending against
his social traditions. It is necessary to adequately help our patients, to
understand the relation of their consciousness to the material world.

C. D. Camp ( Philadelphia).

Gastric Neurasthenia. Hugh MacCallum (The British Medical Journal,
Oct. 20, 1906).
"There is no known functional disease of the stomach that cannot have
its cause and continuity in neurasthenia." Other organs such as the liver,
kidneys, etc., may be similarly affected. Neurasthenia may last for years
with dyspepsia as the only symptom. Signs of such condition are : Tiring
easily, malnutrition, mental irritability, insomnia, cutaneous flushing and
visceroptosis. The author regards as most essential in the treatment of
neurasthenia, the training of the body and mind, especially the latter. In
the discussion, Dr. William Calwell said that it was important to recognize
that neurasthenia might be secondary to chronic stomach affections, es-
pecially as it raised the question of operation. If there was a stomach
lesion operation would be of benefit.

C. D. Camp (Philadelphia).

740 MISCELLANY

The Microscopical Changes in the Nervous System in a Case of
Chronic Dourine, or "Mal de Coit," and a Comparison with
Those Found in Sleeping Sickness. F. W. Mott (The British
Medical Journal, Aug", n, 1906).
Dourine is due to a specific form of trypanosomc and affects equines,
being transmitted like syphilis by coitus. In the central nervous system
of a horse dying of the disease there was found a severe chronic inter-
stitial inflammation of the posterior spinal ganglia, especially severe in the
lumbo-sacral region, where there was also atrophy of the posterior roots
and their fiber continuations in the spinal cord not unlike the lesions in
locomotor ataxia. There was also a suhpial and septal proliferation of the
neuroglia which was not limited to the posterior columns.

C. D. Camp (Philadelphia).

Chorea. From a study and analysis of one hundred and eight cases of
ehorea treated at the Johns Hopkins Hospital and Dispensary.
W. S. Thayer (Journal A. M. A., Oct. 27).
Thayer concludes that there is good reason to think that well-marked
febrile symptoms, without rheumatism, occurring in chorea, especially if
they are accompanied with undue rapidity or irregularity of the pulse, is
at least strongly suggestive evidence of acute endocarditis. It is possible
that the fever may be the sign of a deeper lying infection back of the
chorea, but there is nothing in his study to settle the question whether
chorea represents a secondary infection or a special localization of an
infectious agent responsible for essential manifestations of the disease.
The study of the circulatory conditions in old patients still remains to be
carried out, but Thayer calls attention to the following' points of interest
thus far developed in his investigation: (1) Of 689 cases of chorea ob-
served at the Johns Hopkins Hospital and Dispensary during one or more
attacks, 25.4 per cent, showed evidences of cardiac involvement; such
evidence was present in over 50 per cent, of the patients studied in the
wards of the hospital. (2) Cardiac involvement occurred with somewhat
greater frequency in those cases in which there was a history of acute
polyarthritis than where such history was absent. (3) Cardiac involve-
ment was commoner in cases of chorea with frequent recurrences than in
those in which there was a history of a single attack. (4) In no cases of
chorea treated in the wards of the hospital there was fever of a moderate
extent in almost every instance. (5) In the large majority of the cases
in which high fever was present there was evidence of cardiac involvement.
(6) There is good reason to believe that the presence of fever in otherwise
uncomplicated chorea is, in a large proportion of cases, associated with
a complicating endocarditis.

A Case of Sudden Death Possibly Due to Vagus Inhibition. E. D.
Telford (The British Medical Journal, Aug. 18, 1906) .
A girl, aged eleven years, was operated upon under chloroform for
the removal of tuberculous glands from the right side of the neck. The
operation was tedious, but recovery from the anesthetic was prompt, the
only unusual feature being a pulse rate of 120. Two days later she sud-
denly died. At necropsy it was found that the right vagus nerve dis-
appeared into a mass of tuberculous glands the size of a filbert. The nenre
was swollen for one inch before its entry into the mass, while at the point
of entry it was constricted. The fibers of the nerve were frayed out in

MISCELLANY 741

the interior of the mass. Brouardel quotes a case of sudden death with
similar post-mortem findings. C. D. Camp (Philadelphia).

The Relation Between a Cutaneous Naevus and a Segmental Nerve

Area. G. Lenthal Cheatle (The British Medical Journal, Aug.

18, 1906) .

The author regards as unique in the literature a naevus occupying the

complete area of distribution of the third cervical nerve. The article is

illustrated by photographs, but further data of the case is not given.

C. D. Camp (Philadelphia).

The Bacillus Paralytica ns. F. W. Langdon (Cincinnati Soc. for Medi-
cal Research, October, 1906;
The bacillus paralyticans recently announced by Dr. Ford Robertson, of
Edinburgh, has been the subject of some research work in the clinical
laboratory of the Cincinnati Sanitarium, and pure cultures of the bacillus
and also photomicrographs were shown. It belongs to the diphtheroid
group, but unlike the Klebs-Loeffler bacillus is non-pathogenic to guinea
pigs, although fatal to rats in two or three months. In occurs in rods,
singly and with a tendency to groups of threes, and also in a thread form.
It has been found in the bronchial, alimentary and genito-urinary mucous
membranes, in the cerebrospinal fluid, in the brain, in the walls of the
cerebral blood vessels, in the blood, the urine and other secretions and
tissues. Robertson believes that it gains access to the system mainly
through the respiratory tract and the alimentary canal. Syphilis, alcohol-
ism, etc., are merely contributory factors in breaking down the defenses
of the body against bacterial invasion. The invasion of the blood, lymph
and tissues by the organism gives rise to the production of toxins, which
are responsible for the various trophic, degenerative, convulsive and
paralytic phenomena. The polymorphonuclear leucocytes exert a marked
lysogenic action upon this bacillus, and to this action is attributed the
recession of the bacterial invasion and the remissions so characteristic of
paresis. Like the Klebs-Loeffler bacillus, this organism appears remark-
able for its polymorphism. It occasionally shows barred as well as solid
color forms when stained with methyl blue and carbol fuchsin.

Langdon.

Cerebral Decompression. W. G. Spiller and C. G.-Frazier (Journal A.
M. A., Sept. 1, 8, 15 and 22).
From a rather extensive review of the literature, these authors
concluded that palliative operations in cases of cerebral tumor
are justifiable. Headache is the principal symptom calling for re-
lief; Spiller is somewhat skeptical as regards any beneficial effect on
Jacksonian convulsions. The possibility that operation may obscure focal
symptoms is considered and he advises that palliative operations be per-
formed before general symptoms become intense, and especially before
optic neuritis threatening blindness has developed. The general unanimity
as regards the effects on choked discs of opening the skull makes the
necessity of early operation very evident. Palliative operations are not a
substitute for radical measures. The tumor should be removed when pos-
sible and when sufficient skill is at command. There should be no attempt
to remove a glioma, and Spiller thinks that partial removal is generally in-
advisable. Sometimes complete relief may follow simple opening of the

742 MISCELLANY

skull and dura, but only one case of actual disappearance of a tumor seems
to be on record : that of Horsley. Spiller sums up his views as follows :
(i) "Palliative operations should be performed early in every case in
which symptoms of brain tumor arc pronounced and before optic neuritis
has advanced. (2) Partial removal of a tumor, especially of a glioma, is
a questionable procedure. (3) Palliative operation does not cause atrophy
of a brain tumor, and probably docs not arrest its gowth ; on the other
hand, it probably docs not hasten its growth. (4) Palliative operation is
not to take the place of a radical operation when the latter can be per-
formed without great risk to the patient. (5) In some cases the symptoms
of brain tumor disappear almost entirely for a long time or permanently
after a palliative operation. This result is obtained either by relief of
intracranial pressure or by removal of sonic lesion (meningitis serosa,
etc.), other than Drain tumor, and yet causing symptoms of tumor." The
surgical aspects of the subject are discussed by Dr. C. H. Frazier at some
length. The question whether a palliative or a radical operation is to be
•en is dependent on whether the tumor is operable or not, and there are
two classes of cases, he says, in winch a decompressive operation may be
required. One is when there is reason to believe that the tumor can not
be entirely removed and the other when it can not be localized and yet
the symptoms call for relief. This happens more frequently with cere-
bellar tumors, and in certain cases he has removed from one-quarter to
one third of the cerebellar hemisphere.

Case of Obscure Intracranial Tumor, with Extension to Fourth Ven-
tricle. G. H. Grant Davie (The British Medical Journal, Aug.
11, 1906) .
The first symptom noted was a severe occipital neuralgia which was
always most severe at about 5 A. M., and prevented further sleep. There
was also a choking sensation when lying down. Gait and station were
normal, but the patient had a sensation when walking or "running forward
1 m her toes all the time." The pain later increased in severity and extended
forward to the left ear and angle of the jaw. A kneeling position with
her forehead to the floor gave her the most relief. An eye examination
six weeks before her death showed 6-12 vision, but was otherwise negative.
At necropsy, a layer of soft gelatinous tissue was found covering to a
depth of one-quarter inch the whole of the anterior half of the under
surface of the left cerebellar hemisphere and extending as a delicate cov-
ering over the hinder half of the floor of the fourth ventricle. The
growth was distinct from the adjacent brain and was histologically a round
cell sarcoma with almost complete absence of intercellular stroma. The
ventricles were enlarged and filled with a clear fluid.

C. D. Camp (Philadelphia).

Book "Reviews

Demifous et Demirespon sables. Par Prof. J. Grasset, Professeur de
Clinique, Medicale a l'Universite de Montpellier, Associe National
de l'Academie de Medecine Laureat de Institut. Felix Alcan, Paris.

"Demifous et Demiresponsables," by Dr. J. Grasset, of Montpellier, is
a work of more than ordinary interest. No contribution to psychiatry
could be more opportune than this, for Dr. Grasset discusses the medico-
legal aspect of crime committed by persons who, through genius, heredity,
upbringing or trouble, are not wholly insane, and yet are not wholly sane.
It is a masterly discussion of the whole problem of the "borderland" cases.

He refutes the theories forced upon the nation by antiquated legal
restrictions, that all persons are either crazy or not crazy, responsible or
irresponsible. He establishes a middle class, which, he states, has never
yet been recognized by society ; a class which society must treat, and
against which society must protect itself. He says: "The half-insane
exist. It is equally erroneous and unjust to. class them either with the
insane or with the sane. They are different from the sane in that they
are psychically afflicted, and from the insane in that they preserve a certain
degree of reason."

Prof. Grasset mentions an interesting list of geniuses, including
authors, musicians, reformers of his own and other European countries,
whom he considers, as did Nordau, not wholly sane. But whereas
Nordau unjustly grouped them all with the insane, he more exactly defines
their position as Demifous.

One of the most interesting and opportune portions of his book is that
dealing with "The Demifous Before the Law." "Semi-Responsibility,
Limited Responsibility." "Let us assume," he says, "that a demifous has
committed a crime. He has become injurious to society. He is dangerous.
Society still owes him assistance and treatment, but it also has a right
to defend itself against his misdeeds. For him, one must not choose
cither a prison or an asylum, he needs both." In view of many examples
of the lack of specific legal preparation in dealing with semi-insane
criminals, Prof. Grasset's outline of how the law should be moulded to
treat such individuals is full of wholesome advice, which the medical pro-
fession will rejoice to point out to their legal brethren. Prof. Grasset
believes in shortening sentences, special regimen and penitentiaries, special
surveillance, and treatment after one sentence, and a special institution,
or at least a special section of some institution for the "demi-fous," or
half insane. Jelliffe.

Dews ant> note*

The Boston Society of Psychiatry and Neurology at its regular meet-
ing Oct. 17, 1907, adopted the following expression of its sentiments with
regard to the death of Dr. Charles Follen Folsom: Dr. Folsom was
one of the original and most valued members of the Boston Medico-
Psychological Society, the parent of the Boston Society of Psychiatry and
Neurology. His thoughtful contributions were always listened to with
the attention and respect accorded to an acknowledged authority and his
continued interest in our meetings was felt by all of us as a stimulus to
good work. His public labors were fruitful in many benefits to sufferers
from disorders of the mind. Not only was lie an admirable secretary of
the State Board of Lunacy and Charity, but it was due to the recommen-
dations of the special commission of which he was a member that the
present State Board of Insanity was established and the insane removed
from the almshouses and placed under the direct protection of the State.
His brilliant mind, his fertility of resource in the treatment of disease,
his deep sympathy for his patients and untiring devotion to their needs,
the far-reaching benefits to the insane of the Commonwealth from his
enlightened public work, his warm interest in the labors of his colleagues
and loyalty to the claims of friendship so won our regard and admiration
that we feel his death as a personal and public misfortune.

Note from Dr. Herman H. Hoppe:

At the request of Prof. H. Oppenheim, of Berlin, I gladly make the
following correction : In my article. "Brain Tumor Symptom Complex
Terminating in Recovery," I referred to Oppenheim's article in "Serous
Meningitis." In this article he speaks of a group of cases simulating
cerebellar tumor and expresses the opinion that the symptoms are caused
by some, as yet unknown, pathological change, which can disappear com-
pletely, or possibly by meningitis serosa or internal hydrocephalus. In
my reference I quoted Oppenheim as saying that they are caused by in-
ternal hydrocephalus.

Vol. 34. December, 1907. No. 12.

THE

Journal

OF

Nervous and Mental Disease

©riginal articles

ON ACROCYANOSIS CHRONICA AN.ESTHETICA WITH GAN-
GRENE; ITS RELATIONS TO OTHER DISEASES,
ESPECIALLY TO ERYTHROMELALGIA AND RAY-
NAUD'S DISEASE.*

By Lewellys F. Barker, aI.D., and Frank J. Sladen, M.D.,

OF BALTIMORE.

Vasomotor disturbances are commanding a steadily grow-
ing interest. With the demand for knowledge in regard to-
neuroses in general has come a special effort on the part of
scientific men to make clearer the very indefinite vasomotor
and trophic group. Pathological evidence is gradually ac-
cumulating, and experimental medicine is slowly coming to
its aid.

The group includes erythromelalgia, Raynaud's disease,
and a great number of symptom-complexes resembling these
two somewhat, but not sufficiently to be classified with either.
Scleroderma may be included, but it affects the whole body.
In this paper we wish to discuss those types which affect the
extremities particularly. Cyanosis of the extremities is seen
in many heart and lung conditions, and in Osier's polycy-
themia. The former are easily explicable ; the latter, as Sena-
tor1 points out, may be an affection of the bone marrow.

The idea that the vasomotor tropho-neuroses all belong
to one group is being more generally accepted, and this
is helping much to clear up the indefiniteness of the group.
The most confusing factor has been the number of cases
which do not fit any of the known clinical types. Indeed, it is

*Read at the thirty-third annual meeting of the American Neurological
Association. May 7, 8 and 9, 1907.

746 BARKER AND SLADEN

now commonly suggested that these neuroses may pass from
one type through intermediate stages into a second type.
Kollarits2 mentions cases of erythromelalgia passing into Ray-
naud's disease. Simple acrocyanosis (cyanosis of the extrem-
ities) is often the first stage of erythromelalgia. Legroux3
reports a case of chilblains, passing into permanent local
asphyxia, and later developing symmetrical gangrene.
Sachs1 states "Ii is very certain that erythromelalgia. Ray-
naud's disease, acroparesthesia, and even scleroderma often
merge into each other, or are associated with one another."

< )n analysis the symptoms of these vasomotor trophoneu-
roses fall into three main groups — vasomotor, sensory, and
trophic.

The vasomotor symptoms include ( I ) hyperemia, <2> syn-
cope, and (3) asphyxia; the sensory, (1) pain, (2) hyperes-
thesia, (3) anesthesia, and (4) paresthesia; the trophic. (1)
ulceration. ( 2 ) gangrene, and (3) dystrophies of the skin.

Perhaps the simplest type of vasomotor neurosis is simple
acrocyanosis, a symptom of the vasomotor group, which is a
prominent feature in many more complex neuroses. Mosse12
reported two cases of the simple acrocyanosis in mother and
daughter. Erythromelalgia is characterized chiefly by two
symptoms, hyperemia from the vasomotor group, and pain
from the sensory. Still more complex is Raynaud's disease
with symptoms from all three' of the groups. The vasomotor
are hyperemia, syncope and asphyxia; the sensory, pain, anes-
thesia and paresthesia: the trophic, gangrene. In addition
the distribution, and the course of the disease, are <<i value in
the diagnosis. All these disease- affect chiefly the extremi-
ties, though Weir Mitchell5 described erythromelalgia as more
common in the feet. Raynaud8 stated that his type of spon-
taneous gangrene occurs alike in hands or feet. The course
may be acute, paroxysmal, or chronic.

When the great number of combinations of these symp-
toms possible is realized, it is not surprising that new clinical
types are constantly being described. Among the interme-
diate forms are Schultze's7 acroparesthesia, Xothnagel'ss vas-
omotor neuroses. Cassirer's" acrocyanoses. Cassirer's com-
prehensive monograph® gives a complete description of each

ACROCYANOSIS 747

type of disturbance, and to him credit is due for development
of the idea of unification.

Our interest in the subject has been stimulated by the
following case, which came to the Surgical Clinic of the Johns
Hopkins Hospital for treatment for his toes, and was referred
to the medical side as a probable vasomotor neurosis.

B. J., aet. 44, (General No. 57,972). white, married, walked
into the ward with a slight limp, making use of a cane.

Complaint: "Nervousness and loss of ends of toes."

Family History : Father, 78, alive and well. Mother, 65,
alive and well. Brothers, four, alive and well.

Negative for rheumatism, tuberculosis, neoplasm, or nerv-
ous affections.

Past History: Measles, mumps, chicken-pox and whoop-
ing-cough when a child. Pneumonia when 25 years old, con-
fined to bed three weeks, with good recovery. No diphtheria,
scarlet fever, malaria, typhoid or rheumatic fever.

Head: Not subject to headache. Eyesight is poor and he
uses glasses to read. Cannot read very well, because of eye
pain and vision is blurred. No trouble with hearing. No nose
or throat trouble. No giddy or fainting spells.

Cardio-Respiratorv : No cough. Has shortness of breath
sometimes after exertion, as on going up stairs. No pain in
chest or palpitation of the heart. No expectoration. No
hemoptysis. Had occasional night sweats about two years
ago, which were not severe : none during past six months.

Gastro-intestinal : Negative. Appetite always poor. Di-
gestion apparently normal. Bowels usually move once a day.

Genito-urinary : No kidney or bladder trouble. No trouble
with urination. Had gonorrhea when 18 years old, which
was treated and evidently cured. Denies syphilis. No history
of secondary manifestations.

Neuro-muscular : Negative.

Habits: Smokes and chews tobacco, about five cents'
worth of each per week. From the age of 18 he has been a
heavy alcoholic drinker, up to one month before admission.

Work : Postmaster and station agent, necessitating much
standing and tramping about in the wet and cold in the win-
ter months.

Present Illness: Duration about 10 years.

The onset was gradual with the development of "cramp-
like pains in the legs, which were very severe, and came and
went quick as a flash." There was no sensitiveness of the
skin in the affected areas, but in the attacks the muscles of
the le°s became "hard as rocks.'' sometimes in one leg and
sometimes in both. The attacks were paroxysmal, coming on

748 BARKER AM J SLADEN

at night usually, after a hard day's work, and especially after
much tramping about in cold, damp weather. They might oc-
cur every night for several days, and then he would be free
of them for two or three weeks.

Five years ago they disappeared. At this time he worried
a great deal about his condition and became very nervous. He
would ''tremble all over" and did not feel able to do his work.
He had great difficulty in reading and writing telegrams.

He remembers several attacks of slight numbness in his
fingers, lasting from five minutes to an hour, but does not
think they changed color. Nor was there pain associated
with the numbness. What bothered him most was the change
in the feelings of his legs. The sensations were "not natural."
They gradually became numb and felt as if pins and needles
were sticking in them. He had them massaged for a time,
until he found the skin was being rubbed off without his real-
izing it.

Three weeks before admission, while taking a bath, he no-
ticed the skin over the second toe of the right foot was
wrinkled. On taking hold of it, the nail and part of the end
of the toe came off, absolutely without pain. Several days
later he pulled off the tip of the big toe upon the same foot in
removing his shoes and stockings. There are <*ores also
upon the third toe of the right foot and big toe of the left. At
no time has he experienced any pain. During these three
weeks the feet and legs have been swollen, especially the right,
and their color has been a diffuse deep red, at times changing
to a bluish red. There has been no loss of muscle power, but
a slight stiffness of the ankles and knees has bothered him in
walking.

Examination on admission : Patient was admitted this
noon, walking with a slight limp. He was put to bed and the
feet dressed at once. After removing a dressing of cotton and
carbolic salve, they were cleaned and put up in balsam Peru.
The first two toes of the right foot showed an ulcerating sur-
face with considerable loss of tissue, exposing the bone of the
terminal phalanges. The tissue surface was clean and moist.
There was no pain or tenderness even on the raw surfaces. An
abrasion of the skin of the third toe was covered with a hemor-
rhagic crust. On the plantar surface of the ball of the left big
toe wras a cleanly-cut. round ulcer, rather superficial. Both
legs were edematous to the knees, the right the more so, and
the right was more red and hot. Both feet were cyanotic,
shading to a pink color on the legs. A faint pulsation was felt
in the dorsalis pedis artery of the right foot — a better one,
though still weak, in the post-tibial. A good pulse was felt
on the left. Pulsation was strong in both femoral and popliteal
arteries. No special enlargement or tenderness of the glands

ACROCYANOSIS

749

of the groin.

No red lines of lymphangeitis. Patient com-
plains of anesthesia to touch over the lower legs. Rough ex-
amination shows it present to some degree below the knees.
No pain complained of, even when the fibers of cotton were
being picked from the raw surfaces.

Fig. i. Sketch of right foot, showing slough of the first two toes and
abrasion on the third.

Face flushed. Dilated venules over nose and cheeks. Eyes:
suffused ; pupils react to light and accommodation ; muscular
movements good; sclera clear; conjunctivae rather pale. Ears:
negative for tophi or discharge ; no pain on pressure over audit-

750 HARK UK AND SLADEN

ory canal or mastoid. Lips clean. .Mucous membranes fair color.
Tongue slightly coated with small clean ulcers on edges. Tonsils
a little large. No reddening or plugs. Moderate injection of
pillars and pharynx. Neck negative. Thyroid gland not palpable.
Xo general glandular enlargement.

Chest : Well formed. Epigastric angle about 90 deg. Ex-
pansion fair, equal. Vocal fremitus ever) where present.
Lungs clear on percussion and auscultation, except for occa-
sional squeaking rales scattered here and there.

Heart: Point of maximum impulse not visible or palpa-
ble. Sounds beard best in fourth interspace about 8 cm. from
median sternal line. Relative cardiac dulness to mamillary
line to left in fourth interspace, and 3 cm. to right in third in-
terspace and up to upper border of third rib. Sounds clear at
apex and base. Aortic second and pulmonic second both loud,
pulmonic second slightly the louder.

Pulse: 25 to LL regular in force and rhythm; good size:
moderate tension; vessel wall just felt.

Abdomen: Looks natural. Respiratory movements free.
No tenderness, muscle spasm, or rigidity. Tympany in flanks.
Spleen not felt and dulness not increased. Liver dulness from
fourth interspace to two ringers' breadth below costal margin
in right mamillary line. Edge indistinctly felt.

Genitalia: Negative; no scars, no discbarge. Testicles
normal.

Reflexes: Knee-jerks active and equal: Achilles reflexes
present. Plantar reflexes normal. Biceps, triceps, and perios-
teal radial reflexes active and equal. Abdominal and cremas-
teric reflexes present.

Note: — The accompanying chart shows the partial sensory
disturbance.

Note, 4th day of admission : Arteries at wrist not palpa-
ble. Temporals not increased. Eemoral pulse palpable.

Left arteria dorsalis pedis is palpable, — not felt on right.
During examination right foot becomes bathed in sweat, left
only slightly so. Posterior tibial artery is palpable on both
sides. On left foot is a small round ulcer, on ball of big toe,
covered with bloody scab. On right foot, tip of big toe is
gangrenous, exposing last phalanx ; also second toe. On outer
side of third toe is a superficial ulceration covered with scab.
Right foot the warmer.

Reflexes: Biceps lively on right and left, others not re-
markably active. Knee-kicks present. Babinski negative.

If pulse in right arteria dorsalis pedis is not absent, it is
greatly diminished.

Note, 14th day of admission : After two weeks in bed. the
superficial ulcer on left big toe was healed, as was the abra-
sion on the third toe of the right foot. But the raw surfaces

ACROCYANOSIS

75 1

of the first and second toes on the right showed no such ten-
dency, until the terminal phalanges were disarticulated by
Dr. Sowers. The recovery then was uneventful.

It was at this time, however, that definite hyperesthesia of
the soles of both feet developed. Patient could not endure
the bed clothes upon them at times. As he explained it, '"they
were extremely sensitive."

Note, on 28th clay after admission : Both upper extremi-
ties and lower are moderately cyanosed. The toes look much
as they did before operation, except that the exposed ends of
the bones are missing. There is a palpable pulsation in each
arteria dorsalis pedis. There is very slight anesthesia to pain

- I] ~

Fig. 2. Areas of impaired sensations of touch, pain and temperature.

in lower limbs. Evidently marked disturbance in tempera-
ture sense below knees, especially in lower half of legs. No
marked disturbance in kinesthetic sense in both legs (at toes),
though a little dulled ; sharp at ankles and knees. Hands and
feet are now markedly cyanotic : a considerable increase is
noted in the cyanosis since the examination began. Bone vi-
brations (of tuning fork) are well felt in upper extremities and
in tibia?; but are a little dull in feet. No dulling at all in upper
extremities distally. No hemianopsia. Cyanosis now at wrist.
Marked goose-flesh. It is important to note how the cyanosis
has progressed during the 15 to 20 minutes of examination.

Note on 42nd day : Marked cyanosis of right foot. Big
toe now looks well. Cyanosis of left foot comes out under
examination. Hands cold and cyanotic. Radial pulse good,

752 BARKER AND SLADEN

also that in the arteria dorsalis pedis — the left pulsates more
than the right. Posterior tibial artery beats on both sides.
Some pain in the second toe, and some pus can be expressed.

There is no syncope when the fingers are immersed in ice
water, nor asphyxia when in warm water.

On discharge : Hands cyanotic to-day. Right foot is nor-
mal. Left foot shows slight anesthesia. Knee-jerks are pres-
ent and active. Plantar reflexes normal. Pulse is better in
the left dorsalis pedis artery than in the right. No muscular
atrophy.

The blood examination on admission showed: Red blood
corpuscles, 4,354,000: hemoglobin. 86 per cent, by the Sahli
instrument. It remained practically the same and on dis-
charge there were: 4,644,000 red blood corpuscles, and 85 per
cent, hemoglobin (Sahli).

A leucocytosis of 19,460 on admission was associated with
a slight bronchitis : it fell gradually to 6,740 on rest in bed and
after the amputation and cleansing of the wounds.

The differential count on smears made when the leuco-
cytes were 19,460 was:

Polymorphonuclear neutrophiles .. .468 or 93.6%

Polymorphonuclear eosinophils ... 6 or 1.2%

Large mononuclears 7 or 1.4%

Transitionals

Lymphocytes 18 or 3.6%

Mast cells 1 or 0.2%

Myelocytes o or 0.0%

Total 50ocellsioo%

Xo nucleated red blood corpuscles are found.

The fresh blood at no time showed any evidence of the
presence of parasites.

The coagulation time was delayed, — 10*4 and 123^ m., — on
two observations by the Boggs instrument.

The blood pressure (maximal) varied from 100 to 120 mm,
of mercury by the Riva Rocci instrument.

The temperature rose during a throat infection, and the
increase in the rate of the pulse and respirations was parallel.
Otherwise pulse and respiration were normal.

Urine: 800 to 1.400 c.c. daily: yellow to orange in color:
specific gravity 1.020 on the average: no sugar: an occasional
faint trace of albumin and an occasional granular cast; no
bile pigments.

Sputum and Stools: negative.

Weight, 131 pounds on admission : T27 pounds in second
week : and 133 pounds on discharge.

ACROCYANOSIS 753

An analysis of this case with the schema above described
kept in mind, will make its nosological localization simple.

The vasomotor symptoms present are ( 1 ) cyanosis, and
(2) swelling of the soft parts; the sensory are (1) paresthe-
sia, (2) anesthesia, not in the distribution of any nerve, (3)
hyperesthesia, and (4) no pain; and finally, the trophic are
(1) dystrophy of skin over toes, (2) subsequent loss of tissue,
exposing the bones, and (3) a malum perforans.

Localization : the fingers, the toes, feet and legs, but more
on the right than on the left.

Course: Chronic, progressive, and not paroxysmal.

This agrees, as it will be seen, with no one of the symp-
"tom-complexes above described. In considering the differen-
tial diagnosis a number of diseases might be thought of. The
case can scarcely be regarded as Raynaud's disease. The ab-
sence of syncope and of pain, and the fact that it is not par-
oxysmal distinguish it. There are no attacks of red, white and
'blue fingers. There was, however, gangrene.

Erythromelalgia is characterized by. a hyperemia rather
than a cyanosis : by pain and hyperesthesia, not anesthesia and
•paresthesia: by the absence of gangrene and such trophic dis-
turbances. The dependent position brings on the attack.

Diabetic gangrene with neuritis and arteriorsclerosis is ex-
cluded by the urinary examinations.

Senile gangrene is not warranted by the age of the patient
or the condition of the arterial walls.

Tabes dorsalis. despite the anesthesia and malum perfor-
ans, can be ruled out. The knee-jerks are active on both
sides. The pupils are equal and react to light. The muscle
sense is nearly perfect.

Syringomyelia need not be considered, since the lower
extremities are chiefly affected, the anesthesia does not pre-
sent the type of syringomyelic dissociation, and there is no
segmental distribution of the anesthesia, and no muscular
atrophy.

Peripheral neuritis cannot be excluded. Certainly the per-
ipheral nerves are involved and the alcoholic history and the
plantar hyperesthesia are very suggestive. The muscle power
is not affected. There is no muscular atrophy or fibrillary
twitching. There is no pain. The leprous form (lepra mu-

754 BARKER AND SLADEN

ti'lans) is excluded by there being no thickening of the periph-
eral nerves, especially X. auricularis magnus, nor islands of
anesthesia, nor a leontine facies. How large a part the in-
volvement of the nerves plays in the development of the syn-
drome we cannot be certain.

Finally the symptomatic diagnosis of acrocyanosis or acro-
asphyxia may be made with certainty. This really is but a
symptom, which indeed our case shows prominently. But
Cassirer7 makes this symptom the keystone to many com-
plexes, qualifying it symptomatically by chronica, anesthetica,
hypertrophica. and so on as the case may be. He describes a
case which he thinks is unique, in a maiden of 19. The trouble
followed frost bites. The hands and feet became bluish red
and cyanotic, but not syncope occurred. Paresthesia was com-
plained of. Small fissures on the hands were painless. All the
sensory modalities were impaired somewhat. There was no mus-
cular atrophy and motility was interfered with only by the stiff-
ness of the joints due to the swelling. This complex he calls
"Acrocyanosis chronica anaesthetica," on the basis of symptom-
atology.

XothnageP describes the only other case like it which can
be found in the literature. Briefly, it was in a kitchen maid of
28, Avho was accustomed to soaking her hands in water.
Numbness and tingling in the finger tips appeared first. They
felt dead. Later the hands and feet were involved and cyanosis
developed. There was no pain or muscular atrophy, but the
sensory disturbances were general.

Our case differs from these only in the addition of gan-
grene and ulceration. The other symptoms are almost identi-
cal. So we might agree with Cassirer that our case is one of
Acrocyanosis chronica anaesthetica, — but with gangrene. Consid-
ering the group as a whole, our case is one step from Acrocyan-
osis chronica anaesthetica toward Raynaud's disease.

Cassirer describes many cases which lead to hypertrophy
of the soft parts and resemble acromegaly, like Kollarits' case,
for instance, but in his complete survey of the literature pre-
vious to his time, he found none which led to gangrene.

Legroux3 reports a case of "permanent local asphyxia" of
the hands and feet, following chilblains. The trophic disturb-
ances were marked in the skin and finger nails, and there was

ACROCYANOSIS 755

a spontaneous amputation of the terminal phalanx of the right
forefinger, absolutely without pain. Muscle power was in-
tact. Cassirer does not mention this case among the acro-
cyanoses, but discusses it under Raynaud's disease. Of course
it is clear that it is almost identical with our case.

In another case of Legroux's, following chilblains, acro-
cyanosis was followed by gangrene and spontaneous amputa-
tion of the terminal phalanges of the third and fourth toes of
the left foot and later of the small toes of both feet. But the
analogy is incomplete on account of the presence of pain in the
second amputation. Pain, of course, allies this case still closer
to Raynaud's disease.

Legroux suggests that in these cases the chilblains, the
permanent symmetrical asphyxia, and the subsequent gan-
grene are degrees more and more accentuated of a necro-
pathic dystrophy.

Eisner10 and Sachs" have reported cases of erythromelalgia
associated with gangrene, but these cannot be confused with
our case. The pains and the intensification of the symptoms
when the extremity is in the dependent position make the dis-
tinction clear.

In fine, we have found but one case in the literature similar
to ours — that of Legroux's. These two we feel are intermedi-
ate forms more closely allied to the acrocyanoses than to
either erythromelalgia or Raynaud's disease. And we suggest
as a rational terminology clearly representing the type "Acro-
cyanosis chronica ansesthetica cum gangrama."

BIBLIOGRAPHY.

'Senator, F. "Ueber Erythrozytosis megalosplenica." Ztschr, i. klin.
Med., 1906, XL., 357.

2Kollarits, J. "Acrocyanose mit Schwellung der Weichteile." Deutsches
Arch. f. klin. Med., 1905, LXXXVI., 504.

3Legroux. "Asphyxie locale des extremities. Les rapports avec les
engelures." Ann. de dermat. et syph.. Par., 3.S., 1892, III., 184.

*Sachs, B., and Wiener, A. "Some Tropho-neuroses and Their Rela-
tion to Vascular Disease of the Extremities." Phila. M. J., 1901, VII.,
1 242- 1 246.

"Mitchell, S. Weir. Phila. M. Times, 1872, III., 81; 113. "On a Rare
Vasomotor Neurosis of the Extremities, and on the Maladies with which
It May Be Confounded." Am. J. M. Sc, Phila., 1878, LXXVI., 7.

"Raynaud. M. "De l'asphyxie locale et symmetrique gangrene des ex-
tremites." These de Paris, 1862. "Nouvelles recherches sur la nature et
le traitement de l'asphyxie locale des extremites." Arch, gen de med.,..

756 BARKER AND SLADEN

Par., 1874, I., s ; 189. Barlow, T. Translation of Raynaud's two articles.
Selected Monographs, New Sydenham Society, 1881, 1.

TSchultze. "Ueber Akroparasthesie." Deutsche Ztschr. f. Nervenh.,
1892, III., 300.

"Nothnagel. "Zur Lehre von der vasomotorischen Neurose." Deutsche
Arch. f. klin. Med., 1867, II., 173.

"Cassirer. "Die Vasomotorisch-trophischen Neurose." S. Karger, Ber-
lin, 1 901.

10Elsner. "Ervthromelalgia Associated with Raynaud's Disease." Med.
News, Phila., 1897, LXX., 817.

"Sachs, B. "On Erythromelalgia." Mt. Sinai Hosp. Reports, 1898.

,2Mosse. "Akrocvanosis Chronica." Berl. klin. Wchnschr., 1906,
XLIII., 276.

POST-APOPLECTIC TREMOR (SYMMETRICAL AREAS OF

SOFTENING IN BOTH LENTICULAR NUCLEI AND

EXTERNAL CAPSULES.)*

By John H. W. Rhein, M.D.,

OF PHILADELPHIA.

NEUROLOGIST TO THE HOWARD HOSPITAL; PHYSICIAN TO THE PHILADELPHIA

HOME FOR INCURABLES, ETC.

AND

Charles S. Potts, M.D.,

OF PHILADELPHIA.
ASSOCIATE IN NEUROLOGY, UNIVERSITY OF PENNSYLVANIA. NEUROLOGIST TO

THE PHILADELPHIA HOSPITAL.

The features of interest in the case to be reported are,
clinically, a tremor of the right arm, resembling post-hemiplegic
tremor, and ataxia of the arms and legs, and, pathologically, the
presence of symmetrical lesions of the putamen.

The patient, a man of 58, was admitted to the Philadelphia
Hospital on April 20, 1903, his chief complaint being difficulty
in walking. The family history, as well as the previous history,
were unimportant. Owing to the mental condition of the patient,
a reliable account of the onset of his disease was not obtainable,
his answers being frequently contradictory.

He stated when admitted that his present trouble had begun
3 years previously. He complained of pain in the head, weakness
and numbness of the legs, and weakness of the right arm. At
this time nothing of moment was noted excepting that the right
knee jerk was increased, some ataxia was present in the upper
limbs, and the patient had a tendency to lose his balance if he
turned suddenly while walking. There was no Babinski reflex,
and no apparent weakness in any of the limbs.

He came under the care of one of us (Dr. Potts) in April,
1906. At that time the peculiar movements of the right arm at-
tracted attention. These consisted of alternate flexion and exten-
sion at the elbow and wrist, the hand being supinated. The move-
ments were almost constant, only ceasing for a time if his atten-
tion was distracted. At this examination he told a somewhat
different story than at first, saying that at the beginning of his
disease he noticed weakness of the legs, the left being weaker

*From the Department of Neurology and the Laboratory of Neuro-
pathology of the University of Pennsylvania and from the Philadelphia
General Hospital. Read by title at the thirty-third annual meeting of the
American Neurological Association, May 7, 8 and 9, 1907.

75*

RHEIN AND POTTS

than the right, and that these symptoms dated back eleven years,
following what he called "a cold." Six years later the right arm
became affected, the disorder consisting at first of a difficulty in
writing. Examination at this time showed a somewhat ataxic
gait, which was more apparent with the shoes off. The right leg
was held more stiffly than the left. Station, with the eyes closed,
was poor, and there was also marked ataxia of the arms, especially
.the right. There was apparently no weakness of the arms. The

Fig. i. Linear area of softening in external capsule on right side Upper
limit. (Macroscopical section.)

legs appeared to be somewhat weaker than normal. The biceps,
triceps, and wrist jerks were not marked. The knee-jerks
were prompt, the left being more so. The plantar reflex gave a
normal response. Examination of the eyes showed a sluggish
,'ponse to light, but otherwise they were normal.
The brain and spinal cord were turned over to Dr. William G.
Spiller, who gave them to one of us (Dr. Rhein) for examination.
The specimens were hardened in formalin.

POST-APOPLECTIC TREMOR

759

Horizontal sections of the brain on the right side revealed
the presence of an area of softening which first made its ap-
pearance a short distance above the lenticular nucleus, and was
situated in the external capsule, i. c, between the claustrum and
the internal capsule. This area of softening was linear in shape,
and measured at this level 2.5 cm. in length, and about 1 to 2
mm. in width. While it lay directly external to the fibers of the
internal capsule, it did not cause any degeneration of these fibers.

Fig. 2. Area of softening extending into the middle portion of the right
putamen (microscopical section, section reversed in photograph).

The focus extended downward in a vertical direction to a position
corresponding to the lower limit of the island of Reil. At the
lower level of the lenticular nucleus it destroyed in part the ex-
ternal portion of the putamen in its posterior third. At the level
at which the fasciculus of Titrck is seen ("temporale Briicken-
bahn" — Obersteiner) these fibers were in part destroyed. The
anterior commissure was intact, as were also the fibers of the

/6o

RHEIN AND POTTS

internal capsule. The fibers of the external part of- the foot of the
peduncle, corresponding to the situation of the fasciculus of
Turck, stained poorly. The red nucleus appeared to be intact.

On the left side of the brain there was a similar lesion which
began at a somewhat lower level than the one on the right side,
its upper limit being at about that level where the lenticular nuc-
leus is first seen in horizontal sections, It was situated in the
same relative position as that of the cavity on the right side,
occupying the region of the external capsule between the claus-
trum and the putamen. and measured 3.5 cm. in length, and 10
mm. in its widest portion. It extended downward in a vertical

Fig. 3. Area of softening in the posterior portion of the left putamen
(microscopical section, section reversed in photograph).

direction, and disappeared a little above the level of the lower
border of the island of Reil. The posterior third of the putamen
in its lower part was in large measure occupied by this focus of
softening. The fibers in the retro-lenticular region were more
or less involved.

The fibers in the internal capsule were not degenerated. The
red nucleus appeared to be normal.

POST-APOPLECTIC TREMOR 761

Certain fibers passing inwardly and apparently through the
lenticular nucleus toward the thalamus, stained well on both sides.

In sections from the pons, medulla oblongata and spinal cord
the nerve fibers stained normally. There was no evidence of
descending degeneration in the pyramidal tracts.

The cells of the anterior horns in the cervical and lumbar
regions, stained by hemalum and acid fuchsin, showed no marked
change.

Sections from the cerebellum showed an unusual vascularity
of the dentate nucleus on both sides. The vessels were numerous
and somewhat thickened, and surrounded by a slight round-cell
infiltration, and there was also some fresh hemorrhage about some
of the vessels.

To summarize the pathological findings in this case, there was
an area of softening in each putamen, which caused degeneration
in the fasciculus of Tiirck, on the right side. There was no de-
generation in the motor fibers of the internal capsule, the pons,
medulla oblongata or spinal cord.

Associated with these pathological findings, the tremor of
the right arm and the ataxia of the arms and legs are worthy of
some discussion.

In regard to the first of these symptoms, namely, the involun-
tary movements of the right arm, which resembled a post-hemi-
plegic tremor, it is interesting to note that lesions of the lenticular
nucleus have been thought by some to cause post-hemiplegic
chorea. Among the first to describe cases of this nature was
Demange,1 who, in 1883, reported 11 cases with autopsy, in 6 of
which the lenticular nucleus was the seat of disease.

Sander,2 in 14 cases of athetosis collected from the literature,
found the corpus striatum involved in 7 cases. In the case de-
scribed by Grasser and Rauzier3 the lenticular and caudate nuclei,
and the internal capsule were partly destroyed by an area of
softening.

The putamen was symmetrically diseased in one case described
by Heboid,4 and in a second case the claustrum was also involved
on both sides. He quotes Nothnagel who collected cases of athe-
tosis and hemichorea, in which the lenticular nucleus and the in-
ternal capsule were involved. In Anton's5 case the choreiform
and athetoid movements were on the same side as the lesion in the
putamen, and in Jacob's6 case the contralateral lenticular nucleus
was the seat of the disease.

762 RHEIN AND POTTS

Many cases have been cited in which, besides the lenticular
nucleus, the thalamus has also been involved. This was true in
50 out of 78 cases collected by Bidon.7 In about 100 cases studied
by v. Monakow,* in 70 per cent, to 80 per cent, there was also
lesion of the internal capsule.

On the other hand, bilateral lesions of the lenticular nucleus
may occur without causing tremor, as in Edinger's9 ease, and in
2 cases of Heboid.

If foci of softening or other lesions of the lenticular nucleus
cause tremor, it is hard to reconcile entirely the findings in our
case with this statement, as tremor was only present in the right
arm, while the putamen was diseased on both sides. ( >f interest
in this connection is the opinion of Heboid who believed that a
different explanation for the motor disturbances than injury to
the putamen. must be looked for, at least as far as the outer
portions are concerned.

It should be remembered, however, that in our case the lesion
caused much greater destruction in the left putamen than in the
right, involving, in the former, a large part of the posterior third
of the putamen. while on the right side the lesion was linear in
shape and occupied the external portion, the destruction of the
putamen being less extensive. It may be that the lesion on the
right side was not sufficiently large to cause disturbances of mo-
tion, while the damage to the left putamen. being much more
extensive, was sufficient to give rise to a tremor in the right arm.
This is of course somewhat theoretical.

At least the findings in our case permit the statement that
bilateral lesions of the putamen do not always cause bilateral dis-
turbances of motion.

The pathology of post-hemiplegic disturbance of motion has
not been definitely established, and the views held upon the ques-
tion are far from uniform. ( )n the whole, however, the weight of
evidence is in favor of placing the lesion in one of several locali-
ties, and preferably in the thalamus, or in the pons, in the neigh-
borhood of the superior cerebellar peduncles and red nucleus.
Many observers have, however, described tremors, choreiform
movements and athetosis post-hemiplegic in type, in organic dis-
ease of the cerebellum, medulla oblongata, cortex and spinal cord.

Lesions of the thalamus have been regarded by many ob-
servers as the chief cause of these movements. Since Charcot.10

POST-APOPLECTIC TREMOR 763

in 1873, reported 3 cases with autopsies, in which the lesion in-
volved the posterior portion of the optic thalamus, caudate nuc-
leus, and corona radiata, a number of cases of this character have
been described, namely, those of Stephan,11 Sander, Gowers,12
Bidon, Kahler and Pick,13 Raymond,14 Bischoff,15 and Leyden,"'
who found various lesions affecting the thalamus, with or with-
out involvement of the surrounding tissues.

In 100 cases studied by v. Monakow, it is stated that, in the
majority of cases the lesion was found principally in the thalamus.
In another group of cases the retrolenticular portion of the in-
ternal capsule and the thalamus were the seat of disease, while
in the remainder of the cases the posterior portion of the corona
radiata and the lenticular nucleus were involved.

Raymond, however, on the contrary, noted in 35 cases of
hemiplegia, involvement of the thalamus in only 4 cases, and
Sander believed that there were only a few cases in which the
thalamus alone was involved. Moreover, the thalamus and the
internal capsule were affected together in 20 cases in the literature
studied by Stephan.

The relation of the post-hemiplegic movements to the cere-
bellar peduncles, the tegmentum, and the red nucleus, was prob-
ably first described by Benedickt17 who. in 1874. reported 22 cases
of hemiparesis and chorea caused by a lesion in the cms cerebri,
at the height of the oculomotor nucleus. Halban and Infeld18
added to these 2 cases of their own. in one of which a tuberculous
focus had destroyed the red nucleus in large part, extending al-
most to the decussation of the superior cerebellar peduncles.
Henoch1'' also observed a case with tremor, hemiplegia, and
crossed oculomotor palsy, in which there was found a tuberculous
lesion of the pons and corpora quadrigemina, and Bergen-" col-
lected 10 cases in which the cerebellum and superior cerebellar
peduncles were destroyed, causing incoordination identical with
hemichorea on the same side as the lesion.

The superior cerebellar peduncles, the red nucleus and the
tegmentum were diseased in a case reported by Bonhoffer,21 who
believed that choreiform movements and athetosis were due to a
lesion of the centripetal fibers extending from the cerebellum to
the cerebral cortex, giving rise to a functional disturbance of the
motor cells of the cortex. He advanced three reasons for accept-
ing this view, namely, (1) the constant presence of a lesion of

764 RHEIN AND POTTS

the superior cerebellar peduncles, or its projections into the sub-
cortical ganglia; (2) the hypotonia of the musculature; (3)
the disturbance of voluntary motion in chorea. He thought it
probable that, in consequence of a more or less complete interrup-
tion of the fibers, the centripetal impulses only in part reached
the cortex, while others passed along the centrifugal fibers and
gave rise to automatic movements the character of which de-
pended upon the nature and extent of the lesion.

Pineles22 reported 2 cases of athetosis which he considered of
cerebellar origin, and cited the case of Oliver, in which there was
a glioma of the vermiform process in a case presenting tremors
of the arms and legs. He cited also Menzel's case of choreiform
movements with atrophy of the cerebellum, a similar case of
Meynert's, Ceni's case of atrophy of the right hemisphere of the
cerebellum, and right cerebellar peduncle, with a hemorrhagic
focus in the left red nucleus, and Sander's4 case in which there
were choreiform movements on the right side, caused by a glio-
sarcoma in the right cerebellum, destroying the corpus dentatum.
Pineles concluded that in many cases choreiform movements and
athetosis were caused by disease of the cerebellum, or' the cere-
bellar peduncles. Other cases of a similar nature have been re-
ported by KirschofF.23 Bonhoffer. Huppert,24 Muratoff,25 and
Hammarberg.2f' In Hammarberg's case the movements were
pendulum-like.

Lesions in the medulla oblongata, causing hemichorea, were
described in Bidon's cases (collected from the literature), in v.
Monakow's case and in the cases of Fropier,27 and Broadbent
(in v. Monakow) and Henoch.

Cortical lesions have been described as causing athetoid and
allied movements in the 2 cases of Demange, and those of Bal-
four,28 Beach,29 Korella,30 and Hudovernig.31 Some of these
cases are. however, so meagerly reported as to be of little value.

Opposed to this is the statement of Exner (in Frey) who
collected 167 cases of cortical lesion without one instance of post-
hemiplegic tremor. In this connection, as bearing upon the irri-
tation of the motor tracts as causing post-hemiplegic movements,
must be mentioned the cases in which the internal capsule has
been the seat of the lesion, as illustrated by the case of Demange,
and those collected by v. Monakow, Bidon (29 cases), and others.

Finally, Eisenlohr32 and Anton describe cases in which spinal

POST-APOPLECTIC TREMOR 765

lesions were mentioned as causing the movements under discus-
sion.

Several theories have heen advanced to explain the occurrence
of these movements, among the first of which was that of Charcot,
who believed that they were due to disturbances of a "chorea-
bundle," a view long since abandoned.

Kahler and Pick, who concluded that cysts or areas of soften-
ing in the thalamus, with or without involvement of the internal
capsule, give rise to hemichorea and other disturbances of motion,
believed that these were due to irritation of the pyramidal fibers,
a view also held by Sander,39 Demange. Kolisch,33 Hudovernig,
and Nothnagel,34 Frey40 and others, however, object to this theory
on the ground that the usual result of irritation of the pyramidal
tracts is to cause convulsions and spasms ; that hemiplegia is a
frequent occurrence, while choreiform movements are rare ; that
lesions removed from the motor tracts cause these symptoms ;
that paresis is absent in some cases ; that it is improbable that
complicated movements should remain circumscribed if thus ex-
plained (v. Monakow) ; that the head is affected in deep-seated
lesions, and that these symptoms are infrequent in lesions of the
lenticular nucleus (Frey). Furthermore, it is advanced by some
authorities that cortical lesions rarely cause post-hemiplegic move-
ments, although the cases of Demange controvert this statement.

Von Monakow does not subscribe to the view held by Kahler
and Pick and others, that these movements are the result of irrita-
tion of the pyramidal fibers which is conveyed to the cells of the
anterior horns of the cord, but in his opinion the tissues sur-
rounding the lesion, as in the subthalamic area, the tegmentum
and the pons, become irritated, and that this irritation is trans-
mitted to the motor cortex.

Bonhoffer, in explaining the symptoms, believed that the
different choreiform movements are caused by alterations of the
impulses which normally pass to the cerebral cortex through the
tegmentum. As already stated, he believed that it was plausible
that impulses pass centripetally to the cerebral cortex in part
only while others pass directly in the centrifugal motor fibers,
and give rise to automatic movements.

According to Frey and Stephan, the thalamus is a coordin-
ating center which, when disturbed, gives rise to post-hemiplegic
•disturbances of motion. Frev believed that the cause of these

766 RHEIN AND POTTS

movements is to be found in lesions of the thalamus and hypo-
thalamic region.

Anton held that automatic associated movements origin-
ated in the posterior part of the optic thalamus and its connec-
tions, while the corpus striatum inhibited these movements. There-
fore, lesions of these ganglia cause a lowered inhibition, and in
consequence an increase of the automatic movements, or chorea.

Hainan and [nfeld believed that fibers going through the red
nucleus have to do with a complicated mechanism, and that dis-
turbance of these fibers gives rise to the automatic movements.

According to Sander, disease of the thalamus was the cause
of athetosis in his case, and he expressed the opinion that lesion
of the motor tracts causes in part of the fibers incomplete inter-
ference with the passing of nerve impulses, and that the ac-
cumulation of these impulses centrally from the lesion. /'. c, in
the cortical cells, hecomes so intense from time to time as to
overcome the resistance at the point of the lesion, giving rise to
movements of a rythmical nature.

Pineles inclined to the belief that while these movements may
be associated with irritation of the pyramidal fibers, many of
the facts speak for the relation of chorea to the superior cere-
bellar peduncles. He believed that the choreiform movements
were the result of loss "i function (an "ausfall" symptom).

( )ne is struck, in studying the cases and the various theories
above cited, with the fact that the majority of lesions described
affected centers or fibers which are connected directly or in-
directly with the cerebellum, and it does not seem improbable
that, in some way not perfectly clear, the function of the cere-
bellum, at least as far as co-ordination is concerned, may be dis-
turbed, and. as a result, give rise to choreiform movements, athe-
tosis and tremor, which, according to some observers at least,
may be looked upon as allied disturbances of motion.

The findings in our case may add weight to this view, if we
are correct in assuming that the lenticular nucleus is associated
with the cerebellum by fibers which pass from the lenticular nuc-
leus on one side, to the contralateral cerebellar hemisphere by
way of the ansa lenticularis.

Obersteiner'"' believes that the lenticular nucleus is connected
with the lower olive on the same side, and the opposite cerebellar
hemisphere in this way. and Mills36 states that the corpus striatum

roST-APOPLECTIC TREMOR 767

is connected with the cerebellum through the red nucleus, the
pontine nuclei, and olives, and the other basal ganglionic deposits.

According to Dejerine37 part of the blurs of the ansa lenticu-
laris penetrate into the antero-internal part of the capsule of the
red nucleus, winch is composed of fibers from the superior cere-
bellar peduncles.

These facts justify the assumption, to some extent, that the
lenticular nucleus may have some function relating to co-ordina-
tion through its connections with the cerebellum which it may
have at least indirectly, if not directly, by reason of its rela-
tion with the red nucleus. If, then, as a result of a lesion of the
lenticular nucleus, the fibers associated directly or indirectly
(through the red nucleus or otherwise) with the cerebellum be
interrupted, and thus the functions of the cerebellum be impaired,
may not disturbances of motion arise expressing themselves in
involuntary movements or ataxia?

This brings us to the consideration of the ataxia of the arms
and legs which was present in our case, and offers a possible ex-
planation for this symptom, which is not explained in any other
way by the pathological findings already described.

The tremor in our case, we believe, was not hysterical, as the
patient exhibited no other stigmata of hysteria, although of course
tremor may be the only manifestation of hysteria, as in the case
described by Mitchell and Spiller.38

In Conclusion, we believe :

1. That the lesion in the left lenticular nucleus may have been
responsible for the tremor of the right arm in our case, and the
association of unilateral tremor with bilateral lesion may be ex-
plained by the fact that the lesion in the right putamen was not
extensive enough to set up sufficient irritation to cause this symp-
tom on the left side.

2. That post-apoplectic disturbance^ of motion may be due
to lesions of the lenticular nucleus, the optic thalamus, and the
pons in the region of the superior cerebellar peduncles, and of
the cerebellum, the cause being, in all instances, a disturbance of
co-ordination. When the lesion is extra-cerebellar the cause of
this disturbance is possibly an indirect result of destruction of
fibers related to the cerebellum directly or indirectly through the
red nucleus.

3. That the ataxia in our case may have been indirectly of
cerebellar origin.

768 RHEIN AND POTTS

It must not be forgotten, in drawing- conclusions from an
analysis of the above cited cases, that there are on record in-
stances in which lesions of the posterior portion of the thalamus
("hintere Sehhiigelgegend"), red nucleus, superior cerebellar
peduncles, dentate nucleus, and cerebellum have occurred- without
causing athetoid and choreiform movements (v. Monakow).

We gladly express our thanks to Dr. W. G .Spiller for val-
uable assistance in the study of the specimens.

LITEK \TUKK.

'Demange. Revue de Med., 1883, P- 371-
"Sander. Neurologisches Centralbl., 1897, p. 301.

Grasset and Rauzier. Traitc Prak. des Malad. du System Nerveux,
Vol t. 1894, p. 21S.

^Heboid. Arch. f. Psychiatrie, 1891, 189-'. No. 23, p. 447.

Anton. Jahrb. f. Psych., 189^ and 1897, Vol. 14, p. 141.
'Jacob. In Hainan & Infeld.
Tddon. In Gille^ de la Tourette and Charcot. La Semaine Med., 1900,

p. \2~.

A on Monakow. Nothr -pec. Path. u. Therap., 1897, Vol. 9, p. 318.

'Edinger. In Heboid.

'"Charcot. Malad. du System Nerveux, 1873, Vol. 2, p. 339.

phan. Arch. f. Psych, u. Nervenheilk., 1887, No. 18, p. 734. No.
19. 1888, p. 18.

'~'Gowcrs. In von Monakow.

1=Kollar and Pick. Yiertel Jahresb. f. Prak. Heilk, 1879, Vol. 1 and
Vol. 2, p. 31.

''Raymond. In Frey.

"Bichoff. In Halban and Infeld.

'"Leyden. In Halban and Infeld.

"Benedickt. Nervenpath. u. Elecktrother. 1874, p. 632.

lsHalban and Infeld. Arbeiten aus der Neurol. Institut Obersteiner,
1902, p. 328.
. ''"'Henoch. Charite Annalen, :87s. Vol. 5. p. 46S.

20Bergen. Wien. klin. Rundschau, iqoi, No. I, p. 75.

^Bonhoffer. Monat. f. Psychiatric. 1901. Vol 10, p. 383.

"Pineles. lalirb. f. Psych, u. Neurol., 1899, Vol. 18, p. 182.

"Kirschoff." Arch. f. Psych, u. Nervenkrank. 1881, 1882, p. 647.

"Huppert. Arch. f. Psych, u. Nervenheilk., 1877. No. 4, p. 98.

- Muratoff. Monat. f. Psych, u. Nervenheilk., 1899, Vol. 5, p. 180.

MHamarburg. Nordiskt Mediciniskt Arkiv.. 1890, No. 23, p. 1.

"TFropier. In von Monakow.

2>Balfour. Edinburgh Med. Magazine. 1878.

""Beach. Brit. Med. Tour.. 1880.

'"Korella. Centralbl. f. Nervenheilk., 1887.

"Hudovernig. Arch. f. Psych., 1903, No. ^j, p. 84.
"Eisenlohr. In von Monakow.

^Kolisch. Dent. Zeit. f. Nervenheilk., 1893, Vol. 4. p. 14
Xothnagel. In Gilles de la Tourette and Charcot.

"'Obersteiner. Nervosen Centralorgane, 1901.

""Mills. The Nervous System and Its Diseases, 1898, p. 116.

"Dejerine. Anat. des Centres Nerveux, Vol. 2, 1901, p. 329.

^Mitchell and Spiller. Jour, of Nervous and Mental Disease.

''Sander. Deut. Zeit. f. Nervenheilk., 1898, No. 12, p. 363.

40Frey. Neur. Centbt., 1905, p. 1104.

£octet£ B>rocceMn03

AMERICAN NEUROLOGICAL ASSOCIATION.

Held in Washington, May 7, 8 and 9, 1907.

The President, Dr. Hl'GH T. Patrick, in the Chair.

{Co itiuucd from page 656. )

A STUDY IN HEREDITY.
By Dr. James Jackson Putnam.

This paper discusses the results of the study of a large family, most of
the members of which, through several generations, have been well known
to the writer, many of them personally.

The husband and wife, with whom the history begins, were persons
of active minds, but showing symptoms in the former case of neurasthenia,
in the latter of hysteria. One object of the inquiry was to ascertain to
what extent these disorders had been inherited and whether they gave
place in subsequent generations, to more serious affections of the nervous
system. Apparently the former ui these inquiries could be answered in
the affirmative, at least so far as the neurasthenia was concerned, the
latter in the negative. More serious conditions of the nervous system and
of nutrition have occasionally occurred, but apparently only in a sporadic
manner. Other points of interest are brought out.

HEREDITY IN DISEASES OF THE NERVOUS SYSTEM.
By Dr. Philip Coombs Knapp.

The teachings of Weismann have shown that there is grave doubt
whether acquired characteristics may be inherited, and have pointed out
that one of the chief factors in the inheritance of disease is the pathclogi-
cai change in the germ plasma from various causes, such as intoxication,
infection, constitutional disease or local disease of the generative tract.
• The teachings oi Galton and Mendel have further shown the prob-
ability that morbid characteristics tend to die out in later generations.
The data as to the inheritance of nervous disease are untrustworthy and
unsatisfactory. Simple heredity is rare, and is seen most strikingly in
certain rare diseases, such as Friedreich's ataxia, Huntington's chorea,
etc. The fact thai a number of case- of these rare diseases may exist in
a single family shows thai hereditary influence is an important factor,
but it does not explain the original appearance of the disease, or the oc-
currence of sporadic cases. De Vries' theory of sudden mutation may
possibly explain the original unset of the disease, which leads to such
changes in the germ plasma thai it is reproduced in the descendants.

In the more common forms of nervous disease similar heredity is rare,
but much stress has been laid upon the neuropathic predisposition.

The statistics of heredity in insanity are vitiated by the tendency to

7/0 AMERICAS XEUROLOGICAL ASSOCIATION

regard insanity as a single disease, and to class all varieties under the
one heading. An inquiry was made as to the frequency of neuropathic
and similar heredity in epilepsy. The statistics were found to vary from
ii to 87% of neuropathic heredity, and from 1 to 37.2% of similar
heredity. The neuropathic heredity in epilepsy, however, is no greater
than the amount of neuropathic heredity found in normal individuals, al-
though the similar heredity seems somewhat greater than the percentage
of epilepsy in the community at large.

Another fallacy in this method of estimating morbid heredity is that
many forms of disease, due to many different causes, are brought forward
as indicating inherited weakness of the nervous system, and the etiologi-
cal factors occurring in the patient's own life are too often disregarded.
It seems doubtful whether any acquired mental or nervous disease of
the ancestors can lie the starting point of a pathologically tainted family,
or even of sporadic cases of disease in the descendants, unless there be
^ome general or local cause of injury to the nerve plasma.

Tlie whole question of heredity in nervous disease requires thorough
investigation, and the influence of heredity is certainly not as great as at
present regarded. Even when morbid heredity exists, the tendency to
disappearance of the morbid taint is considerable, and cases of nervous
disease in the family, or even in the individual himself, are by no means
proof that there is morbid heredity, or that the disease will he transferred'
to his descendants.

Dr. D. J. McCarthy said he was very much interested in both of these
papers, and more particularly in the paper on the rather extensive study
of Dr. Putnam's family. He said that anyone who has given this subject
of heredity any thought at all and has looked into the subject for scientific
data must be impressed with the looseness with which the subject has been
investigated by neurologists and by psychiatrists. The great deficiency, so
far as he can study out the matter, is the narrow limits to which those
studying the feature of heredity in nervous and mental diseases confine
themselves. The most that you can get statistics on in the average clinic
or in the average study of heredity, is the general nervous condition of the
parents. As was called attention to, we limit ourselves entirely practically
to the neurological standpoint or to a study of the nervous system. While
it is perfectly true that the acquired characteristics, so far as the nervous
system is concerned, are probably more often transmitted than personal
characteristics (morphological and visceral), we must not lose sight of the
fact that this heredity more often depends upon a physical than a nervous
basis. Probably the most extensive study in heredity that has been made
is in relation to idiocy and similar disorders. Some 28,000 cases have
been collected in which, for instance, the most important etiological factor,
as far as could be determined, was pulmonary tuberculosis in the ancestors.
The question of cancer became a non-important factor, dropping from 3
to 5 per cent. If we are going to study heredity we have to study it not
from the standpoint of the nervous system, but we must consider the
nervous system not as a system by itself, but as a part of the economy,
and the statistics are not valuable unless there is taken into consideration the
question of visceral disease, and not only the question of visceral disease
in general, but especially the question of visceral disease at the time of
the birth of the child. The condition of the mother at the time of the
birth of the child is of especial importance. In making a study of this
kind the important factor of the neurosis cannot be disregarded.

AMERICAN NEUROLOGICAL ASSOCIATION 771

Dr. F. X. Dercum said that he is entirely in accord with Dr. .McCarthy.
We must study the organism as a whole, and the occurrence of such a
fact as a myxedema is of as much importance as any other incident in the
life history of a family. We all of us know that the ductless glands play
a role in the economy, and that the thyroid gland exerts an influence on
the nervous system. And hesides, the signs presented by children who
have this inherited nervous weakness are essentially those of arrest and
feebleness of development, feebleness of resistance, as shown by the
history of infectious diseases of childhood with prolonged convalescence
and feebleness of resistance in a multitude of other ways. It is the
organism as a whole that we should study, with all the incidents of in-
fection, with all the incidents of diseases of various viscera. Doubtless
all of these factors play a role.

Dr. E. Riggs said that apropos particularly of Dr. Knapp's paper he re-
called a conversation with Dr. Savage some years ago. who said: "If I
believed the theories of Maudsley I could not practice medicine. For many
years I have watched clinically, the manifestations of this so-called
heredity. I have seen children who were born, the fathers being insane,
children born the mothers being insane, children born both parents being
insane, and I have watched these children for years and have never seen
any psychopathic developments."

Dr. S. Weir Mitchell said he was tempted to say a few words from quite
a different point of view from that taken by his friends. Perhaps too long
experience had enabled him to have before him the histories of a great many
families, especially in the upper social life of his own city. There would
be found among the recorded cases which it had been his habit to note
carefully since he was a young man, a multitude of histories running
through many generations which enabled him to take on the whole a far
more hopeful view of this question of heredity than i-; usually held. The
interesting part of it to him was one which we too rarely hear brought
up in any of our meetings and usually mis^ here, and that was the thera-
peutics of hope, so to speak, in families where there has appeared in one
generation perhaps a succession of cases of some form of distinctly
neurotic malady, we will say insanity. He said he was thinking now of
a particular family, historically well known, with which lie was very well
acquainted and knew its history for fifty or sixty years. There appeared,
and had appeared for two generations before, in each successive twenty
or thirty years, one, two or three cases of insanity, usually what we call
melancholia. There had been one or two suicides. Then two generations
ago the trouble ceased; some happy marriage or change occurred, and
from that time to this there have been many fruitful marriages in the
family, there have been absolutely no nervous disorders, and what looked
like an exceedingly dangerous probability in regard to those people has
resulted in perfectly wholesome young nun and young women. The mat-
ter he wished to speak of particularly was the question of treatment in the
largest sense. There have come to him in his lifetime many cases where
people have said. "We have had in our family insanity; there have been
many cases. What am 1 to do to insure the future of my offspring ?"~
That was the question lie wished to see dealt with in our discussions.
There come other occasions where we arc called upon to decide the
question of marriage. A woman who has been insane once comes to you
with the question, should she marry, saying "there have been such and'
such cases in my family. Am T justified in getting married?-'

772 AMERICAN NEUROLOGICAL ASSOCIATION

Dr. Mitchell related the history of a family, exceedingly well known
to him, of extraordinary and almost romantic interest. He was consulted
a great many years ago by two maiden ladies who looked like Spanish
people. They were people very well to do in the world, hut not in the
highest social class. They had with them a young woman, a younger
sister by many years, the product of the second marriage of their father.
These ladies related a history which was written down in a book kept
for 150 years, since their migration to America. In that time there had
been in the family nine suicides, there had been countless cases of drunken-
ness, there had been seven persons with epilepsy, and these two sisters
themselves had both been in ayslums, one of them once and one twice, and
felt prepared to go again as they would go to get the services of any
ordinary physician. They said : "We have made a compact between our-
selves. We are the last of this family, and we have resolved never to
marry." They never did. They also said that they had resolved that the
young sister should not marry. The result was what might have been
anticipated. The young woman formed a very proper love affair with a
young German who was quite- comfortably off. He was a decided blond,
the perfect German type. When this was discovered, to the dismay of
the elder women, they asked Dr. .Mitchell what they should do. After
considering' the matter he said they had better take the risk, for the reason
that this young unman did not resemble them at all, and probably took
her physical and mental characteristics from her mother's family. They
accepted his advice, the young people married, and are now fairly old
married people and have had je and happy family with no kind of

neuropathic display.

Or. Mitchell said that before he sat down he wished to express again
li i -- great disappointment at not hearing the therapeutic aspect of nervous
diseases more often brought up at these meeting

Dr. Langdon said we are all aware that the shifting line between the
normal variation and what we may perhaps, for our purpose, term the
pathogenic variation, is an exceedingly important matter. It comes home
to us frequently in our relations with the public. He simply wished to
direct attention to a line of inquiry hearing upon this subject which he
did not remember any one of the speakers referred to; namely, the in-
vestigation of what we may term the potentiality, the dynamic potentiali-
ties, if you plea-;, of these patients; in plain words, how early they
attain the period of usefulness and how long it endures. It is a question
which has at least a bearing on the neurasthenic and other types mentioned
by Dr. Putnam.

Dr. G. Hammond said that the therapeutic aspect of the question is one
which has interested him for many years, and it has been his custom in all
cases of children who seem to. have inherited a neuropathic constitution to
treat them for years with a process of physical culture. He has not
taken the children simply of neurotic parents, but lias taken those who
showed neurotic constitutions by having had one or more convulsions or
chorea or migraine or some other nervous affection. He has treated these
children for years with systematic exercises, making the physical develop-
ment paramount to the mental, insisting that they live a most hygienic life,
with the greatest amount of sleep, with a simple diet and proper physical
outdoor culture, and in many of the cases where the parents have fol-
lowed this method of education he has seen epileptic children grow
up tn lie healthy, vigorous, strong, useful men and women, having healthy

AMERICAN NEUROLOGICAL ASSOCIATION 773

children of their own ; and he believes that this is the one way in which
the neurotic constitution can be eradicated, and he believes that if it is
consistently carried out by the physician and parents we can rescue many
of these neurotic children and make them strong, healthy and vigorous.

Dr. L. P. Clark said that he believes there is a constant law applying
to epilepsy, for the transmission of the disease. He said, if statistics do
not prove that, as he was bound to admit from the testimony submitted
here as well as elsewhere, that they do not, then it is so much the worse
for statistics. The specialist in statistics needs to be called to our help.
He thought any one having a long experience in treating epilepsies will
be very conscious of the fact that there is a definite law which undergoes
a wide variation. It seems to him that neurologists could pursue a line
of investigation with great profit if they would take g'eneral principles
which are accepted by a great community of people as fundamental facts,
treat it as a fundamental fact and try to discover why it is so, ascribing
these views to popular ignorance does not satisfactorily explain them
away.

Dr. A. Meyer said that in attempting to plan the study of the question
of heredity on a large material he had continuously come across the diffi-
culty of ascertaining even the ontogenetic factors of etiology. The history
of the individual brought in is apt to be very faulty, and before one can
hope to get very far with heredity problems we must be on a very much
better footing concerning the ontogenetic etiology in concrete cases. Any
one who tries to formulate the etiology of any patient under observation
knows how extremely difficult any such formulation is at the present
time. And naturally the sizing up of the heredity factors will be cor-
respondingly difficult. Dr. Meyer said that under all circumstances he
would advise not to pay too much attention to any results which are not
obtained on specified instances, such as Dr. Weir Mitchell has recorded,
and such as Dr. Putnam has brought to our notice. They are the concrete
experiences in which something definite has been stated. Of course we
come across a great difficulty in that it is practically impossible to induce
our co-workers to do that which we ourselves would consider incumbent
upon us ; namely, to get the pedigrees of all cases used for generalizations.

Dr. C. L. Dana said he had occasion to pay some attention to this
subject last winter, and he was very glad that the matter had been brought
up at this session. The results of his own studies agree with those given
by the speakers to-day. When he got through working over the subject
of heredity the most dominant impression left was that we have to study
statistics again and get many more facts. He said he wished to state one
instance which he had found in his personal experience to be different
from that given by ordinary writers; that is the relationship, for example,
of alcoholism to insanity. Nearly all text-books say alcoholism is the
cause of from 20 to 25 per cent, of the cases of insanity. He took 300
cases of insanity which came under his personal experience, about which
he knew very well, both the persons and the families. In these the alcohol-
ism as an hereditary factor was less than 5 per cent. So far as the prac-
tical question which Dr. Mitchell has raised comes to one, Dr. Dana said
that he tried to formulate certain rules, and it seemed to him as a result
of his own personal studies that the only serious reasons against marriage
of so-called psychopathies was when there was a direct history of insanity
or psychosis or serious neurosis ; that even this is not enough to cause a
prohibition of marriage if it was on one side alone. • If, however, it was

774 AMERICAN NEUROLOGICAL ASSOCIATION

direct on both sides, it should cause us absolutely to advise against mar-
riage. If it was on both sides in indirect heredity it should cause some
•question, but not, he thought, actual and rigid prohibition.

Dr. Weir Mitchell asked Dr. Dana what he meant by indirect heredity.

Dr. Dana, replying to Dr. Mitchell, said he meant by indirect heredity
where the uncle or cousin or grand-uncle, was insane. If there were a
great many cases of indirect insanity on both sides the problem of marriage
is serious. In other words, if the father had a psychosis alone and the
mother is healthy there is a very large chance of the children being pretty
nearly as well as others. If both father and mother have serious psychoses
lie thought marriage should be forbidden.

Dr. L. F. Barker ■-aid it seemed to him very difficult in this question of
heredity to distinguish what is heredity from what is due to early environ-
ment. He said he was sorry he came in too late to hear all the papers in
discussion, but lie was wondering if much emphasis had been laid upon
the influence of early environment. It seemed to him that what we have
learned aboui tuberculosis is also applicable to a certain extent to the
doctrine of functional neuroses and psychoses.

Dr. (i. L. Walton said the subject had been so thoroughly discussed
from every other point of view that he could not help just mentioning one
point which had been left out Dr. Hammond came nearest to it in speak-
ing of the instruction of neuropathic children in the direction of physical
development and neglecting the mental development. It is of the greatest
importance to train neuropathic children in the direction of cultivating
the commonplace ideal, of discouraging their giving way to fussy dislikes,
as to odors and sounds, and to indecision about doing a thing for fear it
will not be right ; in other words, to the New England conscience. Such
children should be. for example, taught that it is better to do a thing
wrong sometimes than it is to be undecided for half an hour which of two
things to take up. The neuropathic children need cultivation in all such
directions to establish tin commonplace, easy .^oing ideal and to eliminate
tin- exaggerated ego.

Dr. J. J. Putnam said he was glad this subject had come up in this
particular way. as it is certainly a very important one. In closing his part
of the discussion he said he would like to say a few words which would
bear on Dr. Knapp's very interesting communication. He felt that if the
difficulties are so great that we can hardly solve them or solve them satis-
factorily in a scientific way. there are certain broad facts which must im-
press themselves on every one. In studying the histories of large families
we see these degenerative signs showing themselves in one and another
generation like a bit of paper on a stream which appears here and there,
and then disappears, perhaps to be dissolved, or possibly to reappear again a
• deal later. It is important to discover the principle on which this
sort of thing occurs, but we cannot take the facts themselves as indicating
the danger of a racial or community degeneration. If one takes a certain
community, closely shut in from the outside world, one can observe that a
ies of degeneration does go on. If, on the other hand, one takes a
large community, one can pretty quickly see that it does not degenerate ;
that the tendencies which make for progress are greater than those which
make for regression. The larger the number of the streams that come in
the less is the likelihood that the general stream will suffer in any par-
ticular way. Large and active communities tend to improve, and that, too,
in the face of the fact that the complexity of life tends to increase. The

AMERICAN NEUROLOGICAL ASSOCIATION 775

complexity of life does not seem to increase the tendency to degeneration.
Individuals habituate themselves to poor conditions to an extent that
is amazing, and even when living in slums, in had air and in unhygienic
surroundings, in the midst of the clicking telephone, etc., they do not de-
generate. A nation does not degenerate as a nation provided the number
of its citizens is sufficiently large. Dr. Putnam said he thought there was
another large fact which is very important. We see one or another
disease, epilepsy or migraine, reappearing through a certain number of
generations, and we trace it back to an original case. With that case a
certain tendency came in, and we may look upon the first case as a sort
of focus. Can we say that each reproduced copy of the first case is to
the same extent a new focus? This is doubtful. Tendencies die out.
Like the bit of paper on the stream they gradually become softened and
disappear. If this was not so we should all of us be epileptic and have
migraine. Another point is this : Dr. Woods, of Boston, wrote an interest-
ing research on heredity as traceable among the crowned heads of Europe,
where the histories of the different individuals are very well known, and
the conclusion he came to there was that education hardly counted for
anything, and heredity counted for everything. Dr. Putnam said he
thought there was a fallacy in this reasoning, due to the fact that Dr.
Woods divides the people of whom he treats, in regard to their various
qualities, into only ten divisions. It may be true that a given individual
cannot easily raise himself through education from one of these divisions
to another, and yet he may be able to make change enough in himself to
affect greatly his capacity for usefulness and happiness. The historian
might easily overlook an indication of improvement which in the eyes of
a neighbor or a co-worker would be of great importance.

As regards the question of marriage Avhich Dr. Mitchell had referred
to, it seemed to Dr. Putnam that there is another broad consideration
which we ought to bear in mind. There is some truth in the fact that
fine qualities go with qualities which are less desirable, as genius with
morbid excitability. With the power of organization and co-ordination
which makes possible the accomplishment of great results there is un-
doubtedly a danger which is sometimes very manifest, but it would not
do to conclude that we ought to throw over the chance of gain on account
of the chance of the loss. He said he had in mind a family like that de-
scribed by Dr. Mitchell, where drunkenness and psychoses have been
prevalent, where nevertheless the benefit brought to a community by one
or more members has been so great as to more than counterbalance all the
damage done by the others. We ought to consider the community as a
whole, and not only the individual case. The community can afford to
make great sacrifice for the sake of our great leader. The Jukes family
lias been much referred to as one showing the baleful influence of heredity:
the number of criminals and paupers they have produced has been spoken
of many times, lint one careful historian of the Jukes family has noted
that education, environment and imitation played a very large part in this
result.

\s reg'ards the hygienic life, Dr. Putnam said that while he agreed
with Dr. Hammond, he agreed still more with Dr. Walton. We are not
educating people to live on farms. We arc educating them to live in the
cities and in the midst of people.

Dr. P. C. Knapp said he thought that by careful study of the individual
ses, with all the details of the life history in the antecedents and the life

776 AMERICAN NEUROLOGICAL ASSOCIATION

history in the individual, even if we find cases of nervous disease and of
mental disease in the antecedents or even at times in the individual himself,
we can sometimes hold forth great hope. We can assure that patient that
there is no likelihood of an occurrence or recurrence of nervous or mental
diseases in himself, or that, if he marries, there is no likelihood of such an
occurrence in his descendants. That is often difficult to decide, hut in
certain cases he thought we could speak with confidence, and the absolute
pessimism of the French teaching on heredity leaves out any element of
hope. Dr. Knapp said he laid much stress upon the whole life history of
the individual, the importance of faulty training, of faulty nutrition and
of example and environment in the production of a neurotic, unstable dis-
position. He believed, however, that the important thing we must con-
sider is the physical status of the ancestors. In spite of what Dr. Clark
and Dr. McCarthy have said, it is by no means susceptible of proof that
an acquired neurosis in the parent will be followed by a similar neurosis
or any other form of functional neurosis in the child, but if the parent
has a defective physical condition leading to pathological alterations of the
germ plasm, that may produce a weakling physically in every way, and
that weakling may develop neurotic disease. Dr. Dercum's reference to
myxedema leads to a specific application. If a parent has myxedema, and
after the development of that myxedema, if that should be possible, gives
birth to a child, that child might very naturally be expected to be a
weakling on account of pathological alterations in the germ plasm from
the toxic processes involved in the myxedema, but if after the child is
born the parent develops myxedema, especially if we could prove it was
myxedema resulting from some local injury to the thyroid gland, the
question of myxedema as a factor in heredity would be absolutely thrown
out of court. We must make a detailed study of the individual and his
family, taking into consideration all infections, all diseases, and all the
results of education, of nutrition, of feeding, of the whole life and the
special forms of disease which develop in the family, before we can come
to definite scientific conclusions as to the importance of hereditary factors.

(To be continued.)

NEW YORK NEUROLOGICAL SOCIETY.
April 2, 1907.
The President, Dr. Charles L. Dana, in the Chair.
PRESENTATION OF FOUR CASES OF CONGENITAL CERE-
BELLAR ATAXIA.
By Dr. Millicent B. Hopkins.

A mother, aged forty-four years, and three children, all girls, made
up this group. The father of the children was forty-one years of age
and apparently perfectly healthy; his personal and family history were
negative, save that a brother died of heart disease. As to the mother's fam-
ily history, her mother died of cancer of the uterus and her father suffered
from rheumatism and was an alcoholic. The mother attributed her con-
dition to the fact that her mother, during her pregnancy, received a severe-

NEW YORK NEUROLOGICAL SOCIETY 777

blow over the abdomen; otherwise her family history was absolutely nega-
tive. Her personal history had no points of interest, excepting that she
did not walk until her eighth year. She had had six children and no
abortions. One child, a girl, similarly afflicted, died at three years of age
of scarlet fever, while one girl of nine was a normal child, and a boy of
four years was also entirely healthy. Her deliveries were all easy and
normal. The personal history of the children was negative, excepting
that they did not walk until very late.

Dr. B. Onuf said the patients shown by Dr. Hopkins, at least the eldest
girl, seemed to present some choreiform movements of the face or some
ataxia of expression.

Dr. George W. Jacoby, referring to the mother of the children, who
was forty-four years old, said he had never seen a case of congenital cere-
bellar ataxia at such an advanced age.

Dr. Arthur C. Brush said he had one case under his observation at
present in a man about forty-six years old. The patient had been in the
hospital for ten years, and was employed in one of the wards. The case
was a very marked example of cerebellar ataxia.

The President, Dr. Dana, referred to a cast of cerebellar ataxia of a
family type observed by him. In that instance, the disease had de-
veloped in three generations. One member of the family, in whom the
ataxia did not develop until she was about forty, was now nearly seventy
years of age. There was no history of any mental defect in these cases.
In all cases the ataxia developed late.

SCHLOSSER'S ALCOHOL INJECTION INTO THE FORAMEN

OVALE FOR RECURRENT TRIGEMINAL NEURALGIA,

AFTER EXTIRPATION OF THE GASSERIAN

GANGLION.

By Dr. Otto G. T. Kiliani.

The patient was a man, seventy-three years old, a cook by occupation,
and a native of Germany. His family and personal history was negative,
with the exception of the fact that he had been suffering from facial
neuralgia for the past forty-eight years. He attributed his affection to
an injury which he received when he was twenty-five years old. In 1878
his pain became so intense that the second branch of the trigeminus was
resected. He submitted to further operations in 1881, 1884 and 1885, and
after the latter operation he was free from pain for four years. The pain
subsequently recurred, and in 1898 Gasserectomy was performed, which
gave him relief from pain for a year. In 1904 another peripheral opera-
tion was performed, which relieved him for two months. When he was
admitted to the German Hospital, on Dec. 20, 1906, he was having about
one hundred attacks a day. After an ineffectual attempt to find the infra-
orbital nerve, Dr. Kiliani made an injection of alcohol, according to
Schlosser's method, into the third branch, without any result. Accord-
ingly, on Jan. 19, 1907, he made his first injection of two c.c. of alcohol
(80%) into the foramen ovale, after which the patient was free from pain
for three days. Similar injections were made on Jan. 26, and on Feb. 7 and
14. Since these injections he had remained entirely free from pain.

Dr. Kiliani said that these injections of alcohol into the foramen ovale
were done without narcosis, although narcosis had been given the first
time, as he was not positive whether he could rely upon the patient to re-

778 NEW YORK NEUROLOGICAL SOCIETY

main quiet during the operation. The needle was pushed through the
cheek about one inch behind the corner of the mouth, without perforating
the mucous membrane. The left index finger was held as a guide behind
the last molar of the upper jaw or at its site. One thus felt when the
point of the needle struck the external plate of the pterygoid process,
along which the point of the needle was pushed upward for about an
inch and seven-eighths ; there it became arrested, striking the base of the
skull. A further lowering of the handle end of the needle permitted the
point to travel one-eighth of an inch further upward, where it was
definitely arrested. The point of the needle was now pushed backward
about seven-sixteenths of an inch, when it entered the foramen ovale.
The alcohol was then slowly injected. It was not very painful, but was
followed by more or less edema of the eye and the surrounding region.
In one instance it was followed by a rise of temperature, which was
probably due to some other cause.

After demonstrating the method of this operation on the skull, Dr.
Kiliani said that while he did not consider the patient cured without
further injections, he was exceedingly gratified with the result. This
man had already submitted to one central and repeated peripheral opera-
tions without permanent relief, and in such cases, Schlosser's ingenious
method of treatment was certainly worthy of a trial.

Dr. Jacoby said the recurrence of the pain after the supposed extirpa-
tion of the ganglion in the case shown by Dr. Kiliani indicated that
either the ganglion was not removed, or that it had re-formed. The case
was a good illustration of the fact that a recurrence might take place
after any kind of an operation, and for that reason, a comparatively simple
procedure, like the one demonstrated by Dr. Kiliani, was a very welcome
addition to our therapeutic resources in dealing with these intractable
eases of tic douloureux. While the introduction of this long, straight
needle into the foramen ovale was easily carried out, it should be regarded
essentially as a surgical procedure, and the promiscuous injection of
alcohol or other substances into this or other nerves should be dis-
countenanced. While the ultimate results of the operation were still in
doubt, Dr. Jacoby said he thought they would be at least equal to those
of other surgical methods.

Dr. Kiliani, in reply to a question as to whether the method had been
applied to any other nerve, said that personally his experience with it
was limited to the trigeminus. Schlosser, however, with whom the method
originated, had also employed it in sciatica, and had never seen any seri-
ous accidents result as far as the motor fibers of the nerve were con-
cerned, while he had good results in regard to the sensory fibers.
Schlosser had also resorted to it in tic convulsif, injecting the alcohol
for that purpose into the facial nerve close to the styloid process, where
ready access to it was obtainable. The injections were made into the
sheath of the nerve or its immediate neighborhood, and under those
conditions it was simply a question of dosage. In dealing with mixed
nerves, the method should be employed with the greatest precaution.
Professor Schlosser had written a monograph on the subject, which
would shortly appear.

Dr. William M. Leszynsky said he had practised the operation on the
skull, and was surprised to find how readily one could pass a probe into
the foramen ovale, as compared with the foramen rotundum.

Dr. William B. Noyes asked if thefe was much reaction or inflam-

NEW YORK NEUROLOGICAL SOCIETY 779

mation following the injection, and how Dr. Kiliani explained the relief
that followed the procedure. Any radical method of affecting a peri-
pheral nerve that was causing repeated attacks of intense pain, either of
a spasmodic or a continuous nature, must either cause a degeneration of
its nerve fibers, which was distinctly an interstitial change, or cause an
accumulation of leucocytes in the neighborhood of the nerve trunk, either
as an inflammatory reaction, as in counter irritation, and so reduce any
peri-neuritis or neuritis proper.

Dr. Kiliani said he had no explanation to offer as to the effect of
these alcohol injections. As a matter of fact, nobody knew what
neuralgia was or what produced it, and even careful microscopic examina-
tions had failed to reveal any changes in the involved nerve. It could be
safely assumed, however, that the injections of alcohol produced a certain
amount of paresis of the nerve, and during the course of the injection
the patient described the gradual numbness following the distribution of
the nerve. This numbness disappeared in the course of a few days or
weeks, but there was no return of the pain. Neuralgia patients were
cured by the alcohol injections, inasmuch as the pain disappeared en-
tirely, but a number of cases showed a recurrence after about a year,
when a few further injections completed the cure. The operation is so
small and connected with so little inconvenience, that the patients are
quite willing to undergo the treatment again if necessary.

VOICE RECORDS IN NERVOUS AND MENTAL DISEASES.

By Dr. E. W. Scripture.

A method of recording the voice by a very small capsule was demon-
strated, and records of voices in general paresis, hysteria, paralysis
agitans, hemiplegia and epilepsy were compared with normal voice rec-
ords. In these records, the vowels appeared as small waves on a line
whose height indicated the rate of expulsion of breath. The regulation
of the breath in general paresis was seen to be very irregular, while in
hysteria it was erratic.

Curves of occlusives and fricatives were shown. The irregular and
uncertain regulation of breath and muscular action were evident here also
in general paresis. The faintness of breath action in paralysis agitans
was noted. The duration of the sounds was often greatly prolonged in
paresis and multiple sclerosis. The melody of speech was obtained by
measuring the little waves, each singly. The melody of speech in general
paresis showed excessive fluctuation. The peculiar monotony in epileptic
voices was so marked that it could be regarded as a regular symptom of
the disease. The senile tremolo in melody at the beginning of vowels
was shown.

Dr. George H. Kirby said that while attending Professor Kraepelin's
clinic at Munich last summer, he had an opportunity to do some work
with the methods developed by Dr. Scripture for the study of speech de-
fects and voice alterations. Among the patients upon whom the experi-
ments were made there were some with general paresis in whom one
could not find any speech defect by the ordinary tests, yet when the
speech curves were studied one could clearly detect an alteration in the
vibrations from the vowels, and peculiar fluctuations in the melody not
observed in normal persons. These characteristics were quite clear in
the records, but could not be detected otherwise, at least not by the un-
trained ear. The method thus might become really of practical value and

780 NEW YORK NEUROLOGICAL SOCIETY

a diagnostic aid. In one patient with pupillary signs and a speech defect
the diagnosis was between general paralysis and a hysterical psychosis.
The record obtained from this patient showed peculiarities entirely differ-
ent from those obtained from the general paralytics. The further obser-
vation, as well as the anamnesis, made it clear that the case was really
one of hysteria.

Dr. L. Pierce Clark said that Dr. Scripture, for a number of years,
had maintained that the voice of the epileptic was as characteristic as
the facies, or more so, and that he had been induced to undertake with
him a careful analysis of the voice in epilepsy. They had found that par-
ticularly in the grand mal type the voice of the epileptic showed certain
alterations which were quite as characteristic as any of the well recognized
stigmata of epilepsy. In order to test the accuracy of these observations
on the voice in epilepsy, a number of patients at Randall's Island who
were subject to that disease were mixed up with others who were suffer-
ing from various grades of mental deficiency about on a par with those
usually observed in the chronic epileptic, and in nine of these patients out
of ten, Dr. Scripture was able to detect merely from the speech whether
the case was one of epilepsy or not.

Dr. Clark said that these voice studies seemed to him of immense
scientific as well as practical value. For instance, it may be possible in
the near future to roughly record in ordinary case-taking the melody,
pitch and rhythm curves of speech in various functional nervous dis-
orders, such as those of epilepsy, hysteria, neurasthenia and the like
neuroses.

Dr. Onuf asked Dr. Scripture whether in epilepsy he could make the
diagnosis from the voice alone, or whether he required the voice record,
and what was his interpretation of the latter.

Dr. Scripture replied that while the existence of epilepsy could be
recognized, after a little training, from the voice alone, he always pre-
ferred to base his opinion on the actual voice records and curves, when
possible. When these were once heard and recognized, they were distinct
and characteristic. The characteristic voice disappeared after the epilepsy
was cured.

Dr. Leszynsky asked whether these characteristic voice curves were
present in epilepsy of the ordinary type.

Dr. Dana asked how long after the onset of epilepsy this characteristic
voice developed.

Dr. Clark said these questions could not be answered definitely, as
the studies were only begun. The cases that had been studied were of
the chronic type of epilepsy — patients in whom the disease had existed
for periods ranging from two to ten years. The method had not yet
been tried at the Craig Colony. He expressed the view that these char-
acteristic voice curves would become as constant and fixed as other
symptoms of the disease.

Dr. Scripture said the voice characteristics were apparent in the
measurements of the curves long before they could be detected by the ear.

DISCUSSION ON THE ANTI-SYPHILITIC TREATMENT OF

TABES AND PARESIS.

Dr. Dana said he had been treating these forms of nervous disease
for many years by the use of mercury and iodides in the early stages,

NEW YORK NEUROLOGICAL SOCIETY 781

giving the drugs both in mild and heroic doses. Some of the patients
had improved under the method while others had grown worse, and
whether it was really efficacious was a question that was still open for
discussion. In tabes he had seen the treatment applied in the most rigid
manner from the very onset without any effect upon the rapid develop-
ment of the disease.

Dr. George W. Jacoby said that in any discussion of the treatment of
tabes and paresis we could not but primarily consider the etiology of
these affections, and in so doing it became apparent that their relation to
some infection or intoxication was a very definite one.

All clinical observation, as well as other reasons which need not again
be adduced, tended to show that the intoxication which was most fre-
quently met with in the evolutionary history of these affections was that
which was consecutive to syphilitic infection. This experience must
necessarily be followed by the hope that energetic anti-syphilitic treatment
might prevent the full development of the disease, or even effect a cure.
While theoretical reasoning for or against such an effect would have its
place, there could be no doubt that the ultimate decision as to the in-
fluence which mercury and the iodides might have upon the tabic or
paretic process would have to be arrived at as a result of clinical ex-
perience.

Unfortunately, the question was and must remain a very complicated
one. The speaker said he had gone over about one hundred of his cases
of tabes and one hundred of those of paresis with a view to answering
the following questions : 1. Could energetic anti-syphilitic treatment pre-
vent the development of these affections? 2. Could such treatment
•diminish or remove certain symptoms? 3. Could such treatment cure the
disease?

Dr. Jacoby said that as the result of his experience and inquiries the
first question should be answered negatively. He knew it could always
be said that a cure did not develop because anti-syphilitic treatment had
not been inaugurated sufficiently early, yet such negative testimony was
of little value in the face of positive cases which proved the contrary.
Two such cases stood out prominently among his histories of tabes.
One was that of a youth who became infected wtih syphilis. He was
treated by a specialist thoroughly and persistently for three years. Ten
years after infection he consulted Dr. Jacoby for a hyperesthesia in the
territory of one of the branches of the left trigeminus. Careful examina-
tion revealed some hyperesthesia in that territory, and an analgesia of
the cornea. Beginning tabes was suspected. Anti-syphilitic treatment was
again instituted, and for a period of years the patient was more or less
constantly under the influence of mercury and iodides, yet in spite of
the thoroughness of the treatment he developed pupillary rigidity, pains,
loss of foot jerks, loss of knee jerks, ataxia, gastric crisis, and to-day,
twenty years after the infection, he presents a fully developed tabes.

The second case gave much the same history, excepting that the
• diagnosis of probable tabes was made as a result of the occurrence of a
transitory ophthalmoplegia of one eyeball. In spite of vigorous antiluetic
treatment he had recurrent attacks of ophthalmoplegia of both eyes, to-
gether with intense headaches. To-day, fifteen years after infection, he
had a fully developed tabes, with permanent ophthalmoplegia, in spite of
the most strenuous anti-syphilitic treatment.

Dr. Jacoby said that among his cases of paresis there were many

782 NEW YORK NEUROLOGICAL SOCIETY

which had developed in spite of careful treatment with mercury and
the iodides from the time of infection. Only a few weeks ago he saw
such a case, the paresis coming on six years after infection, in a man
who had been under constant treatment by a dermatologist with in-
jections, inunctions and potassium iodide from the very beginning. Such
positive cases led him to say that anti-syphilitic treatment, no matter
how carefully carried out, no matter how early begun, did not prevent
the development of these diseases.

The second question must be answered as follows : Of his one
hundred cases of tabes, five showed improvement while undergoing anti-
syphilitic treatment, and in those the disease had not progressed since.
Yet he was by no means willing to say that this arrest of progress was
due to the treatment, for we knew that very many cases showed a
diminution of symptoms under any or under no treatment, and we knew
that tabes was by no means a necessarily progressive disease. He
thought that in about one-third of the cases it was thus progressive, while
in the remaining ones the process became arrested, or proceeded so very
slowly that the length of life and the economic adaptability of the
patient was not materially impaired. All neurologists had seen cases in
which the tabic process never progressed beyond the point of diagnostic
interest.

The prognosis of tabes certainly was different from formerly, yet he
believed that this was due to a variety of factors and to a more intelligent
care of these patients, rather than to the effect of anti-syphilitic treatment.
He also believed that the differentiation of certain cases of lues spinalis
was at certain stages clinically impossible; furthermore, that there cer-
tainly existed a combination of syphilitic meningeal affection and real
tabes, and in such cases, amelioration or diminution of symptoms might
take place as a result of anti-luetic treatment. In not a single one of
his cases, however, whether the diagnosis of tabes was made or whether
the diagnosis was that of lues spinalis of tabic type was a cure effected.
In all of them the diagnosis could be made at all times, after as well as
before antileutic treatment.

As regarded the question of the curability or arrest of dementia par-
alytica, Dr. Jacoby said he had but a few words. The differences of
opinion that existed, the fact that the French school had recently claimed
so much as a result of mercurial injections in cases of paresis, while the
majority of clinicians claimed never to have seen a cured case, could only
be understood when we considered the difficulties which existed in es-
tablishing an accurate clinical picture of the disease. The more he saw
of these cases and the more he studied them, the more did he come to the
conclusion that a number of divergent clinical pictures were included
under this term. He admitted that there were certain cases of cerebral
syphilis or pseudo-paresis which at certain stages he could not differen-
tiate from true paresis. He admitted, furthermore, that He had great
difficulty in differentiating certain cases of so-called syphilitic insanity
cases with mental excitement and motor restlessness, passing on through
stages of mental enfeeblement with muscular insufficiencies into a com-
plete dementia, from cases of genuine paresis. He admitted also that
some such cases improved under anti-syphilitic treatment, and ran a very
prolonged course. Yet of all his cases of paresis — genuine or pseudo —
not one was now living in which the diagnosis was made more than
ten years ago, and all of the cases which he had controlled had had

NEW YORK NEUROLOGICAL SOCIETY 783

thorough anti-luetic treatment. The speaker said that to him the cure of
paresis meant a mistaken diagnosis. He did not believe that this would
always be the case, but when cures were effected, it would not be by
means of anti-syphilitic treatment, but in consequence of progress in our
bacteriological knowledge, and through the discovery of the toxine which
caused the disease.

Dr. William B. Noyes thought the whole question resolved itself into
a pathological study of syphilis and the toxemias. The pathological
changes observed in syphilis — both in its secondary and tertiary stages —
were practically embraced by round celled infiltration and gummatous
lesions, and in the treatment of those conditions, the ordinary anti-
syphilitic remedies could be relied upon ; these accumulations of round
cells disappeared under iodides, but one could scarcely conceive of mer-
cury or the iodides acting in the same way in dealing with serious de-
generation of tissue caused by toxemia. Whatever the cause might be
in these cases, whether syphilis or not, the fact remained that we had to.
deal with a degeneration of the nerve fibers in the cord or the peripheral
nerves. The speaker said that in certain cases of tabes, which he had been
able to study and follow for years, and where the patients had shown
all the typical symptoms of the disease, including the eye and bladder
symptoms, and all the classical symptoms of tabes, the autopsy had finally
revealed but very slight changes in the posterior columns of the cord, and
somewhat more positive changes in the posterior roots and peripheral
nerves. The most interesting change that was observed was the develop-
ment of delicate new connective tissue, supplanting the degeneration in
the cord, indicating that regeneration was more in the line of new con-
nective tissue than of new nerve fibers. During every year's time that a
tabetic did not grow worse, or improved in his general condition and
local symptoms, we could fairly assume that there was such a substitu-
tion, to some extent, of new connective tissue for the degenerated fibers.
This was practically the condition of the spinal cord in the second or
quiescent stage of tabes. It was certainly far better for the patient than
a progressive degeneration of the entire posterior columns of the cord.

Dr. Noyes said that in tabes he had seen better results from the use
of strychnia and tonics than from the use of anti-syphilitic remedies. In
those cases where there was arterial thickening and the symptoms of
arterio-sclerosis that were usually present in syphilitics, he thought the
administration of small doses of the iodides was allowable, but not with
the idea that they would act as an anti-syphilitic, but simply to improve
the circulation. No one deliberately treated arterio-sclerosis with large
doses of iodides. The speaker said he had seen the ataxia of tabes ag-
gravated by large doses of the iodides, and disappear a-fter their with-
drawal. The use of mercury was frequently followed by improvement in
various nervous conditions, but this improvement was only temporary
unless the disease rested on a syphilitic basis, and even in syphilis the
use of mercury was limited to the early stages, and in later stages to
occasional use when no careful mercurial treatment seemed to have
been carried on. In a tabetic, few physicians would expect to help con-
ditions by the continued use of mercury.

The entire question of the treatment of tabes and paresis rested on
the question of diagnosis. In paresis even more than tabes both pathological
findings at autopsies as well as careful clinical observations indicated that
there was an early sub-acute stage, with the presence of round cells in

784 NEW YORK NEUROLOGICAL SOCIETY

the brain tissue, and a chronic stage, marked by degeneration of the
ganglion cells of the cortex.

Dr. J. Ramsay Hunt said that his experience with the use of anti-
syphilitic remedies in tabes and general paralysis differed but little from
that of the previous speakers. Under such treatment, some of the cases
improved and some grew worse, so that these remedies should be used
with caution in this group of cases. In cases of tabetic optic atrophy,
which was regarded as a para-syphilitic manifestation, he had never seen
improvement follow the use of anti-syphilitic remedies ; on the contrary,
he had occasionally observed the condition grow worse under their use.
If massive doses of iodide or mercury really influenced favorably the
progress of parasyphilitic degenerations of nerve tissue, evidences of this
should be observed in this group of cases (the optic atrophies).

Dr. Hunt said it seemed to him that the improvement observed in
some cases of tabes and paresis might be ascribed to the disappearance of
genuine syphilitic manifestations accompanying the parasyphilis. That
these two forms were not infrequently combined was a common observa-
tion. It was also possible that the milder meningeal and vascular changes
accompanying parasyphilis would be favorably influenced by the use of
these remedies.

Dr. Hunt said his personal attitude toward these cases was as follows:
During the first and second stage of the parasyphilitic disease he em-
ployed anti-syphilitic treatment cautiously from time to time, in the hope
of diminishing any meningeal or vascular exudations, and to counteract
any genuine syphilitic manifestations. Of the two drugs, iodide and
mercury, he gave the preference to the latter.

Dr. William M. Leszynsky said he had seen much harm done in tabes
by the use of mercury and the iodides, and he thought the persistent use
of these drugs for indefinite periods was not justified. He could recall
a number of cases of tabes in which the pupillary symptoms, and es-
pecially beginning optic atrophy were apparently aggravated by the use of
anti-syphilitic remedies. In any case where he was in doubt between cere*
brospinal syphilis and tabes, and the patient had not been subjected to
anti-syphilitic treatment, he always gave him the benefit of the doubt by
administering these drugs.

Dr. Jacoby. in reply to a question as to how he gave his anti-luetic
treatment, said that his method had varied during the past twenty years.
In the majority of his cases, the patients had already received thorough
anti-syphilitic treatment, some by injections, some by inunctions, etc.

Dr. Kirby said that he had had comparatively little experience in the
anti-syphilitic treatment of tabes and general paresis. At the Manhattan
State Hospital, at the present time, such treatment was not applied as a
routine procedure, but only in certain cases, especially those in which the
diagnosis between general paresis and brain syphilis was not clear.
Patients suffering from paresis did not come under his observation until
the disease was already well established. The anamnesis showed, how-
ever, that very few of these patients had been subjected to a thorough
anti-syphilitic treatment. The only hospital cases, therefore, in which
anti-syphilitic treatment had led to any result were those in which some
symptoms of cerebral syphilis accompanied the psychosis.

Dr. Dana said he had in mind certain patients who were affected
with syphilis and subsequently developed manifestations of syphilis of
the nervous system, such as spinal cord symptoms, and who, after they

NEW YORK NEUROLOGICAL SOCIETY 785

had undergone a very thorough and systematic course of anti-syphilitic
treatment in Paris or elsewhere, were instructed to repeat the course once
or twice yearly as long as they lived in order to avoid tabes or paresis.
While he could not speak definitely regarding the efficacy of such a
method of treatment, he did know that it was not always effective, as he
had seen patients who had developed tabes in spite of it.

Dr. J. F. Terriberry thought the fact had been clearly established that
the canonical three-year period or anti-syphilitic treatment was not effec-
tive in checking the later manifestations of the disease. For the past
five or six years his own plan had been to advise all syphilitics to undergo
a two or three months' course of treatment yearly.

With regard to curing tabes or general paresis with anti-syphilitic
drugs, Dr. Terriberry thought that was entirely out of the question, at
least so far as his experience went. In fact, he did not consider anti-
syphilitic remedies indicated in those cases, and he had seen cases of
locomotor ataxia improve after the withdrawal of anti-syphilitic medi-
cation. He had taken this to indicate that the general welfare of the
patient was improved by the withdrawal of those drugs.

Dr. Brush said the worst results he had ever seen in tabes and general
paresis were in those patients who had been subjected to energetic anti-
syphilitic treatment. He could recall cases of tabes in which the symp-
toms, after remaining stationary for years, suddenly became aggravated
by large doses of mercury or potassium iodide, and the patients went down
hill very rapidly. The only good results he had seen from the use of
mercury in tabes were when it was given in small tonic doses.

Dr. Dana said that when a patient had once shown any symptoms of
nervous syphilis, it was perhaps a wise precaution to tell him that he must
take a course of treatment yearly as long as he lives. Such a plan of
treatment, carried out in a moderate way, while perhaps not always effec-
tive, would be apt to prove beneficial.

THE BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY.

March 21, 1907.

The President, Dr. W. N. Bullard. in the Chair.

A CASE OF PROGRESSIVE MUSCULAR ATROPHY OF THE

PERONEAL TYPE.

By Dr. J. J. Thomas.

The boy. H. F., came to the Children's Hospital first on January 27,
1904, when he was two years and two months old. The family was one
of Russian Jews, but this child was born in Boston. The parents were
healthy. The first child. Solomon, had similar trouble. The second
child, at that time a girl of fourteen, and the third, a girl of seven,
were healthy.

The patient had had no illness, and there was nothing of importance
about the birth.

Four weeks before he was brought in he had had an attack in which
he was feverish for four days, and soon after it was noticed that he
turned the feet in when walking. At that time it was noted that the

786 BOSTON NEUROLOGICAL SOCIETY

gait was unsteady, and he had double foot drop. A shortening of the
tendo-Achillis on the left, so that the foot could only be brought to a
right angle. There was wasting of the anterior tibial group of muscles
in both legs, but no weakness of the thigh muscles, the child getting up
with some difficulty, but not climbing up the legs. The knee-jerks were
good.

The following June there was found swelling, redness and tender-
ness of the left tarsal region, and an X-ray showed only bone atrophy,
such as a paralytic would show, and a notch in the lower epiphysis of
the fibula, but did not account for the stiffness of the tarsus. This
condition was treated by the surgeon, and after a time disappeared.
Soon afer this, on June 18, 1904, a general tremor was noticed more
evident in the legs and the anterior muscles of the legs showed an
absence of reaction to the galvanic current. In January, 1905, the
atrophy of the muscles of the lower legs had increased slightly, but it
was noted that the strength of the thigh muscles was good. About this
time he was given a splint to correct the. varus of the left foot, which
was evidently due to the shortening of the tendo Achillis. During this
time, a little over a year, there had been no extension of the weakness
to other muscles, and the paralysis was confined to those of the an-
terior tibial group, and it was concluded that the case was one of an-
terior poliomyelitis, from the history of sudden onset after an acute
illness and the lack of progress of the disease, and in this in spite of the
fact that tin- presence of muscular dystrophy in the older brother was
known.

The child next returned on January 23, 1907, now being five years of
age. It was said that there had been no change, and the boy had
walked better, hut the preceding summer the splints had been left off, as
they had become too small and hurt him. Since this was done they
noticed the foot turned in more, and for two or three weeks they had
noticed the hands being weak.

On examination it was found there was good power of flexion and
extension of the legs on the thighs. No power of dorsiflexion of the
feet, but some plantar flexion. Marked contracture of the tendo-Achillis
on the left and slight on the right. No power to extend the hands in the
arms. No weakness of the muscles of the shoulder girdle. Well-marked
atrophy of the distal portions of all the limbs, with good preservation
of the proximal portions. No pseudo-hypertrophy. Knee-jerks present
and fair. In rising from the floor puts hands on knees quite often, but
does not climb up the legs, and there is no lordosis.

The atrophied muscles, the tibialis anticus, extensor communis dig-
itorum, peronei. gastrocnemius, all the extensor muscles of the
forearm, as well as the vastus externus and internus show no reaction
to strong faradic or strong galvanic currents, no reaction of degen-
eration being present.

Sensation for pin prick was good everywhere and there was no
tenderness of the nerve trunks.

The older brother, S. F., now seventeen years of age, was first seen
when twelve years old. on June 25, 1902, at the Children's Hospital,
but his trouble had been first noticed at the age of three years, when
his parents said he began to walk badly and this had increased grad-
ually.

BOSTON NEUROLOGICAL SOCIETY 7%7

Examination at that time showed marked wasting of forearms,
hands and calves. There was a feeble grasp and double wrist drop,
but fair flexion, and extension of the forearms and the deltoids were
strong. In the lower limbs there was slight power of extension,
with flexion stronger, but no movement of the feet or toes. The
movements of the thighs on the trunk were good. The knee-jerks,
triceps reflex, ankle jerk and plantar reflex were all absent. He could
get up from the floor with difficulty and only with support. There was
no pseudo-hypertrophy, but the triceps had a slightly lumpy feeling.
He walked with balancing from side to side and double foot drop.
There was varus on the right, and valgus on the left, and also a
marked internal strabismus of the left eye.

Sensation was not tested.

This boy had now become helpless, and the case was probably one
of the peroneal type of muscular atrophy, but when first seen showed
some of the characteristic's of the ordinary type of muscular dystrophy,
such as the waddling gait. Later there was marked lordosis also.

The case of the older brother seemed to present some of the char-
acteristics of the transition form lying between the muscular dystrophies
and the peroneal type, such as some of the cases reported by Toby
Cohn, Hanel and Danha'rdt, and these lend strong support to the view
that the peroneal type is closely allied to the muscular form. The
fact that most clear cases show heredity and that they usually begin
in childhood or young adult life, is another argument for the associa-
tion. Sainton in 52 cases found the onset of the disease 40 times before
twenty-two years, with the extremes of two and forty years in the age
of onset.

A CASE PRESENTING DELUSIONS CONCERNING THE

LIMBS.

By Dr. Courtney.

The case showed certain mental features which constitute its main
claim to interest. The patient is an unmarried man of twenty-five
years. Before the illness which led to his present trouble he went to
school and was intelligent and ambitious. Since his illness he has done
nothing. Physically he was of sound habit and given to athletic sports.
With regard to his family history there is nothing noteworthy except
that his sister, the wife of a physician, has exophthalmic goitre. The
patient denied venereal disease, said he used no alcohol and was mod-
erate in the use of tea and coffee. Tobacco he had abused. His
bowels have always shown a tendency to looseness. His weight varied
from 164 to 172 pounds; his height is 5 feet 8% inches.

In September, 1903, he went South, where he almost immediately
contracted typhoid fever with marked dysenteric symptoms. He entered
a hospital and remained there from the middle of September until the
following June. He says he was out of his head on three different
occasions during this time, but remembers much that transpired. He
states that his legs were drawn up by contractures for a long time,
and that they were wasted and tender to the touch. The doctors, he
says, could obtain no knee-jerks.

On his return home he was completely "devitalized," as his brother-
in-law expresses it. He was emaciated to a marked degree, and has

788 BOSTON NEUROLOGICAL SOCIETY

never since fully recovered his weight. What alarmed the family was
his mental condition, which will be spoken of later.

Examination of very recent date shows physical findings as follows:
Patient tall, pale and cadaverous-looking; gait not characteristic; station
with the eyes shut normal. The pupils are somewhat irregular in out-
line, the right more so than the left. The right is also larger than the
left, but both are normal to light and accommodation. The head
shows a fine rotatory tremor, and there is distinct nystagmus when the
eyes are moved to right or left; none with upward and downward
movements. The left brow seems to be less wrinkled than the right;
the other facial movements are normal. There is no marked tremor
of the tongue, which is protruded straight. The speech is not scan-
ning, but at times seems dysarthric and nasal. There is no intention
tremor, and the hand-grasps are powerful — in fact, the general muscu-
lar strength is excellent. Sensation is everywhere normal; the deep
and superficial reflexes also normal.

The weight is about 140 pounds.

Judged by the quickness and accuracy with which the patient per-
formed certain mental tasks set before him, his intellectual activity
seemed unimpaired. His handwriting is normal.

The family state that he cannot be trusted to get the right things
at the store, but the patient says his main difficulty is to remember
whether it is vinegar or molasses, butter or lard he is after. He states
that he always gets the right thing, however.

The striking feature of interest about his mental condition is the
-peculiar delusion he harbors about his legs. He insists with quiet
dignity that the legs he walks about upon are not his legs at all; he
knows they are not his, because his had certain marks which these
do not possess. He says he thinks somebody else has his legs, but he
can't say who. He insists that no amount of argument will convince
him of the falsity of his belief.

In coming to a diagnosis in this case the various progressive de-
generations were considered but ruled out. partly from the history and
partly on the physical findings. The physical signs, such as the nystag-
mus and the tremor of the head, are most logically accounted for on the
basis of unregenerated nerve fibers, while the mental probably came
from the general intoxication. The specific delusion about the legs is
traced back to sensory perversions which arose during the course of
the peripheral neuritic process.

A CASE OF POSTERIOR COLUMN DEGENERATIONS FOL-
LOWING INJURY TO THE POSTERIOR ROOTS OF THE
SEVENTH CERVICAL NERVE.

By Drs. Mitchell and Barrett.

The material for the study came from a patient who died at Danvers
Insane Hospital sixteen days following fracture of both arches of
the fifth cervical vertebra.

The man was forty-seven years of age. For ten years he had led a
Tagabond life, frequently confined for drinking habits, and while intox-
icated fell and sustained the injury mentioned. For three days he was
able to walk about, although there was lessened muscular power. He
was admitted to the Danvers Hospital on the sixth day following in-

BOSTON NEUROLOGICAL SOCIETY 789

jury. At that time he had a temperature of 102 degrees, there was
almost complete paralysis of muscles of trunk and extremities. Had
nephritis, cystitis and a marked impairment of sensations below the
level of the second rib, except for the outer surface of both arms.
He had been examined by physicians on the second day after the in-
jury, and it was reported that the tendon reflexes were present at that
time. All tendon reflexes were absent upon admission to the hospital.
Plantar and cremasteric reflexes remained until the day before death.
At no time were electrical reactions abnormal.

There was progressive impairment of sensory functions to a point
of complete anesthesia over the area mentioned. Patient died of pyelo-
nephritis.

Anatomical findings. — The autopsy showed slight hemorrhagic ex-
udate around the broken ends of bone. The cord was swollen at the
sixth and seventh segments so as to fill the canal. There was appar-
ently no bony pressure at any particular point. At the seventh seg-
ment the transverse sections of cord studied histologically showed
that the injury to the cord was largely confined to the lateral and
anterior portions. Many cells in the anterior horns showed axonal re-
action, while the cells of the posterior column were normal. Under
the Marchi stain the anterior horn was dotted with black, and there were
blackened fibers in the anterior commissure, and there were scattered,
blackened fibers in the anterior columns and a few in the lateral col-
umns. In the posterior columns the principal change was seen in the
entering root fibers. Nearly all the posterior root fibers were black-
ened. Similar findings were less marked in the sixth cervical segment.
The course of the seventh cervical fibers could be traced to the
medulla, and the course of the descending fibers of the seventh nerve
could be traced downward in the comma tract to the sixth dorsal
segment.

The case was interesting clinically as showing loss of deep reflexes
following transverse lesion of the cord. It also presented two inter-
esting anatomical points: First, the injury to the posterior columns in-
volving the entering posterior roots of the seventh nerve, and there
was no injury to the posterior horn, so that the ascending course
of the fibers of the seventh nerve could be traced to the medulla. Sec-
ond, showed that descending fibers of the seventh nerve were traced
in the comma tract to the sixth dorsal segment, lending support to
the theory of exogenous origin of the fibers forming this tract.

Dr. Walton said that Dr. Mitchell's case was of especial interest to
him on account of the reflexes. The suggestion that the loss of knee-
jerk results in a given case from cerebral or upper cord lesion is some-
times met by the objection that there may be coincident lesion in the
lumbar region. It is very gratifying that in this case careful examina-
tion has eliminated such lesion. The loss of reflex was in this case
coincident with the loss of voluntary power resulting from the cervical
lesion. The burden of proof rests, therefore, upon those who would
deny the dependence of the one upon the other.

The preservation of electrical reactions in such cases shows that
the prevailing idea has stood the test of experience, that the electrical
reactions have their seat in the spine purely. On the other hand, the
long prevailing view that the knee-jerk is purely spinal and merely in-
hibited by the brain, requires and is receiving readjustment.

7QO BOSTON NEUROLOGICAL SOCIETY

THREE CASES OF INVOLUTION-MELANCHOLIA.
By Drs. Southard and Mitchell.

These cases displayed in life feelings of unreality, nihilistic delu-
sions and various other signs which tended to mark them as approxi-
mating the features of Cotard's syndrome. The readers did not insist
that the characteristic feelings of unreality displayed by these victims
of melancholia are never found in patients subject to disease other than
melancholia.

The cases discussed were those of a clerk, aged forty-eight; a
mason, age seventy-five, and a shoemaker, age sixty-five. The as-
signable causes were: in the clerk, financial worry; in the mason, senil-
ity and domestic worry: in the shoemaker, nothing. All three cases
showed more or less arteriosclerosis. The alcoholic and venereal his-
tories were practically negative. The mothers of two patients had suf-
fered at the close of life with continuous depressions. All cases showed
ideas of negation, developing in the clerk after slight increase of de-
pression and agitation, with delusions about self and family; in the
mason, after gradual senile failure; in the shoemaker, after a slowly
developing hypochondria. The senile case made a suicidal attempt.

The most remarkable feature of the autopsies in these cases was
the practically normal character of the brains when examined micros-
copically. The visible arteriosclerosis was confined in all cases to the
large branches of the circle of Willis. The senile case showed a small
old cyst of softening in the occipital region, the shoemaker showed a
mild chronic exudative process.

The brains gave little evidence of general or focal atrophy. No
striking alterations in topography or arrangement in layers were de-
tected microscopically. Perivascular pigmentation was found and was
attributed by the readers to the results of advancing years rather than
of a special factor. Common to all three cases was a neuroglia cell
pigmentation in intermediate layers of the cortex. Satellite cell pig-
mentation was not constantly found. Nerve cell pigmentation was con-
stantly found in the elements of moderate size in all parts of the cor-
tex examined. This pigmentation was strikingly brought out by use
of Heidenhain's iron hematoxylin stain. The larger elements failed to
show this characteristic pigmentation. The interest of the work, ac-
cording to the readers, lodged in the somewhat peculiar topographical
distribution of the pigment and its absence in the larger elements re-
lated with the projection system. The readers promised further work
on melancholia.

BRIEF REPORT OF THREE CASES PRESENTING THE FEEL-
ING OF UNREALITY (COTARD'S SYNDROME).

By Dr. Harry W. Miller.

Dr. Miller said he wished to offer in as brief a manner as possible
a few types illustrating the Cotard Syndrome or a feeling of unreality
involving the different fields of consciousness; namely, the conscious-
ness relating to the outside world, the physical and the mental person-
ality, designated respectively by Wernicke as the allopsychic, the soma-
topsychic and the autopsychic fields.

It was his intention to summarize those cases in which he had
observed the feeling of unreality as present in any degree of intensity.

BOSTON NEUROLOGICAL SOCIETY 79*

-He soon found, however, that time did not permit of any such anal-
ysis, so he was forced to offer simply a few typical examples.

He had been much interested in this syndrome since reading Hoch's
review of "Some Recent Papers upon the Loss of Feeling of Reality and
Kindred Symptoms," and Packard's excellent analysis of his reported
case where he offers the hypothesis that the feeling of unreality is
due to a disorder of apperception which in turn is due to an associating
difficulty of some kind.

These cases are offered not with any intention of attempting to
establish an entity, as it is conceded that the syndrome is present in
various psychoses which have no other points of similarity, nor did he
wish to make any estimate of the prognostic value of this complex
of symptoms. Reference was made by Dr. Stedman in his case report
at the last meeting of this society of the unfavorable outcome of those
cases presenting this syndrome, the contention being held that the
presence of the feeling of unreality indicated a dissolution of the per-
sonality which was regarded as a bad omen. He could not submit
any reliable conclusions on this point from a hasty review of his
material. He had found this syndrome most prominent among the cases
which we at the present time designate as the involutional type of mel-
ancholia. He has also found it in dementia prsecox, depressed phase
of manic-depressive insanity and in general paralvsis.

Case I. — Involutional melancholia, illustrative of the feeling of un-
reality, involving all three fields of consciousness, the allopsychic, som-
atopsychic and autopsychic.

L. D. P., fifty-eight years old, on admission to Taunton Insane Hos-
pital in January, 1902: accountant. Dr. Miller read only those parts of
the records which illustrate the above symptoms. He would say in
passing that there were no disturbances of the organic sensations.

The following quotations amply exemplify the feeling of unreality
in the different fields: "This place is sinking beneath the surface of
the earth — the engineers are sick, the fires are all out, the water will
freeze in the pipes and these things you call men will freeze to death
before morning. — I have no stomach and I have no lungs, so I know I
will be dead soon. — That grass is not natural grass, it does not look
natural. — That man is not a man, he is an invention of the devil made
for the occasion. These buildings are not natural — see that sparrow,
see how he moves his head. He is not natural, he is made to do that."
(Shown cherry blossoms.) "Those are not real flowers. Nothing is
real. That squirrel out there is not a real squirrel, it is only an inven-
tion, a mockery. — I am going to be squeezed to death by this tremen-
dous pressure. This is not air here. We are under the ground, under
the water, and there are too many things you call people. We will
all die with the pressure. — These are not rooms, there is only one room.
— You call this place a hospital — why, it is only a shed and there is no
air, no floors, no wall, nothing but a make-believe shed. — We do not
live, we are all dead, we are spirits and some outside thing makes us
talk. — I could not help coming aboard this float."

("What do you mean by aboard?") "This is a float under the
ground, under water. I am dead, you are dead. This place only repre-
sents a room. — You are nothing and I am nothing. It is all an illu-
sion.— I am not talking. It is something in me that talks. I am dead.
It must be some kind of a spirit that does the talking. This body has

792 BOSTON NEUROLOGICAL SOCIETY

been given to me lately. It is just a spiritual affair, held together by
gravity. I think it was taken from down stairs, stuck together and
called me. I have not the least thing to do with this (pointing to him-
self).— I have never been. It is all a dream and an illusion. You are
not alive, nobody is alive, it is all a spiritual representation. — I am losing
this support around me, this body was slapped around me that I rest
on. See, this whole building is vanishing away, it is only a spiritual
building, anyway. It is a building not made with hands. — They talk
about women, there are not any such things, it is only a spiritual dream.
— We do not eat, we just imagine we eat, it all goes, goes out the win-
dow and then vanishes away."

("There is a window, then?") "No, that is just a spiritual represen-
tation, it is really not a window. You cannot see, you cannot smell,
you have no nose, you have no eyes, you think you see and smell, but
you only imagine it."

He was asked to write his sentiments. He wrote: "Life is only
spiritual, animal life as we call it is only guess work. We think we
have a heart, brain and lungs when we do not have any. We don't
breathe at all, it is only a sham. As soon as the spirit leaves us we are
lost. I am not P , they only call me so."

Invariably when he was asked what day it was he would say,
"There is no day, there is nothing." When asked how he was, he
would respond, "I ain't." On another occasion he said, "I don't under-
stand this world. I wish I did. I don't believe there is anything in it
at all. It isn't a world, it is all underground, there is no such thing
as a world, this body is only made out of a log, my head is wood, that
is why I can't hold it up. What is the sense of trying to shave a
wooden face? We are nothing but disembodied spirits. They say they
give me injections, how can they give injections to anything that is just
screwed together? — I ain't anything. I am only a lot of stuff thrown
together. I suppose I am nothing but water and feces. — I am made up
out of boards — don't you see I have no eyes, put your finger in there
and feel that I have no eyes. Oh, I wish I were dead!" ("You say you
are dead.") "Well, I am dead. I died a long time ago. My limbs
are loose from my body. I ain't anything at all." (His nose was
pinched and he was asked what that was.) "It's nothing." ("Did it
hurt?") "Yes, it hurt, but it don't belong to me. See my little neck,
there is nothing goes down it."

("You eat?") "I pretend to."

("How old are you?") "Nothing."

("What year is this?") "They say 1903, but they don't know any-
thing. Nobody knows anything. You could pull my leg off and I
would not know it. It doesn't belong to me. Oh, I don't know what
the matter is with me, — I can't tell anything, — I know these things are
not real — everything is unreal — I haven't anything — never did have any-
thing."

At another time he said, "How do you expect nothing to feel? You
know I am made up of cinders. When I go to bed and get up in the
morning and put on some clothes they fill up with mud. I eat and that
makes it all the worse. I ought not to eat a bit. It is not food any-
how, it is only make-believe food." He struck another patient and when
asked why he had done it, he said, "It wasn't me, it was the action of
this place as it is constantly in motion. Ain't we going down deeper

BOSTON NEUROLOGICAL SOCIETY 793

every day into the ground? You know this is not air we are breath-
ing, it is cinders. — My stomach and intestines are gone and my food
just surrounds me. When I breathe I take it in. Just see what a little
waist I have got, my wrists are very small. My brain is all gone, don't
ycu see how small my Head is? I am blind. My eyes are gone."
("Do you not see me?") "Only apparently."

Case II. — Involutional melancholia; illustrative of the feeling of un-
reality relating chiefly to the physical personality and in a lesser de-
gree to the mental personality. (Somatopsychic and autopsychic.)

S. W., lemale, sixty-one; involutional melancholia of the agitated
type with affectless depression. Onset at the age of fifty-nine. The
feeling of unreality in this patient, as shown from the extracts of
her records, related more prominently to the physical personality.

When asked whom she was, she said, "I am not anything." She re-
fused to eat. as she said her throat was filled up and she could not
swallow.

("What is the trouble?") "I don't know."
("Does your throat trouble you?") "I haven't got any throat."
("What is this?" pointing to her throat.) "Why it used to be a
throat, it is nothing now. You can't have a throat when you can't
swallow. You don't see my throat, do you? — I have no stomach and
no bowels. My bowels cannot move because I have none. I am
nothing."

("What are these?" pointing to hands.) "They are hands, but that
is all there is of me."

("How about those feet?") "If they are feet, what good are they?"
("You have a nose?") " I can't have because I can't smell."
("Your eyes are all right.") "No, I don't see anything." She
named a number of objects shown her correctly.

("How do you explain that?") "Well, I don't see these things;
anything in a room may lie seen, but I cannot see them with my eyes."
("Close your eyes ") "I have not any to close."

("You have ears.") "I hear noises in this room, but not with my
ears. You see, I am different than you. A great deal different, I am
nothing and you are something. I am not living, because I have noth-
ing to live with."

When her throat was pinched she said that she felt it but that it was
not her throat.

"I have no lungs or liver or heart, so how can I be alive?"
("Why do you think you have no internal organs?") "Because I can
not feel them and I know I cannot have any because if I did I would
not feel like this."

Case IK. — Dementia praecox, illustrative of the feeling of unreality
relating to the mental personality (autopsychic t.

Bessie W.. twenty-four. This case of the hebephrenic type and to-
gether witli the feeling of unreality and evidently connected with it was
a feeling of passivity which is not uncommon in dementia praecox.
Furthermore, she has had many hallucinations of hearing, autochthonous
ideas and delusions of control. Her feeling of unreality was shown
by the following: "I don't feel like Bessie at all. Somehow I don't
feel lifelike. It seems as if I cannot get my brain together. I must
have a brain, but it seems as if I cannot use it, yet I think, but it
seems somebody else or something else does the thinking for me. — I

794 BOSTON NEUROLOGICAL SOCIETY

think I am hoodooed or a spell is put on me so that I do not feel nat-
ural. I know that I must be myself, yet I cannot sense it, that I am
anything but a moving object without any control over myself. — I
see and hear but somehow I don't feel lifelike, not natural as I used
to feel."

Careful examination failed to reveal a feeling of unreality in the other
fields of consciousness.

Dr. F. H. Packard said that one of the most striking symptoms of
Cotard's syndrome is what he mentions as a delire de negation and
which Dr. Packard had spoken of as the feeling of unreality. It is not
strange that a symptom which was first described in connection with
involution cases and which occurs so often and so obtrusively in those
cases should have come to be considered as more or less pathogno-
monic involution psychoses and should come to share the bad prog-
nosis of such cases. Further observation, however, has shown that the
same symptom occurs in manic-depressive insanity, in general paralysis,
and in psychopathic states resembling dementia praecox, and it is also
shown that cases which show this symptom in its most extreme degree
do recover.

Therefore, it seemed to Dr. Packard, that we no longer ought to
consider this symptom of such diagnostic and prognostic significance.
At the present time he is strongly inclined to believe that these ideas
of unreality are conceptual in origin and not due to any change in
the organic sensations. It would seem that they may arise in almost
any psychosis, provided certain conditions are present, viz., a confusion
of thought where complex mental activity is required, with the pres-
ervation of a certain amount of clearness and ability to reason to a
certain extent.

If this is the case, the symptom at once becomes accidental, as it
were, secondary to the above-mentioned conditions, and not fundamental.
The reasons for its being noticed so often in involution cases are
(i) that the conditions are right. The characteristic narrowed mental
horizon and the preservation of a certain amount of clearness
are favorable for its development. (2) Because it is more easily no-
ticed in these cases — the same narrowed mental horizon, the poverty of
ideas, allows this symptom to stand out alone more obtrusively with
a greater emptiness of background than is the case in manic-depres-
sive insanity, where the more productive patient not only voices these
ideas but attempts to explain and qualify them to a certain extent, and
even talks about many other things. (3) Dr. Packard is quite sure
that the diagnosis of involution psychosis is sometimes made on this
one symptom and (4) because the long duration sometimes obscures the
prognosis.

In manic-depressive insanity it occurs, as indicated before, where
the confusion is slight and is limited to complex mental activity and
is not seen in cases where the confusion is deep and of quick onset, and
from which the patients emerge quickly.

It also occurs when the conditions are right in those psychopathic
make-ups described by Kraepelin in his chapter on original diseased
states. Many of these cases with acute outbreaks of excitement or delir-
ium with more or less suspicion and absurd ideas closely resemble de-
mentia prsecox, but Dr. Packard has not yet seen it in the classical cases
of dementia praecox. It may occur, but rarely. The reasons are clear —

BOSTON NEUROLOGICAL SOCIETY 795

the conditions are not right. Whenever an association disorder of the
necessary kind is present in these cases there almost always accom-
panies it too great a mental apathy to allow the development of any ideas
in particular, and too great an emotional indifference to bring out such
ideas even if they were present. And finally it occurs in general par-
alysis. Text-books mention it, and he has occasionally seen it, but has
not observed it carefully in those cases.

From this Dr. Packard would conclude that it is not a fundamental
symptom, not a pathognomonic symptom, and that the prognosis of
cases showing it is not necessarily bad, but depends upon the more
fundamental symptoms. Since it occurs in various mental conditions,
at various ages, and varies in its outcome, Dr. Packard would be
rather inclined to doubt its relation to any pathological findings.

Dr. Mitchell said that he had no intention to argue that Cotard's
syndrome was a distinct clinical entity, but he felt that the feelings of
unreality deepening into nihilistic ideas were not necessarily Cotard's
syndrome, because these delusions of negation might be seen in many
different psychoses.

He felt that Cotard's syndrome in its entirety would be seen only in
cases of anxious, agitated melancholia where depressive ideas might
deepen and become transformed into ideas of negation and nihilistic
beliefs. He would agree with others that delusions of negation when
seen in the case of manic-depressive insanity would have no special
prognostic significance, but believes that the group of symptoms de-
scribed by Cotard carries with it a bad prognosis. Many of the pa-
tients die during the height of their psychical disturbance, and he has
seen no case of complete mental restoration following this condition.

periscope

Miscellany

The Gradual Cure of Hysterical Paralysis. H. T. Pershing (Journal
A. M. A., May ii).
The sudden cure by suggestion or otherwise, of hysterical paralyses,
however practicable and tempting in cases in which one can be sure of the
diagnosis and of his power to impress the patient, is not the one to be
generally chosen. Failure may compromise future success, and too prompt
success may have its disadvantages in depriving the patient of the dis-
cipline and enlightenment thai arc necessary to a permanent cure. The
safer way is more gradually to arouse and exercise the dormant kinesthetic
centers, overwhelmed by inhibitory impulses from other centers, due to
the perverted emotional conditions and ideas, by first raising the emotional
tone, encouraging the patients to believe they will recover, and if such
cheering is opposed or resented, appealing to their amour propre by
judicimis suggestions. The physical measures — rest, food, tonics and seda-
tives— while of great importance, are sometimes overvalued, he thinks,
but both mental and physical treatment should be employed in these cases
in harmonious combination. While doing this, the dormant kinesthetic
centers can be acted on specifically by sensory stimulation. Hysterical
anesthesia is not absolute and strong faradic currents, applied to the skin
and muscles, followed by vigorous and even rude, passive motion of the
affected limb, have a powerful tendency to restore the lacking sensations
and ideas of motion. The patient's close attention should be directed to
the anesthetic part and every slight beginning of sensation noted. This
will tend to bring the cortical sensory centers again into relation with the
other centers in the cortex. After awakening some degree of normal
sensibility and overcoming inhibitory fears, the cure can be completed by
exercise in voluntary motion. If the paralysis is nearly total it is as well
to let the first attempts be favored by gravity, which will assure some
motion and encourage the patient to increase it. A beginning once made,
the attempts can be gradually increased, every encouragement being given,
till at length some normal control is obtained, and the patient is able to
practice some assigned exercises in the physician's absence. The length of
time taken in accomplishing the cure may be made an advantage by using
it to carry on a re-education in composure and self-reliance, without which
permanent recovery is impossible. Two cases of typical hysterical paralysis
are briefly described in which this method had been employed with com-
plete success.

Syringomyelia. Extending from the Sacral Region of the Spinal
Cord Through the Medulla Oblongata, Right Side of the
Pons and Right Cerebral Peduncle to the Upper Part of the
Right Internal Capsule (Syringobulbia). William G. Spiller,
M.D. (British Medical Journal, Oct. 20, 1906).
The interesting features in this case are found in the pathological study.

MISCELLANY 797

The extent of the cavity is greater than any heretofore described, and in
fact has even been regarded as impossible. The patient's first symptom
was a weakness in the left foot developing' when he was seventeen years
old, which progressed slowly until, in six years, the whole left side was
paralyzed. The right side then became gradually weaker, and four years
later he was completely helpless. Examination showed atrophy of the
right side of the tongue with a marked impairment of the sense of taste,
especially on that side. There was great impairment of motion in the
arms, especially in the right. There was considerable wasting of the arms
more marked in the distal portions. The right leg also was more affected
than the left, and was 2Y2 inches shorter. Sensation for touch was felt
normally throughout the body, but for pain and thermal sensation the dis-
turbance was pronounced. The patellar jerk was exaggerated on the right
side and diminished on the left. Death was due to bronchopneumonia.
The cavity in the spinal cord began in the lower sacral region in the left
posterior horn to which it was still confined in the upper sacral and lum-
bar region. From the midthoracic region upward the spinal cord was
distorted and flattened. In the medulla there were distinct cavities in
each anterior pyramid ; the one on the right side being larger and cutting
off the fibers of the hypoglossal nerve on that side. In the upper part of
the medulla the cavity in the left anterior pyramid had disappeared. In
the pons ; the cavity in the right side extended nearly to the raphe.
The right adducens fibers were degenerated. In the right cerebral
peduncle the cavity was a narrow slit in the substantia nigra and extended
into the upper part of the crusta near the median side of the peduncle.
In the lower part of the internal capsule the cavity divided; one part
soon terminated, but the other extended upward to within two or three
millimetres of the lower surface of the lateral ventricle, but did not open
into the ventricle. Schlesinger, in his monograph, says that in syringo-
bulbia the cavity does not extend above the fifth nerve and involvement of
the first four cranial nerves indicates a complicating lesion. This case
shows that the third, fourth, or fifth cranial nerves might be involved by
a cavity and that symptoms in the distribution of these nerves need not
necessarily imply a complicating lesion. The atrophy of the right side
of the tongue is explained by the complete degeneration of the hypoglossal
nerve and its nucleus. C. D. Camp (Philadelphia).

Dislocation of Vertebr.e in Lower Cervical Region. William C. Krauss
Annal. of Surg., November, 1906).
In connection with a review of the literature on this subject, Dr.
Krauss reports an interesting case of dislocation of vertebrae in the lower
cervical region, followed by symptoms of complete severance of the
spinal cord. Laminectomy was performed with a result of partial restora-
tion of function later. The report is in brief: Male, 22, healthy, dived
into shallow water, became semi-conscious and devoid of power in arms
and legs. On admission to hospital there existed total paralysis of legs;
arms and hands partially paralyzed. Speech, eyes, pupils and facial
muscles not affected. Head slightly retracted, but moves in all directions
with some pain. Tenderness over spinous process of the fifth cervical
vertebra, and indefinite pain about third thoracic spine. Pulse slow, full,
and good tension. Heart normal, respiration diaphragmatic, no temperature.
Patellar, ankle and plantar reflexes absent. Marked priapism. Patient
able to flex arms, but not to extend them. Movements of fingers and

798 MISCELLANY

thumb impossible. Extension and flexion of forearm greatly weakened.
Adduction of arm, pronation and supination of forearm very weak.
Considerable weakness of deltoids, triceps, and chest muscles, also muscles
about scapula and paralysis of serratus magnus. Triceps and biceps tendon
reflexes absent. Zone of anesthesia corresponds to the level of the second
intercostal space, is symmetrically limited to ulnar side of the arm
and forearm, including the middle, ring and little fingers, and is for
both temperature and tactile senses. Abdomen tense, reflex lost; likewise
the cremasteric. Incontinence of feces. Condition diagnosed as complete
severance of cord at level of sixth cervical. Placed on water-bed and trac-
tion to head. In few days bed sores developed and mild cystitis appeared.
Eighteen days later laminectomy of fifth and sixth cervical performed by
Dr. Roswell Park. Sixth cervical apparently abnormally loose. Dura
appeared normal, but contained large amount of cerebrospinal fluid. Re-
mains of old clot found. Cord seemed flattened and shrunken. No con-
striction above or below. Wound closed with buried and superficial drain-
age. On leaving hospital four weeks later the condition was : Can move
head freely without pain. Area of anesthesia not materially changed.
Can raise arm over head and flex forearms, but flexors of hand are weak;
likewise pronation and supination. Can draw right leg as far as left knee ;
extension and flexion of right foot quite strong. Left leg can be drawn
up to middle of right leg ; extension and flexion of foot very weak. Patel-
lar and plantar and Babinski's reflexes exaggerated; ankle and patellar
clonus present. Abdominal and cremasteric reflexes still absent. Priapism
disappeared and can tell when bladder and bowels are going to act, though
can't control sphincters. Involuntary contraction of leg muscles and
spasmodic flexion of legs and feet an annoying symptom. Eight months
later, patient inclines slightly forward; Romberg present; flexes right leg
upon thigh and pelvis, but can lift left leg only three inches from floor.
Can walk with support. Tendency to fall backward. Gait is spastic;
drags toe of left foot. All motion of arms and shoulders free. Pronation
and supination of forearms good; likewise extension of wrist. Closes
right hand fairly well, writes easily and uses telegraph key. Can open and
close left hand, but without much power. Tendon reflexes of triceps,
biceps and forearm muscles exaggerated, muscle reflexes heightened. Ab-
dominal and cremasteric reflexes absent. There is still some difference
of sensation at level of original zone. Temperature and tactile sense of
left leg normal, but in right leg cannot distinguish between hot and cold.
Breathing still diaphragmatic. This case is of interest since it shows a
marked regeneration and recovery of function following a late operation.

H. C. Cowles (New York).

The Blood Pressure in Paresis. G. L. Walton (Journal A. M. A., Oct.
27).
In order to test the correctness of the general belief that the blood
pressure in paresis is low, the author has examined 108 male patients with
this disease in the Massachusetts hospitals for the insane, with special ref-
erence to this point. He used the Riva-Rocci instrument and employed the
ordinary precautions in making the observations. The average of all the
observations indicated a high rather than a low pressure, but to eliminate
the influence of renal and arterial conditions, he separately tabulates the
results in forty-four cases, without record of renal, cardiac or arterial
disease, which show a tendency to hypotension rather than to hypertension.

MISCELLANY 799

The difference in this respect is not considered of very great value for
diagnosis, the less so since variability rather than high pressure is the
characteristic of the psychoneurotic. The author gives his conclusions as
follows: (i) The average blood pressure in paresis, taken as a whole, is
high. (2) This is doubtless due to the prevalence of atheroma with its
cardiac and renal accompaniments. (3) The average blood pressure in
cases of paresis without atheroma, cardiac enlargement or renal disorder,
is probably somewhat lower than that of health, but the variations are so
great that it can not be said to be uniformly low. (4) The test is not
likely to prove of great practical value in the differentiation of paresis
from other nervous disorders, though here, as elsewhere, it is of great
value in estimating the circulatory condition of the individual.. (5) These
observations are too few to establish a rule with regard to the blood pres-
sure in varying emotional states. So far as they go, however, they tend
to show that: (a) The excited states of paresis are as likely to be accom-
panied by high as by low pressure ; (b) mental depression is accom-
panied by high oftener than low pressure, but that it is not incompatible
with low pressure; (c) while the average pressure in euphoria is perhaps
somewhat lower than in the other mental states of the general paralytic, it
is not inconsistent with high pressure or with pronounced atheroma with
its cardiac and renal accompaniments.

Prognosis of Multiple Sclerosis. O. Maas (Berl. klin. Woch., 44, 7,
1907).
The author makes an interesting communication based on the history
of a patient from Oppenheim's Poliklinik. A 58-year-old woman had had
for eighteen years a typical case of multiple sclerosis, which developed
slowly and progressively. The process then came to a standstill. She
became very much better, and although showing unmistakable signs of
disturbance of the nervous system she has been in this improved condition
for thirteen years. Jelliffe.

The Present Status of Brain Surgery. M. A. Starr (Journal A. M. A.,
Sept. 22).
The author considers that sufficient time has elapsed to enable us to
estimate the value of brain surgery for the relief of tumors, epilepsy and
abscess with considerable accuracy. It is only in localized Jacksonian
epilepsy (about 2 per cent, of all cases), that operation is- indicated and
in only about 20 per cent, of these is it successful. Trephining for epilepsy,
therefore, is of very limited application and is only to be recommended in
a few selected cases which present the necessary guide to both physician
and surgeon. In abscess of the brain, early operation as soon as the con-
dition is diagnosed is imperative, and in cases of skull fracture or con-
cussion followed within two or three weeks by symptoms suggestive of
abscess, even if there are no localizing symptoms, trephining is imperative.
There are many regions of the brain, injuries of which are associated with
no localizing signs. In abscess due to chronic otitis, operation is de-
manded as soon as the diagnosis is made. While statistics show the per-
centage of recoveries after operation for cerebral abscess at present is only
about 60 per cent, there is every reason to believe that it will be much
greater when early diagnosis and immediate operation is the rule. In
brain tumor with positive localizing symptoms, operative interference may
be warranted, but in the far greater number, without localizing symptoms,

800 MISCELLANY

operation promises nothing. Post-mortem statistics indicate that about
10 per cent, of brain tumors are open to surgical treatment, and that the
best results may be expected when the growth is located near the Rolandic
or Sylvian fissures, and the highest mortality when it is in the cerebellum.
The proposition to afford relief in inaccessible tumors by making a con-
siderable opening in the skull to relieve pressure, may be of value in some
cases. Starr mentions one of his own observations in which this procedure
was of benefit and two others in which it failed. In cases of extradural
hemorrhage from traumatism, with symptoms of intracranial pressure,
slow pulse, steady rise in blood pressure, deepening coma, Cheyne-Stokes
respiration, and increasing hemiplegia, all appearing within six hours of
the injury, trephining is sufficiently clearly indicated. The hemorrhage is
usually from the middle meningeal artery, hence a large trephine opening
or a large, bony flap should be made in the area just above the ear. In
apoplexy Cushing has applied successfully, in hospital cases, the test of
the condition of the blood tension in determining the need of surgical in-
tervention to save life. When the blood pressure rises steadily to 250
mm., measured by the Riva-Rocci or the Janeway apparatus, in a case of
apoplexy, and when coincidentally with this there is a slow pulse falling to
50 a minute it may be said thai the case will be fatal unless pressure is
relieved by a considerable opening in the skull, without regard to the
finding or removal of the clot. The best place for this is over the motor
area of the side opposite the paralysis, as the clot may be there. Cushing's
cases show that this operation may sometimes save life in an otherwise
hopeless condition. Cushing has also treated surgically with success new-
born infants who. after a difficult labor, have suffered an extradural or
intradural hemorrhage. Such infants usually die, or if they survive are
defective, hemiplegic, idiotic, etc., and any measure for their relief is
justifiable. It 1- easy in these cases to relieve intracranial pressure by
opening the sutures of the parietal bone with scissors, and his success
warrants urging obstetricians to consider this operation in the case of
asphyxiated infant- of the class described above. Obstetricians see these
cases, and if they are convinced that delays are dangerous the percentage,
Starr says, of idiocy and hemiplegic epilepsy will certainly be reduced.
The last class of cases of cerebral hemorrhage suitable for trephining is
that in which hemiplegia or hemianopsia develops slowly after an injury
and does not come to its height for three or four days. In these there is
probably a surface hemorrhage from a vein in the pia mater and lumbar
puncture will probably reveal blood in the cerebrospinal fluid. The symp-
toms may progress and threaten life, or come to a standstill, leaving the
patient permanently incapacitated. In either case surgery is indicated.
Starr refers here to a case of this kind in which a clot was removed from
the lower third of the Rolandic fissure with good results, and remarks
that many other similar cases, equally successful, could be cited. In con-
clusion he refers to the methods that have been recommended and em-
ployed to cure microcephalic idiocy by relieving pressure on the brain
and permitting its expansion. Experience has shown the uselessness of
such surgery, and it is no longer recommended.

Book "Reviews

Psychotherapeutische Briefe. Von Prof. Dr. H. Oppenheim, Berlin.

S. Karger, Berlin.
Letters ox Psychotherapeutics. By Professor H. Oppenheim, of Ber-
lin University. Translated by Alexander Bruce, M.D. Otto
Schulze & Company, Edinburgh. G. E. Stechert, New York.

So closely following the appearance of Professor Oppenheim's little
pamphlet on psychotherapeutic letters has Dr. Bruce's translation of the
same appeared that we are tempted to commend first the letters them-
selves, and second their excellent translation.

Psychotherapy is the prevalent term to express an old form of thera-
peutics, but further, however, it is a hopeful sign of the times to find men
of such signal ability as Oppenheim taking so decided an interest in the
functional disorders of the nervous system, and devoting their energy to
the building up of a tactful scientific mode of therapy for patients suffer-
ing from such disorders.

These letters are excellent, not better than many an intelligent and
tactful woman might write under similar circumstances, not as good, in
our opinion, as many of George Eliot's or Robert Louis Stevenson's letters,
but few practitioners can hope to have the genius of these letter-writers.
They emphasize, however, many of the little things that are of so much
importance in the treatment of neurasthenic, psychasthenic or other
functional mental states, and afford to those of us not so gifted a clue
as to the proper method of approaching, conversing or writing to these
peculiarly difficult patients.

The translation is admirable. It closely retains the author's helpful,
buoyant style and common sense throughout. Jelliffe.

The Integrative Action of the Nervous System. By Charles Sherring-
ton. Holt Professor of Physiology in the University of Liverpool.
Charles Scribner's Sons, New York.

This monumental work consists of a series of ten lectures delivered by
the author at Yale University as the Mrs. Hepsa Ely Silliman Memorial
Lectures. It is the second lecture course given under the new foundation,
and is a work of some four hundred pages of compressed and valuable
physiological facts.

The chief work done in neurological science has been the mapping of
anatomical tracts and boundaries, but the more exact and detailed study of
functions has lagged somewhat behind. This is natural. In the present
work, however, which is too technical and close to permit a short review,
Sherrington has covered the entire ground work of the more essential
and fundamental conception of neural physiology.

In his early chapters he discusses the unit of the nervous mechanism;
namely, the reflex arc. The reflex is the primary integrative unit. What
the functions are of this elemental reflex and the conditions, electrical
and physical, surrounding it, is the work of his first three lectures. The
receptor is first considered, then the conductor. Variations in susceptibil-
ity, in selective excitability, by a lowering of the threshold for certain
stimuli, are the conditions which are discussed as affecting the functions
of the receptor. In discussing the functions of the conductor. Sherrington

802 BOOK REVIEWS

introduces a new term — the synapse, or the surface contact space, between
the neurones. There is a point where resistance is met with, and which
takes time to overcome. This "synaptic phase" he has carefully measured.
Special consideration is given to the study of variable stimuli in regard
to conductivity.

Inhibition is regarded by Sherrington not as an independent phe-
nomenon, but as a part of the function of excitation, and an essential part.
Reciprocal innervation brings about suppression, and an internuncial
mechanism is posited as necessary for the production of the inhibitory
process.

Sherrington then takes up the problem of the compounding and inter-
actions of reflexes and follows by an analysis of the physiological position
of and reasons for the dominance of the brain.

The interesting position, which will probably lead to much discussion,
is taken that a physiological basis for psychical fusion is not present, nor
is it required.

The work is one of great significance, and though difficult to follow
for the student who has not been saturated with the modern experimental
phvsiology of nerve trunks and fiber tracts, its reading will prove stimu-
lating. Jelliffe.

Gehirn und Seele. Vorlesungen von Prof. Dr. med. Paul Schultz;

Herausgegeben von Dr. Hermann Beyer. Johann Ambrosius

Barth, Leipsig.
This is a series of semi-popular lectures on philosophical subjects given
by Prof. Schultz during the years 1899 to 1904 in the University of Berlin.
They differ from most lectures of the kind in the wideness of their scope,
general philosophical considerations being paramount in the earlier pages,
while later the author discusses at length the question of the reflexes, the
activities of earth worms, heredity, psychical functions of ants and bees,
embryology of the human brain, critique of Gall's phrenology, Broca's
speech centers, Hitzig-Flechsig's theory of association centers, hallucina-
tions, sleep, hypnosis, etc.

There is no attempt at completeness in the present presentation. It is
a readable philosophical treatise, couched in popular language. Jelliffe.

Gesammelte Hirxaxatomische Abhaxdluxgex; mit eixem Aufsatz
ieber Die Aufgaben der Neurobiology. Von Dr. August Forel,
ehemals Professor der Psychiatrie und Direktor der Irrenanstalt
in Zurich, in Yvorne (Schweiz). Illustrated with 12 plates (en-
gravings). Ernst Reinhardt. Miinchen, 1907.
To find Forel's contributions to brain anatomy all published in one
volume, will give great pleasure to his many admirers, and will give to
those less familiar with his work opportunity of appreciating his merit as
one of the pioneers of present-day brain anatomy.

The undersigned, who was so fortunate to be one of the author's
assistants when he was Director of the Insane Hospital, Burghoelzli, and
Professor of the Psychiatric Clinic of Zurich, deems it a particular favor
to have the opportunity of reviewing his work in brain anatomy as em-
bodied in the volume before us.

Those who have worked under Forel cannot but have been deeply
impressed by his powerful personality and intellect, and have carried
away with them rich experience serving as intellectual food for many

BOOK REVIEWS 803

years to come. Under the stimulating influence of his vivacious conver-
sation, always interesting and many-sided, but often deeply philosophical,
the minds of those who listened to him could not help being broadened.
To hear him discuss one day Haeckel's biogenetic law and another time
Kant and"Herbert Spencer, or listen to a discourse on color blindness, or
to his views regarding the interpretation of the marvellous sense of
locality in birds, or again to hear him make a harangue of the French
school with humoristic allusions to the grand diseases issuing from Paris,
such as the grand mal, grand hysterie, grand hypnotisme, etc., was
full of inspiration and of lasting benefit to the listener.

To the reviewer's knowledge Forel's studies in brain anatomy were in
the main initiated under Meynert, and the second* paper of the collection
before us was worked out under Meynert, and to some extent bears the
stamp of his influence. So, for instance, he made use in it of Meynert's
"Abfaserungsmethode," which consists in following fiber tracts by pick-
ing off the adjoining matter by means of a forceps and thus isolating
the tracts.

But even in this paper he was already aware of some of the defects of
Meynert's methods in reaching results and conclusions, and kept himself
to a considerable degree free from them. He later gave expression to this
stand (in his monograph on the tegmental region) in the following words:
"Finally I wish to state that when five years ago, under the guidance of
Professor Meynert, I published the work just mentioned, I was still en-
'tangled in many prejudices and in particular considered most of the
statements of Meynert as well established, which explains many diver-
gences from my present results. The circumstance as well as the fact
that it was my first attempt in brain anatomy, and that I worked with a
less complete material, may serve as an excuse. That on many points I
already then had my doubts, every careful reader will perceive."

The paper referred to bears the title, "Beitrage zur "Kenntnis des
Thalamus opticus und der ihn umgebenden Gebilde bei den Sauge-
tieren." It constitutes a very valuable objective, comparative-anatomical
contribution to the knowledge of the optic thalamus and the structures
surrounding it. Of the points brought out in it, be it briefly mentioned,
that the importance is shown of the development of the pulvinar in defin-
ing the location of the geniculate bodies, which in man with a well de-
veloped pulvinar are crowded outward, but move upward and inward —
particularly the external geniculate body — the lower one descends in the
scale of mammalians. To enter on other details of this work the space
allotted for this review does not allow, except to mention that Forel's
contentions are accompanied by numerous measurements of the struc-
tures in question.

The contribution next in order, entitled ''Untersuchungen fiber die
Haubenregion und ihre oberen Verkniipfungen im Gehirne des Menschen
und einiger Saugertiere ; mit Beitragen zu den Methodon der Gehirn-
untersuchung," was issued from Professor Gudden's laboratory. In
this monograph F. has altogether emancipated himself from Meynert's
influence, and put forth his guiding principle in the following words : "My
leading thought in the following lines as well as in the figures was always
the strict avoidance of all diagrams and of going beyond well established
facts, since I consider these two faults to be the most assailable points of
brain anatomy. May I have been successful." That he indeed was

*The first paper will be discussed at the end of this review.

804 BOOK REVIEWS

successful in carrying his point certainly must impress itself on the
careful reader of these investigations.

His appreciation of Meynert's merits is expressed in the following
words, taken from the same monograph : "The only author who on the
basis of histological researches of the present has dared to attempt to
clear up the mysterious obscurity of the cerebrum and basal ganglia, is
Meynert. This was an extremely meritorious and stimulating attempt."
On the other hand. F.'s perception of .Meynert's failings, while aware of
his greatness, is embodied in the following statement: "It must soon be-
come clear that notwithstanding his perspicacity, his foresight, which un-
questionably bore the stamp of genius, and in spite of his great knowledge
of the brain, the certain and uncertain hypothesis and fact are in his
statements interwi ven with each other in a manner to often make their
separation or distinction impossible."

The above mentioned investigations begin with a subject of historical
interest, one mght truly say: i. e., a careful detailed description of the
Gudden microtome, the instrument by means of which so much splendid
work has been done in brain anatomy, by Gudden's school, v. Monakow,
Dejerine and many others. That instrument had then only recently been
invented by Professor Gudden, and its minute description by Forel, with
pointing out of all its advantages and disadvantages and the avoidance of
the latter, came apropos.

This is followed by a description of the hardening and coloring
technique used by him; with a critical discussion of the methods then in
use. Next the methods of examination of the brain in general and their
delimitations are considered, which again forms an historically interesting
chapter. The "Abfaserungsmethode" of Meynert which has already
been mentioned, is here strongly condemned, owing to its absolute un-
reliability.

Then comes the actual anatomical research which fully deserves to be
designated as a classical treatment of the subject. It gives a masterly
description of the structures forming the subject of study, in which, true
to the principle laid down by him in the introduction, facts are strictly
kept apart from probabilities, and these again from conjectures, giving
each of them their true value. So important are these investigations for
the knowledge, even purely topographically, of the regions described, that
one can hardly tak- up a proper study of these regions without reference
to Forel's work. This has particular reference to the subthalamic region
of which Forel gives a complete map; and, as already pointed out, his
statements are made with such objectivity, free from speculation, that
even as our knowledge of the anatomical connection and physiological
function of the different structures encompassed in these regions ad-
vances, yet the land-marks laid down by him will continue their value as
topographical guides for years and years. This value is greatly enhanced
by the numerous fine drawings accompanying the monograph, and made
by the investigator's own skilful hand.

The investigations on the tegmental region are followed by some
smaller communications and discussions, in which Forel points out the
clearness of the results obtained with Gudden's method, as compared
with the purely anatomical method. Gudden's method "consists in re-
moving from the new-born animal (rabbit, dog) certain parts of the
central or peripheral nervous system. The animal is then allowed to
grow up and one studies both the loss of functions and the secondary

BOOK REVIEWS ' 805

inactivity-atrophy which the structures functionally dependent of the
extirpated part undergo."

He summarizes the results obtained by Guddcn and his pupils, Mayser,
Ganser and Forel himself, as applied to motor nerves, sensory nerves,
nerves < f special sense, cortical motor centres and other structures.

A biief report of some extremely interesting findings in general
paresis and senile dementia then follows, which shows the author's
diagnostic powers. In one ease a hemiplegia was clinically diagnosed
and confirmed post-mortem to be not focal, but the outcome of the diffuse
anatomical process underlying general paresis, predominating in one
hemisphere. In the second case of paresis, the almost complete lack of
physical signs with marked involvement of the psyche led to the diagnosis
of a paresis with affection mainly of the frontal lobes, leaving the motor
centres almost intact ; and the autopsy fully bore out that diagnosis. In
the third case, which was a senile dementia, an atrophy particularly of
the temporal lobe was found as the substratum of word-deafness.

Three preliminary communications on the origin of the auditory
nerve, one of them in conjunction with the undersigned, then follow. The
interesting results embodied therein were obtained by Forel by means of
Gudden's method, which in this special application required a particular
skill.

The contribution next in order, entitled "Einige hirnanatomische Be-
trachtungen und Ergebnisse," reveals some extremely important facts.
We note therein not only the author's early appreciation of the value of
Golgi's work, as achieved with the method of metallic impregnation, but
also the utilization of Golgi's results and of the results obtained with
Gudden's method, for building up the neurone theory. That this theory
indeed is distinctly formulated here already, built up on a substantial
basis, must become clear to every careful reader. Of great interest is
the fact that while His, in an article appearing four months earlier than
that of Forel, had come to a view identical with that of Forel and, there-
fore, could justly claim priority for the formulation of the neurone doc-
trine, nevertheless, Forel could prove that the manuscript of his article
was already in the hands of the publishers at the time when his paper
appeared in print ; so that there could be no question that both had inde-
pendently reached the same result. (See page 210.)

Another important issue in this paper is the thorough study of the
laws underlying the results of Gudden's method, this study being based
on experiments on new-born and adult animals, with variation of the
points of attack in the nerves experimented on.

The paper is full of other important deductions and suggestions which
lack of space forbids to discuss here.

Then follow two communications, one relating to the origin and con-
nections of the auditory nerve ( Zur Acusticusfrage), the other on the
connections of the elements of the nervous system.

In two further short communications the results of counts of nerve
fibers in the oculo-motor nerve of the new-born and adult cat respectively
are given. The work was done by M. H. Schiller but inspired by Forel,
and reveals that the number of fibers of said nerve is virtually the same
in the adult as in the new-born. This observation, if confirmed in other
instances would allow important conclusions as to the manner of growth
of the nervous structures, indicating growth in size rather than by in-
crease in the number of elements.

806 BOOK REVIEWS

The paper succeeding these two communications and entitled "Ueber
das Verhaltniss der experimentellen Atropine und Degenerations methode
zur Anatomie und Histologic des Centralnervensystems," deals again to
a great extent with the method of Gudden and its merits. Here the
writer shows how early he appreciated the general principle underlying
the method of Gudden. As early as 1868 the latter author, having torn
out the facial nerve from the Fallopian canal in new-born rabbits had
thus, contrary to former observations, produced an atrophy of the facial
nucleus, "which he, in his lectures in Zurich demonstrated to us (i. e., to
Forel and other students), macroscopically as a depression of the basis
of the oblongata in the region of the nucleus on the side of operation."
Later this atrophy was verified microscopically by Dr. Mayser, who cut
the brain in serial sections. "Strangely enough," Forel goes on to say,
"von Gudden remained in the belief that this was a peculiarity of certain
nerves only, while I repeatedly expressed to him my conviction that it
must be a general law for all motor nerves; that their central cells of
origin perish, when in the new-born they are separated from the basis
of the brain (or spinal cord respectively)."

Another point deserving quotation here is the broad view he takes as
to the methods which should be pursued in studying the morphology and
functions of the central nervous system : "After the experience of many
years, and basing on my own investigations in the domain of the morpho-
logy and of the functions of the central nervous system, I wish to put
up the following dictum: That all methods of investigation must be
employed hand in hand and compared with each other in their results;
that each brain anatomist and physiologist should know and duly ap-
preciate them, and that in involved conditions as a rule only those results
and theorems should go as established anatomical truths, which have
successfully stood the test and confirmation by all methods." He then
enumerates these methods as follows: First, gross structural anatomy.
Second, study of continuous series of sections. Third, final histology of
the elements. Fourth, comparative anatomy and histology of the central
nervous system. Fifth, embryology. Sixth, the experimental method of
secondary atrophies and degenerations. Seventh, the study of abnormali-
ties of the central nervous system (especially agenesies of the same),
and of pathological cases in general. Eighth, the method of studying
fiber systems by means of the development of the medullary sheaths at
different periods of time. Ninth, the physiological experiment itself.

In this paper Forel also explains the reasons why the work of Gudden
and his school has not received the appreciation and notice which it
deserves, giving, at the same time, the result of researches of Mayser and
Ganser on the origin of the tenth, eleventh and twelfth nerves, and of the
connections of the optic nerve respectively.

The contribution following, published in conjunction with Wl. Onu-
frowicz, deals with the defects of the corpus callosum and is accom-
panied by numerous illustrations made by Forel hmself. This work, be-
cause of its interesting conclusions, has given rise to considerable dis-
cussion.

The book winds up with a brief communication regarding the nuclei of
the glossopharyngeal and trigeminal nerves and two discussions on the
neurone doctrine. In the latter one of these, Apathy's and Bethe's work
are critically reviewed and a reconciliation of their results with the
neurone theory attempted.

BOOK REVIEWS 807

The reviewer has left to the end the paper entitled "The Problems
of Neuro-biology," which appears as the first one in the book. This was
done for the reason that it is the latest one chronologically. It gives a
critical review of our present knowledge of neuro-biology and indicates
the lines along which further knowledge should be gained. From a man
who has enriched this field as much as he by original research and
critical discussion of the work of others, such a review must be welcomed
as very valuable and suggestive. Very modestly he expresses himself on
this point in the introduction of the book, as follows : "I have never-
theless always followed the further development of brain morphology with
interest and endeavored to further its connection with the other branches
of brain science and with neuro-biology in general. May I, therefore, not
be accused of presumption if I precede these old contributions by a brief
study on "The problems of neuro-biology."

The publisher, M. Reinhardt, Muenchen, is to be congratulated and
commended for the manner in which the book is gotten up, and par-
ticularly for the fine reproduction of the numerous illustrations, for which
the original drawings were almost all made by Forel himself.

B. Onuf (Onufrowicz).

Organic and Functional "Nervous Diseases. By M. Allen Starr. Second
Edition, pp. 816. Lea Brothers & Co., New York and Phila-
delphia. 1907.

This is the second and revised edition of Dr. Starr's book and con-
■ tains in addition a section devoted to functional nervous diseases. It has
been so well received that it has been found necessary to put forth a
second edition within a year, and it is so far the most complete book on
nervous diseases attempted by a single American author containing a
treatise on all organic and functional nervous diseases. Its distinguishing
feature is that it is a presentation of the personal experience of over
twenty-five years of neurological practice.

Not much space is given to the anatomy of the nervous system, and
the author does not enter into discussion of the various neurone theories.
Eight chapters, this including 122 pages, are devoted to a consideration of
the nerves and their diseases, their injuries, neuralgia and multiple neuritis.
Without question this discussion is about as complete and well written as
is to be found in any book upon nervous diseases. Dr. Starr's experience
in the treatment of neuralgia of the fifth nerve is interesting. He states
that aconitine is the best remedy, and he gives it in pill form in doses of
1-500 of a grain until constitutional effects are obtained. In the discussion
of the symptoms of sciatica he fails to mention the usual absence of the
Achilles jerk, and in speaking of the symptoms produced by carbon
bisulphite poisoning the author states that he has not found any published
cases in this country, evidently not being acquainted with the cases pub-
lished by Jump and Cruice, and he also does not mention the hysterical
symptoms so common in this disease. He justly says that multiple neuritis
is probably not caused by syphilis.

The diagnosis and localization of spinal cord diseases is next taken up
and well discussed, and the original diagrams used to illustrate the course
of the motor and the various sensory tracts, are excellent and so far the
best that have appeared in any book. He rightly speaks of chronic anterior
poliomyelitis and progressive muscular atrophy as identical diseases, al-
though in the discussion of the symptoms he mentions three types: That

8o8 BOOK REVIEWS

beginning in the muscles of the peroneal group ; second, in those of the
back and trunk ; and third, the usual type beginning in the muscles of the
hand. His description and classification of the muscular dystrophies is
that usually adopted. When speaking of the pathology of tabes dorsalis,
Dr. Starr accepts without reservation that the primary lesion lies in the
posterior spinal ganglia and in the ganglia of the cranial nerves. With
this opinion most neurologists will disagree, for there is more evidence to
show that the disease starts in the posterior roots and that the degenera-
tion of the ganglia is secondary. He believes that while syphilis is a pre-
disposing' cause of tabes, we cannot consider it a syphilitic infection, and
he adopts the most reasonable hypothesis that syphilis leaves a toxin in
the system which weakens the sensory elements of the nervous system.

The author next takes up the diagnosis and localization of brain
diseases. His well known and long experience in this particular depart-
ment of neurology renders his opinions on these matters authoritative. He
inclines to the old and classical views of aphasia, the early publication of
this book probably hindering him from entering into the more recent dis-
cussion of this subject which was excited by Marie and Dejerine. He
accepts the view that lesions of the angular gyrus cause word blindness,
although in the next page he gives illustrations of lesions causing this
symptom, several of which show involvement of the occipital lobe and no
disease whatsoever of the angular gyrus. He ascribes the hemichorea and
hemiathetosis which occasionally remain after lesions of the thalamus as
symptoms of irritation of the motor and sensory tracts passing near it, but
fails to specify the more recent views that these movements are probably
the result of lesions of the superior cerebellar peduncle. When discussing
the symptoms of lesions in the pons he does not mention paralysis of the
associated ocular movements, and he does not devote enough space to the
symptoms of cerebellar lesions. Omissions, however, are only exceptional,
for the general description of the diagnosis and location of brain diseases
is excellent. His discussion of apoplexy is very gt»od. He next takes up
tumors of the brain, and the part of the book devoted to this is without
question very complete with the exception that he does not devote as much
space to the discussion of cerebellar tumors as would seem to be necessary.
His advice as to the treatment of tumors of the brain is sound.

He next takes up bulbar palsy, but he does not lay any special stress
upon the diagnosis between this disease and pseudobulbar paralysis. The
discussion of the cranial nerves and their diseases is complete.

The second part of the book is devoted to functional diseases, and in-
cluded in this are chorea, tics, myoclonus, myotonias, epilepsy, paralysis
agitans, neurasthenia, hysteria and migraine. Considering Dr. Starr'i
well known views that epilepsy is an organic disease, it is rather sur-
prising to find it among the functional diseases. The discussion of neuras-
thenia and hysteria are very brief and not in proportion to the rest of the
book. What there is of this, however, is very good.

The book as a whole is an excellent presentation of the clinical phe-
nomena found in organic nervous diseases. The author's opinions are
presented in a clear, forcible and logical manner, and little doubt is left
in the reader's mind as to what is the author's opinion on any subject.
The book is well balanced and is a distinctly valuable contribution to
neurological literature. T. H. Weisenburg.

INDEX TO SUBJECTS.

Figures with asterisk * indicate original articles, and are accompanied
with title. Figures unaccentuated, accompanied with title, indicate abstracts.

PAGE.

Abscess, Brain 67, 716

Acrocyanosis and Raynaud's

Disease 653, 745

Acromegaly, Epilepsy Associated

with *28o

Tumor of Hypothesis Without. .279

Adiposis Dolorosa 200

Alcohol. Crime and Insanity.... 736

Alcohol in Neuralgia 777

Alcoholism, Stupor from 657

Algesimeter, New 279, 487

Allgemeine Zeitschrift fur Psy-
chiatric 211

Amaurotic Family Idiocy 420

American Neurological Associa-
tion 47, 537, 589, 653, 701, 769

American Journal of Insanity... 58

Amnesia 322

Amnesic Polyneuritic Psychoses . 218

Type Double Consciousness... 50

Amyotrophic Lateral Sclerosis. . 340

Anatomy of Ganglion Cell 218

Anthropological and Psychiatric

View of Penal Reform 62

Antisyphilitic Treatment of

Tabes 780

Aphasia 602. 604. *68i

Discussion on 459

Mental Disease and 272

Aphasia, Pathology of *622

Tactile 612

Apoplectic Tremor 757

Apperception. Case of .530

Apraxia 325. 734

Arteritis. Peripheral Obliterating,

*42. 48
Archiv. fur Psychiatrie und Ner-

venkrankheiten 63. 217, 330

Astereognosis 202

Asylum Dysentery 738

Ataxia. Friedreich's 277

Cerebellar 776

In Children 215

Athetosis. Bilateral 344

Attenuated Responsibility 210

Atrophv. Facial 265

Hemilingual, of Traumatic
Origin *I94

PAGE.

Juvenile Dystrophy and Spinal. 68
Myopathy and Muscular... 14, 47
Neurotic Type of Progressive

Muscular 280

Of Auditory Nerve Tabetic,

738, 350

Progressive Muscular 143

Progressive Spinal, Muscular.. 344
Pseudo-Hypertrophic Muscular *2

Traumatic Hemilingual 53

Automatism, Ambulatory *353

Automatism Clinical Differentia-
tion of Ambulatory 52

Blood Pressure in Paresis 798

Boston Society of Psychiatry and

Neurology 265, 098, 785

Brain 213, 274, 614

Abscess 67, 716

Disease and Psychoses 64

Hypertrophy of 68

Irritation of Motor Area of... 726

Lesions, Glass Models of 711

Reconstruction, New Methods

of 712

Brain Surgery. Status of 799

Brain Tumor.

48, 54. 56. *9". 201. 218, 527. 704

And Pressure 476

Symptoms Simulating *26o

Brain Tumors, Trephining in.... 545

Brown Sequard Paralysis 526

Bulbar Syndrome 342

Carcinomatosis of Cerebrospinal

Meninges 52

Cauda Equina, Lesion of 664

Tumors of 701

Centralblatt fiir Nervenheilkunde

und Psychiatrie 345. 480, 734

Cerebral Decompression 741

Disease. Misleading Symptoms

in 147

Localization and Study of Psy-
chiatry 543

Sclerosis 213

Spinal and Peripheral Nerve

Palsies 65

Surgery, Experiences in 545

Syphilis, Korsakow Symptom

Sl2

INDEX

PAGE.

Complex in 341

Tumor 48. 54, 50, *97, 201,

218, 476, 527, 704

Mental Symptoms of 275

Cerebellar Disease, Cases Simu-
lating 349

Artery, Symptoms Following
Occlusion Posterior Inferior

Cerebellar 48

Disease. Hysteria Presenting

Symptoms of 528

Cerebellar \taxia 776

Cerebellum and Hydrocephalus,

Tumors of 677

Encephalitis, of 344

Weight in Normal and Patho-
logical Conditions 211

Spinal Meningitis 52, 422, 485

Cerebrospinal Syphilis and Dis-
seminated Sclerosis, Resembl-
ance of

Cerebrum, Variations in Struc-
ture of 346

Chorea 740

Hysterical Somnambulism and 476

Huntington's

Unusual Symptom in 660

Choroid Plexus Studies on 720

Consciousne--. Vmnesic Type

Double

And the P.rutes *3I,

Cortical and Subcortical Lesion- 343
Encephalitis, Hemorrhagic. . . .

Hemorrhagic Encephalitis 53

Cortex. Sensory Representation

in the 277

Corpus Callosum, I )evelopment

of 7^i

Tumors of 678

Cotard's Syndrome 79°

Cranial and Spinal Nerve Nuclei.

Location in 62

Nerves. Tabes with Involve-
ment of Many

Cyst, Subcortical, Operation, Re-
sult 594

Degeneration. Genius and 67

Retrograde 219

Posterior Columns 788

Delirium. Chloral 398

Delusion and Error 216

Dementia. Acute Juvenile 64

Dementia Paralytica 51?

Prognosis of 737

Dementia Praecox . . . 6l, 147. 26S. 730
Fundamental Conceptions of. . 331

Dementia. Weak-mindedness 2t6

Diplegia. Facial 204

Delusions of Limbs 787

pace:
Deutsche Zcitschrift fur Nerven-
heilkunde. . . . 56, 141, 278, 474, 675

Diagnosis, Case for 523

Diphtheria Toxemia, Changes

Due to 422

Drug Addictions 68

Encephalitis of Cerebellum 344

Hemorrhagic Cortical 53, 482

Encephalocele, Orbital 421

Encephalomacia, General 266

Enchondroma of Sella Turcica. . 59b

Epilepsy 487, *5<>4, 524

Associated with Acromegaly. .*289
Curability of Rare Form of... 610

In Woman Over Sixty 399

Myoclonia and 220

Opium-Bromide Treatment of. 340
Psychasthenic Attacks Simulat-
ing 411

Treatment of Idiopathic 148

Unilateral Disturbances in

< renuine 340

Epileptic Insanity 217

Epileptics, Blood of 67

Epileptiform Convulsions 667

Eyeball, Dislocation of *39i

Eye Muscles, Paralysis of 543

Facial Atrophy 265

1 )iplegia, Labio-Glossolaryn-

geal Paralysis and 204

Diplegia, Peripheral *I72

i Icmiatrophy. I' ive 141

Nerve, Sensory Symptoms and

Affections of 54°

Palsy 53

False Reminiscence 01

Friedreich's Ataxia 277, 612

serian Ganglia, Plasma Cells

in 486

Geniu- and Degeneratii in 67

Gliomatosis of Pia and Metas-

-i- of Glioma *297

( ,1> >bus and Aura 63

Graves' Disease, Treatment 712

Gyneo >1< igical Surgery 59

Hallucinations, Graphic Kines-
thetic 343

Hallucinosis, Chronic Alcoholic. 345

Habitual Criminal- '. 144

Hematoma Auris 61

Hemianopsia, Migraine and. 52, *I53

Hemiatrophy of Face 329

Hemiepilopticus Idiopathicus,

278, 487
Hemiplegia and I abes, New

Clinical Symptoms 662

In Vascular Lesions, Onset of. 215
Paralvsis Agitans Occurring
After *426, 529

INDEX

813

PAGE.

Symptomatology of 278, 487

Hereditary Spastic Paraplegia. .. 483

Heredity in Man 420, 769, 770

Insanity with Special Refer-
ence to 486

Paresis and 219

Herpetic Inflammation of Geni-
culate Ganglion 54, *73, 709

Hemorrhage in Pons 142

Hemorrhagic Cortical Encephali-
tis 53, 482

Hydrocephalics, Internal... 218, 543

Hyperthermia, Hysterical 266

Hyperesthesia of Visual Fields.. 342
Hypochondria, Surgical Inter-
vention and 731

Hysteria 265

Disturbances of Vision in 409

Eroticism in 732

In Animals 341

Paralytic Ptosis in 613

Presenting Symptoms of Cere-
bellar Disease 528

Tetany, Pseudo-Tetany and... 57

Traumatic 476

Hysterical Hyperthermia 266

Laughter 346

Somnambulism and Chorea... 476

Mutismus 476

Mutism *353

Paralysis 796

Huntington's Chorea 52

Ideas of Reference 481 >

Idiomuscular Hyper-Irritation... 477

Idiocy, Amaurotic Family 420

Insane Commission of St. Louis

City Jail 50. *ny

Conditions, Surgery for Relief

of .-•. 59

Delimitation of General Par-
alysis of . . 545

Pantomime Among 207. 347

Family Care of Feeble-Minded

and 483

Occupation Treatment of 546

Psychial Condition When

Dying 213

Questions of Responsibility... 733
Sense of the Mysterious

Among 145

Some Time Reactions Among.. 147
The After-Care Movement.

50, *H3
Insanity. Alcohol, Crime and.... 7^6

Epileptic 217

General Conditions and 67

Head Trauma As Cause of. . . 282

Notes on Study of 273

Simulation of 210

PAGE.

Special Reference to Heredity. 486
Symptomatic- Prognostic Com-
plex of Manic Depressive.. . 261
Intermittent Claudication... 666,677

Involution Melancholia 790

Journal de Psychologic Normale

et Pathologique 145, 209, 346

Journal de Neurologie 60, 143

Katatonia, Etiology and Symp-
tomatology 212

Lesions, Brain, Glass Models of. 711

Of Cauda Equina 664

Of Lenticular Zone. Sympto-
matology of *622, *724

Of Pons and Tegmentum,

Traumatic *6cj9

Of Spinal Cord. Sensory and
Motor Disturbances in Or-
ganic .-■••:•••. *435

Onset of Hemiplegia in Vas-
cular 215

Medicine. Experiment in Civic,

4, 50. *"7

Medulla, Course- of Central

Fibers in 342

Medulla Oblongata. Softening in. 219

Melancholia 58, 790

Mental and Nervous Disease,

Dispensary Work in *69i

Mental Disease. Aphasia and... 272

Tn Army and "Navy 63

Inanition in 340

Nerve Cells in 483

Pre-Insane Stage of Acute.... 545

Prognosis in 68

Mental Symptoms of Cerebral

Tumor 275

Meninges, Carcinomatosi-. of

Cerebrospinal 52

Meningitis, Cerebrospinal.. . 422. 485
Migraine, Hemianopsia and. 52, *i53

Mi°rainic Psychoses 281

N I ikropsia . 142

Mirror Writing 144

Miscellany,

65, 147. 220, 270. 349, 422. 483. 543

Modern Witchcraft 146

Motor Paralvsis as Early Symp-
tom of Tabes 798

Multiple Neuritis 725

Simulating Progressive Mus-
cular Atrophy 350

Multiple Sclerosis. Bulbar Palsv

in '. 656

Prognosis 700

Psychical Disturbances in 339

Muscular Atrophv. Multiple
Neuritis Simulating Pro-
gressive 3^0

8i4

INDEX

PAGE.

Myopathy and *I4, 47

Neuritic Type of Progressive.. 280

Peroneal Atrophv 785

Progressive 143

Progressive Spinal 344

Pseudo-Hypertrophic *2

Muscular Defects 475

Dystrophy, Peroneal 596

Myasthenia Gravis 214

Myoclonia and Epilepsy 220

Myoclonus 7°3

Epilepsy *504, 524

Myopathy, Landouzy-Dejerine

Form of 707

Myotonia 59&

Myxedema 218

Names, Loss of Comprehension

of Proper *6l7

Neck, Stab Wound of 721

Nerve Cell, Developmenl of Ver-
tebrate 614

Cells in Mental Disease 483

Cells, Metabolism and Action

of 215

Paralysis of Abducens 613

Paralysis of Sixth 661

Regeneration, Autogenetic. . . . 344
Sensory Symptoms and Affec

tions of Facial 540

Sensation of Pressure After
Destruction of Trigeminal.. 728
Nerves, Herpetic Inflammation
of Cervical ami Thoracic... 726
Resection of Posterior Roots

of Spinal 589

Splitting of Afferent Fibers in

Peripheral 542

Tabes, with Involvement of

many Cranial 536

Nervous and Mental Disease,

Dispensary Work in *6oi

Nervous Complications of Spe-
cific Fevers 614

■Nervous Disease, Clinical Obser-
vations 714

Joint affections in 283

Mechanical Treatment of 405

Orthopedic Treatment of 405

Neutral Cells of Central 219

Syphilogenic Diseases of Cen-
tral "Nervous System 478

Neuralgia, Alcohol Treatment of

"Nervous System 777

Neurasthenia. Gastric 739

Of Autointoxication 661

Tropical 69

Neuritis, Multiple 350. 725

Optic . 69, 423

Neuritic Type of Progressive

PAGE.

Muscular Atrophy 280

X cur uses Etiological Role of

Vasomotor Centers in Cardiac. 282
Neurology, Physiologic Concep-
tion of Disease in 349

Neurologisches Centralblatt 341

News and Notes,

151, 288, 35i» 016, 680, 744
New York Neurological Society,

331, 405, 517, 5Q3, 602, 703, 776
New York Psychiatrical Society,

2b2, 668
Obituary.

Folsom, Charles Follcn 744

Macdonald, Alexander E 151

Mendel, E 616

Pickett, William Clendenin... . 288

Optic Neuritis 69,423

Ophthalmoplegia, Progressive... 598

With Paresis 659

Orbital Encephalocele 421

Orientation of Points in Space... 275

Osteoacusia 474

Palsy, Bulbar, in Multiple Scler-
osis 656

Cerebral, Spinal and Peripheral

Nerve 65

Facial 53

Pseudobulbar 613

Pasalysis of Abducens Nerve.... 613
Abdominal, in Anterior Polio-
myelitis 676

\gitans 327

Occurring Vfter Hemiplegia,

*426, 529

Pathologj of 544

Paralysis, Auscultation of Mus-
cles in 145

Brown Senuard 520

Facial Diplegia and Labio^

Glossolaryngeal 204

Hysterical 797

Kernig's Sign in General 61

Landry's 52, 281

Motor, as Early Symptom of

Tabes 198

Multiple Lipoma in General... 27$
Organic Contraction in Pro-
gressive 345

Of eye Muscles 543

Of Insane. Delimitation of

General 545

Of Lower Extremities 724

Of Sixth Nerve 661

Of Subcapularis and Musculo-
cutaneous Nerves 341

Sensory Changes in Progres-
sive 343

Pathology of General 736

INDEX

8i5>

PAGE.

Paralytic I )ementia 518, 737

Ptosis in Hysteria 613

Paranoic Conditions, Psycho-
genetic Factors in 668

Paranoid and Melancholic Cases. 733

Paraplegia, Hereditary Spastic... 483
Infantile 61

Parathyroids in Human Path-
ology 57

Paresis, Accumulated Convul-
sions, Blood Pressure and

General 212, 798

A Study of Reflexes of Lower
Extremities in Sixty Cases

of *43L 537

Cases with Focal Symptoms. .. 481
General, Cord Changes and. .. 65

Have the Forms Altered? *6i7

Heredity and 219

In Skt. Hans Hospital 480

Kernig's Sign in 61

And Trauma 65

Ophthalmoplegia with 659

Pathological Sleep 65

Paroxysmal Tachycardia 282

Periscope.... 57, 141, 206, 272,
339, 420, 474, 543, 612, 675, 730, 796

Personality, the 210

Perverse, the 144

Phila. Neurological Society,

199, 322, 411, 459. 526, 656. 716

Physiologic Conception of Di-
sease in Neurology 349

Polioencephalitis, in Boy of Eight 532

Poliomyelitis 600

Abdominal Paralysis in An-
terior 676

Anterior Chronica 57

Polyneuritis, Phthisical 341

Pott's Disease of Spine 52

Of Cervical Spine * [85

Psychasthenic Attacks Simulat-
ing Epilepsy 411

Psychiatrich-Neurologische

Wochenschrift 216, 730

Psychical Condition of Insane

When Dying 213

Disturbances in Multiple Scler-
osis 339

Psychical Troubles in States of
Stupor 62

Psychiatric Clinic at Munich... 336

Psychiatric Terminology and

Classification 274

Psychiatry and Philosophy.... 739
Cerebral Localization and

Study of 543

Diagnostic Value of Lumbar
Puncture in *22$, *3I2

PAGE.

Psychogenetic Factors in Para-
noic Conditions 668

Pseudoesthesia 145

Psycho-Neuroses, Social Inter-
course as Therapeutic Agent
in *497

Psycho-Neurotics, Classification
of *489

Psychoses, Amnesic Polyneuri-
tic 218

Alcoholic 739

Atypical Alcohol 339

Brain Disease and 64

Korsakoff's *448

Migrainic 281

Psychoses, Puerperal 212

Resulting from Coal Gas As-
phyxiation 147

Tabes and 279

Raynaud's Disease and Acro-
cyanosis 653

Reflex, Anatomical Proof of

Paradoxical 205

Feeding 141

Hyperesthesia 143

In Typhoid Fever, Abdominal. 276

Paradoxical *43l

Patellar 61

Reflexes of Lower Extremities
in Paresis *43T» 537

Revue of Neurology and Psy-
chiatry 481. 738

Revue Neurologique 612

Revue de Psychiatrie et de Psy-
chologique F.xperimentalc 731

Reviews.

Affektivitat, Suggestibilitat, Par-
anoia, by E. Bleuler 285

Analyse von 200 Selbstmordf al-
ien nehst Beitrag zur Prog-
nostik der mit Selbstmordge-
danken verknupften Psychosen,
by H. Stelzner 547

Annual Report of the Central
State Hospital of Virginia .... 548

Arbeiten aus den Neurologischen
Institute an der Weiner Uni-
versitat, by Heinrich Ober-
steiner 548

Beitrag zu Lehre von den Psy-
chischen Epidemien. by W.
Wyegandt 549

Christianity and Sex Problems,
by Hugh Northcote 223

Collected Studies on Immunity,
by Paul Ehrlich 549

Criminal Responsibility, by Chas.
Mercier Ji

Demifous et Demi responsables.

8i6

INDEX

PAGE.

by J. Grassert 743

Die Geschwulste des rechten und
linken Schlafelappens, by Al-
bert Knapp 71

Dissociation of a Personality, by
Morton Prince 424

Emotional Variability in Epilep-
tics, by Gustav Aschaffenburg. 286

Epilepsy, by Wm. Aldren Turner. 551

Gehirn und Seele, by P. Schultz. 802

Gesamndte Abhandhmqen, by
August Forel 802

Histological Studies on the
Localization of Cerebral Func-
tions, by Alfred W. Campbell.. 149

Integrative Action of Nervous
System, by C. Sherrington.... 801

Jahresbcricht ueber die Leis-
tungen und Fortsehritte auf
dem Gebiete der Neurologie
und Psychiatric, by E. Flatau
and S. Bendix 424

La'Melancolie Etude Medicale
et Psychologique 679

Management of a Nerve Patient,
by Alfred E. Schofeld 424

Nervous System of Vertebrates,
by J. P>. Johnston 679

Organic Nervous Diseases, by
M. Allen Starr 807

Physician's Visiting List for 1907 224

Physiology of the Nervous Sys-
tem, by J. P. Morat 550

Primer of Psychology and Men-
tal Disease, by C. B. Burr.... 54S

Prophylaxis and Treatment of
Internal Diseases, by F. Forch-
heimer 550

Psychotherapeutic Letter-, by H.
Oppenheim 801

Studies in the Psychology of
Sex, by Havelock Ellis 223

Treatise on Diagnostic Methods
of Examination, by TT. Sahli. . 351

Treatise on the Motor Apparatus
of the Eyes by George T.
Stevens 284

Text Book of Psychiatry for
Physicians and Students, by
Leonardo Bianchi 149

Ueber Robt. Schumann's Krank-
heit, by P. J. Mobius 224

Ueber Storungen des TTandeln
hei Gehirnkranken, by TT. Liep-
mann 222

Untersuchungen und Studien
uber die Innervation des Peri-
toneum der vorderen Bauch-
wand. by M. Ramstrom 550

PAGE.

Sarcoma of Spine 521

Sciatica 281

Sclerosis, Amyotrophic Lateral.. 340

Bulbar Palsy in Multiple 656

Cerebral 213

Cerebrospinal Syphilis and

Disseminated 660

Combined Posterior and

Lateral 323

Of Lateral Columns 57

Psychical Disturbances in Mul-
tiple 339

Sense of Vibration 676

Sensory and Motor Disturbances
in Organic Lesions of Spinal

Cord." *43S. 59*

Re-Representation in the Cor-
tex 277

Skin Necroses and Hydrochloric

Acid 475

Skull. Fractures of Base of 422

Spasmodic Laughing and Weep-
ing 60

Torticollis 217

Spastic Paraplegia 483

Speech, Agrammatism and Dis-
turbances of Internal 340

Spondylose Rhizomelique 474

Spinal Atrophy and Juvenile

Dystrophy 68

Spinal Cord Changes Following

Secondary General Anemia.. 658

I dislocation 797

Fat Crystals in 719

Malformation of 341

Meningeal Tuberculoma of.... 55
Plea for Study of Intermedio-

Lateral Cell-System of 481

Regeneration 674

Sensory and Motor Disturban-
ces in Organic Lesions of,

*43S. 592

Surgery 54

Diseases, Bladder in 142

Muscular Atrophy. Progressive 344
Nerves. Resection of Posterior

Roots of • 589

Nerve Nuclei. Location in

Cranial and 62

Spine, Pott's Disease of.... 52, *i8s

Sarcoma of 52r

Suicide as Result of Suggestion. 210
Subconscious and LTnconscious

Elements 209

Sureerv, Experiences in Cere-
bral ..545

For Relief of Insane Condi-
tions 59

Gynecological 59

INDEX

817

PAGE.

Surgical Cases, Some Recent.... 59
Intervention and Hypochon-
dria 731

Syphilis, Cerebrospinal and Dis-
seminated Sclerosis 660

Latent 478

Korsakow Symptom Complex

in Cerebral 341

Syphilitic Cases in Copenhagen.. 480
Disturbances of Sensibility.... 341
Syphilogenic Diseases of Central

Nervous System 478

Structure of Olfactory Lobe.... 276

Syringomyelia 517, 523, 796

Trauma Preceding Tabes and. 199

Tabes Dorsalis 66

Ectodermal Germinal Layer

and 478

Incipient 663

In Negress 324

Motor Paralysis as Early

Symptom of 198

New Clinical Symptoms in

Hemiplegia and 662

Psychoses and 270

Re-Education Treatment of.. 593
Trauma Proceding Syringo-
myelia and 199

Ventral Horn Disease in 64

With Involvement of Many

Cranial Nerves 536

Tabetic Atrophy of Auditory

Nerve 7^

Taenia Pontis. Notes on 27$

Tetany 66

Prognosis of 343

Pseudo-Tetany and Hysteria.. 57
Thalamus. Descending Connec-

PAGE.

tions of 342

The "Call of God". 349

Torticollis, Spasmodic 217

Tremor, Pathogenesis of Mer-
curial 613

Tremor, Post Apoplectic 757

Trigeminal Neuralgia and Al-
cohol 777

Trional Cure 480

Post Apoplectic 757

Triplegia, Peripheral Obliterat-
ing Arteritis as Cause of..*42, 48

Tuberculosis in Asylums 274

Tumor, Brain,
48, 54, 56, *97, 201, 218, 476, 527, 704

Frontal 400

Of Hypothesis Without Acro-
megaly 279

In Substance of the Motor

Zone 343

Mental Symptoms of Cerebral. 275

Obscure Intracranial 742

Of Hypophysis 486

Of Right Frontal Lobe 399

Subcortical 330

Symptoms Simulating Brain . . *26o

Tumors of Cauda Equina 701

Of Corpus Callosum 678

Of Cerebellum and Hydrocep-

alus 677

Trephining in Brain 545

Typhoid Fever, Abdominal Re-
flex in 276

Unilateral Wrist-Drop from
Lead 657

Vertebrate Nerve Cell, Develop-
ment of 614

Voice in Nervous Diseases 779

CONTRIBUTORS TO VOLUME 34.

PAGE.

Allen, C L Los Angeles, Cal.

Atwood, Charles New York

Barker, L. F Baltimore

Burr, Charles W. .Philadelphia, Pa.

Camp, C. D Philadelphia, Pa.

Clark, L. Pierce New York

Conzelmann, F. J New York

Dearborn, Geo. V. N.. Boston, Mass.

Dercum, Francis X i'hila.. Pa.

Frv. Frank R St. Louis, Mo.

Gordon, Alfred. ... Philadelphia. Pa.
Hoppc, Herman H.. . .Cincinnati, O.

Hunt. J. Ramsay New York

Ingbert, C. E.. .Independence, Iowa

Jacoby, George \Y .Yew York

Jelliffe, Smith Ely New "> ork

ECarpas, M. J New York

Kirhv. Geo. H New York

Ludlum, S. I) Philadelphia

.Mover. Adult New ^ ork

Mills, Charles K. . .Philadelphia, Pa.

PAG*.

Mitchell, John K. .Philadelphia. Pa.

Munson, J. F Sonyea, N. Y.

Patrick, Hugh T Chicago, 111.

Pomeroy, J. L. .Ward's Island, N. Y.

Potts, Charles S Philadelphia

Rhein, J. H. W Philadelphia

Riggs, Eugene R....St. Paul, Minn.

Sailer, Joseph Philadelphia, Pa.

Schwab, Sidney 1 .... St. Louis, Mo.
Shanahan, Wm. T .... Sonyea, N. Y.

Sladen, F. J Baltimore

Spiller, Wm. G. .. .Philadelphia, Pa.

Spratling, W. P Sonyea, N. Y.

Stevens, John W. . .Amity ville, L I.

Taylor, E. W Boston

Thomas, John Jenks. .Boston, Mass.

lacker, Beverley R Phila, Pa.

Walton, George L Boston, Mass.

\\ eisenburg, T. H Phila., Pa.

White. Wm. A... Washington, 1). C.

ORIGINAL CONTRIBUTIONS.

PAGE.

iSeudo-Hvpertrophie Muscular Atrophv, by Charles E. tngbert, M.D.,
Ph.D." 2

.Myopathy of the Distal Type and Its Relation to the Neural Form of
Muscular Atrophy (Charcot-Marie, Tooth Type), by William
G. Spiller, M.D 14

Consciousness in the Brutes, by George V. N. Dearborn, M.D., Ph.D. 31

Peripheral Obliterating Arteritis as a Cause of Triplegia Following
Hemiplegia, by Charles W. Burr, M.D 42

On Herpetic Inflammations of the Geniculate Ganglion. A New Syn-
drome and Its Complications, by J. Ramsay Hunt, M.D 73

Brain Tumor Symptom-Complex with Termination in Recovery, by

Herman H. Hoppe, A.M., M.D 97

After-Carc and Prophvlaxis and the Hospital Physician, by Adolf

Meyer, M.D., LL.D . 113

The Insane Commission of the St. Louis City Jail, an Experiment in

Civic Medicine, by Sidney T. Schwab, M.D 117

Consciousness in the Brutes, by George V. N. Dearborn, M.D., Ph.D.. 128

Migraine and Hemianopsia, by John Jenks Thomas, A.M., M.D 153

Peripheral Facial Diplegia and Palatal Involvement, by George Wr.

Jacoby. M.D 172

A Studv of the Sensorv Symptoms of a Case of Pott's Disease of the

Cervical Spine, by Frank R. Fry. A.M., M.D 185

Hemilingual Atrophv of Traumatic Origin, bv Smith Ely Jelliffe,
M.D., Ph.D 104

INDEX 819

PAGK.

I lit Diagnostic Value vi Lumbar Puncture in Psychiatry, by j. L.
Pomeroy, M.D 225

Report of a Case of Hysterical Mutism, by John K. Mitchell, M.D... 253

Symptoms Simulating Brain Tumor Due to the Obliteration of the
Longitudinal, Lateral and Occipital Sinuses. A Clinical Case;
by C. Eugene Riggs, A.M., M.D.R 260

A Case of Epilepsy Associated with Acromegaly, by William T. Shana-

han, M.D 289

Gliomatosis of the Pia and Metastasis of Glioma, by William G.

Spiller, M.D 297

Is Epilepsy a Disease of Metabolism? A Review of the Literature, by
J. F. Munson, M.D 303

The Diagnostic Value of Lumbar Puncture in Psychiatry, by J. L.

Pomeroy. M.D 312

Ambulatory Automatism, by Hugh T. Patrick, M.D 353

Two Cases of Dislocation of the Eye-ball Through the Palpebral Fis-
sure, by Beverley R. Tucker, M.D 391

Unilateral Paralysis Agitans Occurring After Hemiplegia, by Joseph

Sailer, M.D 426

A Study of Reflexes of the Lower Extremities in Sixty Cases of
Paresis, with a Special Reference to the Paradoxical Reflex, by
Alfred Gordon, M.D 431

Sensory and Motor Disturbances in Parts Above the Distribution In-
volved in Definite Organic Lesions of the Spinal Cord, by T. H.
Weisenburg, M.D 435

Korsakoff's Psychosis Superimposed Upon Melancholia, by John W.

Stevens, M.D 448

The Classification of Psycho-Neurotics, and the Obsessional Element

in Their Symptoms, by George L. Walton, M.D 489

The Use of Social Intercourse as a Therapeutic Agent in the Psy-
choneuroses, a Contribution to the Art of Psychotherapy, by
Sidney Schwab, M.D 470

Myoclonus-Epilepsy with a Report of Two Additional Cases, by

William T. Shanahan, M.D 504

Have the Forms of General Paresis Altered ? bv L. Pierce Clark,

M.D., and Charles E. Atwood, B.S., M.D '. 617

The Symptomatology of Lesions of the Lenticular Zone with Some
Discussion of the Pathology of Aphasia, by Charles K. Mills,
M.D., and William G. Spiller, M.D 622

Loss of Comprehension of Proper Names, by Frank R. Fry, M.D.... 617

The Symptomatology of Lesions of the Lenticular Zone with Some
Discussion of the Pathology of Aphasia, by Charles K. Mills,
M.D., and William G. Spiller. M.D '...'. 624

Have the Tvpes of General Paresis Altered? bv L. Pierce Clark,
M.D., and Charles E. Atwood. B.S., M.D ". 651

A Case of Aphasia, Both "Motor" and "Sensory," with Integrity of
the Left Third Frontal Convolution : Lesion in the Lenticular
Zone and Inferior Longitudinal Fasciculus, by F. X. Dercum, M.D. 681

Dispensarv Work in Nervous and Mental Diseases, by Smith Ely
Jelliffe, M.D., Ph.D 691

Traumatic Lesion of the Pons and Tegmentum with Direct and
Retrograde Degeneration of the Median Fillet and Pyramid, and
of the Homolateral Olive, by Adolf Meyer. M.D 699

On Acrocyanosis Chronica Anaesthetica with Gangrene; Its Relations
to Other Diseases, Especially to Erythromelalgia and Raynaud's
Disease, by Lewelb's F. Barker, M.D., and Frank J. Sladen, M.D. 745

Post Apoplectic Tremor (Symmetrical Areas of Softening in Both
Lenticular Nuclei and External Capsules), bv J. H. W. Rheiu,
M.D., and Charles S. Ports, M.D 757

o

BINDING SECT. JUN 2 2 1966

RC

The Journal of nervous and

321

mental disease

J78

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