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TLhc  Journal 


OF 


1Fiervou6  anb  /nbental  S^ieease 

AN   AMERICAN    MONTHLY  JOURNAL  OF   NEUROLOGY    AND    PSYCHIATRY 

FOUNDED  IN    1874 

OFFICIAL  ORGAN  OF 

^be  Hmcrican  IRcurolo^lcal  Hesoctatton 
lEbe  IRcw  IPork  IReurolOGtcal  Society 

Boston  Society  of  ps^cbiatr^  and  IReurolOG? 
ITbe  pbilabclpbia  IRcurological  Society  mib 

ITbe  Cbicaoo  IRcurologtcal  iSodct^ 


Dr.   WILLIAM  Q.  SPILLER 


MANAGING  EDITOR  AND  PUBLISHER 


Dr.  SMITH  ELY  JELLIFFE 
41  North  Queen  Street,  Lancaster,  Pa.  64  W.  56th  Street,  New  York  City 


ADVISORY   BOARD  OF   EDITORS 


Dr.  WILLIAM  OSLER 
Dr.  CHARLES  L.  DANA 
Dr.  E.  W.  TAYLOR 
Dr.  CHAS.  K.  MILLS 
Dr.  M.  ALLEN  STARR 
Dr.  ADOLF  MEYER 
Dr.  PEARCE  BAILEY 


Dr.  HUGH  T.  PATRICK 

Dr.  JAS.  J.  PUTNAM 

Dr.  E.  E.  SOUTHARD 

Dr.  FREDERICK  PETERSON 

Dr.  WILLIAM  A.  WHITE 

Dr.  LEWELLYS  F.  BARKER 

Dr.  HARVEY  CUSHINQ 


Volume  43,  1916 


NEW  YORK 

64  West  56th  Street 
1916 


PICS!    OF 

Tmi  Htm  En*  Printinc  company 


■n 


ORIGINAL   CONTRIBUTIONS 

Page 

Reil's  Rhapsodieen.     By  Dr.  W.  A.  White   • I 

The  Family  Form  of  Pseudo-sclerosis  and  Other  Conditions  Attributed 

to  the  Lenticular  Nucleus.     By  William  G.  Spiller   23 

Speech  Conflict.     A  Natural  Consequence  in  Cosmopolitan  Cities— As  an 
Etiological   Factor   in    Stuttering.     A    Preliminary   Report   Based   on 
Two  Hundred  Cases.     By  May  Kirk  Scripture  and  Otto  Glogau..37,  I39 
Localization  of  Function  in  the  Canine  Cerebellum.     By  Ernest  G.  Grey. .   105 
The   Value   and   Meaning  of   the   Adductor   Responses   of   the  Leg.     By 

121 

A.   Myerson    

In  Memoriam— Isaac  Ott,  A.M.,  M.D.     By  Joseph  McFarland  2Di 

A   Comparison    of    the    Mental    Symptoms   Found   in   Cases   of    General 

Paresis  with  and  without  Coarse  Brain  Atrophy.     By  E.  E.  Southard  204 
A  Histological  Study  of  the  Optic  Nerves  in  a  Random  Series  of  Insane 

Hospital  Cases.     By  Myrtelle  M.  Canavan   •  •  •  •  •   217 

The   Role  of   Hallucinations  in  the   Psychoses   Based  upon   a   Statistical 

Study  of  514  Cases.     By  Forrest  M.  Harrison    231 

A   Report   of   Two   Cases   of    Progressive   Lenticular   Degeneration.     By 

Arthur  S.  Hamilton    ^97 

A  Study  of  Some  Cases  Diagnosed  as  Paresis  in  Pre-Wassermann  Days. 

By  Lawson  G.  Lowrey   ^^ 

An  Unusual  Psychasthenic  Complex.     By  George  E.  Price   333 

Dystonia  Musculorum  Deformans  with  Report  of  a  Case.     By  Theodore 

Diller  and  George  J.  Wright   .■■■■337 

Peripheral    Neuritis    with    Korsakow's    Symptom    Complex.      By    Anita 

Alvera   Wilson   ;•:•••  "^4^'  43i 

Tabes  Dorsalis.     A  Pathological  and  Clinical  Study.     By  Baldwm  Lucke  393 

Hydromyelia  and  Hydroencephalia.     By  Alfred  Gordon    4" 

Abnormal  Relation  between  Liver  and  Brain  Weights  m  Forty-two  Cases 

of  Epilepsy.     By  D.  A.  Thom    o^'c'"   "^'^ 

A  Case  of  Atypical  Multiple  Sclerosis  with  Bulbar   Paralysis.     By  Sig- 

mund    Krumholz    ',",".  "^ 

Condition   Occurring  in  the  Aged,  usually  Attributed  to  Cerebral   Arte- 

riosclerosis.     Bv  Chai  les  Metcalfe  Byrnes   4^9 

Tumor  Involving  Crus  Cerebri.     By  W^alter  Timme   505 

Tic  of  the  Abdominal  Muscles.     By  F.  B.  Clarke  .•••••  5io 

Symptoms  in  Infective  Exhaustive  Psychoses.     By  Sanger  Brown    II   .       518 
Pathological  Findings  in  Paralysis  Agitans.     By  E.  M.  Auer  and  G.  P 
McCouch     


532 


CONTRIBUTORS  TO  VOLUME  43 


Allen.  L.   L..   Los   Aiimks,  Lain. 

Atwood.  C.  E.,  New  York 

Aucr.   E.   Murray,   Philadelphia 

Brink,  Lonise,  New  York 

Brown.  Sanger.  White  Plains.  N.  Y. 

Brown.     II.    Sanger,    White    Plains, 

N.  Y. 
Byrnes.  C   M..   Baltimore 
C'anavan.  Myrtclle  M.,  Boston,  Mass. 
Clarke,   I'.   B.,   Milwaukee,  Wis. 
Diller.  Theo..  Pittsburgh,  Pa. 
(jlogau.  Otto,   New   ^'ork 
(Jor.h.n,  Alfred,   Phila.lelphia.  Pa. 
(irey.  Ernest  (».,  Boston,  Mass. 
Hallock.  Frank  Mead,  New  York 
Harrison,    Forrest    M..    Washington, 

I).  C. 
Jclliffc.  Smith  Ely.  New  York 
Jones.      Herl)ert      W..      Minneapolis, 

Minn. 
Kraus.  Walter   Max,   New   ^'ork 


Kruiniioiz,  S.,  Liiica^o,   111. 
Lowrey.  Lawson  G..  Ilatliorne,  Mass. 
Lucke,  Baldwin,  Pliiladelpiiia,  Pa. 
McLouch.  G.  P.,  Philadelphia 
McFarland,  Joseph,  Philadelphia 
Moore.  J.  M.,  Beacon,  N.  Y. 
Myerson,  A.,  Taunton,  Mass. 
Price.  Geo.  E.,  Philadelphia,  Pa. 
Sandy.  W.  C,  Columhia,  S.  C. 
Scripture,  May  Kirk.  New  York 
Sharp,  E.  A.,  Buffalo,  N.  Y. 
Spiller,  Wm.  G..  Philadelphia.  Pa. 
Southard,  E.  E..  Boston,  Mass. 
Taylor,  E.  W.,  Boston,  Mass. 
Thom,  D.  A.,  Palmer,   Mass. 
Timme,  Walter,  New  York 
White,  Wm.  A..  Washington.  D.  C. 
Wilson.    Anita    .Mvera,    Washington, 

D.  C. 
Wright,  Geo.  J.,   Pittsburgh,  Pa. 
\awger,  N.  S.,  Philadelphia,  Pa. 


JOHANN    (  MKISTIAN    RKIL. 


VOL.  43.  JANUARY,  1916.  No.  i 

The  Journal 

OF 

Nervous  and  Mental  Disease 

An  American  Monthly  Journal  of  Neurology  and  Psychiatry,  Founded  in  1874 


©rioinal  Hrticles 


CRITICAL   HISTORICAL   REVIEW 
REIL'S  RHAPSODIEEN^ 

By  William  A.  White,  M.D. 

Reil's  "  Rhapsodies  on  the  Application  of  Psychic  Methods  to 
the  Cure  of  jMental  Disorders "  is  a  work  of  pecuHar  historical 
interest  at  this  time,  representing,  as  it  does,  an  early  attempt  to 
formulate  the  principles  of  psychotherapy,  a  department  of  medi- 
cine which  has  had  such  a  rapid  growth  in  the  present  generatiori. 
This  present  movement  had  its  inception  in  the  use  of  hypnotism 
by  Charcot  (1825-93),  followed  by  Liebault  and  later  by  Bernheim. 
The  limits  of  hypnotism  were  passed  and  the  new  psychotherapeutic 
principles  branched  out  in  several  directions,  particularly  under  the 
leadership  of  Janet  (1859-  ),  and  Dubois,  finally  culminating  in 
a  technique  far  removed  from  hypnotism,  the  method  of  psycho- 
analysis which  had  its  origin  and  vital  impulse  in  Freud  (1856-  ), 
but  has  later  shown  tendencies  to  splitting  along  lines  represented 
by  Adler  and  Jung.  The  growing  importance  of  this  movement  is 
made  apparent  by  the  agitation  for  the  incorporation  of  courses  in 
psychology,  psychotherapy  and  psychiatry  in  the  medical  cur- 
riculum, the  appointment  of  psychologists  to  positions  in  hospitals 
for  mental  disease,  and  the  general  increase  in  the  demand  for 
physicians  trained  in  mental  medicine  in  connection  especially  with 
certain  medico-legal  questions,  particularly  the  problem  of  juvenile 
delinquency,  the  elimination  of  defectives  from  the  school  system, 

^  J.  C.  Reil :  Rhapsodieen  fiber  die  Anwendung  der  ps3'chischen  Cur- 
methode  auf  Geisteszerriittungen,  Halle,   1803. 


WILLIAM  A.  WHITE 

the  treatment  and  education  of  sub-normal  and  exceptional  children, 
and  in  the  mental  hygiene  movement  now'  spreading  over  the 
country.  Not  only  is  there  a  distinct  demand  for  physicians  trained 
in  mental  medicine,  but  also  for  nurses  and  social  workers  in  con- 
nection with  general  dispensary  and  social  service  work. 

With  this  renaissance  of  psychotherapy,  for  it  seems  that  all 
movements  that  appear  new  are  in  reality  only  r^-births,  it  would 
seem  fitting  to  critically  review  one  of  the  most  important  works  on 
psychotherapy  of  a  hundred  years  ago.  Such  a  study,  if  ap- 
proached in  the  proper  spirit,  cannot  be  otherwise  than  helpful  in 
assisting  us  to  understand  the  full  import  of  the  present  movement 
by  throwing  light  on  the  path  along  which  progress  towards  it  has 
been  made.  By  the  proper  spirit  I  mean  the  spirit  that  prompts  to 
an  effort  at  understanding  rather  than  the  spirit  that  discusses  old 
and  discarded  theories  as  nonsense.  The  pen  that  writes  history 
should  be  dipped  in  the  ink  of  understanding  and  not  in  the  acid  of 
criticism.  To  criticize  and  make  light  of  the  past  is  like  scoffing  at 
our  parents  for  we  are  children  of  the  past  and  that  past  has  made 
our  present  possible.  If  we  approach  the  present  inquir\'  in  this 
spirit  we  will  find  much  that  is  profitable  and  much  too  that  may 
well  huml)le  us,  for  we  will  see  in  this  century  old  work  ideas 
clearly  expressed  that  we  had  come  to  believe  were  the  products  of 
our  own  times. 

In  trying  to  give  a  comprehensive  idea  of  this  work  I  shall 
preface  what  I  have  to  say  by  a  short  account  of  the  author.  I 
shall  also  refer,  from  time  to  time,  to  contemporary  medicine  and 
events  of  importance,  but  in  both  instances  only  to  give  the  work 
its  projKT  setting  in  the  spirit  of  its  age. 

Johann  Christian  Reil  was  born  in  the  village  of  Rhaude  in  the 
eastern  part  of  Friesland  on  February  28,  1759.  He  was  the  son 
of  a  Protestant  clergj'man  and  it  was  originally  intended  that  he 
should  follow  in  his  father's  footsteps.  From  the  first,  however, 
he  showed  a  disinclination  for  theological  discussions  and  an 
interest  in  the  .sciences.  His  parents  were  wise  enough  not  to 
oppose  his  natural  inclinations  and  sent  him  to  college  at  Norden 
where  he  rcmainefl  until  twenty  years  of  age.  From  here  he  went 
to  Gotlingen  to  study  medicine.  He  did  not  fit  in  here  at  all  well 
because  of  the  dogmatism,  conservatism  and  restraint  which  were 
intolerable  to  him  and  so  after  a  short  residence  he  went  to  Halle, 
the  scene  of  the  greater  part  of  his  life's  activities.  Here  he  studied 
anatomy  and  surgery  under  Philipp  Friedrich  Theodor  Meckel 
(1756-1803)    the    son    of    Johann    Friedrich    Meckel    for    whom 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  3 

Meckel's  ganglion  is  named,  and  internal  medicine  under  Johann 
Friedrich  Goldhagen  (1742-1788).  He  took  the  degree  in  medi- 
cine here  on  November  9,  1782.  The  thesis  which  he  sustained 
on  this  occasion  was  on  the  subject  of  what  he  called  polycholia. 
He  described  a  yellow  humor  in  the  blood  w^hich  was  not  true  bile 
but  its  principal  element.  The  liver  was  charged  with  its  elimina- 
tion. Its  accumulation  in  the  circulatory  fluid  was  a  cause  of 
disease. 

He  practiced  medicine  in  his  native  county  until  1787  when  he 
was  called  to  Halle  as  professor  extraordinary  of  medicine.  The 
year  following  Goldhagen  died  and  he  succeeded  him  as  professor 
ordinary  of  therapeutics  and  director  of  the  clinical  institute. 

In  1795  or  1796  he  founded  the  "Archiv  fiir  die  Physiologic" 
which  he  first  edited  alone,  but  later  in  association  with  Authen- 
rieth.  In  the  first  number  of  this  journal  appeared  a  one  hundred 
and  fifty  page  article  by  Reil  on  the  vital  force  ("Von  der  Lebens- 
kraft").  In  this  work  he  took  a  position  diametrically  opposed  to 
the  admission  of  any  occult  force.  His  position  was  essentially 
materialistic.  He  believed  vital  manifestations  to  be  explicable  upon 
the  basis  of  physical  causes.  He  attempted  to  apply  the  laws  of 
electricity  and  galvanism  to  vital  phenomena  and  finally  appealed 
to  the  idea  of  polarity  which  played  such  a  large  role  in  con- 
temporary philosophy.  Although  he  had  been  a  pronounced  advo- 
cate of  materialism,  especially  from  the  chemical  point  of  view,  he 
was  finally  constrained  to  admit  that  there  did,  after  all,  exist  a 
difference  between  ordinary  and  organic  chemistry,  however  he 
refused  to  admit  a  dualism  which  was  repugnant  to  his  monistic 
tendencies. 

His  most  extensive,  and  probably  most  important  work  was  his 
work  on  fever  (Erkenntniss  und  Kur  der  Fieber).  This  began  to 
appear  in  1797  and  by  1802  four  volumes  had  been  published.  The 
fifth  volume,  however,  did  not  appear  until  181 5,  about  two  years 
after  his  death. 

In  this  work  he  developed  his  special  idea  of  fever  as  an  exalta- 
tion of  the  irritability  of  a  part  and  sometimes  also  of  the  entire 
system.  The  blood  vessels  and  nerves  he  thought  most  susceptible, 
but  it  might  occur  in  a  single  organ.  He  rejected  the  doctrine  of 
crises  and  critical  days  and  renounced  as  nonsense  all  the  species  of 
fevers  described  in  the  books,  such  as  maligne,  putrid,  gastric, 
bilious.  It  will  be  remembered  that  this  work  antedated  by  fully 
half  a  century  the  introduction  and  use  of  clinical  thermometry. 

During  his  active  practice  of  medicine  and  surgery  he  seems  to 


4  WILLIAM  A.  WHITE 

have  been  pretty  continuously  interested  in  the  mental  manifesta- 
tions of  his  patients.  The  work,  which  it  is  the  object  of  this  paper 
to  review,  was  written  in  1803  and  there  are  many  illustrations  in 
it  from  his  work  on  fever  which  serve  to  elucidate  the  mental  state 
in  conditions  of  acute  illness  and  the  delirium  of  fever. 

In  1805  he  founded  with  Kayssler  the  Magazin  f.  die  psychische 
rieilkunde  of  which  only  three  numbers  appeared.  This  was  fol- 
lowed by  two  volumes  of  the  Beitriig:e  zur  Beforderung  einer  Kur- 
methode  auf  psychischem  \\"ege  which  later  he  edited  with  Hoff- 
bauer.     The  first  part  appeared  in  1807. 

He  was  greatly  interested  in  hydrotherapy  and  founded  a  bathing 
institute  in  Halle  in  which  brine,  douche,  showier,  and  Russian  baths 
were  given.  He  was  the  first  German  author  to  carefully  analyze 
the  physiological  eflfects  and  advise  the  use  of  the  cold  bath  in 
fevers.  He  was  greatly  interested  in  chemistry  and  strongly  empha- 
sized the  importance  of  chemical  processes  in  the  body  and  advo- 
cated the  apj)ointment  of  a  qualified  chemist  at  each  clinical  institute 
to  study  the  secretions. 

He  is  best  known  to  us  because  of  the  association  of  his  name 
with  the  insula,  but  of  the  extent  of  his  work  in  cerebral  anatomy 
let  me  quote  what  Edinger-  says  of  him. 

"  Rcil.  in  particular,  who  first  brought  into  general  use  the 
process  of  artificially  hardening  the  brain,  discovered  a  number  of 
anatomical  facts,  which  were  the  result  of  closest  observation.  As 
hi<;  most  important  discoveries  must  be  reckoned  the  arrangement  of 
the  corona  radiata,  the  nerve-tracts  of  the  crus  cerebri,  whose  rela- 
tion to  the  fibers  of  the  corpus  callosum,  which  pass  transversely 
through  it,  he  was  the  first  to  recognize.  The  lemniscus  and  its 
origin  in  the  corpora  f|uadrigcmina,  the  lenticular  nucleus,  the  island, 
and  many  other  parts  were  first  made  known  through  his  in- 
vestigations." 

Goethe  was  a  jiatient  of  his  and  spoke  in  the  very  highest  terms 
of  him,  writing  that  he  had  observed  him  for  two  weeks  without 
prescribing  anything  but  a  palliative.  Tn  181 1  at  the  opening  of  a 
theater  in  Halle  he  mentions  Reil's  bathing  institute  in  the  prologue 
and  after  his  death  Goethe  again  praised  him  in  verse  at  the 
memorial  excrci-^cs  in  July.  1814.  Recently,  Dr.  Garrison  informs 
mc.  a  memorial  has  been  erected  to  him  in  front  of  the  University 
Clinic  at  Halle. 

'Twelve  Lectures  on  the  Structure  of  the  Central  Nervous  System,  by 
Dr.  Ludwig  Edinger,  tr.  I.y  Milton  Hall  Vittcm,  F.  A.  Davis,  PliilaflHphia, 
1800. 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  5 

At  the  time  of  the  European  coalition  Reil  occupied  himself  in 
perfecting  the  mihtary  hospitals.  After  the  battle  of  Leipsic  he 
was  made  director  general  of  the  hospitals  established  at  Halle 
and  Leipsic.  About  a  month  after  he  died,  November  12,  181 3,  of 
typhus  which  he  contracted  in  the  military  hospitals  where  he  had 
worn  himself  out  trying  to  care  for  thousands  of  wounded  and 
sick  soldiers  under  the  most  trying  and  difficult  circumstances. 

We  now  come  to  the  Rhapsodieen,  but  before  taking  it  up  it 
will  be  interesting  to  see  just  the  place  Reil  assigned  to  psychiatry 
in  the  medical  sciences.  There  are  three  ways,  he  says,  in  which  we 
come  into  relation  with  the  outside  world  and  three  ways  in  which 
we  receive  impressions  from  the  exterior.  These  he  designates  the 
three  receptivities :  they  are  the  mechanical,  the  physico-chemical, 
and  the  psychic ;  to  them  correspond  three  sciences,  anatomy, 
physiology,  and  psychology ;  three  divisions  of  the  curative  art, 
surgery,  jaterie  or  medicine  proper,  and  psychiatry ;  and  three 
means  of  therapeutic  approach,  ackology  (that  is  the  mechanical  or 
surgical),  pharmacology,  and  psychic  means.  Thus  we  see  that 
he  includes  psychiatry  as  a  fundamental  part  of  medicine  and  does 
not  consider  it,  as  it  came  later  to  be  considered,  as  a  branch  apart 
from  the  general  body  of  medicine. 

The  Rhapsodieen  is  a  work  of  some^five  hundred  pages.  It  is 
written  in  the  rather  easy  style  of  a  man  whose  mind  is  a  rich  store- 
house of  experience  and  who  is  detailing  it  much  as  he  would  talk. 
Although  there  is  a  distinct  effort  at  arrangement  of  the  contents 
and  an  orderly  progression,  still  there  are  numerous  repetitions,  the 
same  ground  is  gone  over  in  a  little  different  way,  speculation  and 
actual  experience  are  frequently  found  together,  and  in  general  the 
treatment  of  the  whole  subject  is  such  that  my  account  of  the  con- 
tents cannot  follow  the  order  in  which  the  subjects  are  presented. 
The  work  is,  however,  the  work  not  only  of  a  thinker,  and  of  a 
man  of  wide  clinical  experience,  but  of  one  who  was  a  keen  ob- 
server of  his  patients.  In  my  references  to  Reil's  views  as  ex- 
pressed in  the  Rhapsodieen  I  shall  use  his  forms  of  expression  as 
far  as  possible  without  actually  quoting  him  verbatim. 

He  starts  his  book  with  a  criticism  of  the  asylums,  and  speaks  of 
the  cruel  way  in  which  patients  are  treated  and  the  indolence,  selfish- 
ness and  intrigue  that  are  at  the  bottom  of  this  cruelty,  and  of 
the  stupidity  of  attendants.  When  we  recall  that  he  is  criticizing 
the  asylums  of  the  eighteenth  century  we  can  appreciate  the  depths 
of  ignorance  and  superstition  at  which  this  criticism  is  leveled.  He 
is  convinced,  however,  that  the  public  asylum  is,  on  the  whole,  the 


6  UlLLIAM  A.  WHITE 

best  place  to  treat  the  insane  because  they  are,  in  every  way,  better 
equipped.  Although  physicians  on  the  outside  may  be  capable  they 
have  not  the  advantages  at  hand  which  are  oflfered  by  the  asylum. 
Believing  in  this  way,  we  shall  be  prepared  later  on  to  note  that  he 
has  much  to  say  on  the  methods  of  organization  and  management 
of  these  institutions  which,  in  his  opinion,  are  calculated  to  produce 
the  best  results  in  the  treatment  of  the  patient.     More  of  this  later. 

Just  how  he  came  to  his  belief  in  the  efficiency  of  psychotherapy 
he  does  not  tell  us,  but  we  must  remember  that  his  greatest  literary 
work  was  on  fevers  and  from  the  numerous  references  to  this  work 
in  the  Rhapsodieen  wt-  know  that  he  was  impressed  with  the  mental 
phenomena  his  patients  presented.  We  know  also  of  his  great 
interest  in  the  anatomy  of  the  l)rain.  These  two  interests,  coupled 
with  an  inquiring  and  philosophical  mind,  which  was  constantly 
making  for  explanations  of  the  phenomena  he  saw  about  him,  is  I 
think  the  key  to  the  situation.  He  was  not  only  a  keen  ol^server 
of  abnormal  states,  but  gives  many  examples,  in  his  psychological 
discussions,  to  show  that  he  was  also  a  keen  observer  of  the  phe- 
nomena of  what  we  should  call  today  the  phychopathology  of  every- 
day life.  As  examples  of  these  tendencies  I  select  the  following: 
He  cites  a  fever  patient  who  on  awakening  complained  that  he  had 
become  two  j)ersons.  Ope  of  his  personalities  lay  in  bed,  the 
other  was  walking  up  and  down  in  the  study.  When  he  ate  he 
had  to  eat  for  two  persons,  the  one  in  bed  and  the  one  up.  This 
conrlition  gradually  disaj)peared  when  he  got  better.  As  matters 
of  more  usual  and  not  abnormal  nature  he  tells  of  the  strange 
feelings  one  sometimes  has  on  awaking  at  night  in  a  strange  room 
and  gives  as  an  example  of  the  forgetting  of  certain  periods  of 
our  life  the  experience  of  a  doctor  who  was  awakened  for  advice. 
He  had  the  light  brought,  read  over  the  history  of  the  patient,  wrote 
a  prescription,  ordered  his  horses  for  the  morning  to  make  a  call 
ujM-m  the  patient  and  then  went  to  sleep.  When  he  awoke  he  had 
forgotten  the  entire  incident  and  would  have  remained  unconvinced 
cxccj)!  for  the  evidence  in  his  own  handwriting. 

Helieving  as  he  did  in  the  absolute  unity  of  life  and  having 
strong  mechanistic  leanings  he  naturally  sought  an  explanation 
for  psychic  events  on  the  basis  of  cerebral  conditions.  We  thus 
often -frnd  him  si>eaking  of  o'^cillations  of  the  brain,  and  shaking  or 
shock  of  the  body.  u\  the  brain,  anrl  of  the  psychic  organs 
(Krschrmenmg)  which  I  take  it  might  be  best  translated  bv  bodily 
and  nuntal  stress.  He  speaks  also  of  the  dynamic  temperature  of 
the  iMxly  or  of   some  part.     This   latter,   when   we  remember  his 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  7 

peculiar  idea  of  the  nature  of  fever  and  also  that  clinical  ther- 
mometry was  not  yet  in  existence,  probably  could  best  be  interpreted 
as  irritability. 

Despite  these  vague  expressions,  however,  his  whole  attitude 
towards  the  problem  was  distinctly  pragmatic.  He  observes  wisely 
that  we  reason  too  much  and  observe  too  little  and  so  in  spite  of 
his  conceptions  he  is  quite  free  to  observe  psychological  phenomena. 

He  had  a  broad  grasp  of  the  meaning  of  consciousness  not  only 
from  an  experiential  pOint  of  view,  but  he  evidently  also  sensed 
somewhat  its  genetic  significance.  He  tells  us  that  self  conscious- 
ness unites  the  multiplicities  of  experience  into  a  unitary  self,  that 
it  reflects  the  environment  of  the  immediate  neighborhood  and  of 
the  furthest  reaches  of  the  firmament  including  both  past  and 
present.  We  feel  that  we  have  always  been  the  same  self  in  the 
same  body.  It  reflects  also  the  body  itself,  through  common  sensi- 
bility, the  cenesthesis  (Gemeingefiihl).^  Man  views  the  objects  of 
outer  sense  in  the  form  of  space,  of  inner  sense  in  the  form  of 
time.  JThe  various  organs  of  the  body  are  united  into  one  individual 
through  the  ramifications  of  the  nervovis  system  and  the  brain  is 
the  center  (Hauptbrennpunkt)  of  this  unifying  system.  We  only 
arrive  at  this  integration,  however,  gradually.  The  child  plays 
with  its  limbs  as  it  does  with  its  toys,  it  is  happy  or  unhappy,  laughs 
and  cries,  but  does  not  know  that  it  is  the  person  that  represents 
the  world  and  is  afifected  by  it  pleasantly  or  vmpleasantly.  It  only 
awakes  later  to  a  position  of  freedom  and  the  great  secret  of  its 
own  self.  The  circle  of  experiences  effecting  us  widens  and  widens 
as  we  grow  older  like  the  ripples  from  a  stone  thrown  in  the  sea. 
The  segment  which  we  unite  with  ourselves,  are  conscious  of,  we 
cut  from  the  endless  totality  of  things  as  belonging  to  us. 

This  correlation  and  integration  of  the  individual  Reil  never 
loses  sight  of.  He  speaks  not  only  of  the  harmony  of  action  of  the 
different  parts  of  the  body  through  the  brain  and  of  dynamic  rela- 
tions in  the  psyche  but  says  the  dynamic  relations  of  the  organs  of 
the  psyche  are  disturbed  in  mental  disease.  The  abnormal  con- 
sciousness lacks  unity.  Its  different  tendencies  work  independently 
or  with  others  in  false  relations,  the  synthesis  is  lost,  like  a  ship 
with  mast  and  rudder  gone  it  floats  on  the  waves  of  phantasy  in 
a  strange  world  of  time  and  space.  The  patient  either  does  not 
grasp  the  outer  world  at  all  or  not  correctly  and  as  phantasy  in- 
creases his  consciousness  recedes,  he  is  unable  to  distinguish  the 
real  from  phantasy,  dreams  from  reality. 

2  He  was  the  first  to  introduce  this  idea  of  common  sensibihty  into  sci- 
ence and  to  give  a  comprehensive  anatysis  of  its  significance. 


8  WILLIAM  A.  WHITE 

This  unity  lie  says  is  dependent  upon  the  integrity  of  the  nervous 
system.  The  nervous  system,  the  body,  and  the  mind  stand  in 
intimate  relations.  During  a  surgical  operation  the  whole  strength 
of  the  soul  hangs  on  the  point  of  the  knife. 

Xot  only  was  Reil  an  observer  of  the  psycholog)'  of  ordinary 
events,  but  he  discusses  the  psycholog\'  of  certain  borderland  condi- 
tions, such  as  hypnagogic  states,  and  appreciates  their  significance 
for  the  understanding  of  abnormal  conditions.  And  so  he  tells  us 
that  in  the  state  between  waking  and  sleeping  one  often  cannot  tell 
reality  from  phantasy,  the  sound  of  one's  own  voice  may  seem 
strange  and  not  our  own.  We  may  doubt  our  own  personality  or 
get  it  confused  with  others  and  project  (verpflanzen)  our  qualities 
on  others.  Consciousness  may  fail  to  unite  us  correctly  with  time 
and  space.  The  personality  of  the  soul  and  the  individuality  of 
the  body  disappear  when  consciousness  is  lost. 

The  dream  product  is  due  to  a  partial  waking  of  the  nervous 
system.  So  in  sleep  talking  the  speech  organs  are  awake,  in  sleep 
walking  the  motor  apparatus,  etc.  As  the  nervous  system  awakens 
the  dream  approaches  self-consciousness. 

In  these  psychological  discussions  he  speaks  frc([ucntly  of  the 
|)olarity  of  the  organism  and  uses  such  expressions  as  the  plus  and 
minus  irrital)ility  between  the  antagonistic  systems  and  savs  in  one 
place  that  it  is  the  inversion  of  the  plus  and  mintis  vitality  in  the 
antagonistic  systems  that  produces  insanity.  This  idea  of  polarity 
is  freriucntly  referred  to.  Instinct  he  says  is  a  l)lind  tendency  that 
moves  according  to  a  j)olarity  that  may  conduct  an  imponderable 
fluid.  This  was  all  probably  coupled  in  hi^  mind  with  the  animal 
life  stream  Canimalischer  Lebensstnim )  which  elibs  and  flows, 
increases  and  disperses,  balances  from  jxile  to  pole.  This  life 
stream  is,  in  another  place,  significantly  spoken  of  as  the  electric 
life  stream  felektrische  Lcbcnsstrrtm)  in  his  discussion  of  a  severe 
form  of  e.xcitement  ( Tobsucht )  in  which  the  whole  nervous  system 
is  stressed  to  the  extremest  point  and  its  polarity  disordered. 

It  is  with  reference  to  just  such  a  theory  as  this  that  I  contend 
that  the  historian  should  be  on  his  guard  anrl  not  lay  aside  his 
role  of  investigatf»r  and  assume  that  of  critic.  Of  course  Reil,  like 
everyone  cUe.  must  have  come  face  to  face  upon  innumerable  oc- 
casions*, with  the  i)hrn«>menon  of  opposites.  Aside  from  his  doc- 
trine of  i)olarity  he  mentions  positive  and  negative  means  of  cure, 
and  sthenic  and  asthenic  types  of  mental  diseases  (which  probably 
imiiided  tyi)cs  of  manic-depressive  jisychosis  to  judge  by  the  de- 
scription). How  he  worked  it  out  in  his  own  mind,  though,  of 
course  1  <lo  nf»t  know  and  quite  probably  he  did  not  either. 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  9 

Many  such  theories  come  into  existence,  have  a  vogue  for  a  time, 
then  follows  a  period  when  they  are  for  the  most  part  forgotten  and 
considered  foolish,  and  then  they  are  revived  in  a  somewhat  differ- 
ent form  and  with  the  added  prestige  of  increased  knowledge.  We 
are  familiar  with  the  theory  of  the  iatrochemical  system  of  medicine 
in  the  seventeenth  century  which  attributed  disease  to  an  excess  of 
acid  or  alkali.  We  know  to-day  the  theory  of  acidosis  and  the 
regulatory  mechanism  for  maintaining  the  proper  balance  of  acid 
and  alkali  in  the  body. 

With  regard  to  the  polarity  doctrine  let  me  quote  a  few  words 
from  a  recent  authoritative  monograph.'^  The  authors  state  that 
"  every  visceral  organ  is  supplied  by  sympathetic  fibers,  which  work 
antagonistically  to  the  autonomic. 

"  Hence  it  may  be  stated  that  the  normal  progress  of  functioning 
of  visceral  organs  is  a  well-regulated  interaction  between  two  con- 
trary acting  forces." 

This  particular  verification,  if  it  may  be  called  such,  of  Reil's 
polarity  theory  is  made  very  much  more  interesting  by  his  statement 
that,  in  this  relation  of  polarity  stand  the  laryngeal  and  phrenic 
nerves  and  the  great  sympathetic.  When  we  note  that,  from  the 
description  of  the  distribution  of  the  laryngeal  nerve  (Stimmnerve) 
he  is  really  talking  about  the  vagus  we  get  the  full  significance  of 
his  opposition  of  the  laryngeal  and  the  great  sympathetic. 

We  have  a  further  recent  development  of  this  same  character, 
the  path  of  opposites,  as  it  has  been  called,  in  Bleuler's^  principles 
of  ambivalency  and  ambitendency.  Ambivalency  he  says  gives  to 
the  same  idea  two  contrary  feeling  tones  and  invests  the  same 
thought  simultaneously  with  both  a  positive  and  a  negative  character. 
Ambitendency  sets  free  with  every  tendency  a  counter  tendency. 

This  may  be  the  psychological  basis  which  accounts  for  the 
formulation  of  these  theories  of  opposites,  however,  that  the  whole 
matter  probably  has  much  deeper  roots  is  strongly  indicated  by  such 
a  fact  as  this.  The  "  black  fellow  doctors  "  of  Australia  believe  that 
the  fat  above  the  kidney  is  magic.  If  by  incantation  it  can  be  re- 
moved from  an  enemy  when  he  sleeps  he  will  surely  lose  his  strength 
and  die.''  This  belief  of  primitive  Australian  savages  is  borne  out 
by  present-day  knowledge  of  the  adrenal  glands. 

■*  Eppinger  and  Hess  :  Vagotonia,  A  Clinical  Study  in  Vegetative  Neu- 
rology.    Nerv.  and  Ment.  Disease  Monograph   Series,  No.  20. 

5  Bleuler :  The  Theory  of  Schizophrenic  Negativism.  Nerv.  and  Ment. 
Dis.  Monograph  Ser.,  No.  11. 

^  Howitt :  Native  Tribes  of  South-East  Australia,  Landon,  1904,  cited  by 
Elliott:  The  Adrenal  Glands,  Brit.  Med.  Jr.  (June  27,  1914). 


lo  iriLLIAM  A.  WHITE     ' 

With  regard  to  the  mentally  ill  and  the  symptoms  of  mental 
disease  Rcil  was  at  once  humble  and  seeking  to  understand.  In 
writing  of  the  impulsive  activities  of  these  patients,  he  says  they 
seem  spontaneous  only  because  we  do  not  know  their  causes  and  the 
necessities  which  condition  them. 

The  psyche,  he  says,  is  brought  into  relation  with  the  whole 
body  by  the  nervous  system  and  with  the  outside  world  by  means 
of  the  sense  organs  and  these  impressions  through  the  cenesthesis 
and  the  sense  organs  are  reproduced  through  the  activity  of  the 
brain.  •  Upon  this  basis  he  had  a  very  clear  idea  of  the  importance 
of  bodily  diseases,  especially  of  the  nervous  system,  in  their  influence 
upon  the  psyche.  He  also  recognized  the  efificicncy  of  psychogenic 
factors.  He  says  the  causes  of  mental  disease  either  come  from 
without  or  within.  The  latter  includes  moral  and  intellectual 
affections.  They  both  work  the  same  way  by  injuring  the  normal 
functions  of  the  psyche  in  a  special  way.  Diseases  of  the  bodily 
organs  aflfect  the  psyche  through  the  cenesthesis,  while  he  mentions 
purely  psychic  causes  such  as  anomalous  instincts  and  tendencies, 
lack  of  and  bad  mental  culture,  superstition,  fanaticism,  bigotry,  etc. 

As  evidences  of  his  deep  insight  are  his  statements  that  we  fall 
into  insanity  when  we  seek  the  errors  (of  sense)  not  in  ourselves 
but  outside  and  his  wonderfully  interesting  remark  from  a  psycho- 
analytic standpoint  to  the  effect  that  we  like  to  create  a  world  of 
phantasy  in  which  we  j)lay  a  more  brilliant  part  than  we  do  in 
reality.  The  chikl  likes  to  play  mother,  soldier,  a  king  and  we  are 
amused  at  the  fictions  of  the  painter,  poet  and  actor.  As  an 
example  of  his  humbleness  he  says  that  we  know  nothing  of  the 
nature  of  dementia.  Incidentally  only  one  autopsy  is  mentioned  in 
the  book. 

Now  as  to  the  treatment  which  is  the  real  subject  of  the  Rhap- 
sodiccn. 

In  the  first  place,  he  takes  the  po^^ition  that  mental  disease  must 
be  treated  both  through  the  body  and  through  the  mind.  He  speaks 
of  the  false  treatment  of  insanity  by  blood  letting,  purgatives  and 
emetics.  Anything  that  weakens  the  body  such  a>  enervating 
I)lea.surcs,  sexual  excesses,  deep  gric-f.  narcotics,  belladonna,  hyo- 
scyanni*;.  especially  opium,  spirituous  liquors,  loss  of  blcfod  and 
lymph,  long  sUq)  may  produce  dementia.  One  mu^t  treat  bodily 
conditions  by  prfipcr  physical  remedies  and  psychic  conditions  by 
psychic  means.  He  who  wishes  to  be  a  physician  to  the  soul  must 
he  familiar  with  both.  Woe  to  the  patient  if  the  physician  trie?  to 
treat  his  psychic  pain  with  hellebore  or  his  difficulty  of  thinking  by 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  ii 

trying  to  thin  the  atrabiliary  blood  and  dissolve  a  coagulum  in  the 
portal  vein.  And' then,  very  wisely,  he  observes  that  one  can  quiet  a 
patient  with  opium  but  only  makes  of  him  a  fool  of  another  sort. 
The  normal  dynamic  relations  of  the  brain  are  grounded  in  ideas 
and  through  ideas  they  must  be  rectified  wdien  disturbed. 

We  are  convinced,  he  says,  that  psychic  means  of  cure  were 
known  to  the  Greeks  and  Romans  by  many  references  in  the  writ- 
ings of  Hippocrates,  Celsus,  and  Coelius  Aurelianus.  The  Arabians 
also  used  such  means  as  is  related  in  the  story  of  Al-Rachid's  beau- 
tiful consort  who  as  a  result  of  the  excessively  passionate  embraces 
of  her  master  suffered  a  stiff  arm.  All  means  were  tried  to  heal  it, 
balsam  from  Gilead  and  Mecca,  nard  and  amber,  but  in  vain. 
Finally  a  new  physician,  Gabriel,  was  consulted.  He  cured  her  in 
a  moment  by  pretending,  in  the  presence  of  witnesses,  that  he  was 
going  to  grasp  her  petticoat.  This  angered  the  beautiful  maiden 
who  grasped  with  both  hands  at  the  audacious  doctor.  She  was 
cured  and  the  sultan,  in  the  hope  of  new  embraces,  richly  rewarded 
the  doctor. 

In  harmony  with  his  tendencies  already  noted  we  find  that  he 
has  separated  therapeutic  agents  into  three  classes,  viz. :  chemical, 
physico-chemical,  and  psychic.  The  psychic  means  are  those  means 
which  by  a  special  direction  of  the  psychic  forces,  the  ideas,  feel- 
ings, and  desires  we  bring  about  such  alterations  in  the  organiza- 
tion as  to  cure  the  patient.  The  means  of  this  art,  he  says,  have 
not  as  yet  been  brought  together  into  a  system.  The  application  of 
these  means  requires  more  knowledge  and  skill  than  the  use  of  other 
means.  The  physician  cannot  test  their  strength  as  the  surgeon 
can  that  of  his  tourniquet  or  as  that  of  a  powder  can  be  tested 
by  its  size  and  weight.  He  must  test  them  upon  the  ideas  and  feel- 
ings of  his  patients. 

Psychic  means,  he  is  careful  to  tell  us,  are  those  which  influence 
the  psyche.  They  may  be  material  or  immaterial.  They  are  psychic 
means  nevertheless  if  they  produce  this  result.  Psychic  methods  of 
treatment  are  for  producing  a  cure  and  it  is  indifferent  whether  they 
act  on  the  body  or  on  the  mind  so  long  as  they  bring  about  this 
result. 

Again,  there  are  three  classes  of  psychic  means.  First,  those  of 
a  material  nature  which  affect  the  body  directly  and  so,  through  the 
cenesthesis,  the  psyche;  second,  objects  of  sense  which  operate  espe- 
cially through  association  and  so  stir  up  the  feelings,  imagination,  and 
desires,  and  the  third  consisting  of  signs,  symbols  and  pantomime 
and  especially  speech  and  writing  which  stimulate  ideas,  imagination, 
judgment  and  awaken  the  patient  to  higher  psychic  activities. 


12  UlLLI.-lM  A.  WHITE 

Psychic  agents  which  operate  through  the  body  he  bcHeved  do 
so  through  the  cenesthesis  and  so  atlcct  the  ideas  pleasantly  or  un- 
pleasantly. These  means  exalt  or  depress  the  organic  strength 
locallv  or  generally  and  bring  about  a  feeling  of  well  being  and 
animal  plca>ure  or  pain  and  bodily  discomfort. 

The  bodily  stimulants  that  bring  about  animal  pleasure  arc  first  a 
feeling  of  health.  Wine  and  opium  bring  this  feeling  temporarily, 
warmth,  especially  of  the  sun,  rubbing  softly  with  the  hand  or  some- 
thing soft,  and  the  warm  bath.  The  most  pleasant  bodily  feeHng  is 
that  which  comes  from  copulation. 

The  two  poles  of  the  body,  the  head  and  the  sexual  organs,  stand 
in  noteworthy  opposition.  Shaking  u])  one  end  through  copulation 
and  pregnancy  frees  the  other  of  accumulations. 

Bodily  irritants  that  produce  animal  discomfort  are  mostly  dis- 
ease-producing agents.  Some  of  them  are  hunger,  thirst,  heat,  cold, 
loss  of  sleep,  poisons,  strong  tickling,  itching,  vesicants,  etc.  Water 
is  also  emphasized  as  an  element  for  which  man  has  a  natural  fear. 

These  disagreeable  agents  act  through  the  cenesthesis,  awaken 
attention,  compel  the  cataleptic  to  look  about,  steady  the  unstable, 
etc.  They  stir  up  the  feelings  of  grief,  dejection,  fear  and  other 
affects  with  which  the  mind  busies  itself  and  gives  a  new  direction  to 
the  activities. 

Objects  of  sense  ai)pcal  mostly  to  the  senses  of  vision,  hearing 
and  touch.  An  unbroken  succession  of  objects  can  be  used  or  a 
single  object.  In  the  latter  case  there  must  be  interest.  W^e  cannot 
furnish  interest  but  objects  for  which  the  patient  has  interest.  All 
sorts  of  objects  may  be  used  as  those  that  awaken  fear  and  hope, 
such  as  a  glowing  iron,  or  emotion  as  will  coins  in  a  miser,  and 
sensory  impressions  which  through  their  power  awaken  the  feeling 
of  majesty,  as  thunder  and  lightning. 

Objects  may  be  j)rcsented  to  the  patient  to  name  and  to  give  their 
noteworthy  characteristics.  lie  says,  in  this  connection,  that  this  is 
best  done  by  one  for  whom  the  patient  has  regard.  During  the  time 
the  patient  is  thus  engaged  the  disorder  is  in  abeyance.  He  de- 
.scribes  the  use  of  the  dilTerent  .sense  organs.  Smell  and  taste  are 
more  emotional  than  touch,  hearing  and  vision.  Touch  stimuli  in- 
clude objects  that  arc  smooth  or  rough,  cold  or  warm,  light  or 
heavy.  '  Music  is  a  valuaJjle  way  of  api)ealing  through  the  car  and 
as  for  vLsiial  sensations  he  advises  a  theater  in  the  asylum. 

Hy  signs  anri  symbols,  especially  s|)eech  and  writing,  the  brain 
may  be  compelled  to  oscillation.  The  cataleptic  can  be  awakened, 
the  flighty  fixed,  fear,  passion,  awe,  love,  trust  can  be  called  forth. 
Normal  tendencies  can  be  cultivated  and  bad  ones  dealt  with. 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  13 

All  of  these  discussions  show  a  profound  grasp  of  the  subject 
but  when  we  come  to  examples  of  their  application  we  shall  see 
some  strange  and  very  naive  use  made  of  the  principles. 

He  seems  to  have  believed  that  a  very  potent  form  of  treatment 
was  to  demonstrate  to  the  patient  the  absurdity  of  his  false  ideas. 
A  patient  who  thought  himself  a  king  was  argued  out  of  this  belief 
by  showing  him  that  he  did  not  even  have  power  and  authority 
enough  to  terminate  his  own  imprisonment,  and  also  how  they 
laughed  at  others  with  the  same  idea.  A  woman  who  thought  she 
had  killed  her  son  was  cured  by  telling  her  that  he  was  seriously  ill 
over  her  crazy  idea.  Here,  of  course,  the  appeal  was  clearly  on  the 
emotional  side.  Somewhat  more  bizarre  are  the  following:  A 
patient  refused  to  eat  because  he  believed  himself  dead.  A  casket 
was  placed  beside  him  containing  an  apparent  corpse.  The  patient 
saw  with  astonishment  that  the  corpse  sat  up  and  ate.  He  also  ate 
and  was  cured.  Another  patient  who  thought  himself  dead  was 
being  borne  in  a  casket.  Some  peasants  met  it  on  the  way  and 
made  all  sorts  of  shameful  remarks.  This  so  angered  the  patient 
that  he  sprang  out  and  attacked  them.  A  man  thought  his  legs  were 
of  glass.  He  was  cured  by  his  maid  who  struck  him  a  blow  with  a 
stick.  Angrily  he  sprang  up  and  so  proved  they  were  not  glass  as 
they  bore  his  weight.  Another  patient  thought  he  had  a  glass  nose 
and  on  this  account  would  not  go  out  and  would  only  sleep  sitting 
up.  His  doctor  advised  a  case  for  it  and  as  he  was  applying  it  broke 
a  glass  he  had  concealed.  The  patient  was  distracted  but  the  doctor 
reassured  him  and  said  the  glass  nose  had  been  replaced  by  a  flesh 
nose  as  a  milk  tooth  is  replaced  by  a  permanent  one.  The  patient 
verified  this  by  looking  in  the  mirror  and  by  feeling  and  pulling  his 
nose  and  was  cured.  A  patient  who  believes  he  has  a  frog  in  his 
stomach  can  be  made  to  vomit  in  a  basin  in  which  a  frog  is  con- 
cealed, or  one  who  believes  he  has  a  rabbit  in  his  head  may  have  an 
incision  made  in  the  scalp  and  then  be  shown  a  bloody  rabbit.  It 
must  be  said  in  all  justice  that  these  cases  are  all  quoted,  in  other 
words  the  evidence  is  heresay. 

He  says  of  play  that  it  would  be  a  poor  means  of  treatment  to 
employ  for  one  bowed  down  by  misfortune.  On  the  contrary 
danger  to  husband  or  wife  or  near  relatives  might  serve  to  arouse 
the  patient.  When  one  begins  to  compare  their  sorrows  with 
another's  they  are  on  the  road  to  recovery. 

He  cites  the  example  of  a  man  who  attempted  suicide  by  shoot- 
ing. He  only  wounded  his  cheek,  which  bled  profusely.  The 
wound  healed  and  he  got  well.     Another  was  about  to  throw  himself 


14  WILLIAM  A.  WHITE 

from  a  bridge  into  the  river  when  he  was  set  upon  by  robbers.  He 
used  all  his  strength  to  run  away  and  that  was  the  end  of  his  suicidal 
tendencies. 

Among  these  anecdotes  I  find  two  that  I  have  been  familiar  with 
for  many  years.  I  wonder  if  they  originated  with  Reil  or  have  only 
been  passed  on  by  him.  To  a  visitor  to  the  aslyum  one  patient 
pointed  out  another  and  commented  upon  how  crazy  he  was  because 
he  thought  he  was  the  Son  of  God  and  demonstrated  how  crazy  his 
belief  was  by  adding  that  he  himself  was  God  the  Father.  Another 
patient  induced  a  visitor  to  ascend  to  a  high  gallery  where  the  view 
to  be  obtained  was  beautiful.  When  they  arrived  there  he  told  him 
to  jump  off  and  prove  that  he  had  faith.  The  visitor  answered  that 
it  was  a  nuich  more  difficult  thing  to  jump  up.  The  visitor  went 
down  stairs  and  the  patient  awaited  his  attempt  to  jump  up. 

He  lays  a  good  deal  of  stress  upon  commanding  obedience  and  to 
that  end  the  necessity  for  subjugating  the  patient.  He  thinks  that 
in  taking  a  patient  to  the  hospital  it  is  a  good  plan  to  take  him  at 
night,  in  a  covered  wagon  and  in  a  roundabout  way  so  as  to  make 
the  whole  procedure  as  impressive  as  possible.  This  effort  led  at 
times  to  rather  childishly  simple  means.  For  example  he  cites  the 
case  of  a  patient  who  would  not  eat.  The  doctor  visited  him  in  the 
evening  with  an  impressive  array  of  attendants  with  clanking  chains 
and  putting  his  supper  before  him,  with  fiery  eyes  and  in  a  thunder- 
ing voice  told  him  if  he  did  not  eat  torture  awaited  him.  It  is  re- 
corded that  the  patient  ate  and  recovered. 

When  obedience  is  obtained  then  a  regular  regimen  can  be  carried 
out.  Attention  must  be  awakened  and  if  ordinary  impressions  do 
not  do  this  they  must  be  made  stronger.  If  obedience  and  attention 
are  both  present  then  the  patient  is  on  the  road  to  recovery.  To  do 
this  it  may  be  necessary  to  resort  to  impressions  that  terrify,  such  as 
hot  irons,  the  surprise  bath,  and  placing  the  patient  in  positions  of 
api>arent  danger  in  which  he  has  to  make  a  great  effort  to  save  him- 
self. With  regard  to  the  principles  involved  in  these  methods  I  can 
do  no  better  than  quote  Meyer^ — the  only  reference  that  I  have  seen 
to  this  work  in  English.  He  says,  .speaking  of  the  treatment  of 
paranoiac  conditions: 

"  In  the  face  of  all  the  tendency  to  hopelessness,  even  the  earliest 
writers  on  fixed  and  .systematized  delusions  give  interesting  advice 
as  to  attempts  to  cure.     One  of  the  most  complete  statements  is  con- 

TMcycr:  Tlic  treatment  of  Paranoia  and  Paranoid  States,  Chap.  XIV, 
in  White  and  Jelliffe:  The  Modern  Treatment  of  Nervous  and  Mental  Dis- 
eases, Lea  and  Febigcr,  Philadelphia,   1913. 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  15 

tained  in  Reil's  '  Rhapsodies  on  the  Use  of  Psychic  Treatment  in 
Mental  Disorders'  (1803),  which  contains  a  very  excellent  dis- 
cussion of  the  fixed  ideas  in  partial  insanity  and  their  management. 
He  believes  that  for  the  psj^chical  treatment  of  these  disorders  all 
that  is  needed  is  the  wiping  out  of  the  fixed  idea  (page  324).  With 
it,  all  those  impulses,  yearnings,  and  improper  activities  disappear 
which  arise  from  it  as  from  a  spring.  If  the  idea  is  silenced,  be  it 
only  for  more  or  less  prolonged  intervals,  and  if  thereby  the 
'trembling  cord'  (or  abnormal  part  of  the  nervous  system)  be 
given  temporary  chances  for  rest,  the  dominant  irritability  and 
sensitiveness  on  which  the  morbid  tendency  is  based  is  diminished, 
in  a  measure  as  the  normal  balance  of  forces  in  the  organ  of  mind 
returns,  and  with  it  the  freedom  of  deliberation  and  the  determina- 
tion of  volition  according  to  the  laws  of  reason.  The  patient  is 
enabled  to  realize  the  lack  of  foundation  of  his  fixed  idea  or  to  put 
it  aside  as  something  irrelevant  until  it  finally  fades  by  itself.  This, 
of  course,  depends  on  many  factors :  The  dulling  of  excessive 
irritable  tendencies  of  the  body  which  attract  the  attention  of  the 
hypochondriacal  too  readily ;  the  removal  of  accidental  causes  in  the 
body  and  outside  of  it,  for  instance,  cenesthetic  irritation,  or  objects 
of  love  or  of  hatred;  appropriate  helps  during  the  earliest  develop- 
ment of  the  fixed  idea  which  fight  its  taking  root,  and  finally  the 
pushing  of  matters  which  next  to  the  fixed  or  dominant  one  have 
the  greatest  interest  for  the  patients ;  all  this,  according  to  the  rules 
mentioned  in  regard  to  mental  disorders  in  general.  All  ideas,  how- 
ever much  they  fascinate  us  by  their  interest,  finally  will  fade  in 
the  course  of  time,  if  they  are  aroused  by  events  outside  of  us  and 
not  by  permanent  stimuli  in  and  outside  the  body.  In  these  cases, 
therefore,  everything  depends  on  gaining  that  amount  of  time  which 
cures  the  trouble  thoroughly  before  the  brain  or  its  excessive  tension 
has  received  injuries  which  by  their  nature  would  be  incurable. 

"  Reil  insists  that  we  should  cultivate  in  the  patients  obedience 
and  respect  for  the  persons  who  are  expected  to  arouse  their  senses 
and  to  prepare  them  for  the  treatment  according  to  principles  which 
hold  for  the  treatment  of  all  mental  disease.  The  physician  must 
get  hold  of  their  hearts,  now  by  seriousness  and  severity,  now  by 
leniency  and  by  sympathy  with  their  fate,  especially  where  mis- 
fortunes are  at  the  bottom  of  their  trouble.  Thus  the  physician 
becomes  enabled,  either  by  reasons  and  cautious  admonition  or  by 
coercion,  to  hold  them  down  to  such  steady  physical  pr  mental  work 
as  will  push  aside  their  fixed  ideas  and  bring  such  intervals  that 
they  fade  out  by  themselves.     The  work  must  have  sufficient  variety 


i6  IIILLIAM  A.  WHITE 

in  order  that  the  patient  cannot  associate  it  too  readily  with  his  fixed 
notions.  The  work  must  be  adapted  to  his  capacities  and  Hkings 
and  must  thereby  be  attractive.  Should  we  not  be  able  to  find  any 
topics  which  would  absorb  the  patient  by  their  natural  interest,  Rail 
proposes  to  arouse  the  patient  by  exposing  him  to  various  dangers 
and  emergencies  from  which  the  patient  would  naturally  want  to 
escape;  he  would  put  him  in  a  place  where  his  attention  is  thor- 
oughly absorbed  by  his  being  forced  to  escape  water  jets,  risks  of 
falling  into  ditches,  etc.  (a  procedure  which  Reil  says  could  better 
be  organized  in  public  institutions  than  in  private  homes).  Crude 
as  this  may  seem  the  fundamental  idea  he  has  in  mind  is  quite 
correct.  What  he  means  is  that  we  should  never  surrender  the  hope 
of  being  able  to  get  hold  of  some  vital  interests  by  which  we  might 
be  able  to  absorb  the  patient's  attention  sufficiently  to  make  him 
forget  his  fixed  ideas,  and  for  this  he  would  not  mind  appealing  to 
very  fundamental  interests  of  self-protection.  It  is  a  matter  of 
great  satisfaction  that  our  modern  tendency  to  appeal  to  attractive- 
ness rather  than  to  obedience  and  coercion  also  in  the  domain  of 
ordinary-  education  has  put  at  our  disposal  a  fine  array  of  means  of 
profitable  distractions  which  justly  has  changed  most  of  the  old 
methods  of  school  discipline  of  general  life,  and  make  unnecessary 
the  artificial  and  after  all  barbarous  and  ludicrous  scheme  of  Reil. 

"  Reil  also  gives  accounts  of  clever  and  rapid  treatment  of  many 
of  these  diseases,  which  remind  one  of  what  laymen  and  even  physi- 
cians sometimes  expect  the  psychiatrist  to  use.  Thus  Reil  reports 
(p'l?^  Z'7)  the  case  of  a  young  man  who  was  reasonable  with  the 
exception  of  the  fixed  idea  that  he  was  a  Swedish  prince.  He  was 
sent  for  treatment  to  a  woman  who  had  acquired  a  great  reputation 
in  the  care  of  the  insane.  She  put  him  beside  her  at  the  first  dinner. 
He  spoke  and  acted  for  some  time  in  a  consistent  and  natural  way 
until  all  of  a  sudden  he  digressed  to  his  fixed  idea.  At  the  very 
.«mc  moment  he  received  such  a  slap  in  the  face  that  he  saw  stars. 
This  treatment  which  he  certainly  had  not  expected  from  a  woman, 
and  especially  not  on  the  first  day  after  his  admission,  acted  so 
profoundly  upon  him  that  he  never  mentioned  his  notion  again. 
In  the  same  way,  the  passions  of  fright,  love,  and  hope,  which  are 
based  on  important  objects  of  religion,  honor  and  fear  of  harm  are 
described  as  contributing  to  remove  the  fixed  idea.  When  Orestes 
had  revenged  the  death  of  his  father  with  the  blood  of  his  mother 
Clyfcninestra,  he  became  subject  to  the  delusion  that  their  souls 
followed  him  armed  with  torches  and  snakes.  The  oracle  advised 
him  to  take  a  trip  on   the  ocean   with  his   friend   Pyladcs.     They 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  17 

landed  in  the  Chersonese  and  there  he  was  exposed  to  the  danger 
of  being  sacrificed  to  the  gods  of  the  land.  He  escaped  death  and 
learned  that  he  was  saved  by  his  sister  Iphigenia.  Both  passions, 
fright  and  joy,  so  acted  upon  him  that  he  turned  to  Greece  restored 
and  able  to  take  up  the  reins  of  government.  A  merchant  in  France, 
following  some  commercial  losses,  had  developed  a  fixed  idea  that 
he  was  going  to  starve  in  poverty.  At  that  time  the  Reformation 
broke  out  in  Germany  and  this  attracted  the  attention  of  the 
patient  more  and  more.  He  defended  popism  by  speech  and  writ- 
ing and  was  cured  of  his  delusion.  At  times  it  is  possible  to 
persuade  the  patient  that  he  has  attained  his  purposes ;  or  it  may  be 
possible  to  convince  him  of  the  absurdity  of  his  premises,  etc." 

Reil  is  strong,  however,  in  his  denunciation  of  cruelty  to  patients. 
He  would  only  use  severe  methods  when  there  is  a  distinct  object 
to  be  attained  by  their  use,  but  neither  would  he  hesitate  to  use  any 
measure,  because  of  its  severity,  if  it  was  for  the  good  of  the 
patient.  He  believed  the  patient  should  have  regard  for  the  physi- 
cian. He  cites  the  case  of  a  patient  with  paraplegia  who  was  cured 
by  the  assurance  of  his  physician  that  he  would  be  well  in  six  days.. 
The  prediction  came  true  and  served  not  only  to  make  the  patient 
believe  in  the  doctor  but  also  to  make  the  doctor  believe  in  the 
patient. 

He  writes  most  intelligently  of  work  as  a  therapeutic  agent  and 
believes  our  asylums  should  make  their  patients  work.  He  men- 
tions hand  work,  art  work,  and  mental  work  as  progressive  stages 
in  the  development  of  attention.  We  should  proceed  from  the 
simple  to  the  complex,  from  the  looker  on  to  being  the  actor. 
Dancing  and  swimming  have  the  advantage  that  they  are  valuable 
exercises  for  both  mind  and  body.  Work  should  be  changed  often 
enough  so  the  patients  do  not  lose  interest  and  revert  to  their  fixed 
ideas.  Such  work  as  spinning  he  thinks  too  monotonous  and 
uniform. 

Throughout  these  discussions  he  makes  remarks  that  show 
deep  insight  and  some  are  of  distinctly  psychoanalytic  interest.  He 
says  that  a  certain  procedure  in  the  present  state  of  our  knowledge 
is  not  possible  because  the  nature  of  psychic  means  and  their  causal 
relations  are  little  known,  so  we  cannot  count  on  anything  exact, 
their  use  has  to  rest  in  the  art  of  the  physician  in  particular  cases. 
The  most  important  thing  is  that  the  patient,  from  the  beginning, 
falls  into  the  hands  of  a  skillful  physician.  Failure  at  first  means 
that  subsequent  efforts  are  more  difficult.  In  applying  means  of 
cure  we  must  not  count  too  much  on  the  stupidity  of  the  patient 


i8  WILLIAM  A.  WHITE 

and  must  not  deceive  him.  If  the  physician  loses  the  trust  of  the 
patient  then  the  jintient  should  go  to  another  physician,  even  to 
another  asylum. 

Of  the  important  part  that  desire  plays  he  seems  to  have  had 
some  notion  when  he  remarks  that  we  can  usually  help  the  patient 
most  quickly  when  we  satisfy  his  wishes,  and  perhaps  he  saw  some- 
what the  real  meaning  in  the  case  he  cites  of  the  patient  v/ho  gave 
himself  up  to  drink  and  sexual  excesses  because  his  health  could 
not  be  made  any  worse  than  it  already  was.  The  idea  of  the  con- 
flict is  pretty  clearly  put  by  one  patient  of  Pinel's  whom  he  quotes  as 
saying  that  he  had  a  conflict  between  the  terrible  thing  that  his 
instinct  would  do  and  the  deep  abhorrence  of  his  reason.  His  keen 
insight  for  little  signs  that  betray  what  is  going  on  within  is  evi- 
denced by  his  quoting  the  experience  of  Galen  who  discovered  the 
love  of  a  Roman  lady  for  the  actor  Py lades  by  noting  the  change 
that  came  over  her  face  as  he  accidentally  mentioned  his  name  in 
her  presence. 

Of  dementia  he  says  he  doubts  if  it  is  a  simple  loss  of  under- 
standing. Like  blindness  it  is  a  symptom  and  may  be  due  to  many 
things.     Of  idiocy  he  says  a  chaos  is  included  in  this  classification. 

The  Rhapsodieen  ends  with  an  exceedingly  interesting  discus- 
sion of  the  principles  of  construction  and  administration  of  an 
asylum.  It  should  be  so  constructed  that  all  of  the  powers  for  heal- 
ing are  brought  together  in  harmonious  action.  The  first  step  is 
the  separation  of  the  curable  and  incurable  in  a  hospital  and  an 
asylum  respectively.  A  good  plan  is  to  receive  only  curable  cases 
at  first  so  that  the  real  object  is  not  lost  sight  of.  The  hospital  is  to 
be  so  arranged  in  organization  and  personnel  that  the  pharmaceutic 
and  especially  the  psychic  methods  of  therapy  will  be  most  com- 
pletely practiced.  Reil  saw  this  need  clearly  and  strove  for  the 
erection  of  a  university  psychiatric  institute  in  Halle  and  later  in 
Berlin,  but  without  result. 

He  deplores  that  asylums  are  mostly  used  for  society  to  bear  its 
burdens.  Hospitals,  poorhouses,  prisons,  houses  of  correction,  in 
all  the  patients  lack  fresh  air,  exercise,  diversion,  in  short  all 
physical  and  moral  means  for  cure.  The  reformation  of  asylums 
will  include  a  free  plan  for  the  use  not  only  of  pliarmaccutic  but  of 
p'^ychic  means  of  cure. 

The  hospital,  he  emphasizes,  should  have  a  mild  name  like 
Pcnsionanstalt  fiir  Ncrvcnkranke  or  Hospital  fiir  die  psychische 
Kurmcthode.  One  may  conceal  the  reception  of  the  insane  and 
take  others  that  require  psychotherapy.     The  convalescents  should 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  19 

be  separated  so  they  will  not  see  themselves  mirrored  in  those  about. 

The  asylum,  he  says,  should  be  pleasantly  located,  the  wall  about 
it  only  breast  high  with  a  fence  on  top  so  as  not  to  obstruct  the 
view.  It  should  contain  everything  that  a  residence  for  the  well 
should  have.  There  should  be  one  principal  building  and  a  number 
of  smaller  ones  one  story  high.  This  permits  of  classification  and 
then  it  does  not  look  like  a  prison.  The  windows  without  gratings 
and  the  windows  and  doors  without  bolts  and  chains.  He  suggests 
spring  locks  to  do  away  with  the  prison  appearance  and  feeling. 
On  the  ground  floor  are  located  the  cells  for  the  dangerous  patients 
each  with  a  small  window  and  a  small  door  to  open  and  observe  the 
patient.  The  insane  he  remarks  have  a  specific  odor.  The  rooms 
should  be  tiled  and  plastered  so  as  not  to  absorb  and  so  they  can  be 
readily  washed.  They  should  be  simply  furnished  and  warmed  in 
winter.  All  means  of  cure  should  be  available — shower  and  sur- 
prise baths,  douches,  caves,  grottos,  a  magic  temple,  a  large  place  for 
exercise  and  for  gymnastics,  and  a  place  for  concerts  and  theatricals. 
He  has  more  confidence  in  public  asylums  under  state  control  than 
in  private  asylums  which  may  be  used  as  private  prisons.  He  be- 
lieves in  good  feeding  and  in  work.  Work  lessens  the  wandering  ,.  x 
of  the  imagination  and  makes  for  health,  appetite  and  sleep. 

The  hospital,  which  you  will  note  he  distinguishes  from  the 
asylum,  should  receive  those  patients  needing  psychic  treatment  and 
not  only  the  insane.  It  should  also  receive  those  mentally  dis- 
ordered from  various  illnesses,  such  as  fevers.  These  patients  need 
only  physical  treatment,  but  the  physician  should  have  experience 
with  mental  disease  so  that  he  can  study  the  influence  of  physical 
ills  on  the  mental  disease  and  use  this  knowledge  to  help  cure.  He 
recommends  a  psychologist.  The  psychologist  may  be  combined,  in 
the  person  of  the  physician  or  not — that  is  a  matter  of  indifference 
— in  any  event  he  must  make  his  own  work  as  it  is  not  yet  developed. 
His  function,  he  very  well  expresses  it,  is  to  look  after  the  peda- 
gogics of  the  soul. 

He  thinks  we  should  get  more  profit  from  the  insane  in  the 
asylums.  One  finds  here  people  without  masks  and  sees  what  they 
are  and  can  become  when  the  wheels  are  out  of  order.  The  medical 
use  of  psychology  is  too  little  known.  These  hospitals  should  be 
schools  for  physicians  to  get  instruction  in  the  therapy  of  the  psyche. 
They  should  also  furnish  a  rich  harvest  for  psychology  to  which 
they  have  as  yet  contributed  little. 

So  much  for  the  Rhapsodieen,  a  work  filled  with  the  wisdom 
of  a  profound  thinker  and  a  keen  observer,  and  which  Neuberger, 


23  WILLIAM  A.  WHITE 

the  Professor  of  the  History  of  Medicine  in  \ienna,  says  is  one 
of  the  most  noteworthy  books  of  the  whole  world  literature.  Very 
possibly  Reil  was  influenced  in  his  thinking  along  these  lines  by 
Pinel  (1745-1826)  whose  great  work,  "  Traite  medico-philosophique 
sur  I'alienation  mentale,"  was  written  two  years  before  the  publica- 
tion of  the  Rhapsodieen  (1801).  That  he  was  familiar  with  Pinel 
is  amply  evidenced  by  the  numerous  references  to  his  writings  all  of 
which  seem  to  refer  to  a  German  translation  published  in  Vienna 
in  1801  under  the  title  of  "Abhandlung  iiber  Geistesverirrungen." 
Quite  appropriately  he  has  been  referred  to  as  the  German  Pinel. 
It  is  probable  too  that  he  was  somewhat  influenced  by  the  organology 
of  Gall  (1757-1828),  although  he  only  mentions  him  once  casually. 

From  the  reference  it  would  appear  that  Reil  was  also  familiar 
with  the  work  of  Willis,  probably  Thomas  Willis  (1621-75)  who  is 
credited  with  the  first  description  of  paresis,  but  he  probably  also 
refers  to  a  noted  contemporar}'  who  had  a  private  sanitarium  for 
mental  diseases  near  London.  He  also  cites  Coeleus  Aurelianus 
and  the  works  of  Celsus  who  wrote  so  learnedly  on  the  treatinent 
of  the  insane,  probably  in  the  first  century.  This  seems  to  me  espe- 
cially significant  as  Celsus  laid  such  stress  on  the  use  of  music,  quiet 
and  lovely  surroundings,  and  baths. 

It  seems  that  he  was  devoted  to  some  considerable  extent  to 
philosophy,  and  the  Rhapsodieen  gives  a  reference  indicating  that 
he  had  some  acquaintance  with  the  writings  of  Kant.  It  is  in  con- 
nection with  philosophy  that  he  is  most  frequently  mentioned  and 
by  a  strange  fate  it  is  because  of  that  his  writings  seem  to  be  so 
little  known.  He  is  set  down  ^s  a  vitalist  and  summarily  dismissed 
from  further  consideration. 

Aside  from  the  discussion  as  to  whether  he  was  or  was  not  a 
vitalist,  and  it  has  been  vigorously  disputed  by  his  pupil  Madai,  the 
real  quc-;tion  must  be  directed  to  what  he  accomplished.  If  he 
mooned  his  life  away  spinning  tenuous  theories,  no  matter  what, 
why  then  he  can  be  of  little  interest.  But  if  on  the  contrary  he  was 
a  man  of  action,  a  man  who  brought  things  to  pass,  then  he  is  of 
interest  and  his  life  has  a  valuable  message  to  give  us. 

Even  vitalism  cannot  be  considered  at  present  to  be  in  disrepute. 
I'rofcs^or  Thomj)son  in  his  presirlential  address"  to  the  Zoological 
Section  of  the  British  Association  for  the  Advancement  of  Science 
in  191 1,  says  of  it  "the  hypothesis  of  a  vital  principle,  or  vital  ele- 
ment, .  .  .  has  come  into  men's  mouths  as  a  very  real  and  urgent 
question,  the  greatest  question  for  the  biologist  of  all."     Vitalism 

■Science.  Ocfrilitr  <">.  ion 


HISTORICAL  REVIEW  REIL'S  RHAPSODIEEN  21 

was  born  in  Reil,  if  vitalist  he  was,  by  the  feehng  that  man  has 
always  had  when  he  faced  the  great  mystery  of  Hfe,  that  there  was 
something  that  could  not  be  all  explained  by  the  laws  of  chemistry 
and  physics.  Professor  Thompson,  further  on,  in  his  address  just' 
quoted,  in  speaking  of  mechanistic  explanations  says :  "  But  I  know 
well,  that  though  we  push  such  explanations  to  the  uttermost,  and 
learn  much  in  the  so  doing,  they  will  not  touch  the  heart  of  the  great 
problems  that  lie  deeper  than  the  physical  plane.  Over  the  ultimate 
problems  and  causes  of  vitality,  over  what  is  implied  in  the  organi- 
zation of  the  living  organism,  we  shall  be  left  wondering  still."  And 
what  after  all  is  the  elan  vital  of  Mr.  Bergson  but  the  eighteenth 
century  Lebenskraft  of  Reil  in  a  twentieth  century  dress ! 

After  all  the  problem  presented  by  vitalism  very  probably  belongs 
to  that  group  which  I  call  pseudo-problems  in  the  same  spirit  that 
Meyer"  speaks  of  the  contrast  of  mental  and  physical  as  "  medically 
useless."  Philosophy  serves  as  a  means  of  expression  for  the  phi- 
losopher,^°  it  need  not  necessarily  form  a  basis  of  action.  So  long 
as  it  is  only  a  means  of  expression  and  does  not  get  in  the  way  when 
action  is  demanded,  so  long  as  the  philosopher  does  not  stumble  over 
his  philosophy  in  his  dealing  with  reality  it  matters  little  what  that 
philosophy  is.  The  philosopher  in  his  effort  to  grasp  the  entire 
scheme  of  things  is  simply  not  willing  that  his  desire  should  be 
thwarted  by  the  limitations  of  his  vision  and  so  succeeds  by  inventing 
vital  force  to  account  for  all  ^beyond.  Used  only  in  this  way  it 
need  not  hamper  progress.  It  is  by  a  man's  deeds  that  he  is  known. 
In  this  respect  Reil  does  not  fail  us.  A  man  of  indefatigable 
energy,  constantly  productive,  prominently  known  as  a  physician 
over  a  wide  territory,  the  recipient  of  honors,  occupying  official  and 
teaching  positions,  an  able  ophthalmologist,  who  made  important  ob- 
servations on  the  lens  and  confirmed  the  existence  of  the  macula 
lutea,  a  skillful  surgeon  who  said  "  surget^y  is  not  the  art  which 
heals  by  the  hand;  the  head  must  guide  the  hand";  an  internist,  of 
whose  patients  a  contemporary  (Borne)  said  "Those  who  do  not 
get  well  lose  their  life  but  they  never  lose  hope" ;  and  a  psychiatrist, 
who  in  the  words  of  Neuburger  was  "the  pathfinder  of  psycho- 
therapy," and  as  an  anatomist  "  the  founder  of  the  new  brain 
anatomy."  He  died  at  the  height  of  his  career  and  in  the  perform- 
ance of   his   duty,   of   typhus,   the   same  disease  that   claimed   his 

^  Meyer:  Objective  Psychology  or  Psychobiology  with  Subordination  of 
the  Medically  Useless  Contrast  of  Mental  and  Physical.  Jour.  A.  M.  A., 
Sept.  4,  1915. 

1"  Rank  and  Sachs :  The  Significance  of  Psychoanalysis  for  the  Mental 
Sciences.     Psychoanalytic  Review,  Vol.  II,  Nos.  3  and  4,  et  seq. 


22  WILLIAM  A.  WHITE 

pre(k'cc»or  in  the  University  of  Halle,  Goldhagcn,  and  his  beloved 
pupil  Madai. 

BIBLIOGRAPHY 

1.  J.  C.  Rcil.     Rhapsodieen  iiber  die  Anwendung  der  psychischen  Curmethode 

auf  Geistcszerriittungen.     Halle,    1803. 

2.  T.    C.    Reil.     Kleine    Schriften,    wissenschaftlichen    und    gemeinniitzigen. 

Halle,  1817.     A  collection  of  his  shorter  writings. 

3.  J.  L.  Jourdan.     Notice  historique  sur  Reil.  Jour.  Universe!  des  Sci.  Med., 

Dieuxicme  Arniee,  tome  septieme.  Paris,  1817.  Contains  references 
to  all  his  important  writings  and  is  valuable  as  being  a  contemporary 
review. 

4.  Karl  SudhofF.     Johann  Christian  Rcil  im  Befrciungsjahre   1813.     Miinch- 

cncr  Med.  Wochen.,  No.  46,  1913.  Has  reference  only  to  his  military 
service  in  1813.     Consists  mostly  of  correspondence. 

5.  H.   Boruttan.     Joh.  Christ.  Reil.     Einige  Worte   des  Gedenkens  zum  22. 

Nov.  1913.  Klinisch-therap.  Wochen.,  No.  46,  1913.  A  short  account 
of  his  life  and  works. 

6.  Paul    Richter.    Johann   Christian   Reil.     Berliner   Klin.    Wochen.,    No.   45, 

1913.     A  short  account  of  his  life  and  works. 

7.  G.    Mamlock.     Johann    Christian    Reil.     Zu   seinem    100.    Todestag.    Deut. 

Med.  Wochen.,  No.  46,  1913.  Contains  a  brief  account  of  his  relations 
with  Goethe  and  valuable  references  to  the  literature  bearing  on  this 
relation. 

8.  Max    Neuburger.    Johann    Christian   Reil.     Gedenkrede  gehalten   auf    der 

85.  Versammlung  deutscher  Naturforscher  und  Arzte  in  Wien  am  26. 
September.  1913.  \'erlag  von  F"erdinand  Enke,  Stuttgart,  1913.  A 
very  full  account  of  his  life  and  work  containing  a  number  of  illus- 
trations and  numerous  quotations  from  his  writings. 


THE  FAMILY  FORM  OF  PSEUDO-SCLEROSIS  AND 

OTHER   CONDITIONS   ATTRIBUTED   TO   THE 

LENTICULAR  NUCLEUS^ 

By  William  G.  Spiller,  M.D. 

PROFESSOR    OF     NEUROLOGY     IN     THE     UNIVERSITY    OF    PENNSYLVANIA 

The  conditions  attributed  to  disease  of  the  lenticular  nucleus  are 
numerous.  In  addition  to  Wilson's  progressive  lenticular  degenera- 
tion we  must  include  the  pseudo-sclerosis  of  Westphal  and 
Striimpell,  Huntington's  chorea,  Parkinson's  disease,  spastic  pseudo- 
bulbar paralysis  with  contractures  and  choreo-athetoid  movements 
of  Oppenheim  and  Vogt,  and  Freund  and  Vogt,  Oppenheim's 
dystonia  musculorum  deformans,  and  progressive  athetosis ;  I  ven- 
ure  to  add  to  this  list  v.  Bechterew's  hemitonia  apoplectica  and  cer- 
tain forms  of  carbon  monoxide  poisoning.  Pelissier  and  Borel  have 
reported  a  type  from  the  service  of  Dejerine  which  they  regard  as 
the  unilateral  type  of  lenticular  degeneration.  The  symptoms  were 
tremors  with  muscular  rigidity  confined  to  the  right  limbs,  dy- 
sarthria and  dysphagia,  without  signs  of  implication  of  the  pyra- 
midal tracts.  There  was  no  true  paralysis ;  the  tendon  reflexes 
were  not  distinctly  exaggerated  and  the  plantar  reflex  was  in  flexion. 
The  condition  was  like  that  of  Parkinson's  disease,  but  the  com- 
mencement at  the  age  of  eighteen  years  and  other  features  of  the 
case,  such  as  dysarthria  and  dysphagia,  led  to  the  exclusion  of  this 
diagnosis.  A  case  with  somewhat  similar  features  I  report  in  this 
paper. 

Dejerine  says  the  symptom-complex  of  Wilson's  disease  has 
occurred  without  lesions  of  the  lenticular  nucleus.  He  is  unwilling 
to  attribute  any  positive  symptoms  to  disease  of  this  nucleus,  as 
often  bilateral  lesions  are  found  in  this  region  in  cases  in  which 
clinical  signs  were  wanting,  and  he  believes  a  lenticular  lesion  pro- 
duces symptoms  only  when  it  implicates  the  internal  capsule.  It  is 
impossible  to  accept  this  conclusion  unconditionally,  and  yet  it  is 
impossible  also  at  present  to  explain  why  lesions  of  the  lenticular 
nucleus  sometimes  do  not  produce  symptoms,  why  in  other  cases 
they  cause  distinct  symptoms  as  those  of  progressive  lenticular  de- 

1  Read  by  title  at  the  forty-first  annual  meeting  of  the  American  Neuro- 
logical Association,  May  6,  7  and  8,  191 5. 

23 


24  WILLIAM  G.  S FILLER 

generation,  and  why  the  clinical  picture  of  lenticular  disease  as- 
sumes so  many  variations. 

Wilson,  from  his  clinical  and  experimental  work  on  the  corpus 
striatum  attributed  to  this  structure  little  more  than  a  "  steadying 
influence"  exerted  by  the  lenticulo-rubro-spinal  projection  system 
on  the  innervation  of  the  cortico-spinal  or  pyramidal  system.  It  is 
in  a  way  concerned  with  the  maintenance  of  "tone"  of  the  skeletal 
muscles. 

When  we  consider  the  pseudo-sclerosis  we  find  it  has  not  oc- 
curred in  more  than  one  member  of  a  family  except  in  the  cases 
reported  by  Rausch  and  Schilder,  and  Oppenheim,  referred  to 
later,  and  in  both  instances  in  two  sisters,  and  in  the  cases  of 
Cadwalader.  One  sister  reported  by  Rausch  and  Schilder  showed 
the  first  symptoms  in  her  twenty-sixth  year  and  the  disease  had 
existed  seventeen  years.  There  were  the  brown  pii^incntation  of 
the  edge  of  the  cornea,  insufficiency  of  the  liver,  tremor,  adiadocho- 
kinesis,  and  scanning  speech.  The  disease  began  in  the  second 
sister  in  her  twenty-third  year  and  had  lasted  four  months.  The 
symptoms  were  ver)'  similar  in  the  two  sisters.  Hypertonia  was 
not  present  in  either  case.  Rausch  and  Schilder  regard  the  A\'ilson 
type  of  progressive  lenticular  degeneration  as  a  special  form  of 
pseudo-sclerosis,  and  it  is  important  to  note  that  Wilson  also  in 
his  article  on  the  subject  in  Lewandowsky's  Handbuch  says  pro- 
gressive lenticular  degeneration  seems  to  be  nearly  related  to 
pseudo-sclerosis. 

I  report  in  this  paper  another  family  which  I  think  should  be 
placed  in  the  family  form  of  pseudo-sclerosis.  The  resemblance 
between  the  two  aflfections  is  shown  in  that  one  brother  rci)ortcd  by 
Higier  had  the  Wilson  type  and  the  other  brother  the  pseudo- 
sclerosis. The  nniscular  rii,Mdity,  the  propulsion,  the  slowness  of 
movement  and  bradylalia  suggested  paralysis  agitans  in  the  first, 
and  the  resemblance  to  paralysis  agitans  was  striking  in  two  brothers 
of  the  family  studied  by  me,  as  shown  later.  ITigier  thinks  the 
difTcrenccs  between  the  two  diseases  may  be  only  (luanlitative.  The 
distinctions  iK-tween  them  are  presented  by  Higier  as  follows :  He 
says  pseudo-sclerosis 

Begins  in  persons  who  are  not  hereditarily  affected,  between  the 
fourteenth  and  twenty-sixth  years,  at  times  later,  as  well  as  in  the 
early  thirties;  develops  slowly  to  a  symptom-complex  resembling 
multiple  sclerosis,  and  usually  ends  fatally  before  the  fourth 
deccnnium.     The  chief  symptoms  are: 

Ci)  Tremor  of  the  body  and  strongly  oscillating  tremor  of  the 
hca<l,  arms  and  legs,  which  usnally  lessens  in  ns(  ^r  even  ceases. 


THE  FAMILY  FORM  OF  PSEUDO-SCLEROSIS  25 

(2)  Muscular  rigidity  and  spasticity,  seldom  intense,  most 
marked  in  the  face,  occasionally  also  in  the  external  ocular  muscles. 

(3)  Slow  and  scanning  speech. 

(4)  Epileptiform  and  apoplectiform  attacks. 

(5)  Pigmentation  of  the  skin  and  inner  organs  of  a  dirty 
brown  color,  and  at  the  periphery  of  the  cornea  of  a  brownish  green 
color. 

(6)  Diminution,  rarely  pseudo-sclerotic  enlargement,  of  the 
liver  and  clearly  palpable  or  visible  spleen. 

(7)  Psychic  disturbance,  consisting  of  irritability,  tendency  to 
acts  of  violence,  failure  of  intelligence  and  progressive  dementia. 

Negatively  are :  preserved  muscular  power,  integrity  of  sen- 
sation and  the  vesico-recto-genital  functions,  absence  of  muscular 
hypertonia  and  of  changes  in  the  tendon  and  cutaneous  reflexes, 
absence  of  nystagmus  and  optic  atrophy.  It  is  difficult  to  under- 
stand the  distinction  made  between  hypertonia  and  spasticity. 

Wilson's  disease  is  exquisitely  a  family  disease,  not  congenital 
and  not  hereditary.  It  begins  between  the  tenth  and  twenty-seventh 
years,  develops  slowly  without  remissions  and  ends  occasionally 
acutely  or  subacutely  (after  four  to  thirteen  months)  more  com- 
monly after  three  to  nine  years.  Occasionally  the  disease  lasts 
still  longer,  in  Sawyer's  case  it  lasted  seventeen  years. 

The  features  are : 

(i)  Tremor  of  the  distal  parts  of  the  limbs,  more  or  less 
rhythmical,  bilateral,  of  small  amplitude  and  increased  by  excite- 
ment and  attention.  In  long-standing  cases  the  tremor  occasionally 
appears  as  tonic-clonic  spasms,  although  ceasing  during  complete 
rest. 

(2)  Rigidity  of  the  limbs,  especially  of  the  flexors,  but  also  of 
the  face,  trunk,  bulbar  muscles  (dysarthria,  dysphagia),  exception- 
ally also  of  the  ocular  muscles,  and  shown  by  slowness  of  movement 
and  contracture-like  resistance  to  quick  passive  movements.  The 
contracture  positions  without  true  contracture  are  more  pronovmced 
in  the  proximal  parts  of  the  limbs. 

(3)  Slow,  scanning,  nasal  speech. 

(4)  Cirrhosis  of  the  liver  and  enlarged  spleen,  which  seldom 
cause  symptoms. 

(5)  Psychic  disturbances  as  excitability,  mental  impairment,  in- 
voluntary laughter,  apathy  or  pronounced  dementia,  hallucinations, 
delusions. 

(6)  In  severe  acute  cases  fever,  severe  loss  of  power  and 
wasting. 


2:>  WILLIAM  G.  SFILLER 

Negatively :  Integ^rity  of  the  inner  speech,  of  muscle  strength 
and  sensation,  of  the  puj)ils  and  extra-ocular  muscles,  of  bladder 
and  bowels,  absence  of  spastic  paresis  and  wasting,  absence  of 
Babinski's  sign,  normal  tendon  and  abdominal  reflexes,  no  nystag- 
mus and  no  changes  in  the  eycgrounds. 

Oppenheim  observed  in  his  cases  of  pseudosclerosis  that  the 
tremor  was  not  in  the  muscles  which  cause  fixation  of  the  joints 
necessar)'  for  maintenance  of  a  certain  position,  as  Striimpell  be- 
lieved to  be  the  case,  but  was  in  the  flexors  and  extensors  of  the 
wrist,  and  the  tremor  was  exaggerated  by  active  movement  and 
psychic  excitement.  He  does  not  think  spasticity  excludes  the 
fliagnosis,  and  makes  this  diagnosis  in  one  of  his  cases  in  which 
spasticity  was  present.  He  mentions  that  ankle  clonus  was  present 
in  the  case  of  Fickler  and  Schiitte ;  Oppenheim's  sign  in  A.  West- 
phal's  case ;  and  Babinski's  sign  in  Hosslin  and  Alzheimer's  case. 
He  makes  the  diagnosis  in  two  sisters.  Alcoholism  in  a  progenitor 
has  been  seen  by  A.  Wcstphal,  Hosslin  and  Alzheimer.  Oppen- 
heim sides  with  those  who  put  pseudo-sclerosis  and  Wilson's  disease 
in  one  group.  Rigidity  is  more  prominent  in  Wilson's  disease  but 
is  not  entirely  missing  in  pseudo-sclerosis,  and  varies  in  intensity  in 
Wilson's  disease.  Both  are  extrapyramidal  diseases.  Mental 
symptoms  are  not  so  prominent  in  Wilson's  disease  but  they  were 
absent  in  a  recent  case  of  Striimpell's  of  pseudo-sclerosis  and  in 
one  of  Oppenheim's  three  cases ;  and  slight  in  another.  Epilepti- 
form and  apoplectiform  attacks  are  by  no  moans  constant  in  pseudo- 
sclerosis. 

Bostroem  when  he  wrote  his  paper  on  pseudo-sclerosis  said  25 
cases  of  pseudo-sclerosis  had  been  reported,  of  which  22  were  with 
necropsy  and  these  22  he  used  for  a  study  of  the  disease. 

Tremor  was  present  in  all  cases ;  twice  it  resembled  paralysis 
agitans,  once  chorea.  \'olitional  movements  and  emotional  dis- 
turbance increased  the  tremor,  and  it  was  observed  when  the  patient 
was  at  rest.  Disturbance  of  speech  was  present  in  every  case  but 
one  (Fleischer)  and  was  unlike  that  of  multiple  sclerosis;  it  was 
.scanning  only  once  C\.  Westi)hal),  in  16  cases  it  was  poor  articula- 
tion, stammering,  indistinct.  The  eyegrounds  were  always  normal. 
pupillarj'  reactions  were  i»rcserved.  and  nystagnuis  was  not  ob- 
served. The  abdominal  reflexes  were  normal  in  all  cases  but  two. 
The  patellar  reflexes  were  exaggerated  four  times,  and  were  lively 
three  times:  in  other  cases  they  were  normal,  llypcsthesia  was 
present  in  three  observations.  The  expression  of  the  face  in  19 
cases  was  mask-like  or  was  described  in  some  similar  term.     The 


THE  FAMILY  FORM  OF  PSEUDO-SCLEROSIS  27 

muscles  were  often  rigid,  and  the  gait  was  normal  only  in  two  cases, 
spastic  in  four  cases,  in  the  other  cases  tremulous  or  impossible. 
Difficulty  in  swallowing  was  present  in  10  cases.  The  constant 
mental  symptoms  were  irritability,  excitability,  confusion.  Im- 
pairment of  intellect  was  present  in  15  cases.  Intestinal  catarrh 
was  present  in  7  cases.  The  age  of  onset  was  not  always  given. 
In  most  cases  it  was  between  the  tenth  and  twentieth  year,  the  latest 
onset  was  in  the  twenty-fifth  year.  Where  death  was  not  from 
an  intercurrent  disease  it  was  always  rather  sudden  and  unex- 
pected. The  duration  of  the  disease  was  from  one  to  twelve  years. 
Syphilis  occurred  in  a  few  cases.  Babinski's  reflex  was  absent. 
Cirrhosis  of  the  liver  was  constantly  found  at  necropsy. 

Bostroem  found  marked  lesions  in  the  lenticular  nuclei,  dentate 
nuclei,  and  cortex  of  the  cerebrum  and  cerebellum.  The  right 
lenticular  nucleus  was  not  afifected ;  its  nerve  cells  in  places  had 
disappeared  and  the  glia  had  proliferated.  Normal  ganglion  cells 
were  scarce.  Alteration  of  the  vessels  was  important.  Similar 
changes  were  found  in  the  dentate  nuclei  and  cortex.  He  con- 
cluded that  the  alteration  of  the  liver  and  that  of  the  brain  were 
produced  by  a  common  cause  from  the  same  source,  and  that  it 
must  be  a  toxin  of  intestinal  origin.  Syphilis,  he  thinks,  can  be 
excluded. 

Bostroem's  case  was  thought  at  one  time  to  be  paralysis  agitans. 
His  findings  showed  that  the  lesions  were  extra-pyramidal. 

Contrary  to  his  view  that  the  disease  depends  on  gastro-in- 
testinal  intoxication  is  its  occasional  occurrence  in  families. 

Stocker  believed  the  mental  condition  would  determine  the 
diagnosis  between  Wilson's  disease  and  pseudo-sclerosis.  Mentality 
long  remaining  intact  or  only  slightly  impaired  in  the  form  of  some 
euphoria  speaks  more  for  W^ilson's  disease,  while  early  developing 
dementia  or  change  of  character,  especially  marked  irritability  and 
attacks  of  temper,  also  epileptic  and  apoplectic  attacks  give  the 
diagnosis  of  pseudo-sclerosis.  Stocker  thinks  much  is  included 
imder  pseudo-sclerosis  which  does  not  belong  there. 

Woerkom  reported  a  case  of  pseudo-sclerosis  in  which  he  found 
large  neuroglia  cells  in  the  cerebral  cortex,  basal  ganglia  and  dentate 
nuclei. 

In  Hosslin  and  Alzheimer's  case  of  pseudo-sclerosis  the  whole 
central  nervous  system  was  abnormal,  but  especially  the  corpus 
striatum,  optic  thalamus,  regio  subthalamica,  pons  and  nucleus 
dentatus.  Nervous  tissue  had  disappeared  in  places,  but  glia 
changes  especially  were  striking,  and  glia  cells  were  very  large. 
There  was  also  degeneration  of  the  pyramidal  tracts. 


2S 


WILLIAM  G.  SPILLER 


In  A.  Westphal's  case  the  father  was  alcoholic.  The  patient  had 
a  spastic  paretic  gait  which  W'estphal  says  was  present  in  most 
cases  of  pseudo-sclerosis.  He  found  changes  in  the  glia  nuclei  in 
size,  shape  and  chromatin  substance,  in  the  basal  ganglia  and 
nucleus  dcntatus  like  the  findings  of  Alzheimer. 

Schiitte's  patient  had  a  bilateral,  ankle  clonus.  Schiitte  found. 
great  changes  in  the  cortex  of  the  frontal  lobe,  i.  c,  destruction  of 
the  medullatcd  fibers  and  nerve  cells,  and  overgrowth  of  glia  cells. 
Unlike  W'estphal's  and  Hosslin  and  Alzheimer's  cases  the  changes  in 
the  basal  ganglia  were  slight. 

Mingazzini.  in  the  report  of  a  case  of  a  symptom-complex  re- 
sembling Parkinson's  disease,  attributes  this  complex  not  only  to  a 
cyst  which  destroyed  a  part  of  the  caudate  nucleus,  the  anterior 
fifth  of  the  lenticular  nucleus  and  internal  capsule,  but  especially  to 
the  implication  of  an  extrapyramidal  tract,  viz.,  the  fronto-cerebellar 
tract  which  probably  passes  through  the  anterior  part  of  the  in- 
ternal capsule,  by  which  he  seems  to  mean  the  anterior  limb  of  the 
capsule. 

He  quotes  Pelnar  as  saying  that  when  the  lesion  is  in  the  cere- 
bral peduncle  the  tremor  partakes  of  the  character  of  athetosis. 

Mingazzini  believes  the  lenticular  nucleus  is  dififerentiated  in 
function  according  to  its  various  parts.  The  cells  of  this  nucleus, 
as  shown  by  Ayala,  are  different  in  the  putamen  from  those  in  the 
globus  pallidus,  and  symptoms  vary  according  as  one  or  the  other 
part  of  the  corpus  striatum  is  affected. 

The  symptom-complex  of  the  corpus  striatum  (Anton,  C.  Vogt, 
Oppcnheim)  is  bilateral  athetosis,  spasm,  without  paresis  and 
without  disturbances  of  sensation.  It  is  the  result  of  defect  of  the 
caudate  nucleus  and  putamen  (status  marmoratus). 

Zingcrlc  says  Forster  attributes  the  muscular  spasms  of  paralysis 
agitans  to  the  cerebellum,  and  believes  they  result  from  lesion  of  the 
cortico-ccrcbellar  tracts,  so  that  the  normal  inhibitory  impulses  from 
the  cerebral  cortex  do  not  reach  the  cerebellum.  Kleist  holds  much 
the  same  view. 

Dystonia  musculorum  deformans  Oppcnluim  regards  as  related 
to  idiopathic  athetosis,  and  he  has  seen  the  former  in  members  of 
the  same  family.  Its  position  is  uncertain,  but  there  is  a  possibilitv 
that  it- may  be  dependent  on  lesions  of  the  lenticular  nucleus. 

In  the  cases  of  dystonia  musculorum  deformans  which  I  reported 
in  1913,  the  disea.sc  was  a  family  afTcction.  Two  of  the  patient's 
sisters  had  been  in  the  Philadelphia  General  Hospital  and  died  there. 
All  three  were  of  feeble  mental  dcvelo()nunt.     One  of  the  sisters 


THE  FAMILY  FORM  OF  PSEUDO-SCLEROSIS  29 

had  been  recorded  as  having  "chorea,"  the  other  had  choreiform 
movements  and  walked  with  a  pecuHar  swinging  gait  and  every 
now  and  then  a  shrug  of  the  shoulder.  Her  movements  were 
irregular  and  clumsy  and  much  like  those  of  her  brother.  One 
sister  died  in  1905 ;  the  other  in  1907. 

The  case  of  acquired  spasticity  and  athetosis  that  I  reported  in 
1908  was  one  of  unusual  interest.  At  that  time  the  boy  was  twelve 
years  old  and  had  been  under  my  observation  five  years.  During 
this  period  spasticity  and  athetosis  had  developed  slowly  in  all  four 
limbs,  finally  reaching  such  intensity  that  the  boy  was  confined  to 
his  chair.  He  first  came  under  my  observation  December  15,  1902, 
when  he  was  seven  years  old,  and  at  that  time  the  father  stated 
that  the  boy  walked,  ran  and  jumped  as  other  children,  until  four 
months  before  he  was  brought  to  me,  but  since  that  time  he  had 
gradually  beefi  getting  lame  in  the  left  lower  limb.  I  found  he  was 
unable  to  stand  without  supporting  himself  by  bending  back  the 
knee.  When  he  attempted  to  walk  the  feet  were  wide  apart,  the 
knees  were  close  together,  and  the  lower  limbs  were  spastic.  There 
was  no  spasticity  of  the  limbs  when  the  boy  was  at  rest.  The  lower 
limbs  were  somewhat  weak  when  he  was  walking,  but  very  little, 
if  at  all,  when  he  was  sitting.  The  grip  was  good  in  each  hand,  and 
the  voluntary  power  of  both  upper  limbs  was  good.  The  patellar 
reflexes  were  prompt,  but  there  was  no  clonus.  The  plantar  and 
Achilles  reflexes  were  normal. 

By  1908  the  lower  limbs  had  become  very  spastic,  but  at  times 
this  spasm  yielded,  so  that  the  limbs  could  be  moved  at  most  of  the 
joints  freely,  though  not  to  a  fully  normal  extent.  The  right  lower 
limb  was  usually  kept  extended  with  the  foot  in  the  equino-varus 
position.  The  left  lower  limb  was  partially  contractured  in  flexion 
at  the  knee.  The  lower  limbs  were  not  distinctly  wasted.  The 
spasticity  and  athetosis  of  all  the  limbs  were  intense,  the  tendon  re- 
flexes were  exaggerated  and  Babinski  sign  was  present  on  each 
side.  The  case  is  described  more  fully  in  the  original  report  and  is 
illustrated  by  two  cuts. 

In  the  hemitonia  apoplectica  of  v.  Bechterew  paralysis  does  not 
occur,  or  is  of  very  short  duration,  and  later  only  weakness  is 
found ;  while  convulsive  tonic  movements  are  intense,  and  may 
appear  immediately  after  the  apoplectic  insult  or  some  little  time 
later.  The  spasms  become  weaker  when  the  patient's  attention  is 
not  fixed  upon  the  movements,  and  are  increased  by  excitement. 
The  position  of  the  afl^ected  parts  varies  from  time  to  time  accord- 
ing as  the  spasm  predominates  in  certain  muscles.     These  tonic 


30  WILLIAM  G.  SPILLER 

spasms  differ  from  muscular  contracture  in.  that  the  contracted 
parts  can  be  brought  into  other  positions  by  the  contraction  of 
antagonizing  muscles.  Many  muscles,  often  antagonists,  are  in  a 
state  of  hypertonicity,  and  the  spasms  vary  in  intensity  from  time 
to  time  in  different  parts.  The  spasmodic  limbs  do  not  assume 
the  usual  positions  seen  in  hemiplegia.  Some  of  the  affected 
muscles  are  hypertrophied.  W  Bechtcrcw  believed  that  the  pre- 
dominance of  the  spasms  over  the  hemiparcsis  indicated  that  the 
affection  was  one  in  which  the  pyramidal  tract  was  irritated  but 
onlv  slightly  injured,  that  the  lesion  probably  was  near  the  internal 
capsule,  and  that  it  could  not  be  in  the  cortex,  as  irritation  of  the 
cortical  motor  area  causes  clonic  spasms. 

I  reported  in  1899  a  typical  case  of  hemitonia  apoplcctica  and 
I  believe  this  condition  should  l)e  ascribed  to  the  group  of  lenticular 
affections. 

For  a  long  period  of  years  1  have  observed  a  family  the  members 
of  which  I  think  have  pseudo-sclerosis.  Two  brothers  have  a 
symptom-complex  that  strongly  suggests  paralysis  agitans,  but  the 
resemblance  between  pseudo-sclerosis  and  paralysis  agitans  has 
already  been  noted.  The  condition  of  one  of  Higier's  cases  re- 
sembled paralysis  agitans,  and  this  resemblance  has  been  observed 
also  by  Bostroem.  The  family  cases  of  pseudo-sclerosis  observed 
by  me  are  described  below.  The  ages  of  the  different  meml)ers 
may  be  slightly  inaccurate.  The  sister's  condition  resembles  that 
of  slight  spastic  paraplegia,  but  she  docs  not  have  the  upward  move- 
ment of  the  toes  in  the  Rabinski  reflex. 

Edward,  47  years  old,  has  uscfl  alcohol  freely  since  he  was  17 
years  of  age.  \\'hen  about  30  years  of  age  he  noticed  weakness 
of  his  lower  limbs,  more  of  the  left  lower  limb,  and  gradually  he 
became  weaker  in  all  the  limbs,  so  that  he  was  unable  to  walk  any 
considerable  distance  or  to  make  great  physical  exertion,  but  was  by 
no  means  jjaralyzcd.  He  stated  that  the  treiuor  began  after  the 
weakness.  He  has  never  had  any  jx'iin  in  the  lini1)s  and  was  able 
to  walk  in  the  dark  as  well  as  in  the  light.  In  1904  it  was  noticed 
that  he  draggcfl  the  right  foot  after  he  had  been  walking  some 
distance,  that  both  ui)per  limbs  were  in  continual  coarse  tremor, 
and  that  the  lower  limbs  were  somewhat  spastic.  The  patellar 
reflexes  were  increased,  but  there  was  no  ankle  clonus  and  no 
Babin^iki  sign.  Sensation  was  not  affected.  The  liver  has  seemed 
to  be  of  normal  size.  There  has  been  no  di'^turliaiice  of  speech, 
although  speech  is  rather  slow.     He  denies  syphilitic  infection. 

His  condition  on  January  13,  191 5,  when  he  was  in  my  service, 
I  foimd  to  be  as  follows : 

Touch  anrl  j)ain  sensations  are  normal  in  the  face ;  ocular  move- 
mfiits   :irc  riorinrd.     The  pupils  are  equal,  and   react  promptly  to 


THE  FAMILY  FORM  OF  PSEUDO-SCLEROSIS  31 

light  and  in  convergence,  but  the  excursion  to  light  is  not  very 
great.  He  wrinkles  his  forehead,  closes  his  eyelids,  draws  up  the 
corners  of  his  mouth  in  a  normal  manner.  The  tongue  is  protruded 
centrally,  and  is  moved  normally ;  it  is  not  atrophied. 

The  masseters  contract  well.  No  tremor  of  the  head  is  seen 
except  what  is  communicated  from  the  shaking  of  the  limbs.  He 
is  without  tremor  when  at  complete  rest  and  not  aware  that  he  is 
under  observation.  If  he  notices  he  is  being  watched  or  if  spoken 
to  the  tremor  becomes  ver}-  marked. 

He  holds  the  forearms  partly  flexed  on  the  arms,  and  the  hands 
(especially  the  left)  slightly  flexed  on  the  forearms  and  in  the 
position  of  the  obstetrical  hand.  There  is  also  ulnar  deviation  of 
the  fingers.  The  tremor  is  quite  rapid  and  is  largely  a  to-and-fro 
movement  from  the  elbow,  and  to  some  extent  also,  from  the  wrist. 
In  quality  it  resembles  that  of  paralysis  agitans,  as  does  also  strik- 
ingly the  position  of  each  upper  limb. 

Touch  and  pain  sensations  are  normal  in  the  upper  limbs. 
There  is  much  resistance  to  passive  movement  in  each  upper  limb, 
especially  at  the  elbow,. but  there  is  also  resistance  in  passive  exten- 
sion of  the  fingers  in  each  hand.  The  biceps  tendon  reflex  is  a  little 
prompter  than  normal  on  each  side.  The  finger-to-nose  test  is  well 
performed  on  each  side.     There  is  therefore  no  dysmetria. 

Adiadochokinesis  is  good  in  each  hand,  but  the  movements  are 
slow  and  they  are  interfered  with  by  the  tremor.  The  sense  of 
position  is  normal  in  the  fingers.  Voluntary  movement  temporarily 
arrests  the  tremor  in  each  hand.     There  is  no  muscular  wasting. 

The  trunk  shakes,  but  only  from  movements  communicated  from 
the  upper  limbs.  The  left  upper  abdominal  reflex  is  distinct,  but 
the  other  abdominal  reflexes  are  uncertain.  The  cremasteric  reflex 
on  the  left  side  is  distinct,  but  not  so  distinct  on  the  right  side. 
The  liver  and  spleen  do  not  appear  to  be  enlarged.  The  lower 
limbs  are  well  developed,  they  are  distinctly  rigid  and  passive  move- 
ment is  very  difficult,  especially  at  the  knees.  The  patellar  reflex 
is  much  exaggerated  on  each  side.  There  is  no  patellar  and  no 
ankle  clonus.  The  feet  perspire  very  freely.  The  Babinski  reflex 
is  with  flexion  of  the  big  and  other  toes  on  each  side.  Touch  and 
pain  sensations  are  normal  in  the  lower  limbs. 

The  Achilles  reflexes  are  about  normal.  When  standing  the 
man  has  a  marked  tendency  to  flex  each  knee  and  to  incline  for- 
ward at  the  hips,  assuming  a  position  very  suggestive  of  paralysis 
agitans. 

He  can,  when  he  first  rises  from  the  chair,  assume  an  upright 
position,  but  he  soon,  especially  if  a  little  fatigued,  takes  the  posi- 
tion of  partial  flexion. 

He  drags  his  toes  along  the  ground,  and  his  slippers  are  worn 
at  the  toes,  equally  so  on  both  sides.  The  gait  shows  some  festina- 
tion.     He  has  no  atrophy  anywhere. 

John,  a  brother  of  the  man  just  described,  was  44  years  old  in 
1914.  He  is  now  in  the  service  of  Dr.  Mills  but  has  been  fre- 
quently observed  by  me.    He  has  used  alcohol  freely.    He  contracted 


WILLIAM  G.  SPILLER 


Fig.  I.  Edward,  aged  47  years.  Symptoms  bc-Kun  when  the  man  was 
about  30.  Tremor  and  attitude  those  of  paralysis  agitans.  Rigidity  of  limbs. 
No  Babinski.     Toes  are  scraped  a  little  on  the  floor  in  walking. 


THE  FAMILY  FORM  OF  PSEUDO-SCLEROSIS  ^' 

syphilis  about  nineteen  years  ago.  His  facial  expression  is  very 
suggestive  of  paralysis  agitans.  His  pupils  are  equal  and  respond 
promptly  to  light  and  in  convergence.  He  has  had  a  tremor  of  the 
upper  limbs  for  nineteen  years,  suggesting  that  of  paralysis  agitans, 
and  not  ceasing  during  voluntary  movements.  The  tendon  reflexes 
of  the  upper  and  lower  limbs  are  prompt,  and  the  patellar  reflexes 
may  be  a  little  exaggerated.  There  is  no  upward  movement  of  the 
toes  in  testing  the  Babinski  reflex.  The  muscular  power  of  the 
limbs  is  fair.  There  is  no  ankle  clonus.  The  patellar  reflexes  may 
be  a  little  exaggerated. 

The  tremor  began  in  the  right  lower  limb,  then  affected  the 
right  upper  limb,  then  the  left  upper  limb,  and  finally  the  left  lower 
limb. 

In  standing  the  body  is  bent  slightly  forward  and  the  head  is 
slightly  flexed.  The  upper  limbs  are  slightly  flexed  at  the  elbows. 
The  tremor  is  especially  distinct  on  voluntary  movement.  Pain, 
touch  and  temperature  sensations  are  normal.  He  is  not  capable  of 
great  physical  exertion.  The  gait  is  somewhat  spastic  and  festinat- 
ing.  The  writing  is  illegible  on  account  of  the  tremor.  No 
atrophy  is  found  anywhere.     There  is  no  disturbance  of  speech. 

He  w-alks  with  the  body  bent  forward,  arms  partially  flexed,  and 
shoulders  rounded,  but  his  condition  is  not  as  pronounced  as  is  that 
of  Edward. 

Catherine,  aged  48  years,  was  examined  by  me  January  9,  191 5. 
She  is  a  sister  to  the  two  previously  described  men.  The  father 
died  from  phthisis.  The  mother  had  one  sister  and  one  brother, 
but  neither  had  any  difficulty  in  walking.  Nothing  is  known  of  the 
father's  family. 

Catherine  noticed  the  first  symptoms  about  seven  years  ago ;  she 
began  to  be  clumsy  with  her  feet  in  going  upstairs  or  in  hurrying  for 
a  car,  and  has  been  getting  steadily  worse ;  her  condition  is  worse 
now  than  it  was  one  year  ago.  She  complains  that  her  lower  limbs 
feel  heavy.  She  can  still  walk  in  the  street,  and  recently  walked 
two  squares.  She  has  no  bladder  and  no  rectal  disturbance.  She 
is  the  oldest  member  of  the  family.  One  brother  who  is  forty  years 
of  age,  has  dragged  his  feet  about  five  years. 

In  Catherine  the  pupils  are  equal  and  respond  promptly  to  light 
and  in  convergence.  The  ocular  movements  are  normal.  The 
patient  wrinkles  the  forehead,  closes  the  eyelids,  and  draws  up  the 
corners  of  the  mouth  normally.  The  tongue  and  masseter  muscles 
are  normal.  Tactile  and  pain  sensations  are  normal  in  the  face. 
The  face  has  something  of  the  same  lack  of  expression  seen  in  her 
brothers,  especially  when  she  smiles. 

The  finger-to-nose  test  is  well  performed  on  each  side.  Tactile 
and  pain  sensations  are  normal  in  the  hands,  stereognosis,  sense 
of  position,  diadochokinesis  are  normal  in  each  hand.  The  hands 
when  extended  show  a  fine  tremor  as  in  Graves'  disease.  The 
biceps  jerk  is  a  little  exaggerated  on  each  side,  the  triceps  jerk  and 
wrist  reflexes  are  not  distinctly  obtained.  The  grasp  of  each  hand 
is  good. 


34 


WILLIAM  G.  SPILLER 


V     ♦a-: 


li'..  2.  Joliii.  am-'l  45  yiars.  J  rrmor  of  limiis  like-  tliul  of  paralysis 
agitans  has  existed  about  19  years.  Facics  suggestive  of  paralysis  agitans. 
No  Babinski.  The  man  walks  with  the  body  bent  forward  and  upper  limbs 
partially  flexed. 


THE  FAMILY  FORM  OF  PSEUDO-SCLEROSIS  35 

The  power  in  the  lower  limbs  is  as  good  as  could  be  expected  in 
a  woman  of  her  slight  build.  The  patellar  reflexes  are  distinctly 
and  equally  exaggerated.  The  soles  of  the  shoes  are  worn  away  at 
the  toes.  The  Achilles  reflexes  are  a  little  exaggerated.  There  is  no 
Babinski  sign,  and  the  toes  do  not  move  in  either  direction  from 
irritation  of  the  sole  of  the  foot.  Tactile  and  pain  sensations  are 
normal  in  the  feet.  In  walking  the  toes  are  scraped  along  the 
ground.  No  spasticity  is  present  on  passive  movement.  The  body 
is  inclined  forward  a  little  when  she  walks. 

One  brother,  about  43  years  old,  seems  to  be  normal.  He  has 
two  children,  eight  and  two  years  old  respectively,  and  is  healthy. 

The  following  case  must  be  regarded  as  one  of  extrapyramidal 
hemispasticity,  probably  from  areas  of  rarefaction  in  the  lenticular 
nucleus.  In  some  respects  it  resembles  the  case  of  Pelissier  and 
Borel  to  which  I  have  already  referred.  The  notes  unfortunately 
are  lacking  in  some  details. 

J.  C,  79  years  old,  domestic,  began  to  get  feeble  at  the  age  of 
74  and  was  admitted  to  the  outwards  of  the  Philadelphia  General 
Hospital.  She  never  had  a  paralytic  stroke  but  had  difficulty  in 
moving  about,  and  did  not  have  much  use  of  one  side,  presumably 
the  right,  and  used  a  cane.  The  inability  to  use  the  limbs  developed 
slowly  and  she  became  almost  helpless.  Her  mentality  failed  and 
she  appeared  senile.  Her  loss  of  memory  made  it  impossible  to 
obtain  any  history  from  her.  She  had  almost  constant  flexion  and 
extension  movements  of  the  right  forearm,  and  similar  movements 
in  the  right  lower  limb.  Both  patellar  reflexes  were  increased. 
The  arteries  were  sclerotic. 

Notes  taken  by  me  in  1914  are  as  follows:  The  right  upper  and 
lower  limbs  are  greatly  contractured.  The  right  fingers  are  slightly 
flexed.  The  hand  is  held  at  a  right  angle  with  the  forearm  and  the 
forearm  is  strongly  flexed  on  the  arm.  The  fingers  and  hand  can 
be  fully  extended  but  the  forearm  can  be  extended  only  to  a  right 
angle. 

There  is  a  constant  tremor  of  right  upper  limb  which  seems  to 
be  more  pronounced  at  the  wrist.  This  tremor  is  of  small  ampli- 
tude and  involves  the  fingers  at  times  independently  of  the  wrist. 
The  movements  of  the  fingers  are  of  slight  flexion  and  extension. 

The  biceps  and  triceps  reflexes  of  the  right  upper  limb  are  prob- 
ably increased  but  are  not  readily  obtained  on  account  of  spasticity. 
Occasionally  there  is  a  slight  jerking  of  the  right  lower  limb.  The 
latter  is  contractured  in  flexion  to  the  greatest  possible  degree. 
The  thigh  is  strongly  flexed  on  the  abdomen,  the  leg  is  strongly 
flexed  on  the  thigh,  and  the  foot  points  downward.  Contracture 
of  the  right  lower  limb  is  so  great  that  the  leg  cannot  be  brought  to 
a  right  angle  with  the  thigh.  Attempt  to  do  so  causes  much  pain. 
The  right  patellar  reflex  is  present  but  not  very  active,  as  judged 
by  the  contraction  of  the  quadriceps  muscle.  Pin  pricks  in  the  right 
leg  or  right  forearm  produce  an  expression  of  pain.     She  is  not 


36  WILLIAM  G.  SPILLER 

word  deaf.     Ai>parcntly  she  is  not  motor  aphasic.     She  says  whole 
sentences  correctly  but  is  confused. 

Important  features  of  this  case  are  hemispasticity  and  con- 
tractures of  the  right  upper  and  lower  limbs  to  an  extreme  degree. 
Extreme  spasticity  suggested  that  the  lesion  was  near  rather  than  in 
the  internal  capsule. 

A  necropsy  was  obtained.  No  degeneration  of  the  pyramidal 
tract  of  cither  side  could  be  found  but  numerous  minute  areas  of 
rarefaction  were  found  in  the  left  lenticular  nucleus,  some  also 
were  found  in  the  left  optic  thalamus.  These  areas  were  not 
numerous  in  the  right  basal  ganglia.  The  areas  were  very  small 
and  <iid  not  take  well  the  W'eigert  hematoxylin  stain  or  the  acid 
fuchsin.  These  were  the  only  lesions  I  was  able  to  detect,  and  as 
they  were  in  the  left  basal  ganglia  they  seem  to  explain  the  right- 
sided  spasticity. 

REFERENCES 

Pelissier   and    Kurd.     Rcvuc   Neiirologique   May   30,    1914,   p.   722. 

Dejcrine.     Idem. 

Rausch   and    Schilder.     Deutsche  Zeitschrift    fiir    Nervcnhcilkundc,   Vol.    52, 

Nos.  5  and  6,  p.  414. 
Oppenheim.     Neurologisches  Ccntralblatt,  No.  22,  Nov.   16,   1914. 
Cadwaiader.    Journal  of  the   .American   Medical  Association,  Jan.   31,   1915. 

Another  family  reported  by  Cadwaiader  since  this  paper  was  written 

is   recorded   in  the   .American   Journal   of  the   Medical   Sciences,   Oct., 

191 5.  P-  556. 
Higicr.     Zeitschrift  f.  d.  g.  Neurologie  u.  Psychiatric.  Vol.  23,  1914,  p.  290. 
Bostroem.     Fortschritte  der  Medizin,  Nos.  8  and  9,  Feb.  19  and  26,  1914. 
StfJcker.    Zeitschrift  f.  d.  g.  Neurologie  und  Psychiatric,  Vol.  15,  1913,  p.  251. 
VV'ocrkom.     Nouvelle  Iconographie  de  la  Salpetriere,  1914,  p.  41. 
Hos.slin  and  .-Mzheimer.     Zeitschrift  f.  d.  g.  Neurologie  und  Psychiatric,  Vol. 

8,   1012,  p.  183. 
.\.  W'estphal.     Archiv  f.  Psychiatiie,  Vol.  51,  1913,  p.  i. 
.Schutte.     Idem.,  p.  334. 

Mingazzini.     Archiv  f.  Psychiatric,  \'o!.  55.  No.  2,  p.  532. 
Zingerle.    Journal  fiir  Psychologic  und  Neurologic,  Vol.  XIV,  1909. 
Spiller.    Journal  of  Nervous  and  Mental  Disease,  .Aug.  1913,  p.  529.     Idem.. 

1908.  p.  452. 
\'.    nechtcrcw.     Deutsche   Zeitschrift    fiir   Nervcnhcilkundc,   Vol.    15,    Nos.    5 

and  6. 
Spiller.     Philadelphia  Medical  Journal,  Dec.   16,  1899. 


SPEECH  CONFLICT— A  NATURAL  CONSEQUENCE  IN 

COSMOPOLITAN   CITIES— AS  AN  ETIOLOGICAL 

FACTOR  IN  STUTTERING.    A  PRELIMINARY 

REPORT  BASED  ON  200  CASES^ 

By  May  Kirk  Scripture  and  Otto  Glogau,  M.D. 

OF   NEW    YORK    CITY 

Stuttering  has  been  recognized  as  a  disease  for  many  centuries 
and  many  theories  have  been  advanced  concerning  its  etioIog)^ 
Numerous  ^vriters  upon  the  subject  differ  in  regard  to  the  im- 
portance of  the  causative  agents. 

In  order  to  throw  some  Hght  on  the  etiology  of  stuttering  as 
met  with  in  the  cosmopolitan  city  of  New  York  we  went  over 
the  histories  of  the  last  two  hundred  cases  of  stuttering  that  were 
admitted  to  the  neurological  department  of  Columbia  Univer- 
sity at  the  Vanderbilt  Clinic  and  propose  making  a  few  deduc- 
tions from  our  statistics.  This  article  will  be  devoted  to  the 
study  of  nationality  of  the  patients  and  the  apparent  conflict  of 
language  due  to  the  overwhelming  majority  of  foreign-speaking 
parents  whose  children,  in  learning  English,  develop  a  stutter- 
ing habit. 

However,  before  discussing  this  point  at  length  let  us  devote 
a  few  moments  to  the  opinions  of  well-known  avithorities  upon 
the  etiology  of  stuttering. 

Most  all  authors  agree  in  believing  that  there  is  usually  a 
predisposition  on  the  part  of  the  patient  toward  stuttering  no 
matter  what  may  be  the  exciting  cause.  Dr.  Hudson  Makuen^ 
states  that  "the  most  important  factor  in  the  etiology  of  stam- 
mering is  heredity  and  this,  notwithstanding  the  fact  that  stam- 
mering is  an  acquired  affection,  in  the  sense  that  speech  itself  is 
an  acquired  faculty.  Heredity,  however,  must  be  held  in  great 
measure  responsible  for  the  various  anomalies  of  the  cortical 
speech  mechanism,  which  sooner  or  later  give  rise  to  the  affec- 
tion under  consideration ;  these  anomalies  are  largely  congenital 
and  vary  in  degree  all  the  way  from  the  grosser,  and  it  may  be 
organic  physical  conditions  of  the  brain,  to  the  minor,  and  so  far 
as  we  can  determine,  functional  anomalies,  which  result  in  an  in- 

1  From  the  Department  of  Neurology,  Columbia  University.  Van- 
derbilt Clinic. 

37 


38  M.IV  KIRK  SCRIPTURE  AND  OTTO  GLOGAU 

stability  or  a  weakness  of  the  speech  areas,,  with  an  ever  present 
tendency  toward  the  development  of  the  afYection." 

Gutzniann-  beside  agreeing  that  heredity  is  a  very  important 
factor  tells  us  that  he  considers  stuttering  more  or  less  a  matter 
of  temperament,  claiming  that  most  stutterers  are  excitable  and 
hasty.  He  also  remarks  that  it  is  not  only  heredity  but  psychic 
infection  which  takes  place  when  a  child  hears  a  mother,  father, 
brother  or  other  relative  stutter.  Heredity,  he  thinks,  can  only 
be  taken  into  consideration  as  the  prime  factor  when  the  patient 
never  saw  or  heard  the  disturbing  relative. 

An  interesting  case  of  heredity  came  to  us  at  the  clinic  a 
few  days  ago.  A  girl  of  13,  who  has  stuttered  ever  since  she 
first  started  to  talk,  was  discovered  to  have  had  a  grandmother, 
uncle  and  aunt  in  Ireland  (maternal  relatives)  w'ho  stuttered, 
but  none  of  whom  she  had  ever  seen,  as  she  was  born  in  this 
country.  We  have  here  in  America  numberless  children  who 
are  far  separated  from  the  foreign  forebears,  thus  giving  us  an 
opportunity  to  study  pure  heredity,  if  only  reliable  data  could  be 
obtained  when  such  cases  present  themselves. 

Some  authors  like  Schrank^  believe  that  stuttering  is  mostly 
found  among  the  mentally  deficient  and  feeble-minded  children ; 
but  from  our  experience  we  are  inclined  to  think  that  this  is  a 
quite  unwarranted  belief,  for  the  majority  of  our  patients  possess 
intelligence  of  normal  degree  while  only  a  small  percentage  come 
from  the  classes  in  the  public  schools  for  mental  deficients.  We 
rather  find  with  Gutzmann  that  non-intelligent  children  are  more 
inclined  to  lisp  than  to  stutter. 

Hlumc*  holds  that  the  most  immediate  cause  for  stuttering  is 
a  dis[>roportion  between  thinking  and  speaking,  i.  e.,  that  the 
command  of  language  does  not  keep  pace  with  the  development 
of  the  thinking  powers,  or  that  the  process  of  thinking  is  too  fast 
for  the  undeveloped  articulatory  organs  to  express.  Then  he 
further  contends  that  it  is  possible  that  just  the  opposite  is  the 
case — that  a  conflict  arises  between  the  organs  of  speech  and  the 
process  of  thinking  when  the  thought  itself  is  slow,  which  causes 
the  muscles  of  the  si)ecch  organs  to  become  rigid,  thus  account- 
ing for  the  twitchings  and  contortions  so  characteristic  of  some 
'itutterers. 

This  disparity  between  the  thinking  process  and  si)ecch  is  vcrv 
noticeable  at  the  early  age  of  three  or  four  when  the  child  at- 
tempts to  use  his  unexercised  muscles  of  the  speech  organs.  One 
child  in  our  clinic,  for  instance,  clearly  shows  this  in  a  most  in- 


SPEECH  CONFLICT  39 

structive  way.  When  he  attempted  at  three  years  of  age  to  ex- 
press the  word  "automobile"  for  the  object,  he  simply  said 
"bile,"  "bile,"  "bile,"  but  a  half  year  later  he  added  the  syllable 
"  mo  "  making  the  word  "  mo  "  "  mo  "  "  bile,"  thus  keeping  a 
repetition  of  three  syllables  for  the  word.  This  and  other  simi- 
lar peculiarities  if  overlooked  by  the  parents  may  lead  to  stut- 
tering. Gutzmann  observes  that  deaf  mutes  who  are  taught 
orally  never  stutter  because  they  learn  speech  under  constant 
supervision  of  a  teacher  and  they  thus  combine  the  idea  with  the 
word  after  the  speech  muscles  have  been  trained. 

It  has  been  noticed  that  the  number  of  stutterers  increases  at 
school  age  (anxiety),  at  second  dentition  (weakening  diseases) 
and  at  puberty  (organic  and  psychic  changes). 

Liebman^  considers  nervousness  as  the  real  foundation  (both 
hereditary  and  acquired)  for  stuttering  and  lays  special  stress  on 
the  abuse  of  alcohol  and  masturbation.  All  investigators  find 
that  the  percentage  of  stutterers  is  much  greater  for  the  male  sex. 
Gutzmann  believes  that  this  fact  is  due  to  the  different  methods 
of  breathing  employed  by  males  and  females.  Liebman  at- 
tributes the  less  stuttering  of  females  to  their  greater  dexterity 
and  grace  of  movement  and  to  the  well-known  fact  that  girls 
learn  to  speak  much  easier  and  earlier  than  boys.  KussmauP 
even  goes  further  in  declaring  that  all  muscular  actions  of  the 
female  are  easier  and  more  pleasing  than  those  of  the  male,  thus 
giving  her  at  an  earlier  age  greater  taste,  finer  tact,  more  grace- 
ful positions  and  a  greater  fluency  of  language,  all  of  which  en- 
able her  to  enter  society  at  an  earlier  period  than  the  male  of  the 
same  age.  Kussmaul  also  believes  that  chronic  stuttering  is 
caused  by  a  congenital  weakness  of  the  syllabary  coordination 
apparatus  so  noticeable  in  young  children. 

Schmalz"  considers  a  cramped  condition  of  the  vocal  cords 
as  a  primary  cause  of  stuttering.  MerkeP  believes  that  stutter- 
ing is  of  a  purely  psychic  origin,  while  Rosenthal  and  Benedict'" 
consider  it  a  coordination  neurosis.  The  basic  factor,  according 
to  Rosenthal,  is  the  congenital  weakness  of  the  respiratory  and 
vocal  apparatus  in  the  medulla  oblongata,  which  suffered  a  nerv- 
ous shock  in  early  childhood  and  never  recovered  and  which 
later  on,  by  the  mere  intention  to  speak,  causes  incoordinate 
movements.  Wineken^^  thinks  that  in  all  stutterers  the  will 
power  is  bounded  by  doubt  (language-doubt). 

Tonsils  and  adenoids  and  other  organic  abnormalities  such 
as  cleft-palate,  highly  arched  palate,  defective  teeth,  tongue  tie, 


40  M.n    KIRK  SCRIPTURE  AXD  OTTO  GLOGAU 

turbinal  hypertrophies,  etc.,  cannot  usually  be  reckoned  as  etio- 
logical factors  but  may  often  be  concomitant  elements. 

KafTemann'-  found  adenoids  in  46  per  cent,  of  stuttering  chil- 
dren. Schellenberg'^  in  50  per  cent.,  \\'incklcr'*  in  30  per  cent, 
and  Gutzmann  in  40-50  per  cent. 

During  the  past  year  we  have  made  special  investigations 
with  reference  to  the  tonsils,  adenoids,  deviated  septums,  catarrhal 
disturbance  of  stutterers  and  lispers  that  lead  us  also  to  beheve 
that  although  they  cannot  be  considered  immediately  etiological 
yet  they  are  so  responsible  for  weakening  the  nervous  system 
that  they  may  justly  be  the  exciting  cause  of  the  mental  dis- 
arrangement that  the  stutterer  shows. 

The  experiences  of  many  writers  prove  that  stuttering  has  a 
central  localization  within  the  brain  although  it  may  be  impos- 
sible to  demonstrate  it  anatomically. 

Kussmaul,"  H.  Schmidt,^"  Lichtinger^"  and  RosenthaP*  pub- 
lish cases  where  after  hemiplegia  the  aphasia  was  followed  by 
stuttering,  thus  intimating  an  anatomical  lesion. 

Moutier"  published  details  of  a  case  of  hemiplegia  where  the 
aphasia  was  preceded  by  a  peculiar  type  of  stuttering. 

Abadie-"  found  also  a  case  of  dysarthric  stuttering  after 
pscudo-bulbar  paralysis  which,  on  account  of  the  difhculty  of 
swallowing,  produced  a  peculiar  utterance. 

Scrofula  is  also  believed  to  be  a  prolific  cause  of  stuttering  by 
many  authors.  Klencke-^  went  so  far  as  to  say  that  stuttering  is 
a  consequence,  a  symptom  or  a  reflex  action  of  manifest  or  in- 
cipient scrofula. 

Coen^^  believes  that  all  stutterers  show  some  nutritive  dis- 
turbance of  the  organism  or  some  under-development  of  the 
thorax.  There  is  great  exception  taken  to  this  theory  because 
it  is  a  well-known  fact  that  many  stutterers  are  Herculeans  in 
stature  and  liealth.  Coen's  theory,  however,  leads  us  to  remem- 
ber that  faulty  breathing  is  present  in  almost  all  cases  of  stutter- 
ing and  may  be,  as  he  says,  the  secondary  pathological  symptom 
which  is  caused  by  disturbance  in  the  medulla  oblongata,  the 
center  of  breathing.  The  pneumographic  curves  of  a  stutterer's 
breathing  show  a  type  of  breathing  that  differs  entirely  from  the 
curve  of  a  normal  breath.  It  has,  however,  not  yet  been  fully 
decided  whether  this  faulty  breathing  of  the  stutterer  is  due  to 
his  speech  disturbance  or  whether  it  is  of  central  origin,  as 
Coen  says. 


SPEECH  CONFLICT  -  41 

Berkhan'^  considers  that  rickets  is  the  main  etiologic  factor 
in  stuttering  and  says  that  the  changes  of  palate  and  jaw  in  rickets 
are  similar  to  those  met  with  in  idiots,  imbeciles  and  deaf  mutes. 
It  is  our  experience  that  rickets  is  an  etiological  factor  in  motor 
aphasia  but  not  in  stuttering. 

The  psychological  phases  of  stuttering  may  be  of  two  kinds — 
(i)  the  psychic  affects  such  as  anxiety  and  fear;  (2)  psychic 
infection  (imitation).  While  authors  of  the  standing  of  Gutz- 
mann  believe  that  the  psychic  depression  of  stutterers  is  never 
the  primary  condition  but  is  always  due  to  the  constant  brooding 
over  their  speech  defect,  Freud,-*  SteckeP^  and  other  psycholo- 
gists believe  that  stuttering  is  the  outward  expression  of  an  in- 
ward mental  conflict.  Frank"*^  considers  it  as  an  anxiety  neurosis 
that  is  produced  in  psychopathic  children  by  fright  in  their  early 
years. 

Laubi's^^  theory  of  stuttering  is  based  on  his  observation  that 
some  children,  when  learning  to  talk,  may  possibly  develop 
language  slower  than  others  and  that  they  are  thus  maae  conscious 
of  the  articular  organs ;  this  is  enough  of  an  exciting  irritant  to 
turn  a  predisposition  into  real  stuttering.  He  cites  instances 
where  this  slow  development  of  language  leads  to  interruptions 
and  repetitions  of  letters  and  syllables. 

Hoepfner-^  compares  the  act  of  stuttering  with  the  compli- 
cated process  of  learning  to  walk.  The  child  first  creeps,  then 
stands,  then  attempts  to  take  a  few  steps  with  assistance  until 
finally  he  walks  alone.  If  having  accomplished  the  act  of  walk- 
ing alone  his  attention  is  constantly  directed  to  his  movements 
the  walking  becomes  unsteady  and  his  steps  will  be  slow  and  less 
skillful.  Even  adults  who  attempt  to  watch  their  steps  find  that 
their  control  becomes  unstable.  Just  so,  Hoepfner  claims,  a 
stutterer  is  delayed  by  strong  cramp-like  movements  when  he  en- 
deavors to  overcome  any  defects  by  reflecting  upon  them. 

FroscheP"  thinks  that  the  nucleus  of  stuttering  lies  in  the 
psychic  condition  of  the  patient  who  becomes  conscious  of  the 
ataxically  disturbed  speech  movements.  He  further  states  that 
in  a  number  of  children  who  are  predisposed  to  stuttering,  there 
is  lacking  that  equilibrium  which  normal  children  possess  with 
reference  to  the  right  proportion  between  speaking  and  thinking ; 
these  normal  children  do  not  express  more  thoughts  than  they  can 
quietly  give  utterance  to  in  words  but  with  the  unbalanced  equi- 
Hbrium  of  the  former,  the  mechanical  apparatus  receives  dif- 
ferent stimuli  and  thus  a  repetition  of  syllables  or  sounds  occurs. 


42  MAY  KIRK  SCRIPTURE  AND  OTTO  GLOGAU 

Froeschel  sng^gests  three  different  stages  of  stuttering — the  first 
stage  is  that  of  the  single  repetition  of  sounds  and  syllables  at 
the  ages  of  4-7;  the  second  stage  is  that  of  exaggerated,  con- 
scious motions  (voluntary  movements  of  the  speech  organs)  at 
the  ages  of  6-10;  the  third  stage  (cramp  stage)  is  preeminently 
the  tonic  cramp  of  the  articulatory  organs  and  other  concom- 
mitant  muscles. 

Xadoleczny^°  considers  the  exigencies  of  the  first  few  school 
years  as  the  purely  psychic,  momentous  factors  of  stuttering.  He 
finds  that  stuttering  occurs  mostly  at  the  stage  where  speech  de- 
velopment is  not  quite  finished  (4  years  or  about)  and  then  again 
from  6-8  years  of  age,  at  the  entrance  to  school  lite.  The  dis- 
l)roportion  between  the  mental  image  and  the  mechanical  expres- 
sion for  it  and  the  endeavor  to  overcome  the  difticulties  of 
language  may  easily  bring  about  interruption  of  smooth  language 
and  cause  the  repetition  of  syllables.  This  ataxia  lasts  much 
longer  in  the  neuropathically  predisposed  child  and  when  further 
exciting  agents,  such  as  fear,  anxiety,  sudden  fright,  etc.,  are 
added  he  becomes  a  stutterer. 

Kraepelin^*  suggests  that  the  psychic  disturbances  are  two- 
fold— expectation  neurosis  and  anxiety,  the  former  of  which 
causes  the  unconscious  twitchings  (impulses  to  activity)  of  the 
muscles  of  speech  and  the  latter  increases  the  stuttering  because 
the  fear  of  being  laughed  at,  reproved  or  scorned  increases  the 
anxiety. 

Scripture^^  states  in  his  "Stuttering  and  Lisping"  that  the 
most  frequent  cause  of  stuttering  is  a  nervous  shock.  Severe 
falls  are  just  as  often  the  cause  of  the  mental  shock  as  are  the 
ghost  stories  and  other  practical  jokes,  and  with  very  young  chil- 
dren, terrifying  experiences,  such  as  are  found  at  amusement  re- 
sorts. Then  there  is  the  mental  contagion  by  intentional  or  un- 
intentional imitation ;  the  condition  of  exhaustion  that  follows 
after  diseases  such  as  whooping  cough,  scarlet  fever,  measles, 
etc.,  and  a  neuropathic  disposition. 

The  analysis  of  our  statistics  of  2CK)  stutterers  makes  us  con- 
clude that  speech  conflict  is  an  etiological  factor  in  stuttering. 
Our  statistics,  as  given  at  the  end  of  the  article,  show  that  among 
171  male  patients  there  were  33  whose  stuttering  was  apparently 
brought  about  by  speech  conflict  exclusively,  while  in  four  cases 
negligent  lisping  in  their  own  language  had  i)reviously  existed. 
Among  the  29  female  patients  there  was  only  one  to  whom  this 
cause  could  be  attributerl.     The  most  striking  feature  concerning 


SPEECH  CONFLICT  43 

these  stutterers  from  speech  conflict  is  the  fact  that  their  stutter- 
ing was  acquired  at  the  ages  of  5-7  years.  Only  in  one  instance 
was  this  later ;  the  age  was  9  years  and  this  was  explained  by  the 
fact  that  the  patient  came  from  Russia  at  the  age  of  7  and  was 
therefore  only  confronted  with  the  problem  of  speech  conflict  at 
a  later  age  than  other  children. 

Sixteen  children  started  stuttering  at  the  age  of  6;  17  at  the 
age  of  5  and  four  at  the  age  of  7. 

It  is  interesting  to  see  in  our  statistics  that  the  onset  of  stut- 
tering, either  psychic  or  organic,  may  be  from  the  ages  of  1-15, 
while  the  stuttering  from  speech  conflict  occurs  only  at  the  ages 

of  5-7- 

Of  the  stutterers  from  speech  conflict  four  had  Italian  parents 
and  three  German  parents ;  in  all  other  instances  the  mother 
language  of  the  children  was  Yiddish,  the  parents  being  Rus- 
sians or  Austrians  (2  cases). 

We  compare  the  speech  conflict  in  foreigners  to  that  dispro- 
portion between  thinking  and  expressing  orally  that  exists  with 
young  children  in  learning  to  talk  in  their  own  language. 
In  the  child's  own  language  speech  conflict  is  an  etiological  fac- 
tor at  the  ages  of  2-4,  while  in  the  foreigner  we  find  this  to  be 
true  at  the  ages  of  5-7.  At  this  age  the  foreign  child  enters 
kindergarten  or  primary  school  and  is  confronted,  for  the  first 
time,  with  an  exclusively  English-speaking  surrounding.  Let  us 
explain  right  here  that  we  do  not  claim  that  every  foreign  child 
because  of  being  confronted  with  the  problem  of  learning  a  new 
language  must  stutter ;  likewise  no  one  would  expect  that  a  na- 
tive-born child  would  become  a  stutterer  just  because  it  has  to 
go  through  the  ataxic  stages  of  speech  utterance  at  tlie  ages  of 
2-4.  In  both  instances,  of  course,  there  must  be  besides  the  ex- 
citing cause  of  speech  conflict,  a  basic  predisposition  of  either 
hereditary  or  acquired  nervousness. 

The  ancestors  of  the  Russian  Yiddish  emigrant  to  this  coun- 
try were  subjected  to  unusual  nervous  strains  which  will  make 
themselves  felt  for  generations  to  come.  Just  think,  for  in- 
stance, of  the  pogroms  in  which  the  nearest  relatives  of  these 
emigrants  were  ruthlessly  mutilated,  wronged  or  killed ;  these 
very  people  themselves  losing  all  their  belongings  and  cast  out  to 
wander.  Bear  in  mind  also  the  fact  that  the  Jewish  nation,  on 
account  of  its  constant,  nomadic  social  conditions,  with  the  hard 
experiences  of  Ghetto  life  and  the  struggles  against  prejudices 
has  developed  a  more  highly  nervous  temperament  to  be  handed 
down  to  the  children  of  its  race  than  that  of  other  nations. 


44  MAY  KIRK  SCRIPTURE  AND  OTTO  GLOGAU 

The  children  of  these  Yiddish  emigrants  to  our  shores  speak, 
in  their  homes,  a  language  whose  very  fundamental  principles 
ditTer  from  English  more  widely  than  any  other  foreign  tongue. 
What  little  English  they  hear  from  parents  or  relatives  forms,  to 
their  minds,  only  another  link  in  that  conglomeration  of  jargon 
already  known. 

When  these  same  children  arrive  at  the  school  age  and  are 
sent  out  to  meet  those  of  their  own  age  trying  to  learn  a  new 
language,  they  are  confronted  with  almost  the  same  problem  as 
when  they  were  first  learning  their  own  language,  except  that  a 
new,  more  exciting  conflict  arises  between  thinking  in  Yiddish 
and  expressing  in  E.nglish.  Now  the  instructor,  with  the  idea  of 
correcting  the  faulty  pronunciation  of  the  Yiddish  child  who 
tries  to  speak  English,  demonstrates  to  him  the  difTerent  posi- 
tions of  the  tongue,  teeth,  hps,  etc.,  for  the  English  consonants 
and  vowels.  In  performing  these  acts  the  normal  child  will  very 
likely  be  inclined  to  revert  to  that  ataxic  stage  where  only  inter- 
rupted or  repeated  syllables  were  attempted ;  this  interrupted 
form  of  speech,  however,  disappearing  when  the  child  has 
mastered  the  command  of  the  motor  organs  of  speech  for  the 
new  language  and  when  he  becomes  so  familiar  with  the  language 
that  he  is  no  longer  required  to  translate  his  thoughts  from  the 
one  to  the  other.  But  all  of  these  preliminary  stages  for  the 
child  of  a  more  or  less  nervous  disposition  work  as  a  constant 
shock  and  may  bring  about  the  acts  of  real  stuttering.  And 
moreover,  as  Liebman  very  aptly  puts  it  when  describing  the 
critical  period  of  speech  conflict  in  the  child's  mother  language, 
the  child  is  not  only  required  to  increase  his  vocabulary  in  a  new 
language  but  is  confronted  with  a  new  fear,  that  of  speaking  to  a 
foreign  teacher  whose  superiority  appalls  him.  This  often  ac- 
counts for  the  disturbances  of  co(')rdination  in  speech,  which  show 
themselves  in  the  hesitation  of  the  foreign  child,  sometimes  on 
account  of  not  quite  understanding  the  question  and  often  on  ac- 
count of  having  to  translate  his  answers  before  expressing  them, 
causing  him  to  give  confused  replies  and  all  of  this  heightened  by 
his  timidity  before  the  teacher  or  the  fear  of  the  other  pupils' 
rifhculc.  At  home,  again,  his  mind  is  kept  in  constant  conflict 
because  of  his  reverting  from  the  English  of  school  and  his  new 
companions  back  into  the  Yiddish  of  his  parents. 

Our  hypothesis  that  speech  conflict  is  an  important  cause  of 
stuttering  in  cosmopolitan  cities  does  not  contradict  any  of  the 


SPEECH  COh^FLICT  45 

above  mentioned  theories.  We  do  not  claim  that  this  so-called 
speech  conflict  will  cause  an  entirely  normal  child  to  stutter,  but 
we  consider  it  rather  the  exciting  cause  to  a  child  so  predisposed. 
We  may,  of  course,  with  !Makuen  assume  that  these  children 
have  inherited  or  acquired  organic  or  functional  disturbances  of 
the  central  organs  of  speech  which  a  speech  conflict  will  be  liable 
to  unbalance.  We  also  believe  with  Gutzmann  that  speech  con- 
flict in  itself  would  not  prodvice  stuttering  unless  the  child  had  a 
rather  labile  temperament. 

Blume's  theory  that  the  disparity  between  the  thinking  process 
and  the  mechanical  expression  of  the  same  causes  stuttering 
quite  fits  with  our  theory  of  speech  conflict  for,  as  we  have 
already  said,  here  the  child  of  5-7  in  grasping  the  new  language 
is  at  the  very  same  stage  as  the  child  of  2-3  who  is  attempting  to 
grasp  its  own  language. 

We  may  compare  the  child's  first  trials  in  the  foreign  language 
with  the  ataxic  speech  (Hiipfner)  of  the  normal  child  who,  on 
becoming  conscious  of  this  hesitating  method  of  expressing  him- 
self, often  becomes  a  stutterer. 

Nadoleczny  shows  us  that  the  intention  of-  overcoming  this 
discrepancy  between  the  word  pictures  and  the  mechanical  ex- 
pressions of  them  leads  to  repetition  of  syllables  in  even  normal 
children  and  to  stuttering  in  neuropathically  disposed  children. 
Here  we  have  to  deal  not  only  with  the  conflict  of  speech  in  the 
Yiddish  child  but  also  with  that  of  the  conflict  of  language. 
When  a  nervous,  predisposed  child  tries  to  overcome  this  double 
conflict  stuttering  is  liable  to  be  brought  about. 

We  also  assume,  with  Kraepelin,  that  the  speech  conflict  is 
responsible  for  an  anxiety  neurosis  which,  of  itself,  may  lead  to 
compulsory  movements  of  the  articulatory  organs  such  as  met 
with  in  stuttering.  And  again,  with  Kussmaul,  we  agree  that 
this  constant  conflict  between  thinking  in  the  old  and  expressing 
in  the  new  language  may  cause  a  chronic  irritation  and  a  con- 
sequent weakening  of  the  syllabary  coordination  apparatus. 

In  the  stutterer  from  speech  conflict  the  will  power  is  bounded 
by  doubt  (Winekin).  In  predisposed  cases  the  nerve  exerting 
speech  conflict,  with  its  constant  changes  of  thought  and  word 
expression  from  one  language  to  the  other — at  home  on  the  one 
hand  and  in  school  on  the  other — produces  a  regular  coordina- 
tion neurosis  (Rosenthal-Benedikt),  that  may  also  be  called  a 
localized  anxiety  neurosis  (Schrank). 


46  M.IV  KIRK  SCRIPTURE  JXD  OTTO  GLOGAU 

This  speech  conflict  will  also  cause  stuttering  in  those  chil- 
dren who,  according  to  Laube,  have  been  slow  in  developing 
speech  or  have  been  afflicted  with  the  interrupted  speech  before 
mentioned. 

With  Liebnian  we  consider  the  nervous  predisposition  of  the 
child  a  basic  factor.  The  same  disparity  in  percentage  of  male 
and  female  stutterers  holds  good  for  this  matter  of  speech  con- 
flict ;  by  their  greater  lingual  dexterity  and  earlier  development 
of  most  of  the  faculties  females  overcome  more  readily  the  diffi- 
culties of  language.  Where  their  ataxic  articulatory  movements 
in  early  speech  development  may  occur  but  do  not  last  very  long, 
the  male  with  the  same  trouble  may  become  a  stutterer. 

Conclusion 

I.  In  38  cases  out  of  200  stutterers  examined  the  etiological 
factor  is  proven  to  be  a  conflict  between  the  mother  tongue  at 
home  and  English  to  be  learned  in  school.  This  speech  conflict 
as  an  etiological  factor  in  stuttering  is  almost  exclusively  met 
with  in  the  Yiddish  child  and  particularly  in  the  male  sex. 

II.  Those  foreign  children  who,  during  their  first  three  years 
in  school,  show  great  difficulty  in  mastering  the  English  language 
and  reveal  such  symptoms  as  hesitation,  repetition  of  syllables, 
etc.,  should  be  sent  to  a  speech  clinic  for  careful  examination  and 
correction  of  the  defects  which,  if  neglected,  may  lead  to  distress- 
ing stuttering.  Teachers,  themselves,  should  have  a  fair  knowl- 
edge of  the  disturbances  of  speech  in  order  to  understand  that 
critical  period  when  speech  conflict  is  apt  to  produce  an  un- 
favorable result  in  the  child's  speech.  Great  care  should  be  taken 
by  the  teachers  to  avoid  any  steps  in  their  work  that  might  in  any 
way  produce  fear  in  the  child  ;  love,  sympathy,  indulgence  and 
patience  should  fill  the  hours  of  labor  with  these  little  pieces  of 
humanity  that  have  been  battered  and  knocked  about  by  this 
struggle  for  existence  under  such  trying  circumstances. 

III.  It  would  In-  will  if  those  children  who  show  the  dis- 
turbances of  this  s[)eech  conflict  could  be  instructed  in  special 
classes  in  the  schools,  so  that  children  not  thus  afflicted  would  not 
be  disturbed  by  psychic  infection. 

We  wish  to  ex[)ress  our  heartiest  thanks  to  Professor  Starr 
for  his  kind  co'iperation  in  transferring  to  us  the  material  and  in 
putting  at  our  disposal  apparatus  with  which  we  are  enabled  to 
carry  out  our  investigations. 

{To  be  continued) 


Society  procceDiPiG? 


AMERICAN  NEUROLOGICAL  ASSOCIATION 

Forty-first  Annual.  Meeting,  Held  in  New  York  City,  May 
6,  7  AND  8,  191 5 

The  President,  Dr.  George  W.  Jacoby,  in  the  Chair 

{Continued  from  vol.  42,  page  827) 

THE  DEVELOPMENT  AND  OPERATION  OF  THE  LAWS  FOR 

HOSPITAL  OBSERVATION  OF  CASES  OF  ALLEGED 

MENTAL  DISEASE  OR  DEFECT  IN 

MASSACHUSETTS 

By  Henry  R.  Stedman,  M.D. 

Wide  scope  of  Massachusetts  laws.  The  provision  a  very  useful  one. 
Advantageous  in  non-criminal  as  well  as  criminal  cases.  Steady  increase 
in  such  commitments.  Opinions  of  committing  magistrates  and  superin- 
tendents of  hospitals.  Distinction  from  temporary-care  acts.  Greatly 
increased  facility  for  accurate  study  of  obscure  cases,  imbiased  opinions 
and  saving  of  expense  to  state  the  chief  advantages. 

Dr.  H.  W.  Mitchell,  Warren,  Pa.,  said  he  did  not  wisli  to  be  consid- 
ered as  holding  any  brief  for  the  commitment  of  persons  committing 
crime,  and  subsequently  pleading  insanity  as  a  defense,  nor  did  he  wish 
to  intimate  that  the  decision  of  the  question  involved  could  be  better  deter- 
mined by  the  resident  physicians  of  insane  hospitals  than  by  others.  He 
desired  to  confine  his  discussion  to  the  methods  employed,  and  not  to  the 
personal  equation  of  the  physicians.  For  some  years  he  had  had  personal 
familiarity  with  the  operation  of  the  so-called  "  observation  laws  "  opera- 
tive in  the  states  of  Vermont,  Maine,  and  Massachusetts,  together  with 
some  experiences  in  Pennsylvania,  where  law  of  this  character  was  not  on 
the  statute  books,  but  where  by  tacit  approval  of  attorneys  and  court,  the 
principle  involved  had  been  put  into  application  in  several  instances.  He 
wished  to  mention  particularly  the  operation  of  the  law  in  the  state  of 
Maine,  where  for  several  years  as  superintendent  of  a  state  hospital,  he 
had  had  official  connection  with  the  workings  of  the  law  which  provided 
that  all  persons  pleading  insanity  as  a  defense  of  crime  committed,  must 
be  sent  to  a  state  hospital  for  the  insane  for  observation  and  detention 
upon  order  of  court. 

The  period  of  detention  was  variable  and  could  be  determined  at  each 
term  of  criminal  court,  to  which  the  superintendent  was  expected  to  make 
report  as  to  whether  or  not  it  was  necessary  to  keep  the  alleged  insane 
person  longer  for  purpose  of  observation  before  forming  opinion  as  to 
the  person's  mental  capacity.  A  tentative  opinion  would  be  presented  to 
the  court,  and  the  physician  could  be  summoned  by  either  side  desiring  his 
testimony.  This  arrangement  was  inexpensive  to  the  commonwealth,  was 
not  prejudicial  to  the  interests  of  the  alleged  insane  person,  but  did  offer 
exceptional  opportunities  for  ascertaining  the  exact  mental  condition  of 
the  person  in  question,  and  allowed  full  opportunity  for  the  examination 
and  observation  that  is  required  to  form  the  basis  of  a  positive  opinion. 

47 


48  AMERICAN  NEUROLOGICAL  ASSOCIATION 

One  who  has  been  obliged  to  visit  a  jail,  or  have  short  interviews  with 
the  alleged  insane,  often  interrupted  by  others  present,  who  may,  or  may 
not.  wish  to  have  the  truth  ascertained,  need  only  recall  such  experiences 
to  form  an  opinion  as  to  the  comparative  advantages  of  the  observation 
law  in  permitting  competent  examination.  In  the  speaker's  personal  expe- 
riences with  many  cases  in  which  the  medical  testimony  had  been  based 
upon  the  hospital  observation,  there  had  been  no  ground  for  the  oft 
repeated  criticism  of  the  character  of  the  medical  testimony,  as  evidenced 
in  many  notorious  trials,  and  he  believed  that  the  method  discussed  by 
Dr.  Stedman  offered  more  relief  than  any  other  from  the  criticism,  some- 
times just,  sometimes  unjust,  that  has  been  current  concerning  the  testi- 
mony of  psychiatrists. 

In  conclusion,  Dr.  Mitchell  wished  to  emphasize  the  protection  which 
would  be  furnished  to  the  good  repute  of  the  family,  and  of  the  person 
whose  first  offense  was  the  result  of  insanity,  by  a  more  liberal  application 
of  the  observation  plan  in  instances  of  persons  whose  mental  condition 
might  properly  be  questioned,  and  he  cited  instances  where  several  per- 
sons suffering  from  general  paralysis,  previously  of  good  character,  had 
been  passed  through  the  courts,  and  committed  as  criminals,  only  to  be 
transferred  soon  to  hospitals  for  the  insane.  A  competent  observation  law 
generally  enforced,  would  protect  the  family  and  the  reputation  of  the 
individual  in  question  from  the  stigma  of  criminalitj',  and  would  conserve 
the  interests  of  the  community.  He  most  heartily  favored  a  general 
application  of  the  observation  law,  and  Dr.  Stedman's  endorsement  of 
the  same. 

Dr.  E.  E.  Southard  could  only  corroborate  what  Dr.  Stedman  had 
said  about  this  group  of  cases.  He  would  like  to  add,  however,  that  the 
Industrial  Accident  Board  had  sent  to  the  Psychopathic  Hospital  a  con- 
siderable number  of  very  interesting  traumatic  psjchoses.  He  thought 
that  it  was  the  first  time  in  Massachusetts  at  least  that  traumatic  psychoses 
had  had  an  entirely  unprejudiced  study  since  heretofore  these  cases  had 
been  subject  to  partisan  examinations  from  the  standpoint  of  either  the 
plaintiff  or  the  defendant  or  both. 

A  number  of  Psychopathic  Hospital  cases  had  astounded  the  lawyers 
of  both  sides  when  it  had  been  shown  by  Psychopathic  Hospital  officers 
that  the  patient  seemed  to  be  both  simulating  and  mentally  diseased  (in 
this  connection  Dr.  Southard  wished  to  call  especial  attention  to  Professor 
Martin's  test  for  the  sensory  threshold  of  faradism  in  the  traumatic  psy- 
choses and  in  so-called  occupation  neuroses.  Traces  of  disease  could  be 
found  by  the  Martin  method  which  were  apparently  not  accessible  to  any 
fither  method).  I'ortunately  the  seven-day  temporary  care  period  has 
now  been  altered  to  ten  days. 

Dr.  Mf>rton  Prince  said  he  was  a  member  of  a  committee  of  the  Insti- 
tute of  Criminal  Law  and  Criminology  which  was  appointed  to  report  a 
l)ill  to  regulate  expert  testimony.  The  committee  consisted  of  lawyers  and 
physicians.  The  former  were  Edwin  R.  Kecdy  (professor  of  law,  North- 
western University),  William  E.  Mikell  (dean  of  the  law  school  of  the 
University  of  Penn.sylvania ),  anrl  Albert  G.  Barnes  (judge  of  the  Supe- 
rior Court  of  Chicago).  The  latter  were  Adolf  Meyer,  Harold  N.  Moyer, 
W.  A.  White  and  Morton  Prince,  all  members  of  this  Association. 

This  movement  was  interesting  particularly  in  one  respect — as  show- 
ing an  attempt  on  the  part  of  the  legal  profession  and  the  medical  pro- 
fession to  get  together.  The  Institute  of  Criminal  Law  and  Criminology 
has  had  the  jtroblem  of  expert  testimony  under  consideration  for  about 
five  years  and  has  studied  it  in  all  its  phases.  Its  committee  has  finally 
drawn  up  a  bill  which  has  been  adopted  by  the  Institute  after  prolonged 


AMERICAN  NEUROLOGICAL  ASSOCIATION  49 

consideration  and  discussion  and  after  being  submitted  to  the  criticism  of 
members  of  the  bar  pretty  widely.  It  has  been  submitted  to  the  criticism 
of  the  New  York  Bar  Association  and  other  criticisms  have  been  taken 
into  consideration.  The  bill  as  finally  adopted  it  is  hoped  will  satisfac- 
torily solve  the  problem  and  will  serve  as  a  sort  of  model  bill  to  be  intro- 
duced in  the  legislatures  of  the  various  states.  It  is  therefore  hoped  that 
if  it  works  satisfactorily  it  will  be  generally  adopted. 

At  any  rate  it  represents  an  attempt  on  the  part  of  the  two  professions 
to  get  together  and  reconcile  their  differences  and  difficulties.  This  at 
least  is  a  gain  and  all  of  us  hope  that  eventually  something  will  be  done 
to  reform  present  methods.  In  Massachusetts  there  has  been  a  great  deal 
of  antagonism  between  the  views  of  the  members  of  the  bar  and  those 
of  the  medical  profession,  and  this  is  probably  true  in  all  of  the  states. 

Dr.  Prince  thought  the  bill  recommended  by  the  Institute  of  Criminal 
Law  and  Criminology  deserves  serious  consideration  on  the  part  of  this 
Association  and  hoped  that  it  will  be  carefully  studied  and  if  it  meets  with 
the  approval  of  the  members  of  this  Association  that  they  will  give  it 
their  support. 

The  essential  points  of  the  bill  are:  (i)  A  provision  for  the  appoint- 
ment of  "  disinterested  qualified  experts  "  by  the  court  in  addition  to  those 
employed  by  either  party;  (2)  a  provision  for  the  examination  in  criminal 
cases  of  the  accused  by  the  expert  witnesses  for  the  prosecution;  (3)  a 
provision  for  the  commitment  of  the  accused  in  criminal  cases  to  a  hos- 
pital for  observation  subject  to  examination  by  all  the  experts  on  both 
sides;  (4)  a  provision  for  written  reports  by  all  experts,  and  (5)  a  pro- 
vision for  consultation  between  all  experts  and  a  joint  report  if  desired. 

Dr.  Walter  Channing,  Brookline,  Mass.,  said  in  regard  to  the  work  of 
Dr.  Stedman,  that  they  feel  in  Massachusetts  they  owe  a  good  deal  to  him 
for  what  he  has  done  in  improving  the  laws  which  were  revised  in  1909. 
These  laws  are  more  liberal,  as  far  as  admissions  are  concerned,  than 
those  of  any  other  state,  and  the  result  of  this  is  that  patients  are  admitted 
at  a  very  early  period.  If  we  did  not  have  these  laws,  the  Boston  Psycho- 
pathic Hospital  could  not  do  a  large  part  of  its  best  work.  Patients  are 
received  and  discharged  in  rapid  succession.  Another  indirect  result  is 
the  increase  in  the  out-patient  clinic.  Many  cases  which  might  go  to  the 
insane  hospital  a  little  later  now  go  to  the  out-patient  department.  It 
seemed  to  Dr.  Channing  that  it  would  be  a  great  step  in  advance  if  the  laws 
relating  to  insane  hospitals  should  as  far  as  possible  be  made  uniform 
throughout  the  country,  the  best  of  them  being  selected  from  each  state. 
He  was  sure  that  nothing  could  do  more  for  the  prevention  of  insanity. 
Until  something  of  the  sort  is  done,  we  shall  go  on  with  our  present  per- 
nicious practice  of  admitting  large  numbers  of  persons  who  might  at  an 
earlier  period  have  been  treated  outside. 


PRELIMINARY  REPORT   ON   THE  TREATMENT   OF   PARESIS 

BY  INJECTIONS  OF  SALVARSAN  AND  DEFINITE  DOSES 

OF  NEOSALVARSAN  INTO  THE  LATERAL  VENTRICLE 

By  Graeme  M.  Hammond,  M.D.,  and  Norman  Sharp,  M.D. 

Selection  of  cases  for  operation.  Cell  count  in  the  spinal  and  ven- 
tricular fluid  before  operation.  Details  of  the  operation.  Injection  into 
the  ventricle  of  serum  taken  from  salvarsanized  blood.  Injections  with 
blood-serum  treated  with  definite  dosage  of  neosalvarsan.  The  immediate 
effect  of  the  operation  on  the  patient.  The  cell  count  in  the  spinal  and 
ventricular  fluid  two  weeks  after  operation.  The  later  effect  on  the  mental 
and  physical  symptoms. 


so  AMERICAX  XEUROLOGICAi.  ASSOCIATION 

A  CASE  OF  WILSON'S  DISEASE-PROGRESSIVE  LENTICULAR 
DEGENERATION— WITH  PATHOLOGICAL  FINDINGS 

By  Frederick  Tilney,  M.D.,  and  G.  M.  Mackenzie,  M.D. 

This  case  presented  a  typical  syndrome  of  progressive  lenticular  degen- 
eration, as  described  by  Wilson.  It  ran  a  moderately  acute  course,  termi- 
nating in  death  in  fifteen  months.  The  outstanding  clinical  features  were 
the  marked  hypertonicity  of  the  somatic  musculature  and  the  evidence  of 
extreme  toxicity.  A  preliminary  report  of  the  pathological  findings  in  the 
brain  is  given  and  with  this  the  histological  findings  of  the  spinal  cord, 
liver,  spleen,  kidney,  thymic  remains,  thyroid,  heart,  lungs  and  supra- 
renal bodies. 

Dr.  H.  H.  Hoppe,  Cincinnati,  said  the  subject  of  Wilson's  disease  in 
its  strict  sense  seemed  to  him  a  closed  chapter.  He  has  a  case  in  his 
service  in  Cincinnati  which  presents  quite  a  number  of  the  features  of 
Wilson's  disease.  It  varies  from  the  type  in  respect  to  the  age,  this  woman 
being  probably  44  or  45  years  of  age.  Also  that  instead  of  the  hyper- 
tonicity being  associated  with  a  constant  tremor,  it  is  associated  with 
constant  athetoid  movements.  It  is  not  typical  of  the  movements  of 
athetosis.  The  facial  muscles  as  well  as  those  of  the  tongue  and  neck  are 
involved  and  are  always  in  a  state  of  hypertonicity  and  in  constant  motion. 
The  arms  and  legs  are  constantly  in  a  state  of  motion  and  the  feet  are 
inverted.  The  mouth  is  not  held  in  the  condition  that  has  been  seen  here 
in  the  pictures,  but  it  is  possibly  due  to  the  fact  that  the  woman's  case 
,  has  not  advanced  sufficienth'.  There  are  no  pathological  changes  in  the 
refle.xes,  excepting  that  they  are  increased.  The  woman's  mental  state  is 
practically  normal,  excepting  that  she  is  always  in  a  state  of  rather  pleasant 
frame  of  mind.  The  other  feature  in  the  case  that  varies  from  Wilson's 
disease  is  the  history  that  some  years  ago  she  had  a  similar  attack  and 
that  there  was  a  remission  to  a  sufficient  degree  to  allow  her  to  go  back  to 
work.  So  that  Dr.  Hoppe  has  come  to  the  conclusion  that  she  has  some 
extrapyramidal  disease  that  is  bilateral  and  possibly  a  type  approaching 
Wilson's  disease.  The  chief  variation  from  the  Wilson's  disease  is  in- 
stead of  there  being  a  tremor  in  the  extremities  there  is  a  constant  athetoid 
movement  of  the  extremities.  There  is  no  change  in  the  size  of  the  liver. 
There  is  no  jaundice.     There  has  never  been  any  fever. 

Dr.  Alfred  Reginald  Allen,  Philadelphia,  said  he  had  read  S.  A.  K. 
Wilson's  two  reports.  Wilson  has  so  limited  the  anatomic  concept  of  his 
disease,  and  so  exactlj'  described  what  it  is  pathologically  as  well  as  clin- 
ically, that  it  would  be  very  difficult  to  make  a  hard  and  fast  diagnosis 
of  uncomplicated  Wilson's  disease  outside  of  the  autopsy  room.  One 
might  say  that  he  considered  a  certain  case  to  be  Wilson's  disease  and 
then  at  autop.sy  might  find,  as  has  been  found  in  a  number  of  cases,  the 
pyramidal  tracts  damagc<l  by  extension  of  the  pathological  process  inward. 
This  would  vitiate  the  diagnosis  of  a  pure  uncomplicated  Wilson's  disease. 
So  far  as  the  age  of  the  incidence  of  Wilson's  disease  is  concerned  the 
twelve  or  thirteen  cases  that  he  reports  show  great  variation  in  age  as 
also  great  variation  in  duration.  Dr.  Allen  said  he  would  like  to  report 
a  rather  interesting  observation.  Dr.  Richard  M.  Pearce  and  he  have  tied 
off  the  bilc-ducts  in  monkeys  and  rabbits  and  then  in  twenty-four  to  forty- 
eight  hours  have  removed  the  greatly  distended  gall-bladder.  The  brain 
has  then  been  removed  and  coronal  sections  3  mm.  in  thickness  through 
the  lenticular  region  have  been  placed  in  this  bile  and  kept  forty-eight 
hours  in  a  refrigerating  chamber  at  a  temperature  varying  between  1° 
and  2"  C.  They  have  found  that  the  outer  part  of  the  lenticular  nucleus 
stands  out   in   markcfl   contrast  to  any  other  nuclear   structure  or  to  the 


AMERICAN  NEUROLOGICAL  ASSOCIATION  51 

cortex.  The  question  naturally  arises  whether  there  be  something  in  the 
liver  condition  which  may  possibly  be  the  primary  etiological  factor  in 
these  cases  and  which  liver  abnormality  may  cause  to  be  thrown  into  the 
circulation  either  an  excess  of  a  normal  substance  or  a  perverted  secretion, 
which,  coming  in  contact  with  the  central  nervous  system,  has  a  particular 
predilection  to  the  outer  part  of  the  lenticular  nucleus  and  stimulates  in 
that  structure  this  peculiar  change. 

Dr.  Schwab  said  he  wanted  to  call  attention  to  the  fact  that  a  lesion 
of  the  lenticular  nucleus  of  the  extra-pyramidal  system  does  not  neces- 
sarily produce  Wilson's  disease.  Two  other  facts  are  essential :  one  is 
cirrhosis  of  the  liver  and  the  other  the  non-participation  of  the  blood 
vessels.  In  the  pathological  findings  Wilson  himself  insists  on  these  two 
facts  and  there  is  no  doubt  that  there  are  any  number  of  cases  of  len- 
ticular disease  produced  by  many  kinds  of  lesion  which  do  not  in  any 
sense  conform  to  the  clinical  type  which  Wilson  has*  so  accurately  de- 
scribed. A  few  years  ago  in  conversation  with  Wilson  he  insisted  that 
the  lesion  was  not  necessarily  a  lesion  of  the  lenticular  nucleus,  but  a 
result  of  some  toxic  process  existing  a  long  time  before  which  produced 
the  lesion  of  the  liver  and  caused  the  symptoms  with  the  non-participation 
of  the  blood  vessels.  There  are  numerous  cases,  for  example  of  syphilitic 
processes,  of  the  lenticular  nucleus  which  produce  the  clinical  picture  of 
Wilson's  disease  which  are  not  Wilson's  disease. 

Dr.  Charles  K.  Mills,  Philadelphia,  said  the  case  was  well  reported 
and  illustrated  and  the  paper  was  another  valuable  contribution  to  the 
study  of  what  is  properly  called  Wilson's  Disease.  What  he  particularly 
arose  to  say  was  rather  along  the  lines  of  the  last  speaker.  It  seemed  to 
Dr.  Alills  in  the  development  of  this  whole  subject  that  the  difficulty  was 
that  of  losing  sight  of  the  most  important  matter,  namely,  that  lenticular 
disease  assumed  different  forms.  Our  minds  turn  too  exclusively  to  Wil- 
son's cases  and  his  symptom-complex  resulting  from  lesions  of  the  len- 
ticula  associated  with  the  cirrhosis  of  the  liver.  What  we  really  need  is 
a  rewriting  of  the  whole  subject  of  lenticular  disease  considered  from  the 
standpoint  of  the  location  and  extent  of  the  lesions  in  the  lenticula  or 
rather  of  striate  disease  from  the  standpoint  of  the  location  of  lesions  in 
the  caudate  or  lenticular  nucleus. 

It  comes  out  in  the  study  of  pure  cases  of  lenticular  disease  what  he 
had  for  a  long  time  believed  and  taught,  that  the  lenticular  nucleus  is  an 
organ  with  important  functions.  It  is  also.  Dr.  Mills  believed,  an  organ 
subdivided  into  functional  areas.  The  important  thing  is  to  get  clear  light 
upon  lenticular  disease  from  the  standpoint  of  the  limitations  and  locali- 
zations of  lesions.  Dr.  Mills  had  seen  a  considerable  number  of  cases  of 
lenticular  disease,  writing  a  paper  on  t'^e  subject  with  Dr.  Spiller  some 
years  ago  and  being  constantly  alive  to  the  interest  and  importance  of  the 
subject  for  more  than  twenty  years. 

It  is  true,  as  the  last  speaker  said,  that  in  part  or  almost  in  whole 
the  symptoms  of  Wilson's  disease  can  be  seen  in  cases  of  syphilis  of  the 
nervous  system.  The  case  reported  by  Dr.  Mills  recently  in  a  paper  on 
bilateral  caudato-lenticular  degeneration  in  a  case  of  syphilis  was  a 
striking  illustration  of  this  fact.  The  symptom  picture  developed  in  an 
adult  progressively  over  a  number  of  years,  seven  or  eight  in  all,  and  was 
in  its  fullness  the  picture  of  the  subacute  infectious  disease  to  which 
Wilson's  name  has  properly  been  given.  His  own  view  was  that  the 
striatum  is  far  from  being  a  vestigial  organ,  as  one  of  his  distinguished 
friends  in  Philadelphia  believes.  He  thought  that  cases  with  special 
symptoms  and  lesions  differently  but  definitely  located  were  proof  of 
this  contention. 


52  .LM  ERIC  AX  NEUROLOGICAL  ASSOCIATION 

The  argument  which  was  incidentally  used  bj-  Dr.  Allen  and  which 
has  often  been  used  in  discussion  of  this  subject,  was  of  little  weight  when 
tlie  cases  were  thoroughly  studied.  The  fact  that  there  may  be  pyramidal 
disease  as  well  as  lenticular  disease  in  the  same  case  had  very  little  weight 
in  Dr.  Mills's  judgment,  although  it  has  been  much  used  by  writers  to 
show  that  an  extrapyramidal  symptomatology  does  not  exist.  It  is  the 
business  of  the  focal  diagnostician  by  his  studies  and  opportunities  at 
necropsies  to  separate  the  pyramidal  and  extrapyramidal  symptomatology 
of  these  cases  and  usually  this  can  be  done. 

Dr.  J.  Ramsay  Hunt  said  the  case  that  had  just  been  reported  was  a 
ver>-  beautiful  conlirmation  of  Wilson's  disease  in  the  strict  sense  in 
which  that  term  should  be  used.  To  Dr.  Hunt  one  of  the  most  interesting 
by-products  of  Wilson's  paper  was  the  relation  of  paralysis  agitans  and 
allied  disorders  to  the  lenticular  nucleus.  Last  year,  Dr.  Hunt  presented 
to  this  association  a  paper  on  Juvenile  Paralysis  Agitans  which  resembled 
very  closely  the  descriptions  of  Wilson's  disease.  It  differed,  however,  in 
the  chronicit}'  of  the  cases  and  the  verj-^  slow  and  progressive  course.  It 
was  really  like  that  of  paralysis  agitans  only  beginning  in  child  life.  Since 
then  an  autopsy  on  one  of  the  cases  showed  no  signs  of  cirrhosis  of  the 
liver,  and  no  macroscopic  evidences  of  lenticular  degeneration.  Dr.  Hunt 
asked  whether  the  clinical  picture  at  all  suggested  the  neurological  picture 
of  Parkinson's  disease,  apart  from  the  question  of  temperature  and  toxe- 
mia which  were  present.  Did  the  rigidity  and  tremor  which  were  present 
suggest  to  him  the  familiar  muscular  conditions  of  Parkinson's  disease? 
Sanderson  reported  not  long  ago  a  case  which  was  similar  to  Dr.  Hunt's 
which  was  also  seen  by  Dr.  Wilson  and  they  regarded  it  as  perhaps  allied 
to  lenticular  degeneration.  Dr.  Hoppe's  case  as  he  described  it  suggested 
rather  the  type  which  was  described  by  Oppenhcim  and  V'ogt  and  which 
was  associated  with  a  marbled  appearance  of  the  outer  portion  of  the 
lenticular  nucleus. 

Dr.  Archibald  Church,  Chicago,  said  the  necessity  of  autopsical  re- 
search was  impressed  upon  him  bj*  a  case  a  year  ago  in  St.  Luke's  Hos- 
pital. A  young  man  of  nineteen  years  had  gradually  gotten  into  the 
condition  and  presented  the  postures  and  clinical  aspect  described  by  Wil- 
son. The  case  corresponded  to  his  clinical  outlines,  with  the  exception  that 
the  reflexes  were  decidedly  brisk,  so  that  at  times  a  clonus  seemed  imma- 
nent but  r)cver  occurred.  Careful  examination  was  made  of  the  liver  by 
the  usual  clinical  methods  in  which  matter  he  had  the  help  of  Dr.  Arthur 
Elliott,  who  made  a  number  of  tests  of  liver  function.  They  are  not  very 
definite,  still  they  were  carried  out  in  a  great  deal  of  detail  and  persistence 
and  gave  them  no  evidence  of  any  liver  involvement,  nor  could  the  liver 
be  palpated  or  otherwise  distinguished  as  abnormal.  The  young  man  is 
still  alive,  so  the  absolute  fliagnosis  is  lacking.  One  or  two  other  pecu- 
liarities in  the  case  mentioned,  that  is  the  tremor,  was  not  so  constant,  only 
occurring  on  passive  or  vohmtary  activity  of  the  extremities.  The  open 
mouth  too  occurred  only  when  the  patient  indulged  in  some  emotional 
expression,  when  his  mouth  opened  and  remained  that  way  for  ten  or 
twenty  minutes.  Dr.  Church  believed  that  Wilson's  disease  of  the  original 
type  probably  does  not  cover  all  cases  assignable  to  the  same  group. 

Dr.  Hugh  T.  Patrick,  Chicago,  said  one  of  the  cases  came  to  aiitopsy 
and  in  one  of  the  cases  exception  was  taken  at  the  time  of  presentation  to 
paralysis.  A  few  weeks  later  a  friend  of  Dr.  Patrick  who  presented  the 
case  in  the  winter  said  in  relating  his  case  a  friend  of  his  suggested  it 
might  possibly  be  a  case  of  Wilson's  disease.  He  sent  after  this  patient 
to  come  into  the  city  and  he  was  repeatedly  examined  and  diagnosis  made 
and  autop.sy  and  the  true  disease  found.  So  in  that  case  the  picture  of 
paralysis  was  correct. 


AMERICAN  NEUROLOGICAL  ASSOCIATION  53 

Dr.  Tilney,  in  closing,  said  that  the  tremor  was  definitely  of  the  agitans 
type,  although  there  were  other  adventitious  movements  in  the  active  vol- 
untary motions  very  similar  to  chorea.  Dr.  Tilney  said  he  could  readily 
see  how  Gowers  called  his  cases  tetanoid  chorea.  The  movements,  how- 
ever, are  of  the  agitans  type,  except  that  they  were  increased  on  voluntary 
motion. 

HISTOPATHOLOGICAL  FINDINGS  IN  A  CASE  OF  LANDRY'S 

PARALYSIS;   DEMONSTRATED  BY  LANTERN  SLIDES 

AND  MICROPHOTOGRAPHS 

By  E.  D.  Fisher,  M.D. 

Points  for  discussion:  (a)  Differentiation  from  poliomyelitis;  (&)  Does 
the  clinical  history  confirm  the  diagnosis?  (c)  Unclassified  microorganisms 
as  etiological  factors  in  meningeal  and  parenchymatous  diseases  of  the  nerv- 
ous system. 

Dr.  Carl  D.  Camp,  Ann  Arbor,  Mich.,  stated  that  some  time  ago  he  re- 
ported a  case  of  acute  unilateral  ascending  paralysis  which  came  to  necropsy 
and  there  were  found  in  the  peripheral  nerves  very  much  the  same  degenera- 
tive changes  that  were  described  here.  At  that  time  he  also  noted  the  abnor- 
mality of  the  anterior  horn  cells  and  regarded  it  as  a  secondary  phenomenon 
to  the  changes  in  the  nerve. 

Dr.  E.  E.  Southard.  Boston,  thought  the  changes  in  the  cases  were  periph- 
eral and  not  central.  His  late  colleague.  Dr.  Emma  Mooers,  had  found  neu- 
ritis in  a  monkey  B  infected  from  a  characteristically  poliomyelitic  monkey 
A.  Material  from  monkej'-  B  had  produced  a  characteristic  poliomyelitis  in 
monkey  C.  Monkey  B,  however,  had,  after  elaborate  study,  demonstrated 
only  neuritis  and  no  central  changes  whatever.  Dr.  Mooers's  work  had 
accordingly  brought  proof  that  there  might  be  a  true  neuritic  form  of  the 
disease  called  poliomyelitis. 

Dr.  Sidney  I.  Schwab,  St.  Louis,  asked  whether  the  possibility  of  the 
neuritis  being  of  bulbar  type  was  considered.  Lately  in  the  St.  Louis  Chil- 
dren's Hospital  they  have  had  such  an  instance  in  which  the  bulbar  type 
was  so  acute  that  the  process  was  very  similar  to  the  type  of  paralysis  Dr. 
Fisher  described. 

Dr.  Israel  Strauss,  New  York,  considered  that  Dr.  Fisher  had  thought 
this  a  case  of  Landry's  paralysis.  Of  course  we  are  all  aware  that  cases  of 
Landry's  paralysis  occur  in  which  no  pathological  lesion  had  been  discovered. 
But  in  the  case  presented  by  Dr.  Fisher  Dr.  Strauss  thought  we  must  bear  in 
mind  the  fact  that  in  the  epidemics  of  poliomyelitis  we  have  had  cases  which 
presented  the  symptoms  of  polyneuritis.  In  fact  that  type  is  being  recognized 
to-day  as  a  distinct  class,  in  which  the  virus  affects  the  peripheral  nerves 
more  than  it  does  the  central  nervous  system.  We  have  even  found  in 
typical  poliomyelitis  a  certain  amount  of  degeneration  in  the  peripheral 
nerves.  From  the  lantern  slides  Dr.  Strauss  admitted  that  the  histological 
appearance  of  the  sections  of  the  cord  were  not  altogetlier  typical  of 
poliomj^elitis. 

There  is,  however,  only  one  proof  available  for  deciding  whether  this 
case  is  poliomyelitis  or  not.  The  microscopical  is  not  the  test.  The  only 
positive  method  is  the  intracerebral  inoculation  of  a  cord  emulsion  into  the 
monkey.  Dr.  Strauss  does  not  believe  there  is  any  other  method  by  wliich 
this  question  could  be  solved. 

Dr.  Singer  said  he  would  like  to  call  attention  to  the  close  similarity  in 
the  picture  of  the  findings  in  the  central  nervous  system  with  those  of  central 
neuritis.     They   correspond   closely   with   the   changes   found   in   pellagra,   in 


54  AMERICAN  NEUROLOGICAL  ASSOCIATION 

some  cases  of  alcoholism  and  in  other  intoxications.  The  chronic  interstitial 
changes  with  well- formed  fibrous  tissue  sliown  in  the  sciatic  nerve,  as  it 
would  seem  to  him.  could  hardly  have  been  due  to  an  inflammation  present 
only  six  weeks. 

Dr.  Fisher,  in  closing,  said  in  regard  to  the  question  of  diphtheria  that 
was  thoroughly  investigated  and  nothing  of  that  kind  found.  Every  possible 
examination  was  made.  Wassermann  reactions  were  carefully  carried  out 
by  the  health  department  and  in  their  own  laboratory.  Cultures  were  tried 
and  found  negative.  As  far  as  the  history  of  the  case  was  concerned  the 
boy  was  perfectly  well  up  to  about  six  weeks  before  his  death.  He  com- 
plained of  a  little  weakness.  He  was  a  very  active  boy.  a  messenger  boy,  and 
rode  a  bicycle  in  his  business.  It  does  not  look  as  if  he  had  much  neuritis 
at  any  time  previous  to  their  observation.  They  can  exclude  anything  like 
chronic  neuritis  as  far  as  clinical  symptoms  are  concerned.  It  appeared 
like  an  ordinary  case  of  polyneuritis.  It  pursued  the  usual  course  described 
in  Landry's  paralysis.  Later  the  upper  extremities  were  affected.  There  was 
marked  atrophy  of  the  hands.  Th.en  difficulty  in  swallowing  and  ocular  palsy 
occurred.  The  patient  almost  died  at  one  time  from  difficulty  of  respiration, 
and  twenty-four  hours  later  died  from  respiratory  failure.  In  regard  to  the 
microscopical  findings  Dr.  Fisher  said  he  would  leave  it  for  Dr.  Ncustaedter 
to  make  reply  to  the  questions  put.  These  specimens  have  been  examined  by 
Dr.  Dunlap,  Dr.  Flexner  and  others,  who  excluded  poliomyelitis.  It  might 
have  been  a  primary  neuritis  with  ascending  changes  passing  into  tlie  central 
nervous  system. 

Dr.  Neustaedter  said  he  would  take  exception  to  the  diagnosis  of  polio- 
myelitis. When  the  type  is  slow  and  begins  in  the  nervous  structures,  there 
is  set  up  an  entirely  different  picture  in  the  anterior  horn.  There  is  much 
perivascular  infiltration  and  pericellular  infiltration.  If  this  were  a  case  of 
poliomyelitis  Dr.  Neustaedter  would  expect  these  characteristics,  and  the 
lesions  should  have  led  to  the  patient's  death  much  earlier. 

OBSERV.\TIOXS   OX   IIKREDITARY  SYPHILIS   AFFECTIXG   THE 
XERVOUS  SYSTEM 

By  Carl  D.  Camp,  M.D. 

Varying  clinical  types  of  hereditary  syphilis  afTecting  the  nervous  system. 
Methods  of  diagnosis.     Relations  of  hereditary  syphilis  to  the  psychoneuroses. 

Dr.  William  W.  Graves,  St.  Louis,  said  tliat  an  individual  who  did  not 
[ircscnt  the  generally  recognized  signs  of  congenital  syphilis,  such  as  Hutchin- 
son's teeth,  inter.slitial  keratitis,  etc.,  the  possibility  of  syphilis  in  him  was 
too  often  exclude<l.  In  his  experience,  congenital  syi)hilis  alone  was  not  a 
frequent  factor  in  the  causation  of  tiie  epilepsies;  neither  was  it  a  frequent 
factor  in  those  cases  we  call  feebleminded.  The  chief  mental  characteristic 
which  he  had  found  in  congenital  syphilitics  was  precocity.  The  main  phys- 
ical characteristic-  of  the  congenital  syphilitic  is  deviation  from  parental  types. 
The  parents  and  cither  ascendants  should  be  used  as  standards  in  our  studies 
and  if  wc  will  d<»  this  we  cannot  fail  to  be  impressed  with  the  deviating 
characteristics  of  the  progeny  of  syi)hilitic  parents.  One  needs  only  to  study 
the  progeny  of  a  few  paretics,  tabetics  and  others  known  to  be  syphilitics  in 
a  comparative  anthropological  and  clinical  waj"  and  he  will  soon  learn  the 
great  value  of  such  studies  in  the  recognition  of  syjihilitic  progeny  and 
.syphilitic  ascendants.  Healthy  parents,  as  a  rule,  beget  a  healthy  progeny. 
Remembering  this  fact  when  wc  find  gross  deviations  in  all  of  the  progeny 
when  these  are  compared  with  the  parents,  we  should  seriously  consider  the 
possibility  that,  syphilid  i"  tli<-  "arcnts  has  been  responsible  for  the  deviations. 


AMERICAN  NEUROLOGICAL  ASSOCIATION  55 

Hence  it  is  that  famil}'  studies  will  enlarge  our  horizon  in  the  recognition  of 
congenital  syphilitics. 

Dr.  Carl  D.  Camp,  Ann  Arbor,  wished  to  emphasize  the  point  that  the 
negative  Wassermann  reaction  on  the  blood  of  the  parents  is  not  a  sufficient 
evidence  of  the  absence  of  syphilis  of  the  child. 

Dr.  Hugh  T.  Patrick,  Chicago,  asked  whether  in  any  of  these  cases  of 
hereditary  syphilis  Dr.  Camp  had  had  a  negative  reaction  on  the  blood  and  a 
positive  reaction  on  the  spinal  fluid. 

CIRCUMSCRIBED  PURULENT  MENINGITIS  LIMITED  TO 
FRONTAL  LOBE;  DUE  TO  SINUSITIS 

By  Samuel  Leopold,  M.D. 

Reports  of  two  cases  with  necropsy.  Unusual  limitation  of  lesion.  Study 
of  the  physical  signs.     Advisability  of  early  operation. 

Dr.  Southard,  Boston,  said  he  had  never  been  able  to  parallel  the  results 
of  meningitis  in  human  cases  with  experimental  meningitis  in  the  guinea-pig. 
He  had  tried  to  bring  evidence  from  human  cases  of  different  degrees  of 
resistance  to  infection  on  the  part  of  various  loci  in  the  meninges.  His  col- 
league, Dr.  Solomon,  at  the  Psychopathic  Hospital,  had  recently  done  work 
with  the  Lange  gold  sol  test  in  postmortem  cases,  showing  a  chemical  differ- 
entiation in  the  different  parts  of  the  cerebrospinal  fluid  system. ^  For  in- 
stance, the  ventricular  fluid  had  had  a  different  gold  sol  index  from  the  sub- 
pial  fluid  and  again  from  the  spinal  fluid. 

Dr.  Carl  D.  Camp,  Ann  Arbor,  said  in  a  case  which  was  found,  at 
necropsy,  to  be  an  acute  meningitis  covering  the  frontal  lobe  due  to  extension 
of  the  infection  from  ethmoidal  sinusitis  there  was,  as  a  symptom,  an  oval 
swelling  of  the  scalp  in  the  median  line.  This  was  due,  apparently,  to  a 
thrombosis  of  the  superior  longitudinal  sinus.  In  this  case  the  meningitis 
was  acute,  the  patient  dying  in  twenty-four  hours. 

Dr.  S.  Leopold,  in  closing,  said  a  lumbar  puncture  was  onl}-  made  in  the 
second  case.  The  first  case  was  moribund,  a  boy  of  14.  who  died  two  hours 
after  Dr.  Leopold  saw  him.  In  the  second  case  a  lumbar  puncture  showed 
the  absence  of  tubercle  bacillus  and  a  differential  of  the  blood  showed  the 
presence  of  89  per  cent,  poh'nuclears. 

Dr.  H.  H.  Hoppe,  Cincinnati,  said  this  subject  was  one  of  intense  interest 
in  a  practical  way.  In  the  first  place  when  we  see  these  cases  of  localized 
meningitis  it  is  impossible  to  tell  what  form  cHnicalh'  the  meningitis  is  going 
to  take.  He  called  attention  to  acute  mastoid  disease  in  young  children  and 
the  rather  quick  development  of  the  facial  paralysis  and  sixth  nerve  disease. 
In  all  of  those  cases  it  was  a  question  as  to  whether  or  not  we  are  going  to 
advise  some  operative  interference  for  the  relief  of  the  brain  condition.  Two 
weeks  ago  Dr.  Hoppe  was  asked  to  see  a  case  of  rather  sudden  development 
of  brain  symptoms.  The  woman  had  acute  headache  on  the  right  side,  per- 
sistent vomiting,  pulse  below  60,  very  little  fever  and  a  history  of  ethmoid 
cell  involvement  suggested  by  the  discharge  of  pus  from  the  posterior  nares. 
The  case  was  so  threatening  that  he  took  the  young  woman  in  his  own  car  to 
Cincinnati  and  placed  her  in  a  hospital  for  nose  and  throat  cases,  thinking 
that  some  verj-  quick  operative  interference  might  be  necessary.  The  only 
objective  signs  were  dropping  of  the  right  eyelid  and  a  congestion  of  the 
right  papilla.  There  was  found  verj'  acute  swelling  of  the  middle  turbinate 
bone  on  the  right  side.  This  was  operated  on  the  same  day  with  quick  relief 
of  the  general  symptoms.    The  headache  improved,  the  vomiting  ceased  and 

1  Boston  Medical  and  Surgical  Journal,  Vol.  CLXXI,  No.  24.  December 
10,  1914. 


56  AMERICAN  NEUROLOGICAL  ASSOCIATION 

the  patient  felt  verj-  much  more  comfortable.  The  operation  on  the  middle 
turbinate  was  followed  by  secondary  swelling  and  after  twenty-four  to  thirty- 
six  hours  the  symptoms  returned.  With  subsidence  of  the  swelling  the 
symptoms  disappeared,  but  returned  after  eight  or  ten  days  and  when  Dr. 
Hoppe  left  Cincinnati  that  was  the  condition  of  the  case.  The  case  is  a  very 
practical  one.  What  are  we  going  to  do  for  these  cases?  This  woman  evi- 
dently has  a  localized  meningitis  somewhere  on  the  surface  of  the  right 
frontal  lobe.  Are  we  going  to  open  up  at  once  or  give  an  abscess  a  chance 
to  form  ?     The  x-ray  examination  was  absolutely  negative. 

MENINGITIS  SYMPATHICA 
By  Israel  Strauss,  M.D. 

Occurrence  in  otitis  media,  mastoiditis,  inflammatory  sinus  thrombosis, 
suppuration  of  the  accessory  sinuses  of  the  cranium  and  brain  abscess. 

Character  of  the  changes  in  the  cerebrospinal  fluid.  Aseptic  character  of 
the  fluid.     Importance  from  a  diagnostic  and  prognostic  standpoint. 

Uifltercntial  diagnosis  from  meningitis  infectiosa  circumscripta  and  men- 
ingitis infectiosa  universalis. 

A  CASE  OF  CENTRAL  AND  PERIPHERAL  NEUROFIBROMATOSIS 
(VON  RECKLINGHAUSEN'S  DISEASE) 

By  Peter  Bassoe,  M.D.,  and  Frank  Nuzum,  M.I). 

Case  of  a  boy  15  years  old  at  death.  From  age  of  four  years  attacks 
once  a  year,  lasting  two  weeks  to  three  months,  of  pain  in  back  near  right 
scapula.  Dragging  of  left  foot  noted  after  first  attack.  At  ten  years  had 
eight  eye  muscle  operations.  Lump  on  left  side  of  neck  noted  three  years 
before  death,  a  pelvic  tumor  three  months  before  death.  Findings  on  exami- 
nation suggested  basal  brain  tumor  and  cord  tumor.  Several  subcutaneous 
nodules  led  to  correct  clinical  diagnosis. 

Necropsy:  Large  neurofibromata  in  both  cerebello-pontile  angles.  Large 
tumor  of  Cauda  equina.  Numerous  small  tumors  on  various  cranial  and 
spinal  nerves,  also  tumors  on  nerve  roots,  in  places  invading  the  cord.  Large 
tumor  outside  rectum. 

A  FREQUENCY  LIST  OF  MENTAL  SYMPTOMS  FOUND  IN  17,000 
INSTITUTIONAL   PSYCHOP.XTHIC   SUBJECTS    (DANVERS 
STATE  HOSPITAL,  MASSACHUSETTS) 

By  E.  E.  Southard,  M.I>. 

The  reader  discusses  briefly  the  findings  of  the  Index  Catalogue  of  symp- 
toms established  by  Dr.  Charles  Whitney  Page  at  tlie  Danvers  State  Hospital. 
Comparisons  arc  drawn  between  the  frequencies  in  the  whole  scries  and  in 
certain  constituent  series,  notably  a  scries  of  100  autopsicd  cases,  which  series 
has  again  been  s[)lit  into  a  "  normal-looking  brain  "  series  and  a  series  with 
gross  'organic  brain  lesions.  Special  attention  is  drawn  to  the  imprecision  of 
the  term  "  dementia." 

Dr.  Singer  said  the  paper  was  an  extremely  interesting  one  from  many 
points  of  view.  He  di«l  not  quite  understand  the  method  under  which  this 
work  was  done.  It  apparently  included  all  cases  which  had  been  committed 
to  the  hosi)ital  since  its  origin.  Dr.  Singer  asked  whether  any  particular 
definition  of  the  term  dementia  was  agreed  on  before  this  investigation  was 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  57 

begun,  and  especially  whether  it  was  that  definition  suggested  by  Dr.  Southard. 
Dr.  Singer  was  in  accord  with  Dr.  Southard  as  to  the  difficulty  in  drawing  a 
conclusion  from  old  records.  It  would  be  interesting  to  know  whether  the 
cases  of  more  severe  dementia  would  not  show  the  greater  histological  changes 
even  if  they  did  not  show  gross  change  in  the  cortex  as  Dr.  Southard  seemed 
to  claim. 

Dr.  Southard  confirmed  remarks  concerning  the  difficulty  of  making  the 
diagnosis,  dementia.  Dementia  is  probably  to  be  best  regarded  as  the  syn- 
drome and  not  as  a  symptom.  Even  the  modern  hospital  records  were  inade- 
quate in  the  matter  of  dementia.  Dr.  Southard  felt  that  most  dementias 
were  either  amnesias  or  attention  disorders,  or  combinations  of  the  two.  He 
further  commented  on  the  errors  in  the  catalogue  method.  He  thought  the 
order  of  frequency  was  of  more  significance  than  the  absolute  numerical 
frequencjr  of  the  symptoms. 


THE  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

April  23,  1915 

The  President,  Dr.  S.  D.  W.  Ludlum,  in  the  Chair 

CEREBELLAR   DIPLEGIA 
By  Williams  B.  Cadwalader,  M.D. 

John  S.,  41^2  years  old,  was  first  seen  in  March,  1915,  at  the  Orthopedic 
Hospital  and  Infirmary  for  Nervous  Diseases.  He  was  the  second  child, 
one  older  brother  and  one  younger  sister  being  healthy.  His  parents  were 
healthy  and  stated  that  he  had  been  born  at  the  full  term  without  compli- 
cations, but  had  developed  slowly,  both  mentally  and  physically.  He  was 
nearly  one  year  old  before  he  could  sit  up,  and  at  that  time  his  parents 
first  noticed  that  his  hands  "  trembled."  He  has  not  yet  learned  to  stand, 
because  of  great  unsteadiness  of  his  legs  and  trunk. 

On  examination  the  child  was  found  to  be  well  formed  and  nourished. 
He  could  not  stand  and  support  his  weight  on  the  legs  without  assistance, 
because  of  severe  incoordination.  When  steadied  by  the  examiner  holding 
both  the  patient's  hands  and  he  attempted  to  walk,  the  legs  were  thrown 
about  in  a  wildly  ataxic  manner.  On  voluntary  movement  of  the  upper 
extremities  there  was  a  marked  intension  tremor.  Muscular  power  of  the 
extremities  was  normal  and  equal,  but  there  was  extreme  hypotonus  of  all 
the  muscles.  The  tendon  reflexes  were  equal  and  active.  The  cranial 
nerves  were  normal.  His  eyes  were  normal  except  for  concomitant  squint. 
Articulation  was  very  indistinct  and  his  mentality  was  below  normal. 

Occasionally  he  has  vomited  for  no  apparent  reason.  His  parents 
said  that  he  had  had  two  attacks  in  which  consciousness  seemed  to  have 
been  disturbed  but  not  entirely  lost,  yet  their  description  was  too  vague 
to  decide  whether  or  not  he  had  had  any  convulsive  movements. 

The  most  striking  features  of  this  case  were  marked  hypotonus, 
asynergia,  ataxia,  disordered  phonation  and  articulation,  titubation,  attacks 
of  causeless  vomiting,  seizures  of  unknown  character,  normal  tendon  re- 
flexes, marked  mental  impairment,  probably  congenital  in  origin  and  caused 
by  defect  of  development  of  the  cerebellum. 


58  PHILADELPHIA  NEUROLOGICAL  SOCIHTV 

\RTERIOSCLEROSIS  WITH   SYMPTOMS   RESEMBLING   PSEU- 
DOBULBAR PALSY  OF  GRADUAL  ONSET 

By  George  E.  Price,  M.D. 

John  McB.,  age  6_>  years,  laborer  by  occupation;  birtliplace  Penn- 
sylvania. 

His  family  history  was  excellent,  both  parents  living  to  be  over  sev- 
enty. Five  sisters  and  two  brothers  are  living  and  in  good  health,  one 
sister  died  at  the  age  of  33  years  and  one  brother  was  killed  when  23. 

The  past  medical  history  is  uneventful.  He  had  the  usual  diseases  of 
childhood,  but  no  other  illness.  \'enereal  infection  was  denied,  but  when 
younger  he  used  alcohol  to  a  considerable  extent. 

The  history  of  his  present  condition  is  as  follows:  Five  years  ago  he 
experienced  some  difficulty  in  walking.  His  legs  seemed  weak  and  he 
had  a  dull  aching  in  his  back  and  lower  extremities.  Next  he  noticed  a 
staggering  in  his  gait  and  also  commenced  to  have  difficulty  with  his  speech. 
All  these  symptoms  gradually  increased  up  to  the  present  time  and  in  addi- 
tion he  has  some  difficulty  in  swallowing.  There  is  also  dribbling  of  urine. 
He  further  complains  of  occasional  headache  and  more  or  less  constant 
dizziness,  the  latter  being  accentuated  when  he  stoops. 

Upon  examination  tlie  gait  was  found  to  be  both  spastic  and  ataxic. 
"Romberg  sign  was  marked.  Tlie  pupils  were  small,  equal  and  reacted 
sluggishly  tu  light  and  accommodation.  There  was  marked  arcus  senilis 
and  occasional  slight  nystagmoid  movements  upon  lateral  excursions  of  the 
eyeballs.     No  external  ophthalmoplegia. 

The  speech  was  thick  and  drawling,  resembling  that  of  pseudobulbar 
palsy.  The  tongue  was  protruded  in  the  mid  line  without  difficulty.  The 
musculature  of  the  face  was  normal.  No  cranial  nerve  involvement. 
There  was  ataxia  of  both  upper  and  lower  extremities,  but  no  adiado- 
chokinesis.  The  reflexes  were  preserved,  the  patella  tendon  reflexes  being 
increased.  There  was  no  ankle  clonus,  but  Babinski's  sign  was  present  on 
both  sides.  Sensation  was  normal ;  there  was  no  astereognosis.  There 
was  no  muscular  wasting. 

The  lungs  were  negative.  There  were  no  cardiac  murmurs,  but  the 
first  sound  of  the  heart  was  diminished,  the  muscle  tone  being  decreased. 
The  pulse  rate  was  slow,  the  radials  being  much  thickened. 

Blood  pressure  (seated)  systolic  150;  diastolic  120. 

An  eye  examination  by  Dr.  Kamerly  was  as  follows:  Media  clear; 
optic  discs  normal ;  retinx  normal.  Veins  in  both  discs  full,  showing  slug- 
gish return  circulation. 

Urinalysis:  Acid  reaction  ;  specific  gravity  1,021  ;  no  sugar,  no  albumen. 
Few  leucocytes,  few  epithelial  cells.     No  casts. 

A  Wassermann  examination  of  the  blood  and  spinal  fluid  was  negative. 

Diagnosis:  The  absence  of  specific  history  and  the  negative  Wasser- 
mann reports  would  exclude  multiple  syphilis. 

The  ape  of  the  patient  and  the  absence  of  optic  atrophy  would  be 
opposed  to  insular  sclerosis.  There  was  no  intention  tremor  and  the 
speech  was  not  scanning,  but  thick  and  drawling. 

The  at"'  of  the  patient  and  the  cardiovascular  condition  point  toward 
p!  •  iierative  changes  in  both  hemispheres  secondary  to  arterio- 

s'  :omatosis,  with  probable  similar  changes  in  the  spinal  cord. 

Dr.  C  }>l.  Byrnes  said  this  case  was  especially  interesting  to  him  since 
he  had  been  studying  some  specimens  some  time  ago  in  Dr.  Spiller's  labo- 
ratory of  what  was  diagnosed  as  a  case  of  cerebral  arterial  sclerosis.  The 
patient  was  seen  by  several  competent  men,  among  tlicm  Dr.  Spiller,  and 
the  cabC  was  diagnosed  as  cerebral  arteriosclerosis.     He  bad  tlic  typical 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  59 

gait  with  short  steps.  The  patient  had  hemiplegia  with  some  mental 
changes.  At  autopsy  no  gross  changes  were  found  in  the  cerebral  vessels. 
For  that  reason  Dr.  Spiller  was  kind  enough  to  let  Dr.  Byrnes  have  the 
brain  to  study  in  more  detail.  About  200  sections  were  made  of  the  brain. 
Nowhere  was  there  even  in  the  cortical  vessels  any  gross  changes.  There 
was,  however,  a  moderate  round  cell  infiltration,  particularly  about  the  left 
chiasm,  about  the  anterior  surface,  and  about  the  cerebellum.  The  round 
cell  infiltration  suggested  luetic  infection.  He  had  marked  nephritis.  The 
question  arises  whether  a  condition  simulating  arteriosclerosis  can  be  due 
to  a  toxic  state.  Dr.  Byrnes  saw  a  case  in  Washington,  in  which  was  a 
nervous  condition  supposed  to  be  caused  by  infection.  There  was  no  his- 
tor}'  of  lues,  but  the  patient  had  chronic  appendicitis.  Strange  to  say  after 
appendectomy  the  condition  entirely  disappeared.  Undoubtedly  toxic  states 
can  produce  these  definite  changes.  Other  cases  have  been  described  by 
neurologists. 

FAMILIAL  MYOCLONUS 
By  John  H.  W.  Rhein.  M.D. 

The  patients  were  two  brothers,  in  whose  family  two  other  members, 
a  sister  and  a  brother,  were  similarly  affected.  The  patients  were  37  and 
39  years  of  age,  respective^.  In  the  case  of  Marion,  aged  39,  the  symp- 
toms began  at  12  years  of  age  and  in  Robert,  aged  2)7^  they  began  at  12 
years  of  age.  In  both  cases  the  disease  began  with  a  tremor  of  the  right 
hand  extending  to  the  right  leg  and  head  and  then  to  the  left  arm  and  leg. 
Robert  has  not  been  able  to  walk  for  several  months  on  account  of  the  vio- 
lence of  the  movement  when  he  attempts  to  walk  and  on  account  of  some 
weakness  not  true  parah'sis  in  the  legs.  The  movements  are  the  same  in 
both  cases  and  consist  of  to  and  fro  movements  of  the  arm  and  hand, 
rotarjr  movements  of  the  head,  the  head  turning  to  tlie  right,  the  muscles 
of  the  trunk  causing  jerking  back  of  the  shoulders  and  a  rotary  movement 
of  the  trvmk.  The  legs  are  affected  to  a  less  degree,  more  in  Robert  than 
in  Marion.  The  tremor  practically  affected  the  entire  musculature  but 
was  more  apparent  in  the  right  arm,  neck  muscles,  trunk  and  left  arm. 
The  movements  are  mild  during  rest  and  become  very  greatly  exaggerated 
upon  emotional  disturbances  and  upon  voluntary  effort.  In  the  case  of 
Robert  there  had  been  contractures  in  the  knee  Joint  which  were  broken 
up  under  ether  and  did  not  return.  The  tendon  of  the  quadriceps  femoris 
was  probably  cut  also. 

There  was  no  spasticity  of  the  knees  although  there  was  some  slight  rigid- 
ity apparent  at  times  in  the  case  of  Marion.  There  were  no  contractures  ex- 
cept of  the  tendon  Achilles  on  one  side,  the  right  in  the  case  of  Robert 
and  the  left  in  the  case  of  Marion.  The  knee  jerks  were  large  and  equal 
on  both  sides  in  the  case  of  Robert  and  slight  and  equal  in  the  case  of 
Marion.  There  was  no  Babinski  phenomenon  or  ankle  clonus  in  either 
case.  There  was  no  nystagmus  or  extra-ocular  paralysis  and  the  pupils 
responded  normally.     There  were  no  sensory  disturbances. 

In  the  case  of  Robert  the  tongue  was  pushed  slightly  to  the  left  and 
was  the  seat  of  a  tremor.  The  jaw  muscles  were  affected  in  both  cases. 
Both  calf  muscles  were  atrophied  in  the  case  of  Marion  and  the  left  thigh 
and  leg  in  the  case  of  Robert.  The  mental  condition  of  these  patients  was 
good.  There  was  some  difficulty  in  speech,  consisting  of  a  jerky  articu- 
lation. There  was  no  true  dysarthria  or  dysphasia.  There  was  no  dys- 
metria,  dyssjaiergia,  or  adiadochokinesis. 

The  family  history  is  as  follows:  The  maternal  grandfatlier  died  of 
apoplexy  and  the  maternal  grandmother  of  cirrhosis  of  the  liver  and 
seniHty.     The   paternal   grandparents   died  of   unknown   causes   in  middle 


6o  PHILADELPHIA  XEUROLOGICAL  SOCIETY 

life.     One  maternal  aunt  died  at  childbirth  and  one  maternal  aunt  and 
two  uncles  were  living  and  well. 

There  were  no  paternal  aunts  or  uncles.  Their  father  died  ot  apo- 
plexy and  their  mother  of  dropsy,  having  had  intermittent  attacks  of  mel- 
ancholia. There  is  no  history  of  nervous  disease  in  the  mother's  or 
father's  family. 

One  brother  died  at  birth  and  another  of  diphtheria.  There  were 
another  brother  and  one  sister  who  were  afYected  with  the  same  disease. 

The  diagnosis  in  these  cases  is  not  clear.  At  first  sight  a  diagnosis 
of  paramyoclonus  multiplex  was  suggested,  but  in  this  disease  voluntary 
acts  quiet  the  spasm  and  in  these  cases  the  reverse  is  true. 

Unverricht  has  described  a  familial  form  of  this  disease  associated 
with  ■  epilepsy.  There  was  an  absence  of  any  history  of  the  latter  in 
these  cases. 

The  absence  of  hypotonia,  dyssynergia,  dysmetria  and  adiadocho- 
kinesis  take  these  cases  out  of  the  category  of  those  described  by  Hunt 
under  the  title  of  dyssynergia  cerebellaris  progressiva.  These  cases  above 
described  resemble  to  a  certain  extent  progressive  lenticular  degeneration 
or  Westphal's  pseudosclerosis.  The  absence  of  pronounced  contractures 
and  spasticity,  and  the  duration  of  the  disease  is  against  the  diagnosis  of 
the  former;  while  the  lacking  of  dementia  which  is  looked  upon  as  char- 
acteristic of  pseudosclerosis  by  many  is  against  the  diagnosis  of  the  latter. 

The  cause  of  the  symptoms  in  these  cases  is  extrapyramidal  as  there 
were  no  exaggerated  reflexes  and  the  Babinski  phenomenon  was  absent. 
It  is  not  improbable  that  the  lenticular  nuclei  arc  the  seat  of  the  lesion 
in  these  cases. 

Dr.  William  (i.  Spiller  said  he  thought,  with  Dr.  Cadwalader,  that 
these  cases  should  be  placed  in  the  pseudosclerosis  class.  The  pseudo- 
sclerosis is  a  condition  concerning  which  we  are  learning  much.  It  seems 
to  be  a  lenticular  degeneration  with  changes  in  the  cortex  from  autopsies 
obtained.  Dr.  Rhein  spoke  of  absence  of  mental  disturbance.  It  is  true 
in  most  of  the  cases  of  pseudosclerosis  there  has  been  mental  disturbance. 
Dr.  Spiller  thought  those  who  state  that  there  must  be  mental  disturbance 
in  pseudosclerosis  are  going  further  than  facts  justify.  Recent  work  has 
demonstrated  that  pigmentation  of  the  cornea  and  of  the  liver  is  a  part  of 
pseudosclerosis.  He  did  not  know  whether  Dr.  Rhein  found  anything  of 
that  kind  in  his  cases.  Dr.  Spiller  said  the  cases  of  pseudosclerosis  he 
had  reported  at  a  previous  meeting  were  in  one  family. 

Dr.  Charles  K.  Mills  said  the  case  presented  looked  in  many  respects 
like  one  of  some  form  of  lenticular  disease.  It  would  be  remembered, 
however,  tliat  the  speaker  believed  we  have  a  cortico-striate  or  strio- 
cortical  apparatus  concerned  with  tonicity  and  it  seemed  to  him  that  a 
cortical  sclerosis  peculiarly  situated  might,  as  might  also  a  lenticular 
sclerosis,  give  the  symptomatology  exhibited  by  the  patient  who  has  no 
sensory  symptoms  an«l  he  believed  no  marked  motor  i)aralysis.  A  pecu- 
liar tremor  seems  to  be  the  most  striking  phenomenon  in  the  case,  without 
abnormal  reflexes.  VV'e  might  have  a  lenticular  or  cortical  affection  without 
any  markerl  mental  reduction,  or  at  least  not  any  more  decided  than  is 
present  in  some  cases  of  lenticular  disease. 

Dr.  Cadwalader  said  that  he  had  presented  the  first  case  just  shown 
by  Dr.  Rhein  before  this  Society  in  December,  1912,  and  it  was  recorded 
in  the  proceedings  under  the  title  of  "  Pseudosclerosis."  Dr.  Cadwalader 
referred  at  that  time  to  certain  similarities  which  it  bore  to  Wilson's  pro- 
gressive lenticular  degeneration. 

In  October  of  1914  he  had  reported  this  case  together  with  another 
in  the  Journal  of  the  American  Medical  Association  as  one  of  Wilson's 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  6i 

lenticular  degeneration,  and  he  still  believes  that  it  belongs  to  this  general 
group. 

The  difference  between  pseudosclerosis  and  lenticular  degeneration  on 
clinical  grounds  is  by  no  means  clear.  Dr.  Cadwalader  could  not  agree 
with  Dr.  Rhein  in  regard  to  his  statement  that  his  patients  did  not  have 
spasticity.  It  is  by  no  means  marked,  but  is,  in  Dr.  Cadwalader's  opinion, 
perfectly  distinct.  The  term  "  spasticity "  perhaps  is  not  a  good  one ; 
"  rigidity  "  might  be  better. 

Striimpell  has  pointed  out  that  the  degree  of  spasticity  is  greater  in 
Wilson's  disease  than  in  pseudosclerosis,  and  considers  this  one  of  the 
distinguishing  features.  Cases  have  been  reported  with  autopsy  by  Ger- 
man authors,  in  which  lesions  similar  to  those  of  pseudosclerosis  were 
found  in  the  cerebellum,  cerebral  cortex  and  different  parts  of  the  basal 
ganglia.  In  one  of  these  cases  the  alterations  of  the  neuroglia  tissue  were 
more  marked  in  the  lenticular  nucleus  than  in  other  parts  of  the  brain. 
It  may  be  that  spasticity  is  more  pronounced  when  the  alterations  are 
greater  in  this  region.  It  seemed  to  Dr.  Cadwalader  that  Wilson's  pro- 
gressive lenticular  degeneration  and  pseudosclerosis  must  be  grouped 
together  and  considered  as  modified  types  of  the  same  general  disease.  It 
is  true  that  this  point  of  view  may  appear  to  be  somewhat  premature, 
nevertheless,  recent  investigations  would  seem  to  indicate  that  this  will 
ultimately  prove  to  be  correct. 

Dr.  Charles  K.  Mills  said  he  would  like  to  say  an  additional  word 
regarding  the  term  tonicity  which  was  called  out  by  what  Dr.  Cadwalader 
had  said  about  the  remarks  of  Dr.  Rhein.  The  cases  of  Wilson's  disease, 
so-called,  after  all  only  represent  one  type  of  acute  or  subacute  disease  of 
the  lenticula  associated  with  disease  of  the  liver.  Most  of  the  symptoms 
present  are  due  to  aberrant  muscular  tonicity.  The  tremor  in  one  of  these 
cases  seemed  to  Dr.  Alills — unless  it  is  simply  an  asynergy  of  cerebellar 
origin  and  of  course  he  did  not  think  it  was  this — the  peculiarity  of  speech 
in  another  of  the  cases  and  most  of  the  symptoms  presented  belonged  with 
symptoms  which  come  under  the  general  head  of  aberrant  muscular 
tonicity.  We  confine  our  discussions  and  descriptions  too  much  to  hyper- 
tonicity  as  shown  in  a  spastic  or  rigid  musculature. 

Dr.  Rhein  stated  that  he  did  not  look  upon  his  cases  as  being  tj^pical 
ones  of  pseudosclerosis,  as  in  his  cases  there  was  no  dementia,  which  was 
characteristic  of  these  cases,  nor  marked  spastic  condition  of  the  muscles. 
In  Dr.  Rhein's  cases  there  was  little  or  no  spasticity.  There  was  at  times 
apparent  resistance  at  the  knee  joint  in  one  of  the  cases,  which  he  looked 
upon  as  the  result  of  the  muscular  contractions  due  to  the  tremor. 

MULTIPLE  SARCOMA  OF  BRAIN 
By  John  H.  W.  Rhein,  M.D. 

Dr.  Rhein  exhibited  the  brain  which  was  the  seat  of  a  multiple  sar- 
coma. The  patient  was  admitted  to  one  of  the  state  hospitals  for  the 
insane,  having  been  found  unconscious  along  the  roadside.  His  condition 
at  the  time  of  his  admission  was  one  o£  partial  amnesia.  He  was  talkative 
but  unable  to  give  his  name.  He  had  a  partial  insight  into  his  condition. 
He  stated  that  he  could  not  get  the  words  but  believed  that  sooner  or  later 
that  faculty  would  come  to  him.  When  shown  an  object  and  told  to  name 
it  he  would  say,  "  I  cannot  for  the  world  tell  you,  but  I  think  it  will  come 
sooner  or  later." 

The  patient  was  56  years  old  and  the  history  otherwise  is  lacking 
except  that  there  were  inequality  of  the  pupils  and  slight  impairment  of 
motion  of  the  right  leg.     The  brain  was  referred  to  Dr.  Rliein  by  Pro- 


62  PHILADELPHIA  XEUROLOGICAL  SOCIETY 

fessor  A.  Hewson  from  the  anatomical  laboratory  of  the  Philadelphia 
Polyclinic  Hospital  for  study. 

On  cross  section  there  presented  in  the  occipital  region  an  encapsu- 
lated brown  mass.  The  superior  portion  of  the  tumor,  however,  appears 
to  have  invaded  the  brain  tissue.  The  tumor  extends  from  the  base  of  the 
occipital  lobe  upwards  for  a  distance  of  5  cm.  and  measures  in  its  cross 
section  4  cm.  by  5  cm.  It  involves  the  cortex  of  the  pole  of  the  occipital 
lobe  as  well  as  the  lateral  cortex.  Anterior  to  this  tumor  is  a  circum- 
scribed mass  measuring  2  cm.  by  1.5  cm.  by  1.5  cm.,  presenting  an  area  of 
soft  material  which  can  be  readily  separated  from  the  brain  tissue  itself. 
Still  anterior  to  this  and  situated  in  the  temporal  lobe  is  a  third  circum- 
scribed area  or  tumor  encapsulated  and  measuring  4.5  by  3.5  cm.  by  2.5 
cm.,  presenting  on  cross  section  a  mottled  appearance.  In  its  internal 
portion  is  a  formed  clot.  Microscopic  study  was  made  of  these  tumors 
and  they  were  found  to  be  cylindrical-celled  sarcomas. 

The  organs  have  not  yet  been  studied  but  there  was  no  external  evi- 
dence of  sarcoma.  Hence,  it  cannot  be  stated  whether  the  growths  in  the 
brain  were  primary  or  not. 

Dr.  John  H.  W.  Rhein  presented  a  brain  showing  cerebellar-pontine 
angle  tumor  measuring  two  inches  in  diameter  which  compressed  the  pons 
and  pressed  upon  the  cerebellum  on  the  left  side.  The  tumor  had  no  con- 
nection with  the  brain  and  could  readily  have  been  removed  if  the  diag- 
nosis had  been  made  early  enough.  The  sj'mptoms  obtained  from  the 
physician  who  had  not  made  careful  notes  consisted  of  incoordination  of 
the  lower  extremities,  attacks  of  migraine,  some  ocular  paralysis.  The 
patient  could  not  walk  without  throwing  herself  all  about  the  room.  There 
was  no  paralysis  of  the  extremities  or  facial  paralj'sis.  Sensation  was 
undisturbed.  The  symptoms  were  of  five  years'  duration  and  occurred 
in  a  woman  of  25. 

Dr.  Ezra  Allen  (by  invitation)  read  a  paper  entitled  A  Study  of  Cell 
Division  in  the  Cerebellum  and  Demonstration  of  a  New  Technic  of  Stain- 
ing Mitotic  Figures. 

REGENERATION  OF  PERIPHERAL  NERVES 
By  J.  Greenman,   M.D. 

For  the  purpose  of  this  discussion  Dr.  Greenman  presented  a  bit  of 
work  which  was  done  in  order  to  secure  exact  data  as  to  the  number  and 
size  of  fibers  in  an  interrupted  nerve  which  had  been  permitted  to  regen- 
erate ;  and  to  compare  the  data  thus  secured  with  the  number  and  size  of 
fibers  in  the  corresponding  nerve  of  the  opposite  side. 

The  proximal  10  mm.  of  the  peroneal  nerve  of  the  albino  rat  was 
invariably  used  for  experimental  purposes.  No  branches  are  normally 
given  off  from  this  portion  of  the  nerve. 

Direct  comparison  of  the  peroneal  nerves  of  the  two  sides  of  tlie  body 
indicates  that  there  is  substantial  S3'mmetry  on  the  two  sides  as  respects 
their  numerical  composition  and  size  of  fiber.  It  was  assumed,  therefore, 
that  the  nerve  of  one  side  might  he  used  for  operation  and  tiiat  of  the 
op|)ositc  side  for  control. 

The  technique  of  operation  is  of  interest  in  this  connection  because 
the  diflficultics  which  were  overcome  have  suggested  certain  practical  appli- 
cations in  surgery  to  be  discussed  later. 

Cutting  the  Nerve— In  the  first  experiments  the  peroneal  nerve  was 
exposed  and  cut,  and  the  wound  closed  in  the  usual  manner  by  sutures  and 
sealed  by  means  of  collodion  and  cotton. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  63 

The  specimens  after  complete  regeneration  were  in  many  instances 
extremely  unfavorable  for  the  process  of  photographing  and  counting 
fibers  in  the  sections.  A  large  mass  of  connective  tissue  usually  formed 
about  and  between  the  cut  ends  of  the  nerve.  Into  this  mass  of  connective 
tissue  the  newly  formed  fibers  ramified  in  many  directions,  making  it 
difficult  if  not  impossible  to  secure  sections  of  the  nerve  in  which  the 
number  of  fibers  could  be  determined. 

Crushing  the  Nerve. — Interrupting  the  fibers  by  crushing  the  nerve 
was  tried.  In  these  cases  the  perineurium  was  left  intact  as  a  tube  con- 
necting the  divided  ends  of  the  nerve  fibers  crushed  within  it.  This  opera- 
tion was  followed  by  rapid  regeneration  of  the  nerve  fibers  within  the 
tube  of  perineurium  and  a  connective  tissue  mass  interfering  with  the 
parallel  arrangement  of  the  nerve  fibers  was  rarely  formed  at  the  point 
of  lesion. 

This  method,  however,  made  it  in  most  cases  difficult  if  not  impossible 
to  locate  the  exact  position  of  the  lesion  at  the  autopsy. 

Wire  Clamp  on  Nerve.— In  order  to  locate  the  exact  point  where  the 
fibers  were  interrupted,  a  No.  26  silver  wire  loop  about  lYz  mm.  in  length 
was  clamped  about  the  nerve  dividing  the  fibers  within  the  perineurium. 
This  wire  loop  was  allowed  to  remain  on  the  nerve.  Regeneration  fol- 
lowed, the  new  formed  fibers  bridging  over  the  wire  loop  to  continue  dis- 
tally  along  the  line  of  the  old  nerve  trunk. 

Sections  of  these  nerves  showed  parallel  fibers  which  in  most  cases 
were  easily  counted. 

This  method  of  interrupting  the  fibers  was  followed  in  all  subsequent 
work. 

The  immediate  eft'ect  of  the  operation  was  invariably  to  cause  a  paral- 
ysis which  resulted  in  a  flexion  of  the  toes  and  a  rotation  of  the  foot 
inward.  This  deformity  disappeared  rapidly  in  many  cases  after  the  lapse 
of  six  to  ten  days  and  it  was  difficult  to  detect  any  abnormality  in  the 
movements  of  the  animal.  This  disappearance  of  the  clinical  signs  of 
paralysis  suggested  a  readjustment  of  muscular  control  so  as  to  mask  in 
a  measure  the  paralysis  produced  by  the  operation. 

An  examination  of  the  operated  nerves  of  a  number  of  animals  imme- 
diately following  the  operation  showed  that  in  every  case  at  the  end  of 
the  fourth  day  there  was  complete  degeneration  of  the  segments  distal  to 
the  lesion. 

The  animals  used  varied  in  age  from  31  days  to  276  days  and  were 
killed  at  periods  varying  from  27  to  105  days  after  the  operation. 

The  right  (operated)  and  left  (intact)  peroneal  nerves  were  re- 
moved, fixed  and  sectioned.  The  animals  were  examined  in  groups  accord- 
ing to  age  at  the  time  of  killing.  Sections  from  the  proximal,  middle 
(nearest  to  point  of  lesion)  and  distal  portions  of  this  10  mm.  segment  of 
operated  nerve  were  examined.  Sections  from  the  middle  portion  of  each 
intact  (left)  nerve  were  examined. 

The  method  of  examination  was  to  make  photographs  of  the  sections 
and  count  the  fibers  by  the  Hardesty  method  of  pricking  a  hole  in  each 
fiber  of  a  photographic  print  and  recording  the  number  automatically  on 
a  counting  machine,  the  procedure  being  controlled  by  reference  to  the 
section  itself  under  the  microscope. 

From  each  section  of  a  nerve  the  forty  largest  fibers  were  selected 
and  the  sectional  area  of  each  fiber,  axis  c}dinder  and  sheath  was  deter- 
mined by  projecting  the  fiber  at  a  magnification  of  4,000  diameters  upon 
ground  glass  and  accurately  outlining  by  hand  the  axis  cj^linder  and  its 
surrounding  sheath.  The  sectional  area  of  these  outlines  was  then  deter- 
mined by  the  planimeter. 


64  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

Of  more  than  300  animals  operated,  44  furnished  the  data  from  which 
these  results  were  obtained. 

Omitting  a  discussion  of  the  details,  tlie  principal  facts  established  are 
as  follows : 

The  peroneal  nerve  of  the  normal  albino  rat  of  135  grams  body 
weight  contains  2,288  myelinated  fibers  in  its  proximal  end  and  2,323 
medullated  fibers  in  its  distal  end.  The  middle  zone  is  estimated  to  con- 
tain 2,306  fibers.  There  is  an  increase  of  1.5  per  cent,  of  the  proximal 
number  as  we  pass  from  the  proximal  to  the  distal  end  of  this  10  mm. 
segment  of  peroneal  nerve  due  to  branching.  The  number  of  fibers  is 
approximately  the  same  for  each  side. 

The  number  of  medullated  fibers  increases  with  body  weight  during 
the  first  276  days  of  life.     Older  animals  have  not  yet  been  examined. 

After  operation  not  only  is  there  complete  degeneration  along  the 
distal  segment  of  the  nerve  but  also  some  retrograde  degeneration  from 
2  mm.  to  3.2  mm.  on  the  proximal  side  of  the  lesion. 

The  general  effects  of  the  operation  are  more  pronounced  on  older 
animals. 

Following  the  degeneration  in  the  operated  nerve,  regeneration,  accom- 
panied by  branching  of  axons,  takes  place  and  there  is  an  increase  of  from 
64  to  249  per  cent,  in  the  number  of  fibers  on  the  proximal  side  of  the 
lesion,  more  than  7.000  fibers  appearing  in  some  cases  just  proximal  to 
the  lesion  in  a  nerve  which  should  show  about  2,300  fibers. 

The  number  of  fibers  found  on  the  distal  side  of  the  lesion  is  less  than 
on  the  proximal  side,  but  the  number  always  exceeds  that  found  in  the 
left  or  intact  nerve. 

On  passing  from  the  most  proximal  end  of  the  operated  nerve  the 
number  of  regenerated  fibers  rapidly  increases  as  the  region  of  the  lesion 
is  approached ;  the  number  decreases  as  we  pass  from  the  lesion  distally. 
Over  13  per  cent,  of  the  excess  regenerated  fibers  arise  from  a  point 
more  than  7  mm.  above  the  lesion. 

Sectional  Area  of  Fibers. — The  average  sectional  area  of  the  ten 
largest  fibers  in  the  middle  zone  of  the  peroneal  nerve  of  a  normal  albino 
rat  of  135  grams  body  weight  was  found  to  be  113.6  square  micra. 

The  average  sectional  area  of  the  ten  largest  fibers  from  the  intact 
(left)  nerve  of  an  operated  albino  rat  of  156  grams  body  weight  is  65.7 
square  micra. 

One  of  the  results  of  operation  is,  therefore,  a  loss  in  sectional  area 
of  nerve  fibers  of  the  corresponding  intact  nerve.  In  this  instance  the 
loss  is  42  per  cent. 

The  intact  nerve  (left)  of  an  operated  animal  contains  fewer  fibers 
than  the  same  nerve  from  a  normal  control  animal  of  the  same  age.  This 
loss  is  one  of  the  effects  of  the  operation  and  was  found  to  be  16  per  cent. 
in  the  cases  examined. 

It  now  remains  to  be  determined  whether  this  loss  in  number  and  in 
sectional  area  of  fibers  in  the  intact  (left)  nerve  of  an  operated  animal  is 
a  general  effect  upon  the  entire  peripheral  system  produced  by  the  opera- 
tion, or  whether  it  is  due  to  the  arrest  of  growth  or  atrophy  during  the 
period  between  operation  and  killing  or  whether  it  is  an  effect  transmitted 
from  the  operated  nerve  across  through  the  cord  to  the  opposite  side. 

The  sectional  area  of  the  ten  largest  fibers  on  the  proximal  side  of 
the  lesion  is  55.8  square  micra  or  15  per  cent,  less  than  the  area  of  the 
fibers  of  the  intact  nerve. 

The  sectional  area  of  the  ten  largest  regenerated  nerve  fibers  on  the 
distal  side  of  the  lesion  is  29.9  .square  micra  or  54  per  cent,  less  than  the 
area  of  tlie  fibers  in  the  intact  nerve. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY 


65 


In  the  normal  albino  rat  of  135  grams  body  weight  the  axis-sheath 
relation  of  the  fibers  of  the  peroneal  nerve  is  as  follows : 

Area  of  axis   51.8  per  cent. 

Area  of  sheath  48.2  per  cent. 

In  operated  animals  in  which  the  fibers  of  both  intact  and  interrupted 
nerves  are  all  diminished  in  total  area,  the  axis  sheath  relation  is  such 
that  in  the  intact  nerve  and  in  the  proximal  and  distal  ends  of  the  operated 
nerve  the  area  of  the  axis  is  relative^  less  than  in  the  fibers  from  the 
normal  animal. 

One  of  the  most  important  points  here  developed  is  the  fact  that 
operation  reduces  the  number,  size  and  axis  sheath  relations  of  fibers  on 
the  intact  side. 

Surgical  Application. — The  rapidity  and  perfection  with  which  a  nerve 
regenerates  within  its  own  unruptured  perineurium  after  the  crushing 
process  above  referred  to  has  led  Dr.  J.  E.  Sweet  to  suggest  an  artificial 
method  of  protecting  a  regenerating  nerve  from  becoming  entangled  in 
an  obstructing  mass  of  connective  tissue. 

A  series  of  albino  rats,  all  100  days  of  age,  was  operated  by  Dr.  Sweet. 
The  same  segment  of  peroneal  nerve  was  selected  for  operation  and  the 
same  for  control  as  in  the  previous  experiments.  In  each  case  the  nerve 
was  cut  and  sutured  with  human  hair  and  a  short  piece  of  celloidin  tube 
impregnated  with  lamp  black  was  placed  over  the  point  of  suture.  The 
animals  were  killed  after  50  days  and  it  was  Dr.  Greenman's  privilege  to 
make  the  examination  of  the  regenerated  nerves,  and  compare  them  with 
their  intact  controls. 

The  characteristic  regenerated  fibers  were  found  in  the  tube  in  nine 
operations  out  of  eleven.  These  regenerated  fibers  appear  in  parallel 
bundles  throughout  the  tube  with  very  much  less  of  the  interlacing  which 
occurs  when  a  nerve  is  sectioned  and  sutured  and  permitted  to  regenerate 
without  protection  from  connective  tissue  masses. 

Sections  through  the  celloidin  tube  show  within  this  tube  an  outer 
layer  of  organized  lymph  gradually  giving  place  to  connective  tissue  struc- 
ture on  its  inner  wall  surrounding  the  nerve. 

The  fibers  in  the  intact  nerve  of  eleven  animals  have  been  counted  and 
show  an  average  of  2,080  fibers  at  the  middle  zone  of  the  10  mm.  of  nerve 
for  a  white  rat  of  150  days  of  age  and  237  grams  body  weight. 

In  three  of  these  animals  the  number  of  fibers  in  the  operated  nerve, 
as  well  as  in  the  intact  nerve,  has  been  determined  and  presents  the  fol- 
lowing results : — 


Age 

Body  Weight 

Fibers  in  Intact 
Nerve 

Fibers  in  the 
Operated  Nerve 

151  days 

151  days 

154  days 

267.5 
265.0 
241.5 

2,129 
2,057 
2,048 

2,581 
3.930 
2.343 

Average  152  days 

258.0 

2,078              1               2,951 

While  the  operated  nerves  show  a  considerable  increase  in  the  number 
of  fibers,  about  the  same  average  as  in  previous  work,  the  extreme  limits 
in  number  of  fibers  found  in  previous  work,  7,611  in  one  instance,  is  not 
reached  in  any  of  these  cases. 

The  determination  of  the  number  of  fibers  in  the  other  operated  nerves 
of  the  series  must  yet  be  made  before  it  is  safe  to  say  that  the  average 
number  of  regenerated  fibers  is  less  when  operation  is  done  in  this  manner. 


66  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

In  nine  operations  out  of  eleven  our  examination  of  the  tube  contents 
leads  one  to  conclude  that  the  indestructible  protecting  tube  favors  rapid 
and  direct  regeneration  and  does  eliminate  to  a  marked  degree  the  con- 
nective tissue  interference. 

The  furtlier  treatment  of  tliis  subject  will  be  given  by  Dr.  Sweet  who 
devised  this  method  of  protecting  regenerating  nerves. 

Dr.  J.  E.  Sweet  said  there  are  certain  problems  in  medicine  and 
surgery  which  can  be  approached  by  animal  experiment;  others  that 
can  only  be  studied  in  the  clinic;  still  others  which  can  only  be  defi- 
nitely solved  by  a  proper  balancing  of  both  methods.  For  example,  the 
study  of  ununited  fracture  is  a  clinical  problem ;  we  cannot,  as  yet  at 
least,  study  it  experimentally  for  normal  bone  will  heal  after  fracture,  and 
the  experimental  animals  are  all  normal  animals.  The  problems  confront- 
ing Us  in  relation  to  the  peripheral  nerves  are  largely  clinical  problems. 
Normally  nerves  will  regenerate  and  unite  after  being  severed;  a  number 
of  cases  are  on  record  of  union  even  after  considerable  loss  of  substance 
and  no  operative  interference.  Just  as  in  ununited  fracture,  the  reason 
why  some  nerves  will  not  unite  may  depend  upon  conditions  quite  apart 
from  the  operative  technique ;  these  reasons  for  failure  not  being  under- 
stood cannot  be  experimentally  reproduced,  therefore  the  problem  is  a 
clinical  problem. 

Suppose  a  severed  nerve  has  been  operated  upon  and  has  healed.  It 
may  have  healed  and  function  may  return,  but  a  careful  study  of  the  result 
would  show  that  it  was  functioning,  in  spite  of  the  operation,  not  because 
of  the  operation.  Or  it  may  not  heal  properly,  function  does  not  return ; 
is  this  perhaps  because  the  operation  was  not  properly  done?  Or  is  it 
because,  perhaps,  the  muscles  supplied  by  the  nerve  have  so  completely 
atrophied  that  no  physiological  demand  exists  for  the  function  of  that 
nerve  ? 

A  clinical  success  does  not  necessarily  mean  that  surgery  has  been 
perfect.  To  illustrate :  Dr.  Sweet  often  has  his  students,  both  under- 
graduates and  postgraduates,  perform  an  end-to-end  anastomosis  of  the 
intestine.  The  dog  recovers  promptly,  shows  no  untoward  symptoms 
whatever,  clinically  it  is  a  success ;  but  an  autopsy  may  show  a  condition 
of  adhesions  such  that  the  only  permissible  conclusion  is  that  nature  lias 
overcome  all  the  difficulties  interposed  by  surgery. 

This,  then,  seemed  to  him  to  be  the  fundamental  problem  in  the  sur- 
gery of  the  peripheral  nerves;  when  we  succeed,  clinically,  do.  we  succeed 
because  of,  or  in  spite  of,  surgery?  When  we  fail,  do  we  fail  because  some- 
thing was  wrong  with  our  technique,  or  because  some  unknown  conditions 
are  present  in  the  muscles  or  the  nerves  which  make  success  impossible? 

When  Dr.  Sweet  learned  of  Dr.  Grecnman's  work  it  seemed  to  him 
that  his  method  of  study  offered  a  means  of  determining  what  we  might 
expect  from  our  techni<iue  alone.  Further,  Dr.  Grecnman's  experience, 
that  he  was  unable  to  accomplish  the  desired  result  by  using  the  standard 
surgical  method  of  direct  suture  of  the  nerve,  with  the  specimens  that  he 
had  preserved  from  these  attempts,  oflfered  at  once  a  control  and  also  the 
proof  that  mere  clinical  success  is  not  necessarily  the  highest  criterion  of 
surgical  technique.  These  rats  all  recovered  clinically,  but  the  results, 
whcn.examinecl  by  Dr.  Grecnman's  method  of  study,  are  far  from  ideal. 

The  method  therefore  adopted  was  to  use  the  same  nerve  in  the  same 
animal  in  which  Dr.  Cireenman's  results  were  obtained.  These  results 
were  then  turned  over  to  Dr.  Greenman  and  judged  by  him  in  comparison 
with  his  standard  of  success. 

An  idea  not  new  in  surgery  was  adopted,  the  idea  of  enclosing  the 
nerve  in  some  sort  of  a  tube  which  would  keep  the  surrounding  connective 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  67 

tissue  from  growing  in  between  the  nerve  ends  and  thus  interposing  an 
insurmountable  barrier  to  the  regenerating  nerve  fiber.  The  principle  is 
not  new,  but  the  tendency  of  surgeons  has  been  to  provide  some  sort  of  a 
tube  which  would  eventually  become  absorbed,  such  as  decalcified  bone,  or 
a  vein  taken  from  the  patient,  or  a  hardened,  formalized  artery  from  an 
animal.  Since  all  absorbable  substances  are  replaced  by  connective  tissue, 
he  proceeded  purposely  to  the  extreme  of  using  a  tube  which  should  not 
be  absorbed, — and  used  celluloid  tubes.  The  tubes  were  further  impreg- 
nated with  lamp  black,  in  order  that  they  could  be  identified  in  the  sec- 
tions. The  nerve  was  cut,  sutured  with  a  single  delicate  silk  thread  or  a 
human  hair  and  a  celluloid  tube  slipped  over  the  anastomosis.  The  results 
are  as  follows : 

Successful    9. 

Negative    i.  No  tube  found.     Tube  may  have  been  there. 

Failure    i.  Nerve  not  in  tube.     May  have  been  pulled  out. 

He  concludes  that  it  is  surgically  possible  to  so  unite  a  severed  nerve 
that  we  can  be  certain  of  a  surgical  success,  not  only  as  judged  by  the 
standard  of  functional  result,  but  also  by  the  standard  of  microscopic 
examination  ;  while  such  a  conclusion  is  not  epoch  making,  he  feels  that 
it  means  this,  that  a  neurologist  can  be  free  of  the  haunting  fear  that 
maybe  the  surgeon  slipped,  somewhere,  and  can  look  for  the  reasons  for 
failure  in  a  given  case  within  the  realms  of  his  own  domain,  such  as  muscle 
atrophy,  disuse  atrophy,  or  in  that  field  alone  understood  by  the  neurolo- 
gist, the  functional  disturbances  of  the  peripheral  nerves. 

Dr.  Spiller  said  this  work  was  interesting  both  from  the  laboratory 
and  clinical  viewpoints.  The  work  of  Dr.  Greenman  had  shown  that  after 
a  nerve  is  cut  there  is  a  very  great  overgrowth  of  nerve  fibers  in  the  cen- 
tral portion  of  the  stump,  greater  near  the  point  of  section.  He  seems  to 
have  proved  that  the  view  is  incorrect  that  the  regeneration  of  a  cut  nerve 
is  entirely  in  the  peripheral  end.  Dr.  Spiller  said  Dr.  Greenman  had  made 
the  statement  that  without  the  tube  he  found  something  like  7,000  nerve 
fibers  in  the  central  end  of  the  nerve  at  the  point  of  section.  If  he  used 
the  tube  he  had  much  fewer.  The  conclusion  would  seem,  therefore,  that 
if  a  tube  be  not  used  there  is  a  greater  growth  of  fibers,  possibly  because 
sclerotic  tissue  interferes  with  regeneration  and  spurs  the  nerve  on  to  the 
formation  of  more  fibers. 

There  was  one  other  point  to  which  he  would  refer,  and  that  is  the 
left  peroneal  nerve  is  considerably  smaller  in  an  animal  in  which  the  right 
peroneal  nerve  has  been  cut  than  in  a  normal  animal.  That  is  a  fact  of 
clinical  interest.  This  result  would  seem  to  be  dependent  upon  the  spinal 
cord.  It  may  be,  therefore,  that  some  of  the  nerve  cells  which  supply  the 
right  peroneal  nerve  are  associated  with  those  which  supply  the  left  peroneal 
nerve.  The  clinical  importance  of  this  is  in  relation  to  work  done  in  arthritic 
muscular  atrophy.  Raymond  showed  many  years  ago  that  if  he  took  a 
certain  number  of  animals  and  produced  joint  disease  in  all  of  them  he 
obtained  no  muscular  atrophy  in  those  in  which  he  had  previously  cut  the 
posterior  roots  in  connection  with  the  joint  affected.  Dr.  Allen,  now  of 
California,  had  repeated  that  work. 

Dr.  Greenman  said  when  there  is  obstruction  in  the  way  of  the 
regenerating  nerve  nature  seems  to  make  every  effort  to  replace  these 
nerve  fibers  by  this  enormous  increase  in  the  number  of  fibers  which  at- 
tempt to  find  their  way  through  the  connective  tissue  at  many  points. 
When  a  tube  is  used  the  path  of  the  regenerating  nerve  is  not  obstructed 
by  connective  tissue,  and  we  have  the  regeneration  of  a  nerve  with  fewer 
fibers.     In  such  a  case  it  seems  to  be  a  perfectly  plain  instance  of  follow- 


68  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

ing  the  line  of  least  resistance,  but  where  there  is  a  large  amount  of  con- 
nective tissue  the  nerve  branches  vary  many  more  times  and  give  this 
large  increase  in  number  of  fibers.  As  to  the  reduction  in  size  of  the 
control  nerve  fibers  as  the  result  of  operation,  there  are  several  factors 
which  should  be  considered.  They  operate  on  an  animal  lOO  days  of  age 
and  kill  it  at  50  days  of  age.  The  operation  may  have  interfered  with  the 
normal  processes  of  growth  in  that  50  day  period.  This  may  account  for 
the  reduction  in  size  on  the  control  side;  then  again  the  operation  may 
produce  a  general  effect  on  the  whole  peripheral  system,  causing  a  reduc- 
tion in  size  of  all  fibers  or  the  effects  of  operation  on  one  side  may  be 
transmitted  to  the  opposite  side  through  the  cord,  resulting  in  reduction 
in  size  of  fibers  only  in  a  selected  region.  Experiments  are  under  way 
to  elucidate  these  points. 

THE  PSYCHOLOGY  OF  STAMMERING 
By  G.  Hudson  Makuen,  M.D. 

Stammering  is  an  affection  characterized  by  the  inability  to  freely  use 
oral  language  in  the  expression  of  thought  and  feeling. 

It  appears  in  two  more  or  less  distinct  stages,  an  initial  or  acute  stage 
and  a  chronic  stage.  The  initial  stage  usually  begins  during  childhood, 
and  the  patient  is  often  unconscious  of  his  difficulties,  while  the  chronic 
stage  is  characterized  by  increasing  difficulties  of  speech  and  a  full  con- 
sciousness of  their  existence.  As  the  patient  begins  to  realize  his  diffi- 
culties, the  secondary  manifestations,  such  as  mental  confusion,  anxiety, 
fear,  and  the  accompanying  autosuggestions,  arise  and  seem  to  assume 
causal  relations  to  the  affection  and  tend  to  aggravate  and  perpetuate  it. 

In  seeking  the  underlying  or  primary  cause  of  stammering,  the  diffi- 
culty has  been  to  find  one  that  will  explain  all  the  various  phenomena  of 
the  affection.  The  most  recent  suggestion  as  to  the  etiology  of  stammer- 
ing and  the  one  that  seems  best  to  meet  the  conditions  is  that  the  affection 
is  due  to  a  weakness  or  irritability  of  the  auditory  speech  center,  and  this 
condition  has  been  called  a  transient  auditory  amnesia. 

Whatever  may  be  the  ultimate  or  predisposing  cause  of  stammering, 
it  is  a  fact  that  stammerers  appear  to  be  unable  to  arouse  into  conscious- 
ness the  precise  auditory  images  of  certain  elements  of  speech  which  are 
absolutely  essential  to  their  prompt  cxternalization.  There  are  doubtless 
many  factors  which  combine  to  bring  about  this  condition,  but  the  condi- 
tion itself  seems  to  be  in  many  respects  amnesic  or  aphasic  in  character, 
and  the  treatment  of  the  affection  which  is  based  upon  this  theory  appears 
to  give  the  most  satisfactory  results. 

The  cure  of  stammering  consists  largely  in  the  restoration  or  develop- 
ment of  a  more  vivid  and  distinct  auditory  imagery  for  speech  sounds. 

Stammerers  are  made  up  of  what  someone  has  called  congenital 
aphasics.  They  begin  life  with  a  weakness  in  the  psychomotor  speech 
centers,  and  unless  they  receive  the  necessary  help  in  the  development  of 
normal  speech  during  early  childhood,  they  acquire  a  faulty  action  in  both 
the  central  and  peripheral  mechanisms  of  speech  which  renders  them  liable 
to  the  develojjmi-nt  <t(  that  particular  form  of  defective  speech  which  we 
call  stammering. 

Dr.  J.  Hcndrie  Lloyd  said  there  were  several  ways  in  which  a  neurolo- 
gist might  approach  this  subject.  In  the  first  place.  Dr.  Makucn's  theory 
that  stammering  is  a  form  of  auditory  amnesia  is  an  interesting,  and  to 
Dr.  Lloyd  a  rather  novel  one.  Dr.  Lloyd  was  in  full  accord  with  Dr. 
Makucn's  idea  that  the  auditory  center  is  the  primary  speech  center,  and 
'"    '    former  paper  before  this  Society  Dr.  Lloyd  put  forward  this  view. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  69 

Bastian's  idea  of  a  "  primary  couplet,"  composed  of  the  auditory  center 
and  the  motor,  or  glosso-kinesthetic,  center,  as  the  primary  speech  zone, 
is  in  accord  with  this  opinion,  and  of  these  two  centers  Dr.  Lloyd  thought 
the  auditory  center  was  the  more  important.  It  is  in  that  center  that  we 
acquire  our  first  knowledge  of  and  our  strongest  hold  on  speech.  It  is 
in  that  auditory  center  that  the  child  learns  its  mother  tongue.  Moreover, 
the  auditory  center  exercises  a  peculiar  control  over  speech.  Its  integrity 
is  absolutely  essential  to  the  exercise  of  the  function  of  speech.  This  is 
so  especially  in  the  child,  while  it  is  learning  to  talk,  and  it  continues  so 
all  through  later  life,  for  motor  speech  depends  upon  our  memories  of 
auditory  speech  :  it  is  simply  a  process  of  reproducing  auditory  memories 
by  vocalizing  them. 

If  stammering  results  from  a  defect  in  that  auditory  center,  we  may 
suppose  that  in  the  stammering  child  that  center  for  some  reason  has  failed 
to  undergo  a  complete  development,  and  that  the  auditory  speech-memories 
are  defective.  They  are  not  entirely  deficient,  but  they  are  sluggish.  The 
child  is  unable  to  summon  them  into  consciousness  with  the  rapidity  and 
precision  that  are  requisite  in  uttering  speech,  and  stammering  results. 
One  difficulty  in  the  way  of  accepting  this  theory  may  be  that  in  the  adult 
who  from  disease  acquires  sensori-motor  aphasia,  we  do  not  see  stammer- 
ing in  its  typical  form  reproduced;  nevertheless,  Dr.  Lloyd  thought  that 
in  some  sensori-motor  aphasics  we  see  something  very  much  like  stam- 
mering. This  for  him  remains  a  subject  for  further  investigation;  and 
in  the  future  he  intends  to  observe  more  carefully  whether  in  these  sensori- 
motor aphasics,  in  whom  the  auditory  as  well  as  the  motor  center  is  in- 
volved, he  can  detect  a  true  condition  of  stammering.  It  must  be  borne 
in  mind,  however,  that  an  undeveloped  organ  does  not  act  precisely  like  a 
developed  organ  that  has  been  injured,  hence  there  may  not  be  a  perfect 
analogy  between  the  two  conditions,  i.  e.,  in  the'  stammering  child  and  in 
the  aphasic  adult. 

The  query  has  arisen  in  Dr.  LIo3'd's  mind,  can  stammering  ever  be- 
due  to  a  lenticular  lesion  ?  The  lenticula,  as  we  know,  is  now  very  much 
in  the  limelight.  Kinnier  Wilson  holds  that  lenticular  lesions  cause  a  sort 
of  jerky  action  in  the  pyramidal  fibers.  Dr.  Mills  thinks  the  defect  is  in. 
a  tonectic  series  of  fibers.  There  seems  to  Dr.  Lloyd  to  be  a  possible 
analogy  in  stammering,  although  it  is  rather  remote.  As  stammering 
usually  begins  in  childhood,  we  should  have  to  suppose  that  the  lenticula 
had  in  some  way  gone  wrong  in  early  development.  As  he  believes  that 
the  lenticula  is  largely  a  vestigial  organ,  he  should  have  no  difficulty  in 
supposing  that  it  is  capable  of  promoting  disorder,  rather  than  of  serving 
any  good  purpose,  but  he  is  not  prepared  to  say  that  it  is  a  universal  cause 
of  stammering.     He  only  throws  this  out  as  a  suggestion. 

It  must  not  be  overlooked  in  this  connection,  moreover,  that  a  very  bad 
form  of  stammering  is  sometimes  seen  in  connection  with  organic  or  devel- 
opmental disorders  in  the  nervous  sj^stem.  There  are  certain  obscure 
forms  of  ataxia,  call  them  cerebellar  or  what  we  please,  in  which  there  is 
widespread  disorder  of  the  motor  functions  in  the  limbs  and  in  which  we 
see  grave  speech  defects,  not  unlike  stammering.  The  same  can  be  said 
of  cerebral  diplegia,  in  which  a  grave  defect  in  the  enunciation  of  speech, 
very  much  like  an  exaggerated  stammering,  is  seen.  In  some  of  these 
organic  stammerings,  however,  the  defect  is  entirely  motor ;  it  can  not  be 
ascribed  to  an  auditor}'  amnesia ;  it  is  due  to  the  same  lesion  that  has 
impaired  to  a  large  extent  the  whole  of  the  pyramidal  system.  Neverthe- 
less, some  of  these  patients  are  entirely  aphasic.  Dr.  Lloj-d  therefore  con- 
cludes that  there  may  be  various  forms  of  stammering,  not  all  of  them 
explainable  by  one  cause. 


7o  PHILADELPHIA  XEUROLOGICAL  SOCIETY 

Finally,  a  word  about  the  psychical  or  emotional  states  seen  in  many 
stammerers'.  Dr.  Makuen  has  called  attention  to  them,  and  has  pointed 
out  their  important  influence  in  confirming  what  we  may  call  the  stam- 
mering psvchosis.  These  are  especially  states  of  apprehension,  fear,  and 
mortification.  Dr.  Llovd  would  liken  them  to  morbid  fears,  or  phobias, 
seen  in  certain  states  which  we  call  psychasthenia.  In  the  stammerer  they 
have  to  do  exclusively  with  the  exercise  of  the  organs  of  speech,  hence 
they  are  kinesthetic ;  or  more  properly  kinetic;  that  is,  they  belong  to^  the 
morbid  fears  which  are  evoked  by  the  ideas  of  certain  movements.  Such 
morbid  fears  of  movement  are  seen  in  other  conditions  than  stammering. 
Moebius  has  described  a  motor  disorder  which  he  calls  akinesia  algera, 
which  depends  apparently  upon  an  inhibitory  imperative  conception.  The 
patient  dreads  to  move  for  fear  of  pain,  which,  however,  is  entirely  imagi- 
nary-. The  affection  is  allied  probably  to  the  intention  psychoses,  such  as 
claustrophobia,  agoraphobia,  etc.  Dr.  Lloyd  formerly  suggested  that  the 
word  kinesiphobia.  fear  of  movement,  better  expressed  the  mental  state 
in  these  patients,  as  there  is  no  real  pain,  but  only  a  morbid  fear  of  pain 
to  be  caused  by  the  movement.  It  is  a  fear  of  pain  analogous  to  the  fear 
of  contamination,  called  mysophobia,  and  is  as  unreal  in  the  one  case  as 
in  the  other.  Dr.  Lloyd's  term,  however,  has  never  gained  currency, 
although  he  still  thinks  it  is  not  a  bad  one.  In  stammerers  there  is  a 
similar  inhibitory  idea,  the  fear  not  of  physical  pain,  but  of  mental  pain, 
such  as  mortification  ;  but  the  two  kinds  of  pain,  physical  and  mental,  are 
strictly  analogous  in  the  psychical  sphere;  and  they  may  act  in  an  iden- 
tical way  to  cause  morbid  phobias. 

Dr.  Makuen,  he  thought,  was  entirely  right  in  ascribing  to  this  phobia 
a  controlling  influence  in  stammerers,  and  he  showed  a  true  insight  into 
the  psychology  of  these  cases  when  he  claimed  that  cure  must  begin  by 
correcting  the  psychosis. ' 

Dr.  Charles  K.  Mills  said  that  the  subject  introduced  by  Dr.  Makuen 
was  one  which  greatly  interested  him,  particularly  in  connection  with  the 
recent  discussions  of  tonic  innervation  and  a  cerebral  tonectic  apparatus. 
It  seemed  to  him  that  some  cases  of  stammering  are  analogous  to  that 
affection  of  which  he  showed  an  example  here  two  or  three  meetings 
since,  and  of  which  he  had  seen  other  instances,  namely,  the  so-called 
perseveration.  This  man  shown  at  the  meeting  referred  to  has  now  almost 
complete  preservation  of  power  in  his  arm  and  leg,  and  yet  on  grasping, 
cither  when  commanded  or  spontaneously,  the  entire  musculature  of  his 
arm  often  becomes  so  contracted  or  hypertonic  that  the  limb  will  not  relax 
for  a  long  time.  Muscular  sense  and  all  forms  of  sensibility  are  normal. 
The  patient  is  incapable,  because  of  some  very  special  lesion  which  is  prob- 
ably destructive  and  in  the  frontal  portion  of  his  brain,  of  properly  inner- 
vating the  tonectic  apparatus  or  this  is  over  innervated. 

Although  Dr.  Makucn's  idea  of  auditory  amnesia  as  an  explanation 
of  the  stammering  is  interesting  and  ingenious,  it  did  not  seem  to  Dr.  Mills 
to  be  sufriciciit.  There  is  probably,  in  at  least  some  of  the  cases  of  stam- 
mering, an  inability  to  rhythmically  innervate  with  muscular  tone  the 
motor  apparatus  for  speech.  Many  stammerers  seem  to  be  perfect  so  far 
as  any  auditory  perception  and  the  peripheral  organs  of  speech  are  con- 
cerned. Therefore,  the  speaker  thought  the  case  was  not  made  out  for 
the  theory  of  transitory  auditory  amnesia  as  the  cause  for  stammering. 
Not  a  few  of  these  cases  have  perfect  articulatory  and  phonatory  organs. 
It  may  l)c  that  the  vocal  cords  are  sometimes  spasmodically  closed  or  too 
much  relaxed,  but  this  is  because  they  arc  aberrantly  innervated.  That 
they  i»osscss  motor  power  is  proved  not  only  by  the  results  of  training, 
hut  by  their  incidental  use  of  language  fluently. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  71 

Psychic  influence — under  the  view  of  aberrant  tonic  innervation  as  a 
cause  of  stammering — as  might  be  expected,  plays  an  important  part. 
Emotion  interferes  with  voHtion  in  cases  of  this  sort. 

With  regard  to  the  part  played  by  the  lenticula  the  speaker  believed 
that  this  could  not  always  be  determined.  The  cerebral  tonectic  appa- 
ratus, according  to  his  view,  was  a  mechanism  intercalated  between  the 
afferent  or  sensory  pathway  and  the  motor  projection  system.  Its  busi- 
ness was  to  adjust  or  correlate  sensory  stimuli  and  motor  discharges, 
giving  to  the  latter  rhythm  or  tone.  This  tonectic  apparatus  was  both  mid- 
frontal  and  striate  and  therefore  lesions  or  functional  disturbance,  either 
of  the  cortex  or  lenticula,  might  give  rise  to  the  phenomena  of  stammering. 
Indeed,  as  tone  is  primarily  dependent  upon  sensation,  although  it  may  be 
secondarily  upon  idea,  an  affection  of  the  sensory  pathway  or  of  the  pyra- 
midal motor  apparatus  might,  of  course,  give  a  form  of  stammering,  that 
is,  of  a  form  of  disturbance  of  phonation,  articulation  and  enunciation. 
In  this  far  the  view  as  to  the  part  played  by  transitory  auditory  amnesia 
might  have  some  force ;  nevertheless,  he  did  not  think  it  was  the  important 
matter  in  most  cases  of  stammering. 

Dr.  Francis  X.  Dercum  said  that  there  was  danger  in  being  carried 
too  far  afield  by  speculation  and  thus  losing  sight  of  important  clinical  dis- 
tinctions. Personally  he  cares  less  for  explanations  than  for  concrete 
facts.  In  his  mind  there  is  not  the  slightest  resemblance  between  an 
aphasic  patient  and  a  stammerer.  There  is  not  the  slightest  loss  of  word 
memory  in  the  stammerer.  The  latter  reads  and  writes  in  spite  of  his 
speech  difficulty.  One  of  the  striking  features  of  the  motor  aphasic  is  the 
associated  alexia.  Again  there  is  no  resemblance  between  the  speech  of 
cerebellar  disease  and  the  speech  of  the  stammerer,  and  this  is  equally  true 
of  the  speech  of  the  diplegic.  Especially  is  it  true  of  the  speech  of  bilen- 
ticular  disease  or  of  the  other  forms  of  pseudobulbar  palsy  among  which 
bilenticular  disease  used  to  be  grouped.  The  stammerer  suffers  from  a 
neurasthenic-neuropathic  affection,  a  psychasthenia,  and  he  presents  all  of 
the  earmarks  of  the  phobias,  tics  and  anomalies  of  will  and  inhibition  com- 
monly observed  in  psychasthenia.  The  defective  inhibition  is  doubtless  to 
be  explained  in  terms  of  the  tics.  In  other  words  the  phenomena  pre- 
sented by  the  stammerer  are  psychasthenic.  In  keeping  with  this  the 
3'oung  lady  whom  Dr.  Makuen  showed  this  evening  presents  a  tic  involving 
both  shoulders ;  at  irregular  intervals  her  shoulders  were  suddenly  raised 
or  heaved  upward  and  forward,  while  the  young  man  presents  a  tic  of 
the  right  arm  consisting  in  sudden  irregularly  recurring  adductions  of  the 
arm  to  the  side.  Similar  movements,  though  less  decided,  'were  also  no- 
ticeable in  the  left  arm.  In  other  words,  the  patients  presented  by  Dr. 
Makuen  are  not  stammerers  alone,  they  also  present  the  phenomena  of 
tic,  or,  better  still,  tic  convulsif.  Dr.  Makuen's  well-known  success  ip  the 
management  of  stammerers  depends  fortunately  not  upon  theoretical  ex- 
planations but  upon  his  sound  practical  methods  of  retraining.  Still  the 
difficulties  are  at  times  unsurmountable.  We  know  how  difficult  it  often 
is  to  get  certain  cases  of  tic  well,  but  the  existence  of  tic  in  these  cases 
proves  that  there  are  similar  factors  at  work  as  in  psychasthenic  cases. 

Dr.  Makuen  regretted  that  he  had  neither  the  time  nor  the  ability  to 
adequately  reply  to  all  the  points  raised  in  the  discussion.  He  had  seen 
many  interesting  examples  of  the  condition  to  which  Dr.  Lloj'd  refers, 
namely,  that  of  fear  in  stammerers. 

He  has  a  man  under  his  care  now  who  is  38  years  of  age,  a  mining 
engineer,  bright,  and  but  for  his  affliction  a  splendid  business  man.  He 
came  to  Philadelphia  and  went  directly  to  the  Adelphia  Hotel,  where, 
tired  and  hungry,  he  ordered  a  dinner  in  a  quiet  corner  of  the  cafe,  and 


72  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

a  man  happened  to  come  in  and  take  the  chair  opposite  to  him,  whereupon 
he  was  thrown  into  such  a  paroxysm  of  fear  lest  the  man  should  try  to 
engage  him  in  conversation  that  he  left  the  table  before  his  dinner  arrived. 
Moreover,  he  says  that  he  has  gone  hungry  for  days  during  business  trips, 
because  of  his  desire  to  avoid  experiences  of  a  similar  nature.  He  says 
that  those  of  us  who  do  not  stammer  cannot  possibly  appreciate  the  feel- 
ings of  those  who  do  under  circumstances  such  as  described.  Dr.  Lloyd's 
paper  had  given  Dr.  Makuen  much  food  for  thought,  and  he  thanked 
him  for  it. 

In  reply  to  Dr.  Mills'  remarks  with  reference  to  the  causation  of  stam- 
mering. Dr.  Makuen  thought  that  the  tonectic  theory  or  the  theory  of  tonic 
innervation  can  scarcely  explain  all  of  the  various  phenomena  of  the  affec- 
tion. For  example,  the  young  woman  presented  at  the  opening  of  the 
meeting  can  talk  perfectly  well  under  certain  conditions.  She  can  talk  in 
concert  with  her  teacher  without  any  trouble  whatsoever,  but  as  soon  as 
she  is  obliged  to  arouse  her  own  auditory  images  of  the  inflected  sounds 
of  speech  she  fails  completely.  There  seems  to  be  something  more  than 
the  lack  of  tonicity  or  tonic  innervation,  and  this  appears  to  be  that  without 
which  no  vocal  sound  is  possible,  namely  the  prompt  recall  of  a  clear  audi- 
tory image  or  character  of  the  sound  to  be  emitted. 

The  conscious  volitional  recall  or  redintegration  of  the  auditory  image 
under  certain  disturbing  mental  or  emotional  conditions  seems  to  be  quite 
impossible,  the  patient  being  unable  to  focus  his  attention  upon  the  images 
with  sufficient  steadiness  to  enable  him  to  externalize  certain  important 
elements  of  speech. 

Referring  to  Dr.  Dercum's  remarks,  Dr.  Makuen  said  that  he  thought 
causes  and  results  are  often  confused  in  considering  the  etiology  of  stam- 
mering. There  are,  to  be  sure,  psjxhasthenic  symptoms  in  all  these  cases 
and  stammering  itself  is  one  of  them,  but  may  not  many  of  these  symp- 
toms be  the  results  of  the  stammering  rather  than  causal  factors?  This 
ground  seems  to  be  all  the  more  tenable,  because  many  of  the  pathogenic 
symptoms,  such  as  the  various  tics,  tend  to  clear  up  as  soon  as  the  patient 
is  relieved  of  his  stammering. 

Dr.  Makuen  does  not  claim  that  the  stammerer  has  verbal  amnesia 
but  only  auditory  amnesia  or  amnesia  for  the  auditory  or  vocal  elements 
in  distinction  from  the  kinesthetic  elements,  of  which  many  of  the  con- 
sonant sounds  are  examples.  The  sounds  of  speech  that  are  registered  as 
kinesthetic  memories  give  the  stammerer  but  little  trouble,  but  those  that 
arc  registered  as  auditory  memories  arc  the  ones  that  seem  not  to  be 
forthcoming  at  the  required  time. 


TRANSLATIONS 

VEGETATIVE    NEUROLOGY.     THE   ANATOMY,    PHYSI- 
OLOGY, PHARMODYNAMICS  AND  PATHOLOGY 
OF  THE  SYMPATHETIC  AND  AUTO- 
NOMIC SYSTEMS^ 

By  Heinrich  Higier 


Authorized  Translation   by   Walter  Max  Kraus,  A.M.,   M.D. 

[New  York]. 

Contents 
I.  Literature. 
II.  Introduction. 

III.  Comparative  Anatomy  of  the  Vegetative  System. 

IV.  Macroscopic  and  Microscopic  Anatomy  of  the  Vegetative  System. 
V.  Embryology  of  the  Vegetative  System. 

VI.  Histology  of  the  Vegetative  System : 

(a)  Of  the  Cranial  and  Sympathetic  Cord  Ganglia. 

(b)  Of  the  Spinal  Cord  Cells. 

(c)  Of  the  Nerve  Fibers. 

VII.  Endocrinous    or    Chromaffinic    Ganglion    Structures    of    Sympathetic 
Origin. 
VIII.  Physiology  of  the  Vegetative  System. 

1.  Autonomy  of  the  Peripheral  Vegetative  System. 

2.  Action,  Sensation  and  Reflex. 

3.  Peculiarities  of  Smooth  Muscle. 

4.  The    Pre-    and    Postganglionic    Branches    of    the    Sympathetic 

Ganglia. 

5.  Synapses  and  Pseudo-synapses  in  the  Ganglia  of  the  Sympathetic 

Cord. 

6.  The  Myoneural  Junctional  Tissues. 

7.  Distinctive  Characteristics  of  Vegetative  Reflexes. 

8.  Simple  and  Visceral  Reflex  Arcs. 

9.  Summated  and  Coupled  Reflexes. 

10.  Langley's  Rule  and  Its  Relation  to  the  Rami  Communicantes. 

11.  Relation  of  the  Sympathetic  Vertebral  Ganglia  to  tlie  Spinal  In- 

tervertebral Ganglia. 

12.  Relation  of  the  Sym.pathetic  System  to  the  Vascular  System. 

13.  Relation  of   the   Cranial  Ganglia  to  the  Ganglia  of  the   Sympa- 

thetic Cord. 

14.  Significance  of  the  Ganglia  of  the  Sympathetic  Plexi  and  of  the 

Terminal  Ganglia. 

15.  Metabolic  Products  as  Stimulants  of  the  Vegetative. 

16.  The  Influence  of  Sensations,  Emotions  and  Intellectual  Activity 

upon  the  Vegetative. 

17.  Partition  of  the  Vegetative  System  into  a  Sympathetic  and  an 

Autonomic  Division. 

18.  Positive   and    Negative    Manifestations    of    Stimulation    in    Both 

Divisions. 

^  Vegetative  oder  Viscerale  Neurologic,  Ergebnisse  der  Neurologie  und 
Psychiatric.     Vol.  II,  No.  i.     Verlag  von  Gustav  Fischer,  Jena. 

73 


74  HEINRICH  HIGIER 

19.  The    Pliysiological    Antagonism    between    the    Two    Parts.     The 

Double  Innervation  of  Organs. 

20.  The  Pliarmacological  Antagonism. 

21.  Distribution  of  tlie  Autonomic  and  Sj-mpathetic  End-stations. 

22.  The    Mid-brain    as    the    End    Station    of    the    Vegetative    Nerve 

Tracts. 

23.  Sensation  in  the  Internal  Organs. 

24.  Sensory.  Motor  and  \isceral  Reflexes  of  the  Viscera. 

25.  The  Influence  of  Intense  Pain  upon  the  Sympathetic  System. 

26.  Psjchovegetative  Cortical  Centers. 

The    Influence   of    Mental   Activity   upon   the   Function    of    End 

Organs. 
Associative  Reflexes  of  Psychic  Origin. 
IX.  The  Pharmacology  and  Pharmodynamics  of  the  yegetative  System. 

1.  General  and  Elective  Viscero-Vegetative  Poisons. 

2.  Exogenous  Poisons  and  Endogenous  Products  (Hormones). 

3.  Vagotropic  and  Sj-mpathicotropic  Drugs. 

4.  Stimulating  and  Paralyzing  Metabolic  Products. 
X    General  Pathology  of  the  Vegetative  System. 

A.  \"agotonia  and  Sympathicotonia. 

B.  Clinical  Variations  of  Vagotonia  and  Sympathicotonia. 

1.  General  and  Local. 

2.  Manifest  and  Latent. 

3.  Outspoken  and  Abortive. 

4.  Permanent  and  Periodic. 

5.  Pure  and  Combined. 

6.  Adult  and  Juvenile. 

7.  Individual  and  Familial. 

C.  The  Relation  of  Vagotonia  to  Many  Physiological  and  Pathological 

Conditions,  Particularly  to  Metabolism,  to  the  Functions  of  the 
Glands  of  Internal  Secretion  and  to  the  Activity  of  the  Mind. 

D.  Neuroses  of  Organs  and  of  the  Glands  of  Internal  Secretion. 

E.  Critical  Observations  upon  Vagotonia  and  Sympathicotonia. 
XI.  Special  Pathology  and  Clinical  Aspects  of  the  Vegetative  System. 

1.  The  Eye. 

2.  The  Tear  Glands. 

3.  The  Mucous  and  Salivary  Glands. 

4.  The  Sympathetic  and  Vagus  in  the  Cervical  Region. 

5.  Esophagus. 

6.  Stomach. 

7.  Small  and  Large  Intestine. 

8.  Rectum  and  Urogenital  Region. 
Q.  Rectum. 

10.  Urinary  Bladder. 

11.  Sexual  Organs. 

12.  Respiratory  Tract. 

13.  Heart. 

14.  Blood  Vessels. 

15.  Sweat  Glands. 

16.  Smooth  Musculature  of  the  Skin  and  Hair. 

17.  Endocrinous  Glands:  Liver,   Pancreas,  Adrenals,  Thyroid,   Para- 

thyroids, Sexual  Glands,  Hypophysis. 

II.  Introduction 

Uii'itM  iiK  icniis  "  aiiinial"  or  "  somatic "'  nervous  system  are 
considered  all  of  those  tracts  which  supply  sense  organs,  or  voluntary 
muscles.  On  the  other  hand,  all  nerve  fibers  which  supply  the 
secretory  parts  of  glands  as  well  as  automatically  acting  organs  hav- 
ing a  smooth  musculature  may  be  considered  under  the  heading 


VEGETATIVE  NEUROLOGY  75 

"sympathetic,"  or  more  generally  speaking  vegetative  nervous  sys- 
tem. Examples  of  these  latter  are  the  intestines,  the  genital  appa- 
ratus, the  pupil,  the  blood  vessels,  the  ducts  of  glands  and  the  skin. 

When  the  question  arises  why  physicians  in  general  know  so 
little  of  the  anatomy  and  physiology  of  the  sympathetic  system,  and 
value  it  so  lightly,  in  comparison  to  the  cerebrospinal  system,  and 
why  the  vegetative  nerves  which  supply  vegetative  organs  are  so 
little  spoken  of  in  all  text-books  and  systems  of  medicine,  this 
answer  naturally  presents  itself.^  That  as  a  rule  that  branch  of 
medical  knowledge  which  plays  a  small  role  in  clinical  medicine  is 
neglected  by  the  majority  of  physicians.  There  are,  to  give  a  well- 
known  example,  large  groups  of  muscles,  as  for  instance  the  deep 
muscles  in  the  neck  and  back,  the  semispinalis,  multifides,  and  inter- 
transversarii,  which,  for  the  same  reason,  are  only  known  by  name, 
or  are  entirely  unknown  to  clinicians. 

This  reason  for  ignorance  is  on  closer  observation  not  only  not 
justifiable,  but  also  without  foundation.  True,  much  mystery  sur- 
rounds the  vegetative  nervous  system,  the  reason  being  that  the 
nervous  control  of  vegetative  organs  and  muscles  is  partly  auto- 
nomic, and  partly  influenced  by  afferent  and  efferent  connections 
with  the  central  nervous  system,  connections  which  cause  a  quite 
different  reaction  from  that  of  the  cerebrospinal  system.  Injury  or 
transection  of  the  ganglia  and  peripheral  fibers  does  not  cause  so 
intense  a  reaction  as  the  same  interference  with  the  cerebrospinal 
ganglia  and  fibers.  These  are  but  mild  and  transitory  manifestations 
of  the  removal  or  injury  of  the  connecting  links. 

The  sympathetic  plays  an  enormous  role  in  the  economy  and 
metabolism  of  the  organism  because  First :  it  not  only  partially  sup- 
plies the  motor  and  secretory  functions  of  those  parts  of  the  body 
which  are  unessential  to  the  maintenance  of  life  (the  extremities), 
but  also  regulates  organs  which  are  essential  to  life,  organs  which 
must  not  cease  functioning  for  one  moment — the  heart,  lungs,  liver, 
stomach,  thyroid,  adrenals,  sweat  glands  and  blood  vessels — and 
second :  its  ganglion  cells  and  nerve  fibers  are  widely  distributed 
throughout  the  entire  trunk,  and  lie  through  almost  the  entire  extent 
of  the  internal  and  external  coverings  and  organs  of  the  body.  The 
fact  that  the  vegetative  system  undergoes  change  in  its  functional 
activity  at  every  step  is  sufificiently  shown  by  the  marked  manifesta- 
tions of  a  physiological  nature  which  every  emotion  produces,  as  for 
example,  palpitation,  pallor,  weeping,  incontinence  of  feces,  mydri- 

1  A  notable  exception  is  to  be  observed  in  the  recently  published  Diseases 
of  the  Nervous  Sj'stem  by  Jelliffe  and  White  (trans.). 


76  HEIXRICH  HIGIER 

asis  and  erection.  Pathologicall\-  the  disturbances  are  seen  in  every 
infection  and  intoxication,  as  for  example,  goose  flesh,  tachycardia, 
bkishing,  sweating  and  dry  moutli ;  as  well  as  in  such  common  dis- 
eases as  tabes  with  its  pupillary  inactivity,  stenocardia,  gastric  crises 
and  bladder  disturbances. 

In  spite  of  this  there  is  scarcely  any  patholog}-  of  the  nervous 
system  of  the  internal  organs,  any  "  visceral  neurolog}-  "  in  com- 
parison to  the  much  detailed  pathology  of  the  peripheral  or  cerebro- 
spinal nervous  system,  whose  smallest  branch  has  its  clinical  signifi- 
canc-e.  This  on  the  whole  applies  as  well  to  pathological  anatomy. 
which  has  only  concerned  itself  with  isolated  tumors,  and  traumatic 
lesions  of  the  cervical  sympathetic  and  the  sympathetic  cord,  as  to 
therapy  which  has  but  little  to  say  outside  of  a  few  operative  pro- 
cedures upon  the  sympathetic  in  Graves'  disease,  epilepsy,  and 
glaucoma. 

During  the  last  few  years  scientific  interest  in  the  sympathetic 
and  autonomic  nervous  systems  has  increased  enormously,  as  the 
many  works  of  an  embryological  (Frorup,  Kuntz)  comparative  ana- 
tomical and  histological  (Broek,  Jacobsohn,  Onuf,  Collins,  L. 
Miiller),  physiological  (Gaskell,  Langley,  Lewandowsky,  Bumke, 
Kreidl,  Karplus),  pharmacological  (Loewy,  Falta,  Rudinger,  Froh- 
lich,  Xoorden,  Meyer),  and  clinical  nature  have  shown  (Head,  Mc- 
Kenzie,  Eppinger,  Hess).  In  these  connections  the  question  of  the 
vegetative  system  will  be  critically  examined.  Only  the  most  sig- 
nificant of  the  large  groups  of  facts  at  our  disposal  will  be  con- 
sidered. A  detailed  discussion  of  this  diflficult  chapter,  including  the 
fundamental  elements  of  its  physiological  and  anatomical  relations, 
of  which  the  majority  of  physicians  are  ignorant,  is  justifiable,  since 
the  new  results  of  histological  investigation  and  of  experimental 
pharmacolog)-  have  given  an  entirely  new  grouping  to  the  older  clini- 
cal and  pathological  material.  Nowhere  is  the  comprehension  of 
clinical  syndromes  and  the  solution  of  many  important  psychological 
problems  so  intimately  connected  with  physiological  and  pharmaco- 
logical viewpoints  as  in  the  realm  of  vegetative  functions. 

Research  to-day  has  opened  up.  so  far  as  the  vegetative  system 
is  concerned,  a  field  so  wide  that  its  limits  are  yet  hidden  in  the  hazi- 
ness of  the  future.  Many  eflforts  will  have  to  be  made  in  the  future 
in  order  to  light  up  this  subject  in  all  its  extent.  The  most  important 
aspect  of  scientific  research  which  has  thrown  light  on  the  vegetative 
system  is  undoubtedly  the  question  of  the  relation  of  this  to  the  mind. 
to  metabolism,  and  to  the  glands  of  internal  secretion.  It  has  taken 
but  a  very  short  time  to  accomplish  a  large  amount  of  work  on  the 


VEGETATIVE  NEUROLOGY  77 

subject  of  the  patholog}'  of  the  vegetative.  This  work  has  extended 
into  the  most  varied  branches  of  medicine,  produced  a  mass  of  stimu- 
lating problems,  and  has  incited  the  spirit  of  research  to  restless 
endeavors.  The  nature  of  the  discussed  matter,  which  in  many  re- 
spects is  but  in  statu  nascendi,  leaves  little  doubt  that  our  resume 
must  be  incomplete,  and,  especially  in  the  general  considerations,  can 
but  suggest  a  few  guiding  points,  special  questions,  which  have  par- 
ticular significance  and  relation  to  the  practical  side  of  the  subject. 

For  the  same  reasons,  a  detailed  review  of  the  literature,  espe- 
cially the  older  literature,  must  be  given,  on  account  of  the  abun- 
dance of  facts  it  contains.  The  experimental  literature,  clinical  and 
purely  morphological,  is  the  basis  of  this  work.  Only  its  most  im- 
portant aspects  will  be  considered  and  even  these  can  not  be  gone 
into  in  great  detail.  A  thorough  discussion  of  the  history  of  the 
subject  is  without  the  purpose  of  this  work.  Only  such  special 
works  as  will  give  new  and  extensive  reference  to  the  literature  will 
be  mentioned. 

Though  many  things  must  yet  be  made  clear,  there  is  enough 
material  at  hand  to  permit  a  fairly  precise  review  of  the  question  of 
vegetative  neurology. 

My  personal  experience  with  the  vegetative  nervous  system  will 
50on  appear  in  a  special  article  "  A  Discussion  of  The  Vagus — Sym- 
patheticus  Relations." 

III.  Comparative  Anatomy  of  the  Vegetative  System 

The  completely  developed  human  nervous  system  is  an  end  prod- 
uct of  a  much  complicated  phylogenetic,  and  a  not  less  complicated 
-ontogenetic  development,  extending  over  a  long  period  of  time.  As 
Edinger  and  v.  Monakow,  \^an  der  Broek  and  Froriep  have  justly 
observed,  it  cannot  be  understood  either  in  its  construction  or  in  its 
functions  without  a  review  of  the  relations  existing  between  the  nu- 
merous successive  phases  of  its  development.  Interesting  points  of 
view  are  derivable  from  embryology  and  comparative  anatomy  which 
help  in  understanding  the  progressive  development  of  the  function  of 
the  vegetative  system. 

All  actions  of  animals,  all  movements  of  the  external  and  internal 
muscles  result  from  conduction  of  stimuli  of  external  or  internal 
origin  to  the  nervous  system. 

The  various  parts  of  the  nervous  system  which  receive  these 
stimuli  are  designated  as  the  "  Urhirn  "  or  archeopallium  of  Edinger. 
This  exists  alike  in  all  animals  from  fish  to  man,  and  only  varies  in 


78  H EI N RICH  H ICIER 

size  according  as  one  or  the  other  sense  is  more  important  for  the 
preservation  of  life  of  the  particular  animal. 

All  activities  in  the  "  Urhirn  "  are  retlexes,  not  only  the  many 
mechanisms  for  movements,  but  also  those  for  inhibition.  These 
latter  make  it  possible  for  the  animal  when  subjected  to  the  influence 
of  all  kinds  of  stimuli,  to  avoid  being  in  continual  activity.  On  the 
basis  of  various  phylogenetic  standards,  the  central  nervous  system 
was  regarded  merely  as  an  apparatus  for  seeking  and  absorbing 
nourishment;  it  was  stimulated  by  the  sense  organs  and  the  nerves 
of  instinct  or  visceral  nerves.  The  oldest  and  simplest  movements, 
both  exteroceptive  and  interoceptive,  are,  in  this  sense,  for  the  pur- 
pose of  maintaining  life,  protecting  the  body,  or  guarding  against 
harmful  stimuli.  The  gradually  developing  new  "  anlagen  "  develop 
at  the  expense  of  the  old,  assuming  functions  which  in  lower  stages 
of  development  were  only  performed  by  the  old  structures,  and  which 
in  higher  stages  of  development  become  rudimentary. 

One  of  the  earliest  organized  forms  of  the  "  urhirn"  of  the  cen- 
tral nervous  system  (invertebrates)  is  that  of  the  loosely  connected 
pairs  of  ganglia,  the  ganglion  system. 

In  the  lowest  vertebrates  the  so-called  metameric  system,  together 
with  the  "  anlage  "of  the  vertebrae,  is  built  up  on  the  ganglion  system 
of  invertebrates.  This  keeps  on  developing,  partly  at  the  expense 
of  the  ganglion  system.  The  metameric  system  develops  from  more 
or  less  similar  segments  of  the  spinal  canal,  each  of  which  has  a  wcll- 
cocirdinatcd  innervation  which  supplies  the  corresponding  segment 
of  the  body.  In  every  metamere,  which  has  an  autonomic  central 
apparatus,  there  is  also  a  related  nervous  equipment  for  the  orderly 
use  of  the  extremity  of  this  metamere.  Following  this  stage  of  de- 
velopment there  is,  as  in  fish,  a  more  extensive  differentiation  of  the 
brain  canal  into  five  brain  segments,  the  telencephalon,  dienccphalon, 
mesencephalon,  metcnccphalon.  myclenccphalon,  in  which  a  cortex  is 
yet  entirely  lacking,  and  in  which  the  dominating  role  and  sharing  of 
the  highest  nervous  connections  belongs  to  the  mid-brain  or  mesen- 
cephalon. 

In  the  next  highest  vertebrates  f  reptiles)  there  is  built  up  upon 
the  now  very  important  mid-brain,  what  has  been  designated  as  the 
cortico-somatic  cerebral  system,  the  new  brain  or  neopallium  of 
Edingcr.     This  is  the  most  important  i)art  of  the  cerebral  cortex. 

In  the  lower  manmials  there  remain  isolated,  relatively  inde- 
pendent nervous  connections  which  have  been  left  from  the  gangli- 
onic metameric  and  mifl-brain  systems. 

In  the  higher  mammals,  the  psychic  growtli  finds  its  anatomical 


VEGETATIVE  NEUROLOGY  79 

expression  in  the  addition  to  the  cortico-somatic  system  of  a  cortico- 
associative  system  with  scattered  association  areas  located  through- 
out the  much  extended  and  folded  surfaces  of  the  cortex.  This 
system,  according  to  v.  Monakow,  represents  in  man  the  preliminary 
worthy  conclusion  of  phylogenetic  development. 

In  this  organization,  old  and  new  phylogenetic  functional  systems 
work  by  the  side  of  and  with  each  other  in  wonderful  fashion.  This 
holds  not  only  for  visceral  and  sensory  stimuli  and  for  impulses 
coming  from  them  but  also  for  the  corresponding  motor  impulses. 
The  new  brain  (neopallium),  present  at  first  only  in  traces,  finally 
comes  to  equal  the  "  urhirn "  or  archeopallium  in  dimension.  In 
monkeys  and  man,  it  even  surpasses  it  in  size.  Thus,  as  has  been 
stated,  the  urhirn  becomes  related  by  fiber  systems  with  a  most  im- 
portant apparatus  which  gives  the  power  to  correlate  sensations  with 
each  other  more  thoroughly,  to  retain  sensations  for  some  time,  to 
make  movements  voluntary,  and  to  relegate  to  the  background  the 
reflex  and  automatic  vegetative  life.  This  leaves  an  animal  with 
more  of  a  "  soul "  and  freed  from  the  continual  activity  of  its  re- 
flexes. 

What  has  been  said  of  phylogenetic  development  holds  also  for 
the  ontogenetic,  which  on  the  whole  is  but  a  much  abbreviated  re- 
capitulation of  the  former.  Even  in  the  human  fetus,  it  is  found 
that  the  myelinization  rule  of  Flechsig  bears  this  out.  Myelin 
sheaths  develop  first  in  the  ganglion  system,  then  in  the  metameric 
system,  then  in  the  mid-brain  system,  and  finally  in  the  cerebral  and 
cortico-associative  systems. 

In  considering  the  world  of  instinct  and  desire  which  is  so  inti- 
mately related  to  the  vegetative  system,  one  must  conclude,  from  a 
biological  viewpoint,  as  v.  jMonakow  has  justly  done,  that  all  nervous 
functions  have  had  their  phylogenetic  origin  in  the  activity  of  the 
oldest  sense  cells  and  the  direct  descendants  of  these  cells.  Among 
these  must  be  included  the  little  known  paraganglion  cells,  the  chro- 
maffin cells  and  above  all  the  cells  of  the  sympathetic  and  autonomic 
ganglia,  i.  e.,  the  ganglionic  system. 

Undoubtedly  one  finds  in  the  ganglion  system  of  quite  low  ani- 
mals a  well-defined  localization  in  the  sense  that  the  various  viscera, 
glands,  excretory  and  sex  organs,  as  well  as  the  circulatory  and 
respiration  apparatus,  etc.,  have  a  separate  and  delicately  constructed 
representation. 

The  ganglion  system  which  in  higher  animals  retains  the  lowly 
role  of  serving  the  vegetative  nervous  functions,  successively  ob- 
tains a  second  representation  in  the  metameric  system,  the  spinal 


8o  HEJNRICH  HIGIER 

cord,  a  third  in  the  brain  stem  (central  gray  matter,  mid-brain  and 
probablv  in  the  corpora  quadngemina  and  optic  thalamus),  and 
finally  a  fourth,  which  is  double,  in  the  cerebral  cortex.  This  is  a 
quite  diffuse  and  spatially  narrowly  bounded,  possibly  strictly  focal 
area  of  cerebral  surface,  lying  near  the  cortical  orientation  system  or 
the  cortico-somatic  system  which  serves  the  purpose  of  innervating 
individual  vegetative  organs. 

Finally,  since  cortical  localization  of  vegetative  functions  in  the 
brain  is  to  be  discussed  more  fully  below,  we  may  say  that  as  far  as 
we  know  definitely,  the  cortex  of  the  cerebrum  only  serves  conscious 
perception  (Gnosia),  conscious  action  (Praxis),  and  the  thought 
innervations  necessary  to  these. 

1\'.  Macroscopic  and  ■Microscopic  Anatomy  of  the  Vegetative 

System 

What  may  be  learned  from  the  macroscopic  anatomy  of  the  sym- 
pathetic, which  not  only  is  the  Alpha  and  Omega  of  the  visceral 
system,  but  also  the  bearer  of  the  burden  of  the  mechanical  work  of 
our  vegetative  life? 

Two  parts  may  be  distinguished:  the  cord  and  the  branches. 

The  cord,  usually  spoken  of  as  the  sympathetic  cord,  is  divided 
into  three  parts — cervical,  thoracic  and  abdominal. 

The  branches  also  are  divided  into  three  parts — those  to  arteries, 
those  to  the  periphery,  and  the  communicating  branches. 

The  fact  that  the  sympathetic  cord  is  a  symmetrical  organ,  lying 
immediately  in  front  of  the  vertebrae  and  parallel  to  it  must  not  be 
overlooked.  Its  extent  is  from  the  base  of  the  skull  to  the  coccyx. 
It  is  extrapleural  and  extraperitoneal,  and  ends  at  its  lower  end  in  a 
loop,  a  thread  or  an  unpaired  ganglion.  In  lower  animals,  as  fish, 
which  preserve  their  segmental  structure  lo  a  marked  degree,  the 
sympathetic  cord  has  a  ganglion  at  the  level  of  each  vertebra,  giving 
it  the  appearance  of  a  string  of  pearls.  Every  sympathetic  ganglion 
lies,  in  the  majority  of  cases,  either  on  the  vertebra,  or  on  the  costal 
process,  and  for  that  reason  is  called  a  sympathetic  or  vertebral 
ganglion.  This  is  in  contrast  to  the  spinal  ganglia,  belonging  to  the 
cerebrospinal  system,  which  are  associated  with  the  posterior  sensory 
root  and  are,  on  account  of  their  anatomic  position  in  the  interver- 
tebral space,  called  si)inal  or  intervertebral  ganglia. 

{To  be  continued) 


THE   DREAM    PROBLEM 
By  Dr.  A.  E.  Maeder 

ZURICH 

(Translated  by  Drs.  Frank  Mead  Hallock  and  Smith  Ely  Jelliffe) 
(Continued  from  vol.  42,  page  767) 

On  the  Question  of  Symbolism   in   Dreams 

When  I  look  over  my  interpretation  of  symbols  during  the 
last  two  years,  it  is  clear  to  me  that  gradually,  and  at  first  quite 
unconsciously,  a  change  came  about  in  my  interpretations.  The 
content  of  the  symbol  is  no  longer  monovalent,  but  has  come  to 
be  of  wider  meaning.  The  sexual  interpretation  has  become, 
so  to  speak,  the  first  step,  in  some  respects  only  the  preliminary 
step  and  instead  the  significance  of  the  contemporary  situation 
of  the  dreamer  has  been  drawn  into  the  matter  more  and  more. 
An  opportune  discussion  of  the  so-called  actual  conflict  in  neu- 
rosis by  Jung  (in  the  Psychoanalytic  Conference),  nearly  two 
years  ago,  confirmed  me  in  my  orientation  and  helped  me  in  this 
change  of  view.  On  the  actual  conflict  I  shall  still  say  some- 
thing in  this  paper  to-day.  I  will  now  enter  more  fully  into  the 
question  of  the  interpretation  of  symbols.  It  can  be  best  dem- 
onstrated by  means  of  an  example. 

In  the  third  edition  of  the  "  Dream  Interpretation ''  Freud 
gives  a  short  symbol  interpretation,  which  I  would  like  to  use  as  a 
starting  point.  This  is  the  dream  of  a  young  man  (p.  207)  :  "  He 
is  in  a  deep  tunneled  passage,  in  \yhich  there  is  a  window,  as 
in  the  Semmering  tunnel.  Through  this  he  sees,  at  first,  an 
empty  landscape,  and  then  he  composes  a  picture  into  it,  which 
is  there  immediately  and  fills  out  the  void.  The  view  is  now 
that  of  a  field  deeply  ploughed  up  by  an  instrument  and  the  fine 
air,  the  idea  of  the  work  so  well  done,  the  blue  black  clods  of 
earth,  make  a  pleasing  impression  on  the  dreamer.  Then  he  goes 
further  and  sees  a  book  on  pedagogics  open  before  him.     He  is 

81 


82  A.  E.  MAEDER 

surprised  that  in  it  so  nuicli  attention  is  paid  to  the  child's  sexual 
feelings,  and  that  makes  him  think  of  me  [Freud]."  The  inter- 
pretation given  is  that  this  is  a  phantasy  of  the  young  man  who 
takes  advantage  of  his  intra-uterine  opportunity  to  spy  upon  the 
coitus  between  his  parents.  The  associations  of  the  young  man 
are  not  given. 

It  is  not  difficult  for  us  to  recognize  the  tunnel  picture  as  an 
exteriorization  of  certain  parts  of  the  body.  /.  c,  the  uterus  and 
the  vagina.  The  ploughing  of  the  tield  is  a  well-known  coitus 
symbol.  This  dream  interpretation  is  evidently  built  on  the 
knowledge  of  these  two  symbols  but  gives  us  no  solution  for 
the  second  part  of  the  dream,  which  contains  the  open  book  on 
pedagogics. 

I  accept  this  interpretation  as  a  preliminary  step  of  the  inter- 
pretation itself.  In  his  "  Transformations  and  Symbols  of  the 
Libido  "  Jung  has  called  our  attention  to  the  problem  of  re-birth. 
I  myself  became  better  acquainted  with  this  subject  summer 
before  last,  by  means  of  my  analysis  of  the  visions  of  the  Floren- 
tine B.  Cellini.  In  this  dream  here  there  seems  to  be  a  similar 
symbol,  for  as  soon  as  I  accept  this  hypothesis,  the  whole  dream, 
part  I  and  part  II,  becomes  entirely  clear.  "  The  young  man  is 
still  in  the  uterus  and  looks  out,"  would  be  the  meaning  of  the 
first  picture,  which  in  conscious  speech  might  be  thus  expressed : 
he  is  still  on  the  path  of  his  mental  regeneration  (development) 
— for  the  idea  of  re-birth  is  an  archaic  picture  for  mental  de- 
velopment, as  Dieterich  has  shown.  The  young  man  looks  out 
and  sees  a  field  being  ploughed  thoroughly.  The  field  is  not 
merely  a  sexual  symbol  but  is  also  a  symbol  of  the  field  of  ac- 
tivity, the  young  man's  own  life  task.  To  plough  the  field  does 
not  mean  merely  coitus,  but  "  to  do  his  work."  The  young  man 
sees  a  new  life,  full  of  work,  before  him  after  his  cure  is  com- 
pleted (birth).  The  emotional  element  of  the  dream  fits  very 
well  to  this.  V>y  this  process  of  thought  the  meaning  of  the  last 
part  of  the  dream  has  also  become  clear;  the  dreamer's  new  field 
of  work  has  been  more  definitely  pointed  out ;  he  will  seek  occu- 
pation as  a  teacher,  out  of  love  for  his  analyst,  and  bearing  in 
mind  the  events  of  his  own  psychoanalysis.  To  guide  others  is 
to  guide  oneself. 

This  interjjrctation  gives  us  a  picture  of  activity  ascribed  to 
the  role  of  the  analyzer;  to  the  patient  himself  it  gives  an  orien- 
tation in  his  cfTorts  and  the  course  of  his  cure.  Of  what  use, 
pragmatically  considercfl,  would  be  to  him  the  interpretation  of 


THE  DREAM  PROBLEM  83 

the  dream  as  the  spying  on  the  sexual  intercouise  between  his 
parents?  Freud's  interpretation  I  regard  as  a  preHminary  step 
of  the  actual  interpretation.  It  is,  so  to  speak,  the  picturesque 
material  which  must  be  translated  into  the  intellectual, — it  gives 
the  "  whence  "  of  the  symbol,  but  not  the  "  whither."  To  put  it 
differently,  it  gives  the  retrospective,  but  not  the  prospective. 
Jung  once  expressed  this  idea  picturesquely,  when  he  said  "  the 
unconscious  speaks  a  pidgin  English  which  must  be  translated 
into  the  language  of  cultured  men."  Adler's  saying  that  the 
sexual  speech  of  neurosis  is  a  "manner  of  speaking"  is  prob- 
ably to  be  taken  in  the  same  sense. 

This  two-sided  nature  of  the  symbol  I  explain  in  my  analyses 
as  follows :  The  searching  out  of  the  symbols  may  be  compared 
to  contemplating  a  tree  of  which  one  considers  the  subterranean 
parts,  the  roots,  and  the  upper  part,  the  trunk,  branches,  leaves, 
etc.  In  the  case  of  the  symbol,  the  sexually  symbolic  is  like  the 
root,  the  intellectual  content  of  the  symbol  is  like  the  trunk  and 
branches. 

You  will  permit  me  another  brief  example  as  illustration : 
rain  magic  and  fertility  magic  among  savage  peoples,  and  which 
are  preserved  even  to-day  in  some  customs  of  our  peasants  here, 
when  regarded  retrospectively  prove  themselves  to  be  entirely 
frank  coitus  symbols.  But  they  are  not  such  only — they  are 
more  than  this.  They  represent  a  frank  attempt  on  the  part  of 
primitive  man  to  represent  and  to  influence  a  process  of  nature, 
that  is,  fructification.  He  is  only  using,  because  of  his  distinctly 
anthropomorphic  tendency,  materials  from  a  procedure  well 
known  to  him,  in  order  to  gain  a  new  conception.  This  is  the 
outcome  of  prospective  reflection.  As  a  matter  of  fact,  w^e  may 
regard  the  concept  of  magic  as  the  mythical  stage  of  meteorology 
and  of  chemistry  as  applied  to  agriculture.  Thus  modestl}"  appear 
the  beginnings  of  our  distinguished  sciences.' 

It  was  my  original  intention  to  show,  by  means  of  Parsifal, 
how  the  Freudian  symbology  stops  short  on  its  way  to  the  right 
goal  of  its  task,  and  thereby  becomes  unfruitful,  but  I  must  re- 
serve this  intention  for  a  later  publication,  as  it  would  make 
this  paper  too  long,  and  I  shall  therefore  content  myself  with 
pointing  out  that  tracing  back  the  grail  and  the  lance  to  the  fem- 
inine and  masculine  genitals  gives  us  an  explanation  only  as  to 
the  original  source  of  these  symbols,  but  not  as  to  their  real  con- 

5  See  the  rich  ethnological  literature  for  clews  to  literature  and  as 
reference  book  W.  Wundt's  "  Folk  Psychology." 


84  A.  E.  MAEDER 

tent.  A  recent  analysis  of  the  Prometheus  myth  gave  me  lately 
a  quite  analogous  experience ;  that  is  to  say,  the  Freudian  myth 
analyses  really  contain  only  the  beginning  of  the  actual  analyses ; 
this  explains,  to  a  great  extent,  why  they  are  so  little  understood 
by  those  who  are  not  initiated.  These  analyses  are  like  the  de- 
cipherings of  the  alphabet  of  an  unknown  language,  but  they  do 
not  arrive  at  a  knowledge  of  the  words  themselves.  Proofs  of 
this  I  shall  give  shortly. 

In  the  interpretation  of  symbols  we  must  not  stop  short  at 
the  concrete  sexual  act ;  it  is  our  task  to  connect  the  prospective 
conception  with  the  retrospective.  Freud  himself,  as  I  gladly 
admit,  was  the  first  to  give  this  interpretation  by  correlating 
rescue  phantasies  of  the  neurotic  with  birth  dreams.  For  the  ulti- 
mate interpretation  of  the  rescue  phantasies  leads  directly  to 
the  motive  of  re-birth.  Putnam,  two  years  ago,  gave  a  discourse 
in  our  circle  which,  as  I  believe  and  regret,  was  little  under- 
stood. In  it  he  very  clearly  indicated  the  position  just  taken. 
The  last  sentence  of  his  address,  which  might  well  serve  as  a 
motto  for  this  part  of  my  paper,  was  this :  "  Rightly  we  boast  of 
having  thrown  light,  from  one  side,  on  the  significance  of  the 
church-steeple.  But  there  still  remains  to  us  the  more  important 
task  of  learning  to  understand  its  other  significance  with  equal 
precision." 

It  is  not  difficult  to  understand  why  some  change  in  our 
methods  has  become  necessary.  What  made  psychoanalysis  as  a 
method  so  fruitful  till  now  was  the  systematic  introduction  of 
genetic  thinking  into  psychology.  Research  is  directed  primarily 
towards  origins,  towards  the  past.  But  research  would  become 
paralyzed  if  it  remained  for  any  length  of  time  one-sidedly  retro- 
spective. A  new  field  of  work  is  now  before  us  and  awaits  our 
efforts.  The  prospective  road  leads  to  reality ;  it  promises  us, 
therapeutically,  the  most  important  insight,  just  as  the  retro- 
spective road  once  meant  for  us  a  great  scientific  gain.  Biology, 
which  has  traced  the  phylogeny  of  the  under  jaw  of  man  back 
to  the  gill  arches  of  the  fish,  after  making  this  important  dis- 
covery returned  to  the  lower  jaw  of  man  in  order  to  examine  and 
better  understand  its  structure  and  function.  We,  ladies  and 
gentlemen,  are  in  a  similar  position  now,  and  must  clearly  admit 
it,  in  order  to  continue  our  work.  The  fine  American  lectures 
which  Jung  has  just  published,  are  a  clear  expression  of  this 
necessity. 


THE  DREAM  PROBLEM  85 

The  prospective  capacity,  which  after  the  numerous  experi- 
ences of  the  last  few  years,  we  may  ascribe  to  the  Hbido  (and 
here  the  merits  of  Jung  are  to  be  prominently  accentuated),  and 
from  which  we  assume  that  it  develops  a  lively  activity  in  the 
unconscious,  stands  in  close  relation  to  the  function  of  the  symbol.. 
We  have  progressively  learned  to  interpret  the  symbolism  as  the 
mythical  organ  of  knowledge,  and  the  symbol  itself  as  expres- 
sion of  as  yet  vaguely  grasped  reality.  I  must  remind  you  of  the 
first  mythical  step  in  knowledge  by  Auguste  Comte,  and  the  im- 
portant contributions  of  H.  Silberer.  In  his  book  "  On  the 
Formation  of  Symbols,"  Silberer  presents  an  early  type  of  the 
symbol  which  he  defines  as  follows :  "  The  first  type  of  the 
symbol  originates  when  the  idea,  vmhindered  by  disturbing  con- 
current ideas  (concurrent  affect-accentuated  complexes),  is 
visualized  on  the  basis  of  this  apperceptive  insufficiency  as  an  idea 
which  has  arisen  on  an  intellectual  basis.*' 

This  first  type  of  symbol  offers  a  theoretical  basis  for  my 
conception — entirely  empiric — of  the  preparatory  and  preparing 
function  of  the  dream  (or  of  the  unconscious).  The  possible 
suitable  solution  of  the  conflicts  are  gropingly  searched  for  and 
expressed  by  the  symbol.  We  must  here  eliminate  entirely  the 
question  of  the  intuition,  which  plays  so  prominent  a  part  in  the 
philosophy  of  Bergson.  All  this  aspect  of  the  symbol  spreads 
beyond  the  confines  of  the  thus  far  accepted  "  censor,"  and  shows 
the  necessity  for  testing  and  broadening  our  conception  of  dream 
psychology. 

The  Tendencies  of  the  Vienna  and  Zltrich  Schools  in 
Psychoanalysis 

Freud  has  given  me  occasion  to  suppose,  in  a  recent  publica- 
tion, that  I  must  have  expressed  myself  in  my  work  on  the  func- 
tion of  the  dream  so  as  to  be  misunderstood,'^  for  he  there  ascribes 
to  me  ideas  which,  as  a  matter  of  fact,  are  not  mine. 

In  this  publication,  to  be  found  in  Vol.  i  of  the  International 
Zeitschrift  fiir  Psychoanalyse,  191 3,  there  is  a  dream,  in  the 
analysis  of  which,  among  other  things,  there  is  to  be  found  an 
indirect  confession  of  a  deed  done  the  day  before.  Freud  here 
shows  that  this  dream  has  a  deeper  meaning  than  only  the  com- 

^  Silberer's  orientation  is   closely  allied  to  ours  in  Zurich,   aunough 
the  two  points  of  view  have  arisen  independently. 
^Jahrbuch,  Vol.  IV. 


86  A.  E.  MAEDER 

paratively  unimportant  confession  read  out.  of  the  translation  of 
the  symbol.  "  So  it  is  proved  that  there  is  no  necessity  to  admit 
there  are  confession  dreams,  just  as  it  is  senseless  to  speak  of 
reflection  dreams  or  warning  dreams."  This  assumption  is  re- 
garded as  a  regression  to  the  preanalytic  period. 

I  consider  Freud  entirely  right  when  he  shows  that  snch  a 
dream  is  not  yet  analyzed  if  the  confession  was  read  out  of  it 
and  when  he  speaks  of  the  regressive  point  of  view  of  such  an 
analvzer.  But  I  must  contradict  him  if  he  assumes'  such  a  point 
of  view  to  be  mine.  I  am  glad  to  be  able  here  to  express  clearly 
that  this  is  an  entire  misunderstanding.  In  order  to  clear  up  the 
situation,  I  have  decided  to  interpret  this  dream  myself  according 
to  the  material  at  our  disposal.  I  suppose  the  analysis,  which 
I  will  now  make  for  you,  would  be  the  same  if  made  by  some 
Zurich  colleague  of  mine.  Thus  it  will  be  possible  for  me  to 
contrast  the  two  interpretations  which  now  e.xist  in  the  psycho- 
analytic movement. 

I  must  begin  by  saying  that  the  particular  dream  is  that  of  a 
nurse,  and  was  analyzed  by  a  lady  patient  of  Freud's,  and  that 
Freud  himself  accepted  the  interpretation  and  carried  it  some- 
what deeper. 

\  lady  suffering  from  doubt  and  compulsion  neurosis  de- 
mands of  her  nurses  not  to  be  permitted  out  of  their  sight  one 
moment,  as  otherwise  she  begins  to  worry  about  what  forbidden 
thing  she  may  have  done  during  the  time  she  was  not  watched. 
One  evening  she  is  resting  on  the  couch ;  she  fancies  she  sees  that 
the  nurse  on  duty  has  dro[)ped  asleep.  She  asks :  "  Did  you  see 
mc?"  The  nurse  starts  up  and  answers:  "Yes,  certainly."  The 
j)atient  now  has  grounds  for  a  new  doul)!  and  repeats  the  same 
question  after  an  interval.  The  nurse  again  asserts  .she  was 
awake  and  at  that  moment  the  maid  brings  in  the  evening  meal. 
This  happens  on  a  TViday  evening.  Next  morning  the  nurse 
tells  a  dream  which  .scatters  the  doubts  of  the  patient.  The 
nurse's  dream :  .She  was  given  the  care  of  a  child  and  she  lost 
it.  On  the  way  .she  a.sks  people  on  the  street  if  they  have  seen 
the  child.  Then  she  reaches  a  large  sheet  of  water  and  goes 
across  a  small  foot  path.  (Later  .she  adds  that  on  this  path  the 
nurse  is  .suddenly  before  her  like  a  mirage.)  Then  she  finds  her- 
self in  a  neighborhood  she  knows  well  and  there  meets  a  woman 
she  knew  as  a  girl,  and  who  at  that  time  was  a  saleswoman  in  a 
grocery  store,  but  later  .she  married.     This  woman  is  standing 


THE  DREAM  PROBLEM  87 

before  the  door  and  the  dreamer  asks  her :  Have  you  seen  the 
child  ?  But  the  woman  is  not  interested  in  this  question  and  tells 
her  she  is  now  separated  from  her  husband,  adding  that  even  in 
marriage  there  is  not  always  happiness.  Then  the  dreamer 
awakes,  quieted,  and  thinks  the  child  will  probably  be  found  at 
some  neighbor's  house. 

I  must  put  aside  a  good  deal  of  material  and  direct  the  reader 
to  Freud's  previously  mentioned  publication.  I  content  myself 
with  repeating  the  interpretation  there  given  and  shall  then  give 
my  own. 

The  lady's  interpretation  of  the  dream  establishes  that  the 
nurse  is  disturbed  at  having  failed  in  the  fulfilment  of  her  duties 
and  is  afraid  of  being  dismissed  on  that  account.  Therefore  the 
dream  contains  a  sort  of  confession.  We  must  emphasize  that  in 
the  morning  the  nurse  tells  the  lady  the  dream,  and  added  that 
Friday  is  often  an  eventful  day  for  her.  (It  was  a  Friday  when 
the  incident  occurred.) 

This  interpretation  is  accepted  by  Freud,  but  he  broadens  and 
completes  it,  since  he  discovers  the  "  deeper  meaning  of  the 
dream,"  the  dream-forming  wish  that  originates  in  the  uncon- 
scious. The  wish  appears  as  follows :  "  Very  well  I  did  close  my 
eyes  and  so  compromised  my  reliability  as  a  nurse ;  now  I  shall 
lose  this  place.  Shall  I  be  as  stupid  as  X.  who  went  into  the 
water?  No,  I  won't  be  nurse  any  longer,  anyway,  I  mean  to 
marry,  be  a  wife,  have  a  child  of  my  own.  Nothing  shall  prevent 
this."  This  last  interpretation  is  not  actually  built  on  ideas  of 
the  dreamer,  but  as  Freud  says,  "  on  our  knowledge  of  dream 
symbolism."  (The  water,  the  whale  in  the  myth  of  Jonah,  the 
narrow  path.) 

In  the  interpretation  which  I  will  not  put  before  you,  I  shall, 
as  in  my  first  example,  distinguish  between  an  objective  and  a 
subjective  phase. 

The  child  who  has  been  lost  is,  of  course,  the  patient  entrusted 
to  the  nurse ;  the  dreamer  might  lose  her  place  and  thereby  come 
to  the  same  condition  as  X.  who  committed  suicide  (mirage). 
The  married  woman  who  is  asked  about  the  child  and  who  is  only 
interested  in  her  own  afl:airs  is,  first,  the  sick  lady,  who  bothers 
the  nurse  quite  a  little  with  her  neurosis.  It  is  evident  tiiat  the 
nurse  has  a  typical  aunt-transference  to  this  lady,  in  which  there 
is  a  distinct  element  of  defiance.  (The  analyzing  lady  has  not 
recognized  herself  in  the  dream,  because  she  is  represented  in 


8S  A.  E.  MAEDER 

too  unconiplimentary  a  manner.)  The  qualification  of  the  sales- 
woman in  the  grocery  store  must  refer,  in  this  phase,  to  the  em- 
ployer from  whom  the  dreamer  receives  her  food.  Freud  draws 
attention  to  another  source,  which  is  certainly  correct — that  is, 
infantile  symbolism,  the  qualification  no  doubt  also  applies  to  the 
aunt,  and  also  to  the  mother  of  the  nurse.  But  the  married 
woman  without  doubt  is  also  the  aunt,  as  Freud  assures  us. 
(The  dreamer  knows  the  place  well;  also  notice  the  circumstance 
that  she  ignores  the  nurse's  questions  about  the  child,  like  the 
aunt  who  was  greatly  opposed  to  a  former  suitor  of  the  nurse.) 
Therefore  we  get  this  meaning:  neither  my  employer  nor  my 
aunt  bother  much  about  me,  they  are  only  interested  in  their 
own  affairs.  The  circumstance  that  the  conversation  takes  place 
before  a  door  in  a  well-known  spot,  leads  me  to  suppose  that  this 
refers  to  the  mother  and  to  the  dreamer's  own  birth.  Pherein 
we  find  an  accusation  against  the  mother,  but  also  an  excusing  of 
herself  from  the  fault  committed.  I  have  been  made  this  way, 
have  been  brought  up  so,  it  is  not  my  fault.  This  makes  compre- 
hensible the  last  sentence  of  the  dream,  the  child  will  probably  be 
found  at  some  neighbor's  house ;  I  need  not  take  the  matter  so 
seriously. 

Now  we  will  take  the  dream  in  its  subjective  phase:  the  child 
entrusted  to  her,  and  which  she  lost  and  was  seeking  across  the 
sheet  of  water,  whence  she  met  the  mirage,  is  her  own  valuable 
personality,  still  a  child,  which  ought  to  grow  up  and  was  lost  as 
the  day  before  she  had  again  showed  herself  to  be  unreliable  in 
her  work  and  defiant,  irritable  towards  her  patient.  We  may  as- 
sume that  the  incident  of  the  day  before  the  dream  was  only  a 
repetition  of  innumerable  faults  which  were  reawakened  on  this 
day  of  misfortunes  (Friday).  The  nurse  finds  herself  before  a 
difficulty  typical  to  her  and  she  reacts  typically.  Witness  the 
aunt-mother  transference. 

The  lost  child  must  be  found,  the  submerged  moral  person- 
ality must  be  born  again,  and  she  actually  stands  near  a  great 
water,  to  which  belongs  the  thought  of  the  Jonah  myth.  The 
joke  of  wriggling  Jonah,  which  belongs  in  the  original  material, 
has -not  been  used  in  the  interpretation  given  us,  but  it  belongs 
here.  The  nurse  does  similarly,  she  wriggles  out  of  her  diffi- 
culty ;  she  docs  not  take  the  matter  seriously ;  why  bother  herself? 
The  chilfl  will  be  found  at  some  neighbor's  house.  I  can't  act 
dififcrently,  I  have  not  been  taught  (accusation  of  aunt,  mother). 


THE  DREAM  PROBLEM  89 

Rebirth  (alias  moral  development)  the  nurse  does  not  succeed 
in  obtaining;  she  is  content  with  some  superficial  consolation. 
Therefore,  we  don't  expect  to  find  any  liberation,  any  relief  from 
her  depression.  As  a  matter  of  fact  we  know  that  after  the 
dream  she  remains  defiant,  does  not  confess  her  fault,  is  irritable 
and  so  forth, — that  is,  she  remains  stuck  in  her  typical  pre- 
dicament. But  the  nurse  must  also  be  identical  with  the  former 
seller  of  foods,  for  we  expect  to  find  after  the  definition  of  the 
dream  which  I  have  to-day  set  forth,  that  on  sufficient  analysis 
all  figures  in  the  dream  will  resolve  themselves  as  personifica- 
tions of  tendencies  of  the  libido.  It  is  so  here  also,  since  the 
nurse  does  not  sufficiently  trouble  about  her  patient ;  she  sleeps 
during  her  hours  on  duty ;  probably  she  dreams  a  good  deal  about 
her  own  affairs.  The  marriage  and  separation  of  the  woman  in 
the  dream  no  doubt  refer  to  her  own  unfortunate  love-atYair,  as 
Freud  has  shown. 

This  dream,  then,  gives  us  a  pictured  representation  of  the 
nurse's  psychic  situation  at  the  time  of  the  occurrence  we  are 
reporting.  It  expresses  the  insufficient  attempts  of  the  dreamer 
to  develop  the  ethical  personality.  It  contains  references  to  a 
new  birth ;  but  also  to  the  failure  of  the  same  and  at  last  the 
dreamer  assumes  the  attitude  of  resigned  indifference.  Accord- 
ing to  my  conception  this  is  not  merely  a  confession  dream, 
although  Freud  ascribes  that  opinion  to  me.  The  dream  may  be 
recognized  indirectly  (in  that  it  is  told  to  the  lady)  and  also 
directly  (by  the  analysis)  as  a  confession.  But  in  the  psychic 
menage  of  the  dreamer  it  has  a  greater  significance  than  either  of 
these,  for  it  pictures  in  symbolic  speech,  a  typical  psychic  reac- 
tion of  the  dreamer  to  a  given  stimulus  from  the  outer  world. 
Its  meaning  goes  much  beyond  its  cause.  The  loss  of  the  place 
would  not  have  been  of  such  great  importance  to  the  nurse ;  such 
employment  is  easy  to  get.  It  deals  with  the  actual  conflict  of 
the  dreamer,  or  rather,  it  deals  unmistakably  with  her  actual  life- 
problem.  I  think  I  am  speaking  entirely  in  Jung's  meaning  of 
the  "  actual  conflict "  and  similarly  as  Riklin  has  done  in  an  ap- 
parently greatly  misunderstood  essay  in  the  Correspondenzblatt 
f.  Schweizer  Aerzte,  except  I  would  prefer  the  expression  "ac- 
tual expression  of  the  fife-task"  to  "actual  conflict." 

I  would  be  greatly  pleased  if  the  contrasting  of  these  two  dif- 
ferent interpretations  of  the  same  dream  might  serve  to  bring 
about  a  better  understanding  of  my  conception,  all  the  more  as  I 


90  A.  E.  MAEDER 

am  convinced  tliere  is  no  difference  of  principle  involved,  but 
only  a  broadening,  or  rather  a  deepening,  in  that  we  take  the 
question  from  its  strictly  sexual  into  the  general  psychological 
field. 

In  order  to  be  rightly  understood,  I  will  try  to  outline  my  atti- 
tude to  Freud's  interpretation.  The  nurse  fails  in  one  place, 
she  is  not  capable  of  adjustment,  her  libido  undergoes  retro- 
gression. Experience  teaches  us  that  in  this  situation  of  the 
libido,  sexual  excitement  easily  takes  place  (notice  the  onanism 
of  neurotics,  following  discomfitures  of  any  kind).  In  a  girl, 
the  wish  for  love,  marriage,  and  a  child,  which  is  justified  bio- 
logically as  well  as  psychologically,  can  fulfil  itself  in  phantasy. 
This  confirms  Freud's  interpi-etation.  If  I  ask  myself,  how  can 
it  be  possible  that  two  dift'erent  interpretations  of  the  same  dream 
may  be  correct,  there  comes  to  me  an  idea  that  I  have  long  har- 
bored, without  following  it  out  sufficiently  thoroughly  and  sys- 
tematically. It  is  this :  The  wish  of  the  girl  for  love  and  a  child 
is  an  expression  of  the  pleasure-principle,  whilst  the  picture  of 
the  nurse's  faulty  adjustment  to  life  and  her  reaction  is  the  work 
of  the  reality  principle.  The  dream,  as  I  interpret  it,  describes 
the  faulty  adjustment  to  reality.  The  two  fundamental  prin- 
ciples of  psychic  happening,  as  formulated  by  Freud,  ought  to  be 
demonstrable  in  the  psychic  phenomena ;  therefore  in  the  dream 
as  well  as  elsewhere.  For  the  last  two  years  I  have  gradually 
received  the  impression  that  in  psychoanalysis  we  have  first 
learned  to  know  the  pleasure  principle  and  its  numerous  mani- 
festations, thanks  to  Freud ;  whereas,  the  reality  principle  as  the 
younger  child  has  been  somewhat  neglected,  and  tliat  its  further- 
ing is  essentially  the  work  of  the  Zurich  school  with  Jung  at  its 
head.  The  following  from  Freud's  interpretation  seems  to  me 
a  confirmation  of  this.  "The  wish.  '  I  want  a  child,'  seems  to  be 
more  aflapted  to  help  the  nurse  over  the  unpleasant  situation  of 
the  reality."  It  looks  like  a  flistinct  accentuation  of  the  ])leasure 
principle  on  Freud's  part.  You  are  aware  that  the  principal  idea 
of  my  contested  article  on  the  "  Function  of  the  Dream,"  is  as 
follows:  "  In  the  dream  there  is  at  work  a  preparatory  arranging 
function  which  belongs  to  the  work  of  adjustment."  This  is  a 
clear  ex[)ression  of  the  emphasis  I  i>lace  on  the  reality  principle. 

The  two  main  principles  here  mentioned  are  after  all  only 
an  expression  of  the  two  typical  forms  of  activity  of  the  libido, 
progressive  and  regressive.  They  are  metaphorically  expressed, 
two  channels  m  ili«-  .li-i-osal  of  the  libido  current.     The  important 


THE  DREAM  PROBLEM  91 

point  is  the  proper  distribution  of  the  same.  They  are  also  com- 
parable to  two  voices  which,  more  or  less  harmoniously,  sing 
the  song  of  Hfe.  In  neurosis,  as  in  the  first  phase  of  cure  by 
analysis,  the  voice  of  regression  drowns  the  other;  this  can  be 
proved  in  numerous  dreams  which  are  to  be  found  in  literature  ; 
I  have  therefore  avoided  giving  examples.  It  is  true  that  in 
all  these  dreams  traces  of  the  drowned  voice  of  progression  are 
demonstrable.  It  is  to  this  point,  it  seems  to  me,  that  the  analyst 
of  the  future  should  attach  the  most  importance,  for  we  are  first 
and  foremost  healers,  and  therefore  it  is  our  duty  to  point  out  to 
our  wandering  patients  the  light  that  shines  in  the  distance.  This 
gleam  of  light  is  to  serve  them  as  a  lighthouse  in  the  storms  of 
passion.  In  the  course  of  the  treatment  the  voice  of  progression 
will  gradually  become  louder,  until  it  finally  takes  the  dominant 
note.  The  connection  between  pleasure  and  displeasure  prin- 
ciple and  the  cathartic  function,  on  the  one  hand,  and  between 
the  reality  principle  and  the  preparatory  function  on  the  other 
can  here  be  merely  indicated.  An  outburst  of  anger,  to  avoid 
internal  tension,  the  striving  for  satisfaction  by  replacements, 
are  frank  unloadings  (cathartic  cleansings)  ;  the  weighing  and 
representing  of  the  solution  of  a  conflict  prepares  for  freedom 
and  leads  to  reality. 

I  am  at  the  end  of  my  presentation.  You  will  be  justified  in 
remarking  that  I  have  not  tried  to  test  the  subject  from  all  sides ; 
I  have,  for  instance,  passed  over  the  dream  as  a  guardian  of  sleep, 
and  left  polemics  aside.  I  did  not  do  so  in  order  to  lighten  my 
task ;  I  may  say  for  my  justification  that  I  primarily  desired  to 
handle  those  points  which  have  become  somewhat  clear  to  me,  I 
have  also  striven  to  bring  as  much  positive  material  as  might  be 
useful  for  the  discussion.  I  hope  that  the  gaps  I  have  been 
obliged  to  leave  may  be  filled  out  by  my  colleague  to  your  satis- 
faction. 


IPcri6cope 

Jahrbiicher  fiir  Psychiatric  und  Neurologic 
(Vol.  34,  Parts  i  and  2) 

1.  Study  of  the  Histories  of  German  Brain-pathology.     M.\x  Neuberger. 

2.  Korsakow's  Psj'chosis  in  Japan.     Toyot.\ne  Wada. 

3.  Daily  Variations  in  the  Electrical  Conductivity  of  the  Human  Body.     Dr. 

V.  Pfuxgen. 

4.  Involution  Phenomenon  in  Cases  with  the  Clinical  Picture  of  Brain  Tumor. 

Emil  Redlich. 

5.  The  Influence  of  Political  Events  in  Mental  Disorders.     C.  Grosz  and  M. 

Pappexheim. 

6.  Dystrophy  Adiposus-genitalis  in  Chronic  Hydrocephalus  and  in  Epilersy. 

J.   ROTHFELD. 

7.  Changes  in  the  Official  Diagnosis  Plan  for  Insane  Institutions.      H.  Schloss. 

1.  German  Brain-pathology. — .'K  resume  of  the  early  ideas  regarding  en- 
cephalomalacia  and  its  relation  to  encephalitis,  thrombosis  and  embolism. 

2.  Korsakozv's  Psychosis  in  Japan. — Wada  reports  two  cases  of  Korsa- 
kow's psychosis  and  calls  attention  to  the  in  frequency  of  this  among  the 
Japanese,  as  onW  seven  cases  have  been  reported.  The  relation  of  Korsa- 
kow's psychosis  to  alcohol  appears  to  be  less  constant  tlian  in  other  countries, 
as  in  none  of  the  reported  cases  was  alcohol  an  etiological  factor.  Altliough 
alcohol  is  freely  used  in  Japan,  alcoholic  psychoses  are  very  rarely  observed. 

The  two  cases  observed  by  the  author  developed  as  a  result  of  nephritis 
and  were  characterized  by  loss  of  memorj',  retrograde  amnesia  and  disorien- 
tation as  to  time,  without  confabulation  and  polyneuritis. 

3.  Variations  in  Electrical  Conductivity. — The  experiments  of  v.  Pfungen 
show  that  the  electrical  resistance  of  the  human  body  varies  with  tlie  dif- 
ferent physical  and  mental  states  of  the  person.  When  accumulations  of  fecal 
matter  occur  in  the  colon  the  electrical  resistance  of  the  body  is  high,  sliowing 
in  some  cases  180,000  ohms.  With  evacuation  of  the  bowels  the  resistance 
was  reduced  to  about  70,000  ohms. 

Mental  states,  as  anxiety,  fear  of  death  or  disease,  etc.,  produce  a  lower- 
ing of  the  electrical  resistance  to  10,000  ohms  or  less — in  one  instance  to 
4,800  ohms. 

4.  Involution  Signs  in  Brain  Tumor. — Rcdlich's  case  began  with  psychical 
symptoms,  especially  forget  fulness,  and  rapidly  developed  a  complete  clinical 
picture  of  brain  tumor,  with  local  .symptoms  as  left  hemiparesis.  liemianes- 
thcsia,  and  left  hemianopsia  indicating  a  location  in  the  right  hemisphere. 

Although  no  evidences  of  lues  could  be  found  and  the  Wassermann  reac- 
tion was  negative,  mercury  was  tried  on  two  occasions  and  aggravated  the 
symptoms.  Under  potassium  iodide  the  condition  improved  and  the  symp- 
toms nearly  disappeared,  leaving  a  slight  atrophy  of  the  left  optic  nerve,  so 
that  patient  could  return  to  his  work  for  nine  months.  Then  the  symptoms 
returned  and  a  tumor  of  the  thyroid  developed.  At  the  autopsy  was  found  a 
malignant  tumor  with  sarcomatous  degeneration  of  the  thyroid  gland,  and  a 
large  tumor  in  the  right  parietal  lobe  having  the  histological  characters  of  a 
diffuse  glioma. 

5.  Political  Events  in  Mental  Disorders. — Grosz  anfl  Pappenheim  describe 

92 


PERISCOPE 


93 


some  of  the  psychoses  which  occurred  during  the  Balkan  War.  The  poHtical 
situation  appeared  to  give  special  color  to  the  dehrious  and  confusional  states 
of  alcoholism,  etc.,  in  persons  who  otherwise  had  no  fear  of  the  war.  In 
general  it  may  be  said  that  the  "  political  symptom  "  was  only  an  accidental 
factor  in  modifying  the  hallucinations  and  was  without  influence  in  the  pro- 
duction of  the  psychoses. 

_  6.  Dystrophy  Adiposus-genitalis  in  Hydrocephalus  and  in  Epilepsy. — 
Redlich  reports  five  cases  of  hydrocephalus  with  dystrophy  adiposus-genitalis, 
of  which  three  were  also  associated  with  epilepsy.  The  dystrophy  symptoms 
are  explained  as  possibly  due  to  the  pressure  on  the  hypophysis  by  the  hydro- 
cephalus in  cases  having  some  disturbance  of  the  functions  of  the  hypophysis 
or  other  ductless  glands.  The  epilepsy  may  also  be  explained  by  a  similar 
disturbance  of  the  hypophysis  by  the  increased  pressure  of  the  hydrocephalus. 
7.  Official  Diagnosis  Records. — Proposed  changes  for  recording  vital  sta- 
tistics and  diagnoses  in  insane  institutions.     Of  local  interest  onl}^ 

E.  A.  Sh.\rp. 

Review  of  Neurology  and  Psychiatry 

(Vol.  XII,  No.  7) 

1.  A  Case  of  Amaurotic  Family  Idiocy.     W.  E.  Hume. 

2.  The  Action  of  Adrenalin  and  Epinine  on  the  Pupil  in  Epilepsy.     R.  AC 

Stewart. 

1.  A  Case  of  Amaurotic  Family  Idiocy. — The  case  described  bears  all  the 
characteristic  clinical  and  pathological  features  of  this  disease.  The  article 
is  accompanied  by  five  microphotographs  and  three  colored  drawings.  The 
case  was  in  the  service  for  a  time  of  Mr.  Wardale,  senior  ophthalmic  surgeon 
to  the  Royal  Victoria  Infirmary,  Newcastle-upon-Tyne. 

2.  Action  of  Adrenalin  on  the  Pupil. — The  patients  experimented  on  were 
mostly  insane  epileptics  at  the  Prestwich  County  Asylum. 

Instillation  of  suprarenal  extract  into  the  eyes  of  an  epileptic  immediately 
after  the  cessation  of  a  fit,  may  give  rise  to : — 

1.  Dilatation  of  both  pupils,  about  35  per  cent. 

2.  Dilatation  of  one  pupil  only,  17  per  cent. 

3.  No  change,  43  per  cent. 

4.  Contraction  of  one  or  both  pupils,  17  per  cent. 

These  conclusions  were  derived  from  the  study  of  the  pupillary  phenome- 
non in  fifty  patients  subject  to  major  epileptic  attacks,  and  some  400  observa- 
tions were  made.  In  none  of  the  cases  was  any  effect  produced  by  the  instil- 
lation of  adrenalin  during  an  interparoxysmal  period. 

The  duration  of  the  mydriasis  was  subject  to  a  wide  variation.  Fre- 
quently the  pupil  remained  dilated  for  fifteen  to  thirty  minutes,  and  then  grad- 
ually returned  to  normal,  but  in  some  instances  it  remained  dilated  for  some 
hours,  and  not  infrequently  a  patient  would  have  another  fit  before  the 
mydriasis  had  passed  off. 

Observations  were  also  made  in  Jacksonian  epilepsj',  congestive  attacks 
in  G.  P.  I.,  organic  hemiplegia  and  a  few  other  affections.  Mydriasis  was 
produced  in  all  cases  in  which  there  was  evidence  of  S5'mpathetic  derange- 
ment or  abnormal  function  of  the  ductless  glands. 

The  writer  concludes  his  article  as  follows : 

With  regard  to  epilepsj^,  not  infrequently  a  disturbance  of  the  normal 
sympathetic  mechanism  takes  place,  which  may  be  readily  shown  by  the  em- 
ployment of  suprarenal  extract  as  a  clinical  test;  further,  this  disturbance 
may  be  unilateral  or  bilateral,  and  is  subject  to  variations  which  cannot  at 
present  be  explained. 


94  PERISCOPE 

It  is  necessary  to  consider  whether  this  sympathetic  derangement  plays 
an}'  part  in  the  production  of  epileptic  fits. 

The  inconstancy  of  adrenalin  mydriasis  in  epileptics,  the  wide  variations 
to  which  it  is  subject,  and  its  occurrence  in  other  convulsive  types,  make  it 
probable  that  the  convulsive  seizure  and  the  sympathetic  disturbance  are 
related,  not  as  cause  and  effect,  but  as  concomitant  effects  of  a  single  patho- 
logical process,  which  has  yet  to  be  determined. 

C.  E.  Atwood. 


Archiv  fiir  Psychiatrie  und  Nervenkrankheiten 
(52  Band,  i  Heft) 

I.  Recent  Syphilis  Investigation  and  Neuropathology.     G.  Steiner. 
II.  A   Contribution   to   the    Study  of   Aphasia,    with    Special   Reference   to 

Amnesic  Aphasia.     F.  A.  Kehrer. 
III.  The  Distribution  of   Fiber   Degeneration  in  Amyotrophic  Lateral  Scle- 
rosis,  with    Special    Reference   to   Changes   in   the   Cerebrum.     E. 
W'exderowic  and  M.  Nikitin. 
IV^  Clinical  and  Anatomical  Contribution  to  the  Study  of  the  Occlusion  of 
the   Posterior   Inferior  Cerebellar  Artery.     K.   Goldstein   and  H. 
>  Baumm. 

V.  Heredity  in  the  Psychoses.     (Continued  article.)     Ph.  Jolly. 

I.  Syphilis  and  Neuropathology. — On  the  basis  of  renewed  interest  in 
syphilis  derived  from  the  discovery  of  its  causative  spirochete,  Steiner  dis- 
cusses the  present  status  of  the  pathological  anatomy  of  the  disease.  He 
points  out  the  desirability  of  studying  the  greatest  possible  number  of  cases 
in  all  stages  of  the  disease  after  a  definite  method,  particularly  in  relation  to 
the  various  reactions  of  the  spinal  fluid  and  the  results  of  animal  inoculation. 
The  question  of  the  relation  of  so-called  meta-syphilis  to  the  disease  is  given 
due  weight,  as  are  the  various  problems  of  "  neurorezidive."  He  finds  that 
these  phenomena  occur  in  the  greatest  number  of  instances  in  the  early 
secondary  stage,  and  that  they  are  distinctly  more  frequent  after  salvarsan 
treatment  than  after  mercury.  The  opinion  now  generally  accepted  is  ex- 
pressed :  that  the  so-called  meta-syphilis  is  to  be  regarded  ratlicr  as  a  late 
manifestation  of  the  disease  itself  than  as  a  special  and  differentiated  affection. 
The  article  gives  an  a<lmiral)le  summary  of  the  knowledge  of  the  disease  in 
its  various  relationships,  and  is  followed  by  an  excellent  bibliography. 

II.  Aphasia. — This  article  is  too  technical  to  permit  of  adequate  review. 
It  offers  a  valuable  discussion  and  data  on  the  obscure  and  difficult  subject  of 
amnesic  aphasia. 

III.  Amyotrophic  Lateral  Sclerosis. — Wenderowic  and  Nikitin  find  dis- 
tinct degenerations  in  the  brain  as  well  as  in  the  spinal  cord  and  in  the  brain 
stem  in  a  carefully  studied  case  of  amyotrophic  sclerosis.  The  chief  interest 
and  the  chief  emphasis  of  the  paper  lies  in  the  degenerations  found  in  tlie 
brain,  apparently  far  removed  from  the  course  of  the  pyramidal  tracts;  espe- 
cially were  lesions  found  in  the  corpus  callosum  as  well  as  in  various  parts 
of  the  cerebral  cortex,  particularly  in  its  motor  regions.  The  authors  feel 
justified  in  denying  the  existence  of  motor  areas  in  the  insula  and  in  the 
gyrus  fo'rnicatus,  since  no  degenerations  were  found  in  those  regions.  Per- 
haps the  most  important  part  of  the  paper  lies  in  the  study  of  the  corpus 
callosum  in  relation  to  associated  motor  functions  of  the  two  hemispheres. 

IV.  Cerebellar  Artery.  Posteri,>r  Inferior. — Goldstein  and  Haumm.  fol- 
lowing the  study  of  several  cases  of  occlusion  of  the  posterior  inferior  cere- 
bellar artery,  present  a  valuable  resume  of  the  symptomatology  of  this  some- 


PERISCOPE 


95 


what  unusual  lesion  in  relation  to  disturbances  of  sensation,  its  distribution, 
disturbances  in  the  distribution  of  the  vagoglossopharyngeal,  taste  disturb- 
ances, sympathetic  involvement,  lesions  of  the  restiform  body  and  of  the  cere- 
bellar tracts.  The  paper  is  of  distinct  value  in  its  detailed  description  of  the 
effects  of  this  somewhat  unusual  lesion.  An  elaborate  table  is  appended  to 
the  article. 

V.  Jolly  (Continued  article.) 

(52  Band,  2  Heft) 

VII.  Contributions  to  the  Pathological,  Anatomical,  and  Clinical   Study  of 
Cerebral  Hemorrhagic  Pachymeningitis.     E.  Ciarla. 
VIII.  Heredity  in  the  Psychoses.     (Article  concluded.)     Ph.  Jolly. 
IX.  The  Failure  of  the  Corneal  Reflex  in  Organic  Nervous  Disease.     R. 

Wolff. 
X.  Family  Cortical  Spasm.     J.  Rulf. 
XL  Pathological  Anatomy  and  Pathogenesis  of  Granular  Ependymitis.     M. 
S.  Margulis. 

VII.  Pachymeningitis  Hemorrhagica. — Ciarla  has  made  a  study  of  up- 
wards of  150  cases  of  hemorrhagic  pachymeningitis  of  the  brain,  and  finds 
that  the  condition  produces  symptoms,  difficult  if  not  impossible  to  differen- 
tiate from  various  other  conditions.  The  apoplectic  and  epileptic  seizures 
frequent  in  dementia  praecox  may  not  occur  in  spite  of  the  existence  of 
pachymeningitis ;  and,  on  the  other  hand,  in  the  absence  of  such  a  pachy- 
meningitis, these  seizures  may  occur. 

VIII.  Heredity  in  Psychoses. — Jolly  offers  a  detailed  and  painstaking 
study  of  heredity  in  connection  with  the  study  of  twenty-one  families  in 
which  various  psychoses  occurred.  He  draws  the  general  important  conclu- 
sion that  the  former  view  is  now  untenable,  that  there  is  a  strong  tendency 
for  families  so  afflicted  to  die  out  in  relatively  few  generations.  His  study 
shows  that  no  degeneration  or  advancing  depreciation  of  the  family  stock 
could  be  demonstrated.  The  degeneration  of  the  race  from  a  psjxhopathic 
standpoint,  if  such  occurs,  is  not  due  to  the  appearance  of  endogenous  ps\-- 
choses,  but  rather  to  an  injury  of  the  germ-plasm,  above  all  by  alcohol  and 
syphilis.  A  detailed  statement  of  the  types  of  psychoses  occurring  in  the 
various  families  leads  to  interesting  conclusions  regarding  heredity.  The 
difficult  subject  can  only  fitly  be  determined  with  fair  scientific  accuracy  by 
the  collection  and  intensive  study  of  a  great  number  of  families. 

IX.  Corneal  Reflex. — The  corneal  reflex  in  organic  diseases  of  the  nerv- 
ous system  is  studied  by  Wolff  on  the  basis  of  a  large  series  of  carefully 
observed  cases.  He  has  carried  further  the  original  observation  of  Oppen- 
heim,  made  in  1900,  who  pointed  out  the  importance  of  this  phenomenon  in 
the  diagnosis  of  organic  disease. 

X.  Cortical  Spasm. — Riilf  calls  attention  to  a  case  of  cortical  spasm,  of 
which  he  finds  but  a  single  other  instance  in  the  literature.  The  patient,  as 
well  as  his  three  sisters  and  his  father,  suffered  from  a  peculiar  spasmodic 
affection  affecting  the  leg,  body,  upper  extremity,  face,  mouth,  and  speech 
muscles,  in  a  way  suggestive  of  Jacksonian  epilepsy.  From  the  fact  of  its 
appearance  in  several  members  of  the  family,  however,  it  appears  unHkely 
that  the  spasm  could  be  due  to  an  organic  lesion  of  the  motor  region.  The 
writer  is  rather  inclined  to  the  hypothesis  of  a  centrally  caused  motor  neu- 
rosis, and  would  classify  it  as  a  family  form  of  cortical  spasm.  The  article 
discusses  the  question  of  hysteria  and  organic  disease  as  possible  explanations. 

XI.  Glandular  Ependymitis. — Margulis  reaches  certain  definite  conclu- 
sions on  the  ground  of  his  investigation  of  granular  ependymitis.     He  finds 


96  PERISCOPE 

that  the  papillae  in  the  afifcction  have  a  distinctive  structure  composed  of  a 
central  portion  built  up  of  a  network  of  glia  fibers. and  glia  cells,  and  that 
these  papillas  may  be  further  classified  as  cellular  or  composed  more  particu- 
larly of  fibrils,  depending  in  general  upon  the  character  of  the  glia  tissue  of 
the  ependyma.  Occasional  granulations  of  the  ependyma  have  no  patho- 
logical significance.  A  great  number,  however,  and  a  wide  distribution  con- 
stitute the  pathological  anatomy  of  granular  ependymitis,  which  is  an  active 
and  progressive  process  of  congenital  origin  dating  from  intra-uterine  life. 
The  process  takes  a  position  between  chronic  inflammation  and  new  growth, 
and  is  to  be  regarded  as  a  congenital,  progressive  gliosis  of  the  central 
nervous  system. 

(52  Band,  3  Heft) 

X\'.  A  Retrospect  in  Connection  with  the  Twentj'-fifth  Jubilee  of  Prof. 
Dr.  Emil   Sioli  as  Director  of  the  Frankfurt  Insane  Hospital. 
A.  Alzheimer. 
X\'I.  The  Cerebrum  of  the  Rabbit.     Franz  Nissl. 
X\'II.  Psychoneuroses  in  Heart  Disease.     Lilienstein. 
XVIII.  The  Anti-social  Actions  of  Epileptic  Children.     Raecke. 
XIX.  The  Use  of  Pyrogenetic  Methods  in  Psychiatry.     A.  Friedlander. 
XX.  A  Contribution  to  Operative  Treatment  of  Epilepsy.     Veit. 
XXI.  A    Contribution   to   the   Mistaken   Diagnosis   of   Hysteria.    Hans 

Wachsmuth. 
XXII.  On  Supernumerary  Phalanges.     P.  GEEL\aNK. 

XXIII.  Dementia  Paralytica  among  the  Jews.     Max  Sichel. 

XXIV.  A  Case  of  Motor  Apraxia.     Noehte. 

XXV.  Association  Experiments  in  Young  Epileptics.     R.  Hahn. 
XXVI.  A    Contribution    to    Our    Knowledge    of    Mental    Disturbances    in 

Eclampsia.    Franz  Jaiinel. 
XXVII.  Clinical  Diagnosis  and  Pathological  Findings  in  General  Paralysis. 

Otto  Markus. 
XXVIII.  The  Significance  of  Lowy's  Phenomenon  in  tlie  Diagnosis  of  Cere- 
bral Arteriosclerosis.    Julie  Bender. 
XXIX.  Psychic  Disturbances  During  Labor.     Paul  Kirchberg. 

XV.  Sioli. — This  number  constitutes  a  Festschrift  for  Professor  Emil 
Sioli.  Alzheimer  reviews  the  work  of  Sioli  during  his  twenty-five  years'  in- 
cumbency as  Director  of  the  Frankfurt  Hospital  for  the  Insane. 

XVI.  Rabbit  Cerebrum. — Nissl  offers  an  anatomical  study  of  the  cerebral 
mechanism  of  the  rabbit,  being  the  substance  of  his  work  when  connected 
with  the  Frankfurt  institution. 

XVII.  Heart  Disease  and  Psychoneuroses. — Lilienstein  pleads  for  a  bet- 
ter classification  of  the  psychoses,  and  urges  that  the  term  paranoia  be  sharply 
limited,  anfl  that  catatonia,  dementia  pra;cox,  and  hebephrenia  be  separated 
from  this  category.  The  same  is  true  of  the  terms  melaMcholia  and  dementia. 
Likewise  in  the  future  various  heterogeneous  disturbances  should  not  be 
classified  under  neurasthenia  and  hysteria;  and  especially  the  psychoneuroses 
which  occur  in  heart  cases  should  be  placed  in  a  group  by  themselves  and 
sharply  separated  from  the  endogenous  psychoses. 

XVIII.  Epileptic  Children  and  Anti-social  Acts.— Raecke  cites  a  number 
of  cases  of  epilepsy  in  children  to  illustrate  the  epileptic  temperament  apart 
from  the  attacks,  and  urges  a  more  careful  treatment  of  these  cases,  and  if 
necessary  their  detention  in  proper  institutions  to  guard  against  danger  to 
their  associates. 

XIX.  Heal  in  Treatment  of  Psychoses. — Fricdl.inder  dwells  on  the  hope- 
lessness of  much  of  the  treatment  in  psychiatry,  and  discusses  the  possibility 


PERISCOPE 


97 


of  a  further  trial  of  various  heat-producing  agents.  He  believes  that  the 
pyrogenetic  treatment  of  the  psychoses  has  a  scientific  foundation  in  the  fact 
that  intercurrent  febrile  diseases  often  influence  psychoses  favorably.  Prac- 
ticall}%  the  experience  of  various  physicians  has  demonstrated  the  possibilities 
of  such  treatment  artificially  produced.  Various  drugs  are  alluded  to  in  this 
connection,  and  the  hope  is  expressed  that  further  researches  may  be  made, 
inasmuch  as  the  results  hitherto  obtained  offer  some  expectations  for  the 
future.  In  connection  with  salvarsan,  mercury,  and  iodides,  he  believes  that 
pyrogenetic  treatment  may  be  used  with  advantage. 

XX.  Operation  in  Epilepsy.— Vek  reports  two  cases  of  epilepsy  in  which 
operative  measures  were  taken.  In  one,  the  operation  was  undertaken  for 
the  removal  of  a  bullet  and  to  prevent  further  complications  which  might  be 
caused  by  the  projectile.  The  epilepsy  itself  was  not  helped.  In  the  second 
case,  operation  likewise  did  not  affect  the  epileptic  attacks.  Insistence  is  laid 
upon  the  necessity  of  long-continued  bromide  treatment  after  operative 
interference. 

XXI.  Hysteria  Diagnosis. — Wachsmuth  in  this  paper  gives  a  series  of 
cases  of  mistaken  diagnoses.  The  contribution  is  of  value  from  a  clinical 
standpoint. 

XXII.  Supernumerary  Digits — As  a  possible  contribution  to  the  study  of 
the  stigmata  of  degeneration,  Geelvink  calls  attention  to  the  rare  anomaly  of 
supernumerary  phalanges.  He  finds  the  deformity  peculiarly  hereditary, 
although  the  rarit\'  of  the  affection  has  prevented  its  careful  study  in  many 
families.  The  cases  are  not  sufficient  in  number  to  determine  the  point  as 
to  the  Mendel  rule  concerning  dominants  and  recessives,  although  after  anal- 
ogy with  other  deformities,  it  may  be  presumed  that  a  dominant  would  be 
shown. 

XXIII.  Paresis  among  Jeivs. — Although  syphilis  is  recognized  as  an 
essential  factor  in  the  production  of  general  paralysis,  this  fact  does  not 
explain  the  disparity  in  certain  regions  between  the  incidence  of  syphilis  and 
dementia  parah'tica.  It  is  evident  that  some  other  factor  or  factors  must 
enter  into  the  determination  of  the  disease.  Recently,  Westhoff  has  ex- 
pressed the  view  that  paresis  is  a  race  disease  which  attacks  particularh^  the 
higher  races,  and  especially  the  Germanic  races,  including  the  related  Slavs 
and  Celts.  This  theory  appears  to  have  many  contradictions.  A  study  of 
the  incidence  of  the  disease  among  the  Jews  shows  that  the  Jews  of  different 
countries  and  regions  vary  in  their  predisposition.  Interesting  statistics  are 
given  on  this  point.  It  is  concluded  that  the  assumption  of  a  race  predispo- 
sition cannot  be  proved.  The  same  factors  predispose  among  the  Jews  as 
among  others.  Possibly  the  frequency  of  the  disease  in  that  race  is  due  to 
the  fact  that  they  have  for  a  shorter  period  been  exposed  to  the  poisons  of 
syphilis  and  alcohol  than  others.  It  is  noticeable  that  Jewish  women  are 
seldom  infected  by  the  disease.  It  is  finally  concluded  that  the  disease  occurs 
with  practically  the  same  frequency  among  the  Jews  and  those  of  other  races, 
and  that  the  observed  differences  are  to  be  attributed  to  external  causes  rather 
than  to  the  influence  of  race. 

XXIV.  Motor  Apraxia. — Noehte  describes  in  detail  and  with  full  com- 
ment a  valuable  case  of  motor  apraxia. 

XXV.  Association  in  Epileptics. — Hahn  narrates  a  series  of  association 
experiments  with  young  epileptics  in  an  attempt  to  show  whether  the  mental 
defect  observed  in  these  cases  is  simply  a  defect  of  development,  or  whether 
it  occurs  in  conjunction  with  more  or  less  normal  development. 

XXVII.  Eclampsia. — Jahnel  studies  in  this  article  the  mental  disturbances 
occurring  in  eclampsia,  and  makes  the  somewhat  obvious  point  that  the 
eclamptic  psychoses  which  he  describes  may  only  be  diagnosticated  by  the 
proof  of  a  foregoing  eclampsia.     It  is  to  be  borne  in  mind  that  convulsive 


9S  PERISCOPE 

seizures  of  other  than  eclamptic  character  may  occur,  and  during  the  puer- 
peral period  may  be  mistaken  for  true  eclampsia.  Epilep.sy  has.  for  example, 
often  been  confused  with  eclampsia.  The  attempt  has  been  made  to  distin- 
guish the  psychoses  occurring  in  connection  with  eclampsia  from  those  related 
to  epilepsy.  A  distinction  should  also  be  made  between  the  delirium  of  alco- 
holism and  that  of  eclampsia.  Various  forms  of  puerperal  psychoses  are  to 
be  distinguished  by  the  absence  of  eclamptic  symptoms. 

XX\'II.  Paresis  Diagnosis. — Markus  believes  tliat  the  surest  diagnostic 
point  in  the  diagnosis  of  paresis  is  the  Wassermann  reaction  in  the  blood  and 
spinal  fluid.  In  by  all  means  the  majority  of  cases  of  paresis,  these  reactions 
are  positive.  Xonne  maintains  that  they  are  positive  in  all  cases.  Markus 
believes  that  a  small  number  do  not  show  the  reaction?,  and  that  in  these  cases 
a  pathological  investigation  may  alone  determine  the  diagnosis.  For  scientific 
reasotis  the  two  series  of  investigations  should  be  undertaken  wherever  pos- 
sible definitely  to  determine  the  diagnosis.  In  the  special  cases  cited  where 
the  pathological  examination  determined  the  diagnosis  of  paresis,  the  Wasser- 
mann reaction  in  blood  and  fluid  was  positive,  whereas  in  those  cases  in  which 
the  histological  examination  pointed  to  other  disease,  the  Wassermann  reac- 
tion was  negative. 

XXVIII.  Arteriosclerosis. — Lowy,  on  the  basis  of  a  study  of  tlie  blood 
pressure  in  the  temporal  artery,  has  stated  that  its  increase  on  bending  the 
head  forward  may  be  regarded  as  a  specific  sign  of  cerebral  arteriosclerosis. 
Bender  investigated  40  cases,  15  with  various  psychoses,  25  with  demonstrated 
arteriosclerosis,  among  which  9  came  to  autopsy.  In  only  two  of  these  cases 
was  Lowy's  phenomenon  demonstrated.  The  others  showed  no  change  in 
blood  pressure.  It  is  the  opinion  of  the  writer  that  the  positive  cases  were 
not  due  to  arteriosclerosis,  but  to  certain  psj'chic  complications,  and  that  the 
phenomenon  might  with  equal  frequency  occur  in  purely  functional  disorders. 

XXIX.  Parturition  Psychoses. — Kirchberg  points  to  the  infrequency  of 
transitory  mental  disturbances  during  and  immediately  after  childbirth.  A 
case  is  reported  in  which  an  excited  mental  state,  with  disorientation  and 
hallucinations,  occurred  shortly  before  the  birth  and  continued  for  some  time 
afterward,  the  whole  abnormal  state  lasting  about  an  hour.  A  number  of 
other  cases  are  reported  from  the  literature. 

E.  W.  T.WLOR. 

MISCELLANY 

Cerebellar  Tumors.     T.  H.  Wcisenburg  and  Philip  Work.     (Journal  A.  M. 
A.,  October  16,  1915.) 

The  authors  discuss  the  symptomatology  and  diagnosis  of  tumors  of  the 
posterior  cranial  fossa.  They  remark  that  the  knowledge  of  cerebellar  symp- 
toms and  localization  has  not  progressed  so  far  as  the  cerebral,  and  in  few 
cases  in  the  literature  has  an  accurate  localization  of  the  lesions  in  connec- 
tion with  the  local  symptoms  been  attempted.  They  believe  the  chief  function 
of  the  cerebellum  is  to  synergize  all  movements  of  the  body.  The  asynergy 
can  be  detected  in  any  part  or  parts,  and  they  emphasize  that  to  make  an 
accurate  diagnosis  of  a  cerebellar  lesion  it  is  necessary  to  take  into  account 
all  other  symptoms  with  those  of  the  cerebellar.  They  have  often  made  a 
diagnosis  of  a  labyrinthine  lesion,  only  to  find  the  cerebellum  involved  and 
vice  versa.  It  has  not  been  infrequent  to  diagnose  lesions  of  the  cerebellum 
when  only  the  superior  cerebellar  peduncle  has  been  secondarily  involved. 
In  accordance  with  their  views  of  cerebellar  function,  lesions  of  the  cere- 
bellum itself  cause  more  strictly  limited  symf)toms  than  those  invading  the 
peduncles.  Most  tumors  of  the  cerebellum  are  gliomatous  and  of  slow 
growth.  Most  of  them  tend  to  invade  the  middle  rather  than  the  outer  part 
of  the  cerebellum,  and  the  vermis  is  almost  always  involved.     It  is  in  this 


PERISCOPE  99 

that  they  believe  are  centered  the  sj^nergic  movements  of  the  upper  trunk  or 
shoulder  girdle,  and  in  the  lower  vermis  the  movements  of  the  lower  trunk 
or  the  pelvic  girdle.  In  the  former  the  feet  are  not  held  widely  apart  when 
walking  or  standing,  and  there  is  no  wabbling  of  the  pelvis.  The  chief  diffi- 
culty is  that  in  attempting  to  stand  or  walk,  the  trunk  leans  or  falls  forward, 
backward,  or  to  one  side  much  more  so  than  in  the  pelvic  girdle  cases  in 
which  there  is  a  more  irregular  gait,  while  the  body  is  held  more  erectly. 
When  the  vermis  is  implicated,  the  staggering  is  mainly  forward  or  backward 
and  when  a  lateral  lobe  is  involved  the  sway  of  the  body  is  to  the  side  of  the 
lesion.  When  the  lateral  lobes  alone  are  implicated,  the  asynergic  movements 
are  present  only  on  the  side  of  the  lesion  in  the  upper  limb  if  the  lesion  is 
in  the  superior  lobe,  and  in  the  lower  limb  if  in  the  lower  one.  The  authors 
place  the  synergic  center  for  eye  movements  in  the  extreme  upper  portion  of 
the  superior  vermis,  and  in  chronic  lesions  confined  to  the  cerebellum  invol- 
untary nystagmus  may  occur.  If  the  nystagmus  is  developed  by  voluntary 
movement  the  lesion  is  probably  extracerebellar.  In  these  cases  direct  stimu- 
lation of  the  vestibular  tract  showed  a  source  of  such  nystagmus.  The  pres- 
ence of  cranial  nerve  symptoms  indicate  this  lesion  is  extracerebellar.  Dizzi- 
ness with  disturbance  of  hearing  is  not  a  cerebellar  symptom.  Involvement 
of  the  motor  fibers  means  pressure  on  the  motor  apparatus  and  not  a  trouble 
confined  to  the  cerebellum.  As  a  rule,  it  indicates  a  pontile  lesion  or  one  in 
the  angle  pressing  on  the  pons.  Our  knowledge  is  not  definite  as  to  the  func- 
tions of  the  fibers  in  the  cerebellar  peduncles.  It  is  supposed  that  the  inferior 
and  middle  peduncles  transmit  impulses  to  the  cerebellum,  and  the  superior 
peduncle  transmits  impulses  from  this  organ.  It  is  probable,  the  authors  hold, 
that  all  the  peduncles  transmit  impulses  in  both  directions,  and  the  special 
functions  of  the  different  peduncles  are  mainly  theoretical  as  yet.  From  our 
present  knowledge,  all  w-e  can  say  is  that  lesions  strictly  confined  to  any  of 
the  peduncles  cause  asj-nergic  s3'mptoms  in  all  parts  of  the  body.  The  special 
symptoms  of  tumors  of  the  different  peduncles  are  given.  Such  growths  are 
mostly  invading  ones,  apparently.  In  lesions  of  the  middle  cerebellar  peduncle 
the  associated  phenomena  consist  of  the  fifth  or  sixth  nerve  symptom  on  the 
side  of  the  lesion  with  sensory  and  motor  phenomena  on  the  opposite  side. 
They  have  never  seen  a  tumor  limited  to  the  inferior  peduncle,  though  they 
have  seen  extensions  of  growth  into  one  or  both.  In  such  growth  the  asso- 
ciated phenomena,  if  the  lesion  extends  into  the  medulla,  should  be  implication 
of  the  vestibular  tract  and  of  the  ninth,  tenth  and  twelfth  cranial  nerves. 
Lesions  of  the  cerebello-pontile  angle  are  not  usually  hard  to  diagnose. 
Cases  have  been  seen,  however,  when  after  such  diagnosis  it  was  found  that 
the  angle  had  been  invaded  secondarily  by  tumors  growing  from  the  cere- 
bellum and  more  rarely  from  the  pons.  The  differential  diagnosis  is  impor- 
tant here  from  a  surgical  point  of  view^  as  such  tumors  offer  little  hope  for 
surgical  removal.  In  the  usual  tumor  growing  from  the  cerebello-pontile 
angle  the  cerebellar  symptoms  are  not  very  marked,  and  the  asynergy  will  be 
limited  to  the  arm  and  leg  on  the  side  of  the  growth,  unless  the  tumor  is  very 
large.  If  there  is,  in  addition  to  the  cranial  nerve  symptoms,  cerebellar 
asynergy  in  the  trunk  and  limbs,  it  is  probable  that  tlie  tumor  grows  either 
from  the  cerebellum  or  from  the  pons,  and  this  point  is  iiuportant  to  be  noted 
in  the  differential  diagnosis. 


TBOO]\  IKCVtCWB 


The  Ethical  Implications  of  Bergson's  Philosophy.  By  Una  Bernard 
Sait,  Ph.D.  Archives  of  Philosophy,  No.  4,  June,  1914.  Science 
Press,  New  York. 

The  fundamental  principles  of  Bergson's  philosophy  are  of  such  vital 
significance  that  an  ethical  application  is  of  necessity  practically  implied. 
Still  it  is  a  matter  of  interest  and  to  many  perhaps  one  of  great  help  that 
these  implied  principles  should  be  developed  more  completely  along  the 
pathway.s  which  Bergson  only  suggests.  In  doing  this  Miss  Sait  has 
given  us  a  valuable  condensation  of  Bergson's  philosophy,  its  funda- 
mental hypotheses  and  the  development  of  them,  such  a  presentation  as 
must  precede  a  discussion  of  tlie  ethical  conclusions  drawn  from  his 
works. 

She  makes  very  clear  at  first  his  distinction  between  reality  and  the 
outer  expression  of  it.  Experience  or  life  is  duration,  the  "stuff"  of 
all  things.  This  is  reality  and  we  enter  reality  as  we  are  able  to  plunge 
with  increasing  degrees  of  tension  into  the  duration  within  us.  The 
present  is  continuous  motion  and  change,  momentary  becoming.  This  is 
the  fleeting  quality  of  intuitive  knowledge,  which  for  the  sake  of  action 
must  be  expressed  in  static  ideas  homogeneously  extended  in  space.  For 
this,  intellect  has  been  created,  merely  the  instrument  of  reality.  Intel- 
lect concerns  itself  only  with  the  external  forms  of  practical  experience; 
though  by  being  thus  crystallized  and  defined  this  becoming,  in  turn, 
receives  a  clearness  and  fresh  incentive  for  further  coincidence  with 
reality. 

Science  deals  with  this  spatial,  practical  sphere  of  knowledge ;  phi- 
losophy must  follow  intuition  in  order  to  penetrate  reality.  The  philoso- 
pher's purpose  is  to  give  us  the  vision  that  will  incite  us  toward  the 
reality.  He  must,  having  a  vision  of  the  whole,  prove  it  genuine  through 
the  use  of  concepts  which  in  turn  must  cover  all  the  facts  in  the  realm 
of  intellect.  By  this  intuitive  penetration  of  reality  Bergson  hopes  for 
a  progressive  philosophy  in  which  all  philosophers  sliall  unite  because 
all  shall  be  occupied  with  reality. 

Consciousness  is  our  own  plunging  into  duration,  finding  ourselves 
and  the  reality  in  which  we  live.  It  is  but  one  qualitative  degree  of  ten- 
sion in  the  concentrated  tension  of  all  duration.  In  its  deepest  moments 
it  is  creative,  joining  the  past  to  the  present,  always  toward  the  future. 
It  must  express  its  creativity  in  the  superficial  realm  of  action  so  it  is 
alternately  creating,  being  defined  in  action,  plunging  again  into  intuition 
in  a  continued  process  of  creating  and  being  extended  by  the  inertia  of 
matter.  In  this  way  it  has  created  the  world  and  organic  life.  Con- 
sciousness exists  through  its  retention  of  the  past  into  the  present.  Man 
is  urged  to  creation  by  a  comparison  of  the  present  and  possible  future 
with  the  past  and  this  is  accomplished  through  perception  aided  by 
mentory. 

The  mcclianism  of  the  brain  allows  recollection  to  present  memory 
"images  for  consideration  and  comparison  with  new  images  seized  through 
perception  in  creative  movement.  Attention  arrests  this  movement  and 
forms  syntheses  and  hypotheses  between  the  new  images  and  those  of 
the  past  in  an  ever-widening  circle  of  memory,  which  penetrates  always 
more  d((i)Iy    into   reality,    while   in    the   realm   of   action   it  increases   in 

too 


BOOK   REVIEWS  loi 

importance  as  it  is  brought  into  connection  with  present  perception.  Our 
personaHties  consist  of  a  vast  interpenetration  of  tendencies,  both  de- 
scended to  us  and  increased  by  self-creation.  From  these  we  must  cease- 
lessly choose  while  we  add  to  them  so  that  Hfe  is  a  growth  and  an 
unfolding. 

The  life-principle  is  found  in  world-creative  power.  All  things  par- 
take of  the  essential  "  stuff,"  duration.  Material  forms  represent  a 
retardation,  a  diminution  of  the  life-force.  Here  even  as  in  individual 
creation  there  are  diverse  potentialities,  the  past  follows  the  present  just 
so  much  of  it  to  be  chosen  as  is  useful  for  further  creation.  All  the 
various  tendencies  seeking  development  are,  however,  parts  of  the  deepest 
reality,  which  Bergson  discovers  by  tracing  back  this  dissociation  to  the 
original  principle  beneath. 

Two  things,  then,  are  emphasized  in  developing  the  ethics  involved. 
There  is  the  unity  of  the  deep,  underlying  reality,  though  in  the  process 
of  creative  evolution  it  has  become  dissociated  into  these  interpenetrating 
tendencies.  Moreover,  each  individual  tendency  like  the  fundamental 
duration  is  continually  creating,  ceaselessly  changing.  In  plunging  into 
reality,  coming  in  varying  degrees  into  coincidence  with  the  life-principle, 
we  must  come  sympathetically  near  other  individuals  and  we  come  to 
realize  that  society  is  made  up  of  an  interpenetration  of  individual  tend- 
encies. Man,  then,  in  realizing  his  own  reality  and  finding  his  own 
creative  activity  and  individual  development,  must  choose  those  possi- 
bilities that  make  for  the  general  good.  His  own  potentialities  are  his 
guide,  but  between  them  he  must  choose,  forming  judgments  as  to  their 
social  value.  Moral  standards  are  not  fixed,  are  not  outward  laws.  We 
have  these  laws  as  indications  of  progress,  but  life  must  constantly  go 
beyond  them  in  fresh  becoming.  It  is  our  approach  to  the  deepest  reality 
that  gives  us  an  ever-increasing  knowledge  of  the  greatest  social  good 
and  greater  power  of  judgment,  while  again  each  expression  of  this  in 
moral  acts  plunges  the  individual  with  fresh  incentive  deeper  into  the 
fundamental  life-principle.  This  life-principle  must  express  purpose,  an 
inherent  purpose  of  development. 

This  can  only  suggest  Miss  Sait's  comprehensive  presentation  of 
Bergson's  philosophy  and  her  development  of  the  ethical  principles  im- 
plied. The  very  flexibility  of  Bergson's  conception  allows  of  a  prag- 
matic development  of  it  in  the  world  of  conduct  and  we  can  but  feel  that 
the  author  here  has  sought  in  some  degree  to  provide  for  a  preconception 
of  an  ideal  society  in  some  future  world  and  of  a  personal,  objective 
God.  In  general,  however,  she  has  deduced  a  very  practical  and  inspir- 
ing ethical  system. 

jELLIFFE. 

Psychology,  General  and  Applied.  By  Hugo  Miinsterberg.  D.  Apple- 
ton  and  Company.  New  York  and  London. 
Professor  Miinsterberg  has  spared  no  pains  in  explaining  the  psycho- 
physical foundations  of  psychology.  With  elaborate  detail  he  describes 
and  illustrates  the  elementary  mental  processes  and  the  more  complex 
ones  into  which  these  combine,  grouping  them  under  causal  psychology. 
His  study  of  mental  activity  is  one  of  physical  cause  and  effect  in  which 
only  explanation  is  sought.  In  order  to  understand  instead  of  to  explain 
there  must  be  an  entirely  different  attitude  than  that  of  purposive  psy- 
chology, in  which  we  enter  into  the  aim  of  the  subject  and  take  a  personal 
stand  in  identifying  ourselves  with  the  act  of  his  will  or  putting  ourselves 
into  a  relation  of  opposition  to  it,  as  the  case  may  be.  Mental  life  is 
examined  from  these  two  standpoints  in  its  individual  and  social  mani- 
festations. 


I02  BOOK   REVIEWS 

But  one  method  of  approach  cannot  be  so  completely  divorced  from 
the  other  theoretically  or  for  practical  purposes.  It  is  true  that  the  author 
while  defining  the  fundamental  and  necessarj'  division  between  the  two 
yet  acknowledges  their  interdependence  and  recognizes  their  separation  as 
more  or  less  arbitrary  for  the  sake  of  examination  and  discussion.  Still 
the  over-emphasis  upon  the  physical  phenomena  accompanying  mental 
action,  which  in  fact  denies  a  "  sub-conscious "  mental  life,  leaves  pur- 
posive psychology-  inadequately  described  and  leaves  causal  psychology 
unrelated  to  the  full  personal  life.  The  attributing  to  the  latter  field  alone 
the  existence  of  cause  and  effect  and  to  purposive  psychology  absolute 
freedom  affords  no  room  for  the  enormous  influence  of  the  unconscious 
past  in  its  determination  even  in  our  choice  of  potentialities. 

A  number  of  chapters  are  devoted  to  the  possible  application  of  the 
exact  measurements  of  causal  psychology,  in  part  already  employed,  to 
various  practical  spheres.  In  the  law  courts,  in  the  adjustment  of  labor 
to  task,  in  all  departments  of  life  psychophysical  activity  may  be  better 
understood  and  adjustments  be  made  through  these  means,  but  how  is 
psychology  to  be  of  practical  service  on  such  a  limited  basis?  Not  merely 
the  activity  tlirough  the  brain  processes,  but  the  whole  psychic  nature  of 
man,  all  the  sum  of  complexes  which  the  author  would  limit  to  these 
activities,  must  be  considered  in  order  to  make  applied  psychology  more 
than  a  limited  or  even  futile  effort.  In  reality,  though  denying  the  broader 
terminolog>-.  the  author  recognizes  the  wider  view,  as  he  shows  in  his 
references  to  the  various  psychotherapies,  but  here,  too,  he  lajs  special 
emphasis  upon  mechanical  measurements  and  their  more  superficial  service 
to  medicine. 

The  book,  however,  is  of  interest  and  value  in  its  exposition  of  mental 
processes  and  their  relation  to  individual  and  social  life,  even  though  one 
must  feel  that  the  point  of  view  is  not  sufficiently  comprehensive.  Certain 
phases  have  been  developed  with  particular  emphasis  and  instructiveness. 
The  insistence  upon  the  reactionary  effect  of  the  motor  discharge  upon  the 
mental  life  is  one  illustration  of  the  practical  significance  of  the  elabora- 
tion of  many  an  important  phase  that  presents  itself  to  such  a  thoughtful 
and  carefully  wrought  psychological  work. 

L.  Brink. 

Ment.\l  Medici nk  and  Nursing.  For  use  in  training-schools  for  nurses 
and  in  medical  classes  and  a  ready  reference  for  the  general  practi- 
tioner. By  Robert  Rowland  Chase,  A.M.,  M.D.  J.  B.  Lippincott 
Company.  Philadelphia  and  London.  $1.50. 
This  volume  contains  a  brief  but  comprehensive  summary  of  the  most 
.salient  points  to  be  considered  in  the  elementary  knowledge  and  treatment 
of  mental  disease.  Its  material  is  presented  in  a  form  admirably  adapted 
to  the  purpose  for  which  the  book  is  written,  as  an  outline  for  fuller  study 
and  an  incentive  toward  it  and  a  simple,  practical  source  of  suggestion 
for  the  busy  general  practitioner,  but  particularly  for  the  nurse.  To  this 
end  Dr.  Chase  outlines  first  briefly  the  anatomy  and  physiology  of  the 
nervous  system  and  the  fundamental  psychic  processes.  From  this  he 
proceeds  to  a  general  consideration  of  insanity  and  its  varying  phenomena, 
ijricfly-dcfining  and  describing  them,  the  disturbances  of  the  various  fun- 
damental mental  processes.  Then  more  in  detail  he  describes  the  various 
ps^xhoses  classified  mainly  according  to  their  general  immediate  exciting 
causes.  Each  one  is  discussed  as  to  its  general  characteristics  and  symp- 
toms with  some  reference  to  its  etiology,  in  short  with  a  brief  summary 
of  the  appearance  and  manifestation  of  each,  with  its  prognosis  and  sug- 
gestions for  treatment.     The  last  two  sections  deal  with  the  subject  from 


BOOK  REVIEWS  103 

the  doctor's  and  nurse's  point  of  view  respectively,  full  of  practical  advice 
and  directions. 

These  are  largely,  however,  symptomatic.  This  is  a  matter  for  regret 
in  a  book  comprising  so  much  valuable  material  in  so  convenient  and 
utilizable  a  form.  There  is  the  spirit  of  sympathetic  understanding  of  the 
mentally  diseased  and  a  recognition  of  the  trend  toward  a  broad  and  deep 
comprehension  of  pathological  mental  phenomena.  Yet  this  latter  is  but 
meagerly  suggested.  The  discussion  is  mostly  of  symptomatic  manifesta- 
tions and  there  is  barely  a  hint  of  treatment  more  than  this.  It  is  the 
old  attitude  that  makes  its  approach  toward  this  fruitful  field  from  the 
wrong  side.  Very  little  reference  is  made  to  the  inexhaustible  extent  and 
activity  of  the  unconscious,  the  fundamental  etiology  uncovered  by  psycho- 
analysis is  untouched.  There  is  not  space  in  this  volume  for  detailed 
exposition  of  any  psychotherapy  but  a  different  point  of  view  would  have 
taken  into  account  the  fundamental  etiology  and  given  therefore  a  work- 
ing basis  which  would  have  revealed  those  channels  in  which  the  practical 
suggestions  made  could  find  a  depth  and  meaning  of  untold  value  to  the 
patient  and  new  interest  to  those  who  endeavor  to  help  him. 

Jelliffe. 

Progressivism — AND    After.     By   William    English    Walling.     The    Mac- 
millan  Company.     New  York. 

Mr.  Walling  is  a  socialist  whose  broad  attitude  of  mind  affords  him 
a  liberal  understanding  of  the  activities  of  society,  economic  and  political, 
as  natural  evolutionary  stages.  The  present  Progressive  movement  he 
conceives  as  an  important  advance  toward  the  ultimate  goal  of  socialism. 
He  does  not  stop,  as  do  some  idealists,  merely  to  consider  this  ultimate 
goal,  but  appraises  carefully  the  practical  issues  already  active  or  foreseen 
by  him  in  the  course  of  development,  which  according  to  his  opinion  leads 
to  complete  socialism. 

We  are  entering  now  upon  the  period  of  the  ascendancy  of  the  small 
capitalists.  State  capitalism  is  the  designation  for  this  stage  of  progress. 
Already  there  are  signs  of  the  succeeding  stage,  that  of  state  socialism, 
when  political  power  shall  gradually  pass  into  the  hands  of  skilled  labor 
and  the  professional  and  salaried  workers,  "  the  aristocracy  of  labor." 
But  complete  democracy  will  only  be  attained  when  socialism  is  ushered 
in,  when  the  masses  of  unskilled  workers  and  semiskilled  shall  all  have 
equal  opportunity  and  equalized  sharing  of  profits. 

Equal  opportunity  Mr.  Walling  insists  upon  as  the  fundamental  basis 
of  true  sociahsm,  true  democracy.  His  book  gives  on  the  whole  an  in- 
structive survey  of  the  advance  of  socialism  throughout  the  world,  pre- 
senting its  aims  and  principles  in  a  spirit  of  broad  and  sober  criticism  and 
valuation  of  the  same. 

A  failure  to  enter  into  the  deeper  psychology  that  underlies  human 
nature  prevents  the  true  evaluation  of  the  existing  structures  of  society 
and  their  place  in  evolution.  This  too  exalts  the  so-called  masses  to  a 
position  for  which  they  cannot  be  prepared  by  a  brief  enjoyment  of  "  equal 
opportunity,"  just  and  important  as  such  opportunity  may  be.  Moreover, 
there  is  failure  to  appreciate  the  psychology  of  racial  advance  which  is 
achieved  in  epochal  stages  through  the  leadership  of  those  whose  vision 
and  power  both  of  ability  and  opportunity  serve  to  lead  on  the  masses 
who  would  continue  upon  a  plane  of  dull  uniformity.^ 

1  See  J.  G.  Frazer :  The  Golden  Bough,  A  Study  in  Magic  and  Reli- 
gion. Part  I,  The  Magic  Art  and  the  Evolution  of  Kings,  2  vols.,  3d  ed., 
Macmillan  and  Company,  London.     Vol.  I,  pp.  216-219. 

Jelliffe. 


I04  BOOK   REVIEWS 

S\TUAX     AXATOMY.     PaTHOLOGY,     AND     THERAPEUTICS;     OR     ThE     BoOK     OP 

Medicixes.     Translation  by  E.  H.  Wallis  Budge.     Two  vols.     Ox- 
ford University  Press,  New  York. 

The  student  of  Hippocratic  medicine,  which  means  every  serious 
inquirer  into  the  history  of  the  development  of  medical  doctrines,  will 
find  in  this  extremely  fascinating  and  rich  collection  much  material  for 
serious  consideration.  Medicine  to-day  is  overloaded  with  the  grossest 
of  animistic  conceptions,  from  which,  largely  through  the  influence  of 
Democritus  and  of  Heraclitus.  the  ancient  Greeks  had  freed  themselves. 
Just  how  these  animisms  returned  into  medicine  in  such  crude  form 
through  the  Oriental-Latin  pathways  that  were  prominent  in  building  up 
Latin  culture,  does  not  now  concern  us.  That  which  is  of  interest  in  this 
traiislation  of  an  ancient  Syriac  text — probably  transcribed  by  some  phy- 
sician in  the  Galen  period — is  that  it  has  preserved  much  Hippocratic 
medicine  as  yet  less  sorely  spotted  by  the  animism  of  the  early  Chris- 
tian eras. 

To  the  neurologist  the  author's  views  on  nervous  anatomy  and  brain 
function  are  of  great  interest. 

To  the  student  of  mental  medicine  it  is  especially  fortunate  that  a 
chapter  on  astrolog>'  should  have  become  incorporated,  and  also  one  in 
folk  medicine — largely  in  the  form  of  prescriptions — for  not  alone  from 
the  standpoint  of  Hippocratic  doctrines  can  we  read  of  the  gradual  modi- 
fications in  medical  ideas — but  in  the  simultaneous  productions  of  the 
Babylonian  and  the  native  animisms  one  can  compare  them  side  by  side. 

Although  the  work  is  primarily  of  value  to  the  student  of  the  history 
of  medicine  it  will  prove  of  service  from  other  points  of  view.  Dr. 
Budge  is  to  be  congratulated  on  giving  us  such  a  volume. 

Jelliffe. 

Notice. — Xcurology  has  been  advancing  so  rapidly  within  the  past 
decade  that  it  has  become  necessary  to  expand  the  media  of  communica- 
tion between  those  interested  in  its  progress  and  its  achievements.  To 
this  end,  three  years  ago  special  psychical  problems  were  relegated  to  a 
new  journal,  the  Psychoanalj'tic  Review,  with  the  hope  that  there  would 
be  enough  space  to  deal  with  the  central  field  of  sensori-motor  neurology, 
which  the  Journal  has  chiefly  represented.  This  hope  has  been  outgrown 
and  the  editors  feel  that  they  can  best  give  expression  to  the  growing 
interest  by  an  increase  in  the  size  of  the  Journal.  There  will  be  there- 
fore two  volumes  a  year  published  instead  of  one.  Each  monthly  issue 
will  be  increased  from  64  to  100  pages.  The  price  of  the  volume  will  be 
$4.fX).     The  year's  series  $8.00. 

The  editors  take  this  occasion  to  thank  the  many  supporters  of  the 
Journal  who  make  this  extension  possible. 

W.  G.  Spiller, 
Smith  Ely  Jelliffe. 


VOL.  43.  FEBRUARY,  1916.  No.  2 

The  Journal 

OF 

Nervous  and  Mental  Disease 

An  American  Monthly  Journal  of  Neurology  and  Psychiatry,  Founded  in  1874 


©riginal  Hrttcles 


ON  LOCALIZATION  OF  FUNCTION  IN  THE  CANINE 
CEREBELLUM! 

By  Ernest  G.  Grey,  M.D. 

ASSISTANT    RESIDENT    SURGEON,    PETER    BENT    BRIGHAM    HOSPITAL 

Introduction 

It  is  only  of  recent  years  that  we  have  arrived  at  a  fairly 
satisfactory  interpretation  of  cerebellar  function.  Most  dissimi- 
lar hypotheses  were  offered  during  the  past  century, — by  Alagen- 
die  (17),  Lussana  (15),  Flourens  (7)  and  Luciani  (13).  While 
evidence  of  localization  of  function  in  the  cerebral  hemispheres 
has  long  been  recognized,  the  proof  of  a  corresponding  division 
of  labor  in  the  cerebellum  has  been — until  recently — inadequate. 
Even  at  the  present  day  the  findings  of  numerous  workers  lead 
them  to  dispute  the  claims  of  localization  (Luciani,  Horsley  and 
Clarke  (16),  etc.). 

During  the  opening  years  of  the  present  century  the  expecta- 
tions fostered  by  Luciani's  researches  were  amply  reahzed  both  in 
anatomical  and  in  physiological  fields.  Smith  (27),  Bradley  (5) 
and  Bolk  (4),  quite  independent  of  one  another,  and  as  a  result 
of  extensive  studies  in  the  comparative  anatomy  and  embryology 
of  the  cerebellum,  presented  a  new  conception  of  its  morphology. 
The  two  latter  investigators  each  constructed  a  schema  depicting 

1  From  the  Laboratory  of  Surgical  Research,  Harvard  Medical  School, 
and  the  Surgical  Clinic  of  the  Peter  Bent  Brigham  Hospital,  Boston. 

105 


io6  ERXEST  G.  GREY 

a  common  fundamental  architecture  of  the  mammalian  cer- 
ebellum. 

The  views  of  Bolk  are  particularly  valuable.  Instead  of  lim- 
iting his  studies  to  anatomical  provinces  he  directed  attention  to 
the  zoological  significance  of  his  findings  and  demonstrated  the 
functional  relationship  existing  between  the  muscular  system 
and  the  cerebellum.  Bolk  showed  that  variations  in  certain  divi- 
sions of  the  cortex  accompany  similar  variations  in  correspond- 
ing muscle  groups — a  measurable  correlation,  in  other  words,  be- 
tween the  development  of  definite  lobuli  and  definite  systems  of 
muscles. 

The  demonstration  of  such  a  relationship  naturally  sug- 
gested convincing  evidence  for  the  theory  of  cerebellar  localiza- 
tion. With  such  an  hypothesis  in  mind  Bolk  ultimately  was  in  a 
position  to  offer  the  anatomical  proof  necessary  to  substantiate 
the  belief  that  each  coordinated  movement  of  the  muscular  sys- 
tem has  definite  cortical  representation. 

Somewhat  later  Pagano  (22),  using  curare  injections,  claimed 
the  existence  of  a  psychic  and  four  motor  centers  in  the  canine 
cerebellum.  The  first  investigator,  however,  to  adopt  these  views 
in  well-planned  and  thorough  physiological  experimentation  was 
Rynberk  (24).  By  means  of  sharply  circumscribed  ablations  of 
the  cerebellar  cortex  involving  specific  lobuli  or  portions  of  the 
same,  Rynberk  found  that  the  postoperative  motor  phenomena 
varied  consistently  with  the  lobulus  or  center  involved.  The  re- 
sults in  a  large  series  of  animals,  studied  from  this  perspective, 
yielded  an  experimental  confirmation  of  the  more  important 
features  of  Bolk's  anatomical  conclusions. 

Luciani,  Jackson,  Edinger,  Horsley  (10),  and  others  have 
shown  that  the  cerebellar  cortex  is  an  afiferent  recipient  organ. 
Tile  intrinsic  and  the  paracerebellar  nuclei  represent  the  only  ef- 
ferent mechanism  of  the  cerebellum.  This  conception  is  perhaps 
best  explained  by  Sherrington  (26)  who  shows  that  this  struc- 
ture is  really  a  central  organ  of  the  proprioceptive  system  which 
controls  the  tonus  of  the  skeletal  muscles. 

Viewing  the  cerebellum,  in  a  broad  sense,  entirely  as  a  motor 
organ,  Kothmann  (23;,  and  Babinski  and  Tournay  (i)  regard 
it  as  a  collection  of  centers,  capable  of  being  dififerentiated. 
These  centers  arc  representative  of  voluntary  or  semi-voluntary, 
automatic  or  semi-automatic  movements  which  enable  the  animal 
to  maintain  given  postures,  to  walk,  and  to  perform  other  motor 
functions   in   a   regular  and    orderly   manner.     The   i)henomcna 


LOCALIZATION  OF  FUNCTION  IN  CANINE  CEREBELLUM     107 

noted  after  certain  ablation  experiments  (abduction  or  adduction 
of  a  limb,  etc.)   Rothmann  explains  as  an  abolition  of  certain 

LO  BUS 

ANTERIOR 


Fig. 


LOBULUS 
ANSIFORMIS 


LOBULUS 
PARAMEOIANUS 

LOBULUS 
MEDIANUS 
POSTE  Rro  P 

I.     Diagram  of  the  canine  cerebellum  to  show  Bolk's  new  subdivisions 
and  nomenclature. 


antagonistic  reflexes  of  the  muscles  which  normally  serve  to  regu- 
late the  statotonus  of  the  extremity  concerned.  "These  are  the 
proprioceptive  reflexes  of  Sherrington. 

Review  of  Studies  on  Cerebellar  Localization 

Since  Rynberk's  work  many  others  have  attacked  the  problem 
of  cerebellar  localization — among  them  Marassini  (19),  Luna 
(14),  Hulshoff-Pol  (11),  Binnert  (3),  Horsley  and  Clarke  (9) 
and  Rothmann  (23).  Such  studies  have  been  continued  in  man 
by  Barany  (2),  Mills  and  Weisenburg  (20),  and  others.  In 
the  following  paragraphs  a  brief  outline  is  sketched  of  the  results 
obtained  from  these  investigations. 

Cms  Priniuin  of  Lohidus  Ansiforiiiis. — Lesions  especially  in- 
volving the  short  lamellae  evoke  symptoms  in  the  homolateral 
forefoot.  The  entire  crus  is  a  foreleg  center  (Rynberk,  Roth- 
mann). The  medial  halves  of  crus  primum  and  crus  secundum 
embrace  the  centers  for  the  fore-  and  hindlegs  respectively  (Pa- 
gano,  Marassini,  and  Luna).  The  "  Hahnenschritt "  or  over- 
raising  of  the  affected  foreleg  appears  only  when  the  crus  primum 
is  completely  destroyed  (Binnert). 

Cms  Secundum  of  Lohulus  Ansiformis. — Lesions  involving 
the  medial  knee  where  this  adjoins  the  lobulus  paramedianus 


108  ERXEST  G.  GREY 

usually  cause  slight  weakness  of  the  homolateral  hindfoot.  Ex- 
tensive destruction  of  this  crus  together  with  the  crus  primum  and 
and  lobulus  paramedianus  cause  also  a  definite  disturbance  of 
the  coordinated  movements  involved  in  running  in  the  homo- 
lateral hind  foot  (Rynberk).  Crus  secundum  is  the  center  for 
movements  of  the  homolateral  hind  foot  (Rothmann).  Curare 
injections  into  the  borderland  between  the  crus  secundum  and 
the  lobulus  paramedianus  affect  the  homolateral  hind  foot  (Pa- 
gano).  Destruction  of  this  crus  leads  to  a  "  Hahnenschritt "  of 
the  four  limbs  and  to  an  uncertainty  in  the  movements  of  the 
homolateral  hind  foot  (Hulshoff-Pols).  Partial  or  superficial 
lesions  of  this  crus  are  insufficient  to  cause  weakness  of  the  hind 
foot.  A  complete  destruction  is  necessary  for  this  purpose  (Bin- 
nert). 

Lobulus  Paramedianus. — A  destruction  of  this  lobulus  usually 
leads  to  forced  movements — rolling  movements  of  the  trunk — 
about  the  longitudinal  axis  of  the  body,  and  to  pleurothotonos 
(Rynberk).  Such  an  ablation  leads  to  pleurothotonos  and  to  a 
"  Paradeschritt "  of  all  four  extremities  (Hulshoff-Pols). 

Lobulus  Simplex. — Lesions  here  usually  result  in  a  tremor  of 
the  head  persisting  for  weeks  or  months  (Rynberk).  Those  in- 
volving the  midline  cause  retraction  backward  of  the  head  with  a 
tendency  of  the  animal  to  fall  backwards  (Luna).  Curare  in- 
jections into  the  vicinity  of  this  lobulus  cause  the  head  to  be 
drawn  backwards  with  a  tendency  of  the  body  to  move  back- 
wards as  well  (Pagano).  Ablations  of  the  vermis  cause  the  ap- 
pearance of  shaking  or  "  Ncin.schiitteln  "  of  the  head  (Luciani). 
Only  double-sided,  deep-seated  lesions  call  forth  this  movement 
of  the  head  (Binnert). 

Lobulus  Mediauus  Posterior. — Extirpation  of  this  lobulus 
causes  no  symptoms  (Rynberk).  Curare  injections  into  this 
region  somewhat  affect  the  trunk  and  the  neck  musculatures 
(Pagano).  Destruction  here  causes  an  ataxia  of  the  hind  legs 
(HulshofT-Pol).  Lesions  of  the  posterior  part  cause  an  an- 
tero-posterior  swaying  of  the  trunk  with  an  inclination  to  fall 
backwards  (Marassini). 

Method 

In  operations  involving  subtentorial  regions  the  surgical  dififi- 
cultics  encountered  in  approaching  the  cerebellum  are  both  nu- 
merous and  important.  Just  as  special  methods  and  tricks  of 
technique  have  enabled  the  neurologic  surgeon  to  enter  provinces 
only  recently  forbidden  (cf.  Oppcnheim's  (21)  change  of  views 


LOCALIZATION  OF  FUNCTION  IN  CANINE  CEREBELLUM     109 

regarding  cerebellar  operations),  so  similar  devices  have  become 
necessities  for  efficient  progress  in  the  experimental  domain  of 
surgery. 

Rynberk  probably  was  the  first  to  suggest  an  approach  to  the 
cerebellum  in  animals  through  the  tentorium.  In  his  reports, 
however,  as  in  the  publications  of  other  workers,  there  is  a  no- 
ticeable absence  of  the  detail  considered  most  essential  for  neuro- 
logical surgery  in  man.  Those  familiar  with  this  field  are  aware 
from  personal  experience  or  through  the  announcements  of  other 
investigators  that  infections  (abscess,  meningitis)  following  such 
operations  form  a  common  and  serious  complication.  Infections 
of  course,  however  trivial,  defeat  the  object  of  every  experiment. 

The  work  reported  here  was  carried  out  in  a  laboratory  where 
the  aseptic  precautions  of  the  modern  hospital  are  rigorously  ob- 
served. The  intratracheal  method  of  anesthesia  was  employed, 
and  not  only  appeared  to  minimize  respiratory  complications  but 
with  its  use  lengthy  operations  produced  less  shock.  During 
each  experiment  the  animal  was  kept  on  an  electrically  heated 
pad.  By  having  the  anesthetist  support  and  properly  flex  the 
head  in  the  approach  to  the  cerebellum  the  difficulties  of  exposure 
were  very  materially  lessened. 

In  experiments  involving  the  crus  secundum,  lobulus  ansi- 
formis,  lobulus  simplex,  lobulus  paramedianus  and  lobulus  medi- 
anus  posterior,  a  posterior  approach  proved  most  satisfactory. 
This  afforded  ample  exposure  for  purposes  of  orientation — neces- 
sarily a  very  important  feature — and  permitted  careful  and  exact 
ablations.  After  splitting  the  superficial  muscles  of  the  head 
and  neck  in  the  median  line  (Mm.  subcutaneous  colli,  occipitalis, 
intermedins  scutulorum,  etc.)  the  homolateral  flap  was  retracted 
lateralward  to  expose  the  temporal  muscle.  The  origin  of  the 
latter  was  then  raised  from  the  parietal  plane  and  the  muscle 
drawn  forward  and  outward.  By  carefully  following  the  sagittal 
plane  of  the  neck  .overlying  the  ligamentum  nuchae  it  was  possible 
to  separate  the  neck  muscles  (Mm.  trapezii,  splenii,  etc.)  to  the 
depth  of  the  first  two  or  three  vertebral  spines  without  encounter- 
ing the  profuse  hemorrhage  frequently  evident  in  such  operations. 
To  expose  the  occipital  bone  (planum  nuchale)  and  the  superior 
nuchal  ridge  it  was  now  necessary  to  divide  the  insertions  of  the 
neck  muscles  in  this  region  (Mm.  splenius,  semispinalis  capitis, 
etc.).  This  led  to  considerable  bleeding  except  when  the  bone 
was  hastily  scraped  with  a  periosteal  elevator  and  the  diploetic 
emissaries  plugged  with  wax.     The  exposure  at  this  stage  re- 


no  ERA' EST  G.  GREY 

vealed  the  dura  bridging  the  atlanto-occipital  articulation.  After 
separating  this  for  a  few  milHmeters  froni  the  overlying  bone, 
the  posterior  arch  of  the  foramen  magnum  was  rongeured  away 
and  the  opening  enlarged  until  the  proper  exposure  of  dura  had 
been  accomplished.  Perfect  hemostasis  is  essential  at  this  stage 
of  the  operation.  After  opening  the  dura  the  various  cerebellar 
lobuli  were  readily  identified. 

To  excise  the  crus  prinium  an  anterior  approach  was  neces- 
sary. After  retracting  the  tem])oral  muscle  well  forward  the 
occipital  ridge  (superior  nuchal  line)  was  removed  with  sharp 
rongeurs.  By  rongeuring  away  sufficient  bone  to  either  side  of 
this  boundary  and  dividing  the  dura  the  posterior  aspect  of  the 
occipital  lobe  and  the  upper  portion  of  the  cerebellar  hemisplierc 
appeared  in  the  wound.  The  bony  tentorium  made  visible  by 
these  maneuvrcs  was  removed  in  part.  Proper  retraction  in  the 
cerebello-occipital  angle  now  brought  into  view  the  entire  lobulus 
ansiformis. 

Previous  to  each  experiment  a  hardened  cerebellum  was  cut 
into  thin  sections  with  a  brain  knife  and  a  study  made  of  the  ex- 
tent and  the  relationships  of  the  lobulus  in  question.  The  pro- 
posed extirpation  was  then  practiced  on  fresh  specimens.  In  this 
manner  a  very  definite  control  of  each  ablation  liecame  possible. 

Early  in  the  course  of  the  experiments  an  animal  was  an- 
esthetized rather  lightly  and  the  cortex  electrically  stimulated. 
The  muscular  responses  were  noted  and  afforded  a  satisfactory 
index  of  the  extent  of  the  canine  motor  area. 

In  the  experiments  reported  here  the  cortex  was  not  resected, 
but  in  accord  with  Sherrington's  suggestion  a  dull-edged  instru- 
ment was  inserted  between  this  layer  and  the  medullary  center 
beneath,  and  moved  about,  at  this  level,  over  the  sensori-motor 
sjjhere.  An  ample  margin  of  cortex  was  always  inckuled  to  in- 
sure a  complete  isolation  of  the  motor  and  sensory  areas.  IMicro- 
scoi)ical  studies  to  control  this  method  showed  a  degeneration  of 
the  nervous  elements  over  the  provinces  involved. 

Due  to  the  nature  of  the  operations  it  was  found  necessary 
to  keep  the  wounds  banrlaged  for  a  number  of  days.  Light, 
snugly-fitting  plaster-of- Paris  caps  proved  indisi)ensable  follow- 
ing the  .sensori-motor  sphere  destructions.  The  animals  usually 
'•■•ceived  a  generous  supply  of  warm  water  by  stomach  tube  im- 
mediately afttr  the  withdrawal  of  the  anesthetic. 


LOCALIZATION  OF  FUNCTION  IN  CANINE  CEREBELLUM     in 

I.  Results  from  Cerebellar  Ablations 

{a)  Experiments hivolving  Entire  Cms Primum  (Unilateral) . 
— There  was  a  noticeable  difference  between  the  fore-  and  hind- 
legs  of  one  side  as  compared  with  those  of  the  opposite  side  until 
about  the  eighth  day  (postoperative).  This  appeared  during  the 
first  forty-eight  to  seventy-two  hours  as  a  weakness  of  the  homo- 
lateral limbs.  For  the  following  five  or  six  days  the  animal  then 
carried  the  hind  paw  of  the  afifected  side  as  though  it  were  slightly 
injured. 

There  was  a  perceptible  limp  and  in  running  the  foot  in  ques- 
tion scarcely  touched  the  ground.  These  features  then  disap- 
peared. On  about  the  third  postoperative  day  the  preliminary 
weakness  noted  in  the  homolateral  foreleg  gave  way  to  a  recog- 
nizable disturbance  of  coordination.  In  walking  and  running — • 
particularly  during  the  latter — there  was  seen  to  be  an  excessive 
lifting  of  the  paw.  A  short  time  afterward  (about  the  fifth  to 
sixth  day  after  operation)  there  appeared  associated  with  this 
hyperflexion  a  definite  abduction  of  the  limb.  This  abduction, 
however,  was  a  feature  only  of  certain  phases  of  the  cycle  of  co- 
ordination involved  in  running.  The  foot  deviated  lateralward 
while  elevated  but  was  not  abducted  during  its  brief  stay  on  the 
Tround.  Tracings  made  of  the  feet  during  locomotion  both  be- 
fore and  after  the  operative  procedures  showed  this  very  dis- 
tinctly. While  these  features  were  still  perceptible  in  the  foreleg 
at  the  end  of  the  second  week,  in  the  succeeding  days  there  was  a 
very  rapid  return  to  the  normal. 

(b)  Experiment  Involving  Entire  Cms  Secundum  (Unilat- 
eral).— During  the  first  few  postoperative  days,  besides  the 
usual  pleurothotonos  (cavity  toward  the  side  of  the  lesion)  a 
weakness  of  the  homolateral  hind  leg  was  perceptible.  On  the 
fourth  or  fifth  day  there  appeared  an  awkwardness  of  this  limb 
consisting  essentially  of  slight  abduction  and  stiffness  in  the 
joints.  Very  soon  the  leg  was  seen  to  drag  when  the  animal 
moved  about.  In  the  second  week,  by  walking  the  animal  on  its 
forefeet,  on  its  two  side  legs,  and  on  its  hindfeet  a  more  definite 
disturbance  of  coordination  was  noted  in  the  part.  Most  strik- 
ing, perhaps,  was  the  excessive  abduction  of  the  hind  leg  during 
the  brief  intervals  it  remained  above  the  ground.  Tracings 
showed  no  appreciable  changes  in  the  relationships  of  the  foot- 
prints. At  the  conclusion  of  the  second  week  practically  all  ab- 
normal motor  features  had  disappeared. 

(c)  Experiment  Involving  the  Lateral  Half  of  Cms  Secim- 


112  ERXEST  G.  GREY 

dum. — A  slight  general  weakness  of  all  the  legs  was  noted  up  to 
the  third  day.  On  the  fourth  or  fifth  postoperative  day  the  ani- 
mal walked  and  ran  well,  displaying  very  little  difference  between 
the  sides.  At  times  there  was  noticed  a  slight  weakness  of  the 
homolateral  limbs,  but  this  never  suggested  definite  disturbances 
of  coordination.  The  end  of  the  first  week  usually  found  the 
animal  in  excellent  condition.  Active  locomotion  at  this  period 
revealed  no  disparity  between  the  limbs. 

{d)  Experiment  Involving  the  Lateral  Halves  of  Crura 
Priumm  and  Secundum. — On  the  first  day  or  two  following  oper- 
ation there  was  a  slight  general  weakness  of  all  the  limbs.  After 
several  additional  days  this  disappeared  and,  in  turn,  slight 
changes  suggestive  of  disturbances  of  the  sense  of  position  made 
their  appearance  in  the  homolateral  legs.  These  were  well  seen 
on  applying  the  "  \'erstellen  "  test — abnormal  postures  of  the 
homolateral  limbs  were  tolerated  for  much  longer  periods  than 
usual.  During  the  latter  part  of  the  first  week,  in  advancing, 
both  the  fore-  and  the  hindlegs  on  the  side  of  the  ablation  showed 
slight  degrees  of  abduction  from  the  longitudinal  axis  of  the  body. 
Footprint  tracings  again  failed  to  show  features  essentially  ab- 
normal. By  the  conclusion  of  the  second  week  the  gait  appeared 
natural. 

(e)  Experiment  Involving  Median  Half  of  Crus  Secundum 
and  Entire  Lobulus  Paramedianus. — Within  the  first  few  days, 
besides  a  slight  general  ataxia,  a  definite  weakness  of  the  homo- 
lateral legs  was  noted.  It  was  only  during  this  period,  while 
the  effects  of  operative  shock  were  still  in  evidence,  that  the  ani- 
mal failed  to  draw  up  the  hind  limb  of  the  affected  side  when  it 
was  hung  over  the  edge  of  a  table  ("  Versenkungsversuch "), 
Toward  the  end  of  the  first  week  the  unsteadiness  appeared  more 
confined  to  the  homolateral  hindleg.  When  walked  on  its  two 
lateral  and  again  on  its  rear  legs  this  local  weakness  was  easily 
detected.  During  this  period  and  in  the  course  of  the  next  seven 
or  eight  days  there  was  evident  a  disturbance  of  the  sense  of  po- 
sition. Both  homolateral  members  retained  abnormal  postures 
for  longer  periods  than  was  usual  in  the  opposite  limbs.  All 
evidences  of  abnormal  locomotion  disai)pcared  between  the  twen- 
tieth'anfl  twenty-fifth  days  of  convalescence. 

(/)  Experiment  Involving  Lobulus  Paramedianus. — Imme- 
fliately  after  operation  and  continuing  for  a  day  or  two  a  definite 
plcurothotonos  was  noted,  the  concavity  of  the  spine  being  directed 
toward  the  side  of  the  lesion.     The  degree  of  plcurothotonos 


LOCALIZATION  OF  FUNCTION  IN  CANINE  CEREBELLUM     113 

here,  however,  was  never  more  marked  than  that  found  follow- 
ing many  of  the  experiments  recorded  above.  No  outspoken 
tendency  to  roll  about  the  longitudinal  axis  of  the  body  was  noted 
at  any  time.  On  the  second  or  third  day  the  animal  was  able  to 
stand  and  feed  itself,  and  within  a  brief  additional  period  (sev- 
eral days)  it  was  capable  of  walking  and  running.  Characteris- 
tic disturbances  of  locomotion  were  not  distinguished  at  any 
period  during  the  convalescence. 

{g)  Experiment  Involving  Lobulus  Simplex. — During  the 
first  four  days  the  animal  was  extremely  ataxic.  Unable  to  stand 
without  support  it  was  frequently  found  leaning  heavily  with  its 
head  and  body  against  the  cage  wall.  Eating  and  drinking  were 
accomplished  only  with  the  assistance  of  the  attendant.  While 
the  ataxia  was  general  and  affected  the  limbs  more  or  less  alike,- 
the  most  striking  impairment  of  the  coordination  responsible  for 
attitude  was  seen  in  the  persistent  agitation  of  the  head  from 
side  to  side.  About  the  fifth  day  the  animal  regained  sufficient 
control  of  its  musculature  to  enable  it  to  make  some  successful 
attempts  at  running.  The  head  and  trunk  continued  quite  ataxic, 
nevertheless.  Sudden  movements  were  particularly  trying,  fre- 
quently causing  the  animal  to  fall  in  one  or  another  direction. 
In  the  course  of  the  following  week  a  gradual  decrease  of  the 
ataxia  ensued.  The  animal  ran  comparatively  well  and  the  limbs 
were  propelled  symmetrically.  During  the  third  week  an  inco- 
ordination of  the  limb  and  trunk  musculature  was  noted  only 
during  jumping,  sudden  turning,  etc.  A  very  slight  to  and  fro 
movement  or  tremor  of  the  head  persisted  for  some  days  longer. 

(Ji)  Experiments  Involving  Only  the  Approach  to  the  Cer- 
ebellum.— Due  to  uncontrollable  hemorrhage  in  two  cases,  the  ab- 
lation experiments  were  conducted  in  two-stage  operations.  In 
each  animal,  during  the  first  attack,  the  approach  was  completed 
as  far  as  the  dura.  The  wounds  healed  per  primam  and  the  sub- 
sequent excisions  of  cerebellar  cortex  (second  stages)  were  con- 
ducted without  additional  complication. 

On  the  second  day  of  convalescence  both  dogs  were  able  to 
stand  and  take  nourishment.  Neither  asymmetry  nor  definite  in- 
coordination of  the  limbs  was  noticed.  Twenty-four  hours  later 
the  animals  ran  about  the  yard,  jumping  and  frolicking  in  normal 
fashion.  At  no  time  during  the  postoperative  period  was  there 
ever  found  any  characteristic  involvement  of  attitude. 

Magnus  and  Kleijn  (18)  have  recently  drawn  attention  to 
the  relations  existing  between  the  tonus  of  the  trunk  and  limb 


114  ERXEST  G.  GREY 

musculatures  and  the  position  of  the  head.  Since  the  approach 
to  the  cerebellar  cortex  affects  the  attachments  of  numerous 
muscles  in  the  suboccipital  province,  it  seemed  likely  that  sur- 
jjical  measures  of  this  nature  would  be  sufficient  in  themselves  to 
influence  posture  and  gait.  The  results  from  the  two  animals 
just  mentioned,  however,  clearly  indicate  that  this  does  not  occur. 

The  Theory  of  Cerebral  Compensation 

The  fact  that  time  gradually  minimizes — often  almost  effaces 
— the  results  of  a  cerebellar  lesion  has  led  to  the  assumption 
of  a  process  of  compensation  on  the  part  of  the  cerebral  mech- 
anism. Such  a  conception,  moreover,  has  found  substantiation  in 
the  results  of  several  workers.  Pagano  (22) ,  for  example,  showed 
that  when  curare  was  injected  into  the  cerebellar  hemispheres  it 
evoked  manifestations  of  motor  excitement.  Furthermore,  if  the 
motor  sphere  on  one  side  of  the  cerebrum  (gyrus  sigmoideus) 
was  extirpated  (on  the  side  opposite  to  the  injection)  previous  to 
the  curare  treatment,  localized  movements  in  the  muscles  of  the 
stimulated  side  no  longer  appeared  and  the  rolling  of  the  body 
about  its  longitudinal  axis  followed  in  an  opposite  direction. 
The  ablation  of  the  motor  spheres  of  both  sides  completely  in- 
hibited the  manifestations  of  motor  excitement. 

Previous  to  these  experiments  Goltz  (8)  had  demonstrated 
that  the  removal  of  the  greater  part  of  each  cerebral  hemis]:>here 
("including  the  sensori-motor  areas)  in  dogs  did  not  prevent  the 
animals  later  from  walking,  swimming,  etc.  More  recently 
Slicrrington  and  Brown  (25)  in  their  interesting  investigations 
on  the  monkey,  report  that  the  recovery  of  -a  limb  (arm)  may 
take  place  fairly  rapidly  after  the  destruction  of  a  large  part — 
if  not  the  whole — of  the  corresponding  area  of  the  motor  cortex. 
This  recovery,  they  believe,  is  not  due  to  a  regeneration  of  the 
area  destroyed.  Also  it  is  not  due  to  a  taking  over,  by  the  cor- 
responding area  of  the  other  cortex,  of  the  movements  of  both 
arms.  Finally,  they  have  found,  it  is  not  attributable  to  a  taking 
over  by  the  post-central  cortex  of  the  functions  of  the  motor 
cortex. 

In  a  scries  of  studies  Luciani  (13)  showed  that  dogs  deprived 
of  one  or  both  cerebellar  hemispheres,  while  prostrated  and 
ataxic  for  a  time,  ultimately  regained  comparatively  efficient  con- 
trol of  voluntary  movements.  By  ingeniously  combining  de- 
structive experiments    Luciani   finally   was   able   to   offer    fairly 


LOCALIZATION  OF  FUNCTION  IN  CANINE  CEREBELLUM     im 

conclusive  evidence  concerning  the  capacity  of  cerebral  function 
to  compensate — in  some  degree  at  least — for  any  loss  of  cere- 
bellar function.  Animals  which  had  regained  the  ability  to  run, 
swim,  etc.,  after  the  removal  of  a  cerebellar  hemisphere  again 
lost  this  ability  when  the  contralateral  sensori-motor  cortex  of 
the  cerebrum  was  destroyed.  The  effects  of  these  combined 
ablations  were  somewhat  enhanced  by  extirpating  the  other 
sigmoid  gyrus. 

At  a  later  date  Lewandowsky  (12)  undertook  investigations 
of  a  similar  nature.  The  ablations  in  his  experiments,  however, 
were  somewhat  less  inclusive.  In  reviewing  the  behavior  of  the 
animals  in  his  series  Lewandowsky  was  led  to  the  conclusion 
that  the  disturbances  of  motility  noted  after  either  cerebral 
(gyrus  sigmoideus)  or  cerebellar  lesions  alone  became  distinctly 
more  marked  and  took  longer  to  disappear  when  such  resections 
were  combined.  It  is  important  to  note  that  though  there  was 
found  to  be  a  distinct  aggravation  of  the  disturbances  in  the  com- 
bined sensori-motor  and  cerebellar  ablations  of  Lewandowsky 
the  symptoms  nevertheless  ultimately  manifested  improvement. 

A  similar  relationship  was  shown  by  Ewald  (6)  to  exist  be- 
tween the  labyrinth  and  the  sensori-motor  areas  of  the  cerebrum. 
The  symptoms  which  disappeared  (by  compensation)  after  de- 
struction of  the  labyrinth  reappeared  and  persisted  after  de- 
struction of  the  cerebral  cortical  zones. 

A  consideration  of  the  several  facts  outlined  above  led  us  to 
believe  that  these  principles  might  be  put  to  use  in  the  problem 
of  cerebellar  localization.  It  has  already  been  shown  that  very 
restricted  ablations  of  the  cerebellar  cortex,  when  properly 
placed,  lead  to  recognizable  changes  in  corresponding  muscular 
provinces.  These,  however,  are  neither  marked  nor  of  long 
duration.  Since  the  destruction  of  certain  pathways  in  the  cere- 
bral cortex  of  animals  with  cerebellar  lesions  seriously  involves 
the  development  of  what  we  usually,  for  want  of  a  better  designa- 
tion, term  the  phenomena  of  compensation,  it  appeared  quite  con- 
ceivable that  small  cerebellar  lesions  combined  with  sensori-motor 
destructions  might  lead  either  to  an  accentuation  or  to  a  pro- 
longation of  the  symptoms  associated  with  the  cerebellar  abla- 
tions alone. 

Animals,  accordingly,  were  prepared  to  accord  with  these 
considerations.  A  number  of  the  dogs  reported  under  the  cere- 
bellar ablation  studies  were  permitted  to  recover  completely  from 


ii6  ERNEST  G.  GREY 

the  effects  of  the  operations.  In  two-stage  operations,  then,  first 
the  homolateral  sensori-motor  areas  (homolateral  as  regards  the 
cerebellar  lesion)  and  later  the  contralateral  sensori-motor  areas 
were  destroyed. 

II.    Results   from    Combined   Destructions   of    Cerebellar 

LOBULI   AND   SeNSORI-MOTOR   SpHERES 

Most  of  the  dogs  reported  under  the  cerebellar  ablation  studies 
were  subsequently  used  for  this  investigation.  In  addition  a 
number  of  healthy  animals  were  subjected  to  sensori-motor  area 
destructions  with  the  expectation  that  the  cerebellar  ablations 
could  be  carried  out  in  subsequent  operations.  Due  to  one  or 
another  complication,  of  the  total  series  of  animals  used,  only 
three  withstood  the  triad  of  operations.  The  phenomena  noted 
in  two  of  the  three  survivors,  nevertheless,  seemed  sufficiently 
outspoken  to  deserve  record. 

(a)  Experiment  Involviug  Lateral  Half  of  Cms  Secundum 
and  Both  Sensori-motor  Spheres. — The  behavior  of  an  animal 
following  this  particular  cerebellar  cortex  ablation  is  reported 
in  a  previous  section  of  this  paper  (Exp.  c.)  and  warrants  no 
additional  comment  here  except,  perhaps,  to  emphasize  that  at 
the  end  of  the  first  week  active  locomotion  revealed  no  disparity 
between  the  limbs.  Following  the  destruction  of  the  homo- 
lateral sensori-motor  area  the  forced  movements  usually  observed 
in  the  wake  of  such  injuries  were  noted.  The  animal  walked  in 
circles  toward  the  injured  side.  There  was  likewise  a  weakness 
of  the  contralateral  limbs,  at  first  marked  but  later  decreasing  in 
intensity.  This  was  more  striking  when  the  dog  was  walked  on 
its  hind  and  then  on  its  forelegs,  when  it  defecated,  in  shaking 
itself,  etc.  In  the  third  week  there  was  still  recognizable  a 
slight  difference  between  the  two  sides.  The  tendency  to  circle 
toward  the  homolateral  side  practically  disappeared  on  the  seven- 
teenth or  eighteenth  day. 

When  the  animal  had  regained  its  normal  nutrition  the  de- 
struction of  the  opposite  sensori-motor  area  was  undertaken. 
During  the  first  week  following  the  operation,  besides  the  circling 
gait-  (toward  the  affected  hemisphere)  and  the  weakness  of  the 
contralateral  limbs,  there  developed  a  definite  chicken  strut 
("  Ilahnentritt ").  The  latter  feature,  however,  persisted  for  a 
short  period  only.  'I'hcre  was  also  evident  the  usual  restless- 
ness  characteristic   of    animals    with    extensive   cortical   lesions. 


LOCALIZATION  OF  FUNCTION  IN  CANINE  CEREBELLUM     117 

This  became  especially  outspoken  when  the  dog  was  held  a  short 
distance  above  the  floor.  Associated  with  the  restlessness  was 
an  apparent  aimlessness  in  its  wanderings.  With  the  head  held 
low  it  trotted  here  and  there  in  the  yard.  Though  it  appeared  to 
see,  it  repeatedly  bumped  into  obstacles. 

Toward  the  end  of  the  third  week  the  weakness  of  the  legs 
contralateral  to  the  last  sensori-motor  destruction  and  the  circHng 
movements  disappeared.  At  times  slight  disturbances  of  coordi- 
nation in  the  hind-leg  homolateral  to  the  cerebellar  ablation  were 
suggested  by  a  certain  awkwardness  of  the  limb.  This  feature, 
however,  never  became  measurable  and  if  a  greater  degree  of 
ataxia  existed  at  any  time  it  was  obscured  by  the  more  accen- 
tuated effects  of  the  recent  cerebral  lesion. 

(&)  Experiment  Involving  Entire  Cms  Secundum  and  Both 
Sensori-motor  Spheres. — The  behavior  of  an  animal  subsequent 
to  this  cerebellar  operation  is  outlined  in  an  earlier  section  of  this 
report  (Exp.  h,  Cerebellar  Ablations).  Following  the  homo- 
lateral motor  destruction  the  symptoms  noted  in  the  cerebellar 
experiment  were  again  evident.  It  was  remarked  that  during 
the  first  day  or  two  (after  the  second  cortical  destruction  also) 
the  animal  failed  to  draw  up  its  hind  leg  promptly  when  it  was 
hung  over  the  edge  of  a  table  ("Versenkungsversuch").  After 
a  seemingly  complete  recovery  the  opposite  sensori-motor  sphere 
was  destroyed  (contralateral  to  the  cerebellar  ablation).  The 
weakness  of  the  opposite  limbs  {i.  e.,  opposite  to  the  cerebral 
lesion)  and  the  circling  movements,  as  usual,  were  marked  the 
first  days  of  convalescence. 

On  the  fifth  day,  however,  a  striking  phenomenon  was  noted. 
In  running  the  hind  leg  homolateral  to  the  cerebellum  was  seen 
to  drag  frequently,  due  apparently  to  a  disturbance  of  equilibrium 
between  the  flexor  and  extensor  groups  of  thigh  muscles.  Hand 
in  hand  with  the  disappearance  of  the  circling  movements  and  the 
weakness  in  the  affected  limbs  this  local  involvement  of  coor- 
dination became  more  evident.  While  running,  the  hind  limb 
deviated  outward  and,  in  walking  the  animal  on  its  hind  legs, 
this  member  appeared  ataxic.  A  tracing  made  during  this  period 
showed,  as  usual,  no  particular  variations  from  the  normal 
arrangement  of  the  footprints.  Toward  the  end  of  the  third 
week  the  forelegs  appeared  equally  strong,  and  no  true  weakness 
could  be  detected  in  the  hind  limbs.  There  still  persisted  in  the 
homolateral  hind  leg,  nevertheless,  a  very  evident  disorder  of 


1 18  ERXEST  G.  GREY 

coordination  (dysmetria) — a  disorder  such  as  is  seen  in  an  animal 
subsequent  to  a  more  comprehensive  lesion  of  the  cerebellum. 
This  was  noticeable  for  many  weeks. 

Frequent  inspections  of  the  dog  for  peripheral  infirmities  were 
always  negative.  The  muscles,  joints,  and  paws  ofYered  no 
clews  to  corroborate  the  suspicions  of  trauma  and  infectious  in- 
volvement, and  the  general  health  and  nutrition  continued  good. 
Five  weeks  after  the  concluding  operative  measures  there  was 
still  observable  a  disproportion  between  the  functional  capacities 
of  the  two  hindlegs. 

Among  workers  in  experimental  physiology,  Rynbcrk  (24)  in 
particular  has  shown  that  the  additional  destruction  of  neighbor- 
ing lobuli  in  the  cerebellum  greatly  accentuates  the  impairment  of 
coordination  noted  after  the  ablation  of  a  single  division  of  the 
cortex.  In  accord  with  such  a  finding  are  the  results  obtained 
from  the  two  experiments,  one  involving  a  resection  of  half  of 
the  crus  secundum,  and  the  other  a  destruction  of  the  crus  as  a 
whole.  The  local  disorders  of  muscular  innervation  in  the 
former  were  vague  and  indefinite ;  in  the  latter  they  were  easily 
discernible.  Though  the  awkwardness  of  the  hind  limb  noted 
in  the  first  animal  was  only  transitory,  it  seems  fair  to  attribute 
it  to  the  experimental  cerebellar  lesion,  for  it  has  been  shown  in 
an  earlier  paragraph  that  the  trauma  resulting  from  a  surgical 
approach  to  the  posterior  fossa,  in  itself,  afifects  in  no  way  the 
posture  and  gait  of  the  animal. 

(c)  Experiment  Involving  Entire  Lohidus  Simplex  and  Both 
Sensori-motor  Spheres. — The  behavior  of  the  dog  following  the 
cerebellar  ablation  is  noted  in  a  previous  section.  Besides  the 
usual  immediate  results  subse(|uent  to  the  sensori-motor  sphere 
destructions  there  followed  certain  noteworthy  phenomena.  The 
animal  as  a  whole  became  quite  ataxic,  and  the  head  oscillated 
rapidly  in  either  direction — as  it  was  seen  to  do  after  the  primary 
cerebellar  injury.  Later  the  incoordination  seemed  more  re- 
stricted to  the  head  and  lo  the  homolateral  limbs  (as  regards  the 
cerebellum).  In  the  course  of  a  number  of  weeks  it  became 
inconspicuous  in  the  extremities,  but  continued  in  the  head  and 
neck.  Like  an  intention  tremor  this  feature  was  chiefly  noted 
when  the  animal  attemi)ted  jmrposive  movements,  such  as  drink- 
ing from  a  pan,  seizing  a  particle  of  food  suspended  in  the  air, 
etc.  Two  and  one  half  months  following  the  final  operation 
there  was  still  fjiscerniblc  an  unsteadiness  of  these  parts,  more 


LOCALIZATION  OF  FUNCTION  IN  CANINE  CEREBELLUM     119 

appreciable  in  the  coarse  tremor  of  the  head  from  side  to  side. 
The  abnormal  features  which  followed  the  original  lobulus  sim- 
plex (cerebellar)  destruction,  it  should  be  emphasized,  disap- 
peared within  a  month. 

In  summing  up  both  the  observations  noted  here  and  those 
already  recorded  by  others  (cf.  section  II),  it  becomes  evident 
that  in  the  hands  of  different  investigators  circumscribed  lesions 
of  the  cerebellar  lobuli  have  yielded  somewhat  varying  results. 
This,  perhaps,  can  be  partly  accounted  for  by  the  fact  that  no  two 
workers  have  excised  exactly  the  same  areas  of  the  cortex  in 
their  experiments.  Viewed  in  a  more  general  way,  however, 
these  results  indicate  that  the  complex  movements  necessary  for 
standing,  running,  etc.,  are  represented  in  more  or  less  local  areas 
in  the  cerebellar  cortex. 

It  is  recognized,  of  course,  that  movements  in  which  several 
parts  of  the  body  are  involved  at  the  same  time  cannot  be  com- 
pletely represented  by  an  area  or  a  center  for  movements  of  any 
one  of  these  parts.  This  means,  as  Mills  and  Weisenburg  (20) 
have  stated,  that  cerebellar  localization  is  more  compound  in  its 
cortical  representation  than  is  cerebral  localization.  In  view  of 
the  work  of  Horsley  and  his  co-workers,  and  others,  it  is  more 
than  probable  that  this  localized  representation  of  movements  is 
purely  afferent  in  nature. 

Conclusions 

1.  The  question  of  a  localization  of  function  in  the  cerebellar 
cortex  is  still  in  dispute.  The  results  of  these  experiments  tend 
to  support  such  an  hypothesis. 

2.  Previous  investigations  have  shown  that  the  gradual 
amelioration  of  symptoms,  which  follows  removal  of  the  cerebel- 
lum, does  not  occur  in  animals  in  which  the  sensori-motor  spheres 
of  the  cerebrum  have  also  been  destroyed. 

When  the  sensori-motor  areas  are  destroyed  some  weeks 
subsequent  to  a  primary  ablation  of  the  crus  secundum  (lobulus 
ansiformis)  or  the  lobulus  simplex  of  the  cerebellum,  the  symp- 
tomatic evidences  of  the  latter  injury,  which  have  subsided,  re- 
appear once  more  and  persist  over  a  long  period.  The  results  of 
these  experiments  accordingly  indicate  the  considerable  value  of 
this  combination  of  lesions  in  the  study  of  canine  cerebellar 
localization. 


120  ERXEST  G.  GREY 

LITERATURE 

1.  Babinski,  J.,  and  Tournay,  A.     XVIIth  Internat.  Congr.  of  Med.,  Lon- 

don, 1913,  Sect.  II,  p.  I. 

2.  Barany,  R.     Wien.  kl.  Wchnschr.,  1912,  25,  2033. 

3.  Binnert,  A.     Academisch  proefschrift.,  Amsterdam,  1908.  8,  153. 

4.  Bolk,  L.     Over  de  physiologische  Beteeknis  van  het  cerebellum,  Haar- 

lem, 1903. 

5.  Bradley,  C.     Jour.  Anat.  and  Physiol,  1903.  37,  112,  221. 

6.  Ewald,  J.  R.     Untersuchungen  iiber  den  Endorgan  des   N.   Octavus, 

Wiesbaden,  1892. 

7.  Flourens.     Recherches  experimentales,  etc.,  Paris,  1842. 

8.  Goltz,  F.     Pfliiger's  Arch.  f.  d.  ges.  Physiol.,  1884,  34,  463 ;  1892,  51,  570. 

9.  Horsley,  V.,  and  Clarke.  R.  H.     Brain,  1908,  31,  45. 

10.  Horsley.  V.     Brain,  1906,  29,  446. 

11.  Hulshoff-Pol,   D.  J.,   Psychiat.   u.   Neurol.   Bladen,   Amsterdam,    1909. 

No.  4,  273. 

12.  Lewandowsky,  M.     Arch.  f.  (Anat.  u.)  Physiol.,  1903,  1/2,  129. 

13.  Luciani,  L.     Ergeb.  der  Physiol.,  1904,  3  Jahrg.,  2  abt,  261. 

14.  Luna,  E.     Anatomische  Anzeiger,  1908,  32,  617. 

15.  Lussana,  F.     Jour,  de  la  Physiol.,  1864.  6,  169. 

16.  MacNalty  and  Horsley.     Brain,  1909.  32.  237. 

17.  Magendie.     Proces  elementaire  de  physiologic,  Paris,  1836. 

18.  Magnus,   R.,  and  Kleijn,  A.  de.     Pfliiger's  Arch.   f.  d.  ges.   Physiol., 

1912,  145,  455. 

19.  Marassini,  A.     Arch.  Italiennes  de  Biol.,  1907,  47,  135. 

20.  Mills,  C.  K.,  and  Weisenburg,  T.  H.     Jour.  A.  M.  A.,  1914,  63,  1813. 

21.  Oppenheim,  H.     Lehrbuch  der  Nervenkrankheiten,  6th  ed.,  ii,  1215. 

22.  Pagano,  G.     Rivista  di  patologia  nerv.  e  ment.,  1904,  9,  209. 

23.  Rothmann,  M.     XVHth  Internat.  Congr.  of  Med.,  London,  1913,  Sect. 

II.  p.  59- 

24.  Rynberk,  G.  van.     Ergeb.  der  Physiol.,  1908,  7,  653;  1912,  12,  538. 

25.  Sherrington,  C.  S.,  and  Brown,  G.     Jour.  Physiol.,  191 1,  43,  209. 

26.  Sherrington,   C.  S.     The  Integrative  Action  of  the  Nervous   System, 

New  York,  1906. 

27.  Smith,  E.    Jour.  Anat.  and  Physiol.,  London,  1903,  37,  320. 


THE   VALUE    AND    MEANING    OF    THE    ADDUCTOR 
RESPONSES  OF  THE  LEG^ 

By  a,  Myerson,  M.D. 

CLINICAL   DIRECTOR   AND   PATHOLOGIST,   TAUNTON   STATE   HOSPITAL;    FELLOW   IN 
PSYCHIATRY,    HARVARD   UNIVERSITY 

In  two  previous  papers  I  have  described  a  series  of  periosteal 
reflexes  invoked  by  percussion  of  the  bones  of  the  lower  ex- 
tremities and  marked  by  the  response  of  the  adductor  muscles. 
Conclusions  reached  in  these  papers  have  been  added  to,  amended 
and  altered  by  the  results  of  the  routine  examination  of  patients 
for  these  reflexes  in  two  years  of  active  psychiatric  hospital  work. 
Therefore,  this  paper  is  written  to  represent  the  facts  and  to 
evaluate  them.  In  addition,  I  wish  to  make  in  passing  some 
observations  on  the  adductor  responses  of  the  arms,  these  re- 
sponses being,  so  far  as  I  know,  in  general  new  to  the  literature. 

There  is  a  fairly  copious  literature  which  concerns  itself  with 
the  adductor  responses  of  the  legs.  Since  the  viewpoint  of  the 
writers  has  been  different  than  my  own,  and,  moreover,  since  their 
technique  and  examination  of  the  reflexes  described  have  dif- 
fered still  more  widely,  their  work  has  but  few  points  of  contact 
with  mine.  The  pioneer  workers  on  reflexes  gave  their  attention 
mainly  to  those  elicited  from  tendons.  Nevertheless,  Erb,  West- 
phal  and  Striimpell  also  mentioned  the  homolateral  adductor  re- 
sponse elicited  from  the  internal  surface  of  the  knee  joint. 
Striimpell  also  pays  some  attention  to  the  contralateral  adductor 
elicited  from  the  patellar  tendon.  This  response,  the  classical 
contralateral  adductor,  aroused  the  attention  of  Sternberg,  Hins- 
dale and  Taylor,  Risien-Russell,  Purves,  Fere,  Marie,  Marinesco, 
Ganeult,  Huismans,  Keller  and  others,  and  opinion  on  its  patho- 
genesis and  meaning  has  varied  very  much.  It  may  be  said  that 
in  general  the  authors  have  considered  this  response  a  patholog- 
ical one  and  indicating  some  disturbance  of  the  nervous  system. 
Other  adductor  responses  were  described  by  Berolotti  and  Vola- 
bra  (a  contralateral  elicited  from  the  sole  of  the  foot),  and  by 
Noica  and  Strominger.  The  attention  paid,  however,  has  been 
scattering  and  unsystematized. 

1  Taunton  State  Hospital  Papers,  1915,  No.  i. 


,22  .-i.  MVERSON 

Ti-chniqiic. — It  is  necessary  to  emphasize  the  method  used  in 
eliciting  the  responses  described  in  this  paper  since  no  point  in 
the  ehcitation  of  reflexes  is  more  important  than  the  posture  of 
the  parts  concerned.  Indeed,  the  posture  is  constituted  by  what 
Sherrington  calls  the  neural  pattern.  Therefore,  a  definite 
posture  means  a  definite  arrangenient  of  neuron  relationships, 
and  it  is  as  necessary  to  maintain  the  same  posture  as  it  is  in 
laboratory  technique  to  use  the  same  chemicals.  It  is  also  neces- 
sary to  state,  since  this  law  of  neurological  technique  is  most 
often  violated,  to  have  the  parts  stimulated  and  the  parts  reacting 
nude.  For  the  adductor  reflexes  in  general  the  patient  lies  on 
his  back  as  much  relaxed  as  possible.  The  legs  lie  somewhat 
abducted  and  slightly  outward  rotated  in  what  may  be  called  the 
normal  posture.  It  is  absolutely  essential  that  the  adductors  be 
relaxed,  since  it  is  obvious  that  if  they  be  contracted  their  move- 
ments cannot  be  observed.  (This,  of  course,  does  not  apply  in 
such  conditions  where  adductor  contracture  is  an  involuntary 
process.)  This  point  will  bear  emphasis  because  where  people 
are  shy,  timid  or  apprehensive,  the  first  group  of  muscles  that 
they  contract  is  the  adductors,  in  what  seems  to  be  an  instinctive 
effort  to  protect  the  genitalia.  With  an  ordinary  Taylor  reflex 
hammer  and  using  force  that  does  not  invoke  pain,  the  following 
sites  are  stimulated:  ist,  the  internal  surface  of  the  knee  joint; 
2nd,  the  external  surface;  3d,  the  internal  malleolus;  4th,  the 
sole  of  the  foot  near  the  arch  ;  5lh.  the  tendo-Achillis ;  6th,  the 
anterior-superior  spine.  In  eliciting  the  7th,  the  response  of  the 
patellar  tendon,  it  is  necessary  partially  to  flex  the  thii^di  upon  the 
hip  and  the  leg  upon  the  thigh.  It  will  be  noted  that  all  of  these 
responses  are  elicited  from  bony  surfaces  except  those  from  the 
Achilles  and  patellar  tendons. 

The  direction  of  the  blow  must  be  considered.  In  the  re- 
sponses elicited  from  the  external  surfaces,  such  as  the  external 
condyle  and  anterior-superior  spine,  the  blow  is  mainly  inward 
though  in  the  latter  case  inward  and  downward.  In  those  re- 
sponses elicited  from  internal  surfaces,  such  as  the  internal  con- 
dyle, the  midflle  of  the  shaft  of  the  tibia,  and  the  Achilles  tendon, 
the  blow  is  directed  outward.  In  those  elicited  from  inferior 
surfaces,  such  as  the  sole  (jf  the  foot  and  the  patellar  tendon 
when  the  knee  is  bent,  the  blow  should  Ik-  upward  and  toward  the 
mirldle  line  of  the  body.  As  will  be  shown  later  the  direction 
of  the  blow  has  much  to  do  with  the  ehcitation  of  these  responses 
and  plays  perhaps  an  important  part  in  their  pathogenesis. 


VALUE  OF  ADDUCTOR  RESPONSES  OF  LEG  123 

Rcsp07iscs. — The  reflexes  described  in  my  previous  papers 
and  here  re-presented  can  be  divided  as  follows : 

1.  A  group  where  the  homolateral  adductor  is  more  lively 
than  the  contralateral,  more  frequently  and  more  easily  elicited 
provided  that  there  is  no  difiference  in  the  reflexes  of  the  two 
sides.     The  sites  of  stimulation  for  this  group  are  as  follows : 

(a)  The  internal  side  of  the  knee  joint ;  that  is  to  say,  the  in- 
ternal condyle  and  the  internal  surface  of  the  head  of  the  tibia. 
This  is  probably  the  most  common  of  the  adductor  responses. 

(b)  The  middle  of  the  shaft  of  the  tibia.  This  response  runs 
closely  second  to  the  above. 

(c)  The  internal  malleolus  which  gives  a  response  not  nearly 
so  often  as  the  above  two. 

(d)  The  Achilles  tendon.  From  this  site  the  response  is 
about  equal  in  frequency  to  that  elicited  from  the  internal  mal- 
leolus. 

2.  A  group  where  the  contralateral  adductor  is  more  lively 
than  the  homolateral,  more  frequently  and  more  easily  elicited, 
providing,  as  in  the  above  group,  that  there  is  no  difference  in 
the  response  of  the  two  sides.  The  sites  of  stimulation  for  this 
group  are  as  follows : 

(a)  The  sole  of  the  foot.  This  is  a  rather  common  reflex 
and  closely  rivals  in  frequency  those  elicited  from  the  internal 
condyle  and  middle  of  the  tibial  shaft  of  the  previous  group. 

(b)  Patellar  tendon.  This,  as  has  been  before  stated,  is  the 
classical  contralateral  adductor ;  that  is  to  say,  stimulation  of  one 
patellar  tendon  gives  an  adductor  response  of  the  opposite  side 
much  more  frequently  than  it  gives  a  homolateral  adductor  re- 
sponse. This  response  is  relatively  infrequent  except  in  patho- 
logical cases. 

3.  A  group  where  the  relationship  of  the  homolateral  and 
contralateral  adductors  cannot  be  said  to  have  a  constant  ratio. 
That  is  to  say,  sometimes  one  finds  the  contralaterals  more  lively 
and  at  other  times  the  homolaterals.  The  sites  of  stimulation 
for  this  group  are  : 

(a)  The  external  surface  of  the  knee  joint  which  gives  a  re- 
sponse about  as  often  as  does  the  patellar  tendon. 

(b)  The  anterior-superior  spine.  This  response,  I  find,  is  some- 
what more  frequent  than  that  elicited  from  the  external  condyle  and 
the  patellar  tendon.  In  my  previous  paper  I  placed  this  group 
with  the  second;  that  is  to  say,  I  stated  that  the  contralaterals 
were  more  frequently  and  more  easily  elicited  than  the  homo- 


124  --i-  MVERSOS' 

laterals.     Experience  has  amended  this  into  the  statement  above 
made. 

Summarizing  the  order  of  frequency  of  these  responses,  it  is 
roughly  put  as  follows:  First,  that  from  the  internal  condyle; 
second,  that  from  the  middle  of  the  shaft  of  the  tibia ;  third,  the 
contralateral  adductor  from  the  sole  of  the  foot;  fourth,  the  one 
from  the  Achilles  tendon  ;  fifth,  and  occurring  about  as  frequently 
as  the  fourth,  that  from  the  internal  malleolus;  sixth,  the  re- 
sponses elicited  from  the  anterior-superior  spine;  seventh,  that 
elicited  from  the  patellar  tendon,  the  classical  contralateral  ad- 
ductor response;  eighth,  and  about  equal  in  f requeue}^  with  the 
above,  the  response  elicited  from  the  external  condyle,  the  ex- 
ternal surface  of  the  head  of  the  tibia. 

Relationship  to  Other  Reflexes 

(a)  Relationship  to  the  Knee  Jerk. — In  a  general  way  it  may 
be  stated  that  these  responses  parallel  in  activity  the  knee  jerk. 
That  is  to  say,  they  appear  under  conditions  in  which  the  knee 
jerk  is  increased.  However,  this  parallelism  in  frequency'  is  but 
a  rough  one  for  there  are  conditions  in  which  ven,'  active  knee 
jerks  are  not  accompanied  by  prominent  adductors  and  especially 
are  not  accompanied  by  the  appearance  of  the  contralateral  ad- 
ductors. That  is  to  say,  the  appearance  of  the  adductor  re- 
sponses, especially  the  contralaterals  presupposes  active  knee 
jerks,  but  the  reverse  relationship  does  not  obtain. 

The  above  relationship  must  be  elaborated  upon  in  order  to 
meet  the  facts  in  the  case.  The  important  factor  in  this  parallel- 
ism is  the  activity  of  the  knee  jerk  on  the  side  of  the  responding 
adductor,  not  on  the  side  of  the  surface  stimulated.  That  is  to 
say,  in  the  homolateral  adductors  the  side  stimulated  and  the  side 
responding  being  the  same,  the  adductors  and  the  knee  jerk  will 
have  a  direct  parallelism.  In  the  contralateral  adductors,  the 
side  stimulated  and  the  side  responding  being  different,  the  im- 
portant fact  is  the  activity  of  the  knee  jerk  on  the  side  responding. 
Marinesco.  Marie,  and  I  have  described  cases  in  which,  with  the 
knee  jerk  absent  on  one  side  stimulation  of  that  side,  even  from 
the  patellar  tendon  itself,  produced  lively  adductor  responses  on 
the  opposite  side,  whereas,  of  course,  there  were  no  adductor  re- 
sponses on  the  side  stimulated. 

It  is  not  to  be  understood  that  because  of  this  relationship 
there  is  some  causal  dej)endency  of  the  adductor  responses  upon 
the  knee  jerk      In  fact,  the  relationship  may  well  be  one  of  coin- 


VALUE  OF  ADDUCTOR  RESPONSES  OF  LEG  125 

cidence.  Up  to  the  present  time,  however,  I  have  never  observed 
a  case,  where,  with  the  knee  jerk  absent  on  one  side,  any  adduc- 
tor responses  could  be  elicited  from  that  side. 

(b)  Relationship  to  the  Ankle  Jerk. — These  responses  have 
no  relationship  whatever  to  the  activity  of  the  ankle  jerk ;  that 
is  to  say,  they  may  be  lively  with  the  ankle  jerks  lively,  they  may 
be  absent  when  the  ankle  jerks  are  absent,  but  on  the  contrary, 
they  may  be  present  when  the  ankle  jerks  are  absent,  and  absent 
when  the  ankle  jerks  are  present.  All  possibilities  are  obtainable. 
In  fact,  and  especially  in  cases  of  early  tabes,  with  lively  knee 
jerks  and  absent  Achilles,  homolateral  and  contralateral  adduc- 
tors may  be  elicited  even  from  the  Achilles  tendon  itself.  That 
is  to  say,  the  site  of  a  tendon  reflex  will  give  an  adductor  reflex 
even  when  the  tendon  response  is  absent. 

(c)  RelationsJiip  to  Babinski,  Oppenheim  and  Gordon  Signs. 
— The  adductor  responses  bear  no  definite  relationship  to  these. 
In  this  they  are  not  different  from  the  knee  jerk  which,  as  is  well 
known,  may  be  markedly  diminished  when  these  signs  are  pres- 
ent ;  as,  for  example,  in  compression  of  the  cord  from  Pott's 
disease. 

{d)  The  above  applies  to  the  relationship  to  ankle  clonus. 
Summarizing  the  above  statements,  the  adductor  responses  have, 
in  my  experience,  appeared  only  when  a  knee  jerk  was  obtain- 
able on  the  side  of  the  adductor  responding.  These  responses 
are  independent  of  the  knee  jerk  of  the  side  stimulated  but  are  di- 
rectly dependent  upon  the  knee  jerk  of  the  side  responding.  Of 
course,  when  the  side  stimulated  and  the  side  responding  are  the 
same,  they  are  then  dependent  upon  the  knee  jerk  of  the  side 
stimulated.  The  above  relationship  is  understood  to  be  probably 
coincidental  and  not  causal.  These  responses  are  independent  of 
the  Achilles  reflex  and  also  of  Babinski,  Oppenheim  and  Gordon 
signs,  as  well  as  ankle  clonus. 

Incidence  in  Health. — In  my  first  paper  I  detailed  the  propor- 
tionate appearance  of  these  reflexes  in  healthy  subjects,  the  group 
studied  at  that  time  being  the  members  of  the  first  and  second 
year  classes  in  the  St.  Louis  University  Medical  School.  Further 
experience  with  normal  subjects  has  led  to  the  following  conclu- 
sions :  Adductor  responses  are  not  prominent  in  young  and  healthy 
adults.  The  homolateral  adductors  from  the  internal  condyle 
and  middle  of  the  shaft  appear  in  a  very  moderate  degree  in  a 
considerable  percentage  of  normal  young  men.  (It  is  obvious 
that  normal  young  women  subjects  are  not  easily  accessible  for 


126  A.  MVERSON 

research  reflex  studies.  However,  it  is  unlikely  that  there  is  any 
marked  diflference  between  the  sexes.)  A  contralateral  adductor 
of  very  moderate  activity  from  the  sole  of  the  foot  appears  in  a 
somewhat  smaller  percentage  of  normal  subjects.  Bertolotti  and 
\'olabra  found  this  reflex  present  in  about  45  per  cent,  of  normal 
subjects.  As  they  used  the  hammer  of  Dejerine,  and,  moreover, 
since  their  subjects  were  picked  from  a  clinic,  the  disparity  be- 
tween their  results  and  mine,  of  about  15  per  cent.,  is  not  difficult 
to  explain.  Sick  ])eople,  that  is  to  say.  persons  presenting  them- 
selves at  a  clinic,  no  matter  for  what  trouble,  are  not  to  be  classed 
as  normal  persons,  and  the  hammer  of  Dejerine  is  a  heavy  ham- 
mer not  to  be  compared  with  the  Taylor  instrument.  Contra- 
lateral adductors  from  the  knee  joint,  from  the  external  condyle, 
and  the  anterior-superior  spine  did  not  appear  amongst  normal 
young  men.  It  is  true  that  three  of  the  students  examined  gave 
these  responses,  but  further  examination  showed  that  these  young 
men  could  not  be  called  normal.  The  homolateral  adductor  from 
the  .\chilles  tendon  appears  occasionally  in  healthy  subjects;  the 
contralateral  from  the  same  source  almost  never. 

It  is  necessary  at  this  point  to  emphasize  the  fact  that  the  term 
"  normal  subject  "  has  been  misused  by  some  of  the  authors.  For 
example,  Hinsdale  and  Taylor  in  their  work  on  the  contralateral 
adductor  from  the  patellar  tendon  used  as  subjects  patients  pre- 
senting themselves  at  a  nerve  clinic.  It  is  true  that  care  was 
taken  to  rule  out  organic  disease,  but  nevertheless  persons  suf- 
fering from  neurasthenia,  "  angst-neurosis,"  and  chorea  are  not 
normal  persons.  F.vcn  when  examining  people  outside  of  a 
clinic  a  complete  physical  examination  is  necessary  in  order  to 
insure  in  so  far  as  is  ])Ossil)le  that  one  is  dealing  with  healthy  per- 
sons. In  the  above  mentioned  stu(l\-  of  the  medical  students  of 
St.  Louis  University,  heart  and  lungs  were  examined,  ])upils  were 
teste<l,  and  all  the  common  neurological  signs  were  investigated 
in  order  to  insure  normality. 

Summarizing,  the  only  adductors  presenting  themselves  in 
health  are  those  from  the  intertial  condyle,  the  middle  of  the  shaft 
of  the  tibia,  the  contralateral  from  the  sole  of  the  foot,  and  liomo- 
lateral  response  from  the  Achilles  tendon.  'Jhese  are  present  in 
a  relati-vely  small  percentage  and  are  not  marked  in  activity,  nor 
are  the  reflexogenous  zones  from  which  they  are  elicited  broad. 
These  arc,  as  a  rule,  usually  .shar])ly  circumscribed.  The  re- 
sponses from  the  external  condyle,  the  anterior-su])erif)r  spine, 
and  the  i)atellar  tendon  are  not  frjund  in  normal  subjects. 


VALUE  OF  ADDUCTOR  RESPONSES  OF  LEG  127 

Incidence  in  Infancy. — This  question  I  wish  to  leave  for  the 
time  without  very  definite  statement.  In  sick  infants,  that  is  to 
say  in  babies  suflrering  from  malnutrition  and  from  acute  infec- 
tions, contralateral  adductors  are  frequent.  It  is  obvious  that 
there  is  great  difficulty  in  exactly  testing  reflexes  in  infants  but 
in  sick  babies  stimulation  of  one  side  will  often  cause  a  movement 
towards  the  middle  line  of  the  other  leg  which,  of  course,  is  very 
good  evidence  of  an  adductor  response.  Concerning  normal  in- 
fants, my  experience  has  not  been  sufficient  to  allow  of  any  state- 
ment. In  children  above  the  age  of  one  year  and  older,  the  ad- 
ductors are  no  more  prominent  than  in  adults. 

Incidence  in  Fatigue. — This  important  question  was  studied 
in  the  following  manner :  Twenty  young  men  competing  in  the 
St.  Louis  Marathon  Race  of  May,  191 2,  were  examined  on  the 
night  before  the  race  and  immediately  after  they  reached  the  club- 
house upon  the  completion  of  their  twenty-six  mile  run.  It  is 
obvious  tliat  these  men  were,  therefore,  examined  at  two  dif- 
ferent periods.  First,  when  their  muscular  efficiency  was  at  its 
height,  that  is  to  say,  just  before  a  race,  when  each  man  was 
trained  up  to  his  best  efforts.  That  these  men  were  fit  and  not 
overtrained  is  evidenced  by  the  fact  that  seventeen  of  them  fin- 
ished in  fairly  good  condition  after  twenty-six  miles  of  running 
along  miserable  roads  and  in  a  heat  of  nearly  ninety  degrees 
Fahrenheit.  Second,  they  were  examined  at  a  period  of  most 
complete  fatigue,  that  is  to  say,  immediately  after  they  reached 
the  club-house  at  the  conclusion  of  the  run. 

(a)  The  Adductor  Reflexes  in  Athletes  at  the  Conclusion  of 
Training. — No  contralateral  adductor  appeared  except  in  two 
cases  when  that  from  the  sole  of  the  foot  was  elicited.  Homo- 
lateral adductors  were  present  in  five  cases  from  the  internal 
condyle  and  the  middle  of  the  shaft  of  the  tibia.  In  all  the  other 
cases  no  adductor  response  of  any  kind  was  elicited.  Moreover, 
the  knee  jerks  and  ankle  jerks  were  only  moderately  active  in  the 
great  majority  of  the  men. 

(b)  The  Adductor  Responses  Under  Conditions  of  Complete 
Fatigue. — At  the  conclusion  of  the  run  seventeen  of  the  men.  that 
is  those  who  finished,  were  examined.  Of  these  none  showed 
any  adductor  responses  whatever.  That  is  to  say,  complete 
muscular  fatigue  caused  the  disappearance  of  the  responses.  In 
accord  with  all  other  observers  who  examined  men  doing  similar 
work  I  found  that  the  knee  jerks  and  ankle  jerks  were  markedly 
diminished. 


128  A.  MVERSON 

The  above  facts  are  very  important.  It  will  be  shown  later 
that  in  certain  so-called  functional  diseases  where  fatigue  is  con- 
sidered by  many  to  play  a  part,  the  adductor  responses  are  lively. 
It  is  obvious  then  that  such  fatigue  must  be  entirely  different 
from  that  caused  by  intense  muscular  work  since,  in  the  latter 
case,  the  adductor  responses  disappear. 

Incidence  in  Disease. — In  a  general  way  it  may  be  stated  that 
disease  or  affection  of  the  upper  or  cortical  motor  neuron  is,  in 
the  organic  diseases,  a  necessary  condition  for  the  appearance  of 
the  adductor  responses.  The  type  of  cases  most  frequently  seen 
in  institutions  for  the  insane  have  necessarily  been  given  the 
greatest  attention  since  the  greater  part  of  the  work  done  by  me 
has  been  in  such  institutions. 

I.  General  Paresis. — In  general  paresis  the  adductor  responses 
are  very  prominent  especially  in  the  early  stages  of  the  disease. 
The  majority  of  uncomplicated  cases  of  general  paresis,  that 
is  to  say,  where  no  degeneration  of  the  posterior  columns  has 
occurred,  show  lively  adductor  responses,  both  contralateral  and 
homolateral.  This,  of  course,  is  parellel  with  the  increase  in 
the  knee  jerks  seen  in  such  cases.  In  cases  of  tabo-paresis  the 
knee  jerks  disappear  and  so  do  the  adductors.  In  certain  cases 
the  ankle  jerks  disappear  while  the  knee  jerks  are  still  lively, 
and  in  such  cases  the  adductors  are  still  present  and  are  lively. 
There  are  transition  cases  in  paresis ;  that  is  to  say,  the  process 
in  the  spinal  cord  has  commenced  but  has  not  yet  brought  about 
an  abolition  of  the  knee  jerks,  and  in  such  cases  the  adductor  re- 
sponses may  be  absent  while  the  knee  jerks  are  still  present. 
Thus  it  may  be  stated  that  in  the  one  great  organic  psychosis  the 
adductors  are  a  conspicuous  feature,  at  least  in  certain  phases  of 
the  disease. 

At  this  point  it  is  logical  to  consider  a  condition  which  many 
writers  have  discussed  but  which  no  one,  so  far  as  I  know,  has 
studied  with  as  much  thoroughness  as  William  W.  Graves,  of 
St.  Louis  ;  namely,  that  of  latent  syphilis.  Graves  has  shown  that 
the  chronic  syjjhilitic  i)rcsents,  even  in  the  periods  when  he  com- 
[)lains  of  no  particular  .symptoms  and  before  the  appearance  of 
tabes-  or  [>aresis  or  any  marked  aortitis,  certain  physical  signs. 
These  signs  are  pigmentation  of  the  skin,  a  certain  pallor  which 
Graves  calls  "cachectic  jiallor"  fthough  I  should  prefer  the  term. 
spastic  pallor),  inequality  or  irregularity  of  the  pupils  which, 
however,  still  react  well  to  light  and  accommodation ;  inequality 


VALUE  OF  ADDUCTOR  RESPONSES  OF  LEG  129 

of  the  reflexes  or  disparity  between  one  group,  say  the  arm  re- 
flexes, and  another,  the  leg  reflexes,  and  certain  changes  in  the 
cutaneous  sensibiHty,  particularly  areas  of  hypalgesia.  Tn  such 
cases  the  adductor  responses  are  frequently  of  great  liveliness, 
as  I  have  found  in  the  study  of  Graves'  cases.  This,  of  course, 
is  in  line  with  the  belief  now  entertained  that  paresis  is  an 
extension  of  chronic  syphilis,  and  in  many  respects  merely  repre- 
sents a  further  stage  of  it,  not  to  be  differentiated  by  any  such 
term  as  parasyphilis. 

2.  Incidence  in  Tabes  Dorsalis. — It  can  be  said  without 
further  detail  that  when  the  knee  jerk  has  disappeared  or  is 
diminished  in  tabes  that  the  adductors  disappear.  Furthermore, 
in  those  occasional  cases  when  the  ankle  jerks  have  disappeared 
but  the  knee  jerks  still  persist  and  are  lively,  the  adductors  may 
be  lively.  I  have  had  at  least  four  well-marked  cases  showing 
this. 

Cerebral  Hemorrhage,  Thrombus  or  Embolism  Causing 
Hemiplegia. — Ganault  especially  studied  the  reflexes  in  this  condi- 
tion and,  in  general,  my  conclusions  agree  with  his  as  to  the 
incidence  of  the  adductor  responses.  These  conclusions  are  as 
follows :  On  the  side  of  the  paralysis,  the  adductor  reflexes  are 
livelier  than  those  on  the  opposite  side  although  they  may  be 
present  and  frequently  are  present  on  both  sides  in  a  manner  not 
found  in  normal  subjects.  This,  of  course,  is  in  accord  with  the 
experience  that  all  the  reflexes  bilaterally  are  increased  in  hemi- 
plegic  conditions.  Furthermore,  such  cases  demonstrate  in  a  very 
remarkable  manner  the  fact  that  the  liveliness  of  the  adductor 
response  is  coincident  with  the  liveliness  of  the  knee  jerk  on  the 
side  responding,  independent  of  the  site  of  stimulation. 

There  exists,  however,  a  complication  in  hemiplegia  which 
frequently  makes  the  different  results  seem  unwarranted.  That 
is  to  say,  there  are  many  cases  of  hemiplegia  in  which  the  ad- 
ductor responses  on  the  paralyzed  side  are  apparently  absent, 
while  those  on  the  opposite  or  non-paralyzed  side  may  be  Hvely. 
In  such  cases  it  %vill  almost  invariably  be  found  that  there  exists 
contracture  of  the  adductor  muscles,  a  very  common  phenomenon 
even  in  early  hemiplegia  and  almost  invariably  present  in  late 
hemiplegia,  and  in  part  responsible  for  the  gait  of  the  hemiplegic. 
If  the  adductor  muscle  be  contracted,  that  is,  exists  in  a  state  of 
chronic  activity  (if  such  a  term  may  be  used),  then  further 
stimulation  of  it  will  result  in  little  or  no  movement  according  to 


130  A.  MYERSON 

the  degree  of  contracture;  that  is.  if  the  muscle  by  virtue  of  its 
contraction  up  to  its  Umit  is  incapable  of  further  movement  then 
no  amount  of  stimulation  by  tapping  the  bone  on  one  side  or  the 
other  will  cause  movement,  and  if  by  virtue  of  its  state  of  con- 
traction it  is  capable  of  only  a  small  amount  of  movement,  then 
the  side  free  to  move,  the  oppposite  side,  may  move  more  when 
stimulated.  The  adductor  contracture  in  hemiplegia  is  in  itself 
a  phenomenon  to  a  certain  degree  similar  to  that  obtained  by 
stimulating  the  lower  extremities,  and  indeed  has  a  pathological 
and  physiological  value  similar  to  that  of  the  adductor  responses. 
In  many  cases  of  adductor  spasm  stimulation  of  the  bones  on  one 
side  or  the  other  will  cause  but  little  visible  movement,  yet  if  the 
hand  be  ])laced  on  the  adductors  concerned  they  will  be  found  to 
contract  in  a  very  sharp,  somewhat  convulsive  manner,  very 
much  unlike  the  response  found  in  normal  persons. 

3.  Incidence  in  Certain  Miscellaneous  Organic  Diseases, 
(a)  Tumors  of  the  Brain. — These  responses  do  not  seem  to  be 
ver)-  j)romincnt  in  those  cases  which  have  come  to  my  observa- 
tion. However,  my  experience  with  brain  tumors  has  been  rather 
scanty  and  most  of  the  cases  have  been  such  where  mental  symp- 
toms predominated  so  that  the  diagnosis  of  tumor  was  not  made 
until  after  the  entrance  of  the  patient  into  the  asylum.  Such 
cases  are  largely  frontal  and  consequently  the  tumor  does  not 
exercise  a  direct  effect  upon  the  reflexes  except  through  pressure. 

(b)  Multiple  Sclerosis. — The  adductor  responses  arc  very 
prominent  in  this  condition  and  frequently  approach  a  clonic 
state.  This,  it  will  be  observed,  is  on  a  par  with  the  tendon 
reflexes  in  general. 

(c)  Compression  of  the  Cord  from  Tumor  and  Pott's  Disease. 
— Here,  the  adductor  responses  follow  the  same  general  prin- 
ciples as  do  the  knee  jerks ;  that  is  to  say,  are  lively  when  the 
degree  of  pressure  is  slight  and  disappear  when  the  reflexes  in 
general  are  diminished  or  abolished. 

(d)  fracture  of  the  Skull. — My  opportunities  for  studying 
these  cases  have  been  limited  to  but  four  cases.  In  one  of  these 
with  the  gradual  a[)i)earancc  of  pressure  symptoms  due  to  a  rup- 
ture-of  the  middle  meningeal  artery,  the  adductor  responses  on 
the  side  concerned  appeared  about  the  same  time  as  did  Babinski 
sign  anfj  disaj)i)earefl  when,  after  tying  of  the  artery  and  rest  in 
bed,  the  cerebral  condition  had  largely  disappeared.  In  the  other 
three  cases  the  adductor  responses  were  not  conspicuous  l)ut  in 


VALUE  OF  ADDUCTOR  RESPONSES  OF  LEG  131 

these  cases  there  was  no  conspicuous  change  in  the  knee  jerks,  and, 
in  fact,  in  one  of  these  cases  there  was  a  general  diminution  of  all 
responses.  A  larger  experience  with  this  condition  would  un- 
doubtedly show  that  there  was  a  coincident  relationship  between 
the  changes  in  the  knee  jerk  and  the  adductor  phenomena. 

(e)  Diseases  of  the  Peripheral  Motor  Neuron. — In  alcoholic 
neuritis  of  which  many  cases  have  been  studied,  the  adductor 
responses  are  absent.  In  anterior  poliomyelitis,  of  which  I  have 
studied  but  a  few  cases,  the  adductors  disappear  when  the  lumbar 
cord  has  been  afifected. 

Functional  Psychoses 

(a)  In  dementia  prsecox  a  certain  number  show  moderate 
homolateral  adductors  and  occasionally  one  finds  contralateral 
adductors  from  the  internal  condyle,  the  shaft  of  the  tibia,  and 
occasionally  from  the  patellar  tendon.  These  latter  cases  are 
few  and  I  cannot  explain  them.  In  general,  in  dementia  prsecox 
the  adductor  responses  are  not  conspicuous. 

{b)  The  above  is  true  of  manic  depressive  insanity.  There 
is  an  irregularity  in  the  liveliness  of  the  responses  in  this  condi- 
tion ;  that  is  to  say,  some  cases  present  lively  reflexes  and  others 
moderately  active  reflexes.  The  adductor  responses  vary  in  the 
same  way  as  do  the  knee  jerks  in  this  condition,  but  it  must  be 
stated  that  both  in  dementia  prsecox  and  manic  depressive  there 
are  many  cases  with  knee  jerks  that  in  point  of  liveliness  ap- 
proach those  elicited  in  general  paresis,  and  yet  in  these  cases  the 
adductor  responses  very  frequently  are  only  moderate  and  rarely 
excessive.  That  is  to  say,  in  the  functional  psychoses  and  in  the 
functional  neuroses  many  cases  of  lively  tendon  reflexes  are  not 
accompanied  by  lively  adductors.  This  form  of  disassociation  is 
found  much  more  often  in  the  "  functional  diseases  "  than  in  the 
organic. 

(c)  Senile  Dementia. — This  term  is  so  loosely  used  in  the 
asylums  in  general  that  no  one  single  group  of  cases  is  concerned. 
Frequently  the  term  is  used  to  cover  a  rather  extreme  degree  of 
the  normal  childishness,  forgetfulness,  and  helplessness  of  old 
age.  Sometimes  it  is  used  when  arteriosclerotic  insanity  is  re- 
vealed by  autopsy,  and  it  also  includes  that  group  of  delusional, 
hallucinatory  states  for  which  the  term  had  better  be  reserved. 
Such  being  the  case  the  discrepancy  in  the  adductor  responses 
found  in  the  condition  so  labeled  must  be  left  open  as  to  causa- 


132  A.  MYERSON 

tion.  In  general,  it  has  seemed  to  me  that  those  cases  in  which 
the  arteriosclerotic  disease  was  evident,  even*when  no  hemiplegia 
was  directly  concerned,  presented  lively  adductor  responses  in  a 
far  greater  percentage  of  cases  than  did  those  presenting  merely 
the  childishness  and  helplessness  of  old  age.  In  other  words,  old 
age  in  itself  was  not  responsible  for  the  appearance  of  the  ad- 
ductors but  cerebral  arteriosclerotic  changes  were.  Those  senile 
delusional  states  that  were  not  associated  with  cerebral  arterio- 
sclerosis, in  general,  did  not  seem  to  give  undue  adductor 
responses. 

Functional  Neuroses 

(a)  Hysteria. — In  hysteria,  as  is  well  known,  the  knee  jerks 
are  very  frequently  extremely  lively  and  indeed  often  accom- 
panied by  what  seems  to  be  movement  of  the  whole  body.  Never- 
theless, as  has  been  pointed  out,  the  response  is  rarely  of  a  spastic 
kind  and  presents  certain  differences,  perhaps  dicernible  only  to 
the  experienced,  from  that  found  in  organic  disease.  In  hysteria, 
the  adductor  responses  are  more  frequent  than  they  are  in  the 
normal  person  but  rarely  approach  the  condition  found  in  paresis. 
The  homolateral  are  frequently  lively  but,  in  such  cases,  there  is 
more  of  a  movement  of  the  leg  and  less  visible  contraction  of  the 
muscle  itself.  That  is  to  say,  there  seems  to  be  something  of  a 
voluntary  effort  to  move  the  leg  imvard  rather  than  an  isolated, 
quick,  sharp  contraction  of  the  adductor  group  of  muscles  such 
as  is  found  in  the  organic  diseases.  The  contralaterals  are  not 
so  conspicuous  though  occasionally  there  is  seen  the  same  move- 
ment as  that  described  above,  a  movement  which  suggests  volun- 
tary innervation  of  the  adductors. 

(&)  Neurasthenia. — What  has  been  said  of  hysteria  is,  to  a 
large  extent,  true  of  neurasthenia  except  with  the  following 
reservations : 

I.  There  is  a  group  of  cases  usually  classed  under  neuras- 
thenia in  which  the  reflexes  are  rather  inactive.  These  cases, 
it  seems  to  me,  belong  to  true  fatigue  states,  especially  caused  by 
overwork  of  a  physical  kind.  In  such  cases,  the  adductor  re- 
sponses are  not  prominent. 

2r.  In  the  true  neurasthenic  conditions  the  reflex  responses  are 
usually  very  active.  These  conditions  arc  usually  marked  by 
worry,  fatigue,  visceral  symptoms,  tremors,  feelings  of  inaptitude, 
failure,  etc.  In  a  miUl  degree  they  are  fref[uently  seen  amongst 
those  whose  work  is  largely  cerebral  and  whose  strain  is  largely 


VALUE  OF  ADDUCTOR  RESPONSES  OF  LEG  133 

mental.  In  such  conditions  the  reflexes  are  usually  exaggerated 
and  in  such  cases  the  adductor  responses  are  relatively  common. 
However,  the  contralateral  responses  from  the  Achilles  tendon, 
from  the  patellar  tendon,  the  condyle  and  the  anterior-superior 
spine  are  almost  never  found.  When  they  exist  some  other 
condition  should  be  suspected,  such  as  incipient  general  paresis, 
v^hich  is  often  mistaken  for  neurasthenia,  latent  syphilis,  hyper- 
thyroidism, etc.  As  a  result  of  my  experience,  /  believe  that  the 
adductor  responses,  whether  homolateral  or  contralateral,  elicited 
from  the  patellar  tendon,  the  anterior-superior  spine,  and  the 
external  condyle  practically  exclude  neurasthenia  as  a  diagnosis. 
There  may  be  neurasthenia  present  in  such  cases  but  there  is  some 
other  organic  condition  also  present. 

There  are  many  questions  as  to  the  physiology  and  patho- 
genesis of  these  responses  that  need  answering.  Of  these  only  a 
few  will  be  dealt  with  in  this  paper.  The  questions  to  be  con- 
sidered may  be  arranged  as  follows : 

I.  What  is  the  bearing  of  these  responses  upon  Pfliiger's 
classical  laws  concerning  the  sort  of  reflexes  ?  The  answer  is  that 
if  these  responses  are  to  be  regarded  as  reflexes  then  they  con- 
trovert his  views. 

(a)  The  law  of  homonymous  conduction  for  unilateral  re- 
flexes (that  is,  if  a  stimulus  applied  to  one  side  causes  movement 
only  on  one  side  that  movement  will  be  on  the  side  of  stimula- 
tion) is  contradicted  by  the  contralateral  from  the  sole  of  the 
foot  which  frequently  is  the  only  response. 

(b)  The  law  of  bilateral  symmetry  (that  is,  a  response 
elicited  by  stimulation  of  one  side  when  it  spreads  further  and 
to  the  opposite  side,  awakens  only  the  symmetrical  mechanisms) 
is  contradicted  by  the  contralateral  adductor  elicited  from  the 
patellar  tendon.  Here,  one  gets  a  knee  jerk  on  the  homolateral 
side  with  a  contralateral  adductor  but  no  contralateral  knee  jerk. 

(c)  The  law  of  unequal  intensity  of  bilateral  reflexes  (that 
is,  if  bilateral  muscular  response  is  elicited  by  unilateral  stimu- 
lation, the  homolateral  response  is  greater)  is  contradicted  by 
the  contralateral  from  the  sole,  from  the  patellar  tendon,  and 
occasionally  by  those  from  the  external  condyle  and  the  anterior- 
superior  spine. 

Sherrington  after  pointing  out  that  these  "  laws "  did  not 
obtain  in  animals  says  very  pertinently  "  that  these  so-called  laws 
of  reflex  irradiation  were  so  generally  accepted  as  to  obtain  an 
eminence  which  they  hardly  merit." 


134  A.  MVERSON 

2.  \\'hat  is  the  essential  difFerence  between  adductor  responses 
and  the  tendon  reflexes?  The  main  difference  Hes  in  the  far 
wider  zone  of  ehcitation  and  this  difference  is  so  marked  in  de- 
gree as  seemingly  to  constitute  a  difference  in  kind.  It  is  only 
occasionally  (Cohn)  that  a  knee  jerk  can  be  elicited  in  any  site 
far  distant  from  the  patellar  tendon  and  so  far  as  I  know  it  is 
never  bilateral  from  unilateral  stiniulation.  The  Achilles  reflex 
can  be  elicited  from  the  sole  of  the  foot  (Graves)  but  this  is 
merely  another  way  of  stretching  the  Achilles  tendon,  while  the 
adductors  are  elicitable  by  the  stimulation  of  many  areas  and  are 
often  contralateral  and  bilateral.  In  this,  they  resemble  a  con- 
tralateral periosteal  arm  reflex  which  I  have  described  as  occa- 
sionally elicited  from  the  clavicle  and  which  is  also  adductor 
in  its  nature.  In  other  words,  the  adductor  type  of  response 
elicited  from  bones  is  not  directly  dependent,  at  least,  upon  any 
segmental  relationship  of  the  sensory  surface  stimulated;  seems, 
on  the  whole,  to  be  selective  in  that  it  occurs  far  more  frequently 
than  other  types  of  response,  and  is  frequently  contralateral  and 
bilateral. 

These  adductor  responses  present  another  point  of  difference 
from  the  tendon  reflexes  in  that  they  are  not  so  constant  in  health 
and,  in  fact,  most  of  the  contralateral  and  bilateral  reflexes  appear 
only  in  disease,  either  organic  or  functional.  This  gives  them  a 
value  which,  while  not  in  any  sense  replacing  the  tendon  re- 
sponses, supplements  their  value. 

3.  What  is  the  relationship  of  these  responses  to  mechanical 
vibration  of  the  pelvis?  This  has  been  a  moot  question  in  the 
discussions  concerning  them.  For  many  of  the  authors  the  ad- 
ductor responses  are  due  merely  to  the  stimulation  by  vibration 
of  the  pelvis.  Others  have  stoutly  contradicted  this  view.  For 
exanijjlc,  Bertolotti  and  Volabra  in  their  consideration  of  the 
causation  of  the  response  called  it  merely  mechanical  and  said 
the  crossed  reflexes  are  best  obtained  in  a  position  which  per- 
mits a  greater  disturbance  of  pelvis  and  spinal  column,  whereas 
Risicn-Kussell,  Hinsdale  and  Taylor  by  manceuvers  which  elim- 
inated the  jar  of  the  pelvis  as  much  as  possible  still  obtain  these 
responses.  Without  entering  any  further  into  the  history  of  the 
discussion  here  follow  some  observations  which  have  a  tentative 
bearing  u|)on  the  direct  causation. 

I.  The  homolateral  responses  are  best  elicited  by  blows  which, 
on  the  whole,  arc  directcfl  outward.  Take,  for  example,  the  in- 
ternal condylar,  the  middle  tibial,  and  the  Archilles  sites  of  stiiu- 


VALUE  OF  ADDUCTOR  RESPONSES  OF  LEG  135 

ulation.  From  these  points  the  contralateral  is  a  less  frequent 
phenomenon  and  one  present  only  with  great  activity  of  the  homo- 
lateral response. 

2.  The  contralateral  is  best  elicited  from  sites  where  the  blow 
is  directed  upward  and  inward.  For  example,  the  sole  of  the 
foot  and  the  patellar  tendon  in  the  position  described  in  this  paper. 
From  these  sites  the  homolaterals  are  less  frequent  and  less  lively. 

3.  From  the  external  condyle  where  the  blow  is  directed  in- 
ward and  the  anterior-superior  spine  where  the  blow  is  directed 
inward  and  downward,  the  predominance  of  one  or  the  other 
adductor  responses  cannot  be  determined.  This  fact,  that  the 
direction  of  the  blow  has  very  much  to  do  with  the  type  of  re- 
sponse, makes  it  seem  possible  that  the  stimulation  which  brings 
about  the  adductor  response  is  indirect  in  its  application.  For 
the  present  I  wish  to  state  that  I  believe  that  the  real  afferent 
limb  of  the  arc  arises  either  at  the  hip  or  in  the  pelvis,  and  not 
at  any  one  of  the  sites  stimulated.  This  receives  some  proof  so 
far  as  the  last  part  of  the  statement  is  concerned  in  the  fact  that 
w^ith  an  absent  knee  jerk  or  ankle  jerk,  stimulation  of  the  patellar 
tendon  or  the  Achilles  tendon  may  bring  about  adductor  responses. 
It  receives  at  least  additional  standing  as  to  value  when  one  con- 
siders the  meaning  of  the  adductor  responses. 

4.  What  is  the  meaning  of  the  adductor  responses?  It  is 
necessary  here  to  consider  first  two  other  matters  which  bear 
upon  the  subject.  First,  the  question  of  contracture  following, 
for  example,  hemiplegia.  In  this,  as  is  well  known,  the  arms 
usually  take  a  flexor  attitude,  the  legs  usually  take  an  extensor 
attitude.  It  is  not  generally  appreciated  that  in  the  case  of  the 
legs  the  contracture  in  the  adductor  muscles  appears  early  and 
is  a  prominent  symptom.  Indeed,  in  certain  conditions,  such  as, 
for  example,  Little's  disease  where  the  lesion  is  bilateral,  rhe 
scissors  gait  is  a  common  phenomenon,  and  the  scissors  gait  is  noth- 
ing more  or  less  than  an  overwhelming  contracture  of  the  ad- 
ductor muscles.  Likewise,  in  primary  lateral  sclerosis,  there  is 
some  tendency  though  not  to  so  marked  a  degree.  That  is  to  say, 
in  the  leg  two  groups  of  muscles  contract  and  these  are  the  ex- 
tensors and  the  adductors.  This  contracture  has  received  various 
explanations.  The  earliest  theory  advanced  by  Charcot  was  that 
the  sclerosis  in  the  pyramidal  tract  was  responsible.  This,  of 
course,  is  now  completely  discarded,  and  the  general  opinion  held 
is  that  with  the  influences  of  the  cerebrum  gone  other  influences 
which  play  particularly  upon  the  groups  of  muscles  contracting 


136  A.  MYERSON 

begin  to  be  felt.  For  Hughlings  Jackson,  Luciani,  Lewandowski 
and  others,  the  cerebellum  entered  into  the  situation  and  caused 
contractures  by  playing  unopposed  upon  these  certain  groups  of 
muscles.  For  others,  such  as  Hitzig,  von  IMonakow  and  Oppen- 
heim  the  contracture  is  produced  by  the  influence  of  the  sensory 
impulses  upon  the  lower  system.  This  latter  explanation  seems 
very  unsatisfactory  to  me  in  view  of  the  fact  that  when  two 
groups  of  muscles  are  affected  in  cerebral  injuries  one  loses 
function  and  the  other  enters  into  a  state  of  enhanced  and  unop- 
posed function.  This  would  make  it  seem  likely  at  least  that  the 
cerebral  injury  brought  paralysis  to  one  group  of  muscles  and 
permitted  unopposed  the  influence  of  some  other  center  upon  the 
other  group.  Sherrington  finds  in  the  nerves  of  the  otic  laby- 
rinth, "  tonus  labyrinth  of  Ewald  "  and  in  the  afferent  nerves  of 
muscles  the  sources  of  the  influence  which  Hughlings  Jackson 
refers  to  the  cerebellum.  In  general,  Sherrington  stands  in  ac- 
cord that  in  these  cases  of  hemiplegic  contracture  and  the  like, 
the  cerebrum  loses  control  of  one  group  of  muscles,  the  so-called 
phasic  group,  while  another  group,  the  so-called  tonic  group, 
comes  under  the  unopposed  influence  of  other  nervous  centers. 
At  this  point  it  is  necessary  to  consider  Sherrington's  views  as  to 
the  distribution  of  tonus.  The  common  opinion  expressed  is 
that  tonus  exists  in  all  muscles  during  life.  For  Sherrington,  the 
contraction  of  one  member  of  a  pair  of  muscles  is  accompanied 
by  the  inhibition  of  the  tonus  of  its  antagonist.  Further,  he  be- 
lieves "the  selective  distribution  of  the  jerk  phenomena  under  the 
ordinary  conditions  employed  for  their  elicitation  to  single  mem- 
bers of  antagonistic  couples,  for  example,  gluteus,  crureus, 
masseter,  and  their  absence  under  those  conditions  from  the  op- 
posite members  of  the  couples,  is  suggestive  that  under  the  con- 
dition taken,  reflex  tonus  may  be  confined  to  one  member  of  an 
antagonistic  pair;  nmnely,  to  that  member  which  is  then  in  reflex 
tonic  operation;  e.  g.,  counteracting  gravity  for  the  preservation 
of  an  habitual  pose  of  the  animal." 

It  is  upon  this  last  statement  that  I  wish  to  lay  emphasis, — 
the  habitual  pose  of  the  animal.  In  man,  in  his  habitual  pose, 
the  muscles  which  counteract  gravity  so  far  as  the  lower  limbs 
are  concerned  are  the  extensor  muscles  and  the  adductors.  These 
constitute  the  tonic  groups,  whereas  the  other  muscles  are  the 
phasic  groups  ;  that  is  to  say,  these  latter  change  the  position  from 
moment  to  moment  while  the  former  groups  tend  to  maintain  the 
habitual  position   and   arc  in   constant   action.     As   Sherrington 


VALUE  OF  ADDUCTOR  RESPONSES  OF  LEG  137 

points  out,  it  is  the  phasic  group  of  muscles  which  is  paralyzed 
in  cerebral  injury  whereas  the  tonic  group  is  increased  in  tonus 
and  this  causes  the  phenomena  of  the  increased  reflexes. 

Second,  one  may  here  consider  the  decerebrated  animal  of 
Sherrington.  The  decerebrated  animal,  especially  if  placed  in  a 
position  where  gravity  exerts  its  influence  to  the  best  advantage, 
takes  a  position  very  much  like  the  hemiplegic  contracture.  That 
is  to  say,  there  ensues  a  pose  which  is  largely  extensor  so  far  as 
the  lower  limbs  and  tail  are  concerned.  Sherrington  does  not 
mention  the  condition  of  the  adductor  muscles  in  these  animals 
but  it  is  unlikely  that  the  adductors  would  play  so  important  a 
part  in  maintaining  the  pose  of  an  animal  as  they  do  in  the 
case  of  man. 

The  opinion  is  advanced  tentatively  that  the  adductor  re- 
sponses belong  to  the  tonic  responses  of  muscles  habitually  main- 
tained in  tonus  by  some  influence  other  than  the  cerebrum;  that 
in  health  this  tonus  being  less  important  for  the  preservation  of 
attitude  than  the  tonus  of  the  extensor  group  of  muscles,  is  not 
to  any  great  extent  demonstrable  as  the  adductor  response,  but 
that  in  disease  of  various  kinds,  but  having  as  their  general  fea- 
ture either  the  functional  or  the  organic,  injury  to  the  cerebrum, 
these  responses  become  manifest  in  the  manner  described. 

Resume 

1.  The  adductor  responses  are  present  in  health  as  mild  and 
occasional  homolateral  and  contralateral  responses  from  sites  de- 
scribed above. 

2.  Fatigue  does  not  increase  them  but  diminishes  them  to 
the  point  of  abolition. 

3.  The  appearance  of  contralateral  adductor  responses  es- 
pecially from  the  patellar  tendon,  the  external  condyle,  the  an- 
terior-superior spine,  and  to  a  lesser  degree  from  the  Achilles 
tendon  is  a  phenomenon  of  disease,  not  necessarily  organic,  but 
usually  such. 

4.  These  responses  bear  at  least  a  coincidental  relationship  to 
the  knee  jerk  of  the  side  responding  and  have  no  apparent  re- 
lationship to  the  knee  jerk  of  the  side  stimulated  or  to  the  Achilles 
tendon  of  either  side. 

5.  The  site  of  stimulation  is  probably  not  so  important  as  the 
direction  of  the  blow  and  the  resultant  stimulation  of  either  hip 
joint  or  pelvis,  and  that  the  part  thus  indirectly  stimulated  (either 
hip  joint  or  pelvis)  acts  as  the  afiferent  limb  of  the  reflex  are  whose 
motor  limb  stimulates  the  adductors. 


138  A.  MYERSOy 

6.  The  adductor  muscles  probably  belong  to  the  tonic  group 
of  muscles ;  that  is  to  say,  those  muscles  innervated  in  the  greater 
part,  though  not  completely,  by  influences  other  than  the  cer- 
ebrum, and  that  with  the  disappearance  or  diminution  of  the 
cerebral  influence  the  tonus  of  these  muscles  is  so  increased  that 
their  reflex  activity  becomes  greatly  enhanced,  resulting  in  the 
phenomena  herein  described,  that  is,  the  homolateral  and  con- 
tralateral adductor  responses. 

REFEREN'CES 

1.  Bertolotti  and  Valobra.     Rev.  Neurologique,  1905,  13,  156. 

2.  Erb.     Arcli.  Psychiat.,  1875,  5.  I95- 

3.  Ganault.     These  Paris.  1898. 

4.  Graves.     X.  Y.  Med.  Record,  1912,  August. 

5.  Hinsdale  and  Taylor.     Internat.  Med.  Alag.,  1895,  4,  369. 

6.  Ilirsliberg.     Rev.  Neurologique,  1903,  11,  712. 

7.  Huismans.     Deuts.  Med.  Woch.,  1902,  28,  886. 

8.  Jackson.     London  Hosp.  Reports,  1864,  i,  460. 

9.  Jackson.     Brain.  1899,  xxii,  619. 

10.  Keller.     Deuts.  Zeitschr.  f.  Nervenh.,  1909.  37,  40. 

11.  Lewandowsky.     Handbuch  der  Neurol.,  Berlin,  1910,  2,  598. 

12.  Lewandowsky.     1905,  Werhand.  d.  Physiol.  Gesellsch.  z.  Berlin. 

13.  Marie.      (Quoted  by  Ganault.) 

14.  Marincsco.     Semaine  Med.,  1898,  April. 

15.  Monakow.      (Quoted  by  Oppenheim.) 

16.  Myerson.     Arch.  Int.  Med.,  1912,  10,  31. 

17.  Myerson.     Boston  Med.  and  Surg.  Journ.,  1913,  169,  380. 

18.  Noica  and  Strominger.     Rev.  Neurol.,  1906,  14,  969. 

19.  Oppenheim.     Text-Book  Nerv.  Dis.  Edinburgh,  1911,  Vol.  ii,  617. 

20.  Pfliiger.     Die    sensorische    Function    des    Ruckenmarks,    Berlin,    1853. 

See  also  Sherrington. 

21.  Risien  Russell.     Am.  Jour.  Med.  Sciences.  1896,  3,  306. 

22.  Sherrington.     Integ.  Action,  Nerv.  Syst.,  New  Haven,  1911,  especially 

pp.  161.  162,  etc.,  305,  etc. 


SPEECH  CONFLICT— A  NATURAL  CONSEQUENCE  IN 

COSMOPOLITAN    CITIES— AS    AN    ETIOLOGICAL 

FACTOR  IN  STUTTERING.     A  PRELIMINARY 

REPORT  BASED  ON  200  CASES^ 


By  May  Kirk  Scripture  and  Otto  Glogau,  ]\I.D. 

OF    NEW    YORK    CITY 

{Continued  from  page  46) 

Statistics  of  171  Male  Stutterers 

(German-Hebrew  and  Austrian-Hebrew  means  :  of  Jewish  race,  born  in 

Germany  or  Austria,  not  speaking  Yiddish  as  mother  tongue, 

but  German) 


Parentage 

No. 

^ame 

Age 

Onset  and  Etiology             .                  Nationality 

and  Mother 

'tongue 

I 

B. 

G. 

13 

Began  to  speak  at  2  yrs.,  to  stutter  at  4  yrs.  U. 

S. 

Ger. 

2 

E. 

E. 

14 

Began   to   stutter  at    7   yrs.   after   pneu- 
monia.    High    arched    palate,    loss    of 

uvula.                                                                 Ger. 

Ger. 

3 

B. 

G. 

5 

Began  10  months  of  age  following  fright 
to  stutter.                                                      U. 

S. 

Yidd. 
Ger. 

4 

B. 

J- 

23 

Fall  at  3  yrs.,  followed  by  stuttering.              Ger. 

Ger. 

Hebr. 

5 

C. 

S. 

21 

Imitation    of    stuttering    bro.ther.     High 

arched  palate,  deviated  septum,  hyper- 

trophied  turbinates.                                       U. 

S. 

U.  S. 

6 

E. 

R. 

II 

Began  to  stutter  at  6  yrs.     Speech  conflict.  U. 

S. 

Ital. 

7 

F. 

H. 

25 

Imitation   of   father   and    two   stuttering 
brothers.                                                            U. 

S. 

U.S. 

8 

F. 

J- 

13 

Began  to  stutter  at   2   yrs.   after  scarlet 
fever.                                                              iU. 

s. 

u.  s. 

9 

G 

R. 

8 

Speech  conflict. 

U. 

s. 

Russ. 
Yidd. 

10 

G 

J. 

10 

Stutters    since    childhood    after    measles. 

Deviated  septum.                                           U. 

s. 

Ger. 

11 

G. 

M. 

12 

Began  to  stutter  at  6  yrs.     Speech  conflict. ; U. 

s. 

Russ. 
Yidd. 

12 

G 

M. 

6 

Stutters  since  2  yrs.  after  pneumonia. 

13 

G 

B. 

9 

Father   stutters.     Fell   into   cellar.     Imi- 
tation and  shock.                                            U. 

s. 

Russ. 
Yidd. 

14 

G 

A. 

14 

Began  to  stutter  at  6  yrs.     Speech  conflict. ' Austr. 

Austr. 

Yidd. 

15 

G 

J- 

12 

Began  to  speak  at  2,  to  stutter  at  6  yrs. 
Had  convulsions  at  6  months.     Speech 

Russ. 

conflict. 

U. 

s. 

Yidd. 

16 

G 

B.  T. 

Speech  conflict.     Onset  at  5  yrs. 

Russ. 

Russ. 

Yidd. 

1  From   the 
derbilt  Clinic. 


Department   of    Neurology,    Columbia   University.     Van- 


139 


140  M.IV  KIRK  SCRIPTURE  AND  OTTO  GLOGAU 

Statistics  of  171  Male  Stutterers. — Continued 


No. 


Name   'Age 


17  G.  M. 

18'  H.  G. 

19  H.W.  T. 

20  H.  L. 

21  H.  E. 


22 

H. 

0. 

23 

H. 

H 

24 

F. 

D. 

25 

E. 

B. 

26 

E. 

F. 

27 

E. 

G. 

H 

28 

.T- 

B. 

G. 

29 

J- 

A. 

30 

K 

E. 

31 

K 

S. 

32  K.  L. 

33  K.  E. 

34!  K.  J. 

35|  K.  N. 
36|  L.  J. 

37  L.  T. 

38  F..  M. 

39  L. H. 

40  L.  Ch. 
I 

41  L.J. 

i 
I 

42  L.  L. 

43  L.  B. 

44  L.  B. 

45  B.  L. 

46  L.  W. 

47  M.  P. 

4«  M.  E. 

49  M.  M. 

50  M.  C. 


Onset  and  Etiology 


Nationality 


Parentage 

and  Mother 

Tongue 


14  Speech  conflict.     Began  to  stutter  at  6 

!     yrs.  U.  S. 

18   Began  to  stutter  at  10  yrs.  after  unknown 

illness.  U.  S. 

Began  to  stutter  at  10  yrs.     Imitation.       U.  S. 

10  Began  to  stutter  at  6  yrs.     Speech  con-i 

flict.  U.  S. 

16   Began  to  stutter  at  5  or  6  yrs.     Speech 

conflict.  JU.  S. 

11  Began  to  stutter  at  i  yr.  by  imitation.       jU.  S. 
Began   to   stutter   in   earliest   childhood, | 

j     following  measles  and  whooping  cough.  U.  S. 

11  Began  to  stutter  at  5  yrs.  following  un- 
'     known  illness.     High  palate. 

13  Began  to  stutter  at  i  yr.  by  imitation 

18  ;Began  to  stutter  at  4  yrs.  following  fright. |U.  S, 
8   Began  to  stutter  at  4  yrs.  by  imitation. 

19  Began  to  stutter  at  4  yrs.  by  imitation. 

12  Onset  at  6  yrs.     Speech  conflict. 

14  Onset  at  2  yrs.     Imitation. 
14  Onset  at  4  trs.     Imitation. 


Onset  at  9  yrs.     Speech  conflict. 

II  Onset  at  4  yrs.  after  fall. 

Onset  at  6  yrs.     Speech  conflict. 

9  Onset  at  4  yrs.  after  whooping  cough. 

2  Few  months  ago  after  fall  on  head. 

I 

13  Onset  at  2]^  yrs.  after  scarlet  fever. 

20  Onset  at  4  yrs.  after  scarlet  fever. 

14  Onset  at  5  yrs.  by  imitation. 
7  Onset  in  earliest  childhood.     Imitation  of 

elder  brother. 

21  Onset    at    i    yr.    after   whooping   c>)ugh 

Also    imitation    of    elder    brother    and 
sister. 
13  lOnset  at  6  yrs.     .Speech  conflict. 

I 
6  Onset  at  5  J^  yrs.  by  fright. 
9  Onset  at  3  yrs.  by  fright. 

16  Onset  at  7  yrs.     Speech  conflict. 

15  Onset  at  11  yrs.      Imitation. 

21  jOnsct  unknown.     Speech  defect. 
I 
Onset  at  4  yrs.  with  kidney  trouble. 

16  Onset  at  7  yrs.     .Si)ccch  conflict. 


[Ital 

U.  S. 

U.  S. 
U.S. 

Russ. 

U.S. 

;Hunga- 
I     rian. 

V.  S. 

Russ. 


Russ. 
Yidd. 
Austr. 
Hebr. 
U.S. 

Ger. 

Ger.. 
U.  S. 

U.  S. 


u.  s. 

Ital. 

u.  s. 

Russ. 

Yidd. 

U.S. 

Ger. 

U.S. 

U.  S. 

U.  s. 

U.S. 

Russ. 

Russ. 

Yidd. 

U.S. 

Ger. 

U.S. 

Russ. 

Yidd. 

Russ. 

Russ. 

Yidd. 

U.  S. 

U.  S. 

Russ. 

Russ. 

Yidd. 

U.  S. 

Ger. 

Hebr. 

U.S. 

Austr 

Yidd. 

U.  S. 

Ger. 

Ital. 

Ital. 

Ital. 

Ital. 

Russ. 

Russ. 

Yidd. 

T»_1 

13  iOnset  at  3  yrs.  after  whooping  cough,  ag-! 
!     gravated     by     imitation     of     younger 

brother  and  fright  Ijy  drunken  father.  U.  S. 


Ital. 
Russ. 
Yidd. 
Austr. 
Russ. 
Yidd. 
Russ. 
Yidd. 
Ger. 
Hebr. 
Hunga- 
rian 
U.  S. 
Russ. 
Yidd. 


Irish 


SPEECH  CONFLICT 
Statistics  of  171  Male  Stutterers. — Continued 


1 
1 

Parentage 

No. 

Name 

Age 

Onset  and  Etiology 

Nationality 

and  Mother 
Tongue 

SI 

M.  C. 

22 

Onset  at  10  yrs.  following  diphtheria. 

U.  S. 

U.S. 

52 

M.  W. 

Onset  at  5  yrs.  following  fright  and  scarlet 

fever. 

u.  s. 

u.  s. 

Si 

M.  B. 

14  Onset  at  4  yrs.  after  scarlet  fever,  aggra- 

vated by  imitation. 

u.  s. 

Ger. 

54 

M.  H. 

II   Onset  at  6  yrs.  following  measles. 

u.  s. 

Austr. 
Hebr. 

55 

M.  J. 

20  Onset  at  5  yrs.     Speech  conflict  at  school. 

Russ. 

Russ. 
Yidd. 

56 

M.  E. 

15   Onset    of    6    yrs.    following    fright,    ag- 

Russ. 

1     gravated  by  imitation. 

u.  s. 

Yidd. 

57 

M.  H. 

14  Early  onset.    Imitation.    Measles,  whoop- 

ing cough  and  scarlet  fever. 

u.  s. 

U.  S. 

58 

M.  B. 

14  Onset  at  6  yrs.  following  fall  on  head. 

u.  s. 

Ger. 
Hebr. 

59 

M.  W. 

15   Onset  at  2  yrs.  after  scarlet  fever. 

u.  s. 

U.S. 

60 

N.  H. 

6  Onset    at    2,V^    yrs.    after    fall.       Feeble- 

minded. 

Eng. 

Eng. 

61 

N.J. 

12 

Onset  at  4  yrs.  after  fright. 

U.S. 

Ger. 

62 

N.  L. 

Onset  at  12  yrs.  after  fright. 

U.  S. 

Russ. 
Yidd. 

63 

0.  H.  G. 

15 

Onset  about  6  mos.  ago.     Imitation. 

Irish 

Irish 

64 

0.  D. 

14 

Onset  at  5  yrs.     Speech  conflict. 

Russ. 

Russ. 
Yidd. 

65 

0.  E. 

13 

Onset  at  6  yrs.     Neurotic  family. 

U.  S. 

Irish 

66 

Speech  conflict.     Onset  at  5  yrs. 

u.  s. 

Ital. 

67 

P.  A. 

15 

Onset  at  7  yrs.     Environmental.     Parents 

died  early.     Bad  surroundings. 

u.  s. 

U.  S. 

68 

P.  T. 

13   Onset  at  5  yrs.     Speech  conflict. 

u.  s. 

Ital. 

69 

P.  G. 

13   Early  onset  following  diphtheria. 

u.  s. 

Eng. 

70 

P.  A.  H. 

20  Onset  at  10  yrs.     Unknown  cause. 

Irish 

Irish 

71 

P.J. 

12 

Onset  at  5  yrs.  following  complication  of 

diseases. 

U.S. 

Ger. 

72!  R.  R. 

12   Onset  at  5  yrs.     Speech  conflict. 

U.S. 

Russ. 

i 

Yidd. 

73 

R.J. 

16  Onset  at  4  yrs.     Unknown  cause. 

Russ. 

Russ. 
Yidd. 

74 

R.  M. 

II  lOnset  at  5  yrs.  after  severe  illness. 

U.  S. 

U.S. 

75 

R.J. 

20  Onset    at    10    yrs.    following    injury,    ag- 
gravated by  imitation  of  two  stuttering 

brothers. 

Austr. 

Austr. 

76 

R.  T. 

13  Onset  at  n  yrs.     Imitation. 

U.  S. 

Russ. 
Yidd. 

77 

R.  C. 

26  jOnset  at  10  yrs.     Fright. 

U.  S. 

U.  S. 

78 

R.  L. 

18  jEarly  onset.     Imitation  of  uncle. 

U.S. 

Russ. 

Yidd. 

79 

s.  0. 

8 

Onset   at    7   yrs.    after   fright    at    school. 

Highly  arched  palate. 

u.  s. 

Ger. 

80 

S.  L. 

15   Early  onset.     Imitation  of  mother. 

u.  s. 

U.  S. 

81 

S.  S. 

18  Onset  at  3  yrs.  following  fright.     Highly 

Austr. 

arched  palate. 

Austr. 

Yidd. 

82 

S.  A. 

18  Onset  at  5  yrs.     Speech  conflict. 

Ital. 

Ital. 

83 

S.  R. 

8 'Early  onset.     Imitation  of  uncle. 

U.S. 

Ger. 

84 

S.  M. 

6 

Four     yrs.     Poliomyelitis     followed     by 

Austr. 

by  stuttering.     Grandfather  stuttered. 

U.  S. 

Hebr. 

85 

S.  S. 

16 

Stutters  since  childhood.     Complete  atre- 

sia of  left  external  auditory  canal.     Air  U.  S. 

Ger. 

conduction  absent.                                        1 

Hebr. 

142 


MAY  KIRK  SCRIPTURE  AXD  OTTO  GLOGAU 


Statistics  of  171  Male  Stutterers. — Coniiimcd 


Parentage 

No. 

N.nme 

^ 

Onset  aod  Etiology 

Nationality 

and  Mother 
Tongue 

86 

S.  S. 

12 

Onset  at  5  yrs.     Speech  conflict. 

Russ. 

Russ. 
Vidd. 

87  .s.  W. 

12 

Onset  at  8  yrs.     Croup. 

U.S. 

Irish 

88   S.  A. 

10 

Cause  unknown.     Early  onset. 

U.S. 

Ger. 

89I  S.  P.  M. 

1 

13 

Onset  at  7  yrs.     .Speech  conflict. 

Russ. 

Russ. 
Yidd. 

90  S.  H. 

14 

Early  onset.     Cause  unknown. 

U.S. 

U.  S. 

91 

S.J. 

23 

Onset  at  6  yrs.  after  scarlet  fever. 

U.  S. 

u.  s. 

92 

S.  R. 

10 

Onset  at    2  yrs.     Father  stuttered  when 

young  and  does  so  still  when  excited. 

Ger. 

Ger. 

93i  T.  D. 

Onset  at  4  yrs.  after  fright. 

U.  S. 

U.S. 

94  T.  J. 

Onset  since  adolescence.     Lowered     mo- 

rality.     Irregular  life. 

U.  S. 

u.  s. 

95  V.  I. 

9 

Onset  at  5  yrs.  after  whooping  cough. 

U.  S. 

Russ. 

96 

W.  L. 

19  'Early    onset.     Unknown    cause.     Speech 

Ger. 

1     conflict. 

U.S. 

Hebr. 

97 

VV.  A. 

18 

Onset  at  9  yrs.     L'nknown  cause. 

U.  S. 

U.  S. 

98 

W.  W. 

II 

Onset  at  7  yrs.  following  "brain  fever" 

1     and  black  measles. 

U.  S. 

U.S. 

99|  \V.  M. 

8}^  Onset  at  6  vrs.     Speech  conflict. 

i 

Russ. 

Russ. 
Yidd. 

loo;  W.  T. 

10  Onset  at  8  yrs.     Imitation. 

U.  S. 

Ger. 
Hebr. 

101   VV.  S. 

9  Onset  5  months  ago.      Imitation. 

U.S. 

Russ. 
Yidd. 

102   W.  G. 

17  Early  onset.     Unknown  cause. 

U.  S. 

U.  S. 

103 

VV.  H. 

4  Onset    at    2    yrs.    following    pneumonia. 

'     Enlarged  tonsils  and  adenoids. 

U.  S. 

U.  S. 

104 

\V.  M. 

21   Onset  at  7  yrs.     Speech  conflict. 

Russ. 

Russ. 
Yidd. 

105 

VV.  D. 

20  jOnset  at  6  yrs.     Speech  conflict. 

1 

Russ. 

Russ. 
Yidd. 

106 

VV.  J. 

16  Onset  at  4  yrs.  after  measles. 

U.  S. 

Ger. 
Hebr. 

107 

V.  E. 

9  Onset  at  5  yrs.  after  pneumonia.     Lisp- 

ing. 

U.  S. 

U.S. 

108 

M.  B. 

6  Negligent    lisping.     Speech    conflict. 

Russ. 

Stutters  more  in  last  few  months. 

U.  S. 

Yidd. 

109 

F.  B. 

6  Unknown    cause.     Since    earliest    child- 

1     hood. 

U.  S. 

Irish 

no 

F.  A. 

14  Whooping  cf)ugh. 

Germ. 

Ger. 

III 

R.  A. 

12  General  nervousness.     Speech  conflict. 

U.  S. 

Russ. 
Yidd. 

112 

M.  VV. 

II 

Onset    at    earliest    childhood.     Unknown 

Russ. 

cause. 

Russ. 

Yidd. 

itj 

M.  M. 

18 

Onset  at  8  yrs.     Unknown  cause. 

Ger. 

Ger. 

114 

H.  G. 

18 

Shock  from  operation. 

U.S. 

Russ. 
Vidd. 

IIS 

<;.  V. 

iS 

Imitati-jn. 

Ital. 

Ital. 

116 

J.  C. 

3 

Mental  deficiency. 

U.  S. 

Irish 

"7 

G.  H. 

38 

Multi|)!e  sclerosis. 

U.  S. 

U.S. 

118 

G. -D. 

l'( 

Onset  after  fright. 

U.S. 

Ger. 

119 

L.  < 

<  )nset  at  6  yrs.     Speech  conflict. 

Russ. 

Russ. 
Vidd. 

120 

H.  C. 

8 

Speech  conflict.     Onset  at  5  yrs. 

U.  S. 

Russ. 
Yidd. 

121 

R.  C. 

8 

Onset  after  typhoid  fever. 

U.  S. 

Ger. 

122I  G.  D. 

II 

Onset  after  exhaustive  illness. 

U.  S. 

Ger. 

SPEECH  CONFLICT  143 

Statistics  of  171  Male  Stutterers. — Continued 


Parentage 

No. 

Name 

Age 

Onset  and  Etiology 

Nationality 

and  Mother 
Tongue 

123 

H.  B. 

18 

Since  early  childhood.     Cause  unknown. 

U.  S. 

U.  s. 

124 

B.  M. 

14 

Imitation. 

U.  S. 

Ger. 
Hebr. 

125 

S.  B. 

Cause  unknown. 

Ger. 

Ger. 
Hebr. 

126 

T.  G. 

13 

Onset  at  6  jts.  from  fright. 

U.  S. 

Russ. 
Yidd. 

127 

H.  W. 

Psychopathia. 

Ger. 

Ger. 
Hebr. 

128 

E.  Z. 

II 

Cause  unknown. 

Ger. 

Ger. 

129 

J.  z. 

16 

Onset  at  5  yrs.  from  fright. 

Russ. 

Russ. 
Yidd. 

130   L.  Z. 

15 

Imitation. 

Russ. 

Russ. 

Yidd. 

131 

E.  G. 

16 

Since  early  childhood.     Cause  unknown. 

U.  S. 

Dutch 

132 

J.L. 

II 

Onset  at  5  yrs.     Speech  conflict. 

u.  s. 

Russ. 
Yidd. 

133 

H.  A. 

17 

Onset  at  6  yrs.     Speech  conflict. 

u.  s. 

Russ. 
Yidd. 

134 

G.  F. 

12 

Onset   at    5    yrs.    from   negligent   lisping. 

Speech  conflict. 

u.  s. 

Ital. 

135 

A.  S. 

Onset  at  10  yrs.  from  fright. 

u.  s. 

Austr. 
Yidd. 

136   S.  L. 

18 

Onset  at  15  yrs.  from  shock. 

Russ. 

Russ. 

Yidd. 

137 

A.L. 

9 

Onset  at  5  yrs.     Speech  conflict. 

U.S. 

Russ. 
Yidd. 

138 

I.  L. 

18 

Imitation. 

U.S. 

Russ. 
Yidd. 

139 

B.  M. 

17 

At  early  childhood  from  lisping. 

u.  s. 

Austr. 
Yidd. 

140 

F.  M. 

13 

Masturbation. 

Ger. 

Ger. 

141 

C.  M. 

16 

Onset  at  5  yrs.     Speech  conflict. 

Russ. 

Russ. 
Yidd. 

142:  H.  M. 

23 

Onset  at  earliest  childhood.     Cause  un- 

known. 

U.  S. 

Irish 

143 

S.  P. 

6 

Onset  at   5   yrs.   from   negligent   lisping. 

Russ. 

Speech  conflict. 

U.  S. 

Yidd. 

144 

S.  R. 

9 

Onset  at  3  yrs.     Cause  unknown. 

Ger. 

Ger. 

145 

A.  R. 

23 

Imitation,  heredity,  masturbation. 

Ital. 

Ital. 

146 

G.  S. 

19 

Onset  at  childhood.     Heredity. 

Ger. 

Ger. 
Hebr. 

147 

A.  F. 

13 

Masturbation. 

Ital. 

Ital. 

148 

W.  F. 

23 

Fright.     Onset  at  5  j^rs. 

U.  S. 

Russ. 
Yidd. 

149 

B.  G. 

II 

Chorea. 

Russ. 

Russ. 
Yidd. 

150 

M.  G. 

18 

Onset  at  7  yrs.     Speech  conflict. 

U.  S. 

Russ. 
Yidd. 

151 

F.  H. 

19 

Cause  unknown. 

U.  S. 

U.  S. 

152 

C.  H. 

28 

Onset  at  earliest  childhood.     Cause  un- 

Russ. 

known. 

Russ. 

Yidd. 

153 

S.  G. 

20 

Onset  at  6  yrs.     Speech  conflict. 

Russ. 

Russ. 
Yidd. 

154 

G.  K. 

13 

Imitation. 

U.S. 

U.S. 

155 

G.  K. 

8 

Mentally  deficient.     Lisper. 

U.S. 

Irish 

156 

W.  K. 

14 

Unknown  cause. 

U.S. 

Ger. 

157 

S.  K. 

18 

Shock  from  accident. 

U.S. 

Russ. 
Yidd. 

144  ^f.-iy  KIRK  SCRIPTURE  AND  OTTO  GLOGAU 

Statistics  of  171  Male  Stutterers. — Continued 


Parentage 

No. 

Name 

Age                            Onset  and  Etiology 

Nationality 

and  Mother 
Tongue 

158 

G.  K. 

IS  Fright. 

Russ. 

Russ. 
Yidd. 

150 

P.  B. 

18  Adolescence. 

U.  S. 

U.  S. 

160 

G.  B. 

12  Masturbation. 

U.  S. 

Ger. 

161 

L.  B. 

14  Onset    at    5    yrs.    from    lisping. 

Speech 

conflict. 

Ger. 

Ger. 

162 

M.  B. 

15  Fright. 

Russ. 

Russ. 
Yidd. 

163 

J.  C. 

19  Onset  at  7  yrs.     Shock  from  fall. 

'Russ. 

Russ. 
Yidd. 

164 

A.  C. 

18  General   nervousness.         Onset   at   early 

Austr. 

childhood. 

Austr. 

Ger. 

165 

A.  S. 

21  Unknown  cause. 

Ital. 

Ital. 

166 

F.  D. 

19  Hysteria. 

U.  S. 

French 

167 

J.  B. 

20  Onset  at  5  yrs.     Speech  conflict. 

U.  S. 

Russ. 
Yidd. 

168 

B.  F. 

6  Onset  a  few  weeks  ago.     Speech  conflict.      U.S. 

Austr. 

1 

Yidd. 

169 

B.  M. 

14  Onset    at    4    yrs.    after    complication    of 

diseases,  including  scarlet  fever 

U.  S. 

U.S. 

170 

M.  B. 

16  Onset    at    4    yrs.    following    fall. 

Sister 

Roum. 

stutters. 

Roum. 

Yidd. 

171 

D.  G. 

1 3  Onset  at  6  yrs.     Brother  of  5  has  started  to' 

Russ. 

stutter.     Speech  conflict. 

Russ. 

Yidd. 

Statistics  of  29  Female  Stutterers 


1 

Parentage 

No. 

Name 

Age                             Onset  and  Etiology                              Nationality 

and  Mother 

! 

Tongue 

I 

M.S. 

6  Since     earliest     childhood.     Only     child. 

1      Mother  had  two  previous  miscarriages.  U.  S. 

Ger. 

2 

L.  W. 

13  jOnset  at  i  yr.  after  scarlet  fever.    Chorea.  U.  S. 

Ger. 

3 

S.  W. 

13  |Onset  after   measles   and    broncho-pneu-i 

Russ. 

1     monia.                                                             U.  S. 

Yidd. 

4 

V.  VV. 

13    Imitation.                                                             JU.  S. 

u.  s. 

5 

M.  T. 

5   From  lisping. 

Ital. 

Ital. 

6 

S.  A. 

Onset    at     early     childhood     after     fall. 

Ger. 

j     Lisping  also. 

U.  S. 

Hebr. 

7 

R.  R. 

10  Onset  10  months  ago  after  excitement. 

U.  S. 

Russ. 
Yidd. 

8 

E.  R. 

16  Onset  at  6  yrs.     .Speech  conflict. 

Ger. 

Ger. 

9 

P.  S. 

13   Basedows. 

U.S. 

u.  s. 

10 

R.  0. 

20  Onset    at    9    yrs.  after    severe  digestive 

Russ. 

1      trouble. 

U.S. 

Yidd. 

II 

E.G. 

14  Onset  at  3  yrs.  after  fall. 

u.  s. 

Irish 

12 

P.O. 

8   Nervousness.     Masturbation. 

Ital. 

Ital. 

»3 

M.  M. 

1 1    From  lisping. 

Hung. 

Hung. 

14 

I.  McD, 

12   From  fright. 

u.  s. 

Irish 

IS 

C.  M. 

21  [Onset  at  8  yrs.  from  fright. 

16 

L.  G. 

ir  'Onset  at  4  yrs.  following  attack  of  ant. 

poliomyelitis. 

Ger. 

Ger. 

17 

.K.  E. 

24  [Onset  at  6  yrs.  from  imitation. 

U.S. 

Ger. 

18 

K.  R. 

14   Imitation.     Adolescence. 

u.  s. 

U.S. 

19 

R.  D. 

12    Imitation. 

u.  s. 

u.  s. 

20 

F.  S. 

II  jOn.set  at  earliest  childhood.     Cause  un- 

Russ. 

1     known. 

U.S. 

Yidd. 

SPEECH  CONFLICT  145 

Statistics  of  29  Female  Stutterers. — Continued 


Percentage 

No. 

Name 

Age 

Onset  and   Etiology 

Nationality 

and  Mother 
Tongue 

21 

I.  F. 

7 

Onset  at  2  yrs.     Had  pneumonia  three 

times  before  3  yrs.  of  age. 

u.  s. 

u.  s. 

22 

T.  F. 

8 

Onset  at  5  yrs.  after  fright. 

u.  s. 

Austr. 
Yidd. 

23 

J.  B. 

15 

Adolescence. 

Russ. 

Russ. 
Yidd. 

24 

M.  C. 

17 

Fright. 

U.  S. 

Bohemian 

25 

R.  G. 

15 

Adolescence. 

Russ. 

Russ. 
Yidd. 

26 

M.  0. 

21 

Onset  at  4  yrs.  following  shock. 

U.  S. 

Irish 

27 

s.  0. 

16 

Onset  at  6  yrs.     Speech  defect. 

U.  S. 

Russ. 
Yidd. 

28 

A.  P. 

Onset  at  7  yrs.  after  fright. 

Russ. 

Russ. 
Yidd. 

29 

A.  S. 

13 

Onset  at  2  yrs.  after  fright. 

Ital. 

Ital. 

Etiology  of  Stuttering  in  171  Male  Stutterers 

Speech  conflict    37 

Imitation   and   heredity    26 

Accident,   fright  and  shock    22, 

Protracted  tinknown  ilhiess   6 

Scarlet  fever   5 

Speech  conflict  and  negligent  lisping   4 

Imitation    and    shock    4 

Measles    3 

Pneumonia     3 

Whooping    cough    2 

Whooping  cough  and  imitation    2 

Diphtheria    2 

Masturbation    2 

Adolescence     2 

Faulty  hearing    

Faulty  hearing  and  f eeble-mindedness   

Environmental    

Psychopathia    

Neurotic    family    

Hysteria    

Poliomyelitis  and  heredity   

Multiple    sclerosis    

Mental   deficiency    

Lisping    

Lisping   and   pneumonia    

Kidney    trouble    

Scarlet  fever  and  imitation   

Scarlet  fever  and  fright   

Whooping  cough,  measles,  scarlet  fever  and  imitation  

Mental  deficiency  and  lisping   

General   nervousness    

Imitation,  heredity  and  masturbation   

General   nervousness    

Chorea     

Brain  fever  and  "  black  "  measles   

Measles  and  whooping  cough   

Unknown  cause    ^7 

171 


146 


MAY  KIRK  SCRIPTURE  AND  OTTO  GLOGAU 


Etiology  of  Stuttering  ix  29  Female  Stutterers 

Fright  and   shock 7 

Imitation     3 

Lisping    - 

A<lolescence     ~ 

Fall  and  lisping   I 

Excitement     ^ 

Imitation  and  adolescence i 

Digestive    trouble    I 

Speech  conflict    ^ 

Nervousness  and  masturbation  i 

Poliomyelitis    i 

Pneumonia     i 

Scarlet  fever  and  chorea    i 

Measles  and  bronchitis    i 

Basedow's    disease    i 

Unknown  cause   _ 4 

29 

Male  Stutterers  from  Speech  Conflict 


Name 

Age 

Onset       ' 

Nationality 

1               Parentage 

E.  R. 

II 

6 

U.  S. 

1              Italian 

G.  R. 

8 

5 

IT.  S. 

Russ.-Yidd. 

G.  M. 

12 

6 

U.S. 

Russ.-Yidd. 

G.  A. 

14 

6 

Austrian 

1        Austr.-Yidd. 

G.  T. . 

\2 

6 

U.  S. 

Russ.-Yidd. 

G.  B. 

T 

5 

Russian 

Russ.-Yidd. 

G.  M 

H.  I 

H.  E..  .. 

J.  A 

K.  L 

L.  L. .  . .  . 

B.  L 

M.  M..  . 
M.  J..!. 

O.  D 

P.  T 

R.  R 

S.  A. 

S.  S 

W.  M..  . 
W.  M..  . 

W.  D 

M.  B 
R.  .A 
L.  ( 
H.  ( 
J    I. 
H.  .\ 
G.  V 

A.  I 

C.  M..  . 
M.  G..  . 

S.  G 

L.  B. 

J.  H 

B.  V 
\).  (, 


14 
10 
16 
12 
16 

13 
16 
16 
20 
14 
1.? 
12 


<) 
\(> 
IK 
20 
14 

2f) 

5 


U.  S. 

u.  s. 

u.  s. 

Russian 

Russian 

U.  S. 

Russian 

Russian 

Russian 

Russian 

r.  S. 

1 '.  S. 

Italian 

Russian 

Russian 

Russian 

Russian 

V.  S. 

r.  s. 

Russian 
V.  S. 
U.  S. 
U.  S. 
U.  S. 

\\  s. 

Russian 

r.  S. 

Russian 

(ierman 

U.  S. 

U.S. 

Russian 


Russ.-Yidd. 
German 
German 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 
Italian 

Russ.-Yidd. 
Italian 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 
Italian 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yidd. 

Russ.-Yi<ld. 
(ierman 

Russ.-Yidd. 

Austr.-Yidd. 

Russ.-Yidd. 


SPEECH  CONFLICT 
Female  Stutterer  from  Speech  Conflict 


147 


Name 


s.  o. 


Age 


Onset 


Nationality 


16 


Parentage 


u.  s. 


Russ.-Yidd. 


Natioxality  of  171  Male  Stutterers 


United   States 

Russia    

Germany   

Italy 


Austria    . . . 
Ireland     . . . 
Hungary    . . 
Roumania 
Unrecorded 


Nationality  of  29  Female  Stutterers 


United  States 

Italy    

Germany    

Hungary    

Russia    


Parentage   (Mother  Tongue)   of  171   Male  Stutterers 

Russian,   Yiddish    

United   States,   English 

German 

Italian    .'.... 

Austrian,   Yiddish    

Austrian,   German    

Irish    

English    !  '  ^ ' ! !  ! . 

French     

Dutch    .........^.....  ..........  ............ 

Hungarian    

Roumanian,    Yiddish    

Unrecorded    


65 

25 

13 

5 

3 

2 

I 

I 

56 

[7- 


22 

3 
2 
I 
I 
29 


56 

i2 
36 
10 

7 
3 
8 
I 

-  I 

I 

I 

I 

14 

171 


Parentage  (Mother  Tongue)  of  29  Female  Stutterers 

U-nited   States.   English    

Russian,   Yiddish 

German    _ 

Irish    

Italian    ' 

Hungarian    

Austria,    Boliemian    .' ' 

Austria,    Yiddish    


Year 
I 

2 

2V2 


Onset  of  Stuttering  in   171   Male  Stutterers 


7 
5 
3 
3 
I 
I 

I 

29 


Number 


148  MAY  KIRK  SCRIPTURE  AND  OTTO  GLOGAU 

Year  Number 

4    , 15 

5    26 

6    23 

7    8 

8    2 

9    3 

10    8 

11     2 

13    2 

15    •. 2 

Earliest   childhood    19 

Uii  recorded    44 

17T 
Onset  of  Stuttering  in  29  Female  Stutterers 

^  ear  Xuii'ber 

2      2 

3      I 

4      2 

6    : 3 

7     I 

8    I 

9    I 

11     I 

12    2 

14    4 

Earliest  childhood   3 

Unrecorded    8 


29 


BIBLIOGRAPHY 


1.  Hudson  Makuen.     A  Study  of  1,000  Cases  of  Stammering,  vvitli  Spe- 

cial Reference  to  the  Etiology  and  Treatment  of  the  Affection.     The 
Therapeutic  Gazette,  June  15,  1914. 

2.  Herman  Gutzmann.     Sprachheilkunde,  Berlin,  1912,  p.  373,  etc. 

3.  Schrank.     Das  Stotteruehcl,  Muenchen,  1877. 

4.  Blume.     Neueste  Heilmethodc  des  Stotteruchels,  Leipzig.  1844. 

5.  Liehmann,  A.     Vorlesungen  iiber  Sprachstoerungen,  Xos.  i  and  2,  Ber- 

lin. 1899. 

6.  Kussmaul.     Die  Stoerungen  der  Sprache,  Leipzig.  1910. 

7.  Schmalz.     Tber  Stammein  nnd  Stottern.     Clarus  und  Radius,  Beitriige 

Bd.  I.  Heft  4. 

8.  Merkel.     Anthropophonik,  Leipzig.   1863. 

9.  Rosenthal.     Beitrag    zur    Kenntnis    und    Ilcilung    des    Stotteruebels, 

W'ien,  1864. 
ID.  Benedikt.     Nervenpathologie  und  Elektrotherapic,  Leipzig.  1874. 

11.  Wineken.     Ueher  das  Stottern.     Henle  und  Pfeufers  Ztschr.,  Vol.  31. 

12.  Kaffcmann. 

13.  Schellcnherg. 

14.  Wincklcr. 
Quoted  hy  Gutzmann. 

15.  Kussmaul.     L.  c. 

16.  H.  Schmidt.     Allg.  Zeitschr.  f.  P.sychiatrie.  Vol.  27,  p.  304. 

17.  Lichtiliger.     Ueher  die  Xatur  des  Stotterns.     Berlinger"  med.  Zcitung. 

1844. 

18.  Rosenthal.     Allg.  Wiener  Med.  Zeitschr..  1867,  Nos.  15  and  16. 

19.  Moutier.     L'aphasie  dc  Broca.  Paris,  1908. 

20.  Ahadie.     Begaiement  dysarthrique  par  lesion  limitec  dc  la  capsule  in- 

terne.    La  parole.  1902. 

21.  Klcncke.     Die  Heilung  des  Stotterns,  Leipzig,  i860.  , 


SPEECH  CONFLICT  149 

22.  Coen.     Sprachanomalien,  Wien  and  Berlin  in  1886. 
22-  Berkhan.      Stoerungen  der  Sprache  und  der  Schriftsprache,  Berlin,  1889. 
1889. 

24.  Freud.     Zur  Psychologic  des  Alltagslebens,   1904. 

25.  Steckel.      Nervoese  Angstzustaende  und  ihre  Behandlung,  Berlin,  Wien, 

1908. 

26.  Frank.     Die  Psychanalyse.  Muenchen,  1910. 

27.  O.  Laubi.     Psychogene  Sprachstoerungen.     M.  f.  Sprachheilk.,   1910. 

28.  Hoepfner.     Stottern  als  assoziative  Aphasie,  Leipzig,   1912. 

29.  Froeschels.     Lehrbuch  der  Sprachheilkunde,   Leipzig  and  Wien,   1912. 

30.  Nadoleczny.     Die  Sprach  und  Stimmstoerungen  im  Kindesalter,  Leip- 

zig, 1912. 

31.  Kraepelin.     Quoted  by  Nadoleczny. 

32.  Scripture.     Stuttering  and  Lisping,  New  York,  1913. 


Socictv  jProcccMiujs 


NEW    YORK    XEUROLOGICAL    SOCIETY 

June  i.  1915 

Tlie  President,  Dr.  W'.m.  M.  Leszyxskv,  in  the  Chair 

SUTURE  OF  MUSCULO-SPIRAL  (SPLITTING  NEUROPLASTY) 
AFTER   EXTENSIVE   DESTRUCTION   OF  THE   NERVE; 
UNUSUAL    ORDER    OF    REGExNERATION,    LIGHT 
TOUCH    APPEARING    BEFORE    THE   OTHER 
FORMS     OF     SENSIBILITY.     PRELIMI- 
NARY' NOTE 

By  R.  H.  M.  Dawbarn,  M.D.,  and  Joseph  Byrne,  M.D. 

Dr.  Dazi'barn's  Report. — This  patient  set.  34,  a  cloth-cleaner,  married, 
with  two  healthy  children,  no  history  of  venereal  disease,  seven  and  one 
half  months  ago  fractured  his  right  humerus  in  the  middle  of  the  shaft. 
Either  then,  or  from  subsequent  unfortunate  manipulation,  the  musculo- 
spiral  nerve  was  divided,  where  it  lies  in  its  groove  in  the  humerus.  The 
radiograph  showed  very  poor  apposition  of  the  fragments,  and  other 
means  failing.  Lane  plating  was  performed.  The  scar  of  the  incision 
can  be  seen.  It  was  hoped  that  the  nerve  might  have  only  been  bruised, 
not  wholly  divided,  and  time  was  given  hoping  for  an  improvement  in  the 
inability  to  use  the  muscles  supplied  by  the  posterior  interosseous  or  arch 
of  the  musculo-spiral.  After  five  months,  at  about  two  and  a  half 
months  ago.  reoperation  was  performed ;  the  musculo-spiral  exposed  in 
its  relationship  above  the  external  condyle,  and  traced  backward  to  its 
groove,  where  it  was  found  severed,  and  above  the  point  replaced  by  scar- 
tissue  for  at  least  two  inches.  Dividing  the  ends  until  normal  nerve- 
tissue  was  reached,  increased  the  gap  to  about  three  inches.  This  interval 
was  bridged  by  plastic  neurotomy.  The  nerve  was  split  at  a  low  point 
of  its  distal  portion,  and  the  long  graft  thus  made  was  swung  backward 
into  the  gap.  and  its  sheath  sutured  to  that  of  the  divided  proximal  end 
with  finest  linen  thread.  Primary  union  was  obtained.  No  other  nerve 
was  injured  so  far  as  could  be  judged  during  this  operation.  Dr.  Byrne 
reports  already  some  little  degree  of  returning  sensibility,  and  the  outlook 
in  time  seems  favorable.  Meanwhile  an  apparatus  is  worn  to  avoid  a 
tendency  to  ovcrflexion  of  the  hand  by  tie  unopposed  activity  of  the 
group  of  muscles  and  the  patient  is  being  treated  by  electricity  and 
massage.. 

Dr.  Byrne's  Report. — The  full  neurological  report  of  this  case  forms 
a  part  of  a  series  of  cases  under  observation,  and  is  reserved  until  the 
study  is  completed. 

After  the  i)lating  oi)eration  the  i)aticnt  had  pain  if  the  arm  were 
moved  or  the  site  of  injury  touched.  This  pain  radiated  down  the  arm 
to  the  back  of  the  hand  and  thumb.     Since  the  nerve  was  sutured  patient 

I. so 


NEW  YORK  NEUROLOGICAL  SOCIETY  151 

has  suffered  from  slight  occasional  "jabs"  of  pain  referred  to  the  site 
of  operation.  He  was  first  seen  by  Dr.  Bj-rne  April  15,  191 5,  that  is  146 
days  post  operative  (plating)  and  17  days  after  nerve  suture.  Examination 
showed  atrophy  of  the  long  extensors  with  dropped  wrist,  some  atrophy 
and  fibrillation  of  the  first  dorsal  interosseus.  The  scar  of  the  skin 
wound  half  an  inch  long  lies  over  the  space.  No  pain  was  felt  unless 
arm  is  jarred  or  site  of  wound  touched.  There  was  loss  for  all  forms 
of  sensibility  over  the  radial  portion  of  the  back  of  the  hand  and  wrist 
and  extending  over  the  radial  area  on  the  thenar  eminence  and  dorsum 
of  thumb.  On  the  back  of  the  hand  the  ulnar  limit  for  light  touch  and 
heat  at  152°  F.  roughly  corresponded  to  the  extensor  tendon  of  the  ring 
finger.  The  ulnar  boundary  for  prick  loss  at  2  was  %  inch  less  than 
that  for  light  touch  loss  whilst  the  boundarj-  for  prick  at  12  and  for  ice 
corresponded  roughly  with  the  tendon  of  the  middle  finger.  The  area  of 
loss  for  all  forms  of  sensibility  included  the  radial  area  on  the  thenar 
eminence,  but  that  for  prick  loss  at  12  was  represented  by  a  space  one 
inch  wide  by  2%  inches  long  lying  between  the  metacarpal  bones  of  the 
index  and  middle  finger,  extending  up  to  the  level  of  the  web  of  the 
thumb  and  index  finger  where  it  tapered  off  like  a  night  cap,  inclining 
over  into  the  middle  of  the  first  interosseus  space. 

Light  touch  was  preserved  in  four  different  small  areas  on  the 
dorsum  of  the  hand.  One  of  these,  A,  chart  April  15,  was  %  inch  in 
diameter  and  located  over  second  interosseus  space  and  metacarpal  of 
middle  finger  at  the  level  of  the  web  of  the  first  interosseus  space. 
Similar  smaller  patches  %  inch  or  less  were  found  as  follows :  B,  on 
same  level  as  A,  but  separated  from  the  latter  by  ^  inch  and  resting 
over  metacarpal  of  index  finger ;  C,  slightly  to  ulnar  side  of  thumb  meta- 
carpal and  slightly  distal  to  middle  of  shaft  of  that  bone;  D,  one  inch 
proximal  to  C  and  ^  to  ^  inch  ulnar  to  it.  The  interrupted  line  in  the 
chart  enclosing  A  and  B  indicates  that  by  increasing  the  stimulus  from 
.0055  to  .0095  the  areas  became  fused.  The  small  area  E  showed  sensi- 
bility for  prick  at  2  preserved  well  within  the  general  area  of  loss  for 
prick  at  2.  In  the  study,  April  19,  similar  small  islands,  A,  B,  C,  were 
found  in  all  of  which  sensibilit\^  for  cold,  ice,  was  preserved.  The  loca- 
tion of  these  areas  does  not  correspond  with  any  of  the  similar  areas  of 
preserved  sensibility  for  light  touch.  The  indentation  at  B  seen  in  boun- 
dary for  cold  loss  on  dorsum  of  hand,  gives  a  clue  to  the  meaning  of 
these  islands  of  preserved  sensibility.  Later  observations  render  it 
almost  certain  that  at  a  slightly  earlier  period  there  existed  an  island  of 
preserved  sensibility  for  cold  at  B,  which  was  not  discovered  at  the 
examination,  April  15,  because  inexact  methods  were  employed. 

The  chart,  April  24,  shows  significant  indentations  in  the  bounds  for 
touch,  prick  and  ice.  The  ulnar  boundary  for  light  touch  loss  has  fused 
with  the  radial  boundary  of  island  A  of  chart  for  April  15,  and  the  upper 
wrist  boundary  shows  an  indentation  that  has  taken  up  island  B  of 
chart  for  April  16.  The  area  of  prick  loss  at  2  has  narrowed  also, 
showing  an  indentation  which  evidently  corresponds  to  island  E  for 
April  15.  Most  significant  of  all  in  chart  of  April  24  is  the  marked  in- 
dentation of  the  boundary  for  ice  loss  at  the  site  of  the  tabatier.  Here 
the  indentation  manifestly  fuses  with  island  A,  April  19.  At  this  date 
islands  for  light  touch  began  to  make  their  appearance  on  the  thenar 
eminence  followed  by  usual  alterations  in  the  boundaries  for  touch  loss. 
Finally  chart,  May  29,  shows  the  following  significant  conditions.  L 
An  area  B,   1%   inches   wide  by  2%    inches   long,   on   dorsum  of   hand 


152  XEir  YORK  XEVROLOGICAL  SOCIETY 

corresponding  to  space  between  metacarpal  bones  of  index  and  middle 
fingers  at  the  level  of  the  web  of  the  first  interosseus  space  in  which 
light  touch  is  preserved  after  shaving,  but  all  other  forms  of  sensibility 
are  lost.  On  this  area  the  pulling  of  a  hair  caused  only  a  sensation  of 
touch  and  the  compass  tests,  though  not  quite  satisfactorj',  have  shown 
so  far  little  if  any  defect.  II.  An  area,  B,  where  light  touch  is  absent 
and  sensation  for  prick  and  ice  preserved.  III.  Small  areas,  E  and  F, 
in  which  sensibility  for  all  degrees  of  heat  and  cold  is  lost  but  prick 
preserved.  IV.  Areas  G  and  //  where  sensibility  for  prick  is  preserved 
and  that  for  all  degrees  of  heat  and  cold  lost.  V.  Area  A,  54  by  ^  inch, 
at  root  of  thumb  on  palmar  aspect,  where  sensibility  for  prick  and  for 
all  degrees  of  heat  is  lost  and  that  for  touch  and  all  degrees  of  cold 
preserved.  A  similar  smaller  area  is  found  at  B  on  the  thenar  eminence. 
VI.  Between  B  and  A  on  the  thenar  enimence  is  another  area.  C,  where 
sensibility  for  prick  is  present  whilst  that  for  light  touch  and  for  all 
degrees  of  heat  and  cold  is  absent. 

Conclusions  are:  I.  that  division  of  the  musculospiral  nerve  in  the 
upper  arm  gives  an  area  of  loss  for  all  forms  of  sensibility,  epicritic  and 
protopathic,  over  an  area  that  roughly  extends  over  the  dorsum  of  the 
thumb,  the  thenar  eminence,  in  part,  and  the  radial  half  of  the  dorsum 
of  the  hand  and  lower  wrist.  Head  and  Sherrin  (Brain,  1905,  28,  116) 
deny  this,  insisting  that  in  order  to  get  other  than  epicritic  loss  in  the 
dorsum  of  the  hand  following  section  of  the  radial  nerve  at  the  wrist, 
section  of  one  of  the  branches  of  the  external  cutaneous  is  necessary. 
Our  conclusion  here  does  not  fairly  controvert  the  statement  of  these 
authors  as  the  circumstances  responsible  for  lesion  of  the  musculo-spiral 
in  our  case  might  well  have  caused  lesion  of  the  external  cutaneous  or  of 
one  of  its  branches.  There  was  no  evidence  of  loss  of  sensibility  on  the 
forearm  beyond  slightly  impaired  sensibility  on  a  very  small  area  for  the 
weak  faradic  current  and  this  was  doubtful.  There  was  no  loss  for  light 
touch,  after  shaving;  compasses  were  perfect  and  there  was  no  evidence 
of  a  line  of  change  for  a  dragged  pin  point.  II.  Pain  referred  to  the  arm 
and  hand  disappeared  when  the  nerve  was  sutured.  This  observation 
has  an  important  bearing  in  the  light  of  the  author's  theory  (N.  Y.  M. 
J.,  May  I,  1915)  of  the  mechanism  of  neuralgic  and  all  forms  of 
paroxsymal  pain  caused  by  injury'or  disease  of  the  nerves.  The  prime 
cause  of  all  such  pains  is  interference  with  normal  conduction  along  the 
nerve  paths.  This  results  in  a  storing  of  potential  in  the  cells  of  the 
sensory  root  ganglia  with  consequent  overflow  centrally  spontaneous  or 
otherwise,  causing  the  paroxysms  of  pain.  When  the  ganglion  cells 
become  exhausted  of  their  stored  potential  the  pain  disappears  until  a 
reaccumulation  of  potential  occurs.  The  anesthetic  and  manii)u!ations 
incidental  to  the  operation,  suturing  the  nerves,  thoroughly  exhausts  the 
sensory  neurone  bodies  of  their  stored  potential.  This,  and  not  the 
restoration  of  anatomical  continuity,  causes  the  immediate  disappearance 
of  the  paroxysms  after  operation,  and  under  such  circumstances  it  takes 
some  time,  usually  days  or  weeks,  before  tlie  potential  has  time  to  re- 
accumulate  in  the  ganglion  cells.  Meanwhile  protopathic  sensibilitj'  has 
returned  to  some  extent  and  this,  which  is  itself  in  the  main  caused  by 
storing  of  potential  in  the  ganglion  cells,  prevents  that  continued  storing 
of  potential  which  ultimately  manifests  itself  in  pain  paroxysms.  Parox- 
ysmal pains  of  neural  origin  always  result  from  defects  in  conduction, 
especially  in  the  pain  and  temperature  paths,  as  demonstrated.  This 
holds  for  all  the  true  neuralgias  and  this  hypothesis  explains  the  results, 


NEW  YORK  NEUROLOGICAL  SOCIETY  iS3 

good  and  bad,  obtained  by  diathermy,  nerve  sections,  electricitj^  etc.,  as 
well  as  the  spontaneous  cures.  III.  The  dissociation  areas  observed 
prove  clearly  that  in  the  peripheral  sj^stem  separate  and  distinct  sets  of 
fibers  conduct  impulses  for  (a)  light  touch  with  possibly  a  separate  set 
for  compasses;  (b)  prick  and  (c)  for  each  of  the  various  forms  of  heat 
and  cold,  although  Dr.  Byrne  has  only  seen  one  or  two  instances  in  which 
epicritic  sensibility  for  cold  was  apparently  preserved  where  sensibility 
for  ice  was  lost.  IV.  The  irregular  mode  of  regeneration  with  the  ap- 
pearance of  island  areas  of  returned  sensibility  with  consequent  indenta- 
tions in  the  boundary  of  lost  sensibility  makes  us  ask  the  question  :  how 
much  of  this  is  due  to  the  procedure  employed  at  operation  and  how 
much  to  the  peculiarities,  overlapping,  of  the  nerve  suppty  of  the  region. 

Head,  after  experimental  section  of  the  radial  nerve  at  the  wrist  and 
both  branches  of  the  external  cutaneous,  in  his  own  arm,  found  an  area 
of  dissociated  sensibility  similar  to  areas  A,  B,  C  and  B  in  our  chart, 
April  15.  His  area  was  in  the  region  of  the  tabatier,  and  on  the  dorsal 
aspect  of  the  wrist.  The  question  arises,  was  the  external  cutaneous 
injured  in  their  case  at  the  time  of  plating  the  bone,  and  if  so,  were  the 
areas  of  disassociation  existent  from  the  time  of  operation,  and  not  the 
result  of  regeneration.  Experiments  would  seem  to  indicate  that  these 
islands  were  result  of  regeneration  possibly  in  areas  supplied  by  a  nerve 
(ext.  cutan.)  that  had  been  injured  but  not  severed.  But  with  this  they 
had  the  unusual  return  of  epicritic  sensibility  for  light  touch  before  the 
return  of  that  for  prick  and  for  heat  and  cold.  Head's  area  would  be 
relevant  here,  but  for  the  fact  that  there  were  found  other  areas  in  their 
case — those  of  loss  for  prick  and  for  gross  heat  and  cold.  The  conclu- 
sion is  that  the  irregular  form  of  regeneration  was  due  in  pare  to  the 
form  of  neuroplasty,  and  partly  to  injury  without  severance  of  the  ex- 
ternal cutaneous  nerve,  and  partly  to  the  peculiarity,  overlapping,  of  the 
nerve  supply  of  the  areas  affected.  Even  this  guess  leaves  much  to  be 
desired  and  a  fruitful  field  invites  further  research  into  the  normal  mode 
of  regeneration  in  nerves. 

EXCISION   OF  BRACHIAL  PORTION   OF  ULNAR   NERVE  FOR 
MULTIPLE     NEURO-FIBROMATA,     WITH     RECIPROCAL 
GRAFTING    OF    THE    ULNAR    NERVE    INTO     THE 
MEDIAN   NERVE,   AND  OF  A   PORTION   OF  THE 
MEDIAN  INTO  THE  ULNAR;  HYPERALGESIA 
OF    MEDIAN    AREA;    MECHANISM;    PAR- 
OXYSMAL NEURAL  PAINS 

By  R.  H.  M.  Dawbarn,  AI.D.,  and  Joseph  Byrne,  M.D. 

The  patient,  a  young  German,  set.  26,  cook,  single,  had  no  venereal  his- 
tory, nor  trauma.  Apparently  there  spontaneously  developed,  beginning  six 
years  ago,  a  long  swelling  over  the  region  of  the  ulnar  nerve,  and  extend- 
ing from  high  in  the  axilla  to  a  point  well  below  the  elbow;  involving  in 
fact  the  entire  brachial  portion  of  this  nerve.  This  was  accompanied  by 
considerable  and  steadily  increasing  tenderness  of  the  diseased  area,  for 
which  condition  relief  was  asked.  The  tumor  mass  was  in  places  as  large 
as  the  fist,  and  was  translucent.  The  muscular  power  of  the  hand,  where 
supplied  by  the  ulnar  nerve,  while  not  wholly  lost,  was  largely  so,  with 
obvious  wasting  of  the  interossei  muscles  and  of  the  thenar  and  hypothenar 
eminences.  Electrical  reaction  (faradic)  was  absent  or  greatly  impaired 
compared  with  the  normal  side.     The  muscles  involved  left  no  doubt  as  to 


154  -V£f{'  YORK  XEVROLOGICAL  SOCIETY 

which  nerve  was  involved  in  the  neuroma.  One  curious  anomaly  was 
observed;  namely,  that  even  immediately  after  the  excision  was  performed 
the  man  was  able  to  extend  his  terminal  phalanges  fully.  One  would  of 
course  have  expected  extension  of  the  first  and  second,  and  flexion  of  the 
last  phalanges,  in  this  condition,  but  Dr.  Byrne  thought  it  not  unlikely  that 
here  the  gradual  loss  of  control  of  the  finger  ends  by  the  ulnar  led  to  a 
gradual  resumption  of  more  complete  control  by  the  common  extensors 
(posterior  interosseus  nerve).  The  condition  must,  Dr.  Dawbarn  thought, 
be  very  rare.  In  operating  on  this  case,  in  order  to  do  bloodless  work  and 
yet  get  abundant  room  in  the  axilla,  Wyeth's  pins,  back  and  front,  were 
used  with  rubber  cording  above  them.  The  tumor  was  followed  to  its  ending 
in  normal  ulnar  nerve  tissue.  This  was  in  the  highest  part  of  the  axilla, 
above,  and  one  inch  distal  to  the  internal  condyle  below.  A  second  and  separ- 
ate incision,  the  scar  of  which  could  now  be  seen,  exposed  the  median  nerve 
high  in  the  forearm.  Next  the  healthy  lower  end  of  the  divided  nerve  was 
tucked  through  a  slit  made  beneath  the  pronator  and  flexor  group  of 
muscles  and  so  brought  into  easy  apposition  with  a  strand  split  off  from 
the  exposed  median  nerve.  Sutures  of  the  finest  linen  thread  were  used 
to  unite  the  sheaths.  The  proximal  end  of  the  ulnar  nerve,  high  in  the 
armpit,  was  inserted  into  an  opening  in  the  sheath  of  the  median  and 
sutured  there.  The  long  incision  healed  by  primary  union.  It  was  united 
by  the  clip  and  strip  method,  using  Michel's  clips  for  24  hours  only;  the 
adhesive  strips  were  removed  after  ten  days.  The  clips  did  not  irritate  as 
when  left  in  for  five  days.  Dr.  Dawbarn  said  that  the  results  of  this 
method  were  so  uniformly  ideal  that  he  had  ceased  practically  to  suture 
wound  edges. 

Dr.  Byrne  said  that  the  interesting  feature  of  this  case  was  the 
hyperalgesia  which  followed  the  surgical  trauma  of  the  median  nerve. 
True  hyperalgesia  of  the  peripheral  nerves  was  a  rare  condition.  It  was 
formerly  called  causalgia  and  mentioned  as  such  by  Weir  Mitchell  in  his 
classic  Injuries  of  the  Nerves.  In  this  case  there  were:  first  week, 
sensory  symptoms;  second  week,  burning  sensation  at  the  roots  of  nails 
in  thumb  and  index  fingers ;  third  week,  whole  median  area  on  palm  and 
fingers  exhibited  hyperalgesia,  the  boundaries  of  which  were  in  contrast  to 
median  and  ulnar  areas.  The  hand  was  pink-lilac,  glossy,  tense.  This 
lasted  two  weeks  and  then  abated.  This  was  due  to  injury  of  the  median 
nerve.  Dr.  Byrne  thought  his  theory  of  pain  in  tabes  and  gastric  crises 
served  to  explain  hyperalgesia  and  all  paroxysmal  pains  of  neural  origin. 
This  was  overstoring  of  potential  in  the  related  cells  of  the  sensory 
ganglia.  This  overloading  of  potential  resulted  in  the  spontaneous  dis- 
charge of  afferent  impulses  brainward  which  caused  paroxysms  of  pain 
referred  to  the  areas  of  distribution  of  the  related  peripheral  fibers.  The 
anesthesia  and  manipulation  incidental  to  the  operation  in  this  case  dis- 
charged the  stored  potential  in  the  sensory  ganglion  cells  and  before  it 
had  time  to  reaccumulate,  conductivity  had  been  reestablished  in  the 
median  nerve. 

Dr.  Dawbarn  presented,  as  his  third  case,  an  account  of  a  thigh  ampu- 
tation, low  down,  in  a  middle-aged  man,  the  operation  having  Ijccn  made 
necessary  by  severe  trauma.  The  surgeon  made  a  common  blunder.  He 
did  not  shorten  the  sciatic  nerve  at  the  time  of  amputation  and  the  patient 
could  not  bear  the  pressure  of  the  artificial  limb.  Whenever  he  at- 
tempted to  walk  he  had  violent  spasms  in  the  thigh  stump.  After  five 
years  he  came  for  relief  and  Dr.  Dawbarn  suspected  a  neuroma.  He  drew 
out  the  terminal  five  inches  of  tlie  sciatic  nerve.  It  was  very  large  and 
vascular.  The  irritation  of  the  neuroma  had  led  to  hypertrophic  changes. 
The  lesson  to  be  drawn  was  that  in  every  amputation  there  should  be  a 


NEW  YORK  NEUROLOGICAL  SOCIETY  155 

shortening  of  several  inches  of  the  pain-bearing  nerves,  for  example,  in  a 
mid-leg  amputation,  the  anterior  and  posterior  tibial  and  internal  and  ex- 
ternal saphenous,  and  musculo-cutaneous.  should  be  shortened.  Formerly 
he  had  doubted  whether  it  was  wise  to  shorten  the  nerve,  because  of  the 
possible  danger  of  atrophy  of  the  trophic  nerves  of  the  skin,  but  he  had 
found  this  did  not  occur.  The  blood  vessels  had  a  very  rich  nerve  supply, 
both  sensory  and  trophic,  and  this  was  carried  by  them  to  the  skin.  Thus 
the  trophic  supply  was  not  cut  off  from  the  skin.  This  should  be  em- 
phasized by  surgical  teachers. 

Dr.  Byrne  said  that  Weir  Mitchell  stated  that  the  nerves  should 
always  be  shortened.  After  injury  nerve  degeneration  passed  inward  as 
well  as  outward.  Several  facts  lent  support  to  the  theory  of  the  storing 
of  potential  in  the  sensory  ganglion  cells,  but  the  actual  proof  of  the 
spontaneous  passage  of  impulses  inward  awaited  future  workers. 

HERPES  ZOSTER  OTICUS,  WITH  FACIAL  PALSY  AND  ACOUS- 
TIC  SYMPTOMS 

By  Norman  Sharpe,  M.D. 

The  previous  history  of  this  patient  was  negative  except  for  excessive 
beer  drinking.  The  present  illness  occurred  in  the  early  part  of  February 
with  an  onset  of  severe  pain  in  right  ear,  headaches,  dizziness,  tendency 
to  stagger,  and  diplopia.  After  a  week  of  these  symptoms  he  noticed 
small  pimples  and  facial  palsy  on  the  right  side  and  with  the  palsy  and 
eruption  came  lessening  of  the  headache  and  pain  and  diplopia  disappeared. 
Examination  at  this  time  at  the  N.  Y.  Eye  and  Ear  Hospital  showed  loss  of 
taste  sense  on  the  right  half  of  tongue,  small  red  spots  on  the  right  side  of 
mouth  and  right  pillars  of  the  fauces.  Three  weeks  after  onset  the  pain 
disappeared  and  headaches  were  only  occasional  and  very  slight.  He 
came  to  the  Neurological  Institute  one  month  after  because  of  the  facial 
palsy.  Several  small  recent  scars  were  found  in  the  concha  of  the  right 
ear  and  there  was  right  facial  palsy,  lateral  nystagmus,  and  the  right 
corneal  reflex  was  diminished.  There  was  slight  hypalgesia  round  the 
concha  of  the  right  ear  and  almost  complete  loss  of  hearing  on  that  side. 
The  urine  was  normal,  the  Wassermann  negative  for  blood  and  cere- 
brospinal fluid,  the  globulin  was  negative  and  there  were  62  cells.  Dr. 
Dench  found  both  tympanic  membranes  thickened  and  depressed.  Two 
months  after  onset  taste  had  partially  returned,  palsy  was  still  evident, 
but  nystagmus  had  disappeared.  Hypesthesia  and  hypalgesia  had  disap- 
peared. The  superficial  and  deep  reflexes  were  normal  from  the  first. 
The  patient  was  one  of  the  class  of  cases,  described  by  Hunt,  of  herpes 
zoster,  attacking  the  sensory  ganglia  of  the  cephalic  extremity.  He  em- 
phasized the  fact  that  in  zoster,  though  one  ganglion  was  primarily  in- 
volved the  adjacent  ganglia  did  not  entirely  escape.  This  should  be  borne 
in  mind  in  order  to  understand  multiple  nerve  complications.  In  placing 
the  lesion  in  this  case  the  site  eruption  was  in  the  distribution  of  the 
seventh,  ninth  and  tenth  nerves.  The  tenth  nerve  could  be  eliminated 
because  of  absence  of  nausea  and  vomiting  and  by  the  fact  that  there  was 
no  eruption  of  the  mastoid  and  postero-mesial  surface  of  the  auricle. 
Other  symptoms  pointed  to  the  geniculate  of  the  seventh,  as  loss  of  taste 
and  facial  palsy.  Loss  of  hearing  pointed  to  involvement  of  the  auditory 
ganglia  or  of  the  eighth  nerve.  This  occurred  by  extension  from  the  in- 
flamed geniculate  ganglion.  The  involvement  was  not  entire.  There  was 
also  slight  involvement  of  the  glosso-pharyngeah  nerve ;  and  diminished 
corneal  reflex  pointed  to  involvement  of  the  Gasserian  ganglion.     The  case 


156  NEW  YORK  SEUROLOGICAL  SOCIETY 

was  one  of  herpetic  zoster  attacking  the  geniculate  ganglion  of  the  facial 
nerve,  with  extension  to  the  auditory  nerve  and  slight  involvement  of  the 
glosso-pharyngeal  ganglia  and  the  Gasserian  ganglion  of  the  fifth  nerve. 

REPORT  BY  DR.  H.  CLIMENKO 

D.  F.,  17  years  old,  single,  student. 

Family  History. — Negative. 

Personal  History. — Measles  and  whooping  cough. 

Present  History. — On  March  8,  1915,  patient  awoke  with  a  sore  throat. 
Three  days  later  he  had  a  catarrh  of  nose.  On  March  14  patient  had  neu- 
ralgic pains  in  the  left  side  of  the  back  of  the  head.  This  increased  in 
severity  and  on  March  18  he  had  severe  pains  in  left  ear.  On  March  21 
Dr.  Mindel  was  consulted  and  found  the  ear  negative.  He  prescribed 
aspirin.  The  pain  in  the  ear  was,  however,  so  severe  that  he  did  not 
sleep  during  the  night.  The  next  morning  he  found  the  left  side  of  the 
face  paralyzed.  Two  days  later  the  temperature  rose  to  102°.  The  patient 
became  constipated,  pain  in  the  ear  was  severe  and  relief  was  obtained  on 
lying  down  and  that  time  the  herpes  appeared.  Together  with  the  appear- 
ance of  the  herpes  patient  vomited  whatever  he  ate,  suffered  from  dizzi- 
ness, buzzing  in  the  ear,  and  things  moved  from  left  to  right. 

On  April  5  pulse  was  80,  resp.  24,  nystagmus  was  lateral  and  rotatory. 
Herpes  of  left  auricle,  canal,  tympanum.  Tenderness  of  auricle ;  complete 
paralysis  of  left  seventh  nerve.     Slight  Romberg. 

Watch  at  about  5  inches :  Deviation  test  negative.  No  caloric  re- 
sponse in  left  ear.  Caloric  nystagmus  in  right  ear  at  45  seconds.  Hypal- 
gesia  at  middle  branch  of  left  fifth  nerve. 

THE  CUTANEOUS   ZONE   01-    TH :   FACI.\L   NERVE 
By  J.  Ramsay  Hunt,  M.D. 

Dr.  Hunt  reviewed  the  symptomatology  of  the  sensory  system  of  the 
facial  nerve. 1  viz.,  (I)  the  geniculate  otalgia  (idiopathic,  reflex,  post-herpetic 
and  tabetic);  (H)  pain  in  the  ear  and  mastoid  region  with  hypesthesia 
of  the  concha,  in  cases  of  facial  palsy  (Fallopian  neuritis)  ;  (HI)  the 
sensory  system  of  the  facial  as  a  reflex  mechanism  in  facial  twitchings 
and  spasms;  (IV)  herpetic  inflammations  of  the  geniculate  ganglion,  a 
syndrome  characterized  by  herpes  zoster  oticus,  facial  palsy  and  auditory 
symptoms.  Anatomically,  the  sensory  system  of  the  facial  nerve  consists 
of  the  geniculate  ganglion;  a  posterior  root,  the  nerve  of  Wrisberg  and 
peripheral  divisions  on  the  distal  side  of  the  ganglion,  viz.,  the  great  and 
small  superficial  petrosal  nerves  with  their  deep  tympanic  branches,  the 
chorda  tympani,  and  somatic  sensory  fibers  coursing  in  the  trunk  of  the 
nerve  and  destined  for  the  central  portions  of  the  external  ear  (the  cuta- 
neous representation  of  the  VH  nerve). 

Dr.  Hunt  referred  to  the  confirmation  of  his  views  by  many  observers, 
and.  notably  the  case  of  tic  douloureaux  of  the  geniculate  system  reported 
by  Clark  and  Taylor  to  the  Neurological  Society  in  June,  k/k).  This  was 
an  obstinate  and  very  severe  otalgia  of  geniculate  origin,  cured  by  section 
of  the  nerve  of  Wrisberg.  It  had  been  observed  by  a  number  of  trained 
neurologists  who  were  agreed  as  to  its  distinctly  neuralgic  character  and 

>  JoL'RN.  Nerv.  a.m/ Mental  Dis.,  1909,  p.  321. 


NEW  YORK  NEUROLOGICAL  SOCIETY  157 

limitation  to  the  area  which  Dr.  Hunt  had  outlined  for  the  geniculate 
system.  After  section  of  the  sensory  root  of  the  seventh  nerve  the  relief 
from  pain  was  immediate,  complete  and  permanent.  A  more  definite 
clinical  proof  of  the  pain  functions  of  the  sensory  facial  or  a  more  com- 
plete confirmation  of  the  views  concerning  geniculate  otalgia,  as  expressed 
by  Dr.  Hunt,-  could  hardly  be  desired.  The  pain  in  this  case  was  localized 
in  the  depths  of  the  ear  and  on  the  anterior  wall  of  the  external  meatus 
with  occasional  stabbing  pains  in  front  of  the  ear.  Following  the  nerve 
section  all  sensory  examinations  of  the  face  and  external  ear  proved  neg- 
ative with  the  exception  that  the  former  area  of  pain  seemed  to  the  patient 
to  be  a  little  less  sensitive  in  the  tests. 

In  a  subsequent  study,^  Dr.  Hunt  had  also  described  various  syn- 
dromes and  complications  resulting  from  herpetic  inflammation  of  the 
geniculate,  auditory,  glossopharyngeal  and  vagal  ganglia.  An  attempt  was 
made  at  that  time- to  indicate  the  respective  cutaneous  and  intra- oral  zones 
of  the  seventh,  ninth  and  tenth  ganglia  by  the  herpes  zoster  method.  The 
geniculate  area  was  found  to  correspond  to  the  following  anatomical  land- 
marks on  the  external  ear;  the  concha,  tragus,  antitragus,  incisura  inter- 
tragica,  antihelix,  fossa  of  the  antithelix  and  the  superior  portion  of  the 
external  surface  of  the  lobule.  The  cutaneous  area  of  the  ganglia  of  the 
ninth  and  tenth  nerves  correspond  to  the  posterior  portion  of  the  tym- 
panum, the  posterior  wall  of  the  auditory  canal  and  a  cutaneous  strip  on 
the  postero-mesial  surface  of  the  auricle  and  the  adjacent  mastoid.  More 
recent  studies  have  made  it  probable  that  the  geniculate  has  also  a  slight 
representation  within  the  auditory  canal  and  on  the  tympanic  membrane 
as  well  as  on  the  posteromesial  surface  of  the  auricle  and  the  adjacent 
mastoid,  thus  sharing  with  the  ninth  and  tenth  nerves  in  the  innervation 
of  these  areas. 

The  intra-oral  zones  of  the  glossopharyngeal  and  vagal  ganglia  are 
represented  clinically  by  herpes  zoster  pharyngis  and  herpes  zoster  laryn- 
gis  respectively,  which  correspond  to  the  mucous  membrane  distributions 
of  the  ninth  and  tenth  nerves.  There  is  evidence  to  show  that  the  genic- 
ulate may  also  retain  an  intra-oral  remnant  of  innervation  indicated  by  the 
occasional  presence  of  herpes  in  the  chorda  distribution  and  in  the  region 
of  the  soft  palate  in  conjunction  with  the  typical  distributions  of  cutaneous 
herpes  in  the  geniculate  area. 

In  the  description  of  the  zones  the  importance  of  anomalies,  varia- 
tions and  overlap  of  innervation  were  especially  erriphasized  by  Dr.  Hunt 
as  well  as  their  vestigial  characteristics.  Since  the  last  publication  by  Dr. 
Hunt  in  iQio,  fourteen  cases  of  isolated  herpes  zoster  oticus  have  been 
available  for  analysis,  including  eight  personal  observations.  Of  this  num- 
ber all  were  associated  with  facial  palsy  and  eight  with  auditory  disturb- 
ances as  well.  As  was  the  case  in  the  earlier  series  recorded,  the  erup- 
tion of  herpes  was  distributed  on  one  or  more  of  the  following  land- 
marks of  the  external  ear,  viz.,  the  concha,  antitragus,  tragus,  incisura 
intcrtragica,  antihelix,  fossa  of  the  antihelix,  superior  portion  of  the 
lobule  and  the  external  meatus.  In  two  of  the  cases  the  herpetic  vesicles 
were  also  distributed  on  the  posteromesial  surface  of  the  auricle  and  ad- 
jacent mastoid.  This  area,  therefore,  represents  topographically  the  gen- 
iculate zone  on  the  external  ear. 

It  was  found  that  the  herpetic  eruption  varied  considerably  in  size 
and  distribution  in  different  cases,  so  that  this  vestigial  sensory  zone  was 
regarded  as  presenting  many  anomalies  and  variations,  as  might  be  ex- 
pected from  its  phylogenetic  history  and  gradual  submergence  beneath  the 

2  Arch,  of  Otology,  1907. 

3  Arch,  of  Intern.  Med.,  June,  1910. 


158  .V£f['  YORK  XEUROLOGICAL  SOCIETY 

encroachment  of  the  trigeminal  and  cervical  areas.  For  the  same  reason 
the  absence  of  any  clear-cut  area  of  anesthesia  was  doubtful  from  the  fact 
that  the  geniculate  zone  was  vestigial  and  its  area  interlaced  with  and  was 
conjointly  innervated  by  the  other  nerves  of  this  region — ninth,  tenth,  fifth, 
and  auricular  branches  of  the  cervical  nerves. 

From  a  study  of  the  anatomy  and  phylogeny  of  the  facial  nerve,  Dr. 
Hunt  concluded  that  the  fibers  for  the  cutaneous  zone  course  with  the 
motor  fibers  in  the  Fallopian  canal,  finding  their  way  to  the  auricle  by  way 
of  the  auricular  branch  of  the  vagus,  the  posterior  auricular  nerve,  and, 
with  the  motor  fibers  destined  for  the  innervation  of  the  minute  mtrinsic 
muscles  of  the  external  ear.  These  muscles,  Dr.  Hunt  stated,  like  the 
cutaneous  sensory  zone,  are  more  or  less  vestigial  in  character.  Dr.  Hunt 
said  that  he  regarded  it  as  especially  significant  that  the  cutaneous  sensory 
zone,  which  is  phylogenetically  very  old,  should  correspond  so  closely  in 
distribution  to  the  small  cutaneous  muscles  of  the  external  ear  which  are 
themselves  vestigial  and  regressive. 

Some  observers,  notably  Dejerine,  had  included  certain  hypesthetic 
areas  of  the  face  and  occipital  region  in  the  geniculate  area.  Dr.  Hunt, 
however,  said  he  believed  that  these  objective  sensory  disturbances  were 
produced  by  concomitant  inflammatory  changes  in  the  Gasserian  and  upper 
cervical  ganglia,  and  therefore  did  not  properly  belong  to  the  geniculate 
zone.  The  objective  sensory  disturbance  within  the  geniculate  zone  in 
cases  of  facial  palsy,  herpetic  inflammation  of  the  ganglion  and  after- 
section  of  the  nerve  of  Wrisberg,  were,  for  the  reasons  stated  above,  very 
slight  (hypesthesia),  and  might  even  be  absent,  because  of  the  vestigial 
character  of  this  cutaneous  zone  and  the  overlap  from  adjacent  distribu- 
tions of  the  fifth,  ninth,  tenth,  and  cervical  nerves. 

Dr.  Hunt  stated  that,  like  the  comparative  anatomist,  the  students  of 
cranial  nerve  components  had  found  somatic  sensory  fibers  in  the  facial 
nerves,  but,  true  to  the  old  anatomical  tradition,  had  referred  them  to  the 
neighboring  trigeminal  and  vagal  systems.  Recently,  however,  Norris  had 
demonstrated  such  a  cutaneous  component  in  the  facial  nerve  of  Siren,  and 
Judson  and  Herrick  had  described  similar  fibers  in  amblystoma.  Dr.  Hunt 
believed  that  if  the  eye  were  fixed  upon  the  possibility  of  a  vestigial 
cutaneous  component  in  the  seventh  nerve,  that  these  might  be  demon- 
strated in  the  entire  vertebrate  series. 

Dr.  Leszynsky  said  as  he  recalled  the  original  case  referred  to  by  Dr. 
Hunt,  there  was  no  involvement  of  the  auditory  or  facial  nerve.  The  pain 
was  limited  to  a  small  area  anterior  to  the  meatus  and  was  different  from 
any  form  of  trigeminal  neuralgia. 

Dr.  Strauss  said  he  saw  the  patient  referred  to  by  Dr.  Climcnko  and 
noted  the  remains  of  the  herpetic  vesicles.  There  were  scars  within  the 
auricle  and  in  testing  him  for  pain,  he  noted  a  certain  degree  of  hypalgesia. 

Dr.  Tilney  said  that  in  listening  to  Dr.  Hunt  he  had  been  convinced, 
somewhat  against  his  will.  He  came  prepared  to  attack  the  proposition 
that  there  was  a  sensory  zone  in  connection  with  the  facial  nerve  in  man. 
There  were  still,  he  thought,  questions  to  be  answered  in  this  connection. 
Dr.  Hunt  had  yet  to  prove  where  the  fibers  from  the  geniculate  ganglion 
terminated,  in  order  to  demonstrate  to  which  component  they  belonged. 
It  had  been  held  by  such  men  as  Herrick,  Strong,  Landacrc  and  others, 
who  had  done  much  to  advance  the  component  theory  of  the  nervous  sys- 
tem, almost  to  its  ultimate  conclusions,  that  the  seventh  nerve  did  not 
contain  general  somatic  sensory  components  but  comprised  only  afferent 
special  cutaneous  fibers  from  the  lateral  line,  splanchnic  sensory  fibers 
from  the  tongue  and,  perhaps,  the  palate  for  taste,  and  afferent  branchial 
motor  to  the  facial  mu.sculature.     Dr.  Hunt's  correspondence  with  Profes- 


NEW  YORK  NEUROLOGICAL  SOCIETY  159 

sor  Herrick  was  more  recent  than  any  views  of  his  with  which  Dr.  Tilney 
was  famihar,  and  Herrick,  according  to  Dr.  Hunt,  seemed  incHned  now  to 
concede  a  somatic  sensory  area  in  the  seventh  nerve  innervation.  Dr.  Hunt's 
arguments  were  cogent  and  he  had  given  excellent  reasons  for  believing 
that  this  cutaneous  facial  area  corresponded  phyletically  to  the  old  zone 
of  the  spiracle.  From  the  clinical  standpoint,  however,  it  seemed  that 
cases  of  otic  herpes  might  not  be  exclusively  due  to  involvement  of  the 
geniculate  ganglion.  The  clinical  history  of  this  syndrome  showed,  in  the 
majority  of  instances,  that  we  were  dealing  rather  with  a  pluri-ganglionic 
disease.  The  interpretation  that  Dr.  Tilney  would  give  of  the  cochlear 
and  vestibular  symptoms  would  be  an  involvement  of  the  ganglion  con- 
nected with  the  divisions  of  the  eighth  nerve,  namely  the  ganglion  of 
Scarpa  and  the  ganglion  spiralis.  Furthermore,  the  pain  and  hyperesthesia 
so  commonly  present  along  the  distribution  of  the  trigeminus  would  indi- 
cate some  involvement  of  the  Gasserian  ganglion;  in  certain  instances 
there  was  evidence  of  vagal  involvement.  One  saw  vago-spastic  condi- 
tions as  well  as  vagotonic  symptoms — nausea,  — vomiting  and  bradycardia 
were  not  unfrequent  accompaniments.  Anatomically  one  could  recognize 
the  relation  of  the  auricular  nerve  of  Arnold  to  the  ganglion  nodosum  of 
the  vagus.  This  latter  nerve  had  been  ascribed  by  anatomists  to  the  inner- 
vation of  the  ear  in  an  area  between  the  tragus  and  antihelix,  the  region 
in  which  the  herpes  most  frequently  occurred,  so  that  it  might  be  possible 
that  we  were  dealing  with  an  inflammation  of  the  ganglion  nodosum,  not 
only  because  of  the  vagal  symptoms  present,  but  because  the  distribution  of 
Arnold's  nerve  corresponded  so  nearly  to  the  herpetic  zone  of  Hunt.  Dr. 
Tilney  said  he  was  very  much  indebted  to  Dr.  Hunt  for  the  light  which 
he  had  brought  to  bear  on  this  subject  and  believed  that  his  argument  held 
good. 

Dr.  Climenko  said  that  the  eighth  nerve  could  be  excluded  in  his  case. 
There  were  no  auditory  symptoms  at  all. 

CASE    OF    FAMILY    PERIODIC    PARALYSIS;    DEATH    OCCUR- 
RING   IN    ATTACK     . 

By  Joseph  Byrne,  A.M.,  LL.B.,  M.D.,  M.R.C.S.   (England). 

This  rare  but  sharply  defined  clinical  entity  presents  the  following 
characteristics,  viz.,  periodic  paralysis,  occurring  in  families.  The  at- 
tacks come  on  usually  in  sleep,  after  unusual  exertion,  excitement  or  die- 
tetic indiscretion,  and  affect  groups  of  muscles,  e.  g.,  the  extensors  of  the 
knees  or  the  whole  musculature  of  the  limbs,  trunk  and  neck.  They  last 
from  an  hour  to  a  week,  the  usual  duration  being  from  ten  to  forty-eight 
hours  (Taylor)  and  then  disappear,  leaving  the  individual  in  an  apparently 
normal  state  of  health  in  the  intervals.  During  the  attacks  the  reflexes, 
superficial  and  deep,  are  absent  in  the  paralyzed  areas  and  there  is  absence 
or  alteration  of  electric  excitability,  and  absent  or  diminished  mechanical 
irritability  in  both  nerve  and  muscle.  The  mind  remains  unaft'ected.  There 
are  no  objective  sensory  disturbances  and  but  few  and  occasional  subjective 
ones,  such  as  discomfort  from  position,  thirst,  itching,  etc.  Attacks  vary 
in  extent  and  severity  but  the  severe  cases  give  one  the  impression  of  a 
patient  with  a  broken  neck  lying  in  bed,  motionless,  able  to  speak  and  think 
clearly  but  utterly  unable  to  help  himself  beyond  indicating  his  wants  and 
giving  directions  to  have  his  head  or  limbs  moved  in  this  or  that  direction, 
so  as  to  promote  comfort. 

Westphal  in  1885  first  described  in  detail  a  typical  case  and  refers  to 
similar  cases  observed  by  Cavare  (1853)  and  Romberg  (1857).     Hartwig 


i6o  NEW  YORK  NEUROLOGICAL  SOCIETY 

(1874)  and  Samuelson  (1876)  each  reported  cases.  In  1882  Schachnevitch 
described  a  like  condition  in  father  and  son,  the  father  dying  from  the 
disorder  at  55.  Here  we  have  the  first  evidence  of  the  hereditary  nature 
of  the  malady.  In  the  same  year  Gibney  reported  two  cases  associated 
with  malaria,  but  these  cases  showed  atrophy  and  sensory  signs  and  are 
not  regarded  as  true  instances  of  family  periodic  paralysis.  Fischl  (1885) 
reported  a  case  and  Cousot  (1886  and  1887)  five  cases  in  one  family. 
Griedenberg  (1887)  reported  one  case,  Goldflam  (1899,  1891)  saw  eleven 
cases  in  one  family.  He  reported  some  of  the  cases  in  accurate  detail  and 
tried  experimental  methods  to  determine  the  etiology  and  pathology. 
Pulaski  (1899)  reported  a  typical  case.  Oppenheim  (1891)  saw  Westphal's 
case  of  1885  again.  He  investigated  the  electrical  changes  and  observed 
during  an  attack  signs  of  temporary  dilations  of  the  heart  with  mitral 
insufficiency.  Burr  (1892-3)  observed  attacks  causing  hemiparesis.  Hirsch 
(1894)  and  Rich  (1894)  each  reported  one  case.  Rich  verified  Oppen- 
heim's  observation  of  temporary  dilation  of  the  heart. 

Other  cases  studied  were  by  Goldflam  (1895),  etiology;  Bernhardt 
(1896),  two  cases  associated  with  muscular  dystrophy;  Mitchell,  one  case 
in  1899;  Putnam  (1900)  a  case  in  which  he  concluded  the  condition  was 
due  to  a  defect  of  coordination;  Crafts  and  Irwin  (1900)  found  the  feces 
in  ethereal  extract  caused  paralysis  lasting  forty-eight  hours  in  rabbits  and 
guinea-pigs,  the  toxin  showing  alkaloidal  characteristics,  the  muscle  showed 
hypertrophy  and  vacuolation  of  fibers,  the  urine  was  toxic  for  rabbits  but 
caused  no  paralysis,  the  blood  showed  marked  lymphocytosis  in  attack, 
the  saliva  was  normal;  they  believed  the  toxin  acted  on  the  spinal  centers. 
Singer  and  Goodbody  (1901)  studied  a  case  in  which  the  heart  was  en- 
larged to  the  left  in  attacks.  They  found  that  experimental  alterations  in 
the  diet,  such  as  increase  or  withdrawal  of  carbohydrates,  had  no  effect. 
They  found  muscle  changes,  but  regarded  them  as  artefacts;  blood,  nor- 
mal in  attacks  and  intervals ;  extract  of  feces  non-toxic  for  rabbits ;  urine 
toxic  for  rabbits.  The  attacks  were  remarkably  reduced  by  diuretics,  e.  g.. 
imperial  drink,  digitalis  and  potassium  acetate.  Buzzard  (1901),  reported 
three  cases  in  a  family.^  The  patient  studied  had  a  feeling  of  "  pins  and 
needles"  all  over  the  body  in  attacks.  Buzzard  points  out  that  the  paral- 
ysis does  not  resemble  curarized  animals,  since  in  these  latter  no  electrical 
changes  are  found  as  demonstrated  by  Bonath  and  Lukes.  He  regards  the 
condition  as  due  immediately  to  two  factors,  viz.,  (a)  chemical  or  physical 
change  in  the  muscle  plasm  and  (b)  lymph  stasis. 

Atwood  (191-2)  studied  three  cases  in  a  family  in  whicli  nine  cases 
had  occurred  in  four  generations.  Death  occurred  during  an  attack  in  a 
cousin  of  one  of  his  patients  from  inability  to  eject  vomitus  from  the  oro- 
pharynx and  in  another  following  bleeding  to  secure  a  specimen  of  blood. 
Atwood  found  marked  intestinal  infection  by  B.  acrogeucs  capsulatis.  The 
urine  in  attacks  showed  increase  in  acidity,  indican  and  sulphate  partition 
with  a  trace  of  albumin.  He  believes  the  cause  is  a  toxin  in  the  circu- 
lating blood.     JChminative  treatment  seemed  to  act  well. 

CJardner  (1913)  reports  a  -single  isolated  case  with  negative  family 
history,  though  the  mother  had  bilious  headaches.  The  attacks  appeared 
as  a  rule  on  Sundays  when  the  patient  played  football  after  feasting  on 
Saturday  afternoon  on  sausages,  cheese  and  beer.  Head  suggested  that 
the  pork  in  the  sausages  might  have  caused  analphylactic  shock.  Gardner 
rejects  this  suggestion  and  considers  the  condition  a  toxic  one  due  to  a 
congenita!  defect  of  metabolism  and  similar  to  periodic  attacks  of  aceton- 
uria,  oxaluria,  uric  acid  explosions,  cyclic  vomiting  of  children,  which 
show  acetonuria  and  ophthalmoplegic  migraine.  In  this  case  the  attacks 
were  controlled  by  restricted  diet  and  elimination  by  the  bowels  and 
kidneys. 


NEW  YORK  NEUROLOGICAL  SOCIETY  i6i 

Types. — Emphasis  has  been  laid  on  the  different  types  of  this  con- 
dition,— the  Goldflam,  the  Holtzapple,  and  the  Clarke  type.  It  may  be 
well  to  outline  briefly  the  main  features  of  the  attacks  as  described  by 
each  of  these  authors.  In  the  first  set  of  Goldflam's  cases  there  was  no 
neurotic  heredity,  transmission  took  place  through  males  and  females,  the 
first  attack  occurred  between  the  ages  of  fifteen  and  twenty  years,  the  fre- 
quency of  the  attack  was  weekly,  to  yearly,  being  more  frequent  in  youth, 
the  paralysis  involved  the  extremities,  trunk  and  neck,  the  duration  of  the 
attacks  was  from  twenty-four  to  seventy-two  hours,  beginning  in  the  even- 
ing or  night;  there  was  constipation,  thirst,  sweating,  drowsiness;  con- 
sciousness was  retained;  there  were  no  sensory  disturbances  except  acute 
itching  which  appeared  in  the  intervals  and  just  as  the  attack  was  about 
to  terminate;  speech  and  bladder  functions  were  normal.  The  physical 
examination  showed  flaccid  paralysis;  reflexes:  plantar,  abdominal  and 
cremasteric  present;  knee  jerks  absent;  sensation  normal;  urine  undi- 
minished. Electrical  examination:  faradic  quantitatively  diminished  in 
arms,  absent  in  legs;  no  reaction  from  muscles  in  arms  and  legs;  facial 
nerve  normal ;  myotatic  irritability  lost.  Between  the  attacks  nerve  and 
muscle  irritability  was  normal  except  in  the  intrinsic  muscles  of  the  hand 
which  showed  R.  D.  Goldflam  occasionally  observed  that  paralysis  was 
limited  to  certain  groups  of  muscles ;  that  attacks  might  be  aborted  or  de- 
layed by  exercise;  that  relapses  might  occur  in  the  state  of  improvement; 
that  the  heart  might  become  arrhythmic  with  a  systolic  basal  murmur, 
accented  second  sound,  faint  first  sound,  but  no  cardiac  enlargement ;  that 
the  pulse  might  be  slow  or  there  might  be  inability  to  swallow  or  a  danger- 
ous asphyxia. 

The  Holtzapple  type  shows  the  condition  occurring  in  a  family  afflicted 
with  other  neurotic  disorders  which  may  possibly  be  regarded  as  equiva- 
lents of  the  paralytic  attacks.  One  case  suffered  from  migraine  until 
thirty,  when  this  was  replaced  by  periodic  attacks  of  paralysis.  Holtz- 
apple observed  a  family  for  twenty-two  years,  covering  four  generations. 
Seventeen  cases  of  paralysis  occurred  in  this  family,  eighteen  cases  of 
sick  headache,  five  cases  of  paralysis  associated  with  headache,  fourteen 
cases  of  uncomplicated  paralysis  and  thirteen  of  uncomplicated  headache. 
Six  died  in  an  attack  of  paralysis,  one  in  Holtzapple's  presence.  The  con- 
ditions of  the  attacks  of  paralysis  were  essentially  similar  to  those  de- 
scribed by  Goldflam. 

The  Clarke  type  seems  to  be  a  milder  form  in  which  there  occurs  ab- 
ruptly and  without  warning  a  more  or  less  complete  inabihty  to  move  any 
of  the  voluntary  muscles.  There  are  no  electrical  changes.  Reflexes  and 
sensation  are  normal.  In  some  cases  the  muscles  supplied  by  the  cranial 
nerves  are  involved,  c.  g.,  eyes,  tongue,  pharynx,  lips  and  muscles  of  in- 
spiration. The  cases  occur  mainly  in  females,  but  the  first  instance  oc- 
curred in  the  male  grandparent.  Some  of  the  males,  not  affected,  showed 
hereditary  taint,  two  had  diabetes,  four  had  acetonuria.  The  attacks  oc- 
curred unexpectedly,  e.  g.,  while  the  patient  was  sitting  in  a  car.  walking, 
or  resting.  They  involved  striated  and  unstriated  muscle.  Micturition 
seemed  to  prevent  or  terminate  the  attacks. 

The  cases  herein  reported  occurred  in  a  family  of  eight,  five  males 
and  three  females.  So  far  the  females  have  escaped.  Three  of  the  males 
have  had  attacks.  The  eldest,  thirty-six  years,  and  the  third  eldest,  thirty- 
two  years,  have  so  far  escaped. 

History.- — Father,  Jewish,  born  in  Russia,  died  nineteen  years  ago,  at 
40.  He  was  one  of  twins,  was  heaJthy  until  a  few  years  before  death, 
when  he  had  stomach  trouble  which  was  alleviated  by  staying  at  Carlsbad. 
He  returned  to  New  York  and  six  months  after  return  had  a  supper  of 


162  NEJV  YORK  NEUROLOGICAL  SOCIETY 

delicatessen  and  beer.  He  awoke  at  4  A.  M.  feeling  very  ill.  At  7  A.  M. 
he  became  paralyzed,  followed  by  loss  of  speech ;  he  tried  to  vomit  but 
failed  to  do  so;  he  was  unconscious  all  day  and  died  at  6  P.  M.  after 
convulsions.  This  was  the  only  attack  the  patient  had.  The  mother,  Rus- 
sian Jewess,  had  diabetes  mellitus  for  past  four  j-ears.  She  appears  healthy 
but  is  uncommunicative.  Her  grandfather  died  suddenly  thirty-seven  years 
ago,  cause  unknown.  Father's  brother  died  twelve  years  ago,  of  illness 
similar  to  father's.  Nothing  is  known  of  collaterals.  In  the  family  under 
consideration  three  sisters  are  alive  and  well,  one  has  five  healthy  chil- 
dren; five  brothers,  A.  is  22.5  years  old;  B.  25  years,  C.  32  years;  D.  36 
jears.  A,  the  youngest  was  seen  in  December,  1914.  He  is  a  student  and 
had  five  attacks  of  paralysis  in  five  years,  the  first  attack  coming  on  at 
17.5  years.  All  were  severe  but  the  last  was  worst  and  lasted  twenty- 
four  hours.  The  patient's  words  are :  "  The  attack  is  preceded  by  head- 
ache, indigestion  and  fever.  The  joints  and  muscles  stiffen  and  tlie  limbs 
become  heavy.  In  from  one  to  three  hours  I  am  completely  i)aralyzed, 
entirely  helpless  with  the  exception  of  being  able  to  roll  my  head  from  side 
to  side.  Even  the  slightest  movement  elsewhere  is  impossible.  My  mind 
is  clear,  I  can  speak  and  understand  what  is  going  on.  My  body  is  abnor- 
mally heavy  to  those  who  lift  it.  I  want  my  body  turned  and  moved  every 
few  minutes.  I  would  like  to  vomit,  but  cannot.  I  cannot  urinate. 
After  an  emetic  the  vomitus  is  green.  After  vomiting  my  condition  is 
better  and  improvement  sets  in  with  the  desire  to  urinate.  When  I  take 
a  purgative  it  acts  if  I  do  not  vomit  it,  but  I  have  no  desire  to  go  to  stool 
until  the  paralysis  passes  away.  In  the  last  attack  I  had  cramps  in  the 
stomach.  I  was  placed  on  the  toilet  and  my  bowels  moved.  This  helped 
me,  as  in  one  hour  I  fell  asleep.  I  awoke  after  three  hours  and  could 
then  move  a  little.  Half  an  hour  later  the  paralysis  was  entirely  gone  but 
some  weakness  in  the  joints  and  muscles  of  the  limbs  remained.  An  hour 
later  I  was  out  of  bed  and  walking  around.  On  the  night  previous  to  the 
last  attack  I  slept  little  on  account  of  fever  and  indigestion,  and  I  was 
somewhat  delirious.  On  other  occasions  should  I  eat  a  heavy  meal  half 
an  hour  before  going  to  bed  my  limbs  are  very  stiff  in  the  early  morn- 
ing. This  passes  away  and  when  my  stomach  is  in  good  condition  I  have 
no  such  trouble." 

The  order  of  the  paralysis  is:  Lower  limbs,  trunk,  upper  limbs,  neck. 
Power  returns  as  follows :  Hands  and  arms,  thigh  rotators  and  feet, 
simultaneously.  Patient  tried  to  urinate  but  could  not  in  an  attack. 
Patient  A.  has  a  peculiar  deformity  of  the  hands.  At  the  metacarpo- 
phalangeal joint  the  four  fingers  are  markedly  deviated  to  the  ulnar  side, 
leaving  a  large  prominence  on  the  radial  aspect  of  the  knuckle  of  the  index 
finger.  The  fingers  are  "  double-jointed."  This  is  apparently  inherited 
from  the  father,  who  had  similar  hands.  One  brother,  B.,  has  similar 
hands. 

Patient  B.,  hc-ight  five  ft.  eleven  in.,  weight  145  ll)s.,  has  had  two 
attacks,  the  first  at  twenty-two  and  last  at  twenty-five.  They  were  similar 
to  those  of  .'\.  He  is  a  clerk,  and  became  quite  helpless  at  office  and  had 
to  be  carried  home.  He  has  slight  neuropathic  traits.  C,  thirty-two  years, 
has  had  no  attacks  so  far.  D.,  thirty- four  years,  has  had  over  a  dozen. 
In  one  jcar  he  had  three  attacks.  He  liked  to  vomit  in  attacks  as  he 
thought  it  relieved  him.  He  had  an  attack  April  6,  1915,  which  proved 
fatal.  E.  has  had  no  attacks,  he  is  healthy,  married,  and  has  one  healthy 
child. 

History  of  D's.  Fatal  Attack.— VaX\tnt  never  drank.  He  smoked 
cigarettes  in  moderation.  Habits  regular  and  temperate,  but  he  fre- 
quently dined  at  restaurants.     This  was  regarded  by  his  family  (orthodox 


NEW  YORK  NEUROLOGICAL  SOCIETY  163 

jews)  as  dissipation.  Was  in  the  army  in  Porto  Rico  in  his  first  attack, 
at  twenty  years.  The  last,  thirteenth,  proved  fatal,  on  April  6,  1915.  On 
April  5  there  was  a  heavy  fall  of  snow;  the  patient  stayed  home  on 
account  of  grippe  cold.  He  had  high  fever  and  his  doctor  prescribed 
powders  and  advised  rest  for  a  week.  Though  forbidden  meat  he  took 
roast  beef,  and  had  chicken  broth  and  two  bottles  of  zoolak.  On  April  6 
he  was  irritable  in  the  morning;  at  noon  he  went  to  purchase  zoolak  and 
on  his  return  met  his  employer,  who  had  come  to  enquire  about  him.  This 
episode  upset  the  patient.  At  i  P.  M.  he  took  two  bottles  of  zoolak  and 
went  to  bed.  At  6.30  P.  M.  he  was  stiff,  although  he  could  still  stand  and 
walk.  He  knew  the  attack  was  inevitable.  He  took  a  mustard  foot  bath 
with  relief.  By  7.30  P.  M.  he  was  completely  paralyzed.  The  order  of 
paralysis  was  lower  limbs,  trunk,  upper  limbs,  neck.  He  was  given  a 
bottle  of  citrate  of  magnesia  to  move  the  bowels.  At  10.00  P.  M.  he  was 
put  on  a  commode  and  the  bowels  moved  freely,  there  being  nothing 
unusual  about  the  movement.  It  was  liquid,  well  mixed,  of  greenish 
golden  color,  no  marked  odor.  No  excess  of  mucus  or  undigested  food. 
After  this  his  clothing  was  changed.  He  complained  of  cold.  At  11.30 
the  patient  was  seen  by  Dr.  Byrne. 

Inspection. — Well  developed,  muscular  young  adult,  well  formed  and 
symmetrical.  No  stigmata  with  the  exception  of  a  large,  coarse  nose, 
and  condition  of  incomplete  hypospadias,  the  glans  penis  presented  two 
openings,  the  upper  one  being  the  true  meatus,  the  lower  about  5  mm.  in 
depth.  No  urine  had  ever  escaped  through  this  to  the  patient's  memory. 
Ears,  hard  palate,  teeth,  well  formed,  regular.  The  forehead  sloped  slightly 
and  the  cranial  dome  was  somewhat  low  and  deficient  looking.  Hands 
and  feet  well  formed.  Limbs  and  trunk  perfect.  Between  attacks  is  well 
but  of  late  has  few  erections  and  no  sexual  desire.  Ejaculation  is  prema- 
ture but  effective.  Patient  lay  in  bed  utterly  helpless  except  that  he  was 
able  to  talk.  The  mind  was  clear.  He  complained  that  his  head  was 
heavy  and  asked  to  have  it  placed  straight  on  the  pillow.  He  had  a  numb 
feeling  in  the  feet  and  felt  fidgety.  He  felt  heavy  as  lead.  He  had 
generalized  headache  and  burning  sensation  in  mouth  and  tongue.  He 
tried  to  cough  but  could  not.  He  tried  to  vomit  but  without  avail.  The 
effort  represented  a  much  enfeebled  activity  of  the  oropharyngeal  muscles. 
Nothing  came  up.  He  complained  of  mucus  in  the  throat  which  was  re- 
lieved by  swabbing.  His  respiration  was  peculiar;  the  abdomen  protruded 
to  an  unusual  degree  and  retracted  abruptly  as  if  forcibly  drawn  in, 
whilst  a  fraction  of  a  second  later  the  anterior  chest  wall  ballooned  out- 
ward. This  was  one  of  the  most  remarkable  features  of  the  attack.  Re- 
spiratory rate  18,  full  and  deep.  The  average  duration  of  inspiration  was 
1.4  sec.  expiration  0.8  sec.  pause  1.6  seconds.  These  were  fairly  normal 
but  there  were  occasional  marked  pauses  lasting  3  or  4  seconds.  Pulse 
84,  full,  soft,  regular.  Heart :  Auscultation,  first  sound  impure,  due  to 
irregular  muscular  action  of  ventricle,  second  sound  relatively  accentuated, 
but  really  diminished,  aortic  second  sound  feeble,  pulmonary  relatively 
accentuated,  no  other  abnormal  sounds.  Abdominal  organs  appeared 
normal;  tongue  moist  and  clean.  Skin  sallow,  warm  and  dry  but  other- 
wise normal.     Temperature  100.6°  F. 

Neurological  Examination.- — Motor :  Can  wrinkle  forehead  and  close 
eyes  tightly.  Shows  teeth  poorly  but  equally  on  both  sides  and  with  mani- 
fest effort.  Strains  when  asked  to  open  mouth  and  does  not  separate  teeth 
more  than  .5  inch.  Facial  expression  on  laughing  feeble  but  symmetrical. 
Putting  out  tongue  costs  an  effort.  Unable  to  trill  tongue  against  hard 
palate.  Cannot  trill  lips.  Can  whistle  feebly.  Says  "  Ah "  but  cannot 
raise  pitch.  Swallows  with  difficulty.  Cannot  open  mouth  against  resist- 
ance.    Can    make    slight    lateral   movements    of   head.     Trunk   and    limbs 


1 64  XEIV  YORK  XEUROLOGICAL  SOCIETY 

powerless,  but  barely  noticeable  movement  of  wrist.  Position  of  hands 
'^  closed.  \\'ith  wrist  extended  he  can  almost  close  hand.  Interossei  and 
lumbricals  powerless.  Can  rotate  left  thigh  but  not  right.  Can  wriggle 
toes  a  little.  Trunk  muscles  flaccid.  Attempts  to  cough,  laugh,  or  vomit 
are  feeble.     Does  not  urinate.     Xo  flatus  passed  at  any  time. 

Reflexes  R  L 

Epigastric     o  o 

Abdominal    o  o 

Cremasteric    x  X     Diminished  on  both  sides. 

Anal     X  X 

Bulbocavernosus  . .  o  o 

Elbow    o  o 

Wrist o  o 

Knee    o  c 

Ankle  x  X     Exaggerated  on  both  sides. 

Ankle  clonus    o  o 

Plantar    o  At  times  dorsal  flexion  of  ankle  with 

knees  flexed,  small  toes  gave  re- 
response,   great   toe   motionless. 

Oppenheim   o  Small    toe    turned    down,    great    toe 

motionless. 

Gordon Toes  turn  Small  toes  up  as  a  whole,  great  toe 

motionless. 

Myotatic  irritability  absent  on  neck,  trunk,  hands  and  limbs,  but 
present  on  calves,  though  absent  in  anterior  tibial  and  peroneal  groups. 
Slight  fibrillation  of  calf  muscles  after  irritation  by  hammer  taps. 

Sensation,  General. — Feels  fidgety.  Xumb  in  feet.  Heavy  as  if  lead. 
Burning  in  mouth  and  tongue.  Headache  general.  No  marked  itching. 
Touch:  Light,  no  loss;  deep,  no  loss;  localization  good  in  both.  Pain: 
Prick,  no  loss ;  no  over-reaction.  Pressure :  Pain  normal,  testicular  and 
ocular  sensibility  good.  Heat:  Gross  no  loss,  no  over-reaction.  Inter- 
mediate no  loss.  Cold :  Ice  no  loss,  no  over-reaction ;  intermediate  no 
loss;  discrimination  good.  Vibration:  Unimpaired.  Passive  position  good. 
Special  Senses — Eyes:  Vision  good.  Movements  well  executed,  slight  con- 
vergence on  looking  up.  Xo  nystagmus.  Pupils  dilated,  equal,  regular, 
react  to  1.  and  a.  Vessels  normal.  Taste:  Preserved  on  anterior  tongue, 
equal.     Smell:  Xormal.     Hearing:  Good,  equal. 

The  patient  was  left  about  1.30  A.  M.  with  instruction  for  continual 
watching,  by  younger  brother,  himself  a  victim  of  disease.  The  patient 
asked  to  have  throat  swabbed  out  and  later  made  signs  to  have  this  done. 
Later  about  2.30  A.  M.  patient  became  very  quiet  and  turned  blue.  The 
brother  tried  to  swab  throat,  but  patient  became  rigid  and  bit  off  the 
swab.  The  brother  tried  artificial  respiration,  but  the  patient  died.  The 
cause  of  death  was  failure  of  the  respiratory  mechanism  through  in- 
volvement of  the  diaphragm  or  exhaustion  of  the  diaphragmatic  neuro- 
mu.scular  mechanism ;  the  latter  is  the  more  probal)lc.  Autopsy  was 
refused. 

Patltology.~Fcw  significant  facts  have  been  found.  Oppenheim 
found  waxy  degeneration  of  muscle  during  attack ;  Goldflam  fouiid  gen- 
eral hypertrophy  and  vacuolization  of  muscle.  Goldflam  and  Bernhardt 
regard  the  condition  as  organic.  The  objection  to  this  is  that  the  attacks 
minimize  with  advancing  age.  The  blood  (Goldflam  and  Taylor)  has 
been    found   to   show   leucocytosis.     The   urine    (Crafts   and    Irwin)    has 


NEW  YORK  NEUROLOGICAL  SOCIETY  165 

been  found  toxic  for  guinea-pigs.  Biller  and  Rosenbloom  found  di- 
minished creatin  and  creatinin  with  increased  undetermined  nitrogen. 
Mitchell,  Flexner  and  Edsall  found  total  anacidity  of  the  stomach  and 
digestive  processes  at  a  standstill,  even  for  starch,  with  gastric  motility 
abolished,  with  diminished  output  of  kreatinin  one  or  two  days  before 
the  attack,  but  consider  this  latter  a  result  rather  than  cause  of  attacks. 
Singer  and  Goodbody  found  the  urine  diminished,  but  otherwise  normal. 

The  disease  must  be  classed  with  conditions  due  to  inborn  errors  of 
metabolism  such  as  albuminuria,  cystinuria,  pentosuria,  etc.  It  develops 
along  with  other  defects  than  those  related  to  metabolism.  The  attacks 
are  associated  with  improper  diet  or  mode  of  living  affecting  the  de- 
fective mechanism.  It  has  been  taken  for  hysteria  with  fatal  results  to 
the  sufferer.  The  lives  of  the  patients  should  be  most  carefully  regulated. 
Individuals  in  a  family  afflicted,  who  themselves  escape,  do  not  seem  to 
transmit  the  condition,  but  consanguineous  marriages  should  be  especially 
guarded  against. 

In  treatment  the  alkalies  (citrate  of  potash)  seem  to  shorten  the 
attacks.  Flexner  and  Edsall  got  negative  results  from  diet,  lavage,  in- 
testinal antiseptics,  quinine,  bromides,  strychnia,  bicarbonate  of  soda,  and 
hypodermoclysis.  Purgatives  and  diuretics  seem  to  act  favorably.  One 
thing  is  certain,  that  persons  afflicted  should  have  at  hand  some  effective 
means  of  carrying  on  artificial  respiration  such  as  the  pulmotor,  the 
O'Dwyer  tube  or  some  similar  contrivance.  As  the  attacks  are  self- 
limited  the  indications  for  all  methods  calculated  to  keep  the  heart  and 
respiratory   mechanisms   going   are   unequivocal. 

Dr.  C.  E.  Atwood  said  that  Dr.  Byrne's  remarks  respecting  mode  of 
death  in  cases  of  family  periodic  paralysis  were  of  especial  interest.  In 
the  family  which  Dr.  Atwood  had  reported,  one  patient  choked  to  death 
during  an  attack,  from  vomited  matter  which  he  was  unable  to  clear  from 
the  throat.  Another  died  in  syncope  when  a  vein  was  opened  to  obtain  a 
specimen  of  blood.  Another  was  burned  to  death  by  fellow  soldiers  in  the 
Russian  army  who  thought  his  attack  of  paralysis  was  an  evidence  of 
malingering.  During  attacks  which  Dr.  Atwood  had,  himself,  witnessed, 
the  patient's  heart  action  was  weak.  This  was  shown  especially  when  the 
patient  was  held  in  a  sitting  or  standing  posture,  faintness  occurring  or 
even  fainting;  and  during  two  attacks  in  one  of  his  patients,  a  cardiac 
bruit  was  distinctly  heard  and  there  was  some  increase  of  the  area  of 
cardiac  dulness,  from  dilatation.  The  intercostal  muscles  were  involved 
in  severe  attacks  and  the  breathing  was  usually  shallow.  Family  periodic 
paralysis  is  a  rare  disease.  Its  pathology  is  not  known.  The  patho- 
genesis of  attacks  from  the  standpoint  of  pathological  chemistry  had 
occupied  a  number  of  observers  without  definite  results.  The  doctor 
would  urge  that  a  careful  personality  study  or  psychoanalysis  of  each 
patient  be  made  if  for  no  other  purpose  than  to  bring  about  an  im- 
proved adjustment  of  the  patient  toward  life  and  environment,  which  the 
nature  of  his  disease  tended  to  alter,  and  to  enable  him  to  sublimate  into 
useful  and  interesting  occupations  when  he  had  become  discouraged  by 
the  frequent  losing,  perhaps,  of  remunerative  positions,  on  account  of 
the  inconvenient  occurrence  of  attacks.  There  was  a  neurotic  element 
present  which  deserved  careful  study ;  but  hysteria  could  be  eliminated. 

Dr.  Tilney  asked  Dr.  Byrne  what  part  of  Russia  his  patient  came 
from. 

Dr.  Byrne  said  he  was  not  able  to  answer.  He  had  only  seen  the 
brother  since  the  patient  died.     He  was  frightened  to  death  on  account  of 


i66  XEIV  YORK  XEUROLOGICAL  SOCIETY 

the  fatal  ending  of  the  case.     There  was,  as  Dr.  Atwood  said,  a  distinctly 
neurotic  element  in  tliese  cases. 

THE    RELATION    OF   LANDRY'S    PARALYSIS    TO 
POLIOMYELITIS 

By  M.  Xeustaedter,  M.D. 

The  disease  was  described  in  1859,  by  Landry,  with  the  following 
s\-mptom  complex :  Individuals,  who  up  to  the  time  of  their  illness  were 
in  perfect  health,  developed  a  flaccid  paralysis  in  the  lower  extremities, 
preceded  by  a  general  malaise  and  paresthesias  in  the  affected  parts. 
Within  a  few  days  the  muscles  of  the  trunk  and  then  those  of  the  upper 
extremities  became  involved  in  the  same  manner.  And,  finally,  the 
muscles  of  deglutition,  articulation  and  respiration  became  paralyzed  and 
the  patient  died  of  respiratory  failure  within  a  few  days  or  weeks.  Oc- 
casionally, some  cases  presented  a  mild  degree  of  these  phenomena  and 
survived  without  leaving  any  residual  paralysis.  In  these  cases  the 
muscles  last  affected  were  the  ones  to  first  recover  their  function. 
Landry  pointed  out  that  there  w^as  no  atrophy  of  the  muscles  and  no 
electrical  changes  in  them  and  that  he  found  no  pathological  changes 
upon  autopsy.  A  great  many  cases,  however,  had  been  reported  that 
varied  from  the  first  description.  Muscle  atrophy  with  electrical  changes 
were  frequently  observed,  sensory  disturbances  were  not  uncommon,  in- 
volvement of  sphincters  were  at  times  reported  and  a  unilateral  or  bilateral 
facial  palsy  of  Bell's  type  had  been  described. 

Owing  to  the  more  advanced  methods  of  examination,  the  concep- 
tion of  the  etiology  and  pathology  of  the  disease  had  undergone  marked 
changes.  Landry  was  inclined  to  ascribe  the  affection  to  a  toxic  process. 
The  fact  that  in  the  majority  of  cases  there  was  an  enlarged  spleen, 
swelling  of  the  lymph  glands,  hemorrhagic  foci  in  the  lungs  and  in- 
testines and  a  nephritis,  pointed  to  a  toxic  or  infectious  process.  Chan- 
temesse  and  Ramon  had  observed  a  large  number  of  cases  of  paralysis, 
clinically  not  dissimilar  to  Landry's,  in  an  epidemic  form  at  an  institu- 
tion for  the  insane,  suggesting  a  possible  infection.  Baumgarten  found 
in  one  case  Bacillus  anthrax  in  the  blood  and  Curschmann  had  cited  a 
case  in  which  t>'phoid  bacilli  were  found  in  the  spinal  cord,  of  whicli 
pure  cultures  could  be  grown.  Centanni  found  in  a  case  of  interstitial 
neuritis,  bacilli  in  the  endoneural  lymph  spaces.  Eisenlohr  had  reported 
a  case  of  Landry's,  due  to  a  mixed  infection.  lie  had  found  a  Sta/^hy- 
lococcus  pyogenes  and  a  Staphylococcus  cercus  albus  in  the  spleen  and 
sciatic  nerve.  In  another  case  he  had  found  several  types  of  bacilli. 
Rcmmlinger  had  found  the  Streptococcus  longns  and  Marinesco,  dip- 
lococci  which  were  partially  enclosed  in  leucocytes.  In  a  case  of  Marie 
and  Marinesco  a  bacillus  similar  to  anthrax  had  been  found  in  the  blood. 
A  virulent  pneumococcus  had  been  shown  to  be  present  in  the  cases  of 
Roger  and  Jcsue  and  of  Courment  and  Benne.  MacNamara  and  Bern- 
stein had  grown  a  tetracoccus  from  the  blood  and  cerebrospinal  fluid  of 
their  case,  'and  Shcppard-Hall  a  streptococcus  from  this  case.  F.  Buz- 
zared  had  isolated  a  coccus  from  the  dura  which  produced  a  flaccid 
I)aralysis  in  animals.  Wdchcnius  had  found  a  Staphylococcus  pyogenes 
albus  in  tlie  spleen  and  peripheral  nerves. 

On  the  other  hand,  in  recent  years,  cases  of  Landry's  paralysis  were 
reported  in  which  no  germs  were  found.     Such  cases  had  been  reported 


NEW  YORK  NEUROLOGICAL  SOCIETY  167 

by  Seifert,  Schultz,  Thomas,  Kapper,  Workman,  Hunter,  Burghart, 
Mesny  and  Meutier,  Pfeiflfer  and  E.  D.  Fisher.  The  pathology  of  the 
disease  was  no  less  uniform.  Not  only  in  former  days,  but  also  in 
recent  years,  the  microscopical  findings  were  negative  in  some  cases,  as 
reported  by  Ormerod  and  Prince,  Seifert,  Kapper,  Hun,  Girandeau-Levy 
and  others.  Goebel  and  Burghardt  reported  cases  with  very  slight 
changes.  In  some  cases  disseminated  foci  of  an  inflammatory  character 
were  found  in  the  bulb  only,  in  others  again  exudates  with  capillary 
hemorrhages  in  the  spinal  cord  only.  Wappenschmidt  placed  particular 
weight  upon  hj'aline  thrombi  in  his  cases,  tending  to  prove  the  theory  of 
Recklinghausen  and  Klebs,  that  they  were  due  to  the  action  of  bacterial 
toxins.  In  a  few  instances  a  marked  swelling  of  the  axis  cylinders  in  the 
anterior  pyramids  was  noticed.  Widal  and  Le  Seurd  mentioned  a  neuritis 
of  the  roots  as  the  only  change. 

Since  the  peripheral  nerves  began  to  engage  the  attention  of  investiga- 
tors of  these  cases,  some  authors  had  been  able  to  demonstrate  extensive 
neuritic  changes  as  the  basis  of  this  disease.  Dejerine  and  Goetz,  Nau- 
werck,  Barth,  Ross,  Putnam,  Klumpke,  Beinet,  Roily,  Pelnar  and  E.  D. 
Fisher  reported  such  types. 

In  recent  years  the  greater  majority  of  cases  reported  were  character- 
ized by  myelitic,  or  rather  poliomyelitic  changes  in  the  cord  and  midbrain, 
namely  by  a  perivascular  and  pericellular  infiltration  of  various  types  of 
cells,  hemorrhages,  thrombosis  and  softening.  In  a  few  instances,  how- 
ever, a  combination  of  the  neuritic  and  poliomyelitic  changes  were  re- 
ported, as  in  the  cases  of  Krewer,  Mills-Spiller,  Guizetti,  and  Knapp  and 
Thomas.  In  these  cases,  Krewer  argued,  the  inflammatory  process  of  the 
peripheral  nerves  was  extended  to.  the  cord  and  bulb  and  this  gave  rise 
to  the  symptom  complex  of  Landry.  With  such  a  varying  etiology  and 
pathology  of  a  disease,  a  uniform  nosological  character  could  certainly 
not  be  thought  of.  The  disease  might  follow  diphtheria,  pneumonia, 
typhoid,  variola,  anthrax,  influenza  and  manifest  itself  as  a  puerperal  poly- 
neuritis. Some  even  reported  cases  that  developed  after  cystitis,  alongside 
of  uremia;  others  claimed  alcohol  and  syphilis  as  an  etiological  factor 
and  a  few  had  observed  the  affection  to  follow  traumata,  complicated  by 
septic  cellulitis. 

Another  important  fact  was  that  one  did  not  know  the  point  of 
entrance  of  the  germ,  nor  had  one  any  proof  of  its  manner  of  dissemina- 
tion. Furthermore  there  was  no  proof  whether  the  toxin  alone,  or  the 
virus,  or  both,  were  responsible  for  the  changes  in  the  tissues. 

Poliomyelitis :  The  symptomatology  of  this  affection  was  by  no  means 
uniform.  In  all  cases,  it  was  true,  fever  was  the  first  symptom,  but  only 
one  third  were  accompanied  by  gastrointestinal  disturbance.  Headache 
and  pain  along  the  spinal  column,  were,  as  a  rule,  a  constant  accompani- 
ment. Meningeal  symptoms  were  present  in  the  large  majority  of  cases. 
Stupor  was  rare.  The  intellect  was  clear.  The  focal  symptoms,  as  was 
well  known,  were  not  uniform.  The  spinal,  cerebral,  bulbar,  pontine,  cere- 
bellar and  mixed  types  had  become  recognizable.  In  the  spinal  type  there 
was,  of  course,  the  flaccid  paralysis  of  one  or  more  extremities,  with 
marked  atrophy,  according  to  which  segments  might  be  involved.  It  was 
rarely  of  an  ascending  character.  In  cases  that  ended  fatally  there  was 
a  simultaneous  involvement  of  the  bulb  and  spinal  cord.  The  cerebral 
cases,  it  was  quite  obvious,  resulted  in  a  spastic  hemiplegia,  with  or  with- 
out epileptiform  convulsions.  The  purely  bulbar  or  pontine  types  showed 
cranial  nerve  involvement.  A  peripheral  facial  paralysis  was  the  most 
common  result.  Ataxia  and  tremors  with  nystagmus  were  found  in  the 
cerebellar  cases.     In  the  mixed  types  the  symptom  complexes  varied  with 


i68  NEIV  YORK  NEUROLOGICAL  SOCIETY 

the  site  of  the  lesions.  Some  authors  described  a  polyneuritic  type,  but 
this  was  rare  and  was  observed  only  in  large  epidemics,  and  finally  a  large 
percentage  of  so-called  abortive  types  were  recorded.  It  was  not  to  be 
gainsaid  that  the  etiology  was  uniform.  The  disease  was  preeminently 
an  infantile  one,  it  occurred  in  epidemic  form  and  showed  very  definite 
seasonal  variations  in  its  incidence.  All  agreed  that  it  was  both  infectious 
and  contagious.  Flexner  and  Noguchi  had  definitely  proven  that  there 
was  a  distinct  coccus  that  produced  the  disease.  Many  important  data 
about  the  character  of  the  virus  were  available.  The  fact  had  been  estab- 
lished by  Dr.  Neustaedter  that  the  nasopharynx  was  the  point  of  entrance 
into  the  system.  The  pathological  changes  of  poliomyelitis  were  uniform 
in  every  case,  no  matter  what  part  of  the  central  nervous  system  was 
afifected,  and  this  was  true  of  clinical  and  experimental  cases  as  well. 
Macroscopically  there  was  a  pronounced  hyperemia  of  the  cord  and 
meninges ;  the  vessels  of  the  brain  were  congested ;  and  there  was  a  fair 
amount  of  edema  of  the  brain  and  cord.  There  was  little,  if  any,  increase 
of  the  cerebrospinal  fluid.  On  section  the  brain  and  cord  had  a  moist, 
translucent,  edematous  appearance,  and  the  gray  matter  of  the  cord  was 
often  swollen  so  that  it  projected  above  the  level  of  the  white  matter. 
Frequently  punctate  hemorrhages  could  be  discerned  with  the  naked  eye. 
The  virus  was  propagated  by  the  lymphatic  system  and  there  were  foci  of 
congestion  in  various  glands.  Histologically,  the  disease  was  character- 
ized by  a  perivascular,  interstitial  and  pericellular  infiltration  of  round 
mononuclear,  polymorphonuclear  and  endothelial  cells.  The  ganglion  cells 
involved  were  those  of  the  anterior  horns,  Clarke's  columns,  spinal  ganglia, 
nuclei  of  the  cranial  nerves  and  basal  ganglia  and  the  cortex.  Chron- 
ologically, the  perivascular  lymph  spaces  of  the  pial  vessels  in  the  anterior 
longitudinal  fissure  of  the  cord  and  tlie  pericellular  lymph  spaces  of  the 
spinal  ganglia  were  the  first  ones  to  be  involved,  sometimes  as  early  as  the 
third  day  of  infection.  Next  came  the  involvement  of  the  central  vessels 
of  the  cord,  then  the  vessels  of  the  white  matter.  Hemorrhages  were 
always  present.  It  was  important  to  show  whether  the  germ  or  its  toxin, 
or  both,  were  at  work.  Whatever  exotoxin  there  was,  was  evidently  a 
negligible  quantity  nor  was  the  endotoxin  very  toxic.  Lastly,  the  cyto- 
logical  findings  in  the  blood  and  spinal  fluid  were  typical.  The  blood 
showed  leucocytosis  with  many  mononuclears.  The  spinal  fluid  was  clear, 
contained  85  per  cent,  or  more  lymphocytes,  the  cell  count  ranging  from  30 
to  900  cells  per  cmm.,  the  globulin  content  was  increased.  The  conclusions 
of  Dr.  Neustaedter,  were,  therefore,  (i)  Landry's  paralysis  was  a  clinical 
entity  with  varying  pathological  changes,  which  might  be  peripheral, 
myelitic  only,  or  neuro-cellular.  Poliomyelitis  was  a  pathological  entity 
with  varying  symptom  complexes.  There  might  be  flaccid  paralysis  with 
muscular  atrophy,  or  spastic  paralysis,  or  cranial  nerve  involvement;  also 
ataxias  and  tremors,  or  mixed  types. 

Dr.  Hunt  said  he  was  inclined  to  make  a  clinical  distinction  between 
poliomyelitis  of  the  Landry  type  and  the  true  Landry's  paralysis.  He 
recognized,  however,  that  the  clinical  type  of  Landry's  paralysis  might  be 
caused  by  a  number  of  crmditions,  among  them  poliomyelitis.  He  said  he 
had  one  case  that  was  different  from  poliomyelitis  in  its  clinical  course  and 
in  which  pathological  study  failed  to  reveal  any  evidences  in  inflammatory 
lesions.  -He  had  always  felt,  therefore,  that  there  was  a  true  Landry's 
disease,  of  obscure  etiology  and  bearing  no  relation  to  poliomyelitis. 

•Dr.  Strauss  asked  Dr.  Hunt  how  he  would  make  the  clinical  differ- 
entiation. 

Dr.  Hunt  said  the  man  wlinm  he  referred  to  was  a  mulatto,  who  came 
from  the  South  Sea  Islands.     On  admission  to  the  hospital  he  had  weak- 


NEW  YORK  NEUROLOGICAL  SOCIETY  169 

ness  of  the  legs,  gradually  progressing;  no  temperature  (or  occasional 
subnormal  temperature).  From  day  to  day  the  motor  weakness  gradually 
increased  and  gradually  ascended.  As  the  weakness  progressed  there  was 
gradual  obliteration  of  the  tendon  reflexes.  The  muscle  responses  were 
retained  and  also  the  electrical  reaction,  although  diminished.  The  man 
finally  died  of  respiratory  failure  on  the  ninth  day.  There  was  a  gradual 
increasing  motor  lethargy  and  the  mental  state  was  of  apathy,  increasing 
with  the  progress  of  the  disease.  There  was  no  disturbance  of  the  sphinc- 
ters. A  very  complete  post-mortem  examination  showed  no  lesions  in  the 
spinal  cord,  except  an  occasional  degeneration  of  the  anterior  horn  cells. 
The  peripheral  nerves  showed  degeneration  and  there  were  curious  changes 
in  the  muscles.  He  regarded  the  condition  as  a  profound  intoxication  of 
the  peripheral  motor  neurones. 

Dr.  Strauss  said  he  would  like  to  say  in  response  to  Dr.  Hunt  that  he 
firmly  believed  there  were  cases  of  acute  ascending  paralysis  that  were 
not  poliomyelitis.  He  thought  there  were  cases  in  recent  literature  that 
had  been  studied  carefully  enough  and  these  had  shown  no  lesion  in  the 
cord,  and  we  could  conclude  that  they  were  not  cases  of  poliomyelitis. 
Poliomyelitis  should  show  lesions  in  the  cord  which  were  characteristic. 
Dr.  Neustaedter,  in  conclusion,  said  that  he  was  inclined  to  view 
Landry's  paralysis  as  a  clinical  entity,  a  syndrome,  without  any  definite 
etiology  or  uniform  pathological  picture.  Poliomyelitis,  was,  on  the  other 
hand,  a  pathological  entity,  its  etiology  was  known,  but  was  of  divers 
symptom  complexes.  That  poliomyelitis  could  not  be  reproduced  at  times 
was  a  known  fact.  Various  factors  might  militate  against  the  experiment. 
The  refractiveness  of  the  animal  was  a  frequent  factor.  But,  because  one 
was  unable  to  reproduce  it  in  some  instances,  one  was  not  justified  in 
denying  the  presence  of  poliomyelitis  as  long  as  the  pathological  picture 
was  characteristic. 

CHICAGO  NEUROLOGICAL  SOCIETY 

October  21,  1915 

The  President,  Dr.  James  C.  Gill,  in  the  Chair 

SOME  FUNDAMENTALS  IN  TESTING  MENTALITY 

By  William  Healy,  M.D. 

This  paper  dealt  with  a  considerable  number  of  points  concerning  the 
giving  and  the  fair  interpretation  of  mental  tests.  In  illustration  of  some  of 
the  points,  one  form  of  the  recently  developed  "  Yerkes  Ideational  Test"  was 
shown. 

Mr.  S.  C.  Kohs  said  he  was  glad  to  have  heard  Dr.  Healy's  paper,  but 
that  there  were  some  points  on  which  he  could  not  agree  with  him.  Referring 
to  Dr.  Healy's  statement  that  the  Binet  scale  was  wholly  inadequate  for  diag- 
nosing special  ability  or  special  disability,  the  speaker  doubted  whether  it  had 
ever  been  claimed,  by  those  properly  qualified  to  make  the  assertion,  that  the 
Binet  scale  was  adequate  for  any  fine,  sharp  distinctions.  He  maintained,  on 
the  contrary,  that  the  scale  was  intended  to  determine  intelligence  levels,  and 
even  at  that,  the  measurement  was  only  rough. 

Dr.  Healy  had  also  stated  that  the  Binet  scale  does  not  indicate  for  what 
the  individual  is  fit.  In  reply  to  this  Mr.  Kohs,  who  had  spent  some  two 
years  at  Vineland,  cited  the  work  of  the  psychological  laboratory  which  drew 
up  an  industrial  classification  based  on  mental  ability  as  indicated  by  the  Binet 


170  CHICAGO  NEUROLOGICAL  SOCIETY 

scale.  The  inmates  of  tlie  institution,  some  four  or  five  liundred,  had  already 
been  measured  by  the  scale  and  their  names  had  been  arranged  in  order  of 
mental  ability.  The  institution  employees  were  then  asked  to  state  what  every 
individual  was  doing  and  also  what  he  was  capable  of  doing.  The  institution 
employees  who  were  caring  for  these  patients  knew  nothing  of  the  results 
of  the  Binet  examination.  The  responses  were  correlated  and  the  following 
was  found :  The  higher  the  patient  in  intelligence  level  the  more  complex  was 
the  work  he  was  able  to  perform,  and  in  general,  the  smaller  was  the  amount 
of  supervision  necessarj-.  Altiiough  this  was  only  an  institution  experience, 
nevertheless,  it  would  probably  work  as  well  outside.  Experience  with  the 
Binet  led  the  speaker  and  iiis  associates  to  believe  that  the  Binet  test  was 
a  very  valuable  thing  in  telling  us  on  what  level  of  complexity  an  individual 
could  work,  and  also,  all  other  things  being  equal,  what  amount  of  super- 
vision would  be  necessary.  Of  course,  he  was  speaking  mainly  of  the  feeble- 
minded. How  that  classification  would  correlate  with  the  normal  individual, 
he  could  not  definitely  saj-,  since  no  experiments  along  this  line  had  ever 
been  made. 

The  point  that  the  Binet  scale  is  not  good  as  a  gauge  for  adults  may 
perhaps  be  true  of  the  normal.  The  speaker's  knowledge,  however,  of  the 
feebleminded  led  him  to  believe  that  the  examinations  made  upon  those  who 
had  been  put  through  the  tests  at  years  widely  separated  showed  the  reactions 
to  be  practically  the  same.  In  some  cases  the  mentality  was  lower,  but  not 
enough  to  make  the  deviation  at  all  marked. 

Mr.  Kohs  concluded  by  indicating  that  the  multiple  joint  test,  demon- 
strated by  Dr.  Healy,  was  open  to  every  objection  launched  against  the  Binet 
test.  The  criticisms  of  the  Binet  scale  can  be  very  easily  transferred  to  any 
other  test  or  scheme  of  tests. 

Dr.  Sydney  Kuh  said  that  if  he  were  to  make  any  criticism  of  Dr.  Healy's 
excellent  paper,  it  would  be  that  he  had  perhaps  not  been  quite  emphatic 
enough  in  bringing  out  some  points  that  he  had  made.  The  fact  that  the  child 
is  a  failure  at  school  is  not  only  not  evidence  that  that  child  is  feebleminded, 
but  a  child  may  be  a  failure  at  school  and  still  be  far  above  the  average  of 
intelligence.  In  fact,  if  it  were  not  objectionable  to  mention  names  at  a 
meeting,  he  might  speak  of  a  man  whom  anyone  present  would  class  amongst 
the  six  greatest  living  alienists,  who  was  known  to  have  been  a  failure  at 
school.  The  fault  is  not  always  with  the  child.  Dr.  Kuh  has  known  instances 
where  the  fault  was  clearly  with  the  teacher.  It  takes  not  only  an  intelligent 
child,  but  an  intelligent  teacher  to  bring  out  the  best  that  is  in  the  child.  He 
has  also  known  other  instances  where  the  fault  was  distinctly  with  the  par- 
ents. Some  children  are  only  able  to  learn  when  prodded;  others  can  only 
work  when  left  alone. 

So  far  as  the  criticism  of  the  Binet  scale  was  concerned,  Dr.  Kuh  fully 
agreed  with  what  Dr.  Healy  had  said.  The  fault  is  not  with  the  Binet  scale, 
but  with  those  who  expect  impossible  things  from  it.  The  application  of  a 
very  little  common  sense  would  tell  us  that  the  results  that  are  obtained  by 
educational  methods  depend  not  solely  upon  the  intelligence  of  the  child,  but 
also  on  the  environment  and  influences  which  affect  the  child.  The  influence 
of  environment  is  liable  to  be  even  more  pronounced  in  at  least  a  certain 
Rroup  of  feebleminded  than  it  is  in  the  normal  individual,  because  of  the 
greater  suggestibility  of  some  of  those  who  are  below  normal  mentally. 

Dr.  Healy  has  spoken  of  the  Pethrick  case.  The  speaker  was  one  of 
those  who  examined  this  young  man,  and  he  thought  that  the  statement  that 
his  mental  age  was  seven  was  simply  an  illustration  of  what  mistakes  one 
can  make  if  one  uses  the  Binet  scale  carelessly.  Pethrick,  so  far  as  the 
speaker  could  judge,  was  away  beyond  the  age  of  seven.  He  was  not  nearly 
so  feebleminded  as  he  wanted  the  examiners  to  believe.     He  was  very  dis- 


CHICAGO  NEUROLOGICAL  SOCIETY  171 

tinctly  simulating  feeblemindedness,  and  the  only  reason  the  speaker  could 
bring  for  considering  him  feebleminded  was  the  exceedingly  feebleminded 
way  in  which  he  simulated  feeblemindedness.  He  showed  a  distinct  defect 
in  his  intelligence  by  the  awkwardness  with  which  he  simulated.  Of  course, 
those  who  have  examined  criminals,  amongst  whom  the  tendency  to  simula- 
tion is  great,  have  often  called  attention  to  the  fact  that  one  can  recognize 
the  underlying  feeblemindedness  by  the  way  in  which  the  simulation  is  done. 

Just  a  word  with  regard  to  the  influence  of  the  emotional  state  upon  the. 
results — which  influence  enters  into  the  Binet  as  well  as  any  other  test,  and 
one  that  is  practically  never  considered.  Anybody  who  has  made  a  study  of 
these  things  will  know  that  there  are  certain  individuals  who  under  the  strain 
of  a  test  can  do  things  that  they  are  incapable  of  doing  at  other  times.  On 
the  other  hand,  there  are  others  who,  under  the  emotional  strain  of  an  exami- 
nation, do  not, come  anywhere  near  displaying  their  normal  intelligence. 

Dr.  Kuh  fully  agreed  with  Dr.  Healy  when  he  said  that  the  Binet  test  is 
of  very  little  value  without  a  very  thorough  study  of  the  social  history,  and  a 
careful  investigation  of  the  opportunities  and  environment  under  which  the 
individual  tested  has  grown  up,  but  this  also  applies  to  all  other  tests,  in  his 
opinion. 

Dr.  H.  I.  Davis  was  also  one  who  had  examined  Pethrick.  After  a  short 
time  in  the  presence  of  this  young  man,  the  speaker  knew  he  was  simulating. 
Among  the  first  questions  asked  Pethrick  was.  What  is  your  name?  and 
Where  do  you  live?  And  in  a  very  ofl^hand  way  he  said:  Please  write  it 
down  for  me.  He  wrote  his  name — Russell  Pethrick — on  a  card  (which  the 
speaker  showed),  and  then  asked  how  to  spell  Parnell.  Despite  this,  the 
speaker  was  satisfied  that  Pethrick  was  feebleminded.  By  sheer  force  of 
deprivation  Russell  Pethrick  could  not  be  anything  but  feebleminded.  He 
could  never  be  normal.  His  hearing  is  very  poor  and  eyesight  is  poor.  He 
could  never  see  the  blackboard  at  school.  By  sheer  deprivation  of  these 
senses  he  could  never  be  normal.  There  was  nobody  around  him  to  put  forth 
any  special  eft'ort  to  overcome  his  shortcomings.  As  said  before,  however, 
he  had  enough  intelligence  to  attempt  to  simulate  and  to  try  to  cover  up  cer- 
tain things. 

Dr.  Wm.  O.  Krohn  had  also  examined  Russell  Pethrick.  While  it  has 
been  said  that  he  only  had  the  intelligence  of  a  child  of  seven  and  a  half 
years,  still  his  account  books  and  everything  pertaining  to  his  daily  work  were 
the  same  as  the  average  boy  of  his  age.  In  playing  cards  Pethrick  could 
count  accurately  and  rapidly.  He  also  appreciated  the  jeopardy  of  his  con- 
dition, because  as  soon  as  the  verdict  was  in,  he  went  in  and  hugged  his 
acquaintances  in  the  jail.  He  had  the  same  difficulties  in  learning  at  school 
as  every  child  who  has  defective  hearing  and  sight. 

Dr.  Krohn  wished  to  emphasize,  if  possible,  still  more  forcibly  the  diffi- 
culties of  applying  any  scale  arbitrarily.  He  referred  to  the  case  of  a  colored 
boy  who  at  the  end  of  his  second  year  of  highly  creditable  work  in  Englewood 
High  School,  had  stolen  some  journal  brasses  from  a  railroad  yard  and  was 
sent  to  Pontiac.  While  there  he  assisted  in  teaching  the  younger  boys  in  the 
school.  After  one  year  he  was  let  out  on  parole ;  came  back  here  and  got  in 
trouble  again.  Laboratory  tests,  it  was  stated,  revealed  that  he  was  only 
eight  years  in  intelligence,  and  yet  he  had  passed  successfully  and  with  credit 
the  second  year  of  the  Englewood  High  School  two  years  before.  Any  test 
applied  arbitrarily  has  its  failings. 

It  seemed  to  him,  furthermore,  not  that  the  test  itself  is  invalid  for  the 
purposes,  but,  as  had  been  suggested,  its  devotees  try  to  make  it  reach  further 
than  originally  conceived  or  planned.  The  over-enthusiastic  zealot  of  any 
ism  is  the  worst  enemy  of  that  ism,  and  by  claiming  more  for  any  system 
than  is  warranted  leads  it  into  disrepute.     Binet's  test  certainly  has  its  place. 


172  CHICAGO  XEi'ROLOGICAL  SOCIETY 

The  point  scale  has  even  a  better  place.  But  no  matter  what  tlie  test,  we 
must  study  the  individual,  as  Dr.  Healy  suggested.  ^lany  children  are  "  ear- 
minded  "  when  they  come  to  school.  At  home  they  have  learned  from  stories, 
from  parents  who  have  instructed  them  by  talking.  They  can  only  learn 
through  the  ear.  They  find  it  hard  to  learn  through  the  eyes,  alone,  from 
books  and  blackboard  and  consequently  do  not  attain  the  standard  of  that 
grade. 

Another  point,  with  regard  to  the  child  being  interested.  The  speaker 
had  a  child  brought  to  him  the  other  day,  w^ith  the  idea  of  putting  him  in  a 
school  for  the  feebleminded.  He  was  twelve  years  of  age,  and  could  not 
spell  cat,  but  he  could  spell  all  the  names  of  automobiles.  He  was  interested 
in  them.  He  was  put  in  a  shop  on  Michigan  Avenue,  and  he  is  clever  and 
bright,  and  can  read  all  the  automobile  catalogues  of  parts  and  prices.  That 
is  a  question  of  the  concrete  as  against  the  abstract,  already  referred  to  by 
Dr.  Healy. 

Dr.  L.  Harrison  Mettler  wished  to  emphasize  two  points  which  had  been 
brought  out  indirectly  by  Dr.  Healy.  It  seemed  to  him  that  in  testing  tlie 
mind  by  the  Binet  method  or  the  apparatus  shown  by  Dr.  Healy,  one  is  hark- 
ing back  to  the  old  idea  that  somehow  or  other  the  mind  is  an  entity  that 
can  be  measured.  In  the  earlier  days  of  philosophy  and  ancient  history  they 
had  the  mind  all  mapped  out.  It  was  arranged  in  psychology  like  a  sort  of 
checkerboard  whereby  you  could  determine  what  you  had  and  did  not  have. 
Then  later  it  was  determined  that  there  were  no  such  things  as  faculties,  but 
mere  cerebral  reactions.  If  one  reads  modern  psj-chology,  its  growth  and 
development,  correctly,  one  comes  to  the  conclusion  that  there  is  no  such 
■entity  as  mind  in  the  sense  of  being  a  measurable  thing.  Each  man  presents 
his  own  individual  reactions.  Those  reactions  are  dependent  upon  physio- 
logical conditions,  various  toxins  and  so  forth,  as  well  as  fibers  and  tracts 
about  which  we  know  as  yet  comparatively  little.  In  the  future  there  prob- 
ably will  be  no  books  written  upon  insanity  as  a  disease  process.  There  will 
be  no  psychiatric  diseases;  but  everj-  man  who  is  unfortunate  enough  to  lose 
his  mind  will  present  his  own  individual  clinical  picture,  depending  wholly 
upon  his  physiological  state  and  his  past  history  and  present  environment. 
This  is  absolutely  different  amongst  us  all.  So  it  seemed  to  Dr.  Mettler  that 
the  marked  trend  in  the  newer  psychology  is  to  a  study  of  the  entire  physiol- 
ogy of  the  individual,  anl  not  to  a  harking  back  to  some  fixed  standardization, 
or  sort  of  rule  of  thumb,  as  worked  out  by  Binet  and  some  others.  Though 
it  seemed  to  the  speaker  that  we  were  working  along  a  wrong  line,  he  admitted 
it  is  well  worth  testing  out.  He  furthermore  said  it  was  refreshing  to  hear 
a  man  with  the  authority  of  Dr.  Healy  take  such  a  careful  and  conservative 
view  as  to  insist  upon  the  many  factors  that  must  enter  into  the  determining 
of  a  man's  mental  state. 

The  other  point  Dr.  Mettler  wished  brought  out  more  strongly  was  that 
a  psychological  examination  diflfered  from  all  other  examinations.  It  is  one 
thing  examining  a  like  thing,  one  mind  examining  another  mind.  It  has  been 
well  remarked  that  every  patient  who  is  having  his  mind  examined  is  at  the 
same  time  examining  the  examiner's  mind.  The  latter  must  remember  tliat 
he,  as  well  as  the  community,  and  the  general  mental  status  of  his  environ- 
ment are  also  under  examination  by  the  patient  or  his  representatives.  This 
point  ought  to  be  emphasized  very  strongly.  For  example  a  patient's  morality, 
his  sexual  trends,  his  desires  and  modes  of  activity  must  all  be  considered  in 
connection  with  the  general  status  of  the  community  in  which  he  lives  and 
has  had  his  development. 

Before  a  community  can  say  absolutely,  except  upon  the  very  broadest, 
coarsest  lines,  what  is  a  normal  mind  that  community  itself  has  got  to  come 
up  to,  or  represent,  the  highest  standard  of  morals,  of  intelligence,  of  learning, 


CHICAGO  NEUROLOGICAL  SOCIETY  173 

and  in  fact  of  everything  that  is  known  in  the  moral  and  intellectual  history 
and  activity  of  the  world.  To  affirm  the  normal  is  a  mighty  task,  and  we  are 
far  from  the  end  of  it.  The  speaker  believed  that  there  was  no  such  thing 
as  a  normal  mind  as  commonly  understood ;  only  an  ever  growing  and  pro- 
gressing state  of  cerebral  reaction.  The  end  of  this  growth  no  one  can  yet 
foresee.  But  at  all  events  it  is  not  yet  in  sight  and  hence  nothing  in  the  way 
of  strict  normality  can  be  predicated  of  it  at  this  time. 

Dr.  Mej^er  Solomon  wished  to  refer  to  a  point  made  by  Dr.  Krohn,  that 
of  imagery.  We  know  that  some  individuals  are  able  to  take  more  with  the 
ear,  some  with  the  eyes.  Dr.  Solomon  stated  that  he  witnessed  Dr.  Healy 
examine  an  individual  who  was  unable  to  pass  a  Binet  scale  in  the  ordinary 
waj^,  but  with  the  emplo3-ment  of  visual  memory  tests  the  child  was  able  to 
pass  the  scale.  That  brings  home  clearly  that  the  Binet-Simon  scale  is  really 
an  auditory  imagery  test  to  a  great  extent.  Only  a  few  of  the  things  in  the 
Binet  scale  bring  out  the  visual  memory  of  the  individual.  Also,  in  the  immi- 
grant, where  we  have  all.  sorts  of  individuals  from  all  parts  of  the  world,  they 
do  not  use  the  Binet-Simon  scale.  It  has  been  a  failure  there  absolutely,  and 
they  must  use  tests  of  the  sort  that  Dr.  Healy  has  helped  to  construct.  One 
race  is  not  like  the  other.  This  is  one  thing  which  should  be  impressed  upon 
us,  that  in  a  city  like  Chicago  we  have  a  combination  of  all  races,  and  since 
the  environment  and  racial  bringing  up  are  big  factors,  we  see  it  here  also 
as  with  the  immigrant — the  Binet-Simon  scale  is  not  applicable  in  too  many 
cases.  With  all,  we  may  say,  however,  the  Binet-Simon  scale  is  a  great  aid. 
In  children  under  ten  years  of  age,  having  language  defect,  in  the  majority 
of  instances  it  works.  In  individuals  over  that  age  it  is  a  problematical  propo- 
sition, and  there  we  must  take  into  consideration  the  life  history  more  than 
at  the  previous  age. 

One  other  thing  which  we  should  always  remember  is  the  medical  aspect. 
The  tonsils,  adenoids,  and  vision  and  general  health  have  a  great  deal  to  do 
with  mental  states  in  many  instances. 

Dr.  Clara  Schmitt  said  one  point  had  come  up  two  or  three  times,  namely, 
the  use  of  language  in  our  tests.  The  speaker  knew  Dr.  Healy  did  not  under- 
value in  his  w"ork  the  place  of  language  in  mental  life,  and  we  should  be 
careful  not  to  undervalue  its  place  in  mental  tests.  Surely  the  higher  processes 
of  mental  life,  reasoning,  and  so  forth,  can  take  place  most  largely  only  with 
language.  We  cannot  get  very  far  in  reasoning  with  concrete  experiences. 
You  could  not  arrive  at  a  law  of  much  far-reaching  effect  with  only  concrete 
experiences.  Language  certainly  does  belong  to  the  highest  phases  of  intel- 
lectual life.  It  is  true  that  we  have  a  great  many  people  who  are  expert  in 
all  the  concrete  phases  of  human  life,  and  j^et  very  inexpert  when  they  come 
to  the  spoken  or  written  symbols.  Yet  that  is  a  very  important  ability  in- 
deed, and  it  is  there  that  we  find  a  great  deal  pf  trouble  in  our  work  with 
school  children.  There  are  a  great  many  children  who  can  test  up  very  well 
with  all  concrete  tests,  yet  never  can  learn  to  read.  That  sort  of  s3'mboliza- 
tion  is  not  possible  with  them.  We  don't  want  to  lose  sight  of  the  fact  that 
this  constitutes  a  very  serious  defect. 

Dr.  Frances  Dickinson  said  that  she  remembered  when  she  taught  school 
in  Chicago  thirty-three  years  ago  that  in  September  she  used  to  have  all  the 
left-overs  who  did  not  pass  the  examinations — about  fiftj'-five  to  sixtj-  pupils. 
There  were  no  two  alike.  The  trouble  is  that  there  are  so  many  children  in 
school  who  have  handicaps,  and  the  teacher  tries  to  teach  all  children  in  a 
class  alike.  The  consequence  is  that  some  of  them  fail.  There  was  not  a 
feebleminded  one  in  the  lot.  All  the  speaker  had  to  do  was  to  use  sense 
enough  to  find  out  what  each  child  lacked,  and  treat  thern  individually.  Much 
depends  on  the  teacher. 

Dr.  Edward  H.  Ochsner  said  that,  as  always,  the  essayist  had  given  us  a 


174  CHICAGO  NEUROLOGICAL  SOCIETY 

great  deal  of  food  for  thought.  One  or  two  of  the  points  brought  out  he 
wished  to  refer  to.  First,  that  historj-  does  repeat  it&elf.  When  the  speaker 
first  began  to  practice  medicine,  there  were  certain  members  of  the  pro- 
fession who  felt  that  they  could  diagnose  almost  everything  with  the  micro- 
scope. It  took  a  long  time  for  the  laboratory  worker  to  discover  that  he 
too  could  make  mistakes,  and  it  is  refreshing  indeed  that  in  the  very  infancy 
of  this  new  science  a  man  like  Dr.  Healy  will  come  before  us  and  tell  us  that 
feeblemindedness  must  be  judged  from  every  possible  point  of  view;  that  the 
laboratory  alone  is  going  to  leave  the  investigator  in  the  lurch  many  times. 
The  one  thing  that  neurologists  and  psychologists  need  to  learn  just  at  present 
more  than  any  one  other  thing  is,  that  feeblemindedness  is  a  big  subject  which 
cannot  be  measured  by  one  single  foot  rule.  These  cases  must  be  investi- 
gated from  ever}'  possible  angle. 

The  second  point  to  which  he  wished  to  refer  was  the  fact  that  it  >vas 
e.xtremely  pleasing  to  those  who  worked  so  hard  to  get  the  bill  for  the  com- 
mitment of  feebleminded  persons  enacted  into  law  to  have  a  man  of  Dr. 
Healy's  ability,  experience  and  standing  in  the  community  to  come  before  the 
Society  and  say  that  the  law,  which  became  effective  on  the  first  of  July,  is  a 
commonsense,  workable  measure.  If  it  is  a  sane  and  reasonable  and  work- 
able law,  you  have  such  men  as  Dr.  Healy  and  such  women  as  Dr.  Towne  and 
many  other  good  citizens  of  the  state  of  Illinois  to  thank  for  it.  One  of  the 
reasons  why  it  is  a  good  law  is  because  every  person  in  the  state  of  Illinois 
who  was  supposed  to  know  something  about  feeblemindedness  was  requested 
to  assist  in  the  drafting  of  the  law.  If  we  could  get  all  kinds  of  people  to 
interest  themselves  in  every  important  measure  which  comes  before  the  legis- 
lature, this  state  and  this  nation  would  be  a  very  much  better  place  to  live  in. 
If  we  could  get  lawyers,  and  doctors,  and  psychologists,  and  sociologists,  and 
judges,  and  farmers,  and  laborers,  and  mechanics,  to  get  together  and  discuss 
and  draft  a  law  on  the  questions  of  labor  and  capital,  the  problem  could  be 
reasonably  solved  within  five  years.  And  so  on  with  all  of  the  important 
problems  that  have  so  much  to  do  with  the  welfare  and  happiness  of  the 
people  of  this  country. 

Dr.  Healy,  in  closing  the  discussion,  said  he  was  much  interested  in  Mr. 
Kohs's  remarks,  also  in  what  he  has  come  to  do  for  us  in  this  community,  in 
his  work  at  the  House  of  Correction.  It  is  to  be  hoped  that  he  will  be  able 
to  answer  some  of  the  problems  which  have  been  suggested  in  the  speaker's 
paper.  By  follow-up  work  he  may  be  able  to  tell  us  something  of  how  far 
we  are  going  to  be  able  to  rely  on  tests  for  telling,  by  an  examination  in  adult 
life,  how  the  individual  ranked  mentally  during  childhood.  At  present  that 
is  not  at  all  certain.  Dr.  Healy  stated  that  he  was  very  familiar  with  the 
work  done  at  Vineland  in  gauging  of  individuals  by  the  Binet  tests.  How- 
ever, it  must  be  remembered  that  tliere  they  are  working  with  institutional 
cases,  cases  which  have  been  already  sent  to  them  with  a  diagnosis  made,  cases 
which  are  obvious,  not  with  the  peculiar  and  difficult  types  so  frequently  seen 
outside  institutions.  Also,  a  word  should  be  spoken  concerning  tlie  use  of 
these  tests  as  applied  down  there  to  adults.  No  doubt  the  Binet  tests  do 
grade  their  cases  very  satisfactorily,  but  can  the  same  be  said  of  adults  on 
the  outside,  where  the  social  opportunities  and  world-experience  have  been 
so  completely  different? 

Concerning  the  Pethrick  case,  the  speaker  felt  there  was  a  great  deal  to 
it  when  the  social  investigations  which  had  been  made  were  turned  into  his 
hands  ;  facts  gathered  by  people  who  were  not  biased  on  either  side. 

Dr.  Schmitt  brought  up  the  question  of  language  and  the  point  that  we 
should  not  undervalue  it  as  a  medium  of  thought.  Of  course,  we  should  not. 
We  may  remember  the  famous  controversy  between  the  Duke  of  Argyll  and 
Max  Mueller  concerning  whether  thoughts  came  before  words  in  the  history 


CHICAGO  NEUROLOGICAL  SOCIETY  175 

of  the  world  or  in  the  development  of  the  individual.  It  is  an  important  point 
to  note  that  language  does  play  a  vital  part  in  our  thought  processes.  An 
estimation  of  an  individual's  mentality  is  never  complete  without  taking  this 
into  account.  And  yet,  as  the  speaker  had  endeavored  to  point  out,  there 
were  many  other  tests  that  were  of  value  for  deciding  whether  or  not  a  per- 
son was  of  normal  mentality. 

Just  such  a  point  comes  out  in  regard  to  the  "  Yerkes  Ideational  Test" 
exhibited  this  evening.  The  early  users  of  this  test,  as  well  as  the  speaker 
and  Dr.  Bronner,  have  found  that  there  are  types  of  individuals,  both  in  the 
normal  and  feebleminded  classes,  who  can  do  this  test  satisfactorily ;  that  is, 
who  can  get  the  idea,  the  scheme  of  it,  in  their  head  so  that  they  can  solve 
the  problem  over  and  over,  and  yet  who  cannot  frame  the  idea  or  scheme 
in  language  that  serves  as  an  adequate  guide  to  the  solution, 

November  18,  1915 

The  President,  Dr.  J.  C.  Gill,  in  the  Chair 

AN  EXPERIMENTAL  STUDY  OF  SUGGESTIBILITY  IN  CHILDREN 

By  Clara  Harrison  Town,  M.D. 

Dr.  Town  said  that  the  term  suggestibility  as  used  in  this  study  signifies 
a  mental  influence  which  caused  the  person  influenced  to  think  and  to  act 
without  the  evidence  of  his  own  will. 

After  a  brief  summary  of  previous  experimental  studies  of  suggestion  in 
the  waking  state,  a  report  was  made  of  a  recent  study.  A  group  of  five  sug- 
gestion tests,  all  devised  by  Binet,  were  used  with  a  group  of  forty  twelve- 
year-old  boys  and  a  group  of  thirty  fifteen-year-old  boys.  The  aim  of  the 
study  was  primarily  to  determine  whether  there  is  a  marked  difl^erence  in  the 
degree  of  suggestibility  at  these  two  ages,  and,  further,  to  determine  whether 
suggestibility  in  one  test  indicates  suggestibility  of  like  degree  in  other  tests. 
The  average  suggestibility,  with  the  A.D.,  S.D.  and  P.E.,  the  coefficient  of 
variability  and  the  P.K.m  were  calculated  for  each  group  for  each  test.  All 
averages  not  justified  by  P.E.  and  P.E.j/  were  omitted  from  final  analysis. 
The  probable  error  of  the  difference  of  averages  for  the  two  age  groups  for 
each  test  was  also  calculated,  and  unless  it  justified  the  differences  they  were 
not  recognized. 

The  averages  of  three  of  the  five  tests  are  worthy  of  consideration, 
those  of  the  other  two  tests  are  invalidated  by  the  size  of  their  probable  errors. 
The  importance  of  the  probable  error  is  shown  by  the  fact  that  age  differ- 
ences in  achievement  might  have  been  inferred  from  these  averages  had  they 
been  considered  without  reference  to  their  probable  errors.  Such  inference 
would  be  unjustified. 

Only  one  test  showed  a  reliable  age  difference.  This  was  Test  4,  which 
depended  entirely  upon  the  arrangement  of  test  material  for  its  suggestion. 

The  correlations  between  the  results  of  Tests  i,  4  and  5  for  the  twelve- 
year  and  for  the  fifteen-year  group  were  worked  out  by  the  "  Product- 
Moments  "  Method  of  Pearson.  There  was  a  correlation  between  Tests  4 
and  5  for  both  age  groups.  This  was  the  only  correlation  found.  It  is  sig- 
nificant that  both  of  these  tests  were  based  upon  judgments  of  visual  stimuli, 
though  the  suggestion  was  in  one  case  purely  personal  and  in  the  other  was 
given  by  a  suggestive  arrangement  of  material.  There  was  no  correlation 
between  the  results  of  the  tests,  one  of  which  was  based  on  a  judgment  of 
weight  and  the  other  on  a  judgment  of  visual  stimuli,  although  the  sugges- 
tion in  both  cases  was  given  by  a  suggestive  arrangement  of  material. 


176  CHICAGO  XEUROLOGICAL  SOCIETY 

Dr.  Moj-er  said  that  his  thought  was  a  possible  differentiation  of  those 
adult  disorders  of  the  nervous  system's  psj-chological  mechanism,  in  which  it 
is  believed  that  suggestibility  is  a  prominent  factor.  Could  these  tests  be  used 
in  such  abnormal  cases?  He  asked  if  any  studies  had  been  made  on  abnormal 
people,  and  he  thought  it  certainly  would  be  better  to  have  a  test  than  a  man's 
individual  judgment  about  it. 

Dr.  Town  replied  that  that  is  why  Binet  devised  these  tests.  Pie  tried  to 
devise  tests  that  would  be  applicable  to  just  such  cases  as  Dr.  Moyer  con- 
sidered. She  was  not  sure  whether  such  tests  had  been  made  or  not  on  abnor- 
mal people;  she  had  seen  no  published  reports. 

Dr.  Harold  N.  Moyer  asked  whether  the  system  described  by  Dr.  Town 
could  be  used  in  adults  also ;  whether  suggestibilitj-  seems  to  be  greater  in  the 
child  than  in  the  adult ;  and  whether  the  system  would  be  of  any  value  in 
studying  the  psychology-  of  adults  in  relation  to  suggestibility,  such  as  we 
understand  it  in  a  medical  way.  Could  tests  be  devised  that  would  be  simple 
for  clinical  application? 

Dr.  Town  replied  that  most  of  the  tests  previously  made  on  suggestibility 
have  been  made  on  adult  subjects,  and  that  suggestibility  seems  to  be  greater 
in  the  child.  The  tests  she  had  described  were  very  simple.  It  only  takes 
fifteen  minutes  to  put  a  boj-  through  all  five.  She  could  not  saj-  just  how 
serviceable  the  tests  would  be,  if  applied  as  Dr.  Moyer  suggested,  but  thought 
the}-  might  be  decidedly  so.  She  is  going  to  try  a  group  of  adults  and  com- 
pare them  with  the  children  later.  It  may  turn  out  that  adults  are  just  as 
susceptible. 

Dr.  Meyer  Solomon  asked  whether  the  visual  images  that  take  place 
would  have  anything  to  do  with  it.  One  might  be  susceptible  without  having 
an  imagery.  He  said  that  in  these  tests,  as  in  all  tests,  if  the  persons  were 
not  interested,  you  could  not  depend  upon  the  reaction,  whereas  a  thing  that 
made  an  appeal  to  the  subject  might  show-  that  he  was  not  susceptible  at  all. 
If  it  were  a  playful  game,  to  a  certain  extent,  it  might  not  show  the  capa- 
bility of  the  child  at  all. 

Dr.  Town  said  the  judged  differences  between  lines  of  the  same  length 
are  so  very,  verj-  slight  that  the  visual  images  are  not  probable.  The  boys 
tested  are  generally  interested.  The  judgment  tests  do  appeal  to  them. 
Theoretically,  what  Dr.  Solomon  had  said  about  a  playful  game  might  be  so, 
but  she  did  not  have  any  indications  of  that  in  her  w-ork. 

Dr.  Clara  Schmitt  said  that  children  are  very  anxious  to  adjust  them- 
selves to  the  situation. 

THE  HISTORY  OF  \  FEEBLEMIXDED  FAMILY 
By  Josephine  E.  Young,  M.D. 

Inhfritcd  deformities  of  a  mother  and  two  children  were  shown  in  tliis 
family,  namely,  atypical  tower  skull,  pupillary  distance  of  95  mm.,  with  diver- 
gent strabismus  and  moderate  degree  of  optic  nerve  atrophy,  very  high 
shoulder  girdle,  positive  Wassermann  tests,  and  mental  defects. 

Other  cases  of  inherited  single  deformity,  such  as  polydactylism,  con- 
genital absence  of  patellae,  deformities  of  hands,  and  of  inherited  multiple 
deformities,  such  as  dyostosis  clcido  craniatis  and  dystrophic  periostalis  hy- 
pcrplastica.  all  mentally  normal,  arc  cited.  Two  distinct  types  of  multiple 
deformity.  Mongolism  and  acrocephalic  syndaktylism,  always  occurring  spo- 
radically with  mental  rlcfect  are  also  cited. 

The  etiology  of  abnormalities  is  discusscfl  with  special  regard  to  latent 
lues  and  disturbance  of  internal  glandular  secretion,  the  latter  more  particu- 


CHICAGO  NEUROLOGICAL  SOCIETY  177 

larly  in  relation  to  cretinism  and  hymus  idiocy.  All  types  and  groups  of 
abnormalities  considered  theoretically  in  the  light  of  De  Vries's  mutation  of 
species  in  plants. 

Dr.  Harold  N.  Meyer  asked  Dr.  Young  if  she  had  found  any  description 
in  the  literature  of  that  race  of  idiots  called  Shah  Dahla's  mice.  The  original 
article  was  published  by  an  Indian  surgeon  in  the  Calcutta  Medical  Gazette. 
The  speaker  wrote  to  him  and  in  reply  received  a  copy  of  the  paper,  which 
he  still  has,  and  some  original  photographs  of  these  idiots.  They  are  a 
peculiar  race.  Their  name  is  suggested  by  the  shape  of  the  head — resembhng 
that  of  a  mouse.  They  are  a  localized  race  of  idiots,  connected  with  the 
shrine.  They  are  feebleminded  and  seem  from  generation  to  generation  to 
have  bred  true.  They  are  protected  by  the  priests  of  this  shrine,  and  I  sup- 
pose arrangements  are  made  to  continue  the  breed  indefinitely.  They  do  the 
begging  for  the  shrine. 

Dr.  Young,  in  closing  the  discussion,  said  that  as  in  all  the  literature  only 
22  cases  of  acrocephalic  syndactylism  had  been  found,  and  these  had  only 
recently  been  collected,  it  was  possible  that  there  might  be  other  cases  similar 
to  those  reported  which  diligent  search  would  reveal. 

COOPERATION  OF  PSYCHOLOGIST  AND  PHYSICIAN 
By  Clara  Schmitt,   Ph.D. 

The  physician  can  be  of  help  to  many  types  of  patients  who  seek  his 
advice  only  in  so  far  as  he  is  a  psychologist.  The  practical  psychologist  can 
be  of  great  use  in  determining  mental  capacities  and  educational  regime  for 
the  problem  children  who  seek  the  advice  of  the  physician.  The  following 
case  illustrates  the  kind  of  cooperation  possible.  It  was  worked  out  between 
the  author  and  the  late  Dr.  D'Orsay  Hecht. 

Bertha  N..  nine  years  of  age,  became  the  victim  of  an  obsession  two  day.s 
before  the  calling  of  the  physician.  The  obsessive  act  consisted  of  the  inser- 
tion of  the  finger  into  the  throat,  causing  suffocation  and  brutality  to  the 
throat.  Physically  the  child  was  frail  in  appearance ;  the  gait  was  spastic- 
ataxic,  that  of  a  diplegia ;  choreatic  movements  of  both  hands ;  a  cerebral 
diplegia,  a  generalized  rigidity  but  more  in  the  legs ;  vasomotor  system  a  little 
but  not  much  impaired ;  sensory  system  normal ;  superficial  reflexes  exag- 
gerated ;  a  Babinski  reaction  on  the  right,  uncertain  left ;  slight  drooping  of 
upper  eyelid ;  reaction  to  light  and  accommodation  somewhat  sluggish ; 
tongue  tremor  of  choreiform  character  and  slight  speech  defect.  The  advice 
given  was  that  the  child  be  observed  for  masturbatory  practices  ;  a  mental 
examination  to  determine  ability  and  educational  possibilities ;  and  a  system 
of  training  and  control. 

The  mental  examination  showed  the  child  normal  in  mental  ability.  The 
examination  also  discovered  a  motor  control  so  poor  that  the  child  was 
thereby  unable  to  carry  out  many  of  the  promptings  of  a  very  active  mind. 
There  was  great  emotional  instability.  Careful  observation  did  not  confirm 
the  suspicion  of  masturbatory  practices.  The  explanation  arrived  at  for  the 
obsessive  act  was  that  the  child  was  constrained  to  it  by  reason  of  having 
been  pushed  out  of  her  customary  place  in  the  family  life  which  was  organized 
about  her  interests  and  needs,  by  a  throat  operation  upon  her  younger  sister. 

The  patient  was  accepted  at  a  private  school  and  given  some  special  atten- 
tion. She  improved  rapidly  in  motor  control,  in  emotional  control  and  made 
normal  progress  in  scholarship.  The  tremor  of  the  fingers  is  still  serious 
enough  to  interfere  with  writing.     This  impedes  her  work  somewhat. 

This  patient  was  saved  to  a  life  of  usefulness  and  happiness  by  a  fortu- 


178  CHICAGO  NEUROLOGICAL  SOCIETY 

nate  diagnosis  and  proper  educational  care.  One  adviser  had  diagnosed  her 
as  mentall)'  defective  and  recommended  an  institution  for  feebleminded  chil- 
dren. Another  advised  tliat  she  be  not  permitted  to  attend  school  but  live  a 
simple  life  in  the  countrj-.  The  latter  recommendation  did  not  recognize  the 
fact  that  she  had  a  very  active  and  capable  mind,  much  hampered  by  the  poor 
motor  possibilities. 

Dr.  Schmitt  said  that  the  school  to  which  the  little  girl  had  been  sent  was 
the  Francis  Parker  School  on  the  North  Side.  It  is  not  designed  for  educating 
such  cases.     They  have  onl}-  a  few  children  in  each  room. 

Dr.  Harold  N.  Moyer  thought  the  analysis  of  the  case  by  Dr.  Schmitt 
was  verj-  interesting.  At  present  our  child  study  is  not  very  broad.  As  com- 
monly carried  out,  it  consits  in  the  application  of  Binet  test  and  removal 
of  adenoids.  This  was  the  first  report  in  which  the  motor  deficiency  in  the 
hands  was  the  predominating  defect  in  the  education  of  a  child  in  a  normal 
way,  and  yet,  after  all,  it  is  only  what  we  see  every  day  and  all  about  us. 
The  ability  to  use  the  hands  for  fine  coordinated  movements  varies  enormously. 

Dr.  Meyer  Solomon  tliought  the  paper  of  Dr.  Schmitt  was  very  inter- 
esting. He  thought  tliat  perhaps  the  family  conditions  might  have  been 
responsible,  to  a  great  extent,  for  the  type  of  reaction  displayed  by  the  child. 
In  view  of  the  fact  that  the  child  was  defective  in  the  motor  sphere,  perhaps 
the  mother  was  responsible  by  loving  her  too  much,  in  this  way  bringing  on 
this  egotistical  projection  of  herself  into  situations  in  which  she  demanded 
attention.  There  was  no  doubt  in  the  speaker's  mind  that  if  the  child  had 
been  permitted  to  remain  at  home,  eventually  she  would  have  been  unfit  to 
hold  her  proper  place  in  the  world,  and  it  is  really  due  to  Dr.  Schmitt  and 
Dr.  Hecht  that  the  child  will  be  able  to  successfully  fight  her  battle  in  life. 

The  whole  problem  opened  up  by  the  paper  is  one  which  ought  to  be 
forced  home  upon  the  profession  more  and  more.  The  fact  that  from  now 
on,  at  any  rate,  we  are  not  going  to  look  after  the  physical  aspects  only,  but 
that  the  mental  are  coming  more  and  more  into  the  field  of  neurology,  the 
speaker  thought  was  encouraging,  since  we  know  that  the  functional  neuroses 
and  psychoneurotic  states  are  far  more  frequent  than  the  organic,  and  the 
outlook  for  these  patients  is  far  better.  It  brings  us  a  great  deal  of  hope  for 
the  future  treatment  and  outcome  in  these  conditions. 

Dr.  James  C.  Gill  asked  if  he  understood  the  essayist  correctly,  namely, 
that  the  limbs  were  spastic  and  a  Babinski  present. 

Dr.  Schmitt  said  that  Dr.  Gill  had  understood  her  correctly.  It  was 
hoped  that  the  child  would  learn  to  control  her  hands  sufficiently  for  writ- 
ing, but  she  has  now  been  in  school  for  three  years,  and  thus  far  has  not 
gained  sufficient  control.  Her  writing  is  so  poor  that  it  interferes  with  her 
school  work  to  some  extent. 

Just  another  incident  in  regard  to  the  motor  control  in  this  little  girl. 
Her  writing  was  so  poor  that  Dr.  Schmitt  recommended  that  they  get  a  type- 
writer for  her,  and  that  maybe  she  could  learn  to  use  that.  She  is  able  to 
hammer  out  a  few  tunes  on  the  piano.  So  it  is  hoped  that  the  typewriter  will 
help  her  in  her  school  work. 

Dr.  Gill  asked  if  there  was  a  double  Babinski  in  this  case,  to  wliich  Dr. 
Schmitt  replied  that  it  was  positive  on  the  left  side. 


XTranelationa 


VEGETATIVE    NEUROLOGY.     THE   ANATO^IY,    PHYSI- 
OLOGY, PHARMODYNAMICS  AND  PATHOLOGY 
OF  THE  SYAIPATHETIC  AND   AUTO- 
NOMIC SYSTEMS^ 

By  Heinrich  Higier 

WARSAW 

Authorized  Translation  by  Walter  Max  Kraus,  A.M.,  M.D. 
[New  York]. 

(Continued  from  page  80) 

The  ganglion  system  described  in  the  section  on  comparative 
anatomy  is  most  conspicuously  seen  in  the  thoracic  and  upper  lumbar 
regions  where  the  segmental  structure  of  lower  animals  is  preserved 
more  than  in  any  other  place.  Thus,  the  twelve  thoracic  vertebra 
ribs  have  twelve  corresponding  ganglia. 

In  the  cervical  and  lumbar  regions,  where  the  embryonic  arrange- 
ment is  lost,  the  ganglia  fuse,  a  fact  which  may  be  seen  by  their 
mulberry-like  form. 

Thus  it  is  found  that  in  the  neck  there  are  fused  growths  of 
ganglia,  superior,  middle  and  inferior  ganglia,  while  in  the  lumbar 
region  several  of  the  ganglia  are  incomplete  and  insignificant-looking. 

So  much  for  the  sympathetic  cord,  its  vertebral  ganglia,  and 
their  relation  to  the  spinal  ganglia  of  the  spinal  cord. 

In  regard  to  the  branches,  the  following  is  the  usual  classification  : 

I.  Arterial  branches  or  vascular  plexi. 

(a)  Cranial  or  carotid  plexus.  This  begins  at  the  upper  cervical 
ganglion,  and  passes  cranialwards,  surrounding  the  carotid  arteries. 
It  supplies  the  cranial  cavity  with  sympathetic  fibers. 

(b)  Thoracico-aortic  plexus.  This  supplies  the  heart,  aorta, 
lungs  and  esophagus. 

(c)  Aortico-abdominal  plexus.  This  encircles  the  three  large 
unpaired  branches  and  supplies  the  abdominal  viscera  and  the  mesen- 
tery with  fibers. 

1  Vegetative  oder  Viscerale  Neurologic,  Ergebnisse  der  Neurologic  und 
Psychiatric.     Vol.  II,  No.  i.     Vcrlag  von  Gustav  Fischer,  Jena. 

179 


1 80  H EI N RICH  H ICIER 

Other  smaller  plexi  are  the  laryngeal,  thyroid,  cardiac,  pulmo- 
nar}-,  esophageal,  celiac,  mesenteric,  renal,  spermatic,  hypogastric, 
uterine,  vesical  and  cavernous. 

II.  Peripheral  branches  connect  with  the  important  cardiac 
branches  of  the  abdominal  cavity.  The  cardiac  branches  are  given 
off  from  the  third  cervical  ganglion  and  from  the  cardiac  plexus. 
The  splanchnic  branches  are  given  off  from  the  lower  six  thoracic 
ganglia  and  go  from  the  thoracic  to  the  abdominal  cavity,  where 
they  supply  the  gastro-intestinal  tract  and  its  appendages. 

III.  Communicating  brandies  connect  the  sympathetic  ganglia 
with  the  anterior  spinal  roots.  This  makes  an  important  connecting 
path  between  the  sympathetic  and  central  nervous  systems. 

In  the  make  up  of  the  sympathetic,  the  third  part  of  the  central 
nervous  system,  there  are  to  be  found  other  large  structures  of  ob- 
scure nature,  as  paraganglia,  chromaffinic  glandular  structures  and 
the  prevertebral  celiac,  cardiac  and  stellate  ganglia.  Of  these  more 
will  be  said  below. 

What  has  been  said  thus  far  includes  the  main  points  of  import  in 
the  gross  anatomy  of  the  human  sympathetic  system. 

It  now  becomes  a  question  of  accounting  for  the  close  relations 
of  the  sympathetic  to  vascular  and  spinal  structures.  What  is  the 
significance  of  the  sympathetic  cord  ?  Is  it  a  special  single  nerve,  or 
a  conglomeration  of  various  nerves?  W^hat  purpose  do  the  sympa- 
thetic plexi,  and  the  large  thoracic  and  abdominal  ganglia  lying  next 
the  vertebral  ganglia  serve?  What  is  the  relation  of  the  rami  com- 
municantes  to  the  sympathetic  cord  on  the  one  hand,  and  to  the 
spinal  cord  on  the  other?  These  are  the  main  questions  which  we 
wish  to  try  to  answer  on  pure  anatomical  bases. 

The  dorsal  spinal  cord,  and  the  near-by  sympathetic  will  serve  as 
a  paradigm  for  the  explanation  of  these  important  questions.  These 
sections  have  retained  more  than  any  others  the  metameric  type,  as 
revealed  by  comparative  anatomical  and  embryological  studies.  They 
offer  opportunities  to  study  the  characteristics  of  the  vegetative 
system  from  a  morphological  point  of  view,  thus  leaving  out  the 
necessity  of  using  the  evidence  to  be  gained  by  delicate  biologico- 
chcmical  reagents.  These  latter  reactions  will  be  considered  later. 
The  metameric  type  of  structure  is  entirely  lacking  in  the  cranial 
part  of  the  vegetative,  while  in  the  cervical  and  sacral  parts  it  is,  as 
has  been  saitl  before,  but  poorly  developed. 

In  long  past  epochs,  as  phylogeny  teaches,  the  "urhirn"  alone 
played  the  role  of  ruling  functions  controllerl  by  the  nervous  system. 
Each  segment  of  the  nervous  system  probably  had  its  own  separate 


VEGETATIVE  NEUROLOGY  i8i 

spinal  and  sympathetic  nerves,  each  metamere  was  autonomous,  and 
had  Httle  to  do  with  its  neighbors.  The  somatic  regions  of  a  seg- 
ment inchided  the  ganghon  cells  of  the  spinal  cord  which  subserved 
the  function  of  transmitting  the  impulses  to  and  from  voluntary 
muscles,  and  of  receiving  impulses  from  the  overlying  skin.  The 
vegetative  regions  supplied  the  automatically  acting  involuntary 
muscles  with  motor  nerves,  and  the  organs  of  its  own  segment  with 
sensory  nerves.  Visceral  receptor  nerves  are  found  not  only  in 
mucous  membranes,  which  are  normally  considered  sensitive  to 
stimuli,  but  also  in  all  the  tissues  and  organs,  as  the  liver,  lungs, 
blood  vessels  and  kidneys.  The  receptors  for  this  part  of  visceral 
innervation  probably  pass  in  the  paths  from  the  spinal  ganglion  cells, 
and  go  thence  to  the  central  system  via  spinal  ganglia. 

The  central  origin  in  the  spinal  cord  of  the  vegetative  tracts  is 
most  probably  in  Clarke's  columns,  and  in  the  lateral  segments  of  the 
gray  matter  (the  lateral  horn  of  the  spinal  cord).  From  there,  the 
nerve  fibers  pass  out  via  the  anterior  roots  as  thin,  white  and  medul- 
lated,  centrifugal  fiber  bundles  (ramus  communicans  albus  s.  effer- 
ens).     They  pass  to  the  vertebral  ganglia  (see  Fig.  i). 

The  fibers  are  always  interrupted  in  a  ganglion,  the  so-called 
"  synapse."  They  then  leave  the  ganglion  cells  as  another  gray, 
motor,  unmedullated  fiber  bundle  (ramus  communicans  griseus  s. 
afiferens).  They  are  centrifugal,  but  never  centripetal.  These  go 
uninterrupted  to  the  peripheral  vegetative  end  organ,  be  it  the  pupil, 
heart,  lung,  stomach,  sweat  glands,  hair  muscle  or  vascular  muscle. 

The  white  rami  branch  ofif  in  the  ganglia  of  the  sympathetic  cord 
in  such  a  way  as  to  yield  three  to  five  branches  which  entwine  them- 
selves about  a  corresponding  number  of  ganglia  (Langley,  Onodi). 
Every  ganglion  cell  of  the  sympathetic  cord  has  but  one  axis  cylinder. 
This,  as  a  gray  fiber,  proceeds  to  the  periphery  (Van  Gehuchten). 

The  communicating  tracts  there  are  divided  in  their  course  into 
a  white  and  gray  branch,  or  more  generally  speaking,  into  a  pre-  and 
post-ganglionic  part.  As  a  rule  the  white  rami  go  from  the  spinal 
cord  to  the  sympathetic  cord,  and  the  gray  rami  go  from  the  sym- 
pathetic cord  to  the  viscera,  or  via  the  spinal  nerves  of  the  end  organs 
at  the  periphery. 

In  a  cross-section  of  a  metamere,  the  following  is  found : 

1.  The  spinal  anterior  horn  with  its  motor  root  for  the  innerva- 
tion of  voluntary  muscle. 

2.  The  spinal  posterior  sensory  horn  and  the  neighboring  trophico- 
sensory  spinal  ganglion  for  the  reception  of  internal  and  external, 
interoceptive  and  exteroceptive  stimuli. 


I83 


HEINRICH  HIGIER 


2.  The  vegetative  spinal  lateral  horn  with  a  ramus  communicans 
albus,  a  sympathetic  ganglion  and  a  ramus  communicans  griseus. 
These  are  intended  for  glandular  and  hollow  muscular  internal 
organs  (visceral  fibers),  and  for  the  end  organs  of  the  skin  (pilo- 
motor, secretory  and  vasomotor  fibers). 


Spinal  Ganglion 


Skin  Sensibility 


Fig.  I 


Stimulation  of  the  sympathetic  nerves  is  usually  not  perceived  in 
consciousness  (normal  failure  of  sensations  from  vegetative  end 
organs)  but  it  increases  the  tone  and  activates  the  nerves  innervating 
smooth  muscle. 

An  attempt  will  now  be  made  to  identify  the  three  metamcric 
divisions  in  other  regions,  including  the  vegetative  system  where  the 
regular  metameric  structure  is  found  in  modified  form,  or  is  entirely 
lost.  The  following,  partly  developmental,  partly  anatomic  consider- 
ations, show  that  the  original  structure  is  lost  and  that  many  new 
structures  have  appeared. 

(a)  The  unequal  distribution  and  inconstant  position  of  the  ver- 
tebral ganglia  or  synapses  in  which  the  interruption  of  the  sympa- 
thetic fibers  takes  place,  causing  the  spino-peripheral  sympathetic 
fibers  to  be  divided  into  two  parts. 

(6)  The  inconstancy  of  the  rami  communicantes  in  contrast  to 
the  regularity  and  constancy  of  the  intervertebral  ganglia. 

(c)  The  unequal  distribution  of  the  important  sympathetic  cen- 
ters in  the  cerebrospinal  gray  matter. 

(d)  The  incongruity  between  embryonic  metamcrcs  and  later 
cranial  and  spinal  segments. 

These  four  questions  will  be  briefly  considered  theoretically  and 
practically,     f  I'or  pictorial  representations  see  Fig.  i  and  Table  I.) 


VEGETATIVE  NEUROLOGY  183 

I.  The  Unequal  Distribution  and  Inconstant  Position  of  the  So-called 
Synapses. — Every  communicating  branch,  after  leaving  the  spinal 
cord,  is  interrupted  in  a  ganglion  cell  of  the  sympathetic,  and  thus 
forms  two  neurones,  in  contrast  to  the  single  neurone  of  the  somatic 
nervous  S3'stem.  But  all  medullated  sympathetic  fibers  are  not  in- 
terrupted in  the  sympathetic  cord.  Many  fibers  go  through  the 
ganglia  undisturbed  to  proceed  upward  and  downward  to  the  next 
ganglion  where  the  medullary  sheath  is  lost  and  the  fiber  is  inter- 
rupted, becoming  post-ganglionic.  In  this  way,  even  the  sympathetic 
cord  becomes  a  path  for  white  sympathetic  fibers. 

The  sympathetic  nerve  or  ganglia,  the  N.  internodius,  which  joins 
the  vertebral  sympathetic,  has  like  these  latter  a  connective  tissue 
sheath  of  Schwann.  A  cross  section  of  this  nerve  is  not  like  that  of 
an  ordinary  nerve  but  contains  both  sheathed  and  unsheathed  fibers 
as  well  as  ganglion  cells.  Therefore  the  N.  internodius  is  not  a 
nerve  in  the  ordinary  sense,  but  a  much  extended  ganglion,  with 
white  rami  communicantes  included.  This  applies  both  to  the  cerv- 
ical and  abdominal  sympathetic  cord  (N.  splanchinus),  both  of  which 
represent  a  union  of  many  white  rami  communicantes  into  large 
nerve  bundles.  The  sympathetic  cord  is,  therefore,  a  morphological 
but  not  a  functional  entity. 

Many  fibers  destined  to  supply  the  viscera,  after  taking  the  above 
described  course  in  the  sympathetic  cord,  proceed  to  groups  of 
ganglion  cells  in  the  body  activities.  Examples  of  such  fibers  are 
those  to  the  heart  and  uterus.  An  example  of  the  ganglion  cell 
groups  is  the  celiac  plexus  with  its  semilunar  ganglion.  Ganglia 
of  this  type  have  been  designated  prevertebral  ganglia  by  Langley 
and  may  be  dififerentiated  from  the  above  described  vertebral  ganglia 
by  the  fact  that  they  only  supply  viscera  and  that  their  post-cellular 
fibers  never  connect  with  spinal  nerves. 

The  sympathetic  plexus,  of  later  phylogenetic  origin,  may  be 
regarded  as  conglomerations  of  pre-  and  post-cellular  fibers.  From 
this  point  of  view  we  must  regard  the  carotid  plexus  which  accom- 
panies the  carotid  artery  to  the  cranial  cavity  as  a  conglomeration 
of  fine  post-cellular  fibers  which  proceed  cranialward  from  the  cerv- 
ical sympathetic.  Prevertebral  ganglia  are  to  be  differentiated  from 
the  vertebral  ganglia  only  by  their  position.  They  receive  pre- 
ganglionic medullated  fibers,  and  give  rise  to  post-ganglionic  gray 
fibers,  just  as  do  the  vertebral  ganglia.  Many  ganglia,  as  the  su- 
perior cervical  ganglia  which  supply  both  viscera  and  skin  glands, 
are  to  be  regarded  as  a  combined  type  of  vertebral  and  prevertebral 
ganglia. 


1 84  H EI N RICH  H ICIER 

But  it  must  be  added  that  all  fibers  do  not  end  in  the  prevertebral 
ganglia.  -Many  go  distahvard,  uninterrupted,  to  reach  the  immediate 
vicinity  of  their  end-organs  and  are  there  interrupted,  the  white 
fibers  becoming  the  gray.  These  ganglia  are  called  peripheral  or 
terminal  ganglia.  They  exist  in  connection  with  such  organs  as  the 
heart,  intestines  and  salivary  glands.  Many  fibers  even  pass  through 
three  ganglia  on  their  way  to  their  end  organs.  Thus,  for  example, 
the  white  dilator  fibers  of  the  pupil  arise  in  Budge's  cilio-spinal 
center,  proceed  as  white  rami  communicantes  through  the  stellate 
ganglion  and  enter  the  superior  cervical  ganglion.  Here  they  are 
interrupted  and  become  gray  rami  communicantes,  going  to  the  pupil. 

Since  the  ganglionic  interruptions,  the  synapses,  do  not  occur 
at  typical  localities,  but  are  found  not  only  in  the  sympathetic  cord, 
but  also  in  prevertebral  and  peripheral  ganglia,  it  has  become  the 
custom  to  follow  the  classification  of  Langley  in  regard  to  the  to- 
pography of  these  structures.  He  divides  the  ganglia  into  three 
orders,  vertebral,  prevertebral  and  peripheral. 

n.  Inconstancy  of  the  Rami  Communicantes. — In  man,  not  every 
spinal  segment  gives  rise  to  a  communicating  branch.  Thus,  for 
example,  the  cervical  part  of  the  spinal  cord,  corresponding  to  eight 
metameres,  gives  rise  to  none  or  only  isolated  white  rami  and  to 
but  three  cervical  ganglia,  the  superior,  middle  and  inferior.  The 
superior  ganglion  receives  its  precellular,  partly  longitudinal,  intra- 
spinal fibers  from  the  upper  dorsal  segments.  Many  other  sympa- 
thetic ganglia  as  well  receive  fibers  from  several  (5-6)  lower  seg- 
ments (Langley).  On  the  other  hand,  the  sacral  sympathetic  gets  its 
white  rami  not  only  from  the  mid  dorsal  and  lumbar  roots,  but  also 
from  higher  segments  (Gaskell).  In  man,  no  white  rami  are  given 
off  below  the  third  lumbar  nerves.  Hence,  as  may  be  seen  on  Table 
I,  the  cervical  and  sacral  sympathetic  are  to  be  regarded  as  undoubted 
collected  white  rami  communicantes. 

On  the  other  hand,  according  to  Gaskell,  the  post-cellular  gray 
rami  springing  from  the  ganglia  join  the  nearest  spinal  nerves. 
These  carry  fibers  for  the  most  part  to  blood  vessels,  glands  and 
muscles  of  the  skin.  This  occurs  even  in  the  sacral  and  cervical 
sympathetic  portions  of  the  sympathetic,  though  they  do  not  have 
white  rami  from  their  corresponding  spinal  cord  segments. 

III.  Unequal  Distribution  of  the  Vegetative  Centers  in  the  Gray 
Cerebrospinal  Axis. — The  vegetative-automatic  centers  are  not 
equally  distributed  in  the  posterior  segments  of  the  gray  matter  of 
the  region  from  the  mid-brain  to  the  sacral  part  of  the  spinal  cord. 


VEGETATIVE  NEUROLOGY  185 

They  lie  compactly  in  various  regions  from  which  the  customary 
topographical  designations  are  derived.  These  centers  of  origin  are 
mesencephalic,  bulbar,  dorso-lumbar  (from  the  seventh  cervical  to 
the  third  lumbar  segment)  and  the  sacral  (from  the  second  to  the 
fourth  sacral  segment).  This  is  not  meant  to  give  the  impression 
that  the  remaining  parts  of  the  cerebro-spinal  axis  do  not  contain 
centers  for  automatically  acting  organs,  but  that  they  are  probably 
there,  either  rudimentary  in  man  or  occupying  but  very  little  space 
(Table  I). 

IV.  Incongrnity  of  the  Embryonic  Metamercs  zvith  the  Later 
Cranial  and  Spinal  Segments. — Every  ganglionic  segment  supplies 
nerve  fibers  to  that  part  of  the  body  which  represents  its  ontogenetic 
and  embryonic  metamere,  not  to  that  part  which  corresponds  to  it  in 
life  (post- fetal  stage).  This  is  the  cause  of  the  enormous  shifting 
and  apparent  variations  from  the  fundamental  type. 

But  a  few  examples  of  this  will  be  given,  examples  which  in  dis- 
cussing the  sensibility  of  the  sympathetic  system  will  be  found  to  be 
of  very  great  practical  importance. 

For  example,  the  testicle  descends  from  the  renal  region  into  the 
scrotum,  which  leads  to  the  apparently  incongruous  fact  that  the 
scrotum  and  the  testicle,  which  seem  to  be  derived  from  the  same 
body  segments,  are  supplied  one  from  the  lower  sacral  nerves,  the 
other  from  the  upper  lumbar  nerves.  This  accounts  for  testicular 
pain  in  nephrolithiasis  and  for  increased  irritability  of  the  external 
genitals  and  maintained  irritability  of  the  testicle  in  conus  and  caudal 
lesions. 

The  phrenic  nerve  arises  from  the  spinal  cord  in  common  with 
the  fourth  cervical  nerve.  It  supplies,  among  other  things,  the  dia- 
phragm and  the  liver,  thus  accounting  for  pains  in  the  arm  in  chole- 
lithiasis and  diaphragmatic  pleurisy. 

Following  the  development  of  the  upper  extremities  which  are 
placed  between  the  second  and  third  ribs,  we  find  that  the  second  rib 
is  supplied  by  the  four  lower  cervical  nerves,  while  the  third  is  sup- 
plied by  two  thoracic  nerves  (this  accounts  for  pain  in  the  upper  arm 
in  stenocardia). 

The  urinary  bladder  is  supplied  by  the  upper  lumbar  nerves  in 
that  part  which  is  developed  from  the  allantois,  while  its  lower  part, 
developed  from  the  cloaca,  is  supplied  by  the  middle  sacral  nerves. 

In  considering  organs  which  are  vegetative  in  function  par  excel- 
lence, the  vagus  takes  a  prominent  place,  since  this  nerve  arising  in 
the  medulla,  that  is  a  cranial  nerve,  supplies  all  of  the  thoracic  and 
most  of  the  abdominal  viscera.     This  happens  because  the  nerve  in 


1 86  H El N RICH  H ICIER 

the  lower  animals  from  which  man  has  developed  extended  far 
caudalward,  and  because  these  organs,  though  far  distant  from  the 
origin  of  the  nerve,  lay  closer  to  the  head  in  these  animals.  This 
applies  particularly  to  the  heart,  lungs  and  stomach.  As  a  matter  of 
fact,  the  apparently  irregular  location  of  the  three  vagal  nuclei  in  the 
medulla  is  in  reality  quite  like  that  of  the  corresponding  motor  sen- 
sory and  vegetative  centers  in  the  cord,  when  it  is  recalled  that  the 
nucleus  ambiguus  is  motor,  the  nucleus  solitarius,  sensory,  and  the 
dorsalis,  visceral,  and  that  the  medulla  is  but  a  continuation  of  the 
spinal  cord  with  this  difference,  that  the  central  canal  is  widened 
into  the  fourth  ventricle  and  the  posterior  columns  and  posterior 
horns  are  pushed  laterahvards. 

As  is  well  known,  the  somato-motor  vagus  nucleus  supplies  the 
voluntary  muscles  of  the  pharynx  and  larynx,  the  somato-sensory 
nucleus  the  meninges,  and  the  mucous  membranes  of  the  external 
auditory  canal,  the  larynx  and  bronchi,  the  visceral  nucleus,  the 
heart,  lungs,  stomach,  liver,  pancreas  and  upper  parts  of  the  in- 
testines. 

What  we  find  of  practical  value  from  the  morphology  of  the 
vegetative  system,  when  we  consider  the  descensus  splanchnicus  (de- 
velopmental progress  caudalward  of  organs)  as  an  example,  is  that 
the  rami  communicantes  of  the  visceral  vagal  nucleus,  from  which 
arise  the  autonomic  fibers  for  the  intestine,  after  passing  through  the 
synapse  of  the  jugular  ganglion  near  the  base  of  the  skull  (corre- 
sponding to  a  sympathetic  vertebral  ganglion),  travel  from  one  half 
to  one  third  the  length  of  the  body  to  reach  the  peripheral  ganglion 
cells  in  its  end  organs. 

After  this  rather  lengthy  departure  from  the  main  plan  of  this 
chapter,  we  shall  now  return  to  the  subject  in  hand  and  give  a  brief 
recapitulation  of  the  anatomic  relations  of  the  most  important  ganglia 
of  the  body. 

The  uppermost  ganglion  of  the  sympathetic  cord,  the  superior 
cervical  ganglion  or  first  sympathetic  ganglion,  receives  its  pre-cel- 
lular  fibers  from  the  last  cervical  segment  (C  8)  and  the  upper 
dorsal  segments  (D  1-3).  These  supply  the  skin  glands,  blood 
vessels  and  pilomotor  muscles  of  the  head  as  well  as  the  dilator 
pupill?e  muscle  and  Mullcr's  flat  orbital  muscle. 

The  inferior  cervical  ganglion  and  the  stellate  or  first  thoracic 
ganglion  supply  accelerator  nerves  to  the  heart  and  most  probably 
vaso-constrictor  fibers  to  the  pulmonary  vessels.  The  preganglionic 
fibers  arise  from  D  1-5. 

The  largest  ganglion  of  the  abdominal  cavity,  the  celiac,  gives  ofif 


VEGETATIVE  NEUROLOGY  187 

the  most  important  branches  in  the  celiac  plexus,  the  major  and 
minor  splanchnic  nerves.  The  first  is  made  up  of  fibers  from  the 
fourth  to  the  ninth  dorsal  ganglion,  the  latter  from  the  tenth  to  the 
twelfth  ganglia.  They  all  leave  the  thoracic  cavity  by  an  aperture 
in  the  diaphragm  and  go  to  the  celiac  ganglion  as  precellular  fibers. 
From  there,  they  go  as  the  mesenteric  nerves  to  supply  the  stomach 
glands,  liver,  pancreas,  spleen,  kidneys,  adrenals,  and  intestines  (as 
far  as  the  descending  colon). 

The  inferior  mesenteric  ganglion  receives  precellular  fibers  from 
the  upper  lumbar  cord  (L  1-3)  and  sends  its  unsheathed  post-gangli- 
onic  fibers  to  the  colon  and  via  the  hypogastric  nerves  to  the  anus, 
bladder,  vesical  sphincter  and  genitals. 

Furthermore  mention  must  be  made  of  the  fact  that  the  middle 
part  of  the  dorso-lumbar  sympathetic  cord  sends  fibers  to  end 
organs  in  the  skin,  the  blood  vessels  of  skeletal  muscles  and  of  all 
the  viscera  between  the  mouth  and  rectum. 

(To  be  continued) 


IPertecopc 

Monatsschrift  fiir  Psychiatric  und  Neurologic 
(Vol.  34.  Xo.  4) 

1.  The  Fechng  of  "  Strangeness."    A.  Kutzixski. 

2.  Contrihution  to  Heterotopia  of  the  Gray  Substance  in  the  Brain.     S.  Oskki, 

3.  Concerning  the  Explanation  of  Suggestive  Symptoms.     Bunxemann. 

4.  Cystic  Tumor  of  the   Brain   with   Symptoms   of   Hydrocephalus   Internus. 

Fr.  a.  Meyer. 

1.  J'ccliuci  of  "  Straiujciicss." — Tlie  theories  of  this  condition  which  have 
been  advanced  by  Wernicke,  Juliusberger,  Goldstein  and  otliers  are  shown  to 
be  fallacious.  It  is  due  to  a  loss  of  a  part  or  all  of  the  physical  or  body  ego. 
We  have  gradually  come  to  automatically  adjust  our  body  complex  in  our 
consciousness  so  that  we  are  not  usually  aware  of  it.  As  a  result  of  a  dis- 
turbance of  the  relationship  a  part  of  the  bodj"  complex  may  become  altered 
and  strange.  At  first  the  patient  says,  for  example,  "  I  feel  as  though  my 
brain  were  dead,"  but  as  the  condition  becomes  more  aggravated  an  actual 
delusion  is  formed  and  the  patient  says,  "  My  brain  is  dead."  A  number  of 
case  abstracts  are  given. 

2.  Heterotopias. — Three  cases  of  heterotopia  of  the  gray  matter  beneath 
the  ependyma  of  the  lateral  ventricles  are  described.  In  two  of  these  were 
well-developed  ganghon  and  pyramidal  cells.  Heterotopic  gray  matter  is 
found  most  often  in  brains  of  cases  of  mental  disorder,  especially  hydro- 
cephalus, epilepsy  and  idiocj'.  They  are  formed  at  about  the  sixth  month  of 
fetal  life  while  the  arrangement  of  the  graj-  and  white  matter  is  in  progress. 

3.  Suggestion  Reactions. — The  author  assumes  that  a  great  deal  of  con- 
fusion exists  as  to  what  constitutes  suggestion.  W'hen  a  hypnotized  person 
is  told  that  a  piece  of  paper  laid  on  his  hand  is  red  hot  iron  and  the  skin 
shows  a  burn  beneath,  this  is  called  suggestion.  But  wliat,  asks  the  author, 
is  suggestion?  By  a  series  of  deductions  and  a  comparison  with  primitive 
principles  he  shows  that  the  only  way  to  understand  such  phenomena  is  to 
conceive  of  a  sensory  stimulus,  a  sensory  "appraisal"  of  the  stimulus  and  a 
sensory  reaction. 

4.  Cystic  Brain  Tumor. — Following  a  severe  fall  upon  the  buttocks  a  boy 
of  thirteen  years  developed  symptoms  which  pointed  strongly  to  a  left-sided 
internal  hydrocephalus.  Death  occurred  after  two  years.  Section  showed 
?j\  infundibular  tumor  of  ectodermal  origin  with  large  cysts  in  both  frontal 
iobes.  The  case  is  thoroughly  described  clinically  and  anatomically,  but  is 
admittedly  such  a  rarity  that  little  of  diagnostic  value  can  be  derived  from  it. 

(Vol.  34.  No.  5) 

1.  The  I'tniction  of  the  Middle  Lobe  of  the  Cerebellum.     M.  Rotiimaxx. 

2.  Psychiatry  and  Child-teaching,  with  Special  Reference  to  the  Question  of 

the  Psycboi)atbic  Child.     E.  Stier. 

3.  Schizophrenic   Symptoms,   Muscular   Excitability  and   Mucosal  Reflexes  in 

a   Case   of   Neurosis    from    Lightning    Stroke. — The   Determination   of 
Indemnity  in  Such  Cases.     K.  Degenkolb. 

188 


PERISCOPE  189 

4.  The  Disease  of  the  Sisters  Weilemann.     M.  Christinger. 

5.  Tumor  of  the  Base  which  Became  Regressive  after  Palliative  Trepanation. 

E.  Roper. 

1.  CcrcbelliDH. — Experiments  upon  dogs  show  that  destruction  of  the 
anterior  lobe  of  the  cerebellum  without  going  into  the  nuclei  causes  astasia 
of  the  head  with  a  tendency  for  it  to  be  drawn  backward.  Later  a  weakness 
of  the  cheeks  and  tongue  with  a  peculiar  ataxia  of  the  lips  and  inability  to 
bark.  The  extremities  also  show  ataxia,  especiall^^  the  shoulder  region. 
Deeper  partial  extirpation  shows  that  the  innervation  of  the  tongue  and 
larynx  is  in  the  cortex  of  the  ventral  portion  near  the  fourth  ventricle.  Ex- 
tirpation of  the  lobus  medianus  posterior  produces  ataxia  of  the  extremities 
and  head  and  weakness  of  the  rump  muscles.  If  only  the  very  anterior  por- 
tion is  affected  a  head  tremor  results.  Total  destruction  of  the  middle  por- 
tion of  the  cerebellum  causes  at  first  total  loss  of  locomotion  which  later 
partially  disappears,  but  leaves  weakness  and  ataxia  of  head  and  limbs.  In 
man  the  middle  lobe  of  the  cerebellum  is  prominently  developed  on  account 
of  his  erect  posture. 

2.  Psychiatry  and  Education. — The  advances  in  the  study  of  feeblemind- 
edness and  allied  conditions  have  been  so  rapid  that,  in  spite  of  the  splendid 
work  of  Kraepelin,  of  Ziehen  and  others,  we  find  ourselves  without  a  satis- 
factory' classification  of  psychopathic  children.  As  a  primary  division  the 
author  recognizes:  (i)  weakminded  children,  (2)  psychopathic  children  and 
{3)  children  both  weakminded  and  psychopathic.  As  psychopathic  he  classes 
those  who  show  abnormalities  in  the  philogenetically  older  life-elements — 
instinct  and  affect.  The  weakminded  are  such  as  show  gross  intellectual 
defect.  The  psychopathic  are  divided  into  two  groups  for  which  he  sug- 
gests the  words  "  hyponitent "  and  "  hypernitent."  The  former  show  re- 
duction in  intensity  of  the  instincts  and  emotions — they  are  usually  of  a 
neuropathic  type.  They  are  weak  in  all  their  fundamental  physiological 
processes,  they  lack  initiative,  are  subject  to  anxiety  and  feeling  of  uncer- 
tainty. The  hypernitent  have  exaggerated  instincts  and  emotions  and  fre- 
quent perversions.  They  usually  require  constant  institutional  supervision. 
A  few  suggestions  as  to  treatment  and  prognosis  are  given,  but  the  main 
object  of  the  paper  is  a  discussion  of  the  relationship  of  psychiatry  to  the 
problem  of  the  care  of  the  defective  children  and  to  encourage  cooperation  of 
those  working  in  the  two  fields. 

3.  Lightning  Neurosis. — A  case  is  described  of  a  man  fifty  years  of  age 
who  received  a  shock  when  a  building  two  hundred  yards  away  was  struck 
by  lightning.  The  symptoms  which  followed  were  somewhat  similar  to  those 
of  schizophrenia  and  there  were  also  certain  neurological  symptoms,  the  most 
important  of  which  were  altered  electrical  reaction  in  a  number  of  the  mus- 
cles and  loss  of  the  palate  and  pharyngeal  reflexes  in  the  mouth.  A  large 
part  of  the  article  deals  with  the  aspect  of  the  case  from  the  standpoint  of 
degree  of  disability  and  amount  of^insurance  recoverable.  The  question  of 
the  mechanism  of  electric  shock  from  a  relatively  remote  lightning  .stroke  is 
also  discussed. 

4.  The  Weilemann  Sisters. — An  interesting  observation  of  three  sisters 
whose  disease  followed  an  almost  identical  course.  Epileptic  attacks  began 
in  early  life  and  deep  dementia  supervened.  The  neurological  picture  ap- 
proached most  closely  to  Marie's  hereditary  ataxia  but  showed  some  distin- 
guishing features.  The  main  symptoms  were  epileptic  attacks,  secondary 
dementia,  cerebellar  ataxia,  choreo-athetosis,  hypotonia,  infantilism.  All  three 
cases  came  to  autopsy  and  showed  atrophy  of  the  cerebellum  and  cerebrum. 
Microscopically  there  was  a  superficial  gliosis  of  the  brain  cortex — no  dis- 
order of  the  cerebellum. 

5.  Brain  Tumor. — A  man  of  forty-four  years  presented  a  typical  picture 


190  PERISCOPE 

of  brain  tumor  wliich  liad  existed  already  two  jears.  In  1898  a  trephine 
operation  did  not  disclose  the  tumor,  but  brain  puncture  obtained  a  large 
quantity  of  fluid.  A  year  after  the  operation  very  pronounced  mental  and 
physical  sjmptoms  still  existed.  He  showed  right-sided  weakness,  hemian- 
opia  and  almost  complete  blindness.  Memory  and  intelligence  were  much 
reduced,  there  were  well-marked  aphasia  and  alexia.  Twelve  years  later  he 
came  to  the  clinic  in  a  greatly  improved  state.  Hemianopia  still  existed  and 
there  was  slight  ataxia  of  the  right  side,  but  otherwise  little  of  importance. 
Mentally  he  had  regained  almost  his  normal  state.  Symptoms  of  gastric  car- 
cinoma were  present  at  this  time  and  an  operation  found  the  condition  hope- 
less. He  died  soon  afterward.  A  large  cystic  defect  in  the  left  globus  pal- 
lidas indicated  the  location  of  the  tumor  which  had  existed. 


(Vol.  34,  No.  6) 

1.  Motor  Aphasia  and  Apra.xia.     H.  Liepmann. 

2.  The  Treatment  of   Brain  Tumors  and  Indications  for  Operation.     L.  Bruns. 

3.  The  Infection  and  Auto-intoxication  Psychoses.     K.  Bonhoeffer. 

4.  Constitutional  Waking  Dreams — a  Contribution  to  the  Pathology  of  the 

Consciousness  of  Personality.     K.  Heilbroxxer. 

5.  Our  Knowledge  of  Allo-esthesia.     Dusser  de  Barexxe. 

6.  Disorders  of  Grammatic  Speech  in  Brain  Disease.     K.  Goldstein. 

7.  Abducens  Paralysis  of  Reflex  and  Otitic  Origin.     W.  Sterling. 

1.  Aphasia  and  Apraxia. — A  brief  but  comprehensive  exposition  of  the 
author's  theories  of  apraxia  given  in  his  usual  clear  and  readable  style. 
There  is  nothing  in  the  article  which  has  not  already  been  published,  but  he 
lays  further  stress  upon  the  apractic  nature  of  motor  aphasia. 

2.  Brain  Tumor. — The  indications  for  operation  are  given  and  the  rela- 
tive operahility  of  the  different  forms  of  tumor  and  of  different  localities  is 
discussed.  Our  better  surgical  technique  and  the  great  strides  that  have  been 
made  in  cerebral  localization  have  widened  the  possibilities  of  operative 
relief.  A  few  years  ago  a  tumor  of  the  cerebellum  was  considered  inoperable 
— now  operations  on  cerebellar  tumors  almost  outnumber  those  on  the  brain. 
A  more  or  less  complete  cure  results  in  about  ten  per  cent,  of  cases  operated 
upon.  When,  however,  one  considers  that  only  about  thirty  per  cent,  of 
cases  of  brain  tumor  are  operable,  the  percentage  of  surgical  cures  to  the  total 
number  of  brain  tumors  is  only  three  or  four.  The  palliative  trepanation  for 
relief  of  pressure  seldom  cures  or  arrests  the  tumor,  but  often  ameliorates 
the  distressing  symptoms  and  prevents  the  occurrence  of  blindness. 

3.  Infection  Psychoses. — Regarding  the  infection  psychoses  the  author 
asks  and  answers  four  questions.  There  are  no  specific  psychoses  for  dif- 
ferent diseases.  The  attempt  to  draw  an  analogy  with  toxic  psychoses,  which 
vary  with  different  toxic  agents,  has  failed.  There  is  no  ground  for  saying 
that  an-;i  psychosis  may  be  caused  by  infectious  disease.  When  such  conclu- 
sions have  been  drawn  it  has  been  because  too  much  importance  has  been  laid 
upon  the  often  accidental  occurrence  of  an  infectious  disease  before  the  out- 
break of  the  psychosis.  Infection  psychoses  cannot  be  divided  according  to 
the  course  of  the  infectious  disease  into  initial  delirium,  infection  delirium, 
collapse  delirium  and  exhaustion  psychosis.  The  disease-picture  in  any  of 
these  periods  may  be  identical  with  that  in  others.  The  whole  group  of 
infection  psychoses  presents  no  symptoms  or  groups  of  symptoms  which  are 
not  found  in  other  psychoses  of  exogenous  origin,  especially  toxic,  but  also 
traumatic  and  circulatory.  Even  if  we  speak  of  psychoses  of  endogenous 
origin  the  only  clinical  picture  which  is  never  found  in  the  endogenous  psy- 
choses is  that  of  the  Korsakoff  amnestic  syndrome  or  of  a  true  delirium. 


PERISCOPE 


191 


4.  Waking  Dreams. — A  case  is  described  of  a  young  man  who  was  sub- 
ject to  waking  fantasies  almost  constantl}^  He  fancied  himself  in  all  sorts 
of  situations — saw  himself  dead  and  lying  in  a  grave.  These  dreams  were 
very  vivid  and  occupied  most  of  his  time.  He  was  a  healthy  individual  and 
there  were  no  other  evidences  of  mental  defect.  The  most  conspicuous  fea- 
ture of  the  condition  was  the  marked  lability  of  the  personal  consciousness, 
which  Bonhoeffer  has  grouped  among  the  degenerative  disorders.  A  com- 
parison of  the  condition  with  that  of  hallucinatory  states  and  deliria  is  gone 
into  and  the  medico-legal  aspects  touched  upon.  There  is  no  doubt  that  such 
patients  should  be  treated  as  mentally  ill  and  receive  at  least  a  certain  amount 
of  supervision.  There  is  also  some  hope  of  much  improvement  with  proper 
treatment  and  education. 

5.  AUoesthcsia. — Alloesthesia  is  a  condition  in  which  a  touch  or  pain 
stimulus  to  one  side  of  the  body  is  felt  in  the  corresponding  location  on  the 
other  side.  The  stimulus  may  or  may  not  also  be  felt  at  the  location  where 
applied.  The  author  undertook  interesting  experiments  upon  animals  which 
consisted  of  hemi-section  of  the  cord  combined  with  strychninization  of  a 
more  caudal  lying  segment  causing  hyper-excitability  of  this  region.  The 
experimental  conditions  seemed  to  be  satisfactorily  analogous  to  previously 
described  clinical  cases  and  showed  that  the  symptom  of  alloesthesia  results 
from  blocking  of  the  sensory  paths  of  one  side  of  the  cord  combined  with  a 
state  of  hyper-excitability  of  a  segment  of  the  same  side  of  the  cord  lying 
caudal  to  the  point  of  section.  If  the  section  and  the  strychninization  were 
more  than  three  segments  apart  the  stimulus  was  felt  on  both  sides. 

6.  Agrammatism. — The  grammatical  construction  of  speech  depends  upon 
two  different  elements.  The  train  of  thought  must  be  arranged  into  a  syn- 
tactic chain  with  proper  arrangement  of  its  divisions.  The  outward  ex- 
pression depends  for  its  correctness  upon  an  intact  speech  apparatus.  Gram- 
matic  disorders  dependent  upon  the  one  are  symptomatically  quite  distinct 
from  those  caused  by  the  other.  The  "  speech  forms  "  of  agrammatism  are 
various.  The  so-called  telegraphic  speech  is  due  to  disorder  of  the  motor 
speech-field.  Sensory  agrammatism  is  a  result  of  amnestic  and  of  central 
aphasia.  Agrammatism  due  to  disorder  of  thought  is  most  9ommonly  found 
in  trans-cortical  aphasia  and  is  shown  by  disorderly  arrangement  of  words 
which,  in  themselves,  are  correctly  formed. 

7.  Abducens  Paralysis. — Two  cases  are  described  in  which  purulent  otitis 
media  was  accompanied  by  abducens  paralysis.  The  symptom  in  each  case 
followed  lumbar  puncture.  Vomiting  was  also  a  prominent  symptom.  Vari- 
ous theories  of  the  cause  of  the  paralj^sis  are  discussed,  of  which  the  reflex 
theory  seems  to  apply  best  to  the  author's  cases. 

J.  W.  MooRE. 

Journal  of  Mental  Science 

(Vol.  58,  No.  241) 

1.  The  Cerebrospinal  Fluid  in  Certain  Mental  Conditions.     William  Boyd. 

2.  Insanity  with  Myxedema.     G.  F.  Barham. 

3.  A  Case  of  Double  Personality.     Bernard  Hart. 

4.  Aphasia    in    General    Paralysis    and    the    Conditions    Associated    with    it. 

Edward  Mapother. 

5.  "  Forced   Feeding."     A   Case   Continuously   Fed   by  the   Nasal   Tube   for 

Over  Nine  Years.     David  Blair. 

6.  Inherited  Tendency  to   Insanity  in   Rural    Population.    James   Frederick 

Carson. 


192  PERISCOPE 

7.  Dr.  Turner's  Paper  on  Classification,  and  Other  Matters.     C.  Mekcier. 

8.  Comments  on  Dr.  Mercier's  Criticism  of  Dr.  Turner's  Paper.     John'  Turner. 

9.  Medical  Examination  of  Backward  Children  in  Schools.     John  Fortuxe. 

1.  Cerebrospinal  Fluid  in  Mental  Conditions. — After  a  discussion  of  the 
properties  of  the  cerebrospinal  fluid  and  the  accepted  methods  of  examina- 
tion, Boyd  describes  the  results  of  examination  of  119  cases,  mostly  of  various 
psychoses.  His  conclusions  in  the  case  of  paresis  and  tabes  coincide  with 
those  of  most  observers,  but  he  has  found  lymphocytosis  also  in  cases  he 
calls  "  dementia  prjccox  "  and  others,  "  epileptics."  Findings  so  contrary  to 
the  usual  would  make  it  desirable  to  have  the  diagnoses  verified  by  detailed 
case  records,  which  are  not  given  in  this  paper. 

2.  Insanity  with  Myxedema. — Barham  calls  attention  to  the  fact  that  there 
are  cases  of  insanity  associated  with  myxedema,  in  which  the  psychical  symp- 
toms do  not  clear  up  although  the  physical  disease  may  disappear  under 
thyroid  treatment.  Analysis  of  a  case  follows  in  which  are  demonstrated  as 
etiological  factors  elements  of  (i)  emotional  conflict,  i.  e.,  unsatisfactory 
marriage,  (2)  alcohol,  (3)  m\xedema,  (4)  insane  heredity. 

3.  A  Case  of  Double  Personality. — Hart  relates  a  case  subject  to  hyster- 
ical amnesias  or  "  fugues,"  the  lost  memories  being  gradually  recovered  by 
hypnosis.  In  the  process  of  anahsis,  certain  repressed  memories  or  "  sore 
spots "  were  reached  which  caused  a  sudden  change  of  demeanor  in  the 
patient.  He  became  very  antagonistic,  repudiated  the  physician,  was  sus- 
picious and  non-cor)perative.  This  state  the  author  called  the  "one  fifth 
man,"  the  usual  cooperative  personality  "the  four  fifth  man."  The  "one 
fifth  man"  gradually  diminished  in  potency  as  the  buried  memories  were 
brought  to  the  surface,  and  he  finally  disappeared  complete!}'  after  the  anal- 
ysis (which  is  not  given)  had  been  sufficiently  carried  out. 

4.  Aphasia  in  General  Paralysis. — Mapother  illustrates  by  appropriate 
cases  the  fact  that  aphasia  may  occur  in  general  paralysis:  (i)  as  a  purely 
functional  condition  without  demonstrable  postmortem  lesion  ;  (2)  as  a  result 
of  special  localized  intensity  of  the  ordinary  morbid  process  constituting  gen- 
eral paralysis:  (3)  from  subdural  hemorrhage;  (4)  from  focal  lesions  caused 
by  arterial  disease  associated  with  general  paralysis. 

5.  Forced  Feeding. — Blair  cites  a  case  in  detail  of  a  woman  patient  who 
was  tube  fed  for  over  nine  years.  He  advocates  the  nasal  method  and  shows 
how  this  is  a  necessary,  safe  and  efficient  routine  measure  as  employed  in 
hospitals  for  the  insane. 

6.  Inherited  Tendency  to  Insanity. — Following  a  general  discussion  of 
the  problem  of  heredity,  quotations  from  some  of  the  literature  and  statistical 
findings  in  1,131  cases,  Corson  gives  twelve  illustrative  pedigrees  with  accom- 
panying charts.  From  these  the  most  striking  features  of  heredity  are:  (i) 
The  persistent  transmission  from  generation  to  generation  seen  in  the  longer 
pedigrees;  (2)  accentuation  of  the  transmitted  tendency  by  unsuitable  mar- 
riage and  by  the  associated  occurrence  of  alcoholism,  phthisis,  epilepsy  and 
other  neuroses;  (3)  tendency  to  elimination  by  the  contending  influence  of  a 
sound  parent  resulting  in  improvement  and  gradual  return  to  normal  in  later 
generations;  (4)  association  of  insanity  with  one  sex  to  a  much  greater 
extent  than  with  the  other  is  seen  in  some  of  the  pedigrees. 

7.  Classification  and  Other  Matters.— A  rather  bitter  and  personally  sar- 
castic attack  by  Mcrcier  on  Turner's  paper  on  "Classification"  which  appeared 
in  a  recent  number  of  The  Journal  of  Mental  Science. 

?>.  Comments  on  Dr.  Mercier's  Criticisms. — Turner  briefly  replies  to  the 
criticism  of  Mercier  in  a  like  manner. 

9.  Back-unrd  Children  in  Schools.— Voriunc  writes  of  the  medical  exami- 
nation of  backward  school  children.  Out  of  12,000  children,  112  were  found 
to  be  feebleminded.     A  printed  card  with  spaces  to  be  filled  on  one  side  by 


PERISCOPE  193 

the  medical  oflficer,  and  on  the  other  side  by  the  teacher,  in  the  case  of  feeble- 
minded or  epileptic  children,  is  appended. 

(Vol.  58,  No.  242) 

1.  Production  of  Leucocytosis  in  the  Treatment  of  Mental  Diseases.     R.  Dods 

Brown  and  Donald  Brown. 

2.  Abnormal  Development  of  Scalp.  T.  W.  McDowall  and  Colin  McDowall. 

3.  Some  Dreams  and  their  Significance.     Sir  George  H.  Savage. 

4.  Varieties   of   Dementia.     Dementia  in  Relation  to   Responsibility.     Robert 

Jones. 

5.  Therapeutic  Value  of  Thyroid  Feeding  in  Mental  Diseases.     Richard  Eager. 

6.  Emanuel  Swedenborg,  Psychologist.     Hubert  J.  Norman. 

7.  Physical  Basis  of  Mental  Disease.     Ivy  Mackenzie. 

1.  Production  of  Leucocytosis. — Starting  with  the  proposition  that  "  some 
forms  of  mental  disorder  are  due  to  toxins,  many  of  which  are  microbic  in 
origin,"  it  seems  a  justifiable  treatment  to  stimulate  the  bodily  defenses  against 
toxemia.  The  authors  review  the  literature  as  to  the  various  methods  of  pro- 
ducing a  leucocytosis,  especially  the  administration  of  nucleic  acid  and  its 
salts,  and  the  metallic  ferments,  and  the  results  in  mental  disease.  They 
treated  nine  patients,  five  of  acute  delirious  insanity,  two  of  melancholia,  one 
of  dementia  prsecox,  catatonic  type,  and  one  of  general  paralysis,  in  several 
cases  of  acute  delirious  insanitj',  there  being  produced  a  quite  marked  leuco- 
cytosis with  physical  improvement  and  decrease  of  excitement. 

2.  Abnormal  Development  of  Scalp. — After  an  exhaustive  discussion  of 
the  literature,  the  authors  conclude  that  corrugations  or  folds  sometimes 
seen  in  the  scalp  over  the  vertex  of  the  skull  are  due  in  the  majority  of  cases 
to  the  fact  that  the  skull  is  abnormally  small,  the  scalp  being  too  voluminous 
for  what  it  enclosed.  In  other  words,  there  is  an  arrested  development  of 
the  skull  but  a  normal  growth  of  the  skin  over  it,  making  it  necessary  for  the 
skin  to  arrange  itself  in  folds.  Where  in  some  cases  there  is  a  normal 
sized  skull,  the  skin  condition  must  be  explained  upon  the  hypothesis  of 
hypertrophy. 

3.  Some  Dreams  and  their  Significance. — Savage  states  that  a  study  of 
dreams  may  assist  in  diagnosis,  that  the  dream  may  replace  the  petit  mal  attack 
or  represent  the  aura  in  an  epileptic,  in  the  latter  case  the  subject  passing  into 
an  automatic  state.  Erotic  dreams  may  give  rise  to  false  charges  of  assault 
in  neurotic  persons.  Dreams  may  be  the  first  symptom  of  a  mental  disorder, 
e.  g.,  a  dream  of  horror,  ushering  in  a  maniacal  attack.  The  author  regards 
"happy  dreams"  in  cases  of  "chronic  melancholia"  as  indicative  of  a  favor- 
able prognosis. 

4.  Varieties  of  Dementia. — Jones  introduces  a  general  discussion  of  the 
question  from  several  standpoints:  (i)  The  actual  meaning  of  the  technical 
term  "  dementia "  and  varieties  seen  in  primary  conditions ;  (2)  amount  of 
"  mental  weakness  "  the  term  connotes,  /.  e.,  that  exists  compatible  with  re- 
sponsibility or  liability  to  punishment;  (3)  question  as  to  the  existence  of 
partial  as  against  complete  insanity  or  partial  as  contrasted  with  complete 
responsibility.  He  concludes  that  the  term  dementia  applies  to  those  states 
of  mental  weakness  which  occur  in  persons  who  have  been  previously  in  full 
and  complete  possession  of  their  normal  or  the  average  intellectual  faculties, 
excluding  idiocy,  imbecility  and  feeblemindedness.  The  actual  commence- 
ment of  dementia  may  be  difficult  to  determine  and  it  is  also  difficult  to  fix 
the  line  of  demarcation  in  dementia  between  the  amount  of  mental  weakness 
consistent  with  responsibility  (senile  persons,  for  example)  and  that  which 
may  be  technically  the  dementia  of  insanity. 


194  PERISCOPE 

5.  Therapeutic  Value  of  Thyroid  Feeding. — Eager,  in  a  paper  which  in- 
cludes a  discussion  of  the  hterature  and  numerous  charts,  both  clinical  and 
statistical,  reaches  some  definite  conclusions.  The  question  arises  as  to  how 
much  the  reported  improvement  in  cases  of  insanity  has  not  been  due  to 
rest  and  nursing  rather  than  thjroid  treatment.  The  treatment  is  costly  and 
requires  considerable  close  attention  of  physician  and  nurse.  The  extract 
appears  to  act  as  a  powerful  alterative.  Cases  of  stupor  or  melancholia  occur- 
ring in  adolescents,  where  the  condition  is  not  of  long  standing,  are  the  most 
likely  to  be  benefited.  Cases  of  dementia  prsecox  or  other  mental  disorders 
with  a  tendency  to  chronicity  are  not  likely  to  be  improved.  Signs  of  im- 
provement do  not  appear  until  about  four  to  six  weeks  after  treatment  has 
been  discontinued. 

6.  Emanuel  Swedenborg,  Psychologist. — While  to  the  average  person 
Swedenborg  maj-  be  associated  with  the  visionary  period  of  his  life  as  exem- 
plified by  his  later  writings,  j-et  his  earlier  work  should  entitle  him  to  a 
lasting  place  as  a  scientist,  a  philosopher  and  psychologist.  Norman  in  his 
paper  gives  extensive  quotations  from  the  writings  of  Swedenborg  tending  to 
show,  following  his  exhaustive  anatomical  study,  his  conception  of  the  physio- 
logical action  of  the  brain  and  nervous  system  and  the  psychological  application. 

7.  Physical  Basis  of  Mental  Disease. — Mackenzie  starts  with  two  gener- 
alizations :  (i)  That  "there  is  essentially  no  difference  in  kind  between  a 
physiological  and  a  pathological  process.  The  distinction  is  an  arbitrary 
one:  the  course  of  disease  is  distinguished  from  that  of  health  only  in  so  far 
as  it  tends  to  compromise  the  continuation  of  a  more  or  less  perfect  adapta- 
tion between  the  organism  and  its  surroundings."  (2)  That  diathesis  or 
heredity  "  is  of  no  practical  importance  from  the  point  of  view  of  eliciting 
etiology,"  that  there  is  some  other  determining  factor.  Taking  dementia 
praecox,  the  author  says  that  there  may  be  an  acute  disease  process  manifested 
at  first  by  some  obvious  disturbances  of  bodily  functions  as  may  be  evi- 
denced, it  may  be,  by  such  symptoms  as  fever,  leucocytosis,  etc.  This  may 
last  for  months  or  years  with  recovery  but  with  a  damaged  brain.  The  patient 
settles  down  into  an  ordinary  dement,  or  a  patient  who  has  recovered  from 
his  brain  disease  so  far  as  possible.  General  paralysis,  however,  is  regarded 
by  the  author  as  a  truly  chronic  and  progressive  disease  and  does  "  not  tend 
to  come  to  a  standstill  in  the  same  manner  as  does  dementia  praecox." 

(Vol.  58,  No.  243) 

1.  Presidential    Address,    Medico-Psychological    Association.     J.\mes    Greig 

SOUTAR. 

2.  Mental  Deficiency  Bill.     Theo.  B.  Hvslop. 

3.  Dementia  Praecox  in  Relation  to  Apraxia.     Robert  Jones. 

4.  Lunacy  Service  in  Germany.     R.  G.  Rows. 

5.  Appendicitis  in  Hospitals  for  the  Insane.    John  Frederick  Briscoe. 

1.  Presidential  Address,  Medico-Psychological  Association. — Soutar  op- 
poses the  tendency  to  belittle  British  psychiatry.  He  feels  that  the  fact  that 
they  "  do  not  possess  institutions  like  the  highly  equipped  state-sUpported 
clinics  and  research  laboratories  which  have  existed  for  many  years  else- 
where," shows  that  their  advocates  fail  to  prove  that  the  results  are  "  com- 
mensurate with  the  financial  burden."  He  is  also  not  in  sympathy  with  what 
he  calls  the  "  false  value "  attached  to  the  possession  of  a  diploma  in  psy- 
chiatry or  the  idea  that  this  diploma  is  essential  for  success  or  advancement 
in  the  service. 

2.  Mental  Deficiency  Bill. — A  lengthy  discussion  of  the  legislative  pro- 
posals for  the  care  and  control  of  the  mentally  defective  opened  by  Dr.  Theo. 
B.  Hyslop. 


PERISCOPE  195 

3.  Dementia  Prcccox  in  Relation  to  Apraxia. — Jones,  using  an  address  by 
Dr.  Mabille  of  France  on  the  above  subject  as  the  basis  for  his  paper,  pre- 
sents a  brief  resume  of  the  theorj^  of  apraxia,  caUing  attention  that  the  ana- 
tomical lesion  is  an  interruption  of  one  or  the  other  groups  of  association 
fibers  or  those  described  as  commissural.  The  case  described  by  Mabille  pre- 
sented peculiarities  such  as  retardation  of  mental  reaction  which  might  be 
interpreted  as  "  ideational  dyspraxia,"  persistence  of  obsessions  giving  rise  to 
the  symptoms  "  perseveration,"  etc.  The  diagnosis  was  in  doubt,  there  being 
suggestions  of  dementia  prsecox,  psjxhasthenia.  hysteria  and  melancholia. 

4.  Lunacy  Service  in  Germany. — Rows  writes  of  the  position  of  assistant 
physicians  in  the  "  asjdum  service  "  in  Germany,  the  conditions  under  which 
they  work,  and  their  qualifications,  also  outlines  the  teaching  and  other  facili- 
ties afiforded  by  the  clinic  at  Munich. 

5.  Appendicitis  in  Hospitals  for  the  Insane. — Briscoe  calls  attention  to  the 
rarity  of  appendicitis  among  the  insane  and  ascribes  this  to  the  system  of 
dieting  and  regulation  of  the  bowels  practised  in  hospitals  for  the  insane. 
Considerable  discussion  followed  this  paper. 

(Vol.  58,  No.  244) 

1.  Mental  Organization.     Henry  AlAyosLEV. 

2.  Presidential  Address.     Sir  George  H.  Savage. 

3.  Death  Certification  and  Registration.     Sidney  Coupland. 

4.  Care  of  the  Defective  in  America.     Winifred  AIuirhead. 

5.  Mental  Disorder  with  Childbearing.     Geoffrey  Clarke. 

6.  Urethritis  in  General  Paralysis.     Harvey  Baird. 

1.  Mental  Organization. — As  opposed  to  the  dualistic  theory  of  mind  and 
body,  Maudsley  discusses  mental  processes  as  the  product  of  the  activity  of 
the  whole  body,  motor  as  well  as  sensory.  The  present  complex  mental 
organization  may  be  considered  the  result  of  a  gradual  transition,  an  organic 
evolution.  The  "  organized  federation  of  many  nervous  plexuses  or  so  called 
complexes  "  seldom  acts  as  a  whole ;  parts  may  be  unduly  exaggerated,  while 
others  are  weakened  or  inhibited. 

2.  Presidential  Address. — A  discussion  of  present-day  problems,  such  as 
heredity  and  Freudian  psjxhoanalysis,  with  a  plea  for  the  cultivation  of  an 
open  mind  with  "  prudent  unbelief." 

3.  Death  Certification. — A  consideration  of  certification  of  death,  histor- 
ically and  otherwise,  with  special  reference  to  the  insane.  The  paper  is  ac- 
companied by  a  number  of  diagrams  and  statistical  tables.  In  the  discussion 
following,  much  space  is  taken  up  with  the  different  points  of  view  as  to  the 
meaning  of  "  primary  "  and  "  secondary  "  causes  of  death. 

4.  The  Care  of  the  Defective  in  America. — A  description  of  some  of  the 
institutions  for  the  feebleminded  of  Massachusetts,  Pennsylvania  and  New 
Jersey. 

5.  Mental  Disorder  in  Child-Bearing. — From  a  study  of  seventy-five  cases 
of  insanity  occurring  during  pregnancy,  the  puerperium  or  lactation,  Clarke 
summarizes  his  conclusions  as  follows : 

1.  That  almost  any  form  of  mental  disease  may  be  met  with  during  preg- 
nancy or  lactation,  but  by  far  the  commonest  varieties  are  the  acute  confu- 
sional  and  the  manic-depressive  psychoses. 

2.  In  these  two  forms  of  mental  disease  the  prognosis  is,  as  a  rule,  good, 
but  in  other  forms  occurring  at  this  time  the  outlook  is  not  nearly  so  hopeful. 

3.  Except  in  some  cases  of  acute  delirium  there  is  no  reason  to  think  that 
toxic  or  hemic  conditions  are  important  factors,  but  the  mental  breakdown 
may  be  looked  upon  as  a  temporary  failure  of  the  mind  to  adapt  itself  to 
physiological  but  unusual  conditions. 


195  PERISCOPE 

6.  Urethritis  in  General  Paralysis. — Baird  made  a  postmortem  examina- 
tion of  sixteen  cases  of  general  paralysis  and  found  evidence  of  urethritis  in 
all  cases.  He  comments  on  the  favorable  action  of  hexamethylene-tetramine, 
and  the  presence  of  "  diphtheroids  "  in  cultures  from  the  urethra. 

W.    C.    S.VNPY. 

MISCELLANY 

Survival  .xno  \'irilexce  of  Poliomyelitic  Microorganism.     Flexner,   Xo- 
guchi  and  Amoss.     (Journal  of  Exper.  Med.,  Vol.  21,  No.  i.) 

In  previous  reports  the  authors  described  their  findings  of  an  organism 
of  poliomjelitis.  They  here  describe  a  strain  which  they  have  cultivated  for 
thirteen  months.  This  minute  microorganism  cultivated  from  poliomyelitic 
tissues  survived  and  maintained  its  pathogenicity  in  cultures  for  more  than 
one  year.  They  also  report  that  upon  inoculation  into  monkeys  poliomyelitis 
may  fail  to  appear  upon  the  first  injection  and  yet  follow  from  the  eflfects 
of  successive  injections  of  the  culture. 

Inoculations  of  cultures  into  monkeys  which  fail  to  produce  paralysis 
may  fail  also  to  induce  resistance  or  immunitj'.  In  this  respect  the  action  of 
the  cultures  resembles  that  of  the  virus  as  contained  in  infected  nervous  tis- 
sues. The  lesions  occurring  in  the  spinal  cord,  medulla,  and  intervertebral 
ganglia  of  the  monkeys,  which  respond  to  the  several  inoculations  of  the 
cultures  are  identical  with  those  present  in  the  nervous  organs  of  animals 
responding  to  injection  of  the  ordinarj^  virus.  Glycerinated  nervous  tissues 
derived  from  the  monkeys  responding  to  several  injections  of  the  cultures 
transmit  experimental  poliomyelitis  to  monkeys  upon  intracerebral  inoculation. 
The  microorganism  inoculated  may  be  recovered  in  cultures  from  the  mon- 
keys which  develop  poliomyelitis;  but  cultivation  from  the  brain  tissue  is 
attended  from  the  usual  difficulties  surrounding  the  obtaining  of  the  initial 
growth. 

The  microorganism  cultivated  from  poliomyelitic  tissues  is  adapted  with 
difficulty  to  saprophytic  conditions  of  multiplication,  but  once  adapted  growth 
readilj-  takes  place  upon  suitable  media.  When,  however,  as  a  result  of 
inoculation  into  monkeys,  the  parasitic  propensities  of  the  microorganism  are 
restored,  it  again  displays  the  marked  fastidiousness  to  artificial  conditions  of 
multiplication  present  at  the  original  isolation. 

The  experiments  reported  in  this  paper  afford  additional  strong  evidence 
in  support  of  the  view  already  expressed,  that  this  microorganism  bears  an 
etiological  relationship  to  epidemic  poliomyelitis  in  tlic  human  subject  and  to 
experimental  poliomyelitis  in  the  monkej'. 

Jki.liki-e. 

CEHKjtKi.i.AK  Fi MTioN.     I.  L.  Mcycrs.     (Journal  A.  M.  A.,  October  16,  1915.) 

Dr.  Meyers  says  that  in  reviewing  the  literature  he  finds  a  number  of 
symptoms  have  been  ascribed  to  the  cerebellum  wliich  did  not  originate  from 
it  at  all.  Lesions  of  the  cerebellum  do  not  cause  sensory  disorders  as  has 
been  attested  by  so  many  observers  that  it  may  be  considered  a  fact  and  the 
exceptional  contrary  statements  disregarded.  This  is  true  also  of  the  mus- 
cular sense.  The  phenomena  following  cerebellar  lesions  are  in  the  motor 
sphere.  If  is  pretty  well  established  that  forced  movements,  the  circus  move- 
ments and  rolling  movements  in  animals  and  the  so-called  imperative  move- 
ments in  man  are  not  of  cerebellar  origin.  The  same  is  true  of  the  Il}^stagmus, 
the  conjugate  deviation  of  the  eyes  and  the  characteristic  attitude  of  the  head 
so  often  observed  after  unilateral  ablation  of  the  ccrebelhnn  in  animals  and 
occasionally  in  cerebellar  disease  of  man.  These  phenomena  are  essentially 
vestibular  in  origin  and  due  to  a  lesion  of  the  vestibular  complex  itself  or  its 


PERISCOPE  197 

oculomotor  tracts.  Clinically,  paralj-sis  in  cerebellar  disease  is  denied  by- 
good  authorities  and  is  also  indicated  by  the  state  of  the  reflexes  which  may 
be  increased  or  normal.  The  view  that  the  cerebellum  exerts  a  motor  effect 
different  from  that  of  the  cerebral  cortex  directly  on  the  periphery  has  been 
held  by  Lu3's  and  developed  by  Hughlings  Jackson  and  supported  by  Horsley. 
Gowers'  theory  that  the  cerebellum  acts  through  the  cerebrum  in  an  inhibitory 
way  is  also  mentioned.  Luciani  holds  that  the  cerebellum  has  the  function 
simply  of  augmenting  those  of  the  other  centers,  lending  them  strength, 
tonicity,  and  effecting  proper  fusion  of  the  cerebral  stimuli.  Loss  of  cere- 
bellar innervation  results  in  asthenia  or  weakness  and  arrhythmia  with  the 
resultant  tremor.  The  phenomenon  of  cerebellar  lesion  in  accordance  with 
this  theory  is  purely  motor  in  character,  analogous  but  not  entirely  identical 
with  those  following  destruction  of  the  rolandic  zone  of  the  cortex.  A  simi- 
lar view  has  been  held  by  Luys  and  developed  by  Hughlings  Jackson. 
Meyers'  experiments  with  the  galvanometric  testing  of  the  cerebellar  func- 
tions are  detailed.  He  operated  on  cats,  removing  in  one  group  the  right 
lobe  of  the  cerebellum,  and  in  another  group  the  left,  keeping  them  under 
observation  for  one,  two  and  three  weeks.  Out  of  all  the  animals  he  selected 
seven,  discarding  all  those  that  did  not  show  marked  unilateral  ataxia  and 
whose  wounds  did  not  heal  promptly.  The  animals  were  allowed  to  recover 
from  the  immediate  effects.  These  experiments,  he  thinks,  support  his  theory 
that  the  function  of  the  cerebellum  is  that  of  control  and  inhibition,  each  half 
exhibiting  its  function  on  the  opposite  half  of  the  cerebrum.  Its  indirect 
effects  in  the  form  of  regulated  movements  manifest  themselves  on  its  own 
side  as  originating  in  the  motor  cortex  of  that  hemisphere  of  the  cerebrum, 
the  motor  impulses,  passing  by  way  of  the  pyramidal  tracts,  cross  to  the  oppo- 
site side  before  reaching  the  spinal  cord.  There  is  a  good  deal  of  evidence 
also,  he  says,  that  there  is  a  structural  linkage  between  the  cerebral  hemi- 
sphere on  one  side  and  the  cerebellar  of  the  other  side,  and  that  the  cere- 
bellum is  subservient  to  the  cerebrum.  The  tremor  appears  to  be  largely 
dependent  on  an  interaction  between  the  cerebellum  and  mid-brain  structures. 
"  To  sum  up,  the  cerebellum  is  a  complex  structure  having  no  direct  effect 
on  the  periphery,  but  acting  primarily  on  the  motor  cortex,  the  paracerebellar 
nuclei,  and  probably  also  the  basal  ganglia  and  ruber.  Its  primary  effects  are 
those  of  inhibiting,  controlling  and  regulating  the  activity  of  these  latter 
structures.      Its  ultimate  effects  are  appropriate  and  rhythmic  muscular  action." 

Tachycardia  Setting  in  with  Acute  Infectious  Thvreoiditis.     D.  D.  Plet- 
new.     (Zeit.  f.  klin.  Med.,  1914,  Band  80,  Heft  3/4.) 

Pletnew  describes  nine  cases  of  acute  infectious  thyroid  disorders  with 
Basedow  sj'mptoms.  He  was  able  to  establish  that  in  the  course  of  different 
infectious  diseases  acute,  inflammatory  diseases  of  healthy  as  well  as  of 
goitrous  and  of  infected  thyroid  glands,  Basedow's  disease,  occurred  as  com- 
plications. These  infectious  changes  may  give  rise  to  purely  local  as  well  as 
to  thyreotoxic  phenomena,  which  produce  tachycardia.  In  these  cases  it  is 
not  a  question  of  hyperthyroidism,  but  of  dysthyreosis.  The  toxic  indications 
seem  to  play  a  part  not  only  in  the  thyroid  gland  alone  but  in  other  glands  with 
internal  secretions  likewise  (pluriglandular  affections).  The  Basedow  goitre 
is  very  closely  related  to  experimental  parenchymatous  thyroiditis. 

Jelliffe. 

Contribution  to  the  Etiology  of  Heine-Medin's  Disease.     F.  Lust  and  F. 
Rosenberg.     (Miinch.  med.  Wochenschr.,  1914,  No.  3.) 

Wickman's  theory  of  the  transmission  of  the  Heine-Medin's  disease  by 
means  of  diseased  or  healthy  virus   carriers  is  at  variance  with  many  epi- 


198  PERISCOPE 

demiological  observances.  The  authors  have  observed  71  cases  of  acute 
poliomyelitis  in  the  Heidelberg  children's  clinic  from  March  to  December, 
1913.  Direct  contact  with  an  infected  person  could  only  be  assumed  in  the 
cases  of  six  of  these  71  patients.  In  the  d6ubtful  significance  of  infection 
by  contact  a  publication  by  Bruno  found  consi<5eration,  in  which  he  called 
attention  to  the  appearance  of  conditions  resembling  paralysis  among  the 
domestic  animals,  especially  among  the  poultry  in  the  poliomyelitis  district 
about  Baden.  In  fourteen  places  where  there  had  been  poliomyelitis  the 
authors  could  fix  upon  animals  that  had  been  attacked  by  paralysis  shortly 
before.  They  were  able  to  examine  anatomically  and  histologically  four  such 
hens,  and  make  experiments  in  transmission  on  other  hens  with  the  brains 
and  spinal  cords  of  the  diseased  hens.  In  the  animals  examined  there  were 
entirely  different  changes,  partly  in  the  central,  and  partly  in  the  peripheral 
nervous  system.  In  no  cases  did  the  transmission  of  a  disease  to  another  hen 
suceed.  >J^o  more  did  hens,  on  further  experimentation,  under  natural  or 
artificial  conditions  of  infection  show  themselves  susceptible  to  poliomj'elitis 
coming  from  humans  or  apes.  There  is  no  justification  they  think  for  identi- 
fying the  disease  authenticated  in  poultry  and  beginning  with  phenomena  of 
paralysis,  with  poliomyelitis  of  humans  and  monkeys. 

Jelliffe. 

Contribution  to  the  Study  of  Xox-industri.\l  Chronic  Mercury  Poison- 
ing. M.  Friedmann.  (Deutsche  Zeit.  f.  Nervenheilk.,  1914,  Bd.  52, 
H.  1-2.) 

A  high  degree  of  nervousness  increasing  for  the  last  four  or  five  years 
to  unfitness  for  service,  and  without  any  plausible  reason,  has  been  found  in 
two  assistants  to  the  post  office  director.  The  following  complications  were 
present :  gastro-intestinal  disturbances,  loss  of  teeth,  skin  affections,  pharyn- 
gitis, rheumatoid  pains  in  the  joints,  intention  tremors,  hysterical  clonic  con- 
vulsions, violent  emotivity.  The  trembling  was  characterized  by  violence  and 
wide  distribution.  In  six  other  cases  post  office  assistants  showed  similar 
phenomena,  although  perhaps  not  such  well-developed  aspects  of  the  disease. 
All  had  been  active  in  the  same  profession  for  years  and  showed  mercurial 
erethism.  In  a  few  cases  the  first  phenomena  appeared  in  three  months  and 
gradually  increased.  But  it  was  only  the  continuance  for  several  years  of 
the  intoxication  which  led  to  unfitness  for  service.  In  these  cases  the  prog- 
nosis seems  less  clear  than  in  the  industrial  form  of  mercury  intoxication. 
Half  of  the  clerks  who  were  there  and  active  at  the  same  time  showed  them- 
selves able  to  resist  the  cumulative  effect  of  the  poison.  Nothing  definite 
could  be  determined  in  regard  to  the  quantity  of  mercury  whicli  would  bring 
about  the  intoxication.  The  quantities  of  poison  in  any  case  are  very  small. 
In  the  post  office  studies  tubes  are  used  and  telegrams  are  sent  froni  the 
Morse  room  on  an  upper  floor.  In  the  mercury  contacts  or  points  there 
was  a  concussion  when  the  current  was  switched  on  or  off,  whereby  drops  of 
the  metal  were  flung  out  and  metal  was  also  evaporated.  In  this  manner  the 
poison  reached  the  atmosphere  of  the  workroom,  and  even  the  floor  was 
covered  with  little  globules  of  the  metal.  The  quantity  of  mercury  spilled 
and  evaporated  daily  was  calculated  to  be  about  one  half  to  two  grams. 

Jelliffe. 

Cerf-beli.ar  Tumors.     E.  G.  Grey.     (Journal  A.  M.  A.,  October  16,  1915.) 

The  proportion  of  patients  with  intracerebellar  growths  that  show  no 
nystagmus  as  a  symptom  has  been  investigated  by  Grey.  Ususally  nystagmus 
is  considered  a  valuable  localizing  sign  in  diseases  of  the  posterior  cranial 
fossa,  but  occasionally  this  signal  fails.     Grey  has  used  the  records  of  Dr. 


PERISCOPE  199 

Gushing  at  Johns  Hopkins  Hospital  before  September,  1912,  and  at  the  Peter 
Bent  Brigham  Hospital  since  that  date.  Of  several  hundred  cases  there  were 
fifty-one  that  were  localized  at  the  operation,  in  eleven  of  which  no  nystagmus 
was  observed  previous  to  operation.  The  lesion  in  eight  of  these  cases  was 
a  glioma  or  a  gliomatous  C3'st,  and  all  parts  of  the  cerebellum  were  involved 
in  these  cases.  Accessory  measures  for  eliciting  nystagmus  were  tried  in 
three  of  the  patients — moving  the  head  as  first  suggested  by  Oppenheim  and 
using  opaque  spectacles  as  recommended  by  Barany — but  without  success. 
In  one  patient  examined  a  fine  nystagmus  finally  appeared  just  previous  to 
the  operation,  and  the  records  of  two  other  patients  illustrate  how  nystagmus 
which  has  been  absent  during  one  period  of  study  may  appear  in  later  exami- 
nations. In  his  summary,  Grey  says  that  all  of  the  cases  in  which  it  was 
absent  contained  intracerebellar  new  growths — 32  per  cent,  of  the  intracere- 
bellar  series.  This  suggests  that  the  absence  of  rhythmic  movements  of  the 
eyes  points  to  intracerebellar  localization  of  the  lesion.  Caloric  examinations 
were  made  in  six  of  the  patients  without  nystagmus,  and  resulted  in  charac- 
teristic n3^stagmus  from  either  labyrinth  in  five.  In  forty  verified  cases  of 
tumors  lying  anterior  to  the  cerebellum,  eight  patients  showed  nystagmus 
before  operation.  The  results  indicate  that  in  many  cases  of  intracranial 
tumor  the  absence  of  nystagmus  cannot  be  accounted  for  by  an  impairment  of 
its  fundamental  mechanism. 

A  New  Symptom  in  Tabes.    H.  v.  Baeyer.     (Miinch.  med.  Woch.,  1914,  No.  20.) 

von  Baeyer  tested  the  sense  of  displacement  and  tension  of  the  skin  (by 
lifting,  pulling  of  folds  of  skin)  in  a  group  of  patients  suffering  from  tabes. 
While  the  healthy  man  can  give  accurately  the  direction  of  these  manipula- 
tions, the  tabes  patient,  who  can  only  give  the  region  of  the  test,  often  makes 
a  mistake.  The  regions  in  which  these  sensory  disturbances  occur  are  not 
identical  with  the  portions  in  which  sensations  of  touch  and  pain  are  lacking. 
This  sensory  quality  seems  to  belong  to  the  deep  sensations;  it  is  perhaps  not 
unimportant  in  the  treatment  of  ataxia. 

Jelliffe. 


Book  IRcvicws 


The  Foundations   of   Normal  and   Abnormal   Psychology.     Rv   Boris 
Sidis.  A.M..  Ph.D..  M.D.     Boston.  Richard  G.  Badger. 

There  is  nothing  funadmentalh'  new  in  this  work  on  psychologj*.  Dr. 
Sidis  brings  again  to  our  attention  the  fact  that  psychologj^  is  a  science 
deahng  objectively  with  the  facts  of  mental  activity  and  as  such  must 
leave  the  discussion  of  the  nature  of  the  reality  of  the  external  world 
upon  which  mental  life  reacts  and  of  tlie  nature  of  mental  activity  itself 
to  metaphysics.  Moreover,  he  frequently  emphasizes  his  position  in  re- 
gard to  psychophysical  activit\-.  that  it  is  merely  a  concomitant  of  mental 
functioning  and  not.  as  many  claim,  the  final  explanation  of  psychical  acts. 

His  explanations  of  the  mental  functions,  both  elementary  and  com- 
plex, is  simple  and  instructive.  He  has  elaborated  an  ingenious  device  of 
moments-consciousness,  explaining  their  formation  and  activity  from 
their  purely  sensori-motor  constitution  and  functioning  up  to  the  highest 
synthetic  moments  of  self-consciousness,  which  contain  representative 
elements.  This  offers  a  purely  mechanistic  device  for  explaining  rudi- 
mentary psychic  life  from  that  of  the  ameba  to  the  reflexes  existent  in 
highest  organisms  as  well  as  the  complex  mental  life  of  the  highest  con- 
sciousness. The  action  of  these  moments-consciousness  are  supposed  to 
explain  all  normal  functioning  and  also  derangement  and  failure  of 
activity,  all  degrees  of  dissociation  and  degeneracy  in  their  various 
pathological  manifestations.  But  it  is  too  limited  in  conception  to  cover 
the  vital  problem  of  complexes  conscious  and  unconscious.  For  the  term 
unconscious  Dr.  Sidis  prefers  a  subconscious  consciousness. 

In  his  whole  reference  to  the  subconscious  he  but  touches  upon  the 
character  and  extent  of  the  submerged  processes  and  their  importance. 
We  can  scarcely  expect  more  from  a  psychology  that  conceives  of  many 
of  the  psychic  state  not  actively  selected  by  the  focus  of  consciousness 
as  simply  dying,  ceasing  to  exist  and  that  denies  such  a  thing  as  the  sup- 
pression of  painful  complexes.  The  book,  therefore,  can  have  only  lim- 
ited bearing  on  the  practical  problems  confronting  the  psychiatrist. 

Jelliffe. 


"2,6  » 


DR.  ISAAC  OTT 


VOL.  43.  MARCH,  1916.  No  3. 


The  Journal 

OF 

Nervous  and  Mental  Disease 


An  American  Monthly  Journal  of  Neurology  and  Psychiatry,  Founded  in  1874 


©rtgtnal  Hrttcles 


IN  IMEMORIAAI— ISAAC  OTT,  A.M.,  M.D. 
By  Joseph  McFarland,  M.D. 

Isaac  Ott  was  born  in  Northampton  County,  Pennsylvania,  pre- 
sumably in  1847.  There  is  some  doubt  about  the  exact  date,  the 
Index  Catalogue  of  the  Surgeon-General's  library  giving  the  date 
as  1844,  the  Directory  of  the  American  Medical  Association  1847. 
Presumably  Dr.  Ott  himself  filled  out  the  blank  with  the  information 
for  the  directory,  so  that  the  latter  ought  to  be  correct,  unless,  as 
some  assert,  he  had  forgotten  the  precise  date  himself. 

He  went  to  school,  among  other  places,  at  the  Belvidere  Academy, 
Hackettstown,  N.  J.,  where  he  prepared  for  Lafayette  College,  which 
he  entered  in  1865.  He  probably  entered  the  medical  department  of 
the  University  of  Pennsylvania  two  years  later,  for  he  was  gradu- 
ated from  that  institution,  with  the  degree  of  Doctor  of  Medicine  in 
1869.  He  delighted  in  and  also  excelled  in  the  science  of  medicine, 
which  he  developed  to  a  remarkable  degree  though  at  the  same  time 
carrying  on  a  practice.  At  various  times  he  attended  courses  or 
carried  on  researches  in  the  Universities  of  Leipzig,  Berlin  and 
Wlirzburg.  He  also  worked  privately  with  Klein  in  London  and 
Bowditch  in  Boston. 

He  interested  himself  in  teaching  and  occupied  various  positions. 
In  1875  he  was  made  demonstrator  of  physiology  in  the  University 
of  Pennsylvania,  and  in  1877  lecturer  in  experimental  physiology  in 
the  same  institution;  in  1878  he  became  fellow  in  biolog>'  in  Johns 


202  JOSEPH   McFARLAND 

Hopkins  University;  in  May,  1894,  he  became  professor  of  physiol- 
ogy  in  the  Medico-Chirurgical  College,  which  position  he  continned 
to  fill  until  1914.  For  two  years  in  his  early  connection  with  the 
Medico-Chirurgical  College,  he  was  its  dean. 

The  energ}'  of  the  man  can  only  be  understood  by  those  who  knew 
him.  For  twenty  years  he  lived  in  Easton,  Pa.,  where  he  carried  on 
a  considerable-sized  and  exacting  general  medical  practice,  yet  dur- 
ing all  that  time,  he  conducted  research  experiments  of  an  original 
and  ingenious  character  and  of  high  scientific  value  in  a  reconstructed 
stable  on  his  property,  acquired  a  large  and  valuable  library  with 
whose  Contents  he  was  thoroughly  familiar,  and  yet  found  time  to 
come  to  Philadelphia  three  days  a  week  to  give  his  lectures  and 
laboratory  demonstrations,  all  of  which  being  condensed  into  these 
periods,  made  the  work  extremely  arduous. 

To  come  from  Easton  to  Philadelphia,  teach  continuously  for 
about  five  hours,  and  then  to  return  to  Easton  again,  constitutes  a 
day's  work  for  which  few  would  find  themselves  adapted,  yet  Dr. 
Ott  did  it  three  times  a  week  for  20  years ! 

As  a  writer  he  was  prolific,  and  an  examination  of  the  bibliog- 
raphies of  foreign  text-books  upon  physiology  and  pharmacology 
shows  him  to  be  one  of  the  best  known  and  most  appreciated  of 
American  writers  upon  those  subjects. 

His  critical  judgment  was  acute.  He  quickly  winnowed  the  wheat 
and  threw  away  the  chaflf  in  scientific  writing,  and  his  appraisal  of 
his  contemporaries  was  surprisingly  thorough  and  accurate.  He 
made  no  enemies;  his  personality  was  genial,  his  manner  kindly,  and 
he  endeared  himself  to  his  colleagues,  his  students  and  his  patients 
as  few  succeed  in  doing. 

An  attack  of  influenza  in  the  late  autumn  of  1914  made  him  ap- 
prehensive of  his  health,  and  he  tendered  his  resignation  as  professor 
of  physiolog}-  in  the  Medico-Chirurgical  College.  With  great  re- 
luctance it  was  accepted  and  he  was  made  emeritus  professor  of 
physiology  and  director  of  the  laboratories  of  experimental  research, 
Dr.  Andrew  W.  Downs  being  elected  professor  of  physiology  in  his 
place.  Notwithstanding  the  apparent  disadvantage  of  his  living  in 
Easton,  and  the  Medico-Chirurgical  College  being  in  Philadelphia. 
Dr.  Ott  actually  and  actively  directed  the  research  work  in  Philadel- 
phia until  the  time  of  his  death,  compelling  his  subordinates  to  go  to 
Easton  for  their  directions  and  with  their  results,  as  he  had  formerly 
come  to  Philadelphia. 

In  December,  191 5,  he  had  another  severe  attack  of  influenza  from 
which  he  again  recovered  but  "  overeager  to  be  about  and  attend  to 


IN  MEMORIAM— ISAAC   OTT  203 

his  patients,  many  of  them  not  so  ill  as  himself,  pneumonia  super- 
vened and  brought  on  cardiac  complications  too  severe  for  his  powers 
of  resistance  and  recuperation,  and  which  caused  his  demise  early 
on  the  morning  of  the  new  year."  His  funeral,  held  from  his 
residence  in  Easton,  on  January  4,  19 16,  was  attended  by  a  large 
delegation  of  the  trustees,  faculties  and  students  of  the  ]\Iedico- 
Chirurgical  College. 

As  the  writer,  who  was  one  of  the  honorary  pall-bearers,  sat  near 
the  casket  containing  the  earthly  remains  of  his  former  colleague, 
an  elderly  gentleman  approached  to  take  a  final  farewell,  and  view- 
ing the  face  of  his  former  physician,  with  tears  streaming  from  his 
eyes,  and  a  heart-break  in  his  voice,  made  the  simple  but  well-justi- 
fied comment  "  good  doctor  "  and  with  bowed  head  turned  away ! 

Dr.  Ott  was  a  member  of  but  few  medical  societies,  probably 
because  of  the  fact  that  he  made  his  home  in  Easton.  He  was, 
however,  at  one  time  the  president  of  the  American  Neurological 
Association. 

His  interest  in  physiology  and  in  physiological  research  is  shown 
by  what  he  leaves  after  him.  Seventy-four  titles  to  literary  contri- 
butions follow  his  name  in  the  Index  Catalogue  of  the  Surgeon- 
General's  Library,  but  do  not,  by  any  means,  reprint  his  entire  work. 
His  chef  d'ouvre  was  his  "  Text-Book  of  Physiology,"  the  fifth 
edition  of  which  was  ready  for  the  press  at  the  time  of  his  death 
and  will  be  carried  through  by  his  successor. 

Two  professorships  of  the  subject  dear  to  his  heart  will  bear  his 
name.  The  first,  with  a  foundation  of  about  one  hundred  thousand 
dollars,  given  in  his  memory  by  his  mother,  is  the  Isaac  Ott  Profes- 
sorship of  Physiology  in  the  Medico-Chirurgical  College,  the  money 
for  which  is  immediately  available ;  the  second,  with  a  large  founda- . 
tion  given  by  Dr.  Ott  himself,  will  be  the  Isaac  Ott  Research  Pro- 
fessorship of  Physiolog}^  in  the  University  of  Pennsylvania,  the 
money  for  which  becomes  available  upon  the  death  of  his  widow. 


A  COMPARISON  OF  THE  MENTAL  SYMPTOMS 

FOUND  IN  CASES  OF  GENERAL  PARESIS 

WITH   AND    WITHOUT    COARSE 

BRAIN   ATROPHY^ 

Bv  E.  E.  Southard 

PATHOLOGIST.   STATE  BOARD  OF  INSANITY,    MASSACHUSETTS  ;   DIRECTOR,   PSYCHO- 
PATHIC HOSPITAL,  BOSTON,  MASS.  ;  AND  BULLARD  PROFESSOR  OF  NEURO- 
PATHOLOGY,   H.^RVARD    MEDICAL   SCHOOL.    BOSTON,    MASS. 

Most  promising  leads  in  psychopathology  accrue  from  the 
well-known  neuropathological  desire  to  prove  "  structural "  as 
many  of  the  so-called  "  functional "  psychopathies  as  possible. 
Though  the  search  for  truly  functional  psychopathies — judged 
by  the  hard  tests  of  the  post-mortem  room — has  to  be  very  keen, 
and  though  the  sure  and  uncomplicated  natural  experiments 
which  bring  to  the  post  mortem  room  suitable  cases  for  crucial 
examination  are  singularly  rare,  yet  the  structuralizing  neurologist 
has  not  yet  come  at  all  near  to  destroying  the  functionalist  hypoth- 
esis. The  position  that  mental  disease  may  well  be  a  disease  of 
function  involving  no  more  than  normal  and  inevitable  physio- 
logical changes  in  the  nervous  system  is  still  perfectly  tenable, 
perhaps  even  correct  for  some  cases.  For  some  time  now  I  have 
been  publishing  in  various  medical  journals  a  number  of  contribu- 
tions to  the  study  of  normal-looking  brains  in  psychopathic  sub- 
jects. My  associates  and  I  have  reported  on  all  available  ma- 
terial at  various  Massachusetts  hospitals  for  the  insane  ( 'J\'uui- 
ton,'  \\'orcester,-  Westborough,^  Boston*)  and  have  made  numer- 
ous references'-"'"  to  the  largest  material  (Danvers)  which  re- 
mains as  yet  unpublished.  A  large  amount  of  work  has  had  to 
be  done  in  this  search  for  i)sychoses  that  shall  be  above  reproach 
as  to  their  functionality.  As  an  instance  of  the  intriguing  nature 
of  the  problem.  I  may  say  that  out  of  153  carefully  examined 
cases  at  Boston  State  Hospital,  Dr.  Canavan  and  I  were  able  to 
find  but  five  entirely  suited  to  crucial  microscopic  examination 

'  BeiiiK  Contributions  of  tlie  State  Board  of  Insanity,  Numhcr  38 
(1913.4).  (HihliiHiraphical  S'ntc. — Tlic  ()rcvious  contrilnition  was  S.  W.  I. 
Contributions  .Number  37  (i<>i5-3)  •'>'  M.  M.  Canavan.  entitled  "  ,'\  Histo- 
logical Study  of  the  Optic  Nerves  in  a  Random  Scries  of  Insane  Hospital 
Cases."  JoiKNAL  of  Nf3<vois  AND  .Mental  Disease,  March,  1916.) 

204 


COMPARISON   OF    THE   MENTAL    SYMPTOMS  205 

and  that  an  orienting  examination  of  these  cases  with  the  micro- 
scope has  already  led  to  disquieting  suspicions.'' 

One  word  is  due  those  who  take  the  advanced  and  (in  my 
opinion)  entirely  correct  ontological  view  that  structure  and 
function  are  in  such  \Q.ry  intimate  dyadic  relation  that  they  form 
to  all  intents  and  purposes  a  unity.  Such  a  conception  I  have 
tried  inadequately  to  develop  in  previous  communications.^'®  I 
trust  that  the  present  series  of  studies  will  be  permitted  to  rest 
outside  the  limits  of  ontological  discussion. 

Logically  interesting,  however,  is  the  progress  which  can  be 
made  by  the  simple  device  of  cutting  an  autopsy  series  or  a 
clinical  series  in  twain  on  the  lines  of  supposed  fvmctionality  and 
structurality.  It  may  be  conceded  that  many  cases  get  pushed 
to  the  wTong  side  of  the  line,  being  called  structural  when  they 
are  really  (on  the  present  conception)  functional,  and  vice  versa. 
But  these  errors  prove  themselves  in  a  manner  familiar  to  those 
employing  the  statistical  method. 

The  readers  of  this  Journal  may  recall  certain  papers  on 
delusions  written  by  Stearns,  Tepper,  and  myself. *''^°'^^  In  two 
of  these  papers  the  hypothesis  was  raised  that  the  various  (non- 
paretic)  cases  in  question  were  really  "  fvmctional  "  in  the  prevail- 
ing sense  of  cases  without  neural  lesions.  In  a  third  paper  I 
resorted  to  material  which  had  to  be  regarded  as  "  structural," 
viz.,  general  paresis ;  but  the  conclusions  founded  thereon  depend 
at  least  as  much  on  the  prevailing  mode  as  did  my  former  con- 
clusions on  somatic^  and  environmentaP°  delusions  in  "  normal- 
looking  brain  "  cases. 

How  many  of  the  symptoms  of  general  paresis  can  safely  be 
correlated  with  the  lesions  of  general  paresis  as  we  know  them? 
This  question  is  exceedingly  important,  dealing  as  it  does  with 
that  mental  disease  about  which  perhaps  we  know  the  most.^--"'^* 
The  error  in  diagnosis  is  low/^'^®'^"  especially  if  compared  with 
the  error  in  psychiatric  diagnosis  at  large, ^^-^^  and  the  number  of 
variables  in  our  equations  is  correspondingly  reduced. 

In  the  study  just  mentioned^^  we  concluded  that  the  char- 
acteristic delusions  of  general  paresis  (found  in  57  per  cent,  of 
all  cases  in  a  routine  series,  and  in  75  per  cent,  of  all  cases  show- 
ing delusions)  are  delusions  about  the  patient's  personality  and 
that  these  delusions  could  be  roughly  correlated  with  frontal  lobe 
lesions  (non-autopsychic  delusions  failing  to  be  so  correlated). 
These  conclusions  were  in  general  harmony  with  findings  in 
dementia  praecox.-^'^^ 


206  E.   E.   SOUTHARD 

For  the  present  purpose  I  have  split  a.  certain  series  of 
autopsied  paretic  cases  in  twain  on  the  basis  of  their  showing 
or  not  showing  substantial  gross  brain  lesions.  The  series  was 
chosen  on  the  basis  of  personal  examination  by  me  at  autopsy 
and  of  careful  registration  of  all  gross  lesions  found.  The  de- 
scriptions made  were  very  particular  and  well-nigh  finical,  since 
they  were  from  the  beginning  destined  to  be  compared  with  gross 
findings  in  various  psychoses  at  one  time  commonly  regarded 
as  functional  (dementia  prsecox.  manic-depressive  insanity). 
Without  here  considering  the  medically  and  therapeutically  inter- 
esting fact  that  in  this  random  series  i8  brains  showed  no  sub- 
stantial gross  lesions  and  a  bare  majority,  20,  yielded  such  lesions. 
I  shall  proceed  to  a  brief  symptom  analysis  from  a  psychopatho- 
logical  point  of  view,  reserving  for  publication  elsewhere^" 
various  medical  implications  of  the  work.  All  cases,  both  with 
and  without  gross  lesions,  possessed  the  characteristic  micro- 
scopic lesions  developed  by  the  Nissl-Alzheimer  school. 

Before  tabulating  the  symptoms  found  in  the  two  "  normal- 
looking  "  and  "  abnormal  "  brain  groups  or  in  what  might  be 
termed  the  "  mild  "  and  "  severe  "  cases,  I  must  add  that  we  are 
in  no  sense  dealing  with  early  and  late  phases  of  the  disease. 
In  fact  the  mild  cases  are  often  the  longest  cases.  There  is  no 
question  of  a  progressively  severer  disease  in  many  cases.  The 
cases  progress,  it  is  true,  in  one  sense  toward  their  death,  and 
they  do  not  very  often  regress.  Moreover  stationary  cases  are 
rarities.  But  a  case  lasting  five  years  is  not  necessarily  an 
anatomically  or  histologically  severer  case  than  one  lasting  two 
years. 

In  explanation  of  the  first  two  tables,  I  must  premise  that 
d  )  The  fourth  columns  contain  the  number  of  symptoms  (named 
in  the  first  column)  found  and  catalogued  in  a  series  of  17,000 
cases  clinically  analyzed  at  Danvers  State  Hospital,  only  a  small 
portion  of  which  have  ever  come  to  autopsy  and  many  of  which 
are  still  alive.  The  analysis  does  not  pretend  to  weigh  the  im- 
portance of  the  symi)toms  listed  or  their  dominance  in  the  various 
cases.  The  17,000  list  is  purely  a  frequency  list.  (2)  The 
entries  in  the  second  column  (mild)  of  Table  I  represent  symp- 
toms in  their  order  of  frequency  in  a  series  of  18  anatomically 
"  mild  "  cases  of  general  paresis,  whereas  in  the  third  column 
(severe)  of  Table  I  appear  symptoms  in  their  order  of  frequency 
in  20  anatomically  "  severe  "  cases.     (3)  The  entries  in  the  second 


COMPARISON   OF    THE   MENTAL   SYMPTOMS 


207 


column  (severe)  of  Table  II  represent  frequencies  in  the  20 
anatomically  **  severe  "  cases  and  those  in  the  third  column  (mild) 
the  corresponding  frequencies  in  the  anatomically  "  mild  "  cases. 

It  occurs  to  me  that  some  question  may  well  be  raised  whether 
anatomical  appearances  can  be  safely  trusted  to  gauge  severity 
of  processes.  Certainly  we  are  aware  that  in  certain  cases  these 
appearances  can  not  be  trusted.  But  I  assume  that  there  can 
be  no  doubt  that,  by  and  large,  the  atrophic  brain  is  more  deeply 
affected  than  the  normal-looking  brain.  At  any  rate  it  is  a 
question  whether  the  microscope  can  be  trusted  much  farther 
quantitatively  at  the  present  time.  And  in  any  event  the  hndings 
both  anatomically  and  symptomatically  indicate  two  groups  of 
cases,  whether  we  choose  to  regard  them  as  "  mild  "  and  "  severe  " 
or  not. 

Without  entering  the  total  field  of  symptomatology  in 
psychiatry,  I  may  perhaps  add  that  I  do  not  necessarily  approve 
the  nomenclature  of  symptoms  here  adopted  and  merely  record 
the  entries  as  they  stand.  The  influences  of  Kraepelin  and  of 
Wernicke  are  plain  in  the  nomenclature,  despite  the  fact  that  a 
majority  of  the  facts  were  collected  before  the  work  of  either  of 
these  masters  had  come  into  close  contact  with  practical  Ameri- 
can psychiatry. 

Those  symptoms  have  been  included  in  all  columns  which 
occurred  in  20  per  cent,  or  more  of  any  of  the  three  series. 

Table  I 

Symptoms  Arranged  in  the  Order  of  those  Most   Frequent  in  the 
Anatomically  Mild  Cases 


20  Severe 

17,000 

II 

3,422 

II 

5,428 

10 

2,419 

3 

6,844 

9 

5,841 

9 

5,015 

6 

2,714 

8 

2,596 

5 

6,903 

7 

4,897 

I 

2,362 

3 

2,051 

4 

4,354 

2 

3.244 

9 

1,180 

6 

885 

4 

413 

6 

3.186 

2 

1.597 

Amnesia 

Motor  restlessness 

Disorientation 

Delusions,  allopsychic 

Dementia 

Depression 

Irritability 

Defective  judgment 

Psychomotor  excitement .  .  . 
Delusions,  autopsychic.  .  .  . 

Destructiveness 

Resistiveness 

Insomnia 

Violence 

Aphasia 

Hallucinations,  not  specified 

Convulsions 

Hallucinations,  visual 

Sicchasia 


10 
9 
8 
7 
7 
7 
6 
6 
6 
6 
S 
5 
5 
5 
5 
4 
4 


2o8 


E.   E.   SOUTHARD 


I  have  italicized  those  figures  in  the  17,000  columns  which 
represent  20  per  cent  or  more  of  the  17,000. 

Table  II 

Symptoms  ^\rranged  in  the  Order  of  those  Most  Frequent  in  the 
Anatomically  Severe  Cases 


20  Severe 


18  Mild 


Amnesia 

Motor  restlessness 

Disorientation 

Dementia 

Depression 

Aphasia 

Defective  judgment 

Delusions,  autopsychic 

Irritability 

Hallucinations,  not  specified 

Hallucinations,  visual 

Euphoria 

Psychomotor  excitement. . .  . 

Incoherence 

Confusion 

Expansiveness 

Insomnia 

Convulsions 

Exaltation 


II 

II 

3.422 

II 

10 

5.428 

10 

10 

2.419 

9 

8 

S.S41 

9 

7 

5.013 

9 

5 

1. 1 80 

8 

7 

2,596 

7 

6 

4.897 

6 

7 

2,714 

6 

5 

885 

6 

4 

3.186 

6 

3 

590 

5 

6 

6.903 

5 

3 

4.130 

5 

I 

2,120 

5 

2 

386 

4 

5 

4.354 

4 

5 

413 

4 

2 

1. 711 

If  we  regard  the  ten  statistically  leading  symptoms  in  the  17,- 
000  cases  as  the  most  frequent  of  all  psychiatric  symptoms,  and 
possibly  as  the  most  important  (although  I  do  not  assert  the 
latter),  then  it  is  of  interest  to  inquire  how  far  paresis  i)artici- 


Tarle  III 

Symptoms  Arranged  in  the  Order  of  those  Most  Frequent  in 
17,000  Cases 


18  Mild 


20  Severe 


Psychomotor  excitement. 
Delusions,  allopsychic  .  . 

Dementia 

Hallucinations,  auditory. 

Motor  restlessness 

Depressif)n 

Delusions,  autopsychic  .  . 

Insomnia 

Incoherence. . . 

Amnesia 

\'iolence.  ., 

Hallucinations,  visual 

Irritability 

Defective  judgment 

Disorientation 

Destructiveness 

Confusion 

Resistiveness.  .  . 
Delusions,  somatic 


6.903 
6,844 
5,841 
5.428 
5.428 
5.015 
4.897 
4.354 
4.130 
3.422 
3.244 
3.186 

2.714 
2.596 
2.419 
2,362 
2,120 
2,051 
1.829 


6 
9 
8 
2 

10 
7 
6 
5 
3 

II 

5 
4 
7 
7 


COMPARISON   OF    THE   MENTAL   SYMPTOMS  209 

pates  in  the  nature  of  mental  disease  at  large  and  how  far  it  is 
differentiated  on  this  statistical  basis. 

The  following  tables  bring  out  the  answer : 

In  a  fourth  table  I  have  placed  the  symptoms  in  order  of 
frequency  as  they  occurred  in  17,000  cases  of  mental  disease 
analyzed  at  the  Danvers  Hospital.  The  first  ten  of  these  symp- 
toms occurred  in  at  least  3,400  cases,  that  is,  in  20  per  cent,  or 
more  of  the  series,  and  the  remaining  nine  are  added  to  secure  a 
statistical  parallel  to  the  facts  in  Tables  I  and  II. 

Table  IV 

General  Paresis 
Mental  Disease  in  General  Anatomically  Mild  Anatomically  Severe 

1.  Psychomotor  excitement  9th  to  12th  13th  to  l6th 

2.  Allopsychic    delusions..  4th  Not  in  first  nineteen 

3.  Dementia    5th  4th  to  6th 

4.  Auditory    hallucinations  Not  in  first  nineteen  Not  in  first  nineteen 

5.  Motor   restlessness    ....  2d  2d 

6.  Depression    6th  to  8th  4th  to  6th 

7.  Autopsychic  delusions..  gth  to  12th  8th 

8.  Insomnia    13th  to  17th  17th  to  19th 

9.  Incoherence    Not  in  first  nineteen  13th  to  i6th 

10.  Amnesia    ist  ist 

11.  Violence    13th  to  17th  Not  in  first  nineteen 

12.  Visual  hallucinations    .  .  i8th  or  19th  gth  to  12th 

13.  Irritability    6th  to  8th  gth  to  12th 

14.  Defective  judgment    . . .  6th  to  8th  7th 

15.  Disorientation     3d  3d 

16.  Destructiveness    gth  to  12th  Not  in  first  nineteen 

17.  Confusion    Not  in  first  nineteen  13th  to  i6th 

18.  Resistiveness    gth  to  12th  Not  in  first  nineteen 

ig.  Somatic  delusions   Not  in  first  nineteen  Not  in  first  nineteen 

Analysis  of  this  table  shows  that  auditory  hallucinations  and 
somatic  delusions  are  the  only  symptoms  which,  while  appear- 
ing amongst  the  first  nineteen  symptoms  of  mental  disease  in 
general,  fail  to  appear  among  the  first  nineteen  symptoms  of 
general  paresis  in  either  the  mild  or  the  severe  group.  It  will 
be  remembered  that  the  first  nineteen  symptoms  in  general  paresis 
were  chosen  as  occurring  in  at  least  20  per  cent,  of  the  cases 
studied,  and  that  but  ten  symptoms  in  mental  disease  at  large 
occur  in  over  20  per  cent,  of  cases.  Hence  the  failure  of  audi- 
tory hallucinations  to  occur  in  any  considerable  number  of  cases 
of  paresis  is  made  more  striking  than  the  absence  of  somatic 
delusions.  The  presence  of  visual  hallucinations,  to  be  sure  at 
the  bottom  of  the  list  among  mild  cases,  but  in  fair  proportion 
among  severe  cases,  is  theoretically  hard  to  explain,  when  taken 
in  conjunction  with  the  paucity  of  auditory  hallucinations.  In- 
dications in  the  literature  point  perhaps  to  optic  nerve  lesions  as 


2IO  E.   E.   SOUTHARD 

a  possible  basis  for  the  visual  Jiallucinatious,  suggesting  an  almost 
illuson-  origin  therefor. 

The  fact  that  ollopsycliic  delusions  are  so  common,  at  least  in 
the  mild  cases,  seems  to  show  that  they  are  not  correlated  with 
auditory  lialluciuations  either  as  cause  or  effect.  It  is  as  if  there 
were  not  even  pseudoreality  to  the  allopsycliic  delusions  and  as  if 
they  did  not  appear  even  to  the  patient  as  representing  centripetal 
{e.  g.,  hostile)  effects.  In  fact,  as  will  appear  below,  these 
allopsychic  delusions  are  associated  more  with  refusal  of  food 
(hallucinatory  tastes  ?,  comments  on  indigestion?)  than  with 
auditory  hallucinations.  The  study  of  allopsychic  delusions  in 
the  paretic  ought  therefore  to  present  conceptions  of  a  quite 
disparate  order  to  those  of  the  victim  of  dementia  prsecox, 
where  auditory  hallucinations  are  so  characteristic  (see  recent 
redeterminations  of  a  statistical  nature  by  Stearns-^). 

The  paucity  of  somatic  delusio)is  in  both  paretic  groups  is 
perhaps  not  surprising  and  is  in  line  with  some  previous  deter- 
minations including  those  of  Southard  and  Tepper.^'  The 
peripheral  origin  of  many  somatic  delusions  or  at  all  events  their 
strong  peripheral  element,  as  claimed  in  previous  papers,"-^*  is 
consistent  with  this  determination.  The  presence  of  a  fair  pro- 
portion of  visual  hallucinations  remains  astounding  except  on  the 
basis  of  optic  nerve  changes  mentioned  above.  Since  Canavan^' 
has  shown  a  high  proportion  of  chronic  optic  nerve  changes  in 
routine  autopsied  cases  of  all  sorts  of  mental  disease  (paretic  and 
non-paretic),  it  might  be  argued  that  visual  hallucinations  should 
be  more  common  in  mental  disease  at  large.  In  point  of  fact 
visual  hallucinations  do  seem  to  stand  somewhat  higher  in  order 
of  frequency  in  mental  disease  at  large  than  might  have  been 
a  priori  supposed.  lUit,  why,  if  visual  Jiallucinations  arc  reallv 
related  (as  some  assert)  with  peripheral  nerve  changes,  should 
not  tactile  and  other  haptic  hallucinations  occur  more  frequently 
in  general  paresis,  in  which  the  perijiheral  nerves  are  not  infre- 
qia-mly  invfjlvcd?  i'criiaps  such  haptic  hallucinations  do  occur 
but  fail  to  reach  the  medical  observer. 

The  agreement  of  both  paretic  groups  in  placing  amnesia, 
motor  restlessness,  and  disorientation  in  one,  two,  three  order  is 
of  great  interest.  If  we  omit  the  anomalous  allopsychic  delusions 
from  the  mild  group  for  the  moment,  then  dementia  would  follow 
as  a  fourth  common  symptom,  b'urther  discussion  is  placed 
below. 


COMPARISON   OF    THE   MENTAL   SYMPTOMS  211 

For  the  purposes  of  Table  IV  we  extended  the  list  of  symp- 
toms from  mental  disease  at  large  to  nineteen  for  comparison 
with  the  nineteen  s}-mptoms  which  we  had  found  to  occur  in  over 
20  per  cent,  of  all  cases  of  paresis.  As  a  matter  of  fact  the  two 
lists  of  nineteen  symptoms  in  paresis  are  not  identical,  and  the 
differences  are  instructive. 

The  following  are  symptoms  which  occur  in  over  20  per  cent, 
of  the  mild  cases  that  do  not  occur  in  20  per  cent,  of  the  severe 
cases. 

Allopsychic  delusions j    9  in  18    j    3  in  20    I      6,844  in  17,000 

Sicchasia 1    4  in  18         2  in  20  i,S97  in  17,000 


Resistiveness 6  in  18        3  in  20    j      2,051  in  17,000 

Destructiveness 6  in  18         i  in  20  2,362  in  17,000 

Violence !    5  in  18         2  in  20  3,244  in  17,000 

I  have  arranged  the  list  arbitrarily  on  the  basis  of  a  vague 
conception  of  the  interrelation  and  possibly  the  intergrading  of 
some  of  these  symptoms.  I  believe  their  mutual  relations  are 
plain:  the  mild  case  of  paresis,  in  more  than  a  fifth  of  all  cases 
and  often  in  far  more  than  a  fifth,  is  reacting  to  his  environment 
(especially  to  his  personal  entourage)  most  markedly.  Let  us 
glance  at  the  symptoms  which  distinguish  the  anatomically  severe 
from  the  mild  cases,  since  they  fail  to  occur  in  20  per  cent,  of  the 
latter. 


Euphoria 6  in  20  |    3  in  18  |          590  in  17,000 

Expansiveness 1  5  in  20  2  in  18  1          386  in  17,000 

Exaltation ]  4  in  20  I    2  in  18  2,711  in  17,000 

Confusion I  5  in  20  i  in  18  2,120  in  17,000 

Incoherence 5  in  20  I    3  in  18  •      4,130  in  17,000 

Here  again,  just  as  perhaps  we  might  separate  two  symptoms 
(allopsychic  delusions  and  sicchasia)  from  the  other  three  which 
form  a  group  by  themselves  among  the  distinguishing  features  of 
the  "mild"  group,  so  we  may  separate  confusion  and  incoherence 
from  the  other  three  mutually  related  symptoms,  euphoria,  expan- 
siveness, and  exaltation  in  the  "  severe  "'  group. 

It  was  the  observation  of  this  contrast  which  caused  me  to 
write  out  the  present  paper  for  this  Journal^  since  I  felt  there 
was  a  general  psychopathological  interest  to  the  contrast,  which 
must  very  probably  be  based  on  structural  differences  in  disease- 
process. 

I  have  throughout  left  the  impression  that  the  structural  dif- 
ferences in  the  two  groups  are  largely  those  of  extent.     Perhaps 


212  E.   E.   SOUTHARD 

extent,  depth,  and  serial  involvement  of  cortex  layers  may  indeed 
have  something  to  do  with  these  functional  diiYerences.  His- 
tological studies  of  striking  instances  of  these  phenomena  may 
well  confirm  one  or  other  of  these  conceptions. 

Meantime  we  should  also  take  into  account  the  habitual  pref- 
erence of  gross  brain  lesions  in  general  paresis  for  the  frontal 
region.  With  this  fact  in  mind,  a  somewhat  speculative  account 
of  the  situation  might  run  to  this  efifect :  That  the  severe  cases 
with  gross  brain  involvement  tend  to  lecn'e  the  parietal  regions 
relatively  intact  and  subject  to  operations  unchecked  by  the  great 
inhibitory  frontal  areas.  The  expansiveness  of  the  paretic  would 
accordingly  resemble  the  hyperphantasia  of  certain  victims  of 
dementia  prsecox.  The  latter  I  have  been  trying  to  associate 
with  the  mild  atrophic  lesions  of  the  parietal  regions  which  atYect 
certain  cases  of  dementia  prsecox.-'  General  paresis  very  prob- 
ably often  possesses  similarly  mild  lesions  of  the  parietal  regions, 
differing  from  those  of  dementia  pr.-ecox  in  being  exudative 
rather  than  merely  degenerative.  But  at  a  time  when  these 
parietal  lesions  are  beginning  to  develop  in  paresis,  the  frontal 
regions  are  doubtless  often  far  on  the  road  to  coarse  atrophy.  In- 
hibitory power  the  frontal  regions  no  longer  possess,  certainly 
over  many  motor  activities,  possibly  over  various  conceptual 
j^rocesses.  Thus  might  be  explained  both  the  resemblances  and 
the  divergences  of  hy])erphantasia  (fantastic  delusions)  and  ex- 
pansiveness (delusions  of  grandeur). 

But  now,  as  has  been  stated,  a  large  minority  of  cases  of 
paresis  fail  to  die  with  coarse  brain  atrophy.  All  these  cases 
have  exudative  lesions  of  more  or  less  prominence,  despite  the 
absence  of  coarse  brain  atrophy.  Just  as  the  mild  lesions  of 
the  parietal  regions  may  produce  (virtually  as  irritative  symp- 
toms) expansiveness  and  attendant  euphoria  and  exaltation  at 
the  same  time  as  coar.se  frontal  destruction  is  leading  to  confu- 
sion, incoherence,  and  a  disintegration  of  the  patient's  entire  at- 
titude to  men  and  things,  so  the  mild  lesions  of  the  frontal  region 
may  be  leading  to  the  above  mentioned  anti-environmental  group 
of  symi)toms  in  the  non-atrophic  grouj).  Action  is  not  inhibited 
in  its  entirety  or  in  its  coarser  manifestations.  The  oi)eration  of 
an  exudative  (and  not  yet  extremely  destructive)  lesion  in  this 
frontal  area  may  act  in  part  to  abolish  the  inhibitions  which  arc 
very  jxjssibly  the  proj)er  function  of  this  area,  but  may  also  act 
in  part  to  irritale,  intcrrui)t,  and  throw  into  disorder  those  inhibi- 
tions.    The  mild  microscopic  lesions  in  these  non-atrophic  cases 


COMPARISON   OF    THE   MENTAL   SYMPTOMS  213 

may  act  to  bring  about  not  the  classical  loss  of  inhibition  but  a 
perversion  of  inhibition,  an  incoordinate  and  irregular  checking 
of  activities,  and  of  those  n?activities  which  proper  conduct  often 
requires.  On  such  lines  could  be  explained  with  some  plausibility 
the  resistk'encss,  destructiveness,  and  violence  which  appear  to 
be  characteristic  of  these  non-atrophic  cases. 

As  to  an  explanation  of  the  delusions  of  persecution  and  re- 
fusal of  food,  the  situation  is  perhaps  not  so  clear.  The  sicchasia 
may  sometimes  be  an  example  of  resistiveness  and  again  due  to 
delusions.  If  the  former,  then  the  symptom  would  best  be  ex- 
plained as  the  result  of  disorder  of  inhibition.  If  the  latter,  I 
can  only  offer  the  analogy  of  dementia  prgecox,  in  which  for  some 
reason  or  other  delusions  (except  fantastic)  are  rather  closely 
associated  with  frontal  lobe  lesions.  The  psychopathology  of 
delusions  is  obscure.  I  hold  the  opinion,  however,  that  delusions 
represent  more  a  disorder  of  believing  than  a  group  of  false  be- 
liefs, rather  more  a  perversion  of  volitional  process  than  of  in- 
tellectual process.  On  this  line  of  reasoning  I  find  it  somewhat 
easy  to  reconcile  the  relation  of  the  mild  frontal  lesions  here 
found  to  delusions  about  the  environment.  Thus  I  would  align 
together  all  five  of  the  distinctive  symptoms  of  the  mild  group 
with  perversions  of  inhibition,  presumably  largely  due  to  frontal 
lobe  lesions  even  though  these  are  hardly  or  not  at  all  repre- 
sented in  the  gross.  In  cases  with  more  extensive  frontal  lobe 
destruction  (coupled  often  perhaps  with  the  establishment  of 
mild  lesions  elsewhere  in  the  cortex),  the  perversions  of  inhibi- 
tion are  replaced  by  frank  losses  thereof :  the  anti-environmental 
tendencies  of  the  mild  cases  are  replaced  by  less  socially  disturb- 
ing yet  more  profound  disorder  of  personality. 

Summary  and  Conclusions 

The  possession  of  a  suitable  statistical  background  (The  Dan- 
vers  Case  Symptom  Index)  has  rendered  w^orth  while  an  orient- 
ing study  in  the  mental  symptomatology  of  general  paresis.  A 
group  of  38  general  paretics  whose  brains  were  specially  exam- 
ined and  described  by  the  writer,  has  been  divided  into  two 
groups  according  to  whether  there  was  or  was  not  coarse  evi- 
dence of  brain  atrophy.  The  cases  without  brain  atrophy  were 
termed  "  mild "  and  those  with  brain  atrophy  were  termed 
"  severe,"  although  these  designations  are  only  approximations 
to  accuracy ;  the  groups  are,  however  in  no  sense  "  early  "  and 
"  prolonged." 


214  E.   E.   SOUTHARD 

Symptomatically  the  two  groups  show  several  surprising  con- 
cordances and  a  number  of  instructive  divergences.  Thus  am- 
nesia, motor  restlessness,  disorientation,  dementia,  and  depression 
lead  both  scries  and  in  that  order  (except  that  allopsychic  delu- 
sions stand  fourth  in  the  "  mild  "  series  and  are  far  less  common 
in  the  "severe").  Arc  amnesia  and  dementia  therefore  in  no 
sense  proportional  to  brain  tissue  lossf 

Nineteen  symptoms  occurred  in  20  per  cent,  or  over  of  the 
paretic  series,  viz.,  the  five  just  mentioned,  and  nine  others  (irri- 
tability, defectiz'e  judgment,  psychomotor  excitement,  autopsychic 
delusions,  insomnia,  aphasia,  hallucinations  of  doubtful  or  un- 
specified nature,  convulsions,  visual  hallucinations)  not  always 
in  like  proportion  in  the  two  series.  Five  other  symptoms  oc- 
curred in  each  series,  but  symptoms  quite  sundered  from  one 
another  in  general  significance. 

The  "  mild  "  cases  showed  a  group  of  symptoms  which  might 
be  itvmtd  contra-environmental,  viz.,  allopsychic  delusions,  sic- 
chasia  (refusal  of  food),  resistiveness,  violence,  destructiveness, 
The  "  severe  "  cases  showed  a  group  of  symptoms  of  a  quite 
different  order,  affecting  personality,  either  to  a  ruin  of  its  mech- 
anisms in  confusion  and  incoherence,  or  to  the  mental  quietus 
involved  in  euphoria,  exaltation,  or  expansiveness. 

Some  speculations  are  offered  in  the  text  as  to  the  perversion 
of  inhibition  or  incoordination  of  inhibition  which  the  largely  ir- 
ritative lesions  of  the  "  mild  "  cases  are  presumably  effecting  in 
the  perhaps  more  seriously  aff'ected  frontal  areas.  When  these 
are  still  more  gravely  affected,  as  to  the  point  of  atrophy,  then 
the  intrapsychic  disorder  might  well  become  more  manifest,  e.  g., 
in  the  distinctive  symptoms  of  the  "  severe "  group  just  men- 
tioned. 

In  a  series  of  17,000  clinical  cases  (of  all  sorts  of  mental 
disease,  alive  and  dead,  recovered  and  impaired)  symptomato- 
logically  analyzed,  there  were  but  ten  symptoms  occurring  in  20 
per  cent,  or  over;  These  were  in  order,  psychomotor  excitement, 
allopsychic  delusions,  dementia,  auditory  hallucinations,  motor 
restlessness,  depression,  autopsychic  delusions,  insomnia,  inco- 
herence, amnesia.  Each  of  these  is  represented  high  in  general 
paresis  (i.  e.,  in  20  per  cent,  or  over)  except  that  auditory  hal- 
lucinations are  infrequent  in  both  "mild"  and  "severe"  cases 
and  allopsychic  delusions  are  infrequent  in  "severe"  cases. 
There  may  be  topograjthical  reasons  for  the  paucity  of  auditory 
hallucinations  in  general  paresis.     The  method  of  jjioduction  of 


COMPARISON   OF    THE   MENTAL   SYMPTOMS  215 

allops\chic  delusions  in  general  paresis  should  be  studied,  since 
there  can  be  no  such  alliance  of  allopsychic  delusions  and  audi- 
tory hallucinations  therein  as  is  perhaps  the  rule  in  dementia 
praecox. 

If  we  consider  the  next  nine  symptoms  in  order  in  17,000 
cases  of  mental  disease  at  large,  viz.,  violence,  visual  hallucina- 
tions, irritability,  defective  judgment,  disorientation,  destructive- 
ness,  confusion,  resistiveness,  and  somatic  delusions,  we  find  only 
the  last,  viz.,  somatic  delusions,  not  represented  in  either  group 
in  fair  proportion,  although  (as  above  stated)  confusion  is  poorly 
represented  in  the  "  mild "  cases  and  violence,  destructiveness, 
and  resistiveness  are  poorly  represented  in  the  "  severe "  cases. 

Aphasia,  hallucinations  of  doubtful  or  unspecified  nature,  and 
convulsions  appear  to  be  frequent  symptoms  in  general  paresis 
that  do  not  figure  at  all  so  largely  in  mental  disease  as  a  whole. 
Besides  these,  sicchasia  of  the  "mild"  group  and  euphoria,  exal- 
tation, and  expansiveness  of  the  "  severe  "  group  appear  to  stand 
out  for  general  paresis  against  mental  disease  as  a  whole. 

The  most  positive  results  of  this  orienting  study  appear  to  be 
the  unlikelihood  of  euphoria  and  allied  symptoms  in  the  "mild" 
or  non-atrophic  cases  and  the  unlikelihood  of  certain  symptoms, 
here  termed  contra-environmental,  in  the  "severe"  or  atrophic 
cases.  Perhaps  these  statistical  facts  may  lay  a  foundation  for 
a  study  of  the  pathogenesis  of  these  symptoms.  Meantime  the 
pathogenesis  of  such  symptoms  as  amnesia  and  dementia  cannot 
be  said  to  be  nearer  a  structural  resolution,  as  these  symptoms 
appear  to  be  approximately  as  common  in  the  "  mild  "  as  in  the 
"  severe  "  groups. 

REFERENCES 

1.  McGaffin.     A  Study  of  the  Forms  of  Mental  Disease  in  Cases  Show- 

ing no  Gross  Lesions  in  the  Brain  at  Autopsy.  Proceedings  of  the 
American  Medico-Psychological  Association,  Maj',   1912. 

2.  Southard.     A  Series  of  Normal-looking  Brains  in  Psjxhopathic  Sub- 

jects.    American  Journal  o"f  Insanity,  April,  1913. 

3.  Southard  and  Canavan.     A  Series  of  Normal-looking  Brains :  Second 

note  (Westboro  State  Hospital  material).  Journal  of  Nervous 
AND  Mental  Disease,  December,  1914. 

4.  Southard  and  Canavan.     A  Series  of  Normal-looking  Brains :  Third 

note  (Boston  State  Hospital  material),  Boston  Aledical  and  Surgical 
Journal,  Jan.  28,  1915. 

5.  Southard.     Psychopathology  and   Neuropathology :   The   Problems   of 

Teaching  and  Research  Contrasted.  Journal  of  American  Medical 
Association,  March,  1912,  and  American  Journal  of  Psychology, 
April,  1912. 

6.  Southard.     The  Mind  Twist  and  Brain   Spot  Hypotheses  in   Psycho- 

pathology  and  Neuropathology.  Psychological  Bulletin,  April,  Vol. 
xi.  1914. 

7.  Southard.     The  Association  of  Various  Hyperkinetic  Symptoms  with 

Partial  Lesions  of  the  Optic  Thalamus.  Journal  of  Nervous  and 
Mental  Disease,  October,  1914. 


2i6  E.   E.   SOUTHARD 

8.  Southard  and  Canavan.     Analysis  of  Five  Cases  of  Quasi  Functional 

Disease  of  the  Mind :  Being  a  Sixth  Note  on  Normal-looking 
Brains  in  Psychopathic  Subjects.  In  preparation,  to  be  submitted 
to  Journal  of  Medical  Research,  1916. 

9.  Southard.     On   the  Somatic   Sources  of   Somatic  Delusions.     Journal 

of  Abnormal  Psychology,  December,  1913. 
ID.  Southard  and  Stearns.     How  Far  is  the  Environment  Responsible  for 
Delusions?     Journal  of  Abnormal  Psychology,  June-July,   1913. 

11.  Southard  and  Tepper.     The   Possible   Correlation   Between    Delusions 

and  Cortex  Lesions  in  General  Paresis.  Journal  of  Abnormal  Psy- 
chology, October-Xovember,   1913. 

12.  Xissl.     Zur  Histopathologic  der  paralytischen  Rindenerkrankung.     His- 

tologische  und  Histopathologische  Arbeiten  iiber  die  Grosshirn- 
rinde,  Bd.  I,  1904. 

13.  Alzheimer.     Histologische   Studien   zur   Differenzialdiagnose   der   pro- 

gressiven  Paralyse.  Histologische  und  Histopathologische  Arbeiten 
iiber  die  Grosshirnrinde,  Bd.  I,   1904. 

14.  Kraepelin.     General   Paresis.     (From   Ein   Lehrbuch   fiir   Studierende 

und  Arzte,  HI  Bd.  H  Teil.  1913. )  Translated  by  J.  \\  .  Moore, 
Monographs  of  Journal  of  Nervous  .^xd  Mental  Disease. 

15.  Southard.     A  Study  of  Errors  in  the  Diagnosis  of  General  Paresis. 

Journal  of  Nervous  and  Mental  Disease,  Vol.  37,  No.  i,  Januar}-, 
1910. 

16.  Orton.     An  Analysis  of  Errors  in  Diagnoses  in  a  Series  of  60  Cases 

of  Paresis.  Journal  of  Nervous  and  Mental  Disease,  Vol.  40, 
1913. 

17.  Morse.     The  Correlations  of  Cerebrospinal  Fluid  Examinations  with 

Psychiatric  Diagnoses — A  Study  of  140  Cases.  Boston  Medical 
and  Surgical  Journal,  Vol.  clxx.  No.  11,  March  12,  1914. 

18.  Southard.     The  Margin  of  Error  in  the  Diagnosis  of  Mental  Disease: 

Based  on  a  Clinical  and  .'Anatomical  Review  of  250  Cases  Examined 
at  the  Danvers  State  Hospital,  Massachusetts,  1904-1908.  Boston 
Medical  and  Surgical  Journal,  August,  1910. 

19.  Southard  and   Stearns.     The   Margin  of   Error  in   Psychopathic  Hos- 

pital Diagnoses.  Boston  Medical  and  Surgical  Journal,  December, 
1914. 

20.  Southard   and    Ayer.     Dementia    Prnecox,    Paranoid,    Associated    with 

Bronchiectatic  Lung  Disease  and  Terminated  by  Brain  .•Abscesses 
(Micrococcus  Catarrhalis).  Boston  Medical  and  Surgical  Journal, 
December,  1908. 

21.  Southard.     A  Study  of  the  Dementia  Praecox  Group  in  the  Light  of 

Certain  Cases  Showing  Anomalies  or  Scleroses  in  Particular  Brain- 
Regions.  Proceedings  of  the  American  Medico-Psychological  As- 
sociation, May,  1910;  also  Am.  Jour.  Lisanity,   1910. 

22.  Southard.     r)n  the  .Absence  of  Coarse  Brain  Lesions  in  Many  Cases  of 

General  Paresis  (paper  to  be  published  in  a  series  of  papers  read  at 
a  conference  at  Danvers  State  Hospital,  Nov.  19,  1915. 

23.  Steams.     Occurrence  of  Hallucinosis  in  500  Cases  of  Mental  Disease. 

Journal  of  Nervous  and  Mkntal  Di.sease,  January,  1915. 

24.  Southard  and  Bond.     Clinical  and  Anatomical  Analysis  of  25  Cases  of 

Mental  Disease  .Arising  in  the  Fifth  Decade,  with  Remarks  on  the 
Melancholia  Question  and  Further  Observations  on  the  Distribution 
of  Cortical  Pigments.  Proceedings  of  the  American  Medico- 
Psychological  Association,  June,   1913. 

25.  Canavan.     A   Histological   Study  of  the  Optic  Nerves  in   a   Random 

Series  of  In.sanc  Hospital  Cases.  (Journal  of  Nervous  and  Mental 
Disease,  March,  1916.) 


A   HISTOLOGICAL   STUDY   OF   THE   OPTIC   NERVES 

IN  A  RANDOM  SERIES  OF  INSANE 

HOSPITAL  CASES^ 

By  AIyrtelle  M.  Canavan^  M.D. 

ASSISTANT  PATHOLOGIST,  STATE  BOARD  OF  INSANITY,  BOSTON,  MASS.  ;   FORMERLY 
PATHOLOGIST    TO   BOSTON    STATE    HOSPITAL 

Introduction 

To  fill  a  gap  in  the  routine  histological  examinations  of  ma- 
terials from  insane  hospitals,  I  examined  in  the  year  191 3  a  series 
of  58  unselected  cases  of  mental  disease  autopsied  in  the  Boston 
State  Hospital.  I  was  personally  somewhat  astonished  to  find 
that  40  of  these  58  cases  or  68  per  cent,  exhibited  changes  in  the 
optic  nerves  and  those  changes  in  most  cases  of  an  obvious  and 
undeniably  important  character. 

I  present  in  tables  below  the  general  statistics  of  these  cases, 
and  a  more  particular  analysis  of  15  cases  in  which  syphilis  was 
demonstrable. 

Of  special  interest  is  one  case  (1913.5)  in  which  a  spirochete 
was  demonstrated  in  the  pial  sheath  of  an  optic  nerve.  The 
nerve  itself  showed  a  slight  loss  of  nerve  fibers  by  the  Weigert 
method.  The  case  w^as  regarded  as  one  of  general  paresis.  It  is 
to  be  regretted  that  no  ophthalmoscopic  examination  was  made 
in  this  case  as  well  as  in  many  other  histologically  interesting 
cases.  This  study  is,  however,  a  purely  orienting  one  and  in 
view  of  its  results,  beyond  question  a  more  thorough  examination 
of  the  eyes  will  be  made  in  future.^  In  fact  it  may  be  advised 
that  an  ophthalmoscopic  examination  should  be  made  (for  scien- 
tific as  well  as  for  practical  purposes)  in  all  cases  in  which  an 
autopsy  has  been  granted  or  is  likely  to  be  granted.  It  may  be 
wondered  how  often  similar  changes  in  other  peripheral  nerves, 

1  From  the  Laboratory  of  the  Boston  State  Hospital.  Contribution  of 
the  State  Board  of  Insanity,  Massachusetts,  Number  yj  (i9i5-3),  presented 
at  a  meeting  of  the  New  England  Society  of  Neurology  and  Psychiatry  at 
State  Infirmary,  Tewksbury,  March,  1914.  (Bibliographical  Note. — The 
previous  S.  B.  I.  contribution  (1915.2)  was  by  E.  E.  Southard,  entitled 
"Anatomical  Findings  in  the  Brains  of  Manic  Depressive  Subjects,"  pub- 
lished in  Transactions  of  the  American  Medico-Psychological  Association, 
Seventieth  Annual  Meeting,  Baltimore,  Md.,  May  26-29,  I9i4- 

217 


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HISTOLOGICAL   STUDY   OF   OPTIC   NERVES  223 

and  especially  in  the  cranial  nerves,  could  be  detected  in  routine 
examinations  of  psychopathic  subjects.  At  present  I  do  not  know 
but  that  the  optic  nerve  findings  may  be  differential  for  that  nerve. 
Degenerations  of  a  chronic  nature  are  shown  in  the  following 
table : 

Boston  State  Hospital 

Optic  Nerve  Changes  in  Unselected  Autopsy  Cases 

Cases  in  random  series',   1913   58 

Cases  with  optic  nerve  changes  (Weigert)  (unilateral,  13  ;  bilateral,  27)  40 
Cases  with  spinal  cord  changes   (Weigert)    34 

S3'philitics   in   series    18 

With  optic  nerve  changes  (unilateral,  3;  bilateral,  12)    .....     l%8 

With  spinal  cord  changes   l%8 

With  optic  nerve  and  cord   ii^g 

Non-syphilitics  in  series   40 

With  optic  nerve  changes   (unilateral,  10;  bilateral,  15)  ....     2^0 

With  spinal  cord  changes   2%0 

With  optic  nerve  and  cord   1%0 

40  cases  with  optic  nerve  changes. 
YiO  were  e5^e  workers. 

What  are  the  changes  seen  in  the  fifteen  syphilitic  optic 
nerves?  In  general,  peripheral  degeneration  of  the  nerve  (see 
Fig.  i).     To  briefly  particularize — in  five  cases: 

B.  S.  H.  No.  9825,  Path.  1913.5. — Female.  Age  56;  diag- 
nosis, general  paresis;  married  twice;  had  two  children  by  first, 
none  by  second  husband.  Had  broken  leg  three  times  by  falls, 
and  had  "  rheumatism  "  for  twenty  years. 


Fig.  I.  Peripheral  degeneration  of  optic  nerve  in  a  syphilitic.  B.  S.  H. 
Path.  1913.31.     Weigert's  myeline  sheath  stain. 

Dtiration  of  her  mental  trouble  was  about  two  years,  six 
months.  She  had  rather  suddenly  become  slovenly,  irritable  and 
erotic;  was  sent  here  because  she  wandered  away  and  her  mem- 


MYRTELLE   M.    CAXAVAN 

orv  failed.  Pupils  were  irregular  and  unequal,  but  reacted  to 
light  and  accommodation.  Xo  ophthalmoscopic  examination  was 
made.     Wassermann  reaction  not  done. 

She  had  absent  knee  jerks,  speech  defect,  ataxia,  tremors  and 
Romberg,  and  her  judgment  was  poor,  and  she  gave  evidence  of 
dementia. 

Sections  of  the  brain  show  marked  infiltration  of  vessels,  dis- 
order and  destruction  of  cells,  and  sections  of  the  cord  show  a 
gummatous  meningitis ;  over  mid-dorsal  region,  and  posterior 
column  sclerosis.  The  optic  nerve  shows  slight  peripheral  loss 
of  myelin  sheaths  and  by  Levaditi  stain  a  spirochete,  located  in 
the  pial  sheath. 

B.  S.  H.  No.  9206,  Path.  1913.8. — Male.  Age  36;  admits 
syphilis  at  27 ;  alcoholic. 

Was  admitted  to  Long  Island  Hospital  complaining  of 
stomach  trouble  when  35,  at  which  time  he  could  only  distinguish 
between  light  and  dark  in  one  eye  and  count  fingers  with  the 
other.  Discs  were  in  state  of  general  pallor.  Knee  jerks  lost, 
but  he  was  not  ataxic. 


~5 


Fig.  2.  Central  dcgcnLTiUion  of  optic  nerve  of  an  arteriosclerotic.     B.  S. 
H.  Path.  1913.60.     Weigert's  myelin  sheath  stain. 


Four  months  later  markerl  optic  atrophy  with  poor  prognosis. 
No  ataxia  and  no  Romberg. 

April  4,  six  months  after  admission,  optic  atrophy  complete, 
ataxic  and  marked  Romberg.     No  mental  symptoms. 

March'  190;,  eighteen  months  after  admission,  and  a  year  after 
his  sight  was  lost,  he  developed  mental  symptoms  for  which  he 
was  committed  to  this  hospital. 

In  order  of  sequence,  (i)  optic  involvement,  (2)  cord  and 
(3)  brain. 


HISTOLOGICAL   STUDY   OF   OPTIC   NERVES 


225 


Sections  show  complete  degeneration  optic  nerves;  marked 
posterior  column  sclerosis. 

B.  S.  H.  No.  ii6go,  Path,  ipis.31. — Male.  Age  54  yrs. 
Marble  worker.     Diagnosis,  general  paresis. 

Widower,  with  one  son ;  had  not  worked  for  three  years,  on 
account  of  rheumatism.  When  he  came  here  he  was  unable  to 
stand,  pupils  rigid  to  light,  speech  defect,  absent  knee  jerks,  mem- 
ory loss,  hallucinated,  and  Wassermann  reaction  positive. 

Whole  period  of  disease  19  months. 

Section  shows  marked  degeneration  of  optic  nerve,  central 
area  best  preserved,  and  posterior  column  sclerosis.     (Fig.  5). 

B.  S.  H.  No.  11740,  Path.  1913.33. — Male.  Age  38  yrs. 
Cigar  maker.  Widower.  Became  blind — ?  how —  but  mental 
symptoms  did  not  come  on  for  some  years  after  the  blindness^ 
(see  Knapp's  report  of  three  cases  in  which  optic  atrophy  was 
the  first  symptom  of  paresis).'* 


Fig.  3.  Pressure   atrophy  of   nerve    from   middle   cerebral   aneurysm. 
B.  S.  H.  Path.  1913.15.     Weigert's  myelin  sheath  method. 


226  MYRTELLE   M.   CANAVAN 

Came  to  hospital  in  a  depression  in  which  he  refused  to  eat. 
Xo  ataxia  nor  incontinence.  Wassermann  reaction  in  serum  and 
in  cerebrospinal  fluid  negative,  though  proteid  content  high — 7 
cells.     Visual  lialluciiiatious. 

Ophthalmoscopic  examination  shows  chalky  white  eyegrounds. 
(i)  Eye  symptoms  preceded  mental  symptoms.  Optic  atrophy 
and  paresis.     No  tabes  dorsalis. 

Sections  show  complete  optic  atrophy,  infiltration  of  vessel  ' 

walls,  and  disorder  and  destruction  of  nerve  cells  in  cortex  though  * 

no  sclerosis  of  the  cord. 

B.  S.  H.  No.  10830,  Path,  jp/j.d^.— Alale.  Age  54  yrs. 
Special  officer.     Taboparetic. 

Age  of  infection  unknown.  Married  twice ;  no  children.  At 
50  complained  of  dizziness  and  would  fall  in  the  street ;  could 
not  get  along  in  the  dark ;  complained  of  failing  eyesight,  shoot-  h 

ing  pains  in  legs,  vomiting  and  gastric  crises.     Impotence — this  • 

worried  him — wished  unnatural  sexual  intercourse.     At  52  be-  ''^ 

came  irritable,  hallucinated,  and  developed  homicidal  tendencies. 
Was  sent  to  the  hospital  at  53 ;  died  at  54. 


Fig.  4.  Choked  disc,  unilateral,  from  multiple  metastatic  carcinomata 
of  brain.     I'>.  S.  H.  Path.  1913.43.     Weigert's  myelin  sheath  method. 

Neurologkally:  Rigid  pupils,  diplopia;  tremor  of  lips,  tongue, 
hand;- gait  ataxic;  Kombcrg -|- ;  tendon  reflexes  absent;  sphinc- 
ters relaxed;  imjjortant  \Va.  R. -J- in  fluid  and  .scrum;  cell  count 
45  to  cu.m.m.;  globulin  ±  ;  salvarsan — 2  injections. 

Summary:  Tabetic  symptoms  first  with  slight  impairment  of 
vision  and  finally  a  psychosis.  Whole  period  of  symptoms,  four 
years.  Posterior  column  sclerosis  definite — optic  nerve  changes 
faint. 


HISTOLOGICAL   STUDY   OF   OPTIC  NERVES 


227 


Of  the  nonsyphilitic,  the  arteriosclerotics  led,  and  the  most 
characteristic  change  in  the  nerves  was  a  degeneration  about  the 
central  artery  of  the  retina  in  the  optic  nerve  (see  Fig.  2). 

One  case  of  more  than  usual  interest  was : 

B.  S.  H.  No.  11321,  Path.  1913.15. — Female.  Age  52  yrs. 
A  laundress,  who  presented  certain  vague  and  anomalous  mental 
symptoms,  with  no  neurological  findings  which  suggested  the 
cause  of  her  illness.  Ophthalmoscopic  examination  was  not 
made  during  her  life.  Suddenly  she  fell  dead  while  arranging 
her  hair  after  dinner.  There  were  inequalities  in  the  optic  discs 
then ;  one  showed  central  cupping  rather  deeper  than  physiologic, 
the  other  showed  a  large  gray  protruding  disc  tentatively  called 
a  choked  disc. 


Fig.  S.  Unilateral  retrobulbar  cyst  with  degeneration.     B.  S.  H.  Path. 
I9I3-59-     Weigert's  myelin  sheath  method. 


Postmortem,  the  left  internal  carotid  had  been  aneurysmal 
and  had  burst.  Before  this  it  had  pressed  on  the  left  optic  nerve, 
producing  atrophy  sufficient  to  allow  blood  to  ascend  into  the 
sheath  of  the  nerve  and  produce  the  picture  as  outlined  (see  Fig. 
3).      (To  be  reported  in  detail.) 

Of  other  lesions,  the  following  is  representative: 
B.  S.  H.  No.  10873,  Path.  1913.43. — Male.  Age  43  yrs.  At 
41  had  right  breast  removed  for  carcinoma,  after  a  swelling  of 
15  years  duration;  recurrence  within  two  years  at  site  and  over 
trunk ;  began  at  this  time  to  be  different  mentally ;  had  delusions 
of  persecution,  and  was  shortly  sent  to  hospital,  where  he  began 
having  convulsions.  Pupils  react  sluggishly.  History  of  con- 
vulsions. Thickness  of  speech.  Mouth  drawn  to  left  side. 
Confusion.  Increasing  number  of  convulsions.  Inequality  of 
optic  fundi.  Unilateral  choked  disc  (later).  'Inequality  of  knee 
jerk. 


328  MYRTELLE   M.    C  AX  A  VAN 

Section  shows  marked  choked  disc  on  left  (see  Fig.  4),  faintly 
on  right ;  no  changes  in  cord.     ^lultiple  carcinoma  of  brain. 

It  may  be  worth  while  to  note  the  methods  employed  in  this 
investigation.  On  account  of  the  fact  that  some  hesitancy  is 
sometimes  felt  to  removing  the  retina  for  study  I  present  a  method 
which  is  cosmetically  perfect  so  far  as  the  restoration  of  the 
appearance  of  the  body  is  concerned.  There  is  nothing  original 
about  the  method,  which  has  been  constructed  from  the  data  of 
various  well-known  handbooks. 

Method:  Peel  the  dura  from  the  anterior  fossae,  and  with  a 
chisel  8  cm.  long  X  i  cm.  wide  cut  an  elliptical  area  from  the 
orbital  plate,  the  center  of  the  ellipse  to  coincide  with  the  slight 
inner  convexity  of  the  orbital  plate,  including  the  sides  of  the 
optic  foramina.     Remove  bone  thus  encircled. 

The  optic  nerve  in  its  dural  sheath  will  present  at  the  proxi- 
mal end  and  the  fat  and  muscles  surrounding  the  nerve  and  globe  at 
the  distal  end.  Lightly  grasp  the  fat  with  a  pair  of  hemostats 
and  with  a  scalpel  dissect  the  nerve  from  the  foramen ;  take  a 
deeper  bite  with  the  hemostats  and  cut  down  on  them  from  the 
distal  end  of  the  ellipse  to  the  globe.  Gently  pick  up  the  dura  at 
the  proximal  end  of  the  nerve  and  exert  traction  loosening  tis- 
sues from  beneath. 

With  the  left  hand  fix  the  globe  in  the  orbital  cavity  by  pres- 
sure from  without  and  pierce  the  sclera  with  sharp  scalpel.  With 
the  hemostats  pick  up  the  cut  edge  of  the  sclera  and  with  curved 
scissors  rapidly  cut  around  the  nerve  head.  A  bit  of  cotton, 
soaked  in  permanganate  and  dried,  is  introduced  into  the  eyeball, 
presenting  a  dark  background  for  the  pupil,  and  the  cavity  is 
closed  by  more  filling  in  with  cotton  until  inspection  from  the  face 
shows  a  full  orbit.  It  is  often  preferable  to  use  a  dark  colored 
material  which  will  pack  better  than  cotton  and  for  this  purpose 
a  bit  of  jute  may  be  recommended. 

After  removal,  examine  the  disc  and  describe  any  gross  de- 
pressions, elevations  or  other  obvious  changes.  The  retinal  vessel 
normally  closely  resembles  one  of  the  meningeal  twigs  of  the  pia 
mater. 

Imx  in  formalin  do  per  ccnt.j  four  to  six  or  more  days. 
Trim  specimen  in  this  wise  (Verhoeflf's  direction)  :  with  curved 
scissors  cli[)  the  sclera  down  to  the  smallest  square  compatible 
with  preserving  the  nerve,  cutting  under  the  retina,  or,  at  least, 
not  detaching  it  from  the  disc.     Sever  the  nerve  within  the  first 


HISTOLOGICAL   STUDY   OF   OPTIC   NERVES  229 

•centimeter  behind  the  globe — this  including  the  inturning  of  the 
central  artery  of  the  retina — and  embed  in  celloidin  after  mor- 
danting in  Weigert  Mordant  I. 

INIount  on  blocks  with  the  disc  parallel  to  the  block,  and  cut 
down  until  the  central  vessels  show  from  the  disc  to  the  proximal 
end  of  the  nerve. 

If  sections  are  desired  for  nuclear  staining,  save  some  at  10 
microns ;  otherwise,  ten  to  twelve  sections  are  available  at  14 
microns.  Cut  in  series — mount  and  stain  in  the  celloidin  sheet 
by  Weigert  myelin  sheath  method. 

The  routine  method  for  the  examination  of  these  optic  nerves 
was  in  all  cases  by  the  Weigert  myelin  sheath  method.  In  order 
to  secure  a  nuclei  stain  after  the  first  mordant  of  Weigert's 
method,  I  used  \^erhoeff's  nuclear  stain,  a  modification  of  the 
classical  hematoxylin  eosin  stain  described  by  him  in  the  Journal 
of  the  American  Medical  Association,  March  14,  1908,  p.  76,  and 
in  the  same  Journal  May  6,  191 1,  p.  1326.  These  two  methods 
were  sufiicient  for  longitudinal  sections. 

Cross  sections  of  the  optic  nerves  were  stained  at  a  plane 
behind  the  turning  in  of  the  arteria  centralis  retinae  and  in  a  num- 
ber of  instances  cresyl  violet  was  used  to  secure  evidences  of 
lymphocytic  infiltration  if  any.  If  such  infiltration  was  evident, 
material  from  the  nerve  in  question  was  examined  by  the  Levaditi 
modification  for  spirochetes  of  Ramon  y  Cajal's  silver  impregna- 
tion.     (The  search  was  rewarded  in  one  instance,  191 3.5.) 

In  a  number  of  instances,  as  suggested  by  clinical  history  or 
for  other  reasons,  the  Alarchi  method  was  used.  No  cases  of 
acute  Marchi  degeneration  were  discovered  in  this  series. 

Conclusions 

1.  Forty  cases  or  68  per  cent,  of  a  random  series  of  58  cases 
of  mental  disease  autopsied  at  the  Boston  State  Hospital  showed 
obvious  and  important  chronic  changes  in  one  or  both  optic 
nerves  (one,  13;  both,  27). 

2.  In  the  same  series  of  58  there  were  but  34  which  showed 
chronic  spinal  cord  changes  by  the  same  method  (Weigert  myelin 
sheath). 

3.  There  were  7  cases  which  showed  very  slight  changes  in 
the  spinal  cord  (although  in  all  instances  definite  changes)  when 
there  were  no  changes  demonstrable  in  the  optic  nerves. 

4.  Of  18  syphilitic  cases  (clinical  evidence  in  some  cases  sup- 


230  MYRTELLE   M.   CAXAVAN 

ported  by  W'assermann  reaction)   there  were  15  showing  optic 
nerve  changes — one  eye,  3;  both  eyes,  12. 

5.  In  one  case  a  spirochete  was  demonstrated  by  the  Levaditi 
method  in  the  pial  sheath  of  the  optic  nerve  in  a  case  diagnosti- 
cated general  paresis  (aUhough  possibly  one  of  cerebrospinal 
syphilis). 

REFERENCES 

1.  Benedict.     Eje  Grounds  in  Psychoses.     Phys.  and  Surg.,  Detroit,  1913, 

XXXV,  289. 

2.  Klieneberger.     Monatsch.  f.  Psych,  u.  Xeur.,  1913,  xxxiii.  519. 

3.  P.  C.  Knapp.Three  cases  ot  General  Paresis  Preceded  by  Optic  \trophy. 

Boston  Medical  and  Surgical  Journal,  January  5,  1899. 

4.  Fuchs.     Text-book  of  Ophthalmology,  p.  590. 


THE  ROLE  OF  HALLUCINATIONS  IN  THE  PSYCHOSES 
BASED  UPON  A  STATISTICAL  STUDY  OF  514  CASES 

By  Forrest  M.  Harrison,  M.D. 

JUNIOR    ASSISTANT    PHYSICIAN,    GO\TRNMENT    HOSPITAL   FOR    THE   INSANE, 
WASHINGTON,   D.   C. 

The  subject  of  hallucinations,  a  term  first  used  and  exploited 
by  the  old  Greek  writers,  is  as  ancient  perhaps  as  the  universe  itself. 
Indeed,  I  am  not  so  sure  but  that  it  even  antedates  the  period 
"  when  Adam  first  swung  himself  from  a  bough  in  the  forest  pri- 
meval and  stood  upon  two  legs."  Certain  it  is,  when  one  glances 
and  pores  over  the  many  volumes  that  have  been  brought  to  the 
attention  of  the  medical  profession  by  legions  of  authors  concern- 
ing these  fallacious  sensory  perceptions,  one  is  forced  to  admit  that 
this  rather  important  and  not  altogether  infrequent  symptom  in  the 
field  of  abnormal  psychology  was  born  way  back  in  the  womb  of 
time  whereof  the  memory  of  man  runneth  not  to  the  contrary,  if  I 
may  purloin  a  phrase  from  the  realm  of  the  law  without  bringing 
adverse  criticism  upon  my  head.  We  have  only  to  recall  a  few  of  the 
more  familiar  Bible  stories  and  teachings,  such  as  the  "  handwriting 
on  the  wall "  at  Belshazzar's  feast  and  the  "  transfiguration  on  the 
Mount"  and  other  incidents  of  like  import,  to  establish  the  fact 
that  hallucinatory  experiences  among  the  prophets  and  saints,  as 
well  as  among  the  plebeian  classes,  who  existed  and  inhabited  this 
world  in  the  prehistoric  days,  were  not  rare  by  any  means.  I  am 
perfectly  willing  to  grant,  of  course,  that  in  a  majority  of  these  in- 
stances, we  are  unable  to  prove  definitely  whether  or  not  they  were 
real  occurrences.  If  we  accept  the  Bible  literally,  we  must  admit 
that  they  were,  yet  careful  students  and  research  workers  into 
matters  religious  have  seen  fit  to  doubt  the  reality  of  some  of  them. 

It  is  a  well-known  fact  that  when  hallucinations  are  accepted  as 
realities  their  influence  on  thought  and  action  is  overwhelming,  in 
fact,  more  potent  than  normal  sensations,  reasonable  arguments, 
and  admonitions.  In  this  connection  it  is  quite  interesting  to  note 
and  a  fact  which  particularly  impressed  me  in  going  over  the 
literature  of  this  subject,  that  men  somewhat  deranged  in  mind,  men 
suffering  with  hallucinations,  have  had  a  tremendous  influence  in 
making  history  and  in  shaping  the  destiny  of  nations  and  the  fate 

231 


232  FORREST  M.   HARRISON 

of  empires.  Legendary  lore  and  the  sacred  books  of  all  nations 
fairly  teem  with  revelations  and  visions  and  profane  history  fur- 
nishes us  with  a  series  of  such  examples,  while  numerous  accounts 
of  hallucinations  in  great  men  and  geniuses  have  come  down  to  us 
from  classical  times. 

The  old  notion  for  instance  that  Mohammed  was  a  mere  im- 
poster  appears  so  difficult  of  belief  that  no  one  of  any  recognized 
skill  in  historical  inquiry  now  upholds  it.  If  we  accept  as  true  the 
doctrine  that  men  cannot  excite  in  others  feelings  which  are  wanting 
in  their  own  breasts,  we  must  admit  that  a  man  without  honesty  of 
purpose  and  totally  destitute  of  religious  faith  could  no  more  found 
a  religious  system  like  that  of  Islam  than  a  man  with  no  ear  for 
nuisic  could  compose  an  opera.  Be  that  as  it  may,  it  has  always 
been  a  great  difficulty  to  explain  how  this  great  man  could  in  good 
faith  say  that  he  had  seen  the  Angel  Gabriel,  and  heard  voices  from 
Heaven  calling  him  the  messenger  of  God,  and  revealing  chapter 
after  chapter  of  the  Koran.  Weighing  all  the  testimony  that  re- 
mains to  us  together,  it  seems  likely  that  Mohammed,^  at  the  com- 
mencement of  his  mission,  was  subject  to  hallucinations  of  hearing 
and  sight,  which  taking  the  tone  of  his  deeply  religious  feelings  and 
his  dislike  to  the  idolatry  and  polytheism  of  the  people  of  Mecca, 
were  interpreted  by  him  as  a  message  from  God.  Under  their  in- 
fluence he  founded  a  religion  which  now  numbers  over  a  hundred 
million  of  votaries  and  which  possesses  to  this  day  a  singular  power 
over  the  minds  of  its  followers. 

The  same  thing  is  true  of  Martin  Luther,-  the  great  German 
reformer,  who  suffered  from  many  hallucinatory  experiences  con- 
cerning Satan,  at  whom  he  once  hurled  an  inkstand  during  a  sermon 
while  laboring  under  extreme  religious  excitement.  There  seems 
to  be  no  adequate  proof  that  the  delusions  and  hallucinations  from 
which  he  suffered  altered  in  any  way  or  even  modified  his  religious 
views,  but  it  is  easy  to  imagine  circumstances  under  which  they 
might  have  done  so,  and  led  Luther  to  become  the  founder  of  a 
new  religion. 

Jeanne  d'Arc^  presents  one  of  the  most  remarkaljle  cases  of  hal- 
lucination on  record.  Beginning  at  the  jnibcscent  period,  and  while 
she  was  tending  her  father's  sheep  on  the  hills  of  Domremy.  the 
voices  which  she  heard  were  interpreted,  in  accordance  with  the  in- 
telligence of  the  times  in  which  she  lived,  as  those  of  angels.  'Ihey 
continued  with  littk-  remission  through  nil  the  eventful  and  terrible 
scenes  of  war  and  carnage  through  which  she  eventually  passed. 
They  brought  solace  and  comfort,  and  sustained  her  in  the  final  ex- 


ROLE   OF   HALLUCINATIONS   IN   PSYCHOSES  233 

periences  to  which  she  was  consigned  by  the  barbarous  usages  of 
the  age, 

Socrates*  told  the  Athenians  that  he  was  continually  influenced 
to  heroic  actions  and  good  deeds  by  a  demon.  These  influences  to 
do  good  were  attended  by  no  voice,  but  he  was  restrained  from  all 
evil  and  danger  by  a  warning  voice  which  was  never  passed  un- 
heeded by  him.  By  strictly  observing  and  attending  to  the  instruc- 
tion of  the  voiceless  good  demon,  he  could  so  influence  his  friends, 
pupils  and  even  strangers  as  to  compel  them  to  do  his  bidding  at  a 
distance  or  when  separated  by  walls. 

Swedenborg,^  who  made  even  more  decided  claims  than  Mo- 
hammed to  hold  communion  with  another  world,  and  indeed,  said 
in  so  many  words  that  he  could  converse  with  angels  and  the  spirits 
of  men  in  Heaven  at  his  pleasure,  suffered  undoubtedly  from  hal- 
lucinations and  at  times  fell  into  fits  of  reverie  and  trance.  When 
Columbus^  was  cast  upon  the  shores  of  Jamaica,  he  heard  a  voice 
reproaching  him  for  his  discouragement  and  lack  of  faith.  Of 
CromwelP  it  is  stated  that  on  one  occasion  he  was  lying  in  his  bed 
very  much  fatigued  when  the  curtains  were  drawn  aside  and  a 
woman  of  gigantic  stature  appeared  to  him  and  prophesied  his  future 
greatness.  As  everyone  will  recall,  Brutus,^  at  the  Ides  of  March, 
surrounded  by  darkness  and  solitude,  seeing  vividly  an  apparition 
which  he  addressed,  demanded  an  explanation  of  her  intrusion,  to 
which  she  replied,  "  I  am  thy  evil  genius.  I  shall  meet  thee  again 
at  Philippi." 

General  Rapp^  relates,  that  going  one  night  unannounced  into 
Napoleon's  tent,  he  found  him  in  so  profound  a  reverie  that  his 
entrance  was  unnoticed.  After  some  time  the  Emperor  turned 
around,  and  without  any  preamble,  seized  General  Rapp  by  the 
arm,  saying  excitedly  and  pointing  to  the  sky,  "Do  you  see  it?" 
The  General  did  not  reply  but  on  the  question  being  repeated  he  said 
he  saw  nothing.  "  What,"  replied  the  Emperor,  "  You  cannot  see 
it !  It  is  my  star !  I  see  it  on  all  occasions !  It  orders  me  to  go 
forward!     It  is  a  constant  sign  of  good  fortune." 

Lord  Herbert,^"  in  writing  his  book  on  the  "  Falsity  of  Revealed 
Religion,"  devoted  to  it  every  spare  moment  he  could  snatch  from 
business.  In  doubt  as  to  its  publication,  he,  on  one  occasion,  prayed 
audibly  for  a  sign  to  guide  his  decision,  and  affirms  that  he  had  no 
sooner  concluded  his  prayer  than  he  heard  a  loud  but  agreeable 
sound  from  Heaven  proceeding  from  a  clear  sky  which  he  inter- 
preted as  a  sign  of  approval.  I  could  go  on  in  this  way  indefinitely 
for  there  is  a  mass  of  material  to  be  had  which  consists  for  the  most 


234  FORREST  M.   HARRISON 

part  of  picturesque  cases  like  those  quoted  above  more  satisfac- 
tory to  the  raconteur,  perhaps,  than  to  the  student.  I  beheve  that 
these  experiences  may  certainly  be  referred  to  a  neurotic  or  psycho- 
pathic make-up,  but  the  narratives  are  in  general  so  confused  and 
contradictory,  and  so  seldom  come  to  us  at  first  hand,  that  it  is 
difficult  to  arrive  at  any  satisfactory  conclusion  concerning  them. 
This  is,  however,  a  rather  unimportant  phase  of  the  subject,  except 
from  a  historical  point  of  view,  but  inasmuch  as  it  shows  in  no 
small  degree  the  importance  of  hallucinations  as  occurring  in  the 
lives  of  those  men  whose  names  are  indelibly  stamped  in  the  pages 
of  history,  I  have  dwelt  at  considerable  length  on  it. 

Let  us  turn  now  to  something  more  material,  more  worth  w'hile, 
more  important,  and  something  which  is  absolutely  necessary  if  we 
are  to  interpret  these  manifestations  correctly  and  in  a  strictly  scien- 
tific manner.  I  refer  to  the  study  of  the  nature,  origin  and  mech- 
anism of  hallucinations.  Of  all  the  clinical  symptoms  of  psychiatry 
there  is  none  which  even  to  the  laity  is  so  characteristic  of  mental 
disorder  as  hallucinations  and  still  it  is  more  difficult  to  explain 
the  psychical  mechanism  of  this  remarkable  phenomenon  than  that 
of  any  other  psychopathic  condition.  Indeed,  ever  since  mental 
diseases  have  been  made  a  subject  of  special  study,  we  have  en- 
deavored to  arrive  at  some  definite  conclusion  concerning  the  origin 
of  false  sensory  perceptions.  Up  to  the  jjresent  day,  however,  no 
satisfactory  explanation  has  been  given,  a  fact  which  is  sufficiently 
well  shown  by  the  comparatively  large  number  of  theories  which 
have  been  oft'ered  by  many  authors.  That  this  should  be  so  is  not 
to  be  wondered  at.  The  great  difficulty  of  explaining  the  psychical 
mechanism  of  any  psychopathic  symptom  or  condition  we  will  ap- 
preciate if  we  consider  that  our  knowledge  of  any  normal  psychical 
processes  consists  only  of  hypotheses.  All  our  modern  psycholog- 
ical doctrines,  ingenious  and  evident  as  they  may  appear,  including 
the  generally  accepted  theory  of  association,  are  after  all  more  or 
less  speculation  without  absolute  and  irrefutable  proof.  One  might 
even  go  so  far  as  to  say  that  it  is  idle  play  to  try  to  explain  the 
mechanism  of  a  diseased  condition  as  long  as  we  do  not  possess 
the  clear  knowledge  of  its  physiological  analogue.  The  two  sciences, 
psychiatry  and  psychology,  however,  form  in  more  than  one  respect 
a  mutual  complement,  and  a  thorough  and  accurate  study  of  any 
psychopathic  symptom  is  apt  to  throw  additional  light  on  the  cor- 
responding p.sychical  processes  and  vice  versa. 

The  first  attempts  to  explain  the  physiological  process  of  false 
perceptions  were  very  misleading  and  consisted  only  of  vague  gen- 


ROLE   OF   HALLUCINATIONS   IN   PSYCHOSES  235 

eralities.  Two  main  points  were  considered  in  the  elucidation  of 
the  problem — on  the  one  hand,  the  sensory  character  of  the  phe- 
nomenon, and  on  the  other,  the  great  part  played  by  the  mental 
state  in  determining  what  the  hallucinatory  object  should  be.  The 
ideational  centers  were  assumed  to  be  locally  separated  from  the 
sensory  centers,  and  this  being  the  case,  it  was  but  natural  to  relegate 
the  imaginative  factors  of  fallacious  perception  to  the  higher  ele- 
ments of  the  cortex  and  to  place  the  sensory  part  to  those  cells 
where  in  popular  parlance,  "  incoming  impressions  are  transformed 
into  sensations.." 

As  to  the  locality  and  extent  of  these  centers  there  was  a  conflict 
of  views.  One  writer^ ^  believed  that  hallucinations  were  provoked 
by  a  diseased  condition  of  the  optic  thalami,  in  which  he  thought 
that  the  sensory  impressions  transmitted  by  the  nerves  and  spinal 
cord  became  realized  as  perceptions.  He  even  indicated  five  little 
masses  of  gray  nerve  cells  within  each  thalamus  in  w^hich  the  sev- 
eral transformations  took  place,  one  for  each  of  the  senses.  Mey- 
nert^-  placed  the  centers  lower  down — that  of  vision  for  instance  in 
the  corpora  quadrigemina.  Ferrier^^  and  others  locate  them  in  the 
cortex  itself. 

It  soon  became  evident  to  the  more  keen  observers  and  thinkers 
that  the  chief  concern  did  not  lie  as  to  where  the  two  centers  were 
located,  but  rather  the  finding  out  of  just  what  started  the  impulse 
in  the  centers  in  hallucinations  wdiere  no  stimulus  is  supposed  to^ 
exist.  Many  writers  ascribed  and  many  still  ascribe  the  initial  im- 
pulse to  the  ideational  centers,  the  so-called  "  centrifugal  psychic 
theory."  Thus,  according  to  Griesinger,^*  "  hallucinations  are  sub- 
jective sensorial  images,  which  are,  however,  projected  outward 
and  thereby  become  apparently  objects  and  realities."  Stearns* 
believes  that  "they  are  perceptions  of  objects  which  have  no  exist- 
ence except  in  the  brain  of  the  person  perceiving  them."  Ireland" 
states  that  "  a  hallucination  is  a  perception  of  a  sensation  arising 
from  changes  wathin  the  organism  without  any  corresponding  change 
in  the  outer  world."  Tuke^*^  declares  that  "  they  are  sensations  ex- 
perienced although  no  external  objects  act  upon  the  periphery  of 
the  sensory  nerves."  Von  Krafift-Ebing^'  in  a  rather  unique  defini- 
tion considers  that  "  hallucinations  are  the  result  of  excitation  of  the 
central  apparatus  of  a  sensory  nerve  by  an  adequate  stimulus  suffi- 
cient to  give  the  force  of  a  sense  impression  to  the  answ^ering  ex- 
citation which  is  projected  outwards."  Kellogg^^  whites :  "An 
hallucination  is  the  vivid  conscious  revival  of  sense  impressions 
without   a  physiological  peripheral   stimulus."      Tanzi^**   concludes 


236  FORREST  M.   HARRISON 

that  "  an  hallucination  is  the  occurrence  of  an  internal  image,  which 
on  account  of  its  remarkable  vividness  is  referred  externally  as  if 
it  had  come  from  without  and  which  is  mistaken  for  an  objective 
reality  "  and  so  on  indefinitely. 

While  the  theories  of  these  authors  had  much  to  commend  them, 
they  were,  I  believe,  based  upon  a  complete  misconception  of  the 
mental  state  in  hallucination  and  of  the  physiological  nature  of  sen- 
sation. Ideas  of  sensation  can  never  rise  to  the  level  of  true  sensa- 
tion itself.  The  want  of  the  feeling  of  sensory  affection  leaves  a 
gap  which  no  psychic  intention  can  bridge  over.  However  vivid 
and  energetic  an  ideational  image  may  be,  it  can  never  receive  the 
stamp  of  sensory  reality,  for  the  most  characteristic  feature  of  a 
sensory  impression,  in  fact  the  very  thing  that  stamps  it  as  such, 
is  the  feeling  of  objectivity,  of  externality  that  goes  with  it. 

Problem,  however,  often  gives  rise  to  problem.  When  we  have 
'discovered  a  continent  or  crossed  a  chain  of  mountains,  it  is  only  to 
tind  another  ocean  or  another  plain  upon  the  farther  side.  And  so 
5n  order  to  account  for  this  feeling  of  externality  and  projection 
outwards  of  hallucinations,  and  also  to  exclude  those  cases  in  which 
the  peripheral  sense  organs  appeared  to  be  involved,  it  became 
necessary  to  add  still  further  hypotheses  to  the  above.  In  this  way 
arose  the  "centrifugal  sensorial  theories,"  whereby  it  was  assumed 
that  the  sensory  channels  became  the  seat  of  a  centrifugal  nerve  cur- 
rent, originating  in  the  higher  ideational  cortical  centers,  and  follow- 
ing thence  to  the  sensorium  and  from  thence  on  downward  in  many 
cases  to  the  sense  organ,  where  the  condition  present  indicated  a 
local  disturbance 

It  did  not  take  long,  however,  to  establish  the  fact  that  both  of 
these  theories  were  inconsistent  with  the  generally  accepted  physio- 
logical beliefs  and  so  the  attempt  was  made  by  some  authors  to 
explain  the  phenomena  on  the  assumption  of  a  reverse,  that  is  to 
say,  a  centripetal  process.  Schlager,^*'  for  instance,  distinguishes 
not  only  between  hallucinations  and  illusions,  but  creates  another 
class,  abnormal  sensations,  strictly  so-called,  which  he  endeavors  to 
explain,  speaking  of  olfactory  cases,  through  polypoid  growths  in 
the  mucous  membrane  of  the  nose,  through  concussion  of  the 
brain,  apoplectic  attacks,  etc.,  that  is  to  say,  through  inadequate 
stimuli.  Lazarus^^  considers  that  in  hallucination  the  sensory 
nerves  are  stimulated  throughout  their  course  to  the  center  by  in- 
ternal processes,  but  he  creates  a  new  class,  "  visions,"  which  he 
explains  on  the  psychical  theory. 

It  is  clear,  however,  that  the  whole  controversy  as  to  whether 


ROLE   OF   HALLUCINATIONS  IN   PSYCHOSES  237 

hallucinations  arise  in  the  ideational  or  cortical  centers,  and  whether 
the  process  travels  centripetally  or  centrifugally  becomes  meaning- 
less when  once  we  conclude  that  the  centers  of  sensation  and  imag- 
ination are  not  locally  separated  but  occupy  the  same  part  of  the 
brain.  This  is  undoubtedly  true  and  with  this  assumption  in  mind 
and  working  along  these  lines,  James"  made  a  distinct  advance  when 
he  evolved  his  theory.  He  holds  that  in  the  cerebral  cortex  the 
sensory  and  ideational  elements  are  the  same  and  that  the  difference 
in  the  process  depends  on  the  intensity  of  the  stimulus ;  that  from 
•the  periphery  is  usually  more  intense  than  that  from  the  neighboring 
regions  of  the  cortex,  and  because  of  the  difference  in  intensity,  we 
tell  reality  from  phantasy.  If,  however,  for  any  reason  the  stimu- 
lation of  these  centers  becomes  as  l.:tense  as  that  from  the  periphery 
the  mind  can  see  no  difference  and  a  hallucination  results.  Parish^^ 
accepts  this  theory  and  says  that  "  cerebral  dissociation  is  the  one 
element  underlying  them  all." 

Stating  his  views  clearly  and  concisely,  and  based  upon  a  care- 
ful consideration  of  a  series  of  cases.  White-*  concludes  that  "  a 
hallucination  is  a  false  perception  and  in  order  to  have  a  false  per- 
ception there  must  be  something  to  perceive  and  that  something  is 
in  the  environment  and  can  only  enter  as  a  factor  into  the  mental 
life  through  the  intermediation  of  sensation."  He  further  concludes 
that  "  hallucinations  are  secondary  sensations  either  arising  in  the 
same  sensory  fields  in  which  they  might  be  considered  as  illusions, 
or  arising  in  other  sensory  fields,  in  which  cases  their  secondary 
character  is  quite  clear."  From  time  to  time  various  additions  have 
been  added  of  minor  importance  and  it  remained  for  Boris  Sidis^^ 
in  a  few  well-chosen  words  to  reveal  the  key  to  the  whole  situation. 
He  concludes:  "A  peripheral  process  often  of  a  pathological  nature 
and  a  subexcitement  of  secondary  sensory  and  ideo-motor  elements 
constitute  the  main  conditions  of  hallucinations.  The  peripheral 
pathological  process  and  the  state  of  dissociation  are  prerequisite 
to  the  formation  of  the  hallucinatory  percept,  while  the  content  of 
such  percept  is  given  by  the  system  of  sensori-motor  and  ideo-motor 
elements.  A  peripheral  process  alone,  even  if  it  be  pathological  in 
nature,  does  not  give  rise  to  hallucination." 

It  may  seem  like  carrying  coals  to  Newcastle  to  present  a  topic 
apparently  so  threadbare  as  this,  but  when  we  shall  come  to  see  how 
common  they  are  and  what  an  important  part  these  hallucinations 
play  in  the  lives  of  those  individuals  who  are  unable  to  adjust  them- 
selves to  their  environment,  this  study  is,  I  believe,  fully  justified. 
Being  fully  aware,  however,  that  there  are  few  subjects  on  which 


238  FORREST   M.   HARRISON 

more  has  been  written,  I  still  have  the  temerity  to  contribute  to  a 
bibliography  already  voluminous,  in  the  hope  of  offering  food  for 
reflection  even  though  I  may  be  unable  to  add  anything  new. 

I  have  selected  from  the  hospital  records  a  group  of  514  cases 
and  studied  them  to  see  first  of  all.  how  many  were  the  subjects  of 
hallucinations,  next,  whether  they  were  of  hearing,  vision,  or  other 
type,  and  lastly  to  determine  whether  there  were  any  which  seemed 
especially  characteristic  of  any  particular  form  of  mental  disease. 
By  taking  the  cases  in  order  of  their  admission,  which  include  col- 
ored as  well  as  white,  male  as  well  as  female,  not  only  all  types 
of  individuals  and  psychoses  are  met  with,  but  all  branches  of  the 
work  of  this  hospital  are  embraced.  It  is  perfectly  obvious  that 
there  is  no  way  of  absolutely  proving  diagnoses,  yet  in  my  series  of 
cases,  a  large  majority  of  whom  have  been  presented  at  the  staff 
conference,  which  is  held  daily  at  our  institution  where  the  history 
is  read  in  full,  the  records  in  the  case  summarized  and  reviewed 
and  the  patient  himself  presented  and  briefly  examined  and  at  which 
time  a  diagnosis  is  made  and  the  opinion  of  the  senior  members  of 
the  stafiF  given,  including  the  superintendent,  this  error  is  practically 
nil.  In  the  same  way  we  can  with  no  degree  of  certainty  state  that 
hallucinations  do  or  do  not  exist.  The  usual  reason  for  a  physician 
to  assume  that  they  are  present  is  that  the  patient  speaks  of  a  sen- 
sation for  which  no  adequate  stimulus  can  be  discovered.  Never- 
theless, we  must  be  guarded  in  our  assumption  that  we  are  dealing 
with  hallucinations  inasmuch  as  errors  may  readily  occur,  for  actual 
perceptions  may  have  taken  place,  and  furthermore,  the  patient  not 
infrequently  mistakes  the  experiences  of  sleep  for  those  of  the 
waking  condition. 

In  making  this  study  I  have  first  of  all  consulted  the  history  of 
the  individual  in  order  that  I  might  determine  the  general  make-up 
of  the  personality  with  which  I  was  dealing,  this  enabling  me  to 
make  a  more  correct  interpretation  of  the  symptoms  which  mani- 
fested themselves.  At  first  I  reviewed  the  medical  certificate  which 
accompanied  each  patient,  but  I  was  soon  forced  to  abandon  this, 
owing  to  the  fact  that  I  found  them  to  be  vmreliablc  and  to  contain 
such  manifestly  absurd  statements  that  no  dependence  could  be 
placed  in  them.  Practically  all  of  my  data,  then,  have  been  collected 
from  going  over  the  routine  mental  examination,  which  is  done  as 
soon  after  admission  as  possible  and  from  the  notes  on  the  cases 
which  are  made  from  time  to  time  by  the  physician  in  charge  or 
his  assistants.  Taking  all  these  things  into  consideration,  it  would 
seem,  therefore,  that  this  study  has  been  as  accurate  from  the  stand- 


ROLE   OF   HALLUCINATIONS   IN   PSYCHOSES 


239 


point  of  approach  as  it  is  possible  to  make  it,  but  we  must  bear  in 
mind,  as  I  have  said  before,  that  there  is  no  way  of  absolutely  prov- 
ing anything.  For  this  reason  the  records  have  been  construed 
rather  literally. 

I  present  the  following  tables  and  statistics,  an  analysis  of  which 
will  reveal  some  interesting-  information : 


Table  I 

Showing  Number  of  'Cases  Studied,  Number  of  Hallucinations,  and  Type 

IN  Each  Disease 


Diagnosis 


Cases  Studied 


M.     FJ^- 


Cases  Show-     Cases  Showing 
ing  Hallucina-   No  Hallucina- 
tions j  tions. 


F.  Total!  M. 


Total 


Type  of  Hallucination 


Aud.     Vis. 


Smell 


Taste  Touch 


Dementia  praecox .  127 
Arterio-sclerotic 

dementia 51 


General  paresis. . .  . 
Senile  dementia .  .  . 

Not  insane 

Unclassified 

Manic  depressive.  . 

Miscellaneous 

Epilepsy 

Prison  psychosis. . . 

Cerebral  lues 

Imbecility 

Paranoid  state  . . .  . 

Hysteria 

Alcoholic  psychosis 


Totals 370  144514 

Percentage .  .  . 


43  170 

16  70 

8  S3 

12  37 

6  32 

10  29 

I7j  28 

12  23 

s'  15 

—  13 

I  13 


30  120  37  13 


50  113 


10 

24 
9 

13 

6 

14 

7 
9 

5 


4S|  15 
26;  3 


60 
29 
28 
32 
16 
22 
9 


17654  230  193  91  284  210   89   14   25   19 
44.74       55.2640.8517.31  2.72  4.86  3.69 


38 


First  of  all,  let  us  inquire  into  the  frequency  of  hallucinations 
among  the  insane  population  in  general.  That  they  are  very  common 
no  one  denies.  EsquiroP**  estimates  that  25  per  cent,  of  all  cases 
of  insanity  show  their  presence  in  one  form  or  another.  His  conclu- 
sions are  not,  as  far  as  I  can  determine,  substantiated  by  a  sys- 
tematic study  and  therefore  we  may  doubt  their  accuracy.  Collect- 
ing the  statistics  of  some  of  the  more  modern  authors  who  have 
worked  along  these  lines  we  find  the  following :  Tuttle-'  reports  the 
examination  of  the  clinical  histories  of  500  consecutive  admissions 
of  persons  to  the  McLean  Hospital  excluding  those  not  insane  and 
the  readmissions.  Of  these  189  had  hallucinations  of  some  sort. 
This  is  37.8  per  cent.  Munson-^  reports  them  present  in  28.5  per 
cent,  of  1,339  cases.  Lane-^  reports  54  per  cent,  in  307  cases. 
Stearns,'^"  who  published  his  results  after  this  study  commenced, 


240 


FORREST  M.   HARRISON 


reports  38.6  per  cent,  in  500  cases  of  consecutive  admission  to  the 
Boston  Psychopathic  Hospital.  My  own  figures,  which  do  not 
exclude  the  readmissions  and  those  diagnosed  as  not  insane,  give  me 
their  presence  in  44.74  per  cent,  of  514  cases  studied.  If  these  two 
classes  are  excluded,  the  percentage  would  of  course  be  higher. 
Let  us  average  the  results  of  the  above  observers  and  my  own: 

Table  II 
Showing  Work  of  Different  Investigators 


Communicated  by 

..       ,  _                         No.  of  Cases 
No.  of  Cases                      Showing 
Observed                   Hallucinations 

Percentage 

Tuttle 

500               '                   189 
1.339                              382 
307                              166 
500             1                 193 
514             '                 230 

37.8 

28.5 

54- 

38.6 

44-7 

Munson 

Lane 

Stearns 

My  own 

Totals 

3,160                           1,160 

40.7 

We  see  from  the  above  table  that  of  3,160  cases  studied  1,160 
showed  the  presence  of  hallucinations.  An  analysis  of  the  percen- 
tage column  gives  us  an  average  of  40.7  per  cent.  We  may,  there- 
fore, I  think,  consider  this  to  be  a  fairly  accurate  and  correct  esti- 
mation despite  the  fact  that  the  different  men  may  interpret  falla- 
cious sensory  perceptions  in  different  lights  and  despite  the  fact 
that  these  figures  represent  the  work  of  a  good  many  different  in- 
vestigators. 

As  to  the  type  of  hallucinations  and  the  various  combinations 
thereof,  I  find  that  by  far  the  larger  part  were  of  hearing  only,  120 
out  of  230  cases  hallucinated  showing  auditory  disturbances  unac- 
companied by  abnormalities  in  the  other  sensory  realms.  This  is 
52.17  per  cent.  A  cursory  glance  at  the  above  table  will  show  how 
very  common  hallucinations  of  hearing  are  and  what  an  important 
part  they  play  in  the  psychic  life  of  the  insane,  and  looking  back  at 
Table  I  we  find  that  out  of  230  cases  in  which  hallucinations  oc- 
curred, auditory  fallacious  perceptions,  either  separately  or  com- 
bined, were  present  in  210  or  91.3  per  cent.  That  this  sense  should 
be  especially  liable  to  hallucinations  does  not  seem  strange.  It  is 
this  sense  which  plays  a  more  important  part  in  our  psychical  life 
than  any  other,  since  we  think  in  words  and  express  our  thoughts 
in  words.  Next  in  frequency  come  auditory  and  visual  combined, 
55  cases  presenting  this  coupling  or  23.91  j)er  cent.  After  these 
two  groups  is  placed  that  of  sight  alone,  this  representing  6.08  per 


ROLE   OF   HALLUCINATIONS   IN   PSYCHOSES 


241 


cent,  of  the  cases,  and  a  very  striking  fact  is  that  the  auditory  and 
visual  disturbances,  either  separately  or  combined,  make  up  189  out 
of  the  total  number  of  cases  hallucinated,  the  same  being  82.17  per 
cent.  The  combination  of  auditory  and  taste  form  the  next  largest 
lot.  Ten  cases  showed  the  presence  of  this  combination,  five  of  which 
occurred  in  the  dementia  praecox  group.  There  were  various  other 
combinations  as  is  shown  by  Table  III  but  not  in  large  enough 
numbers  to  warrant  a  discussion,  some  of  them  occurring  only  once. 


Table  III 
Showing  Character  of  Hallucinations 


gs 

Eg 

Manic 

Depressive 

Art.-Sclerot. 

Dementia 

5  '^ 

-0 

c 
1:3 

■0 

'0  a 

0.2 

"o  0 

(UlJ 

u 

0. 
■5. 

S  ° 

-1 

c 

—  w 
1!   3 

1 

Totals 
Percentage 

Auditory,  alone 

Visual,  alone 

73 
6 

24 

1 
I 

3 
2 

5 
I 

I 
3 

3 

I 

5 
I 

4 



9 

I 

I 

5 

I 

2 

I 
I 
I 

I 
I 

3 

10 

3 

I 
I 

4 

3 
I 

I 

3 

I 
I 

2 
2 

I 
I 

I 

I 
I 

3 

I 

5 

I 
I 
2 

I 

120 

14 
2 

I 

55 

3 
I 

5 

4 

10 

I 

3 

I 

2 

I 
I 
I 
I 
4 

52.17 
6.08 

.86 

Touch,  alone 

3  i  2 
I    — 

! 

•43 
23.91 

1.30 
■43 

2.17 
1-73 
4-34 

•43 
1.30 

Auditory  and  visual .  .  . 

Auditory,      smell     and 

taste 

— 

I 

4 

— 

Auditory  and  smell. . .  . 

Auditory,     visual     and 

touch ; . 

Auditory  and  touch. . .  . 
Auditory  and  taste .... 
Auditory,  visual,  touch, 
taste 

Auditory,  visual,  touch, 
smell 

Auditory,     visual     and 
smell 

Auditory,     visual     and 
taste 

— 

•43 
.86 

Auditory,   visual,   taste 
smell 

1 

•43 

Visual  and  touch 

Visual,  taste  and  touch. 

Smell  and  taste 

All  senses 



— 

•43 

•43 

•43 

1.73 

1 

Totals 

120 

6     1  10  1  24 

9 

13 

4 

3     ^ 

5       '7  12 

9 

T/| 

2^0 

■ 

■ 

It  was  when  I  attempted  to  tabulate  the  content  of  the  variou.i 
hallucinatory  percepts  that  I  found  myself  as  a  ship  wnth  no  rudder 
to  guide  her.  In  each  field  they  took  the  most  diverse  form.  Hal- 
lucinations of  hearing  consisted  of  moanings,  hissings,  clanking  of 
steam  pipes,  words,  phrases,  simple  sentences,  stern  commands  and 
abuses,  spoken  in  all  sorts  of  different  voices  and  tones,  coming 
from  all  directions,  and  causing  various  reactions  on  the  part  of  the 


^42 


FORREST  M.   HARRISOX 


patient.  One  subject  of  auditory  hallucinations  heard  sweet  rap- 
turous music  but  it  was  so  long  and  continuous  as  to  become  very 
tiresome.  In  the  visual  field,  the  patients  saw  flashes  of  light,  whole 
country  sides,  there  were  visions  of  friends,  acquaintances  and  rela- 
tives passing  before  their  eyes  with  a  cloudy  indistinctness,  glaring 
colors  and  animals,  especially  in  epilepsy  and  in  the  alcoholic  psy- 
choses. There  were  frequently  visions  of  the  supernatural,  of 
angels  or  sjnrits,  and  at  the  same  time  expressions  of  happiness  or 
rejoicing,  or  those  of  suffering  and  misery  were  heard  and  a  variety 
of  other  things  of  a  like  nature  too  numerous  to  be  mentioned  here. 
I  folind  it  very  difficult  and  almost  impossible  in  some  instances 
to  isolate  hallucinations-  of  taste,  owing  to  their  very  close  relation- 
ship to  those  of  smell,  but  occasionally  I  would  run  across  a  patient 
who  tasted  blood,  poison  or  feces  in  his  food.  Such  disturbances  as 
these  I  have  interpreted  as  belonging  to  the  gustatory  field.  Hal- 
lucinations of  smell  were  present  in  but  few  cases.  They  were 
generally  of  an  unpleasant  nature  and  related  to  odors  of  dead 
bodies,  poisonous  exhalations,  offensive  odors  of  other  patients,  or 
obnoxious  gases,  which  were  thought  to  exude  through  the  floors 
or  walls  of  the  room  which  the  patient  occupied.  The  most  fre- 
quent hallucinations  of  touch  were  the  various  paresthesias,  electric 
shocks,  and  one  patient  was  continually  having  the  sensation  of 
being  stabbed  by  some  unknown  person.  Based  upon  a  careful 
consideration  of  these  cases,  I  am  forced  to  admit,  as  was  to  be 
expected,  that  no  two  cases  were  alike,  each  presenting  its  own 
individual  characteristics  and  peculiarities  and  the  content  of  the 
hallucinations  seemed  to  point  to  no  form  of  psychosis  in  particular. 


T.\1!LE   IV 

Same  as  Table  I,  Showixg  Percentages 


Diagnosis 


Number! 
Cases   '  Present 
Studied 


Absent     Audi- 


Visual 


Smell 


Taste 


Touch 


.Alcoholic  psychosis |  5  80 

DcmftUia  praecox 170  70.58 

f'rison  psychosis 13  69.23 

Miscellaneous.  .  23  60.86 

Hysteria 6  50 

Epilepsy 15  46.66 

General  pacesis.  53  45. 28 

I  'nclassified 29  44.82 

I'aranoirJ  state 10  40 

Cerebral  lues 13  38.46 

5>onilc  dementia 37  24.32 

Manic  depressive 28  21.50 

Imbecility 10  20 

Art.  sclerotic  dement 70  14.28 

Not  insane (.■ 


20 

29.42 

30.27 

3914 

50 

53-33 

54-72 

55.18 

60 

61.54 

75-68 

78.50 

80 

8572 


80 

66.47 

69.23 

56.52 

33-33 

46.66 

39.62 

41-37 

30 

30.76 

18.91 

17-85 

10 

12.85 


80 

22.35 

46.15 
3478 

33-33 

26.66 

18.86 

1.03 

15-38 
10.81 

7.14 
10 

7.14 


2-94 
1-53 
4-34 


9.43 


2.70 


5.88  5.88 

1.30  1.53 

8.69  8.69 

11.32  5.66 

10         I     — 

7.69  7-69 

5-40  — 

—  3-57 


ROLE   OF   HALLUCINATIONS   IN   PSYCHOSES  243 

Taking  the  cases  in  order  of  the  frequency  of  hallucinations 
as  is  shown  in  Table  IV,  we  find  that  the  alcoholic  psychosis  stands 
at  the  head,  80  per  cent,  of  them  being  hallucinated.  There  was 
such  a  small  number  of  cases  studied,  however,  that  my  series  is  of 
no  value  from  a  statistical  standpoint.  In  the  four  cases  all  pre- 
sented auditory  and  visual  hallucinations  and  were  fairly  character- 
istic, i.  e.,  characteristic  according  to  most  observers — animals, 
snakes,  etc.  Stearns^"  reports  a  series  of  31  cases  of  alcoholic 
hallucinosis,  14  of  delirium  tremens  and  found  hallucinations  in 
every  case.  He  makes  the  statement  that  "  hallucinations  are  indis- 
pensable for  the  diagnosis  of  such  disorders,  but  claims  that  the 
type  of  hallucinations  is  not  a  proper  criterion  for  differentiation 
between  these  diseases." 

Our  attention  is  next  directed  to  the  dementia  praecox  group, 
the  members  of  which  form  a  large  proportion  of  our  population. 
Of  the  170  cases  w^hich  presented  themselves  for  study,  70.58  per 
cent,  were  hallucinated,  66.47  P^r  cent,  showing  auditory,  22.35 
per  cent,  visual,  5.88  per  cent,  taste,  5.88  per  cent,  touch  and 
2.94  per  cent,  smell.  A  careful  analysis  of  the  50  cases  which 
failed  to  show  the  presence  of  hallucinations  reveals  the  fact  that 
ten  of  them  were  catatonic  in  type  and  remained  mute,  negativistic, 
and  inaccessible  during  their  residence  at  the  institution.  Whether 
or  not  they  suft'ered  from  hallucinations  T  am  not  prepared  to  say 
but  a  careful  survey  of  the  notes  of  the  patient's  conduct  from 
time  to  time  gives  us  some  interesting  information.  We  find  such 
expressions  as  these :  "  occasionally  there  is  a  passing  smile  "  ;  "  an 
exclamation  of  surprise  "  ;  "a  threatening  word  or  glance "  ;  "  he  is 
seen  staring  at  wall  and  conversing  with  imaginary  people,"  and 
other  phrases  of  like  nature,  giving  us  a  vague  indication  of  the 
presence  of  actual  hallucinations.  Five  of  the  cases  showed  con- 
clusive evidence  of  their  existence,  even  though  they  were  denied, 
three  of  the  cases  spoke  a  foreign  tongue,  and  could  not  be  examined 
except  with  the  aid  of  an  interpreter,  and  two  were  excited  and 
violent,  making  an  examination  impossible.  In  other  words,  in 
only  30  cases  of  the  entire  number  studied,  could  I,  with  any  degree 
of  certainty,  state  that  hallucinations  did  not  exist.  Practically, 
then,  the  entire  group  showed  evidence  of  this  particular  form  of 
fallacious  perception  and  this  bears  out  the  statements  of  the 
authorities.  White^^  says :  "  Hallucinations  arc  numerous  and 
involve  especially  the  auditory  and  visual  fields."  Tanzi^^ 
states:  "A  phenomenon  of  frequent  occurrence  in  cases  of  de- 
mentia   praecox    is    that    of    hallucinations "    and    Bleuler"-    comes 


244  FORREST  M.   HARRISON 

forward  with  the  observation  that  "almost  every  schizophrenic 
in  institutions  hears  voices."  Glancing  at  Table  III  we  note  that 
71  of  the  cases  presented  auditory  hallucinations  alone,  unaccom- 
panied by  disturbances  in  the  other  sensory  realms.  By  far  the 
greater  number  of  these  cases  were  elementary  in  character ;  a  few 
heard  voices  which  called  them  vile  names  and  accused  them  of 
vicious  practices,  while  a  few  received  warnings  that  they  were 
doomed  to  destruction.  These  particular  types  were  met  with  in  all 
forms,  however.  In  24  of  the  cases  there  was  a  combination  of  the 
auditory  and  visual  hallucinations,  while  in  six  cases  visual  dis- 
turbances were  alone  present.  In  this  latter  group  a  very  striking 
fact  presents  itself  for  consideration.  All  were  of  the  catatonic 
type.  It  would  perhaps  be  well  to  give  a  brief  summary  of  these 
cases.  Case  I  was  a  female  who  saw  her  children  in  the  field  and 
points  to  them.  Case  II  was  a  male  who  stares  continually  at  the 
fireplace  and  sees  witches  and  various  visions  in  the  flames.     Case 

III  saw  living  creatures  like  needles  coming  out  of  her  body.     Case 

IV  sees  the  spirits  of  her  dead  friends.  Case  V  sees  a  pair  of  wings 
floating  in  the  air  upon  which  he  is  to  ascend  to  the  clouds.  Case 
VI  sees  imaginary  persons  stabbing  her  children.  In  the  other 
twenty  cases  of  catatonics  observed,  twelve  had  visual  hallucinations 
combined  with  various  other  sensory  anomalies.  It  would  seem, 
therefore,  that  visual  disturbances,  although  the  number  of  cases 
which  presented  themselves  for  study  is  quite  small  (twenty-six  in 
all),  are  fairly  common,  if  not  peculiar  to  this  particular  type  of 
praecox.  The  rest  of  the  cases  w^ere  scattered  throughout  the  dif- 
ferent sense  areas  in  different  combinations  none  of  which  seemed 
especially  characteristic. 

Next  in  frequency  of  occurrence  of  hallucinations  is  a  group  of 
thirteen  cases  which  have  been  diagnosed  as  prison  psychosis.  Of 
these  9  were  hallucinated  or  69.23  per  cent.  In  these  cases  the 
hallucinatory  experiences  were  active  and  formed  an  important 
feature  of  the  symptom  complex.  All  of  the  sense  fields  were  in- 
volved, the  auditory  and  visual  predominating.  The  hallucinations 
in  the  auditory  field  were  quite  characteristic,  for  in  every  case  they 
were  of  a  persecutory  nature,  voices  telling  them  of  the  injustice  of 
continued  confinement,  and  mocking,  derisive,  provoking  sneers  in- 
citing thcnl  to  an  insane  rebellion  against  the  prison  routine  and 
.strict  discipline  of  institutions.  At  times  the  patients  would  see 
imaginary  persons  come  into  their  rooms  to  torment  them,  poison 
would  be  placed  in  their  food,  and  batteries  were  being  used  upon 
them. 


ROLE   OF   HALLUCINATIONS   IN   PSYCHOSES  245 

In  the  miscellaneous  group  60.86  per  cent,  of  whom  were 
hallucinated,  I  have  placed  those  cases  which  were  present  in  too 
small  numbers  to  be  of  any  value.  Under  this  heading  are  in- 
cluded the  following :  Constitutional  psychopathy  4,  involutional 
melancholia  4,  paranoia  3,  toxic  psychosis  3,  Korsakoff's  psychosis 
2,  alcoholic  hallucinosis  2,  traumatic  psychosis  2,  Sydenham's  chorea 
I,  multiple  sclerosis  i.  As  this  group  in  general  presents  nothing  of 
interest,  I  shall  pass  it  by  rather  quickly.  There  is  one  case,  how- 
ever, which,  inasmuch  as  it  is  rather  unusual,  warrants  a  brief  dis- 
cussion. I  refer  to  the  case  of  psychosis  associated  with  multiple 
sclerosis,  which  showed  both  auditory  and  visual  disturbances.  It  is 
to  be  regretted  that  more  cases  were  not  available  for  study,  although 
it  is  generally  agreed  that  hallucinations,  or  in  fact,  any  sort  of 
mental  disorder,  are  very  rare  in  this  disease.  Oppenheim^^  for 
instance  states  that  "  the  intelligence  is  often  diminished,  the  patient 
is  uninterested  and  forgetful.  High  degree  of  weakmindedness, 
sensory  hallucinations  and  delirium  are,  however,  quite  unusual." 
Redlich^*  states  that  "  sometimes  the  psychic  disturbances  are 
severe;  there  may  be  a  marked  impairment  of  intelligence,  even  to 
dementia  or  confusion,  excitement  with  hallucinations.  These  are 
relatively  rare  and  their  explanation  must  be  sought  in  the  occur- 
rence of  multiple  foci  in  the  cortex  of  the  cerebrum."  Starr^^ 
in  quite  an  extensive  discussion  makes  no  mention  of  any  psychical 
phenomena.  Thus  it  would  seem  that  the  case  studied  presented 
unusual  features,  but  owing  to  the  very  limited  number,  no  definite 
conclusions  can  be  drawn. 

In  six  cases  of  hysteria,  three  or  fifty  per  cent,  were  hallucinated, 
these  being  located  exclusively  in  the  auditory  and  visual  fields. 
There  was  nothing  characteristic  about  their  content,  except  that 
they  appeared  to  be  indicative  of  the  approaching  "  grand  attaque." 
They  took  the  form  of  strange  animals  and  voices  calling  from  afar 
off. 

Fifteen  cases  of  epilepsy  were  studied,  the  result  being  that  46.66 
per  cent,  were  found  to  be  suffering  with  auditory  and  visual 
hallucinations,  the  other  sense  areas  not  being  involved.  Four  of 
the  cases  had  auditory  hallucinations  alone,  while  in  the  other  three, 
the  two  senses  were  combined.  These  hallucinations  were  very 
elementary  and  I  believe  can  be  considered  as  sensorial  aura  since 
they  seemed  to  bear  a  very  definite  relation  to  the  attack.  They 
took  the  form  of  some  buzzing  or  hissing  sound,  or  dazzling  sight, 
or,  as  was  noted  in  three  of  the  cases,  there  were  well-defined 
hallucinations  of  a  terrifying  nature,  as  for  example,  of  flames, 
blood,  or  threatening  language. 


246  FORREST  M.   HARRISOX 

Regarding  general  paralysis  of  the  insane  there  seemed  to  be 
much  diversity  of  opinion  and  I  have  found  no  two  authors  who 
agree  as  to  the  frequency  of  hallucinations  in  this  disease.  The 
most  varied  and  opposite  views. obtain.  This  is  due  perhaps  to  the 
ambiguity  of  the  line  drawn  between  hallucinations,  on  the  one  hand, 
and  delusive  ideas,  illusions  and  paresthesia  on  the  other ;  and  also 
because  of  the  difficulty  of  proving  that  hallucinations  are  really 
present  in  the  advanced  stages.  Generally  only  those  of  a  disagree- 
able nature  are  taken  into  account  and  these  are  regarded  as  causes 
of  the  hyjjochondriacal  delusions  of  the  patient.  Krafft-Ebing^° 
points  out  that  "  in  general  paralysis  hallucinations  are  rare  phe- 
nomena, so  rare  indeed  that  in  their  occurrence  one  is  forced  to 
suspect  a  false  diagnosis,  and  to  refer  them  rather  to  alcoholic 
psychosis."  Parish-^  gives  a  very  instructive  table,  taking  the 
work  of  several  authors  and  averaging  the  results  obtained.  There 
were  1,211  cases  studied  and  hallucinations  were  found  to  be  present 
in  27.4  per  cent.  Gelhorn^^  reports  their  presence  in  32  per 
cent,  of  100  cases  observed.  Dagonet,^*  although  he  indeed 
notes  their  in  frequency,  observed  them  chiefly  and  frequently  in 
the  maniacal  excitement.  Hitizg^^  takes  the  view  that  auditory 
and  visual  hallucinations  are  rare  in  general  paralysis,  but  describes 
those  of  the  organic  sense  as  occurring  frequently.  Baruk*°  be- 
lieves that  hallucinations  occur  more  frequently  than  was  formerly 
supposed.  My  own  series  of  cases,  although  quite  small,  gives  me 
a  much  higher  percentage  than  any  of  the  authorities  quoted,  45.28 
per  cent,  being  hallucinated,  the  auditory  fallacious  perceptions 
predominating. 

Obviously  nothing  can  be  learned  from  an  analysis  of  the  un- 
classified cases,  44.82  per  cent,  of  whom  were  hallucinated.  In 
ten  cases  of  paranoid  state  studied,  40  per  cent,  showed  hallucina- 
tions, taunting  and  insulting  voices  called  after  them  on  the  street, 
making  injurious  insinuations  about  them,  and  sometimes  unseen 
speakers  incidentally  let  words  fall  which  confirmed  the  forebodings 
of  the  i>aticnt.  Some  of  the  cases  believed  that  their  tormentors 
had  poisoned  their  food  from  even  a  distance.  In  some  of  the  cases 
the  hallucinatory  disturbances  were  varied  and  in  others,  they  were 
characterized  by  extreme  monotony  and  were  closely  bound  up  with 
the  dominant  fixed  idea  which  they  illustrate.  Of  thirteen  cases  of 
cerebral  lues  38.46  per  cent,  were  hallucinated,  all  of  the  senses 
being  involved. 

It  is  in  the  manic-depressive  group,  however,  that  we  meet  with 
material   which   is   not   only   interesting  but   valuable.     Only   21.50 


ROLE   OF   HALLUCINATIONS   IN   PSYCHOSES  247 

per  cent,  of  the  cases  showed  halkicinations,  17.85  per  cent,  of  these 
were  auditory,  and  7.14  per  cent,  visual.  These  figures  correspond 
very  closely  to  those  of  Lind,*^  who  in  a  remarkably  accurate 
study  of  244  cases  of  manic-depressive,  found  hallucinations  to  be 
present  in  14  per  cent,  of  the  white  males,  17  per  cent,  of  the  white 
females,  30.7  per  cent,  of  the  colored  males,  and  33.3  per  cent,  of 
the  colored  females.  Averaging  these  results,  we  find  that  in  the 
whole  number  of  cases  studied  he  found  them  to  be  present  in 
23.75  per  cent.  In  the  whole  number  of  cases  which  I  studied 
they  were  present  in  but  ten.  They  were  not  in  the  foreground  in 
any  of  these  and  I  have  sufficient  reason  to  doubt  their  existence  in 
most  of  them.  Those  cases,  in  which  they  were  found  to  be  present, 
were  elated  and  it  seems  quite  possible  and  fair  to  presume  that 
these  supposed  hallucinations  are  but  evidences  of  exaltation,  ecstasy, 
and  playfulness  of  the  phantasy,  for  it  is  a  well-known  fact  that 
hallucinations  are  common  phenomena  of  ecstasy,  where  they  arise 
out  of  one  side  of  mental  activity  and  intense  concentration  to  single 
groups  of  ideas,  conjoined  it  may  be  with  lowered  sensibility.  Cer- 
tain it  is  that  in  mania  many  deceptions  of  sight  and  hearing  occur 
which  exert  a  powerful  though  transitory  effect  on  the  sufferer 
driving  him  to  violent  outbreaks  and  tending  generally  to  bring  on 
acute  attacks.  In  the  tumultuous  rush  of  ideas,  however,  none  of 
which  can  remain  fixed,  hallucinations,  I  believe,  are  generally  of 
minor  importance.  The  suft'erer  cannot  give  them  more  than  a 
passing  attention,  they  disappear  in  the  whirl  of  the  psychical 
processes,  and  do  not  remain  to  burden  the  mind  with  a  fixed  idea 
or  delusion.  Even  when  hallucinations  do  occur  they  are  vague 
and  indefinite  and  indistinct.  The  literature  on  the  subject  points 
to  their  rarity  in  manic-depressive  psychosis.  Remond"  referring 
to  mania  says,  "  Rarer  still  than  delusions  are  hallucinations " ; 
De  Fursac,*"  "Hallucinations  are  rare  and  fleeting";  Diefendorf,''* 
"  Hallucinations  are  rare  except  in  the  delirious  forms  of  the 
manic  phase,  and  in  the  more  marked  stuporous  depression,  but 
even  here  they  are  neither  a  prominent  symptom  nor  persistent 
feature";  G.  Deny  and  Paul  Camus,*^  "The  existence  of  true 
hallucinations  in  the  course  of  the  depressed  states  is  a  rare  phe- 
nomenon " ;  Stansky*''  states  that  "  although  hallucinations  occur 
in  the  exalted  phases  of  manic-depressive  insanity,  yet  they  do  not 
form  a  typical  symptom  thereof,  are  completely  lacking  in  the 
majority  of  cases  and  hardly  dominate  the  picture,  except  in  those 
delirious  conditions  which  are  counted  by  many  authors  as  belong- 
ing to   manic-depressive   insanity."     Ziehen*^   states   that   "  mania, 


248  FORREST  M.   HARRISON 

a  form  of  the  affective  psychoses,  exhibits  in  many  cases  no  dis- 
order in  the  sensory  fields,  nor  is  there  any  remarkable  lowering 
of  the  threshold  of  stimuli."  W'hite^^  says :  "  Hallucinations  are 
not  infrequent.  They  are  usually  elementar}'  in  character,  simple 
and  transitory."  Tanzi"  states  that  "  the  rarity  of  the  occur- 
rence of  hallucinations  in  these  cases  is  a  further  proof  that  melan- 
cholic delusions  do  not  originate  in  the  errors  of  the  senses.  True 
hallucinations  are  absent  in  mania." 

If  then  it  be  true  that  they  are  rare  in  this  particular  psychosis, 
this  fact  at  once  becomes  of  immense  importance  from  a  diagnostic 
standpoint.  The  manic  phase  is  very  often  confused  with  the 
excitement  of  dementia  praecox.  The  presence  of  signs  of  deteriora- 
tion in  the  latter  disease,  however,  will  usually  make  the  diagnosis, 
although  there  are  cases  that  are  extremely  dif^cult  to  differentiate 
and  considerable  time  must  be  allowed  to  elapse  before  a  diagnosis 
is  established.  It  is  in  these  cases  that  the  occurrence  of  hallucina- 
tions in  almost  every  case  of  praecox  and  their  extreme  rarity  in  the 
manic-depressive  group  gives  us  a  clue  and  while  we  are  not  inter- 
ested primarily  in  giving  a  thing  a  name,  yet  we  must  use  them  in 
order  to  classify  and  to  pigeonhole  the  different  cases  so  they  will 
be  ready  for  recall  at  a  moment's  notice..  It  would  seem  then  that 
in  hallucinations  we  have  a  valuable  diagnostic  clinical  symptom  and 
one  easily  elicited. 

Of  the  ten  cases  of  imbecility  studied,  only  two  were  hallucinated 
or  20  per  cent.,  the  disturbances  being  located  in  the  auditory  and 
visual  fields.  In  thirty-seven  cases  of  senile  dementia  only  24.32 
per  cent,  were  hallucinated.  Three  of  these  were  women  and  six 
were  male.  All  of  them  were  deaf  and  this  fact,  I  believe,  accounts 
for  their  failure  to  appreciate  properly  impressions  received  from 
external  agencies  and  so  "the  clanging  of  bells,"  "the  whistling  of 
locomotives,"  or  the  "whir  of  the  trolley  car"  were  misinterpreted 
and  converted  into  the  imperfect  perception  of  voices.  Berkeley** 
says :  "  Definite  hallucinations  are  somewhat  rare  among  the  aged 
in-;ane  and  those  that  occur  are  of  an  elementary  order."  My 
own  figures  bear  him  out.  In  seventy  cases  in  which  the  diagnosis 
of  psychosis  associated  with  arteriosclerosis  was  made  only  ten 
or  14.28  per  cent,  were  hallucinated.  There  seemed  to  be  no  char- 
acteristic type.  As  was  to  be  expected,  the  least  frequent  of  all 
were  the  not  insane,  and  despite  the  statements  of  some  authors  to 
the  contrary,  it  seems  likely  that  they  never  occur  in  a  mentally 
normal  person  and  if  they  occur  alone,  especially  if  the  patient  be 
not  of  a  psychopathic  make-up.  they  are  to   be  looked   on   with 


ROLE   OF   HALLUCINATIONS   IN   PSYCHOSES  249 

suspicion.     There  were  thirty-two  cases  in  my  series,  none  of  which 
showed  any  evidence  of  their  presence  during  their  residence  here. 
From  this  study  I  may  deduce  the  following  conclusions : 

1.  Hallucinations  are  among  the  commonest  of  symptoms  met 
with  in  the  insane,  occurring  in  approximately  40  per  cent,  of  the 
cases. 

2.  Of  the  various  types,  those  of  hearing  are  most  frequent, 
these  occurring  either  separately  or  combined  in  90  per  cent,  of  the 
cases  hallucinated.  Next  in  frequency  are  those  of  hearing  and 
sight  combined,  and  then  come  visual  disturbances  alone. 

3.  The  content  of  the  hallucinatory  percepts  were  not  character- 
istic for  any  particular  psychosis. 

4.  Visual  disturbances  seem  especially  peculiar  to  the  catatonic 
praecox  group. 

5.  Hallucinations  are  common  in  dementia  praecox,  occurring  in 
practically  all  the  cases.  On  the  other  hand,  they  are  rare  in  the 
manic-depressive  group,  seldom  if  ever  occurring  typically.  This 
fact  is  of  diagnostic  importance. 

6.  Hallucinations  are  rare  in  arteriosclerotic  dementia  and  senile 
dementia,  occurring  in  approximately  20  per  cent,  of  the  cases. 

7.  Hallucinations  are  rare  in  sane  persons,  even  though  they 
be  of  a  psychopathic  make-up. 

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Mental  Diseases,  February  25,  1915. 

42.  Remond.     Maladies  mentales,  pp.  76  and  192. 

43.  De  Fursac.     Outline  of  Psychiatry.     Trans,  by  Rosanoflf,  pp.  348,  356. 

44.  Diefendorf.     Clinical  Psychiatry,  p.  383. 

45.  D.  Deny  and  Paul  Camus.     La  Psychose  Maniaque-Depressive,  pp.  40,  45. 

46.  Stransky.     Die  Manisch  Depressive  Irresein,  p.  15. 

47.  Ziehen.     Psychiatric,  pp.  364,  365,  392. 

48.  Berkeley.     A  Treatise  on  Mental  Diseases.     New  York,  1900,  p.  225. 


Socicti?  proceeMnos 


THE  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

October  22,  191 5 
The  President,  Dr.  S.  D.  W.  Ludlum,  in  the  Chair 

Drs.  J.  Hendrie  Lloyd  and  Max  H.  Bochroch  presented  a  patient  with 
symptoms  suggestive  of  rhizomehc  spondylosis. 

Dr.  Francis  X.  Dercum  asked  whether  the  case  had  been  examined  sero- 
logically, whether  the  cerebrospinal  fluid  had  been  studied.  Dr.  Dercum  re- 
gards with  suspicion  any  case  that  presents  any  abnormalities  of  the  light 
reaction.  The  slightest  departure  of  the  light  reaction  from  the  normal 
with  full  preservation  of  accommodation  and  convergence  reactions  points 
to  a  beginning  Argyll-Robertson  pupil. 

Dr.  George  Wilson  said  that  he  had  seen  the  man  in  the  hospital  and  it 
seemed  to  him  the  spondylitis  was  absolute.  While  the  exaggerated  ocular 
reflex  might  be  explained,  he  thought  it  was  stretching  the  point  too  far  to 
ascribe  exaggerated  reflexes  and  loss  of  knee  jerks  to  the  same  disease.  He 
asked  whether  a  Wassermann  had  been  made. 

Dr.  Samuel  Leopold  said  the  test  had  been  made  and  proven  absolutely 
negative. 

Dr.  D.  J.  McCarthy  stated  that  in  this  type  of  case  at  autopsy  he  had  seen 
the  rigid  condition  of  the  spine  due  to  meningitis  externa,  and  this  condition- 
would  explain  this  case.  At  the  American  Neurological  Association  Dr. 
Collins  reported  two  or  three  cases  of  this  type  of  external  pachymeningitis 
with  complete  rigidity  of  the  spine. 

Dr.  George  Wilson  stated  that  when  the  man  was  in  the  medical  ward 
he  had  a  partial  third  nerve  palsy  which  came  on  and  lasted  practically 
twenty-four  hours. 

Dr.  William  G.  Spiller  asked  why  the  case  was  not  considered  one  of 
syphilis.  If  the  man  had  ophthalmoplegia,  loss  of  Achilles  reflex,  a  third 
nerve  palsy,  as  Dr.  Wilson  said,  the  case  might  be  one  of  syphilis. 

Dr.  Dercum  stated  that  the  pupils  examined  by  the  pocket-lamp  are 
shown  to  be  distinctly  unequal  and  also  that  the  light  reaction,  though  present, 
is  exceedingly  slight  and  if  beginning  optic  atrophy  is  present,  the  case  looks 
more  like  one  of  tabes.  The  absence  of  the  knee  jerks  can  be  accounted  for 
by  regarding  the  case  as  one  of  sacral  tabes. 

Dr.  S.  D.  Ludlum  said  the  X-ray  pictures  showed  that  there  was  con- 
siderable exostosis  and  malformation  of  the  bone  which  looked  exactly  like 
spondylitis  deformans ;  and  that  with  the  Wassermann  negative,  the  spinal 
fluid  also  negative,  it  is  hard  to  understand  how  the  man  could  be  considered 
to  have  a  nervous  condition  of  syphilitic  origin. 

Dr.  J.  Hendrie  Lloyd  said  that  he  would  explain  the  loss  of  the  Achilles 
reflexes,  with  preservation  of  the  knee  jerks,  by  a  diff^use  condition  such  as 
we  have  in  spondylitis  deformans.  It  is  perfectly  conceivable  that  the  nerves 
of  exit  and  entrance  presiding  over  the  Achilles  reflex  should  be  interfered 
with  somewhere  in  their  passage  through  the  spine.  He  did  not  think  it  was 
a  case  of  locomotor  ataxia. 

251 


, 


252  PHILADELPHIA   NEUROLOGICAL   SOCIETY 

A  CASE  OF  UNUSUAL  FORM  OF  MYOTONIA 
By  F.  X.  Dercum,  M.D. 

The  following  case  is  presented  because  of  its  unusual  character.  It  is 
clearly  not  a  case  of  Thomsen's  disease  but  notwithstanding  must  be  classified 
under  myotonia. 

C.  A.,  male,  age  9,  was  admitted  to  the  Jefferson  Hospital  September 
ID,  1915. 

The  family  history  is  entirely  negative.  The  mother  and  father  are  both 
living  and  well.  There  is  no  history  of  any  nervous  or  muscular  disease. 
The  patient  is  an  only  child. 

Personal  History. — He  was  born  normally.  There  was  no  dystocia  and 
the  labor  was  not  instrumental.  He  was  breast-fed  and  learned  to  walk  at 
fifteen  months  of  age.  He  began  to  talk  about  the  same  time  but  did  not 
talk  distinctly.  He  was  about  three  or  four  years  of  age  before  he  could 
speak  so  that  he  could  be  understood  readily.  He  was  cleanly  at  the  age  of 
two,  walked  as  well  as  other  children  and  appeared  to  be  a  healthy  normal 
child.  At  six  years  of  age  he  suffered  from  an  attack  of  measles.  Was 
unusually  ill  but  made  a  good  recovery  and  subsequently  played  around 
actively  with  the  neighboring  children.  At  seven  years  of  age  he  suffered 
from  a  sore  throat.  This  was  variously  described  as  diphtheria  aad  as  ulcer- 
ated sore  throat.  He  was  very  ill  but  was  in  bed  for  a  week  onlJ^  After- 
ward he  was  as  active  physically  as  before.  No  change  was  noticeable  in  his 
walk.  When  he  was  not  quite  eight  years  of  age,  April,  1914,  he  suffered 
from  an  attack  of  mumps.  The  attack  appears  to  have  been  severe  and  he 
was  quite  ill  for  two  weeks.  According  to  the  mother  he  never  appeared  to 
be  entirely  well  after  this  attack  and  shortly  afterwards  he  began  limping 
with  his  left  leg.  He  began  to  walk  with  the  left  foot  slightly  turned  out. 
Carried  the  knee  slightly  flexed,  looked  poorly,  was  thin  and  seemed  in  bad 
health.  He  also  began  using  the  arms  in  a  peculiar  manner  and  now  and 
then  fell  when  walking  about  the  house. 

The  involvement  of  the  left  leg  began  sometime  in  April.  1914;  in  No- 
vember of  the  same  year  the  right  leg  began  to  behave  in  a  similar  manner; 
soon  he  could  not  walk  at  all  and  a  little  later  was  unable  even  to  stand. 
About  this  time  he  complained  of  pain  in  his  right  knee.  This  was  some- 
what swollen.     The  swelling,  however,  after  a  time  subsided. 

The  mother  noticed  about  this  time  that  when  he  began  to  move  his  arms 
and  legs  they  would  suddenly  become  stiff  and  would  remain  in  a  condition 
of  spasm  so  that  the  boy  could  not  use  his  limbs.  This  condition  persisted 
with  but  little  change  up  to  the  time  of  his  admission  to  the  hospital. 

Present  Condition. — The  patient  is  a  well-nourished  and  well-developed 
boy  of  nine  years.  His  color  is  good  and  there  are  no  visceral  symptoms. 
When  asked  to  move  his  legs  as  the  boy  lies  upon  the  bed,  it  is  noted  that 
they  become  fixed  in  a  semiflexed  position,  first  one  and  then  the  other. 
This  fixation  persists  for  a  fraction  of  a  minute;  sometimes  for  a  minute 
and  a  half  or  longer,  when  the  muscles  become  relaxed  and  the  boy  is  able 
to  approximately  perform  the  movement  indicated.  When  he  is  placed  upon 
his  feet,  it  is  necessary  to  support  him  to  prevent  him  from  falling.  When 
he  attempts  to  walk,  the  legs  are  at  once  drawn  into  awkward  and  fixed  posi- 
tions by  muscular  spasm.  Only  after  one  or  more  minutes  is  he  able  to 
move  the  limb  and  then  he  performs  the  movements  of  the  act  of  walking 
very  imperfectly.  In  other  words  voluntary  motion  induces  myospasm.  The 
arms  show  a  similar  though  less  marked  condition. 

The  general  neurological  examination  of  the  boy  is  negative.  The  re- 
flexes arc  normal,  there  is  no  ankle  clonus  and  no  Babinski  sign.     When  the 


PHILADELPHIA   NEUROLOGICAL   SOCIETY  253 

muscles  are  percussed,  however,  they  pass  into  spasm,  the  contraction  comes 
on  slowly  and  persists  for  a  minute  or  longer.  Relaxation  does  not  seem  to 
be  complete  for  several  minutes. 

When  the  muscles  are  examined  electrically,  they  present  greatly  in- 
creased faradic  excitability,  the  contraction  approximating  physiological 
tetanus.  Tested  by  the  galvanic  current  it  is  found  that  the  anodal  closure 
contraction  approximates,  indeed  is  equal  to  the  kathodal  closure  contraction. 
In  other  words  the  boy  presents  a  typical  myotonic  reaction.  It  should  be 
added  that  there  is  no  atrophy  nor  is  there  any  hypertroph}'  of  the  muscles. 

There  are  no  sensory  losses.  The  pupils  and  eye  grounds  are  normal. 
Mentally  the  child  appears  to  be  average  in  development.  He  answers  ques- 
tions clearly  and  promptly,  although  his  speech  is  somewhat  slow  and  indis- 
tinct. The  movements  of  the  tongue  appear  also  to  be  somewhat  slow 
though  the  facial  muscles,  tongue  and  muscles  of  deglutition  do  not  seem  to 
be  decidedly  or  even  definitely  involved. 

The  case  is  novel  in  Dr.  Dercum's  experience.  It  is  clearly  one  of  myo- 
tonia. The  history,  however,  lacks  a  familial  character;  no  other  member  of 
the  family  or  relative,  near  or  remote,  suffering  this  affection.  The  fact 
too  that  the  condition  supervened  after  an  attack  of  mumps  is  suggestive, 
though  of  course  this  relationship  may  be  purely  accidental.  It  is  interesting, 
however,  to  note  that  the  boy  had  pain  and  swelling  in  one  of  his  knees  and 
that  possibly  we  have  had  here  to  do  with  sj^mptoms  referable  to  an  infection. 
However,  whatever  the  facts  may  have  been,  the  boy  suffers  evidently  from 
a  muscular  disease  and  not  from  a  disease  of  the  nervous  system  and  it  is 
one  which  must  be  classified  as  a  myotonia. 

Dr.  Charles  K.  Mills  said  that  this  case  was  an  intensely  interesting  one 
and  he  thought  very  unusual.  It  brought  into  the  foreground  the  necessitj' 
of  our  recognizing  what  we  have  been  talking  about  for  a  year  or  so,  that  is 
the  extra-pyramidal  tonectic  apparatus.  This  case  cannot  be  explained  with- 
out the  recognition  of  such  an  apparatus.  It  cannot  be  explained  on  the 
ground  of  a  pyramidal  affection  or  a  myopathy.  Recent  observations  on  the 
cerebral  representation  and  mechanism  of  tone  in  connection  with  lenticular 
affections,  Thomsen's  disease  and  other  disorders  of  tonic  innervation  throw 
doubt  on  the  older  views  as  to  the  muscular  pathology  of  Thomsen's  disease 
and  the  purely  pyramidal  pathology  of  other  nervous  diseases. 

Dr.  Dercum  said  that  if  we  looked  at  the  case  as  one  of  Wilson's  dis- 
ease, we  could  hardly  account  for  the  myotonic  reaction.  This  points  directly 
to  disease  of  the  muscle  substance. 

Dr.  F.  X.  Dercum  presented  a  case  of  probable  brain  tumor. 

Dr.  Spiller  said  he  did  not  understand  why  the  case  should  be  considered 
as  nuclear  in  its  lesions.  To  have  nuclear  lesions  of  all  the  motor  and  sen- 
sory nuclei  of  the  cranial  nerves  on  one  side  would  be  remarkable.  With 
the  history  of  neoplasm  in  the  roof  of  the  pharynx  Dr.  Spiller  thought  the 
diagnosis  should  be  tumor  at  the  base  of  the  skull  on  the  right  side. 

Dr.  S.  F.  Gilpin  and  Dr.  Thomas  B.  Early  read  a  paper  on  the  drainage 
of  the  cerebrospinal  fluid  as  a  factor  in  the  treatment  of  nervous  syphilis. 

Dr.  Charles  M.  Byrnes  said  that  if  he  understood  Dr.  Gilpin's  remarks 
correctly,  it  appears  that  the  author's  idea  is  that  by  repeated  drainage  of  the 
cerebrospinal  fluid  he  hopes  so  to  reduce  the  intraspinal  pressure  that  drugs 
administered  by  the  circulatory  channel  may,  by  osmosis,  eventually  make 
their  appearance  in  the  cerebrospinal  fluid.  Dr.  Byrnes  objected  to  this  rea- 
soning because  of  the  fact  that  osmosis  does  not  depend  upon  fluid  pressure, 
but  upon  the  concentration  and  ionization  of  soluble  salts  on  the  two  sides 
of  a  dialyzable  membrane.  If,  therefore,  mercurial  and  arsenical  salts  when 
administered  through  the  circulatory  channel  exist  in  a  dial3'zable  form,  and 
osmosis  is  the  only  factor  concerned,   they  should  be  demonstrated  in  the 


254  PHILADELPHIA   NEUROLOGICAL   SOCIETY 

cerebrospinal  fluid  regardless  of  variations  in  pressure.  Furthermore,  if  Dr. 
Gilpin's  hypothesis  is  correct,  then  after  a  course  of  mercurial  inunctions  and 
repeated  drainage,  mercury  should  be  demonstrable  in  the  cerebrospinal  fluid, 
but  this  observation  has  not  been  made. 

It  seems  therefore  that  the  authors  have  succeeded  in  producing  slight 
cj-tological  changes  in  the  cerebrospinal  fluid  by  repeated  drainage,  and  that 
the  clinical  improvement  which  the  patients  have  shown  might  just  as  easily 
be  explained  by  the  thorough  course  of  mercurial  inunctions.  It  has  already 
been  shown  that  repeated  drainage  does  alter  the  cell  count  and  globulin  con- 
tent of  the  spinal  fluid,  and  in  Dr.  Byrnes's  observations  the  cell  count  from 
any  one  lumbar  puncture  varies  considerably  if  the  count  is  made  upon  the 
first  or  last  cubic  centimeter  of  fluid  removed. 

Dr.  S.  F.  Gilpin  said  Dr.  Early  could  answer  the  questions  about  the 
cerebrospinal  fluid  examinations.  In  taking  the  cerebrospinal  fluid  the  test 
tube  was  generally  filled  after  a  few  drops  had  escaped  after  the  needle  was 
inserted  and  5  c.c.  withdrawn.  He  said  thej'^  were  following  this  out  quite 
extensively,  treating  quite  a  number  of  cases  since  they  feel  that  they  have 
had  results.  Of  course  he  knew  that  it  was  too  soon  to  look  for  anything 
they  could  count  on  and  he  would  like  to  have  at  least  three  to  five  years' 
work  on  it,  but  as  he  said  in  the  opening  remarks,  somebody  else  was  work- 
ing on  the  same  idea  and  they  thought  they  might  as  well  report  these  cases 
as  a  preliminary  report.  They  tried  once  and  found  no  mercury  in  the 
spinal  fluid,  but  the  patient  was  not  well  under  treatment.  Since  then  they 
had  had  no  chance  to  try  it.  They  had  to  depend  on  the  department  of 
chemistry.  Whether  it  is  mercury  or  something  else  that  passes  from  the 
blood  into  the  spinal  fluid,  they  are  seeing  results  clinically  that  induce  them 
to  keep  at  work. 

Dr.  Alfred  Gordon  asked  whether  Dr.  Gilpin  observed  any  complications 
from  such  frequent  lumbar  puncture,  such  as  frequent  severe  headaches.  It 
seemed  to  him  that  a  matter  like  this  ought  to  be  handled  with  great  care. 

Dr.  Gilpin  replied  that  they  had  no  bad  results,  e.xcepting  in  one  patient, 
who  complained  of  headache  the  same  afternoon,  but  he  had  been  treated 
several  times  since  with  no  ill  effects  and  he  was  the  only  one  who  had  com- 
plained at  all.  They  kept  the  patients  in  bed  twenty-four  hours  after 
puncture. 

A  TUMOR  OF  THE  PARIETO-OCCIPITAL  REGION  WHICH  HAD 
CAUSED  LATERAL  HOMONYMOUS  HEMIANOPSIA 

By  J.  H.  Lloyd,  M.D.,  and  M.  H.  BOCHROCH,  M.D. 

Dr.  M.  H.  Bochroch  gave  the  clinical  history  of  the  patient,  whom  he  had 
seen  in  St.  Joseph's  Hospital.  The  man  was  a  native  of  -Austria,  aged  42 
years,  a  laborer.  His  earlier  .symptoms  had  been  extreme  headache  and  ver- 
tigo, with  stiff'ness  and  pain  in  the  neck.  His  gait  was  rather  unsteady,  with 
a  tendency  to  go  to  the  right.  There  was  also  cerebral  vomiting.  On  admis- 
sion to  the  hospital,  a  few  weeks  after  the  onset  of  his  affection,  he  had  no 
paralysis  of  any  cranial  nerve,  but  later  the  left  third  nerve  was  partially, 
and  the  left  sixth  nerve  completely,  paralyzed.  There  also  developed  in  time 
a  right  facial  paralysis  of  the  cerebral  type.  Pain  and  tactile  senses  were 
preserved  in  the  extremities.  A  right  lateral  hemianopsia  was  observed. 
There  were  also  choked  disks.  A  decompressive  operation  was  done  by  Dr. 
Nassau,  over  the  left  parieto-occipital  region,  immediately  over  the  tumor, 
but  as  the  latter  was  entirely  subcortical,  it  was  not  observed  at  the  opera- 
tion.    Later  the  patient  was  removed  to  the  Philadelphia  Hospital,  where  he 


PHILADELPHIA   NEUROLOGICAL   SOCIETY  25s 

died,  and  the  tumor  was  observed  postmortem.  It  was  a  very  large  growth 
in  the  parieto-occipital  lobe. 

Dr.  J.  Hendrie  Lloyd  said  that  he  had  had  this  patient  under  his  care  at 
the  Philadelphia  Hospital,  to  which  he  had  been  removed  from  St.  Joseph's. 
The  tumor  is  a  very  large  one,  and  is  entirely  subcortical,  occupying  the  left 
parieto-occipital  region.  It  lies  underneath  the  angular  gyrus  and  must  have 
cut  off  its  fibers ;  and  it  must  also  have  interrupted  the  optic  radiations.  It 
is  thus  in  a  position  to  support  Ferrier's  opinion,  that  a  lesion  of  the  angular 
gyrus  is  necessary  for  a  permanent  hemianopsia ;  but  as  it  cuts  off  the  optic 
radiations  going  to  the  occipital  lobe,  especially  to  the  cuneus,  it  also  supports 
the  view  that  the  visual  cortex  is  entirely  in  the  occipital  lobe.  In  other 
words,  it  is  not  determinative  as  between  these  two  opposing  views.  It 
merely  shows  that  a  lesion  in  this  part  of  the  human  brain  causes  an  homony- 
mous hemianopsia. 

The  tumor  probably  made  some  pressure  on  the  structures  at  the  base  of 
the  brain  and  thus  caused  a  partial  paralysis  of  the  third  nerve  and  a  com- 
plete paralysis  of  the  sixth  nerve  on  the  side  of  the  lesion.  Ferrier  found 
that  electrical  stimulation  of  the  angular  gyrus  caused  movements  of  the  eyes, 
but  these  were  probably  excited  by  mere  subjective  visual  impressions.  A 
destructive  lesion  of  the  angular  gyrus  does  not  cause  paralysis  of  the  ocular 
muscles. 

This  patient's  speech  affection,  which  seems  to  have  been  a  form  of 
word-deafness,  as  well  as  it  could  be  made  out  in  a  man  talking  a  Slavish 
dialect,  was  doubtless  due  to  the  large  size  of  the  tumor,  causing  it  to  make 
pressure  on  the  speech-zone,  especially  the  temporal  lobe. 

The  patient  was  also  tested  for  the  Wernicke  pupillary  inaction,  and  this 
was  found  wanting.  The  pupils  reacted  to  light  thrown  on  the  blind  halves 
of  the  retinae.  This  confirmed  the  diagnosis  that  the  lesion  was  situated  pos- 
terior to  the  primary  optic  centers,  which  are  located  in  the  external  geniculate 
body  and  the  corpora  quadrigemina. 

It  is  to  be  regretted  that  the  visual  fields  in  this  case  were  not  charted 
while  the  patient  was  in  St.  Joseph's  Hospital.  It  was  too  late  to  do  it  at 
Blocklej',  as  the  man's  mind  was  too  much  impaired.  Nevertheless,  an 
homonymous  hemianopsia  was  determined  at  both  hospitals  by  competent 
observers. 

Dr.  George  E.  Price  said  he  had  been  much  interested  in  this  case.  The 
man  entered  the  Philadelphia  Hospital  on  Dr.  Price's  service,  and  he  had 
made  the  diagnosis  of  tumor  in  the  occipital  lobe  because  of  the  hemianopsia 
with  absence  of  the  Wernicke  pupillary  inaction  sign,  which  test  Dr.  Reber 
had  made  at  Dr.  Price's  request.  The  other  symptoms  were  thought  to  be 
secondary,  as  the  result  of  pressure.  The  case  was  most  interesting  and  in- 
structive and  he  was  very  glad  to  have  the  opportunity  of  seeing  the  specimen. 

Dr.  Charles  K.  Mills  said  that  as  is  well  known  Dejerine  has  indicated 
and  others  also,  but  he  especially,  that  the  angular  region  is  the  center  for 
word-seeing.  Various  data  point  in  this  direction.  This  center  for  word- 
seeing  is  largely  a  macular  center.  It  is  preeminently  by  the  macula  that 
letter-seeing  and  word-seeing  are  brought  about.  Dr.  Mills  had  no  doubt, 
in  fact  it  had  not  been  questioned  in  this  discussion,  that  there  is  a  macular 
distinct  from  the  panoramic  or  peripheral  representation.  More  than  this, 
there  is  a  half  macular  representation  which  Dr.  Mills  said  he  thought  he 
was  probably  the  first  to  point  out.  Many  years  since  he  observed  two  cases 
in  which  there  was  a  macular  hemianopsia  as  indicated  by  certain  studies  of 
the  patient's  powers  of  recognition  of  words  and  the  halves  of  words.  He 
was  in  favor  of  the  view  that  there  is  a  cortical  representation  of  the  macula 
in  the  angular  or  angulo-occipital  region  in  spite  of  the  observations  of 
Bramwell  and  some  others.     It  is  possible  that  there  may  be  a  macular  repre- 


256  PHILADELPHIA    NEUROLOGICAL   SOCIETY 

sentation  which  has  not  to  do  with  word-,  letter-  or  number-seeing,  but  with 
other  forms  of  central  vision.  In  other  words,  there  may  be  a  higher  and  a 
lower  macular  and  perhaps  a  higher  and  lower  peripheral  representation.  If 
this  be  true  the  lower  cortical  center  will  probably  be  in  the  calcarine  region. 

Dr.  William  G.  Spiller  and  Dr.  George  P.  Muller  reported  a  case  of 
endothelioma  of  the  temporo-occipital  lobe  with  partial  motor  aphasia  from 
enlargement  of  veins  in  Broca's  area. 

Dr.  D.  J.  McCarthy  read  a  paper  on  cerebrospinal  concussion. 

VERBAL  AMXESIA  AND  ALEXIA 
By  Dr.  Alfred  Gordon,  M.D. 

A  middle-aged  man  without  a  history  of  syphilis  and  with  negative  Was- 
sermann  suddenly  lost  consciousness  ten  months  before  he  died.  He  soon 
recovered.  Two  months  later  he  came  under  Dr.  Gordon's  observation.  He 
presented  no  paralysis.  He  had  difficulty  in  recalling  names  of  objects,  but 
he  was  able  to  recognize  when  the  right  name  was  mentioned.  Spontaneous 
speech  was  comprehensible  for  individual  words.  He  recognized  his  mis- 
take. When  reminded  he  could  repeat  the  name  but  he  had  to  do  it  promptly, 
as  otherwise  he  would  forget  it. 

Reading  printed  matter,  also  his  own  previous  writing,  was  difficult. 

Some  time  later  he  developed  a  confusional  state  from  which  he  recov- 
ered in  a  week.  A  later  examination  revealed  the  same  verbal  amnesia  as 
before  but  also  an  inability  to  carry  out  orders.  He  would  do  correctly  the 
first  part  of  the  order  but  not  the  last.  The  reading  was  still  difficult.  A 
third  examination,  made  two  months  later,  revealed  an  aggravation  of  the 
above  symptoms  and  a  distinct  word-deafness  was  present.  Alexia  was  com- 
plete. In  spontaneous  speech  he  was  muddled.  He  had  paraphasia  and 
paragraphia. 

The  eye  examination  showed  a  pathological  condition  only  at  the  last  ex- 
amination, viz.,  choked  disks  and  retinal  hemorrhages. 

There  was  at  no  time  motor  aphasia  or  dysarthria.  An  operation  was 
advised  and  accepted  by  the  patient,  especially  in  view  of  his  severe  headache. 

A  soft  mass  was  found  in  the  left  temporo-parietal  region. 

Suppuration  soon  set  in  and  the  patient  died  at  the  end  of  three  weeks. 
At  autopsy  a  gliomatous  tumor  was  found  involving  the  posterior  portions 
of  the  first  and  second  temporal  gyri,  angular  gyrus  and  a  portion  of  the 
occipital  lobe.     The  lenticular  zone,  also  Broca's  region,  were  intact. 

Dr.  Gordon  then  analyzed  the  verbal  amnesia  from  the  point  of  view  of 
Wernicke's  conception  of  transcortical  aphasia.  The  anatomical  stipulation 
with  regard  to  the  latter  made  by  Wernicke,  namely,  that  the  motor  and  sen- 
sory speech  centers  must  be  intact,  does  not  find  its  corroboration  in  the 
present  case,  in  view  of  involvement  of  sensory  speech  centers.  Dr.  Gordon 
further  discussed  verbal  amnesia  and  considered  it  as  an  initial  manifestation 
of  word-deafness.  He  believes  that  an  inability  to  recall  names  means  a 
deafness  to  one's  own  words.  The  evolution  of  the  symtoms  in  the  present 
case  justifies  Dr.  Gordon  to  make  such  an  assumption.  iMnally,  he  con- 
sidered, the  case  from  Marie's  standpoint.  The  motor  speech  center  and 
Marie's  lenticular  zone  were  intact  in  the  present  case. 


PHILADELPHIA   NEUROLOGICAL   SOCIETY  257 

November  26,  191 5 
The  President,  Dr.  S.  D.  W.  Ludlum,  in  the  Chair 

Dr.  George  Wilson  presented  two  cases  showing  neurological  sj-mptoms 
(muscular  and  optic  atrophy)  following  severe  hemorrhage  from  the  nose 
and  lungs. 

Dr.  T.  H.  Weisenburg  said  that  the  first  patient,  Alexander  Stewart,  he 
remembered  very  well  because  he  was  admitted  while  he  was  on  duty.  The 
point  Dr.  Weisenburg  emphasized  was  that  the  patient  had  optic  neuritis  pre- 
ceding the  optic  atrophy.  Dr.  de  Schweinitz  studied  the  man  at  that  time  and 
thought  this  unusual.  The  second  patient  came  into  Dr.  Weisenburg's  service 
four  or  five  months  previously  and  he  thought  at  that  time  that  the  patient 
had  an  irregular  form  of  spinal  muscular  atrophy. 


A  PATIENT  WITH  ISOLATED  CERVICAL  SYMPATHETIC 
PARALYSIS 

By  H.  Maxwell  Langdon,  M.D. 

Mrs.  M.  E.  H.,  white,  age  28. 

Came  to  the  clinic  of  Dr.  John  K.  Mitchell  with  the  complaint  that  for 
the  preceding  five  or  six  months  lumps  had  appeared  on  various  parts  of  her 
body,  soles  of  the  feet,  arms,  etc.,  appearing  suddenly,  lasting  from  a  few 
hours  to  two  days  and  disappearing  as  suddenly. 

Her  family  history  was  negative  as  far  as  the  present  condition  is  con- 
cerned ;  she  had  had  measles,  mumps,  chickenpox  in  childhood  and  rheuma- 
tism at  times  for  the  past  four  years ;  she  has  one  child  six  years  old,  living 
and  well,  no  miscarriages.  Her  menstruation  is  always  scanty  and  some- 
what painful,  and  very  irregular,  at  times  six  months  absent,  the  last  was 
August  ID,  1915,  and  she  does  not  believe  she  is  pregnant.  She  has  had  a 
large  thyroid  for  the  past  twelve  years,  the  right  lobe  possibly  larger  than 
the  left;  pulse  between  90  and  100.  Has  considerable  frontal  headache  at 
times.     Right  eyelid  has  drooped  past  four  years. 

Physical  examination  except  for  the  above  conditions  was  negative,  ex- 
cept as  concerns  the  ocular  structures,  where  the  following  findings  were 
recorded:  O.  D.  V.  6/60  with  myopia  corrected  6/6,  O.  S.  V.  6/6.  O.  D. 
palpebral  fissure  8  mm.,  O.  S.  fissure  9  mm. ;  O.  D.  pupil  2  mm.,  O.  S.  pupil 
3  mm. ;  O.  D.  exophthalmos  13  mm.,  O.  S.  exoph.  13.5  mm.  Both  pupils 
responded  well  to  Hght  and  accommodation,  ocular  rotations  full  and  equal, 
with  no  nystagmus. 

After  three  drops  of  a  5  per  cent,  solution  of  cocaine,  thirty  minutes 
elapsing:  O.  D.  fissure  8  mm.,  O.  S.  fissure  10  mm.;  O.  D.  pupil  2  mm.,  O.  S. 
pupil  5.5  mm. ;  O.  D.  exoph.  13  mm.,  O.  S.  exoph.  14  mm. 

Ophthalmoscopically  the  media  are  clear,  the  disks  normal  in  color  and 
outline,  and  there  are  no  fundus  changes.  X-ray  examination  of  the  cervical 
region  is  negative  and  the  Wassermann  reaction  is  negative. 

Neurological  examination  is  negative,  there  being  no  sensory  or  other 
disturbances  pointing  to  involvement  of  the  cervical  sympathetic  system,  ac- 
cording to  Drs.  Mitchell,  Eshner  and  Cadwalader,  all  of  whom  have  examined 
her.  Her  knee  jerks  are  normal  and  her  station  good;  there  is  no  sign  of 
clonus  in  any  of  the  extremities. 


258  PHILADELPHIA    XEUROLOGICAL   SOCIETY 

It  seems  impossible  that  the  lesion  causing  the  condition  can  be  in  either 
the  medulla  or  the  cord,  since  there  is  no  sign  of  any  involvement  of  neigh-  M' 

boring  centers  or  tracts ;  the  most  probable  cause  seems  the  pressure  of  the  J, 

thyroid  on  the  nerves  in  the  neck.  * 

Dr.  William  G.  Spiller  stated  that  he  was  reminded  by  seeing  this  woman 
of  a  woman  who  was  in  the  Salpetriere  in  1895.     She  differed  in  some  re- 
spects but  was  like  this  patient  in  others.     The  woman  was  later  reported  by  ^ 
Dejerine  as  a  case  of  unilateral  syringomj^elia,  with  hemiatrophy  of  the  face  £. 
and  sympathetic  paralysis  of  the  face.  » 

In  Dejerine's  patient  the  sympathetic  paralysis  and  hemiatrophy  of  the  0 

face  were  caused  by  a  lesion  of  the  spinal  cord,  whereas  in  Dr.  Langdon's 
patient  these  sj'mptoms  probably  were  produced  by  pressure  of  the  enlarged 
thyroid  on  the  cervical  sympathetic  cord.  Dr.  Langdon's  patient  seemed  to 
Dr.  Spiller  to  have  facial  hemiatrophy. 

Dr.  Samuel  Leopold  presented  a  case  of  paralysis  of  both  external  recti 
muscles  following  injury  of  the  head. 

Dr.  Alfred  Gordon  said  that  while  it  was  true  that  in  the  nuclear  palsies 
the  course  is  usually  progressive,  nevertheless  there  are  cases  on  record  of 
disappearance  of  symptoms  following  infectious  diseases.  He  had  in  mind 
two  cases  of  children  who  had  whooping  cough.  They  became  suddenly 
unconscious  and  on  recovery  paralysis  of  the  external  recti  was  observed. 
Another  patient,  a  woman,  also  had  loss  of  consciousness  and  had  paralysis 
of  the  external  recti.  In  this  case  there  was  no  bleeding  from  the  nose  or 
the  ear.  Could  we  not  consider  here,  in  view  of  the  negativeness  of  the  usual 
symptoms  of  fracture  at  the  base  of  the  skull,  whether  a  nuclear  palsy 
followed  a  little  hemorrhage  in  the  fourth  ventricle.  A  slight  hemorrhage 
there  is  sufficient  to  produce  an  apoplexy.  A  child  whom  Dr.  Gordon  still 
has  under  observation,  who  had  had  an  attack  of  whooping  cough  and  devel- 
oped palsy  of  the  external  recti,  is  rapidly  improving.  In  view  of  the  absence 
of  nose  and  ear  hemorrhage,  which  possibly  excludes  fracture  of  the  skull,  we 
may  admit  in  the  presented  case  a  hemorrhage  in  the  fourth  ventricle.  <, 

A  CASE  OF  SPINAL  CORD  TUMOR  IN  WHICH  THE  SYMPTOMS 
DISAPPEARED  AFTER  SPINAL  PUNCTURE 

By  T.  H.  Weisenburg,  M.D. 

v 
Dr.  Weisenburg  reported  the  case  of  a  patient,  sixty-seven  years  of  age,  'u, 

who  presented  the  symptoms  of  a  spinal  cord  tumor.     This  man  first  com-  ^ 

plained  of  pain  in  the  lower  lumbar  region  in  July,  1914,  the  pain  extending  j; 

first  to  the  thigh  on  the  right  side  and  then  especially  to  the  entire  left  leg,  t 

it  being  of  a  numb  and  then  again  of  a  sharp  and  shooting  character.  Ac- 
companying this  there  appeared  a  gradual  rigidity  of  the  whole  lower  back, 
the  pain  and  rigidity  increasing  to  such  an  extent  that  the  patient  could  not 
walk  without  pain.  Dr.  Weisenburg  saw  him  three  months  after  the  onset. 
.'\t  this  time  the  patient  had  great  tenderness  in  the  lower  part  of  the  spine 
and  hip  with  corresponding  rigidity  and  lack  of  movement,  tenderness  over 
the  left  leg,  no  distinct  disturbance  of  sensation  over  the  left  leg,  but  that 
some  diminution  of  sensation  was  present  was  evident  from  the  nature  of 
the  responses.  Bladder  and  rectal  functions  were  normal.  The  abdominal 
reflexes  were  present.  The  left  cremasteric  reflex  was  absent.  The  right 
knee  jerk  was  quicker  than  normal.  The  left  was  entirely  absent.  The 
.Achilles  jerks  were  normal.  Plantar  irritation  showed  a  distinct  Babinski 
on  both  sides.  As  a  result  of  this  examination  a  diagnosis  was  made  of  a 
dural  tumor  over  the  left  first,  second,  thirfi  and  fourth  lumbar  segments 
pressing  upon  the  cord. 


PHILADELPHIA   NEUROLOGICAL   SOCIETY  259 

A  lumbar  puncture  was  made  between  the  second  and  third  lumbar  ver- 
tebrae, that  is  below  the  end  of  the  cord  and  supposedly  below  the  tumor. 
The  puncture  was  very  painful  to  the  patient  and  a  large  amount  of  bloody 
fluid  came  out  under  great  pressure.  Examination  of  this  showed  nothing 
but  blood  cells  and  was  otherwise  negative.  From  that  time  on  the  pains 
gradually  disappeared  and  the  left  cremasteric  reflex  and  the  left  patellar 
jerk  came  back  within  a  few  days.  When  the  patient  went  home  his  son,  a 
competent  physician,  made  frequent  reports  and  from  this  it  was  apparent 
that  the  Babinski  reflex  disappeared  in  about  two  months'  time.  After  the 
patient  returned  home  the  pain  gradually  disappeared,  and  the  weakness  of 
the  left  leg  became  less  as  was  also  the  case  with  the  rigidity  of  the  spine. 
A  letter  received  from  his  son  a  year  after  the  puncture  stated  that  the  patient 
was  as  well  as  ever,  that  with  the  exception  that  the  left  leg  tired  more  easily 
than  the  right  he  was  altogether  normal  and  had  been  so  for  a  number  of 
months. 

It  is  apparent  from  this  that  there  was  not  present  a  dural  tumor  but  an 
idiopathic  circumscribed  serous  cyst  and  that  the  contents  of  this  were  lib- 
erated at  the  time  of  the  spinal  puncture.  The  interesting  point  about  the 
whole  case  is  that  it  teaches  that  in  every  instance  where  a  spinal  cord  tumor 
is  diagnosticated  a  lumbar  puncture  should  be  made  first  of  all  always  below 
the  tumor  for  the  purpose  of  studying  the  cerebrospinal  fluid  because,  as  it 
has  been  shown,  the  presence  of  a  tumor  higher  up  interferes  with  the  free 
circulation  of  the  fluid  and  certain  pathological  changes  will  be  present  which 
aid  in  the  diagnosis  of  the  tumor.  Secondlj-,  this  case  teaches  that  it  is  advis- 
able to  puncture  at  the  supposed  location  of  the  tumor,  for  it  is  possible,  as 
in  this  case,  that  the  tumor  may  be  cystic  and  all  the  symptoms  disappear. 
Brain  puncture  has  been  advocated  for  the  diagnosis  of  cerebral  tumors  and 
there  is  no  reason  why  a  spinal  puncture,  which  is  much  easier,  should  not 
te  done  in  spinal  cord  tumors. 

A  CASE  OF  HEMIPARESIS  WITH  PRONOUNCED  ASSOCIATED 

MOVEMENTS 

By  William  B.  Cadwalader,  M.D. 

R.  L.  (No.  11415,  U.  of  P.  Dispensary  for  Nervous  Diseases),  male,  aged 
18,  was  referred  by  Dr.  Edward  Martin.  This  patient  stated  that  his  parents 
were  healthy  and  that  he  had  been  weak  in  the  left  arm  and  left  leg  as  long 
as  he  could  remember.  No  details  of  the  onset  could  be  obtained  but  it 
seemed  certain  that  hemiparesis  had  existed  since  birth.  The  pupils  were 
normal  and  the  eye  grounds  were  negative.  The  cranial  nerves  all  acted 
normally.  Voluntary  movements  of  the  muscles  of  the  lower  part  of  the 
face  were  equally  impaired  on  each  side ;  and  muscular  contraction  on  one 
side  seemed  to  cause  a  similar  movement  on  the  opposite  side  of  the  face. 
Strictly  unilateral  voluntary  movement  of  the  lower  facial  muscles  could  not 
be  performed.  With  the  jaws  closed,  the  lips  could  not  be  as  widely  sepa- 
rated as  they  should  have  been  normally.  The  muscles  of  the  upper  part 
of  the  face  were  not  affected.  All  movements  of  the  left  upper  extremity 
were  paretic.  The  finer  movements  of  the  hand  and  fingers  were  awkward 
and  weak.  With  each  movement  of  the  left,  the  paretic  hand,  the  same 
movement  was  also  performed  at  the  same  time  by  the  right  hand,  and  further- 
more, with  each  voluntary  movement  of  the  right  hand,  the  unaffected  one, 
there  was  also  performed  at  the  same  time  the  same  movement  by  the  left 
hand,  the  affected  one,  but  on  account  of  partial  paralysis  the  muscular  con- 
Iractions  of  the  left  hand  could  not  be  so  perfectly  performed  as  they  were 


26o  PHILADELPHIA    XEUROLOGICAL   SOCIETY 

with  the  right  hand.  Unilateral  movement  seemed  to  be  impossible.  Only 
bilateral  movements  of  the  hands  were  observed.  The  same  phenomena  were 
observed  in  the  feet  and  toes,  though  to  a  much  less  degree.  This  did  not 
interfere  with  locomotion.  The  left  leg  was  quite  powerful  but  there  was  a 
perceptible  limp  in  walking.  The  tendon  retiexes  of  the  upper  and  lower 
extremities  were  exaggerated  on  the  left  side  and  on  the  right  side  they  were 
normal.  A  definite  Babinski  sign  was  elicited  on  the  left  and  an  abortive 
type  of  ankle  clonus.     Sensation  of  all  forms  was  everywhere  normal. 

Evidently  there  had  been  a  congenital  defect  or  an  injury  at  birth  of  one 
cerebral  hemisphere.  It  seems  as  if  the  motor  tracks  of  the  sound  side 
innervated  both  sides  of  the  body. 

The  associated  movements  in  this  case  were  very  pronounced  and  did 
not  seem  to  be  affected  by  the  will  or  by  closing  or  opening  the  eyes.  Such 
pronounced  associated  movements  as  this  case  presented  are  uncommon ;  but 
a  similar  case  was  reported  before  this  Society  by  Dr.  Charles  W.  Burr 
in  1913. 

Dr.  Grayson  P.  McCouch  (by  invitation)  read  a  paper  on  a  relation  be- 
tween the  myopathies  and  the  glands  of  internal  secretion. 

Dr.  William  G.  Spiller  said  that  at  a  recent  meeting  of  the  American 
Neurological  Association,  when  he  (Dr.  Spiller)  reported  the  case  briefly 
which  Dr.  McCouch  had  used  in  his  paper,  both  Dr.  E.  W.  Taylor  and  Dr. 
Joseph  Collins  said  that  they  had  very  similar  cases.  The  woman,  compara- 
tively young  as  she  was,  had  cataract.  The  study  of  the  family  form  of 
cataract  is  an  interesting  one  and  recently  attention  has  been  called  to  the 
association  of  the  family  form  of  cataract  with  myotonia  atrophica.  He 
thought  it  would  be  important  if  Dr.  McCouch  would  trace  so  far  as  possible 
the  family  history  of  this  woman  to  see  how  many  members  of  her  family 
have  had  cataract. 

Dr.  H.  Maxwell  Langdon  said  that  familial  types  of  cataract,  while  they 
are  not  common,  are  not  excessively  rare.  Doyon,  of  Oxford,  has  reported 
several  families  with  them.  Dr.  Langdon  has  seen  several  people  with 
familial  types  of  cataract.  There  was  one  family  of  which  five  or  six  mem- 
bers were  students  at  the  University  Hospital  and  none  of  that  family  had 
any  myopathy  which  would  show  to  the  casual  eye.  They  varied  in  age  at 
that  time  from  eight  or  nine  years  of  age  to  the  early  twenties.  Nettleship 
has  reported  several  cases  with  familial  cataract. 

Dr.  McCouch  said  in  regard  to  the  question  of  cataract  there  was  one 
other  possible  relation  that  occurred  to  him.  It  has  been  a  frequent  compli- 
cation not  only  in  myotonia  atrophica,  but  still  more  frequent  in  tetany,  and 
Rundborg  attributes  myotonia  and  tetany  to  hypothyroid  function. 

Dr.  Baldwin  Lucke  (by  invitation)  read  a  paper  on  tabes  dorsalis :  a 
pathological  and  clinical  study  of  250  cases. 

Dr.  Francis  X.  Dercum  said  that  it  was  desirable,  if  possible,  to  arrange 
the  material  of  the  records  in  such  a  way  that  we  could  compare  the  symp- 
toms observed  in  the  earlier  years  with  those  observed  during  relatively  recent 
times.  There  is  an  impression  abroad  that  certain  symptoms,  such  as  mal 
perforans,  Charcot's  joints,  trophic  disorders  generally  and  coarse  ataxia  are 
observed  at  present  somewhat  less  frequently  than  formerly.  He  would  like 
to  know  whether  Dr.  Luckc's  statistics  enabled  him  to  answer  this  question. 

Dr.  Charles  K.  Mills  thought  the  paper  a  valuable  one  and  that  the  So- 
ciety should  thank  Dr.  Lucke  for  it.  In  regard  to  Dr.  Dercum's  remarks  he 
had  the  impression  that  tabes  like  syphilis  itself  has  changed  consiflerably  or 
changed  somewhat  in  the  relative  severity  of  the  special  manifestations.  The 
changes  are  greater  in  nontabetic  syphilis  than  in  tabes.  He  thought  this 
experience  had  been  observed  by  others  who  had  had  experience  now  reach- 


PHILADELPHIA   NEUROLOGICAL   SOCIETY  261 

ing  above  forty  years.  Dr.  Mills's  experience  in  the  nervous  wards  of  the 
Philadelphia  Hospital  was  not  far  short  of  forty  years,  about  thirty-eight 
years,  but,  of  course,  the  wards  themselves  have  increased  gradually  in  size 
from  a  very  limited  number  of  patients  to  the  present  very  considerable 
number.  Dr.  Mills  was  inclined  to  think  that  there  were  more  of  what  might 
be  called  abortive  cases  as  regarded  symptomatology,  that  is,  more  cases  that 
did  not  reach  the  classical  full-fledged  type  of  the  old  or  even  of  the  more 
recent  descriptions  of  the  cases.  Dr.  Alills  thought  that  the  ataxias  were  not 
so  marked  or  so  early  marked  as  formerly,  but  still  it  was  a  subject  about 
which  one  should  not  speak  at  any  length  without  really  getting  down  to 
hard  work  and  preparing  the  data  at  his  command.  This  had  been  done  over 
a  limited  number  of  years  by  Dr.  Lucke  and  the  material  at  Blockley  is 
largely  at  disposal  for  thirty  or  forty  years,  although  the  manner  in  which 
the  notes  have  been  made  during  that  time  has  been  such  as  not  to  give  the 
opportunity  of  making  uniform  and  valuable  observations. 

Dr.  Lucke  said  he  would  like  to  ascertain  whether  the  coarse  type  of 
tabes  changed  in  severity,  but  he  did  not  think  it  was  possible  from  the  rec- 
ords. The  records  kept  ten  years  ago  were  kept  far  better  than  they  are 
kept  to-day. 

PONTO-CEREBELLAR  TUMOR 

By  Alfred  Gordon,  M.D. 

Middle-aged  man  complained  for  many  months  of  headache  and  dizzi- 
ness. The  condition  would  improve  and  then  grow  worse  again.  At  the 
first  examination  made  a  few  months  before  the  patient  died  there  was  some 
headache  over  the  left  frontal  region,  also  some  unsteadiness  in  walking. 
An  objective  examination  revealed  a  very  slightly  exaggerated  knee  jerk  on 
the  left,  but  no  other  abnormal  reflex.  The  eye  examination  was  entirely 
negative.  As  the  patient's  serum  presented  a  positive  Wassermann,  cerebro- 
spinal syphilis  was  thought  of.  Soon  a  second  e:^amination  was  made.  This 
time  there  was  a  slight  tendency  to  fall  to  the  right,  a  very  slight  deviation 
of  the  lower  face  to  the  right  and  a  very  slight  ataxia  of  the  left  hand.  The 
eyes  were  again  negative.  Repeated  examinations  revealed  the  same  left- 
sided  symptoms.  However,  they  were  so  slight  that  they  could  be  easily 
overlooked.  Soon  sensory  disturbances  on  the  left  side  of  the  face  made 
their  appearance.  The  left  facial  palsy  became  complete.  Adiadochokinesis 
was  complete  on  the  left  side.  A  nystagmus  appeared  in  the  left  eye  upon 
turning  the  eyes  to  the  left.  The  left  external  rectus  became  paralyzed.  The 
fundi  of  the  eyes  began  to  show  engorgement  of  the  veins  and  edema  of  the 
papillae  made  its  appearance.  Hearing  of  the  left  ear  was  impaired.  The 
diagnosis  of  a  leftsided  tumor  in  the  cerebello-pontine  angle  was  evident.  A 
subtentorial  decompressive  operation  was  performed.  Some  relief  was  ob- 
tained, but  the  patient  soon  relapsed  and  expired.  A  tumor  was  found  in 
the  place  diagnosed.  It  is  a  round-cell  sarcoma.  Pressure  was  observed  on 
the  cerebellum,  pons,  eighth  nerve  and  deviation  to  the  right  of  the  pons  and 
medulla  was  distinct.  The  case  is  instructive  for  the  reason  of  the  presence 
of  extremely  few  symptoms  during  a  long  period.  They  were  so  extremely 
slight  that  they  could  be  easily  overlooked.  Besides,  eye  symptoms  began  to 
appear  only  toward  the  end.  Although  the  patient  was  syphilitic,  the  neo- 
plasm was  not  syphilitic. 


262  NEIV    YORK   X  EURO  LOGICAL   SOCIETY 

NEW  YORK  NEUROLOGICAL  SOCIETY 

October  5,  1915 

The  President,  Dr.  Wiluam  Leszynsky,  in  the  Chair 

CASE  OF  CEREBROSPINAL  SYPHILIS 

By  E.  G.  Zabriskie,  M.D. 

The  patient  was  a  man  39  years  of  age,  a  locomotive  engineer  by  trade. 
In  October,  1913,  his  brother,  a  railwaj'  engineer,  was  killed  in  a  wreck. 
This  depressed  the  patient  a  great  deal.  He  began  to  be  very  talkative 
and  his  ideas  assumed  an  expansive  character.  He  maintained  that  a  bill 
should  be  introduced  in  Congress  making  bridge  and  trestle  inspection  com- 
pulsory. He  talked  about  it  and  the  accident  all  the  time.  He  became  ex- 
tremely agitated  in  manner  and  speech  and  his  hands  were  so  tremulous  that 
he  had  difficulty  in  feeding  himself.  Dr.  Gaines,  who  examined  him  at  this 
time,  said  he  displayed  no  realization  of  the  seriousness  of  his  mental  condi- 
tion. At  that  time  he  had  Argyll-Robertson  pupils,  unequal  in  size,  irregular 
in  contour,  speech  somewhat  indistinct,  knee  jerks  somewhat  exaggerated,  a 
slight  facial  and  manual  tremor.  He  was  sent  to  the  Johns  Hopkins  Hospital 
where  at  that  time  it  was  learned  that  he  had  in  addition  to  the  above  symp- 
toms a  desire  to  buy  tracts  of  land  in  Florida  and  he  expected  to  become  rich 
thereby.  In  a  short  time  he  developed  marked  insomnia,  talking  constantly 
and  extremely  nervous  and  agitated  in  his  manner,  so  much  so  that  for  a 
period  he  was  unable  to  feed  himself.  His  deportment  was  good  and  his  lan- 
guage proper.  Under  treatment  in  a  sanitarium,  where  it  was  necessary  to 
confine  him,  he  slept  well,  gained  weight  and  became  quiet.  On  February 
19,  20  and  21,  1914,  he  was  in  an  elated,  over-talkative  condition,  expressed 
many  grandiose  ideas  about  his  future  plans  which  were  extremely  visionary 
in  character  and  impossible  of  execution.  He  apparently  did  not  realize  the 
seriousness  of  his  mental  condition.  Physical  examination  was  the  same  as 
that  of  Dr.  Gaines.  There  was  elicited  from  his  past  history  the  fact  that  he 
had  a  primary  sore  about  fifteen  years  ago.  The  examination  at  the  Johns 
Hopkins  serological  department  showed  a  positive  Wassermann  in  the  cere- 
brospinal fluid,  positive  gold  chloride  reaction,  positive  globulin,  thirty  cells. 
Diagnosis  of  general  paresis  was  made.  He  was  given  under  Dr.  Barker's 
direction  five  or  six  injections  of  salvarsanized  serum,  which  were  followed 
by  a  very  marked  clinical  improvement.  He  was  then  given  neosalvarsan 
intraspinously  by  the  Ravot  method  which  was  followed  by  sphincter  incon- 
tinence, spasticity  of  the  legs,  intense  pains  in  the  legs  and  rectum.  Root 
pains  were  very  similar  to  those  at  the  present  time.  The  mental  symptoms 
had  entirely  subsided.  The  patient  had  been  extremely  uncomfortable,  com- 
plaining constantly  of  pain  and  stiffness  in  the  legs,  sleeplessness,  incontinence 
of  urine  and  feces.  He  had  had  three  further  injections  by  the  Swift-Ellis 
method  and  a  series  of  five  intravenous  injections  of  0.5  gm.  salvarsan.  His 
blood  had  become  negative,  but  the  cerebrospinal  fluid  had  remained  con- 
stantly positive.  Cells  and  globulin  remained  plus.  The  mental  attitude  at 
the  present  time  was  that  of  a  man  constantly  introspective  over  his  sad 
plight  and  very  discouraged.  The  physical  examination  showed  unsteady 
station,  spastic  gait;  left  pupil  larger  than  right,  botli  irregular  and  fixed  to 
light.  The  facial  expression  was  dull  and  listless.  Reflexes  of  the  arms  were 
slightly    increased    and    the    abdominals    slightly    exaggerated.     Ankle    jerks 


NEW    YORK   NEUROLOGICAL   SOCIETY  263 

were  present,  left  greater  than  right.  There  was  a  double  Babinski  and  no 
ankle  or  patellar  clonus.  The  serological  findings  were :  blood  Wassermann 
positive ;  cerebrospinal  fluid  positive ;  cells  nine ;  globulin  weakly  positive ; 
gold  chloride  positive.  The  case  was  presented  to  illustrate  the  possible  con- 
sequences of  certain  methods  of  administration  of  salvarsan. 

RESULTS  OF  LXTRASPINAL  TREATMENT  IN  GENERAL  PARESIS 
By  Hanson  S.  Ogilvie,  AI.D. 

The  cases  reported  in  this  communication  presented  at  the  original  ex- 
amination the  classical  syndrome  of  dementia  paralytica.  All  gave  positive 
serobiologic  evidence  of  syphilitic  disease  in  the  cerebrospinal  fluid,  and  all 
but  two  showed  positive  findings  in  the  blood  serum.  The  average  duration 
of  symptoms  was  one  year  and  nine  months,  the  shortest  being  six  months, 
and  the  longest  four  years  and  six  months.  Out  of  the  entire  series  only  five 
were  "  socially  possible  "  when  treatment  was  instituted.  Twenty-two  cases 
had  previously  received  intensive  intravenous  and  intramuscular  treatment 
over  periods  varying  from  six  months  to  two  years,  and  eight  of  this  number 
had  had  remissions  of  from  two  to  eight  months  with  relapse. 

The  method  of  intraspinal  treatment  employed  was  a  modification  of  the 
one  originally  described  by  Swift  and  Ellis.  The  curative  serum  was  of 
standard  strength,  prepared  in  vitro  according  to  a  technique  detailed  by  Dr, 
Ogilvie  in  a  previous  communication.  The  use  of  this  serum  in  more  than 
eighteen  hundred  treatments  has  shown  it  to  be  both  safe  and  effectual  as  a 
curative  agent  in  types  of  syphilitic  nervous  diseases  in  which  intraspinal 
therapy  is  indicated.  In  general  paresis  particularly  Dr.  Ogilvie  has  found 
it  to  be  far  superior  to  serum  prepared  according  to  the  method  of  Swift 
and  Ellis  because  in  this  condition,  more  than  all  others,  a  serum  of  relatively 
greater  strength  and  uniformity  is  essential. 

The  total  number  of  patients  treated  in  this  series  was  thirty-five.  The 
average  number  of  treatments  given  was  twenty-one.  The  minimum  number 
required  to  induce  a  remission  was  six,  and  the  maximum  was  fourteen.  The 
largest  number  given  to  one  patient  was  forty-two.  Salvarsan  intravenously 
and  mercury  intramuscularly  were  given  systematically,  the  intravenous  treat- 
ments being  scheduled  to  alternate  with  the  intraspinal.  The  results  can  best 
be  described  by  dividing  the  cases  into  three  groups:  (i)  those  in  which  com- 
plete clinical  remissions  occurred ;  (2)  those  in  which  remissions  were  incom- 
plete;  and  (3)  those  which  failed  utterly  to  respond  to  treatment. 

The  first  group  comprises  twelve  cases,  or  approximately  thirty-four  per 
cent,  of  the  total.  All  of  these  were  totally  incapacitated  for  work  of  any 
kind,  eight  being  confined  in  institutions  for  the  insane.  In  each  the  remis- 
sions were  clinically  complete,  nine  having  resumed  their  former  vocations 
in  life.  The  average  duration  at  this  time  is  one  3'ear  and  two  months ;  the 
shortest  being  nine  months  and  the  longest  one  year  and  eight  months.  Bio- 
logically four  of  the  twelve  are  completely  negative  in  both  the  blood  and 
spinal  fluid ;  eight  are  normal  as  regards  the  cell  and  globulin  contents,  but 
positive  to  the  Wassermann  reaction  in  the  stronger  titrations.  Aside  from 
a  disappearance  of  tremors,  none  of  these  showed  any  noteworthj^  changes  in 
the  characteristic  physical  signs  except  a  very  appreciable  improvement  in  the 
pupillary  light  reflex  in  three  cases.  There  was  a  marked  improvement  in 
the  general  health  of  all. 

The  second  group  comprises  fourteen  cases,  or  forty  per  cent,  of  the  total. 
All  of  these  were  totally  incompetent,  either  confined  in  institutions  or  kept 
at  home  in  the  care  of  nurses.     The  remissions  induced  were  not  complete 


364  NEIV    YORK   NEUROLOGICAL   SOCIETY 

but  sufficiently  well  marked  to  render  the  patients  socially  possible.  None 
have  been  able  to  resume  their  vocations  but  all  are  able  to  live  at  home  and 
attend  to  their  daily  functions  and  personal  aflfairs  without  attendance.  The 
average  duration  of  remissions  in  this  group  is  twelve  and  a  half  months. 
The  cell  and  globulin  contents  of  the  spinal  fluid  were  influenced  to  varying 
degrees,  the  cells,  in  the  main,  being  reduced  to  normal.  The  Wassermann 
reaction  was  favorably  influenced  in  ten  cases,  but  none  became  completely 
negative. 

The  third  group  comprises  nine  cases,  or  approximately  twenty-five  per 
cent,  of  the  total.  Although  seven  of  these  had  partial  remissions  lasting  from 
one  to  six  months,  none  were  of  the  character  of  the  first  two  groups,  each 
suffered  a  relapse,  and  all  should  be  counted  as  total  failures  both  from  a 
clinical  and  a  biologic  point  of  view.  It  is  interesting  to  note  that  some  of  the 
most  promising  cases  in  the  beginning  were  among  this  group  that  could  not 
be  influenced  by  treatment.  Only  two  had  been  committed  and  four  of  the 
lot  had  shown  symptoms  for  less  than  nine  months. 

Considering  the  results  as  a  whole,  we  have  twenty-six  remissions,  aver- 
aging over  a  year  each,  out  of  thirty-five  cases.  Twelve  of  these  are  clin- 
ically complete,  and  four  of  the  twelve  both  clinically  and  biologically  so. 
Fourteen  are  incomplete  but  the  improvement  was  sufficiently  well  marked  as 
to  enable  the  patients  to  take  care  of  themselves.  Naturally  the  first  question 
that  occurs  to  one  is:  How  permanent  will  the  results  prove  to  be?  Our 
knowledge  regarding  many  obscure  phases  of  the  subject  is  as  yet  so  meager 
that  no  prediction  carrying  any  degree  of  accuracy  can  be  made.  In  true 
parenchymatous  disease  of  the  brain  it  is  practically  impossible  to  secure  a 
complete  negative  Wassermann  reaction.  The  four  negative  cases  in  this 
series  were  probably  not  of  this  type,  but  cases  in  which  the  specific  process 
was  confined  largely  to  the  interstices  of  the  cerebral  tissues.  The  outlook  in 
these  is  probably  better  than  in  the  other  cases  that  are  still  positive  to  the 
Wassermann  reaction,  and  yet  many  cases  of  remissions  of  several  years' 
duration,  occurring  spontaneously  and  without  treatment  of  any  kind,  are  on 
record.  Such  cases  were  undoubtedly  positive  biologically  throughout  the 
entire  period  despite  the  fact  that  no  manifestations  of  the  psychosis  were 
apparent.  Obviously  other  factors  determine  the  duration  of  a  remission  in 
a  given  case  besides  the  presence  or  absence  of  positive  laboratory  findings, 
factors  that  are  as  definite  and  as  elusive  as  those  that  determine  the  escape 
or  involvement  of  the  central  nervous  system  in  the  beginning.  The  estab- 
lishment of  a  remission  is  something  gained,  but  it  is  merely  one  step  in  the 
right  direction.  To  make  it  permanent  difficult  problems  of  immunity  must 
be  solved.  Investigations  along  these  lines  have  already  been  started  and  if 
carried  to  a  successful  completion,  then,  perhaps,  we  may  speak  of  "curing" 
general  paresis. 

In  judging  the  value  of  intraspinal  treatment,  however,  one  cannot  take 
the  duration  of  a  remission  as  the  only  indicator.  No  two  cases,  and  no  two 
series  of  cases,  are  identical.  The  method  is  entitled  to  recognition  as  a  ra- 
tional therapeutic  procedure  by  reason  of  the  fact  that  a  far  greater  per- 
centage of  cases  of  all  kinds  respond  to  it  than  to  the  older  methods  of 
treatment.  In  this  series  over  seventy-four  per  cent,  were  influenced  favor- 
ably to  a  degree  not  approached  by  the  most  heroic  intravenous  treatment 
either  alone  or  with  mercury.  But  here,  as  in  every  other  department  of 
medicine,  the  time  to  treat  the  disease  successfully  is  in  its  incipiency.  The 
value  of  any  kind  of  therapy  must  be  judged  by  its  cause-removing  prop- 
erties solely.  No  method  of  treatment  possesses  inherent  reparative  prop- 
erties. If  intraspinal  treatment  is  efficacious  to  any  degree  in  clinically  well- 
established  paresis,  it  certainly  has  a  field  of  greatest  usefulness  if  employed 
in  the  earliest  stage  of  involvement  before  the  parenchyma  of  the  cortex  has 
become  the  seat  of  degenerative  changes. 


NEW   YORK   NEUROLOGICAL   SOCIETY  265 

In  conclusion  Dr.  Ogilvie  emphasized  the  importance  of  infinite  care  and 
proper  judgment  in  regard  to  serum  strength  and  frequency  of  administra- 
tion. So  many  factors  determine  these  most  essential  features  in  this  work 
that  it  is  utterly  impossible  to  follow  any  fixed  set  of  rules.  Unless  the 
clinical  picture  is  made  more  complex  by  the  presence  of  tabetic  symptoms, 
a  much  stronger  serum  is  indicated  in  general  paresis  than  in  any  other  con- 
dition. A  vital  prerequisite  to  successful  treatment  is  a  clear  conception  of 
the  magnitude  of  the  undertaking.  Not  infrequently  he  had  heard  the  intra- 
spinal method  condemned  on  the  ground  that  it  is  attended  with  too  much 
hazard  to  warrant  its  use,  when  investigations  have  revealed  gross  inaccu- 
racies of  detail  in  the  preparation  of  serum.  Others  have  abandoned  it  be- 
cause three  or  four  treatments  failed  to  bring  results  in  a  given  case.  An 
enormous  amount  of  treatment,  extending  over  many  months,  is  often  re- 
quired before  the  activity  of  the  disease  is  checked.  Such  cases  can  best  be 
controlled  by  maintaining  a  steady,  even  course,  well  within  the  patient's 
tolerance,  than  by  resorting  to  heroic  dosage  at  short  intervals. 


INTRASPINAL  TREATMENT  OF  PARESIS 
By  George  Amsden,  M.D. 

This  report  is  based  upon  16  cases  of  paresis.  Since  the  treatment  was 
started  at  Bloomingdale  up  to  April  13,  1915,  19  cases  of  paresis  had  been 
admitted.  Of  these  14  have  been  treated,  of  the  remaining  5  which  were  not 
treated,  3  were  in  critical  condition  on  admission  and  did  not  recover  enough 
to  make  it  safe  to  begin  it.  In  the  other  two  cases  not  treated,  the  relatives 
opposed  it.  Of  the  14  cases  treated,  all  but  three  are  included  in  this  report. 
One  of  these  was  treated  once  only.  He  became  too  excited  to  treat  and  died 
of  an  intercurrent  pneumonia.  Another  case  was  treated  four  times.  He 
improved  somewhat,  but  was  taken  home  and  became  violent  in  two  weeks. 
The  third  case  was  far  advanced  on  admission.  He  was  treated  six  times 
without  benefit.  Inasmuch  as  he  was  treated  so  little  and  since  also  he  was 
so  dilapidated  on  admission  he  was  excluded,  and  perhaps  unjustly,  from  the 
cases  this  report  is  based  upon.  This  accounts  for  11  of  the  16  cases.  In 
choosing  the  five  initial  cases  the  whole  number  of  cases  in  the  hospital  was 
canvassed.  Very  advanced  cases  were  not  considered.  All  others  were 
accepted  for  treatment  in  which  permission  could  be  obtained.  Two  of  them 
had  been  in  the  hospital  one  year.  This  represents  fully  the  degree  of  selec- 
tion employed  in  putting  together  the  group  of  cases  submitted  to-night  and 
represents  a  fair  average  of  hospital  admissions. 

From  the  point  of  viezv  of  ultimate  outcome  it  is  obvious  that,  for  anal- 
ysis, the  more  recent  cases  are  of  less  value  than  the  older  ones  and  tend  to 
give  the  net  value  a  better  look.  To  avoid  this  as  far  as  may  be  it  is  possible 
to  divide  the  entire  group  into  two.  The  first  group  of  seven  cases  was 
treated  at  about  the  same  time  and  about  two  years  have  elapsed  since  they 
were  undertaken.  The  second  group  of  nine  more  recent  cases  comprise  those 
whose  treatment  began  not  later  than  early  in  the  present  year. 

Of  the  seven  cases  first  treated,  two  improved  only  slightly,  while  five 
reached  a  high  level  of  improvement.  All  of  the  five  cases  which  reached  a 
high  level  of  improvement  retained  this  improvement  for  upwards  of  a  year 
or  more,  three  have  since  relapsed  seriously,  while  two  maintain  this  im- 
provement. 

Of  the  second  group  of  nine,  more  recently  treated  cases,  five  attained  a 
high  or  fairly  high  level  of  improvement,  and  three  of  this  five  have  retained 
it  for  a  considerable  period. 


266  XEIV    YORK   XEUROLOGICAL   SOCIETY 

Roughly,  therefore,  this  entire  group  of  sixteen  cases  would  indicate  that 
about  sixty-two  per  cent,  of  cases  greatly  improve  but  that  all  but  about  twelve 
per  cent,  will  not  retain  improvement  for  a  prolonged  period.  These  cases, 
therefore,  lead  us  to  infer  that  this  method  of  treatment  can  claim  relatively 
little  as  an  ultimately  curative  measure.  Its  favorable  results,  if  any,  can  be 
spoken  of  in  terms  of  remission.  At  the  outset,  an  attempt  to  estimate  the 
value  of  any  treatment  of  paresis  in  terms  of  remission  is  embarrassed  by  the 
fact  that  we  have  no  satisfactory  study  showing  data  as  to  remissions  in 
untreated  cases  whose  diagnosis  was  determined  with  the  precision  now  ap- 
plied to  treated  cases.  We  are  compelled,  therefore,  to  consult  our  general 
impression  as  to  the  variations  in  untreated  cases  and  keep  in  mind  the  danger 
inherent  to  such  a  criterion. 

In  attempting  to  figure  out  the  value  to  be  placed  upon  the  remissions  Dr. 
Amsden  considered  their  duration  and  quality.  In  the  first  place  the  gross 
indications  are  that  about  38  per  cent,  of  the  unselected  cases  to  which  this 
method  is  applied  may  be  expected  to  show  no  improvement  at  all,  but  on 
the  other  hand,  they  are  not  essentially  injured  by  the  treatment.  It  seems 
reasonable  to  suppose  that  the  remainder,  about  62  per  cent,  of  tlie  cases 
treated,  will  show  a  marked  improvement.  Perhaps  the  only  untoward  result 
he  had  was  a  case  of  severe  anemia.  They  had,  however,  admitted  cases  in 
delirium  which  had  probably  previously  been  treated  too  vigorously.  The 
duration  of  the  remissions  in  his  cases  has  in  25  per  cent,  been  over  a  year. 
In  about  19  per  cent,  the  duration  was  between  a  half  and  one  year.  In  the 
remainder,  about  19  per  cent,  the  remissions  lasted  three  months  at  least. 

The  quality  of  the  improvement  as  to  physical  condition  offers  relatively 
little  of  interest.  Pupillary  conditions  remained  essentially  the  same,  in  some 
cases  improving.  Reflexes  were  unaltered  after  treatment.  Tremor  might 
be  diminished,  and  speech  and  writing  defects  were  very  likely  to  be  im- 
proved unless  they  were  very  marked  before  treatment.  Practically  all  the 
cases  in  the  62  per  cent,  referred  to  gained  insight  and  in  most  cases  this 
was  quite  thorough.  A  certain  boyishness  or  undue  enthusiasm  was  present 
in  one  or  two  of  the  patients,  who  were  most  successful  in  their  work  after 
they  left  the  hospital.  For  the  most  part,  however,  the  prevailing  mood  was 
one  of  seriousness,  which  in  some  instances  at  times  attained  to  a  mild 
anxiety.  Otherwise  Dr.  Amsden  was  unable  to  characterize  the  quality  of 
the  remissions  as  much  different  from  normal  well  being.  A  word  should  be 
said,  however,  as  to  the  relapses.  In  three  cases  amounting  to  nineteen  per 
cent.,  the  relapses  for  a  considerable  time  amounted  to  whining  depression, 
in  which  the  individual  suffered  a  good  deal.  The  appreciation  of  the  situa- 
tion was  keen,  as  contrasted  with  the  complacency  which  we  notice  charac- 
terizes the  untreated  cases.  In  two  cases  the  relapses  were  not  much  dif- 
ferent from  those  of  untreated  cases.  In  these  cases,  therefore,  about  44 
per  cent,  enjoyed  a  period  of  well-being  closely  approximating  the  normal 
for  periods  ranging  from  six  to  fifteen  months.  One  patient  has  been  in 
good  condition  for  fifteen  months,  has  done  excellent  work  for  a  year  up  to 
the  present  time.  One  other  patient,  who  lives  in  retirement,  is  still  in  good 
condition  after  fourteen  months. 

From  the  standpoint  of  the  family,  the  resultant  condition  found  in 
treated  cases  is  by  no  means  negligible.  In  all  of  the  62  per  cent,  a  degree 
of  well-being  was  reached  in  which  the  patients  were  capable  of  giving  good 
information  about  their  affairs  and  of  exercising  good  judgment,  at  least  for 
a  short  time.  In  at  least  three  instances,  in  these  cases,  the  status  reached 
was  one  of  considerable  importance  in  arranging  their  affairs.  In  one  in- 
stance the  patient  has  been  notably  successful  and  has  added  very  substantially 
to  his  income.  On  the  other  hand,  if  there  is  derived  from  this  treatment 
an  advantage  to  the  family,  either  in  enabling  patients  to  set  their  estates  to 


NEW   YORK   NEUROLOGICAL   SOCIETY  267 

rights  or  in  exceptional  instances  in  returning  to  earning  capacity,  it  is  not 
yet  clear  as  to  whether  this  may  not  be  offset  by  prolongation  of  the  burden 
which  apparently  these  patients  must  eventually  be  to  their  family. 

Dr.  Amsden  analyzed  these  cases  also  for  the  purpose  of  finding  out 
whether  they  offer  any  suggestions  as  to  what  may  be  the  most  favorable 
kind  of  case  for  treatment.  The  group  is  too  small  to  be  taken  very  seriously 
from  this  point  of  view,  but  he  ventured  to  state  what  he  found  :  There  were 
six  cases  of  the  tabetic  type  and  ten  of  the  cerebral  type.  Of  those  of  the 
tabetic  type,  five  or  84  per  cent,  did  well.  Of  the  ten  of  the  cerebral  type, 
five  or  50  per  cent,  reached  a  high  level  of  improvement.  From  the  point  of 
age  of  the  patient,  there  were  nine  cases  45  years  or  over,  and  seven  below 
45.  Of  those  above  45,  60  per  cent,  improved  markedly,  while  57  per  cent, 
of  those  below  45  made  similar  improvement.  From  the  standpoint  of  appar- 
ent advancement  of  the  disease,  it  is  of  course  obvious  that  advanced  cases 
are  out  of  the  question.  On  the  other  hand,  the  early  fulminating  did  not 
do  as  well  as  those  of  gradual,  but  not  prolonged  onset,  although  the  most 
successful  case  in  the  group  had  marked  symptoms  for  a  year  and  a  half 
before  treatment.  He  was  a  tabetic,  49  years  old.  From  the  point  of  view 
of  the  laboratory  findings,  the  most  favorable  cases  were  those  in  which  the 
cells  in  the  spinal  fluid  were  gradually  and  progressivelj-^  reduced  to  normal 
and  showed  little  deviation  in  the  process  of  reduction.  Usually  the  Wasser- 
mann  reactions  in  the  blood  and  spinal  fluids  were  also  reduced,  but  this 
reduction  did  not  appear  to  be  parallel  with  clinical  improvement.  The  clin- 
ical condition  appeared,  however,  to  follow  the  cell  count  in  this  respect,  that 
a  cell  increase  preceded  an  unfavorable  clinical  change.  It  is  here,  I  think, 
that  the  efficacy  of  treatment  is  more  nearly  demonstrated.  One  repeatedly 
finds  an  increase  of  cells  and  a  tendency  to  clinical  relapse,  followed  by  im- 
provement after  intensive  intraspinal  treatment. 

His  experience  with  treated  and  untreated  cases  leads  him  to  believe 
that  the  intraspinal  treatment  with  salvarsanized  serum  has,  in  a  considerable 
number  of  cases,  a  positive  influence  in  checking  the  progress  of  the  disease, 
at  least  clinically.  It  does  not  stop  it  except  in  very  rare  cases.  In  cases 
where  the  disease  had  not  yet  made  great  progress  and  where  there  is  some 
special  reason  for  the  family  and  patient  to  run  better  than  an  even  chance 
of  temporary  improvement,  especially  as  chance  for  improvement  without 
treatment  is  not  reduced,  the  method  is  encouraging.  It  would  be  unfor- 
tunate if  apparent  poor  permanent  success  in  arresting  the  disease  should 
keep  us  from  trj-ing  it  and  trying  to  improve  it. 


TREATMENT  OF  CASES  OF  CEREBROSPINAL  SYPHILIS 

By  Henry  A.  Cotton,  M.D. 

At  the  Trenton  State  Hospital  thejr  had  been  treating  cases  of  cerebro- 
spinal syphilis  for  over  two  years  and  a  half,  and  they  had  been  able  to  classify 
three  different  types  :  general  paralysis,  tabes  dorsalis  and  cerebrospinal  syph- 
ilis, a  mixed  type,  which  was  neither  tabes  nor  paresis.  The  last  type  showed 
very  marked  sensory  disturbances,  Argyll-Robertson  pupils,  severe  bladder 
disturbances,  but,  as  a  rule,  no  marked  psychosis  and  they  were  consequently 
not  committed  to  the  state  institutions.  Altogether  about  7S  cases  had  been 
treated,  and  at  the  present  time  there  were  twenty-five  patients  under  treat- 
ment. The  treated  cases  fell  into  four  groups:  ist,  arrested  cases  (11  or 
35  per  cent.)  ;  2d,  much  improved  (7  Or  22.5  per  cent.)  ;  3d,  not  improved  (7 
or  22.5  per  cent.)  ;  4th,  cases  which  died  (6  or  19.5  per  cent.).  Subsequent 
observations  would  change  these  figures  somewhat,  but  they  would  not  vary 


268  NEIV    YORK   NEUROLOGICAL   SOCIETY 

to  any  great  extent.  Dr.  Cotton's  experience  had  been  similar  to  Dr. 
Amsden's  with  regard  to  relapses  and  several  of  his  most  promising  cases  at 
the  beginning  of  the  treatment  (some  in  spite  of  persistent  treatment  and 
others  from  the  fact  that  they  were  removed  and  treatment  discontinued)  had 
shown  a  tendency  to  relapse.  In  spite  of  the  fact  that  certain  cases  had  re- 
lapsed, he  thought  the  work  had  been  extremely  encouraging.  An  important 
point  to  be  emphasized  was  that  the  patient  must  be  treated  in  the  incipient 
stage  if  good  re'sults  were  to  be  accomplished.  The  length  of  the  duration 
was  not  always  the  index  of  the  severitj'  of  the  process,  as  some  of  the 
patients,  in  whom  the  duration  was  two  years,  had  done  remarkably  well.  In 
order  for  the  treatment  to  be  effectual  it  had  to  be  administered  early  in  the 
incipient  stage.  The  question  was.  could  this  incipient  stage  be  diagnosed 
by  the  general  practitioner  or  the  consulting  neurologist  or  ps3chiatrist.  He 
thought  the  answer  was  in  the  affirmative.  There  was  no  more  reason  why 
incipient  paresis  could  not  be  diagnosed  than  incipient  tuberculosis  or  any 
other  disease  where  the  treatment  must  be  early  to  be  effectual.  Seventy-six 
per  cent,  of  cases  of  paresis  committed  to  the  state  hospitals  were  insane 
beyond  any  therapeutic  help,  which  left  25  per  cent,  which  could  be  much 
benefitted  by  treatment,  and  often  the  progress  of  the  disease  could  be  mate- 
rially arrested.  The  symptoms  of  incipient  paresis  should  not  be  difficult  to 
recognize  and  in  the  records  of  a  large  number  of  cases  there  were  shown 
definite  periods,  from  three  to  ten  years,  before  thej^  were  committed  to  the 
hospital,  when  the  patient  had  evidences  of  some  neurological  or  psychic  dis- 
turbance. Sensory  disturbances  were  shown,  such  as  dizzy  spells,  delirious 
episodes,  mild  depressions,  neurasthenic  episodes,  irritability,  change  of  dis- 
position, general  inefficiency;  and  on  the  neurological  side,  paresthesias,  blad- 
der disturbances,  defects  of  vision,  changes  in  the  pupils,  changes  in  writing 
and  gait,  high  blood  pressure  without  apparent  cause.  When  such  symptoms 
were  present  in  a  man  of  middle  age  or  even  younger,  especially  with  a  his- 
tory of  previous  syphilitic  infection,  a  thorough  examination  of  the  blood 
and  spinal  fluid  should  be  made.  These  .symptoms  usually  occurred  during 
the  incipient  stage  of  paresis  and  might  well  correspond  to  the  invasions  of 
the  spirochxtae  in  the  meninges.  It  was  possible  that  even  with  a  positive  cell 
count,  increased  globulin,  positive  Wassermann  reactions  in  the  blood  and 
spinal  fluid  and  a  positive  gold  chloride  reaction,  that  such  a  case  might  not 
develop  paresis,  but  chances  were  against  this  assumption,  and  such  a  patient 
should  certainly  be  treated  with  salvarsanizcd  serum  intraspinally,  or  mer- 
curialized serum.  In  two  patients,  in  whom  the  most  prominent  symptom  was 
high  blood  pressure,  one  was  suffering  from  depression,  ideas  of  poverty,  but 
was  attending  to  his  work.  When  examined  he  had  stiff  dilated  pupils,  the 
eye  grounds  suggested  si)ecific  trouble,  and  lumbar  puncture  revealed  plus 
cell  count,  increased  globulin  and  positive  Wassermann  in  spinal  fluid.  The 
blood  Wassermann  was  negative.  This  patient  had  been  successfully  treated, 
and  biologically  and  clinically  he  presented  at  the  present  a  normal  picture. 
The  otiier  patient  was  a  locomotive  engineer  who  was  apparently  perfectly 
well  and  in  the  routine  examination  he  was  found  to  have  a  blood  ])ressure 
of  220.  He  had  a  history  of  syphilis  five  years  previouslj'.  Lumbar  i)uncture 
revealed  S9  cells  per  c.mm.,  4  plus  globulin  and  4  plus  Wassermann  in  the 
spinal  fluid.  The  blood  serum  was  negative.  He  had  no  headache  and  no 
neurological  disturbance,  except  that  the  pupils  were  somewhat  sluggish. 
While  such  cases  could  not  be  called  paresis.  Dr.  Cotton  was  fully  convinced 
that  if  untreated,  such  patients  would,  within  a  year  or  two,  be  classified  as 
such.  Thus  they  were  considered  incipient.  The  general  practitioner  should 
be  educated  to  recognize  the  first  symptoms  of  such  a  stage.  In  the  state 
hospitals  the  disease  had  progressed  too  far  to  be  benefited  by  treatment. 

In  regard  to  methods  of  treatment:  The  Swift-Ellis  was   familiar  and 


NEW    YORK   NEUROLOGICAL   SOCIETY  269 

gave  as  good  results  as  any.  The  criticism  that  the  amount  of  salvarsan 
could  not  be  estimated  had  been  met  by  the  Ogilvie  method  where  a  stand- 
ardized serum  was  used.  The  cerebral  puncture  of  Wardner  had  much  to 
recommend  it,  but  it  was  not  likely  to  produce  results  where  the  Ogilvie  or 
Swift-Ellis  method  had  failed.  Wardner's  method  might  be  more  permanent 
and  might  not  tend  to  relapse  so  much.  The  method  of  Byrne,  mercurialized 
serum,  might  prove  just  as  efficient  as  salvarsanized  serum,  and  the  increase 
in  cost  of  salvarsan  increased  the  necessity  of  a  substitute.  Two  tabetic  cases 
treated  by  this  method  did  not  react  well ;  one  died,  one  recovered  and  did 
well  later.  Recently  he  had  gotten  most  encouraging  results  by  this  method. 
Its  small  cost  was  in  its  favor,  especially  for  dispensary  cases.  The  method 
of  Hammond  and  Sharpe,  ventricular  puncture,  had  no  advantage  over  the 
method  of  Wardner.  A  sixth  method  was  their  own  modification,  whereby 
they  used  the  standardized  serum  of  Ogilvie  for  cerebral  puncture,  and  mer- 
curialized serum  for  both  cerebral  and  intraventricular  puncture.  It  had  not 
been  used  long  enough  to  give  a  final  report  on.  They  had  not  been  able  to 
prevent  relapses.  Some  patients  had  done  well  for  six  months  or  a  year  and 
had  then  relapsed  in  spite  of  treatment.  In  some  the  biological  reactions 
were  positive,  in  some  negative.  A  persistently  strong  Wassermann  reaction 
in  the  spinal  fluid  was  a  bad  prognostic  sign.  Treatment  should  be  continued 
till  the  Wassermann  was  negative.  Most  patients  showed  a  decided  improve- 
ment after  four  or  five  treatments ;  the  cell  count  dropped ;  the  globulin  be- 
came negative,  and  the  Wassermann  much  reduced ;  clinically  also  there  was 
improvement.  With  an  uninfluenced  Wassermann,  however,  the  prognosis 
was  bad,  even  with  clinical  improvement.  They  had  reduced  the  gold  chloride 
test  in  many  cases.  The  intraspinal  treatment  was  not  dangerous.  Eight 
hundred  intraspinal  injections  had  been  given  and  in  only  three  were  there 
irritative  effects.  These  cleared  up  in  a  day  or  two,  but  they  had  severe  pain. 
The  fact  that  they  had  been  able  to  produce  remissions  in  33  per  cent,  of 
cases  with  treatment,  as  against  4  per  cent,  without,  warranted  the  feeling 
that  the  treatment  was  worth  while.  The  treatment  improved  the  physical 
condition  and  prevented  the  patients  becoming  useless  and  bed  ridden.  Inter- 
ruption of  the  treatment  was  dangerous  and  regular  treatment  produced  the 
best  results. 

Lantern  slides  were  shown  illustrating  charts  of  patients. 

Dr.  H.  C.  Solomon,  Boston,  stated  that  when  they  started  this  work  three 
years  ago  at  the  Psychopathic  Hospital,  Dr.  Myerson  had  charge  and  he  pub- 
lished his  results.  Later,  Dr.  Solomon  treated  a  certain  number  of  cases 
intraspinously  and  the  results  were  not  particularly  favorable  and  after  a  few 
months  he  became  discouraged,  as  only  one  case  out  of  the  series  recovered 
completely,  serologically  and  clinically.  They  then  adopted  the  ideas  of  the 
difference  between  the  meningo-vascular  syphilis  and  the  syphilis  centralis 
of  Head  and  Fearnsides ;  between  the  mesenchymal  and  the  parenchymatous 
variety  of  Alzheimer.  In  the  former  type  they  expected  improvement  by 
treatment.  They  felt  unable  in  many  cases  to  differentiate  between  general 
paresis  and  Fournier's  syphilitic  pseudoparalysis  or  Binswanger's  postsyphi- 
litic dementia,  and  therefore  felt  that  treatment  was  indicated.  The  method 
of  treatment  was  salvarsan  intravenously  twice  a  week  and  dosage  varying 
from  0.6  to  1.2  of  a  gram.  Some  cases  also  received  mercury  salicylate,  intra- 
muscularly, once  or  twice  a  week  with  potassium  iodide,  grains  15  to  100, 
three  times  a  day.  In  a  recent  series  of  nine  patients  treated  intravenously, 
two  became  much  worse,  seven  were  now  able  to  go  about  their  business,  one 
woman  had  a  baby  who  had  never  gone  beyond  the  fifth  month  of  pregnancy 
without  miscarriage.  Two  of  the  cases,  indistinguishable  from  general 
paresis,  had  been  serologically  negative  for  many  months  and  had  made  clin- 
ical recoveries.     It  should  be  remembered,  as  Alzheimer  had  pointed  out,  there 


270  NEW    YORK   NEUROLOGICAL   SOCIETY 

were  two  processes  in  general  paresis,  a  meningitic  and  a  true  parenchymatous 
degeneration  with  cell  atrophy.  This  cell  destruction  could  not  be  repaired, 
but  man^-  of  the  symptoms  were  due  to  meningitis  and  not  to  primary  cell 
degeneration,  and  a  good  deal  could  be  done  to  cure  the  meningitis.  One 
early  case,  after  having  considerable  treatment,  died,  and  at  autopsy  showed 
no  evidence  of  meningitis  in  brain  or  cord.  Microscopically  there  was  but 
very  slight  perivascular  infiltration,  but  marked  parenchimatous  degenera- 
tion. Clinically  the  case  was  typically  paretic.  Oppenheim  and  Westphal 
stated  that  in  cases  that  improved  under  treatment  they  had  to  change  tlieir 
diagnosis  of  paresis — if  they  improved  thej'  were  not  paretics.  In  regard  to 
cases  serologically  negative,  Nonne  stated  that  cases  that  were  serologicallj' 
negative  were  not  cases  of  general  paresis. 

Dr.  I.  Strauss,  New  York,  said  he  thought  this  discussion  was  rather  a 
fruitless  one.  Thej*  were  not  exactly  sure  of  their  ground.  They  had  not 
the  statistics,  the  biological  tests,  over  a  long  period  of  time,  to  compare  with 
present  cases,  no  real  scientific  basis  upon  which  to  form  judgment.  Dr. 
Strauss  knew  that  Dr.  Cotton  could  make  a  ])etter  diagnosis  of  paresis  than 
he  could,  but  he  did  not  think  he  would  call  the  engineer,  with  high  pressure, 
a  paresis  case.  He  had  had  such  cases  in  the  hospital  with  no  sign  of  paresis. 
He  had  had  a  bo\-  of  15  with  blood  pressure  of  240  with  3  plus  Wassermann 
in  the  spinal  fluid,  but  that  was  a  case  of  congenital  syphilis,  and  no  one 
would  consider  it  a  case  of  paresis.  He  would  also  take  exception  to  the  case 
•of  the  patient  who  was  depressed,  but  in  whom  the  biological  findings  were 
positive,  as  being  more  than  a  case  of  cerebral  lues.  From  his  standpoint 
that  was  not  paresis.  In  regard  to  the  tabetic  cases  of  Dr.  Cotton,  why  form 
any  judgment  regarding  the  efficacy  of  the  method  because  tabetic  patients 
could  walk?  Fraenkel  taught  tabetic,  bedridden  patients  at  Montcfiore  Home 
to  walk.  It  looked  like  a  miracle,  but  he  accomplished  it.  At  one  time  they 
stretched  their  cords  to  make  them  walk.  All  kinds  of  treatment  could 
bring  results  in  tabes,  even  applying  silver  nitrate  to  the  urethra  was  eflfectual. 
Another  point  was  that  other  kinds  of  treatment  than  salvarsan  had  given 
results  in  paresis,  as  good,  if  not  better  than  those  shown  to-night.  At 
Wagner's  clinic  (Neurol.  Centralbl.)  Pilcz  treated  paresis  with  tuberculin 
injections  combined  with  mercury.  He  reported  in  191 1  that  of  86  cases 
treated,  23  were  able  to  return  to  work.  In  April,  1912,  he  reported  that  of 
the  cases  treated  in  191 1,  46  had  died  and  of  the  26  living,  10  were  attending 
to  work.  If  the  presence  of  a  positive  Wassermann  in  the  blood  and  spinal 
fluid  in  a  patient  who  suff'ered  from  headache  was  to  be  regarded  as  incipient 
paresis,  then  we  had  to  consider  every  case  of  lues  in  the  secondary  stage  as 
belonging  to  this  category.  He  was  certain  that  most  authorities  would  con- 
sider this  as  too  extreme  a  standpoint,  therefore  the  difficulty  in  diagnosis 
was  another  factor  which  rendered  the  discussion  futile. 

Dr.  Bernard  Sachs,  New  York,  said  he  did  not  think  they  could  confine 
themselves  to  general  paresis.  They  could  not  exclude  cerebrospinal  lues ; 
they  must  refer  to  lues  of  the  central  nervous  system.  Every  form  of  general 
paresis  was  lues.  They  must  speak  of  this  treatment  in  its  bearings  uj)on  the 
kind  of  lues  of  the  central  nervous  system,  especially  these  cases  of  assumed 
general  paresis.  In  listening  to  the  clinical  histories  this  evening,  as  presented 
by  Drs.  Zabriskie  and  Cotton,  some  of  them  might  have  disagreed  with  the 
diagnosis  of  [)aresis,  but  all  could  agree  that  they  were  lues  of  the  paretic  or 
tabetic  type.  In  his  work  with  associates  in  hospital  and  in  private  work,  he 
was  among  the  first  to  advocate  intraspinous  treatment.  Since  that  time  he 
had  become  more  indiflfercnt.  and  had  come  to  feel  that  the  method  had  been 
unduly  i)ushed.  The  question  wa«  whether  more  was  accomplished  by  this 
intraspinous  method  than  by  the  intravenous.  The  intraspinous  mctliod  was 
more  difficult  and  more  likely  to  lead  to  serious  complication.s,  and  had  been 


NEIV   YORK   NEUROLOGICAL   SOCIETY  271 

followed  at  times  b}^  disastrous  consequences.  He  felt  that  he  had  seen  as 
great  and  satisfactory  improvement  follow  upon  intravenous  therapy  as  upon 
intraspinous.  They  had  shown  that  very  little  salvarsan  was  found  in  sal- 
varsanized  serum,  and  that  little  was  accomplished  by  that  method.  Almost 
any  injection  had  been  known  to  change  the  cell  count  and  globulin.  He  had 
no  fault  to  find  with  the  Swift-Ellis  or  the  Ogilvie  method.  They  had  been 
most  carefully  studied.  They  had  also  to  determine  whether  more  had  been 
accomplished  by  these  than  by  former  methods  of  treatment.  A  patient  had 
been  referred  a  year  and  a  half  ago  from  the  middle  west.  He  had  all  the 
mental  and  physical  symptoms  of  general  paresis.  He  had  had  six  intrave- 
nous salvarsan  injections  and  the  result  was  that  he  had  improved  sufficiently 
to  be  competent  to  undertake  management  of  a  large  commercial  concern. 
All  that  was  noticeable  was  a  slight  exuberance,  an  undue  optimism,  but  yet 
the  man  was  not  cured.  He  was  mereh^  in  a  remission  and  would  sooner  or 
later  relapse.  There  was  danger  of  attaching  too  much  importance  to  re- 
missions. The  matter  was  an  extremely  difficult  one.  Perhaps  there  were 
more  cases  of  remission  now  than  formerly.  The  period,  one  or  two  years, 
was  too  short  to  speak  of  the  cases  as  really  cured.  One  suggestion  to  the 
larger  hospitals  he  would  make :  the  difficulty  of  getting  salvarsan  would  in- 
crease, and  the  opportunity  was  at  hand  to  compile  very  careful  statistics  as 
to  the  results  of  treatment  in  1915-16,  as  compared  with  the  salvarsan  results 
of  1913-14.  He  did  not  believe  that  slight  changes  in  the  cell  count  were 
very  important.  "  Cured  "  cases  must  not  be  only  biologically  cured,  but  clin- 
ically cured.  The  latter  was  of  more  importance.  He  believed  with  Dr. 
Ogilvie  that  many  more  cases  were  made  socially  possible  with  treatment,  but 
he  was  not  inclined  to  look  upon  these  as  cures,  although  the  results  were,  in 
some  cases,  encouraging  enough  to  warrant  the  treatment.  Personally  he 
should  continue  to  give  his  cases  most  thorough  intravenous  treatment. 

Dr.  Walter  Timme,  New  York,  said  that  he  had  seen  some  of  the  cases 
reported  by  Dr.  Ogilvie,  which  showed  certainly  remarkable  improvement. 
Dr.  Sachs  had  mentioned  that  he  had  obtained  as  much  improvement  with 
the  intravenous  method,  and  stated  that  it  would  do  less  harm  than  the  intra- 
spinous with  salvarsanized  serum.  In  the  past  six  weeks  Dr.  Timme  had 
seen  three  cases  that  had  had  absolutely  no  treatment  for  one  year  to  eighteen 
months.  At  the  beginning  of  this  time  the  spinal  fluid  examination  had  showed 
from  sixteen  to  eighteen  cells,  Wassermann  positive  and  globulin  in  excess  in 
each  case.  They  had  had  no  treatment  of  any  kind  during  the  entire  year. 
Within  the  past  six  weeks  their  fluids  had  been  again  examined  by  competent 
laboratory  workers,  and  the  findings  had  been  returned  absolutely  negative ; 
that  is,  there  were  no  cells,  Wassermann  negative,  no  globulin.  So  it  could 
be  seen  that  intraspinous  treatment,  intravenous  treatment,  and,  in  a  few 
cases,  no  treatment  at  all,  produced  similar  results.  Nonne,  in  Hamburg,  had 
made  similar  observations  on  his  cases. 

Dr.  D.  M.  Kaplan  said  that  general  paresis  was  a  type  of  cerebrospinal 
syphilis  that  could  not  be  cured.  The  patient  would  be  brought  back.  He 
appreciated  what  Dr.  Soloman  said  as  to  the  stubbornness  of  general  paresis. 
One  could  only  influence  the  meningitic  phenomena,  but  could  not  repair  dead 
cells.  Dr.  Cotton  was  more  enthusiastic  than  the  other  speakers.  He  quoted 
a  few  cases  with  remarkable  remissions,  but  he  did  not  call  them  complete 
cures.  He  had  spoken  of  a  plus  Wassermann  without  clinical  manifestations. 
Whether  that  was  general  paresis  Dr.  Kaplan  could  not  say.  but  when  one 
said  syphilis  of  the  central  nervous  system,  it  could  be  included.  General 
paresis  was  incurable  and  the  others  were  more  or  less  curable,  as  Dr.  Sachs 
had  said.  In  Ogilvie's  cases  four  out  of  thirty-five  were  complete  cures  and 
remained  in  good  health.  That  was  a  small  percentage.  The  cases  were  very 
strongly  treated,  intraspinously,  intravenously,  and  intramuscularly.     He  did 


272 


XEIV    YORK   NEUROLOGICAL   SOCIETY 


not  believe  that  one  could  obtain  more  than  temporary  remission,  from  one 
month  to  three  years. 

Dr.  Cotton,  Trenton,  said  that  he  felt  he  could  add  very  little  to  what 
had  been  said.  Most  of  the  criticisms  which  had  been  raised  had  been  an- 
swered in  his  article  on  the  treatment  of  paresis,  now  in  process  of  being 
published  in  the  American  Journal  of  Insanity.  Question  had  been  raised  as 
to  the  diagnosis  of  some  of  the  cases  presented  in  the  demonstration.  Be- 
cause one  or  more  of  the  biological  reactions  might  be  absent,  it  was  no  reason 
to  question  the  diagnosis  of  paresis  in  certain  cases.  To  one  who  had  spent 
fifteen  years  in  a  state  hospital  in  almost  daily  contact  with  paresis  and  with 
the  opportunity  of  making  autopsies  and  studying  the  brains  in  a  large 
majority  of  cases  observed  during  life,  questioning  the  diagnosis  by  one  who 
had  given  little,  if  any,  time  to  the  study  of  paresis  seemed  somewhat  pre- 
sumptuous. He  would  answer  Dr.  Sachs's  criticism  that  one  should  study 
the  remissions  of  untreated  cases  of  paresis  before  one  considered  remissions 
due  to  treatment  by  stating  that  a  number  of  studies  had  been  made  on  this 
subject.  In  the  state  hospital,  one  found,  in  the  127  cases  admitted  over  a 
period  of  seven  years,  that  the  number  of  remissions  in  paresis,  where  the 
cases  were  accurately  diagnosed  by  means  of  lumbar  puncture,  were  at  the 
most  only  4  per  cent.  The  question  of  remissions  had,  he  thought,  been 
thoroughly  treated  in  the  article  mentioned  above.  As  his  figures  corre- 
sponded to  those  of  Dr.  Ogilvie  (33  per  cent,  and  34  per  cent,  of  remissions) 
as  a  result  of  treatment,  he  thought  the  question  was  answered  as  to  the  rela- 
tion of  remissions  to  treatment  or  no  treatment.  He  still  insisted  that  the 
question  of  paresis  should  be  determined  by  the  effects  of  treatment,  that  is, 
even  though  the  patient  had  all  the  clinical  signs  of  paresis  and  the  positive 
biological  findings  were  arrested  by  treatment,  such  a  case  should  not  be  con- 
sidered some  other  form  of  cerebral  lues,  merely  from  the  fact  that  the 
process  had  been  arrested.  The  argument  would  be  the  same  as  to  say  that 
a  person  suffering  from  incipient  tuberculosis  had  never  had  tuberculosis, 
because  the  disease  was  arrested.  The  cases  were  similar ;  it  was  absolutely 
necessary  to  treat  tuberculosis  in  the  incipient  stages  in  order  to  obtain  results. 
It  was  fallacious  to  condemn  the  treatment  of  paresis  because  we  could  not 
cure  the  end  stage.  He  had  not  found,  with  Dr.  Sachs,  that  lumbar  puncture 
was  a  dangerous  procedure.  In  only  three  cases  out  of  800  injections  had 
they  had  irritative  effects.  He  considered  intravenous  injection  of  salvarsan 
attended  with  more  danger  than  intraspinous.  With  some  myocardial  trouble 
intravenous  injection  might  prove  fatal.  This  had  occurred  in  twO'  patients 
in  his  experience.  He  never  had  given  a  full  dose  of  salvarsan  intravenously 
for  the  first  time. 


tTranslatlons 


VEGETATIVE  NEUROLOGY.  THE  ANATOMY,  PHYSI- 
OLOGY, PH  ARM  ADYNAMICS  AND  PATHOLOGY 
OF  THE  SYMPATHETIC  AND  AUTONOMIC 
SYSTEMS 

By  Heinrich  Higier 


Authorized  Translation  by  Walter  Max  Kraus,  A.M.,  M.D. 

[New  York] 

(Continued  from  page  80) 

V.  Embryology  of  the  Vegetative  Nervous  System 

The  discussion  of  the  development  of  the  vegetative  nervous  sys- 
tem of  vertebrates,  and  of  man  in  particular,  is  not  by  any  means 
closed. 

According-  to  the  newest  investigations  of  A.  Cohn,  Kuntz  and 
particularly  Froriep,  the  sympathetic  cord  develops  in  vertebrates 
from  a  pair  of  cell  columns  which  lie  dorsal  and  next  to  the  aorta. 
In  earlier  stages,  cells  wander  from  the  ventral  half  of  the  neural 
canal.  They  leave  it  in  company  with  the  ventral  nerve  roots  as  in- 
differently constructed  primitive  cells,  with  large  nuclei.  They  join 
the  main  branch  of  ventral  nerve  roots.  The  means  by  which  these 
cell  fibers  are  carried  to  the  periphery  are  the  neuroblastic  branches 
which  grow  from  the  medullary  canal  towards  the  periphery,  and 
probably  also  those  fibers  which  later  become  the  preganglionic  fibers 
of  the  autonomic  system.  It  is  these  relatively  coarse  protoplasmic 
threads  which  combine  with  those  of  the  primitive  cells.  The  cell 
processes  then  curve  medial  as  from  the  spinal  nerve  stem  towards 
the  dorso-lateral  wall  aorta.  Near  them  a  group  piles  up  to  make 
the  vertebral  ganglia.  Other  cells  go  further.  They  go  central- 
wards,  combined  with  protoplasmic  threads  which  He  in  the  region 
which  exists  between  the  aorta  and  vena  cardinalis.  These  make 
the  pre-vertebral,  and  further  out  the  peripheral  ganglia. 

273 


274  HEIXRICH  HIGIER 

According  to  Kuntz.  the  prevertebral  plexus  arises  in  a  group  of 
cells  which  lies  ventral  to  the  aorta  in  the  posterior  part  of  the  body, 
while  the  cardiac  and  gastro-intestinal  ganglia  arise  from  groups 
of  cells  which  come  in  from  the  midbrain  and  vagus  ganglia.  One 
may  justly  conclude  that  the  excitatory  neurones  arise  in  cells  which 
have  wandered  from  the  motor  roots,  while  the  sensory  neurones  are 
derived  from  the  posterior  roots.  There  exists,  consequently,  a 
broad  analog)^  between  the  sympathetic  system  and  the  central  nerv- 
ous system.  The  sympathetic  system  is  but  the  part  of  the  central 
system  which  has  functions  corresponding  to  its  part. 

According  to  Froriep,  the  movement  of  cells  to  their  later  places 
is  neither  a  free  wandering  [His'  Keimcells]  or  a  pure  mitotic  split- 
ting [Kohn's  theory  of  syncytiate  or  neurocytial  construction  of  the 
sympathetic  cord]  but  a  combination  of  both  processes,  dependent 
upon  the  established  paths  of  the  outgrowing  neuroblastic  ramifica- 
tions. 

These  latter  come  exclusively  from  the  central  organs  where  the 
corresponding  neuroblasts  occupy  the  dorso-lateral  zone  of  the  spinal 
and  bulbar  anterior  horn  region. 

\T.       ?IlSTOLOGY  OF  THE  SYMPATHETIC  CoRD  AND  Cr.\NIAL  GaNGLIA 
AND  OF  THE   SriNAL  CoRD  CeLLS  AND  NeRVE   FiBERS   OF  THE 

Vegetative   System 

Histologically,  the  sympathetic  system  is  characterized  by  several 
peculiarities  which  may  be  of  diagnostic  value  in  differentiating  it 
from  other  parts  of  the  nervous  system.  The  sympathetic  diflfers 
both  microscopically  and  macroscopically  from  other  parts  of  the 
nervous  system.  The  ganglia  have  a  connective  tissue  sheath  and 
its  nerve  fibers  are  sheathless,  gray  axis  cylinders.  Their  color  is 
due  to  the  absence  of  the  very  refractible.  whitish  myelin. 

The  sympathetic  ganglia  arc  very  hard  to  demonstrate  in  man 
both  microscopically  and  macroscopically.  This  is  due  most  probablv 
to  the  fact  that  the  ganglionic  nodes  lie  very  close  to  tissues  which 
are  rcarlily  fermented  and  destroyed  after  death,  such  as  the  nasal 
nuicous  membrane,  the  buccal  cavity  and  the  intestinal  canal.  Being 
very  poorly  protected,  unlike  central  nervous  system  structures,  they 
are  easily  destroyed. 

Ordinary  staining  methods  give  the  same  picture  in  both  spinal 
cord  and  sympathetic  ganglia — round,  processless,  protoplasmic 
bodies  with  nuclear  substance  and  a  nucleolus  surrounded  by  a  cap- 
'^ulc. — a  fibrillary  tissue.  On  more  careful  examination,  even  with 
this  unreliable  staining  method,  it  has  been  shown  (L.  Miiller)  that 


VEGETATIVE  NEUROLOGY  275 

the  cells  of  the  spinal  ganglia  are  larger,  have  a  more  conspicuous 
capsule  and  more  nuclear  material  than  those  of  the  sympathetic 
ganglia.  More  delicate  staining  methods  (impregnation  with  metals) 
(Ramon  y  Cajal,  Bieischowsky)  or  vital  methylene  blue  staining  (Ehr- 
lich)  show  that  the  fundamental  difference  exists  between  the  cells 
of  the  spinal  ganglia  and  the  sympathetic  cord.  The  former  are  de- 
cidedly larger,  uniformly  oval  or  round  and  have  but  one  process. 
This  process  is  a  uniformly  broad  band  which  either  encircles  the  cell 
or  forms  a  corkscrew-like  figure ;  the  latter — the  sympathetic  cells — 
are  mostly  of  a  multipolar  nature,  have  many  dendrites  and  always 
have  a  nucleus  and  a  nucleolus. 

There  are  great  differences  in  the  structure  of  the  cells,  in  their 
axis  cylinders  and  the  size  of  the  dendrils,  corresponding  to  varia- 
tions in  location  and  function. 

Further  details  about  the  various  structure  of  cranial  ganglia, 
vertebral,  prevertebral  and  organ  ganglia  cannot  be  given  here.  This 
much  may  be  said,  however :  L.  Miiller  has  differentiated  the  main 
types  of  sympathetic  ganglion  cells ;  those  of  the  sympathetic  chain, 
the  solar  and  semilunar  ganglia,  the  ganglion  of  Wrisberg  and  the 
ganglion  bulbi  aortse  on  one  hand,  those  of  the  remaining  ganglia 
on  the  other.  Classifications  may  be  made ;  those  with  extra  and 
intracapsular  processes,  with  thin  or  thick  dendrites,  with  short  and 
long,  ramifying  or  forked  dendrites  (crown  cell  type)  with  thick  or 
thin  capsule   (Klein,  Cajal,  Dogiel,   Michailow). 

Histological  examination  has  also  shown  that  groups  of  ganglion 
cells  do  not  always  form  ganglia.  Furthermore,  they  are  scattered 
through  nerve  trunks  without  causing  any  swelling  in  them  which 
could  be  identified  with  the  naked  eye  as  a  ganglion.  Examples  are 
the  submaxillary  and  Wrisberg's  ganglia. 

The  axis  cylinder  is  readily  dift"erentiated  from  the  dendrites  by 
its  width  and  its  fibrillary  structure. 

The  old  teaching  of  Gaskell  and  Langley  that  the  nerves  of  the 
vegetative  nervous  system  which  are  precellular  or  preganglionic  are 
sheathed,  while  the  postcellular  or  postganglionic  fibers  are  un- 
sheathed, is  still  accepted  generally.  Yet  there  are  exceptions  to  this 
rule  as  the  postcellular  fibers  going  to  the  intestines  via  the  mesen- 
tery, the  precellular  fibers  in  the  ciliary  nerves  and  many  others. 

The  origin  of  the  vegetative  tracts  in  the  spinal  cord  are  readily 
recognized.  The  nucleus  lateralis  or  sympatheticus  may  be  recog- 
nized in  the  dorsal  part  of  the  lateral  horn  of  the  grey  matter  by  the 
size  and  form  of  the  cells.  These  are  smaller  than  the  multipolar 
cells  of  the  anterior  horn,  are  round,  or  pear-shaped,  occasionally 


276  HEIXRICH  HIGIER  .A 

£ 

spindle-shaped,  club-shaped  or  spermatozoa-shaped  and  seem  to  have 
no  processes  on  low  magnification.     (Paracentral  cells.    Jacobsohn.) 

The  vegetative  paths  in  the  medulla  arise  in  similar  cells  of  the 
formatio  reticularis. 

The  anterior  and  posterior  spinal  root  join  to  form  the  short 
spinal  nerve  (Fig.  i).  The  white  rami  communicantes  are  supposed 
to  arise  from  the  posterior  roots. 

The  small  sheathed  fibers  undoubtedly  come  from  the  anterior 
roots.  The  sympathetic  fibers  leaving  the  spinal  cord  are  smaller 
than  motor  fibers.  The  former  measure  about  3  ju,  (see  text),  the 
latter  16 /a. 

The  visceral  fibers  are  readily  recognized  in  the  mixed  motor 
bulbar  nerves  (N.  Vagus)  and  in  the  motor  roots.  The  former 
have  a  thin  sheath.  The  latter  a  thick  one.  Embryology  shows  that 
the  former  are  myelinized  at  a  later  time  than  the  former.  The 
white  rami  go  to  that  sympathetic  ganglia  in  which  the  first  neurone 
ends.  Here  it  comes  in  contact  with  the  second  postcellular  neurone. 
From  thence  it  becomes  a  grey,  sheathless  fiber. 

It  is  worth  noting  that  the  white  ramus,  which  goes  as  a  i  cm. 
long  fiber  to  the  ganglion,  usually  lies  in  the  same  nerve  bundle  as 
the  grey  ramus.  These  latter  return  to  the  spinal  nerve  and  proceed 
l)eripheryward.  For  this  reason,  it  is  not  always  easy  to  differentiate 
between  the  white  and  grey  rami. 

Precise  observations  concerning  the  spinal  centers  of  the  sym- 
pathetic centers,  we  owe  to  English  authors,  most  prominent  among 
which  are  Langley,  Sherrington,  Gaskell,  Onuf  and  Collins.  Re- 
cently Jacobsohn  has  gone  over  the  old  work  by  examining  a  com- 
plete set  of  serial  sections  from  a  human  spinal  cord  stained  by  the 
Xissl  method.  According  to  Jacobsohn,  there  are  two  columns  of 
vegetative  cells. 

(I)  The  lateral  cell-column  is  composed  of  two  parts:  (a)  An 
upper  column  corresponding  to  Langley's  "  Sympathetic  System." 
This  lies  in  the  lateral  horn  of  the  dorso-lumbar  cord  (Cg  —  L.,)  and 
is  designated  the  Nucleus  sympatheticus  lateralis  superior  s.  cornu 
lateralc.  {h)  \  lower  column  lying  in  the  sacral  cord,  from  S^ 
cauflalward.  It  is  placed  between  the  anterior  and  posterior  horns 
and  is  designated  the  Nucleus  sympathicus  lateralis  inferior  s. 
sacralis. 

The  dorsolumbar  column  is  thickest  at  the  upper  dorsal  segments 
and  at  the  upper  lumbar  segments,  that  is  near  the  cervical  and 
lumbar  enlargements  wliere  there  are  collections  of  ganglion  ct-lls 
for  the  extremities. 


VEGETATIVE  NEUROLOGY  277 

(II)  The  medial  cell  column  lies  in  the  medio-ventral  marginal 
zone  of  the  anterior  horn  of  the  lumbosacral  cord,  from  L^  distal- 
ward  and  is  designated  the  Nucleus  sympathicus  medialis  S.  lumbo- 
sacralis.  Low  down  in  conjunction  with  the  Nucleus  radialis,  it 
forms  an  area  of  groups  of  cells  which  takes  up  almost  the  entire 
anterior  horn  and  the  space  between. 

All  the  cells  of  these  three  columns  have  the  following  three 
characteristics:  (i)  They  are  always  in  groups  and  closely  packed 
together.  (2)  They  are  long,  round,  club-shaped  or  vesicular,  rather 
small,  round  cells.  (3)  They  have  a  homogeneous  appearance  and 
are  usually  stained  more  darkly  than  the  larger,  less  closely  packed 
motor  and  sensory  cells. 

Microscopic  investigations  have  established  the  fact  that  the 
above  described  type  of  cell  found  in  the  ganglia  of  the  thoracic 
metameres  are  also  demonstrable  in  the  cranial  structures.  These 
represent  a  conglomeration  of  several  metameric  segments  in  which 
the  position  of  the  intervertebral  spaces,  sympathetic  tracts,  spinal 
and  sympathetic  ganglia  are  considerably  modified.  It  has  been 
shown  that  many  of  the  cerebral  ganglia  are  analogous  to  a  modified 
spinal  ganglion.  Examples  are  the  geniculate  and  Gasserian  ganglia. 
Others  are  mixed  ganglia  resulting  from  the  merging  of  the  sym- 
pathetic and  spinal  ganglia.  An  example  is  the  jugular  vagus 
ganglion.  A  third  group  includes  the  pure  vertebral  or  sympathetic 
ganglia,  the  ciliary,  otic,  sphenopalatinum,  submaxillary  and  sub- 
lingual. The  fibers  for  the  smooth  muscles  of  the  eye,  blood  vessels 
and  the  tear,  salivary  and  mucous  glands  pass  through  this  last 
group  of  ganglia.    ■ 

If  we  start  with  a  cross-section  of  the  medulla,  that  is,  that  plane 
of  the  cerebrospinal  axis  in  which  the  most  important  cranial  nerves 
are  placed,  we  find,  in  addition  to  the  large  multipolar  motor  cells, 
srnall  circumscribed  groups  of  oval  or  pear-shaped  unipolar  cells 
(paracentral  cells).  These  are  the  nuclei  from  which  the  pre- 
ganglionic rami  communicantes  spring.     The  nuclei  are  as  follows 

(Fig.  3): 

(i)   Nucleus  pupillaris    (Bernheimer) — median  to  the  oculomotor 
nucleus. 

(2)  Nucleus  lacrimalis — median  to  the  facial  nucleus. 

(3)  Nucleus    salivatorius    superior    (Kohnstamm) — dorsal    to    the 

facial  nucleus. 

(4)  Nucleus  salivatorius  inferior  (Kohnstamm) — near  the  glosso- 

pharyngeal nucleus. 

(5)  Nucleus  dorsalis  vagi — between  the  motor  and  sensory  vagus 


278  HEINRICH  HIGIER 

nuclei,  i.  e.,  between  the  nucleus  ambiguus  and  the  nucleus 
soHtarius  vagi. 
A  closer  analysis  of  the  anatomical  position  of  the  various  sym- 
pathetic nuclei  shows  that  their  relation  to  sensory  and  motor  nerves 
is  the  same  as  in  the  spinal  cord. 

As  a  paradigm  we  shall  take  the  most  orally  placed  ganglion — 
the  ciliary.  It  is  of  great  clinical  significance.  For  years  well 
known  authors  have  spoken  of  this  ganglion  as  a  spinal  ganglion  or 
a  mixed  ganglion  (Schwalbe,  Budge,  Remak,  His,  Gehuchten, 
Kolhker,  Bach).  A  cross-section  of  the  brain  stem  shows  the  fol- 
lowing :  the  oculomotor  nerve  is  the  anterior  motor  root,  the  tri- 
geminal nerve  is  the  posterior  sensory  nerve,  the  Gasserian  ganglion 
corresponding  to  a  spinal  ganglion  wliile  the  ciliary  ganglion  is  the 
vegetative  ganglion. 

The  white  rami  go  from  the  visceral  nuclei  via  their  correspond- 
ing motor  nerves,  L.  ^Killer  and  Dahl  have  tried  to  establish  this 
on  a  firm  basis. 

Aflferent  and  eft'erent  may  be  difl'crentiatcd  in  the  cranial  ganglia 
as  well  as  in  those  of  the  symi)athetic  chain.  The  white  rami  coni- 
municantes  pass  via  the  anterior  motor  roots  in  the  cranial  as  well 
as  in  the  spinal  region.  IMany  rami  albi  spring  from  cranial  nerves 
and  have  been  anatomically  described  though  the  part  they  play  was 
not  even  thought  of  (Fig.  4). 

(i)   Radix  motorica,  or  R.  albus  ganglii  ciliaris — from  the  oculo- 
motor. 

(2)  Nervus  petrosus  superficialis  major,  or  R.  albus  ganglii  spheno- 

palatini — from  the  facial. 

(3)  Xervus  tympanicus.  and  its  process  going  to  the  otic  ganglion — 

nervus  petrosus  superficialis  minor,  or  R.  albus  ganglii  otici — 
from  the  motor  part  of  the  glossopharyngeal  nerve. 

(4)  The  chorda  tympani,  which  sends  fibers  as  the  R.  allnis  to  the 

submaxillary  ganglion — from  the  motor  nervus  iiitermedius. 
The  ]Jost-cellular  tracts  of  the  cranial  ganglia  are  like  those  of 
the  .symiiathetie  chain,  sheathlcss.  They  supply  smooth  muscle  and 
glands  exclusively.  When  they  have  a  long  path  to  follow  to  reach 
the  organs  which  they  innervate,  they  join  sensory  nerves.  The 
reason  that  the  sympathetic  fibers,  when  they  do  not  form  separate 
nerves,  join  sensory  nerves  and  not  motor  nerves,  is  no  doubt  that 
sensory  nerves  are  more  widely  distributed  and  go  to  all  tissues. 


VEGETATIVE  NEUROLOGY  279 

Glands  of  Internal  Secretion  or  Chromaffin  Ganglion 
Bodies  of  the  Sympathetic  Anlage 

Many  authors  include  in  the  sympathetic  system  various  glands 
which  contain  chromaffin  cells,  that  is  to  say  cells  which  have  a  great 
affinity  to  chromium,  and  on  that  account  take  up  an  intense  brown 
coloration  in  Miiller  potassium  bichromate  solution.  These  cells  all 
develop  from  the  sympathetic  anlage,  and  are  therefore  in  very  close 
relationship  to  the  ganglion  cells.  They  are  found  partly  separate, 
partly  in  small  groups  in  the  sympathetic  system,  in  the  sympathetic 
ganglia,  or  in  large  nerve  networks  about  blood  vessels.  Where 
they  are  found  as  individual  bodies  they  are  designated  paraganglia. 

They  are  for  the  most  part  spherical  with  a  connective  tissue 
capsule  and  are  broken  up  by  large  nerves  and  blood  vessels,  between 
which  the  chromaffin  cells  lie  in  unequal  masses. 

Of  the  larger  chromaffin  bodies  the  following  four  may  be 
named :  (i)  the  carotid  paraganglion  incorrectly  spoken  of  as  a  gland 
[carotid  gland  or  epithelial  organ].  (2)  The  coccygeal  gland  in- 
correctly spoken  of  as  the  sacral  gland  [coccygeal  gland].  (3) 
Aortic  paraganglion  at  the  bifurcation  of  the  aorta.  (4)  The  best 
studied  and  largest  chromaffin  body,  the  suprarenal  body,  the  medulla 
of  the  adrenals,  from  which  the  active  blood  pressure  raising 
adrenalin  is  produced,  a  substance  which  stimulates  the  sympathetic 
system,  and  plays  an  enormously  important  role  in  the  body. 

According  to  AschoiT,  chromaffin  bodies  are  also  to  be  found  in 
the  vicinity  of  or  in  the  paroophoron  and  epididymis  which  are  also 
organs  of  internal  secretion. 

The  chromaffin,  or  more  properly  speaking  phaochrom  cells 
[Poll]  all  develop  from  the  sympathetic  anlage,  and  are  at  least 
closely  related  to  the  ganglion  cells.  The  assumed  transitions  be- 
tween the  two  have  not  received  general  confirmation,  and,  in  spite 
of  the  hypothesis  of  Diarnera  that  the  chromaffin  cells  are  secretory 
epithelial  cells,  H.  Kohn,  one  of  the  first  de'scribers  of  this  picture, 
justly  maintains  the  propriety  of  not  putting  these  cells  in  any 
definite  histological  group  but  in  a  grovip  of  their  own. 

Like  epithelial  cells,  muscle  cells,  and  nerve  cells,  it  also  takes  its 
place  both  embr}'ologically  and  physiologically  as  a  distinct  type  of 
cell  which  is  most  closely  related  to  the  sympathetic  cord. 

These  cells,  which  may  resemble  alike  epithelial  cells,  muscle 
cells,  and  nerve  cells,  also  take  their  place,  both  embryologically  and 
physiologically  as  a  distinct  type  very  closely  related  to  the  sym- 
pathetic cord. 

(To  be  continued) 


periecope 

Review  of  Neurology  and  Psychiatry 
(Vol.  XI I,  Xo.  II) 

1.  The  Pyridine-Silver  Method.     With  a  Xote  on  the  Afferent  Spinal  Xon- 

Medullated  Xerve  Fibers.     S.  Walter  R.\xsom. 

2.  The  Significance  of  the  Unconscious  in  Psjchopathology.     Ernest  Jones. 

I.  The  Pyridine-Silver  Method. — The  pyridine-silver  method  is  a  modifi- 
cation of  the  Cajal  method  which  has  recently  come  into  general  use  in 
America,  and  which  is  easy  and  reliable.  It  was  devised  as  a  differential 
stain  for  non-medullated  fibers,  but  has  been  found  to  be  of  use  in  the  study 
of  a  variety  of  problems.  It  is  being  used  in  a  number  of  laboratories  in  the 
preparation  of  sections  for  class  use  of  the  spinal  ganglia,  sympathetic  ganglia, 
and  spinal  cord. 

An  account  of  the  method  is  given  in  the  hope  that  some  of  the  clinical 
neurologists,  who  have  more  ready  access  than  the  anatomist  to  fresh  patho- 
logical material,  will  use  the  method  in  studying  some  of  the  problems  for 
which  fresh  human  material  is  absolutely  necessary,  and  for  the  solution  of 
which  the  method  is  especially  adapted.  A  brief  account  of  the  method,  and 
an  enumeration  of  the  purposes  for  which  it  has  shown  itself  to  be  adapted, 
is  given,  followed  by  a  brief  statement  of  some  of  the  results  which  have  been 
obtained  by  its  use,  and  an  indication  of  some  of  the  problems  which  await 
solution. 

The  chief  advantages  of  the  pyridine-silver  method  mentioned  are:  (i) 
It  can  be  used  in  a  study  of  the  peripheral  nerves  where  the  other  silver  stains 
fail  to  give  good  results.  (2)  It  is  more  reliable  than  the  other  silver  methods 
and  gives  more  uniform  results.  (3)  Larger  pieces  of  tissue  can  be  success- 
fully stained,  and  the  impregnation  is  more  uniform  throughout  the  block 
than  when  the  old  Cajal  method  is  utilized.  (4)  It  is  a  differential  stain  for 
non-medullated  fibers  having  a  selective  action  for  these  axons,  and  staining 
them  much  darker  than  the  other  elements  in  the  .section.  (5)  It  can  be 
applied  to  decalcified  tissue  allowing  the  staining  in  toto,  and  cutting  into 
serial  sections  of  the  entire  head  of  a  small  animal  or  embryo. 

It  is  obvious  that  a  study  of  tabetic  material  would  help  in  the  solution 
of  the  problems  which  are  here  presented.  Do  the  non-medullated  fibers  in 
the  spinal  nerves  degenerate  in  tabes,  and  if  so,  early  or  late?  What  effect 
does  tabes  have  on  the  non-medullated  fibers  in  the  spinal  ganglia  and  in  the 
dorsal  roots?  Do  the  non-medullated  fibers  in  Lissauer's  tract  degenerate  in 
tabes?  What  relation  do  the  non-medullated  fibers  seen  by  Nageotte  in  tabes 
bear  to  these  normal  non-medullated  fibers?  What  is  the  relation  of  disturb- 
ances of  pain  and  temperature  in  tabes  to  the  degeneration  of  these  fibers? 
These  are  some  of  the  pri>ltlems  which  should  be  investigated,  and  for  the 
solution  of  which  the  pyridine-silver  method  is  especially  adapted.  If  mate- 
rial from  cases  of  tabes  in  different  stages  of  the  disease  could  be  secured 
fresh,  I.  r.,  within  an  hour  after  death,  there  should  be  no  difficulty  in  answer- 
ing these  questions.  Such  an  investigation  should  add  something  to  our 
knowledge  of  tlie  pathology  of  tabes,  and  at  the  same  time  clear  up  the 
physiology  of  the  varieties  of  cutaneous  sensation. 

2X0 


PERISCOPE  28i 

2.  The  Significance  of  the  Unconscious. — A  knowledge  of  the  uncon- 
scious furnishes  an  indispensable  key  to  the  understanding  and  treatment  of 
psychopathological  manifestations.  Very  different  connotations  have  been 
attached  to  the  term.  The  commonest  use  of  the  term  is  the  general  sense  in 
which  it  is  emploj'ed  in  medicine,  for  instance,  in  reference  to  the  uncon- 
sciousness following  a  brain  injury  or  the  administration  of  an  anesthetic. 
This  is  a  "  non-mental "  or  psychophysical  conception. 

A  second  conception  of  the  term  is  the  philosophical  one  that  the  uncon- 
scious part  of  the  mind  is  a  sort  of  lumber  room  to  which  various  mental 
processes  get  relegated  when  they  are  in  a  state  of  inactivity.  These  processes 
are  of  secondary  importance  and  have  no  initiative. 

A  third  conception  of  the  unconscious  is  the  psychoanalytical  one,  devel- 
oped by  Freud.  He  divides  those  mental  processes  that  are  not  accompanied 
by  awareness  into  two  groups,  the  preconscious  and  what  he  calls  the  uncon- 
scious proper,  the  latter  being  the  sense  in  which  the  term  is  used  in  this 
paper.  Freud's  conception  of  the  unconscious  differs  sharply  from  the  pre- 
ceding ones  in  that  it  is  always  a  purely  inductive  one,  being  built  up  upon 
the  basis  of  actual  experience  without  the  introduction  of  any  a  priori 
speculative  hypothesis  ;  it  may  therefore  be  called  the  scientific  conception,  in 
contradistinction  to  the  philosophical  one.  Instead  of  starting  with  any  no- 
tions, whether  precise  or  nebulous,  of  what  the  unconscious  ought  to  be,  he 
investigated  the  actual  mental  processes  that  were  inaccessible  to  his  patients' 
direct  introspection,  and  which  were  only  to  be  reached  by  means  of  some 
technical  procedure  such  as  the  psychoanalytic  one.  As  a  result  of  these 
investigations,  he  acquired  a  gradually  increasing  knowledge  of  the  nature 
of  unconscious  processes,  of  their  content,  meaning,  origin,  and  significance^ 
and  was  therefore  placed  in  a  position  of  being  able  to  formulate  some  gen- 
eral statements  on  these  matters. 

The  statement  of  most  fundamental  importance,  and  the  one  on  which 
the  writer  lays  the  greatest  stress,  concerns  both  the  origin  and  the  content 
of  the  unconscious.  It  is  to  the  effect  that  the  existence  of  the  tuiconscious 
is  the  result  of  "  repression."  By  this  is  meant  that  unconscious  processes- 
are  of  such  a  kind  as  to  be  incompatible  with  the  conscious  ones  of  the  given 
personality,  and  are  therefore  prevented  from  entering  consciousness  by  the 
operation  of  certain  actively  inhibiting,  "  repressing "  forces.  The  incom- 
patibility in  question  is  of  a  moral  order,  the  word  moral  being  taken  in  its 
widest  possible  sense.  The  processes  concerned  flagrantly  conflict  with  the 
moral,  social,  ethical,  modest,  or  esthetic  standards  that  obtain  in  the  person's 
consciousness ;  their  very  existence  would  be  intolerable  to  him,  and  he  auto- 
matically refuses  to  acknowledge  to  himself  their  presence  in  his  mind.  In 
this  action  of  repression  only  a  very  small  part  is  played  by  the  occurrence 
that  may  be  described  as  a  deliberate  conscious  pushing  of  certain  thoughts 
out  of  the  mind,  though  this  is  the  one  with  which  we  are  most  familiar ; 
much  more  extensive  is  the  subconscious  and  automatic  keeping  apart  of  the 
two  sets  of  incompatible  mental  processes. 

Briefly  summarized,  in  a  single  statement:  according  to  psychoanalysis, 
the  unconscious  is  a  region  of  the  mind,  the  content  of  which  is  characterized 
by  the  attribi:tes  of  being  repressed,  conative,  instinctive,  infantile,  unrea- 
soning, and  predpminantly  sexual.  A  typical  example  of  an  unconscious 
mental  process,  illustrating  all  of  these,  would  be  the  wish  of  a  little  girl 
that  her  mother  might  die  so  that  she  could  marry  her  father.  The  six  attri- 
butes in  question,  together  with  others  not  here  mentioned,  make  up  a  con- 
sistent and  clearly-defined  conception  of  the  unconscious  which  is  formulated 
on  the  basis  of  experience  that  may  at  any  time  be  tested. 

The  significance  of  the  unconscious  is  discussed  under  four  headings : 

(i)   A  knowledge  of  the  content  and  mode  of  operation  of  the  uncon- 


282  PERISCOPE 

scious  furnishes  a  key  for  the  understanding  of  numerous  morbid  manifesta- 
tions that  were  previousl}-  incomprehensible.  All  psychopathological  symp- 
toms arise  in  the  unconscious. 

(2)  A  knowledge  of  the  unconscious  makes  clear  not  only  the  m.eaning 
of  these  symptoms  but  also  the  causation  of  them.  Normally,  a  great  part 
of  the  energ}-  pertaining  to  repressed  trends  of  the  unconscious  is  "  subli- 
mated "  (or  diverted)  to  permissible  social  aims.  Many  people  are  unable 
to  achieve  a  renouncement  of  crude  primitive  pleasures  and  a  replacement  of 
them  by  more  or  less  satisfactory  refined  ones.  There  is  ever  a  tendency  to 
regress.  Both  forces  come  to  expression  in  a  compromise  way,  disguised. 
The  compromise-formations  are  called  symptoms.  The  actual  symptoms  do 
not  carry  their  meaning  on  the  surface  but  have  to  be  interpreted  and  trans- 
lated into  the  language  of  the  unconscious  before  this  can  be  reached.  To 
do  this  a  knowledge  is  necessary  of  the  different  mechanisms  by  means  of 
which  the  distortion  is  brought  about  that  changes  the  underlying  repressed 
trend  into  the  manifest  symptom.  The  nature  of  these  mechanisms,  such  as 
displacement  of  the  affect,  inversion,  projection,  introjection,  transposition, 
and  so  on,  was  not  discussed.  The  distortion  is  brought  about  in  perfectly 
definite  ways,  and  through  the  operation  of  specific  factors,  which  vary  in 
their  exact  nature  according  to  the  past  experiences  and  mental  development 
of  the  individual  concerned. 

(3)  The  knowledge  gained  by  investigation  of  the  unconscious  bridges 
over  the  gap  between  the  normal  and  the  abnormal  by  demonstrating  that 
the  same  processes  go  on  in  both,  though  the  control  of  the  unconscious  ones 
by  consciousness  is  greater  in  the  case  of  the  former.  Roughly  speaking, 
insanity  presents  a  picture  of  the  normal  unconscious. 

(4)  The  remarkable  aid  that  this  knowledge  has  yielded  for  the  treat- 
ment of  psychopathological  maladies.  Up  to  the  present  this  has,  it  is  true, 
been  far  greater  in  the  case  of  the  psjxhoneuroses  than  in  that  of  the  psy- 
choses, such  as  dementia  praecox,  but  there  it  has  already  proved  so  valuable 
that  one  is  justified  in  entertaining  the  hope  that  further  researches  may  be 
profitable  from  this  point  of  view  in  the  case  of  the  latter  group  also.  The 
mode  of  action  of  the  treatment,  in  a  word,  is  that  the  overcoming,  by  means 
of  psychoanalysis,  of  the  resistances  that  are  interposed  against  the  making 
conscious  of  the  repressed  unconscious  material,  gives  the  patient  a  much 
greater  control  over  this  pathogenic  material  by  establishing  a  free  flow  of 
feeling  from  the  deeper  to  the  more  superficial  layers  of  the  mind,  so  that  the 
energy  investing  the  repressed  tendencies  can  be  diverted  from  the  production 
of  symptoms  into  useful,  social  channels. 


(Vol.  Xll,  Xo.   12) 

Studies  in  Xeurological  Technique. — No.  2:  Indication  and  Metliod  for  the 
Use  of  the  Electrical  Re-enforcement  for  the  Elicitation  of  the  Absent 
Reflexes.     Waltkr  B.  Swift. 

The  electrical  method  of  reflex  reinforcement  is  indicated  where  reflexes 
are  absent ;  and  where,  at  the  same  time,  other  methods  have  failed  and  that 
absence  is  doubled,  irrelevant,  inexplicable,  or  may  turn  a  diagnosis.  As  for 
method,  avoid  pain,  and  place  electrodes  above  and  below  the  point  of  reflex 
stirriulation,  in  such  a  way  that  reflex  action  may  not  interrupt  the  current. 

C.  E.  Atwood. 


PERISCOPE  283 

Deutsche  Zeitschrift  fiir  Nervenheilkunde 

(53  Band,  1-2  Heft) 

1.  Clinical   Contribution   to   the   Pathological  Anatomy  of   Acute  Ascending 

Spinal  Paralysis   (Landry's  Paralysis).     Langer. 

2.  Pathological  Anatomy  and  Pathogenesis  of  Syringomyelia.     Margulis. 

3.  Pathology  of  Paralysis  Agitans.     Tromner. 

4.  Explanation  of  the  Manifestations  of  Epilepsy.     Bolten. 

5.  Some  Reflex  Investigation,  Namely,   Concerning  the  Presence  of   Certain 

Reflexes.     WCrtzen. 

6.  Observations  and  Investigations  in  Atrophic  Myotonia.     Curschmann. 

7.  The    Valsalva-Morgagni    Law.     A    Contribution    to    the    Time    Preceding 

Aphasia.     Ebstein. 

1.  Pathological  Anatomy  of  Acute  Ascending  Paralysis. — Some  consid- 
eration is  given  to  the  three  forms  of  myelitis  as  described  by  Schmaus, 
namely,  parenchj'matous  degeneration,  infiltration  and  softening.  Other  clas- 
sifications are  mentioned,  particularly  that  of  Lewandowsky.  One  case  is 
reported  and  the  individual  came  to  autopsy ;  the  histological  findings  are 
appended.  The  writer  concludes  that  Landry's  paralysis  can  through  a  degen- 
erative process  appear  in  a  chronic  intoxication.  In  the  rapidly  fatal  case 
death  may  be  due  to  bacterial  toxines.  The  peripheral  nerves  are  usually 
affected,  but  this  is  not  absolutely  necessary.  The  course  of  the  disease  may 
be  so  rapid  that  there  is  but  slight  evidence  of  acute  morphological  change. 

2.  Pathological  Anatomy  and  Parthogcnesis  of  Syringomyelia. — The  ma- 
terial for  this  investigation  was  supplied  by  seven  cases  of  syringomyelia,  and 
in  three  of  these  the  disease  was  combined  with  hydrocephalus.  The  article 
is  elucidated  by  ten  well  selected  illustrations  and  in  these  there  is  shown  a 
widening  of  the  central  canal  with  a  surrounding  gliomatous  proliferation. 
At  times  groups  of  glia  cells  are  found  so  arranged  as  to  present  a  glandular 
appearance  and  tumor-like  areas  of  gliomatosis  are  likewise  met  with.  Two 
cavities  may  be  observed,  one  on  either  side  of  the  cord  and  the  appearance 
of  a  diverticulum  may  be  presented. 

The  writer  goes  on  to  explain  that  through  an  excess  of  cerebrospinal 
fluid  there  is  caused  continuous  pressure  in  the  cavity  and  also  irritation 
which  leads  to  proliferation  of  the  glial  tissue.  The  epithelial  layer  becomes 
atrophied  and  may  loosen  and  disappear.  Through  increased  pressure  by  the 
fluid,  the  cord  atrophies  and  the  nerve  fibers  and  cells  degenerate.  The  clin- 
ical equivalent  of  the  pathologico-anatomical  changes  are  found  in  the  triad 
of  sensory,  motor  and  trophic  symptoms. 

4.  Explanation  of  the  Symptoms  of  Epilepsy. — In  writing  upon  this  sub- 
ject the  author  says  that  genuine  epilepsy  and  numerous  forms  of  cerebral 
are  (in  the  immense  majority  of  cases)  cortical  and  cannot  yet  be  distin- 
guished ;  there  is  a  similarity  in  the  attacks  and  also  in  the  secondary  dementia. 

Cerebral  epilepsy  may  occur  after  diseases  of  the  meninges,  the  brain 
cortex  or  the  deeper  lying  parts,  which  in  general  through  a  sclerotic  process 
causes  circulatory  disturbance  of  the  brain  cortex.  Genuine  epilepsy  is  a 
chronic  autointoxication  arising  through  nutrition  and  metabolic  disturbances, 
the  consequence  of  hypofunction  of  the  thyroid  gland  and  epithelial  bodies 
and  the  failure  to  eliminate  sufficiently  the  poisons.  In  consequence  of  the 
hypothyroidism  the  elimination  of  many  ferments  and  intermediate  products 
is  diminished.  In  cerebral  as  well  as  cortical  epilepsy  there  is  through  the 
diminished  circulation  an  accumulation  of  toxines  in  the  brain  cortex.  The 
attack  must  be  considered  a  reaction  of  the  organism  to  free  itself  of  the 
toxine.  The  blood  gives  its  toxines  off  through  the  kidneys,  lungs  and  skin, 
and  the  brain  cortex  can  then  give  off  its  toxines  to  the  toxine  free  blood.     In 


284  PERISCOPE 

genuine  epilepsy  a  rectal  injection  of  the  freshly  expressed  juice  from  glands 
corresponding  to  those  showing  an  insufficiency  may  cause  a  subsidence  of 
the  symptoms. 

In  the  cerebral  forms  of  epilepsy  a  trephine  operation  may  lead  to  a  bet- 
terment of  the  condition. 

6.  Atrophic  Myotony. — In  this  paper  report  is  made  of  a  man  43  years  of  age 
who  showed  how  much  the  dystrophic  and  tabetiform  symptoms  may  prevail 
in  atrophic  myotonia.  Two  illustrations  demonstrate  the  facies  myopathica 
and  paresis  of  the  orbicularis  oculi.  It  is  also  brought  prominently  forward 
that  trauma  may  be  the  inciting  cause. 

A  careful  search  for  vagotony  or  symatheticotony  did  not  reveal  the 
presence  of  either  bodily  or  pharmacological  evidence  of  that  condition. 

Yawger  (Philadelphia). 


Monatsschrift  fiir  Psychiatrie  und  Neurologic 

(Vol.  35,  No.  I) 

1.  The  Anterior  Central  Gyrus  in  Lesions  of  the  Pyramidal  Tracts  and  in 

Amyotrophic  Lateral  Sclerosis.     P.  Schroeder. 

2.  Feeblemindedness  and  Mental  Aflfections  with  Dwarfism.     W.  Weyg.\ndt. 

3.  The  Symptoms  of  Cerebellar  Disease  and  their  Significance.     M.  Rothm.\nx. 

4.  Blood  Examination  as  a  Clinical  Aid  in  Psychiatry,  with  Special  Reference 

to  Prognosis.    J.  H.  Schultz. 

5.  The  Question  of  Loss  of  Memory  in  Paretics.     M.  Rohde. 

1.  Anterior  Central  Gyrus. — Several  cases  are  described  clinically  and  tlie 
autopsy  findings  are  discussed.  All  cases  of  course  showed  destruction  of 
the  Betz  cells  and  certain  other  large  cells  of  the  motor  cortex  as  the  most 
prominent  feature.  There  was  also  a  glia  increase  which  did  not  correspond 
in  location  and  probably  not  in  time  of  development  with  the  degeneration  of 
the  Betz  cells.  The  six  cases  of  pyramidal  lesion  tend  to  show  further  proof 
of  the  relationship  between  the  pyramidal  tracts  and  the  anterior  (not  the 
posterior  also)  central  gyrus.  They  do  not  show,  however,  that  a  direct 
and  simple  relationship  of  cell  to  fiber  exists  as  in  the  case  of  the  anterior 
horn  cell  and  anterior  root  fiber.  In  fact  there  are  certain  observations 
which  point  to  such  a  relationship  not  containing,  e.  g.,  the  preservation  of 
certain  central  fibers  in  the  pyramid  even  when  practically  all  the  Betz  cells 
are  destroyed.     Numerous  photomicrographs  accompany  the  article. 

2.  Dwarfism. — Attention  is  chiefly  drawn  to  the  multiplicity  of  causes.  The 
author  mentions  no  less  than  fourteen  different  etiological  groups.  All  sorts 
of  combinations  occur.  An  interesting  observation  is  that  of  a  dwarf  who 
again  began  to  grow  after  the  age  of  thirty  years  and  reached  a  normal  height 
but  was  poorly  developed.     Two  similar  cases  are  quoted  from  the  literature. 

3.  Cerebellar  Symptoms. — A  didactic  exposition  of  the  symptomatology  of 
cerebellar  lesions.  The  article  constitutes  a  valuable  resume  and  digest  of  the 
work  done  by  all  authors  in  this  line  to  the  present  date.  The  cerebellar 
affections  are  susceptible  of  localization  as  to  whether  the  lesion  is  in  the 
cortex  or  nuclei,  worm  or  hemisphere,  just  as  in  the  cerebrum.  Affections  of 
the  worm  produce  typical  cerebellar  gait,  often  with  queer  position  of  the 
head,  speech  is  slow  and  indistinct.  Lesions  of  the  cortex  of  the  cerebellar 
hemispheres  cause  symptoms  of  one  side  of  the  body  or  of  one  extremity. 
Ataxia  and  atonia  occur  in  the  same  side  as  the  lesion.  Adiadochokinesis 
and  loss  of  resistance  reaction  are  usually  present.  The  most  marked  symp- 
toms are  the  variation  and  unnatural  directions  of  the  movements  of  the  limbs 
in  carrying  out  an  act.     Affections  of  the  nuclei  produce  giddiness  and  dis- 


PERISCOPE  28s 

order  of  equilibrium,  also  cataleptic  symptoms  and  true  cerebellar  spasmodic 
attacks.  It  must  not  be  forgotten  that  mixtures  of  different  symptoms  are 
common  as  well  as  symptoms  referable  to  other  parts  of  the  brain  and  diag- 
nosis is  still  difficult.  But  the  author  hopes  for  such  improvement  in  the 
future  that  cerebellar  localization  will  be  almost  as  exact  as  cerebral. 

4.  Blood  Tests.— {A  continued  article — to  be  reviewed  at  its  conclusion.) 

5.  Loss  of  Memory  in  Paresis. — Two  cases  are  described  with  especial  detail 
as  to  memory.  The  author  remarks  that  although  paretics  would  be  expected 
to  show  defective  memory  for  events  occurring  since  the  brain  commenced 
to  undergo  organic  change,  it  is  less  likely  that  they  forget  entirely  the  early 
events  of  their  lives.  He  believes  that  these  earlier  memories  are  often  not 
lost  but  only  for  a  time  impossible  of  recollection.  His  cases  showed  extreme 
memory  defect,  but  there  were  fluctuations  and  they  showed  fleeting  recollec- 
tion of  things  which  at  all  other  times  were  apparently  entirely  forgotten. 

(Vol.  35,  No.  2) 

1.  Clinical   and   Anatomical   Contribution  to  the   Study  of   Apraxia   and   the 

"  Motor  Speech  Path."     K.  Bonhoeffer. 

2.  Blood  Examinations  as  Clinical  Aids  in  Psychiatry,  with  Especial  Refer- 

ence to  Prognosis.     J.  H.  Schultz. 

3.  The  Forearm  and  Hand  Tracts  of  the  First  and  Second  Order  in  a  Man 

Born  without  the  Left  Forearm.     C.  Elders. 

4.  Motor  Aphasia  with  Agrammatism  and  Sensory-agrammatic  Disorder.     E. 

Salomon. 

1.  Apraxia. — Clinically  the  case  studied  showed  marked  left-sided  apraxia 
and  also  some  apraxia  of  the  right  side.  There  was  motor  aphasia  and  para- 
graphia. The  brain  showed  several  softenings,  chief  of  which  was  an  almost 
complete  destruction  of  the  corpus  callosum.  This  lesion  accounted  for  the 
left-sided  apraxia.  As  to  the  apraxia  of  the  right  side,  the  author  discusses 
the  various  possibilities  but  does  not  come  to  a  definite  conclusion.  It  may 
have  been  due  to  a  small  lesion  which  was  found  in  the  occipital  lobe  or  to 
the  softening  which  involved  the  first  and  second  left  frontal  lobes.  Or  it  may 
have  been  caused  not  by  any  one  lesion  but  to  the  sum  of  all  of  them.  The 
Broca  area  was  entirely  intact,  showing  that  the  motor  aphasia  must  have 
been  due  to  an  interference  with  the  connections  of  the  Broca  region  with 
the  periphery.  There  was  a  small  lesion  of  the  capsule  but  it  is  known  that 
a  capsular  lesion  is  insufficient  to  produce  motor  aphasia.  The  author  believes 
that  the  case  shows  clearly  the  existence  of  a  second  speech  path,  namely, 
through  the  corpus  callosum  to  the  Broca  area  of  the  right  side.  This  con- 
nection was  destroyed  in  this  case  and  the  lesion,  coupled  with  that  in  the 
capsule,  produced  the  complete  motor  aphasia. 

2.  Blood  E.vaminaiions. — The  author  patiently  made  repeated  examinations 
of  the  blood  in  100  cases  of  mental  disease.  The  hemoglobin  was  estimated, 
red  cells  and  leucocytes  counted  and  differential  counts  made.  The  following 
are  some  of  his  conclusions  :  In  manic-depressive  insanity,  hysterical,  epileptic, 
arteriosclerotic  psychoses,  paresis  and  feeblemindedness  the  number  of  ery- 
throcytes is  normal.  In  all  forms  of  dementia  prsecox  the  erythrocytes  are 
increased.  Eosinophilia  is  characteristic  of  dementia  praecox  stupor  and  dif- 
ferentiates it  from  other  stupors.  "  Capillary  erythrostasis "  produces  the 
vaso-motor  symptoms  of  dementia  prsecox  and  is  prognostically  imfavorable, 
as  is  also  a  lymphocytosis.  The  blood  in  attacks  of  genuine  epilepsy  shows  a 
characteristic  picture — a  lymphocytic  leucocytosis  and  an  eosinopenia.  The 
only  other  condition  which  gives  a  similar  picture  is  a  uremic  convulsion. 
Bromide  medication  causes  an  eosinophilia. 

3.  Neurones  of  Arm. — In   1910   (Monatsschrift,  Vol.  28)    the  author  re- 


286  PERISCOPE 

ported  studies  of  the  first  motor  neurone  in  a  man  born  without  the  left  fore- 
arm. He  now  gives  the  results  of  his  investigations  of  the  other  neurones. 
He  found  the  first  and  second  sensorj-  neurones  absent  and  the  second  motor 
neurone  probably  lacking. 

4.  Motor  Aphasia. —  (A  continued  article.) 

J.  M.  MooRE  (Beacon,  X.  Y.). 


MISCELLANY 

A  Clinically  and  An.\tomilally  Examined  Case  of  Isolated  Loss  of 
Pupil-reflexes  with  Absence  of  Paralysis.  Tabes  and  Cerebro- 
spinal Syphilis.  M.  Nonne  and  Fr.  Wohlwill.  (Neurol.  Centralbl., 
1914,  No.  10.) 

The  authors  report  here  upon  a  case  of  isolated  loss  of  pupil  reflexes, 
clinically  and  anatomicalU'  examined,  in  which  the  spinal  fluid  was  examined 
for  cell  content,  increase  of  globulin,  Wassermann's  reaction  with  negative 
result,  and  in  which  the  brain  and  spinal  cord  were  anatomically  examined, 
without  discovering  a  central  nervous  affection  of  syphilitic  origin  ;  moreover, 
signs  of  tabes  and  paralysis  were  wanting.  Since  the  true  loss  of  pupillary 
reflexes  is  rarely  manifested  from  other  causes,  especially  as  the  result  of 
chronic  alcoholism,  and  here  lues  had  been  present  (infection  thirteen  years 
before),  it  could  only  be  accepted  that  the  isolated  loss  of  pupil  reflexes  rep- 
resents the  clinical  remnant  of  an  earlier  syphilitic,  anatomical  process  which 
had  spent  itself.  The  authors  accept  this  extinction  of  the  process,  since  the 
fluid  reactions  are  negative. 

Jelliffe. 

Contribution  to  Vagotonia.  \V.  Lublinski.  (Berl.  klin.  Wochcnschr.,  1915, 
No.  20.) 

The  vagus  and  the  sympathetic  act  in  opposition.  If  tlie  organs  provided 
with  these  nerves  are  to  function  normally  both  nerves  must  maintain  an  equi- 
librium. If  one  nerve  overbalances  vagotonia  or  sympathicotonia  ajjpears. 
The  first  is  the  more  frequent.  The  author  frequently  had  opportunity  to 
observe:  Laryngospasm.  asthma,  with  complaints  of  cardiac  and  respiratory 
difficulties.  The  diseases  of  youth  are  mostly  concerned,  often  through 
lymphatic  symptoms,  with  glandular  swellings,  enlarged  tonsils,  and  frequently 
also  enlargement  of  the  thyroid.  The  bluish,  glistening  flush  on  the  face, 
outbreaks  of  perspiration,  cold,  bluish  hands  are  striking.  The  palpebral 
fissure  is  narrow,  the  pupils  are  small  and  the  eyes  lusterless.  Frequent  swal- 
lowing movements  are  made  on  account  of  the  excess  of  saliva.  On  the 
upper  part  of  the  body  may  be  noticed  a  mottled  redness,  dermographia. 
Stimuli  in  the  region  of  the  vagus  may  cause  attacks  of  retarded,  temporarily 
intermittent  heart  movements.  Pressure  on  tlie  eyeballs  may  cause  that.  The 
resi)iration  is  shallow,  face  pale,  Aschner's  phenomenon.  Also  on  lying  down 
a  marked  retardation  of  the  jjulse  appears.  Similarly  it  comes  on  in  a  squat- 
ting position  or  on  bending  the  body  forwards.  Moreover,  arhythmia  of 
the  pulse  may  be  observed,  extrasystole.  Whether  it  has  to  do  with  height- 
ened irrttability  of  the  heart  or  injury  of  the  heart  muscles,  the  atropin  test 
will  decide.  With  those  suff'ering  from  vagotonia  even  slight  stimuli  suffice 
to  arouse  alterations  in  the  i)ulse,  and  so  alsf)  will  rci)eated  rising  in  bed.  A 
characteristic  respiratory  disturbance  is  cardiac  obstruction  in  breatiiing,  with 
laryngospasm  and  asthma.  Autf)matically  there  is  impulsion  to  deep  breath- 
ing with  a  convulsive  sensation  in  the  u|)per  air-passages.  Pilocari)in  can 
produce  these  phenomena  artificially.     The  author  looks  upon  vagotonia  as  a 


PERISCOPE  287 

result  of  disturbance  of  inner  secretion.  Vagotonia  can  be  favorably  influ- 
enced by  atropin,  since  that  reduces  the  irritability  of  the  vagus  endings.  The 
atropin  treatment  must  be  a  persistent  one.  Papaverin  0.03  also  acts  favor- 
ably.    As  a  nerve  tonic  arsenic  likewise  recommends  itself. 

Jelliffe. 

Cranial   Nerves   of   Anolis    Carolinensis.    W.    A.    Willard.     (Bull.    Mus. 
Comp.  Zool.  Harvard,  Vol.  LIX,  No.  2,  July,  1915.) 

The  general  summarj^  of  this  complete  and  masterly  study  of  the  cranial 
nerves  of  Anolis  maj^  be  summarized  as  follows : 

1.  Anolis  possesses  the  cranial  nerves  typical  of  the  amniote  vertebrate 
with  one  exception ;  there  was  not  discoverable  any  representative  of  the 
spinal  accessory  nerve  described  in  other  reptiles,  and  the  muscles  innervated 
by  this  nerve  in  other  forms  seemed  to  be  supplied  in  Anolis  wholly  from 
spinal  nerves  posterior  to  the  second  cervical. 

2.  The  ganglia  of  the  V,  VII,  IX  and  X  cranial  nerves  are  distinct  from 
one  another  and  all  of  their  roots  issue  from  the  cranium  through  inde- 
pendent foraminse.  The  ophthalmic  ganglion  also  shows  no  fusion  with  the 
other  portion  of  the  Gasserian  ganglion. 

3.  There  is  a  wide  distribution  of  sj^mpathetic  ganglion  cells  along  the 
aff^erent  rami  of  the  cranial  nerves.  These  form  definite  ganglia  on  the 
palatine  VII  (palatine  ganglion),  nasalis  V  (ethmoidal  ganglion),  maxillaris 
V  (infraorbital  ganglion),  and  on  the  mandibular  V  (mandibular  ganglion). 
The  topographical  facts  would  lead  one  to  associate  the  development  of  these 
ganglia  with  specialization  of  the  glands  of  the  head.  No  medullated  nerve 
fibers  were  found  passing  through  the  connective  tissue  surrounding  these 
glands.  The  presence  of  smooth  muscle  fibers  in  the  head  region  might 
also  affect  the  development  of  the  sympathetic.  The  sympathetic  system 
of  the  head  in  the  matter  of  the  arrangement  of  rami  and  ganglia  (as  worked 
out  incidentally  to  the  study  of  the  cranial  nerves),  when  compared  with 
other  described  forms  of  reptiles,  points  to  the  existence  of  a  typical  reptilian 
type  of  quite  constant  character. 

4.  The  nerve  components  (excepting  the  sympathetic)  reach  their  end 
organs,  or  peripheral  terminations,  through  the  following  nerve  trunks : 
Somatic  sensory,  by  way  of  the  5th  nerve  over  the  ophthalmic  (rmm.  frontalis 
and  nasalis),  maxillary  mandibular  rami.  Somatic  motor,  by  way  of  the 
III,  IV,  VI  and  XII  nerves.  Viscerosensory,  by  way  of  the  VII  nerve 
over  the  palatine  ramus  and  the  chorda  tympani ;  also  by  way  of  the  IX 
nerve  over  the  pharyngeal  ramus  and  probably  Jacobson's  anastomosis  ;  also 
by  way  of  the  X  nerve  over  the  superior  laryngeal  and  recurrent  rami. 
Viscero-motor  (dark  blue),  by  way  of  the  V  nerve  by  a  number  of  inde- 
pendent rami  and  over  the  mandibular  ramus ;  also  by  way  of  the  VII  nerve 
over  the  hyomandibular  division  and  ramus  hyoideus,  also  by  way  of  the 
IX  nerve  over  the  pharjmgeal  ramus,  and  also  by  way  of  the  X  nerve  over 
the  superior  larJ^^geal  ramus.  (0)  This  shows  a  greater  reduction  of  the 
somatic  sensory  (as  indicated  by  peripheral  paths)  in  Anolis  than  is  found 
in  the  described  forms  of  other  groups,  such  components  not  being  found  in 
nerves  IX  or  X  of  Anolis,  although  their  presence  in  the  same  nerves  has 
been  reported  in  each  of  the  other  classes  of  vertebrates.  (6)  Vestigial 
ganglia  exist  in  a  variable  manner  on  the  intracranial  roots  of  X,  which  may 
be  somatic  sensory  in  their  origin. 

5.  The  morphological  character  of  the  fibers  of  different  components  is 
sufficiently  differentiated  to  form  types  peculiar  to  each  component.  But  the 
distinction  in  character  appeared  to  be  less  than  that  described  for  the  lower 
groups  of  vertebrates.  However,  there  was  considerable  individual  variation 
in  the  size  of  fibers.     Nerve  XII  shows  a  marked  difference  in  the  size  of 


28S  PERISCOPE 

fibers  going  to  the  neck  muscles  and  those  going  to  the  tongue  muscles.  In 
this  case  the  smaller  fibers  have  much  the  longer  course.  In  at  least  three 
instances  striated  muscle  fibers  of  visceral  origin  are  innervated  by  nerve 
fibers  of  smaller  caliber  and  lighter  myelin  sheaths  than  is  characteristic  of 
the  other  viscero-motor  components  of  V,  \'II,  IX  and  X.  These  are  the 
ciliary  muscle,  the  protrusor  oculi,  and  the  constrictor  of  the  jugular  vein, 
all  of  which  are  more  closely  associated  with  visceral  functions  than  the 
other  striated  visceral  muscles. 

6.  The  skin  is  well  supplied  with  special  tactile  organs,  which  are  more 
abundant  along  the  jaws  than  elsewhere.  These  organs  are  quite  generally, 
if  not  always,  covered  by  a  thinned  plate  of  the  horny  la3'er  of  the  epidermis, 
which  bears  in  its  center  a  tapering  "  hair."  The  innervation  of  these  hairs 
was  not  determined  beyond  the  fact  of  the  proximity  of  the  strongly  mye- 
linated cutaneous  fibers  in  the  dermis  beneath. 

7.  The  distribution  of  taste  buds  is  such  as  to  preclude  their  innervation 
(save  a  very  limited  number  in  the  laryngeal  region)  by  anything  except  the 
chorda  tympani  and  palatine  \'II.  A  large  proportion  of  the  fibers  carried 
by  these  rami  are  for  such  sense  organs,  their  innervation  fields  being  cov- 
ered for  general  sensory  purposes  by  the  somatic  sensory  of  V. 

8.  Anolis  presents  a  well-balanced  form  for  the  study  of  the  reptilian 
nervous  sj-stem.  It  is  an  active,  responsive  animal  with  well-diflFerentiated 
muscles  and  sense  organs,  yet  presenting  no  excessively  specialized  features. 
It  is  small  enough  readily  to  be  sectioned  and  large  enough  for  experimental 
operations,  and  it  is  suggested  that  degeneration  and  stimulation  experiments 
on  this  form  would  advance  our  knowledge  of  the  reptilian  nervous  organs 
even  more  than  similar  anatomical  work  on  other  forms.  The  anatomical 
work  already  done,  however,  should  be  supplemented  by  the  proper  technique 
to  determine  the  final  nerve  terminations. 

Jelliffe. 


Book  TRcviews 


Hebrew  and  Babylonian  Traditions.  The  Haskell  Lectures  Delivered  at 
Oberlin  College  in  1913,  and  Since  Revised  and  Enlarged.  By  Morris 
Jastrow,  Jr.,  Ph.D.     New  York,  Charles  Scribner's  Sons. 

Professor  Jastrow  has  made  an  interesting  study  of  some  Hebrew  and 
Babylonian  traditions  by  considering  the  divergences  rather  than  the  resem- 
blances as  the  traditions  develop  and  are  utilized  by  the  two  peoples.  These 
divergences  manifest  the  widely  different  trends  in  the  two  nations  and  ac- 
count for  the  very  different  influence  each  has  exerted  in  the  history  of  the 
world. 

The  author  traces  first  the  origin  of  the  contact  of  Hebrews  with  the 
Babylonians,  when  as  migrating  tribes  they  passed  through  the  Babylonian 
lands,  sojourning  there  long  enough  to  adopt  early  traditions  and  make  them 
a  part  of  their  own  obscure  past. 

As  they  pass  on,  however,  through  history  to  a  land  and  a  nationality  of 
their  own,  there  manifests  itself  gradually  a  peculiar  trend  which  expresses 
itself  most  distinctly  only  after  centuries  of  development  of  national  history. 
This  is  the  ethical  monotheism  which  leads  the  Hebrew  nation  and  with  them 
its  traditions  away  from  the  materialism  of  the  Babylonians. 

This  we  are  enabled  to  follow  through  a  comparison  of  three  leading 
traditions  which  hold  their  place  in  different  form  among  the  two  peoples,  the 
tradition  of  the  creation,  of  the  deluge  and  of  the  Sabbath  with  a  considera- 
tion of  views  of  life  after  death  and  of  ethics.  In  the  retaining  of  these 
myths  and  the  utilization  of  them  in  Hebrew  religious  life  their  ardent  expo- 
nents of  that  monotheism  which  recognized  a  just  and  righteous  God  and  built 
up  a  system  of  ethics  on  this  conception  so  distorted  and  colored — or  shall 
we  say  decolorized — the  ancient  traditions  that  only  a  careful  searching  out 
of  origins  with  a  careful  bearing  in  mind  of  the  background  to  the  ancient 
traditions  make  them  recognizable. 

Yet  it  is  just  here  that  Professor  Jastrow  fails  to  open  up  the  very  in- 
stinctive depth  of  human  thought  and  feeling  that  are  of  special  interest  to  us 
in  the  determination  of  the  beginnings  of  ancient  traditions  and  the  form  they 
take  in  national  development  as  well  as  to  explain  fundamentally  each  of  these 
individual  tendencies  which  separated  the  two  nations  in  their  history  and 
influence. 

To  reach  the  conclusion  that  the  myths  were  nature  myths  and  with  the 
Babylonians  reach  in  development  to  astral  theories  of  their  deities  leaves 
much  unexplained  and  does  not  probe  into  the  depths  of  original  meanings 
nor  discover  the  wealth  of  early  sublimation  material  produced  by  these  two 
nations  along  diverging  pathways.  The  book  manifests  also  a  clear  ration- 
alistic attitude  toward  Hebrew  development  and  national  history. 

However,  there  are  many  suggestive  elements  for  the  student  of  begin- 
nings and  the  volume  is  one  that  can  be  read  with  more  than  passing  interest 
and  profit  in  spite  of  its  rather  intellectualistic  attitude  towards  psychical 
phenomena,  seeing  things  as  imposed  from  without  rather  than  as  evolving 
from  within. 

Jelliffe. 


290  BOOK  REVIEWS 

CuNiCAL  Study  of  the  Serous  and  Purulent  Diseases  of  the  Labyrinth. 

by  Dr.  Erich  Ruttin.     Tr.  by  H.  Newhart,   M.D.     Rebman  Company, 

New  York. 
The  interest  in  the  disorders  of  the  labyrinth  is  shared  equally  by  neurolo- 
gists and  ear  specialists.  The  present  volume  adds  another  to  the  many  ))ril- 
liant  studies  which  have  come  from  our  Vienna  colleagues  and  which  is  now 
made  accessible  in  English  through  Dr.  Xewhart's  excellent  translation.  It  is 
a  painstaking,  thorough  and  commendable  volume — small,  but  full  of  valuable 
material  which,  while  not  verj-  deeply  analyzed,  is  so  arranged  as  to  be  of 
service,  particularly  as  an  introduction  to  the  subject.  The  reader  who  has 
carefully  followed  Barany's  work  will  find  this  elementary. 

Jelliffe. 

A  Textbook  of  Xervous  Diseases.  By  Robert  Bing.  Translated  by  Charles 
L.  Allen.     Rebman  Companj^  New  York. 

We  have  had  occasion  to  comment  on  these  lectures  on  nervous  diseases 
on  their  appearance  in  1913  in  their  original  form.  They  here  appear  excep- 
tionally well  rendered  by  Dr.  C.  L.  Allen,  of  Los  Angeles,  whose  excellent 
work  in  the  Journal  is  familiar  to  its  readers. 

Although  the  lecture  form  has  certain  disadvantages  for  systematic  pres- 
entation. Dr.  Bing  has  given  a  book  which  is  better  than  the  usual  one 
cast  in  this  manner. 

The  general  attitude  reflected  is  that  of  the  past  few  decades,  in  which 
sense  these  lectures  are  rehearsing  old  material  rather  than  blazing  a  new  trail. 

PsYCHiATRiscHE  VoRTR.ACE.    Von  Prof.  Dr.  G.  Anton,  Halle.     S.  Karger,  Berlin. 

Five  papers  appear  in  this  third  series  of  the  author's  discourses.  They 
deal  with  problems  of  the  Organization  of  the  Brain  and  the  Spirit,  Dangerous 
Types  of  Men,  Return  of  Function  in  Brain  and  Cord  Disease,  Speech  and 
Thinking,  The  Mental  Type  and  Rights  of  Women. 

They  are  very  delightful  essays  and  may  be  read  to  advantage. 

Die  chirurgi.schen  Indicationen  in  der  Nerve nheilkunde.  Dr.  Siegmund 
Auerbach,  Frankfort.     Julius  Springer,  Berlin.     6.40  marks. 

Dr.  Auerbach  has  added  another  very  practical  book  to  his  credit,  in  which, 
in  a  most  systematic  and  thorough  manner,  he  has  discussed  all  of  the  possible 
neurological  conditions  which  might  profitably  be  handled  by  surgical  means, 
either  palliative  or  curative. 

It  is  an  extremely  useful  volume  for  a  common  viewpoint  for  neurologist 
and  surgeon. 

Die    Abderhaliiensche    Serodiagnostik    in   der    Psychiatrie.     Dr.    Bresler, 
Carl  Marhold,  Halle.     2.40  marks. 
This  small  volume  contains  a  short  summary  of  the  findings  and  sugges- 
tions relative  to  the  application  of  the  .Abderhalden  ferment  reactions  in  psy- 
chiatry.    It  contains  the  literature  to  1914. 

Die  Gesche  Gottfried.  Eine  kriminalpsychologische  Studie.  Von  Dr.  L. 
Sdiolz.     S.  Karger,  Berlin. 

This  short  brochure  brings  the  reader  back  to  the  early  thirties  of  the  last 
century  in  its  consifleration  of  a  notorious  woman  poisoner  of  that  time  and 
concerning  whom  her  advocate  wrote  a  two-volume  life  and  history.  From 
this  time  she  has  been  made  the  subject  of  a  number  of  communications,  this 
being  the  last. 

The  study  will  link  itself  up  well  with  other  female  poisoners,  a  specialty 


BOOK  REVIEWS  291 

to  which  the  sex,  the  author  states,  shows  special  aptitudes,  and  offers  a  num- 
ber of  interesting  suggestive  features  at  a  time  when  the  art  has  largely  gone 
out  of  fashion. 

Jelliffe. 

PsYCHOTHERAPiE.     Par  Dr.  Andre-Thomas.     J.  B.  Baillere  et  Fils,  Paris. 

In  twenty-eight  volumes  Gilbert  and  Canot  have  published  a  series  on 
Therapeutics,  of  which  this  volume  of  Andre-Thomas  is  a  worthy  member. 

In  general  he  follows  the  exposition  of  Dejerine  and  deals  with  the  general 
emotional  rapport  at  the  conscious  level.  Of  the  psychoanalytic  material  there 
is  not  a  trace,  and  the  book  will  commend  itself  to  those  working  at  the  level 
of  the  conscious  activities. 

A  Course  in  Norm.a.l  Histology.  Bj'  Prof.  Rudolf  Krause,  Berlin.  Trans,  liy 
P.  J.  R.  Schmahl,  New  York.     Rebman  Company,  New  York. 

Krause's  beautiful  work  on  histology  is  here  given  in  appropriate  and 
fitting  English  dress.  The  text  is  exceedingly  clear  and  precise,  while  the 
illustrations  are  wonderfully  clear  and  detailed. 

The  portions  devoted  to  the  nervous  system  are  well  done,  but,  as  would 
be  expected  in  a  work  on  general  histology,  only  partly  supply  the  needs  of 
the  neuroanatomist. 

As  a  work  on  general  histology,  however,  it  leaves  little  to  be  desired. 

Jelliffe. 

Des  troubles  psychiques  et  nevrosiques  post-traumatiques.  Par  R.  Be- 
nou,  Nantes.     G.  Steinheil,  Paris. 

The  author,  with  a  singularly  clear  vision  as  to  the  significance  of  what 
is  meant  as  nervous  or  mental  disorder,  has  given  a  pleasing  monograph  on 
post-traumatic  disturbances. 

These  he  has  discussed  under  the  dysthenias,  dysthymies  and  the  dys- 
phrenies,  under  which  headings  he  groups  (a)  asthenia,  asthenomanie,  as- 
thenia prolongee,  manie  chronique,  periodic  dysthenias;  {b)  anxious  hyper- 
thymias,  hypochondriasis,  sinistrosis,  hysterical  crises,  character  disturbances  ; 
(c)  amnesia,  Korsakoff's  syndrome,  confusion,  agnosin,  dementia,  systema- 
tized delirium.     These  are  all  discussed  from  the  point  of  view  of  traumata. 

Jelliffe. 

The  Narcotic  Drug  Diseases  and  Allied  Ailments.  Pathology,  Patho- 
genesis and  Treatment.  By  Geo.  E.  Pettey.  M.D.  F.  A.  Davis  Com- 
pany, Philadelphia. 

Dr.  Pettey  has  given  a  very  human  book.  The  drug  habitue  he  regards 
as  a  blameless  victim  of  disease,  entitled  to  rational  and  skillful  medical  aid. 
This  disease  he  would  envisage  as  one,  a  toxemia,  in  which  respect  only  the 
surface  of  the  subject  is  touched. 

The  vital  and  essential  principle  of  treatment  advocated  is  elimination. 
Little  is  said  of  the  psychological  foundation  of  the  individuals.  It  is  from 
this  aspect  that  the  book  offers  little,  but  from  the  practical  everyday  methods 
which  are  needed  to  handle  the  patients  it  is  especially  full  and  satisfactory. 

Suggestion  und  Erziehung.  Von  Dr.  Leo  Hirschlaff  in  Berlin.  Julius 
Springer,  Berlin. 
This  volume  on  Suggestion  and  Education  appears  as  the  second  of  a 
series  on  borderland  studies  in  medicine  and  pedagogy.  The  author  has 
already  written  a  number  of  papers  on  the  relationships  of  pedagogy  to  hyp- 
notic and  suggestive  therapeutics.     The  present  work  first  presents  a  fairly 


292  BOOK  REVIEWS 

complete  summary  of  the  literature,  giving  in  great  detail  the  various  opinions 
of  numerous  authors.  In  the  second  part  of  the  book  he  has  attempted  a 
critical  exposition  and  interpretation  of  the  phenomena  usually  included  under 
the  symbol  suggestion. 

In  the  final  portion  of  his  book  he  brings  together  the  evidence  to  show 
that  the  educational  significance  of  suggestion  and  hj-pnosis  stands  in  an 
insoluble  opposition  to  the  scientific  knowledge  of  these  two  factors.  He 
attempts  to  show  the  internal  antithesis  between  the  mode  of  action  of  sug- 
gestion and  that  of  education  and  thereby  would  finally  lay  low  the  myth  of 
the  possibility  of  suggestion  as  a  means  of  educational  value. 

The  author  in  a  thoroughly  conservative  and  yet  forceful  manner  cuts 
through  much  of  the  pretentious  medicine  which  is  called  suggestive  medicine 
and  goes  to  the  quick  when  he  sizes  up  the  American  Quackenbos  as  "  one  at 
the  summit  of  exaggeration  and  lack  of  critique,  who  attempts  to  play  the 
role  of  a  Messiah  in  pedagogy;  but  who  is  a  false  prophet  playing  on  human 
credulitj'  througii  the  quasi-mystical  power  of  hypnotism." 

The  book  is  a  thoroughly  incisive  argument  showing  that  educational 
methods  now  in  wide  use  have  nothing  to  gain  from  the  various  methods  of 
hypnotism,  a  conclusion  which  the  recent  researches  on  the  action  of  hyp- 
notism b\-  Ferenczi  have  amply  demonstrated.  The  weak  part  of  the  book  is 
in  the  author's  failure  to  comprehend  the  modus  operandi  of  hypnotic  phe- 
nomena, which  is  due  to  his  ignorance  of  the  psychiatric  literature.  It  is 
also  strange  to  note  that  Meumann's  famous  pedagogic  series  started  a  few 
years  ago  should  have  been  inaugurated  by  Pfister's  masterly  volume  on  Psy- 
choanalysis, which  general  subject  the  author  states  is  the  work  of  Beelzebub. 

SvPHius  UND  NER\tNSYSTEM.  Prof.  Max  Xonue.  Dritte  Auflage.  S.  Karger, 
Berlin. 

We  welcome  a  third  edition  of  Nonne's  masterly  work  on  syphilis  of  the 
nervous  system  which  appears  in  a  markedly  enlarged  and  newly  worked  over 
form  since  the  appearance  of  the  second  edition  five  years  ago. 

In  it  he  has  thoroughh-  gone  over  the  evidence  concerning  the  new  dis- 
coveries of  the  Spirochccta  pallida  and  the  serobiological  studies  on  the  blood 
and  cerebrospinal  fluid.  Many  of  these  did  not  appear  in  the  previous  edition. 
In  the  monograph  on  Syphilis  of  the  Nervous  System  in  White  and  Jelliffe's 
Modern  Treatment  of  Nervous  and  Mental  Diseases  and  in  this  third  edition 
of  Nonne  the  present-day  attitude  toward  these  problems  is  made  available. 

PATHOIX)GIC.^L  Lying,  Accus.atiox,  and  Swindung.  A  Study  in  Forensic 
Psychology.  By  William  Healy,  A.B.,  M.D.,  and  Mary  Tenncy  Healy, 
B.L.     Boston,  Little,  Brown  and  Comi)any. 

This  book  deals  with  a  form  of  delinquency  which  the  authors  define  as 
arising  from  a  condition  pathological  in  itself  and  distinct  from  mental  abnor- 
mality, though  often  found  also  in  borderline  cases,  where  it  is  more  difficult 
to  separate  this  particular  condition.  A  review  of  the  literature  on  this  sub- 
ject shows  that  this  distinction  has  hitherto  not  been  made. 

In  accordance  with  Dr.  Healy's  method  of  long-continued  individual 
work  with  delinquents  a  number  of  cases  are  presented  in  careful  detail  from 
Iiis  investigations,  which  illustrate  this  pathological  trait  as  it  manifests  itself 
in  apparently  purposeless  lying,  and  in  false  accusations,  whether  against  self 
or  others,  and  in  swindling,  the  latter  forms  of  behavior  growing  naturally 
out  of  the  lying  tendency. 

While  these  cases  as  a  rule  do  not  show  definite  mental  aberrations,  espe- 
cially according  to  the  older  classifications,  still  they  are  so  bounrl  with  inner 
psychic  conflict,  particularly  with  sexual  repressions  and  conflicts,  often  purely 


BOOK  REVIEWS  293 

psychical  only,  of  early  childhood  as  well  as  those  due  to  later  experience, 
that  a  close  study  of  each  case  history  but  serves  to  convince  one  emphat- 
ically of  the  actuality  of  Freud's  hypotheses.  The  authors  recognize  the 
values  of  these  beginnings,  but  yet  where  the  cause  of  the  l^-ing  seems  to  be 
other  than  the  fundamentally  sexual,  they  do  not  give  true  weight,  it  would 
seem,  to  such  underlying  factors  as  the  attitude  of  the  subject  to  family  rela- 
tionships and  his  own  place  therein,  imaginary  as  much  as  real.  The  authors 
recognize  this  attitude  but  do  not  seem  to  have  measured  it  up  by  "  the  Qidipus 
footrule,"  particularly  the  "  family  romance  "  side  of  it.  Viewed  in  the  light 
of  this  it  is  most  illuminating  and  also  becomes  clearer  and  more  valuable  as 
an  explanatory  factor. 

However,  the  careful  work  here  reported  in  detail  is  based  on  an  appre- 
ciative understanding  of  individual  psychic  reactions  as  the  causes  to  be 
searched  out  and  is  thoroughly  constructive  in  its  aim.  It  forms,  therefore,  a 
valuable  study  in  its  suggestive  and  in  its  practical  bearing. 

Jelliffe. 

A  Textbook  of  Insanity  and  Other  Mental  Diseases.     By  Charles  Arthur 
Mercier.     Second  edition.     The  Macmillan  Company,  New  York.     $2.25. 

In  his  preface  Mercier  writes  "that  insanity  is  a  subject  but  little  under- 
stood. When  I  began  to  study  it  there  was  no  systematic  knowledge  of  it 
at  all."  It  is  a  pity  that  Heinroth  wrote  or  Reil  rhapsodied,  and  the  long  list 
of  sincere  students  from  the  first  pragmatic  sayings  of  Protagoras  concerning 
the  mental  life  to  the  present  have  all  been  in  vain.  At  last  a  prophet  has 
arisen  and  his  name  is  Mercier. 

He  tells  us  that  "  insanity  is  a  disorder  of  conduct  and  not  of  mind, 
manifestly  and  blatantly  true  though  it  is.  has  made  little  or  no  progress 
toward  acceptance  in  the  twelve  years  since  this  book  was  published."  One 
suspects  Mercier  to  be  blinded  to  the  obvious,  since  from  the  earliest  times 
disordered  conduct  has  been  the  chief  criterion  of  a  disturbance  of  the  psy- 
chical activities. 

Conduct,  we  suspect,  may  be  interpreted  as  the  result  of  a  series  of  mental 
processes.  Possibly  mental  processes  and  mind  are  two  symbols,  which  have 
nothing  to  do  with  one  another  in  Mercier's  mind. 

Mercier  thinks  his  classification  "  water  tight."  He  accepts  the  principle 
of  evolution,  but  it  must  stop  with  Mercier.  All  others  have  failed,  but  his 
is  finally  right.  This  and  other  types  of  gratuitous  assumptions  we  find  in 
the  preface. 

With  such  a  rationalistic  attitude  toward  science  in  general,  what  can 
one  expect?  A  water  tight  series  of  boxes,  arranged  in  a  beautiful  row,  with 
all  the  sizes  marked  on  the  outside,  as  in  a  shoe  shop.  It  is  a  convenient  sys- 
tem for  selling  shoes !  Will  such  intellectualism  work  for  anything  but  the 
callow  weed  of  a  youth  who  wants  to  be  told  a  thing  is  so  because  his  father 
said  so? 

Calvinism  in  religion  has  had  its  day;  the  ipse  dixits  of  ecclesiastical 
authorities  as  working  schemes  for  growing  social  organizations  failed  to 
permit  of  advance  and  have  passed.  Mercier  came  too  late.  Instead  of  being 
a  new  prophet  he  is  hopelessly  Aristotelian  and  intellectualistic. 

We  believe  that  this  work  comes  within  that  group  engaged  in  a  sterile 
discussion  of  the  meaning  of  words  rather  than  one  furthering  an  understand- 
ing of  the  actions  of  things,  and  notwithstanding  the  right  emphasis  put  upon 
conduct,  which  practically  all  psychiaters  have  agreed  upon,  it  is  difficult  to 
understand  what'  the  author  even  means  by  conduct. 

Jelliffe. 


294  BOOK  REVIEWS 

Handbuch  der  Xervenkraxkheiten  im  Kindesalter.  Von  Prof.  L.  Bruns, 
Prof.  A.  Cramer  and  Prof.  Th.  Ziehen.     S.  Karger,  Berlin. 

This  notable  triumvirate  of  talent  has  given  us  a  remarkably  comprehen- 
sive and  extremelj'  satisfactory  work.  Cramer  has  taken  up  Nervous  Chil- 
dren, Hysteria,  Epilepsy,  Chorea,  Stuttering  and  Tics. 

Bruns  has  written  on  the  diseases  of  the  spinal  cord  and  peripheral  nerves 
in  childhood,  with  additional  notes  on  polymyositis  and  related  muscular  dis- 
orders ;  while  Ziehen  has  taken  up  the  disorders  of  the  brain  and  meninges 
in  an  admirable  manner. 

The  whole  makes  a  very  complete  and  satisfying  volume  of  1,000  pages, 
well  illustrated  and  rich  in  facts  and  practical  suggestions. 

Jelliffe. 

Elements  de  Semiolocie  et  clinique  Mentales.  Par  Dr.  Ph.  Chaslin.  Mede- 
cin  de  la  Salpetriere.     Asselin  et  Houzeau,  Paris. 

The  author  has  outlined  for  himself  the  production  of  a  book  which  would 
avoid  the  illusory  compactness  of  a  quiz  compend  on  the  one  hand  and  the 
encyclopedic  diffuseness  of  the  traite  on  the  other.  He  therefore  has  written 
a  manual,  clear  and  precise  in  its  descriptions,  with  marked  accent  on  the 
semiology  and  illustrated  with  many  extracts  from  case  histories.  He  pur- 
posely has  avoided  all  bibliographies  and  omits  all  interpretations,  saying  that 
which  no  modern  psjxhiatrist  can  say  acquainted  with  the  work  of  Kraepelin, 
Bleuler  and  others,  that  thej^  are  purely  metaphysical  and  must  be  remade. 

All  in  all  the  author  has  rid  himself  of  much  useless  lumber,  here  and 
there  giving  an  intimation  that  he  has  done  so  with  intention,  and  has  written 
an  entirely  new  type  of  work  which  has  avoided  descriptive  generalizations 
and  sought  to  describe  what  he  has  termed  types. 

Jelliffe. 

Jahresbericht  ueber  die  Leistungen  und  Fortschritte  auf  dem  Gebiete  der 
Xeurologie  und  Psychiatrie.  Redigiert  von  Prof.  Dr.  L.  Jacobsohn. 
Vol.  XVn,  S.  Karger,  Berlin. 

This  the  latest  volume  of  this  masterly  yearbook  on  neurology  and  psy- 
chiatry revie\<-s  the  literature  of  1913.  There  are  1.600  pages  in  this  number; 
the  references  are  all  inclusive  and  little  of  moment  has  been  omitted.  We 
repeat  what  we  have  so  often  said  with  reference  to  this  work  as  being  the 
most  important  single  publication  in  its  special  field.  It  is  preeminently  the 
most  valuable  reference  library  that  a  worker  in  these  fields  can  possess. 

Jelliffe. 

Die  operative  Erfolge  bei  der  Behandlung  des  Morbus  Basedowii.  Von 
Dr.  Otto  Klinke.     S.  Kargcr,  Berlin. 

This  thesis  received  the  Mobius  prize.  The  author  discusses  the  older 
literature  and  then  goes  over  the  recent  work.  It  is  a  careful  and  valuable 
digest  of  the  voluminous  literature  bearing  on  this  important  topic. 

Orthopadische  Behandlung  der  Nervenkrankheiten.  Von  Prof.  D.  K. 
Biesalski.  Gustav  Fischer,  Jena. 
This  "separate"  from  the  Lehrbuch  der  Orthopedic  of  Lange's  should 
be  made  available  to  all  neurologists  by  reason  of  its  scholarly  and  systematic 
presentation  ;  its  rich  illustrative  features  and  its  many  practical  suggestions. 
By  means  of  it  the  neurologist  and  orthopedist  can  work  together  to  better 
advantage.     It  is  a  work  that  has  long  been  needed. 


BOOK  REVIEWS  29S 

Das  Zittern,  seine  Erscheinungsformen,  seine  Pathogenese  und  kun- 
ISCHE  Bedeutung.  Von  Dr.  Josef  Pelnar,  of  Frag.  Verlag  von  Julius 
Springer,  Berlin. 

This  is  No.  8  of  the  Alzheimer  and  Lewandowsky  monographs.  It  is  the 
most  comprehensive,  minute  and  detailed  study  of  tremors  that  exists  at  the 
present  time  in  medical  literature  and  needs  no  further  comment.  The  working 
out  of  tremors  from  the  mechanistic  and  descriptive  side  is  admirable.  He 
shows  no  comprehension  whatever,  speaking  from  an  interpretative  side,  of 
the  psychogenic  factors  in  tremors,  such  as  in  hysterias,  dementia  praecox, 
compulsion  states,  etc.  His  definition  of  hysterical  tremors  as  "  simulation," 
using  it  in  a  conscious  sense,  is  nonsense. 

One  therefore  is  prepared  to  find  a  masterly  study  of  the  mechanical  fac- 
tors in  tremor  production,  particularlj''  at  the  sensori-motor  levels  of  the 
nervous  system ;  the  vegetative  level  disturbances  are  touched  upon,  but  not 
explained — indeed  perhaps  our  knowledge  of  electrophysiology  is  as  yet  too 
imperfect  to  interpret  these  subtle  synaptic  junction  surface  electrical  phe- 
nomena. The  psj'chic  level  lies  entirely  outside  of  the  author's  cognition 
and  like  many  mechanistic  founded  studies  there  is  no  evidence  to  show  that 
the  problems  even  exist. 

The  book  is  especially  valuable  from  the  purely  descriptive  side.  The 
interpretative  side  is  less  well  organized.  The  author  accepts  the  hypothesis 
that  the  tremor  paralysis  agitans  is  a  cerebellar  spinal  disturbance,  chiefly 
localized  in  the  mesencephalic  pathways. 

Oxidations  and  Reductions  in  the  Animal  Body.  By  H.  D.  Dakin.  Long- 
mans, Green  and  Co.,  New  York. 

Dedicated  to  the  late  Dr.  Christian  Herter,  of  New  York,  whom  neurolo- 
gists enroll  as  one  of  their  own,  this  excellent  volume  by  Dr.  Dakin  should 
be  read  by  all  whose  chemical  interests  and  information  entitle  them  to  have 
opinions  relative  to  the  complicated  problems  of  metabolism. 

The  increasing  knowledge  concerning  vegetative  nervous  activities  prom- 
ises to  open  a  way  to  a  comprehension  of  metabolic  processes ;  a  deep  under- 
standing of  which  is  bound  up  in  the  biochemical  constitution  of  the  human 
body. 

We  welcome  the  attempt  of  the  editors  of  this  series  of  monographs  on 
biochemistry,  and  feel  that  Dakin's  volume  is  an  excellent  contribution  to  the 
value  of  the  series.  German  science  has  shown  its  activity  and  its  compre- 
Iiension  of  the  needs  by  its  rich  issuance  of  small  volumes,  at  reasonable 
prices,  which  may  be  purchased,  and,  having  served  their  purpose,  are  only 
of  historical  value.     The  present  series  of  volumes  is  a  worthy  imitator. 

Dr.  Dakin's  volume  attempts  an  account  of  the  principal  chemical  reac- 
tions, involving  oxidation  and  reduction,  viewed  solely  in  the  light  of  the 
chemical  structure  of  the  substances  involved.  It  is  therefore  preeminently 
chemical. 

When  it  is  realized  that  only  within  comparatively  recent  times  have  the 
details  of  even  some  of  the  simplest  oxidation  and  reduction  processes  been 
grasped,  it  is  a  satisfaction  to  know  that  they  can  be  stated  and  a  source  of 
congratulation  to  have  them  so  well  outlined  as  in  this  small,  inexpensive  and 
thorough  monograph. 

Jelliffe. 

Dengue    und    andere    endemische    Kustenfieber.     Von    Prof.    Dr.    Georg 
Strieker,  in  Miinster.     Alfred  Holder,  Leipzig  and  Wien. 
In  this  continuation  of  Nothnagel's  celebrated  series  the  question  of  coast 
fevers  and  dengue  are  taken  up  in  monographic  completeness.     Dengue  is  of 


2g6  BOOK  REVIEWS 

interest  to  the  neurologist  because  of  its  affinities  to  influenza,  which  latter 
large  medley  is  greatly  in  need  of  careful  revision  from  the  neurological 
viewpoint. 

Nervos,  Zwaxzig  Gespr.\che  zwischen  Arzt  und  Patient.  Von  Dr.  Ludwig 
Scholz  aus  Bremen.  S.  Karger,  Berlin. 
The  author,  following  an  early  custom,  arranges  twenty  short  consulta- 
tions with  an  intelligent  patient  and  expounds  a  fairly  systematic  scheme  of 
psychotherap}-,  following  in  the  main  the  essential  features  of  Dubois'  dia- 
lectics. To  cure  psychogenic  ills  the  patient  must  understand  their  nature. 
This  he  attempts  to  unfold  in  a  readable  and  satisfactory  manner.  Sugges- 
tion also  bulks  fairly  large  in  his  psychotherapeutic  talks. 

Prutcipios  de  Psicologia  Biologica.  Jose  Ingenieros,  Buenos  Aires.  Daniel 
Jorro,  Madrid,  Editeur. 

Dr.  Ingenieros  is  known  for  his  excellent  work  in  psychiatry,  criminal 
anthropology  and  related  activities. 

The  present  principle  of  biological  psychology  serves  to  enhance  his  repu- 
tation and  to  offer  to  its  readers  a  number  of  ways  of  looking  at  psychology 
which,  although  often  followed,  are  yet  always  attractive.  It  is  thoroughly 
modern  and  utilizes  the  general  concepts  familiar  to  the  student  of  the  psy- 
chology of  the  last  two  decades.  It  fails  to  be  ultramodern  in  that  there  is  no 
suggestion  of  the  study  of  the  so-called  unconscious  phenomena.  He  is  not 
a  devotee  of  Bergson,  but  is  more  strictly  formal  and  materialistic,  patterning 
after  Spencer  and  the  Wundtian  school. 

Die  Nervenkrankheiten,  ihre  Ursachen  und  ihre  Bekampfung.     Dr.  ) 

Finckh. 
WiE  BEHANDELN  wiR  Geisteskranke.      Dr.  Hermann  Haymann.      Otto  Gmelin, 

Munich. 
These  two  popular  lectures  are  attractively  presented  in  form  and  mate- 
rial, but  by  reason  of  their  appeal  to  the  lay  reader  interests  us  only  as  to  the 
methods  followed  by  our  German  confreres  in  their  attempts  at  popularizing 
difficult  subjects. 

Ueber  den  Ursprunc  der  geistigen  Fahigkeiten  des  Mensciien.  Von  Ber- 
thold  Kern.  August  Hirschwald,  Berlin. 
In  this  dissertation  held  before  the  Berlin  Society  for  Anthropology  and 
Ethnolog>',  Dr.  Kern  traces  the  evolution  of  the  mental  processes  of  the  indi- 
vidual, the  state  and  the  nation  from  its  primitive  sources.  It  is  an  attractive 
essay  which  states  the  general  evolutionary  hypothesis  in  an  acceptable  manner. 

Grundriss  der  psvcuiatrische.v  Diagnostik.  Von  Prof.  Dr.  Julius  Raeche 
in  Frankfurt.  Fiinfte  Auflage.  August  Hirschwald. 
We  have  had  occasion  to  praise  this  small  volume  which  appears  now  in 
its  fifth  edition.  120  of  its  180  pages  are  devoted  to  the  examination  of  the 
patient.  The  special  part  takes  up  the  psychoses  following  in  large  part  tlie 
Kraepcliati  nomenclature. 


VOL.   43.  APRIL,  1916.  No.  4 

The  Journal 

OF 

Nervous  and  Mental  Disease 

An  American  Monthly  Journal  of  Neurology  and  Psychiatry,  Founded  in  1874 


©riginal  Hrticles 


A  REPORT  OF  TWO  CASES  OF  PROGRESSIVE  LENTICU- 
LAR DEGENERATION 

By  Arthur  S.  Hamilton,  M.D. 

PROFESSOR    OF    NERVOUS    AND    MENTAL   DISEASES,    MEDICAL    SCHOOL,    UNIVERSITY    OF 
MINNESOTA,    MINNEAPOLIS 

AND 

Herbert  W.  Jones,  M.D. 

MINNEAPOLIS,    MINN. 

The  patient,  described  as  Case  I,  was  presented  at  the  meeting  of 
the  Minnesota  Neurological  Society,  November  2;^,  1911,  and  diag- 
nosed diffuse  cerebral  injury,  following  partial  strangulation.  The 
appearance  shortly  afterwards,  of  Dr.  Wilson's  article  on  progres- 
sive lenticular  degeneration,  convinced  us  that  we  were  dealing 
with  a  similar  condition,  and  the  history,  since  obtained  from  a 
variety  of  sources,  has  corroborated  this  opinion.  When  the  case 
was  presented,  we  knew  nothing  of  a  familial  tendency,  or  of  any 
pathological  condition,  antedating  the  injury.  Even  now,  the  rela- 
tives, especially  the  mother,  are  very  loath  to  recognize  the  existence 
of  a  familial  disease  and  we  are  left  with  the  impression  that,  even 
as  recorded,  the  history  may  not  do  justice  to  this  feature,  and  on 
the  contrary,  may  have  exaggerated  the  traumatic  element.  At  a 
subsequent  meeting  of  the  Neurological  Society,  November  21,  1912, 
the  case  was  presented  and  diagnosed  as  one  of  progressive  lenticu- 
lar degeneration. 

297 


298  ARTHUR  S.  HAMILTOX  AND  HERBERT  IF.  JONES 

Case  I.     F.  W.,  male,  age  28  years,  single. 

Familx  history:  The  paternal  grandfather  died  of  pneumonia  at 
seventy-nine  years,  the  paternal  grandmother  from  the  effects  of  a 
cold.  The  maternal  grandparents  were  healthy  and  lived  to  old 
age.  The  grandfather  died  of  cancer.  Four  paternal  uncles  and 
two  paternal  aunts  are  well.  One  paternal  uncle  died  of  "abscess 
of  the  brain  "  and  one  of  unknown  cause.  Three  third  cousins  died 
of  pulmonary  tuberculosis.  The  father  and  mother  are  living. 
The  father  has  leukoderma  and  lumbago  and  the  mother  is  de- 
cidedly nervous.  Lues  is  denied.  Neither  has  any  condition  like 
that  of  the  sons.  There  are  eight  brothers  and  sisters.  All  are 
Hving  and  at  least  fairly  well  except  as  follows:  One  brother  has 
valvular  heart  trouble,  and  another  brother  (case  II)  has  a  condi- 
tion similar  to  that  of  the  patient.  This  brother  has  a  twin  sister 
who  is  well  except  for  some  gastric  disturbance.  A  third  brother 
(case  III)  is  possibly  developing  the  disease.  There  were  three 
miscarriages  between  the  fourth  and  fifth  children,  one  at  one  month 
and  two  at  two  months.  These  are  said  not  to  have  been  artificially 
produced.  The  sex,  age,  and  order  of  birth  of  the  children  are  as 
follows : 

1.  Girl,  age  29,  married,  well. 

2.  Boy,     "     28,  single   (case  I). 

3.  Boy,     "     26,  married,  well. 
,                               4.  Girl,     "     25,  married,  well. 

5.  Boy,  "  23,  single  (case  III). 

6.  Boy,  "  20,  single   (case  II). 

7.  Girl,  "  20,  single  (twin  with  No.  6). 

8.  Girl,  "  14,  single,  well. 

9.  Boy,  "  10,  single,  well. 

Personal  history:  The  patient  was  a  full-term  child,  breast  fed, 
and  weaned  at  eight  months  on  account  of  the  mother's  succeeding 
pregnancy.  He  had  considerable  digestive  trouble  in  early  years, 
but,  in  a  general  way,  was  well  up  to  nineteen  or  twenty  years  of 
age.  He  did  better  in  school  than  the  average  until  fifteen  years 
old,  when  he  was  taken  out  on  account  of  an  attack  of  appendicitis. 
He  is  a  masturbator.  As  a  young  man  he  was  a  good  worker  and 
had  no  trouble  in  holding  a  situation.  He  read  a  great  deal,  liked 
machinery  and.  until  the  onset  of  his  illness,  showed  considerable 
mechanical  skill.  At  nineteen  he  went  to  work  in  a  candy  factory, 
and  at  that  time  did  much  heavy  lifting.  While  engaged  in  this 
work  it  was  observed  that  he  had  so  marked  a  tremor  in  the  right 
hand  that  he  could  scarcely  hold  a  glass  of  liquid  without  spilling  it. 
When  twenty  years  old  he  was  operated  on  for  appendicitis  and 
two  months  later  his  family  noticed  that  he  talked  as  if  his  tongue 
were  thick.  At  the  same  time  his  arms  were  spastic,  and  he  dragged 
his  right  foot.  A  little  after  his  operation  for  a])j)endicitis  he  began 
to  go  into  violent  tempers  when  anything  displeased  him.  Once  he 
tried  to  attack  one  of  his  brothers  on  account  of  a  minor  disagree- 
ment. His  appearance  at  that  time  is  shown  in  Fig.  i.  His  condi- 
tion grew  slowly  worse  during  the  succeeding  sixteen  months.     His 


PROGRESSIVE  LENTICULAR  DEGENERATION 


299 


speech  was  thicker,  and  it  became  difficult  to  understand  him.  His 
right  foot  dragged  more  and  both  hands  shook.  When  about 
twenty-two  years  old  he  left  home  and  there  is  no  clear  record  of 
what  followed  directly  afterward.  Apparently  he  went  West  about 
eight  hundred  miles  to  work  with  a  railroad  construction  gang. 
While  there  he  had  trouble  with  some  Italians  who  are  said  to  have 
placed  a  rope  about  his  neck  and  to  have  dragged  him  along  the 
railroad  track.     After  this  he  set  out  for  home  and  wrote  his  mother 


Fig.  I. 


a  fairly  intelligent  letter  on  a  Thursday  from  a  point  about  seventy 
miles  west  of  his  home.  On  the  following  Sunday  he  was  found 
lying  in  an  open  freight  car  in  one  of  the  railroad  yards  of  Min- 
neapolis. At  that  time  he  could  not  walk,  talk,  or  feed  himself  but 
he  ate  an  enormouus  amount  of  food  when  assisted.  Later  he  im- 
proved considerably  and  was  able  to  tell  that  he  had  ridden  the 
entire  eight  hundred  miles  in  an  open  freight  car  in  extremely  hot 
weather.  Since  this  experience  he  has  been  unable  to  dress  him- 
self most  of  the  time.  Shortly  after  his  return  home  as  above,  he 
fell  downstairs  and  was  unconscious  for  one  half  hour. 

In  January,  1912,  he  had  improved  somewhat  in  the  use  of  his 


300  ARTHUR  S.  HAMILTON  AXD  HERBERT  IW  JOXES 

hands.  He  could  talk  a  little  but  at  times  his  tongue  seemed  to 
stick  to  the  roof  of  his  mouth,  the  saliva  dribbled  from  his  lips 
and  he  was  unable  to  make  a  sound  for  a  few  minutes.  At  such 
times  he  would  grasp  his  chin  with  one  hand  and  after  moving  ii  u]) 
and  down  a  few  times  he  would  swallow  and  could  speak,  though 
still  with  much  difficulty.  At  times  he  wet  his  clothes  but  never 
the  bed.  He  had  an  enormous  a])petite  and  his  mother  said  that 
for  several  years  he  had  "  eaten  enough  for  six  men  "  and  that  he 
was  ready  to  eat  and  drink  again  in  an  hour  after  a  very  full  meal. 
He   smoked    incessantly   but    used    no    alcohol.     His    mother,   also, 


li. 


state<l  that  on  a  number  of  occasions,  lasting  over  a  considerable 
periofl,  he  had  intense  cramp-like  pains  in  the  Ujjper  abdomen  and 
that  his  whole  body  would  be  doubled  up.  For  several  years  at 
intervals,  both  fol'nwing  these  att-cks  and  indejjendently  of  them, 
be  became  markedly  jaundiced.  On  these  occasions,  the  skin  dis- 
coloration generally  ])assed  away  (|uick!y  but  the  eyes  would  remain 
discolored  for  days,  (""or  three  years  he  had  shut  one  eye  on  read- 
ing and  said  that  things  appeared  (loul)le  otherwise. 

His  physical  examinalifin.  j.inuary  23,  1912,  when  he  was  twen- 
ty-five years  (j1<1,  resulted  as  follows:  He  was  a  well  develo])ed  and 
nourished  man  and  weighed  one  hundred  and   forty-nine  pounds. 


PROGRESSIVE  LENTICULAR  DEGENERATION 


301 


His  hands  and  feet  were  cold  and  cyanotic.  There  was  a  yellowish 
tinge  to  the  white  of  the  eyes.  His  muscles  were  of  good  volume 
and  strength.  Much  of  the  time  his  face  had  a  sleepy,  masklike 
expression,  but  frequently  a  broad  grin,  of  long  duration,  would 
spread  over  his  face.  His  tongue  lay  on  the  floor  of  his  mouth 
and  he  was  unable  to  protrude  it  much  beyond  the  teeth.  His 
mouth  was  full  of  saliva  and  this  dribbled  from  his  lips.  His  pupils 
were  equal  and  reacted  to  light  and  accommodation.  There  was  no 
paralysis  of  the  external  ocular  muscles  and  no  diplopia,  but  there 


Fig.  3. 


was  a  well-marked,  irregular,  coarse  jerking  of  the  external  ocular 
'"■luscles  on  lateral  or  upward  vision.  Sight  and  hearing  were  good. 
His  speech  was  very  slow  and  labored  and  only  rarely  could  a 
word  be  understood. 

Frequently  his  jaws  became  set,  especially  when  attempting 
anew  to  speak,  and  it  would  then  be  necessary  to  relax  the  lower 
jaw  with  the  aid  of  his  hand,  before  a  sound  could  be  uttered  (Fig. 
2).     He  often  choked  in  attempting  to  swallow.     He  walked  with 


302 


ARTHUR  S.  HAMILTOX  AXD  HERBERT  If.  JOXES 


a  spastic,  rolling  gait  and  as  he  did  so  the  arms  were  held  in  a  semi- 
flexed attitude  and  the  hngers  in  a  peculiar  jiosition.  (See  Figs.  2 
and  3.)  Both  arms  were  constantly  spastic,  the  left  more  so  than 
the  right.  There  was  also  a  very  marked  spasticity  of  the  throat 
muscles,  but  the  muscles  of  the  entire  body  were  more  or  less  rigid 
(Fig.  3),  especially  on  attempted  movement.  The  left  hand  was 
stronger  than  the  right,  but  the  power  in  the  right  was  fair.  In  lift- 
ing a  glass  of  water  with  either  hand  he  developed  a  very  marked 
tremor  but,  by  assisting  the  hand  holding  the  glass,  with  the  other 


l-K 


(Fig.  4),  he  could  bring  the  water  to  his  lips.  At  times,  on  effort, 
the  tremor  seemed  to  involve  all  parts  of  the  body  but  was  always 
much  worse  in  the  arms  than  in  the  legs.  There  were  no  atrophies 
and  no  sensory  trouble  could  be  made  out.  but  he  said  he  had  some 
numbness  of  the  right  hand  at  times  and  there  was  an  uncertain 
history  of  hypesthesia  of  the  right  hand  and  foot  for  six  months 
after  his  experience  at  the  railroad  cam]).  The  superficial  facial 
reflexes  were  normal.  'I'he  tricei)s.  bicejjs,  and  Achilles  jerks  were 
all  distinctly  active  and  ef|ual  on  the  two  sides.  The  upper,  middle 
and  lower  abdominal  reflexes  were  normal.  There  was  no  ankle  or 
patellar  clonus.     The  plantar  reflex  was  unsatisfactory  but  probably 


PROGRESSIVE  LENTICULAR  DEGENERATION  303 

flexor.  In  the  finger-to-nose  and  finger-to-finger  test  the  tremor 
became  extensive  just  as  the  action  reached  its  cuhnination.  He 
had  poor  control  of  the  bladder  and  had  to  pass  urine  frequently 
during  the  day.  The  urine  was  acid,  specific  gravity  1,030,  and 
contained  no  casts,  but  albumen  and  sugar  were  both  present. 
(The  latter  findings  could  not  be  verified  in  many  subsequent  exam- 
inations.) 

His  intellectual  power  was  not  easily  determined.  At  first  sight 
he  appeared  to  be  a  very  demented  person,  but  on  closer  study  this 
was  not  bot-ne  out.  His  father  thought  he  had  a  good  memory  and 
he  certainly  comprehended  what  was  said  to  him.  At  times  he 
would  make  a  crude  sort  of  joke.  He  often  laughed  in  a  foolish 
way  and  without  any  apparent  cause. 

In  the  fall  of  191 3,  he  was  admitted  to  the  ^linneapolis  City 
Hospital  and  at  that  time  the  following  additional  histoiy  was  ob- 
tained. Subsequent  to  the  examination  above,  he  had  improved 
considerably,  but  in  the  winter  of  1912-13  he  grew  worse.  Sev- 
eral times  he  fell  and  if  anything  upset  his  balance  in  the  least  he 
seemed  unable  to  regain  his  equilibrium.  After  several  of  these  falls 
he  was  unconscious  for  a  time ;  in  consequence  of  the  fall,  his  mother 
thinks.  She  also  stated  that  his  condition  was  very  changeable. 
Thus  on  some  occasions  he  would  call  her  attention  to  the  fact  that 
he  could  lift  a  cup  of  water  with  very  little  tremor  and  shortly 
afterwards  his  hand  would  shake  so  that  he  would  spill  half  the 
water  before  getting  it  to  his  lips.  Sometimes  he  would  go  to  bed 
apparently  feeling  well  and  the  next  morning  would  be  unable  to 
talk  or  walk  and  on  any  attempt  at  the  latter  he  would  fall.  In  the 
same  way  on  some  days  he  could  stand  on  one  foot  and  on  the  next 
he  would  fall,  directly,  on  attempting  to  do  so. 

On  October  9,  191 3,  he  raked  the  lawn.  The  next  day  he  fell 
several  times  and  seemed  almost  helpless  and  was  finally  picked  up 
by  the  police,  lying  on  the  ground,  some  distance  from  home,  and 
taken  to  the  City  Hospital. 

When  examined  there  the  next  day,  he  was  found  lying  in  bed. 
He  was  fairly  well  nourished  and  there  was  no  discoloration  of  the 
skin.  His  eyes  were  open  and  had  a  fixed  stare.  His  face  had  a 
grave  and  masklike  expression  (Figs.  5  and  6)  but  on  recognizing 
the  examiner  it  broke  out  in  a  broad  grin  which  spread  slowly  over 
his  face  (Figs.  7  and  8).  His  mouth  was  always  widely  open  and 
his  lips  were  red,  thick,  and  everted  and  saliva  frequently  dribbled 
from  them.  His  eyes  followed  all  the  actions  of  the  examiner  and 
he  seemed  aware  of  all  that  happened. 

At  the  time  of  this  examination  his  left  arm  was  in  semi-exten- 
sion with  the  hand  straight  on  the  wrist,  the  thumb  and  first  finger 
extended,  the  second  finger  slightly  extended  and  the  other  two 
fingers  firmly  flexed  into  the  palm.  The  right  arm  was  strongly 
flexed  at  the  elbow  and  the  fingers  were  drawn  into  the  palm,  but 
the  two  distal  phalanges  of  the  fingers  were  straight.  The  thumb 
was  only  slightly  flexed.  The  position  of  the  fingers  and  hands 
changed  considerably  from  time  to  time,  as  is  seen  in  the  figures. 
All  motions  and  signs  were  made  with  the  left  hand  and  arm  and 


30-4 


ARTHUR  S.  HAMILTON  AXD  HERBERT  Jl'.  JONES 


especially  with  the  left  first  finger  which  seemed  more  flexible  than 
other  parts.  The  right  hand  and  arm  could  be  brought  down  to 
the  bed  by  the  examiner  with  some  effort  and  would  remain  down 
for  a  time  but  tended  soon  to  return  to  their  former  j)osition  of 
flexion.  It  was  evident  that  the  left  hand  and  arm  were  distinctly 
less  spastic  than  the  right.  His  legs  were  straight  in  bed  and  mod- 
erately stiff,  but  when  handled  in  any  way  they  quickly  became  very 
rigid.  He  occasionally  sat  up  in  bed  and,  to  do  so,  he  caught  his 
toes  under  the  round  at  the  foot  of  the  bed  and  drew  himself  quickly 
and  rigidly  into  the  ujiright  position,     \\hen  the  statement  was  made 


Fig.  5. 

in  his  presence  that  his  arms  were  stiffer  than  his  legs,  he  immediately 
and  vehemently  denied  it  by  signs.  When  given  a  ])encil  lie  always 
held  it  between  the  left  thumb  and  forefinger,  and  lie  wrote  very 
slowly  and  with  difficult,  cramped  movements.  There  were  no 
atrophies. 

So  far  as  could  be  determined  his  vision  was  good.  Tiie  eyes 
were  slightly  prominent.  There  was  no  corneal  pigmentation.  All 
the  external  ocular  movements  were  good  in  power  and  degree,  but 
they  were  jerky  and  irregular  in  character.  There  was  no  apparent 
s|)asticity  in  the  external  ocular  muscles  and  no  diploi)ia.  'i'here 
was  no  definite  von  (iraefe.  but  in  looking  up  the  lids  .sometimes 
moved    f;mtcr    tli.in    the    balls    and    the    sclera    was    shown.      Con- 


PROGRESSIVE  LENTICULAR  DEGENERATION 


305 


vergence  was  good  until  a  nearer  point  was  reached  when  the 
left  eye  always  turned  out.  There  was  lateral  nystagmoid  move- 
ment on  vision  to  either  side  but  the  movement  soon  stopped.  The 
pupils  were  central,  regular,  and  rather  small.  Both  reacted  nor- 
mally to  accommodation  and  sluggishly  to  light.  The  optic  discs 
were  normal. 

The   conjunctival    and   corneal    reflexes    were   probably   ])resent 
but  contraction  was  so  slow  as  to  leave  the  matter  doubtful.     Wink- 


FiG.  6. 


ing  was  notably  infrequent.  Sensation  for  touch,  pain  and  tempera- 
ture was  normal  in  the  face.  Taste  and  smell  were  normal  as  far 
as  could  be  determined.  The  jaws  closed  firmly  and  equally  on  the 
two  sides,  but  slowly  and  only  after  several  efforts.  He  shut  his 
eyes  equally  but  not  firmly,  and  did  not  seem  able  to  wrinkle  his 
forehead,  and  moved  his  mouth  only  faintly  in  attempting  to  show 
his  teeth.  When  asked  to  whistle  he  tried  for  some  time  to  get  his 
hps  together  and  succeeded  to  some  degree  but  not  sufficiently  to 
whistle  and  he  cotild  not  blow  out  a  match.  He  was  later  seen 
making  repeated  efforts  to  get  his  lips  into  position  but  he  was  not 


io6 


ARTHUR  S.  JLIMILTOX  AXD  HERBERT  If.  JONES 


successful  in  whistlins^.  His  smile  was  broad  and  pronounced  and 
was  more  to  the  right  than  the  left.  Hearing  was  good  in  both  ears 
and  there  were  no  subjective  noises. 

When  he  opened  his  mouth  the  tongue  fell  back.  He  could  not 
say  "ah."  on  request,  and  in  his  attempts  no  movement  of  the  palate 
was  seen.  but.  when  he  laughed,  the  palate  moved  equally  on  the 
two  sides.  In  laughing  he  opened  his  mouth  widely  before  emitting 
a  noise  and  then  gave  forth  a  sound  something  like  "  ah,  ha.  ha,  ha," 
with  a  rising  inflection  at  the  end.  The  mouth  remained  open  for 
some  time  after  the  sounds  ceased,  about  sixty  seconds  on  an  average 


(Figs.  7  and  .S).  He  often  breathed  deeply  with  an  inspiration 
like  that  of  a  deej)  snore.  He  could  not  protrude  the  tip  of  the 
tongue  more  than  an  eighth  of  an  inch  beyond  the  teeth,  but  there 
was  no  .'itrophy.  There  was  complete  aphonia  at  the  time  of  the 
examination  except  for  the  sounds  mentioned  above  and  for  cer- 
tain soimds  which  passed  for  "yes"  and  "  nf)."  but  could  not  be  so 
understood  by  an  iniinitiated  person. 

When  fed  he  insisted  on  the  food  being  pushed  well  into  the 
side  of  the  mouth  between  the  cheek  and  the  teeth.  Api)arently  he 
could  not   manage  it  at  all  if  it  were  placed  in  the  center  of  his 


PROGRESSIVE  LENTICULAR  DEGENERATION 


307 


mouth.  He  could  eat  solid  or  semi-solid  food,  fairly  well,  though 
frequently  it  overflowed  from  his  mouth  in  his  attempts  to  swallow, 
but  in  taking  liquids  he  often  choked,  always  in  a  slow  measured 
way,  much  like  his  other  movements  except  not  quite  so  slowly. 
The  sterno-mastoid  muscles  were  spastic  but  of  good  power.  They 
did  not  relax  on  reclining. 

Joint  sense  and  cutaneous  sensibility  to  touch,  pain  and  tem- 
perature appeared  to  be  everywhere  normal. 


Fig.  8. 


Except  when  the  spasticity  was  marked,  the  Achilles,  patellar 
and  forearm  jerks  were  active  and  equal  on  the  two  sides.  The 
triceps  and  biceps  reflexes  were  active,  the  right  more  so  than  the 
left.  The  masseter  and  jaw  jerks  were  slight.  There  was  no 
ankle  or  patellar  clonus.  The  facial  reflexes  were  all  sluggish. 
In  the  abdomen  an  occasional  slight  response  was  obtained  with  a 
sharp  instrument,  usually  there  was  none.  The  cremasters  were 
faint  but  equal  on  the  two  sides.  No  pharyngeal  reflex  was  ob- 
tained, but  he  indicated  that  he  felt  the  irritation.  The  plantar 
reflex  was  flexor  with  Babinski's  and  Oppenheim's  methods.  There 
was  no  definite  loss  of  control  of  the  bladder  or  rectum. 

The   muscles    were   of    good    size   and    power.     Their    tonicity 


3o8  ARTHUR  S.  HAMILTOX  AXD  HERBERT  W.  JONES 

varied  greatly.  Usually  they  were  in  distinct  hypertonus,  but  some- 
times thev  seemed  very  limp  when  his  attention  was  not  drawn  to 
them.  His  mother  had  observed  the  same  condition.  When  in 
sound  sleep  all  his  muscles  were  relaxed. 

At  the  time  of  the  examination  he  was  able  to  stand  on  his  feet 
and  to  walk,  but  with  a  very  stiff  and  spastic  gait.  When  sitting 
with  his  legs  hanging  over  the  edge  of  the  bed  he  was  asked  to  lie 
down  in  the  bed  without  assistance.  At  the  time  he  was  in  an 
erect,  spastic  posture.  After  much  delay  his  body  dropped  back 
on  the  pillow  on  the  right  side.  The  same  movement  elevated  his 
feet  and  legs  and  brought  them  to  the  bed.  He  then  rolled  over 
on  the  bed  so  as  to  lie  on  his  back  and  straightened  his  legs  with  a 
jerk.  He  liked  to  exhibit  his  muscular  strength  and  after  his  at- 
tention was  drawn  to  the  matter  frequently  would  go  through  diflfi- 
cult  movements.  Thus  when  lying  on  his  back  he  was  able  to  flex 
his  thighs  on  his  abdomen  and  finally  to  touch  his  feet  to  the  top  of 
the  bed  above  his  head.  On  several  occasions  he  struck  the  orderly 
with  his  fist  and  once  knocked  him  down.  He  doubled  his  fist  and 
flexed  his  arm  very  slowly,  but.  after  he  had  overcome  a  certain  in- 
ertia, he  struck  quickly  and  with  power. 

As  he  was  unable  to  talk  he  usually  made  known  his  wants  by 
writing  with  a  pencil  on  his  bed  sheet.  This  was  a  matter  of  con- 
siderable difficulty.  When  lying  on  his  back  a  pencil  was  handed 
o  him.  He  took  it  into  his  left  hand  with  much  effort  and  very 
stiffly,  then  suddenly  threw  himself  en  bloc  on  the  right  side  with 
his  entire  body  in  a  stiff'  and  rigid  attitude.  His  head  was  held 
straight  out  and  was  not  supported  by  the  pillow.  The  saliva  flowed 
from  his  mouth.  He  wrote  the  word  "  rocker"  requiring  four  min- 
utes to  complete  it.  "Roc"  required  fifty  .seconds,  spent  mostly 
on  the  "  c."  At  "  k  "  he  stopped  for  one  minute  and  four  seconds 
and  then  (|uickly  wrote  "  e."  Before  the  final  "r"  his  hand  was 
again  held  in  an  absolutely  stiff  and  motionless  attitude  for  over  one 
minute,  after  which  he  quickly  finished  the  word.  As  he  brought 
the  pencil  down  to  the  sheet  to  write,  the  hand  showed  a  coarse 
tremor.  He  held  the  pencil  firmly  on  the  sheet  almost  constantly 
but  at  times  partially  released  it,  and  alway.s  with  the  development 
of  the  same  coarse  tremor  on  regrasping  it. 

On  another  occasion  he  was  seen  to  attemi)t  to  catch,  a  fly  with 
his  left  hand.  The  thuml)  and  forefinger  were  extended  on  the 
hand  which  was  held  susj^ended  for  sometime  waving  back  and 
forth  on  the  horizontal  plane  and  then  suddenly  moved  down  to  the 

He  grasjjcd  an  object  with  the  right  hand  without  tremor,  but 
when  using  the  left  hand  there  was  always  a  slow  tremor,  about 
three  or  four  movements  per  second  and  with  one  to  two  inches 
amplitude.  It  was  certainly  much  less  pronounced  at  this  time 
than  at  his  first  examination.  It  was  absent  when  at  rest.  He 
touched  the  examiner's  finger  with  his  great  toe  without  tremor  and 
withf)Ut  incof'irdination,  but  slowly  and  only  after  securing  relaxation. 
There  was  no  twitching  or  contraction.     The  only  vcjluntary  nnisclcs 


PROGRESSIVE  LENTICULAR  DEGENERATION  309 

which  were  not  spastic  were  those  of  the  eyeballs  and,  at  times,  the 
eyelids. 

At  the  hospital  he  was  often  irritable  and  cranky.  He  would 
go  into  violent  rages  over  trifling  matters  and  tear  up  his  clothing 
and  his  bedside  records.  At  one  time  he  knocked  a  woman  nurse 
down,  in  addition  to  his  experience  with  the  orderly.  Afterwards 
he  would  always  laugh  in  explaining  by  signs  that  he  did  this,  evi- 
dently considering  it  a  great  joke.  He  was  oriented  as  to  time, 
place,  and  persons,  and,  aside  from  his  outbursts  of  passion,  showed 
no  evidence  of  mental  suffering  on  account  of  his  lot.  There  were 
never  any  delusions  or  hallucinations. 

He  slept  soundly  at  night  and  often  during  a  considerable 
part  of  the  day.  Occasionally  he  could  not  be  awakened  suffi- 
ciently during  an  entire  day  to  get  him  to  eat  or  drink. 

Examinations  of  his  liver  usually  showed  the  area  of  dullness 
normal.  On  one  occasion  it  seemed  diminished.  No  nodules  or 
roughness  could  be  felt.  The  cerebrospinal  fluid  contained  four 
cells  per  cm.  The  globulin  and  Wassermann  reactions  were 
negative. 


\- 


-f 


Fig.  9. 


A  sample  of  his  handwriting  in  an  attempt  to  write  "I  want 
my  shoes  "  appears  in  Fig.  9. 

Just  previous  to  the  writing  of  this  paper,  January,  191 5,  the 
patient  has  again  come  under  observation.  He  is  still  moderately 
well  nourished  but  he  is  much  weaker,  more  quiet,  and  shows  fewer 
signs  of  mental  activity  than  on  his  previous  examinations.  Spinal 
tapping  has  been  performed  three  times.  In  no  case  was  there  any 
globuhn  response  or  cell  increase.  Once  the  fluid  had  a  slightly 
cloudy  appearance  and  on  this  occasion  it  was  said  to  contain  some 
"  foreign  bodies,  not  cells."  In  none  of  these  tests  was  the  Wasser- 
mann positive. 

Case  II.     H.  W.,  male,  age  20  years,  single. 

Family  History:  See  Case  No.  I. 

Personal  History:  The  patient  was  a  ptmy  child  up  to  about  six 
or  seven  years  of  age.  When  six  years  old  he  had  a  severe  attack 
of  scarlet  fever,  and,  sometime  in  early  life,  he  had  measles  and 
mumps  but  was  not  very  ill.  He  had  a  mild  attack  of  smallpox 
four  or  five  years  ago.  His  mother  states  that  he  has  had  several 
slight  attacks  of  jaundice  in  recent  years.  He  smokes  a  moderate 
amount  of  tobacco,  but  has  used  no  alcohol.  He  is  a  masturbator. 
He  was  slow  in  school  and  finished  the  eighth  grade  when  seven- 
teen years  old. 

Four  or  five  years  ago  he  slipped  and  fell  on  the  sidewalk, 
striking  on  the  back  of  his  head.     He  lay  still  for  fifteen  minutes 


3IO  ARTHUR  S.  IIAMILTOX  AXD  HERBERT  JV.  JOXES 

and  was  then  helped  up.  He  was  dizzy  and  nauseated  and  this 
continued  for  four  or  five  days  with  some  vomiting'.  There  was 
also  slight  pain  through  the  temples  and  back  of  the  head.  Recov- 
er>-  was  finally  complete.  Four  years  ago  he  was  "  bumped "  by 
an  automobile  and  one  eye  blackened  but  no  serious  symptoms  fol- 
lowed. Two  years  later  he  fell  from  a  wagon  and  struck  on  his 
head.  He  was  dazed  and  "  knocked  out "  for  five  minutes.  He 
then  got  up,  but  staggered  for  some  little  time.  There  was  no 
nausea,  vomiting,  or  dizziness  following  this,  but  everything  "  seemed 


Fig.  10. 


dark  for  half  an  hour  or  so  "  and  he  could  scarcely  see  ol)jccts.     He 
made  a  complete  recovery. 

On  May  30,  1912,  he  was  struck  over  the  right  eye  with  a  black 
jack  and  knocked  down,  after  an  altercation  with  another  man.  He 
was  unconscious  for  over  twenty-four  hours  and  slept  most  of  the 
time  for  .three  days.  There  was  no  headache,  nausea  or  vomiting 
following  this  injury  but  he  was  "numb  all  over  and  felt  as  if 
asleep."  The  numb  feeling  lasted  one  week  and  has  not  since  re- 
turned. For  two  weeks  after  the  accident  he  saw  double  constantly, 
one  object  beside  the  other.  The  patient  insists  that  he  was  normal 
before  this  injury,  had  good  control  of  his  nni.scles  and  could  play 


PROGRESSIVE  LEXTICULAR  DEGENERATION 


3" 


games  like  other  boys,  bin  his  mother  thinks  he  was  somewhat 
ckimsy  even  previously.  It  is  certain,  at  least,  that  shortly  after- 
ward he  had  a  distinct  tremor  in  his  hands  and  a  stiffness  in  his 
legs  so  that  he  could  not  run  well.  This  stift'ness  has  troubled  him  a 
great  deal  since  and  the  right  leg  has  been  worse  than  the  left. 
There  have  been  no  convulsions.  There  is  some  speech  disturbance 
but  no  evidence  as  to  when  it  appeared. 


Fig.  II. 


In  September,  1912,  he  decided  to  go  west  with  some  other  boys. 
Under  their  direction  he  broke  into  a  store  to  get  some  heavy  shoes, 
was  apprehended  and  sent  to  the  State  Reformatory,  September  14, 
191 2,  where  he  still  is. 

When  examined,  very  briefly,  on  September  12,  he  was  clumsy 
in  the  use  of  his  hands  and  feet,  hesitating  in  his  speech  and  com- 
plained of  headache.  His  pupils  reacted  to  light  and  accommoda- 
tion. There  was  a  nystagmoid  movement  and  general  muscular 
hypertonus.  The  patellar  reflexes  were  active  and  the  plantar  re- 
flexes were  flexor. 

A  second  examination  was  made  at  the  St.  Cloud  Reformatory, 
December  7,  191 3. 

Physical  examination:  The   patient  was  five   feet,  eight  inches 


312  ARTHUR  S.  HAMILTOX  AXD  HERBERT  W.  JOSES 

high.  His  ordinary  weight  had  been  one  hundred  and  fifty  pounds, 
and  at  the  time  of  the  examination  was  one  hundred  and  fifty-four. 
His  nutrition  and  general  development  were  exceptionally  good  and 
there  were  no  atrophies.  His  head  was  not  very  large.  The  fore- 
head was  low  and  narrow  (Figs.  lo  and  ii).  The  ears  were  well 
shaped  and  the  palate  was  well  arched.  The  teeth  were  {properly 
set  and  well  preserved.  The  neck  was  muscular  and  unusually 
large.  The  tongue  was  clean  and  there  was  no  pyorrhea.  The 
pulse  was  sixty-six.  full  and  regular.  The  radial  and  temporal 
arteries  were  not  thickened.  The  area  of  superficial  heart  dullness 
was  rather  small.  The  heart  sounds  were  clear  and  there  were  no 
nuirmurs.  The  systolic  blood  pressure  was  one  hundred  and  ten. 
The  patient  said  his  hands  and  feet  became  blue  very  easily,  and  at 
the  time  of  the  examination  the  hands,  feet  and  face  were  all  some- 
what cyanotic.  There  was  no  other  vasomotor  disturbance,  but 
there  was  some  roughness  of  the  skin  over  the  entire  body  and  espe- 
cially on  the  legs.  There  was  no  pigmentation  of  the  cornea  antl  no 
discoloration  of  the  skin. 

The  respiratory  system  was  normal  except  that  several  times 
during  the  examination  he  showed  the  same  deep  inspiratory  action 
as  his  brother,  only  less  frequently.  His  laugh  was  also  nuich  like 
his  brother's,  and.  in  the  language  of  the  guard,  "  he  laughed  with  a 
haw,  haw,  haw,  like  a  mule." 


^, 


Fig.  12. 

He  walked  with  a  stiff,  somewhat  halting  gait  and  held  to  things 
in  going  up  anrl  down  stairs  'ilie  muscles  were  all  large  and  well 
developed.  Motor  {)Owcr  was  good  in  the  neck,  arms,  trunk  and 
legs,  but  the  right  arm  was  distinctly  more  powerful  than  the  left. 
'I'he  legs  were  equal  in  power.  The  arms  (lid  not  tire  with  undue 
readiness,  'ihe  hands  were  alternately  jironated  and  supinated 
very  slowly  but  ef|ually.  He  wrote  with  spme  hesitancy,  but  not 
with  such  slowness  as  his  brother  showed,  and  there  was  an  occa- 
sional slight,  stiff  jerk  of  the  hand,  as  is  seen  in  the  second  "i"  in 
"  MinneajHjlis  "  (Fig.  12). 

There  was  an  almost  constant  coarse  jerking  of  the  right  hand 
and  arm,  increased  on  ctforl,  and  .shown  esi)ecially  in  such  actions  as 
buttoning  his  clothes.  .\t  these  times  the  thumb  tended  to  be  in 
extension  on  the  hand  and  the  little  finger  in  flexion.     There  was  a 


PROGRESSIVE  LENTICULAR  DEGENERATION  313 

similar  slight  jerking"  in  the  left  hand  and  arm.  There  was  no  con- 
tracture but  all  the  muscles  were  hypertonic  and  the  arms  and  legs 
were  very  spastic  when  passively  moved,  the  arms  more  so  than 
the  legs,  and  the  right  arm  more  than  the  left.  There  was  no 
athetosis  and,  aside  from  special  effort,  no  fixed  attitude  in  which 
the  hands  were  held.  The  patient  thought  the  jerking  in  the  right 
hand  had  been  rather  marked  the  preceding  winter  and  better  again 
the  past  summer.  The  guard  said  there  had  been  no  permanent 
change  but  he  and  the  patient  agreed  in  that  it  varied  from  time  to 
time,  and  the  guard  added  that  the  patient's  general  physical  and 
mental  condition  underwent  similar  variations.  The  guard  stated 
also  that  the  patient's  walking  had  improved  since  coming  to  the 
reformatory. 

He  stood  with  eyes  closed  and  walked  backwards  and  forwards 
without  difficulty.  There  was  some  trouble  in  walking  a  crack  but 
no  ataxia  of  the  hands  in  the  finger  to  nose  test.  The  patellar  and 
Achilles  jerks  were  active  but  equal  on  the  two  sides.  The  triceps, 
biceps,  and  supinator  jerks  were  active  and  more  so  on  the  right 
side  than  on  the  left.  There  was  no  ankle  or  patellar  clonus. 
Both  plantar  reflexes  were  uncertain,  sometimes  extensor  and  some- 
times flexor.  The  right  abdominal  reflex  was  normal,  the  left  was 
faint.  The  pharyngeal,  cremasteric  and  organic  reflexes  were  all 
normal. 

Cutaneous  sensibility  was  everywhere  normal  to  touch  (cotton), 
pin  prick,  temperature  changes  and  pressure.  Joint  sensibility  and 
deep  muscle  sense  were  preserved.  Sight,  taste  and  smell  were 
normal  and  equal  on  the  two  sides.  He  distinguished  colors  readily 
and  there  was  no  disturbance  of  the  field  of  vision.  The  pupils 
were  equal  and  reacted  normally  to  light  and  accommodation.  All 
the  external  ocular  movements  were  normal.  There  was  no  diplopia 
or  nystagmus.  The  fundus  examination  was  also  negative.  There 
was  no  disturbance  of  the  motor  or  sensory  divisions  of  the  fifth. 
In  speech  and  in  smiling  the  right  side  of  the  face  was  drawn  up 
more  than  the  left  and  moved  more  freely,  but  in  all  voluntary 
movements  the  two  sides  of  the  face  moved  equally.  He  heard  a 
watch  at  two  and  one  half  feet,  and  air  conduction  was  greater  than 
bone  in  both  ears.  He  complained  of  a  ringing  noise  at  times,  heard 
in  both  ears. 

The  speech  was  distinctly  thick  but  he  knew  this  only  from 
having  been  told  so  and  had  no  idea  when  it  appeared.  He  ate  with 
some  difficulty  and  at  times  choked  on  liquids.  He  could  blow  out 
a  match  but  W'histled  very  badly  and  was  not  able  to  close  his  lips 
firmly.  He  said  test  phrases  correctly  and  fairly  rapidly.  The 
tongue  was  protruded  weakly  into  the  cheeks,  especially  the  right, 
and  only  a  short  distance  beyond  the  teeth.  There  was  no  atrophy 
or  fibrillary  tremor. 

The  genito-urinary  system  was  normal.  He  urinated  about 
eight  times  a  day  and  once  at  night.  He  slept  only  fairly  but  said 
he  seldom  dreamed. 

His  face  had  usually  a  happy,  child-like  expression  and  he  was 
very  mild  in  all  his  speech  and  actions,  but  he  showed  some  vin- 


314  ARTHUR  S.  HAMILTOX  AXD  HERBERT  W.  JOKES 

dictiveness  in  recalling  the  imaginary  grievances  to  which  he  had 
been  subjected.  He  was  oriented  as  to  time.,  place  and  surround- 
ings, and  attended  fairly  well  to  questions  but  was  rather  slow  in  com- 
prehension and  decidedly  slow  in  responding.  His  entire  attitude 
was  childish  and  his  memory  was  deticient.  For  example,  his  state- 
ment as  to  the  details  of  his  illness  was  considerably  at  variance 
with  that  of  his  mother,  and  he  had  difficulty  in  recalling  incidents 
in  which  he  was  concerned  as  recently  as  a  few  months  back.  There 
was  no  special  tendency  to  emotionalism  but  he  s])oke  with  affection 
of  his  home  and  family  and  said  he  wanted  to  return  to  them.  Ap- 
parentlv  there  was  no  real  comprehension  of  the  fact  that  he  had 
committed  a  serious  oft'ense  for  which  he  was  being  punished  arid 
he  seamed  to  think  that  an  application  from  his  parents  was  the 
only  thing  necessary  to  secure  his  release. 

He  was  examined  again  at  the  State  Reformatory  November 
24,  1914.  His  attendant  stated  that  he  had  failed  decidedly  since 
the  preceding  examination  and  this  was  evident  at  once  when  he 
was  seen.  He  came  into  the  examination  room  with  a  decidedly 
spastic  gait.  The  left  arm  was  abducted  from  the  side.  The  fore- 
arm was  strongly  flexed  on  the  arm  and  the  hand  was  flexed  at  the 
wrist.  The  fingers  were  held  in  a  fixed  position,  somewhat  similar 
to  those  of  his  brother  (case  I).  The  right  arm  was  held  against 
his  side  and  flexed  at  the  elbow  but  to  a  less  degree  than  the  left. 
The  right  hand,  also,  w^as  less  spastic  and  less  in  contraction  than 
its  fellow.  By  passive  movement,  the  contractions  in  both  extremi- 
ties were  readily  relieved  but  the  parts  soon  returned  to  their  former 
position  when  released.  Both  feet,  but  especially  the  left,  were 
dragged  on  the  floor.  The  face  had  a  dull,  heavy  and  somewhat 
sleepy  look.  The  lower  lip  drooped  decidedly,  the  face  was  some- 
what flushed,  and  the  hands  and  feet  were  very  cyanotic.  This 
cyanosis  extended  almost  to  the  knees  and  half  way  to  the  elbows. 
He  was  carelessly  dressed  and  his  whole  appearance  was  that  of  a 
much  less  intelligent  man  than  at  his  former  examination.  His 
speech  was  considerably  disturbed  and  none  of  his  words  were 
articulated  clearly,  although  when  an  attempt  was  made  to  get  him 
to  rcsj)ond  to  test  ])hrases,  he  made  no  gross  mistakes.  He  said  he 
had  trouble  in  drinking  liquids,  and  frequently  choked  on  them,  but 
had  no  difficulty  in  taking  solid  food.  He  could  not  whistle  or  blow 
out  a  match  and  when  he  attempted  to  puff  out  his  cheeks,  his  lips 
seemed  weak  and  flal)by.  The  tongue  was  pushed  feebly  into  the 
cheeks  and  was  not  protruded  beyond  the  teeth.  There  was  no 
dribbling  of  saliva.  The  palate  reflex  was  present.  The  external 
and  internal  ocular  muscles  were  normal  in  their  actions.  There 
was  no  nystagmus  or  diplopia.  Sight  and  hearing  were  good. 
The  gross  strength  in  the  legs  and  arms  was  good.  There  was  no 
atrophy  and  no  sensory  disturbance,  either  subjective  or  objective. 
All  the  muscles  of  the  arms  and  the  legs  were  in  di.stinct  hypertonus 
but  this  was  more  marked  in  the  arms  than  in  the  legs  and  more 
marked  in  the  right  side  of  the  body  than  in  the  left.  The  biceps, 
triceps,  supinator,  patellar  and  .\chillcs  jerks  were  active.     A  posi- 


PROGRESSIVE  LENTICULAR  DEGENERATION  315 

tive  ankle  clonus  Avas  developed  on  both  sides  although  persistent 
for  only  a  short  time.  Both  plantar  reflexes  were  unsatisfactory, 
often  flexor  and  never  clearly  extensor.  In  both  hands,  when  in 
action,  there  was  a  distinct  gross  tremor,  much  like  that  of  his 
brother,  with  an  amplitude  of  two  or  three  inches  and  four  or  five 
movements  per  second.  In  bringing  a  glass  of  water  to  his  lips 
with  either  hand,  the  tremor  was  very  pronounced,  but  not  much 
increased  at  the  termination  of  the  movement.  He  recognized  that 
his  condition  was  similar  to  that  of  his  brother  and  that  he  was  seri- 
ously ill.  He  asked  if  it  were  possible  that  he  should  ever  recover, 
and  when  told  that  it  was  not  he  said  "  It  is  hard  luck."  At  first 
he  was  evidently  depressed  but  shortly  returned  to  his  former  state 
of  cheerful  apathy.  Frequently  a  broad  and  persistent  smile  over- 
spread his  face.  He  was  fully  oriented,  asked  after  members  of 
his  family,  especially  his  mother,  and  seemed  interested  in  others. 
He  also  told  some  news  received  in  a  recent  letter.  The  guard 
stated  that  his  memory  was  failing. 

Case  III.  At  the  visit  of  November  24,  1914,  another  brother 
was  seen.  He  had  recently  been  committed  to  the  reformatory 
for  some  lawlessness.  He  was  24  years  old,  of  medium  size,  but 
very  well  developed  and  very  muscular.  At  the  reformatory  he  had 
the  reputation  of  being  "a  bad  man."  A  careful  examination 
failed  to  show  any  sign  of  the  family  ailment  unless  the  fact  that 
the  sole  of  his  right  shoe  was  very  much  worn  at  the  anterior  and 
inner  part,  as  if  he  were  beginning  to  drag  his  right  foot,  can  be 
accepted  as  such.  This  condition  was  limited  to  one  shoe  and 
there  was  no  apparent  cause  for  it  other  than  the  way  in  which  he 
walked. 

Though  not  in  all  respects  typical  of  chronic  lenticular  disease  as 
outlined  by  Wilson  (i),  we  believe  our  cases  belong  in  his  group 
and  we  are  encouraged  in  this  belief  by  the  fact  that  several  of  the 
cases  reported  since  Wilson's  first  description  do  not  coincide  abso- 
lutely with  the  symptoms  as  given  by  him.  The  clinical  picture  as 
developed  by  Wilson  is  essentially  as  follows :  The  disease  appears 
in  young  people  and  while  often  familial  is  not  congenital  or  hered- 
itary. It  is  progressive  and  lasts  a  varying  period  from  a  few 
months  to  several  years  according  to  whether  we  are  dealing  with 
the  acute  or  chronic  type.  The  chief  clinical  signs  are :  a  general- 
ized tremor,  muscular  rigidity  and  hypertonicity,  spastic  contrac- 
tions and  contractures,  dysarthria,  dysphagia,  emotionalism  and  cer- 
tain other  mental  symptoms,  more  or  less  severe.  In  pure  type  the 
disease  is  extrapyramidal,  but,  at  times,  and  especially  late  in  its 
course,  signs  of  secondary  involvement  of  the  internal  capsule  may 
appear.  Atrophic  cirrhosis  of  the  liver,  though  constantly  found 
post  mortem,  is  rarely,  if  ever,  demonstrable  during  life. 

A  careful  examination  of  our  own  cases  shows  them  in  agree- 


3i6  ARTHUR  S.  HAMILTOX  AXD  HERBERT  W.  JONES 

nient  with  most  of  these  fundamental  features.  Thus  the  condi- 
tion is  clearly  familial  but  not,  so  far  as  determined,  hereditary. 
Two  children,  the  second  and  the  sixth  in  the  family,  are  un- 
doubtedly affected,  and  possibly  a  third,  and  at  least  two  others  are 
sufficiently  young  to  have  by  no  means  passed  the  danger  point. 
There  has  been  no  special  tendency  then  to  involve  the  older  chil- 
dren in  the  family,  as  Wilson  found  to  be  true  in  the  familial  cases 
investigated  by  him. 

We  have  already  stated  that  the  history,  as  given,  may  place 
excessive  emphasis  on  traumatism  as  the  etiological  factor.  Addi- 
tional history,  obtained  since  this  article  was  prepared,  makes  it 
doubtful  if  the  choking  complained  of  in  our  first  case  really  ever 
occurred  as  described. 

Cases  I  and  II  are  evidently  of  the  chronic  type  and,  at  the  time 
of  the  report,  have  lasted  eight  and  about  two  years,  respectively. 
The  average  duration  of  eight  chronic  cases,  as  given  by  Wilson, 
was  almost  exactly  four  years.  Three  acute  cases  died  at  four, 
six,  and  seventeen  months  respectively.  Dr.  Homen's  case  (2) 
lasted  seven  years.  Cassirer's  (3)  had  lasted  thirteen  years. 
Sawyer's  case  (4)  (accepted  with  some  reservations  by  Wilson) 
had  lasted  seventeen  years.  Cadwalader's  second  case  (5)  had 
lasted  twenty  years  and  Striimpell's  case  (6)  had  lasted  twenty- 
eight  years  at  the  time  the  reports  were  made.  Therefore,  the  longer 
duration  of  our  cases  than  the  average  determined  by  Wilson,  can 
hardly  be  accepted  as  a  vital  diagnostic  factor  unless  the  other  cases 
mentioned  are  to  be  excluded.  It  may  also  be  added  that,  with 
most  new  diseases,  subsequent  experience  has  usually  added  to,  sub- 
tracted from,  or  otherwise  modified  the  features  of  the  initial 
description. 

In  resjjcct  to  the  motor  phenomena  our  cases  are  not  in  entire 
agreement  with  Wilson's  descrii)tion,  although  here  again  there  has 
been  considerable  variation  in  the  symptoms  described  in  certain 
recent  cases.  Tremor  is  jiresent  in  both  of  our  patients  but  is 
hardly  so  persistent  or  widespread  as  it  appears  to  have  been  in 
most  of  Wilson's  cases.  Moreover  in  case  I  this  tremor  has  grown 
less  in  the  later  stages  of  the  disease,  in  which  respect  it  is  in 
agreement  with  Sawyer's.  Cassirer's  and  Striimpell's  cases,  though 
opposed  to  the  j)rinciple  laid  down  by  Wilson  that  "  as  the  disease 
progresses,  the  tremor,  according  to  the  experiences  of  all  the 
observers,  becomes  worse  in  every  way."  At  the  present  time  the 
tremor  has  largely  disappeared  from  the  right  hand  of  our  case  I. 
It  has  been  .suggested  that  such  a  disaj)pearancc  may  be  exj)lained 


PROGRESSIVE  LENTICULAR  DEGENERATION  317 

on  the  basis  of  a  gradually  increasing  pyramidal  lesion.  In  support 
of  this  suggestion  our  cases  offer  some  evidence.  In  Wilson's 
second  case  the  tremor  is  spoken  of  as  varying  greatly  in  intensity 
from  time  to  time  and  in  two  other  cases  accepted  by  him  for 
analysis,  the  tremor  was  not  quite  so  pronounced  as  in  others.  In 
both  of  our  patients  the  tremor  is  more  marked  distally  than 
proximally,  is  inconstant  in  the  intensity  of  its  manifestations  from 
time  to  time,  is  increased  by  attention  and  excitement,  is  often  prac- 
tically ab.>ent  when  the  muscles  are  at  rest  and  disappears  entirely 
in  sleep.  Especially  in  case  I  it  increases  steadily  in  range  from  the 
inception  of  a  movement  until,  at  the  end  of  the  movement,  it  has 
reached  its  height.  That  a  clear  distinction  can  be  drawn  between 
the  tremor  in  our  patients  and  the  typical  intention  tremor  of  dis- 
seminated sclerosis,  we  do  not  believe,  unless  its  variation  in  degree 
on  different  occasions  can  be  relied  upon  as  a  distinguishing  sign. 

As  has  been  true  in  all  cases  observed  by  others,  hypertonus  has 
been  a  very  pronounced  feature.  In  the  second  case  it  has  in- 
creased steadily  as  we  have  observed  the  progress  of  the  disease  and 
at  all  times  has  been  prominent  in  both  cases,  but  it  has  seemed  to 
diminish  somewhat  in  case  I,  in  the  later  stages,  and,  at  the  present 
time,  there  are  periods  when,  in  the  arms,  it  disappears  and  the  arms 
become,  for  a  few  moments,  even  hypotonic.  This  is  contrary  to 
Wilson's  experience  but  was  true  of  Sawyer's  case  and  in  Cassirer's 
and  other  cases  there  were  distinct  changes  in  the  degree  of  stiff- 
ness at  different  times.  We  have,  also,  on  several  occasions  demon- 
strated in  case  I  that,  in  deep  sleep,  hypertonicity  disappears  every- 
where in  the  body,  contrary  again  to  Wilson's  and  Sawyer's  observa- 
tions. The  hypertonicity  in  the  waking  period  is  seen  readily  in 
the  mask-like  expression  of  the  face  (Figs.  2,  3,  5,  6),  and  in  the 
fixed  attitude  of  the  body  and  extremities.  Thus  when  F.  W. 
(case  I)  is  lying  down  it  is  often  noted  that  his  head  does  not  touch 
the  pillow  and  all  the  muscles  of  the  neck  are  exceedingly  firm. 

Though  contractions  are  pronounced  in  case  I  and  very  distinct 
in  case  II,  no  definite  contractures  have  developed  up  to  the  present. 
Thus  by  patient,  passive  movements,  all  the  contractions  of  the 
muscles  and  the  abnormal  positions  of  the  limbs  in  either  case,  can 
be  overcome  but,  if  the  parts  are  left  to  themselves,  they  quickly 
return  to  their  former  position.  In  both  cases  there  is  a  distinct 
tendency  to  flexion  contraction  of  the  upper  extremities  but  in  both, 
and  especially  in  case  I,  there  is  a  very  pronounced  tendency  to 
hyperextension  of  the  legs.  In  one  of  Gowers's  (7)  cases,  the  legs 
were  extended  at  the  knees  and  the  arms  at  the  elbows.     Wilson 


3i8  ARTHUR  S.  HAMILTOX  AND  HERBERT  W.  JOKES 

states  that  the  only  vohmtary  muscles  not  affected  by  this  hyper- 
tonicity  are  the  extrinsic  ocular  muscles. 

Dysarthria  and  dysphagia  have  reached  an  advanced  stage  in 
case  I.  and  are  fairly  well  developed  in  case  II,  and  evidently  still 
increasing  in  the  latter,  but  in  neither  is  there  a  complete  paralysis 
of  the  palate. 

Probably  in  no  respect  do  our  cases  diverge  so  greatly  in  im- 
portant features  from  Wilson's  description,  as  in  the  evidence  of 
pyramidal  disease.  Wilson  has  shown,  both  clinically  and  patho- 
logically, that  the  motor  involvement  is  essentially  extra-pyramidal 
In  both  our  cases  the  motor  symptoms  were  clearly  extra-pyra- 
midal when  first  seen  but  in  case  I  the  abdominal  reflexes  were 
found  to  be  very  greatly  diminished  in  the  spring  of  191 3,  and,  on 
one  occasion,  during  the  following  summer,  both  plantar  responses 
were  clearly  extensor,  though  repeated  attempts  previously  and 
afterwards,  always  gave  a  flexor  response.  At  the  time  of  writing 
this  article  (1915)  an  extensor  response  is  frequently  obtained  in 
the  left  foot  but  never  in  the  right.  In  the  second  case.  api)roxi- 
mately  one  year  after  the  first  examination,  the  left  abdominal  re- 
flexes were  faint  and  the  plantar  reflexes  were  uncertain,  sometimes 
flexor  and  sometimes  extensor.  At  the  last  examination  (1914) 
there  was  a  double  ankle  clonus  of  short  duration  and  the  plantar 
responses  were  described  as  often  flexor  and  never  clearly  extensor. 
Even  in  these  respects,  however,  the  deviation  from  the  accepted 
type  is  not  necessarily  vital.  In  one  of  Wilson's  cases  (No.  i)  which 
came  to  autopsy,  the  disease  had  slightly  involved  one  internal 
capsule,  and  in  this  case  there  was  an  extensor  plantar  response  on 
the  corresponding  side  and  a  loss  of  abdominal  reflexes  on  both  sides, 
and  in  another  of  his  cases  (IV)  the  abdominal  reflexes  were  lack- 
ing (possibly  due  to  the  condition  of  the  abdominal  wall)  and  one 
plantar  response  was  uncertain.  Also  Sawyer's  case,  at  one  time, 
had  a  double  ankle  clonus  of  short  duration,  and  an  extensor  plantar 
response  on  one  side  was  obtained,  although  both  these  changes 
were  lacking  at  a  later  period.  In  Cassirer's  case  there  was  evi- 
dently some  uncertainty  at  times  as  to  the  jjlantar  response.  In  one 
of  Oppenheim  and  Vogt's  cases  (8)  (a  lesion  of  the  striated  body, 
though  i)robably  not  a  true  case  of  Wilson's  disease)  a  double 
plantar' extension  was  present  at  one  examination.  Vogt  thinks 
there  may  be  two  varieties  of  this  response,  one  a  true  Babinski  and 
the  other  merely  an  evidence  of  spasm,  but  it  seems  to  us  that 
the  nearness  of  the  pyramidal  tract  to  the  lesion  in  the  lenticular 
nucleus  allows  the  assumi)tion  of  a  varying  degree  of  interference 


PROGRESSIVE  LENTICULAR  DEGENERATION  319 

with  the  activity  of  the  pyramidal  tract,  and,  if  so,  this  will  readily 
explain  the  appearance  at  one  time  and  the  absence  at  another,  of 
some  evidence  of  pyramidal  involvement. 

Nystagmus  has  been  present  in  both  our  cases  at  times,  contrary, 
however,  to  all  other  reported  cases,  so  far  as  we  have  observed,  and 
double  vision  has  been  present  at  one  time  in  both,  if  the  record  is 
to  be  relied  upon,  but  only  after  a  history  of  recent  traumatism.  In 
Wilson's  first  case,  the  eyes  are  described  as  "dancing"  before 
coming  to  rest,  and  in  two  recorded  cases  we  have  found  the  state- 
ment that  "  no  true  nystagmus  was  found,"  implying  that  some  sort 
of  unusual  movement  was  present. 

In  case  II  there  was  no  demonstrable  external  or  internal  ocular 
muscle  defect  but  in  case  I  the  external  eye  muscles  had  an  unusual, 
jerky  action  on  voluntary  movement,  although  there  was  no  apparent 
hypertonicity  and  all  movements  were  performed  quickly  and  easily. 

Sawyer  refers  to  attacks  when  his  patient  would  for  a  time  be 
very  much  dazed.  A  similar  condition  was  present  in  case  I,  and 
there  were  several  of  these  attacks  in  the  course  of  the  illness. 
Case  II  presented  the  same  phenomenon,  but  apparently  only  when 
associated  with  some  traumatic  condition.  There  was  also,  in  both 
of  our  cases,  a  marked  variability  in  the  symptoms,  both  mental 
and  physical,  a  condition  to  which  Wilson,  Cowers,  Ormerod, 
Homen  and  others  have  referred.  This  variability  is  well  shown 
in  the  statement  of  the  mother  that  F.  W.  (case  I)  would  some- 
times be  in  very  fair  condition,  on  one  day,  and  the  next  morning 
would  be  unable  to  walk  or  talk. 

Emaciation  and  muscular  weakness  are  symptoms  referred  to 
by  Wilson  as  common  and  significant.  Neither  has  been  present  in 
any  pronounced  degree  in  our  cases  but  this  may  be  because  both 
belong  to  the  group  of  chronic  cases  and  neither  has,  as  yet,  ad- 
vanced sufficiently  far.  In  case  I  there  has  been  a  distinct  falling 
off  in  strength  during  the  period  of  our  observation  and,  at  times, 
the  patient  has  lost  weight  but  there  has  never  been  a  condition  to 
which  the  terms  emaciation  or  great  physical  weakness  could  apply, 
and  even  such  falling  off  in  weight  as  has  been  observed  has  been 
largely  due,  we  believe,  to  the  great  difficulty  in  feeding  the  patient. 

Cassirer,  especially,  has  called  attention  to  cyanosis  of  the  hands 
and  feet  and  the  lessening  of  the  vessel  reflexes  in  his  case  and,  in 
common  with  Miiller  and  Glaser  (n),  believes  that  certain  parts  of 
the  midbrain  have  an  influence  on  the  innervation  of  the  vessels. 
Though  the  cyanosis  and  sluggishness  of  the  vessel  reflexes  were 
well  marked  in  our  cases,  we  can  not  say  that  they  were  greater 


320  .IRTHUR  S.  HAMILTON  AXD  HERBERT  W.  JONES 

than  we  have  observed  in  chronic  progressive  chorea,  for  example, 
where  the  pathological  condition  may  also  well  be  in  the  median  area 
of  the  brain.  Like  other  investigators,  we  have  been  unable  to  find 
any  definite  evidences  of  liver  trouble  but  the  history  of  attacks 
of  javmdice  in  both  cases,  preceding  the  onset  of  symptoms  of 
nervous  disorder,  and  of  cramp-like  attacks  in  the  upper  abdomen 
in  case  I,  associated  with  jaundice,  are  suggestive.  Cadwalader's 
first  patient  had  a  yellowish  skin.  Wilson's  case  I,  four  years 
before  the  known  onset  of  her  final  illness,  had  an  attack  of 
jaundice,  of  five  weeks'  duration,  and  his  case  IV  had  an  attack  of 
jaundice,  of  three  weeks'  duration,  five  years  before  coming  under 
observation. 

The^  laboratory  tests  in  our  cases  are  largely  negative.  No 
urinarj'  findings  of  any  consequence  were  ever  obtained  in  case  II 
and  in  case  I  repeated  tests  of  the  urine  were  negative,  except  at  the 
time  of  the  first  examination,  when  the  urine  gave  a  sugar  reaction 
and  showed  albumen  and  casts.  Why  these  findings  have  not  been 
obtained  later,  we  are  unable  to  say.  Wilson  says  that  glycosuria 
has  not  been  observed  except  in  Anton's  (9)  case.  In  Zappert's 
(10)  case,  which  appears  to  us  a  very  doubtful  instance  of  Wilson's 
type  of  chronic  lenticular  degeneration,  the  ingestion  of  30  gm.  of 
galactose  gave  a  positive  sugar  reaction  in  the  urine. 

There  has  been  no  opportunity  to  do  a  spinal  puncture  except  in 
case  I.  The  only  positive  findings  here  were  "  foreign  bodies"  in  a 
slightly  cloudy  fluid,  present  on  one  occasion  (1914)  and  not  found 
in  some  fluid  withdrawn  a  few  days  earlier  and  again  a  few  days 
later.  A  spinal  fluid  test  made  in  1913  showed  a  clear  fluid  with 
four  lymphocytes  per  cm.,  and  no  globulin  or  W^asscrmann  reaction. 

Mental  symptoms,  in  some  degree,  have  been  present  in  most  of 
the  recorded  cases  but  there  has  been  much  variability  in  the  degree 
of  involvement  and  frequently  such  expressions  as  "  the  patient 
seems  much  more  demented  than  he  really  is  "  are  found  in  ])ub- 
lishcd  reports.  In  case  1  our  oijjjortunities  for  dctfrniining  the 
mental  state  were  much  better  than  in  case  II  but  in  both  there 
has  been  a  progressive  mental  deterioration  since  they  were  first 
observcfl. 

l',ven  at  the  beginning  of  case  1  it  was  stated  that  the  patient 
would  go  into  a  violent  rage  without  adequate  provocation.  W  hen 
first  seen  by  us  his  dull,  listless  expression  suggested  a  rather  well- 
developed  dementia  but  when  spoken  to  his  face  would  become 
animated,  he  attended  well  to  what  was  said,  comprehended  readily, 
was  well  oriented  and  showed  at  least  fair  judgment  in  what  he 


PROGRESSIVE  LENTICULAR  DEGENERATION  32t 

said  and  did.  Later,  in  the  hospital,  he  always  seemed  pleased  to 
see  any  one  he  knew  and  was  very  anxious  to  converse  with  him 
as  far  as  his  limited  writing  capabilities  permitted.  When  visited 
by  his  mother,  he  would  take  advantage  of  the  opportunity  to  ask 
to  be  removed  from  the  hospital  and  would  complain  of  various  ill 
treatments,  but  as  a  rule  he  was  good-tempered  and  cheerful,  and, 
although  he  seemed  in  a  way  to  realize  his  situation,  he  gave  little 
evidence  of  being  depressed  by  it.  At  times,  with  little  or  no  cause, 
he  would  become  very  angry,  and  at  such  times  his  actions  were 
vicious  so  far  as  circumstances  permitted,  but  afterwards  the  afifair 
always  seemed  to  him  more  a  matter  of  fun  than  anything  else  and 
he  would  take  considerable  pleasure  in  indicating  by  gestures  what 
he  had  done.  Thus,  for  example,  he  always  took  pride  in  indicating 
how  he  had  kicked  a  woman  nurse  in  the  breast,  so  as  to  knock 
her  over.  Apparently  he  did  not  maintain  ill  feeling  against  any 
one  at  whom  he  had  been  angry. 

During  his  first  admission  to  the  hospital  he  was  able  to  walk 
about  a  little,  and  he  would  pick  up  papers  and  magazines  and  seem 
to  comprehend  their  contents,  and,  so  far  as  could  be  determined, 
recall  what  he  had  read.  There  was  no  aphasia  including  agnosia 
and  apraxia.  His  writing  was  very  difficult  to  read  but  he  used 
words  properly  and  could  spell  with  accuracy  such  words  as  he 
used.  At  his  first  examination  he  followed  the  "actions  of  the 
physician  with  apparent  interest  and  seemed  aware  of  all  that 
happened.  As  time  passed,  this  power  of  attention  decreased  until 
now  it  is  possible  to  walk  up  to  his  bedside  and  go  through  a  con- 
siderable examination  with  scarcely  any  change  in  his  stolid,  heavy 
expression. 

During  the  earlier  part  of  his  observation  he  laughed  freely  and 
on  slight  provocation  and  his  laughter  was  most  peculiar,  though 
the  term  "  explosive  "  which  appears  in  Wilson's  and  other  articles, 
hardly  characterizes  it.  Under  sufficient  provocation,  a  smile  would 
spread  slowly  over  his  face.  His  mouth  would  open  widely  and 
at  the  same  time  he  would  emit  a  peculiar  sound.  When  once  set, 
the  face  would  remain  fixed  in  this  position  so  long  as  to  be  ex- 
tremely ludicrous.  A  good  illustration  of  his  appearance  when 
laughing  is  seen  in  Figs.  7  and  8.  At  present  his  laughter  is  much 
less  frequent,  the  evidence  of  mirth  is  much  less  marked  and  the 
sound  accompanying  it  is  not  often  heard.  An  evidence  that  his 
mental  power  is  by  no  means  gone,  however,  lies  in  the  fact  that 
he  has  recently,  under  tutelage,  acquired  a  certain  facility  in  the  use 
of  the  sign  language,  carried  on  mostly  with  the  right  forefinger. 


322  ARTHUR  S.  HAMILTOX  AND  HERBERT  H'.  JOXES 

The  mental  condition  in  case  II  is  somewhat  diti'ercnt  from  that 
in  case  I.  Here  the  evidence  of  true  dementia  is  more  clear. 
Althoui,di  the  patient  is  still  able  to  speak  in  an  understandable  way, 
his  language  is  childlike  and,  though  twenty  years  old,  he  gives  the 
impression  of  one  whose  mind  is  that  of  a  much  younger  person. 
He  is  not  alert  and  talkative  but  w'hen  his  attention  is  drawn 
strongly  to  what  is  said,  he  seems  to  comprehend.  When  the  matter 
is  brought  before  him,  his  progressive  disease  seems  to  cause  much 
more  mental  pain  than  is  the  case  with  the  brother,  but  at  other  times 
he  is  happy  and  enjoys  himself,  especially  when  he  can  be  out  in 
the  grounds  of  the  reformatory.  Incontinence  of  the  urine  and 
feces  is  now  frequently  present  although  not  so  when  he  was  first 
seen.  This  condition  seems  to  us  much  more  the  result  of  a  lack  of 
interest  in  the  matter  than  of  any  special  sphincter  weakness. 

Thus  far  we  have  contented  ourselves  with  describing  the  rela- 
tion of  our  cases  with  chronic  lenticular  degeneration.  A  possible 
pathological  and  even  clinical  relationship  between  chronic  lenticular 
degeneration  and  paralysis  agitans  has  been  often  described,  and 
Striimpell  (6),  in  a  recent  article,  announces  his  belief  that  paralysis 
agitans,  pseudo-sclerosis  and  Wilson's  disease  all  belong  to  the 
same  group.  Paralysis  agitans,  without  agitation,  he  regards  as 
particularly  like  Wilson's  disease.  Nevertheless,  it  seems  hardly 
necessary  to  defend  our  cases  against  a  diagnosis  of  paralysis 
agitans,  giving  this  disease  its  usual  recognition  as  a  distinct  entity. 
That  they  may  not  belong  with  the  Westphal-Striimpell  type  of 
pseudo-sclerosis  is  by  no  means  so  clear  and  the  more  the  cases  are 
multiplied  under  these  two  headings  the  more  difficult  does  the  dis- 
tinction become.  Several  cases  are  now  on  record,  generally  ac- 
cejjted  as  pseudo-sclerosis,  where  the  autopsy  has  revealed  a  very 
definite  lesion  of  the  lenticular  nucleus  though  none  in  which  the 
changes  in  this  region  have  been  so  pronounced  as  in  Wilson's  cases, 
or  where  the  changes  were  so  clearly  limited  to  the  lenticular  and 
subthalamic  regions.  The  liver  apjjears  to  be  in  much  the  same  con- 
ditifin  in  the  two  diseases  but  in  the  cases  of  pseudo-sclerosis  a  large 
amount  of  pigment  has  been  described  in  the  internal  organs  and  this 
has  also  been  found  clinically  in  the  outer  ring  of  the  cornea.  As- 
suming that  there  may  be  a  clear  differentiation  between  Wilson's 
disease  and  pseudo-sclerosis,  it  would  appear  that  the  early  and 
marked  mental  flisturbance  insisted  ujjon  so  strongly  by  Striimpell, 
in  the  latter,  together  with  the  hemi-paresis  and  ])ara-paresis  and  the 
corneal  jjigmentation,  all  argue  strongly  against  the  admission  of 
our  cases. 


PROGRESSIVE  LENTICULAR  DEGENERATION  323 

In  conclusion  we  may  refer  briefly  to  the  differential  diagnosis 
from  pseudo-bulbar  palsy.  The  history  of  traumatism  in  our  cases 
may  at  first  suggest  svich  a  diagnosis,  but  when  one  recalls  the 
familial  nature  of  the  disease,  its  slowly  progressive  character,  the 
failure  of  any  definite  signs  of  pseudo-bulbar  palsy  to  appear 
directly  after  the  accidents  and  the  lack  of  such  clear  and  constant 
signs  of  pyramidal  tract  involvement  as  would  certainly  be  present 
if  one  were  dealing  with  true  pseudo-bulbar  palsy,  it  seems  that  the 
diagnosis  may  be  dismissed  except  in  the  sense  mentioned  by  Wilson, 
that  the  geniculate  fibers  may,  at  some  subsequent  period,  become 
involved. 

Note:  F.  W.  (case  I)  died  March  13,  1915,  and  the  autopsy 
showed  an  enlarged  spleen,  a  typical  cirrhosis  of  the  liver  and  a 
bilateral  lesion  of  the  lenticular  nuclei.  A  complete  description  of 
these  findings  will  be  given  at  a  later  time. 

REFERENCES 

1.  Wilson.     Progressive  Lenticular  Degeneration.     Brain,  Part  IV,  Vol.  34, 

March,  1912. 

2.  Homen.     Eine   eigenthiimliche   Familienkrankheit,   unter  der   Form   einer 

progressive  Dementia,  mit  besonderem  anatomischen  Gefund.     Neurol. 
Centralbl..  Bd.  IX,  S.  514,  1890. 

3.  Cassirer.     Ein     Fall    von    progressiver    Linsenkernerkrankung.     Neurol. 

Centralbl.,  Nr.  20,  October  16,  1913. 

4.  Sawyer.     A  Case  of   Progressive  Lenticular   Degeneration.     Brain,   Part 

III,  Vol.  35,  February,   1913. 

5.  Cadwalader.     Progressive  Lenticular  Degeneration.     Jour.  A.  M.  A.,  Vol. 

LXIII,  No.  16,  October  17,  1914. 

6.  Striimpell.     Miinch.  Med.  Woch.,  Nr.  2,  S.  104,  January  i,  1914. 

7.  Cowers.     See  Wilson's  article,  p.  304. 

8.  H.  Oppenheim  u.  Vogt.     Jour.  Pysch.  u.  Neurol.,  XVIII,  1911.     Quoted 

from  L'hermitte,  La  Semaine  Medicale,  No.  11,  March  13,  1912. 

9.  Anton.     Dementia   choreo-asthenica  mit  juveniler  knotiger.     Hyperplasie 

der  Leber.,  Bd.  LV,  S.  2369,  November  17,  1908. 

10.  Zappert.   Progressive  Linsenkerndegeneration  (Wilson).  Wien.khn.  Woch., 

Nr.  7,  February  12,  1914. 

11.  Midler  u.  Glaser.     tjber  die  Innervation  der  Gefasse.     Deutsch.  Zeitschr. 

f.  Nervenheilk.,  XLVI,  S.  329. 


A   STUDY  OF  SOME   CASES   DIAGNOSED   AS   PARESIS 
IX    PRE-WASSERMAXX  DAYS^ 

Bv  Lawsox  G.  Lowrey,  A.M..  M.D. 

FELLOW    IX    NEUROP.\THOLOGY,    HARV.^RD    MEDICAL   SCHOOL;   PATHOLOGIST,   DANVERS 
ST.VTE    HOSPITAL,    HATHOKXE,    MASS. 

CONTENTS 

Page 

I.  Introduction    3-4 

Selection  of   Cases    3-4 

Object  of  Analysis    325 

Methods  325 

II.  Analysis  of   Cases    325 

The  "  Possible  "  Group :  13  Cases  325 

I   Confirmed. 
I   Unclassed. 
II   Not  Confirmed,  of  which  4  are  Dementia  PrEecox. 

The  "  Probable  "  Group :  17  Cases  3-7 

0  Confirmed. 
17  Not  Confirmed,  of  which  10  are  Dementia  Precox. 

The  "  Certain  "  Group :  28  Cases   327 

8  Confirmed. 
6  Unclassed. 
14  Not  Confirmed,  of  whicli  7  are  Dementia  Prsecox. 

III.  Discussion — Importance  of   Spinal   Fluid   Examination.     Differentia- 

tion between  Paresis  and  Dementia  Praecox  330 

IV.  Summary    33i 

I.  Introduction 

It  has  been  customary  for  many  years,  at  the  Danvers  State  Hos- 
pital, to  present  newly  admitted  cases  before  the  assembled  staflf  for 
diaj^nosis.  Records  of  such  staff  meetings  have  been  kept  since 
May,  1898.  For  some  years  past  every  case  admitted  has  been  so 
presented. 

Between  May,  1898,  and  the  early  i)art  of  1912  (prior  to  the 
routine  use  of  the  Wassermann  test)  paresis  was  considered  in  the 
diagnosis  of  about  810  cases  so  presented.  The  Wassermann  test 
on  the  blood  serum  was  made  a  part  of  the  routine  examination  of 
|)atients  admitted  in  May,  1912  (although  used  in  selected  cases 
in  1910J,  and  no  case  is  here  considered  in  which  a  Wassermann 
test  was  obtainefl  before  diagnosis. 

'  No.  56,  Danvers  State  Hospital  Papers.  Read  by  invitation  before  the 
meeting  of  the  New  luigland  Society  of  Psychiatry  and  Neurology,  North- 
ampton, Mass.,  March  30,  191 5. 

324 


PARESIS  IN  PRE-WASSERMANN  DAYS  325 

In  the  fall  of  1914,  58  of  these  cases  were  still  in  the  hospital. 
While  we  must  realize  that  these  are  unusual  cases,  in  that  the 
majority  of  the  real  cases  of  paresis  diagnosed  in  the  period  under 
consideration  were  dead,  it  nevertheless  seems  worth  while  to  ana- 
lyze these  cases  and  determine  {a)  the  correct  diagnoses  and  (t>) 
the  confusing  symptoms.  Such  a  study  should  be  of  aid  in  avoid- 
ing such  errors  in  the  future.  This  study  gives  no  idea  of  the 
accuracy  in  the  diagnosis  in  paresis,  which  has  been  estimated  by 
Southard  (i)    (on  autopsied  Dan  vers  cases)  at  85  per  cent. 

These  58  cases  fall  conveniently  into  three  groups,  which  are 
considered  separately.  In  13  cases,  paresis  is  considered  "possible," 
since  paresis  could  not  be  excluded,  although  the  case  was  classed 
in  some  other  group.  In  group  2  there  are  17  cases  in  which  the 
diagnosis  is  considered  "  probable,"  opinion  among  the  staff  being 
divided,  but  favoring  paresis.  The  third  group  comprises  28  cases 
considered  "  certainly  "  paresis,  all  members  of  the  staff  concurring 
in  the  diagnosis. 

The  method  of  investigation  was  as  follows :  The  chief  facts  as 
regards  onset,  signs  and  symptoms  and  course  were  tabulated.  A 
brief  examination  was  then  made  of  each  case  with  reference  to  the 
chief  neurological  and  mental  findings  of  paresis.  The  blood  serum 
(in  all  but  a  few)  was  submitted  to  the  Wassermann  test,  and  in 
certain  cases  (where  there  was  a  positive  blood  test,  or  where  the 
symptoms  were  sufficiently  indicative)  the  spinal  fluid  was  also 
submitted  to  the  Wassermann  test  and  to  the  other  tests  which  are 
applied  in  this  laboratory — /".  c,  albumen  content,  globulin  content, 
number  of  cells,  and  the  gold  sol  reaction.  As  is,  of  course,  well 
known,  cases  of  paresis  in  which  biological  alterations  in  the  spinal 
fluid  are  not  present  are  almost  unknown.  The  converse — that 
psychoses  such  as  dementia  prsecox  and  manic  depressive  insanity 
practically  never  show  such  alterations — is  also  true.  Hence,  in 
these  cases,  such  examinations  are  of  great  value  in  checking  up 
the  diagnoses. 

II.  Analysis  of  Cases' 

Group  I:  "Possible" ;  ij  Cases 

Eleven  of  these  cases  are  definitely  not  paretic.  The  final  diag- 
noses were  all  determined  as  the  result  of  clinical  observation  alone, 
and  none  have  been  in  any  way  altered  as  a  result  of  the  present  in- 

~  Such  sj'mptoms  as  depression,  excitement,  hallucinations,  etc.,  are  not 
included  in  this  brief  list,  since  they  are  not  in  themselves  at  all  characteristic 
of  paresis. 


326  LAirSOX  G.  LOU'REY 

vestigation.  In  none  of  these  was  paresis  definitely  ruled  out  when 
presented  at  staff  meeting. 

They  were  admitted  at  varying  times  between  1897  and  191 1, 
and  the  duration  in  the  longest  case  is  about  18  years.  The  final 
diagnoses  are :  dementia  prsecox,  4 ;  manic-depressive,  i ;  alcoholic 
dementia.  3;  imbecile  (alcoholic),  i  ;  chronic  delusional  insanity,  i  ; 
organic  dementia,  i.  There  was  knee-jejrk  alteration  in  7  cases 
(exaggerated  5;  lost  2);  pupillary  abnormalities  in  5  (inequality 
and  irregularity;  sluggish  light  reaction  in  2)  ;  5  were  demented; 
3  were  euphoric ;  i  gave  a  syphilitic  history. 

Thfe  blood  Wassermann  was  negative  in  8  (including  the  case 
with  specific  history)  and  was  not  done  in  3. 

The  two  remaining  cases  in  this  group  are  of  some  interest, 
the  first  because  the  possibility  of  paresis  has  been  confirmed,  the 
second  because,  despite  observation  over  a  prolonged  period,  the 
correct  diagnosis  is  still  undetermined. 

C\SE  I.  Hosp.  No.  16564,  Male.  Admitted  Jan.,  1912.  Age 
41.  Mother  senile  dement.  Father  alcoholic.  Uncle  tubercular. 
Brother  epileptic.  Gonorrhea  and  venereal  sore  at  20.  Attempted 
suicide  at  16.  Alcoholic  since  20.  Delirium  tremens  once.  Mar- 
ried five  years ;  one  miscarriage  and  one  livmg  child.  Three  faint- 
ing spells  in  191 1.  At  time  of  entrance  excited,  restless,  fiight  of 
ideas,  visual  hallucinations,  insomnia,  euphoria,  mannerisms.  Pu- 
pils unequal,  sluggish  reaction  to  light.  Knee  jerk  increased.  Diag- 
nosis: manic  depressive  insanity,  manic;  paresis  not  excluded.  At 
present :  left  pupil  larger  than  right  and  stiff  to  light.  Right  is 
irregular,  has  a  slight  light  reaction.  Knee  jerk  normal.  Tremor 
of  hands.  No  speech  or  memory  defect.  \\'assermann  reaction  : 
blood,  twice  doubtful,  spinal  fluid  positive.  .Albumen  and  globulin 
increased  ;  gold  test  positive :  63  cells  per  cubic  millimeter.  Deter- 
mined diagnosis:  paresis. 

Case  2.  Hosp.  No.  15689.  Male.  Admitted  July,  1910.  Age 
30.  Onset  in  1906  with  a  "paralytic"  stroke  from  which  he  made 
a  good  recovery.  In  1908  epileptoid  attacks  began.  These  came 
about  once  in  two  months  with  a  period  of  confusion  following. 
These  attacks  gradually  became  more  freqtient,  and  he  was  com- 
mitted to  Danvers  in  1910  after  a  very  severe  attack,  which  left  him 
resless.  deluded  and  apparently  hallucinated.  He  gradually  cleared 
uj).  There  was  slight  right  hemiplegia,  knee  jerk  increased,  and  a 
Romberg  sign.  Following  his  convulsions  he  shows  ankle  clonu."? 
anfl  HaJ)inski  sign.  The  convulsions  start  in  the  left  forearm  (he 
once  had  27  convulsions  in  one  day).  Diagnosis:  Brain  tumor 
preferrefl :  syjjhilitic  dementia?  paresis?  Blood  Wassermann  nega- 
tive in  191 1.  -Anti-specific  treatment  pushed  with  no  effect.  At 
the  Mas.sachusetts  General  Hospital  in  191 2  he  was  regarded  as  a 
case  of   insular   sclerosis  and   there   were  "no  signs  indicative  of 


PARESIS  IN  PRE-IVASSERMANN  DAYS  327 

brain  tumor."  At  present,  all  tests  on  the  fluid  are  neg^ative.  Knee 
jerk  much  increased,  right  more  than  left.  SHght  euphoria.  Left 
side  of  face  is  full.  Left  hand  and  arm  weak  and  incoordinate. 
Speech  defect,  marked  memory  defect,  marked  attention  defect. 
This  unclassed  case  seems  to  be  perhaps  a  case  of  tumor  involving 
the  right  postcentral  gyrus,  or  a  case  of  epilepsy. 

Group  II :  Probable;  i/  Cases 

This  group  presents  some  interesting  problems  in  the  differential 
diagnosis  of  paresis,  but  it  is  very  difficult  to  present  satisfactorily. 
The  problems  are  not  sufficiently  important  to  present  an  abstract 
of  each  case,  so  I  shall  simply  state  the  conclusions. 

Not  one  of  these  cases  is  clinically  or  serologically  paresis.  The 
determined  diagnoses — most  of  them  the  result  of  clinical  observa- 
tion alone — are :  dementia  prsecox,  10 ;  alcoholic  dementia,  3  ;  para- 
noid condition,  i  ;  imbecile,  I  ;  toxic  psychosis,  i  ;  arteriosclerotic 
dementia,  i.  The  blood  Wassermann  was  positive  in  one  case, 
negative  in  14  and  not  taken  in  2.  All  tests  on  the  spinal  fluid  were 
negative  in  4  cases  (including  the  case  of  dementia  praecox  with 
positive  blood). 

Analysis  of  symptoms  likely  to  be  confusing  shows  that  knee 
jerk  alterations  occurred  in  11  cases  (absent,  i;  exaggerated,  10) 
and  pupillary  alterations  in  9  (unequal,  2;  irregular,  i  ;  sluggish,  2; 
consensual  reaction  lost,  i  ;  vuiequal  and  irregular,  i  ;  unequal  and 
sluggish,  2).  Five  presented  speech  defect;  5  showed  grandiose 
delusions ;  5  were  demented ;  4  showed  a  Romberg  sign.  Three 
gave  histories  of  syphilis,  but  the  Wassermann  is  not  positive  in 
any  of  them,  nor  are  there  signs  of  paresis. 

The  high  incidence  of  dementia  prsecox  in  the  determined  diag- 
noses is  of  interest.  Li  the  case  books  the  diagnoses  were  as  fol- 
lows:  Paresis?  3;  paresis  or  alcoholic  dementia,  2;  paresis  or  de- 
mentia prsecox,  6 ;  paresis,  organic  dementia  or  dementia  prsecox,  i ; 
paresis  or  manic-depressive,  2;  paresis  or  organic  dementia,  1. 
Dementia  prsecox  was  not,  therefore,  considered  in  the  diagnosis  of 
as  many  cases  as  eventually  turned  out  to  be  such.  It  is  further- 
more clear  that  the  differentiation  of  these  two  psychoses  is  not 
always  easy  on  clinical  grounds  alone. 

Group  III:  Certain;  28  Cases 

It  is  necessary  to  divide  this  group  into  two  subclasses:  {A)  8 
cases  which  are  clinically  and  serologically  confirmed.  {B)  20 
cases  in  which  the  dias^nosis  was  not  confirmed. 


32S  LAIVSOX  G.  LOirREY 

At  the  time  of  presentation  before  the  staff  for  diagnosis,  all 
members  agreed,  but  in  lo  cases  the  diagnosis  had  been  changed 
before  this  study  was  undertaken. 

(A)  The  clinical  course  and  laboratory  findings  substantiate 
the  diagnosis  in  all  8  cases.  One  case  has  died  since  this  study  was 
begun,  with  confirmatory  autopsy.  The  others  present  typical  clin- 
ical pictures.  In  7  cases  the  blood  Wassermann  is  positive,  and  all 
tests  are  positive  in  the  fluid  in  all  8  cases.  The  duration  has  been 
three  years  in  two  cases ;  4  years  in  2 ;  5  years  in  i  ;  6  years  in  i  ; 
II  years  in  i. 

(/?)  This  group  of  20  cases,  none  of  whom  are  j^aretic,  fall  into 
2  classes:  (i)  14  cases  in  which  some  other  diagnosis  is  certain  and 
(2)  6  cases,  which,  for  one  reason  or  another,  must  be  left  un- 
classed. 

(i)  Of  these  14  cases,  7  ^re  cases  of  dementia  pra^cox,  and  in 
5  of  these  the  diagnosis  was  long  ago  corrected.  Among  these, 
the  blood  Wassermann  is  negative  in  6,  positive  in  i.  In  two 
cases  all  tests  in  the  spinal  fluid  are  negative.  The  duration  in 
these  cases  is  from  11  to  18  years. 

In  the  remaining  7  cases  of  this  subgroup,  the  blood  Wasser- 
mann is  negative,  and  all  tests  in  the  spinal  fluid  are  negative  in  2. 
The  determined  diagnoses  are:  organic  dementia  (arteriosclerotic), 
I  ;  alcoholic  conditions,  3 ;  hypochondria  with  involution  features,  i ; 
paranoid  condition,  i  ;  manic-depressive,  i. 

The  symptom  analysis  of  the  14  cases  shows  pupillary  abnor- 
mality in  12 — I  presenting  unequal  pupils;  3  .sluggish,  i  irregular 
and  sluggish;  3  unequal  and  sluggish;  2  unequal  and  irregular:  i 
unequal  and  irregular,  without  reaction  to  light  or  accommodation ; 
I  unequal,  irregular  and  sluggish.  Kneq  jerk  alterations  occurred 
in  12  cases — i  absent,  2  unequal  and  9  exaggerated.  Tremors  of 
various  types  occurred  in  6;  5  showed  speech  defect;  4  a  Romberg 
sign. 

(2)  The  6  unclassed  cases  merit  individual  consideration,  since 
each  presents  some  unusual  problem  of  diagnosis.  In  all  cases  the 
diagnosis  of  paresis  was  unanimous  when  patient  was  presented. 

C,\SE  I.  Male.  IIosp.  No.  14043.  Age  41.  Admitted  Janu- 
ary, 1 90S.  First  committed  to  Danvers  at  the  age  of  38,  when  the 
findings  were  much  the  same  as  at  this  second  commitment — with 
knee  jerk  normal,  confusion,  s])eech  defect,  visual  hallucinations, 
and  slight  pupillary  light  reactions.  In  1910  there  were  delusions 
of  grandeur,  euphoria  and  speech  defect.  In  191 3  and  again  in 
1914  the  blood  Wassermann  was  negative,  and  all  tests  in  the  fluid 


PARESIS  IN  PRE-IVASSERMANN  DAYS  329 

are  negative.  IMemory  is  fairly  good.  Hallucinations  denied.  He 
stammers  (teeth?).  Tells  a  very  involved  story — running  from  one 
subject  to  another.  Pupils  unequal,  good  light  reaction.  Knee 
jerk  normal.  Slight  general  tremor.  Grandiose  delvisions.  Not  a 
paretic — exact  diagnosis  uncertain. 

Case  2.  ]\Iale.  Hosp.  No.  14077.  Admitted  January,  1908. 
Age  46.  Onset  at  40  with  an  apoplectic  attack  with  subsequent 
great  memory  loss.  History  of  syphilis.  At  time  of  entrance : 
Pupils  small,  equal,  slow  light  reaction;  knee  jerk  increased;  feet 
drag  in  walking ;  emotional  and  mental  instability.  Blood  Wasser- 
mann  negative  in  1910,  and  blood  and  fluid  are  both  entirely  nega- 
tive now.  Physical  signs  at  present  are  those  of  residuals  of  shock, 
plus  a  great  memory  defect.  The  most  probable  diagnosis  in  this 
case  is  arteriosclerosis  (the  arteriosclerosis  perhaps  due  to  syphilis). 

Case  3.  Male.  Hosp.  No.  15795.  Admitted  September,  1910. 
Age  42.  Father  died  at  62  suffering  from  same  condition,  also 
called  paresis.  Insanity  on  maternal  side.  In  1906  patient  became 
careless,  forgetful,  sat  around  and  did  not  work.  Three  months 
later  there  was  a  convulsion  followed  in  a  month  by  another  and 
from  then  until  the  time  of  commitment  there  was  a  convulsion 
about  every  four  months.  The  head  turned  to  the  right,  there  were 
clonic  spasms  of  the  right  arm  and  leg  with  cyanosis.  Occasional 
vomiting  at  the  end.  Every  three  or  four  days  a  mild  seizure,  when 
he  was  confused  but  not  unconscious.  At  time  of  entrance,  knee 
jerk  diminished,  pupils  large,  irregular  and  unequal  and  dilating  to 
strong  light.  Speech  defect.  Optic  atrophy.  Disorderly.  Con- 
fused. Shattering  of  recent  memory.  Condition  at  present  un- 
changed. Frequent  convulsions.  Tells  same  story  now  as  when 
he  first  came.  The  blood  and  fluid  were  each  twice  negative  to  all 
tests.     This  is  certainly  not  paresis.     Possibly  epileptic  or  tumor. 

Case  4.  Female.  No.  161 11.  Admitted  in  April,  191 1.  Age 
51.  ]\Iarried.  Five  living  children.  One  died  at  three  days.  Two 
miscarriages.  Onset  at  41  with  gait  difficulty  and  diminution  of 
vision.  At  time  of  entrance,  blind;  apprehensive;  knee  jerk  dimin- 
ished ;  pupils  stifif  to  light.  At  present  she  is  bed-ridden  ;  the  eyes 
constantly  roll  to  the  right  and  are  apparently  corrected  voluntarily  ; 
pupils  are  unequal,  slightly  irregular  and  do  not  react  to  light ;  has 
no  insight;  knee  jerk  absent;  incontinent.  Blood  and  fluid  Wasser- 
mann  negative ;  slight  increase  in  globulin  and  albumen ;  6  cells  per 
cu.  mm.  There  is  a  slight  change  in  the  third,  fourth  and  fifth 
tubes  in  the  gold  test. 

The  most  probable  diagnosis  in  this  case  seems  to  be  tabo-paresis, 
(in  which  the  laboratory  findings  are  often  confusing). 

Case  5.  Alale.  No.  16356.  Admitted  August,  191 1.  Age  34. 
Always  wild.  History  of  syphilis.  Brother  admitted  to  Danvers 
last  summer  and  is  a  paretic.  At  time  of  entrance,  patient  showed 
lively  reflexes,  ptosis,  no  light  reaction  in  right  pupil,  slight  in  left, 
elated,  irritable.  In  1912-13-14  the  blood  Wassermann  was  nega- 
tive. In  1 914  the  fluid  was  negative  on  two  occasions.  Pupils 
are  unequal,  and  right  is  stiflf,  while  the  left  reacts  sHghtly  to  light. 
Knee  jerk  normal.     Mentally  he  is  much  like  a  neurasthenic. 


330  LAirSO.y  G.  LOW  RE  Y 

This  seems  most  probably  a  case  of  manic-depressive  insanity. 

Case  6.  Male.  Hosp.  No.  16456.  Admitted  November,  191 1. 
Age  40.  At  ^^  trouble  with  walking;  feet  dragged.  Physical 
signs  those  of  spastic  paraplegia.  Mental  symptoms  a  short  time 
before  admission.  At  time  of  entrance,  spastic  paraplegia  ;  both 
pupils  reacted  fairly  well  to  light ;  euphoria  ;  grandiose  ideas ;  dimin- 
ished pain  sense  below  the  knee.  At  present,  ])upils  unequal  and 
irregular,  good  light  reaction  ;  knee  jerk  much  increased  ;  marked 
dementia  ;  euphoria  :  speech  defect ;  clonus  ;  double  Babinski.  Was- 
sermann  negative  on  both  serum  and  fluid  twice.  Marked  albumen 
and  globulin  excess ;  cell  count  26  per  cu.  mm. ;  gold  reaction  posi- 
tive for  syphilis.  This  case  is  probably  one  of  paresis ;  against 
this  however  are  the  active  pupils  and  the  negative  Wassermann. 

III.  Discussion 

If  we  consider  only  the  cases  in  which  j)aresis  was  "certain" 
(by  unanimous  agreement  of  the  staff)  we  fmd  only  8  cases  in 
which  the  diagnosis  has  been  unequivocally  substantiated  (with  2 
more  in  which  it  is  probable).  Six  (or  4)  cases,  for  various  reasons, 
remain  unclassed  :  while  of  the  remaining  14.  7  are  cases  of  demen- 
tia pr?ecox.  It  is  striking  that  the  determined  diagnoses  of  dementia 
prwcox  (in  all  groups)  far  exceed  the  number  of  cases  in  which 
this  diagnosis  was  considered  at  the  time  of  presentation. 

The  fact  that  paresis  and  dementia  pr?ecox  may  often  be  hard  to 
distinguish  has  received  but  little  attention,  at  least  in  modern 
literature.  Kraepelin,  in  the  1913  edition  of  his  text-book,  says 
(\'ol.  II.  pp.  ^22-2^)  :  "Bei  der  Abgrenzung  der  Paralyse  von  der 
verschiedenartigen  Zustandbildern  der  Dementia  prgecox  werden 
aus  der  verschiedenen  Art  der  sich  entwickelnden  psychischen 
Schwiiche  gewisse  Schliisse  moglich  sein.  In  der  Paralyse  steht 
die  Gediichtnisschwache,  die  Unklarheit  sowie  die  Beeinflussbar- 
keit  der  Stimmung  und  des  Willens  im  \'ordergrund,  bei  der  De- 
mentia pr?ccox  dagegen  die  gemiitliche  Stumpfheit  bei  Erhaltung 
des  Ciedachtnisses  und  der  Klarheit,  ferner  die  eigentiimliche 
Verlust  des  Zu.sammenhanges  zwischen  Vorstellungen,  Gefiihls- 
regungen  und  Willen.  Dcm  paralytischen  Schwachsinn  fehlen  die 
\'erschrobenhcit,  die  Manicren  .sowie  die  periodischen  Ivrregungen, 
dem  Stuj>or  der  zahc,  unbeeinflussbare  Negativismus,  wenn  auch 
Xahrungsverweigcrung.  Stummheit,  Keaktionslosigkeit  liingere  Zeit 
hinflurch  bestehen  kfinncn." 

Again  (Vol.  ill.  p.  965):  "Die  Abgrenzung  der  Dementia 
pn-ecox  von  der  I'aralyse  hat  (lurch  das  cytologische  und  nament- 
lich  das  .serologische  Untersuchungsvcrfahren  fa.st  alle  ihre  friih- 
eren   .Schwierigkcitcn   verloren.     Bei   der  gelegentlich  vorkommen- 


PARESIS  IN  PRE-WASSERMANN  DAYS  331 

den  Verbindung  mit  Lues  finden  wir  wohl  Komplementablenkung 
ini  Blute  und  vielleicht  Zellvermehrung  in  der  Spinalfliissigkeit, 
niemals  aber  die  fur  die  Paralyse  so  kennzeichnende  Wassermann- 
sche  Reaktion  in  der  letzteren.  Beritcksichtigt  man  weiter  die 
korperlichen  Zeichen  der  Paralyse,  namentlich  die  reflectorische 
Pupillenstarre,  die  Sprach-  und  Schriftstorung,  die  mit  Herder- 
scheinungen  einhergehenden  An  fall,  so  wird  die  Unterscheidung 
meist  leicht  sein,  zumal  auch  schon  das  Leben Salter  der  Kranken 
gewisse  Anhaltspunkte  fuer  die  Beurteilung  liefert" 

Since  we  have  found  in  the  analysis  of  these  cases  that  many  of 
the  physical  signs  are  often  confusing — as  a  case  of  dementia  prsecox 
may  have  unequal,  or  irregular  pupils,  or  the  light  reaction  may  be 
"  sluggish,"  with  active  knee  jerk,  etc. — it  appears  that  serological  in- 
vestigation is  very  important  in  all  cases  in  which  paresis  is  sus- 
pected. It  is,  of  course,  true  that  in  the  majority  of  cases  prolonged 
clinical  observation  will  establish  the  correct  diagnosis.  We  have, 
however,  in  the  Wassermann  and  spinal  fluid  tests,  a  method  which 
allows  us  to  verify  or  disprove  the  certainty  or  suspicion  of  paresis 
in  a  very  short  time.  This  cannot  be  too  strongly  emphasized. 
{A  forthcoming  paper  will  deal  in  full  with  the  results  of  such 
tests.) 

It  is  worth  while  pointing  out  that  no  such  group  of  cases  (/.  e., 
cases  in  which  paresis  was  positively  diagnosed)  could  be  found 
among  the  patients  admitted  since  the  Wassermann  and  spinal  fluid 
tests  became  a  part  of  the  routine  observation  of  patients,  in  which 
we  would  find  the  diagnosis  of  paresis  made  in  cases  which  were 
not  paretic,  or  belonging  to  the  brain  syphilis  group.  This  point 
has  been  made  by  Morse  (2),  in  connection  with  her  summary  of 
the  results  of  spinal  fluid  tests.  Had  the  Wassermann  and  spinal 
fluid  tests  been  known  at  the  time  these  patients  were  presented  for  • 
diagnosis,  paresis  might  have  been  confirmed  or  excluded  in  all  the 
cases  presented  in  this  paper  at  that  time. 

Summary 

1.  Data  are  presented  dealing  with  58  cases  diagnosed  with 
more  or  less  certainty  as  paresis  at  Danvers  between  May,  1898, 
and  May,  1912  (prior  to  the  routine  use  of  the  Wassermann  test). 

2.  Of  13  cases  in  which  paresis  was  not  excluded,  i  is  a  paretic 
and  I  remains  unclassed.  Of  the  other  11,  4  are  cases  of  dementia 
precox,  and  the  diagnoses  were  long  ago  established. 

3.  Of  ly  cases  in  which  paresis  was  the  probable  diagnosis,  not 
one  is  a  paretic.     Ten  are  cases  of  dementia  prsecox. 


332  LAirSOX  G.  LOWREY 

4.  Of  2'^  cases  in  which  paresis  was  certain.  8  are  paretic,  and  2 
more  are  probably  so.  14  cases  can  be  definitely  classed  elsewhere 
and  7  are  cases  of  dementia  prsecox.  The  other  four  cases  are  not 
paretic,  but  cannot  be  classed. 

5.  The  serological  investigation  of  cases  in  which  paresis  is 
suspected  is  an  absolute  requisite  for  establishing  a  correct  diagnosis. 
Had  the  Wassermann  and  spinal  fluid  tests  been  known  at  the  time 
these  patients  were  presented  for  diagnosis,  paresis  might  have  been 
immediately  excluded  or  confirmed.  Clinical  observation  over  a 
sufficient  length  of  time  will  correct  the  diagnosis  in  the  majority 
of  cases,  but  this  method  has  very  obvious  disadvantages. 

6.  This  study  presents  a  basis  for  the  conclusion  that  dementia 
prcccox  is  often  extremely  hard  to  differentiate  from  paresis.  A 
case  of  dementia  precox  may  present  unequal  pupils,  exaggerated 
knee  jerks,  etc.,  and  it  is  here  that  laboratory  tests  are  of  great  aid. 

I  must  express  my  deep  obligation  to  the  senior  members  of  the 
clinical  stait  for  much  valuable  assistance  and  advice,  without  which 
this  study  could  not  have  been  completed. 

REFEREX'CES 

1.  Southard.  E.  E.      A  Study  of  Errors  in  the  Diagnosis  of  General  Paresis. 

Jour.  Xerv.  and  Mext.  Dis.,  Vol.  37,  1910. 

2.  Morse,  Mary  »E.     Correlations  of  Cerebrospinal  Fluid  Examinations  with 

Psychiatric  Diagnoses.     -A.  Study  of  140  Cases.     Boston  Med.  and  Surg. 
Journ.,  Vol.  CLXX,  1914. 


AN  UNUSUAL  PSYCHASTHENIC  COMPLEX^ 
By  George  E.  Price,  M.D. 

ASSOCIATE    PROFESSOR    OF     MENTAL    AND    NERVOUS    DISEASES,     JEFFERSON     MEDICAL 
COLLEGE,   PHILADELPHIA 

The  following  case  of  psychasthenia  (Janet)  or  neurasthenic 
neuropathic  insanity  (Dercum)  is  so  unusual,  yet  so  clear  cut  and 
with  such  a  definite  etiology,  that  its  presentation  seems  justified. 
It  presents  an  added  interest  in  the  light  of  the  modern  ideas  regard- 
ing the  psychology  of  the  psychoneuroses  as  advanced  by  Janet, 
Freud  and  others. 

Case  Report. — E.  W.,  a  patient  at  the  Philadelphia  General  Hos- 
pital, age  39  years,  white,  single,  laborer,  a  native  of  North  Caro- 
lina. 

The  family  history  does  not  show  any  nervous  or  mental  disease. 
The  father  died  at  83  of  pneumonia  ;  the  mother  of  "  a  fever  "  at  yy. 
Five  brothers  and  two  sisters  are  living  and  well ;  four  brothers  died, 
two  of  consumption,  one  of  brain  abscess  and  one  (an  alcoholic)  of 
a  complication  of  diseases.     One  sister  was  killed  in  an  accident. 

The  medical  history  of  the  patient,  aside  from  his  peculiar  attacks, 
is  as  follows :  He  had  no  infectious  diseases  except  measles,  mumps 
and  "  scarlatina."  He  masturbated  up  to  the  age  of  fifteen  years 
and  suffered  from  sunstroke  three  times  when  fifteen.  He  denies 
venereal  disease,  but  has  been  a  moderate  user  of  alcohol.  It  ap- 
pears that  he  has  been  something  of  a  wanderer,  having  lived  in  New 
Mexico  and  Arizona  while  engaged  as  a  lumberman. 

His  present  illness  started  at  the  age  of  eighteen  years,  and  con- 
sists of  attacks  in  which  he  becomes  excited  and  screams,  curses, 
stamps  his  feet  and  strikes  out  with  his  arms.  This  latter  part  of  the 
attack  has  been  aptly  described  as  "  shadow  boxing  "  by  Dr.  Emer- 
son, the  interne,  who  has  witnessed  numerous  spells.  During  the 
attack,  the  man  is  perfectly  conscious  and  afterward  can  recall 
everything  that  transpired.  He  has  never  injured  himself  nor  any 
one  else,  nor  has  he  fallen,  bitten  his  tongue  or  voided  urine  during 
the  paroxysms.  There  is  no  headache  nor  somnolence  following 
the  attack  and  after  it  is  over  he  will  resume  whatever  he  was  en- 
gaged in  prior  to  its  onset.  The  attacks  now  occur  from  two  or 
three  to  six  or  eight  times  daily,  although  while  working  in  the 
woods,  he  has  had  them  as  infrec[uently  as  one  a  week. 

The  frequency  of  the  spells  is  affected  by  the  patient's  general 

1  Case  presented  before  the  Philadelphia  Psychiatric  Society,  March 
12,  1915. 

333 


334  GEORGE  E.  PRICE 

condition,  as  they  occur  oftener  when  he  is  fatigued.  They  may 
come  on  (hiring  the  day  or  night,  but  only  when,  he  is  awake,  and  he 
has  had  them  when  alone  and  also  when  so  situated  as  to  expose  him- 
self to  the  ridicule  of  those  about  him. 

The  interesting  feature  of  the  case  developed  when  the  patient 
was  questioned  regarding  an  aura.  He  had  none  of  the  varied 
sensory  phenomena  which  frequently  initiate  epileptic  attacks,  but 
just  before  the  {)aroxysm,  he  would  always  be  thinking  deeply  of  an 
incident  which  occurred  in  his  younger  days.  When  questioned 
further  in  regard  to  this  incident  he,  with  evident  reluctance,  said 
that  when  i8  years  old,  while  out  walking  with  a  younger  sister,  they 
were  attacked  by  a  gang  of  young  ruffians  who  beat  him  up  badly 
and  criminally  assaulted  his  sister.  It  is  only  when  his  thoughts 
dwell  on  this  happening,  that  the  attacks  occur. 

Upon  examination,  the  patient  was  found  to  be  well  nourished, 
with  normal  gait  and  station.  His  pupils  were  equal  and  reacted 
promptly  to  light  and  accommodation.  The  musculature  of  the  face 
was  normal  and  there  was  no  evidence  of  cranial  nerve  disturbance. 
The  tongue  was  tremulous  and  protruded  in  the  median  line.  Heart, 
lungs  and  abdomen  were  negative.  The  abdominal,  cremasteric  and 
all  tendon  reflexes  were  normal.  Babinski  reflex  and  ankle  clonus 
were  absent.  The  extremities  presented  no  palsies,  tremors  nor  in- 
coordination. All  sensations  were  normal.  There  were  no  hys- 
terical stigmata.  ^Mentally  clear ;  no  hallucinations,  illusions  nor  de- 
lusions :  memory  and  attention  good.  No  persistent  emotional  state. 
The  general  intelligence  was  above  the  average.  Blood,  urine  and 
Wassermann  negative. 

Diagnosis. — Various  diagnoses  have  at  different  times  been  made 
of  the  attacks — such  as  petit  mal,  hysterical  epilepsy  and  tic.  In 
psychic  epilepsy,  while  the  attacks,  as  in  this  case,  are  usually  similar 
in  character,  consciousness  is  clouded  during  the  attack,  there  is 
more  or  less  complete  amnesia  regarding  the  details  of  the  outburst 
and  the  paroxysm  is  followed  by  headache  and  somnolence.  More- 
over, it  is  rare  for  pure  psychic  epilepsy  to  develop  without  at  some 
time  the  occurrence  of  convulsive  phenomena.  (A  case  of  psychic 
epilepsy  without  other  epileptic  phenomena  was  reported  by  the 
writer  in  the  Jouk.val  of  Nkrvous  and  Mental  Disease,  Sept.,  1913, 
Vol.  40,  No.  9.)  As  in  this  case  consciousness  is  never  lost  and  mem- 
ory of  all  that  occurred  during  the  attack  is  preserved,  wt  may  rule  out 
cjjilepsy.  In  addition  to  these  points,  instead  of  the  subsequent 
headache  and  somnolence,  there  is  an  actual  feeling  of  relief  after 
the  spell  is  over.  Hysteria  may  be  excluded  by  the  absence  of  the 
hysterical  stigmata  and  the  occurrence  of  the  spells  when  the  patient 
is  alone. 

The  diagnosis  of  tic  aj)pears  to  be  justified  and  I  regard  the  at- 
tacks as' the  expression  of  a  psychasthenia  and  the  result  of  deficient 
inhi))ition  from  disorder  of  the  will. 

General  Discussion. — Our  case  represents  one  of  a  group  of  ob- 
sessions, all  possessing  the  same  general  characteristics.    They  con- 


AN  UNUSUAL  PSYCHASTHENIC  COMPLEX  335 

stitiite  the  neurasthenic  insanity  of  the  older  French  writers,  the 
neurasthenic  neuropathic  insanity  of  Dercum  and  the  psychasthenia 
of  Janet. 

In  this  group  belong  the  phobias,  or  special  fears,  as  of  high 
places,  of  crowds,  of  dirt,  etc.,  the  obsessions  resulting  from  inde- 
cision, in  which  class  are  found  the  timorous  and  the  counters ;  ob- 
sessions resulting  from  deficient  inhibition,  of  which  the  case  re- 
corded above  is  an  illustration  ;  and  obsessions  due  to  deficient  zvill. 
All  these  special  forms,  as  pointed  out  by  Dercum,  have  their  proto- 
type in  the  various  psychic  symptoms  of  ordinary  neurasthenia. 

The  essential  features  of  all  psychasthenic  obsessions  are  im- 
potence of  the  will  wnth  preservation  of  the  intelligence,  complete 
consciousness  of  the  condition  and  unimpaired  reasoning  power. 
These  characteristics  of  the  obsessions  enable  us  readily  to  distin- 
guish them  from  the  impulsive  acts  of  the  imbecile  or  epileptic. 
There  is,  as  a  rule,  a  neuropathic  heredity  and  this  feature  has  been 
so  pronounced  as  to  lead  Charcot  and  Magnan  to  consider  obsessions 
as  a  sign  of  degeneracy  and  having  no  relationship  to  neurasthenia 
except  as  a  complication  (Regis). 

Dercum,  objecting  to  Janet's  term  "  psychasthenia  "  on  the  ground 
that  "  soul  weakness  "  takes  us  rather  too  far  afield,  uses  the  desig- 
nation "  neurasthenic  neuropathic,"  recognizing  by  the  double  ap- 
pellation both  the  nervous  exhaustion  of  the  patient  and  the  element 
of  degeneracy  or  neuropathy  in  his  heredity. 

Other  characteristic  features  of  these  obsessions  are,  the  absence 
of  hallucinations,  the  concomitant  anxiety  and  the  fact  that  the  con- 
dition never  terminates  in  dementia.  The  attacks,  whatever  their 
special  character,  are  essentially  intermittent  and  paroxysmal  and  of 
indefinite  duration. 

It  has  been  my  experience  that  pathological  fears  or  phobias  are 
more  often  seen  by  the  doctor  than  the  other  forms  of  psychasthenic 
obsessions.  Sometimes  the  obsession  becomes  the  cause  of  much 
inconvenience,  as  in  the  case  of  one  of  my  patients  who  had  a  fear 
of  rapid  movement  and  therefore  in  going  from  one  city  to  another 
was  obhged  to  travel  on  trolley  cars  or  way-trains.  Another  patient 
developed  a  dread  of  going  far  from  home,  and  as  he  was  a  travel- 
ing salesman,  his  obsession  was  obviously  most  unfortunate  and  ul- 
timately led  to  his  giving  up  his  work. 

Psychology. — Billod  was  the  first  to  call  attention  to  the  disorder 
of  the  will  as  being  the  underlying  and  essential  factor  in  the  de- 
velopment of  obsessions.  Each  one  of  us,  as  the  result  of  our 
various  mental  activities,  is  constantly  having  impulses  which  are 


336  GEORGE  E.  PRICE 

passed  upon  by  our  judgment  and  normally  are  controlled  by  the 
will,  which  permits  and  reinforces  certain  ot  these  impulses  and 
restrains  or  inhibits  others.  \\  hen  the  will  is  deficient  in  its  power 
of  inhibition,  acts  are  performed  against  the  judgment  and  will  of 
the  individual  and  with  full  consciousness  of  the  act. 

According  to  the  newer  psychology,  phobias  are  the  result  of 
pathological  association,  the  obsession  of  indecision  becomes  a  "  con- 
flict "  and  the  obsession  of  deficient  inhibition  is  believed  to  re])re- 
sent  the  attempt  to  suppress  or  submerge  in  the  subconscious  mind 
a  painful  recollection  which,  from  time  to  time,  escapes  into  the 
field  of  consciousness  and  finds  its  outward  expression  in  some  form 
of  motor  reaction,  the  whole  being  spoken  of  as  a  "  complex." 

Thus  the  psychological  explanation  of  our  case  would  seem  to  be 
the  attempt  at  repression  of  the  painful  memory  of  the  shocking 
affair  which  occurred  when  the  patient  was  eighteen  years  old,  his 
natural  feelings  regarding  the  incident  and  his  outward  manifesta- 
tion or  expression  of  them  by  cursing,  shouting  and  striking.  Taken 
all  together  this  would  form  the  complex,  the  thought  of  the  outrage 
bringing  to  the  surface  the  motor  reaction  or  the  "  attack." 

Freud  would  find  a  sexual  foundation  for  all  neuroses  and  while 
it  is  true  that  there  is  a  sexual  element  in  the  incident  which  served 
as  a  starting  point  for  the  obsession  of  our  patient,  the  writer  has 
known  of  quite  as  marked  symptoms  arising  from  occurrences  ab- 
solutely devoid  of  sexual  content. 

Treatment. — Our  patient  has  not  escaped  the  psychanalysts,  but 
still  retains  his  tic.  It  is  perhaps  possible  that  the  etiolog}'  was  not 
sufficiently  obscure  to  provide  a  favorable  field  for  what  Lloyd  has 
aptly  termed  "  subterranean  therapeutics."  However,  a  tic  of  over 
twenty  years'  duration  is  not  apt  to  disappear  under  any  form  of 
treatment.  It  is  of  interest'to  note  in  this  connection,  that  our 
patient's  attacks  were  much  less  frequent  when  he  was  in  good  phys- 
ical condition  and  living  in  a  wholesome  environment  and  that  they 
were  always  worse  when  he  was  fatigued. 

While  the  prognosis  must  always  be  guarded  in  i)sychasthenia, 
excellent  results  are  frequently  obtained  by  rest  methods  combined 
with  psychotheraj)y  in  the  form  of  suggestion,  explanation  and  en- 
couragement, etc.,  adapted  to  meet  the  needs  of  the  individual  case. 


DYSTONIA  ^lUSCULORU^I  DEF0R:\IANS  WITH  REPORT 

OF  A  CASE* 

Bv  Theodore  Diller,  M.D.,  and  George  J.  Wright,  M.D. 

PITTSBURGH 

A  review  of  the  literature  since  October,  191 1,  when  Oppen- 
heim^  described  a  form  of  myospasm  to  which  he  gave  the  name 
dystonia  musculorum  deformans,  would  seem  to  indicate,  from 
the  number  of  cases  reported  at  least,  that  his  work  had  resulted  in 
renewed  interest  and  critical  study  of  that  large  group  of  illy  defined 
and  understood  cases  characterized  by  hyperkinesia.  In  a  discus- 
cussion  of  a  paper  read  by  Fraenkel  before  the  New  York  Neurolog- 
ical Society  in  December,  191 1,  Collins-  stated  that  he  could  not 
see  any  profit  in  bestowing  a  new  name  on  a  class  of  cases  with 
which  we  had  been  familiar  for  many  years,  and  that  we  all  have 
a  certain  conception  of  what  was  meant  by  the  tic  neuroses,  and 
he  did  not  think  there  was  any  remarkable  deviation  in  the  cases 
described  by  Oppenheim  from  descriptions  that  embodied  a  por- 
trayal of  the  tics.  Other  writers,  among  them  Dana,"  have  as- 
serted these  cases,  in  their  opinion,  should  be  put  in  the  torticollic  or 
tic  group ;  and  FraenkeP  in  his  paper  suggested  the  very  happy 
name  of  "  tortipelvis."  And  yet  while  it  is  true  we  have  no  concep- 
tion of  what  this  disorder  actually  is,  and  have  only  theories  on 
which  to  base  its  pathology,  one  cannot  help  but  feel  from  a  study 
of  the  cases  reported  that  this  additional  classification  of  the  hyper- 
kinesias has  been  exceedingly  helpful.  Most  of  the  cases  had  pre- 
viously to  Oppenheim's  paper  been  more  or  less  satisfactorily  diag- 
nosed as  hysteria,  Huntington's  chorea,  chronic  chorea,  myospasm, 
tic,  double  athetosis ;  and  not  a  few  cases  in  spite  of  certain  marked 
differences  have  been  improperly  labeled  for  years  because  of  our 
acknowledged  more  or  less  generalized  conception  of  tic  movements. 
Spiller^  describes  a  case  of  a  man  who  had  been  a  patient  at  Block- 
ley  for  years,  and  who  was  recorded  as  having  "  tic  "  or  Hunting- 
ton's chorea.  He  had  never  been  satisfied  with  either  diagnosis. 
After  having  had  Oppenheim's  paper  called  to  his  attention  he 
studied  the  case  again  with  the  possibility  of  dystonia  in  mind  and 

*  A  paper  read  in  abstract  before  a  meeting  of  the  Pittsburgh  Academy 
of  Medicine,  February  i,  1916. 

337 


338  THEODORE  DILLER  AND  GEORGE  J.  WRIGHT 

reached  the  conckision  that  the  niovenients  which  he  had  long  con 
sidered  atypical  really  belonged  to  those  of  that  disease. 

Any  one  who  has  had  the  opportunity  to  study  a  case  of  dys- 
tonia must  at  once  be  struck  by  certain  peculiar  features  of  the 
disease,  and  with  Fraenkel  and  JellilTe,  must  agree  wnth  Oppenheim 
that  the  disease  is  rare  and  one  of  the  most  remarkable  encoun- 
tered, considered  as  a  clinical  type  at  least,  asi'de  from  its  essential 
relationship  to  other  already  well-known  groups.  The  nosological 
boundaries  of  this  group  of  cases  characterized  by  hyperkinesia  be- 
ing so  unsatisfactory  and  indefinite,  we  have  good  reason  to  thank 
Ziehen  and  Oppenheim  for  giving  us  an  additional  and  definite  clas- 
sification into  which  it  has  been  possible  for  writers  in  this  country 
and  abroad  to  place  with  more  or  less  satisfaction  a  considerable 
number  of  cases. 

Since  Oppenheim's  report  in  October,  191 1,  of  the  four  cases  on 
which  he  based  his  paper,  and  Ziehen's  reference"  to  five  cases  at 
the  meeting  of  the  Psychiatrischer  Verein  in  Berlin,  December,  1910, 
with  the  publication  of  three  of  these  five  cases  by  Von  W.  Schwalbe 
(Berlin,  1908),  notable  papers  have  appeared  by  Fraenkel  with  a 
report  of  four  cases  in  December,  191  i.  and  l)y  Hregnian"  with  a 
report  of  three  cases  in  July,  1912.  Flatau  and  Sterling"^  described 
two  cases  in  1912.  In  more  or  less  detail  single  cases  have  been  re- 
ported by  Biach,**  Spiller,^  Abrahamson,^''  Belling,^ ^  Bregman,^^ 
Bernstein, ^^  Hegier,'*  Climenko,'^  and  Bonhoefifer.^*' 

In  his  original  description  Oppenheim  stated  the  disease  was  a 
chronic  progressive  one  afifecting  children  l)etween  the  age  of  eight 
and  fourteen,  and  characterized  by  a  deformity  around  the  pelvis 
and  clonic  and  tonic  myospasms  afifecting  chiefly  the  muscles  of  the 
thigh,  pelvis  and  lower  lumbar  region.  Other  muscles  might  be  in- 
volved, in  fact  the  disease  usually  began  in  the  uj^per  extremities, 
but  its  chief  and  ultimate  seat  was  the  muscles  associated  with  loco- 
motion. ( )ther  muscles  in  his  cases  were  never  involved  in  the  same 
degree.  In  the  recumbent  jKjsition  most  of  the  deformities  and  the 
myos|>asms  disapjjeared.  C)u  standing  and  esi)ecially  in  walking 
the  characteristic  deformities  and  the  so-called  "dromedary  gait" 
appeared,  presenting  a  truly  striking  picture,  and  it  was  this  that 
suggested  the  diagnosis  of  hysteria,  as  these  cases  were  believed  to 
be  by  m.any,  even  by  Oppenheim  and  his  pupils. 

Definite  signs  of  organic  disease  of  the  nervous  system  were  not 
fouiid  in  any  of  Oppenheim's  cases;  and  yet  in  his  opinion  we  are 
not  flealing  with  a  neurosis  but  a  disease  based  on  fine  pathological 
changes   in   the  cortex   cells   controlling   muscle   tone,   resulting   in 


DYSTONIA  MUSCULORUM  DEFORMANS  339 

"  dystonia  " — a  disturbance  of  the  proper  coordination  of  muscle 
tone.  There  arises  therefrom  a  kind  of  "  mobile  spasm,"  express- 
ing itself  in  a  mixture  of  tonic  and  clonic  movements.  According 
to  Oppenheim  it  is  very  important  not  to  consider  this  simply  a 
state  of  hypertonia ;  because  with  the  tendency  to  tonic  spasm  of 
certain  muscles  there  could  be  found  also  a  definite  hypotonia. 

As  described  by  Oppenheim  this  disease  picture  is  definite  and 
striking,  and  he  insists  on  a  close  analogy  of  symptoms  before  grant- 
ing the  identity  of  other  reported  cases.  The  five  cases  presented  by 
Ziehen  and  Schwalbe  are  discarded  by  Oppenheim  because  there 
were  lacking  the  clonic  spasms,  the  hypotonia,  and  the  increase  of 
spasm  on  standing  and  walking.  Fraenkel's  four  reported  cases 
conform  more  clearly  with  the  description  given  by  Oppenheim — ■ 
all  four  were  characterized  by  pelvic  deformities  and  by  tonic  and 
clonic  myospasms  about  the  pelvic  girdle.  Other  cases  reported 
differ  in  rather  important  details,  especially  in  the  absence  of  hypo- 
tonia, the  mode  of  onset  and  the  degree  and  location  of  involve- 
ment. In  addition,  in  certain  cases,  puzzling  features  have  been 
noted.  In  Bregman's  first  case  there  were  noted  pain  in  the  most 
severely  affected  extremity,  hypertrophy  in  the  cramp  affected 
muscles,  unexplainable  non-degenerative  atrophy  in  some  of  the  small 
muscles  of  the  hand,  and  a  myotonic  reaction  in  some  muscles  in 
the  forearm.  In  another  case  of  Bregman's  the  torsion  spasm  was 
chiefly  one-sided  and  there  was  a  slight  involvement  of  the  face 
muscles.  In  the  case  reported  by  Biach  there  was  some  atrophy  of 
the  muscles.  Bernstein's  case  showed  that  speech  was  partly  af- 
fected. The  truth  of  the  matter  is  we  are  dealing  with  a  wide- 
spread constitutional  disorder ;  and  the  lesion,  assuming  that  the 
pathology  is  anatomic,  is  probably  not  definitely  the  same  in  each 
case,  the  nature  and  extent  of  the  symptoms  depending  on  the 
location  and  degree  of  involvement.  It  would  seem  after  all  the 
essential  condition  in  dystonia  musculorum  is  the  peculiar  torsion- 
like tonic  and  clonic  condition  of  the  muscles  which  alone  ought  to 
stamp  the  disease  clinically ;  the  picture  presented  then  by  the  in- 
dividual case  would  vary  according  to  the  function  of  the  muscle 
groups  involved.  In  the  beginning,  the  symptoms  may  be  very 
sharply  localized  and  developed  further  only  after  considerable  lapse 
of  time.  One  case  of  Oppenheim's  beginning  in  the  right  foot  did 
not  develop  further  for  eighteen  months ;  and  Flatau- Sterling  re- 
port a  case  where  for  two  years  the  affection  was  limited  to  the 
lower  extremity. 

Since  all  the  reported  cases  show  the  disease  begins  in  child- 


340  THEODORE  DILLER  AXD  GEORGE  J.  WRIGHT 

hood,  we  should  be  particularly  careful  and  watchful  for  an  eventual 
extension  of  symptoms  and  not  let  the  more  or  less  monosymp- 
tomatic  character  of  the  afTection  lead  us  into  a  hasty  diagnosis  of 
hysteria.  We  wish,  therefore,  to  lay  especial  emphasis  on  the  pecu- 
liar character  of  the  muscle  involvement,  which  shows  a  somewhat 
stable  or  constant  condition  of  tonicity,  varying  in  intensity  and 
with  a  marked  tendency  to  torsion,  and  further  complicated  by 
movements  of  a  clonic  type.  Voluntary  movements  are  possible 
but  performed  as  if  there  was  a  conflict  of  muscle  groups.  The 
movements  cease  during  sleep  almost  entirely  ( in  some  cases  reported, 
entirely)  as  well  as  in  the  recumbent  position  with  mental  quietude. 
Mental  excitement  or  even  attraction  of  the  attention  and  especially 
the  erect  position  and  walking  bring  out  the  movements  in  their 
most  characteristic  form.  There  are  no  muscular  weaknesses,  con- 
tractures (in  the  true  sense),  ataxia,  sensory  disturbances,  abnormal 
electrical  reactions,  characteristic  changes  of  the  reflexes,  or  other 
symptoms  pointing  definitely  to  central  disturbances.  The  intelli- 
gence is  not  disturbed ;  and  suggestion  and  other  therapy  has  been 
without  effect.  Leszynsky''  referred  to  a  case,  reported  by  Fraenkel, 
in  which  under  his  care  psychotherapy  apparently  did  some  good, 
but  there  was  a  recurrence.  No  reported  case  of  cure  has  come  to 
light  by  this  or  other  means. 

The  cause  of  this  disease  is  so  far  unknown,  although  Oppen- 
heim,  as  has  been  stated,  believes  the  affection  is  on  an  organic 
basis.  Biach  also  claims  the  disease  is  organic  with  location  of  the 
lesion  in  the  back  part  of  the  brain,  the  medulla  and  the  upper  part 
of  the  cord.  On  the  assumption  of  an  organic  lesion.  Jellift'e^^  sug- 
gested it  might  be  found  in  some  portion  of  the  cerebello-thalamo- 
cortical  arc.  However,  there  is  one  autopsy  recorded  so  far,  by 
Ziehen, ''^  in  which  the  tindings  were  negative. 

As  a  matter  of  interest  it  is  well  to  note  the  different  names  that 
have  been  given  for  this  affection  by  the  different  authors.  Oppen- 
heim  suggested  "  dysbasia  lordica  progressiva  "  and  "  dystonia  mus- 
culorum deformans"  with  preference  for  the  latter.  Ziehen  used 
the  term  "  tonic  torsion  neurosis,"  and  Flatau-Sterling  suggested 
"progressive  torsion  spasm  of  children."  Von  Bernstein,  in  an 
attempt  to  give  credit  to  the  first  investigators,  would  suggest 
"  Ziehen-Op[)cnheim  disease."  As  we  have  noted,  Fraenkel  has 
added  the  happy  term  "  torti|>clvis." 

The  following  case  history  is  presented  as  an  example  of  mus- 
cular dystonia  as  we  understand  it ;  and  while  the  patient  does  not 
now  and  apparently  never  has  shown  the  characteristic  involvement 


DYSTONIA  MUSCULORUM  DEFORMANS  341 

of  the  pelvic,  lumbar  and  thigh  muscles,  we  believe  the  involvement 
of  the  neck,  shoulders  and  the  upper  extremities  is  of  the  same  type. 

Case  Report.  George  L.,  aged  32,  single,  Hebrew,  was  first 
seen  October  28,  191 3,  consulting  Dr.  Diller  because  of  uncon- 
trollable spasmodic  movements  of  the  arms,  shoulders  and  head. 
He  states  there  is  no  history  of  nervous  disease  of  any  kind  in  his 
family  anywhere  that  he  knows  of.  He  does  not  remember  a  single 
detail  about  the  onset  of  his  trouble  except  that  he  had  it  for  some 
time  previous  to  the  age  of  fourteen,  at  which  time  he  first  consulted 
a  physician.  He  cannot  remember  whether  his  condition  is  better 
or  worse  at  the  present  time.  He  went  to  school  up  to  the  age  of 
15  or  16  and  kept  up  with  boys  of  his  class.  He  learned  to  write 
and  does  so  now  with  an  indelible  pencil  and  can  with  an  effort  use 
pen  and  ink.  For  years  he  has  been  earning  his  living  by  selling  in- 
struments, clinical  thermometers,  etc.,  to  physicians  in  their  offices. 
His  habits  are  good.  He  attends  to  his  business  regularly  and  is 
able  to  make  a  modest  living  out  of  it. 

Examination:  The  patient  is  afifected  with  peculiar  movements 
of  both  arms,  the  shoulders  and  the  head.  The  movements  are 
nnich  more  pronounced  in  the  left  arm  than  the  right,  where  they 
appear  to  be  of  only  moderate  intensity.  The  head  movements  are 
less  than  those  of  the  left  arm  and  more  than  those  of  the  right  arm. 
In  the  left  upper  extremity  the  movements  affect  all  the  muscles  and 
extend  to  the  shoulder  and  neck.  The  muscles  especially  affected  are 
the  triceps,  the  trapezius,  and  the  upper  part  of  the  pectoral.  In 
the  right  upper  extremit}^  the  muscles  of  the  hand  and  fore-arm  are 
only  slightly  involved,  the  muscles  chiefly  affected  being  the  trapezius 
and  several  small  muscles  attached  to  the  scapula.  The  sterno- 
cleido-mastoid  muscle  on  both  sides  is  not  affected  nor  are  any  of 
the  deep  muscles  of  the  neck. 

The  movements  are  very  difficult  to  describe.  They  are  neither 
those  of  a  tremor,  nor  choreic,  nor  a  tic,  nor  an  athetoid  movement, 
althovigh  somewhat  suggestive  of  all  of  them.  The  movements  of 
the  left  arm  appear  more  like  a  convulsive  movement  which  the 
patient  is  trying  to  control.  The  patient  hooks  his  left  arm  behind 
his  back,  partly  to  fix  the  arm  and  partly  to  hide  the  movements. 
A  closer  observation  reveals  the  fact  that  the  muscles  are  tonic  and 
afifected  with  a  clonic  torsion-like  movement.  By  a  strong,  appar- 
ently painful  effort,  the  patient  can  pick  up  an  object,  such  as  a 
pencil,  a  key,  etc.,  with  the  left  hand  and  also  with  the  right  hand 
with  much  less  difficulty.  There  is  no  involvement  of  the  muscles 
of  the  lower  extremities,  the  pelvis  or  the  lumbar  muscles.  The 
gait  is  perfectly  normal. 

The  back  shows  a  moderate  but  distinct  scoliosis  to  the  right  in 
the  upper  dorsal  region.  The  muscles  of  the  left  side,  particularly 
the  trapezius,  are  found  in  a  condition  of  hypertonia  with  clonic 
movements.  Under  excitement,  when  the  movements  are  most 
severe,  the  scoliosis  is  most  distinct ;  on  lying  down  and  when  quiet 
the  deformity  is  much  less  marked. 


342  THEODORE  DILLER  AXD  GEORGE  J.  IV RIGHT 

There  is  no  speech  disturbance,  no  apparent  mental  defects  and 
no  involvement  of  the  facial  muscles.  There  are  no  disorders  of 
sensation  of  any  kind,  no  muscular  atrophy  or  weakness.  The 
pupils  are  normal.  The  knee-jerks  are  exaggerated,  the  right  tri- 
ceps exaggerated,  the  left  not  obtainable  on  account  of  the  spasm. 
There  is  no  Babinski  and  no  clonus.  The  soles  of  the  feet  are 
almost  painfully  hyperesthetic. 

All  of  these  movements  are  worse  on  standing,  occur  constantly 
when  walking  and  especially  are  marked  under  observation  and 
mental  excitement  Lying  quietly  alone  on  a  couch  the  movements 
cease  entirely  and  the  muscles  may  be  found  in  the  normal,  soft,  re- 
laxed condition.  All  movements  cease  in  sleep.  The  muscles  of 
the  left  arm  appear  to  be  larger  and  firmer  than  those  of  the  right. 
The  measurement  of  the  contracted  left  biceps  is  31.5  cm.  while 
that  of  the  right  is  28.5  cm.     The  patient  is  normally  left-handed. 

The  patient  has  made  quite  a  study  of  his  condition  and  believes 
that  by  using  suggestion  he  might  be  cured.  He  observes  that  "  If 
I  did  not  think  of  them,  there  would  not  be  any  movements." 

BIBLIOGRAPHY 

1.  Oppenheim.     Neurologisches  Centralblatt,  XXX  Jahr.,  s.  1090. 

2.  Collins.     JouRXAT-  Xervous  and  Mental  Disease,  XXXIX,  p.  261. 

3.  Dana.     Idem,  XXXIX,  p.  259. 

4.  Fraenkel.     Idem.  XXXIX,  pp.  360-74. 

5.  Spiller.     Idem,  XL,  p.  529. 

6.  Ziehen.     Xeurologisches  Centralblatt,  XXX  Jahr.,  s.  109. 

7.  Bregman.     Xeurologisches  Centralblatt,  XXXI  Jahr.,  s.  885. 

8.  Flatau-Sterling.     Xeurologisches  Centralblatt,  XXXI  Jahr.,  s.  245. 

9.  Biach.     Wien.  klin.  Wchnschr..  XXV,  1912,  p.  503. 

10.  .Abrahamson.     Jolrxal  Nervous  and  Mental  Disease,  XL,  p.  38. 

11.  Belling.     Idem,  XLI,  p.  148. 

12.  Bregman.     Jahresbericht,  Vol.  XVII,  p.  880. 

13.  Bernstein.     Revue  Xeurologique,  Jul}',  1913.  p.  35. 

14.  Hegier.     Jahresbericht,  Vol.  XV.  p.  663. 

15.  Climenko.    Journal  Nervous  and  Mental  Disease,  XLI  I,  p.  167. 

16.  Bonhoeffer.     Xeurologisches  Centralblatt,  XXXII  Jahr.,  s.  137. 

17.  Lesznskv.     Journal  Nervous  and  Mental  Disease,  XXXIX,  p.  260. 

18.  Jelliffe.     Idem,  XXXIX,  p.  261. 

19.  Ziehen.     Neurologisches  Centralblatt,  XXX  Jahr.,  s.  no. 


PERIPHERAL  NEURITIS  WITH  KORSAKOW'S  SYAIPTOM 

COMPLEX 

By  Anita  Alvera  Wilson,  ]\I.D. 

ASSISTANT     PHYSICIAN,     GOVERNMENT     HOSPITAL     FOR     THE     INSANE,     WASH- 
INGTON,  D.   C. 

Alcoholic  paralysis  was  first  described  in  1822,  by  James  Jack- 
son. In  1852,  Alagnus  Huss  in  the  study  of  fifty  cases  classified  them 
according  to  the  most  prominent  symptoms,  into  epileptic,  convulsive, 
paralytic,  anesthetic  and  hyperesthetic  types  which  he  considered  due 
to  lesions  of  the  spinal  cord  and  medulla.  Duchenne  de  Boulogne,  in 
1855,  reported  similar  cases  which  he  supposed  to  be  of  spinal  origin. 
In  1864,  Dumesnil  published  the  first  case  in  which  the  lesion  was 
found  in  the  periphery,  but  his  observations  were  not  confirmed  until 
ten  years  later  bv  Eichhorst.  Henry  Hun,  one  of  ovir  own  investiga- 
tors, was  one  of  the  first  to  inform  us  of  the  pathological  changes  in 
this  disease  in  his  article  which  appeared  in  1885,  but  it  was  not  until 
1887  that  it  was  considered  to  be  associated  with  definite  mental 
symptoms.  In  that  year  Korsakow  published,  in  Russian,  a  series 
of  cases  showing  a  disturbance  of  psychic  activity  with  alcoholic 
paralysis  and  its  relation  to  psychic  disturbance  with  multiple  neu- 
ritis of  non-alcoholic  origin. 

In  1890,  he  published  the  result  of  his  research  work  in  German, 
naming  the  disorder,  "  Cerebropathria  psychica  toxemia,"  and  mak- 
ing it  a  clinical  entity.  This  caused  an  angry  controversy.  Tilling 
did  not  believe  this  described  psychosis  existed  in  infectious  neuritis 
but  later  admitted  it.  KraepeHn  calls  it  a  metalcoholic  psychosis,  and 
makes  it  one  of  the  subdivisions  of  alcoholic  psychosis.  He  thinks 
that  it  is  only  a  different  expression  of  the  same  disease  process. 
Bonhoeffer  and  Raiman  consider  it  a  disease  entity  and  relate  it 
closely  to  delirium  tremens,  calling  it  chronic  alcoholic  delirium. 
Ziehen  calls  it  acute  hallucinatoria  paranoia  with  amentia.  Krucken- 
.berg,  who  has  observed  many  cases,  claims  Korsakow's  psychosis  is 
a  combination  of  chronic  alcoholism  and  senile  symptoms.  Dupre 
looks  upon  it  as  a  chronic  psychopolyneuritis  with  dementia.  Knapp, 
Redlich,  and  Nacke  regard  it  closely  associated  with  amentia, 
Jolly  believes  it  a  form  of  delirivmi  tremens.  However,  the  major- 
ity of  investigators  agree  with  Korsakow. 

343 


344  AX  IT  A  ALVERA  UlLSON 

By  "  Korsakow's  Psychosis "  we  mean  a  mental  disturbance 
which  is  preceded  by  years  of  severe  alcoholic- misuse,  especially  of 
"  Schnapskonsum,"  but  the  exact  etiology  is  as  unknown  as  it  was 
twenty-hve  years  ago.  Probably,  as  Kraepelin  thinks,  it  is  not  due 
to  alcohol  itself  but  to  an  auto-intoxication  from  ])oisonous  metabolic 
products,  formed  in  the  system  of  chronic  alcoholics,  which  accumu- 
late in  the  blood,  injuring  the  brain  and  peripheral  nerves,  and  caus- 
ing conditions  which  prevent  their  elimination.  Bronchord,  Charrin, 
Roger,  Leyden  and  Rosenheim  believe  that  ptomaines  and  leuco- 
mains  are  formed  in  great  number  and  cause  the  toxemia.  Why  in 
so  many  drinkers  only  comparatively  few  have  the  disease  is  still 
unknown. 

Although  drinking  is  much  more  prevalent  among  men,  the  dis- 
ease is  relatively  more  frequent  among  women.  This  predisposition 
of  the  female  sex  must  l)e  referred  to  a  greater  susceptibility  of  the 
nervous  tissue  in  general  or  to  special  peculiarities  of  the  female  or- 
ganism. -According  to  Kraepelin.  women  form  only  lo  per  cent,  of 
the  entire  number  of  alcoholics,  but  comprise  33  per  cent,  of  the 
cases  of  Korsakow's  psychosis.  Of  63  cases  which  he  observed,  18 
were  women  and  16  of  these  were  pure  cases  of  Korsakow's  psy- 
chosis. Of  49  males,  29  were  characteristic.  SoukenhofT  and  Bou- 
tenko  found  that  in  192  cases.  112  were  men,  80  women  and  75  per 
cent,  were  alcoholic  in  origin.  Multiple  neuritis  was  absent  in  9 
per  cent,  of  the  men.  In  men  the  toxin  seems  more  likely  to  mani- 
fest itself  by  acute  cerebral  symptoms  than  by  those  of  the  peripheral 
nerves.  Toxic  neuritis,  especially  alcoholic,  is  more  frequent  among 
those  who  have  sedentary  habits.  It  is  caused  by  steady  drinking 
of  small  amounts  of  the  si)irituous  liquors,  brandy,  whiskey,  ab- 
sinthe, vermouthe.  rum  and  gin  and  is  sometimes  due  to  excessive 
indulgence  in  beer,  when  forty  or  fifty  glasses  are  consumed  daily. 
Mcflicinal  uses  of  alcohol  should  not  be  forgotten. 

The  majority  of  cases  occur  between  the  ages  of  thirty-five  and 
fifty.  Only  24.5  per  cent,  of  Kraejielin's  |)atients  were  younger  than 
forty  years.  Of  20  cases  admitted  to  the  fjovermnent  Hos])ital  for 
the  Insane,  since  1907.  17  were  between  the  ages  of  30  and  50. 
There  were  t  i  white,  and  two  colored  females,  and  seven  white 
males.  The  psychoses  in  all  were  due  to  alcoholic  excess.  In  seven 
females,  it  was  caused  by  alcohol,  morphine  and  cocain.  Five  cases 
showed  luetic  infection. 

Korsakow's  syndrome  may  also  occur  in  arteriosclerosis,  con- 
cussion of  the  brain  or  other  head  trauma,  diabetes  and  general 
paralysis,  in  such  infectious  diseases  as  basic  syphilis,  tuberculosis, 


PERIPHERAL  NEURITIS  345 

typhus  and  malaria,  and  in  various  psychoses  as  acute  haUucinatory 
paranoia,  senile  and  apoplectic  dementia  and  states  of  amentia. 
Knapp  and  Mendel  described  various  forms  of  acute  or  chronic 
poisoning  as  from  lead,  arsenic  and  hydrogen  sulphide  accompanied 
by  this  symptom  complex.  Cases  due  to  brain  tumor  and  strangulation 
have  been  reported  by  Servas  and  Pfeifer.  Stierlin  observed  it  as- 
sociated with  carbon  monoxide  poisoning  and  O'Malley  found  simi- 
lar symptoms  in  a  patient  in  the  Government  Hospital  for  the 
Insane.  Recently  Henderson  published  an  article  on  Korsakow's 
psychosis  occurring  during  gestation.  One  of  auto-toxic  origin  has 
been  cited  by  O'Malley  and  Franz. 

Sometimes  the  onset  of  this  psychosis  is  insidious  and  slowly 
progressive,  in  other  cases,  sudden.  About  one  half  of  Kraepelin's 
cases  developed  gradually,  and  one  fourth  of  them  were  preceded  by 
delirium.  Frequently  the  early  symptoms  are  irritabihty,  lack  of 
ambition,  restlessness,  slight  confusion,  forgetfulness  accompanied 
by  severe  headache,  vertigo  or  fainting  attacks.  The  patient  may 
become  stuporous  and  sit  or  stand  staring  into  space  in  a  dazed 
manner.  Korsakow  divided  his  cases  into  two  classes — those  pre- 
ceded or  accompanied  by  delirium  and  those  characterized  by  confu- 
sion or  stupor.  Chronic  gastritis,  insomnia,  general  neuralgic  pains 
or  severe  pains  in  joints  and  limbs,  intensified  by  exercise,  alcoholic 
tremors,  twitchings,  and  progressive  feebleness  in  movement,  pres- 
ence of  Romberg  sign  and  ataxia  may  precede  the  paralysis  or  the 
legs  may  give  way  suddenly.  Soon  there  is  a  complete  paralysis 
of  the  extensor  muscles  of  the  feet  and  legs  which  occasionally  ex- 
tends up  the  thigh.  Later  the  extensors  of  the  hands  and  forearms 
are  attacked.     The  flexors  of  both  extremities  may  be  affected. 

The  paralyzed  muscles  are  flaccid  and  soon  show  symmetrical 
atrophy.  They  do  not  respond  to  mechanical  irritation  as  demon- 
strated by  the  absence  of  the  deep  reflexes.  There  is  usually  no  reac- 
tion to  the  f  aradic  current,  but  excitability  may  be  produced  by  a  very 
strong  current.  Galvanism  produces  the  reaction  of  degeneration. 
Sometimes  strong  galvanic  currents  only  wall  produce  any  contrac- 
tion, showing  that  the  muscles  are  affected  directly  by  the  toxins. 
The  characteristic  limp  wrist-drop  and  foot-drop  appear  early.  The 
deformity  of  the  extremities  varies  in  different  stages.  In  the  hands 
there  is  usually  a  hyperextension  of  the  first  phalangeal  joint,  a 
flexion  of  the  second  and  third,  extension  of  the  metacarpal-phalan- 
geal joint  and  hyperextension  of  the  thumb.  An  adduction  of  the 
first  metacarpal  bone  prevents  apposition  of  the  thumb  to  the  fingers 
giving  the  characteristic  claw-like  appearance  (main  engrift'e).    The 


346  AX  IT  A  ALVERA  UlLSON 

hands  are  flexed  at  the  wrist.  Later,  the  muscles  become  conlractured 
and  atrophied  and  the  tingers  now  straight  and  adducted  are  held 
firmly  fixed.  The  feet  are  extended  at  the  ankle,  the  heel  elevated. 
The  first  joint  of  the  toes  may  be  hyperextended,  the  second  flexed. 
The  plantar  and  peroneal  muscles  become  contracted  and  the  sole  of 
the  foot  can  not  be'  apposed  to  the  floor.  The  knees  are  partially 
flexed.  There  may  be  ankylosis  of  the  smaller  joints.  The  pains  in 
the  muscles  may  be  excruciating  and  there  is  extreme  sensitiveness 
to  pressure  along  the  course  of  the  diseased  nerves.  Zones  of  anes- 
thesia and  hyperesthesia  can  be  demonstrated  in  the  paralyzed  parts. 
The  patient  frequently  complains  of  perverted  sensations  as  "pins 
and  needles,"  numbness,  formication,  or  the  feehng  of  pressure 
girding  the  extremities.  Following  the  paralysis,  there  may  be 
abolition  of  tactile  sense  and  partial  loss  of  deep  sensibility.  Sen- 
sations of  temperature  or  pain  are  never  entirely  lacking,  but  may 
be  retarded. 

The  characteristic  gait  of  the  paretic  which  is  due  to  loss  of  mus- 
cular sense  is  one  of  the  earliest  symptoms  The  weak  extremities 
cannot  raise  the  toe,  so  he  awkwardly  lifts  the  foot  as  if  to  step  over 
a  high  obstacle.  Since  this  symptom  is  more  marked  in  some  cases, 
Dreschfeld  designated  these  persons  as  ataxic,  rather  than  paralytic, 
but  they  are  not  free  from  paralysis.  Wcstphal  and  Charcot  dif- 
ferentiated this  "steppage  gait"  from  that  of  the  tabetic.  The 
Romberg  symptom  is  present  in  both  conditions. 

The  vasomotor  symptoms  are  variable.  The  extremities  may  be 
cold  or  hot  or  profuse  sweating  may  occur.  They  are  usually  pale 
at  first  but  after  the  paralysis  occurs  become  ])urple  and  swollen, 
and  the  skin  has  a  glossy  appearance.  The  lines  of  the  face  may 
look  ironed-out  from  paresis  of  the  facialis,  there  may  be  a  dis- 
turbance of  speech  and  writing,  difficulty  of  swallowing,  paralysis 
of  the  eye  muscles,  especially  of  the  sixth,  nystagmus,  unequal  pupils, 
or  limited  movement  of  the  eyes.  If  the  eyes  do  not  react  to  light, 
this  may  be  an  indication  of  lues.  Aphasia,  agraphia  and  apraxia, 
epileptiform  attacks,  cortical  epilepsy,  monoplegias  and  hemiplegias 
or  other  symptoms  of  central  irritation  may  ap]:)ear  'Ihcre  may  be  a 
serious  change  in  the  entire  organism  which  expresses  itself  in 
gradual  emaciation.  Flabbiness,  dilatation  and  enfeeblement  of 
the  heart  muscle,  signs  of  chronic  pulmonary  congestion  with  dysp- 
nea, disease  of  the  liver,  qualitative  changes  in  the  urine,  bladder 
disturbances,  arteriosclerosis  and  persistent  vomiting  may  develop. 
The  phrenic  and  vagus  nerves  may  become  paralyzed  and  cause 
death. 


PERIPHERAL  NEURITIS  347 

The  mental  symptoms  forming  Korsakow's  symptom-complex 
are  characterized  by  disorientation,  a  defective  power  of  observa- 
tion (Merkstoring),  a  retrograde  amnesia,  and  confabulation,  which 
is  the  most  important  symptom  in  the  syndrome.  As  Kraepelin  says 
the  patient  forgets  in  a-  few  minutes  what  he  has  just  experienced 
or  desired  to  remember,  although  he  is  clear  and  understands  with- 
out difficulty  what  is  said  to  him,  but  he  is  wholly  unable  to  gather 
any  new  experiences,  or  appreciate  the  development  of  events.  He 
forgets  what  he  did  a  half  hour  before,  and  as  it  is  impossible  to 
make  him  retain  the  explanation,  his  confusion  can  not  be  overcome. 
He  forgets  the  beginning  and  goal  of  his  story,  and  relates  new 
ideas  which  White  designates  "  opportune  confabulations."  Bon- 
hoeffer  calls  this  "  embarrassment  confabulation."  Impressions  do 
not  remain  and  are  not  associated.  Strong  impressions  may  remain 
but  without  any  connection  with  present  or  following  events. 

The  first  result  of  this  disturbance  is  disorientation,  especially 
as  to  time,  although  immediate  valuation  and  comparison  of  short 
intervals  of  time  show  no  essential  disturbance.  The  patient  re- 
joices daily  anew  to  make  the  acquaintance  of  the  physician.  He 
will  say  that  he  does  not  remember  the  names  of  those  about  him, 
but  he  feels  as  if  he  knows  them.  Events  just  preceding  the  out- 
break of  the  disease  are  more  easily  forgotten.  Years  and  decades 
may  be  erased  from  his  life.  He  cannot  tell  how  or  when  he  be- 
came sick  or  \vhether  it  happened  yesterday  or  last  year.  His  mem- 
ory may  be  good  for  intermediate  periods  of  time  wnthout  any  ar- 
rangement of  sequence.  According  to  Gregor,  even  the  memories 
which  the  patient  still  retains  cannot  be  brought  into  any  timely  order 
as  all  intermediate  links  are  lacking.  This  confusion  of  sequence 
varies  in  different  individuals,  as  it  bears  a  certain  relationship  to 
the  mental  vivacity.  Kraepelin  states  that  exact  investigation  by 
measuring  tests  shows  a  lessening  of  comprehension  to  one  sixth  of 
the  normal.  Gregor  and  Romer  found  that  the  time  needed  for  a 
complicated  reaction  compared  with  that  for  a  simple  reaction  was 
disproportionately  lengthened.  This  impairment  is  scarcely  de- 
tected by  the  usual  tests.  The  memory  pictures  appear  so  slowly, 
recognition  is  more  difficult. 

The  power  of  observation  is  much  impaired  about  one  third  or 
one  fourth  of  normal.  Brodman  and  Gregor  made  many  tests  by 
having  the  patients  memorize  a  series  of  senseless  syllables.  At  the 
height  of  the  disease,  there  was  a  total  inability  to  remember  any  of 
them  but  after  a  large  number  of  repetitions,  eight  or  twelve  were 
retained.     Some  were  remembered  150  days  after  constant  repeti- 


348  .AX  IT  A  AW  ERA  WILSON 

tion,  and  there  was  a  simultaneous  improvement  of  memory  and 
observation.  Kraepelin  did  not  find  any  improvement  when  mental 
problems  in  arithmetic  were  repeated.  Morstadt  found  that  they 
invented  replies  and  showed  a  marked  tendency  to  adhere  to  them. 

His  falsifications  and  pseudo-reminiscences,  or  "  hallucinations 
of  memory  "  as  W'ehrung  says,  may  be  associated  with  his  delusions 
or  actual  experiences.  As  the  patient  is  hypersuggestible  these 
fabrications  may  be  started  by  "  leading  questions,"  which  White 
terms  "  suggestion  confabulation,"  or  something  in  his  environment 
may  stinuilate  him  to  spin  out  a  web  of  marvelous  fantasy.  This 
depends  on  the  mental  activity  of  the  patient.  He  may  be  dull  and 
apathetic,  answering  only  in  monosyllables  and  evasively,  or  living 
in  a  world  of  fancy,  replies  readily  and  does  not  appreciate  his 
errors. 

The  content  of  this  confabulation  often  shows  delusions  of  a  perse- 
cutory and  a  grandiose  nature.  He  may  have  enemies  disguised  who 
plot  against  him,  poison  his  food  and  take  advantage  of  him  at  night. 
The  grandiose  ideas  may  simulate  those  of  a  paretic.  He  may  enjoy 
wonderful  travels,  covering  long  distances  in  a  short  time,  acquire 
an  enormous  fortune  or  attain  a  much  coveted  position. 

The  emotional  status  is  variable  and  greatly  influenced  by  sug- 
gestion.    Emotional  apathy  is  the  usual  result. 

Kraepelin  believes  that  for  general  clinical  reasons,  it  is  to  be 
thoroughly  recommended  that  this  disease,  developing  on  the  basis  of 
alcohol,  be,  as  a  matter  of  principle,  separated  from  all  disease  pic- 
tures of  other  genesis,  even  though  they  ofifer  the  same  symptoms. 
He  feels  that  since  we  get  a  similar  picture  in  paresis,  it  should  warn 
us  not  to  overvalue  the  clinical  importance  of  the  disturbances  of  ob- 
servation and  attention  and  memory  falsifications.  We  must  hold 
to  the  precept  that  disease  processes  of  undoubtedly  different  origin 
cannot  be  alike  in  nature  even  though  their  clinical  pictures  at  times 
cannot  be  clearly  diiTerentiated.  A  study  of  the  history  of  develop- 
ment and  course  of  the  disease  with  a  careful  observation  of  the 
individual  disturbances  will  show  valuable  differences  in  spite  of  all 
similarities  between  the  clinical  picture  of  infectious  and  alcoholic 
diseases.  Thus  the  confusion  and  excitement  in  the  beginning  of 
those  infectious  cases  which  resemble  Korsakow's  psychosis  do  not 
simulate  delirium  tremens.  The  semi-stupor  and  confusion  are 
more  marked,  while  the  hallucinations  are  less.  The  trembling  and 
characteristic  restlessness  are  absent.  The  entire  mood  has  no  alco- 
holic coloring.  The  prognosis  seems  to  be  essentially  more  favor- 
able than  in  the  alcoholic  forms. 


PERIPHERAL  NEURITIS  349 

In  differentiating  between  Korsakow's  psychosis  and  general 
paralysis,  Kraepelin  says  that  emphasis  must  be  placed  on  the  pre- 
vious history.  In  the  one  case  we  have  lues,  in  the  other  alcohoHsm  ; 
in  one  a  general  failure  of  memory  and  inability  to  learn,  in  the 
other  a  predominating  disturbance  of  observation  and  attention.  In 
one  case  paralytic  attacks  with  rapidly  recovering  symptoms  of  lame- 
ness, in  the  other  fainting  spells  and  epileptiform  attacks  with  no 
after  results.  In  one,  slow  development  of  the  well-known  pro- 
dromal symptoms  ;  in  Korsakow's  psychosis  pronounced  neuritic  dis- 
turbances, paralysis  of  the  eye  muscles,  the  characteristic  trembling, 
speak  far  more  for  Korsakow's  psychosis,  while  indications  of  aphasia, 
stumbHng  over  syllables,  symptoms  of  cerebral  paralysis  and  above 
all  the  Arg}-ll-Robertson  pupil  make  dementia  paralytica  probable. 
In  the  psychic  field,  the  apathetic  or  humorous  mood  of  the  alcoholic 
may  be  contrasted  with  the  demented  bliss  of  the  paralytic,  and  the 
circumscribed  disturbances  of  memory  and  observation  of  the  former 
with  the  impaired  judgment  of  the  latter.  With  paralytics,  the 
memory  weakness  does  not  seem  to  be  limited  by  time,  but  may  also 
include  the  events  of  their  youth.  At  the  same  time,  it  is  often  very 
difficult  to  differentiate  between  a  developing  Korsakow's  psychosis 
with  marked  weak-mindedness  and  brain  disturbance,  and  paresis, 
if  the  spinal  fluid  can  not  be  examined. 

A  similar  trouble  is  met  with  in  separating  Korsakow's  psychosis 
from  certain  arterio-sclerotic  and  syphilitic  mental  disturbances.  In 
arterio-sclerotic  diseases,  cerebral  symptoms  predominate  through- 
out in  contrast  to  the  neuritic  symptoms  in  the  foreground  of  Kor- 
sakow's psychosis,  and  general  memory  weakness,  in  contrast  to  the 
disturbance  of  observation  and  memory  falsifications.  The  mood 
of  an  arterio-sclerotic  is  more  whiny  or  apathetic,  compared  with 
the  contentment  of  the  alcoholic. 

The  syphilitic  brain  diseases  are  likewise  characterized  by  appear- 
ance of  center  s3'mptoms,  frequently  of  a  more  transitory  nature, 
while  neuritic  signs  are  generally  absent.  On  the  other  hand,  marked 
disturbances  of  observation,  memory  falsifications  as  well  as  paral- 
ysis of  the  eye  muscles  may  be  observed,  so  that  mistaking  them 
for  Korsakow's  psychosis  is  very  easy.  The  diagnosis  becomes  less 
certain  if  we  are  confronted  by  alcohol  and  lues.  The  diagnosis 
can  be  confirmed  by  cytologic  and  serologic  findings. 

In  presbyophrenia,  we  also  observe  a  picture  of  severe  disturb- 
ances of  observation,  loss  of  orientation  and  memory  falsification, 
but  we  always  deal  with  a  patient  of  more  advanced  age,  while  Kor- 
sakow's psychosis  develops  between  the  ages  of  30  and  50  in  55  per 


350  ANITA  ALVERA  WILSON 

cent,  of  the  cases.  There  is  an  absence  of  previous  alcohoHc  his- 
tory and  of  the  neuritic  symptoms.  TiUing  first  called  attention  to 
the  fact  that  presbyophrenia  begins  with  fainting  spells  or  apo- 
plectiform attacks  with  intercurrent  periods  of  agitation  and  appre- 
hension. The  patient  is  communicative,  often  talkative,  takes  an  in- 
terest in  his  surroundings.  He  shows  a  peculiar  childish  emotional 
state  and  a  certain  busy  restlessness  especially  at  night.  The  loss 
of  retention  seems  to  be  also  much  more  extensive,  so  that  the  patient 
often  has  lost  the  simplest  required  knowledge  and  does  not  compre- 
hend quite  evident  contradictions  with  daily  experience.  His  his- 
tory is  essentially  different  from  that  in  Korsakow's  psychosis. 
Difficulties  of  differentiation  will  therefore  occur  at  most  only  in 
such  cases  in  which  great  misuse  of  alcohol  and  its  results  exist 
simultaneously. 

The  course  of  recovery  is  slow  and  quite  uniform.  The  hal- 
lucinations are  substituted  by  a  roaring  in  the  ears  or  seeing  bright 
lights,  and  those  finally  grow  less  frequent  and  are  lost.  The  patient 
may  have  some  insight  and  his  judgment  may  be  good.  "  He  becomes 
more  skillful  in  covering  the  lapses  of  memory.  He  lacks  inclina- 
tion to  serious  occupation  and  lives  without  wish  or  action.  I\Iany 
things  are  left  undone  because  he  thinks  he  has  already  done  them 
or  he  may  repeat  an  act."  The  polyneuritis  gradually  disappears 
and  the  amnesia  gradually  improves.  There  remams  a  permanent 
weak-mindedness^  with  or  without  disturbance  of  observation  and 
attention.  Hallucinations  may  continue.  Korsakow  thinks  a  cure 
is  possible.  Wernicke  says  the  prognosis  is  favorable.  Baedeker 
and  Tightmeyer  report  recoveries.  Baedeker  reports  a  case  of  a 
university  professor  who  had  Korsakow's  psychosis,  but  was  later 
able  to  carry  on  scientific'teaching  as  before.  Tilling  never  observed 
a  cure.  Bonhoeffer,  Knapp,  Stanley  and  Kaufmann  feel  that  there  is 
always  a  mental  weakness  affecting  the  memory  and  the  emotional 
state.  Kraepelin  is  skeptical.  Several  writers  feel  that  a  larger 
number  recover  than  shown  by  statistics. 

The  duration  is  from  four  months  to  two  years. 

In  six  of  the  20  cases  admitted  to  the  Government  I  fospit.d  for 
the  Insane,  the  paralysis  was  lacking;  three  had  a  mild  multiple 
neuritis  and  the  others,  had  a  typical  perii)heral  paralysis;  six  were 
discharged  recovered;  four  discharged  imjjroved,  and  four  died; 
six  patients  are  in  the  hospital  at  ])resent.  In  all  these  the  physical 
symptoms  have  improved,  but  each  case  shows  mental  deterioration, 
and  five  show  a  jirogressive  dementia.  'I'he  sixth,  admitted  in 
August,    1907,   was  an   actress  associated   with   Richard    Mansncld 


PERIPHERAL  NEURITIS  351 

for  several  years.  Both  her  grandfather  and  father  held  high  posi- 
tions in  the  U.  S.  Government.  Her  mother  was  a  well-known 
society  woman.  Patient  shows  little  mental  impairment,  most  no- 
ticeably by  inaccuracy  of  dates  and  the  estimation  of  time.  She  has 
a  tendency  to  retain  erroneous  impressions.  She  is  still  able  to 
quote  Shakespeare  and  other  parts  of  plays  she  had  memorized,  to 
translate  foreign  languages,  goes  into  the  city  and  does  her  own 
shopping,  and  last  year  coached  the  hospital  dramatics. 

The  pathological  changes  in  this  disease  are  very  similar  to  those 
found  in  delirium  tremens  but  are  more  extensive  and  of  a  chronic 
nature.  Usually  a  simple  degenerative  parenchymatous  neuritis 
occurs  followed  by  atrophy.  The  toxins  seem  to  have  a  selective 
action  in  paralyzing  certain  peripheral  nerves  of  the  hands  and  feet 
as  in  diphtheria,  the  poison  has  a  preference  for  the  nerves  control- 
Hng  deglutition  and  respiration.  "The  peronei,  tibialis,  radial,  ulnar 
and  median  are  usually  attacked.  The  sciatic,  crural,  musculo- 
cutaneous, circumflex,  optic,  pneumogastric  and  pleuric  nerves  may 
be  affected.  The  degenerative  changes  are  more  marked  in  the 
myelin  sheath  of  the  finer  branches.  Some  cases  show  a  more  ex- 
tensive lesion  in  the  periphery ;  others  in  the  central  nervous  system 
which  is  believed  by  Cole  to  be  due  to  a  degeneration  of  the  entire 
neurone,  manifested  in  the  periphery,  although  the  disease  is  a  gen- 
eral one,  as  senile  gangrene  may  be  the  result  of  a  general  arterio- 
sclerosis. 

The  changes  in  the  cord  are  most  marked  in  the  anterior  horn 
cells  and  the  ganglia  cells,  especially  in  the  lumbar  region.  It  consists 
in  the  disintegration  of  Nissl's  granules  which  become  finely  gran- 
ular and  lost  their  power  of  absorbing  aniline  dyes.  The  atrophy 
is  similar  to  that  in  amyotrophic  lateral  sclerosis.  The  change  is 
most  marked  about  the  nuclei  which  show  decentralization  and 
chromatolysis,  and  have  a  tendency  to  gravitate  toward  the  peri- 
phery, much  distorted  in  shape,  There  is  often  a  deposit  of  pig- 
ment in  the  cell  with  a  rarification  of  the  fibrillar  substance.  The 
axones  show  an  increase  of  connective  tissue  in  the  endoneurium 
and  perineurium,  with  marked  congestion  of  the  blood  vessels, 
capillary  hemorrhages,  small  cell  infiltration  and  later  fibrous  and 
hyaline  degenerative  changes  in  the  vessel  walls,  which  Gudden 
found  was  most  extensive  in  the  smaller  vessels.  Although  there  is 
a  degeneration  of  the  fibers  in  Goll's  column  there  is  no  plasma  cell 
infiltration  as  in  paresis.  BonhoefTer  believes  the  hemorrhages 
which  occur  in  the  first  stage  of  the  disease  in  this  part  of  the 
cord  are  due  to  thrombosis  caused  bv  the  circulating  toxins,  rather 


352  ANITA  ALVERA  WILSON 

than  to  the  less  pronounced  changes  in  the  vessel  walls,  but  Alz- 
heimer claims  they  are  true  encephalitic  centers.  Similar  changes 
are  found  in  Clarke's  column. 

Several  investigators  have  demonstrated  uniform  changes  in  the 
cortical  cells  especially  of  the  third  and  sixth  layers.  Some  of  the 
pyramidal  cells,  particularly  the  Betz  cells,  become  swollen,  and 
pigmented,  granules  disintegrated,  nuclei  distorted  and  decentral- 
ized and  the  dendrites  and  axones  broken  and  atrophied.  There 
is  a  proliferation  of  the  glia  cells  and  a  thickening  of  the  pia 
but  to  a  lesser  degree  than  in  paresis.  The  degenerative  changes 
show  a  greater  preference  for  gray  matter,  especially  around  the 
aqueduct  of  Sylvius  and  the  third  ventricle.  Here  there  is  a  great 
proliferation  of  blood  vessels  with  hemorrhages  which  often  cause 
a  paralysis  of  the  eye  muscles,  making  the  clinical  picture  similar  to 
that  of  poliencephalitis  acuta  hemorrhagica  superior  described  by 
Wernicke.  In  the  substantia  nigra  the  thickening  of  the  vessel 
walls  is  extensive.  The  degenerative  changes  are  most  widespread 
in  the  first  and  second  frontal  and  anterior  central  convolutions,  in 
the  occipital  lobe,  along  the  calcarine  fissure,  and  in  the  corona  and 
in  the  internal  capsule.  The  intercortical  and  tangential  fibers  show 
similar  changes.  Cells  and  fibers  in  the  medulla  and  cerebellum 
show  the  same  degenerative  processes  as  the  cerebrum. 

Storcli  and  Forester  believe  that  the  lesions  of  the  cortical  as- 
sociation fibers  cause  the  peculiar  mental  state,  and  that  the  dis- 
orientation depends  upon  the  lack  of  ])eriphcral  sensation. 

The  first  thing  to  do  is  to  eliminate  the  toxic  agent.  Cowers, 
Bernhardt  and  Oppcnheim  feel  that  in  cases  of  weak  heart,  the 
alcohol  should  not  be  withdrawn  at  once.  In  the  stage  of  invasion. 
Starr  recommends  the  free  use  of  large  doses  of  salol ;  salicylic  acid 
or  sodium  salicylate  have  important  result>.  He  suggests  that 
potassium  or  bromide  be  combined  with  them,  partly  because  these 
drugs  counteract  the  unfavorable  symptoms  produced  by  the  salicin 
compounds  and  jjartly  because  they  are  indicated  in  the  hyper- 
esthetic  irritable  condition  of  the  patient.  Sometimes  morphine 
must  be  given  for  severe  pain.  Hot  or  cold  applications  may  help — 
hot  better  in  the  chronic  condition.  Cases  associated  with  syphilis 
or  malaria  are  treated  by  their  specifics.  In  the  chronic  stage, 
str)xhnine  in  doses  from  %„  to  ^/{o — 3,  4  or  6  times  in  24  hours, 
Fowler's  solution  three  to  five  drops  t.i.d.  Even  if  they  increase 
the  mental  irritability,  they  should  be  continued.  The  remedies 
used  in  the  chronic  stage  are  to  increase  the  repair  in  the  nerves  and 
to  nouri'-h  the  muscles.     The  tonic  trcatnunl  of  the  drugs  will  .lid 


PERIPHERAL  NEURITIS  353 

the  nerves,  but  massage,  warm  baths  and  electricity  do  both. 
Massage  increases  the  circulation.  The  baths  produce  a  general 
sedative  effect  and  are  preferable  to  hypnotic  drugs.  De  Kraft 
says  that  warmth  has  a  sedative  effect  upon  the  nerve  endings  and 
upon  the  vaso  vasorum,  improving  the  circulation,  relieving  con- 
gestion in  the  splanchnic  and  cerebral  vessels  and  has  a  general 
helpful  eft'ect  upon  the  musculature  of  the  vessels  themselves,  pre- 
venting sclerotic  conditions. 

After  the  acute  symptoms,  as  pain  and  tenderness  in  the  extremi- 
ties, have  subsided,  the  application  of  electricity  will  hasten  the 
progress  of  nerve  regeneration.  The  opinions  of  the  electrothera- 
peutists  differ  as  to  whether  the  faradic  or  galvanic  current  be  used 
first.  De  Kraft,  explaining  the  effects  of  electricity,  says  that 
stimulation  of  the  cutaneous  nerves  by  faradic  currents  produces 
contraction  of  voluntary  and  involuntary  muscles  and  is  irritant  to 
nerve  endings.  When  combined  with  the  galvanic  current  there  is 
less  fatigue  and  exhaustion  due  to  its  effect  on.  the  circulation.  As 
a  therapeutic  agent,  the  galvanic  current  has  polar,  interpolar  and 
general  eft'ects.  Acid  ions  accumulate  at  the  positive  and  alkaline 
at  the  negative  pole.  The  positive  pole  is  sedative  to  sensory  end- 
ings and  is  a  vaso-constrictor.  At  the  negative  pole  there  are 
accumulations  of  fluid,  liquefaction  and  an  alkaline  caustic  effect. 
The  negative  pole  is  irritant  to  nerve  endings.  It  acts  as  a  vaso- 
dilator. The  interpolar  effects  are  tonic.  The  use  of  high  fre- 
quency currents  fulfils  certain  definite  indications  but  none  exceed 
the  wave  current  in  value.  The  high  tension  alternating  current  is 
dependent  practically  upon  the  thermic  eft'ect  which  is  produced  by 
the  resistance  of  the  tissue  to  the  passing  electrodes,  also  to  the 
general  molecular  oscillation.  The  sinusoidal  current  produces  a 
gradual  contraction  and  relaxation  of  muscular  structures,  tending 
to  rebuild  and  restore  the  lax  muscular  conditions  by  squeezing  out 
effete  products  with  absorption  of  new  materials.  A  mild  current 
may  be  applied  half  an  hour  over  the  degenerated  nerves  and  over 
the  spine  at  the  level  of  the  nerve  roots  which  supply  the  affected 
extremity.  Starr  suggests  that  the  muscles  be  exercised  for  three 
or  four  minutes  every  other  day  till  the  patient  recovers.  High- 
heeled  shoes  will  facilitate  walking — the  patient  should  be  en- 
couraged to  take  a  few  steps  each  day  and  the  distance  gradually 
increased  until  he  has  confidence  in  himself,  then  he  should  walk 
unassisted.  If  the  contracture  of  the  posterior  tibial  muscles  can 
not  be  overcome,  division  of  the  tendo  Achillis  may  be  necessar}^ 

The  memory  weakness  may  be  improved  by  daily  retention  tests, 


354  AXITA  AW  ERA  WILSON 

as  suggested  by  Gregor.  The  events  of  the  patient's  life  should  be 
often  consecutively  reviewed  until  he  can  learn  to  estimate  time. 

After  reviewing  the  literature  concerning  polyneuritis  with 
Korsakow's  symptom  complex,  we  may  conclude  that  it  is  a  disease 
entity,  since  it  is  always  caused  by  alcoholic  excess  and  is  character- 
ized by  the  constant  mental  symptoms  of  deterioration,  disturbance 
of  observation,  memor}-  weakness  and  confabulation,  usually  ac- 
companied by  definite  symptoms  of  a  general  polyneuritis,  which 
may  be  preceded  by  stupor  or  delirium  developing  slowly  or  sud- 
denly, followed  by  muscular  weakness,  loss  of  deep  reflexes,  a 
characteristic  gait,  presence  of  the  Romberg  sign  and  nystagmus, 
followed  usually  by  a  complete  paralysis  manifested  by  wrist  and 
foot  drop. 

The  syndrome  may  occur  in  various  forms  of  poisoning,  in- 
fectious diseases,  pregnancy,  head  traumas,  and  be  associated  with 
other  psychoses. 

The  principal  conditions  from  which  it  needs  to  be  differentiated 
are  general  paralysis,  certain  arterio-sclerotic  and  syphilitic  di.seases 
and  presbyophrenia. 

The  course,  unless  aborted,  is  slow  and  uniform.  The  physical 
symptoms  disappear,  but  a  mental  impairment  results,  although  a 
few  believe  in  complete  recovery.  The  duration  is  from  four 
months  to  two  years. 

The  pathological  changes  occur  in  the  peripheral  nerves,  cord  and 
brain,  and  are  characterized  by  degeneration  and  atrophy  of  the 
myelin  sheath,  a  disintegration  of  the  nerve  cells  shown  by  distor- 
tion and  decentralization  of  the  nuclei,  pigmentation,  disappearance 
of  Xissl's  granules,  hemorrhages  and  small  cell  infiltration,  fibrous 
and  hyaline  degeneration  and  proliferation  of  the  glia  cells. 

Treatment  is  eliminative,  sedative,  nourishing  and  tonic  for  the 
physical  condition,  retention  exercises  for  the  memory  defect. 

The  only  case  I  have  had  an  opportunity  to  follow  throughout 
its  course  is  here  reviewed  because  it  is  not  only  of  scientific,  but  of 
social  interest,  since  it  shows  the  danger  of  ignorantly  using  a 
proprietary  medicine,  and  demonstrates  one  of  the  benefits  of  the 
Foofl  and  Drugs  .Act. 

{To  be  continued) 


©octets  procceMnge 


NEW  YORK  NEUROLOGICAL  SOCIETY 

Held  with  the  Section  on  Neurology  and  Psychiatry  of  the  New  York 
Academy  of  Medicine 

November  g,  1915 

The  President,  Dr.  William  Leszynsky,  in  the  Chair 

OBSERVATIONS    REGARDING    THE    CONDITION    OF    SPASTIC 
PARALYSIS  DUE  TO   INTRACRANIAL  HEMORRHAGE 

By  WilHam  Sharpe,  M.D. 

Ten  cases,  showing  the  results  in  patients  on  whom  decompression  had  been 
performed,  were  presented  by  Dr.  Sharpe.  He  stated  that  50  per  cent,  of  the 
cases  of  spastic  paralj-sis  were  due  to  intracranial  hemorrhage ;  the  remaining 
cases  being  due  to  meningo-encephalitic  conditions,  following  acute  infection 
and  agenesis  and  lack  of  development  of  the  cortex  or  pyramidal  tracts.  The 
history  of  the  cases  showing  signs  of  intracranial  pressure  was  carefully  stud- 
ied as  regards  difficult  labor,  convulsions  after  birth  and  ophthalmological  signs, 
and  confirmation  w^as  sought  by  lumbar  puncture  and  measurements  of  the 
pressure  of  the  cerebrospinal  fluid.  719  cases  had  been  examined  up  to  Novem- 
ber I,  1915,  and  of  these  194  were  considered  to  be  due  to  intracranial  hemor- 
rhage. 176  cases  had  been  operated  upon,  of  the  selected  type,  showing  definite 
signs  of  intracranial  pressure.  Twelve  deaths  had  occurred.  Eighty-six  cases 
showed  a  visible  hemorrhagic  cyst  at  the  site  of  operation  ;  in  seven  the  cyst 
was  subcortical.  But  from  this  series  Dr.  Sharpe  concluded  that  the  majority 
was  supracortical,  rather  than  cortical  or  subcortical ;  the  impairment  was 
due  to  the  pressure  of  the  overlying  cyst  and  not  primarily  to  a  destruction 
of  nerve  cells.  The  summary  of  cases  shown  was :  I.  Child  with  compres- 
sion over  left  parietal  area,  with  right  spastic  hemiplegia,  due  to  instruments, 
was  operated  April,  1914.  Removal  of  depressed  bone  done,  leaving  a  large 
defect.  Recovery  was  rapid  after  operation,  so  that  the  child  was  normal  at 
present.  II.  Case  of  difficult  labor  and  convulsions  after  birth ;  the  child  was 
unable  to  sit  up  or  use  arms,  and  had  extreme  spastic  diplegia.  Two  months 
ago  a  right  decompression  was  done,  and  later  a  left  decompression.  Child 
could  now  walk  and  was  much  improved,  but  the  forehead  still  bulged  mark- 
edly. There  was  a  hemorrhagic  cyst,  due  to  the  rupture  of  the  longitudinal 
sinus.  III.  Child  of  2  years,  was  operated  on  six  weeks  ago.  There  was  a 
right  spastic  hemiplegia  with  a  hemorrhagic  cyst  over  the  left  temporal 
sphenoidal  area.  IV.  Child  3  years  of  age,  a  spastic  diplegiac  from  instru- 
mental delivery,  had  a  left  subtemporal  decompression  done.  A  tense  edema- 
tous cortex  was  found,  under  high  pressure,  but  no  rupture  of  cortex  oc- 
curred. V.  Child,  7%  years  old,  instrumental  delivery,  with  typical  left  spastic 
hemiplegia,  had  a  left  subtemporal  decompression  done.  He  had  since  begun 
to  pick  up  and  take  his  place  in  school.     VI.  Child  with  right  spastic  hemi- 

355 


356  XEIV  YORK  XEUROLOGICAL  SOCIETY 

plegia.  A  left  subtemporal  decompression  was  done.  There  was  a  history 
of  instrumental  deliver}-  and  convulsions  after  birth..  Operation  exposed  a 
cyst  lying  on  the  upper  portion  of  the  temporo-sphenoidal  lobe.  Tlie  cyst 
was  in  the  cortex  in  this  case  and  there  was  primary  destruction  of  the  cells, 
so  that  the  arm  had  improved  much  less  than  the  leg.  VII.  Child  at  eight 
months  was  unable  to  raise  hand  and  unable  to  walk  at  2^'  3'ears.  Improved 
after  operation.  VIII.  A  left  spastic  hemiplegia  with  convulsions,  operated 
October,  1913.  IX.  Right  extreme  spastic  diplegia  with  convulsions,  operated 
November,  1914.  X.  A  girl  of  12  jears,  had  two  operations.  A  typical 
edematous  thickened  arachnoid  was  found.  The  cortex  did  not  rupture. 
The  girl  was  doubled  up  before  operation,  with  knees  to  chin.  She  could  now 
walk,  but  with  an  awkward  gait.  XI.  Boy,  ten  years,  with  severe  spastic 
diplegia  and  impaired  mentality,  had  two  operations  and  was  now  much  im- 
proved. XII.  Case  of  difficult  labor.  Extreme  spastic  diplegiac,  was  oper- 
ated one  year  ago.  This  case  had  sucli  liigh  intracranial  tension  that  a 
protrusion  of  the  bon}-  edge  of  the  decompression  had  resulted.  In  regard 
to  cases  generally,  Dr.  Sharpe  said  that  operation  on  one  side  generally  re- 
lieved the  pressure  sufficiently,  though  a  second  operation  was  often  neces- 
sary, as  in  this  last  case.  Autopsies  were  being  performed  on  all  cases  to 
check  the  diagnostic  findings.  He  thought  the  mental  improvement  was  very 
much  more  important  than  the  physical  improvement.  Prognosis  was  worse 
when  the  children  had  convulsions.  In  about  50  per  cent,  of  the  cases  con- 
vulsions ceased  after  the  decompression.  The  operation  was  a  subtemporal 
decompression,  a  permanent  removal  of  an  area  of  bone  beneath  the  temporal 
muscle.     The  dura  was  always  opened  and  left  opened. 

Dr.  Bernard  Sachs  said  that  twenty-five  years  ago  Dr.  Peterson  and  he 
had  reported  140  cases  of  cerebrospastic  states,  particularly  in  the  young.  At 
that  time  thej'  were  not  unmindful  of  the  possibility  of  curing  these  cases 
by  operation.  Some  of  them  were  operated  on  by  Dr.  Gerster,  particularly 
cases  associated  with  epilepsy.  They  did  not  attempt  to  do  decompression. 
They  attempted  to  find  the  lesion  and  were  willing  to  take  the  risk  of  a  suc- 
ceeding paralysis.  The  reason  for  discouragement  was  that  only  one  of  five 
or  six  showed  any  focal  lesion.  That  was  in  accord  with  the  pathology  of 
these  conditions.  It  was  gratifying  now  to  learn  the  frequency  of  cystic 
conditions  in  these  cases.  They  thought  the  cases  cortical,  not  subcortical. 
He  was  surprised  to  learn  the  actual  number  of  cysts  found  in  these  cases 
and  was  further  surprised  to  sec  the  extremel}^  gratifying  results  following 
decompression.  These  results  justified  surgical  interference.  Dr.  Sliarpe 
should  be  congratulated.  The  results  proved  that  cysts  must  be  extremely 
frequent.  That  was  the  only  reason  for  the  decompression  operation. 
Otherwise  he  did  not  see  how  the  success  could  be  explained.  The  only  other 
theory  would  be  a  meningo-encephalitis,  that  is,  that  there  was  a  hemorrhage 
with  adhesions.  Decompression  might  relieve  a  brain  that  was  partially  con- 
stricted b}'  meningitic  adhesions. 

Dr.  Ramsay  Hunt  said  that  he  would  like  to  congratulate  Dr.  Sliarpe  on 
the  excellent  results  he  had  obtained  in  this  discouraging  group  of  cases. 
There  seemed  to  him.  however,  to  be  another  explanation  for  this.  Focrster 
had  improved  these  cases  by  relieving  stimuli  which  originated  peripherally, 
by  spinal  decompression  and  rhizotomy.  Would  it  not  then  1)C  possible  by 
lowering  the  normal  intracranial  pressure,  and  by  breaking  up  adhesions, 
cysts,  etc.,  to  diminish  cerebral  stimuli  and  the  tendency  to  increased  muscle 
tone?  In  other  words,  to  do  by  a  cerebral  operation  what  Foerster  had 
accomplished  by  ojicrations  on  the  lower  neurones  and  thus  diminishing  irri- 
tative stimuli  by  another  route.  Dr.  Hunt  said  that  he  had  not  been  able  to 
confirm  Dr.  Sharpe's  findings  in  regard  to  the  optic  disks.  He  was  inclined 
to  think  that  Dr.  Sharpe  laid  too  mucli  stress  on  the  ophthalmoscopic  changes. 


NEW  YORK  NEUROLOGICAL  SOCIETY  357 

Dr.  Sachs  said  that  in  cases  examined  twenty-five  j'ears  ago  they  did  not 
find  a  single  case  of  optic  neuritis  or  of  choked  disk. 

Dr.  Norman  Sharpe  said  that  the  sign  of  pressure  which  was  noted  in 
the  eye  was  a  blurring  of  the  disk,  but  the  vessels  were  tortuous.  The  duras 
were  alw'ays  thickened.  It  was  impossible  to  get  them  together  after  they 
were  once  cut.     The  brain  bulged  at  the  opening. 

Dr.  Foster  Kennedy  said  that  an  important  point  was  that  Dr.  Sharpe 
stated  that  cases  suitable  for  operation  were  those  where  pressure  was  known 
to  exist  by  reason  of  the  pathological  findings  in  the  optic  nerve.  Were  the 
majority  of  these  pathological  conditions  confirmed  bj^  Dr.  Sharpe,  by  the 
findings  in  the  cerebrospinal  fluid?  The  resultants  of  increased  pressure  in 
the  optic  nerves,  other  than  definite  dilatation  of  the  veins,  blurring  of  the 
disk,  disturbance  of  the  retinal  field,  were  extraordinary  and  difficult  to 
teach  to  the  ordinary  student,  and  one  would  not  be  able  to  get  a  guide  from 
such  considerations  alone  as  to  whether  the  head  should  be  opened  or  not. 
Would  it  not  be  more  just  to  widen  the  basis  of  evidence  with  the  idea  that 
one  should  only  operate  on  cases  corroborated  by  an  increase  of  pressure  of 
the  cerebrospinal  fluid  and  possibly  by  the  degree  of  spasticity?  He  felt  it 
might  be  difficult  to  follow  all  of  Dr.  Sharpe's  ophthalmological  observations. 

Dr.  A.  S.  Taylor  said  that  Dr.  Kennedy's  last  remark  that  the  field  of 
operation  should  be  broadened  was  well  taken.  Ophthalmological  signs  were 
difficult  to  find.  There  were  cases  where  there  was  no  other  indication  of 
intracranial  pressure  but  increased  spasticity.  The  brilliant  results  obtained 
might  be  explained  by  other  reasons.  Four  or  five  years  ago  Dr.  Clarke  had 
100  spastic  cases  at  Randall's  Island  examined  ophthalmologically,  and  no 
evidence  of  intracranial  pressure  was  found  in  a  single  one. 

Dr.  William  Leszynsky  said  that  for  a  great  many  j'cars  he  had  examined 
all  of  such  cases  ophthalmoscopically.  He  had  yet  to  see  anything  that  could 
be  demonstrated  as  optic  neuritis  or  papilledema.  Dr.  Sharpe  had  demon- 
strated cyst  formation  during  life.  Cyst  formation  was  a  terminal  condition 
and  had  been  seen  at  autopsies  in  a  number  of  cases. 

Dr.  William  Sharpe  said  that  in  regard  to  the  selection  of  the  cases,  that 
did  not  depend  on  any  one  sign.  All  points  were  considered — the  history  of 
difficult  labor,  convulsions  after  birth,  spasticity,  ophthalmoscopic  findings, 
and  especially  the  measurement  of  the  pressure  of  the  cerebrospinal  fluid  in 
lumbar  puncture.  He  thought  that  frequently  ophthalmologists  did  not  con- 
sider there  was  intracranial  {)ressure  unless  there  was  a  high  degree  of 
choked  disks.  One  did  not  find  a  high  degree  of  choked  disk  or  papilledema 
in  these  cases  as  the  pressure  was  not  a  primary  tumor  pressure,  but  the 
mechanical  pressure  of  a  recent  or  old  hemorrhage.  He  did  not  operate 
unless  the  cerebrospinal  fluid  showed  a  high  pressure,  and  so  confirming  the 
ophthalmoscopic  findings.  The  cases  should  be  operated  upon  as  soon  as 
possible  after  birth  and  then  normal  children  resulted.  These  cases  were  not 
cures  but  they  were  great  improvements  in  children  that  were  practically 
derelicts. 


A  NEW  SYSTEM  OF  DEVELOPING  MUSCLE  CONTROL  IN  THE 
TREATMENT  OF  PARALYTIC  CASES 

By  Bess  M.  Mensendieck,  M.D. 

The  patient  exhibited,  a  boy  of  11  years,  had  been  carefully  trained  for 
six  months  in  individual  muscle  exercise  and  control.  He  had  weighed  81 
pounds  and  was  diagnosed  as  a  case  of  spastic  paraplegia  with  pes  equino- 
varus.     He  had  walked  with  both  heels  4.5  cm.   from  the  ground  with  no 


35S  XEIV  YORK  XEUROLOCICAL  SOCIETY 

action  of  the  pcroneus  longus.  glutsei,  sacro-spinalis,  or  the  broad  muscles  of 
the  back.  He  had  a  large  protruding  abdomen  with  flabby  recti,  and  was 
extrtynely  lazy  and  sluggish  in  disposition.  The  bowels  were  chronically 
loose.  He  could  not  dress  or  undress.  He  could  sit  up,  but  when  standing 
or  walking  he  was  inclined  to  drop  to  the  ground  and  was  quite  unable  to 
rise  from  the  ground.  Massage,  osteopathj-  and  electricity  were  used  without 
result.  At  the  present  time  the  boy  is  able  to  walk  without  swaying  and 
able  to  pound  heels  on  the  floor,  showing  the  tibialis  anticus  function  com- 
pletely restored.  The  abdominal  muscles  were  firm.  The  fat  had  disap- 
peared about  the  thighs  and  knees.  The  bowels  had  become  normal  and 
movements  regular.  The  boy  could  dress  and  undress  standing  up.  He  no 
longer  dropped  to  the  ground.  He  was  allowed  to  go  to  school  and  took 
interest  in  other  boys.  He  was  no  longer  lazy  and  sluggish.  Half  the  cure 
could.be  said  to  have  been  effected  and  in  another  six  months  the  normal 
functions  could  be  restored.  The  case  was  shown  to  illustrate  the  possibilities 
of  volitional  innervation  to  bring  about  the  perfect  static  antagonism  of  the 
muscles.  Dr.  Mensendieck  put  the  patient  through  exercises  illustrating  the 
isolated  action  of  various  muscles  under  volitional  control  of  the  patient. 
The  boy's  control  of  the  muscles  was  remarkable  and  the  results  extremely 
gratifying. 

Dr.  Bernard  Sachs  said  that  the  first  impression  he  had  of  this  boy  was 
that  the  case  was  pseudohypertrophic  paralysis.  He  very  soon  eliminated  that 
diagnosis  because  the  condition  presented  none  of  the  absolutely  character- 
istic symptoms.  When  the  child  first  came  he  had  typical  spastic  paraplegia 
with  the  knees  and  legs  locked.  He  could  not  stand  up  and  had  extreme 
contracture  of  the  posterior  groups  of  muscles.  The  deep  reflexes  were  ex- 
aggerated. The  boy  was  bright,  but  very  obese.  The  calves  were  flabby  and 
stout,  not  like  the  pseudohypertrophic  cases.  A  disseminated  sclerosis  was 
suspected.  This  type  of  case  was  important  enough  to  bring  to  the  attention 
of  neurologists.  The  case  was  beyond  surgical  help  and  he  was  glad  to  put 
the  boy  in  Dr.  Mensendieck's  hands  as  she  had  accomplished  by  dint  of 
patient  exercise  and  thorough  knowledge  of  anatomj^  an  innervation  of  the 
muscles  to  a  greater  extent  than  he  had  believed  would  be  possible.  He 
knew  that  some  of  his  learned  young  friends  claimed  to  do  such  things,  but 
in  this  case  more  had  been  done  than  he  had  ever  seen  done  before.  He  was 
anxious  to  submit  cases  of  poliomyelitis  to  Dr.  Mensendieck  to  see  what  she 
could  do  with  them. 


CASES  OF  SPINAL  CORD  TUMORS,  TREATED  BY  UNILATERAL 

LAMINECTOMY 

By  A.  S.  Taylor.  M.D.,  J.  W.  Stephenson,  M.D..  et  al. 

The  first  patient,  a  man  of  33  years,  with  previous  negative  history,  was 
operated  on  in  July,  191 5.  Eight  months  previously  he  had  begun  to  feel 
weak  in  the  knees,  with  signs  of  numbness  and  dragging  of  feet.  It  was 
found  he  had  spastic  paraplegia  with  left  drop-foot.  The  abdominal  reflexes 
.were  absent. 

Dr..  Stephenson  said  the  sensory  changes  in  this  patient  showed  tempera- 
ture absolute  to  the  level  of  the  eighth  dorsal.  The  cerebrospinal  fluid  was 
negative  except  for  heavy  globulin.  Pain  was  never  present.  At  operation 
an  endothelioma  was  found  at  the  level  of  the  sixth,  seventh  and  eighth  dorsal 
vertcbrse,  and  was  removed  in  toto.  One  week  after  operation  hyperesthetic 
areas  became  acute.  One  month  after  operation  he  could  walk  well  and  at 
present  he  had  perfect  bladder  control.  The  only  subjective  symptoms  were 
occasional  pain  in  the  back  and  unpleasant  sensation  in  the  left  abdomen. 


NEJV  YORK  NEUROLOGICAL  SOCIETY  359 

Dr.  Ta\'lor  stated  that  it  had  been  said  that  unilateral  laminectomy  was 
no  good,  that  one  could  not  get  a  tumor  out.  In  this  case  the  tumor  was 
3  cm.  long  by  2  cm.  in  width,  was  attached  to  the  dura,  but  arose  from  the  pia- 
arachnoid.  The  tumor  was  easily  removed  and  hemorrhage  controlled  with 
warm  saline  solution.  The  man  had  now  a  normal  spinal  column  and  the 
muscles  were  well  attached  to  the  spinous  processes. 

The  next  case,  one  of  meningo-m3'elitis,  was  shown  by  Drs.  Taylor  and 
Beling.  The  man  had  a  negative  family  history.  At  15  he  had  a  fall  and 
injured  his  back  but  showed  no  ill  effects  from  this.  He  worked  later  as  a 
motorman  and  was  exposed  to  extremes  of  temperature.  Three  or  four 
months  before  admission  to  the  hospital  he  suffered  from  cramps  in  the  left 
leg  which  caused  him  to  get  up  at  night.  He  was  tired  in  the  morning.  On 
November  2,  1914,  while  standing  on  a  table,  he  lost  his  balance  and  fell 
backwards,  straining  the  lumbar  region.  Next  morning  he  had  violent  pain, 
but  went  to  work.  The  pain  increased  and  his  legs  felt  as  if  weights  were 
attached.  At  the  City  Hospital  it  was  found  that  he  had  sensory  loss  in  the 
feet  and  retention  of  urine.  Examination  showed  knee  jerks  present,  no 
Babinski,  no  clonus,  right  foot-drop,  plantar  reflexes  diminished,  vesical 
weakness  and  frequency  of  urination,  and  complete  loss  of  sensibility  in  the 
sacral  second  and  third.  The  bowels  were  constipated.  Blood  and  spinal 
fluid  Wassermann  were  negative.  Since  operation  the  sensory  disturbances 
were  unchanged.  The  man  walked  better,  the  left  foot  being  slightly  spastic, 
the  right  foot  hypertonic.  Dr.  Ta3dor  did  a  unilateral  laminectom}^  on  the 
right  side.  The  dura  was  normal  except  for  increased  tension.  Inside  of  the 
dura  there  was  a  curious  condition.  The  cord  was  quite  congested  and  to 
the  right  of  the  midline  there  was  a  sheaf  of  dilated,  varicose  veins,  one  half 
inch  broad  and  one  inch  and  a  half  long,  at  the  site  of  maximal  interference 
with  the  cord  function.  No  attempt  was  made  to  remove  the  veins,  but, 
avoiding  injury  to  the  cord,  three  or  four  catgut  ligatures  were  passed  round 
them  with  a  curved  needle  and  a  multiple  ligation  was  done  and  the  wound 
was  closed.  The  man  had  intense  pain  for  four  daj^s,  only  partly  relieved  by 
morphine.  The  fourth  day  this  subsided.  The  backbone  was  normal  with 
muscles  firmty  attached. 

Dr.  Bernard  Sachs  said  he  would  not  be  inclined  to  describe  the  case  as 
one  of  meningo-myelitis. 

Dr.  Joseph  Byrne  and  Dr.  Taylor  presented  the  third  case.  Dr.  Byrne 
said  that  on  Octobe;r  15,  1914,  this  young  man,  while  playing  football,  at- 
tempted to  make  a  catch  while  an  opponent  tackled  him  around  the  waist. 
The  patient  was  thrown  to  the  ground,  after  which  some  bone  was  found  to 
be  "  out "  about  the  left  knee.  A  physician  "  shot  the  bone  into  place  "  on  the 
field.  The  patient  remained  in  bed  for  five  weeks,  when  he  discovered  he 
had  drop-foot.  On  April  28,  1915,  at  Fordham  Hospital  Dr.  Byrne  found 
that  on  the  motor  side  he  had  paralysis  and  moderate  atrophy  of  the  tibialis 
and  peroneal  groups,  dorsal  flexion  of  the  foot  and  toes  being  impossible. 
Myotatic  irritabilitj'  was  present  in  both  groups  but  was  considerably  dimin- 
ished as  compared  with  the  right  leg,  more  especially  in  the  peroneal  group. 
On  the  sensory  side  there  was  loss  for  light  touch  and  prick  over  an  area 
on  the  tibial  side  of  the  dorsum  of  the  foot  bounded  on  its  outer  side  by  the 
axial  line  through  the  third  toe.  The  loss  for  light  touch  extended  up  the 
outer  aspect  of  the  leg  to  a  point  on  the  shaft  of  the  fibula  ten  inches  from 
the  tip  of  the  external  malleolus.  Slight  over-reaction  to  prick  was  present 
over  the  roots  of  toes.  All  sensory  tests  were  quantitative.  Operation  was 
decided  on.  Dr.  Taylor  found  the  nerve  at  the  site  of  injury  to  consist  of  a 
mass  of  scar  tissue.  On  section.  Dr.  John  H.  Larkin  found  the  mass  to 
consist  mainly  of  connective  tissue.  Few  healthy  fibers  were  present  and 
there  was  only  slight  evidence  of  attempts  at  regeneration.     After  operation 


36o  XEir  YORK  NEUROLOGICAL  SOCIETY 

the  sensory  loss  was  greater  than  before,  and  on  the  foot  corresponded  re- 
markably with  the  sensory  loss  in  the  hand,  following  section  of  the  radial 
branch  in  the  forearm.  The  external  popliteal  was  evidently  the  analogue 
of  the  musculo-spiral  in  the  arm.  Over  an  area  on  the  outer  portion  of  the 
leg  prick  was  preserved,  but  touch  and  cold  (ice)  were  absent.  Similar  dis- 
sociation areas  had  been  found  by  Head  and  by  the  speaker  on  the  hand  after 
section  of  the  radial  branch  in  the  forearm. 

Dr.  Taylor  said  that  external  dislocation  of  the  knee  was  the  probable 
diagnosis,  as  no  fracture  of  the  upper  end  of  the  tibia  was  now  indicated  by 
X-ray.  The  nerve  damage  was  for  one  inch,  just  behind  the  head  of  the 
fibula.  It  was  imbedded  in  scar  tissue.  One  inch  of  the  nerve  was  resected. 
The  knee  was  kept  sharply  flexed  for  a  month  to  allow  complete  nerve  union. 

Dr.  Terriberry  asked  if,  when  the  surgeon  took  out  one  inch  of  the 
nerve,  was  there  not  considerable  traction  upon  the  remaining  portion? 

Dr.  Taylor  said  that  the  nerve  could  not  have  been  brought  together  with- 
out a  little  tension,  but  in  doing  nerve  suture  one  had  to  get  as  good  anatom- 
ical union,  without  forming  scar  tissue,  as  was  possible.  It  was  necessary  to 
get  good  apposition  before  suture. 


INJURIES    OF    THE    PERIPHERAL    NERVES,    PRODUCED    BY 
MODERN  WARFARE  (WITH  EXHIBITION  OF  LANTERN 

SLIDES) 

By  C.  Burns  Craig,  M.D. 

This  paper  was  based  upon  ten  months'  observations  at  the  American 
Ambulance  Hospital  at  Neuilly  sur  Seine,  and  upon  impressions  gained  by 
some  visits  to  the  Salpetriere  and  other  Paris  hospitals.  It  should -be  stated 
that,  in  a  large  base  hospital,  the  proportion  of  injuries  to  vital  parts,  as 
compared  to  those  less  serious,  did  not  represent  the  proportionate  varieties 
of  wounds  occurring  in  battle.  The  majoritj'  of  men  wounded  in  brain, 
abdomen,  heart,  or  large  arteries,  died  on  the  field.  Thus  70  per  cent,  of 
wounds  in  base  hospitals  were  in  arms  or  legs.  All  these  wounds  had  a 
neurological  aspect.  Various  kinds  of  pain  and  paresthesia,  the  cutaneous 
anesthesia  surrounding  some  large  wounds,  and  efifect  of  weather  upon  pain 
were  worthy  of  attention.  In  this  paper,  by  injuries  to  peripheral  nerves,  was 
meant  only  those  wounds  in  which  some  marked  paralytic  effect  was  pro- 
duced, distal  to  the  wound,  indicating  that  one  or  more  of  the  principal  nerve 
trunks  had  been  damaged.  Varying  degrees  of  disability  were  observed,  and 
the  lesion  might  be  motor,  or  sensory,  or  both.  Mild  cases  of  loss  of  func- 
tion in  hand  or  foot  cleared  up  rapidly,  provided  the  part  was  not  kept  mo- 
tionless. One  of  the  greatest  lessons  learned  in  the  war  in  taking  care  of 
wounds  on  a  large  scale  was  to  avoid  immobility  of  a  wounded  extremity. 
Even  when  fracture  existed  this  might  be  avoided.  In  the  early  days  of  the 
war  there  resulted  a  number  of  cases  of  "  causalgia,"  so  st>'led  by  Weir 
Mitchell,  and  stated  by  him  to  be  frequent  during  the  Civil  War.  This 
was  due  to  immobilization  of  the  arm  and  hand  by  the  use  of  splints  and 
slings.  It  could  be  avoided  by  an  overhead  suspension  device,  used  exten- 
sively in  Dr.  Ralke's  service.  It  provided  elevation  of  the  part,  and  per- 
mitted sufficient  movement  to  afford  exercise.  This,  in  conjunction  with 
early  massage,  prevented  causalgia  and  shortened  convalescence.  Considering 
the  enormous  number  of  wounds  of  the  extremities,  both  of  the  bones  and 
soft  parts,  the  in  frequency  of  completely  severed  nerves  was  quite  remarkable. 
This  was  accounted  for  by  the  resiliency  and  elasticity  of  the  nerve  trunks, 
which  permitted  a  certain  degree  of  displacement  without  rupture.     Ten  per 


NEIV  YORK  NEUROLOGICAL  SOCIETY  361 

cent,  of  peripheral  nerve  injuries  were  completely  severed  nerves.  However, 
all  s3'mptoms  of  completely  cut  nerves  might  be  simulated  by  severe  contusion 
or  compression  of  the  nerve,  and  only  direct  examination  at  the  site  of  injury 
could  determine  the  nature  of  it.  The  proportion  of  peripheral  nerve  in- 
juries to  the  total  number  of  wounded  was:  musculo-spiral  12  per  cent., 
sciatic  ID  per  cent.  Dr.  Craig  gave  instances  of  the  following  injuries:  (i) 
Injury  to  the  glosso-pharyngeal  nerve  with  persistent  paralysis  of  the  uvula. 
(2)  Contusion  of  the  facial  nerve  with  recovery.  (3)  Injury  to  the  lumbar 
sacral  plexus,  with  considerable  improvement.  (4)  Isolated  injury  to  the 
median  from  rifle  wound  in  forearm,  outcome  unknown.  (5)  Peripheral 
paralj'sis  of  right  facial  nerve  from  rifle-ball  wound,  unimproved  after  four 
months.  (6)  Small  sciatic  completely  severed  and  contusions  of  greater  sci- 
atic ;  six  months  after  the  patient  was  able  to  walk  alone  with  normal  gait. 
(7)  Injury  of  median  and  musculo-spiral  nerve  by  contusion;  two  months 
after,  no  improvement  in  resultant  paralysis.  (8)  Injury  to  entire  brachial 
plexus;  nine  months  after,  only  incomplete  restoration  of  function  in  arm 
and  hand.  (9)  Complete  division  of  both  musculo-spiral  and  great  sciatic, 
with  no  improvement  in  paralysis  four  months  later.  (10)  Almost  complete 
severance  of  sciatic  with  no  return  of  function  after  seven  months.  (11) 
Injury  to  the  internal  saphenous,  with  anesthesia  and  paresthesia  persisting 
after  six  and  a  half  months.  (12)  Case  of  compression  of  the  popliteal  with 
complete  recovery.  (13)  Injury  to  the  posterior  tibial  nerve  with  compres- 
sion and  atrophy  due  to  dense  cicatrix,  patient  observed  for  two  months  with 
no  alteration  of  sensation.  (14)  Olecranon  almost  blown  away  by  shrapnel 
and  elbow  joint  exposed.  Diagnosis  of  lesion  of  ulnar  nerve  and  damage  to 
median  nerve.  Patient  operated  on  by  Dr.  Blake  and  radial  border  of  ulnar 
nerve  found  severed  with  formation  of  neuroma  at  the  site.  The  contused 
median  was  almost  completely  recovered  after  five  months.  The  partially 
severed  ulnar  showed  faulty  recovery.  (15}  Sciatic  nerve  completely  trav- 
ersed by  fragment  of  shell ;  even  with  this  slight  damage,  without  severing 
of  the  nerve,  six  months  elapsed  before  approximately  complete  recovery. 

Dr.  Ramsay  Hunt  said  that  they  were  all  very  much  interested  in  the 
neurology  of  war  and  it  was  gratifying  to  hear  from  someone  who  had  had 
actual  experience  of  this  kind  at  the  front.  The  treatment  of  injuries  of 
the  peripheral  nerves  would  be  one  of  the  great  medical  advances  which  this 
war  would  develop.  When  such  masters  as  Marie,  Dejerine  and  Oppenheim 
were  concentrating  their  efiforts  on  nerve  injuries,  no  doubt  great  results 
would  be  achieved.  It  was  interesting  to  note  what  a  large  number  of  irrita- 
tive conditions  from  compression  were  amenable  to  treatment,  by  simple  dis- 
section of  the  sheath,  and  relieving  the  nerve  trunk  from  pressure  and  adhe- 
sions (neurolj'sis).  Another  t3-pe  full  of  interest  was  the  partial  lesion  of 
a  nerve,  the  dissociated  syndrome.  Dr.  Craig  had  mentioned  such  cases 
where  the  projectile  caused  partial  or  isolated  injury  of  certain  fasciculi. 
Such  lesions  were  very  rare  in  civil  life.  Dejerine  had  devoted  especial  atten- 
tion to  the  "  s}-ndrome  dissocie."  Neurological  surgeons  seemed  to  be  in 
harmony  as  to  the  treatment  of  injuries  of  the  peripheral  nerves.  Practically 
all  recommended  conservatism.  One  French  surgeon,  Delorme,  had  advo- 
cated radical  procedures,  excising  large  sections  of  the  nerve  trunk,  but  his 
views  had  aroused  considerable  discussion,  and  most  agreed  that  the  nerve 
should  not  be  sacrificed,  but  only  the  scar  tissue  removed,  and  that  any  normal 
fibers  and  fasciculi  should  be  preserved. 

Dr.  Goodhart  said  that  the  German  surgeons  made  it  a  rule  not  to  inter- 
fere with  fresh  wounds  at  all.  After  the  infection  was  passed  they  did  not 
hesitate  to  cut  into  the  tissue  months  afterwards.  In  sheath  surgery  the 
nerves  were  sutured,  using  fat  and  fascia  and  arterial  tissue.  This  protected 
the  nerve.     In  resection  of  neuromata  defects  of  nerve  tissue  were  filled  in 


362  XEir  YORK  XEUROLOGICAL  SOCIETY 

by  segments  of  other  nerves.  \'on  Hofmeister  recommended  the  method 
devised  by  him  of  double  nerve  grafting.  Both  ends  of  a  divided  nerve, 
which  could  not  be  directly  resected,  were  implanted  into  a  parallel  nerve 
which  acted  onlj'  as  the  bridge.  A  healthy  motor  or  sensory  nerve  could  be 
utilized  for  this  purpose. 

Dr.  William  Lesz3^nsky  said  he  had  been  much  impressed  with  the  pic- 
tures representing  the  degree  of  trophic  disturbance  after  injury  of  the  sci- 
atic nerve.  It  was  almost  identical  with  that  after  an  ill-advised  injection  of 
the  nerve  with  alcohol.  The  patient  had  been  seen  by  several  members  of 
the  society. 

Dr.  Craig  said  that  the  point  of  discussion  this  evening  seemed  to  be  as  to 
whether  these  cases  should  be  operated  on,  and  if  so,  when.  In  France  it  was 
universal  to  wait  until  signs  of  infection  had  cleared  up  and  then  every  case 
which  presented  evidence  of  serious  nerve  lesion  was  opened  up.  Many  were 
cases  of  infiltration  of  connective  tissue,  which  became  exceedingly  hard  and 
blocked  the  nerve.  Cases  of  compression  of  the  fiber  had  a  favorable  prog- 
nosis but  where  the  nerve  was  partially  or  wholly  severed  he  was  very  pessi- 
mistic after  ten  months'  observation,  but  it  would  take  years  for  a  nerve  like 
the  sciatic  to  grow  again. 


December  7,   1915 
Tlie  President,  Dr.  William  Leszvnskv,  in  the  Chair 


BRAIX,  SHOWING  TUMOR  OF  THE  PONS,  INVADING  ONE  CRUS 
CEREBRI.  WITH  UNUSUAL  SYMPTOMS 

By  Walter  Timme,  M.D. 

The  history  of  tlie  patient  was  as  follows  :  In  July,  1913,  a  boy.  14  years 
old,  was  hit  on  the  head  by  a  playmate.  He  fell,  rose  unassisted,  though  dizzy 
for  a  moment.  In  August,  five  weeks  later,  he  fell  again  and  struck  the  back 
of  his  head,  though  without  apparent  after-effect.  One  week  later  the  father 
noticed  the  boy's  speech  was  affected  and  about  that  time  the  gait  became 
unsteady.  Coincident  with  these  changes  headache  began,  cliicfly  occipital, 
and  there  was  nausea  though  no  vomiting.  The  father  noticed  priapism  for 
two  or  three  hours  every  night.  By  September  15  his  sight  was  affected  and 
his  sight  became  progressively  worse.  Since  August  his  stature  increased 
markedly  and  he  showed  marked  drowsiness.  On  September  25  he  was  ad- 
mitted to  the  hospital,  where  shortly  he  became  so  unruly  and  restive  he  had 
to  be  sent  home.  His  status  on  admission  was:  Gait  staggering,  swaying, 
chiefly  to  the  left,  but  occasionally  to  the  right;  occipital  headache;  nausea; 
no  vomiting  at  first  and  no  tremor;  right  facial  tremor  when  smiling,  t.  c, 
emotional.  Examination  of  the  eyes  by  Dr.  Holden  on  September  25  showed 
the  following :  Diplopia,  due  to  weak  external  rectus ;  nystagmus  L.  R. ; 
vision  20/30.  with  white  and  red  fields  normal ;  discs  pink,  veins  slightly 
dilated.  October  26  there  was  beginning  papilledema  with  hemorrhage  in 
both  fundi  with  normal  color  fields.  There  was  then  found  incoordina- 
tion with  ataxia  of  hands  and  feet;  R.  L.  Reflexes  gave  a  greater  right 
knee  jerk,  a  double  Habinski  and  Oppenheim,  more  on  right;  right  abdom- 
inals sluggish;  left  absent;  epigastric  absent;  cremasteric  equal;  right  ell)OW 
jerk  exaggerated;  left  doubtful;  asynergia  marked;  hearing  normal;  Weber 
and  Rinne  tests  gave  normal  conduction  ;  adiadochokinesis  of  the  right  hand. 
The   cerebrospinal    fluid    was    normal.     A    general    diagnosis    of    tumor   was 


NEW  YORK  NEUROLOGICAL  SOCIETY  363 

made  without  special  localization.  The  patient  was  kept  track  of  by  Dr. 
Timme  and  more  marked  S3'mptoms  were  noted.  He  had  two  right  unilateral 
convulsions  and  there  was  gradual  impairment  of  the  motor  functions  on  the 
right  side  and  of  the  trigeminus  on  the  left.  Joint  sense  was  normal.  Aste- 
reognosis  was  absolute  on  the  right  side.  The  boy  was  unable  to  give  any 
information  about  an  object  in  the  hand.  A  moderate  spasticity  of  the  right 
leg  appeared,  but  no  clonus.  Finally  there  was  slight  diminution  of  the  cuta- 
neous sensibilit}^  of  the  entire  right  side.  These  signs  pointed  to  localization 
of  the  tumor  in  the  crus  and  pons,  probablj-,  of  the  left  side,  as  well  as  the 
thalamus  extending  posteriorlj'  to  the  origin,  but  not  involving  the  facial 
and  auditory-  nerves,  at  any  rate  not  bej^ond  the  motor  fifth.  The  patient  be- 
came progressively  worse,  with  respiratory  weakness,  verging  on  the  Cheyne- 
Stokes  type.  Before  surgical  interference  could  be  attempted  he  died  of 
respiratory  paralysis.  Before  exhibiting  the  brain  Dr.  Timme  pointed  out 
the  following  interesting  facts.  First,  the  astereognosis  was  due  to  imperfect 
sense  perception  from  the  right  periphery  and  was  no  true  cortico-psychic 
astereognosis.  Second,  it  was  important  to  examine  always  for  sensory  and 
motor  function  separately  of  the  fifth  nerve.  In  this  case  the  difference  prob- 
ably marked  the  boundary  of  the  tumor  laterally.  Third,  it  was  important 
to  differentiate  between  crude  differences  of  sensibility,  but  also  between  the 
finer  difference.  Lastly,  and  most  important,  the  symptoms  of  priapism  and 
skeletal  growth  pointed  to  irritation  of  the  pineal  gland  or  the  hypophysis. 
In  none  of  the  eighteen  cases  of  these  tumors,  before  published,  were  such 
symptoms  noted.  Were  they  produced  by  pressure  within  the  third  ventricle, 
transmitted  to  the  pineal  gland,  or  to  the  hj-pophyseal  stalk,  or  were  they 
originated  by  direct  pressure  of  the  left  crus  cerebri  which  laterally  en- 
croached on  the  middle  line  against  the  h^'pophysis,  and  superiorly  against 
the  pineal?  As  the  ventricles  were  hardly  distended,  it  was  fair  to  assume 
that  the  increased  mass  of  the  left  crus  cerebri  was  the  irritative  cause  of 
these  symptoms.  Furthermore,  the  s3'mptoms  of  increased  intracranial  pres- 
sure came  on  after  the  growth  phenomena.  Autopsy,  by  Dr.  Casamajor, 
showed  a  very  much  enlarged  brain,  the  ventricles  were  only  slightly  dis- 
tended, with  a  pons  very  much  distorted  and  enlarged,  especially  on  the  left 
side.  This  enlargement  was  caused  by  an  extensive  pontine  tumor  mass 
which  reached  forward  through  the  left  crus  cerebri  to  the  left  thalamus,  and 
posteriori}'  nearly  to  the  beginning  of  the  medulla,  extending  slightly  into  the 
brachium  pontis  of  the  left  side ;  involving  in  this  extended  locus  the  left 
median  fillet,  the  red  nucleus  with  the  emerging  rubrospinal  tract,  the  left 
brachium  conjunctivum,  the  left  motor  fifth  root  and  the  thalamic  nuclei 
with  their  radiations  downwards ;  and  compressing  the  pj'ramidal  tract  of 
the  left  side,  as  well  as  by  transmitted  pressure,  that  of  the  right  side 
also  in  less  degree.  Both  the  hypophysis  and  the  pineal  gland  were  normal. 
The  tumor  proved  to  be  a  glioma.  In  taking  up  the  interesting  features 
of  rapid  increase  in  growth  and  sexual  irritation,  it  was  to  be  noted  that 
in  not  one  of  the  eighteen  published  cases  of  tumor  of  the  crus  cerebri 
were  they  present.  In  view  of  the  normal  condition  of  the  hypophysis  and 
of  the  pineal  gland  it  was  incumbent  upon  one  to  theorize.  There  were  four 
possibilities.  First :  neighborhood  pressure  by  the  left  crus  upon  the  hj'po- 
physeal  stalk ;  second,  pressure  by  the  left  corpus  quadrigeminum  against  the 
pineal  gland  ;  third,  congestion  of  the  basal  blood  vessels,  thereby  affecting 
the  hypophysis  secondarily;  and  fourth,  interference  with  the  tractus  ha- 
benulse  interpeduncularis.  A  similar  case  had  been  reported  where  an  inter- 
peduncular growth  pressed  upon  the  hypophysis,  but  never  where  the  actual 
crus  was  enlarged  and  produced  such  sj'mptoms.  Cases  had  also  been 
reported  where  an  enlarged  hypophj'sis  impinging  upon  one  or  the  other  crus 
produced   spasticity  and   exaggerated   reflexes.     This   may  have  been  a  con- 


364  NEW  YORK  NEUROLOGICAL  SOCIETY 

verse  case.  It  was  kr.own  that  symptoms  referred  both  to  rapid  growth  and 
sexual  irritation  were  present  in  pineal  gland  tumors,  so  that  a  similar  course 
of  reasoning  with  the  pineal  gland  might  be  considered  as  the  cause  of  the 
symptoms.  The  specimen  was  presented  to  illustrate  the  relationship  of  the 
crural  tumor  with  the  pineal  gland  and  the  hj'pophysis. 

Dr.  Abrahamson  spoke  of  a  case  of  encephalitis  of  the  posterior  pedun- 
cular area  and  the  pons,  at  present  in  the  Montefiore  Home.  A  considerable 
similarity  as  to  signs  existed.  There  were  crossed  hemiplegia ;  crossed  aste- 
reognosis,  plus  lesser  disturbances  of  the  threshold  of  pain  and  tactile  sensa- 
tion; crossed  disturbances  of  the  sense  of  postural  movements,  but  less  of 
the  posture  sense;  homolateral  oculomotor  involvement;  crossed  ataxic 
tremor,  namely,  of  the  upper  extremity  and  less  marked  homolateral  tremor. 
Dr.  Abrahamson  could  not  agree  with  Dr.  Timme's  explanation  of  the  occur- 
rence, of  the  astereognosis. 

Dr.  M.  Allen  Starr  said  that  it  seemed  to  him  that  in  regard  to  the  sexual 
disturbance  that  the  work  of  Gushing  had  established  the  intimate  relation- 
ship of  the  hypophysis  to  the  sexual  functions.  These  symptoms  must  be 
ascribed  to  some  disturbances  of  the  function  of  the  pituitary  body.  Dr. 
Gushing  had  also  called  particular  attention  to  the  effect  of  pressure  by 
tumors  upon  the  circulation  in  the  arteries  of  the  medulla  and  base  of  brain. 
Was  it  not  possible  therefore  tliat  the  pressure  of  this  tumor,  instead  of  irri- 
tating the  hypophysis  by  pressure  merely,  may  have  had  some  effect  by 
causing  very  marked  congestion  and  a  hyperactivity-  in  the  gland  and  that 
this  produced  priapism  and  marked  growth  of  the  bones,  which  was  charac- 
teristic of  disease  of  the  hypophj-sis? 

Dr.  Timme  said  that  Marburg  had  studied  one  case  of  pineal  gland  in- 
volvement showing  these  symptoms  of  sexual  disturbance  and  rapid  growth 
in  a  child  of  ten,  so  that  the  s>-ndrome  could  be  attributable  to  either  one  of 
the  two  glands.  Personally  he  agreed  with  Dr.  Starr  that  it  was  the  hypoph- 
ysis rather  than  the  pineal.  The  pineal  gland  could  adjust  itself.  The 
hypophysis  could  not.  If  the  case  was  merely  one  of  pressure  every  tumor 
would  show  the  same  symptoms,  but  they  did  not.  The  pressure  in  the  ven- 
tricles in  this  case  was  very  slight,  indeed  almost  normal,  so  that  the  symp- 
toms could  not  be  secondary  to  the  disturbance  in  the  ventricles.  The  symp- 
toms existed  before  anj-  papilledema  appeared. 


A   GASE   OF   BOMB   WOUND   OF   THE   RIGHT   TEMPERO- 

SPHEXOIDAL  LOBE.  WITH  SOME  REMARKS  ON  THE 

HEREDITARY    GHARAGTER    OF   LEFT   BRAINED- 

NESS  AND  RIGHTHANDEDNESS 

By  Foster  Kennedy,  M.D. 

The  |)atient  referred  to  was  a  soldier,  wounded  on  August  5,  1915,  near 
Arras,  in  first  line  trenches.  He  was  admitted  to  the  Hospital  Militaire,  Ris 
Orangis,  September  25.  191 5.  The  man  stated  that  while  making  hand 
grenades  he  "  suddenly  became  unconscious,"  but  he  remembered  dimly 
being  bandaged  in  the  trenches  and  being  carried  to  the  second  line.  He  was 
redressed  by  ambulance  men  and  carried  to  a  field  hospital.  He  remained 
completely  conscious  and  did  not  lose  consciousness  again.  He  received  anti- 
tetanus serum  immediately  after  being  wounded.  On  August  7  he  was  operated 
on  without  anesthetic.  He  did  not  know  whether  anything  was  extracted 
or  not.  He  had  no  convulsion  or  headache  or  any  difficulty  with  speech. 
Four  days  after  the  injury  the  left  arm  and  leg  felt  "  as  though  they  had  been 
slept  on,"  but  this  became  better  when  he  got  up.     This  feeling  of  numbness 


NEW  YORK  NEUROLOGICAL  SOCIETY  365 

was  present  when  admitted  to  the  Ris  Orangis  hospital.  He  never  had  pain 
in  the  left  arm  or  leg.  On  September  25  he  said  he  felt  very  well.  Over  the 
right  temporal  and  lower  temporo-parietal  region  there  was  a  wound.  A 
scar  existed,  apparently  the  result  of  a  semicircular  subtemporal  decompres- 
sion. An  infection  had  evidently  occurred  in  the  wound,  the  upper  sutures 
having  broken  and  the  whole  skin  flap  having  fallen  about  5  cm.  The  pos- 
terior margin  of  the  skin  flap  was  turned  in.  The  upper  portion  was  clean, 
with  a  granulating  surface  measuring  8  by  2i/>  cm.  In  the  posterior  margin 
of  this  wound,  behind  the  ear,  there  was  a  sinus  about  5  cm.  long,  which 
extended  inward  and  forward  parallel  to  the  external  auditory  canal.  There 
was  a  marked  bone  defect  and  the  brain  pulsated  in  the  granulating  area. 
Examination  showed :  pupils  equal,  with  brisk  reactions ;  sight  emmetropic 
on  left  side.  The  right  eye  was  myopic  by  four  diopters.  Optic  discs  :  the 
left  showed  some  tortuosity  of  the  veins.  The  physiological  pit  was  filled  in 
and  the  left  upper  temporal  quadrant  was  obscured  by  slight  swelling.  The 
right  fundus  was  normal.  Dr.  Kennedy  here  pointed  out  that  the  formation 
of  the  myopic  eyeball  was  such  as  to  permit  rapid  drainage  of  edema  accumu- 
lating at  the  nerve  head,  in  consequence  of  this  a  well-marked  papilledema 
occurring  in  a  myopic  ej'e-ball  was  not  at  all  a  common  phenomenon.  One 
would  be  justified  in  believing  that  had  the  patient  had  normal  vision  in  both 
eyes,  he  would  have  had  some  papilledema  in  both  fundi.  There  was  no 
nystagmus,  diplopia  or  strabismus.  The  lower  jaw,  on  opening  the  mouth, 
swung  to  the  right  side,  this  being  not  due  to  a  lesion  of  the  motor  root  of 
the  fifth  nerve,  but  to  a  fracture  of  the  right  zygoma.  The  general  hypes- 
thesia  of  the  left  side  was  seen  in  the  face  as  elsewhere,  but  there  was  no 
localized  fifth  nerve  paralysis.  Seventh  nerve:  the  left  frontalis  muscle 
moved  actively,  the  right  not  at  all.  On  the  other  hand  he  could  only  close 
the  left  eye  weakly.  The  left  lower  face  was  distinctly  paresed  for  both 
voluntary  and  emotional  movement,  thus  showing  damage  respectively  to 
both  the  right  facial  cortical  center  and  the  right  optic  thalamus.  The  right 
frontalis  muscle  was  inactive  probably  because  the  twigs  of  the  right  facial 
nerve  supplying  it  were  involved  in  the  bomb  wound  and  operation  scar 
already  described.  The  right  membrana  tympani  had  been  ruptured  and  hear- 
ing proportionately  diminished  in  the  right  ear.  The  tongue  swung  mark- 
edly to  the  right  on  protrusion.  The  swinging  of  the  lower  jaw  to  the  right 
had  overcome  the  tongue's  hemiparetic  tendency  to  go  to  the  left.  The 
patient  was  an  intensely  lefthanded  man.  He  had  no  word  deafness  what- 
soever and  he  named  objects  of  which  he  had  visual  recognition  promptly  and 
accurately.  He  had  no  apraxia  or  alexia.  His  memory  was  good.  He  read 
and  wrote  in  a  manner  only  interfered  with  by  hemianopsia  which  on  the  left 
side  was  complete  to  the  fixation  point.  Patient's  father  and  mother  were 
both  righthanded  persons.  He  was  an  only  child  and  knew  of  no  other  left- 
handed  persons  in  his  connection.  Motor  system  :  there  was  distinct  and  gen- 
eral softening  and  atrophy  of  the  muscles  of  the  left  arm  and  leg,  there 
being  a  difference  between  the  left  and  right  upper  arm  of  2.5  cm.,  between 
the  two  thighs  of  2.5  cm.  and  between  the  two  legs  of  2  cm.  There  was  no 
tremor  or  athetosis.  Slight  ataxia  of  the  sensory  type  existed  in  the  left 
upper  extremity.  The  weakness  in  the  left  arm  was  more  marked  than  that 
in  the  left  leg,  though  proportionately  less  marked  than  that  in  the  left  face. 
He  could  not  stand  on  the  left  leg  alone.  There  was  considerable  tituliation, 
probably  the  result  of  a  lesion  of  Tiirck's  bimdle,  uniting  the  pons  and  the 
temporal  region.  There  was  distinct  lowering  of  touch  and  superficial  pain 
and  deep  muscle  pain  sensation  over  the  whole  of  the  left  side  of  the  body. 
No  mistakes  were  made  in  sense  of  position  nor  in  the  discrimination  of  tem- 
perature. There  was  a  slight  slowness  in  the  recognition  of  unseen  objects 
held  in  the  left  hand,  but  in  this  regard  also  no  mistakes  were  made.     Re- 


366  XEir  YORK  XEUROLOGICAL  SOCIETY 

flexes :  all  deep  reflexes  on  the  left  side  were  exaggerated  in  degree.  Abdom- 
inal reflexes  were  present  on  the  right  and  absent  on  the  left  side.  Plantar 
reflexes :  right  flexor,  left  extensor.  Dr.  Kennedj'  pointed  out  that  owing  to 
the  fact  that  the  patient  was  left  handed  to  an  extraordinary  degree,  one 
would  have  been  justified  in  looking  for  a  correspondingly-  marked  degree 
of  disturbance  in  speech,  manifested  in  him  as  a  result  of  the  massive  injury 
sustained  by  the  right  temporo-sphenoidal  lobe.  He  showed  a  photograph  of 
the  patient,  together  with  two  radiographs  of  his  skull,  which  showed  frag- 
ments of  the  grenade  and  the  driven  bone  flung  through  the  cortex  and  em- 
bedded in  the  right  occipital  lobe.  It  was  pointed  out  that  the  usual  teaching 
up  to  the  present  time  had  been  that  in  lefthanded  individuals,  the  centers 
subserving  the  function  of  speech  were  to  be  looked  for  in  the  right  side  of 
the  brain;  therefore  a  sudden  injury  of  such  severity  as  that  described  in  this 
patient  should  have  severely  crippled  the  patient's  communication  with  the 
outside  world.  In  view  of  the  seriousness  of  the  lesion,  it  was  only  possible 
to  suppose  that  the  patient's  immunity  from  this  condition  lay  in  the  fact  that, 
in  spite  of  his  lefthandedness,  as  far  as  his  speech  centers  were  concerned, 
he  was  leftbrained.  Dr.  Kennedj-  discussed  some  of  the  theories  which  had 
been  put  forth  to  account  for  the  prevalent  condition  of  righthandedness. 
He  said  that  flint  instruments  of  the  paleolithic  period  showed  that  there  had 
been  as  many  lefthanded  tools  as  those  adapted  for  the  right  hand,  conse- 
quently only  in  the  evolution  of  mankind  had  righthandedness  become  more 
and  more  a  general  characteristic.  Ophthalmologists  had  pointed  out  that  in 
the  vast  majority  of  people  the  right  eye  dominated  over  the  left,  and  some 
of  them  had  ascribed  the  dominance  of  the  right  hand  to  this  condition.  In 
the  case  under  discussion  the  right  eye  was  myopic  and  the  left  normal.  Con- 
ceivably under  this  condition  the  patient's  lefthandedness  might  have  thus 
arisen.  On  the  other  hand  the  hereditary  trend  was  entirely  righthanded,  and 
presumably  leftbrained,  that  is  to  say,  he  had  acquired  lefthandedness,  though 
by  heredity  he  was  leftbrained.  In  this  connection  a  case  was  quoted  of  a 
woman,  22  years  of  age,  at  the  National  Hospital  for  Paralyzed  and  Epileptic 
in  London.  This  girl  developed  leftsided  Jacksonian  convulsions,  the  result 
of  luetic  thickening  of  the  dural  and  pial  membranes  on  the  right  brain. 
After  each  attack,  over  a  period  of  twelve  months,  she  became  temporarily 
aphasic.  She  was  entirely  a  righthanded  person.  Her  paternal  and  maternal 
heredity  showed  lefthandedness.  These  considerations  would  make  one  con- 
sider tiie  advisability  of  investigating,  not  only  whether  or  not  the  patient  was 
right  or  lefthanded,  but  also  whether  or  not  the  family  stock  showed  any 
anomalies  in  this  regard. 

Dr.  Sachs  said  that  there  was  one  point  that  could  be  noted  without  going 
back  to  the  history  of  ancestors.  The  majority  of  children  were  ambidex- 
trous. Almost  every  child  was  born  so  and  remained  so  until  taught  to  use 
the  right  hand  more  than  the  left.  There  were  relatively  few  exceptions  to 
this  rule.  Parents  had  trouble  in  teaching  the  child  to  use  its  right  hand 
in  preference.  Many  children  would  be  lefthanded  if  not  taught  to  use  the 
right.  Centuries  of  civilization  had  insisted  that  the  right  side  of  the  body 
was  better  than  the  left.  Dr.  Sachs  thought  it  was  largely  a  matter  of  arti- 
ficial education.  In  studies  of  the  child's  brain  in  early  life  the  speech  func- 
tion was  not  found  exclusively  in  the  left  hemisphere.  There  were  as  many 
changes  in  one  hemisphere  as  the  other. 

Dr.'S.  E.  JellifFc  said  in  reference  to  riglit  and  lefthandedness,  Stier  had 
done  a  beautiful  piece  of  work  in  the  German  army  for  a  series  of  seven 
years.  He  had  approached  the  problem  from  the  hereditary  standpoint.  He 
had  examined  all  the  records  of  the  recruits  and  had  come  to  the  general 
conclusion  that  lefthandedness  represented  an  ancestral  type  of  the  race 
which  was  inferior  to  the  righthanded  type  and  therefore  not  the  successful 


NEW  YORK  NEUROLOGICAL  SOCIETY  367 

type,  and  it  had  therefore  been  slowly  eliminated.  Lefthandedness,  prag- 
matically considered,  was  an  hereditary  problem.  The  early  biological  deter- 
miners were  as  yet  very-  uncertain,  but  there  was  some  relation  between  the 
successful  races,  which,  migrating  northward,  did  come  into  a  definite  position 
to  heliotropic  influences.  The  position  suggested  regarding  sun  position  and 
righthandedness  was  not  as  nonsensical  as  man}^  superficial  critics  had 
assumed. 

Dr.  Ramsay  Hunt  said  he  could  cite  a  case  which  had  some  bearing  on 
the  question  of  the  speech  disturbance  raised  by  Dr.  Kennedy,  viz.,  a  left- 
handed  young  man  who  had  an  abscess  of  the  left  temporal  lobe,  with  right 
hemiplegia  and  right  hemianopsia  with  definite  disturbances  of  speech  of  the 
sensory  type.  He  was  a  lefthanded  man,  but  in  spite  of  that  had  developed 
a  disturbance  of  speech  from  a  lesion  on  the  left  side  of  the  brain.  The 
symptoms  of  aphasia  did  not  last  long  and  in  a  month  or  six  weeks  all  speech 
trouble  had  disappeared,  the  hemiplegia  and  hemianopsia  persisting.  Although 
this  man  was  by  nature  lefthanded  and  performed  most  of  the  acts  w^ith  the 
left  hand  which  were  usually  done  by  the  right,  it  was  not  so  in  all  things, 
e.  g.,  he  was  a  typewriter  by  occupation  and  performed  this  work  like  a  right- 
handed  man.  It  was  probable  that  such  a  man  was  not  leftbrained  or  right- 
brained,  so  to  speak,  but  was  rather  ambicephalic.  This  would  be  one  expla- 
nation for  the  disappearance  of  the  aphasia  in  such  a  case,  the  speech  mech- 
anism having  a  bilateral  distribution. 

Dr.  Fisher  said  that  he  would  like  to  relate  a  case  wdiich  he  saw  that  day 
of  left  hemiplegia  in  a  righthanded  woman.  Her  mother,  brother  and 
daughter  were  lefthanded.  In  regard  to  Dr.  Sachs's  remark  about  ambidex- 
terity, he  doubted  that  that  was  entirely  true.  If  one  tried  to  teach  a  left- 
handed  boy  to  write  with  his  right  hand,  it  was  a  most  difficult  matter.  Dur- 
ing his  lifetime  he  retained  greater  facility  with  the  left  hand. 

Dr.  Kennedy  said  he  would  like  to  ask  Dr.  Hunt  about  the  parents'  right 
or  lefthandedness  in  the  case  he  had  cited.  This  was  the  very  point  that  it 
would  seem  worth  while  to  investigate  because  the  reasons  given  in  the  litera- 
ture for  aphasia  with  anomalous  handedness  were  not  very  convincing.  It 
might  be  worth  while  to  see  whether  or  not  there  was  a  sinistral  tendency  in 
the  family  in  which  the  case  occurred. 

Dr.  L.  Pierce  Clark  asked  Dr.  Kennedy  if  the  man  in  the  first  case  cited 
was  particularl}^  clever  and  dextrous  in  the  use  of  his  hands  before  the  injury. 
Lefthanded  children  never  became  very  clever  in  the  use  of  the  right  hand. 

Dr.  Kennedy  said  he  had  had  no  data  upon  that  point. 


CASE  OF  SYMMETRICAL  WOUNDS  OF  TEMPORAL  REGION 

By  Foster  Kennedy,  M.D. 

A  man  came  into  the  hospital  from  the  trenches.  When  the  bandages 
were  taken  off,  two  wounds,  with  marked  bone  defects,  absolutely  symmetrical, 
were  shown  of  each  temporal  region.  He  could  see  perfectly  well.  The 
wounds  were  the  result  of  a  bomb  explosion  which  had  happened  at  his  feet. 
The  dura  was  seen  pulsating  vigorously  in  the  wounds,  on  both  sides.  The 
X-ray  showed  two  large  defects,  each  the  size  of  a  dollar.  The  man  had  been 
struck  by  two  symmetrical  pieces  of  shell  which  had  wounded  him  simul- 
taneously. The  case  was  not  interesting  neurologically,  as  beyond  his  wounds 
he  had  no  physical  signs. 


368  XEIJ-  YORK  XEUROLOGICAL  SOCIETY 

ASSOCIATED  JOINT  AND  NERVE  LESIONS  IN  EXPERIMENTAL 

STREPTOCOCCUS  INFECTIONS;  THEIR  ANALOGY  TO  THOSE 

OCCURRING  IN  CHRONIC  DEFORMING  POLYARTHRITIS 

AND  SPONDYLITIS  DEFORMANS  (BECHTEREW) 

By  William  P.  Nathan,  AI.D.  (by  invitation) 

Dr.  Nathan  stated  tliat  the  neurological  symptoms  associated  with  poly- 
arthritis and  spondylitis  were  those  which  were  usuall}-  associated  witli  com- 
pression of  the  spinal  roots,  or  very  slight  compression  of  the  spinal  cord. 
In  order  to  discover  the  cause  of  these  symptoms  the  spine  and  epidural 
spaces  in  eighteen  dogs  injected  with  streptococci  were  examined.  In  six  of 
these  there  was  definite  involvement  of  the  spine,  endosteal  and  subperiosteal 
marrow  changes  in  the  bodies  of  the  vertebrae.  These  clianges  were  asso- 
ciated with  periosteal  edema  and  epidural  exudate.  All  these  changes  corre- 
sponded with  those  found  in  the  joints  elsewhere.  Hence,  it  was  concluded 
that  in  those  cases  in  which  there  were  neural  symptoms  associated  with  poly- 
arthritis, the  spine  and  epidural  space  were  involved. 


ON  VARIOUS  FORMS  OF  SPONDYLITIS.  WITH  LANTERN  SLIDES 
AND  RADIOGRAPHIC  DEMONSTRATION 

By  Bernard  Sachs,  M.D. 

The  patient  presented  was  a  man,  36  years  of  age,  admitted  to  the  Mt. 
Sinai  Hospital  November  I,  1915,  complaining  of  pains  in  the  spine.  In  the 
family  the  father,  mother  and  one  brother  had  tuberculosis.  The  patient  had 
had  gonorrheal  infection;  lues  denied.  Twelve  months  previously  the  right 
hip  was  painful,  and  three  years  previously  there  had  been  pains  in  the  lower 
dorsal  spine,  especially  at  night.  On  May  15,  before  admission,  he  began  to 
have  shooting  pains  in  the  spine.  A  laminectomy  was  performed  at  another 
hospital.  After  this  his  condition  was  worse.  He  could  not  raise  his  arms 
to  his  head.  He  had  no  incontinence  of  urine  or  feces.  Fifteen  j^ears  ago 
Dr.  Sachs  had  seen  a  similar  case  and  had  advised  operation,  because  tumor 
was  suspected,  but  nothing  was  found  except  thick  strands  along  the  inner 
surface  of  the  column.  This  present  patient  on  examination  showed  slight 
lateral  nystagmus,  rigid  neck  and  limitation  of  movement  upward.  Achilles 
jerks  were  increased;  wrist  jerks  increased;  rigid  spine  was  present  with 
tenderness  over  cervical,  lumbar  and  sacral  regions  with  hyperesthesia  and 
hyperalgesia.  The  spine  could  not  be  bent.  Both  upper  extremities  were 
paralyzed,  with  the  exception  of  slight  movements  in  tlie  fingers.  The  Was- 
sermann  test  was  four  plus.  X-ray  examination  showed  that  there  was 
marked  spondylitis  of  the  fourth,  fifth  and  sixth  thoracic  vertebrae  and 
eleventh  and  twelfth  lumbar.  The  fundi  and  discs  showed  sliglit  temporal 
pallor  with  contracted  arteries  and  slight  scotoma.  At  operation  the  twelfth 
thoracic  vertebra  was  excised  and  an  examination  showed  normal  bone.  The 
patient,  when  put  upon  specific  treatment,  showed  marked  improvement  in 
four  weeks.  It  was  found  that  the  lesion  was  absolutely  specific,  the  possi- 
bility of  tuberculous  spondylitis  having  been  considered  and  excluded. 

The  subjects  of  Dr.  Nathan's  and  Dr.  Sachs's  presentations  being  similar, 
both  were  discussed  together. 

Dr.  Gibncy  (by  invitation)  opened  the  discussion  by  saying  that  he  was 
very  much  interested  in  the  subjects  presented  by  both  Drs.  Saciis  and  Nathan. 
Dr.  S?chs  was  confronted  with  the  same  problem  in  regard  to  studying  plates 
that  he  had  been  confronted  with.     Dr.  Sachs  was  enthusiastic  and  thought 


NEW  YORK  NEUROLOGICAL  SOCIETY  369 

that  the  roentgenologist  could  make  one  see  things  as  he  saw  them.  The 
question  was  whether  these  were  degenerative  or  hypertrophic  processes.  The 
lipping  process  might  be  tuberculous  or  it  might  be  caused  by  other  infective 
diseases,  x^t  the  Forty-second  Street  Hospital  they  had  had  a  group  of  cases 
with  pain,  stiffness  and  other  unexplained  symptoms,  and  they  were  going 
into  the  question  of  the  teeth  as  a  causative  factor.  All  teeth  were  X-rayed, 
and  those  showing  evidence  of  Rigg's  disease  or  peridental  infection  were 
suspected.  The  dentist  was  asked  to  examine  and  interpret  the  X-ray.  A 
few  years  ago  one  held  the  opinion  that  every  tooth  showing  an  apical  abscess 
must  come  out,  but,  at  a  meeting  of  the  orthopedic  section,  a  dentist  showed 
the  result  of  treating  such  a  tooth  through  the  root  canal  and  there  was 
apparently  new  bone  formation.  It  had  become  the  practice  now  to  save 
more  teeth  than  formerly  and  have  them  so  treated.  Sometimes  adenoids 
and  tonsils  in  older  people  were  found  to  be  the  focus  of  infection.  A 
laryngologist  now  examined  the  throats  and  a  thorough  search  was  made  for 
the  source  of  the  disease.  Dr.  Sachs's  differentiation  was  a  good  one.  Dr. 
Gibney  said  he  was  interested  to  hear  the  statement  that  the  "  neurologist 
discovered  the  early  signs  "  and  that  the  "  orthopedic  surgeon  the  later  signs  " 
of  disease.  He  had  thought  the  condition  was  exactly  the  reverse.  He  always 
impressed  upon  the  students  the  necessitj-  of  early  diagnosis  and  told  them 
that  if  they  did  not  make  a  diagnosis  before  deformity  occurred,  they  were 
culpable  and  ought  to  be  prosecuted.  They  looked  to  the  neurologist  later 
to  help  them  out. 

Dr.  George  R.  Elliott  (by  invitation)  said  that  Dr.  Nathan's  interesting 
experiments  were  in  the  line  of  clearing  up  the  subject  of  nerve  findings  in 
connection  with  multiple  arthritis.  For  many  years  writers  clung  to  a  nerve 
origin  for  so-called  arthritis  deformans.  This  was  largely  based  upon  the 
rather  bilateral  nature  of  the  arthritis.  A  great  deal  was  said  about  a  prob- 
able implication  of  the  anterior  horn  cells,  motor  and  trophic.  This  theory 
graduall}'  fell  into  disuse  and  was  dropped.  It  was  known  that  the  arthritis 
was  not  alwaj's  bilateral.  In  fact  it  was  frequently  irregular  in  distribution. 
The  past  few  years  had  brought  forward  a  new  theory  which  clinically  had 
been  generally  accepted.  This  theory  was  the  logical  outcome  of  the  now 
generally  accepted  view  of  the  infective  etiology  of  arthritis — that  the  organ- 
ism causing  the  arthritis  might  involve  the  nerve  tissue  also.  Pojmton  and 
Paine,  Triboulet  and  others  had  dwelt  upon  this.  Triboulet's  well-worked-up 
autopsy  illustrated  this  theory.  His  patient  had  multiple  arthritis,  together 
with  extensive  nerve  lesions  causing  localized  muscular  atrophies  and  other 
signs  of  nerve  implication.  There  was  a  clear  history  of  puerperal  infection. 
The  autopsy  showed  extensive  epidural  exudation,  explaining  all  the  nerve 
findings.  The  puerperal  infection  was  accepted  as  the  common  focus  of 
origin.  Dr.  Nathan's  experiments  seemed  to  corroborate  such  a  clinical 
belief  and  doubtless  would  do  much  to  clear  up  the  subject.  Dr.  Elliott 
would  like  to  ask  Dr.  Nathan  what  kind  of  streptococcus  he  used,  it  being 
important  that  the  organism  be  nonsuppurative,  did  he  attenuate  his  organ- 
isms or  mutate  them  in  accordance  with  the  transmutationists?  In  regard  to 
Dr.  Sachs's  presentation.  Dr.  Sachs  had  seemed  to  dwell  a  good  deal  upon 
the  so-called  "  lipping "  in  his  demonstration  of  the  interesting  X-ray  find- 
ings. That,  Dr.  Elliott  thought,  was  too  much  dwelt  upon  in  the  text-books, 
while,  in  fact,  it  had  little  or  nothing  to  do  with  the  real  nature  of  any  par- 
ticular disease.  It  meant  simply  the  result  of  some  irritation  stimulating 
osteogenetic  cells.  This  irritation  especially  in  the  spine  was  commonly 
trauma  or  static  disturbance.  Bone  was  thrown  out  at  points  of  ligamentous 
and  muscular  attachments  when  subjected  to  strain.  Bridge  formation  often 
meant  nothing  more  than  this.  In  X-ray  studies  made  of  laboring  men 
over  fifty  years  of  age  "  lipping  "  and  bridge  formation  were  common  where 


37"  XEir  YORK  XEUROLOGICAL  SOCIETY 

no  subjective  symptoms  were  complained  of.  In  one  of  the  large  London 
hospitals,  where  this  point  was  especially  studied  50  per  cent,  of  the  spines 
of  hard  working  men  showed  at  autopsy  more  or  leSs  "  lipping  "  and  bridge 
formation,  where  there  had  been  no  complaint  during  life. 

Dr.  Ramsay  Hunt  said  that  a  little  over  a  year  ago  he  had  considered 
this  subject  at  some  length  on  the  basis  of  his  own  experience  (four  cases) 
and  the  records  which  were  available  in  the  literature  (Am.  Jour.  Med.  Sci., 
1914,  p.  114).  He  had  gathered  in  all  100  cases  that  seemed  to  him  to  meet 
the  requirements  for  the  diagnosis  of  syphilis  of  the  spine.  One  striking 
thing  about  this  series  was  the  great  preponderance  of  the  cervical  location. 
Half  of  the  lesions  were  localized  in  the  uppermost  portion  of  the  cervical 
region.  He  found  that  25  per  cent,  showed  neural  complications.  These 
were  divided  pretty  equally  between  cases  where  only  the  plexus  or  the  nerve 
roots  were  involved,  and  cases  that  presented  symptoms  of  compression  and 
paraplegia.  One  case  recorded  by  Dr.  Hunt  was  unusual.  It  came  on  like 
acute  mj-ositis  (wry  neck).  Generally  speaking  in  this  group  of  cases  the 
spinal  symptoms  outweighed  in  importance  and  frequency  the  symptoms  of 
bone  disease  as  shown  by  the  X-ray.  The  majority  of  cases  would  come 
under  the  heading  of  a  perispondylitis.  In  the  later  stages  only  would  there 
be  breaking  down  from  necrosis  and  carious  osteitis.  Very  difficult  cases 
were  those  presenting  the  clinical  picture  of  Pott's  disease,  but  with  a  positive 
Wassermann  reaction.  Dr.  Hunt  cited  the  case  of  a  young  girl,  17  years  old, 
who  developed  the  typical  picture  of  Pott's  disease,  but  with  a  positive  Was- 
sermann. Her  mother  had  also  a  positive  Wassermann,  and  there  was  no 
history  or  symptom  of  tuberculosis.  Dr.  Hunt  would  warn  neurologists  to 
consider  the  question  of  syphilis  carefully  even  when  tlie  case  appeared  to  be 
caries  of  tubercular  origin. 

Dr.  W.  R.  Townsend  (by  invitation)  said  he  had  studied  bone  syphilis 
and  he  did  not  think  that  "lipping"  was  characteristic  of  syphilis.  He  thouglit 
it  would  be  found  in  many  classes  of  cases.  He  did  not  mean  that  the  con- 
dition of  the  vertebrae  shown  was  not  characteristic  of  Pott's  disease,  but  a 
little  "lipping"  did  not  necessarily  mean  syphilis.  It  might  occur  with  syphilis 
or  it  might  occur  in  osteoarthritis  or  even  in  normal  spines.  There  were  all 
kinds  of  variations  in  the  vertebrae.  A  little  raising  of  one  edge  could  not  be 
taken  as  characteristic  of  any  disease.  Later,  when  breaking  down  of  the 
bodies  occurred,  that  was  a  different  thing. 

Dr.  I.  Strauss  said  in  the  matter  of  the  X-rays  that  he  did  not  under- 
stand Dr.  Sachs  to  mean  that  "lipping"  was  an  evidence  of  specific  disease. 
They  were  all  aware  that  slight  changes  in  the  bone  occurred  in  many  per- 
sons. The  syphilitic  case  shown  by  Dr.  Sachs  had  distinct  changes  in  the 
body  of  the  vertebra.  Dr.  Hunt's  case  had  a  wry  neck;  he  also  had  marked 
hyperesthesia  in  the  cervical  region,  which  led  him,  in  connection  with  the 
X-ray  and  Wassermann,  to  make  a  positive  diagnosis.  Lipping  was  not  to 
be  regarded  as  significant  unless  there  were  symptoms  of  nerve  involvement. 
Dr.  Nathan's  paper  was  interesting.  The  diagnosis  of  rheumatism  was  being 
discarded.  Rosenow's  work  on  its  bacterial  origin  had  furthered  this  view. 
Dr.  Nathan  seemed  to  have  found  exudate  in  the  periosteum  in  addition  to 
the  bone  condition.  He  had  seen  sections  which  showed  exudation  clearly 
and  changes  in  the  neighborhood  of  the  nerve  roots,  though  no  distinct 
damage  to  the  nerve  roots,  but  changes  in  juxtaposition  to  the  nerve  roots 
might  cause  degeneration  in  the  stroma.  In  one  case  of  Dr.  Sachs's  the 
contention  of  Dr.  Nathan  scemetl  to  be  proven,  that  was  in  the  individual 
who  had  a  staphylococcus  infection.  This  was  followed  by  a  stapliylococ- 
cxmia  for  several  months,  then  by  subperiosteal  abscess.  The  patient  had 
his  leg  amputated,  and  then  began  paralysis  in  the  remaining  limb.  This 
level  lesion  increased  so  rat)idly  that  operation  was  performed  by  Dr.  Elsberg, 


NEIV  YORK  NEUROLOGICAL  SOCIETY  371 

and  in  the  laminae  was  found  a  pachymeningitis.  There  was  dense  fibrous 
exudate  containing  pus.  The  dura  was  not  opened.  The  patient  made  a 
complete  recovery.  This  was  in  accord  with  the  symptoms  produced  in  dogs 
by  Dr.  Nathan.  In  regard  to  malignant  growth,  there  had  been  two  cases  in 
the  hospital  with  very  instructive  X-ray  findings.  Sometimes  intradural 
tumors  might  cause  rarifying  change  in  the  bones  which,  if  one  was  not 
careful,  might  be  considered  as  syphilitic  changes.  In  one  case  compression 
of  the  cord  symptoms  became  very  distinct.  Laminectomy  was  performed 
and  an  intradural  neoplasm  was  removed.  With  this  there  had  been  distinct 
signs  in  the  b'ones. 

Dr.  C.  A.  Elsberg  said  he  had  five  times  operated  on  patients  with  intra- 
dural neoplasm  in  whom  the  X-ray  showed  spondylitis.  Each  one  had  been 
treated  for  spondylitis  or  arthritis  of  the  vertebrae  on  account  of  changes  in 
the  bones  such  as  had  been  shown  by  Dr.  Sachs.  The  patient  of  Dr.  Strauss 
had  a  tumor  behind  the  first  two  cervical  vertebrae,  and  projecting  into  the 
foramen  magnum.  On  accoimt  of  the  X-ray  picture  the  case  was,  for  a  time, 
considered  spondylitis  by  neurologists  and  orthopedists. 

Dr.  S.  E.  Jelliffe  said  the  discussion  emphasized  the  need  for  a  thorough 
search  all  over  the  body  for  sources  of  infection,  not  only  teeth,  but  frontal 
sinuses,  mastoid,  cecum  colon,  prostate,  kidneys,'  etc.  Infections  were  pos- 
sible from  anj^  of  these  hidden  sources  in  spinal  arthritic  patients. 

Dr.  Nathan  said  he  was  aware  there  were  four  cases  reported  with  au- 
topsy findings  in  which  epidural  changes  were  found.  They  had  used  two 
or  three  strains  of  streptococci  in  their  experiments.  One  was  from  Dr. 
Noble  at  Bellevue  Hospital  which  produced  the  spinal  lesion ;  one  was  a 
hemolytic  streptococcus  from  a  throat  culture  at  Mt.  Sinai,  cultivated  from 
agar  slants.  The  strain  was  not  attenuated  as  dogs  were  very  resistant  to 
streptococci.  With  regard  to  the  X-ray  of  the  spine,  this  had  its  dangers. 
No  diagnosis  should  be  made  from  the  X-ray  of  the  spine  alone.  Not  only 
minor  changes,  but  gross  changes  should  be  considered  in  connection  with 
the  clinical  symptoms.  The  finer  degrees  of  lipping  might  be  due  to  partial 
crushing  and  softening  of  the  vertebrae  which  occurred  in  all  inflammatory 
conditions.  In  examining  a  large  number  of  spines  it  would  be  found  that 
there  was  more  or  less  deformity  irrespective  of  the  cause  of  death.  Diag- 
nosis should  only  be  made  in  connection  with  other  clinical  findings.  All 
hospital  cases  had  a  Wassermann  taken.  They  had  had  patients  with  a  posi- 
tive Wassermann  who  were  relieved  by  specific  treatment,  but,  on  the  other 
hand,  some  patients  with  a  positive  Wassermann  were  not  relieved  at  all. 
That  patients  with  syphilis  might  have  something  else  as  well  was  not  always 
recognized.  It  should  be  remembered  that  in  such  patients  all  abnormal  con- 
ditions were  not  due  to  syphilis. 

Dr.  Bernard  Sachs  said  he  had  not  done  Dr.  Jaches  justice  by  his  expo- 
sition of  the  X-ray  plates.  There  was  a  large  series.  The  attitude  of  the 
speakers  to-night  was  what  his  had  been  in  the  beginning  of  his  studies  of 
the  subject,  that  is,  that  the  plates  showed  very  little.  Now,  they  had  found 
that  the  X-ray  studies  were  extremly  important.  To  Dr.  Elliott  he  said  that 
he  did  not  mean  the  lipping  was  entirely  specific.  It  was  part  of  general 
spondjditic  changes.  Dr.  Ramsay  Hunt  had  remarked  upon  the  surprising 
preponderance  of  luetic  caries  cervicalis.  Lumbar  cases  were  very  rare;  cer- 
vical lues  much  more  common.  It  was  connected  with  spondylitis  rather  than 
osteitis.  He  had  been  surprised  to  note  the  relative  frequency  of  spondylitis. 
He  had  seen  about  thirty  cases  in  three  years — cases  sent  to  the  medical  and 
neurological  service,  not  on  account  of  bone  changes.  He  thought  medical 
and  neurological  men  saw  the  early  cases.  He  felt  if  he  had  done  nothing 
else  he  had  started  interest  in  a  somewhat  neglected  subject.  Spondylitis 
should  be  an  active  subject  of  interest  to  neurologists. 


tTransIatione 


VEGETATIVE   NEUROLOGY.     THE  ANATOMY,   PHYSI- 
OLOGY. PHARMODYNAMICS  AND  PATHOLOGY 
OF  THE  SY.MPATHETIC  AND  AUTONOMIC 
SYSTEMS 

Bv   Hetxricii    Higier 


Authorized    Translation    by    Walter    ]Max   Kraus.    A.'SL,    M.D. 
[New  York]. 

{Continued  from  page  279) 

What  are  the  physiological  characteristics  of  the  vegetative  ner- 
vous system?  The  proof  of  even  the  most  simple  of  these  is  more 
or  less  difficult  to  obtain  since,  with  the  exception  of  the  cervical 
sympathetic,  the  structures  are  very  inaccessible.  The  retro-pleural 
and  retro-peritoneal  ganglion  nodes  and  nerve  borders  are  so  hard 
to  get  at  that  transection,  stimulation  or  extirpation  on  the  living 
animal  can  hardly  be  done.  In  reviewing  the  separated  functions 
of  the  vegetative  system,  localized  in  the  cerebral  cortex  (neopal- 
lium), the  cerebrospinal  axis  (archa;opallium),  the  ganglia  and  the 
periphery  respectively,  we  find  the  following : 

I.  Autonomx  of  the  Peripheral  Vegetative  System. — There  is 
a  distinct  autonomy  and  independence  of  the  periphery.  For  ex- 
ample, the  progress  of  digestion  is  possible  without  the  influence  of 
the  cerebrospinal  axis  as  experienced  in  the  simultaneous  transec- 
tion in  dogs  of  the  spinal  cord  and  vagus  nerve.  Animals  in  whom 
a  part  of  the  spinal  cord,  or  even  the  entire  brain,  has  been  removed, 
live  without  them,  digesting,  voiding  and  develoi)ing.  The  inde- 
penflence  of  the  peri[)hery  is  anatomically  proven  by  the  fact  that 
smooth  muscle  docs  not  degenerate  after  its  nerves  are  cut.  It  is 
as  yet  inulecided  whether,  since  the  end  organ  can  functionate  inde- 
pendently, there  are  ganglion  cells  in  its  walls  as  in  the  blood  vessels, 
or  whether  the  autonomy  resides  in  the  protoplasm  of  the  organs 
themselves.  It  is  noteworthy  that  many  organs  have  no  ganglion 
cells  in  their  walls  and  that  the  emliryonic  heart  muscle  contracts 

372 


VEGETATIVE  NEUROLOGY  373 

rhythmically  for  a  time  even  though  it  has  no  ganglion  cells.  The 
physiological  relations  are  therefore  quite  different  than  in  the 
cerebrospinal  system,  in  which  permanent  and  severe  changes  occur 
in  circumscribed  disease  of  the  brain  and  interruption  of  conduction 
bundles.  In  lesions  of  the  sympathetic  ganglia  or  their  peripheral 
branches,  there  is  at  most  a  transitory  disturbance  of  function  in 
the  corresponding  organ.  In  many  cases  it  is  demonstrable  that 
after  the  cerebrospinal  axis  has  been  cut  off  there  is  complete  paral- 
ysis ;  e.  g..  in  intrinsic  muscles  of  the  eye  and  sphincter  anus.  This, 
however,  gradually  disappears. 

The  entire  process  of  an  increase  of  peripheral  irritability  of 
muscle  is  identical,  according  to  Lewandowsky,  and  justly  so,  with 
the  isolation  phenomena  as  Munk  describes  it  and  which  has  long 
been  recognized  as  characteristic  of  the  vegetative  nervous  system. 
This  is  never  dependent  upon  the  absence  of  inhibition  and  never 
occurs  immediately  after  isolation  of  the  organ  has  taken  place. 

2.  Action,  Sensation-  and  Reflex. — Under  normal  conditions  there 
is  no  voluntary  control  of  the  activities  of  the  vegetative  nervous 
system,  nor  do  visceral  reflexes  to  mechanical  or  sensory  stimuli 
occur  via  the  brain  or  spinal  cord  in  the  usual  fashion. 

3.  Peculiarities  of  Smooth  Muscle. — -The  physiology  of  the  irrita- 
bility of  smooth  muscle  shows  (Nagel,  Zierl)  that  the  latter  is  un- 
commonly reactive  to  mechanical  and  thermal  stimuli  and  less  re- 
active to  electrical  stimuli ;  the  latter  must  be  continuous  in  character 
in  order  to  have  an  influence  upon  the  somewhat  sluggishly  reacting 
smooth  muscle.  Single  induction  shocks  or  discharges  from  a  con- 
denser are  less  active.  Interrupted  or  constantly  increasing  continu- 
ous currents  produce  reactions.  wSmooth  muscle  is  particularly  sus- 
ceptible on  account  of  its  sluggishness  to  summated  stimuli.  All 
skin  stimuli  seem  to  cause  tonic  reflexes,  reflex  activity  of  a  tetanic 
or  tetanoid  character  which,  as  is  seen  in  the  goose  flesh  due  to  the 
activity  of  the  pilo  erector,  does  not  persist  for  a  long  time  after  the 
cutaneous  stimulation  has  ceased.  The  rigor  mortis  of  smooth 
muscles  may  last  twenty-four  hours  after  death,  as  is  seen  by  the 
marked  anemia  and  goose  flesh  of  cadavers. 

4.  The  Pre-  and  Postganglionic  Branches  of  the  Sympathetic 
Ganglia. — It  is  noteworthy,  from  a  physiological  point  of  view  that, 
as  Langley  has  established,  there  is  but  one  ganglion  between  the 
cerebrospinal  axis  and  the  peripheral  or  internal  end  organs.  Thus 
any  given  stimulus  must  pass  through  an  intermediary  station  in 
order  to  reach  the  end  organ.     When  the  end  organ  is  of  a  secretoiy 


374  H EI N RICH  HIGIER 

nature,  or  is  motor  with  smooth  muscle,  the  motor  nerve,  whether 
it  be  sympathetic  or  autonomic,  can  only  exert  its  influence  on  the  or- 
gan through  a  vegetative  ganglion  and  through  post-ganglionic  fibers 
(Fig-    O. 

The  results  of  transection  are  the  same  whether  the  ]ire-gang- 
lionic  or  post-ganglionic  fiber  is  cut.  The  resulting  irritability  of 
the  periphery  occurs  more  rapidly  and  more  intensely  after  tran- 
section of  the  post-cellular  fiber  than  after  cutting  of  the  pre- 
cellular.  It  is  noteworthy  also  that  in  cutting  a  branch  of  the 
vegetative,,  or  in  extirpating  a  ganglion,  that  regeneration  only 
occurs  between  pre-cellular  and  pre-cellular,  and  between  post-cellu- 
lar and  post-cellular  fibers.  Unless  this  type  of  regeneration  occurs 
there  is  no  complete  disappearance  of  the  manifestations  of  transec- 
tion. Some  physiologists  deny  that  there  is  inherent  tone  in  the 
vegetative  ganglia. 

5.  Synapses  and  Pscudo-Synapscs  in  tlic  Ganglia  of  the  Sympa- 
thetic Cord. — The  unity  of  anatomical  structure  of  the  vegetative 
nervous  system  implies  a  unity  of  pharmacological  action  which 
would  prove  the  division  between  vegetative  and  sensory  motor 
nerves  (Langley  &  Dickinson).  The  effects  which  are  brought 
about  by  stimulation  of  the  vegetative  nerve  fibers  after  they  have 
left  the  gray  matter  of  the  central  nervous  system,  may  be  stopped 
at  once  if  a  i  per  cent,  solution  of  nicotine  is  painted  upon  the 
ganglion  between  the  place  of  stimulation  and  the  periphery.  Sen- 
sori-motor  nerve  functions  are  uninfluenced  by  this  procedure. 
Nicotine,  which  in  large  doses  paralyzes  the  ends  of  all  somatic 
nerves,  in  small  doses  acts  upon  the  pre-ganglionic  neuron  and  not 
upon  the  post-ganglionic. 

If  the  symjjathetic  fibers  pass  through  more  than  one  station,  c.  g., 
the  pupilo-dilator  fibers  which  cross  the  stellate,  inferior  and  su- 
perior cervical  ganglia,  then  painting  these  ganglia  successively  with 
nicotine  and  stinndating  peripherally  with  a  faradic  current  will 
show  in  which  ganglia  the  synapse  is  placed ;  that  is  to  say,  where 
the  sympathetic  fiber  does  not  pass  through  but  is  broken  and  comes 
in  contact  with  a  new  physiological  neuron. 

In  the  above  cited  example,  painting  with  nicotine  only  destroys 
the  electrical  conductivity  of  the  pupillary  fibers  when  nicotine  is 
painted'upon  the  superior  cervical  ganglion.  The  results  of  pharma- 
cological methods  are  quite  in  accord  with  the  degeneration  anatom- 
ical  method. 

We  arc  indebted  for  our  knowledge  of  most  of  the  anatomical 
bases  of  the  reflex  tracts,  which  we  shall  consider,  to  the  animal  ex- 


VEGETATIVE  NEUROLOGY  375 

periments  of  Langley  and  his  coworkers.  They  worked  out  the 
central  origin  and  the  peripheral  extension  of  the  vertebral  sym- 
pathetic ganglia  by  means  of  the  nicotine  method. 

6.  TJic  Myoneural  Junctional  Tissues. — Pharmacological  experi- 
ments with  the  paralyzing  action  of  nicotine  and  the  stimulating 
action  of  adrenalin  (which  stimulates  all  ends  of  the  sympathetic 
system)  have  shown  a  further  physiological  characteristic  (Wesse- 
ley,  Langley,  Lewandowsky).  Alanifestations  of  the  above  named 
substances  could  be  obtained  months  or  even  a  year  after  extirpation 
of  the  ganglia,  or  after  degeneration  following  transection  of  either 
pre-cellular  or  post-cellular  fibers.  Adrenalin  does  not  act  on  every 
nervous  part  of  the  doubly  innervated  end  organ;  that  is,  upon  the 
sympathetic  apd  autonomic.  It  only  acts  upon  the  end  organs  which 
are  innervated  by  the  sympathetic ;  consequently,  the  toxic  action 
does  not  occur  upon  the  degenerated  nerve  ending  but  upon  a  chem- 
ically differentiated  part  of  the  end  organ  which  is  in  some  ways 
associated  with  the  sympathetic  nerve  endings.  This  has  been  called 
by  Dickinson,  Langley  and  Elliott  neuro-muscular  end-plate. 

This  substance  which  is  placed  between  nerve  endings  and  the 
smooth  muscle  cells,  has  also  been  called  myo-neural  junction  by 
Froelich. 

7.  Distinctive  Characteristics  of  Vegetative  Reflexes. — Organic 
motor  reflexes  travel  via  the  vegetative  nerve  and  are  accomplished 
with  the  aid  of  involuntary  muscle  (scrotal  reflex,  colonic  reflex,  in- 
ternal anal  reflex,  etc.).  The  reflex  contraction  of  a  smooth  muscle 
is  slow  in  comparison  to  the  energetic  reflex  activity  of  a  cross- 
striated  voluntary  muscle.  In  many  reflexes,  as  for  example-  the 
cilio-spinal,  the  reflex  activity  is  only  carried  out  by  smooth  muscle ; 
in  others,  e.  g.,  the  bladder  reflex,  the  smpoth  muscle  is  aided  by 
cross-striated  voluntary  muscle.  In  almost  all  these  reflexes  the  ac- 
tivity may  take  place  more  or  less  completely  without  any  interven- 
tion of  the  central  nervous  system. 

8.  Simple  and  Visceral  Reflex  Arcs.- — Some  reflex  areas  are 
very  simple,  as  for  example  the  esophagus  reflex ;  others  are  exceed- 
ingly complicated,  as  the  erection  reflex.  Let  us  take  as  an  example 
the  well-known  ejaculation  reflex.  The  stimulation  aroused  in  the 
sensory  end-organ,  the  glans  penis,  travels  via  the  N.  dorsalis  penis 
and  the  N.  pudendus  communis  to  a  spinal  ganglion  of  the  lower 
sacral  roots  and  from  here  via  fibers  of  the  cauda  equina  to  the  lum- 
bar ejaculation  center  where  the  centripetal  part  of  the  arc  ends. 
From  this  point,  the  motor  activity  passes  by  the  lumbar  communi- 
cating branches  and  the  hypogastric  nerves  to  the  pelvic  tracts  and 


376  HEINRICH  HIGIER 

from  here,  via  gray  post-cellular  fibers  to  the  powerful  smooth  mus- 
culature of  the  end  organs,  the  spermatic  cord,  seminal  vesicles  and 
prostate. 

The  path  of  the  reflex  arcs  of  the  head  ganglia  are  very  much 
more  complicated  because  the  development  of  the  head  from  its 
constituent  metameres  is  not  clear  cut  and  the  topographical  rela- 
tions of  the  sympathetic  ganglia  are  extremely  complicated.  As  a 
paradigm,  the  reflex  which  initiates  the  secretion  of  the  parotid  gland 
via  the  otic  ganglion  may  be  cited.  The  reflex  may  be  divided  as 
follows:  (a)  The  impulse  passes  through  the  sensory  fibers  in  the 
N.  lingualis  or  the  N.  mandibularis  via  the  trigeminus  to  the  ob- 
longata.^ (/')  Thence  it  travels  through  the  sensory  fibers  of  the 
chorda  tympani  whose  trophic  center  lies  in  the  geniculate  ganglia 
and  onward  via  the  X.  intermedius  to  the  medulla.^  Finally  it 
travels  via  the  taste  fibers  which  pass  via  the  N.  glossopharyngeus 
to  its  nucleus  in  the  brain  (Fig.  3). 

The  centrifugal  part  of  the  arc  is  no  less  complicated  than  the 
centripetal.  The  fibers  pass  from  the  nucleus  salivatorius  inferior 
in  the  middle  part  of  the  glosso-pharyngeal  nerve  via  the  X.  tym- 
panicus,  the  X.  petrosus  superficialis  minor  to  the  otic  ganglion  and 
from  here  via  the  sheathless  post-cellular  fibers,  which  travel  with 
the  sensor)'  auriculo-temporal  nerve  to  the  parotid  ganglia. 

ilie  question  is :  Are  such  complicated  tracts  always  necessary 
to  the  existence  of  reflex  activity  in  vegetative  organs;  or  do  certain 
reflexes  pass  from  the  spinal  cord  and  medulla  only  to  the  nerve 
tissues  which  are  placed  near  or  in  the  organs  themselves. 

Miiller  &  Dahl  have  recently  answered  this  important  question 
in  the  following  fashion :  Reflexes  which  travel  solely  from  the 
walls  of  organs  via  their  plexi  occur  only  in  those  instances  in  which 
the  sensor\-  stimuli  which  cause  muscular  contraction  or  glandular 
activity  do  not  reach  the  brain  and  scarcely  enter  consciousness 
(stomach,  intestines,  heart,  etc.).  The  refle.x  arc  for  these  so-called 
axon  reflexes  does  not  lie  in  the  spinal  cord  but  in  a  vegetative 
ganglion  just  without  or  ju>t  within  the  organ  itself.  On  the  other 
hand  the  reflex  arc  is  quite  complicated  in  all  organs  communicating 
with  the  outer  world,  whose  activities  depend  upon  exogenous  irrita- 
tion of  sensory  nerves  which  carry  con.scious  and  localizable  sensation. 
In  these  instances  it  is  a  question  of  a  primary  irritation  of  a  sensory 
nerve  which  is  carried  to  consciousness  and  the  transference  of  the 
stimulus  to  the  vegetative  ganglion  cells  of  the  cerebrospinal  gray 

'  The  path  is  then  to  the  pons  and  tliencc  to  tlic  nuclcns  salivatorius 
inferior. 


VEGETATIVE  NEUROLOGY  377 

axis.  The  centers  for  erection,  ejaculation,  secretion  of  sweat,  se- 
cretion of  sebum,  secretion  of  saliva,  secretion  of  tears  and  pupillary 
contractions  are  examples.  From  this  point  the  irritation  passes 
via  the  corresponding  rami  communicanti  to  the  peripheral  ganglion 
cell  groups  which  belong  to  the  organ  involved.  The  post-ganglionic 
tracts  are  of  varying  length,  from  one  millimeter  to  several  centi- 
meters and  even  longer  according  to  the  locality  of  the  ganglion  cell 
which  has  interrvipted  the  path.  Thus  the  synapse  may  lie  very 
close  to  the  end  organ,  or  it  may  be  very  far  from  it. 

(To  be  continued) 


IPcriecopc 

Journal  of  Mental  Science 
(Vol.  60.  No.  248) 

1.  Serum  and  Cerebrospinal  Fluid  Reactions  and  Signs  of  General  Paralysis. 

George  M.  Robertson. 

2.  Vaccine  Treatment  in  Asylums.     W.  Ford  Robertson. 

3.  Villa  or  Colony  System.     T.  E.  Knowles  Stanskield. 

4.  Dysentery,  Past  and  Present.     H.  S.  Gettings. 

5.  Leucoc\-tosis  in  Mental  Disease.     D.  J.  J.vckson. 

6.  Albumen  in  Cerebrospinal  Fluid.     H.  D.  M.\cPhail. 

7.  Enteric  Fever  at  Oniagh  District  Asylum.     Patrick  O'Doherty. 

8.  Pupil  and  its  Reflexes  in  Insanity.     A.  H.  Firth. 

1.  Scnmi  and  Cerebrospinal  Fluid  Reactions. — Robertson  in  "The  Mori- 
son  Lectures,  1913  "  discusses  the  historj-.  methods  of  conducting  and  signifi- 
cance of  the  serum  and  cerebrospinal  fluid  reactions  in  general  paralysis,  dif- 
ferentiating especially  other  .syphilitic  conditions.  The  positive  Wassermann 
reaction  in  the  spinal  fluid  is  called  the  "  paramount  sign  "  in  general  paral- 
j'sis,  occurring  only  in  two  other  allied  conditions,  i.  e.,  tabes  and  cerebro- 
spinal syphilis.  Increase  of  globulin,  the  presence  of  albumen  and  of  plasma 
cells  very  rarely  fail  as  confirmatorj'  signs  in  general  paralysis. 

2.  Vaccine  Treatment  in  Asylums. — After  outlining  the  methods  of  prepa- 
ration of  vaccines  and  the  therapeutic  indications  in  conditions  which  may 
be  present  not  only  in  the  sane  but  also  in  the  insane,  W.  Ford  Robertson 
again  calls  attention  to  his  formerly  expressed  view  of  the  importance  of 
the  "diphtheroid  infections"  in  the  etiology  of  tabes  and  syphilis.  He  says, 
"  ow-ing  to  the  almost  universal  prejudice  that  leads  to  the  uncritical  accept- 
ance of  syphilis  as  the  exclusive  cause  of  tabes  and  general  paralysis,  in  spite 
of  the  incompleteness  of  the  evidence,  such  infections  and  intoxications  (t.  e., 
of  the  genito-urinary  system)  are  still  almost  entirely  neglected  in  their  rela- 
tion to  chronic  diseases  of  the  nervous  system.  He  feels  also  that  "  puerperal 
insanity  "  lends  itself  to  such  treatment,  as  does  also  a  large  proportion  of 
manic-depressive  psychoses.  His  views  as  to  general  paralysis  and  tabes  and 
also  as  to  manic-depressive  insanity  would  arouse  a  severely  critical  dis- 
cussion, to  saj'  the  least,  in  an  audience  of  American  psychiatrists. 

3.  Villa  or  Colony  System. — Knowles  advocates  acute  hospitals  with  a 
concentration  of  medical  and  nursing  skill  and  facilities  for  care  and  treat- 
ment for  the  "  10  per  cent."  who  have  a  prospect  of  recovery.  For  the  large 
chronic  group  of  cases  he  advocates  so  far  as  possiljle  the  communal  life  of 
a  country  village,  the  villa  or  cottage  type  of  asylum  most  nearly  approaching 
this  by  affording  the  best  facilities  for  the  employment  of  patients  and  for 
giving  them  the  maximum  of  personal  freedom.  A  cheaper  form  of  con- 
struction can  be  cmployefl  and  the  cost  of  maintenance  reduced  by  patient 
labor.  Additional  accommodations  can  be  provided  more  readily  than  in  the 
barrack  type  of  asylum. 

4.  Dysentery. — An  extended  adjourned  discussion  of  a  paper  on  "  Dysen- 

378 


PERISCOPE  379 

tery,  Past  and  Present,"  by  H.  S.  Gettings,  appeared  in  the  Journal  of  Mental 
Sciences,  October,  1913. 

5.  Leucocytosis  in  Mental  Disease. — After  a  number  of  blood  counts 
were  made  in  different  types  of  cases  called  "  acute  mania,  acute  melancholia, 
acute  manic-depressive  insanity,  general  paralysis,  dementia  prsecox  and  epi- 
leps}^"  Jackson  gives  his  conclusions  as  follows  : 

1.  Cases  of  acute  confusional  insanity  present  a  fairly  well  marked  pic- 
ture, namely,  a  poh-nucleosis  and  eosinophilia. 

2.  Cases  of  manic-depressive  insanity  and  dementia  prsecox  show  varia- 
tions in  the  leucocytic  formula  resembling  (i)  but  not  so  well  marked  nor 
so  constant. 

3.  That  a  continuous  polynucleosis  and  eosinophilia  point  towards  re- 
covery and  hj-poeosinophilia  and  absence  of  polynucleosis  point  towards 
chronicity. 

4.  Recovery  may  be  hastened  by  stimulation  of  the  leucocytes  by  tere- 
bene,  etc. 

5.  The  remission  stages  of  general  paralysis  are  characterized  by  lympho- 
cytosis and  seizures  by  pol^niucleosis. 

6.  Remissions  in  general  paralysis  may  be  prolonged  by  suitable  doses 
of  tuberculin. 

7.  Cases  of  delusional  insanity  and  terminal  dementia  do  not  exhibit  a 
leucocytosis. 

8.  Epileptics  show  a  polynucleosis  in  their  preparoxysmal  condition  and 
a  diminution  in  the  leucocji:es  in  their  inter-paroxysmal  state. 

Sufficient  data  in  the  illustrative  cases  are  not  given  to  establish  the  dif- 
ferent diagnoses  which  do  not  apparently  conform  to  any  one  generally 
accepted  classification. 

6.  Albumen  in  Cerebrospinal  Pluid.^ln  a  very  brief  paper,  MacPhail 
comments  on  the  results  of  the  examination  of  the  fluid  from  seventj'-seven 
patients  by  the  Eshbach  albumen  meter.  An  excess  of  albumeti  indicates  pro- 
found changes  in  the  central  nervous  system.  General  paralysis  always  shows 
an  increase,  the  greater  the  amount,  the  worse  the  immediate  prognosis.  The 
highest  was  .3  per  cent.,  the  lowest  in  any  case  .03  per  cent.  It  was  rare  to 
obtain  an  amount  in  excess  of  .05  per  cent,  in  purely  functional  cases.  Excess 
of  albumen  and  high  cell  count  go  together.  If  the  amount  of  albumen  is  .1 
per  cent,  or  over,  the  case  is  almost  certainly  one  of  general  paralysis,  but 
if  the  amount  is  as  low  as  .03  per  cent.,  there  is  quite  possibly  no  marked 
change  in  the  nervous  system. 

7.  Enteric  Fever. — An  account  of  an  outbreak  of  enteric  fever  in  the 
Omagh  District  Asylum  which  was  traced  to  a  sewage  contaminated  well,  the 
water  of  which  was  used  for  drinking,  culinary  and  bathing  purposes. 

8.  Pupil  and  its  Reflexes  in  Insanity. — A  long  continued  paper  discussing 
the  pvipil  in  health  and  in  the  various  types  of  psychoses. 

\V.  C.  Sandy   (Columbia.  S.  C). 


American  Journal  of  Insanity 
(Vol.  LXXI,  No,  2) 

1.  A  Criticism  of  Psychanalysis.     C.  W.  Burr. 

2.  The  Pathology  of  General  Paresis.     C.  B.  Dunlap. 

3.  Medical  Examination  of  the  Mentally  Defective.     L.  L.  Williams. 

4.  Applied  Eugenics.     Sanger  Brown. 

5.  Translation  of  Symptoms  and  Mechanisms.     Q.  L.  Carlisle. 

6.  Psychoses  in  the  Colored  Race.     Mary  O'Malley. 

7.  An  Estimate  of  Adolf  Meyer's  Psychology.     G.  V.  Hamilton. 


38o  PERISCOPE 

8.  Dementia  Pnecox,  Paraphrenia.  Review  of  Kraepelin's  Latest  Conception. 

Geo.  H.  Kirby. 

9.  Mental  Disturbances  in  Acute  Articular  Rlieumatism.     R.  H.  H.vskell. 

10.  Cortex  Lesions  in  Dementia  Praecox.     E.  E.  South.\rd. 

11.  Internal  Secretion  Glaiids.     E.  M.  Auer. 

1.  A  Criticism  of  Psychanalysis. — A  rather  sharp  criticism  of  the  au- 
thor's erroneous  concepts  of  the  Freudian  doctrines,  as  misinterpreted  by 
him  from  the  writings  of  some  American  adherents.  It  is  impossible  in  an 
abstract  to  do  more  than  register  the  author's  unfavorable  opinion  as  to  the 
scientific  basis  and  the  practical  utility  of  the  teachings  of  the  Vienna  psy- 
chologist, neither  of  which,  judging  from  the  evidence  in  the  criticism,  are 
at  all  within  the  grasp  of  the  author. 

2.  The  Pathology  of  General  Paresis. — A  review  of  our  present  knowl- 
edge of  general  paresis,  the  most  essential  point  in  w'hose  pathological  anatomy 
the  author  considers  the  perivascular  exudate  throughout  the  central  nervous 
system.  So  far,  however,  we  have  not  succeeded  in  strictlj^  correlating  the 
local  anatomical  change  with  clinical  symptoms.  That  the  spirochaeta  pallida 
is  directl}'  responsible  for  these  changes  there  seems  to  be  practically  no 
doubt  now,  but  the  search  for  this  organism  in  sections  is  tiresome  and  dis- 
heartening, as  the  methods  of  staining  are  very  capricious.  Again,  it  is  not 
always  easy  to  differentiate  the  changes  of  general  paresis  from  those  of 
cerebral  syphilis  and  in  fact  they  exist  alongside  of  one  another,  though  as  a 
rule  the  changes  of  paresis  are  readily  distinguishable  from  those  of  syphilitic 
meningitis.  The  clinical  differentiation  again  is  not  always  easj',  but  from 
a  practical  point  of  view  this  is  not  so  important,  since  they  are  best  consid- 
ered as  varieties  of  the  same  disease  (though  of  different  prognosis). 

We  know  too  little  of  the  life  historj-  of  the  spirochaeta  pallida  to  answer 
such  questions  as,  what  is  going  on  during  periods  of  remission  clinically  of 
paresis,  whether  there  is  a  special  strain  of  this  organism  which  has  a  par- 
ticular affinity  for  the  nervous  system,  etc.  It,  however,  appears  safe  to 
assert  that  "  general  paresis  is  essentially  a  generalized  infection  with  the 
spirochaeta  pallida,  in  which  the  central  nervous  system  stands  out  more 
prominently  than  any  other  part."  On  anatomical  grounds  the  author  feels 
that  by  the  time  the  diagnosis  is  made  the  damage  will  be  already  considerable 
and  looks  to  prophyla.xis  in  syphilis  itself  as  the  hope  of  the  future. 

3.  The  Medical  Examination  of  Mentally  Defective  Aliens:  Its  Scope 
and  Limitations. — A  discussion  of  the  problems  which  confront  the  public 
health  and  marine  hospital  medical  officers  in  the  examination  of  immigrants, 
especially  at  the  port  of  New  York.  While  far  from  satisfactory  and  im- 
posing a  heavy  responsibility  upon  these  medical  men,  the  e.xisting  laws  un- 
doubtedly have  effected  the  exclusion  of  a  large  number  of  mental  defectives 
who  would  likely  become  criminals  or  dependents,  though  many  of  the  higher 
grade  defectives  undoubtedly  get  by.  On  account  chiefly  of  the  immense 
material  which  must  be  handled  in  a  limited  time  the  examiners  are  greatly 
hampered  in  their  efforts  to  render  exact  justice  both  to  the  immigrant  and 
to  the  community  and  an  increase  in  the  number  of  examiners  and  inter- 
preters and  more  space  in  which  to  work  seem  to  the  author  great  desiderata. 

4.  Applied  Euf/euics. — A  discussion  of  some  of  tlie  problems  of  eugenics 
with  criticism  of  the  tendency' to  enact  hasty  and  ill-considered  legislation 
bearing-  on  this  subject. 

5.  The  Translation  nf  Symptoms  into  their  Mechanisms. — .Xn  attempt  to 
refer  the  symptoms  observed  in  nine  women,  whose  cases  the  author  considers 
as  belonging  to  the  class  of  the  constitutional  depressions,  to  the  presence  in 
their  subconscious  spheres  of  certain  uiifulfillablc  wishes  of  sexual  character. 
The  interpretations  of  the  symptoms  are  in  strict  accordance  with  Freudian 
ideas,  hence  the  sexual  element  is  of  course  uppermost.     Unfortunately,  the 


PERISCOPE  381 

prognosis  is  unfavorable,  since  the  essential  basis  in  each  case  is  an  irreme- 
diable situation.  However,  "  the  disturbing  affect  complex  cannot  be  entirely 
sublimated  by  the  patient,  but  it  may  be  robbed  of  the  greater  part  of  its 
dynamic  value  by  thorough  and  vigorous  ventilation."  This  has  been  done 
in  one  case  which  was  able  to  return  home  apparent!}^  normal. 

6.  Psychoses  in  the  Colored  Race. — The  authoress's  study  extends  over  a 
period  of  four  years  and  three  months  and  is  based  upon  a  comparison  of 
455  white  and  345  colored  females  admitted  to  the  Government  Hospital  at 
Washington.  On  account  of  the  mixture  of  races  there  are  practically  no 
really  full  blooded  negroes  in  the  United  States  to-day,  according  to  Hoff- 
man, who  thinks  that  while  the  admixture  of  Caucasian  blood  renders  the 
mind  of  the  mulatto  quicker,  he  does  not  really  excel  the  black  man  in  capac- 
ity. The  authoress  traces  interestingly  the  psj'chological  traits  of  the  negro 
character  and  its  bearing  upon  the  SA^mptoms  in  mental  disorders,  then  studies 
the  relative  frequency  of  the  different  forms  of  mental  disease  in  the  white 
and  in  the  negro.     She  draws  the  following  conclusions  : 

1.  The  facts  brought  out  warrant  the  conclusion  that  insanity  has  largely 
increased  among  negroes  since  their  attainment  of  freedom. 

2.  The  mental  mechanism  in  different  psj'choses  does  not  differ  essen- 
tially in  the  two  races. 

3.  Dementia  prsecox  is  the  preponderant  disease  tj^pe  among  the  colored 
but  it  is  not  greatly  disproportionate  to  the  same  tj-pe  among  whites.  The 
hebephrenic  t3'pe  predominates  in  both  races  ;  there  is  more  catatonia  among 
negroes,  more  paranoid  dementia  among  whites. 

4.  The  manic-depressive  psj'chosis  is  less  prevalent  among  negroes  than 
among  whites,  the  manic  tA-pe  being  more  frequent,  the  melancholic  less  fre- 
quent among  the  colored. 

5.  Involutional  melancholia  and  depressions  are  rare  in  the  colored,  and 
since  their  moral  standards  are  less  strict  and  social  conventions  are  less 
regarded,  the  absence  of  self-depreciatory  ideas,  etc.,  is  noticeable. 

6.  The  prevalence  of  sj'philis  among  the  colored  has  had  a  marked  effect, 
and  general  paresis,  cerebral  syphilis  and  luetic  affections  are  far  more  fre- 
quent than  among  wdiites. 

7.  While  negroes  consume  large  quantities  of  alcohol,  they  seem  to  have 
a  certain  immunity  to  it  and  its  toxic  effects  are  less  lasting  than  in  whites. 

8.  Paranoid  conditions  are  found,  but  true  paranoia  is  rare,  especially  in 
negro  females. 

9.  Hysteria  is  rare  in  the  colored. 

7.  An  Estimate  of  Adolf  Meyer's  Psychology. — A  review  of  the  chief 
points  of  Meyer's  psjxhological  teaching  which  the  author  does  not  find 
sufficient!}^  clear  to  be  of  great  practical  use  in  psychiatry,  but  which  if  formu- 
lated in  somewhat  more  definite  manner,  which  he  indicates,  he  thinks  would 
furnish  a  useful  working  h3-pothesis  at  least. 

8.  Dementia  Prcccox,  Paraphrenia  and  Paranoia:  Review  of  Kracpelin's 
Latest  Conception. — Kraepelin  has  recently  restated  his  views  on  dementia 
prsecox  which  do  not  appear  to  be  essentiall}^  modified  and  he  has  enlarged 
his  disease  picture  by  the  introduction  of  a  number  of  subvarieties.  Under 
the  head  of  "  Endogenous  Deteriorations "  he  forms  two  large  groups, 
Dementia  Prgecox  and  Paraphrenia.  Both  of  these  develop  independenth'  of 
anj'  external  causes  w'hich  we  can  discover  and  are  chronic  psychoses  with 
more  or  less  mental  impairment.  Under  dementia  prsecox  he  describes  the 
following  varieties : 

1.  Dementia  Simplex.  A  gradually  increasing  apathy  with  impoverish- 
ment of  ideas  and  lack  of  interest.  No  hallucinations  or  delusions.  Begins 
about  puberty  or  even  in  childhood. 

2.  Hebephrenia.     Progressive  rapid  deterioration  with  peculiar  behavior. 


3S2  PERISCOPE 

hallucinations,  ideas  of  grandeur,  scattering  of  thought,  emotional  variability. 
Particularly  characteristic  are  silly  behavior,  uncalled  for  laughter  and  in- 
fantile attitudes. 

3.  Simple  depressive  or  stuporous  forms,  which  are  followed  by  gradual 
deterioration. 

4.  Depression  with  delusion  formation. 

5.  Excited  forms,  of  which  there  are  the  following  subvarieties : 

(a)  Circular  Type.  Usuallj-  begins  with  a  depressed  phase,  with  delu- 
sions and  subsequent  excitement.  The  persistent  senseless  excitement  is 
most  characteristic  for  this  form. 

(b)  Agitated  Type.  Continued  restlessness  and  excitement,  passing  into 
deterioration,  with  or  without  remissions. 

(f)  Periodic  Type.  Infrequent,  shows  an  episodic  course  of  excitement 
followed  by  remissions.     The  intervals  varj-.  but  the  outcome  is  deterioration. 

6.  Katatonic  Forms.  These  cases  show  an  alternation  of  katatonic  e.x- 
citement  and  stupor  which  is  characteristic. 

7.  Paranoid  Forms.  Delusions  and  hallucinations  are  the  most  promi- 
nent symptoms,  but  in  addition  there  are  the  characteristic  symptoms  of 
dementia  praecox.     This  group  contains  the  two  types  of 

(a)  Dementia  Paranoides  Gravis.  Delusion  formation,  later  peculiar 
behavior  and  emotional  deterioration.  Occurs  especially  in  middle  life  and 
later. 

(b)  Dementia  Paranoides  Mitis.  Paranoid  type  with  long  persistence 
of  hallucinations  and  delusions,  but  in  which  the  personality  is  less  severely 
damaged  than  in  the  preceding  form. 

8.  Forms  with  Marked  Speech  Confusion  (Schizoplasia).  This  is  shown 
particularly  in  the  end  stages  with  relatively  less  deterioration  in  other  fields. 

The  lines  between  the  different  groups  cannot  always  be  sharply  drawn 
and  they  shade  into  one  another.  The  excited  and  katatonic  forms  are  apt 
to  have  long  remissions  while  in  the  simple,  hebephrenic  and  paranoid  forms 
remissions  are  much  less  common.  The  katatonic,  hebephrenic  and  first 
paranoid  type  are  most  apt  to  sink  into  deep  dementia.  Kraepclin  looks  upon 
all  these  varied  clinical  pictures  as  manifestations  of  an  underlying  disease 
which  he  conceives  to  originate  from  some  endogenic  cause,  probably  some 
perverted  glandular  activity,  or  from  some  nervous  tissue-damaging  toxine 
elaborated  within  the  bodj-.  As  to  the  symptomatology,  Kraepelin  singles 
out  the  will  and  the  emotions  as  the  chief  elements  of  mental  life  and  reduces 
the  primary  symptoms  of  dementia  praecox  to  disturbances  in  these  fields. 
He  does  not  think  that  dementia  praecox  is  so  much  allied  to  the  constitutional 
ps3'choses  as  to  epilepsy,  both  diseases  probably  depending  upon  some  pro- 
gressive destructive  disease  process  most  often  beginning  in  childhood  or  in 
adolescence. 

A  large  number  of  cases  of  dementia  praecox  show  marked  peculiarities 
of  mental  make-up  long  before  the  onset  of  a  definite  psychosis.  The  fol- 
lowing are  singled  out  by  Kraepelin  as  the  most  frequent  types  of  person- 
ality found  in  dementia  praecox  cases. 

1.  Shut  in,  seclusive  tj'pe,  mostly  males. 

2.  Sensitive,  irritable,  excitable,  obstinate  type,  mostly  women. 

3.  Lazy,  unsteady,  shiftless,  mischievous  type,  mostly  boys,  who  often 
become  -tramps  or  criminals. 

4.  Good-natured,  pliable,  conscientious,  diligent  type,  mostly  bojs,  who 
are  marked  by  avoidance  of  youthful  naughtiness.  These  peculiarities  are 
thought  by  Kraepclin  to  be  the  earliest  signs  of  dementia  pra;cox,  and  he  even 
suggests  that  these  different  types  arc  rci)resented  later  in  the  clinical  picture 
of  the  p.sychosis  itself,  c.  g..  seclusive,  obstinate  traits,  as  negativism,  odd 
behavior,  as  mannerisms,  irritability  as  impulsiveness,  while  easily  influenced, 


PERISCOPE  383 

liable,  over-conscientious  personalities  have  traits  later  transformed  into  au- 
tomatic obedience  and  suggestibility.  Individuals  who  show  some  of  the 
above  traits  but  have  later  no  psychoses  may  possibly  be  considered  as  having 
had  formes  frustes  of  dementia  prsecox. 

As  to  the  cause  of  dementia  prsecox,  while  this  is  unknown  Kraepelin 
thinks  that  the  weight  of  evidence  is  in  favor  of  an  autointoxication  of  some 
sort,  and  he  is  firmly  convinced  that  in  this  disease  we  have  to  do  with  a 
widespread  and  severe  disease  of  the  cerebral  cortex,  founding  his  opinion 
on  the  work  of  Nissl  and  Alzheimer.  If  Alzheimer's  findings  are  confirmed, 
disease  of  the  small  cell  layers  of  the  cortex  must  be  considered  responsible 
for  the  mental  disturbances  most  characteristic  of  dementia  prgecox. 

Paraphrenia  includes  cases  formerly  classified  in  part  as  dementia  praecox, 
in  part  as  paranoia.  It  is  differentiated  from  dementia  prsecox  by  the  fact 
that  the  main  disturbance  is  in  the  intellectual  sphere  and  the  peculiar  dis- 
turbances of  will  and  the  marked  emotional  deterioration  so  characteristic 
of  dementia  praecox  is  not  present.  On  this  account  the  disruption  of  the 
personality  is  not  so  marked.  Kraepelin  recognizes  four  subforms  of  para- 
phrenia : 

1.  Paraphrenia  systematica.  This  includes  a  large  part  of  the  cases  of 
Magnan's  "  Delire  chronique  a  evolution  systematique." 

2.  Paraphrenia  expansiva.  A  smaller  group  characterized  by  florid  delu- 
sions of  grandeur  and  of  persecution  with  a  prevailing  exaltation  of  mood 
and  mild  excitement.  Visual  hallucinations  are  common.  These  cases  Kraepe- 
lin formerly  considered  as  chronic  mania.  It  occurs  almost  exclusively  in 
women. 

3.  Paraphrenia  confabulans.  A  small  group  in  which  falsifications  of 
memory  dominate  the  picture. 

4.  Paraphrenia  phantastica.  Abundant  delusions  of  absurd,  disconnected 
and  changeable  form. 

For  a  small  group  of  cases  Kraepelin  still  reserves  the  name  of  paranoia, 
which  he  now  looks  upon  as  the  reaction  of  an  abnormally  constituted  per- 
sonality to  the  struggle  of  life.  It  is  the  outgrowth  of  personal  difficulties 
in  adaptation  to  the  environment,  not  of  disease  processes,  as  are  dementia 
praecox  and  paraphrenia.  These  people  show  great  overvaluation  of  self 
combined  with  suspiciousness.  There  is  gradual  development  of  an  intel- 
lectually produced  and  unassailable  delusion  with  integrity  of  the  person- 
ality. There  are  no  hallucinations,  disturbances  of  the  will  or  of  emotion 
as  in  dementia  praecox.  The  delusion  of  greatness  crops  up  apparently  after 
all  kinds  of  internal  conflict  and  represents  the  fulfilment  of  secret  wishes 
and  day  dreams.  Most  of  these  cases  can  get  along  in  society,  many  being 
known  as  reformers,  statesmen,  founders  of  new  religions,  philosophers,  etc. 

9.  Mental  Disturbances  Associated  ziith  Acute  Articular  Rheumatism. — - 
A  comprehensive  report  of  the  mental  symptoms  in  two  cases  of  acute  rheu- 
matism with  marked  psychic  disturbance  of  the  nature  of  a  hallucinatory 
delirium  with  marked  episodes  of  fear  and  in  one  case  with  a  curious  idea 
that  he  had  been  dead  and  that  the  doctors  had  warmed  him  up  again.  The 
author  then  reviews  the  literature  of  the  subject  and  discusses  the  possible 
pathogenesis  of  these  cases  and  their  treatment. 

10.  The  Topographical  Distribution  of  Cortex  Lesions  and  Ano)nalics  in 
Dementia  Prcecox,  zvith  Some  Account  of  their  Functional  Significance. — 
Continued  article.     Will  be  abstracted  when  complete. 

11.  The  Psychical  Manifestations  of  Disease  of  the  Glands  of  Internal 
Secretion. — A  discussion  of  this  subject  as  presented  in  the  literature  with 
some  observations  of  the  author.     He  draws  the  following  conclusions  : 

I.  "  In  the  etiology  of  the  affective  psjxhoses  we  are  evidently  dealing 
with  a  biological  disturbance." 


384  PERISCOPE 

2.  "  The  glands  of  internal  secretion  phj-siologically  act  not  as  fnde- 
pendent  units,  but  on  the  contrary-  mutually  influence  functional  activity." 

3.  "  The  occurrence  of  insanity  at  puberty  and  adolescence  after  severe 
physical  and  mental  strain  and  at  the  time  of  the  menopause,  all  periods 
when  the  metabolic  changes  are  intense,  and  the  occurrence  in  syndromes 
unquestionabh-  the  result  of  disease  of  the  glands,  internal  secretion  of 
idioc\-.  imbecility,  depression,  mania  and  dementia  suggest  strongly  that  the 
true  etiology  of  the  affective  psychoses  lies  in  the  glands  of  internal  secretion." 

C.  L.  Allen  (Los  Angeles). 


Archiv  fiir  Psychiatric  und  Nervenkrankheiten 

(53  Band,   i   Heft) 

I.  Erj-thromelalgia.     M.\x   Schirm.\cher. 
11.  A  Clinical  and  Anatomical   Contribution   to  the  Diseases  of  the  Cen- 
tral Xervous  System.     Elsa  K.^uffm.xxx. 
III.  Enuresis  and  Occult  Spina  Bifida.     Scharnke. 
I\'.  The  Pathography  of  the  Julian-Claudian  Dynasty.     Friederich  Kann- 

GIESSER. 

\'.  On  the  Graphologic  Signs  of  Feeblemindedness.     Georg  Lomer. 
\'I.  Clinical  and  Pathologic-anatomical  Contribution  to  the  Study  of  Echi- 

nococcus  of  the  Cord  and  Cauda  Equina.     Public  Ciuffini. 
\'II.  Treatment  of  the  Aphasias.     Emil  Froschels. 
VIII.  Mental   Excitement  and   Inhibition   from  the   Standpoint  of   the  Jodl 
Psjchologj'.     Harry  M.^rcuse. 
IX.  The  Ps\-chopathology  of  Religious  Delusions.     Otto  Craemer. 
X.  Pupillary  Disturbances  in  Dementia  Praecox.     Frieda  Reichmann. 
XI.  Legal  Medicine  and  Homosexuality.     P.   Xacke. 

I.  Erythromelalgia.. — Schirmacher  reviews  on  the  basis  of  a  carefully 
studied  case  our  knowledge  of  erythromelalgia,  first  described  by  Weir 
Mitchell  in  1872.  Other  cases  reported  in  the  literature  are  also  cited.  It  is 
concluded  that,  in  spite  of  the  fact  that  in  all  cases  of  erjthromelalgia  vessel 
changes  of  the  nature  of  sclerosis  were  found,  a  causal  relation  between  this 
fact  and  the  phenomena  of  the  disease  should  not  forthwith  be  assumed. 
It  is.  on  the  whole,  probable  that  erythromelalgia  is  an  independent  disease, 
and  that  the  alterations  of  the  vessels  are  merely  a  chance  accompaniment. 
In  general,  nothing  has  been  determined  as  to  the  ultimate  cause  of  the 
affection,  but  the  s3'mptoms  are  of  such  a  character  that  it  seems  probable  the 
etiology  is  to  be  sought  in  disease  of  the  sympathetic  system.  The  view 
advanced  by  Cassirer  and  Senator,  that  erythromelalgia  is  due  to  paralysis 
of  the  vaso-constrictors  or  spasm  of  the  vaso-dilators,  is  somewhat  supported 
by  the  beneficial  effect  of  adrenalin  in  the  case  reported  by  the  author.  In 
one  case  carefully  studied,  postmortem,  certain  pathological  cells  were  found 
in  the  .sympathetic  ganglia  as  well  as  in  the  substance  of  the  adrenals, — a 
matter  perhaps  of  importance  but  demanding  further  confirmation. 

II.  Pernicious  .incmia. — Katiffmann  discusses  the  disturbances  in  the 
nervous  system  occurring  in  pernicious  anemia,  and  reviews  briefly  the  litera- 
ture on  this  subject.  She  describes  in  detail  a  case,  the  essential  features  of 
which  are  as  follows:  A  man  of  48.  with  clearly  defined  pernicious  anemia, 
low  hemoglobin,  greatly  reduced  red  cells,  and  symptoms  on  the  part  of  the 
nervous  .system  consisting  in  weakness  of  the  legs,  increase  of  the  knee  re- 
flexes, with  clonus  and  Babinski  phenomena,  together  with  a  marked  psy- 
chical disturbance,  the  autop,sy  showing  typical  lesions  in  the  organs,  with 
pronounced  degenerations  throughout  the  spinal  cord.     The  relation  of  the 


PERISCOPE  385 

alterations  in  the  nerve  tissue  and  in  the  blood  vessels  is  discussed,  with  the 
conclusion  that  presumably  both  are  due  to  a  common  cause.  A  description 
of  the  pathological  findings  is  given,  and  the  distribution  of  the  lesions.  Of 
particular  importance  is  the  fact  that  the  mental  disturbances  found  a  pos- 
sible explanation  in  certain  anatomical  changes  in  the  brain. 

III.  Enuresis  and  Spina  Bifida. — Scharnke  discusses  the  common^f  rec- 
ognized distinction  between  enuresis  and  incontinence  as  depending  in  the 
first  instance  upon  a  functional  disorder,  and  in  the  second,  upon  organic  dis- 
ease Little  light  has  been  thrown  upon  the  condition  known  as  enuresis, 
due  to  a  variety  of  purely  theoretical  hypotheses  which  have  from  time  to 
time  been  advanced  in  explanation.  The  object  of  the  paper  is  to  consider 
the  recently  advanced  theory  expressed  by  the  term  myelodysplasia,  on  the 
basis  of  a  collection  of  cases.  From  this  investigation  the  assumption  seems 
justified  that  the  enuresis  of  adults  is  due  to  a  cause  appearing  in  childhood 
but  not  developing  until  after  the  time  of  puberty,  namely,  the  so-called  mye- 
lodysplasia. The  whole  subject  of  enuresis  is  detailed  from  a  physiological 
standpoint,  and  the  various  theories  of  occurrence  described.  The  X-ray 
in  these  cases  shows  alterations  in  the  sacrum  and  the  symptomatology  indi- 
cates further  a  hypoplasia  or  dysplasia  in  the  lower  part  of  the  spinal  cord, 
and  possibh'  also  in  the  cauda  equina.  The  anatomical  proof  of  these  latter 
changes  is,  however,  as  yet  lacking.  In  general,  therefore,  it  appears  to  the 
author  that  enuresis  as  it  occurs  in  adults  is  due  to  an  occult  spina  bifida  in 
the  majority  of  cases  rather  than  to  the  ordinarily  recognized  functional 
disturbances. 

IV.  Julian-Claudian  Dynasty. — Kanngiesser  presents  a  learned  disserta- 
tion on  the  life  history  and  diseases  of  the  Julian-Claudian  dj-nastj^  which 
should  prove  of  interest  to  neurologists  and  psychiatrists,  and  in  general  to 
students  of  medical  history. 

V.  Graphology  and  Feeblemindedness. — Lomer  believes  that  the  subject 
of  handwriting  as  a  diagnostic  means  maj^  be  placed  on  a  more  scientific 
basis  than  has  hitherto  been  dorie.  As  a  criterion  of  mental  development  or 
defect,  handwriting  must  be  considered  of  first  importance.  A  study,  there- 
fore, of  its  characteristics  in  the  feebleminded  may  lead  to  conclusions  of 
importance.  The  paper  constitutes  a  profound  study  of  this  subject  and  may 
well  be  brought  to  the  attention  of  those  interested  in  the  determination  of 
objective  indications  of  mental  defect,  especially  in  patients  of  high  grade 
and  medium  tj^pes. 

VI.  Echinococcus  of  Cord  and  Cauda  Equina. — Ciuffini  draws  attention 
to  the  relative  infrequency  of  echinococcus  of  the  cord,  and  points  out  the 
difficult}^  of  making  a  correct  diagnosis,  not  only  on  account  of  this  fact,  but 
also  because  the  sj'mptoms  are  not  particularly  characteristic.  On  the  basis 
of  a  case  operated  upon  with  good  result,  in  which  the  echinococci  were  found 
in  the  cauda  equina  and  the  conus  terminalis,  the  entire  subject  is  discussed, 
together  with  its  differential  diagnosis,  with  the  inclusion  of  a  summary  of 
54  cases  described  in  the  literature.  The  paper  is  of  value  in  calling  attention 
to  an  unusual  condition  which  should  at  least  be  considered  in  otherwise 
inexplicable  disturbances  involving  the  cord  at  its  various  levels. 

VII.  Treatment  of  Aphasias. — Froschel's  attempts  to  outline  a  systematic 
treatment  of  aphasia  based  on  a  careful  classification  of  the  forms  in  which 
it  nia^'  occur.  For  this  purpose  he  divides  the  aphasias  into  the  following 
general  groups:  (i)  Pure;  word  deafness  or  subcortical  sensorj'  aphasia. 
(2)  Receptive  ;  deficiency  in  understanding  speech,  difficult}'  in  spontaneous 
speech,  and  in  repetition.  (3)  Expressive  cortical  sensory  aphasia :  under- 
standing of  speech,  defect  in  spontaneous  speech,  and  agraphia.  (4)  Trans- 
cortical sensory  aphasia ;  failure  in  the  understanding  of  speech,  with  re- 
tained capacity  to  repeat;  spontaneous  speech  defective.  (5)  Cortical  motor 
aphasia.     (6)   Subcortical  motor  aphasia. 


386  PERISCOPE 

\'III.  Jodl's  Psychology  and  Mental  Sii/us. — Marcuse  is  of  the  opinion 
that  the  psychology*  elaborated  by  Jodl,  although  hitherto  little  recognized  in 
psj'chiatry,  is  of  positive  value.  He  describes  in  some  detail  the  basis  of 
Jodl's  psychological  conceptions  under  three  different  types  of  mental  ac- 
tivity'; the  first  stage  constituting  those  psychical  reactions  which  occur  as 
the  immediate  result  of  stimuli;  a  second  stage  in  which  are  reproduced  in 
consciousness  the  effects  of  stimuli  previously  exerted  ;  and  the  third  stage, 
which  includes  abstract  thought  and  in  general  the  highest  psychological 
processes.  Jodl  conceives  the  whole  psychical  capacity  of  man  as  a  specific 
force  of  the  central  nervous  system,  which  in  its  higher  stages  is  determined 
by  the  morphological  constitution  of  the  organism.  The  conceptions  of  devel- 
opment and  energy  must  be  considered  as  the  essential  doctrines  of  his  psy- 
cholog>-.  W'ith  these  general  conclusions  as  a  basis,  Marcuse  discusses  the 
fundamental  psj-chiatrical  disturbances  and  expresses  the  belief  that  Jodl's 
theories  have  a  very  definite  practical  application  in  determining  diagnosis 
and  prognosis. 

IX.  Religious  Delusio>ts. — Craemer  traces  from  its  simple  Ijeginnings  the 
well  recognized  mental  disturbances  associated  with  the  religious  conscious- 
ness. The  paper  offers  a  systematic  discussion  of  the  method  by  which,  in 
predisposed  persons,  religious  conceptions  may  evolve  into  a  sj'stematized 
delusional  system. 

X.  Pupillary  Changes  in  Dementia  Prcccox. — Reichmann  calls  attention 
to  the  observation  made  by  Westphal,  in  1907,  concerning  striking  pupillary 
phenomena  occurring  in  a  patient  suffering  from  dementia  praecox.  To  this 
condition  he  gave  the  name  of  catatonic  pupillenstarri',  by  which  he  designated 
the  transient  loss  of  light  and  convergent  reaction  of  the  pupils,  which 
usually  go  hand  in  hand  with  changes  in  the  outline  of  the  pupils.  Following 
this  work,  many  observations  were  made  on  pupillarj'  changes  in  dementia 
prsecox,  with  the  general  result  that  a  temporary  loss  or  slowing  of  the  reac- 
tion was  observed  in  many  of  the  cases.  On  the  basis  of  this  work,  the 
opinion  was  expressed  that  dementia  praecox  must  be  regarded  as  an  organic 
disease.  Meyer's  work  followed,  showing  that  changes  in  pupillary  reaction 
up  to  complete  inactivity  might  be  induced  by  localized  abdominal  pressure. 
Stimulated  by  these  observations;  Reichmann  has  further  investigated  the 
subject,  with  the  object  of  determining  how  far  these  observations  were  acci- 
dental and  not  dependent  upon  the  existence  of  a  definite  mental  disease. 
She  concludes  that  the  statements  advanced  by  Westphal  cannot  be  unequivo- 
cally accepted,  and  that  a  definite  explanation  is  by  no  means  as  yet  deter- 
mined. It  appears,  however,  probable  as  a  working  hypothesis  that  there  is 
a  connection  between  certain  vasomotor  disturbances  and  disturbances  of  the 
iris  innervation,  which  may  well  form  the  basis  of  further  work  on  the  subject. 

XI.  Homosexuality  and  Legal  Medicine. — In  considering  the  relation  of 
legal  medicine  to  homosexuality,  Xacke  concludes  that  homosexuality  is 
usually  congenital  and  does  not  in  itself  indicate  either  degeneration  or  dis- 
ease ;  although  naturally  such  a  perversion  may  occur  in  persons  of  deficient 
mental  development,  it  by  no  means  follows  that  actual  degeneration  is  a  pre- 
requisite for  its  occurrence.  Such  degeneration  is  rather  the  exception  than 
the  rule. 

K.  W.  T.wi.oR. 


ISoolk  iRevtews 


DiAGXOSTiK  DER  Xervexkraxkheitex.  Voii  Prof.  Dr.  Alexander  Margulies 
in  Prag.  Erster  Band.  Allgemeiner  pathologischer  Teil.  S.  Karger, 
Berlin. 

This  little  volume  partakes  of  the  nature  of  a  small  semiology.  It  is  con- 
cise, authentic  for  the  most  part,  a  little  old-fashioned,  but  withal  an  excellent 
small  quiz  compend  sort  of  an  affair. 

Lehrbuch  DER  PSYCHiATRiscHEX^  DiAGXOSTiK.  Von  Privatdozcnt  Dr.  Adal- 
bert Gregor.     S.  Karger. 

This  new  claimant  for  favor  impresses  one  very  favorably.  The  author 
adopts  the  Heidelberg-IUenau  schemes,  patterned  largelj-  after  Kraepehn,  and 
gives  a  model  systematic  series  of  methods  of  case  examination. 

L'Aphasie.     Par  Dr.  H.  Bernheim.     Octave  Doris  et  Fils,  Paris. 

This  little  brochure  contains  Bernheim's  attitude  of  mind  towards  the 
aphasia  question  expressed  in  simple  and  concise  language.  There  exists  no 
cortical  center,  he  says,  which  conserves  the  memory  of  the  movements  nec- 
essary for  articulation  or  for  writing.  If  lesions  in  Broca's  or  Egner's  re- 
gions can  cause  aphasia  or  agraphia,  it  is  simply  because  the  fibers  going  from 
the  frontal  area,  where  internal  speech  is  formed,  have  their  communications 
with  the  bulbar  and  spinal  nuclei  broken.  This  is  the  author's  general  notion 
on  the  question. 

Die  akute  uxd  chroxische  ixfektiose  Osteomyelitis  des   Kixdesalters. 
Von  Dr.  Paul  Klemm.     S.  Karger,  Berlin. 
Osteomj-elitis  is  a  frequent  cause  for  neurological  complications  and  pit- 
falls.    The  author's  work  will  prove  of  value  in  recognizing  a  comparative!}^ 
rare  source  of  neurological  difficulties. 

Lehrbuch  der  allgemeixex  und  speziellen  Psychiatrie.  Von  Dr.  Erwin 
Stransky.     i.  Allgemeinen  Teil.     F.  C.  W.  Vogel,  Leipzig. 

In  general  we  are  not  in  sympathy  with  that  part  of  psychiatry  which  is 
called  general  ps5'chiatry.  We  do  not  see  much  use  in  discussing  large  gen- 
eralizations which  have  no  real  value  and  which  are  being  left  behind  in  the 
growth  of  science. 

General  discussions  of  etiology  are  of  no  more  value  in  psychiatry  than 
they  would  be  in  general  medicine.  They  have  misled  the  student  and  con- 
tinue to  foster  the  idea  of  a  single  psychosis,  called  insanity,  just  as  if  but 
one  affection  of  the  chest  existed  to  which  one  attached  a  diagnostic  label. 

The  tendenc}^  to  generalize  about  the  psjxhoses  has  resulted  in  great  harm 
and  has  been  a  form  of  mental  shackle  handed  down  from  time  immemorial. 
No  one  can  object  to  a  discussion  of  mental  phenomena  and  of  their  inter- 
pretation as  symptoms,  but  to  be  fed  up  with  pages  and  pages  of  general 
directions  of  how  to  treat  psychoses  becomes  wearisome. 

Stransky  falls  into  this  same  pitfall.  Imagine  anyone  writing  on  the 
general  pathology  of  lung  disease  at  the  present  time.  There  is  no  such 
thing  as  lung  disease  to  have  a  general  pathology.  Pneumonias  have  a  pathol- 
ogy. Carcinoma  of  the  lung  has  a  pathology,  but  what  common  general 
pathology  lies  at  the  base  of  these?     There  is  no  general  pathologj'  of  the 

387 


388  BOOK  REVIEWS 

psj'choses.  There  is  a  special  pathology'  for  paresis ;  a  fairl}-  definite  series 
of  changes  in  a  few  other  psychoses ;  there  is  no  known  pathological  basis 
for  others.  A  general  pathology  is  worthless.  It  is  worse.  It  is  directly 
misleading. 

Seen  from  the  older  point  of  view,  this  volume  of  Stransky's  is  excellent, 
but  from  the  attitude  of  mind  that  would  deal  with  the  psychoses  as  with  any 
other  region  in  medicine,  it  is  deplorable. 

Die  psvchologischex  Methodex  der  Ixtelligexzprufung  uxd  derex  An- 
WEXDUXG  AX  ScHULKixDERX.  \^on  William  Stern.  Johanii  Ambrosius 
Barth,  Leipzig.     Marks,  3. 

This  excellent  brochure  of  approximatelj^  100  pages  contains  an  enlarged 
and  amplified  discussion  of  the  general  subject  as  originally  presented  by  him 
at  the  Berlin  psjchological  congress. 

This  revision  and  amplification  has  taken  the  author  beyond  the  ordinary 
limits  of  a  "  Sammelbericht  "  in  that  he  has  included  criticisms  of  methods,  his 
own  trends,  and  particularly  his  understanding  of  advances  to  be  made  in  the 
testing  of  the  intelligence  of  children.  By  all  those  working  in  these  fields 
Stern's  paper  should  be  attentivel}^  studied. 

Igxatius  Loyola.     Vom  Erotiker  zum  Heiligen.     Eine  pathograpliische  Ge- 
schichtsstudie.      \'on  Dr.  med.  Georg  Lomer.     Joliann  Ambrosius,  Barth. 
Mk.  2.80. 
Lomer  has  here  made  an  extremely  fascinating  psjxho'.ogical  exposition 
of  the  life  and  character  of  Ignatius  Loj-ola,  the  founder  of  the  Jesuit  order. 
At  the  same  time  he  has  well  shown  the  great  sublimation  power  of  religious 
activities  and  the  religious  spirit.     In  some  ways  one  can  draw  striking  par- 
allels between  the  hysterical  youthful  stages  of  Loj-ala  and  Alary  Baker  Eddy, 
both   seeking   sensory  gratifications   through   their   hysterical   symptoms,   and 
the   later   m^'stical   developments   with    the    foundings   of   new   orders.     The 
development  in  Loyola's  case  is  well  sketched,  although  we  cannot  feel  that 
Lomcr's  point  of  view  is  clear,  nor  his  grasp  of  the  mechanisms  of  religious 
activities  adequate.     He  has  written  an  interesting  book,  but  missed  a  great 
opportunity. 

K'uxo  Fu  TzE,  A  Dramatic  Poe.m.  By  Paul  Carus.  The  Open  Court  Pub- 
lishing Co.,  London,  Chicago.     50  cents. 

It  requires  skill  and  more  than  a  superficial  knowledge  of  Cliinese  ethical 
thought,  as  well  as  of  Chinese  history  with  its  sharp  contrasts  between  the 
high  ideal  of  its  great  sage  and  the  avarice  and  bloodj^  tyranny  of  many  of 
its  rulers,  to  make  such  a  brief  drama  as  this  of  real  vital  interest.  But  this 
philosophy,  such  {ihascs  of  history,  Mr.  Carus  has  touched  with  just  the  skill 
that  presents  Confucius  in  very  human  form,  the  great  teacher  and  exemplar 
of  Chinese  ethics,  sustained  by  the  devotion  and  emulation  of  his  immediate 
followers,  his  pupils,  but  otherwise  disheartened  and  apparently  defeated 
because  of  the  corruption  and  worldliness  of  those  in  political  autliority. 
Perha[)S  the  form  of  the  drama  might  have  been  more  thoroughly  pervaded 
with  the  peculiarly  Chinese  mode  of  life,  but  the  true  spirit  of  Confucius's 
sincere  .and  finally  successful  endeavor  after  a  practical  code  of  right  living 
and  betterment  of  his  nation  is  shown  througlidut.  It  is  a  pleasing  picture 
out  of  the  remote  past. 

The  foreword  gives  a  kej-  to  the  understanding  of  the  movement  of  the 
drama  as  it  represents  the  i)criods  of  the  sage's  life  with  their  varying  success 
or  apparent  failure.  It  gives  also  in  a  brief  statement  of  the  main  points 
of  Chinese  j)hilosoi)hy  some  valuable  and  suggestive  hints  as  to  the  evolution 
of  this  thought   thruugli   early,  concrete  conceptions  of   fundamental   princi- 


BOOK  REVIEWS  389 

pies  and  processes,  conceptions  which  still  cling  to  the  higher  philosophical 
abstractions. 

Nature  and   Nurture  in    AIental  Development.     By  F.  W.   Mott,    M.D., 
F.R.S.,  F.R.C.P.     Published  by  Paul  B.  Hoeber,  New  York. 

This  book  contains  in  a  small  space  a  great  deal  of  important  fact  pre- 
sented in  exceedingly  interesting  form  and  of  practical  value  for  the  control 
of  inheritance  and  environmental  factors  pertaining  to  mental  life. 

It  reviews  the  structure  and  functioning  of  the  nervous  organism  in  man; 
by  comparison  of  the  normal  brain  with  that  in  which  the  higher  centers  are 
wanting  or  have  degenerated  it  shows  how  dependent  mental  activity  is  upon 
these  structures.  While  doing  this,  however,  the  author  never  confuses  the 
relative  importance  of  mind  and  its  instrument,  to  serve  as  which  he  clearly 
maintains  is  the  sole  function  and  distinction  of  the  brain.  His  aim  is  to  show 
the  influence  of  nature,  that  is  inheritance,  and  of  nurture,  prenatal  and  post- 
natal factors,  particularly  of  nutrition,  which  affect  the  body  in  its  relation 
to  the  brain  and  nervous  system,  upon  mental  conditions  and  character. 

He  has  emphasized  with  especial  clearness  several  important  considera- 
tions. He  speaks  understandingly  of  the  two  great  instincts  which  determine 
activity,  the  reproductive  or  racial  and  the  nutritive  or  self-preservative.  The 
sexual  glands  are  the  special  organ  of  the  former,  as  the  brain  is  of  the  latter 
instinct.  The  influence  upon  both  of  these  of  heredity  and  environment,  or 
nature  and  nurture,  are  discussed  in  view  of  his  practical  purpose.  Both  of 
these  organs  are  especially  protected  by  nature  against  injurious  effects,  but 
are  influenced  by  prolonged  action  of  certain  causes. 

This  is  discussed  in  the  simple,  clear  treatment  of  heredity.  Inherited 
tendencies  and  dispositions  occur  rather  than  directly  acquired  characteristics. 
There  are  causes  indirectly  affecting  the  germ  cells  and  so  modifj'ing  the 
inheritance,  accentuating  these  tendencies  or  limiting  resistance  in  the  off- 
spring and  actual  invasion  of  the  embryo  bj^  the  toxic  agent  as  in  syphilis. 

Of  interest  is  the  section  on  the  social  inheritance  of  the  individual,  in 
which  there  is  a  distinction  between  external  acquisitions  of  cultured  society 
and  the  development  of  the  potentiality  of  the  brain  which  would  be  pre- 
served to  the  individual  even  were  all  external  environment  suddenly  with- 
drawn. 

These  and  other  significant  topics  suggestively  treated  are  applied  defi- 
nitely to  social  questions  especially  the  life  of  the  child  and  make  the  book 
a  valuable  practical  guide  to  parents  and  teachers  and  other  social  workers. 

Jelliffe. 

The  Eight  Chapters  of  Maimonides  on  Ethics  (Shemonah  Perakim).     A 
Psychological    and    Ethical    Treatise.     Edited,    Annotated    and    Trans- 
lated with  an  Introduction.     By  Joseph  I.  Gorfinkle,  Ph.D.     Columbia 
University  Press,  New  York. 
A  bit  of  rare  treasure  of  wholly  delightful  reading  are  these  eight  chap- 
ters of  Maimonides,  the  eminently  practical  philosopher  and  physician  of  the 
twelfth  century,  one  of  the  number  of  Hebrews  living  under  Moslem  rule. 
Dr.    Gorfinkle   having   discovered   in   the   course   of   his    study   this   treasure 
marred  by  corruptions   occurring  as   the   original   work  has   passed  through 
frequent   manuscripts,    editions    and   translations,   decided   it   was   worth   his 
while  to  reconstruct  the  original  and  very  literal  Hebrew  translation  from  the 
Arabic,  in  which  Maimonides  wrote,  made  by  Samuel  ihn  Tibbon  under  the 
advice  and  with  the  high  esteem  of  the  author  himself.     This  volume  contains 
as  a  result  the  Hebrew  manuscript  and  a  translation  of  it  into  English,  together 
with  an  introduction  giving  a  brief  history  of  Maimonides's  life  and  ethical 
writings  with  an  outline  of  the  contents  of  the  Eight  Chapters. 

These  were  written  as  an  introduction  to  Maimonides's  larger  works  on 


390  BOOK  REVIEWS 

ethics,  which  subject  for  him  belongs  under  tlie  division  of  practical  philoso- 
phy. They  are  written  for  the  laity  and  are  therefore  made  very  simple  in 
statement,  avoiding  as  far  as  possible  philosophical  and  metaphysical  discus- 
sion. His  aim,  however,  as  in  his  larger  work,  is  to  harmonize  the  teachings 
of  the  philosophers  with  those  of  the  Talmud,  whose  authority  he  venerates. 

The  short  treatise  is  a  direct  and  practical  discussion  of  the  soul  and  its 
faculties;  to  which  of  these  faculties  belongs  man's  choice  of  virture  or  vice; 
the  health  of  the  soul,  which  depends  upon  cultivation  of  the  virtues  by  turn- 
ing toward  them  and  practising  them :  and  the  supreme  purpose  of  the  soul 
toward  which  all  must  tend,  namely,  the  obtaining  of  such  knowledge  of  God 
and  attaining  to  such  nearness  to  Him  as  is  possible. 

Under  the  rational  faculty  of  the  soul  belong  intellectual  virtues  and  vices. 
The  moral  ones  belong  to  the  appetitive  faculty,  which  here  includes  the  sen- 
sitive. The  nutritive  and  imaginative  faculties  have  no  part  in  voluntary 
activity  as  we  know  from  the  fact  that  they  work  while  we  sleep. 

Virtue  is  the  mean  between  two  extremes  which  as  excesses  constitute 
the  vices.  In  order  to  acquire  virtue  or  to  cure  his  soul,  has  a  man  deviated 
from  the  mean  of  virtue  it  is  necessary  for  him  to  turn  far  toward  the  oppo- 
site extreme  from  the  one  in  which  his  vice  lies  that  a  proper  median  adjust- 
ment shall  be  reached.  In  order  to  do  this  is  will  be  necessary  to  consult  the 
sages  just  as  one  physically  ill  applies  to  his  physician  for  enlightenment  and 
direction  in  regard  to  bodily  health.  In  accordance  with  this  principle  Mai- 
monides  places  the  saint,  that  is,  one  who  has  no  inclination  to  evil,  above 
the  one  who  only  by  severe  striving  has  overcome  evil  desires.  The  prophet 
still  higher  in  honor  than  the  saint  is  he  who  has  drawn  near  to  God.  to  whom 
the  barriers  between  him  and  God  have  become  few.  Moses  attained  the 
greatest  height,  but  one  partition,  that  of  the  material  flesh,  remaining. 

The  last  chapter  is  concerned  with  a  discussion  of  man's  free  will.  Mai- 
monides's  conviction  of  the  freedom  of  choice  is  firm,  but  he  must  reconcile 
with  his  assertion  the  teachings  of  Scripture  and  of  the  Rabbis  that  God  has 
made  it  impossible  at  times  for  man  to  choose  the  right.  God  has,  says  Mai- 
monides.  as  a  punishment  for  former  sins  taken  away  man's  power  of  choice, 
his  freedom  of  will.  The  subtle  sophistry  here,  which  meets  us  in  other 
places  as  well,  contains,  however,  deeper  truth  which  belongs  also  to  a  human- 
istic doctrine  of  free  will,  where  man  by  ill-doing  would  himself  curtail  or 
destroy  his  ability  to  choose.  Such  deeper  truth  outreaches  and  redeems  the 
rationalism  of  his  age  and  environment  which  the  author  seeks  to  defend. 

The  subtlety  of  his  thought  manifests  itself  at  the  close  of  this  last  chap- 
ter in  an  exalted  metaphysic  in  which  he  sets  forth  the  impossibility  of  attain- 
ing to  a  knowledge  of  God  or  the  understanding  of  His  essence,  for  this  is 
God,  His  knowledge,  His  essence,  all  His  attributes  are  God  and  not  com- 
prehensible by  human  knowledge. 

Maimonides's  vision  was  clear.  In  the  practical  simplicity  of  liis  etiiics 
he  shows  himself  an  advance  spirit  of  his  age.  His  adherence  to  tradition, 
both  of  philosophy  and  the  narrower  traditions  of  his  native  faith,  does  not 
obscure  the  truth  of  his  thought  nor  destroy  the  value  of  his  ethics.  The 
Eight  Chapters  are  well  worth  careful  reading.  Jelliffe. 

Goethe.  With  Si'Eci.al  Consider.vtion  of  His  Philosophy.  By  Paul  Cams. 
The*  Open  Court  Publishing  Company,  Chicago  and  London. 
There  is  rather  too  much  statistical  fact  compressed  in  the  first  part  of 
this  book.  The  details  of  Goethe's  life  with  his  relations  to  his  contempo- 
raries might  have  been  preserved  in  more  vital  manner.  Beside  this  the  pro- 
fusion of  illustration,  while  in  itself  highly  interesting  and  valuable,  detracts 
one's  attention  from  the  main  interest  of  the  book.  But  aside  from  these 
things  the  author  has  succeeded  in  his  aim  to  make  this  new  work  on  Goethe 
a  unique  presentation  of  him. 


BOOK  REVIEWS  391 

This"  is  not  a  biography  nor  a  criticism.  The  reader  is  made  acquainted 
with  Goethe  the  man,  not  so  much  as  he  lived  his  outer  life  but  rather  in  the 
developing  and  creating  soul  which  manifested  itself  throughout  his  works. 
Mr.  Carus  lets  Goethe  speak  for  himself  by  introducing  extracts  from  his 
biography  and  quoting  largely  from  his  poetry. 

His  life  was  more  free  from  external  care  than  that  of  many  writers,  but 
his  greatness  of  soul  led  him  to  a  knowledge  of  truth  through  larger  expe- 
riences of  the  inner  life,  so  that  all  his  work  is  largely  biographical,  a  record 
of  truth  won  through  personal  experience. 

His  objectivity  was  a  cause  of  his  success  and  an  index  of  his  healthy 
state  of  mind  and  attitude  toward  the  world,  although  his  earlier  works  reveal 
a  somewhat  morbid  period. 

His  philosophy  is  the  expression  of  a  poet,  hence  it  was  not  a  formulated, 
definitely  ordered  system.  He  was  impatient  of  the  narrow  literalness  of  his 
contemporaries  and  yet  had  no  sympathy  either  with  that  criticism  which  tore 
asunder  long  reverenced  traditions,  whether  in  religion  or  in  literature.  He 
revered  the  Christianity  in  which  he  had  been  reared  even  while  unable  to 
accept  its  narrower  tenets.  His  religious  inclinations  were  tinged  with  mysti- 
cism, tended  toward  ancient  polytheism  and  showed  also  a  curious  leaning 
toward  the  Roman  Catholic  ritual  and  organization. 

Influencing  his  science  as  his  philosophy,  his  poetry  prevents  a  truly  sci- 
entific representation  of  nature.  Still  here  he  did  important  work  and  ahead 
of  his  generation  accepted  the  doctrine  of  evolution  and  contributed  signally 
to  its  acceptance. 

The  selections  which  Mr.  Carus  has  given  are  those  which  manifest  the 
variety  of  Goethe's  stjde  and  the  range  of  his  interest  and  thought.  There 
are  delicate  verses  like  the  little  night  song  written  upon  the  wall  of  a  hunter's 
hut,  poems  also  that  describe,  though  somewhat  heavily,  what  nature  meant 
to  him  and  those  which  give  noble  expression  to  religious  aspiration  and 
conviction.  There  are,  moreover,  manj^  illustrations  of  his  ready  humor  and 
epigrammatic  wisdom. 

The  selections  made  from  Faust  and  the  discussion  accompanying  these 
bring  out  well  the  relation  of  the  masterpiece  to  Goethe's  own  life  and  phi- 
losophy. It  was  the  work  of  his  entire  life  and  in  Faust  are  embodied  the 
poet's  own  fearlessness  and  independence  of  mind,  willing  to  accept  both  the 
pleasure  and  pain  if  only  he  may  live  in  the  fullest  sense  a  man  and  achieve 
for  the  world  something  beyond  that  already  possessed.  When  Faust  has 
erred,  "  has  destroyed  his  old  ideals,  he  feels  in  himself  the  power  to  build 
them  up  again,"  and  in  this  lies  his  soul's  final  salvation.  It  is  here  that  is 
found  the  message  of  Goethe's  life,  expressed  through  Faust,  true  satisfac- 
tion and  happiness  in  the  higher  realm  of  endeavor  and  lasting  achievement 
of  service  to  mankind. 

It  is  this  which  Mr.  Carus  finds  and  gives  us  in  the  consideration  of 
Goethe's  life  in  the  light  of  his  philosophy,  the  poet  and  the  man  who  realizes 
this  greater  truth  in  aspiration  and  accomplishment  through  his  own  crea- 
tive power. 

Der  Alptraum.     Zu  seiner  Beziehung  zu  gewissen  Formen  das  mittelalter- 

lichens  Aberglaubens.     Von  Prof.  Ernest  Jones.     Deutsch  von  Dr.  E. 

H.  Sachs.     Deuticke,  Leipzig  v.  Wien. 

This  is  the  fourteenth  volume  of  the  Schriften  zur  angewandten  Seelen- 

kunde,  edited  by  Prof.  Freud.     Dr.  Jones's  study  on  the  nightmare  is  known 

to  our  readers.     We  call  attention  to  the  fact  that  it  has  been  translated  into 

German  as  one  of  this  most  interesting  series,  three  of  which,  Wishfulfillment 

and  Symbolism  in  Fairy  Tales,  Dreams  and  Myths,  The  Myth  of  tlie  Birth 

,of  the  Hero,   have  been   translated   into   English   and  have  appeared   in   the 

Nervous  and  Mental  Disease  Monograph  Series. 


1Rotc6  ant)  IFlcws 


ALIENISTS  AND  NEUROLOGISTS 

The  Chicago  Medical  Society  announces  the  fifth  annual  meeting  of 
Alienists  and  Neurologists  of  the  United  States,  to  be  held  under  the  auspices 
of  the  Chicago  Medical  Societ}-,  June  19  to  23,  1916,  at  La  Salle  Hotel. 

We  wish  to  invite  you  to  attend  these  meetings  and  participate  by  paper 
or  take  part  in  the  discussion  of  the  various  subjects  and  otlier  matters  that 
may  come  before  the  conference.  We  hope  to  enlist  your  valuable  assistance 
in  a  campaign  of  education  of  physicians  and  the  public  as  to  the  causative 
forces  of  mental  deficiency  and  will  appreciate  j'our  assistance.  As  physi- 
cians and  the  public  have  taken  great  interest  in  these  meetings  the  Chicago 
Medical  Society,  even  though  at  great  expense,  has  decided  to  continue  these 
annually  without  expense  to  others. 

Resolutions  were  passed  at  the  meeting  in  1915  requesting  the  governors 
of  the  various  states  to  appoint  committees  to  investigate  the  causative  forces 
of  feeblemindedness. 

Reports  of  these  committees  will  be  made  at  the  meeting  in  1916.  The 
reports  of  the  general  committee  will  be  forwarded  to  the  governors  of  each 
state.  Resolutions  will  be  formulated  bj'  the  conference  that  will  be  in- 
structive to  legislatures,  to  the  end  that  reasonable  laws  may  be  passed  that 
will  in  a  measure  at  least  be  preventive  of  mental  deficiencj'. 

The  governors  and  boards  of  administration  or  control  are  taking  great 
interest  in  these  meetings  and  giving  us  valuable  assistance  to  carry  forward 
this  movement.  We  hope  also  to  interest  the  editors  of  the  various  medical 
journals  in  this  movement  and  through  them  enlist  the  help  of  physicians. 
If  a  campaign  of  education  were  made  against  the  causative  forces  of  mental 
defectiveness  as  there  is  against  tuberculosis,  a  wonderful  amount  of  good 
would  result.  This  subject  should  interest  us,  first,  from  a  humanitarian 
standpoint;  second,  from  an  economic  standpoint.  The  judges  of  our  courts 
are  acquainting  themselves  with  mental  diseases;  they  give  us  the  information 
that  a  large  per  cent,  of  crime  is  committed  by  mental  defectives  and  a  large 
percentage  of  the  prisoners  in  our  penal  institutions  are  also  defectives  and 
should  not  have  been  confined  to  prisons  of  this  kind,  but  sent  to  farm  colo- 
nies or  other  reformatory  institutions  with  proper  environment.  In  our  state 
asylums  there  are  many  cases  of  insanitj'  wiiich  if  they  iiad  been  diagnosed 
early  could  have  been  cured.  This  is  especially  the  case  as  regards  dementia 
precox  and  lues.  The  state  would  not  have  been  burdened  with  tiie  im- 
mense expense  of  their  long  confinement  and  their  families  would  Iiave  been 
relieved  of  the  humiliation  of  their  commitment. 

There  has  been  no  branch  of  medicine  so  neglected  as  the  stufly  of  mental 
diseases  and  psychology. 

There  should  be  a  great  reform  in  this  respect  witliin  the  near  future. 

W.  T.  Mkfford, 
Secretary  of  Conference, 

2159  Madison  Street. 

Wm.  O.  Krohn,  Chairman, 
20  F..-ist  M;iflisoii   .Street. 


392 


VOL.    43.  MAY,  1916.  No.  5. 

The  Journal 

OF 

Nervous  and  Mental  Disease 

An  American  Monthly  Journal  of  Neurology  and  Psychiatry,  Founded  in  1874 


©rigtnal  Hrticles 


TABES  DORSALIS.     A  PATHOLOGICAL  AND  CLINICAL 
STUDY  OF  250  CASES^ 

By  Baldwin  Lucke,  M.D. 

(From  the  McMancs  Laboratory  of  Pathology,  University  of  Pennsylvania, 
and  the  Nervous  Wards  of  the  Philadelphia  General  Hospital) 

The  purpose  of  this  paper  is  to  analyze  the  symptoms  and  patho- 
logical findings  of  250  cases  of  tabes  dorsalis,  and  to  compare  the 
results  with  similar  statistics.  All  of  the  patients  have  been  inmates 
of  the  Philadelphia  General  Hospital  at  some  time  during  the  past 
ten  years.  Only  those  cases  which  have  been  thoroughly  studied  by 
members  of  the  neurological  staff  have  been  utiHzed,  hence  only 
250  cases  have  been  selected  from  a  much  larger  material. 

"  Selected  "  is  not  used  in  the  sense  that  special  cases  have  been 
picked  out,  but  merely  that  incomplete  or  insufficient  records  have 
not  been  made  use  of.  Even  with  such  precautions  against  errors 
of  all  sorts,  it  must  be  borne  in  mind  that  in  the  class  we  deal  with 
the  patients  possess  but  limited  intelligence  and  can  often  not  be 
made  to  realize  the  importance  of  exercising  their  memory,  or  telling 
the  truth. 

Not  unmindful  of  the  above,  I  yet  believe  that  a  study  of  a 
large  number  of  tabetics  may  prove  of  some  slight  value,  especially 
since  it  has  been  stated  by  Nonne  and  confirmed  by  others  that  the 
type  of  tabes  is  changing  to  one  of  less  severity. 

^  Read  by  invitation  before  the  Philadelphia  Neurological  Societ\',  No- 
vember, 1915. 

393 


394  B.lLDiriX  LUCKE 

This  paper  then  is  to  serve  as  a  record  of  the  type  of  locomotor 
ataxia  as  it  exists  at  present  amongst  the  poorer  class  in  America. 

The  Philadelphia  General  Hospital  is  a  charitable  institution. 
Most  persons  of  this  series  are  laborers,  or  have  no  regular  occupa- 
tion. !Most  have  lived  a  rather  stormy  life,  and  have  committed  all 
sorts  of  excesses  in  their  pretabetic  existence ;  this  I  mention  because 
of  the  belief  that  tabes  differs  somewhat  in  dift'erent  walks  of  life. 
All  the  statistics  are'  based,  unless  otherwise  stated,  on  250  cases. 
207  or  82.8  per  cent,  are  white  males.  29  or  1 1.6  per  cent,  are  white 
females.  13  or  5.2  per  cent,  are  black  males,  i  or  0.4  per  cent,  is 
a  negress.  The  ratio  between  males  and  females  is  therefore 
8.5:1.0. 

I  have  been  able  to  find  but  three  other  American  statistics  on 
tabes,  namely,  Thomas'  (1889),  Bonar's  (1901),  Collins'  (1903). 

Thomas  (in  cases)  gives  the  proportion  as  7:1,  Bonar  (286 
cases)  as  6.5:1,  and  Collins  (140  cases)  as  7.5:1.  European 
writers  give  widely  variable  proportions,  ranging  from  i  :  i  (Leon- 
hard)  to  27:  I  (Fulton). 

These  variations  are  probably  due  to  lack  of  homogeneity  of 
material ;  some  statistics  coming  from  private,  some  from  dis- 
pensary and  others  from  hospital  practice. 

Mendel  and  Tobias  have  recently  calculated  the  mean  ratio  of 
forty  European  reports,  and  find  the  average  proportion  to  be  7.5 :  i. 

Bonar  determined  the  relative  frequency  of  tabes  amongst 
patients  suffering  with  nervous  diseases  (Starr's  clinic,  Columbia 
University).  He  found  that  of  11,271  male  cases  2.147  P^''  cent. 
were  tabetics,  while  of  11,563  females  only  0.35  per  cent,  suffered 
with  tabes.     The  patients  were  ambulatory  cases. 

In  our  institution  among  4,322  inmates  of  the  men's  nervous 
wards,  there  were  355  cases  of  tabes,  or  8.21  per  cent.,  and  among 
2,056  female  nervous  patients  91  tabetics  or  4.42  per  cent.  (This 
calculation  was  made  for  the  years  1906,  1907,  1910-1913  incl.) 

In  other  words,  i  of  every  12.46  male  and  i  of  every  22.60 
female  [patients  in  the  nervous  wards  were  tabetics.  (This  ratio  is 
founfl  \MA  to  be  constant.) 

Mendel  and  Tobias,  who  have  given  special  attention  to  tabes 
in  women,  attribute  the  f^rcponderance  of  male  tabetics  to  the 
greater  frequency  with  which  syphilis  occurs  in  the  male  sex.  In 
supi)ort  of  this  statement  I  give  the  following  data  from  the  records 
of  the  venereal  wards  of  this  institution.  During  six  years  (V.  S.) 
there  were  1,621  cases  of  lues  in  the  men's  and  559  in  the  women's 
wards;  that  is  about  three  times  (290)  as  many  men  as  women 
suffered  with  syphilis. 


TABES  DORSALIS  395 

As  to  the  etiolog}'  of  tabes  there  is  at  present,  I  believe,  no 
doubt  in  any  one's  mind  that  Moebius's  dictum  "  Omnis  tabes  e  lue  " 
is  correct.  However  it  will  be  well  nigh  impossible  to  get  lOO  per 
cent,  of  the  patients  to  admit  luetic  infection.  Denial  of  syphilis 
may  be  attributed  to  direct  misstatements  for  reasons  of  shame,  etc., 
or  to  lack  of  memory,  or  to  the  fact  that  in  a  great  many  cases  the 
primary  or  secondary  lesions  are  so  slight  as  not  to  be  noticed  by 
people  who  by  nature  are  not  observant. 

Of  our  cases  only  141  or  56.4  per  cent,  admitted  lues.  In  46 
cases  it  w-as  noted  whether  secondary  eruptions  followed  the  chancre. 
28  patients  or  60.8  per  cent,  disclaimed  secondary  lesions.  Collins 
states  that  in  85  tabetic  patients  who  admitted  syphilis  fully  80  had 
but  a  slight  infection.  He  states :  "  In  many  of  the  cases  in  which 
a  history  of  syphilis  w^as  made  out  the  patient  maintained  that  the 
initial  lesion  was  very  slight — a  pimple  or  a  slight  abrasion,  and  the 
rash,  which  was  scarcely  noticeable,  lasted  only  a  few  days  or  a 
week  or  so."  Similar  observations  are  reported  elsewhere ;  I  feel 
that  this  is  significant,  especially  since  Rosenow's  recent  work  on 
selective  action  of  various  strains  of  streptococci  and  microorgan- 
isms. In  view  of  the  fact  that  but  slight  primary,  slight  and  rapidly 
fading  secondary,  and  seldom  if  ever  tertiary  lesions  of  lues  occur 
in  tabes  I  am  inclined  to  believe  that  more  than  one  strain  of 
the  Treponema  pallidum  exists,  and  that  tabes  is  caused  by  a  strain 
of  this  microparasite  which  has  a  special  selective  affinity  for  the 
central  nerve  axis.  In  support  of  this  theory  I  wish  to  call  atten- 
tion to  the  comparative  rarity  of  locomotor  ataxia  amongst  certain 
races. 

In  1892  Burr  failed  to  find  a  single  case  of  tabes  in  a  full-blooded 
negro.  Lloyd  in  1893,  in  a  footnote  appended  to  a  report  of  a  case 
of  tabes  in  a  negress  occurring  in  this  institution,  states :  "  It  has 
been  claimed  that  locomotor  ataxia  is  rare,  even  unknown  in  the 
negro  race.  Its  occurrence  has  certainly  been  rare  in  Blockley,  for 
the  above  case  is  the  only  one  seen  there  during  recent  years." 

In  our  series  we  have  13  negroes  and  i  negress;  whether  these 
are  full-blooded  Africans  or  whether  admixture  of  Caucasian  blood 
existed  in  some  or  all  I  am  unable  to  state.  In  Collins's  series  of 
140  cases  there  were  4  negroes,  and  i  negress ;  in  Thomas's  series  of 
III  cases  5  negroes.  Therefore  tabetic  colored  patients  made  up 
about  5  per  cent,  of  each  series.  The  explanation  for  this  rarity  of 
locomotor  ataxia  in  a  notoriously  syphilisrsoaked  race  might  well 
be  along  the  lines  of  the  various  strains  of  treponema  theorv  ad- 
vanced  above.     Syphilis   manifests   itself   in   many    forms;   it  like 


396  BALDWIX  LUCRE 

uremia  and  hysteria  will  mock  most  any  disease.  May  it  not  be  that 
the  African  negro  possesses  a  relative  natural  immunity  against 
that  strain  of  the  treponema  which  presumably  causes  tabes,  and 
may  not  this  barrier  of  immunity  be  gradually  broken  by  increasing 
admixture  of  white  blood  ? 

What  holds  true  of  the  African  applies  to  the  Chinese  as  well. 
While  there  is  no  case  of  tabes  in  a  Chinese  in  this  series,  there  has 
been  at  least  one  case  of  this  sort  in  the  Philadelphia  Hospital  (re- 
ported in  P.  G.  H.  reports  by  W'.  B.  Irish  from  the  service  of  Dr. 
Lloyd).  Collins  also  reports  a  case  in  his  series.  Jeffery  and 
Maxwell  in  their  book,  "  Diseases  of  China,"  state :  "  Syphilis  is  one 
of  the  most  common  diseases  of  China,  and  as  we  have  already 
stated,  transverse  myelitis  of  almost  certain  syphilitic  origin  is  rela- 
tively common.  W'e  therefore  find  it  difficult  to  account  for  the 
absence,  we  believe  the  total  absence,  of  true  locomotor  ataxia. 
Among  some  twelve  thousands  in-patients  and  more  than  four  times 
that  number  of  out-patients  seen  by  us  in  Formosa,  we  have  not  yet 
come  across  a  single  case  which  in  any  way  could  be  mistaken  for 
tabes  dorsalis,  and  the  same  is  the  experience  of  our  colleague  in 
Shanghai ;  nor  do  we  know  of  any  well-authenticated  case  reported 
from  China. 

"  As  we  have  already  said  the  absence  of  the  disease  is  quite  a 
mystery  to  us."  Another  point  in  the  substantiation  of  my  theory 
I  find  in  Frambesia  tropica  (yaws),  a  tropical  disease  resembHng 
clinically  syphilis,  and  caused  by  the  Treponema  pertenue,  an  organ- 
ism so  closely  allied  to  Treponema  pallidum  that  it  cannot  be  differ- 
entiated from  the  same.  Its  course  is  characterized  by  the  mildness 
of  symptoms  and  by  the  absence  of  affection  of  the  nervous  system. 

It  is  especially  difficult  to  obtain  luetic  history  in  women.  Men- 
del and  Tobias  from  the  literature  and  their  own  oliservations 
estimated  that  only  59.3  per  cent,  of  females  admit  luetic  anamnesis. 
Tabes  occurs  now  and  then  in  virgins.  In  the  cases  of  Mendel  and 
Tobias  these  authors  were  always  able  to  trace  the  disease  to  either 
congenital  or  extragenital  syjjhilis  so  that  they  add  to  the  above 
quoted  saying  of  Mocbius  "  \'irgo  non  fit  tabetica  nisi  per  parentes 
aut  per  luem  insontium." 

Since  the  Philacleljjhia  General  Hospital  is  the  only  institution 
in  the  City  which  admits  as  inmates  any  considerable  number  of 
patients  suffering  with  lues  or  tabes,  I  have  compared  the  number 
of  luetic  and  tabetic  patients  in  the  institution  for  six  years  (V.  S.). 
This  was  done  in  the  hope  of  throwing  some  light  on  the  ratio  in 
which  these  diseases  exist.     During  the  period  stated  1,621  cases  of 


TABES  DORSALIS 


397 


lues  occurred  in  the  men's  venereal  and  355  cases  of  tabes  in  the 
men's  nervous  wards ;  giving  a  ratio  of  4.76 :  i  or  20.96  per  cent. 

In  the  female  venereal  wards  there  were  559  cases  of  lues  and 
91  female  tabes  occurring  at  the  same  time ;  giving  a  ratio  of 
6.25 : 1  or  16  per  cent.  I  do  not  wish  to  state  that  20  per  cent,  of 
male  and  16  per  cent,  of  female  syphilitic  patients  suffer  from  that 
form  of  lues  which  eventually  causes  tabes ;  but  these  figures  show 

TABLE  I 


to  <  < 

Ol  I  til 

LU 

< 

0 

10 

0- 

5-9 

17 

10-14 

29 

15-19 

22 

20-24 

18 

25-29 

8 

30-34 

6 

35-39 

1 

40-45 

1 

1— 
-z. 

LU 

u 

UJ 

D. 

"^  <  r5 

UJ  X  ^ 

z 

UJ 

UJ  o\ 

5   1 

^_  in 

UJ 

m 

T 
0 

0 

T 

1 
0 

1 

■!i- 

1 

0 

1 

1 
0 

2e.i 

25 

A 

24 

/\ 

23 

/  \ 

22 

/  ^ 

21 

/ 

V 

20 

\ 

19 

/ 

\ 

* 

18 

/ 

v 

17 

/ 

^ 

\ 

16.2 

/ 

\ 

15.3 

/ 

\ 

14 

/ 

\ 

13 

/ 

\ 

12    ' 

/ 

\ 

11 

1 

' 

10 

/ 

9 

/ 

8.1 

/ 

7.2 

6 

5.4 

\ 

4 

\ 

3 

\ 

2 

k 

1 

\ 

0.9 

U 

, 

Incubation  period  of  tabes. 

that  syphilis  in  any  form  occurs  more  frequently  in  men  than  in 
women,  further  than  this  they  may  or  may  not  possess  some  value 
in  showing  a  possible  proportion  between  these  diseases. 

I  purposely  have  omitted  data  concerning  other  so-called  etio- 
logical factors,  as  trauma,  alcoholism,  sexual  excesses,  exposure  to 
cold,  etc.  One  or  all  of  these,  if  searched  for,  may  be  found  in 
practically  any  one  of  our  patients.     While  any  of  these  conditions 


398  BALDiriX  LUCKE 

may  act  as  adjuvant  to  lues,  may  even  perhaps  hasten  the  occur- 
rences of  tabes,  they  are  certainly  not  the  cause  of  the  disease. 

The  importance  which  they  are  given  in  some  writings  is  a  relic 
of  the  days  when  nothing  at  all  was  known  concerning  the  etiology 
of  locomotor  ataxia. 

lucuhation  period  of  tabes:  This  is  calculated  from  the  state- 
ments of  III  persons  who  admitted  chancre  and  stated  how  many 
years  thereafter  tabetic  symptoms  made  their  appearance.  Here 
again  the  calculation  depends  upon  the  truthfulness  and  the  memorv 
of  the  patient,  and  since  the  subjective  symptoms  of  the  beginning 
of  tabes  are  often  slight,  our  figures  must  be  taken  as  the  minimum 
average.  It  was  found  that  15.34  years  was  the  average  period 
which  elapsed  between  primary  sore  and  beginning  tabetic  symptoms. 
Table  I  shows  graphically  the  result  of  this  investigation. 

The  incubation  period  ranges  from  three  years  to  forty-five  (i 
case),  with  the  maximum  percentage  between  10-14  years. 

In  Frey's  recent  paper  on  850  cases  of  tabes  he  also  found  this 
period  as  containing  the  highest  percentage. 

The  extremes  reported  in  the  literature  are : 

Frej-,  I  case  with  incubation  period  of  6  weeks. 

Frey,  l  case  with  incubation  period  of  2  months. 

Bliimel,  i  case  with  incubation  period  of  i  year. 

Bonar,  10  per  cent,  of  his  cases  with  incubation  period  of  less  tlian  i  year. 

Schafifer,  i  case  witli  incubation  period  of  1^2  years. 

Kron,  I  case  with  incubation  period  of  2  years. 

Thomas,  2  cases  with  incubation  period  of  30  to  40  years. 

Bonar,  i  case  after  40  years. 

Raymond,  i  case  after  45  years. 

Chiray-Cornelius,  I  case  after  50  years. 

Schiiller,  i  case  after  50  years. 

I  have  data  on  but  three  women  here ;  the  average  incubation 
period  was  5.33  years.  Mendel  and  Tobias  report  47  cases  of 
women  where  the  incubation  period  could  be  exactly  determined. 
It  ranged  from  three  to  thirty  years,  with  an  average  of  14.25  years. 

The  average  incubation  period  for  negroes  in  our  series  was 
24.83  years,  in  6  cases,  being  therefore  longer  than  the  average. 

I  do  not  possess  sufficiently  exact  data  to  state  the  bearing  which 
antisyphilitic  treatment  has  on  the  incubation  ])eriod  of  tabes. 

Very  few  patients  took,  as  far  as  could  be  ascertained,  treat- 
ment. •  When  treatment  was  taken  it  was  seldom  kept  u\)  longer 
than  three  months.  However  even  so  the  incubation  period  in  these 
cases  averaged  13  years,  or  about  2  years  less  than  the  average. 
According  to  figures  of  luilenburg^  Drubler,  Schuster,  Mendel  and 
Tobias,  etc..  thorough  antisyjjhilitic  trcatiiKiit  reduced  the  incuba- 


TABES  DORSALIS 


399 


tion  period  to  one  half  the  average  of  their  nontreated  cases,  that 
is  to  say  from  5  to  8  years  against  12  to  16  years.  Even  in  in- 
sufficiently treated  cases  the  incubation  period  was  shortened.  All 
this  refers  of  course  to  Hg  treatment. 

The  explanation  of  this  phenomenon  may  be  that  Hg,  as  has 
often  been  stated,  seldom  really  cures  syphilis,  and  the  treponeraa 
may  be  stimulated  to  greater  activity  by  the  drug.  So  much  for  the 
etiology  of  tabes. 

TABLE  II 


20-24 
25-29 
30-34 
35-39 
40-44 
45-49 
50-54 
5  -59 
60-64 
65-70 


U.  U3 

0  ul 

.  U3 

o< 
zo 

h- 
z 

LU 
U 

cr 

lU 
Q. 

z 

UJ  S 

5  1 

1-  0 

UJ  '^ 

I 

\ 
0 

0 

1 

■J- 

0 

CT. 

i 
0 

0 

1 

2 

23.7 

15 

22 

^ 

23 

21 

/\ 

53 

20 

/ 

\ 

41 

19 

/ 

\ 

40 

18.4 

/ 

\^ 

25 

18.2 

/ 

^ 

■^^ 

15 

17 

' 

\ 

7 

16 

\ 

\ 

2 

15 

\ 

\ 

14 

\ 

> 

L 

13 

\ 

\ 

12 

\ 

\ 

11.2 

\ 

\ 

10.3 

\ 

9 

/ 

\ 

8 

/ 

/ 

\ 

6.7 

/ 

\ 

5 

\ 

4 

^ 

V 

3.2 

1 

\ 

2 

/ 

\, 

1 

/ 

\ 

\ 

0.9 

/ 

\ 

Age  incident  of  tabes. 


The  average  age  at  which  subjective  symptoms  made  their  ap- 
pearance is  difficult  to  determine,  since  patients  will  only  seek  treat- 
ment when  their  symptoms  are  troublesome;  there  is  no  age  how- 
ever in  which  tabes  may  not  occur;  in  our  cases  it  varied  froin 
23  to  65  years.  With  the  average  of  42.34  years,  the  highest  per- 
centage of  cases  occurred  between  35  and  39  years,  as  shown  in 
Table  II. 

The  table  graphically  represents  the  age  incident.  The  average 
age  for  women   (27  cases)   is  40.96  years.     The  average  age   for 


400  BALDWIX  LUCKE 

negroes  48.28  years.  In  America  Bonar  finds  the  average  age  for 
tabes  (sex  not  stated)  to  be  between  30  and '40  years  (40.16  per 
cent,  of  his  cases). 

Thomas  finds  38  per  cent,  of  his  cases  to  be  between  30  and  40 
years  and  40  per  cent,  between  40  and  50  years. 

Collins  gives  38.5  years  as  the  favorite  age  period. 

In  Europe  Frey  finds  the  favorite  age  period  for  man  to  be 
between  30  and  40  years. 

Kron,  Mendel  and  Tobias,  etc..  give  similar  figures.  In  short 
tabes  in  men  usually  begins  in  a  little  earlier  period  of  life.  This, 
I  believe,  may  readily  be  explained  by  the  fact  that  men  enter 
sexual  life  at  an  earlier  age  than  women,  and  consequently  are  ex- 
posed to  luetic  infection  sooner  than  the  opposite  sex. 

In  our  series  we  have  no  cases  of  so-called  juvenile  tabes.  A 
considerable  number  may  however  be  found  in  literature. 

Tabes  developing  after  the  sixtieth  year  does  not  appear  to  be 
uncommon ;  Mendel  and  Tobias  report  3 ;  Long  and  Cramer  4 ; 
Thomas  i  such  case.  The  various  points  of  the  age  incident  are 
summed  up  in  the  following  table.  The  first  column  gives  the 
averages  of  the  entire  series ;  the  second  of  women  ;  the  third  of 
negroes.  The  figures  in  parenthesis  are  the  number  of  cases  used 
for  the  calculation. 

TABLE  III 

( ieneral  Women  Negroes 

Average  age  at  which  chancre  appeared  25.31  yrs.  22.25  yrs.  26.5    yrs. 

(121)  (4)  (6) 
Average    age    at    which    symptoms    ap- 
peared      42.34  yrs.  40.96  yrs.  48.28  yrs. 

(250)  {27)  (14) 

Average  incubation  period   15.34  yrs.  5-33  yrs.  24.83  yrs. 

(Ill)  (4)  (6) 
Average  age  at   which   patient  came   to 

the   hospital    4763  yrs.  4548  yrs.  5107  yrs. 

(250)  (29)  (14) 

The  averages  for  women  and  for  negroes  are  estimated  on  too 
small  a  material  to  be  of  much  value. 

Symptomatology ;  symptoms  in  their  chronological  order:  The 
first  column  of  the  table  contains  the  initial  symptoms  in  order  of 
their  frequency;  the  second  and  third  columns  the  [)crcentage  with 
which  these  .symptoms  occurred  as  a  second  or  third  symptom;  the 
fourth  column  the  percentage  of  the  symptoms  when  they  occurred 
at  a  later  period  in  the  course  of  the  disease;  the  fifth  column  the 
sum-total  of  their  occurrence.     For  example,  a  symptom  listed  in 


TABES  DORSALIS 


401 


the  third  column  is  one  which  was  preceded  by  two  other  symptoms. 
Here  again  we  are  dependent  upon  the  patient's  memory.  Some- 
times certain  symptoms  will  appear  at  the  same  time,  and  some- 
times a  long  period  will  elapse  between  symptoms,  while  in  other 
cases  they  follow  'each  other  in  more  rapid  succession.  Unfortu- 
nately I  have  not  been  able  to  satisfactorily  ascertain  the  period 
between  the  symptoms ;  unless  one  deals  with  people  with  more 
than  ordinary  intelligence  this  is  well  nigh  impossible,  unless  ac- 
curacy is  greatly  sacrificed.  The  figures  in  parenthesis  preceding 
the  percentages  in  the  diiiferent  columns  denote  the  number  of  times 
in  which  this  or  that  symptom  occurred  during  the  respective 
periods. 


Initial 
Symptoms 


2d  3d 

Symptoms      Symptoms 


Later 
Symptoms 


Lancinating  pains  in  lower  ex- 
tremity   (78)  31.2  !  (59)   23.6  ;  (31)    12.4 

Paresthesia     or     numbness     of  I  ( 

lower  extremities (44)   17.6  |  (29)    11. 6  ;  (21)     8.4 

Weaknessof  lower  extremities.  .  (41)   16.41(35)   14.0    (19)     7.6 


Staggering  or  unsteady  gate. . .  . 

Sphincter  disturbances 

Visual  disturbances 

Lancinating  pains  in  upper  ex- 
tremities  

Rheumatoid  pains  in  body  or 
back 

Visceral  crises 

Paresthesia  or  numbness  in 
upper  extremities 

Girdle  sense 

Vertigo 

Lancinating  pains  in  head  and 
face 

Joint  pains 

Rectal  tenesmus 

Visceral  tenesmus 

Loss  of  sexual  power 

Difficulty  in  articulation 


(31) 
(21) 
(16) 


11.4 
8.4 
6.4 


(14) 
(12) 

(II) 
(5) 
(3) 

(3) 
(3) 
(2) 
(I) 
(I) 
(0) 


5-6 
4.8 

4.4 
2.0 
1.2 

1.2 
1.2 
0.8 
0.4 
0.4 


(14)     5.6,    (6 


(18 

(7 

(9 
(16 

(5 

(o 
(2 
(o 
(o 
(6 
(I 


28.8  j  (76)  30.4 
8.4  I  (33)  13-2 
5.2  '  (29)   II. 6 


7.2 
2.8 


o 

0.8 
o 
o 

2.4 
0.4 


(11)     4-4 

(13)     5-2 

Not 
tabulated 

(29)  II. 6 
(94)  37-6 
(51)   20.4 


2.4      (4)      1.6!    (3)      1.2 


(4) 
(6) 


1.6 

2.4 


(4) 
(5) 


1.6 
2.0 


179    71.6 

107    42.8 

Not 
tabulated 

(V.L) 
218    87.2 
169   67.6 
109   43.6 

(27)   10.8 

(20)     8.0 
(30)   12.0 


3.6  (5)  2.0  (9)  3.61  (34)  13.6 
6.4  (28)  II. 2  (28)  ii.2|(77)  31.2 
2.0      (i)     0.4      (i)     0.4  '"  (10)     4.0 


(0) 
(I) 
(2) 
(o) 
(6) 
(I) 


0.4 
0.8 


2.4 
0.4 


(o) 
(I) 
(3) 
(4) 
(15) 
(4) 


o 

0.4 

1.2 

1.6 

7.0 

1.6 


(3) 
(7) 
(7) 
(5) 
(28) 
(6) 


2.8 
2.8 
2.0 

[i-S 
2.4 


The  above  table  is  based  on  the  entire  series  of  250  cases.  The 
number  of  females  (29)  and  of  negroes  (131)  is  too  small  to  be  of 
value  for  chronological  tabulation;  I  have  therefore  merely  totalled 
some  of  the  more  important  symptoms. 

Females  Negroes 

Lancinating  pains   25  times  or  85  per  cent.  12  times  or  86  per  cent. 

Staggering  gait  18  times  or  62  per  cent.  12  times  or  86  per  cent. 

Sphincter   disturbances    18  times  or  62  per  cent.  5  times  or  36  per  cent. 

Paresthesia    or    numbness     of 

lower   extremities   13  times  or  45  per  cent.  5  times  or  36  per  cent 


402  BALDinX  LUCRE 

Females  Xegroes 

Weakness  of   lower  extremity 

calculated    for    first    three 

symptoms  only    ii  times  or  38  per  cent.  8  times  or  57  per  cent. 

Girdle  sense  8  times  or  28  per  cent.  5  times  or  36  per  cent. 

Gastric   crises    5  times  or  17  per  cent.  i  time    or    7  per  cent. 

Visual    disturbances    6  times  or  20  per  cent.  7  times  or  50  per  cent. 

The  above  tables  are  self-explanatory  and  require  but  little  com- 
ment. Lancinating  pains,  somewhere  in  the  body,  lead  the  per- 
centages of  the  initial  symptoms  and  occupy  first  place  in  the  total. 
This  holds  true  in  women  and  negroes  as  well.  Most  writers  find 
this  symptom  in  approximately  the  same  percentage  of  cases. 
Collins  finds  them  as  the  initial  symptom  in  24.6  per  cent. ;  Spillmann 
and  Perrier  in  41.9  per  cent.;  Mendel  and  Tobias  (in  women)  in 
27.84  per  cent.  The  total  percentage  is  given  as  88.25  per  cent,  by 
Limbach ;  82.35  per  cent,  by  Frey  ;  90  per  cent,  by  Collins ;  79.5  per 
cent,  by  Bernhardt,  etc.  The  lancinating  pains  in  face  or  head  were 
observed  in  cases  of  '"  optical  "  and  "  cervical "  tabes.  Collins  re- 
ports them  as  occurring  in  1.58  per  cent,  of  his  cases  as  initial  symp- 
toms. "  Rheumatoid  "  pains  in  back  are  especially  often  mistaken 
for  rheumatism,  and  indeed  several  patients  had  been  treated  for 
this  before  admittance.  They  are  reported  by  Mendel  and  Tobias 
as  occurring  in  12.47  P^i"  cent,  of  his  cases  (women)  as  initial 
symptoms. 

Weakness  of  lon'cr  extremities:  This  symptom  has  only  been 
tabulated  if  it  occurs  as  one  of  the  first  symptoms,  since  sooner  or 
later  most  all  tabetic  cases  will  complain  of  weakness. 

By  disturbance.>  of  vesical  function  is  meant :  frequent  desire  to 
urinate,  retention,  constant  dribbling,  etc.  Rectal  disturbances  in- 
clude :  obstinate  constipation,  diarrhea,  loss  of  sphincter  sense,  etc. 
Many  of  the  symptoms  coexisted  or  occurred  at  the  different  periods 
in  the  same  case,  for  this  reason  no  attempt  has  been  made  to  sepa- 
rate them  except  to  ascertain  the  relative  frequency  of  the  dis- 
turbed function  of  the  two  sphincters.  In  the  169  cases  which 
showed  sphincter  disturbances,  the  rectal  sphincter  was  alTected  in 
70  and  the  vesical  sjjhincter  was  affected  in  143. 

Thoinas  records  vesical  disturbances  in  63  per  cent. ;  Bernhardt 
in  74  per  cent,  of  their  cases. 

Girdle  sense:  In  this  category  belong  5  cases  in  which  a  sense 
of  constriction  occurred  about  the  arm,  both  legs,  both  thighs,  the 
chest  and  neck. 

Loss  of  sexual  poxcer:  Our  figures  are  probably  loo  low.  'fhcy 
will   serve  however  as  an   index  as  to  the   frequency   with   which 


TABES  DORSALIS  403 

patients  note  this  symptom  and  call  the  physician's  attention  to  it. 
In  the  great  majority  of  cases  reported,  this  symptom  was  not 
elicited  by  direct  question  but  stated  voluntarily  by  the  patient. 
Anosmia  was  observed  in  2  cases  or  0.8  per  cent.  Deafness  was 
noted  in  2  cases  or  0.8  per  cent.  Frey  found  it  in  4  cases  of  his 
series. 

Insanity,  other  than  paresis,  in  locomotor  ataxia,  occurred  in  6 
cases  or  2.4  per  cent.  It  was  not  possible  from  the  record  to 
diagnose  the  type  of  mental  aberration,  except  that  paresis  could 
be  excluded.  Burr  gives  an  account  of  4  such  cases ;  Henderson 
reports  5  cases  and  reviews  the  literature  on  the  subject.  He  states 
that  acute  hallucinatory  disturbances  are  the  most  typical  form  of 
this  mental  disorder,  but  quoting  Krapelin  "  many  patients  are  sad 
and  take  a  hopeless  view  of  things  and  are  filled  with  depressing 
thoughts  and  fears."  The  feature  which  especially  distinguishes 
these  cases  from  paresis  are.  according  to  Henderson,  absence  of 
any  defect  of  memory,  of  speech  or  writing  and  of  facial  tremor. 
One  of  our  cases,  while  not  a  paretic,  did  have  however  complete 
loss  of  memory.  Frey  and  others  regard  these  mental  disturbances 
as  being  purely  of  the  nature  of  an  accidental  complication  and 
having  nothing  whatsoever  to  do  with  locomotor  ataxia. 

Tabetic  Symptoms  axd  Signs  ix  Order  of  their  Frequency 

Per  Cent. 

1.  Romberg  sign   96.4 

2.  Absent  knee  jerks   90.0 

3.  Lancinating  pains    88.4 

4.  Staggering  gait  87.2 

5.  Argj'll-Robertson   pupil    80.0 

6.  Ataxia  in  upper  extremities   68.2 

7.  Sphincter  disturbances   67.6 

8.  Sensory  disturbances    58.2 

9.  Visual  disturbances   43.6 

ID.  Paresthesia  and  numbness  of  feet  and  lower  extremities  ....  42.8 

11.  Girdle  sense  31.2 

12.  Ptosis   of   eye-lids    23.2 

13.  Paresthesia  or  numbness  in  hands  or  upper  extremities  13.6 

14.  Strabismus    12.0 

15.  Visceral   crises    12.0 

16.  Loss  of  sexual  desire  1 1.5 

17.  Charcot  joints   9.2 

18.  Vertigo    4.0 

19.  Mai  perforans   3.2 

20.  Pain  in  j  oints   2.8 

21.  Rectal  tenesmus    2.8 

22.  Mental  degeneration  (other  than  paresis)   2.4 

23.  Hemiplegia    2.4 

24.  Vesical  tenesmus    2.0 

25.  Difficulty  in  articulation  2.0 

26.  Deafness   1.2 

27.  Anosmia 0.8 


404  BALDinX  LUCRE 

Objectu'e  Symptoms 

Visual  disturbances  occurred  in  109  cases  or  43.6  per  cent,  of  tliese 
Failing  eye-sight  occurred  in  63  cases  or  25.2  per  cent. 

Diplopia  occurred  in  46  cases  or  18.4  per  cent. 

Optic  atrophy  occurred  in  ^7  cases  or  16.0  per  cent. 

Nystagmus  occurred  in  2^  cases  or    9.2  per  cent. 

It  is  seen  therefore  that  certain  eye  symptoms  occurred  simultane- 
ously ;  especialy  frequently  did  this  happen  in  nystagmoid  move- 
ments and  optic  atrophy.  This  latter  condition  was  observed  by 
Frey  in  28.16  per  cent.;  by  Tnichs  in  15  per  cent.;  by  Gowers  in 
13  per  cent.;  by  Marie  in  20  per  cent.;  Collins  found  it  in  14  per 
cent.  Bonar  in  a  collective  study  of  the  1,088  cases  reported  by 
Grosz.  Berger,  Limbach,  Thomas  and  himself,  found  it  in  20.4  per 
cent. 

Charcot  and  others  of  the  earlier  writers  believed  that  after  the 
occurrence  of  optic  atrophy,  further  progress  of  tabes  ceases. 
Benedikt  stated  that  all  symptoms,  even  in  advanced  cases  of  tabes, 
retrograde  as  soon  as  optic  atrophy  appears.  Foerster  found  that 
optic  atrophy  modifies  the  tabetic  symptoms.  Von  Malasie  states 
that  in  his  cases  symptoms  remained  stationary.  Bonar  reports  a 
case  which  developed  no  further  symptoms.  Marie  and  Leri  do 
not  believe,  however,  that  optic  atrophy  prevents  ihc  development 
of  ataxia. 

There  are  at  the  present  time  two  patients  in  the  Philadelphia 
General  Hospital  in  whom  complete  blindness  was  an  early  symp- 
tom, and  which  I  cite  apropos  of  the  above :  J.  C,  male,  colored,  age 
43  years.  Tabetic  symptoms  began  at  the  age  of  27  years,  with 
pain  in  the  back,  and  about  the  rectum.  Afterwards  his  eyesight 
became  diminished  ;  he  had  paresthesia  and  numbness  of  both  feet 
and  weakness  of  the  legs.  His  gait  was  decidedly  ataxic.  Two  and 
a  half  years  after  onset,  vision  was  completely  gone.  At  the  present 
time,  that  is  16  years  after  the  onset  of  tabes,  he  walks  without  a 
stagger,  and  with  only  that  hesitancy  usually  observed  in  the  blind. 

N.  S.,  white,  female,  age  33  years.  Symptoms  began  at  the  age 
of  28  with  lancinating  pains  in  left  lower  extremity  and  numbness 
of  legs ;  vision  gradually  failed  until  2  years  after  onset,  she  be- 
came totally  blind.  Her  ataxic  gait,  not  very  pronounced  before 
her  blindness,  is  now  decidedly  worse. 

It  Is  of  interest  to  note  that  in  one  of  the  blind  cases  (J.  C.) 
Romberg's  sign  is  not  so  great  with  eyes  open,  while  he  promptly 
will  sway  and  even  fall  to  the  ground  if  he  close;,  his  eyes.  The 
other  case  has  a  marked  Romberg's,  which  is  more  decided  with 
eyes  closed.  Optic  atrophy  occurred  in  4  of  the  29  female  patients, 
13.7  per  cent.,  and  in  4  of  the  14  or  28.6  per  cent,  negroes. 


TABES  DORSALIS  405 

Mendel  and  Tobias  found  optic  atrophy  somewhat  less  in  females 
than  in  males.  The  difference  is  however  not  sufficiently  great  to 
draw  conclusions.  All  writers  agree  that  the  optic  nerve  usually 
is  affected  early  in  the  disease  and  rarely  becomes  aft'ected  in  the 
ataxic  stage.  Diplopia  is  almost  always  transitory  and  usually  an 
early  symptom.  Collins  found  it  in  22  per  cent. ;  Limbach  in  26.5 
per  cent. 

Nystagmus  or  nystagmoid  movement  is  rare.  In  our  cases  they 
occurred  most  often  in  blind  tabetics.  Bonar  finds  the  symptom 
in  2.44  per  cent.  In  women  it  occurred  in  one  of  our  cases,  in 
negroes  in  3  cases. 

Pupils,  Ptosis,  and  Paresis  of  Eye-muscles 

Typical  Argyll-Robertson  pupil  occurred  in  200  cases  or  80     per  cent. 

Sluggish  reactions  or  no  reactions  occurred  in  32  cases  or  12.8  per  cent. 

Normal  reactions  occurred  in  18  cases  or     7.2  per  cent. 

Unequal  pupils  occurred  in  86  cases  or  33.6  per  cent. 

Irregular  pupils  occurred  in  34  cases  or  13.6  per  cent. 

Unequal  and  irregular  pupils  occurred  in  20  cases  or    8     per  cent. 

Ptosis  of  both  eye-lids  occurred  in  17  cases  or     6.8  per  cent. 

Ptosis  of  left  eye-lid  occurred  in  16  cases  or    6.4  per  cent. 

Ptosis  of  right  eye-lid  occurred  in  4  cases  or     1.6  per  cent. 

Ptosis  therefore  occurred  in  37  cases  or  14.8  per  cent. 

Paresis  of  eye-muscles  occurred  in  30  cases  or  12.0  per  cent. 

Frey  finds  Argyll-Robertson  pupils  in  70.54  per  cent. ;  normal 
reaction  in  4.7  per  cent,  and  no  reaction  or  sluggish  reaction  in  24.72 
per  cent. ;  unequal  pupils  in  52.35  per  cent. ;  Bonar  finds  Argyll- 
Robertson  pupils  in  78.69  per  cent. ;  Limbach  in  70  per  cent. ;  Col- 
lins in  yy  per  cent.  Mendel  and  Tobias  find  unequal  pupils  in 
62.5  per  cent. ;  Collins  in  23  per  cent. 

Eye-muscles:  Paresis  of  one  or  the  other  muscle  of  the  eye  occurs 
with  great  frequency.  Very  slight  grades  were  not  taken  into  con- 
sideration. Collins  found  paresis  in  10  per  cent,  of  his  cases ; 
Bonar  in  12  per  cent. ;  Mendel  and  Tobias  in  13.8  per  cent.  In 
our  cases  the  oculomotor  was  affected  14  times,  the  abducens  and 
trochlear  both  8  times.  This  predominance  of  third  nerve  involve- 
ment is  generally  noted. 

Ptosis  of  eye-lids:  Is  often  transitory.  Why  the  left  lid  should 
be  more  often  aft'ected  is  difficult  to  explain. 

Reflexes:  Only  the  patellar  reflex  is  considered  in  this  paper. 
It  was  found  to  be : 

Absent  on  both  sides  in  217  cases  or  86.8  per  cent. 

Absent  on  one  side  in  8  cases  or  3.2  per  cent. 

Diminished  in  11  cases  or  4.4  per  cent. 

Normal  in  6  cases  or  2.4  per  cent. 

Increased  in  8  cases  or  3.2  per  cent. 


4o6  BALDWIX  LUCRE 

In  one  of  the  8  cases  where  the  knee  jerk  was  absent  on  one  side, 
tabes  was  compHcated  by  hemiplegia ;  in  another  by  Charcot  joint 
of  the  knee. 

In  all  of  the  cases  where  knee  jerks  were  normal,  there  was  an 
absence  of  the  Arg}-ll-Robertson  pupillary  phenomenon.  In  three 
of  the  six  cases  the  pupils  reacted  sluggishly  and  w^ere  unequal  or 
irregular.  In  the  other  three  the  pupillary  reaction  was  normal 
and  the  cases  were  at  an  early  stage.  All,  however,  presented  such 
typical  tabetic  symptoms  as  lancinating  pains,  paresthesia,  etc.  In 
two  cases  where  the  reflex  was  increased,  hemiplegia  was  a  compli- 
cation ;  two  others  are  listed  as  optical  tabes ;  one  as  cervical  tabes ; 
in  two  pupillary  reaction  was  normal.  One  was  the  youngest  case 
(22^)  of  this  series.  • 

Limbach  reports  absence  of  the  knee  jerks  in  92  per  cent,  and 
alterations  in  the  reflex  in  4.25  per  cent.  Collins  finds  the  reflex 
absent  in  84.3  per  cent. ;  normal  in  4.3  per  cent. ;  sluggish  in  5.7  per 
cent.  Frey  notes  absence  in  only  56.47  per  cent,  of  his  cases,  with 
diminution  in  5.17  per  cent.  Thomas  reports  absence  in  81  per 
cent. ;  Bonar  in  95.2  per  cent. ;  Von  Sarbo  in  91  per  cent. ;  Bernhardt 
in  95.6  per  cent.  In  women,  jMendel  and  Tobias  find  absence  on 
both  sides  in  62.85  per  cent. ;  on  one  side  in  6.25  per  cent. ;  normal 
in  15  per  cent.;  increased  in  7.05  per  cent. 

Romberg's  sign:  Romberg's  phenomenon  was  present  in  241  cases 
or  96.5  per  cent.  Nine  cases  or  4.5  per  cent,  showed  no  swaying 
standing  with  the  feet  together  and  eyes  closed.  Romberg's  sign 
was  found  present  by  \^on  Sarbo  in  93  per  cent. ;  Limbach  in  88.75 
per  cent. ;  Bonar  in  79  per  cent. ;  Thomas  in  76  per  cent.,  while  Frey 
noted  it  in  but  54  per  cent.  In  women  Mendel  and  Tobias  found  it 
in  81.7  per  cent.;  Friedrichsen  in  90  per  cent,  and  Fehre  in  71  per 
cent. 

Sensation:  Fehre  believes  that  disturbances  of  sensation  are  the 
most  frequent  symptom  of  tabes.  In  a  number  of  our  cases  this 
symptom  is  unfortunately  not  rccordcfl  with  sufficient  lucidity  to 
make  use  of  in  a  paper  of  this  sort.  I  have  for  this  reason  refrained 
from  classifying  the  various  objective  sensory  disturbances,  realiz- 
ing that  such  tabulation  would  be  incomplete.  In  stating  that  in 
only  58.2  per  cent,  of  our  cases  there  were  objective  disturbances 
of  one  sort  or  the  other  I  am  not  unmindful  that  this  is  probably 
too  low  a  figure.  The  percentage  might  be  regarded  as  a  minimum 
and  not  as  an  average  finding. 

Arthropathies:  Occurred  in  23  cases  or  9.2  per  cent. ;  in  7  cases 
there  were  bilateral  arthropathies.     The  joints  affected  were :  Right 


TABES  DORSALIS  407 

knee  joint  in  9  cases ;  left  knee  joint  in  5  cases ;  both  knee  joints  in 
4  cases;  right  knee  joint  and  metatarso-phalangeal  joints  in  i  case; 
both  ankle  joints  in  2  cases ;  left  ankle  joint  in  i  case.  In  one  case 
Charcot  joint  (knee)  occurred  as  the  first  symptom  of  tabes.  I  have 
seen  another  case  in  the  surgical  wards  of  this  hospital  (not  included 
in  this  series)  where  a  Charcot  joint  of  the  knee  constituted  the 
initial  tabetic  symptom.  Ballet-Barbe,  Trommer,  Kredel  and  others 
report  similar  cases.  Thomas  found  arthropathies  in  5  per  cent. ; 
Mendel  and  Tobias  iri  women,  y.'/  per  cent.;  Limbach  in  1.75  per 
cent. 

In  29  women  Charcot  joint  occurred  twice;  in  13  Negroes  once. 
It  would  appear  from  the  study  of  the  literature  that  arthropathies 
occur  more  often  in  women.  In  our  series,  which  contains  a  high 
percentage  of  arthropathies,  they  occur  relatively  as  frequently  in 
the  male  as  in  the  female  sex. 

Spontaneous  fracture  in  tabes:  Occurred  in  but  one  case,  a 
woman,  who  suffered  about  10  years  after  the  onset  symptoms,  a 
fracture  of  the  femur.  This  fracture  was  the  result  of  a  slight 
fall.  The  fracture  caused  but  little,  if  any,  pain.  At  the  present 
time,  6  years  after  fracture,  union  has  not  taken  place.  Another 
case,  not  included  in  this  series,  is  at  present  in  the  surgical  wards 
of  the  institution. 

Mal-perforant:  Was  found  in  8  cases  or  3.2  per  cent.  The  per- 
forant  ulcer  always  occurred  on  the  foot.  It  affected  the  left  foot 
in  4,  the  right  in  3  cases  and  both  feet  in  i  case.  None  of  our 
women  or  blacks  showed  the  condition.  Mendel  and  Tobias  found 
it  in  one  of  their  female  cases  only. 

Footdrop:  Occurred  in  9  cases  or  3.6  per  cent.  In  8  cases  the 
condition  was  bilateral ;  in  i  case  only  the  left  foot  was  affected. 
This  symptom  appears  to  have  received  scant  attention  in  the  lit- 
erature. 

Hemiplegia  and  tabes:  Occurred  in  6  cases  or  2.4  per  cent. 
This  to  me  appears  as  a  remarkably  low  percentage  if  one  considers 
that  in  a  great  many  tabetics,  the  cardio-vascular  system,  either  as  a 
result  of  tabes  or  because  of  the  preceding  lues,  has  undergone 
marked  changes. 

Duration  of  tabes:  56  cases  died  while  in  the  hospital ;  of  these 
48  were  men  and  8  were  women.  The  average  age  at  time  of  death 
was  54.96  years  or  8.01  years  after  the  symptoms  began;  in  women 
54.12  years  or  8.00  years  after  onset  of  tabes.  Judging  from  this, 
sex  appears  to  exert  no  influence  on  duration  of  the  disease. 

In  49  cases  a  definite  cause  of  death  is  stated,  in  the  other  7 


4o8  BALDWIX  LUCKE 

cases  no  cause  further  than  "  tabes  "  is  determined.  Twenty-one 
cases  or  43  per  cent,  died  of  an  intercurrent  acute  disease.  Thirty- 
two  cases  or  57  per  cent,  died  of  a  chronic  disease. 

Causes  of  death:  The  principal  cause  of  death  as  determined  by 
autopsy  or  clinically  was : 

Chronic  diffuse  nephritis   in  15  cases 

Lobar  pneumonia   in  7  cases 

Pulmonary  tuberculosis in  5  cases 

Sepsis  due  to  gangrene  in  4  cases 

Myocardial  degeneration    in  4  cases 

Apoplexy   in  3  cases 

Broncho-pneumonia    in  2  cases 

Edema  of  the  lungs    in  2  cases 

Acute  parenchymatous  nephritis   in  i  case 

Pyonephrosis    in  i  case 

Gastro-enteritis    in  i  case 

Tuberculous   enteritis    in  i  case 

Acute  cardiac  dilatation   in  i  case 

Intestinal   paralysis    in  i  case 

Carcinoma  of  esophagus    in  i  case 

In  detail  the  duration  of  tabes  was  less  than  one  year  in  8  cases. 

I  to    4  years  in  12  cases 

5  to    9  years  in  13  cases 

10  to  12  years  in    9  cases 

15  to  19  years  in     9  cases 

20  to  24  years  in     3  cases 

25  to  29  years  in     o  cases 

30  to  34  years  in     2  cases 

It  seems  of  interest  that  a  high  percentage  of  cases  died  of  inter- 
current infections.  This  probably  for  the  reason  that  their  vitality 
was  below  par  as  can  be  expected. 

The  Gross  MoRnio  Findings  in  23  Tabetics  Coming  to  Autopsy 

(Onl\-  the  important  findings  are  here  recorded) 

Cardiovascular  Systetn 

Mj'ocarditis,  chronic  interstitial   8  times 

Brown  atrophy  of  the  heart   2  times 

Fatty  infiltration  of  the  heart  3  times 

Aneurysm  of  the  aorta  2  times 

Chronic  valvulitis    7  times 

Arteriosclerosis,    marked    9  times 

Marked  secondary  dilatation  of  tlic  heart   6  times 

Pulmonary  System 

Tuberculosis   (active)    ; 5  times 

Lobar    pncumpnia    4  times 

Broncho-pneumonia    i  time 

Congestion  and  edema  of  the  lungs  7  times 

Emphysema    7  times 

Hypostatic  pneumonia   j  times 

Gangrene  of  lung   i  time 


TABES  DORSALIS  409 

Digestive  System 

Fatty  degeneration  of  the  liver   2  times 

Atrophic  cirrhosis  of  the  liver   2  times 

Catarrhal  and  ulcerative  enterocolitis    i  time 

Tubercular   enteritis    i  time 

Acute   peritonitis i  time 

Carcinoma  of  esophagus   i  time 

Central  Nerz'ous  System 
Cerebral   apoplexy   i  time 

Genito-urinary  System 

Chronic  urethritis    2  times 

Chronic  interstitial  nephritis   17  times 

Cloudy  swelling  of  kidneys   i  time 

Acute  parenchymatous  nephritis  i  time 

Chronic   suppurative   cystitis    8  times 

Pj'onephrosis  or  p3'elitis   5  times 

Gangrene   of    scrotum    i  time 

A  study  of  these  findings  will  show  that  there  are  no  distinctive 
gross  morbid  changes  in  the  organs  of  tabetics.  The  chronic  lesions 
found  are  to  be  expected  in  all  elderly  syphilitics,  belonging  to  the 
class  of  patients  with  which  we  deal.  The  kidneys  seem  to  suffer 
especially.  In  a  study  of  the  urine  of  213  cases  of  tabes,  either  al- 
bumen or  casts  or  both  occurred  in  109  cases  or  in  over  50  per  cent. 
In  conclusion  I  wish  to  express  my  grateful  appreciation  to  the 
members  of  the  neurological  staff,  and  their  assistants  for  permit- 
ting me  to  use  freely  the  record  and  material  of  their  department. 
Particularly  are  my  thanks  due  to  Drs.  Burr  and  Ingham  for  many 
valuable  suggestions. 

REFEREXXES 

Bonar.  A  Study  of  the  Cases  of  Tabes  Dorsalis  in  Prof.  M.  Allen  Starr's 
Clinic,  Columbia  University.  Jourx.\l  of  Nervous  axd  Mental  Dis- 
ease, 1901,  Volume  XXVIII. 

Bliimel.  Die  aetiologische  Bedeutung  der  Sjphilis  fur  die  Tabes  dorsalis, 
Inaug.  Diss.,  Berlin,  1909. 

Burr,  Charles  W.     The  Frequenc}^  of  Locomotor  Ataxia  in  Negroes.     JouR- 
x.\L  OF  Nervous  and  Mental  Disease,  April,  1892. 
The  Causes  of  Death  in  Tabes.     Journal  of  Nervous  and  Mental  Dis- 
ease, 1912,  Volume  39. 
Insanity,   Other  than   Paresis,   in  Locomotor  Ataxia.     American  Journal 
of  Insanit}',  Volume  LXX,  1914. 

Bernhardt,  M.  Beitrag  zur  .\etiologie  und  Pathologic  der  Tabes  dorsalis. 
Berlin  klin.  Wochenschr.,  49,  1912. 

Benedikt.  tjber  die  Prognose  und  Therapie  der  Tabes.  Wiener,  klin.  Presse, 
1887. 

Berger.     Zur  Aetiologie  der  Tabes.     Breslauer  arzt.  Zeitschr.,  1S79. 

Charcot.     Traite  de  Medecine. 

Collins,  Joseph.  Tabes  Dorsalis  ;  a  Study  of  140  Cases  of  Locomotor  Ataxia. 
The  Aledical  News,  1903,  January. 

Eulenburg.  Beitrage  zur  Aetiologie  und  Therapie  der  Tabes  dorsalis,  namens- 
lich  iiber  deren  Beziehung  zur  Syphilis.     Virchows  Arch.,  Bd.  99. 


4'o  BALDWIN  LUCKE 

Frey,    Ernst,     t'her   klinische    Formen.    Symptomatologie    und    Verlauf    der 

Tabes  auf  Grund  von  850  Fallen.     Ztschr.  f.  d.  gesammte  Neurologic 

und  Psychiatrie  Originale.  14,  1912-1913. 
Fuchs.     Tabes  und  Auge.     Wien.  klin.  Wochensch.,  14,  1912. 
Fehre.     Beitrag  zur  Lehre  iiber  die  Tabes  bei  den  Weibern.     Inaug.  Diss., 

1 901. 
Friedrichsen.     Uber  die  Tabes  dorsalis  beim  werblichen  Geschlecht.     Inaug. 

Diss.,  1893. 
Grosz.     Ref.  in  centralbl.  f.  d.  prakt.  Augenheilkunde,  1896,  p.  18. 
Gowers.     Diseases  of  the  Nervous  System. 
Henderson.     Tabes  Dorsalis  and  Mental  Disease.     Review  of  Neurology  and 

Psychiatry,  191 1,  Volume  IX. 
Jeffery  and  Maxwell.     Diseases  of  China. 
Irish.     Two  Cases  of  Locomotor  Ataxia :  One  in  a  Chinaman,  the  Other  in 

a  Negress.     Philadelphia  Hospital  Reports,  Volume  III,  1896. 
Kron.     Cber  Tabes  dorsalis  beim  weiblichen  Geschlecht.     Deutsche  Ztsch.  f. 

Nervenheilk.,  Bd.  XII,  1898. 
Tabes  fragen.     Monatsch.  f.  Psych,  u.  neurol.,  Bd.  24. 
Limbach.     Statistisches  zur  Symptomatologie  der  Tabes  dorsalis.     Deutsche 

Ztsch.  f.  Nervenheilk.,  1895,  Bd.  7. 
Lloyd.     Philadelphia    Hospital    Reports,    Volume    III,    page    173.     Footnote. 

Philadelphia  Hospital  Reports,  Volume  II,  1893. 
Mendel  and  Tobias.     Die  Tabes  der  Frauen.     Monatsschr.  f.  Psych,  u.  Neu- 
rologic, 31,  1912. 
Moebius.     Cber  die  Tabes.     Berlin,  1897.  S.  Karger. 
Nonne.     t'ber  die  Bedeutung  der  Syphilis  in  der  Aetiologic  der  Tabes,  etc. 

Fortschr.  der  Med.,  1903. 
Rosenow.     Elective  Localization  of  Streptococci.     Journal  American  Medical 

Association,  1915,  Volume  LXV. 
Raymond.     Etiologie  du  tabes  dorsalis.     Progres  Med.,  1892,  No.  24. 
Schaflfer.     Tabes  dorsalis.     Lewandowsky's  Handb.  d.  Neurologic,  II,  Berlin, 

Julius  Springer. 
Schuster,   P.     Hat  die   Hg.   Behandlung  der   Syphilis   Einfluss   auf   das  Zu- 

standekommen   metasyphilitischer   Nervenkrankheitcn.     Deutsche   med. 

Wochenschr.,  1907. 
Cber  die  antisyphilitische  Behandlung  in  der  Anamnese  der  an  metasyphi- 

litischen    und    syphilitischen    Nervenkrankheitcn    Leidenden.     Leipzig, 

1907.  C.  W.  Vogcl. 
Schuller.     Cber  atypische  Verlauf  sformen  der  Tabes.    Wien.  med.  Rundschau 

1906.     3  Falle  von  Tabes.     Wien.  klin.  Wochensch.,  1908. 
Spillmann  et  Perricr.     Particularites  symptomatique,  etc.,  dans  unc  series  de 

105  cas  dc  tabes  dorsalis.     Lc  Journal  Medical  Frangais,  1909. 
Thomas.     An  Analysis  of  the  Cases  of  Tabes  in  the  Johns  Hopkins  Hospital 

and  Dispensary,   from  the  Opening  in   May,   1889,  to  December,   1898. 

Bulletin  Johns  Hopkins  Hospital,  1899. 
von  Malaise.     Die  Prognose  der  Tabes  dorsalis.     Monatsschrift  f.  Psychiatrie 

u.  Neurologic,  1906. 
Von  Sarbo.     Die  Rolle  der  Lues  bei  der  Tabes  und  der  Paralysis  progressiva. 

Pester  Med.  Chir.  Presse,  1898. 
Klinische  und  statistischc  Daten  zur  Symptomatologie  der  Tabes.    Deutsche 

Ztsch.  f.  Neurologic,  Bd.  22,  1913. 

(For  further  literature  see  Frey,  and  Mendel  and  Tobias,  where  a  very 
complete  bibliography  is  given.) 


HYDROMYELIA  AND  HYDROENCEPHALIAi 
By  Alfred  Gordon,  M.D. 

The  pathogenesis  of  spinal  cord  cavities  is  far  from  being  defi- 
nitely established.  Considerable  uncertainty  exists  on  this  sub- 
ject. The  reason  lies  partly  in  the  fact  that  under  the  term  of 
syringomyelia  have  bgen  described  cavities  of  various  origin  and 
of  various  structure.  The  majority  of  writers  admit  that  a  gliosis 
which  develops  in  the  central  part  of  the  spinal  cord  and  subse- 
quently becomes  disintegrated  is  the  chief  factor  in  formation  of 
cavities,  although  no  less  an  authority  than  Weigert  says  that  the 
conception  of  syringomyelia  as  softened  central  gliosis  has  no* 
foundation. 

Cavities  in  the  cord  have  been  observed  in  association  with 
various  malformations  of  the  cerebrospinal  axis  such  as  acrania, 
encephalocele,  congenital  hydrocephalus,  diplomyelia  and  spina 
bifida.  Here  the  condition  of  the  cord  was  attributed  to  a  con- 
genital anomaly  on  the  same  basis  as  the  associated  malforma- 
tion, and  the  mechanism  consists  of  a  secondary  softening  of  glia 
tissue.  This  was  the  view  held  by  Virchow,  Leyden,  Pick, 
Kahler  and  Striimpell. 

The  role  of  an  inflammatory  state  or  other  changes  of  the 
ependyma  has  been 'emphasized  by  some  observers  as  a  cause  of 
cavity  formation :  shrinking  and  dilatation  of  the  central  canal 
with  increased  transudation  follows,  exactly  like  ependymitis  and 
hydrocephalus  develops  in  the  brain. 

In  chronic  inflammation  of  cord  tissue  softening  may  occur 
and  cavities  form.  Huismans-  speaks  of  cases  with  chronic  pro- 
gressive infectious  myelitis  in  which  softening  developed  because 
of  embolism  or  thrombosis  of  the  central  vessels  of  the  cervical 
cord  (Myelitis  longitudinalis). 

Compression  at  any  level  of  the  cord  may  produce  a  dilata- 
tion of  the  central  canal  above  or  below  the  compression  and  give 
rise  to  syringomyelic  symptoms.  In  Lhermitte's  and  Boveri's 
case^  there  was  an  exostosis  of  the  basillary  process  of  the  occipital 

1  This  paper  was  read  and  the  specimens  were  exhibited  before  the 
Philadelphia  Neurological  Society,  December  i8,  1914. 

2  Zeitschrift  f.  klin.  Med.,  1903,  Bd.  48,  p.  329. 

3  Revue  Neurologique,  1912,  No.  6,  p.  385. 

411 


412  •  ALFRED  CORDON 

bone  which  compressed  the  lower  part  of  the  medulla  and  a  dila- 
tation of  the  central  canal  was  found.  It  extended  from  the 
medulla  down  to  the  loth  thoracic  segment.  Alquier  and  Lher- 
mitte  found  cord  cavities  in  cases  of  spondylitis. 

In  cases  of  meningitis  cavities  have  been  found  within  the 
cord.  Saxer*  observed  them  in  cured  cerebrospinal  meningitis 
in  which  the  patients  happened  to  die  from  other  causes.  Philippe 
and  Oberthiir^  speak  of  a  pachymeningitic  form  of  cord  cavities. 
Charcot  and  JofTroy  observed  them  in  hypertrophic  form  of 
pachymeningitis.  Lazarew*'  speaks  of  tuberculous  and  syphilitic 
meningomyelitis  with  cavity  formation  in  the  cord. 

Increased  pressure  of  the  cerebrospinal  fluid  may  lead  to 
dilatation  of  the  central  canal.  This  has  been  proven  experi- 
mentally by  Rosenbach,  Eichhorst  and  Lepine.  The  latter"  in- 
jected blood  in  the  cord  of  dogs  and  guinea-pigs.  Change  of  air 
pressure  followed  and  in  a  few  minutes  he  found  the  central 
canal  and  the  lymph-spaces  dilated  and  filled  with  blood.  By 
the  mechanism  of  increased  pressure  can  be  explained  hydro- 
myelia  in  various  congenital  or  pathological  conditions  of  the 
brain.  The  brain  cavities  may  become  dilated  as  well  as  the 
aqueduct  of  Sylvius  and  thus  influence  enlargement  of  the  central 
canal  of  the  cord.  Thus  Homcn  found  5  cases  of  internal  hydro- 
cephalus in  12  cases  of  syringomyelia  and  Hinsdale  15  times  in 
150  cases  of  syringomyelia. 

The  vascular  doctrine  of  cavities  in  the  cord  has  its  place 
among  others.  Almost  all  the  authors  who  have  written  on  the 
subject  admit  more  or  less  pronounced  lesions  of  the  blood  ves- 
sels in  every  case.  New  formation  of  vessels,  their  sclerosis, 
their  obliteration,  hyaline  degeneration,  rupture  of  their  walls 
and  particularly  of  their  external  wall.  Raymond  for  example 
thought  that  the  cavities  in  syringomyelia  develop  at  the  expense 
of  conjunctival  membrane  of  vascular  origin:  the  adventitia  be- 
comes hyperplasic  and  the  blood-vessels  become  obliterated  ;  the 
nervous  tissue  suffers  secondarily. 

An  analysis  of  all  the  al)Ove-nientioiK(l  factors  demonstrates 
the  fact  that  multi]jle  causes  may  ])roduce  cavities  in  the  cord 
and  if  .syringomyelia  means  cavity  formation  there  are  syringo- 
myelias and  not  a  .syringomyelia. 

Considering  the  seat  of  the  cavity  or  cavities  two  chief  varie- 

*  ZicKlcr's  licitr.iKc  k/)J,  p.  2yfy 
'•  Revue  Xcurol..  lytx).  Xo.  4. 
^  Deut.  Ztschr.  f.  Xerv..  irjoH. 
^  fitudes  sur  licmatoinyelics,  1900. 


HYDROMYELIA  AND  HYDROEXCEPHALIA  413 

ties,  I  believe,  may  be  emphasized.  The  first  embraces  cases  in 
which  the  central  canal  does  not  participate  in  the  pathological 
process ;  the  lesion  may  press  against  it,  disfigure  it  but  has  no 
direct  relation  to  it.  The  cavity  originates  in  the  posterior  cornua. 
This  is  the  common  finding  in  syringomyelia.  In  the  second 
variety  the  central  canal  is  the  point  of  departure;  it  becomes 
dilated  and  by  doing  so  it  penetrates  the  cord  tissue  in  various 
places  and  deforms  it ;  an  ependymitis  may  be  the  origin  of  the 
condition.  In  both  groups  the  vascular  system  probably  plays  an 
important  role  in  the  process  of  destruction  of  tissue  and  in  the 
formation  of  cavities.  This  form  of  cavity  formation  was  recog- 
nized long  ago  by  Ollivier  and  Lancereaux  under  the  name  of 
hydromyelia  and  considered  by  them  to  be  congenital  in  origin. 

Hydrocephalus  seems  to  stand  pathogenetically  close  to  hy- 
dromyelia and  syringomyelia.  Numerous  instances  have  been 
reported  of  combination  of  both  affections.  They  explain  the 
psychic  and  cerebral  disorders  that  are  encountered  in  such  cases. 
Schlesinger  observed  in  56  cases  of  syringomyelia  4  times  hydro- 
cephalus. The  above  mentioned  Homen's  and  Hinsdale's  cases 
also  Kupferberger's  cases^  which  simulated  tumors  of  the  brain, 
Langhans"-*  and  Kiewlicz'^°  cases  all  tend  to  show  the  compara- 
tive frequency  of  such  an  association.  This  fact  together  with 
the  occurrence  of  syringo-  or  hydromyelia  in  spina  bifida,  anen- 
cephalia,  porencephaly,  cerebral  gliomata,  microgyria  observed  es- 
pecially by  Schiiller,^^  also  by  Oppenheim,  Schultze,  Hoffmann, 
Heubner,  Dejerine  and  others — all  tend  to  show  that  there  must 
be  an  etiological  relation  and  of  a  teratological  nature,  viz.,  de- 
velopmental anomaly  of  both  portions  of  the  cerebrospinal  axis. 

A  very  interesting  observation  in  such  cases,  especially  when 
the  hydromyelitic  form  of  cavities  is  present,  is  that  there  are 
very  few  or  no  clinical  symptoms  during  life.  An  anatomo- 
clinical  case  of  this  nature  came  recently  under  my  observation. 
Until  the  age  of  ten  the  patient  was  in  good  health.  Two  years 
following  a  severe  trauma  a  few  symptoms  developed.  At  no 
time  did  she  present  any  mental  disturbances  and  repeated  exam- 
inations failed  to  reveal  any  sensory  disturbances  characteristic  of 
syringomyelia.  Also  in  spite  of  the  bulb  being  involved  no  symp- 
toms referable  to  that  portion  of  the  brain-stem  were  present. 
Pathologically   I   found  besides  the  enormous  dilatation  of  the 

8  Deut.  Ztschr.  f.  Nerv.,  1893,  Bd.  4. 

9  Virchow's  Archiv,  Bd.  64,  s.  175. 

10  Ibid..  Bd.  20,  s.  21. 

11  Jahrb.  f.  Psych.,  Bd.  26,  s.  365. 


414  ALFRED  GORDON 

central  canal  of  the  cord  and  of  the  ventricles  of  the  brain  with 
extraordinary  deformity  of  nervous  tissue  also  marked  vascular 
changes  viz.,  thrombosis  of  the  anterior  spinal  artery  and  of 
numerous  small  vessels  within  the  cord  and  medulla.  The  latter 
were  seen  mostly  near  the  anterior  portion  of  the  cord,  viz.,  near 
the  thrombotic  anterior  spinal  artery.  Moreover  a  certain  degree 
of  meningitis  was  also  present  in  the  vicinity  of  the  peripheral 
thrombotic  arteries.  The  simultaneous  occurrence  of  a  marked 
dilatation  of  the  cerebral  cavities  also  of  the  central  canal  of  the 
cord  and  the  beginning  of  somatic  disturbances  at  an  early  age 
together  with  almost  total  absence  of  the  corpus  callosum — all  these 
facts  speak  in  favor  of  a  congenital  malformation  of  the  cerebro- 
spinal axis.  The  vascular  disturbances  mentioned  above  prob- 
ably participated  to  a  certain  extent  in  the  pathological  process 
of  the  cord  but  undoubtedly  the  malformation  of  the  central  canal 
together  with  the  presence  of  a  considerable  amount  of  glioma- 
tous  tissue  could  not  have  been  produced  exclusively  by  a  vas- 
cular lesion  of  that  character,  neither  by  the  accompanying  slight 
meningeal  inflammation.  Besides,  the  coexisting  enormous  dila- 
tation of  the  brain  cavities  and  absence  of  the  corpus  callosum 
were  not  accompanied  by  conspicuous  lesions  of  the  cerebral  vas- 
cular system. 

The  case  is  as  follows. 

Girl,  22  years  of  age,  Austrian  by  l)irth,  was  in  good  health 
up  to  the  age  of  ten.  At  that  time  she  had  a  fall  with  loss  of 
consciousness  after  which  she  was  ill  for  (juite  a  while.  Parents 
could  not  state  how  long  and  in  what  particular  way  she  was  ill. 
At  the  age  of  12  it  was  noticed  that  the  fingers  of  her  left  hand 
became  spastic  and  contracted,  also  that  her  head  was  drawn  for- 
ward. The  latter  condition  continued  and  became  more  and  more 
pronounced  during  the  following  three  years.  At  the  same  time 
the  parents  noticed  that  her  gait  was  not  steady  and  she  could  not 
walk  along  a  straight  line  Headache  and  dizziness  were  the 
other  complaints  at  that  time.  She  was  l)rought  to  this  country 
3  years  ago.  She  then  complained  of  severe  headache  and  was 
losing  power  in  her  left  arm  and  leg;  there  was  also  severe  pain 
in  the  affected  limbs.  When  she  came  under  my  observation  she 
presented  the  following  symptoms.  She  appeared  considerably 
older. than  she  or  her  parents  claimed.  Her  face  was  wide  and 
its  skin  was  thick.  The  form  of  the  head  was  particularly  strik- 
ing. It  resembled  a  square  Ijox,  the  lateral  sides  of  which  were 
bulging,  the  tcmjKjral  regions  were  therefore  i)rotruding.  The 
forehead  was  perfectly  flat.  There  was  a  marked  kyphosis  and 
scoliosis  to  the  right.  The  patient  complained  of  considerable 
headache,  also  of  vertigo  when  she  attempted  to  raise  her  head 
from  the  pillow.     She  was  very  somnolent  and  presented  a  very 


HYDROMYELIA  AND  HYDROENCEPHALIA  415 

marked  general  asthenic  condition :  the  least  exertion  such  as 
raising  her  arm  off  the  bed  exhausted  her.  The  entire  left  side 
was  paretic,  but  there  was  no  spasticity.  Increased  knee-jerk, 
ankle-clonus  and  the  extension  toe  phenomenon  were  present  on 
the  same  side.  Superficial  and  deep  sensations  were  normal  over 
the  entire  body;  the  least  touch  or  pin  prick  was  promptly  per- 
ceived by  the  patient.  The  eyes  presented  a  peculiarity,  viz., 
marked  nystagmus  when  the  eyes  were  turned  to  the  left,  iDut  not 
to  the  right  side.  Otherwise  there  was  nothing  pathological  in 
the  fundi,  ocular  muscles,  in  the  pupillary  reflexes  and  visual 
fields.  No  palsy  of  any  of  the  cranial  nerves  was  present.  No 
symptoms  referable  to  the  medulla  were  noticed.  She  could 
swallow  easily,  spoke  distinctly  and  there  was  no  difficulty  of 
breathing.  The  sphincters  were  intact  and  the  mentality  fair. 
She  responded  correctly  to  all  questions,  although  slowly,  and 
the  memory  was  good. 

Gradually  a  weakness  of  the  right  arm  and  leg  developed  and 
at  the  same  time  the  paresis  of  the  left  side  increased,  so  that  at 
the  end  of  5  weeks  the  left  side  was  totally  paralyzed.  No  spas- 
ticity was  noticed  on  either  side.  The  headache  kept  on  increas- 
ing, the  somnolence  became  very  much  pronounced  so  that  she 
had  to  be  aroused  for  food.  She  gradually  lost  control  of  both 
sphincters.  The  nystagmus  remained  unaltered.  Gradually  the 
asthenia  increased  and  finally  the  patient  expired.  The  Wasser- 
mann  test  made  several  times  on  the  blood  was  invariably  negative. 

Autopsy  showed  the  following  findings.  Scalp  thick ;  calva- 
rium  shell-like  and  transparent ;  dura  very  thin  and  tense ;  menin- 
geal vessels  very  thin  and  straight.  Blood-vessels  of  cortex  were 
much  congested.  Cerebral  lobes  were  bulging.  A  thin  and  tense 
membrane  covered  the  optic  chiasm  and  when  the  latter  was  sev- 
ered there  was  an  outpouring  of  an  unusually  large  qviantity  of 
clear  straw-colored  fluid.  Beneath  this  membrane  was  noticed 
an  opening  at  the  base  of  the  brain  of  one  half  inch  in  diameter 
which  led  directly  into  the  right  lateral  ventricle,  which  was  greatly 
dilated  and  filled  with  clear  straw-color  fluid.  The  pituitary 
gland  was  found  somewhat  enlarged. 

The  spinal  cord  presented  the  most  interesting  condition. 
From  the  upper  cervical  region  down  to  the  lumbar  region  the 
spinal  cord  was  flattened  and  upon  pressure  showed  distinct  fluc- 
tuation. On  the  anterior  surface  of  the  cord  extending  from  the 
lower  portion  of  the  medulla  down  to  the  upper  thoracic  segment 
lies  a  thrombotic  blood-vessel  giving  the  impression  of  a  longi- 
tudinal, hard,  round  mass  closely  attached  to  the  cord. 

After  hardening  both  brain  and  cord  in  10  per  cent,  formalin 
sections  were  made.  A  transverse  antero-posterior  section  of 
the  brain  showed  an  extraordinary  dilatation  of  both  lateral  ven- 
tricles. The  corpus  callosum  was  almost  entirely  destroyed  and 
thus  both  lateral  ventricles  being  in  communication  presented  one 
large  cavity  very  much  dilated,  so  that  the  peripheral  walls  sur- 
rounding the  cavity  consisted  of  a  small  amount  of  brain  tissue. 
The  entire  section  of  the  brain  resembled  a  deep  cup-like  shell 


4i6 


ALFRED  GORDON 


whose  walls  were  thin  and  the  center  of  which  was  occupied  by 
displaced  basal  ganglia.  The  caudate  nuclei  were  pushed  exter- 
ally,  the  internal  capsules  were  pushed  outwards  and  inwards,  so 
that  the  characteristic  formation  of  limbs  and  knee  was  totally 
absent.  The  optic  thalami  were  pushed  backward,  so  that  their 
shape  was  no  more  oval ;  they  presented  square  masses.     Of  the 


Fi...  I.    Ilvd 


yciroL'nct.i)nalia. 


corona  radiata  only  small  portions  were  seen  entering  the  remain- 
ing cortical  areas.  The  various  lobes  as  seen  from  this  section 
were  thin.  The  lateral  ventricles  on  their  inner  middle  surface 
comniunicatcd  with  the  base  of  the  brain  through  a  very  large 
opening  which  would  admit  the  thumb  of  an  adult.     The  cerebel- 


HYDROMYELIA  AND  HYDROENCEPHALIA 


417 


lum  on  Its  anterior  border  when  severed  from  the  cerebrum  pre- 
sented a  deep  cavity  extending  laterally  from  one  end  to  the  other 
At  the  base  of  the  brain  the  two  temporal  lobes  were  close  to' 


gether  and  the  chiasma  together  wnth  the  neighboring  portions 
were  markedly  displaced. 

Cross  sections  of  the  spinal  cord  revealed  a  hollow  tube  ex- 


4i8  ALFRED  GORDON 

tending  from  the  uppermost  segment  of  the  cord  down  to  the 
lower  thoracic  portion.  The  form  of  this  tube  was  various  ac- 
cording to  the  level :  it  was  oval  in  the  cervical  portion  and  in  the 
shape  of  letter  S  in  the  thoracic  region.  The  disfigurement  of 
the  nervous  tissue  surrounding  the  hollow  tube  was  enormous  so 
that  in  the  lower  medulla  there  was  great  difficulty  in  distinguish- 
ing the  anatomical  arrangement  of  various  portions  of  nervous 
tissue. 

Microscopical  study  of  the  cord  and  medulla  revealed  the  fol- 
lowinsr  condition. 


Fig.  3.     Cervical  Segment 

Lozu'er  Cervical  Segment  (Fig.  ?). — The  entire  section 
showed  an  extreme  disfigurement  of  the  nervous  tissue.  It  pre- 
sented a  cavity  branching  out  in  several  places  and  surrounded 
by  the  following  elements  counting  from  within:  a  uniform  mass 
evidently  of  g]i(jmatous  structure  thicker  in  some  places  than  in 
others  an<l  following  the  branched  ])arts  of  the  cavity  ;  it  was  par- 
ticularly seen  in  what  appeared  to  be  the  anterior  i)ortion  of  the 
cord.  The  gliomatous  tissue  was  surrounded  by  the  substance 
of  the  cord  itself  in  which  it  was  difficult  to  discern  anterior  or 
|)Osterior  tracts  and  gray  matter.  Here  and  there  cells  were  seen 
but  the  entire  cord  tissue  was  pushed  outward  by  the  dilated 
central  canal.  In  two  i)laccs  the  above  mentioned  thickened  lin- 
ing of  the  cavity  reached  the  ])cri])]icry,  and  its  thickened  portion 
which  ai)])arently  r()rrcs])onded  to  the  anterior  fissure  was  in  com- 


HYDROMYELIA  AND  HYDROENCEPHALIA 


419 


munication  with  the  exterior  of  the  cord ;  in  that  space  were  seen 
thrombotic  vessels  forming  a  chain  between  the  pia  and  the  Hn- 
ing  of  the  cavity.  In  the  same  place  a  degenerative  condition  of 
the  adjacent  white  libers  was  seen  more  on  one  side  than  on  the 
other.  Small  degenerated  areas  were  also  seen  in  other  parts  of 
the  section.  The  pia  surrounding  the  segment  was  thickened 
only  in  some  places.  The  dura  mater  was  markedly  thickened 
anteriorly.  A  number  of  thrombotic  blood-vessels  were  seen 
within   and  especially  in  the  anterior  portion  of   the   segment. 


Fig.  4.     Thoracic  Segment. 


Thoracic  Segment  {Fig.  4). — Here  a  very  narrow  central 
cavity  was  observed  which  apparently  stretched  out  laterally  and 
branched  out  at  its  extreme  lateral  ends  thus  separating  and  de- 
forming the  cornua  as  well  as  the  white  matter.  The  entire  nar- 
row cavity  was  surrounded  by  thick  gliomatous  tissue  in  the 
midst  of  which  were  seen  many  thrombotic  blood-vessels.  The 
lining  of  the  central  cavity  was  thicker  on  the  posterior  than  on 
the  anterior  half.  The  gliomatous  tissue  followed  the  branchings 
of  the  cavity,  formed  diverticula  and  surrounded'  them.  The 
white  matter  surrounded  the  central  gliomatous  tissue  and  its  di- 
verticula and  in  some  place  showed  degenerative  changes.  Some 
thrombotic  vessels  were  seen  at  the  periphery  of  the  cord  in  its 
anterior  portion. 


420 


ALFRED  GORDON 


Lumbar  Segment  (fig.  t). — The  central  jijlioniatous  tissue 
presented  the  shape  of  V.  Anteriorly  it  contained  in  the  center 
an  opening  of  V  and  laterally  it  extended  into  the  cornua  pushing 
them  externally  and  deforming  them  The  entire  mass  was  em- 
braced in  a  circular  way  by  the  gray  matter  of  the  section,  more 
on  one  side  than  on  the  other.  The  longitudinal  part  of  the 
gliomatous  tissue  extended  posteriorly  almost  to  the  periphery 
and  contained  a  longitudinal  cavity.  Anteriorly  the  glia  tissue 
was  continuous  with  the  anterior  fissure  of  the  cord.  Some  de- 
generative areas  were  seen  in  the  white  matter  near  the  glioma- 
tous tissue  and  close  to  the  periphery  which  was  surrounded  by 
thickened  pia.  Xo  thrombotic  blood-vessels  were  seen  at  this 
level. 


Fk;.   5.     Lumhar   Segment. 


Sectlo)i  at  the  Lo7cest  Part  of  tlir  Medulla. — Many  cavities 
were  seen.  Two  very  large  ones  were  situated  in  the  central 
jjortion  more  anteriorly  than  ])osteriorly.  Small  narrow  ones 
and  of  various  shape  were  seen  throughout  tlie  section.  P'nor- 
mous  masses  of  glifjmatous  tissue  surrounded  these  cavities. 
The  two  large  cavities  branched  out  in  various  directions.  The 
disfigurement  and  destruction  of  the  entire  segment  was  very 
striking.  White  nerve  fibers  were  seen  scattered  throughout  the 
section.  Narrow  tracts  of  fibers  ran  at  an  angle  to  be  decussated 
but  were  interru])ted  by  masses  of  gliomatotis  tissue  or  were 
largely  absent.  Columns  of  (loll  were  greatly  degenerated:  only 
a  few  isolated  fibers  were  seen.  Dilated  and  thrombotic  blood- 
vessels were  seen  within  and  anteriorly  to  the  section.  The  sur- 
rounding pia  and  flura  were  decidedly  thickened,  especially  in 
the  anterior  portion  of  the  section. 


HYDROMYELIA  AND  HYDROENCEPHALIA 


421 


Section  at  the  Level  of  the  Olives  (Fig.  6). — The  fourth 
ventricle  was  covered  with  a  thick  layer  of  gliomatous  tissue. 
On  one  side  within  the  wall  of  the  ventricle  was  seen  a  cavity  sur- 
rounded by  glia  tissue.  One  of  the  pyramids  presented  evidence 
of  partial  degeneration,  while  the  other  was  intact.  Many  dilated 
and  thrombotic  blood-vessels  were  seen  in  the  space  between  and 
in  front  of  the  pyramids,  and  in  the  same  area  the  pia  surround- 
ing the  pyramids  was  thickened  and  in  some  places  the  outer 
layer  of  the  pia  was  continuous  with  the  thickened  outer  layer  of 


Fig.  6.     Medulla. 


the  much  dilated  and  thrombotic  vessels.  The  same  condition  of 
blood-vessels,  of  pyramidal  fibers,  of  the  walls  of  the  fourth  ven- 
tricle and  of  the  meninges  was  found  at  higher  levels. 

The  aqueduct  of  Sylvius  was  dilated  and  its  walls  were  cov- 
ered with  gliomatous  tissue  irregularly  distributed,  thicker  in 
some  places  than  in  others  ;  the  thickest  mass  was  found  in  its 
posterior  portion. 


ABNORMAL  RELATION  BETWEEN  LIVER  AND  BRAIN 
WEIGHTS  IN  FORTY-TWO  CASES  OF  EPILEPSY 

Bv  D.  A.  Thom,  M.D. 

PATHOLOGIST   TO   THE    MONSON    STATE    HOSPITAL,    PALMER,    MASS. 

This  paper  or  rather  note  is  along  the  same  Hne  of  research  that 
Dr.  ^Nlyerson  of  the  Taunton  State  Hospital  reported  in  the  Journal 
OF  Nervous  and  Mental  Disease,  July,  1914,  and  it  was  due  to 
the  fact  that  Myerson  reviewed  a  small  group  of  epileptic  cases  at 
the  Monson  State  Hospital  that  my  interest  in  the  abnormal  relation 
between  the  liver  and  brain  weights  was  aroused.  Myerson  divided 
his  cases  into  four  groups: 

1.  The  emaciated  and  non-emaciated  senile  dementias. 

2.  The  dementia  prsecox  group  on  which  Southard  based  his  paper, 

"  Focal  Lesions  in  Dementia  Prsecox." 

3.  Emaciated  general  paretics. 

4.  Small  group  of  epileptics,  non-emaciated,  dying  and  autopsied  at 

the  Monson  State  Hospital. 
It  is  regarding  this  latter  group  of  cases  that  I  wish  to  contribute 
my  findings. 

As  these  data  were  collected  and  an  arbitrary  standard  accepted 
for  normal  liver  and  brain  weights  before  Dr.  Myerson's  paper 
came  to  my  notice,  I  find  that  I  have  given  a  little  more  freedom  to 
the  limits  to  which  the  weights  of  these  organs  must  confine  them- 
selves and  still  be  called  normal,  I  also  accepted  the  liver-brain 
weight  ratio  as  7-6  instead  of  16-13,  but  these  changes  in  no  way 
aflfect  the  ultimate  results.  These  data  were  collected  from  forty- 
two  cases  of  clinically  certain  epilepsy  which  came  to  autopsy  at  the 
Monson  State  Hospital  during  the  past  two  and  one  half  years. 
Those  cases  were  considered  which  died  in  a  well-nourished  condi- 
tion, where  the  terminal  disease  was  of  short  duration,  and  the 
patient  of  such  an  age  that  development  was  complete,  yet  discard- 
ing those  cases  of  advanced  years  where  senile  changes  miglit  be 
suspected  on  account  of  the  advanced  years. 

Most  of  the  cases  in  this  series  at  the  time  of  death  were  between 
seventeen  and  forty-five  years  of  age.  Pulmonary  edema,  broncho- 
pneumonia, lobar  pneumonia,  status  epilepticus  and  asphyxia  were 
the  causes  of  death  in  over  90  per  cent,  of  the  cases,  so  that  the 

422 


ABNORMAL  LIVER  AND  BRAIN  WEIGHTS  423 

gross  lesions  found  at  autopsy  could  not  well  be  attributed  to  the 
terminal  disease.  It  is  in  such  a  series  as  this  that  one  might  expect 
to  find  the  normal  7-6  liver-brain  ratio  hold  good ;  but  it  was  the 
rather  large  number  of  cases,  twenty-six  (62  per  cent.),  in  this 
series  where  the  brain  outweighed  the  liver  that  I  offer  as  an  excuse 
for  the  publication  of  this  note.  I  have  put  my  comparative  data  in 
tabulated  form  and  summarized  them  briefly  to  show  that  not  only 
was  there  an  abnormal  relation  existing  between  the  liver  and  brain 
weights,  but  in  only  a  very  limited  number  of  cases  did  the  weights 
of  these  organs  fall  within  the  limits  of  what  I  arbitrarily  accepted 
as  normal  hver  and  brain  weights.  I  have  made  no  distinction  be- 
tween the  normal  weight  of  male  and  female  organs,  but  have  wid- 
ened the  normal  limits  to  include  both,  viz.,  normal  liver  1,500-1,800 
grams;  normal  brain  1,250-1,400  grams. 

Summary 

Brain  heavier  than  liver 26  cases  (62  per  cent.) 

Liver  heavier  than  brain 16  cases  (38  per  cent.) 

Abnormal  Relation  between  Liver  and  Brain  Weights,  26  Cases 

Brains 

Brains  weighing  between  1,250  and  1,400  grams  (normal)   8  cases 

Brains  weighing  over  1,400  grams   8  cases 

Brains  weighing  less  than  1,250  grams  10  cases 

Livers 

Livers  weighing  between  1,500  and  1,800  grams  (normal)   2  cases 

Livers  weighing  over  1,800  grams   0  cases 

Livers  weighing  less  than  1,500  grams 24  cases 

Sixteen  Cases  of  Liver  and  Brain  Weights  Normal 
Brains 

Brains  weighing  between  1,250  and  1,400  grams  (normal)   6  cases 

Brains  weighing  over  1,400  grams   4  cases 

Brains  weighing  less  than  1,250  grams   6  cases 

Lii'ers 

Livers  weighing  between  1,500  and  1,800  grams  (normal)   6  cases 

Livers  weighing  over  1,800  grams   2  cases 

Livers  weighing  less  than  1,500  grams   8  cases 

Summary  of  Weights  in  42  Cases 

Normal  Overweight  Underweight 

Livers    8  cases  2  cases  32  cases 

Brains    14  cases  12  cases  16  cases 

Of  the  sixteen  cases  where  the  relative  liver  and  brain  weight 
was  normal,  in  only  two  were  the  weights  of  the  liver  and  brain 
both  within  the  normal  limits  in  the  same  case,  z.  e.,  forty  of  the 
forty-two  cases  studied  revealed  either  an  abnormal  relation  between 
the  liver  and  brain  weights,  or  that  one  of  the  organs  was  of  abnor- 


424  D.  A.  THOM 

mal  weight.  In  some  cases  both  conditions  were  true.  The  most 
common  gross  abnormahties  named  in  order  of  their  frequency  were 
as  follows:  Atrophy  of  Hver,  atrophy  of  brain,  overweight  of  brain 
(probably  due  to  edema  or  hydrocephalus),  hypertrophy  of  liver. 
The  liver  is  most  commonly  diminished  in  size  by  some  structural 
alteration  such  as  cirrhosis,  acute  parenchymatous  degeneration,  and 
the  hypertrophies  are  apt  to  be  due  to  tumors,  abscesses,  fatty  and 
amyloid  degeneration,  acute  congestion  and  in  some  cases  cirrhosis. 
The  question  now  arises  to  what  extent,  if  any,  can  the  convul- 
sions be  attributed  to  those  pathological  changes  found  in  the  liver ; 
or  more  broadly  and  more  practically,  to  what  extent  can  the  ab- 
normal functioning  of  a  normal  brain  be  due  to  structural  changes 
in  organs  remote  from  the  nervous  system?  And  are  we  justified 
in  feeling  that  the  abnormal  functioning  of  a  normal  brain  mav  be 
secondary  and  the  structural  alteration  in  other  organs  the  ])rimary 
process  ?  Is  it  true  that  in  our  efforts  along  special  lines  of  research, 
especially  in  the  study  of  the  nervous  system,  that  we  are  holding  the 
brain  at  such  close  range  that  we  are  losing  sight  of  the  system  as  a 
whole,  of  which  the  brain  is  only  one  of  the  many  comi)onent  parts? 
With  such  striking  examples  before  us  as  uremic  and  infantile  con- 
vulsions and  those  following  the  administration  of  exogenous 
poisons  such  as  strychnine,  with  autoi)sy  material  presenting  striking 
pathological  changes  in  the  liver,  kidneys,  spleen,  ductless  glands, 
etc.,  associated  with  brains  that  defy  macroscopic  examination  as  to 
their  abnormalities,  it  would  not  be  surprising  to  find  that  much 
of  interest  developed  from  a  careful  study  of  the  visceral  organs, 
both  in  the  psychoses  and  epilepsies. 


A  CASE  OF  ATYPICAL  MULTIPLE  SCLEROSIS  WITH 
BULBAR  PARALYSIS^ 

By  Sigmund  Krumholz,  M.D. 

This  girl  is  eighteen  years  old,  born  in  Chicago,  doing  general 
housework  at  home. 

Mother  and  two  older  sisters  and  herself  are  afflicted  with 
otosclerosis.  Two  other  children  died,  one  at  nineteen  years  of 
cardiac  rheumatism,  the  other  at  thirteen  months  in  a  convulsive 
attack  ;  otherwise  family  history  negative. 

Birth  and  early  childhood  of  the  patient  normal.  At  three 
years  had  measles  and  diphtheria ;  at  age  of  six  years  was 
operated  on  for  suppurative  cervical  adenitis  on  the  left  side  of 
the  neck.  At  twelve  years  had  tonsillectomy  performed,  and 
again  in  March,  1913,  had  undergone  another  tonsil  and  adenoid 
operation.  Since  the  age  of  thirteen  years  has  had  a  spastic 
torticollis.  Her  hereditary  otosclerosis  gradually  developed, 
beginning  at  the  age  of  six  years.  Intelligence  normal.  Menses 
regular.     Habits  good. 

About  July,  1912,  suffered  a  slight  contusion  of  the  left  side 
of  neck,  and  dates  the  onset  of  present  complaint  to  this  accident. 
The  patient  complained  of  a  dull  continuous  pain  on  the  left  side 
of  the  back  of  the  neck,  radiating  upwards  and  homolaterally, 
and  for  the  last  three  months  (about  one  year  after  date  of  onset) 
the  pain  was  also  present  at  the  right  side  of  the  neck. 

In  May,  191 3,  the  patient  experienced  a  neuralgic  pain  on  left 
side  of  the  forehead,  accompanied  by  hoarseness  and  dry  cough, 
which  was  soon  followed  by  impairment  of  speech  and  voice. 
The  latter  two  functions  became  gradually  more  affected,  and 
about  one  month  later  the  patient  experienced  difficulty  in  swallow- 
ing, so  that  liquids  would  at  times  partly  regurgitate  through  the 
nose,  and  sometimes  swallowing  of  food  would  excite  a  cough- 
ing spell.     Fever  was  at  no  time  observed. 

On  September  9,  191 3,  Dr.  Krumholz  first  saw  the  patient,  at 
the  request  of  Dr.  Joseph  C.  Beck,  and  obtained  the  history  just 

1  Read  before  the  Chicago  Neurological  Society,  Dec.  17,  1914. 

425 


426  SI  CM  VXD   KRVMHOLZ 

described,  and  on  examination  found  a  bright,  well-nourished 
and  normally  developed  young  girl.  The  history  was  gotten  with 
some  difficulty,  on  account  of  the  combined  deafness  and 
dysarthria  of  the  patient.  Her  speech  was  thick,  indistinct  and 
nasal  in  character,  and  her  voice  dysphonic.  Left  half  of  the 
tongue  felt  spongy,  and  was  thinner  than  the  right,  presenting 
slight  corrugations  and  marked  fibrillary  twitchings,  and  on  pro- 
trusion it  deviated  to  the  left  side.  The  velum  palati  hung  down 
lower  on  the  left  than  on  the  right  side,  and  on  phonation  was 
not  elevated.  The  uvula  was  drawn  over  towards  the  right  side. 
Laryngoscopic  examination  by  Dr.  Joseph  C.  Beck  discovered  a 
paralysis  of  the  left  vocal  cord.  The  patient  found  difficulty  in 
the  articulation  of  words  which  contained  the  linguals  r,  1,  n,  etc., 
and  pronounced  them  indistinctly,  but  the  enunciation  of  the 
labials,  p,  b.  w,  etc..  was  not  in  any  degree  defective.  On 
drinking  water,  there  was  some  regurgitation  through  the  nose. 
The  sensation  of  the  left  side  of  the  pharynx  was  not  as  acute  as 
on  the  right.  The  eyeballs  moved  in  all  directions  normally  and 
without  any  nystagmus.  The  pupils  were  round,  equal  in  size, 
and  reacted  readily  and  efficiently  to  light  and  convergence;  no 
anophthalmos ;  no  exophthalmos ;  the  corneal  and  conjunctival 
reflexes  were  present.  The  eye  grounds  were  normal.  The 
upper  and  lower  facial  muscles  contracted  sufficiently  and  equally 
on  both  sides.  The  masseters  well  innervated.  No  disturbance 
to  touch,  pain  and  temjjcrature  sense  on  either  side  of  the  face 
and  forehead. 

The  neck  is  short  and  thick  like  her  mother's.  The  head  is 
slightly  drawn  to  the  right.  The  face  and  chin  directed  slightly 
to  the  left  and  upward,  Init  only  when  not  self-conscious.  The 
posterior  muscles  of  the  neck  on  the  left  side  feel  on  palpation 
like  one  hard  mass.  Ui)on  bending  the  head  to  the  right,  the 
left  sterno-mastoid  muscle  becomes  extremely  tense.  Rotation 
and  side-to-side  bending  of  the  head  is  limited.  The  upper  third 
of  the  left  trapezius  is  slightly  thinner  and  possibly  weaker  than 
the  right.  Xo  fibrillary  twitchings.  There  was  some  tenderness 
on  jjressure  over  the  jjosterior  i)art  of  the  neck,  especially  on 
the  left  sirle.  but  no  objective  sensory  disturbance  to  be  detected 
over  the  neck  and  head,  nor  on  any  other  part  of  the  body. 

At  the  root  of  the  left  side  of  the  neck  above  the  clavicle 
a  slightly  enlarged  gland  could  be  palpated,  but  no  other  glands. 
The  lower  end  of  the  left  sterno-mastoid  muscle  was  markedly 
thickened  ;  the  thyroifl  was  not  enlarged. 


SCLEROSIS    WITH   BULBAR    PARALYSIS  427 

The  reflexes  of  both  patellar  and  Achilles  tendons  were  ex- 
aggerated on  both  sides,  more  on  the  right  side.  No  ankle  clonus. 
Positive  Babinski  was  only  at  times  obtainable  on  the  right,  not 
on  the  left,  side.  Biceps,  triceps,  and  periosteal  reflexes  were 
increased  bilaterally,  but  a  little  livelier  on  the  right  side.  The 
abdominal  reflex  was  present. 

September  13,  191 3,  the  physical  findings  and  subjective 
symptoms  remained  unchanged.  No  distinct  change  in  the  taste 
sense.  Temperature,  98.4°  ;  pulse,  88.  The  contractions  of  the 
neck  muscles  to  the  galvanic  current  were  lightning-like  in  char- 
acter on  both  sides.  Heart,  lungs,  and  abdominal  viscera  nega- 
tive. No  palpitation  or  dyspnea.  There  is  a  scar  over  the  left 
antero-lateral  side  of  the  neck,  due  to  the  old  operation  for 
cervical  adenitis. 

September  15,  1913:  Tuberculin  test  with  Koch's  O.  T.,  gave 
a  slight  local  reaction,  but  no  constitutional  effect  was  observed. 

September  25,  1913:  The  sero-biological  findings  were: 
Wassermann  in  both  blood  serum  and  spinal  fluid  negative.  The 
cell  content  and  the  globulin  not  in  excess.  Lange's  colloidal 
gold  test  negative.     No  bacteria  in  spinal  fluid. 

Blood  count:  Lymphocytes,  40;  large  mononuclears,  13.3; 
large  polynuclears,  33.3;  eosinophiles,  13.3.     Urinalysis  negative. 

November  14,  1914:  Blood  finding  same,  except  tubercular 
fixation  faintly  positive. 

September  27,  1913:  The  condition  of  patient  considerably 
improved.  Absence  of  dysphagia  and  regurgitation.  The  speech 
was  much  more  distinct  than  previously,  and  the  fibrillary  twitch- 
ings  of  the  tongue  markedly  diminished,  and  its  consistency  on 
the  left  side  harder  than  on  previous  examination.  The  reflexes 
are  about  the  same.  No  Babinski,  but  positive  Gordon  on  right 
side.  On  examination  of  the  eyes,  a  horizontal  nystagmus  could 
be  seen  distinctly  on  directing  the  patient  to  look  to  the  side. 
This  symptom  could  not  be  obtained  on  previous  examinations. 

Dr.  Krumholz  did  not  see  the  patient  again  for  over  one  year, 
until  November  14,  1914.  Dr.  J.  C.  Beck  told  him  that  he  had 
operated  on  the  patient  November,  19 13,  which  operation  will  be 
described  by  Dr.  Pollock;  and  his  notes,  which  Dr.  Beck  kindly 
furnished,  give  record  that  the  patient  feels  better  and  that  the 
pain  in  the  back  of  the  neck  diminished  considerably,  but  that  the 
described  paralysis  of  the  tongue,  soft  palate  and  larynx  did  not 
change  materially,  that  a  haziness  in  the  outline  of  the  discs  was 


428  SIGMiWD   KRUMHOLZ 

to  be  noticed.  In  Dr.  Krumholz's  repeated  examinations  of  the 
patient,  November,  191 4,  he  found  the  unilateral  glosso-laryngo- 
palatine  paralysis  about  the  same  as  in  September,  1913.  except 
that  the  tongue  was  more  corrugated,  and  the  optic  discs  were 
hazy  in  outline,  and  that  the  remote  torticollis  remained  sta- 
tionary. 

In  considering  the  differential  diagnosis,  cerebrospinal  syphilis 
has  to  be  excluded,  on  account  of  the  absence  of  the  general 
clinical  luetic  symptoms,  and  negative  sero-biological  report, 
which,  to  a  great  extent,  also  spoke  against  a  pachymeningitis  in 
the  area  of  the  exits  of  the  affected  nerves,  or  in  the  cervical 
region  of  the  cord. 

Aneurysm  at  the  base  or  acute  bulbar  paralysis,  due  to  hemor- 
rhage, etc.,  had  to  be  ruled  out,  since  the  patient  had  no  cardiac 
disease,  nor  any  etiologic  factor  producing  arteritis. 

Again,  the  absence  of  acute  symptoms  excluded  poly  en- 
cephalitis. 

Chronic  progressive  bulbar  paralysis  had  to  be  eliminated 
from  the  diagnosis  on  account  of  the  remission  of  the  symptoms, 
the  youth  of  the  patient,  the  limitation  of  the  lesion  to  one  side, 
and  the  absence  of  involvement  of  the  facial. 

Again,  paralysis  of  the  trunks  of  the  pneumogastric  and  hypo- 
glossal nerves  caused  by  tumor  pressure  (  for  instance,  enlarged 
tuberculous  glands )  from  without  at  their  exits,  or  along  their 
course  at  the  upper  part  of  the  neck,  before  their  divergence 
from  each  other,  had  to  be  excluded,  because  the  general  picture 
of  the  disease  did  not  conform  with  such  diagnosis.  In  lesions 
at  the  jugular  foramen  (exit  for  ninth,  tenth,  and  eleventh 
nerves)  or  in  affections  of  their  branches  in  their  side-by-side 
course  at  the  upper  part  of  the  neck,  the  laryngo-palatal  paralysis 
is  always  accompanied  by  paralysis  of  the  neck  muscles  (trapezius 
and  sterno-cleido-mastoid).  This  patient  has  a  remote  acquired 
reflex  spastic  torticollis  since  her  thirteenth  year,  prob;d)]y  due 
to  muscular  irritation,  produced  by  cervical  Ivniph  nodo,  but  a 
recent  paralysis  of  the  spinal  portion  of  the  spinal  accessory 
nerve  could  not  be  detected.  In  paralysis  of  this  branch  of  the 
eleventh  the  scapula  assumes  a  swinging  position.  The  head  is 
drawn  towards  the  unaffected  side,  on  account  of  the  unopposed 
action  of  the  healthy  sterno-cleido-mastoid  muscle,  which  is  ex- 
clusively supplied  i>y  the  eleventh  nerve.  In  this  case,  as  above 
stated,  there  is  a  limited  sidc-to-side  motion,  and  tension  on  the 


SCLEROSIS    WITH   BULBAR   PARALYSIS  429 

left  sterno-mastoid  and  contraction  of  the  trapezius,  due  to  a 
spasm,  but  no  flaring-out  of  the  scapula,  nor  distinct  bending  of 
the  head  towards  the  healthy  side.  On  electrical  test,  these 
muscles  do  not  respond  to  the  reaction  of  degeneration. 

Again,  polyneuritis  of  the  branches  of  the  tenth,  eleventh  and 
twelfth  nerves  had  to  be  ruled  out,  because  the  general  affections 
(influenza,  diphtheria,  etc.)  which  lead  to  lesions  of  these  nerves 
usually  produce  bilateral  paralysis  ;  while  tuberculous  peripheral 
neuritis  is  very  rare,  and  probably  always  secondary  to  tuber- 
culous meningitis.  This  patient,  with  the  exception  of  pain  in  the 
back  of  the  neck,  presented  no  symptoms  of  meningeal  irritation. 

Besides,  the  fibrillary  twitching  of  the  atrophic  tongue, 
although  occurring  in  neuritis,  is  usually  a  sign  of  nuclear 
aflfection. 

Again,  the  exaggerated  reflexes  and  transitory  Babinski  imply 
afifection  of  the  upper  motor  neuron.  No  extracranial  lesion, 
with  the  exception  of  a  vertebral  compression  of  the  cord,  could 
have  produced  the  endogenic  neuron  afifection  in  our  ]jatient. 
The  Roentgen  pictures  showed  no  lesion  of  the  vertebrae  and 
skull. 

Again,  the  nystagmus  cannot  be  explained  upon  a  disease 
affecting  the  tenth,  eleventh  and  twelfth  nerves  after  their  escape 
from  the  skull.  This  symptom,  if  not  normal,  represents  a  dis- 
turbed function  of  the  vestibular  nerve,  or  in  the  connection  of 
its  nucleus  with  the  cerebellum.  If  we  stretch  our  imagination 
and  overlook  the  character  of  the  nystagmus,  then  the  otosclerosis 
could  be  held  responsible  for  its  presence.  But  in  otosclerosis 
the  involvement  of  the  labyrinth  is  rare,  and  the-character  of  the 
labyrinthine  nystagmus  is  such  that  the  slow  component  of  the 
nystagmus  is  directed  toward  the  side  of  the  irritating  lesion.  In 
this  patient  the  slow  phase  of  the  nystagmus  is  directed  toward 
the  median  line,  which,  according  to  J.  Gordon  Wilson,  is  char- 
acteristic of  an  intracranial  nystagmus. 

The  above  enumerated  diseases  practically  exhaust  all  that 
may  be  considered  in  dififerential  diagnosis,  and  leave  as  a  sub- 
stratum of  the  disease  in  question  some  affection  in  the  depth  of 
the  stem  destroying  the  left  nucleus  ambiguus,  the  left  nucleus 
hypoglossus,  the  left  and  possibly  the  right  pyramidal  tracts,  and 
the  vestibular  nuclei.  These  anatomical  structures  are  separated 
from  each  other  by  the  interposition  of  important  fiber  systems 
(sensory  fibers  of  the  fifth  nerve,  fibers  of  pain  and  temperature 


43°  SIGMUXD   KRUMHOLZ 

sense  to  the  body),  the  destruction  of  which  would  present  char- 
acteristic objective  sensory  disturbance.  These  facts  force  the 
assumption  that  two  or  more  lesions  are  responsible  for  the 
clinical  syndrome  of  this  disease.  The  behavior  of  the  symptoms 
is  characteristic  of  one  of  those  diseases,  the  lesions  of  which  are 
disseminated,  namely,  disseminated  cerebrospinal  syphilis,  which 
was  already  excluded,  and  multiple  sclerosis. 

After  the  laryngo-glosso-palatine  paralysis  had  distressed  the 
girl  for  several  weeks,  it  receded  to  a  marked  extent.  At  this 
examination,  when  the  improvement  was  noticeable.  Dr.  Krum- 
holz  observed  for  the  first  time  a  distinct  nystagmus.  In  October, 
1913,  the  outline  of  the  optic  discs  appeared  hazy  and  haziness  is 
still  present.  This  remission,  intermission  and  appearance  of  new 
symptoms  is  most  characteristic  of  multiple  sclerosis.  Atrophy 
and  long  intermissions  are  rare,  but  do  occur.  Oppenheim  men- 
tions in  his  text-book  his  observations  of  "  hemiatrophia  lingualis  " 
in  multiple  sclerosis.  Fuerstner  published  a  case  of  multiple  scle- 
rosis with  fibrillary  tremor  of  the  atrophic  tongue,  and  on  necropsy 
found  a  sclerotic  process  distributed  in  the  medulla  and  hemi- 
spheres. Goodhart  reports  a  case  of  multiple  sclerosis  in  a  twenty- 
four-year-old  girl,  who  had  sensory  paresis  in  the  hands  and  flac- 
cid motor  paralysis  of  the  lower  extremities,  which  gradually  dis- 
appeared within  six  months,  and  after  an  intermission  of  seven 
years  developed  the  classical  symptom-complex  of  the  disease. 
Kennedy  reports  two  cases  of  multiple  sclerosis  with  nuclear 
facial  paralysis.  My  patient.  Xo.  2  on  the  program,  who,  to  my 
regret,  failed  to  come  here  to-night,  is  almost  a  counterpart  of 
Goodhart's  case. 

The  finding  of  tuberculous  glands  at  the  operation  is  interest- 
ing, in  whicii  connection  may  be  noted  Stan  Fleshen's  recent  pre- 
liminary rqiort  of  eighteen  cases  of  multiple  sclerosis  with  distant 
tuberculous  lesions,  wherein  he  expressed  the  opinion  that  tuber- 
culous lesions  in  distant  organs  are  probably  the  specific  etiolog- 
ical factors  of  the  disease. 


PERIPHERAL  NEURITIS  WITH  KORSAKOW'S  SYMPTOM 

COMPLEX 

By  Anita  Alvera  Wilson,  M.D. 

ASSISTANT     PHYSICIAN,     GOVERNMENT     HOSPITAL     FOR     THE     INSANE,     WASH- 
INGTON,   D.    C. 

{Continued  from    page   S54) 
Case  is  as  follows : 

C.  L.,  a  white  married  female;  admitted  to  the  Government 
Hospital  for  the  Insane,  July  22,  1914. 

The  medical  certificate  which  accompanied  the  patient  stated : 
One  brother  died  of  tuberculosis  following  pneumonia.  Patient 
addicted  to  some  form  of  morphine  from  1898  to  1910.  Addicted 
to  alcohol  from  January  to  May  15,  1914.  Last  five  years,  hyster- 
ical attacks  which  were  relieved  by  having  a  good  cry.  First 
symptoms  were  manifested  in  September,  1913,  by  mental  aberra- 
tion. Present  symptoms  :  Patient  is  disoriented  in  all  fields,  memory 
for  recent  events  is  practically  nil.  Fails  to  recognize  those  with 
whom  she  is  familiar.  Has  retrospective  falsifications — thinks  she 
was  down  on  the  iVvenue  last  night.  Has  wrist  and  foot  drop, 
many  nerves  being  tender.  Probable  cause :  Grief,  trouble,  alcohol. 
No  suicidal  or  homicidal  tendencies. 

Status  on  admission:  Patient  was  admitted  to  the  ward  on  a 
stretcher,  laughed  and  talked  to  the  nurses  in  a  rambling  manner 
while  being  bathed.  She  showed  falsifications  of  memory,  con- 
fusion of  sequence  of  time,  and  confabulation.  Was  completely 
disoriented  and  had  a  mistaken  identity  of  those  about  her.  Wrist 
drop  and  foot  drop  present,  pain  on  pressure  over  the  deep  nerve 
trunks.  She  complained  of  a  peculiar  feeling  in  the  extremities, 
could  not  tell  whether  it  was  pain  or  numbness.  No  nystagmus. 
Aside  from  a  peculiar  odor  of  the  body,  showed  no  signs  of  personal 
neglect. 

Family  history:  No  history  of  mental  disorder  in  the  family.  A 
brother  used  alcohol  to  excess. 

Personal  history:  Born  in  Slatedale,  Pa.,  November  11,  1866. 
Birth  and  infancy  normal.  No  illnesses  in  childhood.  Began 
school  at  seven  and  left  at  17,  in  the  eighth  grade.  She  enjoyed 
school  life,  especially  the  dramatics.  She  outdid  her  companions 
in  all  their  sports,  especially  in  swimming  and  diving  and  was  nick- 
named "  dare-devil."  During  her  girlhood  had  violent  crying  spells 
and  had  to  be  left  alone  at  these  times.  Although  she  was  very 
sensitive  she  got  along  well  with  her  friends  and  her  family.     After 

43 « 


432  ANITA  ALVERA  WILSON 

leaving  school,  she  \vorked  in  a  slate  factory,  for  a  short  time,  then 
went  to  New  York  and  worked  in  ISIacy's  department  store  nearly  a 
year.  At  eighteen,  eloped  with  her  present  husband,  four  years 
her  senior ;  a  shipping  clerk  at  that  time.  He  was  a  man  of  good 
habits  and  their  married  life  was  happy.  Eleven  months  after 
marriage,  a  son  was  born.  Labor  was  instrumental,  followed  by 
"  milk "  fever.  Four  months  later,  the  baby  died,  and  although 
she  was  disappointed,  she  did  not  seem  unnaturally  sad.  About 
this  time  began  having  strange  "  spells,"  like  fainting  attacks, 
although  the  usual  remedies  never  prevented  her  losing  conscious- 
ness. She  knew  when  these  spells  were  coming  on  but  could  not 
prevent  them.  At  these  times  would  say  strange  things,  as,  "  Your 
mother  was  here  this  morning  and  treated  me  terribly."  Then  she 
would  stare  peculiarly  and  fall.  She  showed  no  pallor,  cyanosis  or 
dyspnea  or  frothing  at  the  mouth,  ^^'ould  be  unconscious  ten  or 
fifteen  minutes.  These  would  recur  every  other  day;  gradually 
they  became  less  frequent  and  in  three  months  disappeared  entirely. 
(Reference  to  her  mother-in-law  at  these  times  seemed  to  be  due  to 
the  fact  that  she  did  not  belong  in  her  husband's  social  sphere,  and 
she  had  refused  to  meet  his  mother  because  she  felt  that  she  would 
not  be  accepted  by  her  husband's  family.)  In  June,  1887,  another 
son  was  born,  delivery  instrumental.  Patient  sustained  a  laceration 
of  the  second  degree.  She  did  not  seem  strong  after  the  births  of 
her  children,  and  in  1887  and  1895,  had  attacks  of  inflammatory 
rheumatism,  from  which  she  recovered  slowly.  In  1897,  was 
nauseated  for  months.  The  physicians  were  unable  to  discover  the 
cause,  and  it  was  finally  decided  that  it  was  symptomatic  and  would 
be  relieved  after  the  laceration  was  repaired ;  this  was  done  the 
following  year.  A  year  later,  the  old  symptoms  returned,  stomach 
had  to  be  pumped  out  every  other  day  and  finally  the  sight  of  the 
stomach  tube  would  cause  a  fainting  attack.  In  1900,  a  friend 
recommended  some  medicine  which  she  took  about  ten  years,  with 
more  or  less  relief.  After  the  Food  and  Drugs  Act  was  passed, 
it  was  found  that  this  medicine  contained  a  large  amount  of 
morphine  and  alcohol.  This  annoyed  her  very  much,  and  she  had 
a  hard  time  overcoming  the  habit.  She  had  previously  been  very 
happy  in  her  home,  did  her  own  sewing,  took  full  charge  of  her 
child  and  devoted  all  her  time  to  her  family.  She  always  enjoyed 
company  and  everyone  liked  her.  She  had  a  sweet,  affectionate 
manner,  was  practical  and  economical.  She  taught  in  Sunday 
School  and  was  interested  in  an  Esperanto  Club.  However,  her 
disposition  changed  perceptibly,  she  began  fretting  over  little  things 
and  was  irritable.  In  1907,  her  father  and  brother  died;  and  in 
191 1,  her  mother,  who  had  been  her  constant  care  for  two  years, 
died  suddenly  in  her  arms  which  caused  a  nervous  shock.  Because 
of  religious  differences,  members  of  her  own  family  became 
estranged  and  disagreed  over  i)roperty.  In  the  meantime,  she  cared 
for  three  members  of  her  husband''^  family  during  their  last  illness, 
and  her  health  became  imjjaired.  She  then  tried  to  get  interested 
in  Spiritualism  and  found  she  could  move  tables  and  write  yards 


PERIPHERAL  NEURITIS  433 

of  poetry  at  the  hands  of  the  spirits.     She  soon  found  that  this  was 
doing  her  harm,  so  desisted. 

Present  illness:  In  1909,  complained  of  feehng  badly,  had  head- 
ache, general  weakness,  drowsiness,  irritability,  restlessness,  anorexia 
and  some  gastric  disturbance.  Was  treated  for  a  month  in  a  local 
hospital — cause  not  ascertained.  In  November,  had  what  her  hus- 
band called  an  hysterical  attack.  She  became  more  restless,  was 
constantly  rubbing  her  hands  over  her  face,  fussing  with  her  hair, 
had  the  habit  of  gritting  her  teeth,  seemed  to  hate  the  sight  of  her 
husband  ;  if  he  spoke  to  her,  would  become  irritable  and  profane  ; 
accused  him  of  attempting  to  choke  her.  She  talked  fooHshly  and 
would  hide  in  the  bath  room,  and  told  her  husband  she  would  kill 
herself  if  he  did  not  leave  her  alone.  On  one  occasion  he  caught 
her  as  she  was  about  to  jump  from  a  second-story  window.  These 
attacks  came  on  about  three  times  a  year  at  first,  and  the  paroxysm 
would  last  half  an  hour  or  more.  They  gradually  increased  in 
duration  and  frequency.  Sometimes  they  would  be  preceded  by 
vomiting  and  general  weakness,  and  the  patient  would  frequently 
faint.  She  went  to  Cape  Cod  for  four  months  without  any  benefit. 
In  September.  191 3,  was  taken  with  severe  pains  in  the  abdomen — 
appendicitis  was  diagnosed.  The  next  day  it  seemed  more  like 
impaction ;  two  days  later  had  a  recurrence  of  her  usual  attacks. 
Since  that  time  has  complained  of  poor  eyesight;  examination  was 
negative.  Early  in  October,  1913,  seemed  stuporous  and  desired  to 
stay  in  bed.  When  urged  to  get  up  became  excited,  yelled  pro- 
fanely, pulled  her  hair,  made  suicidal  and  homicidal  threats.  She 
was  taken  to  a  local  hospital  for  a  week.  Early  in  November,  1913, 
she  complained  of  feeling  badly  again ;  was  given  some  brandy  and 
milk.  She  immediately  became  excited,  and  ran  out  into  an  alley 
shrieking.  After  a  few  days  was  able  to  conduct  her  home  as 
usual.  In  December,  1913,  became  restless  at  night,  would  get  up 
and  finally  go  back  to  bed  and  go  to  sleep.  It  was  discovered  she 
was  using  whiskey.  She  seemed  sleepy  and  stuporous  most  of  the 
time.  Quart  bottles  were  found  wrapped  in  towels,  in  stockings 
and  hidden  in  her  shoes.  For  about  a  month  she  had  purchased 
four  quarts  and  a  half  of  whiskey,  at  a  dollar  a  quart.  She  denied 
this  indulgence  and  did  not  seem  to  mind  the  deprivation  of  it. 
April  19,  1914,  complained  of  lameness  in  ankles  and  legs,  espe- 
cially when  climbing  stairs,  and  thinking  it  was  rheumatism,  the 
usual  remedies  were  applied.  This  gradually  grew  worse  and  on 
May  20,  1914,  she  was  unable  to  walk.  May  28,  wrist  drop  de- 
veloped, suffered  from  girdle  sensation,  pressure  of  tight  clothes, 
tight  shoes  and  had  excruciating  pains  in  the  extremities.  On  one 
occasion,  it  was  necessary  to  give  her  morphine.  She  was  taken 
to  a  local  hospital  for  a  week ;  later,  had  a  nurse  at  home.  Her 
paralysis  became  more  complete;  her  mental  symptoms  more  pro- 
nounced. Thought  the  neighbors  had  hurt  her  feelings,  that  all 
her  friends  had  gone  to  war  and  she  was  fighting  Indians ;  that  the 
white  and  colored  were  having  battles  with  terrible  slaughter,  on 
the  pavements;  that  her  dead  relatives  were  around  her,  especially 


434  AXITA  ALVERA  WILSON 

her  mother ;  that  cats,  dogs  and  babies  were  in  her  bed.  She  re- 
peatedly told  them,  that  something  was  under  her,  and  that  she 
was  afraid  she  was  smothering  her  baby.  She  prayed  a  great 
deal  for  herself  and  family.  She  had  no  aversion  for  her  husband 
but  frequently  called  him.  Thought  she  had  been  shopping  and 
doing  various  things  about  the  house.  She  was  admitted  here  July 
22,  1914. 

Mental  examination  two  days  after  admission:  She  answered 
the  questions  willingly  and  seemed  to  comprehend  their  meaning. 
Apparently  realized  her  uncertainty  and  would  invariably  make  her 
answer  a  question.  Whenever  her  memory  failed  her  she  had  a 
tendency  to  confabulate.  Her  paralyzed  condition  seemed  to  give 
her  no  anxiety.  She  frequently  said  she  should  be  up  and  doing 
the  work.  She  spoke  in  a  low,  soft  voice  with  more  or  less  effort. 
Dyspnea  became  more  marked. 

Stream  of  talk:  Was  coherent  and  free,  full  of  fabrications, 
showed  a  retrograde  amnesia. 

Emotional  status  and  attitude  of  mind:  She  showed  emotional 
instability  and  often  wept,  at  times  would  laugh  heartily.  She  said 
she  was  depressed — worried  because  her  mother  w'as  in  poor  health, 
but  after  all  she  was  only  a  step-mother.  Her  father  was  well  and 
she  had  visited  him  early  that  morning. 

Hallucinations  and  delusions:  She  admitted  hearing  strange 
noises  by  saying  that  very  often  when  she  was  considering  what  to 
do  she  could  mentally  hear  her  mother's  advice  urging  her  to  be 
careful  of  fire.  The  voice  was  distant  and  clear.  She  heard  many 
voices  at  a  distance  swearing  but  did  not  feel  that  they  were  directed 
toward  her ;  they  sounded  natural.  She  was  not  able  to  tell  from 
whence  they  came — thought  some  came  from  God.  She  saw  an 
angel  that  looked  like  a  male  cousin  of  whom  she  was  very  fond. 
He  looked  natural  but  was  dressed  differently.  Kept  telling  her  to 
beware  of  dynamite,  that  she  was  too  careless.  She  was  trying  to 
cut  down  a  dead  tree  to  get  a  swarm  of  bees.  She  saw  a  picnic  of 
twenty-five  babies  mostly  under  five  years  of  age,  and  she  saw  stairs 
with  beautiful  children  going  up  and  down  happily.  Sometimes  the 
most  beautiful  flowers  and  plants  were  around  her,  and  colored 
lights.  These  imaginary  people  were  always  kind  to  her.  She  felt 
that  these  hallucinations  had  been  going  on  for  fifteen  years. 

Dreams:  Her  dreams  were  usually  pleasant  about  her  home  in 
the  countr}- ;  horses  said  she  goes  fishing  a  good  deal  in  her  dreams 
and  often  dreams  of  her  sister.  Her  last  dream :  "  I  thought  my 
sister  had  left  the  bottom  of  the  house  open  and  her  baby  and  my 
baby  were  taken  from  their  cradles.  It  was  only  done  in  a  joke, 
and  we  got  them  in  six  hours.  They  didn't  get  any  disease.  Both 
were  as  .clean  as  could  be." 

Insicjht  and  judgment:  She  had  no  insight  in  her  condition.  Said 
she  came  to  Washington   from   1  Pennsylvania  to  finish  college  and 

was  married  to (giving  her  brother's  name).     Said  she 

was  not  brought  here  but  was  visiting.  Her  first  trouble  was  dis- 
location of  the  knee  two  weeks  ago,  when  she  had  an  accident  with 


PERIPHERAL  NEURITIS  435 

her  father's  horse;  that  if  she  could  get  out  and  exercise,  she 
would  be  all  right.  Said  she  was  scared  because  she  had  been  away 
from  everyone  she  knew.  She  did  not  believe  there  was  anything 
wrong  with  her  mind. 

Orientation:  She  is  completely  disoriented  for  time,  place  and 
person ;  thought  it  was  June,  1908,  in  the  autumn  ;  that  she  was  in 
Albany,  N.  Y.,  in  an  educational  center.  She  thought  she  had  come 
from  her  home  in  Lehigh  Co.,  Pa.,  to  meet  an  English  girl  whose 
name  she  could  not  remember.  She  thought  everyone  knew  her 
here  because  her  brother  had  been  here  a  number  of  years.  She 
was  able  to  dififerentiate  the  nurses  from  the  patients.  She  thought 
she  had  seen  the  physician  before,  and  gave  her  a  fictitious  name 
(and  has  adhered  to  it  since). 

Memory  for  remote  events:  Patient  could  tell  fairly  accurately 
what  had  happened  in  her  life  preceding  her  marriage.  She  had 
completely  forgotten  everything  within  the  past  twenty  years.  She 
showed  uncertainty  in  giving  details  and  dates. 

Memory  for  recent  events:  Patient  could  not  remember  what 
she  had  said  or  what  she  had  done  only  a  few  minutes  previously. 
She  could  not  give  any  account  of  her  illness  or  the  experiences 
which  led  to  her  commitment.  Soon  after  her  husband's  visit  she 
would  ask  if  he  were  coming  to  see  her.  She  could  not  remember 
whether  she  had  eaten  or  of  what  the  meal  consisted. 

Special  memory:  Tests  were  fairly  well  done.  She  could  not 
remember  historical  dates. 

General  memory:  Was  inaccurate,  especially  for  time. 

Intelligence  tests:  These  were  fairly  well  done,  although  she  left 
out  words,  showing  the  usual  memory  defects.  Calculations  were 
inaccurate.  She  was  able  to  repeat  the  days  of  the  week  and  the 
months  forward  and  backward  slowly.  Retention  tests  were  poorly 
done,  and  when  her  memory  failed  her,  she  had  a  tendency  to  add 
new  ideas. 

Physical  Status 

General  type  and  appearance:  Patient  is  a  large,  well  nourished, 
well  developed  white  woman.  Face  asymmetrical.  Nose  deviates 
to  left.  Muscles  of  face  have  an  ironed-out  appearance.  Expres- 
sion sad  and  subdued. 

Respiratory  system:  Nothing  abnormal  detected.  Dyspnea 
present. 

Circulatory  system:  Veins  on  right  breast  prominent,  otherwise 
negative. 

Alimentary  system:  Tongue  thickly  coated,  breath  offensive. 
Bowels  constipated.  Scar  i^  inches  long  above  the  pubis  present, 
site  of  old  operation.  Maculo-papular  eruption  present  in  left 
hypochondriac  region. 

Genito-urinary  system:  Nothing  abnormal  detected. 

Glandular  system:  No  glands  palpable. 

Nervous  system — subjective  complaints:  Patient  complains  of 
hands  and  feet  feeling  peculiar ;  she  does  not  know  whether  it  is  the 


436 


ANJTA  ALVERA  WILSON 


Fig.   I.     Characteristic   wrist-drop.   i.crii)hcral  iniiriti>,  at   tiiiu    ui    adiiiisM.-i 


PERIPHERAL  NEURITIS 


437 


Fig.  2.     Characteristic  ankle-drop  at  time  of  admission. 


438 


AX  IT  A  AW  ERA  UlLSON 


numbness  or  coldness.  At  times,  when  her  foot  gets  tangled  in 
the  bedding,  she  feels  as  though  something  \vas  pulling  her  and 
then  she  gets  delusions  that  dogs  are  tugging  at  her  feet.  Com- 
plain^  of  neuralgic  pains  in  extremities. 


Fi(i.   3.     Six   months   al'tt-r   admission.     Paralysis   of   wrists   much    iniijrovcd. 
Paficnt  is  alilc  to  feed  herself.     Contracture  of  little  finger  remains. 


Lutaucous  soisihilltlcs:  There  are  areas  of  anesthesia,  par- 
esthesia and  hyperesthesia  over  paralyzed  hands,  forearms,  feet  and 
legs.  As  the  patient's  replies  were  .so  uncertain,  no  definite  areas 
could  be  marked  out.     The  anesthesia  ^-eenied  more  marked  towards 


PERIPHERAL  NEURITIS  439 

the  extremity  and  the  hyperesthesia  along  the  course  of  the  radial 
and  musculo-cutaneous  nerves  in  the  upper  extremity  and  anterior 
tibial  and  peroneal  in  the  lower  extremity.  When  pressure  was 
made  over  the  deep  nerve  trunks,  pain  was  referred  to  the  hand 


Fig.  4.     Six  months  after  admission.     Paralj-sis  is  less  in  all  the  limbs.     Pa- 
tient is  able  to  walk  with  assistance. 

and  foot.  A  repetition  of  the  test  did  not  seem  to  intensify  the 
pain.  She  was  not  able  to  differentiate  cotton,  cloth,  wood,  glass, 
rubber  or  sponge  by  the  sense  of  touch.  The  whole  left  side  seemed 
more  hypersensitive  than  the  right,  although  her  response  was  vari- 


440  AXITA  AW  ERA  WILSON 

able.  There  was  an  impairment  of  muscular  sense.  Patient  was 
not  able  to  tell  which  toe  or  hnger  was  manipulated.  Her  sensa- 
tions of  pain  seemed  more  acute  as  her  replies  were  more  uncer- 
tain.    There  was  no  aphasia  or  apraxia  present. 

Motor  functions:  Facial  muscles  were  coordinated  and  under 
control,  although  they  appeared  weakened,  especially  around  the 
mouth,  shown  by  the  tremor.  Wrist  and  ankle  drop  were  present. 
Romberg  was  not  tested  as  patient  could  not  stand.  No  atrophies 
or  hypertrophies.     Profuse  perspiration  present  and  a  sour  odor. 

Reflexes:  Superficial  reflexes  were  normal.  Triceps  and  patellar 
reflexes  absent.  There  was  no  ankle  clonus  and  no  Babinski. 
Pupils  reacted  to  light  and  accommodated  normally.  There  was  no 
nystagmus. 

Cranial  nerves:  Patient  was  not  able  to  differentiate  any  of  the 
gustatory  or  olfactory  test  solutions.  Speech  and  audition  not  im- 
paired. 

Laboratory  findings:  The  urine  examination  and  Wassermann 
reaction  with  the  blood  serum  were  negative  on  admission. 

Treatment:  Patient  was  kept  in  bed  and  given  extra  nourishing 
diet ;  strychnine,  gr.  3';i(»  every  four  hours,  and  a  tablet  of  Blaud's 
with  arsenic,  every  four  hours. 

The  first  month,  patient's  condition  remained  unchanged.  She 
did  not  realize  that  she  was  paralyzed,  how  long  she  had  been  here, 
continued  to  have  a  mistaken  identity  of  those  about  her  and  to  con- 
fabulate. Some  days  she  was  very  restless  and  depressed,  fre- 
quently weeping.  She  felt  that  her  feet  and  legs  were  tied  together 
and  that  her  corsets  were  on  too  tight.  She  would  weep  when  her 
husband  visited  her,  would  tell  him  that  she  never  saw  a  doctor  or 
nurse  or  received  any  medicine.  Her  husband  found  that  she  had 
forgotten  practically  everything  that  had  happened  within  the  past 
twenty  years. 

The  last  of  October,  she  was  still  complaining  of  pain  in  her 
limbs,  and  the  muscles  showed  some  contracture.  She  was  allowed 
to  sit  up  in  a  chair  every  day  for  several  hours  but  she  did  not  ap- 
preciate that  her  feet  touched  the  floor.  Mental  condition  showed 
slight  improvement.  She  was  very  restless.  Physical  examination 
at  this  time  showed  little  change.  The  paralyzed  muscles  were 
more  atrophied  and  the  paralyzed  extremities  had  a  purple  color. 
The  circulation  was  sluggish  and  there  was  some  swelling.  Her 
replies  when  cutaneous  sensibilities  were  tested  showed  much  uncer- 
tainty.    The  hypersensitiveness  seemed  less. 

In  Xovember,  she  confabulated  less,  some  days  not  at  all. 

I'hysical  examination  made  December  21,  showed  that  the  tactile 
and  nuiscle  sense  had  improved :  Patient  was  able  to  tell  the  shape 
of  different  articles  placed  in  her  hand,  whether  they  were  soft  or 
hard,  but  could  not  differentiate  cotton  from  cloth.  Stereognostic 
sense  was  normal.  Her  replies  to  the  cutaneous  sensibility  tests  were 
more  accurate,  especially  for  pain  and  heat.  The  interossei  muscles 
showed  more  atrophy  and  the  concavity  of  the  hand  was  greater. 
Patient  was  given  daily  mild   faradic  treatments  for  half  an  hour 


PERIPHERAL  NEURITIS  44i 

over  the  paralyzed  muscles  and  along  the  spinal  column  at  the  side 
of  the  spinal  roots  of  the  diseased  nerves. 

In  January,  she  showed  marked  mental  improvement.  She  was 
able  to  feed  herself  and  attempted  to  walk,  being  supported  by  two 
nurses.  She  had  a  tendency  to  push  her  feet  before  her  and  it  was 
difficult  to  make  her  attempt  to  take  steps. 

Physical  examination  made  January  23  showed  less  hypersensi- 
tiveness  and  practically  no  anesthesia.  Patient  still  complained  of 
numbness  in  the  extremities.     The  reflexes  were  still  absent. 

Since  that  time,  she  has  shown  more  improvement — is  able  to  do 
many  things  for  herself,  and  walks  unassisted.  She  keeps  her  body 
slightly  stooped  to  balance  herself  and  her  gait  is  spastic  and  slow. 
The  sensation  in  the  extremities  is  nearly  normal  and  there  is  a 
slight  response  when  the  deep  tendons  are  tapped. 

Patient  will  leave  the  hospital  April  12,  191 5,  for  a  visit. 

Here  we  have  a  psychosis  developing  in  a  white  female  in  the 
fourth  decade,  who  gives  a  history  of  having  hysteriform  seizures 
for  several  years  in  early  womanhood,  which  no  doubt  predisposed 
to  the  development  of  a  psychosis  caused  by  the  use  of  proprietary 
medicine  containing  a  high  percentage  of  alcohol  and  morphine,  in 
tablespoon  doses  three  times  daily,  for  about  twelve  years.  The 
early  symptoms  were  manifested  by  headache,  drowsiness,  anorexia, 
and  gastric  irritability,  changed  disposition  and  irritability ;  later, 
had  definite  periods  of  excitement  and  showed  suicidal  and  homi- 
cidal tendencies,  followed  by  muscular  weakness  and  severe  pain  in 
extremities  which  developed  into  complete  paralysis,  with  wrist  and 
foot  drop,  loss  of  reflexes,  perverted  sensations,  pain  on  pressure 
over  deep  nerve  trunks,  accompanied  by  disorientation,  a  defective 
power  of  observation,  retrograde  amnesia  and  tendency  to  con- 
fabulate. 

The  alcoholic  history  with  presence  of  polyneuritis,  the  age  of 
the  patient  and  the  negative  reaction  of  the  Wassermann  will  aid  us 
in  differentiating  it  from  syphilitic  disease  or  arteriosclerosis,  and 
we  can  safely  make  the  diagnosis  of  Korsakow's  Psychosis. 

A  recent  Literary  Digest  quotes  that  statistics  of  the  United 
States  Internal  Revenue  Department  show  that  per  capita  con- 
sumption of  alcoholic  beverages  is  steadily  increasing  despite  the 
steady  growth  of  prohibition  legislation,  and  figures  in  the  National 
Bulletin  show  that  in  1899,  with  6,000,000  people  living  under 
"  dry "  laws,  the  combined  consumption  of  malt  and  spirituous 
beverages  was  16.91  gals,  per  capita.  In  1907,  with  35,000,000 
Hving  under  "  dry  "  laws,  the  combined  consumption  of  these  bever- 
ages was  23.58  gals,  per  capita.     In   1914,  with  48.000,000  living 


442  AXITA  ALVERA  WILSON 

under  ''  dry  "  laws,  the  combined  consumption  of  these  beverages 
was  25.00  gals,  per  capita. 

If  this  estimation  is  true,  it  would  be  interesting  to  watch  out  for 
an  increase  in  the  number  of  cases  of  "  Korsakow's  Psychosis." 

REFEREXXES 

1.  Bolton.  G.  C.     De  la  presbyophrenic   (Wernicke)    la  forme  senile  de  la 

psychose   de    Korsakow.     Jour.    f.    Psychol,    u.    Neurol.,    191 1,    XVIII, 
239-246. 

2.  de  Kraft.     Treatment  of  Neuritis  by  Electricity.     Internat.  Clinic,  Phila- 

delphia, 1914,  24. 

3.  Henderson.    David    K.     Korsakow's    Psychosis    Occurring   During    Preg- 

nancy.    Johns  Hopkins  Hosp.  Bulletin,  Vol.  XXV,  No.  283,  September, 
1914. 

4.  Hisholt,  A.  W.     Korsakow's  Psj'chosis  and  the  Amnesic  Symptom-Com- 

plex, with   a  Report  of  Three  Cases.    Jour.   Med.   Association,    1911, 
LVII.  1974-1980. 

5.  Humphries,  F.  H.     Constant  Currents  of  High  Intensity  and  Low  Den- 

sity in   the  Treatment  of   Neuritis   and   Polyneuritis.     Jour.   Advance 
Therapeutics.  New  York.  1914,  XXXII,  376-379. 

6.  Hun.  Henry.     American  Journal  of  the  Medical  Sciences,  April,  1885. 

7.  Hurd.     Korsakoff's    Psychosis.     Report   of    Cases.     Journal   of    Insanity, 

1899,  62. 

8.  Kauffmann,  A.  F.     Zur  Frage  der  Heilbarkeit  der  Korsakowschen  Psy- 

chose.    Zeitschr.  f.  die  ges.  Neurol,  und  Psv.,  Berlin,  1913.     Orig.  XX, 
488-510. 

9.  Korsakow.     Arch.  f.  Psychiatric,  XXI,  669. 

10.  Kraepelin,  E.     Psychiatric.     8  Auflagc,  1910. 

11.  Meyer,  E.    Zur  pathologischen  Anatomic  des  Korsakowschen  Symptomen- 

Komplexes  alkoholischen   Ursprungs.     Arch.    f.   Psychiat.  und   Nerve- 
krankheiten.     Band  1912,  XLIX,  469-481. 

12.  Meyer,   Gottfried.     Ein   Beitrag  zu   der   Lehre  von  dem   Korsakowschen 

Symptomencomplexc   mit  besonderer   Berucksichtigung  seiner  trauma- 
tischen  Aetialogie.     Kiel,  1913,  Schmidt  &  Klaunig. 

13.  Miller,  Harry  W.     Korsakoff's  Psychosis — Report  of  Cases.     Journal  of 

^  Insanity,  495-523- 

14.  Nacke,  P.     Ein  fall  von  atypischen  Krampfen  und  wochenlang  andanern- 

dcm  Korsakoff.     Arch,  fiir  Psychiatric  und  Nervenkrankheiten,  Band 
XLIX,  372-395- 

15.  O'Malley,    Mary.     Amer.    Jour,    of    the    Medical    Sciences,    Vol.    CXLV, 

1 913.  865. 

16.  O'Malley  and  Franz.     American  Journal  of  Insanity,  LXV,  No.  2,  1908. 

17.  Starr,  M.  A.     Nervous  Diseases — Organic  and  Functional. 

18.  Tiling.     Ueber  alkoholische  Paralysis  und   infectiose   Neuritis  multiplex. 

1897,  Allgem.  Zeitschr.  f.  Psychi.,  XLVIII.  549. 

19.  Thoma,    Ernest.     Beitrag   zur   pathologischen    Anatomic   der    Korsakow- 

schen Psychose.     AUgemeine  Zeitschrift  fiir  Psychiatric,  Band  LXVII, 
579-587- 

20.  White,  William  A.     Outlines  of  Psychiatry. 

21.  Ziehen,  Th.     Psychiatric.     4th  Auflagc,  1911. 

22.  Ziehen,  Th.     Text-book  of  Psychiatry. 


Society  lProccebin09 


BOSTON  SOCIETY  OF  PSYCHIATRY  AND  NEUROLOGY 

November  i8,  1915 

The  President,  Dr.  Walter  E.  Paul,  in  the  Chair 

A  NEW  TREATMENT   FOR   PARALYSIS   AGITANS 

By  Walter  B.  Swift,  M.D. 

Reference  was  first  made  to  a  paper  offered  a  year  and  a  half  previously 
reporting  the  cessation  of  tremor  in  a  case  of  paralysis  agitans  for  ten  days. 
No  cause  for  this  could  be  ascertained.  Since  then  a  treatment  has  been 
sought  to  accomplish  the  same  thing.  This  consists  in  slow  arm  movements 
in  various  directions  repeated  for  fifteen  to  twenty  minutes  three  times  a  day. 
The  patient  shown  acknowledged  that  tremor  had  entirely  stopped  for  one 
or  two  periods  of  an  hour  long  and  for  two  evenings  of  several  hours ;  also 
there  is  some  general  relief,  such  as  less  muscular  spasm,  more  ease  and 
quietude  of  mind,  less  pain  and  tiredness  from  muscular  contraction. 

THE  TEACHING  OF  NEUROPATHOLOGY,  (a)  THE  STUDENT 

TYPE 

By  Walter  B.  Swift,  M.D. 

Dr.  Swift  showed  that  the  usual  type  of  student  was  not  necessarily  over- 
observant,  but  from  his  work  in  note-taking  and  cramming  constituted  an 
entity  which  might  be  described  as  a  hearing,  slightly  collaborating,  writing 
individual.  In  order  to  meet  the  demand  for  the  course  as  required  in  Tufts 
Medical  School  Dr.  Swift  instituted  efforts  to  change  this  type.  Methods 
employed  are  reserved  for  a  later  report.  The  new  type  of  student,  which 
was  held  as  the  ideal,  could  be  described  as  a  seeing,  largely  collaborating, 
talking  individual.  Reference  is  made  to  college  students  as  an  illustration 
of  the  former  type;  and  to  intellectual  work  later  in  life  as  naturally  evolving 
the  latter  type.  Higher  standard  of  scholarship  resulted  from  this  effort  to 
change  the  usual  hearing,  slightly  collaborating,  writing  individual  into  the 
seeing,  largely  collaborating,  talking  individual. 

TWO  CASES  OF  CEREBRAL  HEMORRHAGE  SIMULATING  BRAIN 

TUMOR 

By  J.  B.  Ayer,  M.D. 

Oppenheim  says  in  his  text-book :  "  I  have  only  once  found  choked  disc 
in  chronic  recurrent  hemorrhage."  This  statement  alone  seemed  to  be  suffi- 
cient excuse  for  offering  two  cases,  in  which  there  was  not  onlj'  choked  disc, 
but  other  evidence  of  increased  intracranial  pressure,  so  closely  simulating 
brain  tumor  that  operation  was  performed  in  each  case. 

443 


444     BOSTOX  SOCIETY  OF  PSYCHIATRY  AXD  XEUROLOGY 

Case  I. — Man.  50  years  of  age.  One  year  ago  had  had  a  "  shock."  fol- 
lowing which  he  remained  generally  weak,  though  not  paralj'zed,  complaining 
of  dizziness  and  headache,  aggravated  during  the  three  weeks  just  previous. 
Examination  suggested  moderate  increase  of  intracranial  pressure,  with  sus- 
picion of  tumor  in  the  cerehello-pontine  angle  on  account  of  deafness,  marked 
cerebellar  ataxia,  speech  disturbance,  and  a  questionable  Babinski  right.  The 
eye-grounds  showed  moderate  papilledema  with  patches  of  exudate,  and  on 
account  of  high  blood  pressure  and  albuminuria,  the  diagnosis  of  nephritis 
was  also  held.  Subtemporal  decompression  relieved  all  symptoms  somewhat 
and  the  patient  was  discharged  with  a  diagnosis  of  "  probable  brain  tumor." 

Two  months  later  he  was  found  dead  on  the  bathroom  floor.  Autopsy 
showed  a  large  hemorrhage  as  the  immediate  cause  of  death.  The  brain  was 
found  to  contain  many  other  hemorrhages  of  size  varjing  from  the  head  of 
a  pin  to  that  of  a  large  lima  bean.  At  least  five  ages  of  hemorrhage  were 
suggested  bj-  the  difference  in  color  between  them.  No  tumor  was  evident. 
Chronic  interstitial  nephritis  and  hypertrophy  of  heart  were  also  present. 

Here.  then,  was  a  case  of  chronic  interstitial  nephritis  with  papilledema, 
in  which  the  cerebral  symptoms  were  such  as  to  suggest  the  progressive  irri- 
tation of  a  tumor,  but  which  were,  in  fact,  due  to  successive  hemorrhages 
associated  with  general  cardiorenal  disorder. 

Case  II. — A  man  of  35  was  said  to  have  had  a  "  shock  "  a  few  days  pre- 
vious to  examination.  He  was  dull  and  confused  mentallj^  exhibiting  a  par- 
tial right  hemiplegia.  Headache,  dull  and  continuous.  Choking  of  both 
discs,  most  on  the  right  (3  diopters).     Urine  negative. 

A  diagnosis  of  brain  tumor  was  thought  likely  and  parietal  decompression 
performed.  Considerable  increase  of  intracranial  pressure  was  found,  but  no 
evidence  of  tumor. 

One  year  later  this  patient  died  and  autopsy  showed  the  cause  of  death 
to  be  a  large  hemorrhage  of  the  brain.  Xo  tumor  was  found,  but  an  old 
hemorrhage  of  considerable  size  occupying  a  portion  of  the  caudate  nucleus, 
internal  capsule  and  corona  radiata  appeared  as  the  evident  cause  of  symp- 
toms the  year  previous,  which  had  led  to  operation  for  supposed  brain  tumor. 

Dr.  Walter  B.  Swift  said  that  Starr  reports  a  very  interesting  case  of 
some  slowly  advancing  lesion.  The  patient  knew  three  languages :  English, 
German  and  French,  and  lost  one  first,  then  another,  retaining  English,  his 
first  learned — or  mother  tongue.  It  would  be  of  interest  to  know  if  Dr. 
Ayer  has  found  in  his  successive  lesions  any  new  evidence  for  more  minutely 
located  cortical  areas,  as  is  shown  in  this  case  reported  by  Starr. 

Dr.  Taylor  said  he  saw  no  reason  why  there  .should  not  be  mild  optic 
neuritis  and  even  choking  of  the  discs  due  to  intracranial  pressure  in  recent 
hemorrhage  of  the  brain,  and,  as  a  matter  of  fact,  slight  disc  changes  are 
common  in  apoplexy.  The  striking  thing  is  that  the  changes  are  so  extensive 
and  last  so  long.  He  mentioned  another  case,  in  which  there  seemed  to  be  a 
pretty  definite  brain  tumor  syndrome,  including  a  marked  swelling  of  the  optic 
discs,  though  not,  to  be  sure,  typical  "  choked  disc,"  in  which  case  operation 
had  failed  to  show  tumor.  Subsequent  autopsy  showed  cerebral  hemorrhage 
as  the  cause. 

Dr.  Knapp  said  that  slight  disturbances  in  the  optic  nerves,  blurring  of 
the  outljnes  of  the  disc,  tortuosity  of  the  vessels,  congestion  and  slight  swell- 
ing— were  not  uncommon  in  apoplexy,  but  so  great  swelling  as  three  diopters 
was  extremely  rare.  He  had  advised  the  operation  in  this  case,  but  could 
recall  only  the  fact  that  before  the  history  of  bleeding  was  known,  blood  had 
been  taken  for  a  Wassermaim  without  any  disturbance,  but.  after  it  was 
known  that  the  man  was  a  "bleeder,"  they  became  apprehensive  even  at 
giving  a  hypodermic. 


BOSTON  SOCIETY  OF  PSYCHIATRY  AND  NEUROLOGY    445 

PHYSIOLOGICAL  CONSIDERATIONS  IN  THE  DIFFERENTIAL 

DIAGNOSIS  OF  NEURASTHENIC,  HYSTERICAL,  AND 

PSYCHOTIC  SYMPTOMS 

By  Donald  Gregg,  M.D. 

Dejerine  and  Gauckler,  in  their  book  upon  the  psychoneuroses,  deal  with 
symptoms  involving  the  autonomic  system^almost  entirely.  Janet  in  his  book, 
"The  Major  Symptoms  of  Hysteria,"  deals  with  symptoms  involving  for  the 
most  part  the  central  nervous  system. 

Many  psychotic  cases  show  a  seeming  lack  of  correspondence  between 
the  emotional  condition  and  symptoms  involving  the  autonomic  system. 

The  suggestion  is  here  made  that  neurasthenic,  hysteric  and  psychotic 
symptoms  are  possibly  to  be  distinguished  from  one  another  on  physiological 
grounds  based  upon  a  differentiation  between  symptoms  involving  mainly  the 
voluntary  nervous  system  as  in  hysteria ;  symptoms  involving  mainly  the  auto- 
nomic system,  as  in  neurasthenia,  and  symptoms  showing  possibly  a  break 
between  the  emotional  activity  of  an  individual  and  his  autonomic  nervous 
system  as  in  a  psychosis. 

Dr.  Walter  B.  Swift  said  this  attempted  correlation  between  neurasthenia 
and  the  autonomic  nervous  system,  and  between  hysteria  and  the  central 
nervous  system  is  very  interesting.  It  immediately  brings  up  an  array  of 
points  of  attack.  The  Freudians  should  have  a  word.  But  if  both  of  these 
lesions  can  be  shown  to  have  cerebral  signs,  Dr.  Gregg's  correlation  breaks 
down.  Neurasthenia  mentally  presents  a  picture  of  over-active,  uninhibited 
overflow  of  mental  functions  from  poorly  inter-controlled  brain  centers. 
Hysteria  shows  a  type  of  mental  function  where  isolated  brain  areas  seem  to 
work  while  others  are  relegated  to  unconsciousness.  This  is  shown  in  the 
suggestive  way  a  hysteric  may  be  led.  All  this  is  of  course  on  the  conscious 
side.  If,  then,  as  we  know,  neurasthenia  is  an  overflow  of  numerous  poorly 
interrelated  brain  centers,  and  hysteria  a  type  of  suggestively  isolatable  brain 
centers,  neither  of  these  entities  can  be  counted  out  of  the  central  nervous 
system. 


HEREDITARY  ANCHYLOSIS  OF  THE  PROXIMAL  PHALANGEAL 
JOINTS  (SYMPHALANGISM)! 

By  Harvey  Gushing,  M.D. 

There  are  many  recognized  forms  of  congenital  malformation  of  the 
hands  and  feet.  Walker  in  igoi  described  the  type  of  deformity  that  is  made 
the  subject  of  this  paper,  and  showed  that  the  lesion  had  been  transmitted 
through  five  generations,  though  the  number  of  his  recorded  cases  was  too 
small  to  justify  a  definite  conclusion  on  the  Mendelian  basis.  Farabee  in 
1905,  and  Drinkwater  in  1908,  showed  that  another  type  of  deformity  of  the 
hands,  known  as  brachydactylism,  was  a  dominant  unit  character,  transmitted 
in  accordance  with  Mendel's  law. 

The  lesion  in  the  condition  under  discussion  consists  of  a  congenital 
anchylosis,  or  failure  of  formation  of  the  joints,  between  the  proximal  and 
middle  row  of  phalanges,  resulting  in  a  condition  that  is  known  in  the  com- 
munity as  "  stifif  fingers,"  in  contradistinction  to  the  normal,  which  are  called 
"crooked  fingers."  This  condition  has  been  transmitted  through  seven  gen- 
erations, the  progenitor  of  the  family  having  migrated  from  Scotland  to 
Virginia  in  1700.  There  are  connections  of  the  family  still  in  Scotland  who 
carry  the  trait. 

1  This  paper  will  appear  in  full  in  the  January  number  of  "  Genetics." 


446     BOSTOX  SOCIETY  OF  PSYCHIATRY  AXD  XEUROLOGY 

In  the  Virginia  branch,  which  has  been  made  the  object  of  this  statistical 
study,  the  record  has  been  secured  of  312  descendants,  among  whom  there 
are  84  affected  persons,  a  few  more  than  the  25  per  cent,  of  the  total  number 
which  would  have  been  expected.  Excluding  the  incomplete  families  of  the 
first  three  generations,  in  which  were  recorded  few  other  than  the  affected 
persons  carrj-ing  the  trait,  there  are  72  completed  families,  comprising  302 
individuals,  78  of  them  being  affected,  namely,  25.8  per  cent.  Of  these  72 
completed  families,  44  of  them  were  from  the  mating  of  unaffected  parents, 
with  152  unaffected  children.  Of  the  28  families  in  which  there  was  an 
affected  parent,  there  were  150  children,  78  of  them,  or  52  per  cent,  carrying 
the  trait.  It  has  been  observed  that  the  trait  may  be  transmitted  in  outspoken 
form  by  a  parent  in  whom  it  is  inconspicuous,  though  never  by  unaffected 
parents.  The  trait,  moreover,  is  transmissible  by  either  sex,  and  both  hands 
and  feet  of  the  affected  individuals  may  be  involved. 

The  trait,  in  short,  behaves  as  a  simple  Mendelian  dominant,  with  an  equal 
chance  among  the  offspring  of  affected  individuals  that  it  will  be,  or  will  not 
be,  inherited. 

Dr.  Paul  asked  what  happens  to  the  flexor  sublimis  digitorum. 

Dr.  Gregg  asked  if  Dupuytren's  contraction  also  followed  Mendelian 
lines,  as  suggested  in  a  group  of  cases  known  bj'  him. 

Dr.  Taylor  spoke  of  a  family  group  which  he  had  studied  recently,  in 
whom  a  vago-glosso-pharyngeal  paralysis  developed  in  members  of  the  family 
in  the  fifth  decade. 

Dr.  Knapp  thought  that  the  hypothesis  of  a  defective  development  of  the 
phalangine  from  failure  of  the  center  of  ossification  was  not  a  satisfactory 
explanation  of  the  condition.  In  such  an  event,  if  the  phalanx  showed  in- 
creased growth  to  make  up  the  deficit,  there  should  be  no  partial  joint  or 
enlargement  of  the  bone  at  the  place  where  the  phalango-phalangine  joint 
ought  to  be.  It  seemed,  therefore,  that  the  trouble  was  due  to  a  failure  of 
development  of  the  joint  rather  than  the  bone.  Although  the  brachydactylism 
was  a  striking  feature  in  some  of  these  cases,  there  were  no  changes  such  as 
are  seen  in  the  very  marked  brachj-dactylism  of  achondroplasia, — the  mush- 
rooming of  the  bones,  the  deformity  and  the  presence  of  peculiar  excres- 
cences on  the  bones.  As  a  contrast  to  the  strict  conformity  to  the  doctrines 
of  Mendel,  as  shown  in  these  cases,  he  mentioned  a  family  in  which  poly- 
dactylism  was  pronounced, — an  additional  digit  on  both  hands  and  both  feet. 
He  had  known  several  members  of  the  family  and  had  been  informed  that 
the  condition  had  existed  for  at  least  seven  generations,  but  it  manifested 
itself  only  in  the  first-born  child,  especially  if  not  exclusively  in  the  males. 
He  inquired  as  to  the  functional  capacity  in  the  hands  of  these  "  stiff-fingered  " 
people. 

December  23,  1915 

The  President,  Dr.  W'.m.thr  E.  P.\ul.  in  the  Chair 

THE  TEACHING  OF  NEUROPATHOLOGY.     II.  CHANGING  THE 
STUDENT  TYPE 

By  Walter  B.  Swift,  M.D. 

Mention  of  two  i)revious  types  was  made,  which  were  shown  in  a  previous 
paper.  The  method  employed  of  changing  the  type  consists  in  calling  atten- 
tion to  cuneal  functions  in  contradistinction  to  temporal  lobe  functions  as  an 
avenue  of  obtaining  knowledge.  Excessive  note-taking  was  dispensed  with; 
and  in  place  first-hand  observation  of  tissue  was  substituted.     There  was  no 


BOSTON  SOCIETY  OF  PSYCHIATRY  AND  NEUROLOGY     447 

objection  made  to  notes  taken  after  observation.  This  new  standard  was 
maintained  throughout  the  course ;  and  resulted  in  replacing  temporal  lobe 
functions  with  cuneal  functions. 

A  CASE  OF  "ESSENTIAL  TREMOR"  WITH  A  NEW  TREATMENT 
By  Walter  B.  Swift,  M.D. 

A  case  that  previously  showed  marked  tremor  in  the  face,  right  arm  and 
leg  and  slight  tremor  on  the  other  side.  The  child  when  first  seen  could  not 
talk  without  marked  constant  tremor ;  the  writing  was  unsteady ;  and  patient 
had  to  hold  pen  with  both  hands.  She  could  not  feed  herself  or  drink  water. 
Could  not  sit  still.  After  about  two  years'  treatment  all  these  symptoms 
diminished  three  fourths.  The  tremor  is  markedly  improved ;  she  can  now 
sit  still ;  she  can  write  with  one  hand,  and  feed  herself,  and  drink  at  table. 

In  brief,  a  marked  case  of  "  Essential  Tremor  "  is  treated  for  two  years 
with  slow  movements  of  face,  arm  and  body  and  is  three  fourths  relieved. 


PATHOLOGICAL  FINDINGS  IN  THE  SEMILUNAR  GANGLION  IN 
THE  PSYCHOSESi 

By  A.  Myerson,  M.D. 

The  semilunar  ganglion  shows  two  types  of  change.  First,  an  acute  type 
corresponding  in  every  respect  to  the  ordinary  axonal  reaction.  This  was 
prominently  present  in  five  cases  :  one  of  acute  exhaustion,  three  of  enteritis, 
and  one  of  generalized  tuberculosis.  Second,  chronic  changes  indicating  a 
metabolic  disturbance  rather  than  any  inflammatory  process  and  for  which 
the  term  coined  by  Levaditi,  "  neurathrepsia,"  seems  proper.  The  concept 
of  neurathrepsia  stands  in  contrast  with  that  of  neuronphagia  in  that  in  the 
latter  the  phagocytes  and  satellites  are  phagocytic  for  the  injured  nerve  cells. 
In  neurathrepsia,  as  preeminently  exemplified  by  the  semilunar  ganglion,  pig- 
mentation of  two  kinds  is  prominent :  first,  the  ordinary  lipochrome  pig- 
mentation, and,  second,  an  oxyphilic  pigmentation.  These  pigmentary  proc- 
esses may  go  on  to  complete  disintegration  of  the  cell.  Nuclear  changes  also 
are  very  comrhon.  The  capsule  shows  mild  reactive  processes  manifested  by 
swelling  of  the  nuclei  of  the  capsulary  cells  and  increase  in  their  number  as 
well  as  the  encroachment  upon  nerve  cells.  Interstitial  connective  tissue 
shows  a  moderate  increase. 

Contrasting  the  interstitial  changes  with  the  changes  found  in  the  central 
nervous  system,  the  Gasserian  ganglion  and  the  adrenal  gland,  structures 
related  by  form  or  by  function,  a  very  marked  peculiarity  of  the  semilunar 
ganglion  is  the  absence  of  inflammatory  products,  such  as  leucocytes,  plasma 
cells,  lymphocytes,  etc.  In  small  numbers  there  is  present  an  eosinophilic 
connective  tissue  cell  which  bears  some  relationship  to  the  changes  found. 

It  is  concluded  first  that  the  semilunar  ganglion  shows  precocious  senility 
and  secondly  it  is  affected  by  general  processes  going  on  throughout  the  body. 
Findings  by  other  workers  indicate  that  in  the  symptomatology  of  general 
disorders,  injury  to  the  peripheral^  located  nervous  cells  is  to  be  considered 
and  the  appropriate  therapy  is  strongly  recommended. 

Dr.  Southard  said  he  thought  the  pathological  study  of  the  sympa- 
thetic nervous  system  most  important.  He  questioned  if  the  changes  spoken 
of  cannot  be  an  index  of  the  integrity  of  the  musculature  of  the  intestine  or 
of  whatever  part  is  concerned.  He  thought  that  Alzheimer's  "  central  neu- 
ritis "  really  was  a  "  general  neuritis." 

^  To  appear  in  toto  in  tlie  American  Journal  of  Insanity. 


44S     BOSTOX  SOCIETY  Of  PSYCHIATRY  A.\D  XEUROLOGY 

EPIDURAL  IXTRASPIXAL  TUMOR  OF  TWO  YEARS'  DURATION; 
OPERATION.    RECOVERY 

By  W.  E.  Paul,  M.D. 

The  patient,  a  rugged  woman  of  43  jears,  first  noticed  in  November,  1913, 
that  her  feet  were  clumsy  in  walking.  Soon  some  numbness  developed  in  her 
feet  and  she  stumbled  and  fell  at  times.  Hot  water  was  not  felt  by  the  left 
foot  and  the  numbness  increased  upward  in  the  left  leg  so  that  she  did  not 
feel  the  prick  of  a  pin.  The  right  leg  was  weak  but  prick  and  heat  were 
recognized.  No  pain  or  tenderness ;  sphincters  unimpaired.  Some  eight 
weeks  elapsed  during  which  these  sj-mptoms  developed.  She  entered  the 
Massachusetts  General  Hospital  January,  1914,  examination  showing :  Pupils 
equal,  reacting  well  to  light  and  distance,  knee  jerks  lively,  especially  the 
right,  position  sense  in  toes  normal,  ankle  jerks  normal.  Babinski  suggested 
on  right  but  no  clonus ;  abdominal  reflexes  not  obtained.  Touch  felt  every- 
where without  apparent  loss.  Temperature  and  pain  senses  diminished 
throughout  the  left  leg  and  left  half  of  the  trunk  to  a  level  just  above  um- 
bilicus; on  the  right  there  was  also  impairment  of  pain  and  temperature 
appreciation.  Gait  unsteady.  Both  blood  and  spinal  fluid  showed  negative 
Wassermann.  X-ray  revealed  nothing  abnormal  in  the  vertebrse.  Diagnosis 
of  syringomyelia  was  made. 

In  December,  1914,  she  reentered  the  hospital  with  accentuation  of  her 
previous  symptoms  and  the  diagnosis  of  syringomyelia  was  again  made. 

August  3,  1915,  she  again  entered  the  hospital  and  was  hardly  able  to  get 
about.  Romberg  marked.  Ankle  clonus  had  developed  on  the  right  and 
there  w^as  double  patellar  clonus,  with  Babinski  on  right  only.  Touch  sense 
was  preserved  but  pain  and  temperature  senses  were  practically  lost  up  to  the 
sixth  dorsal  level.  Though  touch  was  appreciated  everywhere,  the  change  of 
sensation  at  the  sixth  dorsal  level  was  determined  by  the  pin  point  as  being 
different  and  less  natural  below  this  level  than  above  it;  it  was  not  deter- 
mined by  sharp  delimitation  of  pain  and  temperature  sensibility  at  this  level. 

The  spinal  fluid  findings  on  the  three  different  occasions  were  as  follows: 


Jan.  9,  1914. 

Pressure    150  mm. 

Cells   per   c.mm...8 

Noguchi    globuli..3  plus 

Nonne  phase   ....  Faintly   positive 


Dec,  19  -4. 


Strong  positive 
Faintly  positive 


Gold   chloride    . . .  Pathological,      but    Syphilis 
negative      for 
sj'philis 

Wassermann    Negative  Negative 


Aug.,  1915 

210  mm. 

5 

Strong  positive 

Moderately  posi- 
tive 

Sj'philis  or  non- 
tubercular  tumor 

Negative 


The  objective  symptoms  pointed  to  intra-mcdullary  disease  of  the  cord, 
and  in  the  first  eight  weeks  of  the  disease  it  was  regarded  as  a  myelitis; 
later  the  evidence  seemed  to  justify  the  view  that  syringomyelia  existed.  At 
the  last  visit  in  August,  1915,  the  suspicion  of  a  tumor,  other  than  gliosis,  was 
strengthened  by  the  partial  degree  of  spinal  impairment,  combined  with  a 
marked  level  of  sensory  change  at  the  sixth  dorsal  segment.  Exploratory 
laminectomy  was  advised  and  i)erformed  by  Dr.  W.  J.  Mixtcr  on  August  17. 
A  tumor  presenter!  at  the  fifth  vertebral  level,  extra-durally,  and  was  com- 
pletely removed  ;  it  measured  4x2  cm.  A  cup-like  depression  existed  in  the 
fifth  vertebra  conforming  to  the  tumor. 

Diagnosis  of  tumor  (J.  H.  Wright  J,  fibrosarcoma. 


BOSTOX  SOCIETY  OF  PSYCHIATRY  AND  NEUROLOGY     449 

Surgical  recovery  was  uncomplicated  and  functional  return  was  very 
rapid ;  at  the  end  of  eight  weeks  the  use  of  the  legs  was  practically  complete 
and  sensory  restoration  had  taken  place.  Reflexes  were  still  active  but  the 
Babinski  and  clonus  had  disappeared. 

It  would  be  of  interest  to  examine  the  progress  of  symptoms  from  cord 
pressure  to  determine  whether  any  tj'pical  order  existed.  Are  all  the  nerve 
tracts  afifected  alike  or  do  they  fail  one  after  another  and  what  is  the  order 
of  functional  block?  In  this  case  the  order  approximately  was :  (i)  posterior 
columns;  (2)  lateral  tracts;  (3)  antero-lateral  tracts  ;  (4)  sphincter  control- 
ling tracts.  Least  vulnerable  were  the  tracts  conveying  touch  sense.  The 
order  of  severity  is  practically  the  same  as  that  for  invasion.  In  keeping 
with  the  right-sided  location  of  the  neoplasm  is  the  partial  Brown-Sequard 
distribution  of  symptoms  suggested  by  the  greater  spasticity  on  the  right  and 
the  greater  sensory  impairment  on  the  left.  The  time  development  of  symp- 
toms as  well  perhaps  as  the  absence  of  subjective  pain  indicates  that  the 
effects  of  pressure  were  chiefly  on  the  columnar  tracts  and  not  on  the  roots 
or  commissural  crossings  of  the  temperature  and  pain  tracts. 

Patient  appeared  and  seemed  normal  in  every  way. 

Dr.  Alixter  showed  the  tumor  and  made  remarks  on  the  surgical  aspects 
of  the  case. 

Dr.  Knapp  said  he  had  found  the  cases  of  spinal  cord  tumor,  initiated  by 
very  intense  pain,  to  be  in  the  minority,  especially  the  cases  in  which  he 
had  advised  operation.  A  certain  amount  of  dull  aching,  not  very  exactly 
localized,  was  most  common.  He  had,  within  a  week  or  two,  seen  a  case 
which  he  reported  before  the  American  Neurological  Association  in  1913,^ 
which  had  had  a  very  curious  history,  the  explanation  of  which  was  very 
difficult.  About  a  j'ear  after  an  extra-dural  growth  had  been  removed  the 
symptoms  returned.  Fearing  a  possible  recurrence,  a  second  operation  was 
performed ;  only  a  little  accumulation  of  fluid  was  found  and  the  patient  made 
a  good  recovery,  walking  as  well  as  Dr.  Paul's  patient.  About  a  year  after 
the  case  had  been  reported  the  symptoms  again  returned.  Mindful  of  the 
previous  experience  and  thinking  that  there  was  another  accumulation  of 
fluid,  repeated  lumbar  punctures  were  made,  at  first  with  slight  relief,  but 
later  with  no  benefit.  Consequently,  a  third  operation  was  performed.  There 
was  no  compression  from  the  scar,  no  adhesions  within  the  dural  cavity,  but 
again  there  seemed  some  excess  of  cerebrospinal  fluid.  She  again  made  a 
perfectly  good  recovery.  Two  or  three  months  ago  the  symptoms  began  to 
return,  and  she  is  now  in  the  hospital  for  more,  lumbar  punctures  and  possibly 
a  fourth  operation,  with  as  much  trouble  as  ever,  a  fairly  marked  spastic 
paraplegia  with  slight  sensory  symptoms. 

Dr.  J.  J.  Putnam  said  he  had  seen  the  patient  from  time  to  time  and  that 
he  had  postponed  operation  not  believing  that  there  was  a  cord  tumor,  but 
that  he  had  finally  recommended  it,  seeing  that  the  case  was  otherwise 
hopeless. 

With  reference  to  Dr.  Knapp's  case,  he  said  that  he  had  had  a  case  where 
pain  was  associated  with  assumulation  of  spinal  fluid  subsequent  to  opera- 
tion, which  when  let  out  brought  about  a  permanent  cure. 

PSYCHIATRIC  CONTRIBUTIONS  TO  THE  STUDY  OF 
DELINQUENCY 

By  Herman  Adler,  M.D. 

The  subject  of  delinquency  is  one  which  has  attracted  the  attention  of 
experts  in  many  fields  from  earliest  times.     Of  late  years  there  has  been  a 
1  Journal  of  Nervous  and  Ment.\l  Disease,  January,  1914. 


45°     BOSTOX  SOCIETY  OF  rSYCHIATRY  AXD  XEUROLOGY 

.tendency  to  regard  delinquency  as  a  manifestation  of  abnormality  if  not  of 
disease.  While  the  attitude  of  the  community  is  changing  in  regard  to  delin- 
quency and  taking  on  more  the  attitude  of  regarding  delinquency  as  com- 
parable to  disease  and  therefore  to  be  treated  with  sympathy  and  constructive 
remedies,  the  law  remains  searching  for  responsibility.  We  are  apt  to  blame 
the  law  and  exalt  science  in  this  connection.  The  truth  of  the  matter  is  that 
medicine,  and  psychiatry  in  particular,  have  not  yet  delimited  the  problem  or 
discovered  sufficient  facts  to  warrant  definitions  of  such  precision  that  the 
law  can  note  them.  When  it  comes  to  definitions,  we  find  nothing  very  satis- 
factor}'.  The  law  has  been  passed  in  Massachusetts  recognizing  the  defective 
delinquent  as  ,"  an  individual  who  has  committed  an  offense  not  punishable 
by  death  or  imprisonment  for  life,  but  who  ordinarily  might  be  committed  to 
a  state  prison  and  so  forth,"  as  mentally  defective.  The  English  Mental 
Deficiency  Act  of  1913,  which  was  to  become  operative  in  1914,  but  was  pre- 
vented by  the  war,  classifies  idiots,  imbeciles,  feebleminded  persons  and  moral 
imbeciles.  The  classification  of  psychopathic  personality  as  contained  in 
Kraepelin's  Psychiatric,  eighth  edition,  volume  IV,  describes  a  number  of 
groups  of  individuals  belonging  to  the  "  not  insane,  not  defective "  group. 
In  analyzing  an  individual  there  are  two  points  to  be  considered :  First,  the 
intelligence  of  the  individual,  that  is,  his  abilit\-,  consciously  and  logically,  to 
direct  his  conduct ;  secondly,  the  emotions.  The  intelligence  is  the  most 
recently  developed  faculty.  The  emotions  have  been  developed  out  of  in- 
stincts, and  are  much  older  in  the  history  of  the  development  of  the  indi- 
vidual. In  health  there  is  a  reciprocal  relation  between  the  two  which  is 
more  or  less  in  equilibrium.  It  is  manifestly  impossible  to  analyze  human 
nature  in  the  present  state  of  our  knowledge.  It  also  seems  probable  that  it 
will  be  many  generations  before  this  will  be  done  with  such  a  degree  of 
accuracj-  that  scientific  prediction  may  result.  We  are  therefore  in  the  same 
position  in  which  Ehrlich  found  himself  when  he  first  proposed  his  side  chain 
theory  of  immunity.  It  will  take  the  psj-chologists  and  neurologists  a  long 
time  to  prepare  accurate  explanations  of  recognized  phenomena,  just  as 
Ehrlich  said  it  would  take  the  chemists  a  hundred  years  to  explain  the  phe- 
nomena of  immunity.  Introspective  psychology  with  painstaking  psycho- 
analysis of  the  individual  cases  is  too  time-consuming  to  be  employed  on  the 
large  scale.  We  need  methods  which  will  enable  us  to  deal  with  the  increas- 
ing number  of  subjects  that  come  under  our  professional  care.  With  this  in 
mind,  and  using  the  terms  that  follow  as  symbols,  without  any  idea  that  they 
represent  actual  underlying  conditions,  just  as  Ehrlich  used  symbols  for  his 
side  chain  theory,  the  following  classification  is  proposed.  All  individuals 
with  mental  or  social  difficulties  can  be  grouped  into  three  headings:  The 
first  group  is  one  in  which  the  intelligence  is  found  to  be  below  the  lowest 
normal  level.  This  is  called  the  group  of  defects  or  inadequacy.  Into  this 
class  fall  the  feebleminded,  the  oligophrenias  of  Kraepelin.  the  end  stages  of 
dementia  praecox,  and  all  other  deteriorating  psychoses,  of  senile,  organic 
dementia,  etc.  The  next  group,  the  group  of  the  emotional  unstable,  or  emo- 
tional instability,  includes  individuals  who  have  average  intelligence  or  better, 
but  who  show  in  their  conduct  the  predominating  influence  of  the  emotions. 
The  third  group,  the  paranoid  group,  includes  individuals  of  average  intelli- 
gence or  better  in  whom  the  emotional  influences  are  of  secondary  nature, 
but  whose  main  difficulties  are  a  result  of  mistakes  in  logical  thought  proc- 
esses. The  egocentric,  contentious,  i)rcjudiced,  cynical  or  vindictive  indi- 
vidual belongs  to  this  group.  These  three  groups  can  be  separated  only  theo- 
retically. There  arc  many  cases  which  fall  on  the  border  between  two  or 
three  of  these  Krf)ups.  A  distinction  is  to  be  made,  in  the  main,  on  the 
behavior  of  the  individual  as  observed  in  the  course  of  years  rather  than 
f)n  ;i  dcfmitf  quantitativi-  flifTcrence  to  be  observed  in  a  single  examination. 


BOSTON  SOCIETY  OF  PSYCHIATRY  AND  NEUROLOGY    45 x 

The  introspective  psychologist  will  attempt  to  determine  in  each  individual 
by  psychoanalysis  or  other  means  what  the  mechanism  of  the  disturbance  is. 
He  may  succeed  in  doing  this  and  still  be  unable  to  treat  the  future  course 
of  the  case.  The  behavioristic  psychologist  will  not  lay  too  much  weight  on 
the  results  of  a  single  examination,  but  will  lay  more  emphasis  on  the  history 
of  the  case.  This  behavioristic  method  offers  the  hope  of  a  short  cut.  The 
examination  of  a  hundred  cases  of  unemployment  made  at  the  Psychopathic 
Hospital  gave  the  following  results :  The  hundred  cases  consisted  of  men 
between  the  ages  of  25  and  55.  Of  one  hundred  cases,  forty-three  were  para- 
noid, thirty-five  defective,  and  twenty-two  emotionally  unstable.  The  para- 
noid and  defective  groups  together  form  78  per  cent,  of  all  these  cases.  The 
paranoid  individuals  average  20.6  months  for  each  job,  the  defectives  average 
24.7  months  per  job,  while  the  emotionally  unstable  average  50  months  for 
each  job.  The  difference  in  the  accounts  of  the  careers  of  these  people  and 
those  of  the  average  healthy  person  consists  in  an  apparent  inability  of  the 
delinquent  to  learn  by  experience.  Ehrlich,  in  devising  his  side  chain  theory, 
borrowed  a  generalization  from  Weigert,  to  the  effect  that  when  the  body  is 
injured  in  such  a  waj'  that  death  does  not  result,  the  result  is  an  over- 
production of  defenses.  Thus,  a  fractured  bone,  when  it  knits,  will  produce 
a  union  which  is  stronger  than  the  original  bone.  The  injection  of  a  sub- 
lethal dose  of  toxin  will  result  in  immunity,  that  is  an  over-production  of 
antibodies.  One  might  apply  this  law  to  the  formation  of  habits,  good  or 
bad,  to  the  acquisition  of  mental  control  in  delinquents.  If  the  individual  is 
exposed  to  conditions  which  are  not  enough  to  permanently  disable  him,  he 
should  react  by  an  over-production  of  defenses.  The  threshold  for  this 
reaction  must  lay  at  a  different  level  in  each  individual.  This  must  be  deter- 
mined in  each  case.  By  careful  training,  based  on  the  analysis  of  the  indi- 
vidual it  should  be  possible  to  influence  the  future  conduct  of  these  indi- 
viduals. Nothing  can  be  gained  by  endeavoring  to  increase  the  intelligence 
of  a  mental  defective.  Nothing  can  be  expected  from  an  attempt  to  change 
the  personality  of  a  paranoid  individual.  A  great  deal  can  be  accomplished, 
however,  in  controlling  the  emotional  instability  of  the  third  group.  What 
is  desired,  therefore,  is  a  system  of  mental  and  emotional  exercises  for  the 
purpose  of  habit  formation.  This  might  be  designated  as  orthopsychics. 
Educational  training  rather  than  punishment  are  the  methods  that  hold  out 
a  chance  of  success.  These  individuals  are  unable  to  learn  well  by  expe- 
rience, but  though  they  often  recognize  the  full  significance  of  their  circum- 
stances, their  experiences  have  no  corrective  influence.  To  punish  such  an 
individual,  therefore,  is  to  increase  his  intoxication  rather  than  to  strengthen 
his  defenses.  It  is  like  administering  alcohol  to  the  patient  suffering  from 
delirium  tremens.  We  may  draw  a  final  analogy  from  immunity  in  applying 
therapy:  in  the  first  place,  protection  against  the  immediate  effects  of  the 
acute  attack.  This  means  freeing  them  from  their  immediate  difficulties, 
supplying  them  with  food  and  lodging,  helping  them  to  recover  from  alcohol 
and  so  forth,  and  in  the  seccftid  place,  immunization,  building  up  at  a  rate 
which  should  be  determined  in  each  individual  case,  the  defenses  by  training, 
not  by  overwhelming  the  organism,  but  by  gradually  strengthening  it. 

Professor  Dearborn  said  this  very  interesting  paper  lays  emphasis  both 
in  the  review  of  Kra-epelin  and  in  the  author's  own  constructive  part  on  the 
defects  of  the  feelings  as  contrasted  with  those  of  what  we  ordinarily  speak 
of  as  intelligence  or  intellect.  The  interesting  suggestions  of  a  therapeutic 
nature  would  seem  to  be  most  hopeful  in  those  cases  in  which  these  defects 
in  the  feelings  may  be  traced  to  disturbances  or  failures  of  natural  expression 
in  early  life.  The  dissociation  between  the  intelligence  and  the  feelings 
which  appears  in  these  cases — the  schism  between  the  two — is  rather  hard  to 
describe  psychologically.     Recently  he  had  been  reading  the  attempt  of  Ziehen 


452     BOSTOX  SOCIETY  OF  PSYCHIATRY  AXD  XEUROLOGV 

in  this  respect.  In  tlie  ordinary  cases  of  feeblemindedness,  the  defects  are 
most  evident  in  the  fields  of  ideation  and  reasoning;  if,  for  example,  you 
test  the  abilit>-  to  form  general  concepts  or  notions  of  a  somewhat  abstract 
nature,  you  will  of  course  find  grades  of  feeblemindedness  in  which  these 
concepts  are  not  possible.  But  there  are  cases  which  must  still  be  judged 
feebleminded  and  particularly  of  this  moral-delinquent  type,  where  you  do 
find  the  abilitv-  to  form  such  abstract  notions,  c.  g.,  those  of  "justice," 
"  truth,"  and  "  goodness."  Ziehen  would  then  say  that  in  the  delinquent  cases 
there  is,  however,  an  absence  of  the  "  feeling  tone  "  which  normally  accom- 
panies such  concepts;  that  ordinarily,  when  we  say  "justice,"  with  that  ab- 
stract concept  there  is  an  accompanying  "  feeling  tone,"  but  that  in  the  case 
of  these  delinquents  this  quality  is  lacking.  Professor  Dearborn  was  not  sure 
whether  psychologically  this  is  more  than  a  descriptive  term.  There  still 
remains  the  question  as  to  zi'hy  there  is  this  failure  in  these  relations. 

Dr.  Myerson  said  it  seemed  to  him  that  the  defective  delinquent  can  be 
well  considered  from  the  angle  that  Dr.  Adler  has  considered  him,  as  one 
whose  failure  may  lie  in  any  one  of  the  three  fields  he  has  described.  More 
fundamentally,  he  may  be  considered  as  an  individual  who  is  unable  to  adapt 
himself  to  the  society  in  which  he  lives,  that  is  to  saj',  he  can  neither  resist 
the  temptation  of  the  present  moment  nor  learn  by  experience.  This  mal- 
adaptation,  or  inadaptability,  may  arise  from  several  causes.  It  may  arise, 
as  Dr.  Adler  has  pointed  out.  from  true  defect.  It  ma\'  also  arise  from  dis- 
harmon)-.  For  example,  the  sex  instinct  may  be  over-developed ;  the  intelli- 
gence may  be  average,  the  will  power  on  other  matters  may  be  average,  but 
because  of  the  overwhelming  or  disproportionate  development  of  the  sexual 
instinct  his  conduct  will  lead  him  into  perpetual  conflict  with  society.  Espe- 
cially is  this  true  of  young  girls  of  the  type  often  classed  as  defective  delin- 
quents. Disharmony  between  an  overwhelming  desire  and  a  moderate  power 
of  resistance  may  give  rise  to  persistent  delinquent  conduct  in  an  individual 
who  otherwise  is  not  defective.  Many  of  our  greatest  men  have  been  per- 
sistent offenders  against  the  sexual  laws  of  society,  but  their  greatness  has 
pardoned  what  would  otherwise  classify  them  as  delinquents,  whereas  the 
same  oflfenses  in  an  individual  of  moderate  powers  would  not  be  tolerated, 
and  the  individual  would  be  considered  as  a  defective  delinquent.  In  other 
words,  in  addition  to  true  defect,  as  a  cause  of  delinquency,  we  must  add 
disharmony,  hyperdevelopment  of  certain  instincts  and  as  a  result  failure  to 
conform  to  the  usages  of  society. 

Dr.  Lyman  Wells  said  it  has  come  out  in  the  discussion  tliat  we  have 
quite  a  large  number  of  delinquent  cases  nondefective  according  to  ordinary 
intelligence  tests.  At  the  same  time  they  show  defects  of  adaptation  to  the 
environment.  Their  failures  are  independent  of  defects  of  intelligence,  and 
one  wonders  whether  we  are  not  dealing  with  a  beginning  psychosis,  even 
dementia  prsecox.  where  the  intelligence  is  fairly  well  preserved.  To  test 
these  cases  experimentally  you  are  not  concerned  with  how  much  the  indi- 
vidual knows,  but  rather  his  ability  to  use  that  knowledge,  and  that  leads 
you  experimentally  into  the  choice  reaction  procedures,  where  you  have  a 
definite  situation  where  the  subject  knows  the  proper  reaction,  but  you  want 
to  determine  how  quickly  and  correctly  he  makes  that  series  of  reactions. 
They  had  been  working  on  that  at  McLean  during  the  past  year,  and  while 
the  material  is  not  yet  very  large,  there  have  appeared  two  of  the  tests  they 
had  been  using  which  separate  the  normal  group  from  the  psychotic  group 
pretty  sharply.  That  gives  some  ground  for  hope  that  they  shall  be  able  to 
add  to  the  Binet,  Simon  and  other  scales  in  time  a  .scale  which  will  give  some 
measure  of  the  adaptation  of  the  individual.  The  separation  of  the  normal 
from  the  pathological  group  is  so  far  indepedent  of  the  diagnostic  entities, 
dementia  praecox.  manic  depressive  iii'^anifv  or  psychopathic  inferiority. 


BOSTOX  SOCIETY  OF  PSYCHIATRY  AND  NEUROLOGY     453 

Professor  Frankfurter  (Harvard  Law  School)  said  there  was  one 
sentence  that  Dr.  Adler  dropped  he  should  like  to  comment  on.  He  thought 
one  cannot  help  reading  criminalistic  literature  these  days  without  feeling 
that  the  rather  wasteful  contest  between  the  lawyer  and  the  doctor  is  grad- 
ually coming  to  an  end,  and  that  each  recognizes  the  interrelation  o.f  his  own 
department  to  the  other.  Dr.  Adler  pointed  out  the  fundamental  reason  why 
the  law  is  still  not  accepting  what  some  of  the  medical  profession  insist 
upon.  The  reason  is  that  this  profession  has  not  yet  given  that  sufficiently 
authoritative  data  that  the  law  can  apply,  as  it  must,  in  generality  of  cases. 
But  the  times  are  much  more  propitious  for  the  developing  of  the  kind  of 
results  which  this  discussion  here  indicates.  The  old  classical  theory  of 
criminology  that  Gilbert  and  Sullivan  expressed,  that  the  punishment  must 
fit  the  crime,  while  still  practised,  is  certainly  a  vanishing  theory.  The 
whole  tendenc}^  of  courts  in  this  country  indicates  a  growing  activity  on 
the  part  of  the  law  to  receive  what  science  has  to  give.  Also,  in  this  country, 
there  is  evidence  of  a  growing  study,  much  more  striking  on  the  Continent, 
of  the  individualization  of  punishment,  as  indicated  in  systems  of  parole,  the 
utilization  of  psychopathic  laboratories  and  the  like.  Law  shows  a  readiness 
to  take  over  material  from  the  medical  profession  as  soon  as  that  can  furnish 
the  data.  He  thought  that  it  will  never  come  fully  till  there  is  a  growing 
recognition,  as  there  is,  of  the  need  of  coordinating  the  social  sciences.  We 
shall  never  make  a  marked  progress  towards  utilizing  what  data  there  is  till 
we  do,  what  for  instance  the  Universit^^  of  Berhn  has  done,  in  gathering 
doctors  and  lawyers  and  judges  and  that  vague  profession,  the  social  workers, 
into  a  cooperating  scientific  group.  Professor  Frankfurter  was  talking  a  few 
nights  ago  with  one  of  the  most  thoughtful  judges  of  New  York.  He  and 
his  court  had  just  been  struggling  through  a  case  involving  the  defense  of 
insanity.  He  said  that  he  felt  sure  that  the  time  has  arrived  when  some- 
thing more  satisfactory  must  be  ready  for  application  by  the  court,  some 
more  satisfactory  technique  in  ascertaining  the  fact  of  insanity  than  the 
present  methods.  Professor  Frankfurter  told  him  of  some  of  the  things  that 
the  Psychopathic  Hospital  was  doing  here,  and  trying  to  do  in  Chicago,  and 
what  they  were  trying  to  do  on  the  Continent,  and  he  said  in  effect  that  the 
bar  and  bench  would  surely  be  most  eager  to  apply  new  data  as  soon  as  the 
medical  profession  had  worked  out  authoritative  data  and  technique  for 
application. 

It  seemed  to  him  one  essential  in  the  situation  is  the  recognition  on  the 
part  of  the  medical  profession,  as  it  has  done  very  generously  in  talks  some 
of  them  at  the  Law  School  have  had  with  Dr.  Southard  and  Dr.  Adler,  that 
the  determination  of  these  facts,  the  application  of  these  medico-sociological 
facts,  cannot  be  done  without  the  cooperation  of  the  legal  profession,  for 
instance,  the  determination  of  insanity,  or  at  least  legal  consequences  of  the 
determination  of  insanity  must  be  made  by  the  legal  profession.  Just  as 
soon  as  that  is  recognized  by  the  medical  profession  and  by  the  legal  pro- 
fession, and  time  and  good  temper  are  no  longer  w-asted  over  a  dispute  to 
serve  where  both  must  serve,^just  so  soon  will  we  have  a  more  creative  atmos- 
phere for  the  progressive  development  of  the  participating  social  sciences, 
and  also  for  the  progressive  salvage  of  the  part  of  the  community  which 
everybody  recognizes  can  be  saved  to  a  larger  extent,  or  at  least  can  be 
treated  with  less  ignorance  than  is  at  present  the  case. 

Dr.  Knapp  said  he  felt  that  Dr.  Adler's  classification  of  this  delinquent 
class  had  much  to  justify  it,  but  exact  definition  was  difficult.  A  certain 
definition  was  of  course  essential  in  making  any  classification,  but  there  was 
always  the  danger  in  dealing  with  the  subject  from  the  legal  point  of  view 
lest  the  terms  of  the  definition  be  exalted  into  a  fetish  and  the  classification, 
which  must  necessarily  at  present  be  elastic,  be  made  too  rigid  and  precise. 
Another  difficulty  also  arose.     In  the  majority  of  cases,  it  is  comparatively 


454     BOSTOX  SOCIETY  OF  PSYCHIATRV  AXD  XEl'ROLOGY 

an  easy  task  to  determine  intellectual  defect.  Our  tests  of  intelligence,  even 
though  not  ideal,  help  us  in  the  problem.  Even  our  marking  S5stem  in  our 
colleges,  so  often  laughed  at,  is  of  some  worth,  as  is  shown  by  the  fact  that 
a  greater  percentage  of  the  men  who  lead  their  class  make  good  in  later  life 
than  do  the  average.  Our  tests  for  emotional  stability,  however,  are  far  less 
trustworthy,  and  it  becomes  a  difficult  matter  to  demonstrate  such  cases  to 
the  court  and  the  jury.  As  to  those  of  defective  will  power,  it  is  open  to 
question  whether  that  is  not  a  metaphysical  speculation.  If  we  take  out 
intellectual  defect  and  emotional  instability,  how  much  will  is  left.''  The 
difficulty  with  the  legal  side  of  the  question  is  not  entirely  due  to  the  fact 
that  the  medical  profession  has  not  definitely  determined  the  facts,  but  that 
the  law  is  unwilling  to  admit  new  points  of  view,  even  when  clearly  estab- 
lished. Thus,  mental  defect  is  clearly  established,  but  the  bench  is  not  ready 
to  take  a  step  forward,  as  Chief  Justice  Shaw  did  many  jears  ago,  and  recog- 
nize limited  responsibility  due  to  such  defect,  but  it  stands  pat  on  the  old 
decisions. 

Dr.  Adler  said,  in  closing,  he  felt  that  perhaps  his  classification  was  taken 
in  a  little  different  way  from  what  he  intended  it  to  be.  He  had  no  intention 
to  explain  these  phenomena.  He  stated  that  the  explanation  was  quite  be- 
yond us  at  present.  He  thought  the  points  that  have  been  raised  are  just 
the  sort  we  want  to  know  about.  Once  we  can  answer  the  questions  Dr. 
Myerson,  Dr.  Southard  and  Dr.  Wells  have  asked,  he  thought  we  will  be 
able  to  explain  some  of  the  phenomena  we  are  now  doubtful  about.  Because 
we  cannot  agree  in  these  various  ways,  and  cannot  explain  it,  it  might  be 
possible  to  analyze  the  difficult}-  from  a  behavioristic  point  of  view.  He  did 
not  insist  on  paranoid  or  emotional  instability.  He  picked  out  what  seemed 
to  him  to  be  the  chief  characteristic  in  the  behavior  of  each  group.  There  is 
a  group  which  apparently  lacks  something — whether  judgment  or  will  or  a 
number  of  other  possibilities  it  is  not  always  clear — but  it  seems  as  though 
some  of  these  people  do  not  react  in  a  way  a  person  with  full  knowledge  and 
will  power  would  react.  Then  there  are  other  cases  in  which  the  discrepancy 
between  the  conduct  and  exciting  moment  is  due  more  to  positive  character- 
istics than  to  negative  characteristics  or  to  emotional  reactions.  As  Kraepe- 
lin  has  pointed  out,  there  is  a  defective  will  in  almost 'all  of  these  cases.  He 
did  not  want  to  enter  into  an  explanation  of  these  different  phenomena,  but 
merely  wanted  to  make  a  short  cut  towards  the  classification  and  arrive  at 
some  agreement  as  to  what  characteristic  classes  should  be  in  order  that  we 
should  be  able  to  deal  with  these  cases  as  they  come  to  us.  Just  what  the 
physician  is  able  to  do,  what  to  treat,  what  is  curable,  the  diseases,  the  mech- 
anisms, we  do  not  know.  As  we  were  able  to  treat  syphilis  with  mercury 
long  before  we  knew  the  disease,  so  we  might  get  the  remedy  for  these  cases 
long  before  the  mechanism  was  explained. 

J.\NUARY  20,   1916 

The  President,  Dr.  EI)W.^RD  B.  L.^ne,  in  the  Chair 

THE  CORRELATION"  OF  BRAIN  ANATOMY,  MENTAL  TESTS,  AND 

SCHOOL  OR   HOSPITAL  RPXORDS  IN  A  SERIES  OF 

FEEBLEMINDED   SUBJECTS    (WAVERLEV 

ANATOMICAL  RESEARCH  SERIES) 

By  E.  E.  Southard,  M.D. 

Dr.  Southard  presented  an  account  of  the  first  instalment  of  work  on 
the  brains  of  the  feebleminded  done  under  the  auspices  of  the  Waverley 
School   for   Feebleminded.     He  called   attention   to  the  extraordinarily  small 


BOSTON  SOCIETY  OF  PSYCHIATRY  AND  NEUROLOGY     455 

amount  of  work  which  has  been  done  upon  the  anatomy  of  brains  of  feeble- 
mindedness, speaking  of  the  work  of  Bourneville,  Hammarberg,  and  the 
early  work  of  Wilmarth  in  this  country.  He  spoke  of  the  present  as  an 
auspicious  period  for  work  in  this  field  on  account  of  the  great  achievements 
in  cortex  topography  of  recent  years.  He  described  the  systematic  photog- 
raphy of  the  brains  from  above,  below,  from  the  two  sides  and  from  the  two 
mesial  aspects,  and  of  the  further  photography  of  frontal  sections.  There- 
upon microscopic  work  could  be  done  with  the  full  advantage  of  correlations 
with  the  gross  appearances,  such  as  anomalies,  atrophies  and  other  focal 
lesions. 

Another  reason  for  working  eagerly  at  this  topic  at  this  time  was  the 
fact  that  mental  tests  are  now  available,  so  that  we  can  compare:  {A)  the 
psychometric  level  of  the  patient,  {B)  the  functional  level  of  the  patient  as 
exhibited  clinically  and  educationally,  (C)  the  level  of  brain  development. 

The  speaker  insisted  upon  the  importance  of  studying  efficiency  in  the 
material  of  feeblemindedness.  He  considered  that  feeblemindedness  forms 
the  best  material  now  available  for  research  in  efficiency  and  called  attention 
to  the  fact  that  all  the  modern  books  upon  efficiency  had  neglected  the  field. 
Just  as  the  Montessori  method  was  a  logical  descendant  of  the  work  of 
Seguin,  so  new  ideas  in  the  education  of  the  normal  derive  from  the  more 
modern  work  in  the  education  of  the  feebleminded. 

If  correlations  between  the  psychometric  and  practical  capacity  levels  of 
the  patients  on  the  one  hand  and  the  trained  brains  on  the  other  can  be  made, 
then  possibly  something  new  concerning  the  nature  of  work  in  this  connection 
and  comparison  between  appearances  in  the  parietal  lobes  and  those  in  the 
frontal  lobes  would  obviously  be  of  importance. 

Robert  M.  Yerkes,  Ph.D.,  said  Dr.  Southard  had  suggested  so  many 
things  to  talk  about  that  he  was  almost  afraid  to  begin.  Moreover,  there  are 
so  many  things  that  ought  to  be  said  about  psychological  examining,  espe- 
cially the  Binet  method  (many  of  them  not  agreeable  to  say),  that  he  was 
still  more  timid  about  beginning. 

He  was  not  quite  sure  how  far  the  psychological  findings  which  Dr. 
Southard  had  mentioned  are  based  upon  Dr.  Fernald's  observations  and  how 
far  upon  the  results  of  the  Binet  scale.  He  should  himself  rather  depend 
upon  the  former  than  the  latter,  for  the  Binet  scale  has  shortcomings  which 
are  especially  unfortunate  in  such  an  investigation  as  Dr.  Southard's. 

The  scale  was  devised  by  a  man  who  was  meeting  a  practical  demand 
for  a  rough  method  of  classifying  children  with  respect  to  their  intellectual 
capacity.  From  the  point  of  view  of  many  of  us  (and  he  thought  Binet  him- 
self if  he  were  here  would  agree  with  them),  the  method  has  been  used 
neither  intelligently  nor  fairly,  for  it  has  been  applied,  beyond  the  intentions 
of  its  originators,  to  the  study  of  adolescents  and  adults. 

It  is  a  heterogeneous  multiple  scale  consisting  of  a  variety  of  tests  chosen 
to  suit  the  different  years  of  age,  especially  through  childhood.  Its  results 
are  at  best  very  rough  and  only  in  a  general  way  indicative  of  the  mental 
level  of  the  individual.  There  is  nothing  differential  about  them — nothing 
that  can  be  safely  used  in  correlation  with  the  anatomical  findings  that  Dr. 
Southard  has  presented.  The  fact  that  the  scale  is  complex,  or,  rather,  con- 
sists of  a  number  of  scales,  counts  against  it,  especially  for  such  purposes  as 
Dr.  Southard's.  For  no  two  years  of  age  are  precisely  the  same  mental  func- 
tions measured.  For  this  reason,  unless  all  the  tests  of  the  Binet  series  are 
presented,  individuals  do  not  get  the  same  opportunity  for  credit. 

Mental  development  varies  extremely  in  rapidity  at  different  ages.  The 
growth  of  intelligence  between  two  and  three  years  is  much  greater  than  that 
between  eleven  and  twelve.  When  we  attempt  to  arrange  brains  or  Lntellects 
in  order,  on  the  basis  of  Binet  measurements,  we  meet  difficulties  which  are 


456     BOSTOX  SOCIETY  OF  PSYCHIATRY  AXD  X  EURO  LOGY 

due,  not  to  the  things  measured,  but  to  the  nature  of  our  measurhig  scale. 
While  the  present  Binet  method  is  practically  satisfactory  for  the  years  be- 
tween five  and  ten,  it  is  less  satisfactory  below  the  age  of  five,  and  eminently 
unsatisfactory  above  the  age  of  twelve. 

He  had  attempted  to  touch  on  two  or  three  of  the  points  raised  by  Dr. 
Southard.  He  inquired  also  concerning  the  relative  values  of  the  point  scale 
and  the  Binet  scale  for  the  purposes  under  consideration.  He  should  unhesi- 
tatingly answer  his  question  thus :  Neither  the  point-scale  method,  as  at 
present  used,  nor  the  Binet  method  is  reasonably  adequate.  The  situation 
demands  more  accurate  measurements  than  either  of  these  scales  can  possibly 
supply.  The  investigators  should  obtain  measurements  of  perception,  mem- 
ory, imagination,  suggestibilitj',  judgment,  reasoning  and  various  other  mental 
functions  in  order  to  have  at  hand  a  reasonably  accurate,  although  rough, 
description  of  the  mental  constitution  which  a  given  brain  represents. 

Very  recently  he  watched  the  psychological  examination  of  a  delinquent 
adolescent  who  is  also  mentally  defective  without  being  below  average  intelli- 
gence. The  examination,  lasting  one  and  one  half  hours  and  consisting  in 
the  main  of  the  point-scale  and  the  Binet-scale  measurements,  showed  nothing 
strikingly  peculiar  about  the  individual.  The  chances  are  that  the  difficulties 
lie  in  the  affective  rather  than  in  the  intellectual  sphere.  This  aspect  of 
mental  life  neither  of  the  scales  in  question  adequately  measures.  The  indi- 
vidual in  question  would  almost  certainly  rank  according  to  the  Binet  scale 
as  a  moron ;  bj-  the  point  scale  as  a  person  of  approximately  average  intelli- 
gence. The  Binet  findings  might  tempt  one  to  account  for  the  delinquency 
by  appealing  to  inferior  intelligence.  This  case  indicates  both  a  serious  weak- 
ness of  the  Binet  method  and  one  of  the  most  insistent  demands  made  of  the 
psychological  examiner.  It  is  not  sufficient  that  the  intellectual  level  of  an 
individual  be  stated.  It  is  necessary  that  the  various  aspects  of  mind  be 
measured  and  that  a  general  description  be  presented  as  a  result  of  such 
measurements. 

What  we  most  need  is  the  intelligent  use  of  psychological  methods  which 
are  already  at  hand  and  which  can  be  made  to  yield  practically  serviceable 
results  when  applied  to  the  various  mental  functions.  We  shall  soon  begin 
to  move  backward  instead  of  forward  if  we  insist  on  using  rough  measure- 
ments of  intelligence  for  other  purposes  than  those  of  preliminary  classifica- 
tion. Certain  social  shortcomings  or  failures  are  due  to  feeblemindedness 
and  many  others  are  due,  either  wholly  or  in  a  large  part,  to  mental  pecu- 
liarities other  than  intellectual. 

There  is  yet  another  aspect  of  this  subject  which  he  felt  impelled  to 
mention.  Even  among  medical  men  there  is  an  impression  that  mental  or 
psychological  examinations  may  be  made  to  good  advantage  with  relatively 
little  training.  Many  physicians  have  spoken  about  learning  how  to  give 
"  mental  tests,"  as  they  call  them.  It  is  usually  their  thought  that  a  week 
or  two  of  instruction  and  practice  should  enable  them  to  do  this  work 
satisfactorily. 

This  attitude  seems  extremely  unfortunate.  It  is  true  tliat  an  intelligent 
person  can  learn  the  techni(iue  of  the  Binet  and  the  point-scale  methods  in 
a  very  short  time,  but  it  is  also  true  that  without  an  excellent  knowledge  of 
the  science  of  mind,  and  without  a  thorough  grasp  of  the  principles  of  mental 
measurement,  the  results  obtained  by  such  amateur  examiners  are  likely  to 
be  of  little  value.  The  point  is  this:  Psychological  examining  demands  not 
only  skill  in  observing,  but  to  as  great  an  extent,  skill  in  interpreting  the 
results. 

There  is  every  reason  why  psychological  examinations  should  lie  re- 
garded by  the  medical  profession  as  are  other  forms  of  examination.  The 
work  must  be  placed  upon  a  professional  basis  if  it  is  to  be  made  safely 


NEW  YORK  NEUROLOGICAL  SOCIETY  457 

serviceable  and  maintained  in  good  repute.  At  present  there  is  serious  risk 
that  mental  "  testing  "  may  become  a  matter  of  ridicule  because  of  the  care- 
less and  unintelligent  work  of  incompetent  examiners. 

Dr.  Walter  E.  Fernald  said  there  is  very  great  need  of  such  a  study  as 
Dr.  Southard  is  making.  When  we  consider  the  vast  advance  in  the  past 
decade  in  our  knowledge  of  feeblemindedness  from  the  pedagogical,  psycho- 
logical, economic  and  eugenic  angles,  it  is  rather  remarkable  that  our  knowl- 
edge of  the  pathology  of  the  mentally  defective  has  been  added  to  but  little 
during  that  period.  As  Dr.  Southard  has  said,  the  best  work  was  done  two 
or  three  decades  ago  by  Bourneville,  Hammarberg  and  Wilmarth. 

It  is  rather  to  be  regretted  that  the  cases  in  this  first  series  necessarily 
come  within  the  "  museum  "  group  of  extreme  cases  of  mental  defect,  re- 
ferred to  by  Dr.  Southard.  The  literature  on  the  subject  abounds  in  these 
"  sport "  cases  of  the  unusual  and  spectacular  variety  rather  than  those  of  the 
ordinary  cases  of  imbecility  and  moronity.  As  a  matter  of  fact,  there  is  no 
literature  pertaining  to  the  pathology  of  the  so-called  moron  group  except 
that  rather  sketchy  part  of  Tredgold's  revised  treatise,  which  is  based  on  a 
very  small  number  of  cases  in  which  the  degree  of  defect  and  the  actual 
existence  of  defect  is  more  or  less  a  matter  of  conjecture. 

Until  we  have  consolidated  our  lines,  as  our  military  friends  would  say, 
by  bringing  up  the  pathological  salient,  we  shall  not  be  able  to  develop  the 
most  effective  methods  of  dealing  with  feeblemindedness,  especially  with  re- 
gard to  possible  prevention.  We  have  practically  no  knowledge  as  to  the 
exact  pathological  conditions  in  cases  of  hereditary  defect.  No  studies  have 
as  yet  been  made  combining  the  results  of  eugenic  research,  the  type  and 
degree  of  the  defect,  and  the  exact  brain  conditions  which  are  responsible 
for  the  defective  mentality.  If,  in  a  large  series  of  cases,  we  can  correlate 
the  family  history  and  the  personal  history,  the  history  of  accidents  and  dis- 
eases, the  pedagogical  history  and  the  psychological  measurements  with  the 
pathological  findings,  there  seems  to  be  a  possibility  that  avenues  of  preven- 
tion may  be  opened  up  of  which  we  know  nothing  at  this  time. 


NEW  YORK  NEUROLOGICAL  SOCIETY 

January  4,  1916 

The  President,  Dr.  W.  M.  Leszynsky,  in  the  Chair 


RECURRENT   FACIAL   PALSY  AND   ITS   RELATION    TO   THE 
SO-CALLED  FACIOPLEGIC  MIGRAINE 

By  J.  Ramsay  Hunt,  M.D. 

Dr.  Hunt  prefaced  his  paper  by  saying  that  migraine  was  occasionally 
associated  with  motor  cranial  nerve  palsies  which  were  usually  limited  to  the 
ocular  nerve.  The  first  contribution  to  the  subject  was  by  Mobius  in  1884, 
who  described  a  periodical  recurrent  oculo-motor  palsy.  A  few  years  later 
Charcot  described  similar  cases  as  ophthalmoplegic  migraine.  There  were 
now  about  100  cases  in  the  literature  of  this  subject  and  it  was  a  well- 
established  clinical  type.  It  was  rather  extraordinary  that  such  a  complica- 
tion of  migraine  should  be  limited  to  the  ocular  nerves.  The  other  motor 
cranial  nerves,  with  the  exception  of  the  facial,  seemed  to  escape.  The  evi- 
dence in  favor  of  a  facioplegic  type  of  migraine  was,  however,  very  uncertain. 
Therefore  Dr.  Hunt  wished  to  present  to  the  Society  his  own  convictions  in 


45«  -V£/r  YORK  NEUROLOGICAL  SOCIETY 

regard  to  the  relationship  of  the  so-called  facioplcgic  migraine  to  recurrent 
facial  palsy.  In  his  paper  Dr.  Hunt  stated  that  recurrent  or  relapsing  facial 
palsy  was  a  term  which  had  been  used  to  describe  a  group  of  cases  charac- 
terized by  a  peculiar  tendency  to  multiple  attacks  or  recurrences.  The  palsy 
might  always  recur  on  the  same  side — the  relapsing  type,  or,  frequently,  there 
was  involvement  of  alternate  sides.  The  individual  attacks  might  be  sepa- 
rated by  months  or  years  and  did  not  differ  in  etiology  and  symptomatology 
from  usual  clinical  types  of  peripheral  facial  palsies.  The  interesting  point 
was  the  frequency  of  occurrence  in  a  single  individual  and  the  underlying 
pathological  tendencies  which  might  favor  a  predisposition.  This  tendency 
was  not  always  confined  to  one  individual,  but  familial  and  even  hereditary 
types  were  sometimes  encountered.  Oppenheim  had  recorded  a  family  in 
which  three  members,  all  sufferers  from  diabetes,  had  recurrent  attacks  of 
facial  palsy.  The  frequency  of  the  relapsing  form  of  Bell's  palsy  was  greater 
than  was  generally  supposed.  Remak,  in  200  cases,  noted  recurrence  in  3  per 
cent.  Bernhardt  placed  the  percentage  as  high  as  7.2  per  cent.  The  etio- 
logical factors  were  the  same  as  those  which  caused  facial  palsy  with  one 
attack :  viz.,  rheumatic  or  refrigeration  palsy  after  exposure  to  cold ;  infec- 
tions and  intoxications,  such  as  diabetes,  syphilis,  otitis  media,  and  perhaps 
also  the  congenital  narrowing  of  the  stj^lo-mastoid  foramen,  which  w-ould 
predispose  the  nerve  to  pressure  from  slight  inflammatory  reactions.  In 
Bernhardt's  series,  otitis  media,  sj-philis  or  diabetes  was  present  in  a  third  of 
the  cases.  Two  other  types  of  relapsing  facial  palsies  should  here  be  men- 
tioned. These  had  found  their  way  into  medical  literature  and  were  widely 
quoted  as  examples  of  periodical  facial  palsy  in  the  sense  in  w-hich  this  term 
was  used  by  Mobius  to  describe  the  oculo-motor  palsies  associated  with  mi- 
graine. One  type  was  based  on  a  fragmentary  clinical  report  by  Hatchek, 
where  relapses  of  facial  paralysis  were  observed  in  a  child  with  basal  tumor. 
This  case  he  regarded  as  analogous  to  the  so-called  periodical  oculo-motor 
palsies  of  the  Mobius  type.  No  clinical  data  had  been  given  in  the  report, 
and  jet  an  attempt  had  been  made  to  establish  an  important  clinical  group  on 
this  slight  and  uncertain  evidence.  Most  neurologists  of  experience  had 
probably  observed  such  intermittent  and  transient  attacks  of  facial  palsy  from 
pressure  in  cases  of  tumor  beneath  the  tentorium,  and  yet  would  not  think  of 
giving  them  this  interpretation.  Another  type  was  founded  upon  the  oft- 
quoted  contribution  of  Rossolimo,  entitled  "  Relapsing  Facial  Palsy  in  Mi- 
graine." In  this  case  a  woman,  aged  28,  had  been  subject  since  the  age  of 
puberty  to  recurrent  attacks  of  migraine,  an  inheritance  from  the  mother. 
She  had  at  various  times  four  attacks  of  facial  palsy,  in  all  of  which  the 
accom[)anying  pain  was  localized  in  and  around  the  mastoid  region.  In  the 
first  attack  the  pain  was  situated  in  the  region  of  the  left  mastoid  and  supe- 
rior maxilla,  and  lasted  a  week.  It  was  accompanied  by  tinnitus  aurium  and 
a  metallic  taste  on  the  tongue,  and  was  followed  by  a  typical  facial  palsy  on 
the  left  side,  from  which  she  recovered  in  five  months.  The  attending  physi- 
cian at  the  time  ascribed  the  condition  to  an  exposure  to  cold.  Three  years 
later,  there  was  a  similar  attack,  after  sleeping  by  an  open  window  on  a  train. 
The  right  facial  palsy  which  ensued  cleared  up  in  about  five  months.  Two 
years  later,  there  was  palsy  on  the  right,  preceded  by  localized  headaches, 
and  three  years  after  the  left  side  was  again  involved  with  pain  and  the 
usual  symi)toms  of  facial  palsy.  This  case  was  reported  by  Rossolimo  as  one 
of  migraine  with  relapsing  facial  palsy,  in  which  he  assumed  an  etiological 
relationship  between  the  migraine,  which  was  undoubtedly  present,  and  the 
recurrences  of  facial  palsy.  On  this  evidence  Rossolimo  postulated  a  facio- 
plcgic type  of  migraine,  similar  in  nature  to  the  ophthalmoplegic  variety  of 
Mf)bius.  which  had  an  established  place  in  literature.  This  case,  however, 
stood  alone  and  presented  insufficient  grounds  on  which  to  base  such  analogy, 


NEW  YORK  NEUROLOGICAL  SOCIETY  459 

the  symptomatology  not  differing  in  the  least  from  the  usual  clinical  picture 
of  relapsing  facial  palsy. 

In  regard  to  pain  in  facial  palsy,  it  was  well  known  since  the  studies  of 
Webber  and  Testaz,  and  especially  in  Dr.  Hunt's  own  contributions  to  the 
sensorj^  functions  of  the  facial  nerve,  that  severe  pain  was  a  frequent  pre- 
cursor and  accompaniment  of  facial  paralysis.  When  present  it  was  localized 
in  the  ear  and  mastoid  region,  often  radiating  to  the  occiput  and  trigeminal 
distribution.  The  pain  under  such  circumstances  might  reach  an  extreme 
degree  of  intensity  and  persistence,  and  was  quite  sufficient  in  itself  to  explain 
the  severe  localized  headache  in  the  Rossolimo  case,  and  might  well  give  rise 
to  suspicion  of  a  migrainous  seizure.  That  migraine  coexisted  in  this  case 
there  could  be  no  question,  but  as  both  migraine  and  facial  palsy  were  com- 
paratively frequent  maladies,  it  required  no  great  stretch  of  the  imagination 
to  explain  their  joint  occurrence  in  the  same  individual,  and  yet  etiologically 
unrelated  and  distinct.  While  the  idea  advanced  by  Rossolimo  was  sug- 
gestive, there  was  no  reason  at  the  present  time  for  accepting  a  facioplegic 
type  of  migraine — an  opinion  which  was  shared  by  other  workers  in  this  field. 
The  cases  reported  by  Dr.  Ramsay  Hunt  were  as  follows :  Case  I :  Woman, 
23,  with  relapsing  alternating  facial  palsy,  associated  with  pain  ;  three  attacks. 
Case  H:  Woman,  21,  with  relapsing  alternating  facial  palsy  with  pain.  (The 
girl's  father  had  similar  attacks.)  Case  HI:  Man,  45,  with  recurrent  facial 
palsy,  accompanied  by  pain  ;  three  attacks.  The  conclusions  drawn  from  these 
cases  were  that  recurrent  or  relapsing  facial  palsy,  associated  with  pain  in 
the  ear  and  occipital  region,  was  therefore  merely  a  peripheral  paralysis  of 
the  seventh  nerve,  in  which  was  manifested  a  peculiar  tendency  to  multiple 
attacks  or  recurrences.  The  symptomatology  corresponded  in  all  its  essen- 
tials to  the  more  usual  type.  The  theory  of  Despaigne  on  the  narrow  exit 
at  the  stylo-mastoid  foramen  which  might  predispose  the  nerve  to  com- 
pression was  ingenious,  but  called  for  more  definite  pathological  confirmation. 
The  possibility  of  coexisting  diabetes  should  alwaj's  be  considered.  Most 
cases  were  of  infective  or  refrigeration  origin.  In  the  infectious  or  rheu- 
matic groups  there  was  simply  a  constitutional  tendency  to  peculiar  local 
reactions  to  cold  or  infections,  very  similar  to  those  observed  in  tonsillitis, 
lumbago,  sciatica,  with  well-known  tendencA'  to  recurrence.  A  pathological 
theory  of  the  rheumatic  origin,  advocated  by  many,  was  that  of  a  perineuritis 
of  the  facial  nerve,  similar  to  brachial  and  sciatic  perineuritis  of  rheumatic 
origin.  Such  a  lesion  would  be  favored  by  the  exposed  situation  of  the 
nerve,  and  swelling  of  its  structures  within  the  Fallopian  aqueduct  being 
immediately  registered  as  pressure  palsy.  This  would  be  enhanced  by  a  con- 
genitally  narrow  canal.  This  might  explain  some  of  the  familial  and  heredi- 
tary types.  Peripheral  facial  palsy  as  a  sequela  of  the  migraine  attack,  the 
facioplegic  migraine  of  some  writers,  was  not  a  clinical  entity.  If  the  facial 
nerve  had  any  relation  to  migraine  which  was  so  well  established  in  the  case 
of  the  ocular  nerves,  this  relationship  had  yet  to  be  established.  The  cases 
already  published  gave  insufficient  grounds  for  any  such  assumption.  Titles 
like  "periodical  relapsing  facial  palsy"  and  "facioplegic  migraine"  were 
misnomers  which  had  crept  into  some  of  the  best  monographs  dealing  with 
the  subject.  Such  terms  were  misleading  and  denoted  nothing  more  than 
transient  intermittent  facial  palsy  as  a  focal  symptom  of  basal  tumor  in  the 
one  case,  and  the  not  uncommon  relapsing  facial  palsy  associated  with  pain 
in  the  other.  It  was,  of  course,  self  evident  that  migraine  and  facial  pals}^ 
both  of  which  were  common  affections,  might  be  met  with  in  the  same  indi- 
vidual, but  were  etiologically  distinct.  Dr.  Hunt  added  that  his  three  cases 
must  be  classified  as  recurrent  facial  palsies,  associated  with  localized  neuritic 
pains.  There  was  very  definite  and  severe  pain,  preceding  and  during  the 
attacks.     Otherwise  they  were  typical  facial  palsies.     This  was  the  point  that 


46o  XEir  YORK  XEUROLOGICAL  SOCIETY 

he  wished  to  make  in  regard  to  paraljtic  complications  of  migraine.  At  the 
present  time  one  could  only  recognize  as  an  established  clinical  group  of 
motor  cranial  nerve  palsies  that  of  the  ocular  nerves,  viz.,  the  third  nerve, 
rarely  the  abducens,  and  very  rarely,  the  trochlearis.  The  optic  nerve,  and 
especially  its  termination  in  the  retina  as  well  as  the  sensory  trigeminus,  had 
rarely  shown  involvement.  The  other  cranial  nerves  were  not  involved  in 
migraine.  He  thought  the  teaching  expressed  in  most  standard  monographs 
on  this  subject  regarding  a  facioplegic  migraine  was  wrong.  In  the  Rosso- 
limo  case  the  connection  between  the  palsy  and  the  migraine  was  very  doubt- 
ful, and  Hatchek's  case  was  merely  a  transient  intermittent  paralysis,  asso- 
ciated with  basal  tumor. 

Dr.  W.  M.  Leszynsky  said  that  it  seemed  to  him  that  those  who  had 
seen  large  numbers  of  cases  of  facial  palsy  could  come  to  no  other  conclu- 
sion than  that  formulated  by  Dr.  Hunt.  For  a  number  of  years  Dr.  Leszyn- 
sky had  studied  facial  palsy  without,  however,  going  into  such  detailed  study 
of  sensory  disturbances,  excepting  for  pain,  as  had  Dr.  Hunt.  He  found  that 
quite  a  large  proportion  of  patients  had  pain.  It  was  assumed  that  refrigera- 
tion had  acted  on  the  terminal  filaments  of  the  fifth  nerve,  as  well  as  the 
facial,  and  had  thus  produced  pain.  In  regard  to  migraine,  it  was  rarely  that 
patients  suffered  from  this,  coincident  with  facial  palsy.  He  had  seen  all  of 
in  other  tj'pes,  that  is,  oculo-motor,  hemianopic  and  hemiparetic,  but  not 
the  so-called  facioplegic. 

Dr.  S.  E.  Jelliffe  said  that  he  had  been  very  mucli  delighted  to  hear  Dr. 
Hunt  call  attention  to  the  facioplegic  syndrome  in  migraine.  He  believed  it 
to  occur  more  commonly  than  the  few  scattered  records  would  lead  one  to 
suppose,  and  that  it  should  be  allied,  not  only  to  the  ophthalmoplegic,  but  to 
the  hemiplegic,  brachioplegic  and  to  other  isolated  palsy  syndromes  in  the 
leg  and  other  parts  of  the  body  which  were  a  part  of  the  migraine  syndrome. 
It  was  but  one  of  a  series  of  related  and  correlated  disturbances.  He  felt 
sure  that  it  was  more  useful  to  regard  the  kaleidoscopic  variations  seen  in 
the  migraine  syndrome  as  dynamic  trends,  rather  than  so-called  definite 
static  types.     Pigeonhole  neurology  should  be  going  out  of  fashion. 


PROGRESSIVE   LENTICULAR   DEGENERATION    (WITH    EXHIBI- 
TION OF  LANTERN  SLIDES) 

By  F.  J.  Farnell,  M.D.,  and  A.  H.  Harrington,  M.D. 

This  paper  was  read  by  Dr.  Farnell.  The  case  was  one  of  a  young  girl, 
in  whom  the  symptoms  appeared  at  the  age  of  puberty.  The  case  ran  a  four 
years'  course,  the  patient  finally  dying  in  a  state  institution  for  the  insane. 
Lantern  slides  were  shown  illustrating  microscopical  sections  of  the  liver 
and  brain. 

Dr.  F.  Tilncy,  in  discussing  Dr.  Farnell's  paper,  said  he  wished  to  express 
his  appreciation  of  the  excellent  presentation  of  this  case,  which  seemed  to 
him  typical  of  the  disease  described  by  Wilson.  It  had  especial  interest  in 
connection  with  the  case  of  Wilson's  disease  which  he  presented  to  the  Neu- 
rological Society  last  winter.  Since  that  time  Dr.  MacKenzie  and  he  had  been 
progressing  with  the  pathological  work.  The  brain  was  ready  for  cutting  in 
serial  sections  and  detailed  pathological  study  had  been  made  of  the  other 
organs.  He  thought  it  very  essential  in  the  preparation  of  the  brains  obtained 
from  such  cases  that  the  material  be  so  treated  as  to  make  possible  the  study 
of  serial  sections.  One  of  the  most  important  question  concerning  Wilson's 
disease  at  the  present  time  was  the  anatomical  relation  and  pathological  con- 
dition of  the  lenticular  nuclei.     These  could  not  be  studied  as  thoroughly  as 


NEW  YORK  NEUROLOGICAL  SOCIETY  461 

need  be  in  any  other  way  than  by  serial  sections  of  the  entire  brain.  Con- 
cerning the  general  subject  of  progressive  lenticular  degeneration,  there  were 
certain  clinical  aspects  which  should  be  considered.  First,  in  the  matter  of 
tremor,  as  summarized  from  the  reported  cases  of  the  disease.  If  it  was 
expected  that  anything  typical  or  characteristic  was  to  be  observed  in  Wilson's 
disease,  so  far  as  the  tremor  was  concerned,  the  discrepancies  in  the  pub- 
lished descriptions  would  soon  dispel  that  idea.  One  observer,  for  instance, 
described  the  tremor  as  coarse,  another  spoke  of  it  as  rapidly  changing  move- 
ments like  chorea.  This  no  doubt  led  Gowers  to  term  the  condition  "  tetanoid 
chorea."  It  had  also  been  described  as  tremulousness.  The  place  in  which 
the  tremor  began  imparted  no  characteristic  feature  to  it.  In  the  majority 
of  cases  it  first  appeared  in  the  right  hand  and  was  noticed  when  the  patient 
wrote.  Nearly  as  often  it  made  its  first  appearance  simultaneously  in  the  legs 
and  arms.  Less  frequently  it  occurred  in  both  arms  alone  and  in  a  few  cases 
in  the  tongue.  The  tremor  was  usually  described  as  rhythmical,  but  the  ref- 
erences in  this  particular  were  thoroughly  unsatisfactory.  Its  rate  was  vari- 
ously described  as  rapid  or  slow  and  its  amplitude  given  as  one  to  four  inches. 
On  the  other  hand,  in  some  cases,  it  was  noted  as  an  extremely  fine  tremor. 
As  a  rule,  voluntary  action,  as  well  as  emotional  excitement,  increased  the 
tremor,  while  it  disappeared  when  the  patient  was  resting.  This  statement, 
however,  was  not  made  in  all  the  reports,  so  that  there  seemed  to  be  no  strik- 
ing uniformity  in  the  statements  concerning  the  tremor.  This  was  also  true 
of  the  description  of  contractures.  There  were  few,  if  any,  references  to  the 
character  of  resistance  against  passive  movements,  the  myotonic  status  of 
muscles,  the  myotatic  and  electrical  irritability.  Even  the  distribution  of  the 
contractures  was  none  too  fully  described.  In  the  matter  of  contractural 
attitudes  one  feature  did  not  stand  out  in  all  the  cases,  namely,  the  abduction 
of  the  angles  of  the  mouth  and  the  separation  of  the  lips  due  to  contracture 
of  the  facial  muscles,  which  gave  the  patient  a  silly,  almost  idiotic  expression. 
This  occurred  in  100  per  cent,  of  the  cases.  A  rather  characteristic  con- 
tractural attitude  was  seen  in  the  hands  and  fingers,  namely,  adduction  of  the 
thumb  with  extension  at  all  its  phalangeal  joints,  flexion  of  the  fingers  at  the 
metacarpo-phalangeal  joints,  with  extension  at  the  phalangeal  joints.  This 
latter  arrangement  might  affect  one  or  two  of  the  fingers,  usually  the  index 
and  middle,  while  the  ring  and  little  fingers  were  held  completely  flexed  in 
the  palm  of  the  hand.  This  general  attitude  was  seen  in  60  per  cent,  of  the 
cases.  In  the  remainder,  however,  the  fingers  were  flexed  into  the  palm  and 
the  hand  was  in  extreme  pronation.  In  about  50  per  cent,  of  the  cases  the 
feet  and  toes  assumed  a  similar  characteristic  attitude.  The  feet  were  in  a 
position  of  equino-varus,  while  the  toes  were  flexed  at  all  joints.  In  the 
remaining  cases  the  contractural  attitude  of  the  feet  and  toes  was  varied  and 
irregular,  so  that  with  regard  to  contractural  attitudes  progressive  lenticular 
degeneration  did  not  seem  to  produce  any  distinct  type  comparable,  for  in- 
stance, with  that  of  paralysis  agitans.  In  fact,  the  attitudes  of  Wilson's  dis- 
ease might  easily  be  mistaken  for  a  number  of  other  conditions.  The  changes 
in  affective  tone  and  in  emotive  expression,  said  to  be  so  characteristic  of 
progressive  lenticular  degeneration,  as  well  as  indicative  of  a  lesion  in  the 
basal  ganglia,  did  not  seem  to  deserve  the  importance  attached  to  them.  To 
believe  that  the  basal  ganglia  of  themselves  were  responsible  for  control  of 
the  affective  tone,  was  turning  back  to  the  ancient  history  of  neurology.  Dr. 
Tilney  said  that  his  work  on  pseudo-bulbar  palsy  in  which  he  published  an 
analysis  of  the  findings  in  91  autopsies  of  this  disease,  showed  that  in  one 
half  the  cases  with  no  lesion  in  the  lenticular  nucleus,  caudate  nucleus  or  the 
optic  thalamus,  there  were  typical  laughing  and  crying  attacks,  while  in  one 
half  the  cases  with  lesions  in  these  parts,  no  such  attacks  were  observed  or 
reported.     This  seemed  to  be  an  argument  absolving  the  lenticular  nucleus, 


462  XEir  YORK  XEUROLOGICAL  SOCIETY 

caudate  nucleus  and  optic  thalamus  of  at  least  some  of  the  responsibility 
ascribed  to  them  in  controlling  affective  tone.  Within  the  past  two  jears 
Rausch  and  Schilder  had  cited  a  number  of  cases  of  pseudo-sclerosis  and 
stated  as  a  result  of  their  findings  that  there  existed  a  hereditary  degenerative 
disease  simultaneously  involving  the  liver  and  brain ;  that  the  cases  described 
by  Wilson  were  only  a  well-defined  subgroup  of  pseudo-sclerosis  and  that 
in  all  of  these  cases  it  was  presumably  a  complete  involvement  of  the  brain 
though  the  subcortical  motor  apparatus  was  affected  most  severely.  Dr. 
Tilney  said  in  conclusion  that  he  had  not  intended  his  remarks  as  adverse 
criticism  of  the  brilliant  work  already  done  in  this  disease.  He  had  tried  to 
point  out  that  while  one  might  recognize  it  as  an  entitj',  there  was  not  as  yet 
full  anatomical,  physiological  or  clinical  recognition  of  its  individuality.  It 
was  rather  his  object  to  make  a  plea  for  a  more  careful  and  extensive  study 
of  such  of  these  cases  as  came  to  one's  notice,  especially  an  anatomical  inves- 
tigation, since  through  this  disease  there  was  offered  an  opportunitj'  of  shed- 
ding light  upon  a  part  of  the  nervous  system  which  had  so  long  baflled  them, 
and  yet  was  so  intimately  concerned  in  the  evolution  of  the  brain,  namely, 
the  corpus  striatum. 

Dr.  George  M.  MacKenzie  (who  discussed  this  paper  by  invitation)  said 
that  he  had  been  particularh'  interested  in  the  pathological  findings  in  cases 
of  Wilson's  disease.  Dr.  Farnell's  case  conformed  in  most  details  to  the 
typical  cases.  The  most  striking  and  most  constant  pathological  finding  in 
this  disease  was  the  cirrhosis  of  the  liver;  in  fact,  it  had  been  present  in 
every  case  reported  and  might  be  regarded  as  a  sine  qua  non  for  a  complete 
diagnosis  of  progressive  lenticular  degeneration.  Everj^  case  had  advanced 
cirrhosis  of  the  liver  and  in  these  livers  there  was  a  striking  uniformity  of 
appearance.  The  livers  were  smaller  than  normal,  nodular  and  firm.  In 
Dr.  Farnell's  case  the  cirrhosis  was  earlier  than  usual.  Naturally  the  ques- 
tion at  once  occurred  of  the  relation  of  this  form  of  cirrhosis  to  the  ordinary 
hepatic  cirrhosis  in  children.  This  was  not  an  extremelj'  rare  condition  in 
children,  though  much  less  common  than  in  adults.'  Schlichthorst  had  col- 
lected over  loo  cases,  and  Howard  in  this  country  collected  63  cases.  A 
striking  difference  between  cirrhosis  in  children  and  that  in  progressive  len- 
ticular degeneration  was  that  the  latter  was  entirely  without  symptoms.  In 
only  one  of  the  reported  cases  of  the  latter  had  there  been  a  slight  transient 
jaundice  some  years  before  and  this  might  very  well  have  been  the  ordinary 
catarrhal  jaundice.  There  had  never  been  ascites  or  gastric  hemorrhages 
or  evidences  of  dilatation  of  collateral  circulation.  In  the  ordinary  cirrhosis 
of  children  symptoms  were  always  present.  In  all  the  Wilson's  disease  cases 
there  was  marked  evidence  of  attempts  at  regeneration,  shown  b)'  the  active 
separating  of  the  bile  ducts  in  the  connective  tissue  bands  and  also  by  the 
mitotic  division  of  the  liver  cells,  resembling  in  the  formation  of  irregular 
masses  of  cells  in  which  the  architecture  of  the  lobule  was  lost.  The  lesion 
in  the  lenticular  nucleus  varied  greatly.  It  was  rather  surprising  that  in  the 
case  of  Dr.  Farnell,  of  four  years'  duration,  that  it  was  not  more  marked. 
The  lesion  in  the  carefully  studied  cases  had  varied  from  slight  discoloration 
and  s()onginess  to  complete  softening  and  excavation  of  the  nucleus.  In  gen- 
eral the  chronic  cases  had  more  marked  changes  than  the  acute,  but  this  had 
not  been  constant.  To  explain  the  cases  without  lenticular  changes  Wilson 
was  forced  to  fall  back  on  the  hypothesis  that  the  nucleus  might  be  dynami- 
cally disturbed  to  a  degree  sufficient  to  produce  marked  symptoms  without 
any  nuclear  changes  discoverable  by  available  methods.  The  gaping  spaces 
about  the  blood  vessels  described  as  a  lesion  by  Wilson  might  be  seen  in 
otherwise  normal  brains  and  were  probably  an  artefact  due  to  shrinkage 
during  fixation.  In  any  disease  in  which  the  pathogenesis  was  so  obscure 
as  it  was  in  these  cases,  it  was  worth   while  to  have  thorough  examinations 


NEW  YORK  NEUROLOGICAL  SOCIETY  .        463 

made  not  onl}-  of  the  liver  and  basal  ganglia  but  also  of  the  peripheral  nerves, 
muscles  and  spinal  cord.  They  were  still  very  much  in  the  dark  as  to  the 
point  of  origin  of  this  interesting  disease. 

Dr.  Bernard  Sachs  said  he  had  seen  a  number  of  cases  which  had  come 
under  this  heading.  One  striking  thing  was  that  the  anatomical  findings 
were  not  at  all  of  such  a  character  as  to  account  for  the  symptoms  during 
life.  He  was  much  impressed  with  the  opinion  that  there  was  much  more 
pecuHar  to  this  condition  than  the  mere  lenticular  degeneration.  If  there 
were  no  more  than  that  they  had  not  enough  to  account  for  the  symptoms. 
The  lenticular  degeneration  would  seem  to  be  a  part  of  a  very  much  more 
widespread  anatomical  change  in  the  entire  brain.  During  the  reading  of  the 
paper  he  had  remembered  that  nearly  thirty  years  ago  he  and  Dr.  Seguin  had 
a  patient  of  sixty  j-ears  of  age,  with  such  a  condition — tremors  and  gradually 
developing  contractures,  and  marked  psychic  change.  Dr.  Seguin  had  ob- 
served that  only  a  universal  gliosis  involving  every  part  of  the  brain,  both 
cortex  and  ganglia,  could  account  for  the  condition.  Dr.  Sachs  did  not  believe 
that  they  would  be  able  to  accept  the  diagnosis  of  lenticular  degeneration  for 
this  clinical  group  of  symptoms.  Until  the  study  of  a  number  of  brains  was 
so  accurate  that  they  could  exclude  changes  in  the  other  parts  of  the  brain, 
the  cortex  and  neighboring  ganglia,  they  could  not  accept  this  definition.  He 
was  not  convinced  by  Wilson's  paper  that  the  entire  brain  had  been  satisfac- 
torily examined.  There  were  perhaps  great  changes  in  the  cellular  elements, 
in  the  ganglion  cells  of  the  cortex  and  the  spinal  cord,  that  could  not  be  defi- 
nitely stated  to  be  actually  normal.  This  was  shown  by  the  pictures  to-night. 
He  had  to  express  his  appreciation  of  the  excellent  way  in  which  the  subject 
had  been  presented.  He  did  not  feel,  however,  that  they  had  even  fairly 
started  upon  the  study  of  this  very  difficult  subject.  He  did  not  believe  that 
progressive  lenticular  degeneration  would  remain  as  a  clinical  entity. 

Dr.  Ramsay  Hunt  said  the  question  of  the  symptomatology  in  this  disease 
was  very  interesting,  especially  in  its  relation  to  paralj-sis  agitans  of  the  juve- 
nile form.  When  he  first  read  Wilson's  paper  he  gathered  the  impression 
that  it  would  be  difficult  to  separate  his  disease  clinically  from  juvenile  paral- 
ysis agitans,  except  for  the  quicker  course  and  the  more  toxic  symptoms. 
Sawyer  reported  a  clinical  case  of  eight  to  ten  years'  duration,  which  in  its 
symptomatology^  simulated  Wilson's  disease,  though  the  course  was  milder. 
Wilson  examined  this  case  and  acknowledged  its  symptomatology  and  rela- 
tionship to  the  type  he  had  described.  They  had  such  cases  of  juvenile 
paralysis  agitans  at  the  Montefiore  Home.  One  patient,  very  many  years  in 
the  Home,  died,  and  the  brain  was  examined.  There  were  no  lesions  in  the 
lenticular  nucleus  and  the  liver  was  normal.  In  this  case  the  juvenile  paral- 
ysis began  at  six  years.  Dr.  Tilney's  question  as  to  tremors  was  a  good  one, 
but  the  tremor  in  paralysis  agitans  varied  in  character  and  degree,  apparently 
depending  upon  the  degree  of  rigidit3^  Dr.  Hunt  said  he  regarded  Wilson's 
disease  as  an  encephalitic  or  gross  lesion  in  the  lenticular  region,  whereas  in 
paralysis  agitans  there  was  probably  a  more  specialized  lesion  in  the  nature 
of  a  system  disease. 

Dr.  F.  J.  Farnell  closed  the  discussion  by  adding  that  in  his  case  for  sev- 
eral months  before  death  there  was  marked  toxemia,  and  in  going  over  the 
slides  it  was  difficult  to  tell  which  cells  were  degenerated  from  the  toxic 
process  and  which  from  the  disease  itself.  The  spinal  cord  cells  were  recog- 
nized as  not  being  entirely  normal  but  were  not  considered  to  be  involved  in 
the  special  disease  process. 


464  XEir  YORK  NEUROLOGICAL  SOCIETY 

SOME   THERAPEUTIC    SUGGESTIONS    DERIVED   FROM    THE 

NEWER   PSYCHOLOGIC   STUDIES   UPON   THE   NATURE 

OF  ESSENTIAL  EPILEPSY 

By  L.  Pierce  Clark.  M.D. 

The  author  first  called  attention  to  the  fact  that  the  modern  trend  of 
research  into  the  nature  and  treatment  of  the  neuroses  and  psychoses  was  dis- 
tinctly based  upon  a  fuller  recognition  of  the  importance  of  psychogenic 
factors  than  neurologists  had  held  or  seemed  at  present  willing  to  admit. 
Even  in  the  so-called  organic  disorders,  such  as  paresis  and  arteriosclerotic 
conditions,  the  interpretation  of  the  psychotic  reactions  in  such  was  to  be 
sought  on  the  ground  of  considering  these  mental  disorders  as  functional  or 
psychogenic,  rather  than  structural  ones  in  the  ordinary  acceptance  of  the 
term. 

Next  followed  a  short  exposition  of  his  theory  of  the  nature  and  patho- 
genesis of  essential  epilepsy.  The  individual  has  an  inherent  defect  in  in- 
stincts which  constitutes  more  or  less  distinctly  the  so-called  epileptic  consti- 
tution. Various  types  of  stress,  ultimately  psychic  in  character,  cause  the 
predisposed  individual  to  react  awaj^  from  his  difficulty  bj'  a  loss  of  con- 
sciousness, as  shown  in  the  periodic  attacks,  and  the  main  motive  of  the  whole 
mechanism  of  his  attack  is  to  gain  a  riddance  of  the  particular  adaptive 
demand  and  gain,  through  regression  to  the  unconscious,  a  state  of  peace 
and  harmony,  comparable  to  that  of  infancy  or  before  reality  has  become 
part  of  the  environmental  demand. 

Attention  was  called  to  the  importance  of  the  recognition  of  the  essential 
makeup  of  potential  epileptic  children  and  the  degree  and  character  of  earliest 
training  necessitated  in  the  handling  of  them.  He  reemphasized  the  impor- 
tance of  the  release  of  the  frankly  established  epileptic  from  a  too  severe  or 
stressful  environment  and  pointed  out  the  empirical  manner  in  which  this 
had  been  a  part  of  the  best  phase  of  treatment  in  the  past.  As  a  positive 
factor  in  the  further  treatment  of  such  individuals  he  pointed  out  the  neces- 
sity for  employing  varied  interests  of  work  and  play  to  keep  them  in  closer 
contact  with  that  environment  which  had  been  rendered  simple.  He  gave  a 
number  of  experiences  of  gaining  the  cooperation  of  the  patients  in  the  gen- 
eral scheme  of  psychologic  treatment  and  the  outcome  of  the  same,  the  best 
method  being  found  in  the  working  out  of  the  mechanism  of  the  patient's 
adaptation  to  a  phase  of  everydaj-  reality  to  which  he  could  fully  respond, 
slowly  making  an  effort  to  vary  the  same  and  increase  the  power  of  interest 
and  adaptation  as  the  patient  learned  the  successive  grades  of  life  lessons 
entailed  by  such  a  principle.  In  conclusion,  Dr.  Clark  called  attention  to  the 
great  importance  of  a  more  extended  study  of  the  mental  factors,  both  the 
defects  in  makeup  and  the  nature  of  the  precipitating  causes  for  the  con-' 
vulsive  episodes,  and  the  demand  for  a  much  better  grade  of  psychiatrically 
trained  assistants  on  the  part  of  nurses,  physicians  and  teachers,  and  that  in 
its  best  sense  the  treatment  was  a  broadly  educational  one  in  which  a  psychia- 
trical insight  into  the  difficulties  to  be  handled  was  absolutely  necessary. 

Dr.  S.  E.  JellifFe,  at  the  risk  of  appearing  pedagogic,  ventured  to  recall 
to  the  Society  his  retiring  address  given  one  year  previously.  Herein,  while 
reviewing  the  work  of  the  Society,  he  had  expressed  the  view  that  it  was 
possible  to  classify  neurological  activities  under  three  general  groups,  which 
mutually  integrated  and,  interacting,  made  up  the  sum  tf)tal  of  nervous  struc- 
tures and  functions.  It  was  essential  first  to  relinquish  the  worn-out  con- 
ception that  the  human  organism  was  a  reservoir  of  energy.  It  was,  more 
strictly  speaking,  a  transformer  of  energy.  Its  transforming  mechanisms 
might   appropriately   be   divided    into   three   levels,    not    separated    one    from 


NEW  YORK  NEUROLOGICAL  SOCIETY  465 

another,  but  evolving  the  one  into  the  other.  At  the  lowest,  by  which  he 
meant  the  phylogenetically  oldest  level,  the  specific  energy  carrier  was  the 
hormone.  Through  these,  regulated  by  the  vegetative  nervous  structures,  the 
general  metabolic  upkeep  of  the  machine  was  made  possible.  With  the 
gradual  evolution  of  animal  structures,  sensori-motor  mechanisms  became 
increasingly  important,  and  by  means  of  the  reflexes,  outside  energy  was 
transformed  for  bodily  adjustment;  finally,  for  social  needs,  the  psyche 
utilized  the  symbol  as  the  specific  energy  transformer.  To  him  the  whole 
quarrel  between  the  somatic  and  the  psychogenetic  attitudes  was  the  mutual 
inability  of  each  to  understand  the  aspect  of  the  other.  For  the  somatist  and 
the  mechanist,  the  human  body  was  nothing  but  hormones  and  reflexes ;  for 
the  vitalist  there  were  only  symbols.  Man,  however,  was  a  biological  entity, 
living  in  a  social  milieu,  and  it  was  necessary  to  regard  him  as  a  transformer 
of  energy  at  all  three  levels.  Dr.  Jelliffe  felt  that  his  point  of  view  did  away 
with  many  so-called  difficulties.  Just  as  the  vegetative  and  the  sensori- 
motor systems  had  their  evolutions,  so  also  had  the  symbolic  systems.  To 
comprehend  mental  phenomena,  then,  it  was  necessary  to  get  at  the  evolution 
and  modifications  of  symbols.  This  entailed  a  comprehensive  study  of  the 
gradual  formation  of  language,  institutions,  ceremonials,  customs,  etc.,  etc. 
Whereas  this  was  completely  comprehended  by  any  attentive  student  of  Dar- 
winian concept,  previous  attitudes  of  mind  had  taken  into  consideration  chiefly 
conscious  phenomena ;  they  had  neglected  the  unconscious,  which  were  vastly 
more  important.  Expressed  in  a  fractional  form,  one  might  compare  the 
conscious  as  a  numerator  of  one,  while  the  denominator  is  made  up  of  the 
accumulations  of  100,000,000  years.  Practically,  all  discussions  of  symbolic 
values  had  been  expressed  in  terms  of  the  numerator,  the  conscious  moment, 
whereas  in  reality,  behind  every  symbol  there  lay  the  entire  past  of  man's 
evolution,  back  to  the  laws  which  govern  the  movements  of  the  solar  system. 
The  symbol  simply  expressed  the  apex  of  this  evolutionary  system.  "  For 
man,  then,"  he  said,  "  it  is  more  important  to  view  the  phenomena  of  life  from 
the  standpoint  of  symbolic  significance."  So  far  as  the  epileptic  problem  was 
concerned,  this  seemed  the  only  possible  thing  that  would  lead  to  a  complete 
view  of  the  entire  situation.  It  was  perfectly  evident  to  the  simplest  intelli- 
gence that  a  hormone  disturbance  could  so  change  the  neurological  machine 
as  to  make  it  a  bad  energy  transformer,  and  this  might  result  in  the  phe- 
nomena known  as  an  epileptic  fit.  Similarly,  a  tumor  or  other  gross  lesion 
could  produce  the  same  results  through  interference  with  the  reflex  arcs. 
But  it  should  be  equally  evident  if  one  should  rise  above  the  level  of  physico- 
chemical  explanations  that  the  epileptic  phenomena  resulted  from  failures  of 
the  symbolic  functions  of  the  human  being.  Dr.  Clark  had  emphasized  this 
attitude  and  had  contributed  largely  to  its  proof. 

Dr.  John  T.  MacCurdy  (by  invitation)  discussed  Dr.  Clark's  paper.  He 
said  that  he  considered  it  a  privilege  to  state  the  opinion  that  this  careful 
work  of  Dr.  Clark's  represented  the  consummation  of  investigations  which 
promised  much  for  epileptics.  That  statement  should  be  qualified,  perhaps, 
by  saying  the  promise  was  for  those  who  were  fortunate  enough  to  come 
under  Dr.  Clark's  care.  Whether  it  would  mean  anything  for  epileptics  as  a 
whole  would  depend  upon  the  attitude  of  the  profession.  The  psychogenetic 
standpoint  had  not  been  adopted  by  many  physicians  for  two  reasons  :  first, 
there  was  a  belief  in  the  minds  of  the  profession  that  some  day,  somehow,  a 
psychophysical  parallelism  would  be  established.  Whether  this  was  to  be 
reasonably  expected  one  could  not  say,  but,  at  least,  none  of  the  present 
methods  of  investigation  showed  that  it  was  a  hopeful  view.  There  was 
probably  no  pathologist  who  had  dealt  with  the  anatomy  of  the  brain  who 
could  say  that  there  was  a  rigorous  psychophysical  parallelism.  This  was 
perhaps  essentially  a  religious  rather  than  a  scientific  faith.     Advance  of  sci- 


466  NEW  YORK  XEUROLOGICAL  SOCIETY 

eiice  had  been  blocked  by  adherence  to  set  opinions  and  the  materiahstic 
attitude  of  contemporary  science  represented  a  faith  in  the  ultimate  similar 
to  earlier  religious  creeds  rather  than  a  scientific  theory.  Another  tendency 
acting  against  the  psj-chogenetic  standpoint  was  that  people  flew  from  one 
extreme  to  the  other.  They  said  if  treatment  were  not  based  on  a  physical 
conception,  then  it  was  Christian  Science  or  New  Thought.  He  held  that 
the  profession  might  well  regard  the  success  of  quackery  with  scientific  awe. 
It  was  a  daily  occurrence  that  patients  left  regular  practitioners  and  were 
cured  by  charlatans.  Results  were  results  and  should  be  studied.  They 
should  find  out  why  the  quacks  cured,  rather  than  eliminate  psychic  treatment 
as  a  delving  in  the  occult.  Mental  events  should  be  considered  as  belonging 
strictly  within  the  domain  of  science.  The  human  organism  was  not  merely 
liver,  heart,  kidney  and  brain,  operating  as  it  were  in  vitro.  It  was  a  more 
complex  structure  with  integrated  functions.  The  attitude  of  the  average 
medical  man  was  that  the  patient  was  a  conglomeration  of  organs  such  as 
might  occur  in  an  earthworm.  There  was  no  realization  that  a  large  part  of 
man's  adaptation  was  i\ot  on  a  physical  plane,  but  was  largely  mental. 


ZTranelattons 


VEGETATIVE    NEUROLOGY.     THE   ANATOMY,    PHYSI- 
OLOGY, PHARMODYNAMICS  AND  PATHOLOGY  OF 
THE    SYMPATHETIC   AND   AUTONOMIC 

SYSTEM 

Bv  Heinrich  Higier 


Authorized  Translation  by  Walter  Max  Kraus,  A.M.,  M.D. 
[New  York]. 

{Continued  from   page   377) 

9.  Some  vegetative  reflexes  are  produced  by  a  single  stimulus ; 
e.  g.,  the  secretion  of  saliva.  Others,  however,  such  as  the  ejacula- 
tion of  spermatozoa,  require  summated  stimuli.  In  summated 
stimulation,  the  impulse  begins  at  the  end  of  the  summation  and 
travels  from  the  vegetative  centers  to  the  neighboring  spinal,  or 
bulbar  centers,  or  cross-striated  musculature.  For  example,  the  act 
of  vomiting,  an  anti-peristaltic  contraction  of  the  smooth  muscula- 
ture of  the  stomach,  is  followed  by  contractions  of  the  voluntary 
pharyngeal  muscle.  Another  example  is  the  contraction  of  the  cross- 
striated  voluntary  muscle  of  the  constrictor  urethrse,  the  bulbo-  and 
ischiocavernosus,  the  muscles  of  the  legs  and  back,  subsequent  to 
the  contraction  of  the  smooth  muscle  of  the  seminal  vesicles,  vas 
deferens  and  prostate. 

These  parallel  manifestations  which  follow  summated  stimuli  do 
not  alter  in  the  least  the  principal  mechanism  of  the  vegetative 
reflexes. 

10.  There  are  many  exceptions  to  the  general  rule  that  the  pre- 
ganglionic tracts  are  sheathed,  the  post-ganglionic,  sheathless.  Thus 
far  examined,  some  of  the  pre-cellular  esophageal  and  cardiac 
branches  are  gray  and,  on  the  other  hand,  some  of  the  post-cel- 
lular ciliary  and  mesenteric  nerves  are  white.  The  sheathed  fibers 
of  the  ramus  communicans  albus  are  to  be  considered  as  those  fibers 
which  are  pre-ganglionic  and  through  which  the  spinal  cord  exerts 
its  influence  upon  the  vegetative  ganglia  and  thus  upon  the  nerves 
which  spread  to  the  corresponding  end  organ.  The  white  branches 
are  thus  motor,  centrifugal.  The  gray  fibers,  the  rami  communicantes 
grisei   which   travel  peripheralward,   are   also   motor   in   character. 

467 


468  HEIXRICH   HIGIER 

They  regulate  the  activity  of  the  vegetative  structures  of  the  skin 
and  of  the  visceral  organs  of  the  cranial,  thoracic  and  abdominal 
cavities  through  the  intermediary  station  of  the  ganglia  in  the 
sympathetic  cord. 

11.  There  are  normally  sheathless  fibers  springing  from  the  gray 
branches  or  from  the  ganglia  of  the  sympathetic  cord  whose  path 
is  spinahvard  or  to  the  senson,'  spinal  ganglia.  We  may  only  guess 
their  function  at  the  present  time.  These  anastomoses  may  either 
carr)'  recurrent  nerves  to  the  blood  vessels  of  the  vertebral  canal, 
or  sensory  centripetal  sympathetic  fibers. 

The  communication  which  exists  between  both  systems,  that  is 
between  the  sensory  tracts  and  the  sympathetic  ganglia,  may  be  ob- 
served in  all  the  cranial  ganglia.  An  example  of  this  is  the  ciliary 
ganglion  whose  small  branch  (radix  longus)  passes  to  a  branch  of 
the  first  branch  of  the  trigeminal  nerve  (n.  nasociliaris). 

The  microscopic  course  of  these  fibers  in  the  ganglia  is  not  clear 
up  to  now  since  many  authors  have  been  of  the  opinion  that  there 
were  no  sensory  centripetal  elements  among  the  fibers  coming  from 
the  ganglion  cells  and  that  the  sensory  fibers  going  to  the  ganglia 
did  not  end  therein  but  passed  through  or  were  merely  mechanically 
associated.  Experimental  investigation  with  extirpation  of  sym- 
pathetic ganglia  (ganglion  stellatum,  ganglion  cervicale,  ganglion 
ciliare)  and  subsequent  careful  examination  of  the  cerebrospinal  axis, 
or  experiments  which  disturb  the  sensory  supply  of  an  organ  with 
subsequent  examination  of  the  corresponding  sympathetic  ganglia, 
have  not  as  yet  yielded  harmonious  results. 

Whether  the  sympathetic  is  really  exclusively  motor  in  character, 
centrifugal,  whether  the  sensory  impulses  from  vegetative  organs 
pass  through  the  customar}-  posterior  routes,  and  the  sensory  nerves 
to  the  cerebrospinal  axis  will  be  discussed  later. 

12.  The  "anlage"  of  the  sympathetic  nervous  system  stands,  as 
is  well  known,  in  close  relationship  with  the  vascular  system  in  all 
parts  of  the  body.  The  maintaining  of  the  close  proximity  of  the 
sympathetic  cord  to  the  neighboring  blood  vessels  is  still  obscure,  in 
spite  of  the  fact  that  post-cellular,  sheathless  nerve  bundles  or  plcxi, 
regularly  pass  to  these. 

An  example  of  this  may  be  found  in  all  the  intracranial  ganglia, 
e.  (J.,  the  cilary  ganglion  sends  a  fine  branch  (radix  synipalhica)  to 
the  ojjhthalmic  ple.xus  which  winds  around  one  of  the  cranial  blood 
vessels,  the  ophthalmic  artery.  Whether  stimuli  arc  carried  by  these 
fibers  from  the  plexus  to  the  ganglion,  or  whether  stimuli  pass  from 
the  ganglion  to  the  distribution  of  the  vcssc-l-.  is  ';til],  j)hysiologically 
speaking,  unknown. 


VEGETATIVE   NEUROLOGY  469 

13.  The  function  of  the  gangHa  in  the  vegetative  system  is  not 
entirely  known.  Outside  of  what  has  been  mentioned  above  con- 
cerning the  ganglia  of  the  sympathetic  cord,  it  may  be  said  that  they 
regulate  the  activity  of  the  peripheral  vessels,  the  sweat  glands,  the 
skin  muscles,  and  also  send  fibers  to  all  the  internal  organs  and  the 
large  vessels  of  the  thoracic,  abdominal  and  pelvic  cavities.  All  the 
blood  vessels  of  the  cranial  cavity  are  supplied  with  nerves  which 
have  their  origin  in  mesencephalic  and  bulbar  parts  of  the  vegetative 
nervous  system. 

Outside  of  these,  the  following  structures  exist:  {a)  Ciliary 
ganglion  lying  in  the  posterior  part  of  the  orbit  which  supplies  the 
sphincter  iridis  and  the  ciliary  muscle;  (&)  the  spheno-palatine 
ganglia  lying  on  the  pterygo-palatine  fossa  which  supplies  the 
lachrymal  gland  and  the  mucous  glands  of  the  naso-pharynx ;  (c)  the 
otic  ganglia  lying  under  the  foramen  ovale  which  supplies  the  parotid 
gland;  {d)  the  submaxillary  and  sublingual  ganglia  which  supply 
the  corresponding  glands ;  {e)  the  autonomic  ganglia  (the  bulbar 
part  of  the  vagus  domain)  which  lie  in  organs  and  which  supply  the 
glands  and  muscles  of  the  trachea,  the  bronchi,  the  heart  muscle  and 
the  gastrointestinal  tract  from  the  mouth  to  the  descending  colon 
(Fig.  i);  (/)  the  ganglion  mesentericum  inferium,  hypogastricum 
and  hemorrhoidale  which  lie  in  the  upper  and  lower  parts  of  the 
pelvis,  supplying  the  muscles  and  glands  of  the  descending  colon, 
the  sigmoid,  the  anus,  the  genital  apparatus  and  the  blood  vessels 
thereunto  belonging. 

14.  It  is  not  possible  to  identify  the  individual  functions  of  the 
cells  of  a  ganglion,  when  that  ganglion  has  cells  whose  paths  go  to 
different  organs  and  control  different  functions. 

Even  the  significance  of  the  vegetative  paths  is  not  entirely  clear. 
L.  Miiller  observes  quite  justly  that  we  do  not  know  whether  these 
tracts  merely  serve  the  purpose  of  transferring  impulses  coming  from 
the  spinal  cord  or  whether  they  are  also  reflex  paths  bearing  sensory 
impulses  from  internal  organs  which  give  rise  to  motor  impulses. 
This  much  is  certain,  that  after  exclusion  of  the  abdominal  and 
cord  ganglia  of  the  sympathetic  system,  such  organs  as  the  heart, 
blood  vessels,  stomach  and  intestines  continue  their  activity  suf- 
ficiently to  maintain  life. 

Inhibitory  and  accelerator  activities  are  to  be  ascribed  to  the 
vagus  and  sympathetic  nerves,  while  the  initiation  of  activity  seems 
to  lie  in  the  ganglion  cells  of  the  organs  themselves. 

15.  In  addition  to  the  above-mentioned  sensory  stimuli,  con- 
scious or  unconscious,  and  exogenous  pharmacological  stimuli  as 
pilocarpin,  atropin  and  nicotin,  there  are  endogenous  stimuli  which 


470  HEIXRICH   HIGIER 

affect  the  activity  of  the  vegetative  nervous  system.  These  are  in- 
ternal secretions  as  thyreoiodo  globuhn,  adrenalin  and  the  peristaltic 
hormone.^ 

1 6.  The  intense  reaction  which  all  vegetative  end-organs  show 
subsequent  to  stimuli  of  cerebral  origin,  as  for  example,  pain  or 
rapid  changes  in  the  emotional  sphere,  is  certainly  a  physiological 
characteristic.  The  reaction  manifests  itself  clinically  in  terror, 
fear,  pain,  anxiety,  anticipation,  shame,  annoyance  and  joy.  The 
activities  of  the  heart,  pupil,  vasomotors,  sweat  glands,  gastro- 
intestinal tract,  bladder,  tear  glands  and  sebaceous  glands,  etc.,  are 
considerably  altered. 

H.  Xusbaum  states,  and  quite  justly,  that  we  can  have  no  psychic 
experience  of  any  kind,  joy,  sorrow  or  any  other  without  there  being 
reactions  of  a  definite  nature  in  our  body.  Strange  as  it  may  seem, 
it  is  true  nevertheless  that  we  should  be  without  shame  did  we  not 
blush,  and  without  rage  if  our  muscles  did  not  contract,  our  heart 
beat  more  rapidly  and  thump  in  our  breasts,  and  if  we  had  not  all 
those  other  changes  in  our  vegetative  organs  which  accompany  the 
emotional  activity  of  rage.  "  That  the  mind  acts  upon  the  body 
and  the  body  acts  upon  the  mind  in  that  important  sphere  of  psychic 
activity,  the  ehiotional,  is  quite  clear." 

It  is  significant  that  this  psychoreflex  manifests  itself  in  many 
ways.  The  different  emotional  states  have  qualitatively  dift'erent 
manifestations  in  various  parts  of  the  body. 

That  which  applies  to  sensory  stimuli  and  emotions  also  applies 
to  ever)'  mental  act  of  the  individual.  Every  psychic  activity,  every 
voluntary  impulse,  every  fixation  of  attention,  every  stimulating  idea 
brings  with  it  a  reaction,  for  all  psychic  activites  are  accompanied 
by  emotional  variations  and  feelings.  We  are  not  only  governed  by 
pure  sensory  stimulation,  but  also  by  higher  intellectual,  ethical  and 
esthetic  feelings. 

The  proof  of  this  which  lies  in  the  older  studies  upon  psycho- 
physical parallelism  promises  to  be  further  confirmed  in  the  future 
thanks  to  the  more  recent  studies  concerning  the  pupil  (continuous 
pupillary  activity)  and  the  vasomotors  (variations  in  the  blood 
volume  in  the  brain  and  at  the  periphery).  The  continual  minute 
oscillations  of  the  vegetative  nervous  system  bear  witness  that  the 
sum  of  -stimuli  going  to  the  central  nervous  system  is  always  vary- 
ing; that  the  tone  of  the  vegetative  tracts  is  always  varying  (L. 
Miillerj,  that  the  mirror  of  our  consciousness,  i.  e.,  our  vegetative 
balance  is  never  quite  stationary  (Bumke). 

'  Cholin  may  be  added  to  these. 

{To  he  coutiuucd) 


IPertecope 


Psychiatric  Bulletin  of  the  New  York  State  Hospitals 

(Series  2,  Volume  9,  No.  i,  January,  1916) 

1.  Studies  on  Alcoholic  Hallucinoses.     C.  V^on  A.  Schneider. 

2.  The  Relation  of  Pelvic  Diseases  to  Mental  Disorders.     Anne  E.  Perkins. 

3.  Dry  Permanent  Standards  in  the  Wassermann  Reaction  and  a  Technique 

Based  on  their  Use.     S.  Morse. 

4.  Clinical  Studies  in  Epilepsy.     Pierce  Clark.     (A  continued  article.) 

I.  Alcoholic  Hallucinoses. — In  this  discussion  of  the  alcoholic  hallucinoses 
Schneider  expresses  views  somewhat  at  variance  with  classical  conceptions. 
He  draws  a  distinct  line  between  delirium  tremens  and  the  Korsakoff  psy- 
choses on  the  one  hand,  and  the  acute  hallucinoses  on  the  other.  The  alco- 
holic hallucinoses  do  not  arise  from  the  abuse  of  alcohol  alone.  Neither  in 
the  physical  signs  nor  in  the  mental  conditions  are  there  evidences  of  toxemia. 
On  the  other  hand,  mental  factors  play  an  important  part.  Indeed,  these 
clinical  pictures  are  brought  out  by  mental  factors  alone — cases  in  which 
alcohol  can  be  entirely  excluded  as  the  cause.  The  views  of  a  number  of 
writers  are  cited  to  substantiate  this.  The  acute  alcoholic  hallucinoses  seem 
very  closely  related  to  manic  depressive  disorders,  and  patients  suffering  from 
this  condition  are  of  manic  personality.  An  alcoholic  hallucinosis,  in  a  case 
which  eventually  develops  in  dementia  prsecox,  is  an  incident  in  the  course  of 
this  latter  disease,  rather  than  that  there  is  any  close  relationship  between 
the  two  conditions.  To  consider  these  views  in  more  detail :  The  general 
question  of  alcohol  as  a  cause  or  factor  in  insanity  is  first  dealt  with. 
Schneider  quotes  a  number  of  investigators,  W.  Bevan  Lewis,  Mott,  and 
others,  to  the  effect  that  alcohol  has  been  overrated  as  a  cause  of  insanity. 
The  abuse  of  alcohol  is  very  prevalent  among  healthy-minded  people,  outside 
of  institutions,  and  an  alcoholic  heredity  is  not  limited  to  the  insane.  The 
writer  does  not  believe  that  the  homosexual  tendencies  attributed  by  some 
writers  to  alcoholics  are  to  be  found  in  the  case  of  the  hallucinoses.  These 
individuals  generally  lead  normal  sexual  lives.  Hirchfield,  ui  an  analysis  of 
a  thousand  homosexuals,  found  that  16  per  cent,  only  were  married,  50  per 
cent,  were  impotent  and  53  per  cent,  never  attempted  coitus.  In  the  halluci- 
noses 77  per  cent,  were  married,  and  nearly  all  were  vigorous  and  normal  in 
their  sexual  life.  The  question  of  the  relationship  of  the  alcoholic  psychoses 
to  other  psychoses  is  considered.  The  writer  does  not  thing  they  have  much 
in  common  with  dementia  prsecox.  The  personality  is  quite  different.  In  the 
hallucinoses  the  personality  is  of  the  open  and  frank  type,  and  the  individuals 
are  robust,  jovial  and  social.  This  is  in  contrast  to  the  well-known  seclusive- 
ness  of  dementia  prsecox. 

A  number  of  facts  are  referred  to  to  show  the  relationship  of  manic 
depressive  disorders  to  the  hallucinoses.  Kirby's  findings  in  Race  Psycho- 
pathology  show  that  the  Irish  are  most  subject  to  both  alcoholism  and  manic 
depressive  insanity.  H.  M.  Pollock  shows  that  the  usual  age  of  onset  in 
alcoholic  psychoses  is  forty-two  years.     Dementia  prsecox  begins  much  earlier. 

471 


472  PERISCOPE 

The  alcoholic  has  the  same  unstable,  social  makeup  as  the  manic,  and  the 
writer  thinks  that  the  alcoholic  hallucinoses  should  be  allied  to  the  manic 
depressive  type,  or  at  least  to  the  functional  recoverable  psychoses.  Schneider 
next  raises  the  question  whether  alcohol  is  the  all  important  factor  in  the 
alcoholic  hallucinoses.  Many  sprees  are  entirelj'  without  mental  symptoms. 
When  the  hallucinosis  does  occur  mental  factors  are  prominent  precipitating 
causes.  One  finds  just  such  precipitating  causes  as  occur  in  manic  depressive 
cases.  Moreover,  acute  hallucinoses,  clinically  identical  with  the  alcoholic 
tj-pe,  have  frequenth-  been  observed  where  no  alcohol  is  present.  Such  cases 
have  been  observed  by  a  number  of  writers. 

In  his  material  the  writer  has  made  the  following  observations:  (i) 
"  That  the  patient  has  suffered  manj-  previous  and  succeeding  debauches  with- 
out mental  trouble ;  (2)  that  there  is  always  a  precipitating  shock  exclusive 
of  alcohol;  (3)  that  subsequent  debauches  do  not  cause  mental  breakdowns 
unless  another  mental  shock  is  experienced.  In  fact,  readmissions  of  the 
hallucinations  are  not  the  rule;  (4)  that  the  condition  follows,  in  frequent 
cases,  withdrawal  of  alcohol,  attendant  depression  and  worry,  while  the  con- 
tent of  the  hallucinosis  is  determined  by  the  cause  of  the  worry;  (5)  that 
the  makeup  is  in  the  majority  joUj',  open,  sociable,  rather  excitable  and  dis- 
tinctly frank."     A  number  of  case  reports  are  given  to  illustrate  these  views. 

The  article  brings  to  our  attention  the  fact  that  the  alcohol  hallucinoses 
depend  upon  factors  other  than  alcohol  alone.  Mental  causes  are  important, 
and  possibly  are  necessary  factors  in  the  evolution  of  the  psychosis.  Schneider 
goes  rather  farther  than  this  in  his  concluding  paragraph :  "  Alcoholic  hallu- 
cinosis is  a  misleading  term  for  the  psychosis,  because  definite  precipitating 
factors  other  than  alcohol  are  present  and  necessary  in  its  production,  and 
are  often  reproduced  in  the  psychosis,  which  shows  their  importance;  be- 
cause alcohol  is  not  the  only  factor  or  the  most  important  factor  or  even  a 
necessary  factor  in  its  production,  as  shown  by  numerous  hallucinoses  iden- 
tical in  course  and  outcome,  where  alcohol  and  other  toxic  factors  can  be 
excluded ;  because  debauches,  both  before  and  after  attacks,  when  the  mental 
precipitating  factor  is  absent,  cause  no  difficulty;  because  other  psychoses  in 
the  same  individuals,  in  which  alcohol  plays  the  same  part,  are  not  called 
alcoholic." 

2.  Pehnc  Diseases  and  Mental  Disorders. — The  study  of  the  relation  of 
pelvic  diseases  to  mental  disorders  is  by  no  means  a  new  one,  but  so  many 
extravagant  statements  about  the  cure  of  mental  disorders  by  surgical  opera- 
tions have  been  made  from  time  to  time  in  the  past  that  it  is  refreshing  to 
have  the  views  of  one  who  has  first-hand  knowledge  gained  by  long  expe- 
rience. The  views  here  expressed  show  broad  understanding  and  good  judg- 
ment. The  article  may  be  studied  to  advantage  both  by  the  surgeon  who  has 
the  preconceived  idea  that  much  insanity  may  be  cured  by  some  sort  of  a 
gynecological  operation,  as  well  as  by  the  psychiatrist,  who  thinks  that  in 
attempting  to  relieve  mental  symptoms  by  surgical  interference,  little  or 
nothing  is  to  be  expected. 

Dr.  Perkins,  whose  observations  have  extended  over  a  period  of  eight 
years,  made  pelvic  examination  upon  four  hundred  and  seventy-eight  of  the 
patients  admitted;  65  per  cent,  were  diseased.  Manj'  different  disorders  were 
found,  among  the  most  frequent  being  lacerated  perineum,  retroversion,  lac- 
erated cervix,  endometritis,  parametritis,  salpingitis  and  fil)roma  uteri.  Rela- 
tively more  disease  states  were  found  in  the  manic  depressive  group  (manic 
depressive  78  per  cent.,  dementia  pra;cox  58  per  cent).  This  is  explained  by 
the  fact  that  the  manic  depressive  temperament  is  peculiarly  sensitive  to 
various  influences,  mental  and  physical.  The  pelvic  disease  appears  to  be  but 
one  factor  etiologically ;  yet  in  some  cases  the  mental  state  appears  to  be  a 
direct  result  of  this  diseased  condition,  and  the  mental  symptoms  are  relieved 


PERISCOPE  473 

by  operation.  There  is  probably  a  psychopathic  tendency  in  such  cases,  but 
they  might  escape  an  attack  if  they  remain  in  good  physical  health.  Cases 
are  described  in  which  a  surgical  operation  reUeved  a  diseased  pelvic  condi- 
tion and  resulted  in  prompt  mental  recovery.  One  case  recovered  promptly 
after  an  operation  for  retroversion.  Some  j-ears  later  after  an  automobile 
accident  the  adhesions  were  broken  up.  The  patient  again  became  depressed 
and  her  mental  sj-mptoms  were  again  relieved  by  a  ventral  fixation.  The 
patient  again  became  depressed  in  the  menopause,  however,  and  no  pelvic 
disease  was  demonstrated.  Another  case  developed  a  depressive  exhaustive 
psychosis  after  a  severe  infection  with  gonorrhea  which  was  followed  by 
peritonitis.  She  eventually  recovered  after  careful  gynecological  treatment. 
A  third  case  was  relieved  of  an  attack  of  depression  by  a  ventral  fixation. 
This  same  patient  developed  a  depression  two  years  later.  A  hysterectomy 
was  performed  before  her  admission,  but  this  time  she  did  not  recover  until 
several  months'  residence  in  an  institution.  Of  the  478  cases  examined, 
anomalies  of  development  of  the  generative  organs  were  found  in  eleven 
instances.     No  anomalies  were  found  in  the  epileptic  group. 

The  manic  depressive  cases  were  most  benefited  by  operations,  the  de- 
mentia prsecox  least.  A  number  of  interesting  cases  of  the  former  type  were 
observed.  One  elderly  woman  had  apparently  been  kept  maniacal  for  months 
by  a  severe  procidentia,  hemorrhoids  and  a  double  inguinal  hernia.  She 
recovered  promptly  after  the  operation  and  has  been  healthy  and  well  ever 
since.  One  patient  with  involutional  melancholia  made  a  surprising  recovery 
after  the  removal  of  the  cervical  poly,  the  bleeding  of  which  had  convinced 
her  that  she  had  cancer. 

Remarkable  improvement  was  noticed  in  one  case  of  epilepsy  of  twenty 
years'  standing.  This  patient  had  a  lacerated  cervix  and  perineum  on  admis- 
sion. She  was  ill-nourished  and  seemed  demented.  She  improved  wonder- 
fully after  the  operation.  Her  convulsions  came  down  from  thirty-nine  in 
two  and  one  half  months  to  two  in  five  months.  She  went  home  and  has  been 
capable  in  her  housework  ever  since,  having  but  one  or  two  convulsions  a 
year.  Another  epileptic  was  greatly  benefited  and  able  to  leave  the  hospital 
after  hysterectomy  for  a  fibroid.  Sixteen  cases  of  dementia  prsecox  were 
operated  upon  without  mental  benefit. 

In  a  number  of  cases  attacks  were  precipitated  by  operation.  The  post- 
operative psychoses  bore  no  constant  relationship  to  the  severity  of  the  opera- 
tion. The  writer  discusses  the  question  of  operations  in  nervous  and  mental 
patients,  and  the  knowledge  which  she  has  gained  could  be  utilized  to  advan- 
tage by  the  surgeon  who  has  occasion  to  operate  on  this  type  of  case.  Pa- 
tients without  nervous  capital  should  not  be  operated  upon  if  it  can  be  avoided  ; 
serious  neurasthenic  states  or  psychoses  may  follow.  The  after  care  is  im- 
portant, and  the  practice  of  hurrying  patients  out  of  the  general  hospital  in 
a  few  days  after  a  laparotomj-,  to  take  up  their  home  responsibilities,  may  lead 
to  serious  results.  In  mental  conditions  arising  from  artificial  menopause 
a  number  of  vasomotor  disturbances  and  emotional  disorders  are  met  with, 
especially  if  the  operation  is  during  the  child-bearing  period.  These  symp- 
toms generally  disappear  after  a  few  months.  The  fact  that  the  patient  has 
knowledge  of  the  character  of  the  operation  may  aggravate  the  symptoms. 
The  writer  adds  an  interesting  note  on  some  observations  she  has  made  of 
insane  imbeciles.  These  findings  are  quite  in  keeping  with  numerous  other 
reports  on  this  subject:  "Among  24  cases  of  insane  imbeciles  studied,  15 
were  known  to  be  infected  with  syphilis,  gonorrhea  or  both  ;  19  had  been 
sexual!}-  irregular,  9  had  had  illegitimate  children  (one  three,  one  five).  Two, 
who  were  married,  had  each  five  children." 

3.  Permanent  Wasscrmann  Standards  and  Technique. — This  article  deals 
with  the  technique  used  in  the  laboratory  routine,  routine  tests,  etc..  at  the 


474  PERISCOPE 

Psjchiatric  Institute,  Ward's  Island.  The  plan  is  to  standardize  all  reagents 
and  methods  of  procedure  so  that  all  reports  to  the  various  state  hospitals 
will  be  uniform.  The  details  of  standardization  and  technique  are  given  in 
detail.     They  are  not  suitable  for  abstract. 

4.  Epilepsy. — Continued  article.  Sanger  Brown  II. 

MISCELLANY 

Synthetic  Genetic  Study  of  Fe.\r.     G.  Stanley  Hall.     (Am.  Jour.  Psychol- 
ogy. 191 6.) 

Hall  defines  fear  as  an  "  anticipation  of  pain,"  not  a  prevision  but  a  gen- 
eralized forefeeling  that  something  more  painful  is  threatening.  This  can 
only  be  based  on  some  former  experience  in  individual  or  racial  existence. 
Fear  reaches  back  into  the  past  even  while  its  function  is  to  prepare  for  the 
immediate  "  next  thing  "  which  will  be  an  efficient  reaction  when  the  dreaded 
stimulus  comes.  In  this  way  it  contracts  the  past  and  the  future  into  an 
intense,  full  moment  of  the  present.  By  this  setting  toward  an  intense  re- 
sponse it  has  become  an  important  educative  force  and  a  chief  spur  to  psychic 
evolution.  At  the  same  time  it  limits  the  field  of  interest  and  attention,  in 
its  preparation  to  meet  the  situation,  and  inhibits  certain  psychic  processes 
and  organic  activities  while  intensifying  others.  It  is  therefore  both  dj^namo- 
genic  and  inhibitor}-.  For  a  time  the  most  incoherent  and  convulsive  move- 
ments may  be  the  most  advantageous,  but  these  disorganize  coordination  and 
ordinary  modes  of  adaptation,  and  repeated  fear  leads  to  the  establishment 
of  the  unusual  reactions.  But  it  also  sets  in  motion  the  stronger  reactions 
which  arouse  vitality,  stimulate  to  ventures  and  risks  in  order  even  to  create 
and  enforce  these  higher  reactions.  Man  learns  to  control  fear  and  make  it 
the  servant  of  the  higher  culture. 

The  manifestations  of  fear  may  be  studied  in  endless  variety  and  degree, 
so  extensive  has  grown  its  hold  upon  mankind.  This  multiplicitj^  however, 
is  subject  to  synthetic  arrangement  and  may  be  traced  to  one  generic  root. 
This  Hall  finds  fundamental.  It  belongs  to  the  most  elementary  reactions 
tending  to  the  preservation  and  recuperation  of  life.  Its  origin  probably  lies 
in  the  first  amebic  reflex  withdrawal  from  pain  stimulation  and  has  increased 
in  complexity  up  to  our  present  day  defensive  and  oflfensive  setting  toward 
objects  of  fear.  It  is  then  an  early  psychic  element  on  the  basis  of  aflfcctivity, 
a  flushing  up  which  follows  hard  upon  the  evolution  of  pleasure-pain.  From 
this  a  diathesis  of  fear  has  been  gradually  built  up  and  it  is  this  that  is  inher- 
ited, rather  than  the  effects  of  specific  objects  feared.  A  consideration  of 
shock  and  the  reactions  aroused  by  it  illumines  the  nature  of  fear,  and  reveals 
the  all-pervasive  traces  of  ancestral  experience.  Shock  is  peculiar  in  that  it 
comes  unanticipated,  it  takes  us  without  warning.  The  higher  psychical  func- 
tions are  not  prepared  for  it.  It  calls  into  action  rather  those  earlier  responses 
which  have  been  long  side-tracked  and  dispensed  with.  It  activates  the 
lowest  level  of  the  nervous  system,  producing  elementary  somatic  disturb- 
ances, respiratory,  circulator}',  secretory,  musculatory.  It  may  release  action 
upon  any  level,  but  its  effects  are  usually  reversionary  with  a  downward 
tendency  on  the  phyletic  scale.  Where  these  stimuli  have  been  adequately 
met  in.  the  past  heightened  experience  has  formed  the  power  to  deal  with 
them,  but  often  inadeciuatcly  received  they  tended  to  develop  and  fix  a  low 
level  response  which  is  less  under  the  control  of  the  cortex.  This  form  of 
reaction  can  be  found  all  the  way  from  the  reverse  reaction  of  the  mutilated 
plant  up  to  the  "  moral  relapse  to  savagery  "  of  criminals. 

Shock  comes,  then,  without  anticipatory  fear,  but  develops  a  new  fear 
of  itself.  We  dread  the  pain  and  strain  that  it  gives,  but  even  more,  perhaps, 
the   revelation   to   ourselves   and   others   of   our   reactions   on   these   primitive 


PERISCOPE  475 

levels.  The  fear  then  becomes  an  obsession  to  which  we  react  bj-  a  tension 
and  a  repression,  out  of  which  in  turn  grow  the  substitutions. 

Hall  refers  here  to  Adler's  study  of  compensation.  (A.  Adler,  Studie 
iiber  Minderwertigkeit  von  Organen,  1907,  p.  92,  also  Uber  den  Nervosen 
Charakter,  1912,  p.  195.)  This  is  a  process,  mostly  psychic,  by  which  a  con- 
genitally  inferior  or  subefficient  organ  is  compensated  by  subsequent  over- 
development or  by  the  vicariating  of  some  other  organ  for  it.  The  nervous 
system  reinforces  through  this  law  of  compensation  both  atrophy  and  hyper- 
trophy in  the  effort  to  adjust  to  effective  adaptation.  If  the  brain  fails  in 
this  effort  the  neuroses  and  psychoneuroses  result.  There  is  a  sense  of  insuf- 
ficiency and  incompleteness.  Out  of  this  feeling  of  inferiority,  inadequacy 
and  great  inner  intension,  a  general  anxiety  arises. 

"  Sex  anxieties,"  Hall  says,  "  are  symbols  of  this  deeper  sense  of  abate- 
ment of  the  will  to  live,  ...  to  illustrate  in  our  personality  the  whole  estate 
of  man."  Sex  plays  a  large  part  because  its  pleasures  are  most  intense  and 
vitality  at  its  height  during  sex  activity;  also  because  upon  it  depends  the 
immortality  of  the  race.  It  is,  moreover,  through  sex  that  inner  dishar- 
monies are  transmitted,  while  on  the  other  hand  it  performs  the  greatest 
service  in  restoration  through  love  and  cross  fertilization.  Sex  defect,  how- 
ever, both  impairs  the  efficiency  of  inheritance  and  is  in  itself  most  readily 
inheritable,  so  that  here  we  have  the  most  favorable  soil  for  anxiety  and  for 
specific  fears.  This  fearsomeness  is  easily  transferred  to  other  realms  and 
hides  itself  under  substitutions  and  symbolisms.  Other  forms  of  fear  have 
their  own  independent  causations,  although  they  may  use  in  part  the  same 
mechanisms  found  in  sex  fears. 

Hope  and  fear,  then,  are  based  on  the  desire  to  attain  the  fulness  of 
development,  and  fear  and  shock  warn  us  that  we  are  falling  short  of  this 
attainment.  From  the  genetic  standpoint,  according  to  Hall,  hope  and  fear 
are  the  creators  of  consciousness  itself,  from  its  lowest  to  its  highest  forms. 

The  author  goes  on  now  to  discuss  a  number  of  specific  phobias,  which 
he  traces  in  the  multiplicity  of  intensive  experiences  which  have  marked  the 
long  history  of  the  race.  His  ingenious  tracing  of  the  various  forms  of  fear, 
typical  of  countless  others  to  which  he  can  only  refer,  carries  conviction. 
These  past  experiences,  which  were  vital  at  certain  periods  to  the  race,  must 
have  left  some  trace. 

But  there  is  a  different  attitude  toward  the  whole  question.  It  is  as  if 
Hall  had  reached  the  genetic  beginning  only  of  the  mechanism  at  work  and 
traced  this  \yidely  in  its  manifestations  and  its  influence  upon  men.  Even 
here  he  seems  to  have  departed  somewhat  from  the  conception  of  an  inherited 
diathesis  rather  than  of  specific  object  fears.  His  study  of  the  past  lies 
among  the  obvious  causes  and  reactions  of  fear  which  accompanied  man's 
evolutionary  history. 

There  was  some  active  cause  stirring  beneath  these,  some  energizing 
force.  Hall  is  not  entirely  unmindful  of  this.  He  alludes  to  it  in  "  the  will 
to  live  "  to  reach  "  the  whole  estate  of  man,"  but  he  has  strangely  disregarded 
it  as  the  motive  power  which  would  have  unified  this  discussion,  focussing  all 
fear  in  one  energizing  source.  Instead  of  this  he  leaves  his  reader  with  a 
sense  of  scattered  disunity  in  his  thought. 

He  has  carved  out  and  set  apart  sexual  fear,  disposing  of  Freud's  con- 
ception as  too  narrow  to  include  all  fear.  It  is  just  here  that  he  misses  the 
"  libido  "  energy  concept  that  would  have  embraced  all  fear  in  the  one  vital- 
izing source.  He  uses  the  term  sex  in  the  old  limited  way  instead  of  giving 
it  the  broader  all-cornprehensive  concept  of  the  dynamic  life  force,  immor- 
tality principle.  His  failure  to  stand  in  this  attitude  toward  his  discussion 
leads  to  the  overemphasis  of  the  nutritive  element  in  the  struggle  of  man 
with  his   environment  which  produced  the   fears.     This  again   is   due  to  the 


476  PERISCOPE 

occupation  with  the  obvious  rather  than  the  fundamental  and  dynamic  in  the 
consideration  of  these  fears. 

It  is  difficult  to  see  why  certain  objects  which  he  discusses,  or  indeed 
the  many  which  he  only  mentions,  should  have  become  so  impressively  objects 
of  fear  that  we  still  react  to  them  as  our  ancestors  did  in  other  circum- 
stances, when  such  reaction  was  a  part  of  the  adaptation  necessarily  in  process 
of  acquisition,  unless  there  was  some  cause  inherent  in  our  predecessors  as 
in  us  which  made  these  objects  of  supreme  importance. 

One  can  utilize  the  facts  which  are  brought  forward  in  this  discussion 
and  perhaps  find  in  them  the  manifestations  of  the  libido  concept,  which  will 
help  one  to  a  more  pragmatic  understanding  of  fear.  Hall  has  made  passing 
allusion  to  the  ambivalence  of  fear  and  desire,  but  without  this  unifying 
libido  concept  it  could  not  find  the  place  in  his  discussion  that  it  demands. 
External  objects  of  fear  which  must  be  dealt  with,  at  once  and  effectively, 
may  be  soon  disposed  of,  but  that  anxiety  and  dread  that  linger  within  one 
arise  from  the  frustration  of  desire  due  to  the  increasing  restrictions  of 
society.  Thus  certain  objects  bound  up  with  desire  become  constant  objects 
of  dread  and  fear  and  call  forth  strong  emotional  reactions. 

Some  of  the  elements  of  the  fears  considered  become  significant  from 
this  point  of  view.  Hall  mentions  particularly  the  various  attributes  of  the 
serpent  which  impress  different  individuals.  Why  should  this  one  enemj'  of 
mankind  have  produced  such  a  profound  and  lasting  impression  upon  his 
fears  unless  it  stimulates  fundamental  desires  symbolically  bound  with  these 
very  characteristics?  If  we  consider  thus  the  serpent's  phallic  significance, 
it  is  far  easier  to  explain  the  universality  of  snake  worship  and  reverence, 
as  well  as  the  tj-pes  of  fear  which  they  inspire  to-day.  The  fear  of  cats,  too, 
which  is  taken  up  in  great  detail,  can  be  referred  to  a  related  source  of  desire 
symbolically  expressed,  and  the  peculiar  manifestations  of  this  phobia  take 
on  an  explicable  significance.  They  seem  to  rest  upon  the  "  polymorphous 
perverse"  libido  channels  of  infantile  reactions. 

Our  attention  has  been  directed  to  the  respiratory  reactions  as  the  re- 
sponse to  the  earliest  libido  demand  of  the  newborn  child.  This  most  vital 
demand  not  only  persists  as  necessary  to  existence,  but  it  is  intimately  bound 
with  our  pleasure-pain  reactions,  not  the  least  in  the  sexual  life.  It  is  not 
strange,  therefore,  that  intense  and  complicated  anxieties  arise  in  this  con- 
nection. Pavor  nocturnus  doubtless  represents  low  level  reactions,  which 
Hall  attributes  to  the  insufficient  resistance  on  the  part  of  a  neurotically 
disposed  child  to  the  impulses  which  arise  in  the  deepest  layers  of  sleep. 
Then,  he  says,  we  have  slipped  down  into  the  earliest  ages  of  human  life 
and  any  disturbance  arising  from  without,  or  from  within  the  neurotic  con- 
stitution, releases  these  early  defensive  mechanisms,  with  which  our  arboreal 
ancestors,  perhaps,  met  the  ever-present  disturbers  of  sleep.  Again,  he  but 
touches  upon  the  real  causal  explanations.  He  says  that  pavor  lacks  the 
analysis  that  Freud  has  given  to  sex.  It  is,  on  the  contrary,  the  broader  in- 
clusiveness  of  Freud's  sex  theories  that  have  covered  pavor  nocturnus  and 
reveal  in  it  the  fundamental  libido  striving,  however  much  it  may  utilize  the 
early  response  levels.  The  respiratory  striving  is  manifest,  together  with 
other  reflex  activities,  but  these  are  all  bound  inextricably  with  phantasy 
formation  which  seeks  the  various  energy  outlets. 

Erelithophobia  finds  its  motivating  cause  in  this  energy  concept.  Hall 
reminds  us  how  much  more  important  was  once  the  function  of  the  skin 
than  it  is  to-day.  But  this  is  not  alone  the  cause  of  the  marked  reactions 
and  the  related  phobia  considered  under  this  head.  The  skin  was  then  as  now 
an  organ  through  which  the  libido  could  find  outlet  at  all  levels,  in  reflex 
activities,  in  vital  contacts  and  in  the  gradual  sublimation  of  these.  Need 
for  protection  and  defense,  or  even  the  more  obvious  shame,  which  gradually 


PERISCOPE  477 

arose,  explain  only  to  a  slight  extent  the  extensive  meaning  the  unconscious 
attaches  to  the  skin  as  a  libido  territory,  especially  with  erotic  significance. 

Claustrophobia  and  agoraphobia,  too,  have  their  chief  determinants  in 
the  unconscious  motivation  and  energizing  of  the  early  acquired  reactions, 
and  these  latter  can  serve  to  illustrate  but  not  explain  the  peculiar  manifesta- 
tion of  these  as  of  all  phobias  and  their  intensive  and -persistent  influence 
upon  the  individual.  A  reflex  memory  of  troglodytic  days  may  abide  but 
the  infantile  desire  after  the  mother's  womb,  a  return  forbidden  by  reality, 
is  far  more  efficient  to  activate  an  ambivalent  anxiety  into  an  intense  fear  of 
wells,  such  as  Hall  mentions,  or  of  any  of  the  objects  which  the  neurotic  finds. 

Fear  and  desire,  so  closely  bound,  arise  from  the  one  source.  This  was 
already  an  activating,  energizing  power  with  our  remote  ancestors,  so  that 
their  fears  too  arose  from  it.  External  causes  and  the  reactions  may  have 
intensified  the  fears  and  serve  to  some  extent  to  condition  still  our  feehng 
and  behavior,  but  the  fundamental  explanation  lies  in  the  immortal  libido. 

Jelliffe. 

The  Disco\'ery  of  Time.  James  T.  Shotwell.  (The  Journal  of  Philosophy, 
Psychology  and  Scientific  Methods,  Vol.  XII,  Nos.  8,  lo  and  12,  April 
15,  May  13  and  June  12,  1915.) 
This  is  a  highly  interesting  discussion  of  time,  its  gradual  appreciation 
and  appropriation  by  man.  Time  is  presented  in  such  a  vital  manner  as  will 
surely  recall  the  fact  of  its  reality.  This  the  author  says  there  has  been  a 
tendency  to  overlook.  It  is  so  much  easier  to  measure  man's  conquest  of 
things  of  space,  that  the  other  half  of  life  is  neglected.  Time  is  no  less  real 
but  it  belongs  to  that  everlasting  flux  ceaselessly  appearing,  ceaselessly  dis- 
solving within  the  heart  of  things,  and  all  that  is  seized  of  it,  in  the  very- 
apprehension,  becomes  at  once  static,  no  longer  vitally  real.  However,  for 
long  ages,  time  was  apprehended  only  in  the  deeper  sense.  Men  had  not 
learned  to  measure  it  for  exact  control  of  nature  and  regulated  activities.  They 
lived  in  the  present,  but  dimly  emerging  from  the  emotional  stage,  where  the 
intellectually  guided  imagination  was  as  yet  barely  taking  hold  of  the  future, 
an  attitude  which  directs  interest  still  to  the  romance  of  vague,  indefinite 
time  rather  than  to  the  well-defined  times  and  seasons  marked  by  dates. 
Necessit3%  however,  compelled  man  to  find  some  way  of  thus  marking  time 
if  he  was  to  advance  and  control  the  course  of  things.  Foresight  depended 
upon  a  practical  grasp  of  it,  and  a  system  of  measurement  must  be  found. 
Shotwell  guides  us  through  a  rapid  survey  of  this  effort  on  the  part  of  the 
various  advanced  nations  of  antiquity.  The  periods  of  the  moon  were  tried 
and  long  held  sway.  The  Egyptians  early  discovered  the  more  accurate 
dependence  upon  the  sun,  while  Assyria  began  late  in  her  history  to  develop 
a  real  knowledge  of  astronomy.  The  thrusting  of  the  days  of  the  week  into 
the  month  regardless  of  the  time  division  illustrates  the  preponderance  of 
primitive  superstition  and  belief  in  the  consideration  of  time.  The  sense  of 
the  deeper  vital  reality,  however  mistakenly  manifested  in  superstition,  was 
too  potent  to  be  easily  replaced.  Hence  the  slow,  long  delayed  growth  of 
the  practical  system.  Shotwell  remains  upon  the  surface  of  these  things  but 
seems  to  be  groping  for  the  more  profound  interpretations  which  are  fraught 
with  the  most  real  meaning  of  time  as  of  all  things.  Of  the  surface  achieve- 
ment he  has  promised  more  chapters  in  the  future. 

Jelliffe. 


Booft  IRcviews 


Bodily  Changes  in  Pain,  Hunger,  Fear  and  Rage.  An  Account  of  Recent 
Researches  into  the  Function  of  Emotional  Excitement.  By  Walter  B. 
Cannon.     D.  Appleton  and  Company,  New  York  and  London. 

The  interrelations  of  the  vegetative  and  psychic  levels  of  tlie  nervous 
■system,  and  the  interdependence  of  their  activity  demand  increasing  atten- 
tion. Their  importance  is  assured  and  they  have  entered  the  field  of  careful 
experimental  research.  This  contribution  from  the  Harvard  laboratory 
speaks  stronglj',  from  the  physiological  side,  of  this  fundamental  interplay 
of  mind  and  body,  and  suggests  the  value  of  this  in  the  economy  of  life. 

The  book  is  the  result  of  four  years  of  very  definite  experiments  upon 
the  effect  of  some  of  what  the  author  calls  the  "major"  emotions  upon  bodily 
conditions.  Certain  external  signs  of  physical  response  to  emotional  stimuli 
are  easily  recognized,  but  it  is  the  reaction  of  deep-lying  organs  which  calls 
for  investigation,  and  which  is,  moreover,  of  vital  importance.  This  has 
heen  the  subject  of  the  study. 

Cannon  first  briefly  reviews  the  results  obtained  by  previous  observers 
in  regard  to  the  relation  of  the  emotions  to  the  digestive  processes,  and  thus 
brings  into  view  the  antagonistic  action  of  the  three  different  divisions  of  the 
•vegetative  system.  These  he  then  very  graphically  presents,  both  anatomically 
as  well  as  in  their  threefold  functioning.  The  cranial  autonomic  serves  to 
•conserve  the  resources  of  the  body,  the  sacral  division  to  release  tension,  and 
the  sympathetic,  whose  action  is  more  extensive  and  diffuse,  rather  than 
restricted,  also  acts  as  an  antagonist,  whenever  it  comes  into  contact  with 
either  of  the  other  divisions. 

On  this  physiological  basis  Cannon's  observations  were  made.  In  condi- 
tions of  emotional  excitement  there  are  obvious,  external  evidences  of  the 
activity  of  the  sympathetic  nerves.  But  some  internal  change  seems  to  take 
place  which  determines  a  prolongation  of  the  first  direct  effects. 

Tliis  phenomenon  led  to  a  detailed  study  of  the  secretion  of  adrenin 
from  the  adrenal  glands.  These  glands  are  supplied  by  the  sympathetic 
system,  it  has  been  proved,  and  when  this  system  is  activated  by  the  emotions, 
there  occurs  a  marked  secretion  of  this  substance.  This  fact  is  attested  by 
varied  experiments  described  in  detail,  and  so  also  is  the  effect  of  the  secreted 
adrenin  upon  various  tissues  of  the  body. 

These  can  be  merely  indicated  here.  Through  the  action  of  adrenin  sugar 
is  increased  in  the  blood;  by  its  influence  the  blood  supply  is  increased  in 
those  organs  likely  to  be  called  into  activity  in  response  to  the  emotions ; 
muscle  fatigue  is  abolished  ;  and  the  coagulability  of  the  blood  is  hastened. 
These  arc  all  unconscious  processes,  and  this  causes  the  very  promptness  of 
their  response  which  establishes  their  utility. 

For  these  involuntarily  produced  effects  of  the  activity  of  the  sympa- 
thetic division  amply  prepare  the  body  for  the  reactions  toward  defense  or 
toward  the  violent  exertion  which  tlie  emotions  demand. 

Special  attention  is  given  to  hunger,  which  Cannon  finds  to  be  the  result 
of  reflex  contractions  oi  the  alimentary  canal,  or  in  other  words,  "a  signal 
that  the  stomach  is  contracted  for  action."     It  is  therefore  classed  with  the 

478 


BOOK  REVIEWS  479 

other  primitive  emotions  as  a  determinant  of  the  reflex  activity  of  the  body. 

The  interrelation  of  the  three  divisions  of  the  autonomic  system  mani- 
fests itself  in  the  dominance  of  the  sympathetic  division,  in  its  antagonistic 
action  in  regard  to  the  other  two.  This  is  demanded  by  the  response  to  quick 
action  called  forth  by  the  emotions.  But  it  illustrates  also  the  harmful 
effect  of  uncontrolled  emotional  reactions  which  hold  the  functions  of  the 
cranial  and  sacral  divisions  of  the  autonomic  in  abeyance. 

Sometimes,  however,  the  sacral  innervation  seems  to  prevail  even  under 
great  emotion.  Cannon  admits  the  difficulty  of  explaining  this.  This  is  sug- 
gestive of  the  extent  of  this  problem  still  before  investigators,  for  the  work 
is  only  begun.  The  finesse  and  extent  of  the  emotional  interactivity  with 
physical  reactions,  calls  for  all  the  resources  of  psychical  as  well  as  physio- 
logical investigation. 

Cannon  closes  with  a  timely  plea  for  a  rational  outlet  in  healthful,  manly 
sports  for  these  unquenchable  primitive  emotions  and  their  reflex  activities. 
Modern  militarism,  he  says,  in  its  highly  perfected  artificiality  no  longer 
provides  them. 

In  general  survey,  one  might  say  that  this  work  marks  a  great  advance 
in  the  experimental  method  to  render  provable  a  number  of  facts  which  have 
been  known  empirically  for  thousands  of  years.  The  literature  of  psychiatry 
abounds  in  observations  with  which  the  author  is  unacquainted,  hence  a  cer- 
tain not  unbecoming  naivete. 

One  only  has  to  go  one  step  further  to  prove  the  entire  range  of  the 
psychoanalytic  observations  of  the  past  decade  and  that  is  to  recognize  the 
force  of  the  emotions  which  are  operating  under  unconscious  repression. 
Cannon  is  working  with  evident  conscious  emotional  reactions,  the  psycho- 
analyst with  repressed  ones.  Hence,  Cannon's  work  will  be  a  useful  har- 
monizer  and  tend  to  show  from  the  physiological  side  the  truths  underlying 
the  whole  psj'choanalytic  situation. 

Jelliffe. 

Eros.  The  Development  of  the  Sex  Relations  through  the  Ages.  By 
Emil  Lucka.  Translated  by  Ellie  Schleusner.  G.  F.  Putnam's  Sons, 
New  York  and  London. 

Th€re  is  a  twofold  power  in  this  book  that  compels  attention  from  begin- 
ning to  end.  It  lies  first  in  the  form  which  portrays  with  a  new  vividness 
the  growth  of  the  love  life  in  the  race  embodying  it  in  men  who  move  over 
the  stage  of  history,  particularly  of  that  of  the  middle  ages,  that  period  just 
emerging  from  obscurity,  and  who  are  here  depicted  clearly,  distinctively  in 
their  service  in  representing  and  forwarding  the  advancing  stages  of  the 
erotic  nature  of  man.  In  the  second  place  there  is  a  power  in  the  author's 
thought  and  the  consistency  and  conviction  with  which  he  maintains  his  thesis 
which  no  less  sustains  our  interest,  and  which  the  evident  sympathy  and  com- 
prehension of  the  translator  have  preserved  to  us  in  this  edition. 

Lucka  briefly  reviews  the  sexual  life  of  early  man,  in  few  words  setting 
forth  strikingly  its  salient  features,  and  showing  that  it  was  in  no  wise  con- 
nected with  love.  Even  among  the  Greeks  love  was  a  sentiment  unknown 
in  marriage,  confined  to  a  few  legends  which  rather  foreshadowed  a  future 
ideal  than  represented  actual  conditions.  To  early  man  sexual  satisfaction 
was  easy  and  natural.  It  brought  with  it  no  problems,  no  complications.  It 
was  an  incident  of  easy  fulfilment,  then  easily  forgotten,  while  man  passed 
on  to  the  acquisition  of  necessities  in  the  struggle  with  nature. 

There  arises,  however,  gradually  some  sense  of  individual  desire  for 
power,  for  organization,  for  restricted  sexuality,  for  recognition  of  a  man's 
own  offspring.  These,  even  later  more  highly  developed  monogamy,  are 
based  on  economic  reasons,  sexual  love  has  not  yet  entered. 


48j  book  REllEWS 

But  with  the  rise  of  Christianit\-  a  great  new  factor  has  appeared  which 
is  to  dominate  Europe  and  distinguish  its  thought  and  feehng  from  that  of 
the  older  civilizations.  This  is  the  element  of  personalit}'.  Lucka  introduces 
here  a  chapter  on  the  Birth  of  Europe  in  order  to  develop  a  background  upon 
which  he  can  trace  the  influence  of  this  new  factor  upon  erotic  feeling  and 
the  new  manifestation  of  erotic  desire  that  wrought  itself  out.  True  to  his 
definition  of  history-  he  introduces  it  to  present  not  a  record  of  facts  but  the 
creative  development  of  new  values  in  desire  and  their  achievement  through 
representative  men.  In  the  erotic  life  this  new  sense  of  personality  was  a 
yearning  after  metaphysical  love.  The  asceticism  of  the  Church  had  con- 
demned sexuality  establishing  a  sharp  dualitj'  between  the  sensual  and  the 
spiritual,  which  belonged  to  another  world.  And  j-et  men  had  awakened 
to  the  joy  and  inspiration  of  a  personal  love.  It  formed  the  theme  of  song 
and  storj-,  created  the  devotion  of  chivalry,  it  was  poured  out  even  upon 
nature  and  transformed  the  perfect  form  of  ancient  sculpture  into  vital, 
breathing  structures  of  Gothic  art.  How  then  shall  men  reconcile  the  power 
of  this  new  love  and  the  need  of  deliverance  from  the  evil  which  is  condemned. 

It  remained  for  certain  great  souls  to  grasp  the  metapln-sical  love,  deify 
its  object  and  project  it  into  the  heavens,  there  to  unite  it  with  man's  salva- 
tion. Thus  it  glorifies  the  Virgin  Mary,  placing  her  even  on  an  equality  with 
God.  It  raises  the  individual  loved  one  to  Mary's  side  and  brings  her  to  the 
salvation  of  her  lover.  "  Dante  possessed  this  vision,"  Goethe  found  it,  but 
for  him  it  was  necessary  to  "  seek,  strive  and  err."  This  metaphysical  love 
reached  its  tragedy  in  Michaelangelo,  for  whom  this  love  became  greater 
than  his  work  and  made  all  his  creative  activity  seem  as  nothing. 

The  sexual,  however,  is  never  denied.  It  exists  undiminished  but  apart 
from  the  metaphysical  ideal.  It  is  not  strange,  therefore,  that  men  crave  still  a 
new  development  which  shall  in  turn  have  its  exponents  in  those  who  appre- 
hend and  make  real  a  further  stage  in  erotic  evolution.  The  demand  of 
modern  life  is  for  a  synthesis  of  these  two  elements  of  eroticism.  The 
object  of  love  must  be  no  longer  removed  to  a  transcendental  sphere  but 
must  satisfy  the  personality  with  the  higher  spiritual  love  in  the  ideal  woman 
found  here  upon  earth. 

As  the  individual  epitomizes  the  history  of  the  race,  so  each  man  must 
himself  pass  through  these  separate  erotic  stages.  Wagner  was  the  great 
representative  of  this  principle,  and  he  has  given  immortal  expression  to 
these  periods  of  development  in  the  stages  of  his  musical  production.  In 
Parsifal  Lucka  sees  a  possible  foreshadowing  of  a  plane  of  erotic  develop- 
ment yet  to  be  reached,  when  sexual  love  shall  have  been  finalh-  outgrown 
and  replaced  by  mysticism. 

Such  is  the  thesis  of  the  book.  But  as  one  follows  its  stirring  presenta- 
tion, one  is  dashed  now  and  again  upon  some  rock  of  resistance  and  can  but 
feel  that  it  is  the  author's  own  complex,  that  his  power  symbol  and  satisfac- 
tion lying  in  the  metaphysical  and  transcendental  are  sweeping  him  on  to 
unfounded  conclusions  divorced  from  solid  reality,  the  actual  evolutionary 
achievement  of  the  race.  Lucka  anticipates  the  criticism  that  he  has  departed 
from  the  accepted  theory  of  the  sexual  as  the  base  of  all  love.  It  would  seem 
to  us  that  his  whole  book  is  an  intense  revelation  of  the  sexual  in  its  broadest 
sense,  the  truly  and  completely  erotic  underlying  all  these  manifestations  of 
lov€,  even  the  most  exalted  striving  anrl  attainment  of  greatest  metaphysical 
souls.  To  a  certain  amount  of  mysticism  he  attributes  a  sexual  basis.  To 
us  the  diflFerence  in  these  manifestations  would  seem  to  lie  not  in  the  source 
but  in  the  degree  and  kind  of  sublimation  conceived  and  attained. 

Then,  though  he  has  skillfully  touched  upon  the  nature  of  the  sexual 
life  of  earl}'  man,  researches  into  primitive  customs  certainly  do  not  reveal 
such  simplicity  of  the  erotic  life.     True,  primitive  man  is  not  yet  the  victim 


BOOK  REVIEWS  481 

of  modern  complicated  repressions,  but  the  sexual  seems  to  press  upon  him 
from  every  side,  demanding  countless  taboos,  burdensome  restraints,  endless 
ceremonials,  even  while  allowing  him  a  liberty  and  license  which  prevent  the 
psychical  complications  that  cultural  restraint  brings  in  its  train. 

Nor  again  does  the  position  of  woman  in  eroticism  seem  so  simple  as 
the  author  sees  it.  He  admits  here  the  pathological  attitude  that  hysterically 
finds  a  mystic  outlet  for  genuine  sexuality,  but  on  the  whole  he  conceives  of 
woman  as  serene  and  unperturbed  throughout  man's  long  struggle  in  erotic 
development.  Again  he  seems  strangely  unmindful  of  the  enormous  part 
that  sexuality  has  played  since  the  dawn  of  human  life,  a  part  in  which  the 
course  of  woman's  erotic  life  also  has  passed  through  stages  of  such  varying 
significance  that  she  too  has  been  the  victim  of  violent  repressions  which 
have  created  for  her  psychic  problems  and  developmental  attitudes  no  less 
urgent  than  those  of  man. 

Lucka's  denial  of  "  Schopenhauer's  instinct  of  philoprogenitiveness"  would 
lie  behind  this  attitude.  To  assert  that  there  is  an  instinct  of  love  apart 
from  and  beyond  the  reproductive  desire  most  broadly  considered  would 
draw  false  lines  of  distinction  through  the  erotic  life  and  its  racial  history. 
This  too  would  lead  to  that  chapter  which  seems  to  accept  the  love  death  as 
a  form  of  high  attainment  in  the  spiritualized  erotic  sphere  instead  of  giving 
its  true  auto-erotic  value. 

The  book  is  full  of  stimulating  thoughts  and  it  reaches  out  to  a  high 
sublimation  of  love.  Yet  by  its  very  force  of  thought  combined  with  its 
power  of  diction  one  feels  hurled  from  the  true  foundation  of  things  and 
projected  upon  the  author's  own  complex  reactions. 

Jelliffe. 

Appletox's  Medical  Dictionary.  Edited  by  Smith  Ely  Jelliffe,  A.M.,  M.D., 
Ph.D.,  assisted  by  Caroline  Wormeley  Latimer,  M.D.,  A.M.  D.  Apple- 
ton  and  Company,  New  York  and  London. 

The  scope  of  the  purpose  of  this  new  dictionary  is  denoted  by  the  choice 
of  the  editors  who  have  prepared  it  for  use.  Dr.  Jelliffe  and  Dr.  Latimer, 
together  with  those  who  have  collaborated  with  them,  represent  the  various 
fields  of  science  which  belong  to  medical  work  and  contribute  to  its  knowl- 
edge and  activity. 

Especial  stress  has  been  laid  upon  the  newer  terms  which  have  arisen 
to  express  the  advance  of  knowledge  and  the  broadening  of  concept  in  the 
fields  of  neurolog>'  and  psychiatrj-.  This  has  been  done  in  that  spirit  of 
open-mindedness  and  comprehensive  grasp  of  pragmatic  principles,  which 
must  prove  the  efficiency  of  the  language  tools  that  are  used  and  open  the 
way  to  a  newer,  broader  and  more  effective  service.  Terms  are  conceived 
and  defined  in  that  broader  attitude  that  anticipates  and  furthers  development 
through  serviceableness,  and  which  is  the  attitude  of  the  newer  psychology 
and  philosophy  of  nervous  and  mental  as  well  as  of  all  disease. 

To  this  pragmatic  end  there  has  been  an  elimination  of  matter  grown 
superfluous,  a  simplification  of  external  form  and  expression.  This  has  pro- 
duced a  volume  of  convenient  size  and  extent  for  practical  working  purposes. 

There  is  room,  however,  for  greater  clearness  of  detail  in  form,  and  for 
the  further  extension  of  the  principle  of  workable  utility  in  arrangement. 
This  latter  would  revolutionize  the  old  crystallized  forms  of  classification  as 
we  see  them  in  the  table  of  nerves,  for  example,  and  make  the  classification 
illustrative  rather  of  the  actual  functional,  experiential  source  of  develop- 
ment. To  such  alteration,  however,  the  fundamental  attitude  of  the  dic- 
tionarjr  opens  the  way. 

A  valuable  appendix  has  been  added  which  will  serve  as  a  practical  guide 
in  various  directions  where  technical  accuracy  is  of  special  importance. 

L.  Brink. 


482  BOOK  REVIEWS 

Nature  and  Nurture  in   Mental  De\-elopment.     Bv  F.  W.   Mott,   M.D., 
F.R.S.,  F.R.C.P.     Paul  B.  Hoeber,  New  York.  ' 

This  small  volume  is  fairly  crowded  with  facts  and  suggestions,  all  of 
fundamental  importance  and  sound  value.  In  the  first  place  it  comes  from 
one  familiar  with  a  subject  vast  in  its  origin  and  in  its  possibilities  for  the 
improvement  of  the  race  and  of  the  individual.  Then,  though  the  subject 
matter  here  is  presented  in  a  somewhat  rhetorical  style  as  befits  rather  the 
lectures  in  which  it  first  appeared,  yet  so  truly  scientific  are  the  given  facts 
and  presented  in  so  direct  and  forcible  a  manner  that  they  appeal  not  only  to 
the  social  worker,  the  teacher,  and  the  intelligent  parent,  but  are  of  distinct 
value  to  the  phj'sician  as  well. 

For  the  outlines  of  the  structure  and  functioning  of  the  nervous  system 
are  very  carefully  though  briefly  given,  with  special  attention  to  the  history  of 
development  of  both  in  their  relation  to  their  environment,  prenatal,  natal 
and  postnatal,  and  in  the  effect  of  the  environment  as  well  as  heredity  in 
determining  the  mental  character  and  ability. 

In  the  latter  part  of  the  book  attention  is  given  to  the  various  ways  in 
which  this  question  of  environmental  conditions  or  nurture  may  be  theo- 
retically considered  and  practically  worked  out  through  medical  inspection 
in  schools,  separate  schools  for  the  physically  or  mentally  disabled,  care  and 
instruction  of  the  mother  and  all  the  ways  which  are  being  entered  by  the 
social  worker. 

It  is  not,  however,  this  general  outline  that  rouses  our  interest  chiefly. 
Dr.  Mott's  facile  handling  of  the  subject  of  heredity  emphasizes  with  con- 
vincing clearness  the  importance  of  inherited  mental  tendency  for  strength 
or  w-eakness  rather  than  of  specific  factors  or  agents  pathologic  or  otherwise, 
and  with  this  the  hopefulness  that  lies  in  the  social  watchfulness  which  can 
counteract  the  inherited  neuropathic  tendency,  removing  the  causes  which 
would  attack  it  and  moreover  strengthening  the  weak  points  by  proper 
measures. 

The  inherent  potentiality  of  the  brain  is  capable  of  marvelous  develop- 
ment through  the  proper  associative  paths,  even  when  it  lies  dormant  for 
want  of  stimulus  from  without,  which  is  most  strikingly  illustrated  in  the 
cases  of  Helen  Keller,  Laura  Bridgman  and  Marie  Huertin.  who  showed  this 
potentiality  in  a  marked  degree  when  avenues  of  approach  had  been  found 
for  them  other  than  those  of  hearing  and  sight,  from  which  they  were  cut  off. 

Herein  lies  the  social  heritage  which  has  formed  a  brain  of  superior 
tendencies,  abilities,  potentialities,  which  is  apart  from  the  acquisition  of 
language  and  all  other  external  tools  and  products  of  the  ages  of  racial 
advance.  The  author  has  not  gone  at  all  extensively  into  the  purely  psychical 
factors  behind  mental  behavior,  but  there  is  no  confusion  between  the  physical 
basis  of  mind  and  the  mental  activity  itself.  Here  again  he  moves  with  a 
clear  handling  of  facts  and  suggestive  theories  for  further  research,  as,  for 
example,  in  the  action  of  the  chemical  hormones  upon  tlie  nervous  system, 
and  therefore  their  relation  with  the  mind. 

It  is  possible  only  to  point  out  a  few  of  these  topics  that  follow  rapidly 
upon  one  another  in  the  author's  comprehensive  and  well  grounded  presenta- 
tion of  the  subject.  The  whole  attitude  of  the  book  is  well  worth  closer 
attention,  while  its  substance  and  form  arc  stimulating  to  a  high  degree. 

Jki.mkfe. 


I'ROFIiSSOK    AI.MKKI     \  AN    ( ,i;i  1 1  (  1 1  ll-X. 


1Rotc6  anb  IRewe 


©bituari? 

The  passing  of  a  great  man  calls  upon  us  to  consider  what 
advance  has  been  made  through  his  life,  how  far  his  activities  and 
researches  have  brought  us  to  a  higher  plane  of  achievement. 

The  death  of  many  notable  leaders  in  neurology  and  psychiatry 
in  the  last  few  years  turns  attention  to  the  increase  in  knowledge  and 
effectual  service  in  these  fields,  which  have  resulted  from  the  work 
of  these  leaders  and  revolutionized  the  theories  and  methods  of  the 
laboratory  as  of  the  clinic. 

The  Editors  of  the  Journal  have  recorded  by  special  obituary 
notice  the  loss  among  its  own  countrymen  in  the  recent  past  of  such 
men  as  Weir  Mitchell,  D'Orsay  Hecht,  Isaac  Ott,  and  others.  It 
wishes  to  present  as  well  some  account  of  the  lives  of  those  who 
are  laying  down  their  work  in  foreign  countries,  in  order  to  mark 
the  impress  of  these  lives  upon  neurological  and  psychiatrical 
progress  in  the  individual  service  they  have  rendered  to  it. 

ALBERT   VAN   GEHUCHTEN 

The  death  of  Prof,  van  Gehuchten,  of  Louvain,  marks  the  pass- 
ing of  a  masterly  figure  in  the  neurological  world.  The  tragedy 
that  befell  his  work  as  a  result  of  the  destructive  conflict  waging 
in  Europe  has  served  to  throw  his  personality  and  work  into  even 
stronger  relief. 

His  death  occurred  in  Cambridge,  December  9,  1914.  where  he 
had  taken  refuge  a  few  months  previously  when  the  entrance  of 
the  Germans  into  Louvain  had  interrupted  his  work  as  professor  of 
anatomy,  pathology  and  treatment  of  diseases  of  the  nervous  system 
in  the  University  of  Louvain.  Valuable  records  of  his  work 
extending  over  the  past  ten  years  were  lost  in  the  destruction  of 
his  city  and  country  homes.  Warmly  welcomed  in  England  van 
Gehuchten  had  rallied  from  the  effect  of  the  catastrophe  and  was 
devoting  himself  with  a  return  of  his  former  ardor  to  his  work, 
for  which  the  English  had  put  at  his  disposal  the  laboratory  of  the 
Research  Hospital  together  with  a  contribution  from  the  Rocke- 
feller fund.  His  brilliant  methods  of  work  combined  with  his 
purely  disinterested  spirit  of  scientific  research,  illumined  now  by 
a  hopeful  courage  that  could  surmount  his  misfortune  and  enable 
him  to  begin  work  afresh,  won  for  him  a  still  greater  measure  of 

483 


4S4  OBITUARIES 

that  esteem  and  affection  which  had  been  his  from  students  and 
colleagues. 

He  was  however  suddenly  attacked  by  an  illness  which  neces- 
sitated an  operation.  This  was  successfully  performed  and  re- 
covery seemed  assured  when  a  severe  distress  in  the  region  of  the 
heart  was  followed  quickly  by  his  death. 

His  first  publication,  in  1886,  on  the  structure  of  the  muscle  cells, 
marked  the  beginning  of  his  skillful  investigation  and  brilliant  ex- 
position in  the  field  of  biological  science,  which  he  later  developed 
particularly  in  the  study  of  the  central  nervous  system. 

He  largely  contributed  to  the  establishment  of  the  present  day 
indispensable  conception  of  the  neuron  as  an  independent  and  funda- 
mental unit,  with  its  protoplasmic  j^rolongations  for  cellulipetal 
transmission  and  its  axis  cylinder  prolongation  for  cellulifugal  trans- 
mission, and  the  conduction  of  impulses  from  one  neuron  to  another 
by  the  propinquity  of  the  terminals  of  the  axis  cylinder  of  one 
neuron  to  the  protoplasmic  prolongations  of  the  other.  This  formed 
the  basis  for  all  his  later  researches. 

He  refined  the  methods  of  Golgi  in  the  examination  of  the  finer 
nerve  structures  by  his  methods  of  methylene-blue  staining.  His 
study  of  the  true  origin  of  motor  nerves  rested  upon  his  investiga- 
tion of  the  phenomena  of  chromatolysis.  Later  he  studied  with  an 
exactitude  of  result  the  intracerebral  or  medullary  course  of  the 
motor  nerves  and  certain  central  nerve  tracts,  and  the  origin  and 
termination  of  the  peripheral  nerves,  also  the  tracts  of  certain  bundles 
of  neurons  in  the  cerebrospinal  axis,  in  which  he  identified  each 
one  of  the  peripheral  nerves. 

His  investigations  led  him  to  radical  advance  in  neurological 
surgery.  The  tearing  out  of  a  nerve,  he  demonstrated,  resulted  in 
degeneration  of  the  central  as  well  as  the  peripheral  portion  of  the 
nerve,  since  the  degeneration  was  due  to  the  atrophy  of  the  cells 
from  which  it  originated  rather  than  the  mere  separation  of  the 
nerve.  Dissection  of  the  nerve  prevented  such  violent  injury  to  the 
nerve.  In  obstinate  neuralgia  of  the  trigeminal  nerve  he  advocated 
the  bringing  about  of  atrophy  of  the  originating  cells  and  so  de- 
struction of  the  nerve  and  elimination  of  j)ain  by  excision  of  the 
nerve  branches. 

He  worked  on  the  organic  lesions  in  dementia  pr^ecox,  searched 
out  the  pathogenic  processes  of  rabies,  solved  the  problem  of  the 
inhibitive  fibers  of  the  heart  by  tracing  the  connection  of  these 
fibers  to  the  pncumogastric  nerve  itself  instead  of  to  the  spinal 
nerve  and  contributed  much  to  the  knowledge  of  acute  anterior 
poliomyelitis  in  the  adult. 


-IK    Wil.l.lAM     k      i,i»\\l.l<- 


OBITUARIES  485 

These  and  many  other  resuUs  of  his  labors  famihar  now  to 
neurology  all  indicate  the  distinguished  service  he  has  rendered.  He 
was  distinguished  as  a  clinician  no  less  than  as  a  laboratory  scientist 
and  his  methods  of  instruction  were  unique  in  brilliancy  and  variety, 
the  cinematographic  illustrations  with  which  at  times  he  accom- 
panied his  lectures  attracting  special  attention.  His  methods  were 
characterized  throughout  by  remarkable  skill  and  an  accuracy  which 
he  also  demanded  from  others.  He  displayed  moreover  a  boldness 
of  innovation  in  therapeutics  but  even  more  in  surgery.  All  of 
these  elements  contributed  to  the  lasting  results  of  his  work,  the 
elucidation  of  some  of  the  most  important  problems  in  neurology 
and  psychiatry. 

WILLIAM  RICHARD  GOWERS 

■ 

On  May  4,  191 5,  death  removed  one  of  the  most  notable  figures 
in  the  English  medical  field.  Sir  William  Gowers  was  distinguished 
by  a  certain  dynamic  forcefulness  which  manifested  itself  in  his 
thought  and  in  his  vigorous  methods  of  activity,  combined  with 
breadth  of  observation,  clear  perception  and  constructive  imagina- 
tion. 

He  early  applied  these  efifective  forces  to  the  chaotic  condition 
that  marked  the  knowledge  of  nervous  diseases,  particularly  on  the 
pathological  side,  when  he  entered  the  field.  He  possessed  the 
faculty  for  generalizing  and  systematizing  the  chaotic  facts,  and 
directed  this  clear  constructive  activity  to  the  abundance  of  material 
which  he  himself  obtained  in  his  investigations  in  pathological 
anatomy  and  clinical  symptomatology. 

He  was  bold  in  thought.  The  sometimes  over-positive  dogmatic 
assertion  of  his  views  was  motivated  by  his  zeal  for  neurological 
advance  together  with  a  certainty  of  his  own  conclusions.  His  very 
positiveness  always  aroused  interest  and  stimulated  his  hearers  to 
thovight  and  discussion,  if  only  in  opposition.  He  was  thus  always 
an  inspiring  teacher.  He  grew,  however,  more  tolerant  and  was 
ever  willing  to  listen  to  the  views  of  others.  Moreover,  in  spite  of 
the  confidence  based  upon  the  accuracy  of  his  observations,  he  was 
cautious  and  reluctant  to  express  himself  in  regard  to  prognosis. 

His  originality  as  an  investigator  and  his  power  as  a  teacher 
evidenced  themselves  most  in  his  work  upon  the  diseases  of  the 
spinal  cord.  Here  he  demonstrated  the  intimate  relation  between 
the  anatomy  and  the  symptomatology.  His  publication  in  1880  of 
Diagnosis  of  Diseases  of  the  Spinal  Cord,  followed  later  by  a  similar 


486  OBITUARIES 

volume  on  diseases  of  the  brain,  filled  a  i)ressing  need  and  demon- 
strated that  keen  observation,  which  distinguished  him  throughout 
his  career  as  the  greatest  diagnostician  of  his  time.  His  book  con- 
tained a  description  of  the  hitherto  unrecognized  tract  of  fibers  in 
the  gray  matter,  the  area  of  descending  degeneration,  which  he 
called  the  anterolateral  tract,  but  which  Bechterew  later  described 
and  named  Gowers'  tract.  He  was  most  widely  known,  however, 
through  his  Manual  of  Diseases  of  the  Nervous  System,  a  standard 
authority  not  in  England  alone  but  in  many  other  countries.  He 
built  so  appreciatively  upon  the  work  of  Hughlings  Jackson  and 
other  leaders  in  neurology  that  the  principles  and  rules  he  laid  down 
are  those  which  guide  the  neurologist  to-day.  The  ability  to  execute, 
his  own  illustrations  for  his  publications  added  to  their  great  value. 

He  contributed  also  in  earlier  days  to  the  study  of  the  per- 
centage of  hemoglobin  and  li'vmiber  of  corpuscles  and  greatly  im- 
proved the  hemoglobinometer,  which  is  now  however  no  longer  in 
use.  His  work  extended  itself  moreover  to  ophthalmology,  epilepsy 
and  syphilis. 

The  prodigious  amount  of  material  at  his  disposal  was  obtained 
from  his  masterly  power  of  observation  and  his  ability  to  record  in 
shorthand.  Phonography  was  a  particular  hobby  with  him  and  he 
encouraged  the  practice  in  other  students.  To  this  end  he  founded 
the  Society  of  Medical  Stenography  and  published  in  shorthand  an 
organ  of  this  society. 

Gowers  gratefully  emi)hasizcd  the  value  of  his  early  training 
with  a  country'  physician  and  the  foundation  of  botany  then  laid 
This  was  always  a  source  of  interest  with  him  and  had  proved  a 
practical  aid  in  medical  training,  accuracy  and  the  like.  He  was 
also  skillful  in  etching  and  exhibited  at  the  Royal  Academy. 

He  was  the  recipient  of  many  honors.  Dublin  recognized  his 
achievements  with  an  M.D.,  Edinburgh  bestowed  the  degree  of 
LL.D.,  a  number  of  foreign  .societies  included  him  among  their 
membership,  the  American  Neurological  Association  being  one  of 
them.  He  was  knighted  on  the  occasion  of  the  Queen's  Jubilee  in 
recognition  of  his  family,  professional  and  social  greatness,  for  in 
all  he  represented  the  highest  English  type.  He  had  been  appointed 
also  to  positions  of  increasing  responsibility  and  importance  and 
been  made  a  fellow  of  the  Royal  .Society  for  his  work  on  nervous 
diseases.  His  last  few  years  were  lived  in  the  (|uiel  retirement  of 
invalidism. 


SIR    THOMAS    SMITH    CLOl'STON. 


OBITUARIES  487 

SIR  THOMAS  SMITH  CLOUSTON 

In  the  death  of  Sir  Thomas  Clouston  on  April  19,  191 5,  Scot- 
land has  lost  her  great-hearted,  painstaking  leader  in  psychiatry. 
This  descendant  of  the  Norsemen,  born  in  the  Orkneys,  bore  him- 
self proudly  and  freely  in  his  relations  with  men,  prizing  more  than 
the  knighthood  with  which  he  was  honored  a  few  years  before  his 
death,  the  freedom  of  Kirkwall,  the  capital  town  of  Orkney,  which 
he  received  in  1908,  and  the  Norse  galley  in  silver  presented  to  him 
at  the  dinner  given  him  by  his  assistants  past  and  present,  when  he 
retired  from  the  office  of  physician  superintendent  of  the  Royal 
Edinburgh  Asylum  after  thirty-five  years  of  service. 

His  fresh  vigorous  nature  received  an  impetus  to  thorough  honest 
work  at  the  grammar  school  of  Aberdeen,  which  has  turned  out  so 
many  famous  men,  and  he  profited  by  the  teachings  of  the  brilliant 
circle  of  men  who  in  the  middle  of  the  last  century  heralded  the 
dawn  of  a  new  conception  of  mental  disease.  His  student  days 
already  marked  him  as  a  man  of  distinguished  attainment  and  signal 
honors.  His  first  gold  medal  was  won  through  his  graduation  thesis 
on  the  nervous  system  of  the  lobster.  The  presidency  of  the  Royal 
College  of  Physicians  of  Edinburgh,  of  the  Edinburgh  Medico- 
Chirurgical  Society  and  of  the  Medico-Psychological  Association 
were  among  the  later  honors  bestowed  upon  him. 

His  contributions  to  psychiatrical  foundations  were  of  the  de- 
scriptive type  but  his  descriptions  of  adolescent  insanity  have  formed 
a  basis  for  later  development  in  the  conceptions  of  dementia  prsecox. 
They  included  also  a  study  of  general  paresis  in  children. 

These  contributions  were  the  result  of  that  method  of  careful 
and  original  observation  which  he  sought  successfully  to  make  a 
part  of  the  work  of  the  asylum,  for  it  was  due  to  his  efforts  that 
the  psychiatrical  laboratory  became  a  part  of  the  Scottish  asylum. 
His  work  was  also  distinctly  propagandist  and  to  this  end  he  strove 
to  give  psychiatry  an  equal  standing  with  other  branches  of  medi- 
cine. His  own  appointment  to  lecture  at  the  University  of  Edin- 
burgh was  the  first  of  its  kind  and  he  had  the  satisfaction  of  seeing 
there  the  establishment  of  a  separate  chair  of  psychiatry,  while  it 
was  also  largely  the  result  of  his  efforts  that  an  academic  diploma 
in  this  branch  was  granted. 

His  work  was  always  closely  bound  with  teaching  and  he  sent 
forth  a  large  band  of' trained  men.  His  "Clinical  Lectures  on 
Mental  Disease"  became  extensively  known  and.  have  widely  pro- 
mulgated his  methods  of  treatment  and  his  conceptions  of  mental 
disease. 


488  OBITUARIES 

His  long-  administration  of  the  Royal  Asylum  displayed  his 
ability  to  grasp  essentials  and  was  demonstrated  particularly  in  the 
building  of  Craig  House,  a  department  for  private  patients.  His 
insistence  on  the  medical  idea  of  hospital  administration  firmly 
established  the  supremacy  of  modem  scientific  methods  of  treatment. 

He  was  always  deeply  interested  in  questions  of  public  moral 
welfare  and  lectured  to  large  eager  audiences  laying  down  sound 
practical  advice  in  matters  of  eugenics,  marriage  and  divorce,  whicli 
this  country  is  assimilating  to-day.  He  bore  a  prominent  part  in 
the  establishment  of  a  council  of  public  morals  for  Scotland. 

His  stanch  adherence  to  former  associates  and  their  teachings, 
which  had  once  influenced  him,  was  illustrated  by  the  tenacity  with 
which  he  held  to  opinions  of  Laycock  and  Skae,  which  however  he 
was  willing  to  modify  to  a  considerable  extent.  A  certain  aloofness 
prevented  the  making  of  many  close  friends  among  his  acquaint- 
ances. His  time  was  moreover  well  filled  with  hi>  public  as  well 
as  his  professional  duties. 

Success  with  his  patients  was  assured  hy  his  good  judgment, 
ready  intuition,  a  broad  sympathy  which  understood  and  took  into 
account  all  circumstances,  and  his  advice  extended  to  the  entire 
welfare  of  the  patient.  These  qualities  with  his  wide  experience 
made  him  an  ideal  consultant. 

He  was  in  all  things  a  man  who  brought  things  to  pass.  "  He 
was  a  spring  from  the  north  land  l^ringing  fresh  waters  while  carv- 
ing new  channels. 

Jki.i.ifff.. 


The  Los  Angeles  Society  for  Neurology  and  Psychiatry  has  heen  organ- 
ized with  Dr.  H.  G.  Brainerd  as  president  and  Dr.  E.  II.  Williams  as  secretary. 

The  State  Hospitals'  Medical  .\ssociation  of  the  State  Hospitals  of  Illi- 
nois wish  to  announce  their  ne.xt  meeting  at  the  Anna  State  Hospital.  .\nna, 
Illinois,  May  25-26.  1916.     .Ml  physicians  are  cordially  invited. 


(^Z^ 


VOL.   43.  JUNE,  1916.  No.  6. 

The  Journal 

OF 

Nervous  and  Mental  Disease 

An  American  Monthly  Journal  of  Neurology  and  Psychiatry,  Founded  in  1874 


©rtginal  Hrttcles 


A  CLINICAL  AND  PATHOLOGICAL  STUDY  OF  A  CONDI- 
TION OCCURRING  IN  THE  AGED  USUALLY 
ATTRIBUTED  TO  CEREBRAL  AR- 
TERIOSCLEROSIS^ 

By  Charles  Metcalfe  Byrnes,  M.D. 

INSTRUCTOR   IN    CLINICAL    NEUROLOGY,   JOHNS    HOPKINS    UNIVERSITY 

Through  the  kindness  of  Dr.  Wilham  G.  Spiller  an  opportunity 
has  been  given  me  to  study,  chnically  and  pathologically,  a  type  of 
nervous  disorder  frequently  observed  in  the  aged,  which  is  often 
correctly  diagnosticated  as  cerebral  arteriosclerosis. 

Vascular  disturbances  within  the  central  nervous  system  present 
a  varied  clinical  picture,  depending  upon  the  degree  of  sclerosis,  its 
extent  and  distribution,  and  the  development  of  such  accidents  as 
hemorrhage,  thrombosis,  or  embolism.  The  symptoms,  therefore, 
may  be  transient  or  permanent,  localized  or  general,  or  there  may 
be  a  combination  of  general  and  localizing  features.  These  several 
types,  particularly  the  diffuse  variety  described  by  Collins  (i),  are 
familiar  disorders,  and  only  the  important  symptoms  will  be  ab- 
stracted from  the  records  of  the  four  patients  who  have  furnished 
the  material  for  this  contribution. 

Three  of  the  patients  were  from  the  wards  of  the  Philadelphia 
General  Hospital  and  the  notes  upon  a  fourth  case  were  given  to  me 
from  the  personal  records  of  Dr.  Spiller,  who  in  each  instance  con- 
firmed the  diagnosis  of  cerebral  arteriosclerosis. 

1  From  the  Department  of  Neurology  and  the  Laboratorj^  of  Neuro- 
pathology in  the  University  of  Pennsylvania. 

489 


490  CHARLES  METCALFE  BYRNES 

J.  M..  a  male,  past  the  age  of  seventy,  was  observed  sitting  in  a 
chair  apparently  inattentive  to  his  surroundings.  The  drooping 
shoulders  and  head,  expressionless  countenance,  marked  emotional- 
ism, and  the  partly  open  mouth  from  which  saliva  was  dribbling, 
contributed  to  the  general  picture  of  senility  and  impaired  mentality. 
When  attempting  to  arise  from  the  chair  all  movements  were  slow 
and  deliberate,  and  in  walking  the  short  quick  step  with  the  feet 
wide  apart  were  quite  characteristic.  There  were  no  evidences  of 
ataxia,  paralysis,  sensory  disturbances,  or  degenerative  involvement 
of  the  pyramidal  tracts.  The  peripheral  arteries  and  retinal  vessels 
were  sclerotic  and  tortuous,  and  arcus  senilis  was  marked. 

F.  S.,  a  male,  past  middle  life,  experienced  some  difficulty  in 
speech  and  unsteadiness  in  walking.  All  movements  were  slowly 
performed,  but  not  so  much  so  as  in  the  previous  case,  and  mental 
impairment  was  less  pronounced.  When  walking,  the  feet  were  placed 
wide  apart;  the  stride  was  short  and  quick;  and  when  performing 
this  movement  with  the  eyes  closed,  there  was  some  unsteadiness 
which  was  intensified  when  standing  with  the  feet  together.  There 
was  evidence  of  slight  ataxia  in  the  uj^jper  extremities  in  performing 
the  finger-nose  test,  and  in  the  lower  extremities  when  performing 
the  heel-tibial  test.  This  condition  was  more  pronounced  upon  the 
right  side.  No  gross  sensory  disturbances  were  detected.  The 
pupils  were  unequal,  the  right  slightly  larger  than  the  left,  and  both 
reacted  slowly  to  light  and  during  accommodation.  All  deep  re- 
flexes were  present  and  slightly  exaggerated,  but  equally  so  u])on 
the  two  sides.  There  was  no  ankle  or  j)atellar  clonus  and  plantar 
stimulation  produced  a  normal  response.  The  peri])heral  vessels 
were  markedly  sclerotic. 

E.  M.,  a  patient  of  Dr.  Heubner,  of  AUentown,  Pa.,  was  referred 
on  October  30,  191 2,  to  Dr.  Spiller,  who  has  given  me  the  following 
notes:  The  patient  is  a  male,  66  years  of  age,  and  a  carpenter  by 
occupation.  He  complained  of  almost  constant  pain  in  the  forehead, 
anfl  stated  that  last  June  almost  a  quart  of  blood  was  removed  in 
order  to  give  him  relief.  For  the  i)ast  two  years  there  has  been 
some  difficulty  in  walking.  While  walking,  but  only  then,  he  has 
fallen  about  five  times  and  has  had  occasional  attacks  of  uncon- 
sciousness. These  attacks  sometimes  last  an  hour,  but  have  never 
been  associated  with  convulsions.  Upon  arising,  and  also  at  other 
times,  he  has  suffered  from  dizzy  spells,  and  memory  has  failed,  so 
that  he  does  not  comprehend  quickly. 

Fxaniination  shows  that  the  patient's  comprehension  of  ques- 
tions is  very  slow  The  j)upils  are  e(|ual  ancl  the  iridcs  respond 
freely  to  light  and  in  convergence.  The  remaining  cranial  nerves 
api)car  to  be  normal.  .Arcus  senilis  is  marked.  The  biceps  reflex  is 
feeble  f)n  each  side,  and  there  is  a  fine  tremor  of  each  hand,  espe- 
cially during  motion,  lie  arises  from  a  chair  and  begins  walking 
with  extreme  difficulty  and  takes  very  short  stej)S.  There  is  no 
paralysis  or  ataxia  in  any  of  the  extremities.  The  patellar  reflexes 
are  about  normal,  and  the  Achilles  reflexes  ])robably  are  present, 
but  were  not  obtained  because  of  the  difficulty  in  making  the  patient 
relax  his  muscles.     There  is  no  real  spasticity  of  the  extremities. 


STUDY  OF  CONDITION  OCCURRING  IN  AGED  491 

The  kidneys  are  said  to  be  in  good  condition.  The  radial  arteries 
are  not  particularly  rigid,  and  the  heart  sounds  are  clear.  The 
blood  pressure. has  not  been  determined. 

J.  W.,  a  male,  76  years  old,  was  admitted  to  the  Philadelphia 
General  Hospital  October  3,  1907,  where  he  died  January  30,  1908. 
I  did  not  have  an  opportunity  to  observe  this  patient  during  life, 
but  the  anatomical  material  was  placed  at  my  disposal.  The  clinical 
history  and  examination  are  abstracted  from  the  hospital  records. 

The  family  history  is  unimportant.  When  a  child  he  had  measles 
but  was  otherwise  healthy  until  the  age  of  61.  He  denied  lues; 
there  was  no  evidence  of  secondaries ;  and  the  marital  history  was 
insignificant.     Alcohol  and  tobacco  were  used  moderately. 

Fifteen  years  ago,  after  suiTering  from  headache  and  vertigo,  he 
suddenly  fell  and  lost  consciousness.  Upon  regaining  consciousness, 
the  right  side  was  paralyzed  and  speech  was  "  peculiar."  The  dura- 
tion of  these  symptoms  is  not  known,  but  it  is  probable  that  in  a 
short  time  recovery  was  complete,  for  he  enjoyed  good  health  for 
about  ten  years,  when  he  again  complained  of  headache  and  vertigo, 
which  occurred  at  intervals  for  a  period  of  five  years  and  terminated 
in  a  second  "  stroke  "  described  as  follows  : 

After  some  slight  exertion  he  tried  fo  sit  down,  but  suddenly  fell 
to  the  floor  and  lost  consciousness.  This  attack  lasted  only  about 
three  minutes,  when  he  was  able  to  get  up  and  walk  with  assistance, 
but  the  right  leg  was  weak  and  the  right  arm  was  paralyzed  with  the 
exception  of  slight  movement  in  the  fingers.  The  face  was  not 
afifected  and  he  could  talk  better  immediately  after  the  stroke  than 
when  admitted  to  the  hospital.  There  was  no  difficulty  in  swallow- 
ing nor  was  he  aware  of  any  sensory  disturbance  upon  the  right 
side.  During  the  following  two  months,  he  recovered  some  use  of 
the  right  arm,  but  vision,  which  was  good  before  the  attack,  has 
gradually  failed  so  that  he  is  now  almost  entirely  blind.  Sphincter 
control,  which  was  lost  at  the  time  of  the  "  stroke,"  has  not  been 
regained.  ' 

The  patient  talks  monotonously  and  indistinctly  and  there  is  defi- 
nite mental  impairment.  The  muscles  are  poorly  developed  and 
the  peripheral  vessels  are  markedly  sclerosed.  There  is  evidence  of 
slight  paresis  of  the  right  side  of  the  face  and  the  tongue  is  deviated 
to  this  side,  but  is  under  good  control.  All  movements  can  be  per- 
formed with  the  arms,  with  some  limitation  upon  the  right  side.  He 
places  this  arm  over  the  head  with  a  peculiar  jerky  movement,  but 
is  finally  successful.  Ataxia  is  present  in  both  arms.  The  right 
biceps  jerk  is  not  obtained  but  the  muscle  reflex  is  present.  The 
triceps  jerk  is  exaggerated.  Both  of  these  reflexes  are  hyperactive 
in  the  left  arm.     There  are  no  contractures. 

Both  legs  are  moved  normally  in  all  directions,  with  some  limita- 
tion upon  the  right  side.  Ataxia  in  both  legs  is  extreme,  and  more 
pronounced  in  the  right.  Edema  and  scars  of  old  ulcers  are  ob- 
served upon  both  legs.  The  deep  reflexes  at  the  knee  and  ankle 
are  equally  exaggerated  upon  the  two  sides,  but  there  is  no  clonus, 
and  plantar  stimulation  gives  a  normal  response.  The  following 
additional  note  was  made  by  Dr.  Spiller:  "Ataxia  in  both  lower 


492  CHARLES  METCALFE  BYRXES 

extremities  is  extreme  and  the  limbs  are  slightly  flaccid.  There  is 
slight  ataxia  in  the  upper  limbs."  Examination  of  the  blood  showed 
marked  anemia,  and  the  urine  contained  albumen. 

Twenty-eight  hours  after  death  an  autopsy  was  performed  by 
Dr.  Sykes,  who  made  the  following  notes :  "  Coronary  arteries 
prominent  and  tortuous.  The  mitral  and  aortic  leaflets  are  thick, 
rigid,  markedly  sclerosed,  and  covered  with  numerous  calcified  no- 
dules. The  aorta  has  numerous  calcified,  sclerotic  areas  throughout 
its  entire  length.  The  kidney  shows  evidence  of  chronic  interstitial 
nephritis."  Apparently,  no  note  was  made  upon  the  gross  appear- 
ance of  the  central  nervous  .system  when  it  was  removed,  and  when 
examined  by  me  it  had  been  in  formalin  solution  for  several  months. 
The  cerebrospinal  vessels  were  not  sclerotic  and  there  were  no  calci- 
fied areas  or  aneurysmal  dilatations.  The  convolutions  of  the  brain 
were  of  good  size  and  shape  and  the  pia  was  not  adherent.  Since 
no  gross  changes  were  observed  upon  sectioning  the  hemispheres, 
brain  stem,  and  spinal  cord,  it  was  suspected  that  a  microscopic 
study  of  the  tissue  would  furnish  valuable  information. 

Very  minute  lesions  are  sometimes  responsible  for  quite  a  definite 
group  of  clinical  symjjtoms.  and  in  such  cases  the  histological  studv. 
to  be  of  any  value,  must  be  thorough.  Accordingly,  microscojnc 
sections  from  the  following  cerebral  areas  were  carefully  examined : 
The  right  and  left  optic  nerves,  the  optic  chiasma,  the  inferior  por- 
tion of  the  medulla  through  the  twelfth  nucleus,  the  right  and  left 
paracentral  lobes,  the  anterior  central  convolution  of  each  hemi- 
sphere, the  left  internal  capsule,  the  left  superior  temporal  convolu- 
tion in  the  region  of  the  operculum,  the  right  and  left  cuneus  about 
the  calcarine  fissure,  and  the  superior  vermis  of  the  cerebellum. 

Transverse  sections  from  the  first  cervical,  cervical  enlarge- 
ment, low  cervical,  mid-thoracic,  twelfth  thoracic,  and  lumbar  seg- 
ments of  the  spinal  cord  were  also  studied. 

Cross-sections  were  made  from  the  following  cerebral  arteries: 
The  right  and  left  anterior  cerebral,  the  left  middle  cerebral  within 
the  Sylvian  fissure,  the  intracranial  portion  of  both  internal  carotids, 
the  right  and  left  posterior  cerebral,  and  the  basilar. 

The  nervous  tissue  was  stained  with  hcnialuni  and  acid-fuchsin. 
W'eigcrt's  myelin  stain.  Bielschowsky's  neurofibrillar  method,  and 
thionin.  Uemalum  and  acid-fuchsin,  and  Mallory's  elastic  tissue 
stain  were  used  for  the  arteries. 

In  all,  fifty- four  microscopic  preparations  were  carefully  ex- 
amined by  Dr.  Spiller  and  my.self  and  in  none  of  them  did  we  find 
any  single  lesion  which  we  felt  was  sufficient  to  account  for  the 
symjjtoms  in  this  case;  nor  were  there  sufficient  evidences  of  thick- 
ening in  the  blood  vessels  to  suj)port  a  diagnosi.*?  of  cerebral  artcrio- 
sciero.sis. 

My  desire  for  completeness  would  lead  me  to  include  a  descrip- 
tive paragraph  for  each  of  the  fifty-ftnir  sections,  but  consideration 
for  those  who  may  have  occasion  to  refer  to  this  study  makes  me 
feel  that  a  general  summary  of  the  j)athological  changes  is  prefendile. 

In  several  parts  of  the  brain  and  spinal  cord  there  is  considerable 
round-cell  infiltration,  which  is  particularly  marked  about  the  optic 


STUDY  OF  CONDITION  OCCURRING  IN  AGED 


493 


chiasma  (Fig.  i).  This  infiltration  extends  for  a  short  distance 
along  the  sheath  of  each  optic  nerve,  but  does  not  show  a  peri- 
vascular arrangement.  The  fibers  of  the  optic  nerve  are  not  de- 
generated, and  the  axis  cylinders  are  healthy  looking.  The  pial  and 
intraneural  vessels  show  slight  thickening  of  the  media  but  are  no- 
where occluded.  Similar  evidences  of  a  moderate  inflammatory 
reaction  are  found  upon  the  surface  of  the  right  anterior  central 
convolution,  the  left  superior  temporal  convolution,  the  cortex  of 
the  superior  vermis,  and  to  a  lesser  degree  upon  the  surface  of  the 


Fig. 


I.     Photomicrograph  of  a  section  of  the  optic  chiasma,  showing  round- 
cell    infiltration.     Hemahim    acid    fuchsin    stain. 


pons  and  pyramids.  Moderate  infiltration  is  also  observed  in  por- 
tions of  the  spinal  meninges,  particularly  in  the  cervical  and  high 
dorsal  regions,  wher.e  it  is  most  pronounced  upon  the  posterior  sur- 
face of  the  cord. 

In  the  nervous  tissue  proper,  there  is  no  evidence  of  hemorrhage, 
softening,  or'  degeneration  in  the  internal  capsule,  and  the  pyram- 
idal fibers  of  the  pons  appear  to  be  normal.  There  are,  however, 
variable  degrees  of  cellular  disintegration.  The  Betz  cells  show 
increased  pigmentation  and  moderate  chromatolysis.  Similar 
changes  are  observed  in  the  nucleus  of  the  twelfth  cranial  nerve,  in 
the  Purkinje  cells  of  the  superior  vermis,  and  in  the  anterior  horn 
cells  of  the  spinal  cord.  In  many  sections  there  is  distinct  shrinkage 
of  the  cerebellar  cortex,  and  "many  of  the  Purkinje  cells  are  com- 
pletely disintegrated.  Although  the  right  and  left  halves  of  the 
brain-stem  and  spinal  cord  were  not  dififerentiated  when  the  tissue 
was  imbedded,  it  is  quite  obvious  in  the  sections  that  cellular  disin- 
tegration is  more  pronounced  in  one  half  than  in  the  other,  and 
further  investigation  has  shown  that  the  cellular  alteration  is 
greater  in  the  right  side  of  the  cord.  In  the  cervical  region  of  the 
cord,  where  the  cellular  changes  are  more  pronounced,  it  is  found 


494 


CHARLES  METCALFE  BVRXES 


that  in  one  of  the  sections  twenty-seven  anterior  horn  cells  can  be 
counted  in  one  half,  while  the  opposite  half"  contains  onlv  seven. 
This  loss  of  cellular  substance  is  probably  not  due  to  technical 
methods,  since  no  cellular  spaces  were  observed  and  one  of  the 
horns  is  slightly  shrunken.  In  the  middle  thoracic  cord,  these  cel- 
lular changes  are  confined  mostly  to  the  nucleus  dorsalis.  while  the 
anterior  horn  cells  are  more  nearly  normal  than  elsewhere.  The 
lumbar  cord  shows  only  slight  cellular  disintegration  which,  as  in 
the  cervical  region,  is  more  marked  in  the  right  half. 

Weigert  preparations  from  the  upper  cervical  segment  and  the 
cervical  swelling  show  moderate  degeneration  in  each  half  of  the 
posterior  column.  This  degenerated  area  begins  at  the  periphery  in 
the  region  of  the  paramedian  septum  and  extends  ventro-medial- 
ward  for  about  three  fourths  the  depth  of  the  posterior  column,  and 
is  situated  almost  entirely  in  the  fasiculus  cuneatus  in  the  region 


Fig.  2.     Cross-section  of  tlic  first  cervical  segment  of  the  spina!  cord,  sliowing 
degeneration   in  eacli  half  of  the  posterior  cohnnii.     Weigert  stain. 


occupied  by  fibers  arising  from  the  lower  cervical  nerves.  Under 
the  microscope,  this  area  shows  definite  absence  of  medullatcd  fibers 
and  has  the  a|)j)earance  of  a  degenerated  area  which  can  be  followed 
for  a  short  distance  into  the  lower  |)art  of  the  cervical  swelling  (h^ig. 
2).  There  is  no  degeneration  elsewhere  in  the  spinal  cord,  and  the 
pyratnidal  fibers  are  normal  throughout. 

.Micrcjscojjic  examination  of  the  cortical  and  intraspinal  arteries 
shows  no  occlusion  or  marked  thickening  of  the  vessel  wall,  and 
considering  the  advanced  age  of  the  i)atient.  the  arteries  at  the  base 
of  the  brain  are  surprisingly  normal  in  appearance.  The  media  is, 
in  general,  slightly  thickened,  and  takes  the  stain  poorly,  and  occa- 


STUDY  OF  CONDITION  OCCURRING  IN  AGED  495 

sionally  there  is  moderate  proliferation  of  the  intima  in  the  larger 
vessels,  bvit  in  none  of  them  is  the  lumen  occluded  or  greatly  reduced 
in  size.  There  is  no  perivascular  infiltration.  The  elastic  tissue  is, 
in  general,  diminished  in  amount,  and  slightly  fragmented.  Occa- 
sionally all  three  coats  of  an  artery  are  reduced  in  thickness  and 
slightly  evaginated,  but  not  to  the  extent  of  aneurysmal  formation. 


Q 
c   , 


Fig.  3.  Cross-section  of  llit  k-il  middle  cerebral  artery,  showing  mod- 
erate sclerosis,  which  is  more  marked  than  in  the  other  cerebral  vessels. 
Hemalum  acid  fuchsin  stain. 

A  cross-section  of  the  left  middle  cerebral  artery  (Fig.  3)  represents 
fairly  accurately  the  more  pronounced  pathological  changes  which 
are  present  in  the  cereljral  vessels. 

Although  the  histological  examination  of  the  cerebral  vessels  does 
not  confirm  the  clinical  diagnosis  of  cerebral  arteriosclerosis,  there 
are  other  important  i)athological  changes  which  may  explain  some 
of  the  symptoms.  There  were  marked  changes  in  the  peripheral 
vessels,  chronic  intersitial  nephritis,  anemia,  moderate  local  menin- 
geal infiltration,  and  disintegration  of  the  Purkinje  cells,  the  cells  of 
the  nucleus  dorsalis  and  the  anterior  horn  cells  of  the  spinal  cord. 
In  the  absence,  however,  of  a  localizing  cerebral  lesion  or  cerebral 
arteriosclerosis,  it  is  difficult  to  explain  the  two  attacks  of  right  hemi- 
plegia with  persisting  hemiparesis,  almost  total  blindness  and  mental 
impairment. 

Conditions  indicating  localized  organic  lesions  of  the  central 
nervous  system  without  confirmator}^  pathological  evidence  have 
been  recorded.  Not  infrequently,  the  pathological  study  in  such 
cases  has  been  incomplete,   or  when  a  more  thorough  search  has 


496  CHARLES  METCALFE  BYRNES 

been  made  the  presence  of  minute  aneurysmal  dilatations,  micro- 
scopic areas  of  softening,  or  hemorrhage,  have  been  demonstrated, 
and  in  the  absence  of  these,  the  symptoms  have  been  attributed  to 
toxemia,  pseudo-tumor,  or  arterial  spasm.  Chronic  interstitial 
nephritis  with  defective  elimination,  anemia,  and  enfeebled  circula- 
tion, offer  suitable  conditions  for  the  production  and  accumulation 
of  toxines,  and  it  is  not  unlikely  that  some  of  the  symptoms  in  the 
case  which  I  have  studied  might  be  due  to  chronic  renal  or  gastro- 
intestinal intoxication.  Although  the  clinical  examination  was  made 
before  the  introduction  of  the  Wassermann  reaction,  the  presence 
of  moderate  round-cell  intiltration  in  the  meninges,  particularly 
about  the  chiasma,  together  with  evidences  of  old  leg  ulcers  suggests 
the  probability  of  a  syphilitic  toxemia. 

That  certain  toxines  exhibit  a  degree  of  selectivity  for  particular 
nervous  structures,  is  an  opinion  supported  not  only  by  clinical  ob- 
servation, but  also  by  experimental  pharmacolog)'  and  toxicology. 
The  eft'ect  of  strychnine  upon  the  motor  neurones,  of  cocain  upon  the 
sensory  system,  and  the  localized  paralyses  of  the  infectious  diseases 
and  metallic  poisons  are  familiar  illustrations.  Uremic  or  syphilitic 
toxemia,  then,  even  in  the  absence  of  arteriosclerosis,  might  explain 
the  cellular  changes  in  the  cerebral  cortex,  the  lower  motor  neurone, 
and  in  the  cerebellum  with  resulting  mental  impairment,  flaccidity, 
sphincter  paresis,  and  ataxia.  It  is  also  conceivable  that  such  symp- 
toms may  be  transitory  or  permanent,  de])cn(ling  upon  variations  in 
the  intensity  of  the  toxemia  and  in  the  degree  of  cellular  derange- 
ment. In  spite  of  this  apparently  selective  property  of  toxic  sub- 
stances it  is  difficult  to  imagine  the  cortical  cells  of  the  two  hemi- 
spheres so  unequally  aft'ected  that  hemiplegic  symptoms  are  pro- 
duced by  a  poison  distributed  through  the  general  circulation.  It  is 
true,  evidences  of  cellular  disintegration  may  be  present,  and  to  all 
appearances  of  equal  intensity  in  the  two  hemispheres  ;  but,  unfortu- 
nately, except  in  the  jjresence  of  complete  disintegration,  cytology 
has  not  reached  that  degree  of  exactness  which  has  enabled  one  to  say 
when  any  particular  cell  has  ceased  to  function  or  exceeds  its  limit 
of  recuperative  ability. 

There  is.  however,  some  clinical  evidence  which  suggests  the 
occurrence  of  toxic  paralyses  of  the  central  nervous  system  and 
toxic  hemiplegias.  Btjrnstein  (2)  records  the  case  of  an  epileptic 
boy  fourteen  years  of  age,  who  for  six  years  suffered  from  intermit- 
tent attacks  of  lameness,  characterized  by  flaccid  paralysis  in  certain 
muscles,  ataxic  gait,  ankle  clonus,  reaction  of  degeneration,  and  ab- 
sence of  sensory  changes.     Recovery  after  each  attack  was  complete. 


STUDY  OF  CONDITION  OCCURRING  IN  AGED  497 

The  author  is  of  the  opinion  that  the  condition  was  due  to  toxemia 
but  does  not  suggest  its  probable  source.  Hochhaus  (3)  has  re- 
ported interesting  observations  upon  seven  patients  in  whom  there 
were  evidences  of  locaHzed  disease  of  the  brain  for  which  no  ana- 
tomical explanation  could  be  determined.  Six  of  his  cases  pre- 
sented the  clinical  symptoms  of  cerebral  hemorrhage  or  thrombosis, 
and  although  no  gross  lesions  were  found  at  autopsy,  the  patholog- 
ical examination  was  not  sufficiently  thorough  to  permit  of  trust- 
worthy conclusions.  Arteriosclerosis  was  pronounced  in  three  of 
the  specimens,  and  in  none  of  his  cases  was  syphilis  excluded. 
Hochhaus  attributed  the  symptoms  to  pseudo-tumor,  arterioscle- 
rosis, localized  cerebral  congestion,  and  toxemia.  He  makes  no  sug- 
gestion as  to  the  character  of  the  toxine,  but  from  a  study  of  his 
cases  I  find  that  all  but  one  patient  had  some  nephritis ;  and  one  in 
particular  showed  a  definite  relationship  between  the  severity  of 
symptoms  and  the  degree  of  albuminuria.  The  author  refers  to  a 
case  of  toxic  hemiplegia  reported  by  Oppenheim  in  which  the  symp- 
toms developed  in  a  carcinomatous  patient  without  anatomical 
changes  in  the  brain  substance ;  and  a  similar  case  by  Finkelnburg 
occurring  in  a  patient  with  carcinoma  of  the  pancreas.  A  suggestive 
case  of  toxic  periodic  paralysis  occurring  in  a  boy  seventeen  years 
old  is  reported  by  Gardner  (4).  The  attacks  were  characterized  by 
complete  loss  of  power  in  the  head,  arms,  and  legs,  and  had  been 
preceded  for  several  years  by  attacks  of  migraine,  which  ceased 
when  the  paralytic  phenomena  developed.  There  was  no  loss  of 
consciousness  or  sensory  disorder,  but  the  deep  reflexes  were  lost, 
and  the  muscles  did  not  respond  to  electrical  stimulation.  A  patho- 
logical study  was  not  made,  and,  because  of  the  marked  indicanuria, 
the  author  is  of  the  opinion  that  the  condition  was  due  to  defective 
metabolism  with  liberation  of  toxic  substances. 

An  interesting  pathological  study  of  seven  cases  of  paralysis 
without  gross  anatomical  changes  in  the  brain  has  been  made  by 
Rhein  (5).  All  of  these  cases  had  marked  renal  disturbance;  in 
six,  there  were  positive  evidences  of  lues ;  and  in  the  seventh,  syph- 
ilis was  suspected.  Cerebral  arteriosclerosis  was  pronounced  in  all 
but  one  of  the  specimens,  and  microscopic  areas  of  softening  were 
occasionally  observed.  Although  these  changes  were  probably  suffi- 
cient to  account  for  the  symptoms,  Rhein  thinks  the  condition  was 
due  to  uremic  or  syphilitic  toxemia,  and  remarks  that :  "  The  diag- 
nosis in  old  people  is  more  difficult  on  account  of  the  resemblance  to 
symptoms  following  hemorrhage  or  softening."  His  belief  in  the 
toxic  nature  of  the  affection  is  encouraged  by  the  experiments  of 


49S  CHARLES  METCALFE  BYRXES 

Castaigne.  who  injected  the  spinal  fluid  of  uremic  patients  into  the 
brains  of  guinea-pigs  and  produced  marked  convulsions,  terminat- 
ing fatally. 

Cases  of  hemiplegia  without  discoverable  anatomical  lesion  were 
observed  by  Andral  and  were  thought  to  l)e  due  to  cerebral  conges- 
tion, and  Sands  (6),  in  1856,  made  a  study  of  two  cases  of  fatal 
hemiplegia  at  Bellevue  Hospital,  in  which  the  cerebral  findings  were 
entirely  negative.  Both  occurred  in  young  adults  and  in  neither  was 
there  evidence  of  nephritis  or  arteriosclerosis.  In  one  of  the  cases, 
a  microscopic  study  was  made  of  the  cerebral  hemispheres,  corpora 
striata,  optic  thalami,  crura,  pons,  and  anterior  columns  of  the 
spinal  cord,  and  all  were  found  to  l)e  "  perfectly  normal."  There 
was,  however,  marked  disease  of  the  mitral  leaflets.  The  probabil- 
ity of  syphilis  is  not  mentioned  and  the  author  olYers  no  explanation. 

A  short  time  later,  Draper  (7)  rei)orted  from  the  same  hospital, 
the  study  of  two  more  fatal  cases  of  hemiplegia  in  which  no  gross 
lesion  was  foimd  at  autopsy.  One  occurred  in  a  young  adult  who 
gave  a  positive  history  of  lues  and  showed  periosteal  nodes  u])on 
the  tibife ;  and  the  second  case  had  had  syphilis  "  in  all  its  forms." 
It  was  suggested  by  one  of  the  attending  ])hysicians  at  Bellevue  that 
the  paralysis  might  have  been  due  to  the  "syphilitic  j)oison  acting 
either  by  virtue  of  its  toxic  properties,  or  indirectly  by  its  effect  u])on 
the  nutrition  of  the  brain." 

W'eisenburg  (8)  from  a  study  of  two  cases  of  hemiplegia,  with 
marked  nephritis,  in  which  no  gross  changes  were  found  in  the 
brain,  concludes  that  the  paralyses  were  of  uremic  origin  ;  and  War- 
rington (9)  contributes  additional  evidence  in  supjxjrt  of  the  toxic 
origin  of  cerebral  or  spinal  lesions  from  an  anatomical  studv  of  a 
case  of  carcinoma  uteri,  which  had  shown  evidences  of  bulbar  in- 
volvement, without  demonstrable  changes  in  the  nervous  system. 

Although  the  selective  action  of  a  circulating  toxine  is  a  luore 
or  less  speculative  explanation  for  the  development  of  localizing 
cerebral  synijjtoms.  convincing  studies  have  been  made  bv  Rossi 
(10)  and  Fickler  (ii)  upon  toxic  cerebellar  disease  in  which  the 
.symj)toms  were  not  unlike  those  usually  attributed  to  cerebral  arte- 
riosclerosis. The  former  studied  the  brain  of  a  ])aticnt,  66  vears 
old,  who  gave  a  history  of  severe  diarrhea  of  six  weeks'  duration. 
As  this  condition  improved,  he  noticed  that  he  walked  "  like  a 
drunken  man."  and  liad  difficulty  in  speaking.  These  nervous  symj)- 
toms  were  gradually  progressive,  and  characterized  by  difticulty  in 
walking,  ataxia,  disturbance  in  speech,  exaggerated  reflexes,  sjjhinc- 
ter  weakness,  and  positive  Babinski.     There  was  no  nystagmus  or 


STUDY  OF  CONDITION  OCCURRING  IN  AGED  499 

strabismus,  and  the  pupils  reacted  normally.  No  gross  changes 
were  found  in  the  brain  except  slight  atrophy  of  the  superior  vermis. 
Microscopically,  the  Purkinje  cells  and  cortical  layers  of  the  vermis 
were  definitely  atrophic  and  there  was  some  loss  of  fibers  in  the 
central  portion  of  the  dorsal  columns  of  the  spinal  cord.  The  cer- 
ebral arteries  were  not  thickened  and  the  meninges  appeared  to  be 
normal.  The  condition  was  regarded  as  a  primary  atrophy  of  the 
cerebellum  beginning  in  the  Purkinje  cells,  and  probably  dependent 
upon  gastro-intestinal  toxemia.  Fickler  concluded,  from  a  review 
of  the  literature  and  his  study  of  eight  cases  of  cerebellar  disease, 
that  a  condition  exists  in  the  aged  which  might  be  called  senile  cere- 
bellar involution  ;  and  it  is  usually,  but  not  invariably,  associated 
with  sclerotic  changes  in  the  cerebral  vessels.  Among  other  causes, 
he  mentions  acute  and  chronic  cerebellar  ataxia  from  the  absorption 
of  gastro-intestinal  toxines.  alcohol,  syphilis,  and  other  infectious 
diseases.  In  those  cases  of  toxic  origin,  there  is  no  arteriosclerosis 
and  the  most  marked  changes  are  confined  to  the  cerebellar  cortex, 
with  only  slight  secondary  degeneration.  Similar  observations  have 
been  made  by  Thomas  (12),  Dejerine  and  Thomas  (13),  and  in  a 
later  study  by  Garbini  and  Rossi  (14)  of  a  patient  fifty-five  years 
old,  who  sufl:ered  from  right  hemiplegia,  dysarthria,  and  dysphagia. 
The  only  changes  found  at  autopsy  were  sclerosis  and  atrophy  of 
the  cerebellum,  from  which  it  was  concluded  that  the  cerebellum 
acts  as  an  accessory  coordinating  speech  center,  and  that  the  dysar- 
thria and  dysphagia  were  due  to  incoordinate  movements  of  the 
j)rimary  speech  mechanism.  It  is  not  unlikely  that  the  speech  defect 
in  the  case  which  I  have  studied  may  be  of  this  origin. 

Symptoms  resembling  those  of  cerebral  arteriosclerosis  have 
been  observed  in  a  case  of  chronic  purulent  meningitis  studied  by 
Schlesinger  (15),  although  he  does  not  compare  the  two  conditions. 
The  moderate  meningeal  infiltration  observed  in  my  sections  was 
not  sufficient,  however,  to  account  for  the  hemiplegic  symptoms  nor 
did  it  suggest  a  chronic  purulent  afl:'ection,'and  its  pathological  im- 
portance is  due  largely  to  the  evidence  it  furnishes  in  favor  of  the 
.syphilitic  nature  of  the  disease.  It  is  interesting  in  this  connection, 
that  some  time  before  the  publication  of  Schlesinger's  paper.  Sir 
William  Osier  (16)  reported  a  case  without  autopsy,  in  which  ten 
attacks  of  transient  mutism  occurred,  with  numbness  of  the  right 
side.  The  patient  had  previously  consulted  a  well-known  specialist, 
w^ho  made  a  diagnosis  of  "  chronic  meningitis,"  which  was  not  con- 
curred in  by  Dr.  Osier,  who  attributed  the  condition  to  arterioscle- 
rosis and  vascular  spasm. 


500  CHARLES  METCALFE  BYRNES 

Inability  to  explain  satisfactorily  the  symptoms  in  my  case  en- 
entirely  upon  a  theory  of  chronic  intoxication  or  meningeal  infiltra- 
tion, and  the  presence  of  marked  peripheral  arteriosclerosis  suggest 
the  probability  that  such  symptoms  might  be  due  to  the  changes  in 
the  peripheral  vessels.  Naturally,  as  the  cranial  cavity  is  approached, 
the  pathological  importance  of  a  peripheral  vascular  lesion  becomes 
more  evident,  and  a  recent  thesis  by  Ferry  (17)  calls  attention  to 
the  development  of  cerebral  symptoms  from  occlusion  of  the  extra- 
cranial vessels.  Although  his  cases  showed  evidences  of  cerebral 
edema  or  areas  of  softening  sufficient  to  account  for  the  gradually 
progressive  hemiplegia,  there  was  no  sclerosis  of  the  cerebral  ves- 
sels. A  study  of  the  extracranial  and  cavernous  portions  of  the 
internal  carotid  arteries,  however,  showed  marked  thrombosis  with 
almost  complete  occlusion,  which  was  usually  confined  to  one  side, 
but  occasionally  involved  both.  Similar  observations,  he  states, 
have  been  made  by  Lancereaux  and  Bristowe,  and  the  condition  is 
thought  to  be  due  to  syphilitic  arteritis  and  atheroma.  The  fact  that 
surgical  ligation  of  both  carotid  arteries  has  been  practiced  without 
the  development  of  local  cerebral  symptoms  discredits  somewhat  the 
pathological  significance  of  Ferry's  observations,  but  he  attempts  to 
meet  this  objection  by  quoting  from  Le  Fort,  who  maintains,  that  in 
surgical  ligation  a  thrombus  is  formed  at  the  point  of  ligation  which 
advances  to  the  first  bifurcation  of  the  artery.  If  collateral  circu- 
lation is  established  before  the  thrombus  reaches  the  bifurcation  of 
the  common  carotid  artery,  cerebral  symptoms  do  not  develop.  If, 
however,  the  clot  reaches  the  bifurcation  and  passes  into  the  internal 
carotid  branch,  hemiplegic  symptoms  are  likely  to  occur. 

Unfortunately,  I  did  not  have  an  opportunity  to  examine  the 
carotid  arteries  in  my  case,  but  with  the  marked  peripheral  scle- 
rosis, it  may  be  reasonably  assumed  that  there  was  impairment  of 
the  general  circulation  and  cerebral  malnutrition.  Under  such  con- 
ditions, even  transitory  disturbances  in  the  general  circulation  might 
be  sufficient  to  produce  localizing  .symptoms  from  an  already  impov- 
erished brain.  An  interesting  study  of  the  effects  produced  by 
interruption  of  cerebral  circulation  has  been  made  by  Sand  (18), 
who  examined  the  l^rain  of  a  patient  subjected  to  i)rolonged  chloro- 
form anesthesia  during  an  operation  for  osteomyelitis.  .\t  the  close 
of  the  operation  syncope  developerl,  the  pulse  could  not  be  felt,  and 
the  patient  was  thought  to  be  dead,  .\fter  an  hour  he  was  partially 
resuscitated,  so  that  he  would  answer  f|Ucstions  vaguely,  respond  to 
a  pin  prick,  and  protrude  the  tongue  when  asked  to  do  so.  The 
puj)ils  responded  nf)rmally,  and  there  was  no  paralysis,  biu  he  was 


STUDY  OF  CONDITION  OCCURRING  IN  AGED  501 

incontinent.  Death  occurred  nine  hours  later,  and  the  autopsy 
showed  sHght  edema  of  the  brain  and  cord,  but  no  other  gross  lesion. 
Microscopically,  the  nerve  cells  were  in  various  stages  of  disintegra- 
tion and  this  change  was  especially  pronounced  in  the  cerebellum, 
where  there  was  almost  complete  disappearance  of  the  Purkinje 
cells.  These  cellular  changes  were  thought  to  be  due  to  the  inter- 
ruption of  the  circulation  rather  than  to  the  direct  action  of  chloro- 
form, since  the  liver  did  not  show  changes  characteristic  of  chloro- 
form intoxication.  This  observation  is  interesting,  when  it  is  re- 
called that  similar  changes  were  found  in  the  cerebellar  cells  of  my 
specimens,  and  that  both  toxemia  and  circulatory  disorders  may 
have  been  contributing  factors. 

It  is  not  improbable  that  sclerosis  of  vessels  more  distant  than 
the  carotid  arteries  might  produce  symptoms  resembling  those  of  a 
cerebral  lesion.  The  observations  of  Boullay  (19),  in  183 1,  upon 
the  cause  of  "  string-halt  "  in  the  horse,  and  a  later  study  by  Charcot 
(20)  upon  a  similar  condition  in  man  demonstrated  the  relation 
between  these  symptoms  and  changes  in  the  arterial  wall.  Throm- 
bosis and  arteriosclerosis  are  usually  present,  but  the  symptoms  of 
intermittent  claudication  may  occur  without  thickening  of  the  ar- 
terial wall,  and  the  condition  is  generally  confined  to  one  or  both 
lower  extremities.  The  resemblance  of  this  affection  to  an  associ- 
ated group  of  symptoms  sometimes  observed  in  Raynaud's  disease, 
and  the  occasional  absence  of  changes  in  the  peripheral  vessels  have 
encouraged  the  belief  that,  in  some  cases,  intermittent  claudication 
is  due  to  arterial  spasm  alone ;  hence,  it  has  become  known  by  some 
writers  as  dysbasia  intermittens  angiospastica.  The  disease  is  not 
always  confined  to  the  lower  extremities ;  but  occasionally  one  or 
both  arms  have  been  aft'ected.  Erb  (21)  and  Determann  (22)  have 
recorded  cases  in  which  the  leg,  arm,  and  tongue,  upon  the  same  side, 
were  involved.  During  the  attack,  the  pulse  in  the  lingual  artery 
was  obliterated. 

Intermittent  lameness,  as  originally  described,  showed  no  evi- 
dence of  involvement  of  the  spinal  cord.  Cases  have  been  observed, 
liowever,  in  which  symptoms  indicating  spinal  involvement  were 
l^resent.  Pathological  examination  revealed  sclerosis  of  both  the 
peripheral  and  intraspinal  vessels,  and  a  diagnosis  of  spinal  inter- 
mittent claudication  was  made.  It  is  only  a  step  from  these  observa- 
tions to  imagine  spasmodic  closure  of  the  cerebral  vessels,  and  the 
term  cerebral  intermittent  claudication  has  been  adopted  to  account 
for  a  number  of  transitory  cerebral  symptoms  of  apparently  vascular 
origin.     Such  a  conception  finds  some  support  from  a  clinical  and 


502  CHARLES  METCALFE  BVRXES 

pathological  study  of  migraine,  with  its  associated  transitory  para- 
lytic phenomena. 

The  inaliility  to  demonstrate  a  nervous  mechanism  for  the  cer- 
ebral vessels  and  the  general  belief  that  they  are  therefore  incapable 
of  transitory  constriction  and  dilatation  have  been  the  main  support 
of  those  who  oppose  the  theory  of  cerebral  intermittent  claudication. 
There  is,  however,  clinical  and  experimental  evidence,  in  favor  of 
the  independent  irritability  of  the  vessel  wall,  and  the  presence  of 
vasoconstrictor  libers  to  the  cerebral  vessels  has  received  some  sup- 
port from  experimental  physiolog}'.  Edge  worth  {2^)  from  a  clin- 
ical study  of  four  cases  of  transient  hemiplegia  attributes  the  con- 
dition to  intermittent  contraction  of  the  cerebral  arteries  and  is  in- 
clined to  accept  W'igger's  experimental  studies  upon  vasoconstrictor 
nerves  to  the  cerebral  vessels.  In  a  later  paper,  Phillips  (24)  con- 
tends that  it  is  not  necessary  to  assume  the  presence  of  vasocon- 
strictor nerves  to  the  cerebral  vessels,  since  it  is  known  that  certain 
drugs  when  circulating  through  a  vessel  isolated  from  all  nerve  con- 
nections will  produce  temporary  constriction  ;  and  it  is  therefore 
reasonable  to  assume  that  circulating  toxines  in  the  body  may  pro- 
duce the  same  effect. 

If  the  cerebral  vessels  possess  independent  contractility  it  is 
necessary  to  assume  the  presence  of  some  irritating  substance  in  the 
general  circulation  which  stimulates  the  muscle  coat  directly.  Ar- 
teriosclerosis, increased  demands  upon  the  circulation,  and  hyperex- 
citability,  are  regarded  as  essential  conditions  in  the  development  of 
intermittent  arterial  spasm  ;  while  gouty  and  rheumatic  states,  meta- 
bolic disorders,  and  gastrointestinal  toxemia  are,  according  to 
Russell  (25),  predisj)osing  factors.  But  a  condition  of  general  tox- 
emia alone  does  not  explain  satisfactorily  the  spasm  of  a  localized 
va.scular  area,  which,  of  course,  must  be  assumed  if  localizing  cer- 
ebral symptoms  are  to  be  exi)lained  upon  a  theory  of  vascular  spasm. 
Physiological  experiments,  however,  seem  to  indicate  that  contrac- 
tion of  even  a  small  portion  of  an  artery  does  occur ;  but  that  some 
local  condition,  either  within  the  arterial  wall  itself  or  from  without, 
is  essential.  Hobhouse  (2),  in  discussing  Russell's  paper,  quotes 
from  Sherrington  as  follows :  "  Local  tonic  spasm  of  short  lengths 
of  small  arteries  arc  seen  in  experiments.  If  the  student  touches  the 
artery  or  if  heat  or  cold  is  applied,  a  spasm  occurs  which  may  lead 
to  almost  complete  closure."  Sherrington  further  suggests  that  in 
diseased  arteries  une(|ual  elasticity  at  a  point  of  commencing  change 
might  be  sufficient  mechanical  stinnilus  to  produce  contraction  in 
the  neighboring  arterial  wall.      I'arker  ( 2y }   takes  exception  to  the 


STUDY  OF  CONDITION  OCCURRING  IN  AGED  503 

theory  of  arterial  spasm  and  would  explain  the  symptoms  of  cer- 
ebral intermittent  claudication  upon  the  selective  action  of  toxic 
substances  for  certain  groups  of  nerve  cells,  and  a  similar  opinion 
has  been  expressed  by  Heard  (28).  Herz  (29),  however,  attributes 
the  condition  to  extraventricular  systole. 

Two  interesting  clinical  papers  have  been  published  by  Langwill 
(30)  and  Edgeworth  (31)  in  which  transitory  hemiplegia  is  at- 
tributed to  the  spasmodic  closure  of  the  cerebral  vessels  ;  which,  in 
their  opinion,  may  be  caused  by  the  toxemia  of  nephritis  and  occur 
independently  of  arteriosclerosis.  In  one  of  Allan's  (32)  four  cases 
of  transient  paralysis,  the  probable  toxic  nature  of  the  affection  is 
strikingly  illustrated.  The  patient,  a  young  man,  who  gave  a  pre- 
vious history  of  rheumatism,  had  suffered  for  three  years  from 
transient  paralysis  of  the  left  side,  of  ten  or  twenty  minutes'  duration 
During  the  interval  between  attacks  the  urine  was  quite  normal,  but 
following  a  seizure  it  almost  invariably  contained  a  heavy  albumi- 
nous precipitate.  Allan,  however,  is  of  the  opinion  that  the  symp- 
toms were  due  to  arterial  spasm  induced  by  circulating  toxines  ab- 
sorbed from  the  gastrointestinal  tract,  and  refers  to  the  experiments 
of  Dixon  and  Dale  which  showed  that  toxic  substances  derived  from 
putrid  meat,  when  injected  into  the  circulation,  produced  arterial 
constriction.  In  two  cases  of  Raynaud's  disease,  studied  by  Semon 
(33)  and  Fox  (34),  syphilitic  toxemia  was  thought  to  be  the  cause 
of  the  arterial  spasm. 

Whatever  view  may  be  entertained  concerning  the  occurrence  of 
angiospastic  phenomena  and  localizing  cerebral  symptoms  in  the 
absence  of  confirmatory  pathological  changes  in  the  brain,  it  ap- 
pears that  any  explanation  must  be  more  or  less  speculative ;  and 
while  this  study  may  not  have  contributed  any  positive  information 
to  the  present  conception  of  such  conditions,  it  has,  at  least,  been 
instructive  through  its  negativeness. 

That  so  striking  a  clinical  picture  of  general  and  local  cerebral 
arteriosclerosis  can  occur  in  the  absence  of  sclerotic  changes  in  the 
cerebral  vessels  is  of  interest.  Although  the  histological  examina- 
tion furnishes  no  satisfactory  explanation  of  the  symptoms,  it  is  not 
improbable  that  they  may  have  been  due  to  uremic  or  syphilitic  tox- 
emia, extracranial  arteriosclerosis,  or  spasmodic  constriction  of  the 
peripheral  or  cerebral  vessels. 

BIBLIOGRAPHY 

1.  Collins,  J.      A  Definite  Clinical  Variety  of  Cerebral  Arteriosclerosis.      Jour. 

Nerv.  and  Ment.  Dis.,  1906,  xxxiii,  750. 

2.  Bornstein,  M.     Uber  die  paro.xysmale  Lahmung.     Deut.  Zeit.   f.   Nerven- 

heilk.,  1908,  XXXV,  407. 


504  CHARLES  METCALl-E  BYRNES 

3.  Hochhaus.     f'ber  Hirnerkrankungen  mit  todlichem  Ausgang  oline  Anato- 

mischen  Befund.     Deut.  Med.  Wochnr.,  1908.  xxxiv,  1657. 

4.  Gardner,  \V.     A  Case  of  Periodic  Paralysis.     Brain,  1912-13,  xxxv.  243. 

5.  Rhein.  J.  \V.     A  Pathological  Study  of  Seven  Cases  of  Paralysis  without 

Gross  Anatomical  Change.     Jour.  .\mer.  Med.  Assoc,  1906,  xlvi.  1705. 

6.  Sands.  H.   B.     Two  Cases  of  Fatal   Hemiplegia  with  Absence  of   Post- 

mortem Appearance.     New  York  Med.  Times,  1856,  v,  17. 

7.  Draper,  W.  H.     Two  Cases  of  Fatal  Hemiplegia  with  Absence  of  Lesion 

after  Death.     Xew  York  Med.  Times,  1856,  v,"  90. 

8.  Weisenburg,  T.  H.     Uremic  Hemiplegia.     Proc.   Path.   Soc.   Phila.,   1904, 

vii,  62. 

9.  Warrington.     Notes  on  a  Case  of  Advanced  Carcinoma  Uteri  with  Some 

Symptoms  of  Bulbar  Palsy  and  Almost  Negative  Microscopic  Findings. 
Rev.  Xeurol.  and  Psychiat.,  1905.  516 

10.  Rossi,   I.     Atrophic   Primitive   Parenchymateuse   du   Cervelet  a   Localiza- 

.  tion  Corticale.     Nouv.  Iconog.  de  la  Salpt.,  1907,  xx.  66. 

11.  Fickler,  A.     Klinische  und  pathologischanatomische  Beitriige  zu  den  Er- 

krankungen  des  Kleinhirns.     Deut.  Zeit.  f.  Nervenheilk.,  1911,  xli,  306. 

12.  Thomas.  A.     Atrophic  du  Cervelet  et  Sclerose  en  Plaques.     Rev.  Neurol., 

1903.  xi.  121. 

13.  Dejerine,  J.,  et  Thomas,  A.     L'atrophie  Olivo-Ponto-Cerebelleuse.     Nouv. 

Iconogr.  de  la  Salpt.,  1900,  xiii,  330. 

14.  Garbini  et  Rossi.     L'influence  du  Cerveler  sur  la  Coordination  du  Langage 

.Articule.     Rev.  Neurol.,  1911,  xix,  384  (review). 

15.  Schlesinger,   H.     'Cber   Meningitis   im    Senium.     Neurol.   Centralb.,    1912, 

xxxi,  1283. 

16.  Osier,  Sir  William.     Transient  Aphasia  and  Paralysis  in  States  of  High 

Bloodpressure    and    Arteriosclerosis.     Canad.    Med.    Ass.    Jour.,    1911, 
October,  p.  919. 

17.  Ferry.    M.     De    L'Hemiplegie    progressive    par    Endarterite    a    Distance. 

These  de  Paris,  1913. 

18.  Sand.  R.     Les  Alterations  quentraine  dans  le  system  nerveux  de  I'homme 

une  interruption  prolongee  de  la  circulation.    Rev.  Neurol.,  I9ii,xix,  68. 

19.  Boullay.     Arch.  Gen.  de  Med.,  1831.  xxvii,  425. 

20.  Charcot.     Sur  la  Claudication  Intermittente.     Comp.  Rend,  de  la  Soc.  de 

Biol..  1858,  V,  s.  ii,  225. 

21.  Erb.  W.     Zur  Kausitick  der  intermittierenden  angiosklerotischen   Bewe- 

gungstorungen.     Deiit.  Zeit.  f.  Nervenheilk.,  1905,  xxix,  465. 

22.  Determann.     Intermittierendes   Hinken   eines   Arms,   der  Zunge   und   der 

Beine.     Deut.  Zeit.  f.  Nervenheilk.,  1905,  xxix,  152. 

23.  Edgeworth,  F.  H.     On  the  Diagnosis  of  Transitory  Hemiplegia  in  Elderly 

Persons.     The  Pract.  Lond.,  1909,  Ixxxii,  613. 

24.  Phillips,  J.     Hypertonic  Contraction  or  Intermittent  Closing  of  the  Cere- 

bral Arteries.     Cleveland  Medical  Journal.  1012,  xi,  693. 

25.  Russell.  W.     Intermittent  Closing  of  Cerebral  Vessels.     Brit.  Med.  Jour., 

1909,  ii,  1109. 

26.  Hobhouse,  E.     Brit.  Med.  Jour.,  1909,  ii.  1313. 

27.  Parker,  G.     Brit.  Med.  Jour.,  1909,  ii,  1409. 

28.  Heard.  J.  D.     The  Significance  of  Transient  Cerebral  Crises  and  Seizures 

as  Occurring  in  .Arteriosclerosis.     Edinbg.  Med.  Jour.,  1910,  v,  n.  s.  417. 

29.  Herz.    M.     Zur    Symptomatologie    der    zercbralen    arteriosklerose.     Wien 

klin.  Wochnschr.,  1910.  159. 

30.  Lanpwill.  H.  G.     Transitory  Hemiplegia  with  Notes  on  Two  Cases.     Scot- 

tish Med.  and  Surg.  Jour.,  1906,  xviii.  509. 

31.  Edgeworth.  F.  M.     On  Transitory  Hemiplegia  in  Elderly  Persons.     Scot- 

tish Med.  and  Surg.  Jour.,  1906,  xix,  414. 

32.  Allan.  G.  A.     Arterial  Spasm  in  the  Brain,  Associated  with  Transient  and 

Permanent  Paralysis.     Glasgow  Med.  Jour..  1910,  Ixxiv,  23. 
2,3.  Semon.  H.  H.     Raynaud's  Syndrome  and  Svphilis.     Brit.  Med.  Jour.,  1913, 

i.  278. 
34.  Fox,  H.     Raynaufl's  Disease.     Jour.  Cut.  Dis.,  incl.  Syphilis,  1913,  xxxi,  782. 


TUMOR    INVOLVING   THE   CRUS    CEREBRI    (WITH 
UNUSUAL  ENDOCRINE  SYMPTOMS) 

By  Walter  Timme,  M.D. 

ASSISTANT    PHYSICIAN,     NEUROLOGICAL    INSTITUTE;     CONSULTING    NEUROLOGIST, 
VOLUNTEER    AND    NEW    ROCHELLE    HOSPITALS 

Tumors  of  the  crus  cerebri  usually  give  a  symptomatology  de- 
pendent upon  the  possible  positions  that  the  tumor  may  assume  in 
relation  to  the  three  important  anatomical  divisions  of  the  crus — 
namely  the  basis,  the  tegmentum,  and  the  corpora  quadrigemina. 
The  tumor,  if  small,  may  involve  only  one  of  these,  giving  sharply 
defined  limited  symptoms.  But  usually,  besides  the  direct  symptoms 
produced  by  the  tumor  growth,  there  are  those  arising  from  the 
pressure  exerted  by  the  neoplasm  upon  more  remote  cell  groups  and 
tracts  within  one  or  both  of  the  other  crural  divisions.  Such  a 
growth  involving  the  basis  pcdunciili  gives  a  so-called  Weber  syn- 
drome, oculomotor  palsy  of  one  side  with  crossed  paralysis ;  involv- 
ing the  tegincutiiin,  an  oculomotor  palsy  with  crossed  choreiform 
or  athetoid  movements,  Benedikt's  syndrome ;  and  involving  the 
corpora  quadrigemina,  presents  the  syndrome  of  Nothnagel  (i) 
with  ocular  muscular  palsy,  cerebellar  ataxia  and  disturbances  in 
hearing. 

There  are  of  course  various  combinations  of  these  to  which  are 
superadded  the  distant  symptoms  in  the  case  of  larger  tumors. 
Cases  heretofore  reported  conform  more  or  less  completely  with  this 
theoretical  scheme.  Unexplained  symptoms  wdiich  have  thus  far 
been  described  in  the  literature  are  inordinate  laughter,  which  oc- 
curred in  2  cases  reported  respectively  by  Hunt  (2)  and  Spiller  (3), 
and  reduction  of  body  temperature  on  the  paralyzed  side,  in  the  cases 
of  Gamier  (4),  Mendel  (5)  and  Ramey  (6).  To  these  I  now  desire 
to  add  a  case  in  which,  apart  from  the  fairly  classical  symptoms  of 
oculomotor  involvement  with  crossed  paralysis,  ataxia  and  inco- 
ordination of  cerebellar  type,  there  were  added  abnormally  rapid 
skeletal  growth  and  sexual  precocity.  Rhein  (7)  published  a  series 
of  18  cases  of  tumor  of  the  crura  which  he  had  thus  far  found  in 
the  literature,  and  in  none  of  them  were  such  conditions  present. 
While  the  tumor  here  presented  was  not  solely  confined  to  the  crus 

505 


5o5  J  r  ALTER   TIM  ME 

cerebri  but  extended  down  to  the  pons,  yet  there  will  be  little  diffi- 
culty in  separating  the  symptoms  due  to  that  part  below  the  crus 
from  the  gross  picture. 

In  July,  191 3,  a  boy.  fourteen  years  of  age,  with  a  negative  pre- 
ceding history,  was  hit  on  the  head  by  a  playmate.  He  fell,  and 
though  he  arose  unassisted,  was  dizzy  for  a  minute  or  two  after- 
wards. In  August,  about  5  weeks  later,  while  running,  he  fell  and 
struck  the  back  of  his  head  without  any  apparent  after-effects.  One 
week  later,  or  about  August  2^,  the  father  noticed  that  the  boy's 
speech  was  affected,  his  articulation  not  being  clear  and  perfect  as 
formerly.  At  the  same  time  his  friends  began  to  notice  a  gradual 
change  in  his  gait,  which  had  become  unsteady.  Coincident  with 
these  changes,  headache  began,  located  chiefly  in  the  occipital  region. 
With  the  advent  of  headache,  nausea,  though  no  actual  vomiting, 
also  began.  With  these  changes,  and  indeed  as  early  as  any  of 
them,  tlie  father  began  to  notice  priapism  in  the  boy  lasting  from 
two  to  three  hours  each  night.  About  the  15th  of  September  his 
sight  began  to  bother  him  and  this  got  progressively  worse.  Since 
the  beginning  of  August  his  stature  increased  two  to  three  inches, 
that  is,  within  five  weeks  ;  the  rapid  growth  involved  his  extremi- 
ties also,  so  that  shoes  which  were  bought  in  the  early  summer  no 
longer  fitted  him.  He  became  withal  more  and  more  drowsy  and 
at  times  it  was  difficult  to  awaken  him  for  examination.  He  was 
admitted  to  the  Neurological  Institute  on  September  25,  on  the  serv- 
ice of  Dr.  Pearce  Bailey.  \\  bile  here  he  was  very  unruly  and  re- 
sistive, constantly  crying  to  go  home,  so  that  it  was  necessary  to 
discharge  him  for  a  time. 

His  status  on  entrance  was  as  follows:  A  staggering,  swaying 
gait  towards  the  left  side  chiefly,  but  also  occasionally  to  the  right ; 
occipital  headache ;  nausea ;  no  vomiting  at  first  and  no  tremor. 
There  was  a  right  facial  weakness  seen  chiefly  in  smiling,  i.  e.,  emo- 
tional in  character.  His  eyes  were  examined  by  Dr.  Holden  on 
September  25  with  the  following  result :  Diplo])ia  was  present,  pos- 
sibly due  to  the  weak  left  external  rectus.  Nystagmus,  coarse  in 
character,  greater  when  looking  to  the  left,  with  the  slow  component 
to  the  right,  was  constant.  X'ision  20  30  each ;  hy])ero]jia  ;  with 
white  and  red  fields  normal.     Discs  -were  jMuk.  veins  slightly  dilated. 

On  October  26  a  beginning  papilledema  with  hemorrhage  was 
first  noticed  in  both  fundi  with  normal  color  fields. 

There  was  incot'irdination  with  ataxia  of  hands  and  feet ;  right 
greater  than  left.  The  reflexes  gave  a  greater  right  knee  jerk,  a 
double  Babinski  and  C)p])C'nheim,  greater  on  the  right.  dou])tful  on 
the  left  at  times;  abdominals,  right  sluggish,  left  absent;  ej)igastrics 
likewise;  cremasterics  ccjual.  h'lbow  jerk,  right  exaggerated,  left 
doubtful ;  asynergia  was  well  marked  in  the  usual  movements  of 
equilibration.  Hearing  unaffected.  Weber  and  Rinne  tests  showed 
normal  conduction,  'ihere  was  irregular  pointing  by  and  adia- 
dochokinesis  of  the  right  hand.  The  cerebrospinal  fluid  was  nega- 
tive.    The  penis  and  scrotum  were  unduly  developed.     An   X-ray 


TUMOR  INVOLVING  CRUS  CEREBRI  507 

of  the  skull  showed  no  abnormal  sella  turcica,  nor  other  pathological 
condition.  ' 

From  these  findings  a  general  diagnosis  of  tumor  was  made 
w^ithout  special  localization.  I  personally  kept  track  of  the  patient 
\vhile  he  was  at  home  and  noticed  gradually  an  exaggeration  of  the 
signs  and  symptoms.  The  drowsiness  and  headaches  became  more 
marked.  He  had  two  unilateral  convulsions  involving  the  right  side. 
Following  them  there  was  added  an  Oppenheim  on  the  left  side  and 
a  gradual  impairment  of  the  motor  functions  of  the  trigeminus  on 
the  left  side.  Joint  sense  was  unimpaired.  Astereognosis  was 
absolute  on  the  right  side,  the  boy  being  able  to  give  no  information 
wdiatever  of  the  object  in  that  hand.  A  moderate  spasticity  of  the 
right  leg  began  to  appear  but  no  clonus.  Finally  there  was  elicited 
by  means  of  my  esthesiometer  (8),  a  slight  diminution  of  cutaneous 
sensibility  of  the  entire  right  side.  These  signs,  together  wnth  the 
foregoing  status,  enabled  us  to  localize  the  tumor  as  one  involving 
the  crus  and  pons  of  the  left  side,  and  extending  posteriorly  to  the 
origin  of,  but  not  including,  the  facial  and  auditory  nerves — at  anv 
rate  beyond  the  origin  of  the  motor  fifth.  The  possibility  of  an 
enlarged  left  crus  impinging  upon  the  hypophysis  or  its  stalk,  was 
also  considered  probable. 

As  the  patient  became  progressively  Avorse  with  daily  attacks  of 
respiratory  weakness,  verging  on  the  Cheyne-Stokes  type,  it  was  im- 
perative that  surgical  interference  be  undertaken,  albeit  there  was 
no  increase  in  the  papilledema  and  scarcely  any  diminution  in  vision. 
He  was  again  brought  to  the  Institute  on  October  27,  but  before 
anything  could  be  done,  he  died  of  respiratory  paralysis. 

In  analyzing  the  symptoms  I  would  like  to  call  attention  to  several 
interesting  and  important  points  brought  out  in  the  examination. 
First,  the  astereognosis  was  probably  due  to  the  imperfect  sense 
perceptions  from  the  right  periphery  and  the  reciprocal  imperfect 
motor  adjustment  on  the  same  side,  therefore  it  was  no  true  cortico- 
psychic  astereognosis  ;  secondly,  I  w'ould  like  to  point  out  the  im- 
portance of  examining  always  for  the  sensory  and  motor  functions 
separately,  of  the  fifth  nerve.  In  this  case  this  difference  possibly 
marked  the  limit  of  the  tumor,  laterally ;  the  motor  root  cells  lying 
centrally  to  the  sensory.  Thirdly,  there  is  seen  the  importance  of 
difi'erentiating  not  only  crude  changes  of  sensibility  on  symmetrical 
areas  of  the  body,  which  in  this  case  elicited  nothing;  but  also  and 
especially  the  finer  changes.  This  gave  us  one  of  the  requisite  signs 
for  localization.  Lastly,  and  most  important,  I  would  like  to  call 
attention  to  the  symptoms  in  this  case  pointing  to  irritation  of  either 
the  pineal  gland  or  the  hypophysis,  those  of  priapism  and  of  skeletal 
growth.  In  none  of  the  18  cases  of  tumor  of  the  crus  heretofore 
published,  were  such  symptoms  mentioned.  As  neither  of  these 
glands  was  abnormal,  as  shown  at  the  necropsy,  were  they  produced 


5o8 


WALTER  TIM  ME 


by  the  pressure  within  the  third  ventricle  transmitted  to  the  pineal 
gland  or  to  the  hypophyseal  stalk,  or  were  they  originated  by  direct 
pressure  of  the  left  crus  cerebri  (which  centrally  encroached  on  the 
middle  line)  upon  the  hypophysis,  and  superiorly  against  the  pineal? 
As  the  ventricles  were  hardly  distended,  it  is  fair  to  assume  that 
the  increased  mass  of  the  left  crus  cerebri  was.  the  irritative  cause  of 
these  symptoms.  Furthermore  the  signs  of  increased  intracranial 
pressure  came  on  after  the  growth  ])henomena  had  appeared  and 
therefore  these  could  not  have  depended  on  this  general  pressure 
increase.  Another,  though  very  remote  possibility,  is  that  the  fibers 
of   the   commissura   habenularum    (some   of   which   penetrate   and 


A  transverse  sectit/ii  uf  ll.e  brain  showing  the  enlarged  left  cms  cerebri 
impinging  against  the  stalk  of  the  hypophysis  ventra'.ly,  and  against  the  pineal 
gland  dorsally.  The  very  slight  distension  of  the  ventricles  is  also  to  be 
remarked. 


become  part  of  the  pineal  gland),  in  their  further  course  from  the 
glandula  habemiU'e  to  the  glandula  interpedtmcularis  as  the  tractus 
habcnul.'c  interi)cduncularis,  arc  interfered  with  in  their  course 
throtigh  the  crus  by  the  tumor,  thus  affecting  ihe  function  of  the 
pineal.  In  such  an  event,  however,  all  ttimors  of  the  crtis  should 
show  similar  symptoms — which  they  do  not.  These  fibers  more- 
over are  presumed  to  be  merely  vestigial  in  character. 

These  remarks  are  of  course  based  upon  the  assumption  that 
interference  with  either  the  hypo]>hysis  or  the  pineal  gland,  or 
perhaps  both,  influences  the  evolution  and  control  of  skeletal  growth 
and  sexual  precocity. 


TUMOR  INVOLVING   CRUS  CEREBRI  509 

The  autopsy  by  Dr.  Casamajor  showed  a  brain  very  much  en- 
larged, the  ventricles  only  slightly  distended,  with  a  pons  very  much 
distorted  and  enlarged,  especially  on  the  left  side.  This  enlarge- 
ment was  caused  by  an  extensive  pontine  tumor  mass  which  reached 
forward  through  the  left  crus  cerebri  to  the  left  thalamus,  and 
posteriorly  nearly  to  the  beginning  of  the  medulla,  extending  slightly 
into  the  brachium  pontis  of  the  left  side ;  involving  in  this  extended 
locus,  the  left  median  fillet,  the  red  nucleus  with  the  emerging  rubro- 
spinal tract,  the  left  brachium  conjunctivum,  the  left  motor  fifth 
root,  and  compressing  the  pyramidal  tract  of  the  left  side  as  well  as 
by  transmitted  pressure  that  of  the  right  side  also  in  lesser  degree. 
The  hypophysis  was  normal  in  size.  The  pineal  gland  was  roughly 
triangular  in  shape  with  a  large  transverse  diameter  of  12  nmi.  and 
its  anteroposterior  10  mm.  This  represents  a  gland  rather  large  in 
size  although  within  normal  variation.  The  tumor  proved  to  be  a 
glioma. 

The  sketch  shows  a  transverse  section  of  the  brain  giving  the 
relations  of  the  tumor  to  the  pineal  gland  (which  is  also  reproduced 
in  the  picture),  and  to  the  hypophyseal  stalk. 

BIBLIOGRAPHY 

1.  Nothnagel.     Ein  Fall  v.  Gehirntumor  in  d.  Vierhiigelgegend.     Wiener  Med. 

Blatter,  1889. 

2.  Hunt,  J.  R.     Amer.  Journ.  Med.  Sc.  1904,  p.  514. 

3.  Spiller,  W.  G.     Journ.  Nerv.  and  Ment.  Dis.,  1905;  Arbeiten  aus  d.  Neu- 

rolog.  Inst.  Vienna,  Deuticke,  1907. 

4.  Garnier.     Rev.  Medic.  De  Test..  1902,  p.  590. 

5.  Mendel.     Berliner  klin.  Wochenschrift,  1885,  p.  468. 

6.  Ramey.     Rev.  de  Med.,  1885.  p.  489. 

7.  Rhein,  J.  H.  W.     Tumor  of  the  Crus  Cerebri.     Journ.  A.  M.  A.,  Nov.  7, 

1914  (with  review  of  cases  previously  published). 

8.  Timme.  W.     Nature  of   Cutaneous   Sensation  with  an   Instrument  for  its 

Measurement.     Journ.  Nerv.  and  Ment.  Dis.,  April,  1914. 


TIC  OF  THE  ABDOMINAL  MUSCLES  OF  13  YEARS' 

DURATIOX.    STUDY    OF   A    CASE    WITH 

NECROPSY^ 

Bv  F.  B.  Clarke,  M.D. 

MILWAUKEE,    WIS. 

If  one  may  judge  from  the  literature,  abdominal  tic  is  not  fre- 
quently seen.  The  case  forming  the  basis  of  this  paper  was  dis- 
tinctly of  the  abdominal  type,  and  was  under  observation  in  the 
Philadelphia  General  Hospital,  for  a  period  of  seventeen  years,  hav- 
ing been  observed  l)y  various  members  of  the  neurological  stalT. 
Notes  were  made  l)y  Drs.  Burr,  Potts,  Weisenburg,  McConnell, 
Spiller  and  others.  Dr.  W'eisenburg  had  cinematograjihs  made 
which  unfortunately,  are  not  available.  At  death  from  myo- 
cardial degeneration,  March  22,  191 4,  a  necropsy  was  secured.  For 
the  notes  in  this  case  and  the  necropsy  material,  I  am  indebted  to 
Dr.  \\'.  G.  Spiller. 

A  muscular  movement  constituting  a  tic  represents  a  psycho- 
motor adjustment  initiated  as  a  reaction  to  an  external  cause  or  an 
idea  ;  in  addition,  such  a  movement  must  have  become  habitual  by 
frequent  rejjetition.  It  is  usually  held  that  in  its  onset  a  movement 
later  to  become  a  tic  is  conscious  and  voluntary.  This  is  probalily 
true  when  the  cause  is  external  or  physical,  but  when  resulting  from 
an  idea,  it  may  be  conscious  but  involuntary,  in  the  sense  that  it 
represents  an  involuntary  motor  reaction  made  possible  by  a  lack  of 
inhibition  of  the  will.  After  a  muscular  movement  becomes  habit- 
ual, it  is  no  longer  conscious  and  involuntary,  but  becomes  uncon- 
scious and  involuntary,  although  co(")rdinaled,  since  muscles  ])hysio- 
logically  groui)ed  are  called  into  actifin. 

In  its  inception,  a  tic  is  a  jnirposive  act,  since  it  represents  a 
movement  the  purpose  of  which  is  to  secure  relief.  Later  the  cause 
may  disappear,  and  then  the  movement  becomes  purposeless. 

While  a  tic  is  involuntary,  it  is  to  a  certain  extent  under  the  con- 
trol f)f  the  will,  since  it  may  be  preveiUed  from  occurring  for  a  short 
time  if  the  patient  directs  what  will-power  he  may  have  against  its 

*  From  the  Laboratory  of  Neuro-PatholoKy  of  the  University  of  Penn- 
sylvania and  the  I'liilaiUli)liia  (ieneral  Hospital.  Read,  by  invitation,  before 
the  Pliiladelphia  XeuroloKical  Society  January  28th,  1916. 

5'o 


TIC  OF  ABDOMINAL  MUSCLES  511 

repetition,  but  it  is  in  this  direction  that  the  individual  is  least  ca- 
pable mentally,  and,  therefore,  inhibition  of  the  tic  even  for  a  short 
time  is  extremely  difficult.  A  tic  may  be  temporarily  inhibited  by 
the  attention  of  the  ticeur  being  fixed  upon  the  performance  of  an 
agreeable  task,  which  requires  highly  specialized  skill.  Meige  and 
Feindel  ( i  ),  in  their  excellent  monograph,  describe  a  man  who  was 
afflicted  by  many  and  various  tics,  yet  when  engaged  in  a  game  of 
billiards  or  fencing,  he  did  not  tic.  It  is  equally  true  that  wdienever 
engaged  in  an  unpleasant  or  difficult  task  which  results  in  a  feeling 
of  inadequacy,  the  tic  is  exaggerated.  Whenever  a  ticeur  feels  that 
he  is  under  observation  or  his  attention  is  directed  to  his  infirmity 
the  movement  becomes  more  violent. 

Patrick  (2)  called  attention  to  the  fact  that  the  voluntary  inhi- 
bition of  a  tic  produces  a  feeling  of  malaise,  followed  by  a  feeling 
of  relief  and  satisfaction  after  the  movement  overcomes  the  inhi- 
bition and  is  accomplished.  Inhibition  of  a  tic  by  the  exercise  of  the 
will  can  be  brought  about  and  maintained  for  a  short  time,  but  it 
occasions  such  mental  discomfort  that  inhibition  cannot  be  main- 
tained. 

Charcot  (3)  taught  that  a  tic  was  a  physical  expression  of  a 
psychic  disease,  which  view  was  later  held  by  Brissaud,  Meige  and 
Feindel  and  others.  He  also  held  that  the  irresistible  impulse  to  tic 
and  the  succeeding  content  were  evidences  of  the  functional  nature 
of  the  disease. 

An  understanding  of  the  mental  state  of  the  ticeur  is  of  impor- 
tance, since  it  offers  an  explanation  of  why  an  ordinary  movement  of 
everyday  life  may  become  habitual  and  therefore  a  tic. 

Itard  (4),  in  1825,  called  attention  to  the  "  infantilism  of  tiquers," 
and  later,  Charcot,  Brissaud  and  many  others  recognized  that  there 
was,  in  patients  so  afflicted,  a  defective  mental  endowment.  They 
are  of  a  class  deficient  in  will  power,  rather  than  in  intellect,  and  it 
is  this  inequality  of  development  which  is  most  strikmg.  Infantile 
reactions  to  environment  in  tiquers,  guided  by  the  emotions  rather 
than  by  judgment,  easily  angered  and  of  strong  likes  and  dislikes, 
rapidly  changing  without  cause  are  quite  characteristic. 

Clinical  History. 

Case  G.  G.,  admitted  to  the  Philadelphia  General  Hospital  Sep- 
tember 16,  1897,  where  he  remained  until  his  death  on  March  22, 
1914,  was  under  observation  for  a  period  of  seventeen  years.  Dur- 
ing this  time  he  was  observed  by  several  members  of  the  neurolog- 
ical staff,  and  frequent  notes  were  made  by  Drs.  Burr,  Potts,  Mc- 
Connell  and  Spiller.     His  symptoms  having  remained  comparatively 


512  F.  B.  CLARKE 

the  same,  the  notes  made  by  Dr.  Spiller  a  relatively  short  time  be- 
for  death  will  be  used. 

family  History. — Father  and  mother  died  at  an  advanced  age, 
from  unknown  causes.  Three  brothers  and  two  sisters  are  living 
and  well. 

There  is  no  history  of  serious  illness,  operations  or  accidents 
occurring  prior  to  his  present  illness.  The  beginning  of  his  pres- 
ent trouble  dates  back  twelve  years,  to  an  injury  which  was  as  fol- 
lows :  While  assisting  in  unloading  a  press,  some  part  of  the  ap- 
paratus gave  way  and  the  patient  fell  backward  to  the  ground.  A 
crowbar  fell  and  struck  him  across  the  right  side  of  the  abdomen 
and  lower  part  of  the  chest.  Following  the  injury,  he  was  uncon- 
scious (time  not  stated),  and  was  confined  to  bed.  During  this 
time  there  was  difficult  and  painful  urination,  and  at  times,  blood 
was  passed.  Immediately  after  the  injury  he  suft'ered  from  short- 
ness of  breath,  and  muscular  twitchings  of  the  back  occurred,  at 
times  lasting  for  several  hours,  occurring  from  one  to  five  times 
each  week.  These  attacks  were  sometimes  brought  on  by  hard  work 
or  worry.  His  trouble  became  progressively  worse,  and  he  devcl  • 
oped  what  he  describes  as  "  fits."  The  entire  body  would  twitch, 
but  he  never  lost  consciousness.  These  attacks  sometimes  lasted 
for  several  hours,  and  occurred  four  or  five  times  a  week.  For 
relief  he  went  to  the  Episcopal  Hos])ital,  where  he  was  confined  to 
bed  for  several  months  and  was  discharged  as  incurable. 

After  leaving  the  hospital  he  developed  attacks  in  which  he 
would  lose  power  in  his  arms  and  legs,  causing  him  to  fall,  but  he 
never  became  unconscious.  It  is  stated  that  excitement  always 
brought  on  one  of  these  attacks,  which  persisted  for  some  years. 

In  1901,  four  years  after  entrance  to  the  Philadelphia  General 
Hospital,  it  is  noted  that  he  had  abdominal  spasms  which  were 
brought  to  his  attention  by  shortness  of  breath.  They  were  at- 
tributed by  him  to  pain  in  his  abdomen,  which,  as  he  expressed  it, 
w^as  so  severe  as  to  "  double  him  up,"  and  he  would  feel  as  if  his 
"  insides  were  leaving  him."  He  complained  of  considerable  pain 
and  tenderness  over  the  lower  end  of  the  spine.  This  complaint  was 
persistent,  beginning  in  the  dorsal  region  and  increasing  as  the 
lumbar  region  was  reached.  It  is  noted  that  there  was  a  slight  cur- 
vature backward  in  the  dorsal  region.     Skiagraph?  were  negative. 

At  one  i)eriod  of  his  residence,  a  cast  had  been  a])plied  to  the 
trunk,  in  order  to  determine  if  sui)port  would  in  any  way  influence 
the  pain  described  above,  but  it  difl  not. 

In  apfjcarance,  he  is  an  old  man.  The  mouth  is  always  kc])t 
open,  and  the  tongue  shows  a  fine  tremor. 

Gait  and  Station. — The  patient  states  that  he  cannot  walk  with- 
out the  aid  of  his  crutch  on  his  right  side.  In  walking  the  body  is 
bent  to  the  right  about  15°,  and  there  is  a  contraction  forward  of 
the  trunk  and  head,  due  to  the  abflominal  spasm.  The  feet  are  al- 
ways wide  apart,  and  the  stej>  measures  about  twelve  inches  in 
height.  When  the  crutch  is  taken  away  the  abdominal  spasms  be- 
come much  wor.'^e.  and  he  would   fall  if  not  supj^orted. 

With  the  aid  of  his  crutch  he  docs  not  sway  with  the  eyes  closed 


TIC  OF  ABDOMINAL  MUSCLES  513 

and  the  feet  together,  but  as  soon  as  the  crutch  is  removed  he  will 
fall  in  a  heap. 

Chest. — Barrel  shaped,  bulging  distinctly  in  lower  part.  The 
two  sides  are  symmetrical  and  the  expansion  is  poor,  breathing  being 
largely  of  the  costal  type.  Dyspnea  is  marked  when  he  lies  on  his 
back,  but  relieved  when  position  is  changed  to  the  side.  The  lungs 
are  normal. 

Heart. — Area  of  dullness  normal.  Sounds  are  distinct,  and  of 
fair  muscular  quality.  No  murmurs  or  accentuation  of  aortic  or 
pulmonic  sounds. 

Abdomen. — Soft  and  flabby,  but  fairly  fat.  There  is  a  small, 
soft,  superficial  tumor  mass  at  the  costal  margin  in  the  left  side. 
The  abdominal  movements  will  be  described  later. 

The  musculature  of  the  upper  extremities  presents  no  atrophies 
or  spasticities.  The  muscles  are  soft  and  flabby.  He  can  perform 
all  active  movements  well,  and  resistance  to  passive  movements  is 
equal  on  the  two  sides,  but  less  than  normal.  The  same  condition 
is  found  in  the  lower  extremities. 

The  deep  reflexes  have  shown  great  variability.  Earlier  in  his 
history  they  were  quite  uniformly  noted  as  exaggerated,  but  during 
the  last  eight  years  they  have  been  noted  as  diminished  or  absent  at 
various  examinations  by  the  same  examiner. 

The  following  notes  were  made  about  six  months  apart :  The 
biceps  and  triceps  are  prompt  and  slightly  exaggerated  on  the  left 
side ;  normal  on  the  right.  Patellar  and  Achilles  reflexes  are  absent 
on  both  sides.     There  are  no  pathological  reflexes. 

Six  Months  Later. — The  patellar  reflexes  are  present,  but  greatly 
diminished  on  both  sides.  The  same  is  true  of  the  ankle  jerks. 
"  On  stroking  the  sole  of  the  right  foot,  the  great  toe  is  at  first 
slightly  flexed,  then  decidedly  distended.  This  is  a  constant  phe- 
nomenon, and  at  times  it  seems  to  constitute  almost  a  true  Babinski. 
The  great  toe  on  the  left  is  never  dorsal  flexed.  There  is  no  ankle 
or  patellar  clonus." 

Superficial  Reflexes. — Abdominal  and  epigastric  cannot  be  tested. 
Cremasteric  on  the  left  is  exaggerated,  while  the  right  is  sluggish. 
It  is  noted  that  upon  stroking  the  inside  of  the  right  thigh,  the  left 
cremasteric  is  much  more  active  than  the  right. 

Sensation  to  touch,  heat  and  cold,  and  pin  prick  is  normal.  No 
sphincter  disturbances. 

E\es. — Vision  is  good.  Irides  react  to  light  and  convergence. 
On  testing  the  eye  reflex  there  is  a  constant  contraction  and  relaxa- 
tion of  the  lids. 

Hearing  is  impaired,  probably  due  to  age. 

Tic  of^the  Abdominal  Muscles. — The  abdominal  muscles  are  in 
a  state  of  constant  contraction  and  relaxation  during  passive  inspira- 
tion and  expiration,  but  during  deep  inspiration  the  contraction 
ceases  to  reappear  with  expiration.  The  entire  movement  is  wave- 
like, spontaneous,  and  followed  by  two  shorter  or  two  longer  con- 
tractions. When  the  patient  believes  himself  to  be  unobserved,  the 
tic  is  not  marked,  but  under  the  slight  stimulus  of  observation  it 
becomes,  at  times,  so  marked  as  to  force  the  air  out  of  the  chest  with 


514  F.  B.  CLARKE 

such  violence  that  the  sound  is  plainly  heard,  and  there  is  marked 
dyspnea  due  to  the  power  and  frequency  of  the  muscular  move- 
ments. In  lifting  the  limbs  from  the  bed.  thereby  fixing  the  ab- 
dominal nuiscles,  there  is  much  less  contraction,  but  the  dyspnea  is 
proportionally  greater. 

The  oblique  muscles  seem  to  take  part  in  the  tic  movement  feebly 
except  under  excitement,  and  then  contract  strongly.  Contraction 
of  all  the  abdominal  muscles  with  the  umbilicus  as  the  fixed  point, 
gives  to  the  abdomen  a  pyriform  appearance. 

On  watching  the  lower  part  of  the  chest  during  contraction,  there 
is  a  distinct  impulse  on  the  right  side,  as  if  the  liver  were  being 
pushed  forcibly  against  the  abdominal  wall.  Upon  spreading  the 
palms  of  the  hands  over  the  lower  part  of  the  chest,  leaving  about 
four  inches  between  the  thumbs,  there  is^  during  each  contraction, 
a  decrease  of  at  least  one  inch  between  them. 

During  each  tic  movement  the  symphysis  pubes  and  the  costal 
margin  are  brought  much  nearer  together,  the  head  sharply  ex- 
tended, due  to  the  contraction  of  the  abdominal  muscles  and  not  to 
contraction  of  the  muscles  of  the  neck,  although  at  times  the  latis- 
simus  dorsi  takes  part  in  producing  the  movement  of  the  head.  The 
traj)ezius  is  never  seen  to  contract.  The  respirations  usually  aver- 
aged twenty-five  per  minute,  and  were  rarely  below  twenty. 

Death  occurred  March  22,  1914,  at  the  age  of  69,  from  myo- 
cardial degeneration.  Sections  were  studied  :  of  the  medulla  ;  fourth, 
fifth,  sixth,  seventh  and  eighth  cer\'ical ;  first,  second,  third,  fourth 
and  twelfth  thoracic:  first,  second  and  third  .lumbar  segments;  also 
sections  of  the  recti  abdominis  at  two  dififerent  levels. 

In  previous  cases  studied,  involvement  of  the  nervous  system 
has  not  been  found,  nor  was  there  any  change  in  sections  studied  in 
this  case,  except  those  incident  to  age.  Even  the  sections  of  muscle 
did  not  .show  hypertrophy,  as  one  might  expect. 

Oppenhcim  describes  a  case  in  which  the  tensor  fasci?e  latae.  the 
extensors  of  the  thigh  and  the  rectu  abdominis  had  been  affected  for 
six  years,  resulting  in  a  marked  hypertrophy. 

It  is  interesting  to  note  the  fact  that  the  psychoneurosis  had  its 
beginning  as  the  result  of  the  injury,  as  he  had  been  able  to  work, 
and  had  n(A  manifested  symptoms  of  a  peculiar  mental  state  prior 
to  that  time.  That  thefe  was  a  definite  injury  was  shown  by  the 
period  of  uncon.sciousness  and  i)ainful  urination  accompanied  by 
hematuria.  That  the  physical  trauma,  in  this  case,  was  productive 
of  a  [jsychoneurosis  lasting  for  twenty-nine  years  is  evidenced  by  the 
immediate  development  of  nniscular  twitchings,  convulsions  of  a 
I).sychogenic  nature  anfl  later  by  abdominal  tic. 

The  "fits,"  as  he  called  them,  were  of  two  distinct  types;  one  is 
described  as  a  "jerking"  of  all  of  the  muscles  of  the  body,  without 
loss  of  consciousness  or  falling,  and  the  other,  as  a  "  weakness  of  all 
the  muscles  of  the  body,  causing  him  to   fall,  without   losing  con- 


TIC  OF  ABDOMINAL  MUSCLES  515 

sciousness  or  having  twitching  of  the  muscles."  These  psychic 
manifestations  persisted  for  about  sixteen  years  and  gradually  dis- 
appeared, to  be  followed  by  the  abdominal  tic  which  was  present 
until  his  death  thirteen  years  later. 

Oppenheim  considers  that  tic  may  result  from  an  external  cause 
or  an  idea.  In  this  case,  while  the  trauma  had  occurred  long  before 
the  development  of  the  tic,  yet,  to  the  patient,  the  trauma  persisted, 
because  he  always  complained  of  pain  in  the  lower  dorsal  region, 
and  it  would  seem  probable  that  the  tic  movement  was  initiated  as  a 
relief  from  this  pain.  However,  the  original  trauma  was  a  potent 
factor  in  bringing  about  a  peculiar  psychic  state  which  made  the  tic 
possible. 

The  exact  mental  mechanism  by  means  of  which  an  idea  results 
in  a  tic  is  not  well  understood,  although  it  is  probable  that  the 
majority  of  the  tics  owe  their  origin  to  an  idea  rather  than  a  periph- 
eral irritation.  Obsessive  thinking  and  tics  are  so  frequently  pres- 
ent in  the  same  individual,  that  one  is  forced  to  recognize  the  pos- 
sibility of  the  same  cause  as  productive  of  both. 

An  obsession  represents  a  substitution  proc-ess  in  which  the  affect 
has  been  separated  from  its  original  distressing  idea,  and  becomes 
associated  with  an  idea  not  repellant,  which  by  reason  of  being  fre- 
quently forced  into  consciousness,  entails  a  motor  reaction.  Fre- 
quent repetition  of  this  motor  reaction  leads  to  its  becoming  habitual 
and,  therefore,  a  tic. 

Clark  (5)  states  that  when  an  obsession  is  productive  of  a  motor 
reaction,  it  cannot  be  removed  until  the  idea  itself  has  been  removed. 

Abdominal  tic,  occurring  as  the  result  of  an  idea,  is  well  de- 
scribed by  Janet  (6)  :  A  woman  who  had  been  twice  pregnant, 
thought  she  was  pregnant  a  third  time,  as  violent  movement  of  the 
abdominal  wall  occurred.  She  was  taken  to  a  hospital  for  the  pur- 
pose of  delivery,  but  was  not  pregnant.  After  being  transferred  to 
the  Salpetriere  the  abdominal  distention  disappeared,  but  the  tic  per- 
sisted, consisting  of  violent  upward  movements  of  the  abdominal 
wall,  the  recti  being  firmly  contracted.  The  upward  movement  of 
the  umbilicus  was  interrupted  from  time  to  time  by  the  contraction 
of  the  oblique  muscle,  which  pulled  the  abdomen  from  side  to  side. 
This  tic  was  repeated  about  ten  times  per  minute.  The  patient  later 
became  pregnant,  but  the  tic  never  disappeared. 

The  second  case  was  even  more  remarkable.  A  woman  suft'ered 
from  the  fixed  idea  that  there  was  an  animal  in  her  abdomen. 
There  was  a  sharp  severe  contraction  of  the  recti  muscles  above  the 
umbilicus,  then  an  invagination   of  the  contracted  portion  by  the 


5'^  F.  B.  CLARKE 

oblique  muscles.  The  pictures  descriptive  of  this  movement  are 
very  striking. 

There  was  a  slight  deformity  of  the  lower  dorsal  and  lumbar 
spine  in  my  case.  The  skiagraphs  were  negative.  This  deformity, 
in  the  absence  of  organic  disease,  may  have  resulted  from  the  psychic 
shock  of  the  injury.  Carriere  (  /.)  describes  the  case  of  a  young  boy 
who  developed  a  deformity  of  his  spine  after  an  altercation  with  a 
playmate ;  there  was  also  a  well  marked  abdominal  tic.  Both  dis- 
appeared after  hypnotism. 

It  may  be  observed  that  the  tic  of  G.  G.  had  many  features  which 
would  suggest  a  spasm  of  the  abdominal  muscles,  rather  than  a  true 
tic,  but  spasms  of  muscles  always  require  a  pathological  irritatioii  in 
some  part  of  the  reflex  arc.  Moreover,  muscular  spasms  are  con- 
fined to  a  single  muscle  or  one  group  of  muscles,  rather  than  to 
muscle  groups  coordinated  for  the  purpose  of  a  definite  function. 
Study  of  the  necropsy  material  did  not  reveal  such  a  cause,  although 
the  patient  always  complained  of  pain  in  his  lower  dorsal  region, 
nor  would  we  expect  a  pathological  irritation,  provided  one  was 
present,  to  persist  for  a  period  of  thirteen  years  without  becoming 
more  marked  or  losing  its  irritating  property. 

That  an  irritation  of  the  reflex  arc  of  the  lower  thoracic  region 
may  give  rise  to  a  spasm  of  the  abdominal  muscles,  producing  sim- 
ilar movements  to  the  ones  described  in  this  patient,  is  shown  by  the 
case  described  by  Chipault  (8).  There  were  paroxysms  of  pain  in 
the  subcostal  region,  accompanied  by  violent  contraction  of  all  the 
muscles  of  the  right  abdominal  wall,  the  movements  occurring  at 
intervals  of  a  few  minutes  to  several  hours.  At  operation,  the 
eighth,  ninth,  and  tenth  dorsal  roots  were  found  to  be  comi:)ressed 
by  an  infiltration  and  thickening  of  the  jiia  arachnoid. 

That  the  character  of  the  abdominal  muscular  contraction  in  my 
case  is  typical  of  a  tic  is  shown  by : 

(a)  Rhythmical  character,  each  contraction  being  followed  by 
two  longer  or  two  .shorter  ones  of  like  character. 

(b)  Coordination  of  nuiscles  of  the  abdominal  wall  in  i)r()(iucing 
a  contraction,  characterized  by  the  pyriform  appearance  of  the  ab- 
domen with  the  umbilicus  as  the  center. 

(c)  Increase  in  violence  of  the  tic  by  consciousness  of  observa- 
tion, leading  to  well  marked  dysjmeic  attacks  due  to  the  power  of 
the  muscular  contractions,  preventing  j)roper  movement  of  the  dia- 
I)hragm  in  abflominal  breathing. 

(d)  Resemblance  of  the  tic  movements  to  purposive  movements. 

(e)  .Automatic  character,  as  shown  by  the  inal)ility  to  inhibit  the 
tic,  and  the  unifnnn  and  persistent  character  of  the  tic. 


TIC  OF  ABDOMINAL  MUSCLES  517 

(/)  The  mental  state.  That  there  was  an  abnormal  mental 
state  is  shown  by  the  persistent  psychogenic  convulsions  for  a  period 
of  sixteen  years,  also  by  the  mental  process  which  necessitated  a 
crutch  in  walking,  although  there  was  no  physical  infirmity  render- 
ing it  necessary.  As  a  further  evidence  is  the  fact  that  many  symp- 
toms of  a  psychic  nature  disappeared  when  the  necessity  for  earning 
a  living  had  been  removed. 

An  interesting  clinical  observation  was  the  variability  of  the 
reflexes,  especially  of  the  lower  extremities,  which  were  noted  to  be 
diminished,  and  at  other  times,  absent,  by  the  same  observer.  At 
times  there  was  dorsal  flexion  of  the  great  toe  on  the  right  followed 
by  extension.  A  study  of  the  cord  did  not  give  an  explanation  for 
this  variability. 

BIBLIOGRAPHY 

1.  Meige  and  Feindel.     Les  tics  and  leur  traitement,  p.  15. 

2.  Patrick,  H.  T.     Remarks  on  Tics  and  Chorea.     Jour.  Amer.  Med.  Assoc, 

May  I,  1909. 

3.  Charcot.     Legons  du  Mardi,  1887-8,  p.  124. 

4.  Itard.     (Meige  and  Feindel,  p.  76.) 

5.  Clark,  P.  L.     Mental  InfantiHsm  in  Tic  Neuroses.     New  York  Med.  Rec, 

February  7,  1914. 

6.  Janet,  Pierre.     Neuroses  et  Idees  Fixes,  pp.  310-12. 

7.  Carriere,  G.     Sur  un  cas  de  paramyoclonus  multiplex  et  de  lordo-scoHose 

hysteriques  dans  un  enfant.     Nord  Medicale,  Maj'  i,  1902. 

8.  Chipault.     Neuralgie  des  VHP,  IX^  et  X",  racines  dorsales  avec  tic  abdom- 

inal.    Gazette  des  Hopitaux.  March,  1902. 


ON    THE    INTERPRETATION    OF    SYMPTOMS    IN    THE 
INFECTIVE   EXHAUSTIVE   PSYCHOSES 

Bv  Sanger  Bkowx,  II..  :\I.D. 

ASSISTANT    PHYSICIAN,    BLOOMINGDALE    HOSPITAL 

The  infective  exhaustive  psychoses,  or  as  they  have  more 
properly  been  termed,  the  toxic  exhaustive  psychoses,  have  been 
isolated  as  a  clinical  group  only  comparatively  recently.  The  de- 
scriptions are  lacking  in  a  number  of  details.  We  have  been  given 
no  very  clear  interpretation  of  many  of  the  symptoms,  and  there  is 
often  much  haziness  as  to  just  what  cases  should  be  included  in  this 
group.  The  typical  cases  are  quite  readily  recognized,  but  when 
there  are  unusual  features  there  may  be  much  difficulty  in  under- 
standing the  symptomatology  and  in  making  the  diagnosis. 

Because  of  these  difficulties,  we  feel  that  the  clinical  descriptions 
should  be  improved  in  certain  respects.  When  this  is  accomplished 
we  may  be  able  to  interpret  certain  symptoms  more  readily,  and  to 
learn  the  origin  of  others.  In  this  communication,  therefore,  we 
shall  suggest  the  use  of  a  somewhat  schematic  arrangement  by  which 
the  symptoms  may  be  described  under  different  headings,  according 
to  the  basis  on  which  they  arise.  It  is  hoped  that  by  emphasizing 
the  importance  of  certain  symptom  complexes,  an  explanation  of 
some  of  the  more  obscure  symptoms  may  be  possible.  We  also 
emphasize  here  the  close  relationship  of  these  toxic  exhaustive 
I)sychoses  to  certain  other  toxic  reactions.  Finally,  we  shall  indicate 
a  few  directions  in  which  further  study  is  desirable. 

Yet  it  cannot  be  said  that  we  lack  clinical  descriptions  of  toxic 
exhaustive  states.  Kraepelin'  has  described  them  very  fully.  Bon- 
hoeffer-  has  also  given  us  excellent  clinical  pictures ;  but  both  these 
descriptions  are  unsatisfactory  in  certain  respects.  One  difficulty 
is  that  these  writers  use  a  great  many  terms  in  a  way  which  were 
formerly  intended  for  dementia  praecox.  The  terms  negativism, 
mutism,  stercopathy,  catatonia,  etc.,  used  freely  by  these  writers, 
have  a  quite  different  significance  in  acute  toxic  exhaustive  states 
than  they  have  in  dementia  pr?ecox.  Any  one  who  is  not  already 
familiar  with  the  flifferent  clinical  pictures  would  he  misk-d  by  this 

'  Kraepelin.  Das  infcktif)se  Irrcsein   (Hth  edition). 
2  Bonhoeffer,  Die  Symptomatischcnpsyclioson.  etc.,  igio. 

Si8 


SYMPTOMS  IN  INFECTIVE  EXHAUSTIVE  PSYCHOSES     519 

terminology  alone.  Again,  while  in  other  psychoses,  the  manic  de- 
pressive for  example,  the  symptoms  are  grouped  under  certain 
fundamental  headings — some  symptoms  occurring  because  of  a 
mood  change,  some,  such  as  flight,  distractibility,  etc.,  dependent 
upon  disorders  of  association,  etc. — while  this  grouping  of  symptoms 
is  made  in  our  description  of  the  manic  depressive  psychoses,  the 
toxic  exhaustive  states  are  described  under  no  such  definite  headings 
and  in  no  ordered  way.  Added  to  this,  a  great  many  psychogenic 
symptoms  are  present,  such  as  one  sees  in  dementia  praecox. 
Kraepelin  has  offered  very  little  explanation  of  these  symptoms  and 
Bonhoeft'er  pays  comparatively  little  attention  to  them.  Bleuler,  on 
the  other  hand,  says  that  when  any  such  symptom.s  occur  the  cases 
are  to  be  regarded  as  schizophrenic.  We  feel  that  for  clinical 
reasons  and  for  further  study  the  need  of  closer  dift'erentiation  is 
quite  evident. 

Dr.  Hoch'^  has  given  a  resume  which  is  most  helpful  in  under- 
standing the  delirious  states  of  these  disorders.  He  divides  all 
deliria  into  two  main  groups,  the  psychogenic  and  the  organic.  By 
an  organic  delirium  is  not  necessarily  meant  a  condition  dependent 
upon  gross  brain  lesions,  in  the  way  in  which  we  generally  employ 
the  term  organic,  but  rather,  it  is  meant  that  some  definite  toxic  or 
exhaustive  factor  is  the  causative  agent.  The  symptoms  of  these 
organic  deliria — such  as  the  disorientation,  the  peculiar  nature  of  the 
hallucinations,  the  changes  in  clearness  of  consciousness,  etc. — are  all 
quite  characteristic.  This  is  in  contrast  to  the  psychogenic  delirious 
states,  in  which  the  apparent  delirium  (hysterical  delirium)  has  to 
do  with  some  topic  of  dynamic  value  in  the  subconscious.  This 
latter  state  is  not  a  true  delirium,  but  until  Dr.  Hoch  pointed  out  the 
distinction,  the  two  conditions  were  not  satisfactorily  differentiated. 

With  these  preliminary  remarks,  we  may  now  proceed  with  the 
main  outline  of  the  description.  In  order  that  a  definite  type  may 
be  kept  in  mind  by  the  reader,  we  may  consider  as  typical  cases 
either  a  post-typhoid  toxic  exhaustive  psychosis  or  a  post-puerperal 
psychosis.  With  these  cases  as  types  we  propose  to  give  an  outlme 
of  the  symptomatology  under  headings  which,  it  is  hoped,  will  be 
useful  for  the  interpretation  of  symptoms  and  for  further  study. 

Now  in  accordance  with  Dr.  Hoch's  observations,  we  see  much 
that  is  organic  in  these  toxic  exhaustive  psychoses,  using  the  term 
organic  in  the  way  in  which  he  has  used  it.  The  frank  delirium, 
the  slight  elevation  of  temperature,  the  deranged  state  of  the  ali- 

3  The  Problem  of  Toxic-Infectious  Psychoses,  August  Hoch,  New  York 
State  Hospital  Bulletin,  1912,  v,  384. 


520  SAXGER  BROWN 

mentary  canal,  the  slurring  speech  in  some  cases,  and  a  number 
of  other  symptoms,  all  point  in  this  direction.  We  propose,  there- 
fore, to. separate  out  all  those  symptoms  which  seem  definitely  de- 
pendent upon  organic  (/.  c,  toxic  or  exhaustive)  factors,  and  de- 
scribe them  separately.  This  entire  group  of  symptoms,  or  this 
symptom  complex,  we  shall  designate  as  tiie  organic  part  of  the 
reaction.  Under  this  heading  fall  all  the  physical  signs  of  toxemia 
or  exhaustion,  few  as  they  are  in  many  instances. 

But  after  we  have  described  the  symptoms  which  we  have  spoken 
of  as  organic,  there  remain  many  other  symptoms  to  be  described. 
There  is  a  definite  mood  change  in  most  cases,  either  before,  during, 
or  after  the  delirium.  The  anxiety  and  the  depression  may  be  ex- 
treme. Elation  is  common,  and  well-marked  manic  symptoms,  such 
as  flight  of  ideas,  distractibility,  rhyming,  etc.,  may  be  met  with  in 
delirious  utterances.  In  the  subsequent  confused  period  much  real 
depression  may  be  observed.  All  these  symptoms  we  propose  to  re- 
gard separately  and  grouj)  under  another  heading.  This  symptom 
complex  with  manic-like  characteristics  we  shall  term  the  affective 
part  of  the  react io)i. 

Finally,  we  must  speak  of  another  group  of  symptoms  which  are 
met  with  in  varying  degrees  of  importance  in  nearly  all  toxic-ex- 
haustive states.  These  are  the  trend  reactions,  the  delusional  forma- 
tions, etc.  These  symptoms  may  be  very  transitory,  and  dependent 
upon  lack  of  clearness,  but  again  they  may  be  of  very  definite  dynamic 
importance.  All  the  symptoms  which  appear  to  be  of  psvchogoiic 
origin  we  shall  group  under  another  heading,  which  is  termed  the 
psychogenic  part  of  the  reaction.  Since  our  knowledge  of  the 
origin  of  psychogenic  symptoms  in  general  is  less  complete  than  that 
of  organic,  for  example,  so  in  this  instance  we  will  be  al)le  to  do 
little  more  than  mention  the  symptoms  under  this  group.  Their 
interpretation  may  vary  with  dififerent  observers  but  their  presence 
should  be  recognized  by  all. 

To  summarize,  we  would  describe  the  symptoms  seen  in  the 
toxic  exhaustive  psychoses  under  these  three  headings:  the  organic 
part  of  the  reaction,  the  affective  ])art,  and  the  psychogenic  part. 
These  are  all  seen  in  any  given  case  and  often  at  the  same  time. 

Before  outlining  the  symptoms  which  we  consider  of  the  most 
significance  under  these  headings,  we  may  recall  to  the  reader  cer- 
tain stages  in  the  coiirse  of  these  psychoses  which  should  be  kept  in 
mind.  At  the  onset,  there  is  the  jirodromal  stage,  during  which 
there  is  much  irritability,  anxiety,  etc.  These  symptoms  are  mainly 
of  aflfcctive  character  and  may  last  for  a  few  days  only.     Next  often 


SYMPTOMS  IN  INFECTIVE  EXHAUSTIVE  PSYCHOSES     521 

comes  a  frank  delirium,  in  which  the  organic  part  of  the  reaction 
is  most  in  evidence.  Then  may  come  a  prolonged  stage  of  the 
psychoses,  which  for  want  of  a  better  term,  we  may  refer  to  as 
the  confused  period.  This  latter  stage  may  endure  for  weeks  or 
even  months.  Many  psychogenic  features  are  often  in  evidence, 
and  out  of  it  it  appears  that  chronicity  occasionally  develops.  With 
these  different  phases  of  the  entire  reaction  in  mind,  we  may  now 
proceed  with  the  description  of  the  individual  symptoms.  It  is 
hoped  that  a  somewhat  detailed  enumeration  of  symptoms  will  be 
excused  by  the  fact  that  we  wish  to  bring  together  all  symptoms 
belonging  to  definite  symptom  complexes. 

The  Organic  Part  of  the  Reaction. — Of  all  the  symptoms  seen 
in  toxic  exhaustive  states,  that  which  seems  most  closely  associated 
with  the  physical  disorder — the  elevation  of  temperature,  the  tox- 
emia from  the  infection,  etc. — is  the  delirium.  As  both  Kraepelin 
and  Bonhoeft'er  have  mentioned,  this  delirium  may  be  initial,  febrile, 
or  post- febrile.  While  the  symptoms  are  much  the  same  in  all,  our 
experience  has  been  mainly  with  post-febrile  cases.  These  cases 
develop,  after  a  few  prodromal  symptoms,  in  a  few  days,  or  even 
weeks,  after  the  acute  physical  symptoms  and  the  fever  have 
subsided. 

In  delirium,  necessarily,  the  clouding  of  consciousness  must  be 
the  most  important  feature.  The  orientation  is  entirely  lost  in  all 
respects.  Such  patients  mistake  the  physicians  or  nurses  for  rela- 
tives. They  call  to  their  friends,  etc.,  who  they  think  are  just 
outside  or  above  them.  They  often  think  that  they  are  at  home — 
in  a  hotel,  on  the  train,  etc.  They  have  no  appreciation  of  time, 
or  of  the  chronology  of  passing  events.  Symptoms  dependent  upon 
a  loss  of  personal  orientation  are  quite  prominent  at  times.  Patients 
speak  of  their  own  bodies  in  an  impersonal  way  as  "  it."  They  also 
feel  that  the  body  is  changed  in  a  most  distorted  way — the  legs  are 
shortened,  the  eyes  are  twisted.  These  symptoms  are  rather  dif- 
ferent from  the  sense  of  bodily  change  in  cases  of  depression,  but 
the  differentiation  is  at  times  difficult. 

Memory  is  of  course  interfered  with  where  consciousness  is 
clouded.  There  is  generally  complete  amnesia  for  the  deeper  levels 
of  the  delirium — but  certain  occurrences  may  be  remembered ; 
"  islands  "  of  memory  are  retained.  Well-marked  fabrications  are 
often  seen  and  are  quite  as  definite  as  in  the  polyneuritic  psychoses. 

The  perceptive  faculties,  whose  integrity  is  necessary  for  the 
understanding  of  complex  situations,  passing  events,  etc.,  are  im- 
paired.    Some  such  patients  cannot  read  a  simple  paragraph  under- 


522  SANGER  BROWN 

standingly.  They  read  word  by  word  and  do  not  comprehend. 
They  comprehend  some  one  detail  only  of  a  picture ;  they  cannot 
comprehend  the  general  presentation.  In  speaking  to  them  in  long 
sentences,  phrases  only  are  understood.  These  symptoms  may  in 
part  be  dependent  upon  failure  of  attention  but  probably  in  part 
only,  as  there  seems  to  be  a  disorder  of  those  directing  forces  which 
are  necessary  to  make  a  series  of  ideas  comprehensible. 

The  hallucinations  of  delirious  states  are  quite  characteristic. 
Those  of  sight  are  often  very  distinctive.  They  are  more  marked 
at  night.  Often  the  patients  see  a  series  of  events,  a  parade,  a 
wedding,  or  a  short  scene  in  a  play.  They  often  see  moving  pictures 
on  the  wall.  \'ery  often  the  objects  they  see  are  much  distorted. 
They  see  imps,  small  people,  people  cut  in  half,  people  with  their 
limbs  off,  their  heads  off,  etc.  This  type  of  visual  hallucinations 
is  quite  characteristic  of  these  deliria.  It  may  be  accompanied 
by  a  depressive  or  fearful  affect  and  then  it  is  in  every  way  com- 
parable to  the  toxic  delirium  of  delirium  tremens.  Hallucinations 
may  be  induced  or  suggested  by  pressure  over  the  eyeball  or  by  the 
use  of  pictures,  or  even  blank  paper. 

The  hallucinations  of  hearing  are  very  vivid.  They  generally 
consist  of  disconnected  words  or  phrases,  in  contrast  to  the  hallu- 
cinations in  dementia  praecox,  for  example,  where  the  hallucinations 
are  a  part  of  connected  trends  of  thought.  The  toxic  exhaustive 
patient  often  hears  voices  which  relate  to  his  former  working  life. 
In  such  cases,  the  term  "  occupation  delirium,"  which  has  been  used, 
is  quite  descriptive  of  the  mental  state.  In  some  cases  the  voices 
seem  to  come  from  inanimate  objects,-  such  as  a  vase  of  flowers; 
or  the  sound  of  heels  on  the  floor  is  interpreted  as  a  voice.  Such 
patients  often  hear  someone,  perhaps  relatives,  being  tortured  or 
burned  just  outside  the  door.  With  the  agreeable  affective  states, 
beautiful  music  may  be  heard  and  this  is  not  infrequently  accom- 
panied by  visions  of  angels  floating  in  the  air.  A  marked  religious 
coloring  to  the  visual  hallucinations  is  not  infrcf[uent. 

Hallucinations  of  the  senses  of  taste  and  smell  are  probably  more 
frcfjucnt  in  these  disorders  than  in  any  other,  and  so  are  of  some 
diagnostic  significance.  Such  patients  often  speak  of  their  food  as 
filth,  .sj)oiled  meat,  or  human  flesh.  They  describe  an  odor  or 
taste  which  to  them  justifies  this  conclusion. 

•  Very  characteri.stic  of  these  deliria  are  the  hallucinations  of 
touch.  This  is  probably  an  indication  of  a  certain  degree  of  toxic 
neuritis,  as  there  may  be  either  a  mild  paresthesia,  or  a  well-defined 
polyneuritis.     Very  frequently  the  patients  speak  of  bugs  crawling 


1 


SYMPTOMS  IN  INFECTIVE  EXHAUSTIVE  PSYCHOSES     523 

on  the  face.  They  feel  insects  on  the  hands  and  arms.  They  may 
request  frequent  baths,  and  an  inquiry  will  reveal  that  this  is  to  get 
rid  of  these  sensations. 

All  cases  of  delirium  should  be  examined  frequently  for  changes 
in  clearness  of  consciousness.  At  one  time  in  the  day  they  may  be 
entirely  disoriented ;  again,  perhaps  after  a  short  rest,  they  may  be 
nearly  clear  for  a  short  time,  and  realize  where  they  are.  The 
symptoms  are  worse  at  night,  and  the  hallucinations  of  the  night 
may  be  spoken  of  as  a  dream  on  the  following  day.  By  command- 
ing the  attention  these  patients  may  be  raised  temporarily  from  the 
delirium,  to  relapse  quickly  when  left  alone.  Cases  of  mental  ex- 
haustion dependent  upon  broken  cardiac  compensation  show  that 
changes  in  the  state  of  consciousness  are  clearly  dependent  upon  the 
heart  condition. 

States  of  stupor  come  as  a  natural  sequence  after  the  more 
profound  deliria.  In  these  conditions  attention  cannot  be  even 
momentarily  gained. 

Another  group  of  symptoms  which  one  should  never  fail  to 
investigate  are  the  paraphasic  symptoms.  These  are  readily  over- 
looked, unless  specially  investigated.  The  use  of  a  wrong  word 
is  very  common.  Some  slight  difficulty  in  naming  objects  may 
occur  temporarily  and  there  is  a  similar  difficulty  in  the  use  of 
objects. 

There  are  a  number  of  physical  acconipaniments  of  delirious 
states  which  should  be  mentioned.  In  the  febrile  deliria  there  is 
hyperpyrexia,  but  we  are  at  present  referring  to  those  deliria  which 
start  some  days  or  weeks  after  the  acute  febrile  condition  has  sub- 
sided. These  post-febrile  delirious  states  are  accompanied  by  a 
slight  elevation  of  temperature,  but  in  this  case  the  temperature 
does  not  appear  to  be  of  etiological  significance.  The  patients  gen- 
erally have  the  ■  appearance  of  being  physically  ill.  The  lips  are 
dry,  tongue  is  coated,  the  eyes  are  heavy,  and  there  is  considerable 
muscular  exhaustion.  The  pulse  is  often  wiry  and  rapid,  and  the 
extremities  may  be  cold.  The  pupils  are  often  dilated.  Consider- 
able difficulty  in  articulation  may  be  observed  along  with  the  para- 
phasia. The  speech  may  be  definitely  slurring  with  considerable 
tremor  of  the  facial  muscles. 

More  marked  evidences  of  toxic  involvement  of  the  nervous 
system  may  be  manifest.  Added  to  the  paresthesia  a  well-marked 
polyneuritis  may  exist.  Cases  of  this  kind  have  been  observed, 
following  such  exhaustive  and  toxic  states  as  the  puerperivim  and 
typhoid  fever.     Complete  recovery  is  observed  in  these  cases.     The 


524  SAXGER  BROlf'N 

characteristic  multiple  neuritis,  with  the  delirium,  fabrications  and 
retention  defect,  are  symptoms  very  similar  to  those  seen  in  the 
alcoholic  Korsakow's  psychoses,  and  one  seems  justified  in  conclud- 
ing that  both  states  arise  on  a  similar  toxic  basis. 

In  summar}',  it  appears  that  the  rapid  heart,  the  dilated  ])upils. 
the  deranged  gastro-intestinal  tract,  the  slurring  and  ataxic  speech 
and  the  occasional  cases  of  multiple  neuritis — it  appears  that  these 
symptoms,  accomjjanied  by  a  delirium,  are  sufficient  to  indicate  the 
ph\-sical  basis  on  which  these  states  arise.  The  term  organic  de- 
lirium seems  entirely  appropriate. 

Tlie  Affective  Part  of  the  Reaction. — When  we  have  described 
the  organic  side  of  these  psychoses,  many  mental  syni])toms  are  left 
unmentioned.  We  shall  now  indicate  the  extent  to  which  alTective 
or  mood  changes  are  responsible  for  a  certain  group  of  symptoms. 
By  these  affective  reactions  we  are,  of  course,  not  referring  to  manic- 
depressive  attacks  which  are  brought  out  by  physical  illnesses,  but 
rather  to  mood  changes  and  allied  symptoms  which  are  an  integral 
part  of  the  toxic  exhaustive  psychoses. 

Depressive  symptoms  may  be  observed  at  the  onset,  that  is  dur- 
ing the  prodromal  stage,  before  the  delirium.  This  may  merely  be 
the  apprehension  and  irritability  seen  in  any  serious  physical  illness, 
or  it  may  be  marked  by  extreme  anxiety  and  restlessness  with  sui- 
cidal impulses. 

During  the  delirious  phase  the  depression  may  continue.  An 
anxious  apprehensive  state  is  not  uncommon  and  this  is  generally 
associated  with  hallucinations  of  a  fearful  character ;  the  thought 
content  is  in  keeping  with  this  affect.  Any  suicidal  attempts  are 
liable  to  be  of  an  impulsive  nature,  arising  from  a  clouded  sensoriimi, 
rather  than  the  deliberate  and  planned  attempts  of  the  manic-de- 
pressive depression. 

Of  more  interest  during  the  deliriovis  state  are  the  manic-like 
features.  These  symptoms  are  very  like  those  seen  in  manic-de- 
pressive cases.  A  definite  elation  may  be  i)resent,  and  the  utterances 
are  manic-like.  There  may  be  rhyming  and  distractibility  with 
play  on  words.  .\t  the  same  time,  the  productions  are  generally 
intersj;crsed  with  delirious  utterances  which  are  not  a  part  of  defi- 
nite manic  pictures.  There  may  be  uukIi  motor  activity,  but  this  is 
quite  likely  to  be  purposeless.  It  arises  in  a  clouded  sensorium, 
where  the  environment  is  not  fully  appreciated.  With  the  elated 
mood,  however,  and  the  volubility  with  distractibility  and  rhyming, 
these  cases  may  be  indistinguishable  from  manic-depressive  reac- 
tions, if  one  relics  on  the  clinical  picture  alone.     In  such  instances  a 


SYMPTOMS  IN  INFECTIVE  EXHAUSTIVE  PSYCHOSES     525 

definite  afifective  reaction  is  undeniable  and  the  difficulties  of  diag- 
nosis are  increased  by  the  fact  that  some  manic-depressive  cases  at 
the  onset  show  transitory  exhaustive  symptoms. 

In  toxic  exhaustive  states,  not  only  elation,  but  a  certain  euphoria 
and  grandiose  tendency  may  temporarily  be  in  evidence.  Bon- 
hoefifer  has  reported  some  instances,  and  we  have  observed  two  such 
cases,  although  they  are  probably  infrequent. 

Not  uncommonly,  the  more  profound  the  delirium  the  more  the 
mood  tends  to  be  one  of  elation,  except  of  course  when  degrees  of 
stupor  are  reached.  In  the  milder  cases,  in  which  there  may  for 
brief  periods  be  some  vague  insight,  the  mood  is  one  of  anxiety  or 
apprehension.  There  is  probably  no  constant  relationship,  however, 
between  the  mood  change  and  the  depth  of  the  delirium. 

During  the  prolonged  confused  period  following  the  delirium  the 
mood  is  variable.  More  frequently  there  is  an  anxious  depressed 
state  during  which  many  psychogenic  features  are  in  evidence.  The 
depression  is  genuine,  as  contrasted  with  the  more  shallow  mood 
reactions  of  dementia  prsecox.  Marked  variability  of  mood  may  be 
in  evidence,  suggesting  the  ability  of  affect  seen  in  organic  brain 
disease.  Occasionally  a  considerable  degree  of  elation  may  be  pres- 
ent during  this  period  but  this,  in  our  experience,  is  unusual. 

From  what  has  been  stated,  it  will  be  observed  that  definite  af- 
fective reactions  are  present  throughout  the  various  phases  of  toxic 
exhaustive  states.  At  times  the  affective  reactions  are  slight ;  again 
they  may  be  so  marked  as  to  dominate  the  clinical  picture  and  thereby 
lead  to  a  faulty  diagnosis. 

We  are  inclined  to  regard  these  aff'ective  changes  in  the  same 
way  as  they  are  regarded  in  organic  brain  disease.  In  cases  of 
early  paresis  we  at  times  see  manic  pictures,  and  in  such  cases  the 
diagnosis  may  be  established  only  by  the  presence  of  definite  phys- 
ical signs  and  positive  laboratory  findings.  In  cerebral  arterioscle- 
rosis both  manic  and  depressed  states  occur.  In  all  these  cases  it 
appears  that  the  underlying  characteristics  of  the  personality  are 
accentuated  during'  such  periods  of  impaired  mentality.'  In  the 
toxic  exhaustive  states  the  higher  control  is  likewise  removed  and 
the  natural  tendencies  of  the  personality  are  expressed  in  an  exag- 
gerated form.  An  additional  toxic  element  may  be  present  to  ac- 
count for  the  mood  change  ;  we  know,  for  example,  that  tubercular 
patients  are  often  slightly  elated.  Of  the  nature  of  these  latter 
factors,  however,  and  of  the  way  in  which  they  act,  we  have  no  very 
definite  knowledge. 

The  PsvcJwgenic  Part  of  the  Reaction. — By  the  psychogenic  part 
of  the  reaction  we  refer  to  the  delusional  trends,  the  peculiarities  of 


526  SANGER  BROWN 

the  behavior,  syniboHsm,  etc.,  which  are  observed  in  these  disorders. 
Such  symptoms  may  occur  during  the  doHriuni,  but  are  generally 
more  marked  during  the  subsequent  confused  period. 

Peculiarities  of  behavior  and  the  delusional  interpretations  seem 
dependent  upon  two  main  factors  during  this  confused  state.  Some 
symptoms  seem  dependent  upon  the  perplexity,  the  confusion,  the 
inability  to  think  clearlS'  and  to  entirely  comprehend  the  environ- 
ment. Thus  these  symptoms  seem  of  quite  superficial  origin  and 
are  comparatively  benign  in  character.  Other  symptoms,  of  more 
definite  psychogenic  origin,  are  the  expression  of  underlying  trends 
of  the  personality  which  are  allowed  to  come  to  the  surface  during 
a  period  of  impaired  mental  control.  These  symptoms  are  of  more 
serious  character.  In  some  cases  it  appears  that  most  of  the  symp- 
toms can  be  accounted  for  by  the  perplexity  and  lack  of  clearness. 
In  others  the  trends  are  very  deeply  rooted  and  seem  to  l)e  a  more 
grave  psychotic  manifestation. 

Although  the  symptoms  rising  out  of  the  confusion  are  not  of 
the  same  significance  as  the  deeper  trends,  we  feel  that  they  are  best 
referred  to  here.  The  oddities  of  conduct  and  behavior  are  also  to 
be  spoken  of  at  this  time. 

First,  as  regards  the  conduct.  These  patients  while  apparently 
clear  and  free  from  delirium  show  many  oddities  of  behavior.  It 
is  in  the  description  of  these  traits  that  Kraepelin  and  Bonhoeflfer 
have  used  many  terms  as  they  are  used  in  dementia  prseco.x.  The 
patient  does  not  answer  and  so  the  term  mutism  is  used.  He  stands 
about  inattentive  to  surroundings,  and  the  term  stereopathy,  resislive- 
ness,  etc.,  are  employed.  \\'e  feel  that  these  symptoms  arise  from 
quite  dift'erent  sources  than  in  dementia  praecox,  and  so  the  use  of  such 
terms  here  may  be  misleading.  If  one  investigates,  it  is  found  that 
the  conduct  is  peculiar  Ijccause  of  perplexity,  or  because  of  failure 
to  understand  the  environment.  Dementia  i)ra:?cox  patients  showing 
similar  symptoms  are  not  as  a  rule  perplexed.  They  are  quite  clear 
and  fleliberate.  In  the  toxic  exhaustive  states  there  is  much  appre- 
hension and  uncertainty.  This  lack  of  complete  clearness,  then,  is 
probably  responsible  for  many  of  the  oddities  of  behavior.  Patients 
after  recovery  will  explain  that  they  do  not  renieni])cr  this  period 
of  their  illness  very  clearly,  and  they  give  (juite  reasonable  explana- 
tions for  many  of  the  symptoms. 

Lack  of  complete  appreciation  of  the  environnicnt  may  be  indi- 
cated in  other  ways.  At  night  such  jjaticnts  are  confused,  and  gen- 
erally distressing  dreams  have  the  value  of  reality.  It  is  as  yet  diffi- 
cult for  them  to  distinguish  between  the  reality  of  their  environment 


SYMPTOMS  IN  INFECTIVE  EXHAUSTIVE  PSYCHOSES     527 

and  the  unreal  circumstances  of  the  delirium.  This  mixture  of 
clearness  and  unclearness  explains  some  of  the  delusional  ideas. 
The  hallucinations  continue  at  night  as  a  residual  of  the  delirium. 
Such  states  may  continue  for  weeks  or,  in  an  exhausted  individual, 
for  months. 

A  patient  of  this  sort,  under  observation  some  time  ago,  was  very 
assaultive,  apparently  without  cause.  She  always  wished  to  visit 
the  cellar ;  the  physician  was  improperly  treating  her  child,  etc.  A 
study  of  her  case  revealed  that  she  was  quite  clouded  at  night,  al- 
though clear  during  the  day.  In  her  dreams  she  seemed  to  see  the 
nurse  crushing  her  child  under  her  knee.  She  saw  the  children 
about  to  be  run  over  by  a  wagon,  etc.,  in  fact,  a  number  of  symp- 
toms indicated  that  some  residuals  of  the  delirium  were  present  at 
night.  These  impressions  had  all  the  vividness  of  reality,  and  the 
patient  in  the  morning  was  unable  to  form  correct  judgments. 
When  assured  of  her  mistakes,  she  had  insight  for  the  time  and  the 
suspicions  cleared  temporarily,  only  to  reappear  towards  evening, 
or  after  a  restless  night.  Thus  a  number  of  the  symptoms  seem  to 
be  quite  readily  explained,  and  were  of  benign  origin.  Other  symp- 
toms observed  in  this  case,  however,  were  of  more  serious  sig- 
nificance. 

In  the  above  explanation  of  symptoms,  it  might  be  inferred  that 
the  deeper  psychogenic  factors  are  of  minor  importance  in  these 
delirious  and  confused  states;  yet  when  we  learn  of  certain  other 
manifestations,  we  find  that  many  important  psychogenic  symptoms 
come  to  the  surface  at  this  time. 

These  more  serious  symptoms  often  come  out  after  the  delirium 
has  entirely  disappeared.  Such  symptoms  are  very  similar  to  the 
trend  reactions,  delusional  formations,  etc.,  seen  in  dementia  prjecox, 
or  occasionally  in  the  atypical  manic  states.  They  have  as  a  rule 
a  favorable  prognosis.  It  is  when  these  symptoms  are  marked  that 
Bleuler  regards  the  cases  as  essentially  schizophrenic.  While  we 
hesitate  to  accept  this  generalization,  since  thereby  many  psychoses 
of  various  types  are  regarded  as  primarily  schizophrenic,  still  the 
conception  serves  a  useful  purpose  by  emphasizing  the  psychogenic 
elements  in  a  number  of  conditions. 

Even  during  the  acute  stage  of  the  delirium,  which  we  have  re- 
garded as  essentially  organic,  many  psychogenic  features  may  be  in 
evidence.  It  is  not  our  object  to  discuss  the  origin  of  these  symp- 
toms here,  as  this  whole  subject  requires  separate  consideration. 
Some  observers  lay  much  stress  on  the  dynamic  significance  of  these 
psychogenic   symptoms.     We  prefer,   for  the  present,  at  least,  to 


52S  SANGER  BROWN 

regard  them  as  secondary  manifestations,  released  by  reason  of  an 
impaired  higher  control,  just  as  in  the  case  when  such  symptoms 
occur  in  gross  organic  brain  disease. 

We  have  indicated  the  method  which  seems  most  practical  to  us 
for  the  study  of  the  toxic  exhaustive  psychoses.  What  is  essentially 
organic  is  recorded,  the  delirium  and  the  physical  signs  particularly 
coming  under  this  designation.  The  afifective  symptoms  are  observed 
and  their  significance  considered.  Finally,  the  psychogenic  part  of 
the  reaction  must  be  given  due  consideration.  Only  in  this  way  can 
we  determine  the  importance  of  these  various  symptomatic  expres- 
sions. 

It  remains  to  be  shown  how  these  general  views,  as  expressed 
above,  may  be  utilized  for  the  better  understanding  of  certain  clin- 
ical conditions.  We  feel  that  as  regards  the  organic  part  of  the 
reaction  in  particular  a  somewhat  broader  conception  than  is  gen- 
erally entertained  may  be  indicated.  Since  this  organic  part  of 
the  reaction  is  regarded  as  a  very  definite  reaction  on  the  part  of  the 
nervous  system  to  toxic  or  exhaustive  factors,  we  may  exjiect  these 
distinctive  symptoms  to  appear  wherever  such  factors  are  found. 
This  symptom  complex,  as  we  have  here  described  it,  is  found  in  a 
number  of  states  which  are  not  always  considered  in  connection  with 
the  toxic  exhaustive  psychoses.  We  shall  now  indicate  some  of 
these  conditions,  and  point  out  the  general  relationshij)  between 
them. 

We  wish  particularly  to  ])oint  out  the  close  relationship  of  the 
drug  psychoses  to  this  general  toxic  exhaustive  group.  Dr.  Hoch 
emi>hasized  this  some  years  ago,  and  he  also  indicated  that  the  alco- 
holic psychoses  should  be  similarly  considered.  The  subgrou])ing 
for  both  drug  and  alcoholic  ])sychoses  is  quite  satisfactory,  j)rovidc(l 
we  do  not  lose  sight  of  the  broader  interpretation. 

The  drug  deliria  bear  a  striking  resemblance  to  the  delirious 
states  which  we  have  been  describing  above.  The  hallucinations, 
the  disorientation,  the  fabrications,  etc.,  are  all  much  the  same  in  the 
two  conditions.  Similar  physical  signs  such  as  speech  disorders, 
parajjhasia,  tremor  of  the  facial  muscles,  etc.,  are  commonly  met 
with.  Indeed,  a  differentiation  cannot  be  made  from  the  clinical 
picture,  alone.  This  indicates  the  definite  nature  of  these  organic 
reactions  in  drug  cases. 

Likewise,  the  alcoholic  deliria  have  quite  identical  features.  An 
acute  alcoholic  delirium  (delirium  tremens)  is  remarkably  like  a 
toxic  exhaustive  delirium,  the   fear  in  the  alcoholic  cases  being  a 


SYMPTOMS  IN  INFECTIVE  EXHAUSTIVE  PSYCHOSES     529 

distinctive  feature.  The  alcoholic  Korsakow's  psychoses,  during 
the  acute  phases,  are  in  every  way  comparable  to  the  polyneuritic 
psychoses  following  typhoid  fever  or  the  puerperium. 

We  should  always  keep  in  mind,  therefore,  that  in  the  drug  and 
alcoholic  deliria  we  are  dealing  with  reactions  in  every  way  com- 
parable to  toxic  exhaustive  states.  The  nervous  system  reacts  in 
a  similar  way  to  many  different  toxic  agencies. 

We  see  this  organic  reaction  (still  using  the  term  in  this  par- 
ticular sense),  in  yet  another  group  of  cases.  We  see  toxic  ex- 
haustive deliria  arising  as  secondary  symptoms  in  a  number  of  the 
psychoses  of  gross  organic  brain  disease.  Thus  in  paresis,  cerebral 
lues,  cerebral  arteriosclerosis,  fracture  of  the  skull  (traumatic  de- 
lirium), etc.,  we  encounter  transitory  delirious  states. 

These  delirious  states,  when  so  observed,  are  in  every  way  sim- 
ilar to  the  other  deliria.  A  bromide  delirium  is  very  like  the  transi- 
tory delirium  at  times  observed  in  paresis,  and  a  delirium  arising 
in  the  course  of  cerebral  arteriosclerosis  may  resemble  any  other 
toxic  exhaustive  state.  Thus  in  the  psychoses  of  organic  brain  dis- 
ease, we  encounter  these  same  organic  deliria,  occurring  here  as  a 
secondary  symptom. 

While  emphasizing  the  organic  character  of  these  deliria,  we 
wish  to  refer  to  a  clinical  observation  which  appears  to  be  of  con- 
siderable significance.  We  do  not  encounter  this  type  of  delirium 
in  the  functional  psychoses — in  dementia  prsecox  for  example.  At 
least  this  has  been  our  experience.  States  of  stupor  and  states  of 
acute  confusion  occur,  but  not  the  true  delirium.  When  an  organic 
delirium  occurs  a  toxic  agent  of  some  sort  should  be  considered. 

In  manic-depressive  cases  we  do  occasionally  see  these  delirious 
conditions,  but  they  probably  arise  as  complications,  brought  out  by 
physical  exhaustion,  refusal  of  food,  and  loss  of  sleep.  They  are 
secondary  symptoms,  and  are  transitory. 

We  would  therefore  emphasize  the  distinctive  character  of  this 
organic  reaction  wherever  it  is  found.  It  is  observed  primarily  in 
the  toxic  exhaustive  psychoses,  being  here  a  leading  symptom  but 
supplemented  by  affective  reactions  and  psychogenic  features.  It  is 
brought  out  by  such  well-known  toxic  agents  as  drugs  and  alcohol. 
Finally,  it  appears  as  a  secondary  and  generally  as  a  transitory 
symptom  in  the  psychoses  associated  with  organic  brain  disease. 
We  feel  that  it  is  desirable  to  emphasize  the  general  identity  of  this 
symptom  complex,  which  arises  under  so  many  different  circum- 
stances. 


530  SAXGER  BROWN 

Returning  to  the  more  formal  aspect  of  infective  exhaustive  dis- 
orders, one  may  point  out  a  few  directions  in  which  further  study 
is  desirable. 

We  have  no  very  clear  idea  of  the  personality  of  the  individuals 
who  sutler  from  these  psychoses.  Possibly  a  physical  predisposi- 
tion may  be  found — a  tendency  to  physical  fatigue  or  to  neurasthenic 
states.  It  seems  probable  that  there  are  no  very  constant  features 
of  the  personality  (such  as  we  hnd  in  manic-depressive  cases,  or 
dementia  pra?cox,  for  example),  but  the  study  of  a  well-observed 
group  of  cases  would  doubtless  be  of  interest. 

The  duration  of  some  of  these  cases  is  much  longer  than  is  gen- 
erally realized.  We  recently  observed  a  case  of  nearly  three  years' 
duration.  On  retrospect,  there  appears  to  be  no  reason  for  changing 
the  diagnosis.  Such  cases  are  probably  more  frequent  than  a  study 
of  the  literature  would  indicate.  They  may  be  overlooked,  or  re- 
garded as  dementia  precox. 

The  outcouic  is  a  matter  of  importance.  It  was  formerly 
thought  that  all  such  cases  recovered,  provided  they  survived  the 
acute  period.  Bonhoefifer*  states  that  permanent  defect  is  rare,  but  he 
mentions  a  post-typhoid  case  with  defect  symptoms  of  long  standing, 
observed  by  ^lonkemoller.  Kraepelin  definitely  speaks  of  a  chronic 
type,  but  he  does  not  describe  them  very  clearly ;  indeed  the  whole 
question  of  the  outcome  in  certain  instances  is  not  very  clearly 
understood.  If  true  chronicity  exists,  it  is  of  interest  to  know 
whether  it  is  primarily  due  to  physical  factors,  or  whether  mental 
elements  play  a  part. 

The  question  of  chronicity  is  of  more  than  mere  academic  inter- 
est. If  such  cases  exist,  and  are  wrongly  diagnosed  as  dementia 
praecox,  erroneous  deductions  might  readily  be  drawn  regarding  the 
patholog}'  of  the  latter  disorder.  In  toxic  exhaustive  psychoses 
definite  and  distinctive  nerve  cell  changes  may  be  found.  These 
changes  have  not  been  consistently  demonstrated  in  dementia  precox. 

In  concluding,  the  main  features  which  have  been  brought  out  in 
the  above  pages  may  be  briefly  summarized.  The  toxic  exhaustive 
p.sychoses  are  made  up  of  a  number  of  elements ;  these  elements  may 
be  designated  as  the  organic,  the  affective  and  the  psychogenic. 
These,  factors  may  be  present  in  varying  degree  in  any  given  case, 
and  .some  of  the  .symptoms  may  be  more  prominent  than  others  dur- 
ing dififcrcnt  phases  of  the  psychosis.  In  order  to  understand  and 
interpret  the  symptoms,  it  is  desirable  to  keep  in  mind  these  three 

♦  Die  Symptomatischenpsychosen,  p.  55. 


SYMPTOMS  IN  INFECTIVE  EXHAUSTIVE  PSYCHOSES      531 

aspects  of  the  symptomatology.  This  will  help  us  to  determine 
what  etiological  or  diagnostic  significance  to  give  to  each.  Some 
cases  may  be  of  short  duration  and  show  mainly  organic  features; 
others  of  equally  benign  character  may  show  marked  affective 
reactions.  Those  which  show  a  prolonged  psychogenic  reaction  are 
probably  more  serious,  although  a  number  of  these  symptoms  may 
be  benign,  and  dependent  upon  lack  of  clearness.  A  prolonged 
course  does  not  necessarily  warrant  an  unfavorable  prognosis. 

We  have  attached  considerable  importance  to  the  organic  symp- 
tom complex,  as  it  is  felt  that  this  part  of  the .  reaction  forms 
a  bond  beween  all  toxic  exhaustive  states.  It  connects  these  dis- 
orders with  other  reactions  which  are  generally  grouped  separately 
— notably  the  drug  psychoses  and  the  alcoholic  psychoses.  More- 
over, one  can  recognize  this  same  organic  type  of  reaction,  as  a 
secondary  symptom,  in  the  psychoses  associated  with  gross  organic 
brain  disease.  This  enables  us  to  understand  why  an  acute  episode 
in  cerebral  arterioscleroses  may  resemble  a  drug  delirium,  or  why 
the  delirium  of  early  senile  dementia  may  resemble  a  post-febrile 
psychosis.  This  organic  group  of  symptoms  is  a  reaction  on  the 
part  of  the  nervous  system  to  toxic  or  exhaustive  agencies ;  while 
these  agencies  may  vary  greatly,  they  probably  interfere  with  func- 
tion in  much  the  same  way,  and  so  the  same  reactions  are  brought 
out. 

We  have  indicated  some  of  the  directions  in  which  further 
study  is  desirable.  A  full  understanding  of  the  personality  of 
these  individuals  may  be  of  considerable  aid  in  interpreting  a 
number  of  the  symptoms.  Further  studies  in  this  direction  may 
suggest  a  reason  why  certain  cases  are  quite  benign,  and  others 
are  quite  prolonged.  Fuller  information  may  eventually  be  given 
about  cell  changes  and  other  pathological  findings ;  the  brain  cell 
changes  arising  from  acute  toxic  agencies  are  well  known,  but 
those  existing  in  chronic  toxic  states  are  not  readily  recognized.  In 
order  to  carry  out  these  studies  successfully,  it  is  desirable  that  the 
cases  be  clearly  differentiated  clinically,  lest  cases  be  included  which 
do  not  belong  to  this  group. 


PATHOLOGICAL  FIXDLXGS  IX  TWO  CASES  OF 
PARALYSIS  AGITANS 

Bv  E.  Murray  Auer,  M.D.  and  Grayson  Prevost  McCough,  M.D. 

PHILADELPHIA 

(From  the  Laboratory  of  Xeuro-Patholog>'.  University  of  Pennsylvania, 

Philadelphia) 

Thou£^h  the  symptoms  occurring  in  paralysis  agitans  have  long 
been  attributed  by  many  clinicians  to  cerebral  changes,  pathological 
demonstrations  of  the  same  have  been  advanced  only  within  the  last 
few  years.  Gowers,  Westphal  and  Grashay  observed  cases  of 
paralysis  agitans  in  which  the  tremor  disappeared  after  an  attack 
of  hemiplegia.  On  the  other  hand  Krabl^e  (i)  described  a  tremor 
of  the  type  of  paralysis  agitans  as  occurring  acutely  after  a  ])aralytic 
attack  and  persisting  after  the  return  of  motor  function.  Souques 
(2)  considered  the  lesions  as  being  cerebral  and  sometimes  cortical. 
Brissaud  regarded  the  peduncular  region,  especially  the  locus  niger, 
as  the  seat  of  the  lesion.  Maillard  (3)  attributed  the  condition  to 
arteriosclerosis.  Alquicr  (4)  found  small  areas  of  disintegration 
in  the  brain  though  the  motor  region  of  the  cerebral  cortex  was  well 
preserved  in  the  majority  of  his  cases.  Haskovec  and  Basta  (5) 
described  marked  develoiMiient  of  neuroglia  along  the  axis  cylinders 
of  the  white  substance  of  the  central  nervous  system  and  of  the 
peripheral  nerves.  In  the  brain  they  found  marked  changes  in  the 
neuroglia  cells,  nuclear  defects.  picnomorj)hia,  rarefaction  of  cyto- 
plasm and  vacuolization,  more  advanced  than  the  age  of  the  case 
warranted.  There  were  slight  sclerotic  changes  in  the  vessels  and 
hyaline  dbgeneration  in  the  capillaries.  Sj)ielmcyer  (6)  considered 
that  the  neuroglia  played  an  im])ortant  part  in  the  pathology  of 
paralysis  agitans  and  described  a  certain  form  of  neuroglia  cells 
similar  to  ameboid  cells  found  in  the  white  substance  of  the  central 
nervous  system  in  six  cases.  F.  H.  Levy  (7)  maintained  that 
Spielmeyer's  ameboid  neuroglia  cells  were  by  no  means  a  constant 
finding  and  suggested  that  these  might  be  the  result  of  post-mortem 
changes.  Borgherini  (8)  noted  in  the  cerebellum  widening  of  the 
perivascular  lymph  spaces  and  thickening  of  the  vesseFwalls  and  in 
the  medulla  oblongata  thickening  of  the  vessel  walls,  overgrowth  of 
glia  and  pigmentation  of  the  glia  cells. 

532 


PATHOLOGICAL  FINDINGS  IN  PARALYSIS  AGITANS        533 

On  purely  theoretical  grounds  Kleist  (9)  and  Zingerle  (10)  in 
1908  suggested  the  region  of  the  lenticular  nucleus  as  the  site  of 
the  principal  lesion  of  paralysis  agitans.  Winkler  (11)  described 
a  loss  of  fibers  in  the  lateral  nucleus  of  the  thalamus,  in  the  inner 
limb  of  the  lenticular  nucleus,  in  the  subthalamic  region,  in  the 
tegmentum  and  in  the  pons.  Manschot  (12)  reported  a  loss  of 
both  fibers  and  cells  in  the  thalamus,  most  marked  in  the  lateral 
nucleus  and  atrophy  in  the  putamen  and  subthalamic  region.  Jel- 
gersma  (13)  found  marked  reduction  in  both  size  and  number  of 
the  radial  fibers  in  the  lenticular  nucleus,  most  marked  in  the  globus 
pallidus.  The  strio-luysian  fibers  were  atrophied.  The  ansa  lentic- 
ularis.  ansa  peduncularis  and  the  H  bundle  of  Forel  were  scarcely 
recognizable.  There  were  similar  changes  in  the  lateral  nucleus  of 
the  thalamus  with  atrophy  of  the  superior  cerebellar  peduncles  and 
of  the  region  between  them.  In  a  thorough  study  of  the  region  of 
the  basal  ganglia  F.  H.  Levy  (14)  observed  the  same  reduction  of 
both  radial  and  medullary  laminal  fibers  in  the  lenticular  nucleus 
and  of  the  ansa  lenticularis,  and  even  more  important  were  the 
cellular  changes  he  noted  in  the  lenticular  nucleus,  the  nucleus  of  the 
substantia  innominata  (Aleynert's  nucleus  of  the  ansa  lenticularis), 
the  nucleus  lateralis  thalami  and  the  dorsal  nucleus  of  the  vagus. 
In  the  lenticuar  nucleus  there  was  advanced  degeneration  of  the 
ganglion  cells  and  replacement  by  an  overgrowth  of  neuroglia.  The 
glia  fibers  were  irregular  and  thick ;  the  cells  large  and  rich  in 
plasma.  The  large  ganglion  cells  of  the  globus  pallidus  were  rela- 
tively slightly  involved,  though  they  were  shrunken  and  showed 
some  nuclear  degeneration.  Senile  fibrillary  changes  were  also 
noted.  The  nucleus  of  the  substantia  innominata  showed  wide- 
spread senile  cell  degeneration  of  a  honeycombed  or  granvdar  nature. 
Both  this  nucleus  and  the  dorsal  nucleus  of  the  vagus  showed  intra- 
cellular inclusions,  staining  light  red  with  eosin  and  taking  all  the 
basic  stains.  The  nucleus  lateralis  thalami  and  the  nucleus  para- 
ventricularis  showed  nuclear  changes  and  sometimes  two  or  more 
nuclei  in  one  ganglion  cell.  Senile  and  sclerotic  vascular  changes 
were  frequently  found.  The  perivascular  spaces  were  enlarged  and 
often  filled  with  cells.  Around  many  of  the  vessels  were  bodies 
staining,  with  eosin  and  with  basic  stains  which  Levy  regarded  as 
products  of  degeneration  precipitated  from  the  tissue  fluids  probably 
during  fixation.  In  many  cases  there  were  lymphocytic  infiltrations, 
frequently  in  the  inner  half  of  the  globus  pallidus  and  the  paraven- 
tricular zone  of  the  thalamus.  AI.  Lowy  (15)  found  symmetrical 
areas  of  softening  in  the  lenticular  and  caudate  nuclei  in  the  case  of 
paralysis  agitans  without  tremor. 


534      E.  Mi'RRAY  AVER  AXD  GRAVSOX  PREVOST  M'COUCH 

F.  H.  Levy  called  attention  to  the  clinical  resemblance  of  many 
cases  of  paralysis  agitans  with  early  onset  (between  the  thirtieth  and 
fortieth  years  of  life)  to  the  progressive  lenticular  degeneration  de- 
scribed by  Wilson  (i6).  The  changes  in  the  lenticular  region  are 
also  similar  though  much  greater  in  Wilson's  disease.  Wilson  in  a 
description  of  the  findings  in  his  third  case  stated :  "  The  posterior 
two  thirds  of  the  putamen  in  its  complete  transverse  extent  and  to  a 
less  degree  the  corresponding  parts  of  the  middle  zone  of  the  len- 
ticular nucleus  were  the  seat  of  an  obvious  softening.  The  sub- 
stance of  the  nucleus  was  discolored,  friable,  pitted,  as  it  were, 
worm-eaten.  There  were  a  number  of  small  holes  in  it,  evidently 
related  to  blood  vessels ;  many  were  clear  cut  and  empty  and  around 
these  the  degeneration  of  the  nucleus  seemed  at  its  maximum.  The 
minute  vessels  which  remained  stood  out  from  the  surface  of  the 
section,  were  patent,  tore  very  easily  and  when  extracted  left  but  a 
gaping  hole.  The  whole  substance  of  the  nucleus  in  the  affected 
area  was  greatly  shrunken,  slightly  hollowed  out  and  clearly  in  an 
early  stage  of  definite  cavitation.  The  diameter  of  the  minute 
pimched  out  holes  averaged  one  to  one  and  one  half  millimeters, 
the  length  of  the  degenerated  area  was  two  and  a  quarter  centi- 
meters, and  its  greatest  breadth  three  quarters  of  a  centimeter." 

In  describing  the  pathological  findings  of  a  similar  case  Cad- 
walader  (17)  observed,  "when  examined  under  the  low  power 
microscope  a  number  of  small  irregularly  scattered  areas  of  soften- 
ing were  readily  detected  in  the  lenticular  nucleus  of  each  side. 
These  areas  of  softening  varied  considerably  in  size,  the  largest  being 
about  the  size  of  a  ])in,  whereas  numerous  points  of  beginning 
softening  appeared  to  be  much  smaller.  On  the  whole  these  areas 
of  softening  were  more  numerous  in  the  putamen  than  in  the  globus 
pallidus.  In  the  middle  of  one  of  the  larger  areas  of  softening  as  a 
rule  the  small  artery  stood  out  prominently,  although  the  perivascular 
space  was  dilated.  The  surrounding  tissue  appeared  to  be  contracted 
and  there  was  a  considerable  space  between  it  and  the  blood  vessel 
which  contained  a  few  compound  granular  cells  and  a  quantity  of 
debris.  The  tissue  in  the  region  of  the  softened  area  contained  a 
marked  increase  of  neuroglia  cells  and  when  stained  with  hemalum- 
fuchsin  appeared  to  be  firmer  and  denser  than  normal.  The  large 
nerve  cells  of  the  putamen  seemed  to  be  less  numerous  than  in  the 
normal  condition.  The  internal  ca])sulc.  the  optic  thrilanuis  and  the 
'  external  cai)sule  revealed  nothing  abnormal. 

Spiller  (18),  in  a  rc])ort  on  a  case  of  contractiue  of  the  limbs  of 
the  right  side,  observed  "that  numerous  areas  of  rarefaction  were 


PATHOLOGICAL  FINDINGS  IN  PARALYSIS  AGITANS        535 

found  throughout  the  basal  gangha  of  the  left  side  and  were  most 
numerous  in  the  putamen  of  the  lower  part  of  the  lenticular  nucleus. 
These  areas  were  of  much  the  same  size,  small,  and  had  a  marked 
moth-eaten  appearance.  They  were  not  in  connection  with  blood 
vessels.  Often  they  appeared  as  cavities  but  more  careful  focusing 
would  show  that  they  consisted  of  loose  neuroglia  tissue.  They  were 
not  conspicuous  in  the  basal  ganglia  of  the  right  side,  and  for  this 
reason  among  others  they  could  not  be  regarded  as  artefacts.  There 
was  no  atrophy  of  the  lenticular  nucleus  or  of  any  of  the  tracts 
connected  with  it." 

Case  L- — H.  W.,  female,  single,  age  67,  housework,  admitted  to 
the  University  of  Pennsylvania  Hospital  June  26,  1909,  died  Feb- 
ruary 2,  1910.  Her  history  stated  that  in  1904  she  began  to  be 
nervous  and  her  hand  became  tremulous.  This  tremor  gradually 
became  worse.  Her  examination  at  that  time  stated  that  her  voice 
was  feeble  and  tremulous,  her  face  expressionless  and  there  was  a 
pill-rolling  movement  of  the  fingers  of  both  hands.  She  had  a  be- 
ginning arcus  senilis  but  the  eye  examination  was  otherwise  nega- 
tive. She  protruded  her  tongue  in  the  median  line  and  there  was 
marked  tremor.  The  muscles  of  her  arm  were  flabby  and  the  motor 
power  was  less  than  average.  The  biceps  and  triceps  jerks  were 
exaggerated.  There  was  a  typical  pill-rolling  movement  of  the 
fingers  of  both  hands,  which  was  temporarily  checked  on  voluntary 
movement.  The  motor  power  of  the  limbs  was  decreased.  The 
patellar  and  Achilles  reflexes  were  increased.  There  was  no  ankle 
clonus  and  plantar  irritation  caused  plantar  flexion  of  the  big  toes 
of  both  feet.  In  walking  the  body  was  held  forward,  the  arms  were 
flexed  at  the  elbows  and  the  steps  were  short  and  shufiiing.  She 
died  of  an  intercurrent  pulmonary  condition. 

Case  H. — "  M.  G.,  female,  married,  8  children,  age  58,  admitted 
to  the  University  of  Pennsylvania  Hospital  December  2,  1907,  died 
January  5,  1908.  She  was  an  excessive  drinker  of  beer.  In  1903 
she  observed  a  feeling  of  weakness  in  the  left  arm  which  later  de- 
veloped a  tremor.  Early  in  1906  the  right  arm  became  similarly 
aft'ected.  About  this  time  her  lips  and  tongue  began  to  tremble  and 
she  had  difficulty  in  talking  and  swallowing.  She  later  noticed  that 
the  lower  limbs  were  becoming  weak  and  felt  numb.  Her  face  had 
a  fixed  mask-like  expression.  The  eyes  on  examination  revealed 
nothing  abnormal.  There  was  a  coarse  tremor  of  the  upper  and 
lower  lids  of  both  eyes,  and  a  nystagmoid  movement  of  both  eyes 
on  lateral  deviation.  There  was  a  coarse  tremor  of  the  lips  and  of 
the  tongue  which  she  protruded  only  partially  with  great  difficulty. 
The  musculature  of  both  arms  was  flabby  and  the  motor  power  weak. 
The  biceps  and  triceps  jerks  were  exaggerated  on  both  sides  ;  the 
left  possibly  more  so  than  the  right.  There  was  a  pronounced  pill- 
rolling  movement  of  the  fingers  of  both  hands  which  ceased  momen- 
tarily on  voluntary  movement.  The  lower  limbs  were  rigid  and  the 
muscle  power  weak.     The  patellar  jerks  and  Achilles  jerks  were 


536      E.  MURRAY  AVER  AXD  GRAYSOX  PRETOST  M'COUCH 

exaggerated.  In  walking,  with  assistance,  the  body  was  bent  for- 
ward and  the  head  held  in  flexion.  She  walked  on  her  toes,  with 
short  shuffling  steps.  There  was  no  ankle  clonus  and  plantar  irrita- 
tion caused  plantar  flexion.     Her  mentality  was  impaired. 

In  a  study  of  the  brain  of  the.>e  two  cases  of  paralysis  agitans 
horizontal  serial  sections  were  made  through  the  region  of  the  basal 
ganglia  and  stained  with  \\'eigert's  axis  cylinder  stain,  with  Nissl's 
thionin  method  and  with  hemalum  and  acid  fuchsin.  Owing  to  the 
age  of  the  material  the  thionin  sections  stained  poorly  es])ecially  in 
the  lenticular  nucleus.  Consequently  several  of  the  cell  changes 
noted  were  determined  in  hemalum  and  acid  fuchsin,  and  even  in  the 
W'eigert  sections.  Bearing  in  mind  the  inadequacy  of  the  Weigert 
fiber  preparations  for  the  determination  of  cellular  changes  and  of 
any  method  which  fails  to  stain  fat  for  the  diagnosis  of  fiber  de- 
generation, much  that  is  probably  pathological  must  ])ass  luimen- 
tioned  and  only  the  degenerations  that  are  sufficiently  advanced  to  be 
unquestionable  will  be  reported. 

Of  the  findings  common  to  both  cases  it  may  be  stated  that  there 
was  no  gross  atrophy  of  any  of  the  basal  ganglia.  Under  low  power 
the  most  obvious  change  \vas  the  presence  of  many  small  irregular 
circumscribed  areas  of  rarefaction  containing  a  few  neuroglia  cells 
and  debris.  Several  of  these  rounded  patches  coalesced  to  form 
multiple  areas  irregular  in  gross  outline ;  the  edge  being  usually 
notched  by  the  borders  of  the  component  small  areas.  The  largest 
multiple  areas  were  about  a  millimeter  in  diameter.  Most  of  them 
were  about  one  fourth  of  a  millimeter.  The  vast  majority  of  these 
areas  were  not  associated  with  blood  vessels,  though  in  a  few  in- 
stances they  trespassed  on  the  perivascular  spaces.  Where  these 
areas  occurred  in  a  fiber  tract  some  of  the  fibers  were  cut,  others 
spanned  the  patch  uninterrupted.  They  were  not  confined  to  any 
single  region.  Though  most  ])lentiful  in  the  lenticular  nucleus  they 
were  found  in  the  thalamus,  in  the  caudate  nucleus,  the  internal  and 
external  capsules,  the  claustrum,  the  corpus  subthalamicum,  in  short 
everywhere  excej)t  the  cortex  and  the  red  nucleus.  They  were 
identical  in  type  with  the  areas  described  by  Spilkr  in  his  case  of 
hemi-contracture  as  giving  the  section  a  moth-eaten  ai)pearance. 

A  finding  of  a  very  different  nature  was  the  ])resence  of  round 
holes  with  sharply  cut  margins,  sometimes  circumscribed  by  an  over- 
growth of  glia  fibers.  These  holes  are  clean  cut  as  though  "  jnuiched 
out  "  and  contained  no  neuroglia  or  debris.  Whether  they  originally 
contained  vessels  and  were  merely  excessively  large  ])erivascular 
spaces  it  would  be  difficult  to  determine.  They  remind  one  strongly 
of  the  holes  describe<l  by  Wils(jn  and  by  Cadwalader  in  progressive 
lenticular  degeneration.      In  the  case  of  .\i.  ( i.  these  were  met  only 


PATHOLOGICAL  FINDINGS  IN  PARALYSIS  AGITANS        537 

occasionally ;  in  that  of  H.  W.  they  were  still  more  rare  and  when 
they  did  occur  were  small  and  were  not  lined  by  any  circumscribing 
growth  of  glia  fibers.  They  were  found  chiefly  though  not  ex- 
clusively in  the  lenticular  nucleus. 

In  both  cases  the  perivascular  spaces  w^ere  slightly  enlarged,  in 
a  few  instances,  containing  basic  staining  deposits  round,  oval  and 
crescentic  in  shape.  In  one  instance  at  least  the  perivascular  space 
appeared  to  have  served  as  a  mould  for  such  a  deposit  which  filled 
the  entire  lumen,  forming  a  doughnut-shaped  mass  completely  sur- 
rounding the  vessel.  These  deposits  were  more  frequently  found  in 
the  tissue  immediately  about  the  perivascular  spaces,  they  were  too 
large  for  corpora  amylacea  and  showed  no  concentric  lamellation. 
It  seems  probable  that  they  are  identical  with  those  described  by 
F.  H.  Levy  as  products  of  degeneration  precipitated  from  the  tissue 
fluids  during  the  process  of  fixation. 

In  accordance  with  the  findings  of  Jelgersma,  F.  H.  Levy  and 
others,  we  noted  a  distinct  reduction  in  the  number  of  fibers  in  the 
external  medullary  lamina  dividing  the  putamen  from  the  globus 
pallidus  and  in  the  radial  fibers  streaming  from  the  putamen  through 
the  globus  pallidus.  The  latter  showed  marked  granulation  with 
\\'eigert  stain  suggestive  of  a  degenerative  process. 

Cellular  changes  in  the  corpus  striatum  were  ill  defined.  The 
cells  of  the  caudate  nucleus  and  putamen  and  the  small  cells  of  the 
globus  pallidus  failed  to  stain  well  with  any  of  the  stains  used. 
In  the  case  of  H.  W.  the  cells  of  the  centrum  medium  on  both  sides 
and  of  the  corpus  subthalamicum  on  the  left  were  excessively 
shrunken,  leaving  distinct  pericellular  spaces.  In  many  instances 
the  cytoplasm  w^as  vacuolated  and  the  nucleus  absolutely  obliterated. 
In  the  case  of  M.  G.  these  structures  show^ed  no  such  signs  of  de- 
generation. The  occurrence  of  these  moth-eaten  patches  destroy- 
ing as  they  did  in  many  instances  portions  of  the  fiber  tracts  might 
readily  account  for  much  of  the  symptomatology  occurring  in 
paralysis  agitans  and  like  conditions. 

In  brief  the  pathological  changes  noted  in  the  region  of  the  basal 
ganglia  in  the  two  cases  studied  were : 

1.  Areas  of  rarefaction  containing  neuroglia  cells  and  debris 
giving  the  tissue  a  moth-eaten  appearance. 

2.  Clean  punched  out  holes  possibly  excessively  enlarged  peri- 
vascular spaces  from  which  the  vessels  may  have  dropped  out. 

3.  Round  and  oval  basic  staining  deposits  chiefly  in  the  peri- 
vascular space  and  adjacent  tissues. 

4.  Diminution  in  the  number  of  the  external  medullary  laminal 


53S      E.  MURRAY  ACER  AXD  GRAVSOX  PREVOST  M'COUCH 

and  of  the  radial  fibers  of  the  lenticular  nucleus  with  some  evidence 
of  degeneration  of  the  latter. 

5.  Failure  of  the  cells  of  the  corpus  striatum  to  stain  well  which 
latter  may  possibly  have  been  due  to  the  age  of  the  material. 

6.  In  one  case  advanced  degeneration  of  the  cells  of  the  centrum 
medium  on  both  sides  and  of  the  corpus  subthalamicum. 

We  wish  to  express  our  thanks  to  E)r.  William  G.  Spiller  for 
placing  the  above  material  at  our  disposal  and  for  many  kind  sug- 
gestions in  the  preparation  of  this  paper. 

REFERENCES 

1.  Krabbe.     Ztschr.  f.  d.  gesamte  Neurol,  u.  Psychiat.,  1912,  p.  571. 

2.  Souques.     Revue  Neurol.,  1912,  xx  (i).  718-727. 

3.  Maillard.     La  Maladie  de  Parkinson.     These  de  Paris,  1908. 

4.  Alquier.     Gazette  des  Hopitaux.   1909. 

5.  Haskovec   and   Basta.     Nouvelle   Iconographie   de   la   Salpetriere,   Mars- 

April,  1913. 

6.  Spielmeyer.     Neurol.  Centralbl..  1910;  Deutsche  Med.  Wochnschr.,  191 1. 

7.  F.  H.  Lev}'.     Lewandowsky's  Handbuch  der  Neurologie,  Vol.  II. 

8.  Borgherini.     Riv.  Sperim.  de  Freniatr.,  1891. 

9.  Kleist.     Unters.   zor   Kenntnis   der  psychomotorischen   Bewegungsstorun- 

gen  der  Geisteskranken.     Leipzig,  1908-1909. 
ID.  Zingerle.     Journ.  f.  Psychiat.  und  Neurol.,  1909,  xiv,  81-114. 

11.  W'inckler.     Quoted  by  Jclgersma. 

12.  Manschot.     Lewandowsky's  Handbuch. 

13.  Jelgersma,  G.     Verhandl.  d.  Gesellschaft  deutsch.  Naturforsch.  u.  Aerzte, 

Leipzig,  1909,  2  Teil,  2  Hefte,  383-388. 

14.  F.  H.  Levy.     Jahresversammlung  der  Gesellschaft  der  deutschen  Nerven- 

arzte  im  Breslau,  September  29,  1913. 

15.  M.  Lowy.     Berlin  klin.  Wochenschr.,  1913. 

16.  Wilson.     Brain,  1912. 

17.  Cadwalader.     Jour.  Am.  Med.  Assoc,  January  30,  1915. 

18.  Spiller.    JouRN.\L  OF  Nervous  .\nd  Ment.vl  Dise.\se,  January,  1916. 


Society  IProcecMngs 


THE  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

December  17,  1915 

The  President,  Dr.  S.  D.  W.  Ludlum,  in  the  Chair 

A  CASE  OF  PELLAGRA,  WITH  AUTOPSY.  IN  A  CHILD 

By  Charles  W.  Burr,  M.D.,  and  W.  B.  Cadwalader,  M.D. 

M.  A.,  Italian,  female,  11  years  old,  came  to  the  Dispensary  of  the  Ortho- 
pedic Hospital  and  Infirmary  for  Nervous  Diseases  February  8,  1915. 

The  mother  stated  that  she  herself  was  healthy  and  that  the  patient's 
father  died  of  heart  disease.  Four  other  children  were  healthy.  The  patient 
began  to  walk  at  eleven  months  and  to  talk  a  little  later.  She  was  healthy 
until  five  years  of  age,  when  she  had  some  illness  in  which  the  feet  were 
swollen,  and  she  passed  a  great  deal  of  urine. 

Present  trouble  began  when  the  child  was  ten  years  old  with  weakness 
and  stiffness  in  the  legs  and  mental  slowness.  . 

Examination. — General  appearance  is  that  of  a  rather  high-grade  imbe- 
cile. The  gait  is  both  spastic  and  ataxic.  The  right  leg  is  more  aft'ected 
than  the'  left.  She  tends  at  times  suddenly  to  fall  to  the  right  side.  The  right 
knee  jerk  is  plus,  plus;  the  left  plus.  There  is  no  ankle  clonus  and  no  Ba- 
binski.  The  plantar  reflex  is  normal  and  active.  No  mechanical  limitation 
of  movement  is  observed  in  the  hips,  knees  or  ankles.  The  spine  is  held 
rigid,  the  head  is  bent  a  little  forward  but  there  is  no  tenderness  on  jarring 
or  tapping  the  spine.  On  standing  there  is  slight  lateral  spinal  curvature, 
which  disappears  on  lying  down.  She  has  incontinence  of  urine.  There  is 
an  erythematous  rash  on  the  face,  around  the  eyes  and  on  the  hands  and 
wrists.  There  is  no  anesthesia  anywhere.  Wassermann  reaction  is  negative. 
The  heart  and  lungs  are  normal. 

Though  her  appearance  is  imbecilic,  her  intelligence  is  good.  She  spells 
well,  writes  quickly  and  legibly,  draws  plane  geometrical  figures  well;  solids 
she  can  not  draw  accurately.     She  is  somewhat  awkward  with  her  fingers. 

Eye  Report  by  Dr.  Langdon:  Vision —  O.  D.  5/25;  O.  S.  5/25.  Pupils  3 
mm.  Prompt  and  equal  reactions.  Ptosis  of  left  eye.  Palpebral  fissure 
about  7  mm.  Visual  axes  parallel.  Constant  slow  lateral  nystagmus.  Con- 
jugate lateral  rotation  short  as  in  upward  rotation.  Media  clear.  Discs  oval, 
somewhat  pale.     Margins  clear,  no  fundus  changes. 

She  was  admitted  to  the  hospital  March  24,  1915. 

She  improved  somewhat  under  cacodylate  of  soda  and  iron.  The  ery- 
thema on  hands  and  face  entirely  disappeared  and  she  was  discharged. 

She  was  readmitted  July  26,  191 5,  scarcely  able  to  walk  on  account  of 
spasticity.  There  was  a  bright  red  eruption  over  the  forehead  and  around 
the  eyes.  On  July  30  her  temperature  rose  to  105%  and  she  began  to  vomit. 
In  a  few  hours  she  became  unconscious,  had  convulsive  twitching  of  the  left 
arm  and  leg,  breathing  became  difficult  and  stertorous,  the  neck  and  legs  be- 
came stiff.  The  spinal  fluid  was  microscopically  normal.  During  the  third 
day  the  right  arm  seemed  paralyzed  but  she  soon  regained  use  of  it.     There 

539 


54°  PHILADELPHIA  XEUROLOGICAL  SOCIETY 

was  Babinski  jerk  on  both  sides,  the  knee  jerks  were  spastic,  Kernig's  sign 
was  present,  and  there  were  ankle  and  patella  clonus.  She  died  August  4, 
1915- 

Autopsy.— August  4,  1915.  Skin  healthy.  Herpes  labialis.  Lungs:  gen- 
eral hypostatic  edema.  Heart:  rigid  contraction  left  ventricle,  and  dilatation 
right  ventricle.  Liver  negative.  Spleen  negative.  Pancreas  hard,  nodular 
and  slightly  hemorrhagic.  Kidneys  congested.  Adrenals  negative.  Intestines 
negative.  Throat  negative.  Internal  genitalia  negative.  Brain  showed  gen- 
eral venous  congestion  and  edema.  Dura  was  tightly  adherent  to  the  skull 
over  the  entire  cranial  wall.     The  spinal  cord  was  grossly  negative. 

Pathological  Report  of  Dr.  Williams  B.  Cadwaladcr. — The  brain  and  cord 
were  preserved  in  formalin  solution  and  examined  February,  1916. 

Sections  were  made  from  blocks  of  different  levels  of  the  spinal  cord, 
medulla  oblongata  and  the  motor  cortex.  The  Marchi  stain  was  used  but 
was  of  no  use,  the  specimens  having  been  in  formalin  two  or  three  months 
previously.  Weigert  hemalun  and  Nissl  stains  were  used.  The  sections  of 
the  cerebral  cortex  showed  nothing  abnormal,  but  sections  of  the  spinal  cord 
showed  considerable  disease. 

The  most  marked  changes  were  found  in  the  thoracic  region  ;  and  con- 
sisted of  degenerative  changes  of  ganglion  cells  of  the  anterior  horns  and 
diffuse  degeneration  of  the  white  matter.  The  anterior  horn  cells  were 
swollen,  the  nuclei  sometimes  seemed  to  be  displaced  to  the  peri])hery  and 
there  was  some  chromatolysis.  There  was  no  round  cell  infiltration  of  the 
pia.  The  anterior  and  posterior  roots  appeared  to  be  normal.  With  the 
Weigert  stain  diiTuse  degeneration  of  the  nerve  fibers  was  seen  throughout 
the  lateral  and  antcro-lateral  regions.  The  posterior  columns  were  aflfected, 
but  less  severely  than  in  other  parts.  The  anterior  portion  of  the  posterior 
columns  close  to  the  gray  commissure  seemed  to  have  escaped.  There  were 
numerous  holes  irregularly  scattered  about  the  periphery  from  the  antero- 
lateral region  as  far  as  the  exit  of  the  posterior  roots  where  the  axis-cylinders 
seemed  to  have  entirely  disappeared.  The  white  matter  on  either  side  of 
the  median  fissure  close  to  the  anterior  spinal  artery  was  also  degenerated. 
The  distribution  of  the  degeneration  did  not  conform  strictly  to  the  distri- 
bution of  any  one  tract  of  fibers.  It  appeared  to  be  a  diffuse  endogenous 
process  and  not  a  true  systemic  degeneration.  The  blood  vessels  were  not 
sclerotic. 

Many  of  the  cells  of  tlie  nuclei  situated  in  the  floor  of  the  fuurtli  ventricle 
appeared  somewhat  swollen  and  some  appeared  to  be  undergoing  chromatoly- 
sis, including  the  chief  nucleus  of  the  hypoglossal  nerve,  the  small-celled 
nucleus  of  the  hypoglossal  nerve,  the  chief  auditory  nucleus  and  Deiters' 
nucleus.  The  tenth,  twelfth  and  eighth  nerve  fibers  outside  the  medulla 
oblongata  were  partially  degenerated  as  shown  by  the  Weigert  stain.  The 
pyramids  in  the  medulla  oblongata  were  not  affected,  but  the  fibers  situated 
in  the  lateral  part  of  the  medulla  oblongata  of  both  sides  stained  poorly  with 
the  Weigert  stain,  particularly  in  the  region  occupied  by  the  tractus  spino- 
cerebellaris  ventralis  and  the  tractus  spino-vestibularis. 

The  interesting  points  in  the  case  were  the  manner  of  death,  evidently 
due  to  a  sudden  increase  in  intoxication,  and  the  marked  spinal  symptoms. 

COMPLETE    EXTERIOR   OPHTHALMOPLEGIA    FOLLOWING    AN 
ATTACK   OF   SEVERE   COUGHING 

By  G.  E.  dc  Schwcinit/.,  M.D.,  and  W.  G.  Spiller,  M.D. 

Exterior  ophthalmoplegia  developing  suddenly  after  severe  coughing  must 
be  unusual,  and  for  this  reason  the  following  case  history  is  placed  on  record. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  541 

A  girl,  aged  4,  consulted  Dr.  de  Schweinitz  on  March  9,  1915.  The 
mother  and  father  of  this  child  are  healthy,  and  the  child,  so  the  mother 
maintains,  has  always  been  in  good  health,  except  for  one  or  two  of  the  usual 
illnesses  of  childhood.  The  mother  particularly  insisted  that  her  daughter's 
mentality  had  always  been  excellent  and  that  she  had  been  normal  in  all 
respects.  Eight  days  before  she  came  for  examination,  owing  to  a  severe 
cold,  she  coughed  violently  all  of  one  night  and  day,  and  to  some  degree  for 
about  one  half  of  the  following  day,  so  severely  that  the  child  was  unable 
to  hold  the  head  up.  According  to  the  mother,  there  was  no  fever,  no  hebe- 
tude, and  no  other  symptoms  indicative  of  a  severe  infection.  To  Dr.  Spiller 
the  mother  stated  that  the  ocular  conditions  presently  to  be  noted  were  not 
noticed  until  two  or  three  days  after  the  coughing  spell.  But  she  also  stated 
to  Dr.  de  Schweinitz  that  immediately  on  the  cessation  of  the  coughing  the 
eye  complications  were  observed. 

I5_  _  15 

Ocular  Examination. — Vision  O.  D.  XL;  O.  S.  LXX.  Naturally,  this 
record  of  acuteness  of  vision  may  not  be  entirely  accurate,  owing  to  the 
youth  of  the  subject.  The  response  of  the  pupils  to  the  ordinary  stimuli  was 
present,  but  rather  slow  in  developing.  Ophthalmoscopically  no  lesions  were 
discovered.  The  discs  and  retinal  circulation  were  normal;  there  was  no 
macular  lesion  (the  child  is  of  the  Jewish  race).  Efforts  to  map  the  field  of 
vision  were  not  very  successful.  Certainly  there  were  no  marked  changes. 
In  one  examination  it  seemed  as  if  the  right  fields  were  a  little  more  con- 
tracted than  the  left  fields,  but  hemianopsia  could  not  be  developed. 

The  lateral  movements  of  the  eyes  were  entirely  abolished,  there  was  not 
the  slightest  upward  movement  nor  the  faintest  torsion  movement.  Each  eye 
retained  a  very  faint  downward  movement,  not  more  than  i  mm.  The  func- 
tion of  the  ciliary  muscle  was  intact. 

The  patient  was  given  five  grains  of  iodid  of  sodium  three  times  a  day. 
At  the  expiration  of  six  days  of  this  treatment,  together  with  rest  and  the 
use  of  laxatives  as  required,  a  faint  action  of  the  left  internus  was  detected. 
One  week  later,  the  previous  treatment  being  unchanged,  the  child  developed 
a  marked  bilateral  convergent  strabismus,  of  about  15  degrees,  and  at  inter- 
vals there  occurred  sharp  attacks  of  bilateral  convergent  strabismus,  so  that 
the  corneas  were  well  buried  behind  the  inner  commissures.  There  was  not 
the  faintest  return  of  power  to  rotate  the  eyes  either  upward  or  outward. 
The  downward  rotation  had  increased  to  5  mm. 

At  the  expiration  of  twenty-three  days  the  mother  returned  with  the  child 
and  stated  that  two  weeks  prior  to  this  visit,  therefore  about  the  first  of 
April,  the  patient  had  acquired  a  sore  throat  which  was  believed  to  be  diph- 
theritic and  which  was  treated  with  antitoxin.  The  mother,  however,  de- 
clared that  before  this  sore  throat  developed;  therefore  about  the  last  of 
March,  and  probably  approximately  three  weeks  after  the  ophthalmoplegia 
had  appeared,  there  had  been  a  great  improvement  in  all  the  ocular  move- 
ments. These  were  carefully  studied  a  few  days  later,  when  the  child  showed 
a  convergent  strabismus  of  the  right  eye  of  10  degrees,  right  abduction  being 
markedly  limited,  although  not  quite  obliterated.  The  inward  movement,  or 
adduction  of  this  eye,  was  almost  restored,  being  within  5  degrees  of  normal. 
There  was  a  slight  convergent  strabismus  of  the  left  eye,  about  5  degrees, 
with  limitation  of  the  outward  movement.  The  inward  movement  of  this 
eye  was  practically  normal,  the  cornea  reaching  to  within  i  mm.  of  the  inner 
canthus.  The  upward  and  downward  movements  of  the  eyes  appeared  to  be 
fully  restored   (Fig.  i). 

Two  weeks  later  there  was  practically  complete  restoration  of  the  eye 
movements,  upward,  downward,  to  the  right  and  to  the  left,  and  in  oblique 
directions.     Since  this  date  the  child  has  not  been  seen,  although  efforts  have 


542 


PHILADELPHIA  XEUROLOGICAL  SOCIETY 


been  made  to  secure  an  examination.!  It  is  known,  however,  that  the  child 
at  the  present  time  is  in  good  condition.  We  regret  to  state  that  no  expert 
examination  of  the  cardio-vascular  system  was  made.  There  was,  however, 
no  apparent  lesion  of  any  of  the  bloodvessels.  Efforts  to  obtain  a  Wasser- 
mann  test  were  ineffectual. 

In  summary  the  ocular  conditions  primarily  were :  Complete  exterior 
ophthalmoplegia,  without  loss  of  the  levator  action  (absence  of  ptosis),  no 
involvement  of  the  interior  ocular  muscles  supplied  by  the  third  nerve  (iris 
and  ciliary  muscle)  ;  normal  ophthalmoscopic  appearances  :  doubtful  contrac- 
tion of  the  right  visual  field,  but  certainly  no  hemianopsia.  The  first  evi- 
dence of  recovery  was  observed  in  the  left  internus,  followed  by  recovery  of 
the  right  internus ;  the  abducens  action  continuing  to  be  defective.     The  next 


recovery  of  motion  occurred  i»ractically  at  tlic  same  time  in  the  upward  and 
downward  movements,  with  slight  return  of  the  torsion  movement.  Ulti- 
mately, between  two  and  three  months  after  the  onset  of  the  ophthalmoplegia, 
there  was  practically  entire  restoration  of  ocular  movements,  with  only  a 
slight  limitation,  about  lo  degrees,  in  the  downward  rotation. 

In  general  terms  it  may  be  said  that  hemorrhage  in   the  corpora  (|uad- 

1  Since  this   report  was  made  the  chilrl   has  been   examined  ;   the  ocular 
rotations  are  normal  in  all  respects. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  543 

rigemina,  the  result  of  coughing,  should  be  regarded  as  a  possible  etiologic 
factor  in  the  palsy,  and  in  this  regard  the  possible  or  probable  effect  of  con- 
genital syphilis  should  be  considered,  although  none  of  the  stigmata  of  this 
condition  was  present. 

Hemorrhage  may  occur  in  the  spasms  of  whooping  cough,  but  in  these 
circumMances  an  infectious  disease  is  present,  and  it  is  impossible  to  exclude 
the  possibility  of  a  localized  encephalitis  if  symptoms  indicate  a  brain  lesion. 
Neither  of  the  authors  saw  the  child  whose  history  is  reported  in  this  paper 
at  the  onset  of  the  ocular  palsies,  but  the  mother's  statements  that  the  child 
at  this  time  did  not  have  fever,  diarrhea,  nausea  nor  vomiting,  and  did  not 
appear  to  be  sick  in  any  way  excepting  the  cold,  and  was  not  drowsy,  may 
be  accepted  as  reliable.  Had  the  ocular  palsy  developed  so  rapidly  from  an 
infection  through  the  throat,  fever  at  least  would  have  been  probable,  for 
young  children  react  quickly  to  severe  infection  with  fever.  Whooping 
cough  may  be  excluded. 

The  case  is  of  importance  as  showing  that  severe  coughing  alone  probably 
may  produce  hemorrhage  in  the  region  of  the  oculomotor  nuclei,  though  one 
might  suspect  that  congenital  syphilis  had  made  the  vessels  more  liable  to 
rupture. 

The  implication  of  the  sixth  nerves  may  be  explained  by  the  lesion  affect- 
ing the  posterior  longitudinal  bundles.  If  the  connection  in  this  bundle  be- 
tween the  nucleus  of  the  internal  rectus  of  one  side  and  the  nucleus  of  the 
external  rectus  of  the  other  side  be  broken,  the  synchronous  movement  of 
the  eyeballs  toward  the  side  of  the  external  rectus  palsy  probably  would  be 
abolished  (paralysis  of  associated  lateral  movement),  and  if  both  posterior 
longitudinal  bundles  were  affected  both  external  recti  muscles  would  be  par- 
alyzed. Such  a  paralysis  as  occurred  in  this  case  in  its  method  of  implication 
of  the  ocular  muscles  suggests  a  lesion  in  the  region  of  the  corpora  quad- 
rigemina.  The  escape  of  the  inner  muscles  of  the  eyes  suggests  a  lesion  of 
the  oculomotor  nuclei,  if  the  view  of  certain  investigators  be  accepted  that 
the  nuclei  of  these  muscles  are  to  be  found  in  the  Edinger-Westphal  nucleus 
of  each  side.  This  nucleus  is  distinct  in  the  grouping  of  cells  forming  the 
oculomotor  nuclei. 

The  method  of  return  of  function  also  suggests  nuclear  lesion.  The  first 
recovery  of  function  was  observed  in  the  left  internus,  and  this  was  soon  fol- 
lowed by  recovery  of  the  right  internus.  The  schemes  that  have  been  de- 
vised as  representative  of  the  position  of  the  various  groups  of  cells  in  the 
oculomotor  nuclei  for  the  innervation  of  the  different  ocular  muscles  may 
be  viewed  with  suspicion,  but  it  seems  probable  that  the  internal  recti  muscles, 
situated  near  the  median  line  of  the  face,  are  represented  by  nuclei  also  near 
the  median  line  of  the  cerebral  peduncles,  and  therefore  recovery  of  function 
in  one  of  these  muscles  should  be"  followed  soon  by  recovery  of  function  in 
the  other,  in  proportion  as  release  of  their  nuclei  from  the  effect  of  hemor- 
rhage pressure  occurred. 

Dr.  Alfred  Gordon  said  that  when  he  read  the  announcement  of  Dr.  de 
Schweinitz  and  Dr.  Spiller's  case  of  ophthalmoplegia  following  cough  he 
immediately  made  arrangements  to  bring  to  the  meeting  a  little  child  whom 
he  had  under  observation.  The  mother  wrote  him  that  the  child  had  a  cold 
and  could  not  come.  The  history  was  almost  similar  to  that  of  Drs.  de 
Schweinitz  and  Spiller.  The  mother  stated,  when  she  brought  the  child  in 
1913,  that  three  months  previously  the  child  coughed  incessantly  and  in  the 
most  violent  way  for  three  days.  The  mother  said  she  had  never  seen  an 
attack  so  severe.  At  the  end  of  three  days  she  noticed  that  the  child  could 
not  raise  her  eyelids  and  the  eyes  became  "  crossed,"  to  use  her  own  expres- 
sion. Ptosis  was  present  in  both  eyes  and  there  was  paralj^sis  of  both  ex- 
ternal recti  and  a  paresis  of  the  right  internal  rectus.  Nystagmus  on  lateral 
movements  was  observed.     A  complete  eye  examination  was  made  by  an  oph- 


544  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

thaimologist  and  no  otlier  changes  of  any  kind  were  found.  Neurologically 
the  child  was  examined  and  absolutely  nothing  abnormal  was  found.  The 
chiH  was  healthy  and  perfectly  normal  prior  to  this  trouble.  The  Wasser- 
mann  test  was  refused  by  the  mother  and  Dr.  Gordon  began  treating  the 
child  with  sodium  iodid.  At  the  end  of  three  months  the  child  began  to 
show  improvement.  A  few  weeks  later  some  improvement  was  noticed  at 
first  in  the  internal  rectus  and  later  in  the  external  recti.  Ptosis  remained 
persistent  in  both  eyes.  The  mother  ceased  to  come  to  the  clinic  and  Dr. 
Gordon  saw  the  child  only  occasionally.  He  saw  the  child  about  a  month 
before  this  meeting  and  the  palsies  had  entirely  disappeared,  the  external  recti 
had  regained  their  function  but  he  still  noticed  a  slight  ptosis.  The  recovery 
took  a  considerably  longer  time  than  in  tlie  case  of  Dr.  de  Schweinitz  and 
Dr.  Spiller. 

Dr.  J.  Hendrie  Lloj-d  said  that  one  possible  explanation  occurred  to  him 
in  reference  to  this  very  interesting  case.  It  required  certainly  bilateral 
lesions  which  would  catch  the  third,  fourth  and  sixth  nerves.  It  was  difficult 
to  see  where  bilateral  lesions  would  do  this  unless  it  was  in  the  course  of 
these  nerves  through  the  cavernous  sinus.  The  third,  fourth  and  sixth  nerves 
run  through  the  cavernous  sinus.  The  lining  membrane  of  the  sinus  lies 
on  the  inner  side  of  each  nerve.  The  whole  body  of  the  blood  flowing 
through  the  sinus  is  in  a  position,  if  any  great  pressure  is  brought  to  bear 
upon  it,  to  squeeze  or  hit  these  nerve  trunks.  We  know  the  great  power 
that  can  be  exerted  through  a  column  of  fluid  in  a  closed  vessel,  like  in  a 
tube.  This  is  a  well-known  principle  of  hydraulics  of  which  engineers  avail 
themselves.  In  this  case  the  child  had  been  subject  to  very  violent  coughing 
attacks.  Every  one  of  these  coughing  attacks  meant  the  congestion  of  blood 
in  the  cavernous  sinus,  and  every  time  she  coughed  violently  she  squeezed 
or  hit  the  nerves  between  the  column  of  blood  on  the  inside  and  the  bony 
wall  on  the  outside.  This  explains  clinically  the  accident  better  than  any 
explanation  offered.  Dr.  Lloyd  said  he  did  not  see  how  hemorrhage  beneath 
the  corpora  quadrigemina,  i.  c,  in  the  nuclei  beneath  the  aqueduct  of  Sylvius, 
could  explain  paralysis  of  the  sixth  nerve.  There  was  one  objection  to  the 
idea  of  a  succession  of  the  nerves  in  the  cavernous  sinus,  namely,  that  the 
internal  muscles  of  the  eyes  were  not  involved.  Dr.  Lloyd  supposed  that 
testing  the  power  of  accommodation  in  a  child  four  years  old  was  rather 
difficult  to  do.  There  was  another  difficulty,  the  fact  that  there  was  no 
ptosis.  It  would  seem  that  all  the  fibers  of  the  nerves  should  be  involved, 
therefore  ptosis  should  occur.  We  know,  however,  that  in  injuries  to  nerves 
all  the  fibers  may  not  be  involved.  We  may  have  injuries  to  peripheral 
nerves  in  which  some  of  the  fibers  are  involved,  but  not  all.  If  it  is  con- 
tended that  this  paralysis  in  the  present  case  was  caused  by  hemorrhage  in 
the  nuclei,  we  have  got  to  suppose  that  minute  hemorrhages  were  present  in 
nuclei  as  far  apart  as  those  of  the  third  and  fourth  nerves  in  the  midl^rain 
and  of  the  sixth  nerves  in  the  pons.  That  is  a  difficult  thing  to  conceive. 
Against  this  theory  also  is  the  rapid  recovery.  Now  we  have  something  like 
this  case  in  cases  of  bilateral  paralysis  of  the  sixth  nerves  following  blows  on 
the  head.  Dr.  Shumway  read  an  interesting  paper  before  the  Neurological 
Society  some  time  ago,  in  which  he  spoke  of  bilateral  injuries  of  the  sixth 
nerves  from  such  blows.  We  may  have  these  injuries  to  the  sixth  nerves 
without  any  evidence  of  injury  to  the  .skull,  such  as  fracture.  They  are 
caused  simijly  by  succussion  to  the  nerve  trunk,  probably  where  it  passes 
under  the  posterior  clinoid  process.  This  is  analogous  to  what  has  probably 
happened  in  Dr.  de  Schweinitz  and  Dr.  Spillcr's  case. 

Dr.  Alfred  Gordon  said  in  reference  to  the  case  that  he  reported  it  was 
quite  difficult  to  assume  that  the  lesion  was  in  the  cavernous  sinus  because  if 
it  is  true  that  paralysis  of  both  external  recti  occurred  through  the  conges- 
tion of  the  cavernous  sinus  or  a  hitting  of  the  sixth  nerve,  as  Dr.  Lloyd 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  545 

expressed  it,  why  were  only  some  branches  of  the  third  nerve  affected  through 
the  procedure  and  not  all?  He  is  inclined  to  diagnose  multiple  hemorrhages 
as  they  give  a  better  idea  of  the  condition  than  a  hitting  of  only  some 
branches  of  the  nerve  through  congestion  of  the  blood  vessels.  In  regard 
to  what  Dr.  Leopold  said,  namely,  that  it  was  difficult  to  admit  that  cough 
could  produce  such  hemorrhage:  we  can  not  ignore  the  fact  that  apoplexy, 
hemiplegia,  loss  of  consciousness  may  occur  during  intense  physical  efforts, 
such  as  constipation,  lifting  heavy  weights,  paroxysms  of  cough.  A  con- 
tinuous cough  of  three  days  and  nights  can  therefore  easily  explain  the  hem- 
orrhage in  his  case. 

Dr.  de  Schweinitz  agreed  with  Dr.  Leopold  that  the  possibility  of  infec- 
tion had  not  been  ruled  out  by  the  studies  in  the  case  of  the  patient  whose 
clinical  history  had  been  recorded,  although  such  investigations  as  had  been 
made  failed  to  establish  an  infection  as  an  etiological  factor.  He  was  in- 
clined to  agree  with  Dr.  Gordon  that  violent  coughing  should  be  considered 
as  a  possible  cause  of  hemorrhage  in  the  sense  in  which  it  had  been  suggested 
as  a  possible  cause  of  this  ophthalmoplegia,  and  referred  to  various  forms  of 
ocular  hemorrhage,  subconjunctival  as  well  as  retinal,  which  were  undoubt- 
edly due  to  the  strain  of  excessive  coughing.  Interested  as  he  was  in  Dr. 
Lloyd's  ingenious  and  original  theory,  Dr.  de  Schweinitz  doubted  its  appli- 
cability. Were  it  so,  other  nerves  in  the  same  region  should  havt  suffered, 
and  no  symptom  of  their  involvement  was  present.  He  explained  how  by 
means  of  the  shadow  test  the  amount  of  accommodation  could  be  measured. 

Dr.  William  G.  Spiller  said  that  Dr.  Llo3'd's  explanation  was  most  in- 
genious, but  it  is  improbable  that  a  lesion  of  each  cavernous  sinus  would 
pick  out  the  nerve  fibers  affected  symmetrically  in  this  case  and  allow  others 
to  escape.  The  ophthalmic  division  of  the  fifth  nerve  was  not  affected  on 
either  side.  It  was  not  necessary  to  assume  that  hemorrhage  occurred  in  the 
sixth  nerve  nuclei,  as  destruction  of  each  posterior  longitudinal  bundle  prob- 
ably would  greatly  interfere  with  the  function  of  the  sixth  nerves. 

Dr.  E.  A.  Leonard  (by  invitation)  read  a  paper  on  The  Results  of  Treat- 
ment in  Cases  of  Delirium  Tremens. 

Dr.  Alfred  Gordon  said  that  in  a  German  journal  a  man  recentlj-  reported 
about  eighty  cases  of  delirium  tremens  treated  systematically  by  lumbar  punc- 
tures. In  some  cases  two  or  three  were  done,  in  other  cases  only  one.  The 
reporter  called  the  attention  of  the  profession  to  this  simple  method  of  treat- 
ing chronic  alcoholics  without  having  recourse  to  any  other  remedy.  The 
amount  of  spinal  fluid  withdrawn  was  between  20  and  30  c.c.  ' 


January  28,  1916 

The  President,  Dr.  S.  D.  W.  Ludlum,  in  the  Chair 

A  CASE  OF  BULBAR  PALSY 

By  Augustus  A.  Eshner,  M.D. 

A  man,  43  3'ears  old,  employed  for  some  nine  years  in  the  United  States 
Arsenal  at  Frankford,  for  perhaps  half  of  this  time  in  the  manufacture  of 
cartridges  and  for  the  remaining  half  in  the  soldering  of  lead  boxes,  pre- 
sented himself  at  the  Orthopedic  Hospital  in  the  service  of  Dr.  John  K. 
Mitchell  with  widespread  muscular  weakness  and  wasting,  difficulty  in  swal- 
lowing and  scarcely  distinguishable  mumbling  speech.  There  was  some  doubt 
as  to  the  order  of  invasion,  but  the  symptoms  had  set  in  about  two  j-ears 
previously,  and  they  had  been  gradually  progressive.  In  the  course  of  their 
evolution  the  lower  jaw  was  the  seat  of  periodic  recurrences  of  pain  and 


546  PHILADELPHIA  XEUROLOGICAL  SOCIETY 

eventually  the  gums  became  sore  and  the  teeth  loosened,  finally  being 
removed. 

On  examination  the  musculature  generally'  was  found  deficient,  with 
fascicular  twitching,  especially  in  the  muscles  of  the  neck  and  chest.  The 
thenar  and  hypothenar  eminences  were  flattened  and  the  interosseous  mus- 
cles of  the  hands  were  w-asted,  in  greater  degree  on  the  left  side.  The  knee- 
jerk  was  increased,  also  in  greater  degree  on  the  left,  and  the  Babinski  reflex 
was  present.  Station  was  steady  and  the  dynamometer  registered  120  on 
the  right  and  40  on  the  left.  The  eyes  presented  no  fundus  change  and  no 
muscular  derangement. 

The  Wassermann  reaction  was  negative.  The  red  blood  corpuscles  num- 
bered 4.450,000  in  the  cubic  millimeter.  The  hemoglobin  percentage  was  70. 
No  basophilic  degeneration  was  noted  in  the  red  blood  cells.  Lead  could  not 
be  isolated  from  the  urine.  The  affected  muscles  exhibited  only  slight 
quantitative  changes. 

Although  the  patient  in  this  case  was  exposed  for  a  long  period  to  the 
influence  of  lead  in  the  absence  of  conclusive  affirmative  evidence  there  must 
be  some  doubt  as  to  whether  this  metal  acted  as  the  etiologic  factor  in  the 
development  of  the  lesions  of  the  nervous  system  underlying  the  charac- 
teristic clinical  picture.  The  case  is  a  close  counterpart  of  that  of  a  painter 
exhibited  by  Dr.  Mitchell  before  this  Society  in  1909  and  in  whose  spinal 
cord,  later  examined  bj-  Dr.  Cadwalader,^  were  found  disease  of  the  ganglion 
cells  in  the  anterior  horns  and  degeneration  of  nerve-fibers  in  the  lateral 
columns. 

A  CASE  OF  HYSTERIA 
By  Augustus  A.  Eshner,  M.D. 

A  man,  50  years  old,  while  engaged  in  unloading  a  boat,  was  struck  on 
the  right  arm  by  a  large  bucket  of  coal  falling  from  a  great  height.  The 
member  was  quite  severely  injured,  and  the  bone  was  broken  in  two  places. 
Under  treatment  union  took  place  and  the  wound  healed.  Ten  months  later 
the  man  presented  himself  at  the  Orthopedic  Hospital  in  the  service  of  Dr. 
John  K.  Mitchell,  with  a  violent  tremor  of  considerable  range  in  the  right 
hand,  together  with  less  marked  tremor  in  the  remaining  members.  In  addi- 
tion, he  complained  of  pain  referred  to  the  spine  and  running  up  to  the  head, 
and  of  crackling  sounds  in  the  ears.  There  was  also  pain  in  the  thighs. 
Sleep  was  poor  and  disturbed  by  jerking  in  various  parts  of  the  body.  The 
man  stated  that  in  the  course  of  his  illness  he  had  lost  twenty-one  perfect 
teeth,  without  any  apparent  lesion  of  the  gums. 

On  examination  the  right  hand  was  found  in  violent  agitation  when  free 
and  unsupported,  the  jactitation  ceasing  when  the  member  was  supported 
within  the  coat.  This  jerking  had  set  in  when  the  splint  employed  in  the 
treatment  of  the  fracture  of  the  arm  had  been  removed  after  a  period  of 
seven  weeks.  Some  movement  was  perceptible  also  in  the  left  hand.  At 
this  time  the  man  was  unal)lc  to  walk  without  aid,  the  legs  giving  way  at 
times.  Sensibility  was  preserved  in  the  affected  member.  The  knee-jerks 
were  exaggerated  and  station  was  fairly  good. 

Under  treatment  with  static  electricity  and  various  nervine  drugs,  together 
with  verbal  suggestion,  marked  imi)rovcment  has  taken  place,  but  the  pecu- 
liar violent  movement  persists  when  the  arm  is  free  and  unsupported  and 
it  ceases  when  the  arm  is  thrust  within  the  coat  or  is  supported  in  some  other 
way  and  stroked  with  the  other  hand. 

The  man  is  now  able  to  go  about  with  facility  and  comfort,  but  he  has 
not  resumed  his  occupation. 

*  Journal  of  Nervous  and  Mental  Disease,  March,  1912. 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  547 

This  case  is  interesting,  among  other  reasons,  on  account  of  the  peculiar 
movement  in  the  right  upper  extremit}^  which  resembles  in  its  behavior 
somewhat  that  presented  by  a  patient  long  under  the  observation  of  the  late 
Dr.  S.  Weir  Alitchell,  and  in  whom  after  death  no  organic  change  was  found 
by  Dr.  Spiller  in  the  central  nervous  system. 

Dr.  Alfred  Gordon  asked  as  to  the  condition  of  the  reflexes,  sensations 
and  other  data  in  the  second  case. 

Dr.  Eshner  stated  that  he  could  not  supply  the  information  asked  for  by 
Dr.  Gordon  in  the  second  case.  The  first  case  was  clearly  one  of  amyo- 
trophic lateral  sclerosis,  w^ith  bulbar  involvement. 

A    CASE    PRESENTING    ATROPHY    OF    THE    RIGHT    LOWER 

EXTREMITY,    WITH     INCREASED    REFLEXES    AND 

POSITIVE    BABINSKI    SIGN. 

By  Williams  B.  Cadwalader,  M.D. 

V.  J.  S.,  male,  aged  17  years,  was  admitted  to  the  University  Hospital  on 
January  13,  1916,  complaining  of  weakness  and  wasting  of  the  right  lower 
extremity.  The  patient's  father  was  said  to  have  had  syphilis ;  his  mother, 
two  older  brothers  and  two  younger  sisters  are  living  and  well.  The  patient 
states  that  he  had  been  well  until  1913.  when  he  had  an  attack  of  what  he 
had  been  told  was  rheumatism.  This  condition  was  characterized  by  pain 
on  movement  in  the  joints  of  both  lower  extremities  and  also  in  the  righl 
hand.  There  was  no  redness  nor  swelling.  After  a  few  weeks  he  made  a 
complete  recovery.  In  September,  1914,  he  again  had  some  pain  in  the  region 
of  his  hip  joints,  which  was  increased  by  movement.  It  disappeared,  how- 
ever, after  a  few  days. 

He  states  that  since  September,  1914,  his  right  lower  limb  has  been 
gradually  growing  weak  and  the  muscles  have  been  wasting.  In  all  other 
respects  he  is  entirely  well. 

On  examination,  his  eyes,  cranial  nerves,  upper  extremities  and  internal 
organs  were  found  to  be  normal.  The  muscles  of  the  right  lower  limb  are 
moderately  and  uniformly  atrophied  and  there  is  weakness  in  proportion  to 
the  wasting.  The  tendon  reflexes  are  exaggerated  but  on  the  right  side  they 
are  distinctly  greater  than  on  the  left.  There  is  a  distinct  Babinski  sign  on 
the  right  but  not  on  the  left  side.  Ankle  clonus  is  absent.  Sensation  is 
normal.     There  is  no  incoordination,  ataxia  nor  tremor. 

Examination  of  the  joints  by  Dr.  Edward  Martin  revealed  nothing  ab- 
normal and  in  his  opinion  the  atrophy  is  not  related  to  joint  disease.  This 
was  later  confirmed  by  Dr.  Pancoast,  who  made  x-ray  studies.  Dr.  Leopold 
made  an  electrical  examination  and  reported  that  the  muscles  reacted  nor- 
mally to  the  faradic  current. 

The  Wassermann  reaction  was  negative.  Blood  count  and  urine  exami- 
nation were  also  negative. 

The  combination  of  atrophy  of  gradual  onset  with  increased  reflexes 
and  Babinski  sign  is  a  difficult  one  to  explain.  If  it  were  not  for  the  presence 
of  the  Babinski  sign  and  the  joint  condition  could  have  been  demonstrated, _ 
then  arthritis  with  muscular  atrophy  would  seem  to  explain  the  case,  but  the 
presence  of  the  Babinski  sign  in  itself  must  indicate  some  disturbance  of  the 
upper  motor  neuron.  It  would  seem  possible  that  this  patient  had  had  an 
infection  which  had  caused  pain  in  his  joints  simulating  rheumatism  and 
that  the  spinal  cord  had  been  involved  as  in  acute  anterior  poliomyelitis,  sorne 
of  the  anteror  horn  cells  being  destroyed,  causing  atrophy,  and  the  morbid 
process  extending  laterally  to  involve  the  pyramidal  tracts,  producing  the 
Babinski  sign  and  increased  tendon  reflexes.     The  fact  that  this  boy's  father 


548  PHILADELPHIA  XEi'ROLOGICAL  SOCIETY 

had  Iiad  syphilis  might  be  important  but  no  evidences  of  syphilis  iiave  been 
discovered  in  this  patient. 

Dr.  Dercum  said  that  this  was  of  course  not  a  case  of  primar\-  neurotic 
atrophy.  The  historj-  pointed  unmistakably  to  an  infection.  However,  in 
some  of  its  aspects  it  suggests  a  primary  neurotic  atrophy.  Dr.  Dercum 
had  himself  placed  on  record  two  cases  of  the  latter  affection  in  which  the 
knee  jerks  were  preserved.  It  is  also  well  known  that  in  autopsies  in  cases 
of  primary  neurotic  atrophy,  the  changes  are  by  no  means  limited  to  the 
peripheral  nerves,  but  also  involve  the  spinal  cord.  On  the  whole  he  was 
inclined  to  accept  Dr.  Cadwalader's  explanation.  The  absence  of  spasticity 
is  further  in  keeping  with  this  explanation ;  there  is  also  no  evidence  of 
spastic  gait. 

Dr.  J.  Hendrie  Lloyd  said  he  thought  the  subject  of  the  relation  of  mus- 
cular atrophy  to  sj-philis  was  an  interesting  and  rather  novel  one.  He  did 
not  know  to  what  extent  this  case  brought  it  up,  because,  as  he  understood, 
there  was  no  evidence  of  specific  infection.  We  do  know,  however,  that 
there  are  cases  of  marked  muscular  atropln'  in  patients  who  have  suffered 
from  a  primary  sore.  Only  tliat  afternoon  Dr.  Lloyd  had  been  going  over 
one  of  the  cases  at  the  Philadelphia  Hospital  of  extreme  muscular  atrophy 
in  all  four  limbs  in  a  j-oung  man.  The  .symptoms  came  on  two  years  after 
the  primary  sore.  The  patient  had  a  positive  Wassermann  reaction.  As  in 
all  cases  of  nervous  syphilis,  the  type  was  what  we  see  in  poliomyelitis,  except 
that  the  symptoms  came  on  without  the  evidence  of  an  acute  infection. 
There  was  not  an  abrupt  onset  w^th  fever  and  pain,  such  as  we  see  in  polio- 
myelitis. The  progress  was  slow,  first  in  one  set  of  muscles  and  then  in 
another.  Dr.  Lloyd  said  he  had  another  case  in  a  man  at  Blockley  which 
had  impressed  that  fact  upon  him.  This  man  was  a  very  robust,  perfectly 
developed  fellow,  over  six  feet  tall,  who  had  atrophj-  of  all  the  muscles  of 
one  thigh  from  his  hip  to  his  knee.  There  was  nothing  to  account  for  it, 
except  that  the  patient  had  had  a  .syphilitic  infection  a  few  years  before  the 
onset  of  the  trouble.  He  had  no  pain,  no  alteration  of  his  cranial  nerves  or 
reflexes,  no  evidence  of  syphilis  in  the  action  of  his  eye  muscles,  but  lie  had 
had  syphilis  ;  and  as  a  result  some  years  later  he  began  to  have  very  marked 
muscular  atrophy  of  the  muscles  of  his  thigh.  It  was  of  the  type  seen  in 
poliomyelitis.  This  subject  is  referred  to  by  comparatively  few  authors. 
McDonagh,  however,  in  his  recent  work  on  the  Bijologj'  of  Syphilis,  includes 
muscular  atrophy  as  one  of  the  symptoms.  Nor  should  there  be  any  surprise 
that  muscular  atrophy  is  one  of  the  symptoms  of  syphilis.  If  the  spirochete 
gets  into  the  parenchyma  of  the  posterior  tracts  it  causes  locomotor  ataxia ; 
if  in  the  brain  cortex,  it  causes  paresis.  In  these  cases  of  muscular  atrophy, 
the  spirochete  probably  gets  into  the  parenchyma  of  the  anterior  horns.  In 
these  cases  also  the  type  of  amyotrophic  lateral  sclerosis  is  sometimes  seen. 
Or,  again,  there  may  be  a  primarj-  lateral  sclerosis,  without  muscular  atrophy. 
Some  years  ago  Dr.  Lloyd,  with  Dr.  Ludlum,  had  put  on  record  a  series  of 
cases  of  primary,  or  essential,  lateral  sclerosis,  all  occurring  in  syphilitic 
subjects.  In  these  cases  doubtless  the  organism  of  syphilis  finds  lodgment 
in  the  lateral  tracts,  just  as  it  does  in  tabes  in  the  posterior  tracts. 

Dr.  Cadwalader  said  that  he  had  considered  this  case  from  exactU'  the 
same  point  of  view  Dr.  Lloyd  had  spoken  of,  but  there  seemed  too  little  evi- 
dence of  syphilitic  infection  to  warrant  drawing  such  conclusions.  Dr.  Cad- 
walader said  that  he  believed  many  cases  of  amyotrophic  lateral  sclerosis 
were  syphilitic  in  origin.  Also  some  cases  of  muscular  dystrophy  and  some 
cases  of  spinal  muscular  atrophy  must  be  syphilitic. 

Dr.  S.  I".  f]il|)in  showed  a  case  of  paralysis  agitans  in  a  negro. 
Dr.   Dercum    said   this   was  the   second  case  of  this  kind   he  had   seen. 
Several  years  ago  Dr.  Burr  showed  a  case  of  this  affection  in  a  negro  before 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  549 

the  Society.     Dr.  Gilpin's  case  is  one  of  typical  paralysis  agitans  and  occur- 
ring in  the  negro,  it  is  very  rare. 

Dr.  N.  S.  Yawger  presented  a  case  of  a  lesion  probably  confined  to  one 
posterior  horn  of  the  spinal  cord  throughout  the  thoracic  region. 

Dr.  J.  S.  Rodman  and  Dr.  W.  B.  Cadwalader  presented  a  case  of  cerebral 
abscess  apparently  cured  by  operation. 

Dr.  A.  A.  Eshner  asked  whether  the  abscess  was  merely  intracranial  or 
subdural  or  really  cerebral.  Its  superficial  character,  as  well  as  its  mode  of 
origin  and  the  results  of  operation  would  seem  to  suggest  the  former  rather 
than  the  latter. 

Dr.  George  E.  Price  said  the  high  leukocytosis  was  interesting.  In  un- 
complicated intracranial  abscess  it  was  apt  to  be  below  14,000;  while  in  men- 
ingitis it  ran  from  14,000  upwards.     In  this  case  the  meninges  were  involved. 

Dr.  Rodman,  in  closing,  said  if  he  had  failed  to  make  it  clear  that  this 
was  a  real  cortical  abscess  he  had  missed  the  whole  point  in  presenting  the 
case.  There  was  a  superficial  abscess  as  well.  The  superficial  abscess  was 
between  the  skull  and  the  scalp.  The  abscess  beneath  the  dura  was  in  the 
brain  substance  itself,  about  2  cm.  below  the  surface  of  the  cortex. 

Dr.  Charles  K.  Mills  and  Dr.  George  Wilson  presented  a  case  of 
Sprengel's  deformity:  congenital  elevation  of  the  scapula. 

Dr.  Wilson  said  the  patient  walked  with  difficulty  because  she  probably 
had  tabes,  she  had  sharp  pains  and  lost  reflexes,  also  incontinence  of  urine. 
The  lack  of  motion  of  the  upper  limb  was  due  to  lack  of  motion  of  all  the 
shoulder  muscles,  atrophy  of  the  trapezius  and  deltoid.  The  scapula  fails 
to  descend.     It  is  an  embryological  condition. 

Dr.  William  G.  Spiller  read  a  paper  on  tabetic  ocular  crises.^ 

Dr.  Dercum  said  that  Dr.  Spiller's  paper  called  to  mind  the  intense  oph- 
thalmic migraine  so-called  which  we  every  now  and  then  meet  with  in  paresis, 
especially  in  the  early  stages.  Every  now  and  then,  among  the  early  symp- 
toms presented  by  paresis  we  meet  with  intense  pain  referred  to  the  eyeball 
or  to  the  orbit  or  immediately  adjacent  regions.  These  attacks  are  usually 
of  short  duration.  They  are  put  down  in  the  older  textbooks  as  attacks  of 
ophthalmic  migraine.  It  is  not  impossible  that  they  are  really  attacks  analo- 
gous to  the  tabetic  crises  which  Dr.  Spiller  has  described. 

Dr.  George  E.  Price  inquired  as  to  the  length  of  the  individual  attacks. 
He  thought  the  duration  of  the  attacks  would  have  a  bearing  on  the  differ- 
ential diagnosis  between  ophthalmic  migraine  and  tabetic  ocular  crises. 

Dr.  Alfred  Gordon  said  tabetic  ocular  crises  as  well  as  crises  of  other 
cranial  nerves  are  rare.  In  the  last  edition  of  Gowers  no  mention  is  made  of 
them.  In  connection  with  this  a  brief  history  of  a  case  of  tabes  under  Dr. 
Gordon's  care  will  be  of  interest.  The  patient  had  attacks  of  the  following 
nature:  all  of  a  sudden  she  would  be  taken  with  a  deafness  of  the  left  ear 
with  dizziness.  There  was  no  pain.  The  attack  came  on  suddenly  and  dis- 
appeared suddenly.  She  had  for  a  number  of  months  attacks  of  this  char- 
acter. Evidently  it  was  very  likely  a  tabetic  crisis  consisting  of  a  disturbance 
of  function  of  the  eighth  nerve.  Sudden  attacks  of  this  character  lasting  a 
fraction  of  a  minute  and  consisting  of  deafness  with  vertigo  and  without 
pain  are  exceedingly  rare.  He  examined  a  patient  for  objective  sensory  dis- 
turbance of  the  ear  in  which  there  was  no  trace  of  involvement  of  the  fifth 
nerve,  but  this  striking  symptom  of  sudden  deafness  of  the  left  ear  and  ver- 
tigo, although  without  pain,  reminds  one  of  tabetic  crises. 

1  Published  in  the  Journal  of  the  American  Medical  Association,  March 
18,  1916. 


5SO  PHILADELPHIA  XEUROLOGICAL  SOCIETY 

Dr.  Charles  K.  Mills  said  the  case  was  interesting  and  had  been  well  pre- 
sented by  Dr.  Spiller.  There  was  only  one  point  about  this  patient  to  which 
he  would  refer.  So  far  as  his  description  of  what  he  sees  is  concerned,  Dr. 
Mills  was  inclined  to  attribute  that  to  his  emotional  and  imaginative  tenden- 
cies. He  is  a  well  known  case  at  Blockley.  Almost  every  member  of  the 
staff  has  at  times  heard  him  discoursing  on  the  Lord,  the  stars,  salvation  and 
damnation,  etc..  much  after  the  manner  of  his  description  of  his  visions  in 
the  attacks  described. 

Dr.  Spiller  said  the  man  he  presented  has  attacks  at  various  times  during 
the  da3'  and  they  disappear  as  suddenly  as  thej'  come.  He  did  not  believe 
the  visual  phenomena  could  be  attributed  to  vivid  imagination,  because  they 
were  always  associated  with  agonizing  pain  and  intense  lachrymation. 

Dr.  Charles  K.  Mills  said  he  did  not  mean  to  infer  that  the  case  was 
not  such  as  Dr.  Spiller  described.  He  had  seen  the  man  in  one  of  his  visual 
attacks  a  short  time  since.  He  merely  wished  to  indicate  that  the  patient's 
imagination  would  tend  to  expand  a  real  visual  appearance.  H  he  saw  a 
lizard  or  a  lobster  in  his  optic  crises  his  imagination  was  sufficient  to  call  up 
a  train  of  other  visions. 

Professor  Ulric  Dahlgren  of  Princeton  Universitj-  read  a  paper  on  the 
primitive  balancing  apparatus  in  vertebrates. 

Febru.xrv  25,  1916 
The  President,  Dr.  Francis  X.  Dercum,  in  the  Chair 

Drs.  S.  D.  Ingham  and  William  E.  Robertson  presented  a  case  in  which 
spinal  tumor  had  been  removed  ten  months  previously. 

Dr.  John  H.  W.  Rhein  asked  if  there  had  been  at  any  time  any  abdominal 
pain,  and  what  the  present  reflexes  were. 

Dr.  Ingham  said  the  reflexes  of  both  legs  \vere  absent  constantly  from 
the  time  of  the  first  examination. 

Dr.  P.  de  Long  showed  a  case  of  tabes  with  paralysis  agitans. 

Dr.  Theodore  Weisenburg  said  he  had  asked  Dr.  de  Long  to  show  this 
case  because  he  thought  it  was  very  unusual.  He  had  known  this  man  for 
sixteen  or  seventeen  years.  He  always  thought  him  a  tj'pical  case  of  tabes 
dorsalis.  Six  or  seven  years  ago  Dr.  Weisenburg  noticed  that  the  man  had 
a  tremor  of  the  right  upper  limb,  then  in  the  head  and  now  in  both  lower 
limbs.     It  is  a  very  unusual  complication. 

Dr.  Rhein  said  that  he  had  presented  before  the  Section  on  Nervous  and 
Mental  Di.seases  of  the  American  Medical  Association,  in  June,  1904,  a  case 
of  locomotor  ataxia  in  which  there  was  a  tremor  resembling  paralysis  agitans. 
The  pill-rolling  position  of  the  fingers  was  well  illustrated,  the  tremor  being 
fine  and  rhythmical  and  bilateral.  Voluntarj'  effort  quieted  the  movements 
temporarily,  after  which  they  became  more  intense.  The  pathological  study 
of  the  case  showed  the  usual  findings  of  well-advanced  tabes.  Arterial 
change  could  not  even  be  compared  with  that  found  in  cases  of  paralysis 
agitans  in  which  it  has  been  claimed  that  the  lesions  resemble  those  of  old 
age.  Xo  degeneration  of  the  muscle  spindles  was  found.  This  case  was  one 
of  tabes  associated  with  paralysis  agitans. 

CEREBRO-CEREBELLAR  ATAXIA 
By  Alfred  Gordon,  M.D. 

Girl  of  17,  made  her  first  attempt  to  walk  at  18  months.  Began  to  speak 
only  at  2  years  of  age.     From  that  time  her  speech  remained  deficient.     She 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  551 

would  stumble  and  fall  while  walking  until  the  age  of  12,  and  then  began  to 
improve.  More  marked  improvement  commenced  three  years  ago.  At  that 
time  she  showed  marked  ataxia  of  both  hands,  had  to  be  fed;  gait  swaying, 
feet  scraped  the  floor.  Was  mentally  defective,  could  not  progress  in  studies. 
The  speech  was  deliberate  with  accentuation  of  syllables ;  enuresis. 

Present  status. — Intelligence  below  normal.  With  Binet-Simon  test  the 
mentality  is  that  of  a  child  of  10.  Gait  peculiar:  walks  stooping,  sways 
slightly  at  each  step ;  slight  scraping  of  the  floor ;  stands  well  on  one  foot, 
but  not  on  the  other;  in  turning  around  a  tendency  to  fall;  no  spasticity; 
knee  jerk  +- (-.  Ankle  clonus  slight  on  both  sides.  Babinski  distinct  on  left, 
but  not  always  obtainable  on  right;  slight  ataxia  of  arms.  Sensations 
normal ;  speech  overprecise,  slow ;  eyes  normal,  no  nystagmus.  Wassermann 
test  negative.     Family  history  negative ;  born  at  term. 

Comment. — The  cerebral  symptoms  are:  evidences  of  pyramidal  tract 
involvement,  speech  and  mental  status.  The  cerebellar  symptoms  are  :  ataxia 
of  arms  and  legs,  station  and  absence  of  rigidity.  Progressive  improvement 
of  motor  symptoms  is  noticeable.  In  1903  Batten  described  "  congenital  cere- 
bellar ataxia "  and  the  symptoms  are :  onset  in  early  life,  unsteadiness  of 
head,  trunk,  limbs,  unsteadiness  in  sitting,  standing,  walking,  slowness  in 
swallowing,  alteration  in  speech,  tendency  towards  recovery,  but  speech,  mild 
degree  of  ataxia  and  uncertainty  in  gait  remain.  In  1913  L.  P.  Clark  de-. 
scribed  "  cerebro-cerebellar  diplegia,"  the  symptoms  of  which  are :  cerebellar 
ataxia  and  mental  defect;  unusual  flaccidity  of  the  limbs,  especially  in  the 
upper  ;  ataxia  in  all  limbs,  straddling  gait,  dysmetria,  no  changes  in  reflexes  ; 
tendency  towards  improvement  especially  in  cerebellar  symptoms,  but  speech 
and  mental  deficiency  remain  unaltered.  In  this  case  also  cerebral  and  cere- 
bellar s3-mptoms  are  present;  evolution  of  symptoms,  progressive  improve- 
ment and  the  remaining  condition  are  all  the  same  as  in  Batten's  and  Clark's 
cases  ;  only  in  their  cases  the  reflexes  are  normal ;  in  Dr.  Gordon's  they  are 
-| — j- ;  Babinski  and  ankle  clonus  present.  Therefore  cerebral  symptoms  are 
preserved.  Batten's,  Clark's  and  Dr.  Gordon's  case  are  identical  in  essential 
features.     Nature:  probably  congenital  defect  in  cerebrum  and  cerebellum. 

Dr.  Cadwalader  stated  that  the  case  that  Dr.  Gordon  referred  to  and 
which  he  had  reported  before  this  Society  about  one  year  ago  under  the  title 
of  Cerebellar  Diplegia,  seemed  to  him  quite  different  from  the  case  Dr. 
Gordon  had  just  exhibited.  Dr.  Gordon's  patient  did  not  seem  to  Dr.  Cad- 
walader like  the  type  of  case  that  Clark,  Batten  and  others  have  reported, 
because  spasticity  was  present  with  increased  tendon  reflexes  and  in  the 
typical  cases  of  cerebellar. diplegia  hypotonicity  was  perhaps  the  most  striking 
feature.  The  patient  Dr.  Cadwalader  had  reported  was  extremely  hypotonic, 
did  not  have  a  Babinski  sign  and  was  extremely  ataxic  and  tremulous. 

Dr.  Gordon  said  that  ankle  clonus  was  present  on  both  sides  and  the 
knee  jerks  exaggerated.  In  Batten's  and  Clark's  cases  the  reflexes  were 
normal.  In  regard  to  the  Wassermann  test  the  patient  has  been  tested  twice 
and  both  times  the  results  were  negative. 


AN  UNUSUAL  SPINAL  CORD  CASE 

By  T.  H.  Weisenburg,  M.D. 

Patient  is  a  man  about  forty-five  years  of  age.  His  history  is  that  about 
eight  months  ago  he  began  to  be  weak  in  the  left  leg  and  in  a  month  or  so 
in  the  right  leg,  and  since  then  he  has  noticed  a  gradual  increase  of  weakness 
in  the  lower  limbs,  until  when  he  was  admitted  to  the  hospital  six  months 
later  he  was  unable  to  walk  at  all.  An  examination  then  showed  foot  drop 
on  both  sides  and  inability  to  move  the  toes  and  feet  below  the  knees.     There 


552  PHILADELPHIA  XEUROLOGICAL  SOCIETY 

was  a  disturbance  of  sensation  for  pain  and  temperature  but  not  for  touch 
over  both  lower  limbs  to  about  the  middle  of  the  thigh.  In  the  course  of  about 
a  month  the  weakness  in  both  lower  limbs  extended  until  he  could  not  move 
his  feet  at  all  and  the  disturbance  of  sensation  has  extended  until  he  is 
unable  to  have  any  form  of  sensation  over  both  lower  limbs  and  abdomen  to 
a  point  on  the  right  side  corresponding  with  the  umbilicus  and  the  left  about 
two  inches  below.  Almost  from  the  beginning  his  bladder  and  rectum  have 
been  involved,  until  at  the  present  time  there  is  total  loss  of  bladder  control. 
Examination  showed  an  unusual  condition  in  his  reflexes.  The  patellar  jerks 
were  increased,  the  Achilles  jerks  w^ere  lost  and  plantar  irritation  caused  no 
movement  of  the  toes,  but  irritation  bj'  the  Oppenheim  method  gave  a  dis- 
tinct extensor  response  on  both  sides.  It  is  interesting  in  testing  this  method 
that  if  the  irritation  was  over  the  anterior  tibial  group  the  corresponding 
group  responded  alone,  while  if  the  irritation  was  over  the  peroneal  group 
only  this  group  responded.  In  the  course  of  a  week  or  two  the  responses  of 
the  toes  changed  very  much,  inasmuch  as  plantar  irritation  if  sufficiently  long 
continued  causes  an  extensor  response  of  the  toes.  It  must  be  remembered 
that  this  patient  had  complete  loss  of  sensation  for  all  forms  and  yet  plantar 
irritation  caused  a  distinct  response  of  the  toes  which  according  to  Babinski 
is  impossible. 

The  interesting  point  about  this  case  outside  of  the  phenomena  men- 
tioned is  that  the  responses  by  irritation  either  over  the  plantar  surface  or 
over  the  leg  at  once  eliminates  the  location  of  the  lesion  from  the  lumbo-sacral 
area  and  places  it  higher  up,  that  is,  about  the  ninth  or  tenth  thoracic,  which 
is  the  limit  of  the  loss  of  sensation,  for  if  the  lesion  were  in  the  cells  of  the 
anterior  horn  supplying  the  tibial  and  peroneal  group  of  muscles,  no  irritation 
would  cause  a  response.  This  is  a  very  important  point  in  spinal  diagnosis 
and  has  not  been  sufficiently  emphasized. 

Dr.  Charles  K.  Mills  said  he  had  seen  this  patient  in  his  service  at  I'lock- 
lej".  The  diagnosis  seemed  to  him  to  be  pretty  clearly  a  lumbo-sacral  myelitis 
or  a  thoracico-lumbo-sacral  myelitis.  It  was  unusual.  Dr.  Mills  thought,  to 
see  the  Beevor  sign  demonstrated  in  that  way.  One  interesting  point  was  the 
ability  to  obtain  dorsal  tension  in  the  absence  of  sensation.  He  thought  the 
.case  required  thought  and  discussion.  There  must  be  some  transfer  of 
afferent  stimuli  in  order  that  this  reflex  should  be  brought  out  and  therefore 
it  was  likely  there  was  some  retention  of  the  integrity  of  the  cord  in  the 
region  concerned  with  the  Bal)inski  reflex.  He  did  not  think  that  the  diagnosis 
of  peripheral  multiple  neuritis  would  fit  the  case. 

Dr.  Weisenburg  thought  that  the  presence  of  extensor  response  on 
plantar  irritation  was  evidence  of  the  fact  that  sensation  was  not  entirely  lost. 

Dr.  Gordon  inquired  whether  Dr.  Weisenburg  has  asked  the  man  when 
he  pressed  deeply  on  the  muscles  of  the  leg  whether  he  felt  the  pressure, 
that  is.  had  Dr.  Weisenburg  tested  for  deep  sensation. 

Dr.  Weisenburg  replied  the  man  had  an  absence  of  all  sensibility.  He 
was  surprised  that  Dr.  Gordon  was  not  able  to  obtain  his  reflex  as  lie  thought 
this  was  precisely  the  kind  of  case  in  which  Dr.  Gordon  had  claimed  tliat 
his  reflex  was  of  value. 


A  CASE  OE  XOX-TRAUMATIC  ISOLATED  CERVICAL   SYMPA- 
THETIC PARALYSIS 

By  H.   Maxwell   Langdon,   M.D. 

Mrs.  E.  G.,  aged  48,  complaining  of  flrooping  of  right  eyelid  for  thirteen 
years.  No  history  of  trauma,  does  not  know  when  it  began.  Patient  well 
in  every  other  way  except  for  a  moderate  enlargement  of  the  thyroid.     Stout, 


PHILADELPHIA  NEUROLOGICAL  SOCIETY  553 

well-nourished  woman.  Wassermann  negative.  Right  lid  droops,  pupil  is 
small.  Eyes  are  negative  except  in  so  far  as  the  lid,  pupil,  and  ocular  posi- 
tion are  concerned,  there  being  slight  enophthalmos.  O.  D.  palpebral  fissure 
measured  4.5  mm.,  O.  S.  fissure  7  mm. ;  O.  D.  pupil  measured  1.5  mm.,  O.  S.  pupil 
2.5  mm. ;  O.  D.  exophthalmos  measured  15.5  mm.,  O.  S.  exoph.  16.5  mm.  After 
three  drops  of  a  5  per  cent,  solution  of  cocaine  and  waiting  thirty  minutes, 
O.  D.  fissure  measured  5  mm.,  O.  S.  fissure  9  mm. ;  O.  D.  pupil  measured  1.5 
mm.,  O.  S.  pupil  4  mm.;  O.  D.  exophthalmos  measured  15.5  mm.,  O.  S.  exoph. 
measured  17  mm.,  making  it  quite  sure  there  was  paresis  of  the  right  cervical 
sympathetic;  the  right  side  of  the  face  was  also  less  well  developed  than 
the  left. 

Dr.  F.  H.  Clark  (by  invitation)  reported  a  case  of  tic  of  the  abdominal 
muscles  of  eighteen  years'  duration,  with  necropsy  {See  page  510.) 

Dr.  Weisenburg  said  he  remembered  this  patient  very  well,  as  he  had 
been  in  Bleckley  for  a  long  time.  He  had  taken  moving  pictures  of  him 
six  or  seven  years  ago  and  again  several  years  before  he  died.  The  tic  in 
the  first  picture  was  very  marked,  in  the  latter  not  quite  so  marked  and  it 
was  his  impression  that  it  became  less  as  the  patient  grew  older.  The  pic- 
tures of  this  patient  were  shown  before  the  International  Medical  Congress 
in  London  in  1913.  It  is  interesting  that  most  of  the  neurologists  expressed 
themselves  that  they  had  not  seen  a  similar  case. 

Dr.  Langdon  said  one  thing  struck  him:  that  the  majority  of  tics  come 
from  an  idea ;  the  commonest  form  is  that  of  oculomotor  spasm  and  that 
comes  from  a  mild  low-grade  conjunctivitis,  which  will  be  present  a  short 
time.  He  has  seen  it  any  number  of  times  in  children  and  it  is  kept  up  by 
the  continual  closing  of  the  orbicularis,  and  if  it  is  treated  more  or  less 
actively  with  lotions  containing  zinc  the  tic  will  often  quiet  down  if  taken 
in  its  earliest  form.  He  thought  many  of  them  go  on  for  years  because  not 
treated,  not  from  an  idea,  but  as  an  actual  condition. 

The  form  of  tic  which. ophthalmologists  most  frequently  see  is  blepharo- 
spasm, which  usually  does  not  start  from  an  idea,  in  his  experience,  but  with 
some  form  of  mild  conjunctival  inflammation,  which  in  turn  is  kept  up  by 
the  spasm  of  the  orbicularis,  and  so  a  vicious  circle  is  set  up.  The  best  treat- 
ment is  a  lotion  containing  astringents,  especially  zinc,  though  the  habit  once 
formed  is  at  times  quite  difficult  to  overcome. 


TUMOR  OF  THE  DURA 
By  John  H.  W.  Rhein,  M.D.,  and  Thomas  Adams,  M.D. 

The  man,  aged  48,  colored,  was  admitted  to  the  Howard  Hospital  January 
5,  1916,  at  1.30  a.m.  Upon  admission  the  left  arm  and  leg  were  the  seat  of 
convulsive  movements.  The  patient  was  conscious  and  talked  intelligently 
and  said  the  convulsive  disturbances  came  on  at  midnight  and  that  this  was 
the  first  attack.  The  left  arm  and  leg  seemed  weak  and  he  was  unable  to  lift 
the  left  leg  from  the  level  of  the  table.  The  pulse  was  hard  and  bounding. 
The  patient  was  put  in  bed,  the  convulsions  persisting.  He  bit  his  tongue, 
the  left  side  of  the  face  became  drawn,  and  he  became  unconscious  at  the 
end  of  an  hour.  The  blood  pressure  was  over  300  mm.  Venesection  was 
done  and  four  ounces  of  blood  withdrawn.  The  convulsions  ceased  and  he 
became  quiet. 

Upon  examination  by  Dr.  Rhein  the  following  day  he  presented  the  fol- 
lowing condition:  Conjugate  deviation  of  the  eyes  to  the  right,  pupils  inactive 
and  equal,  breathing  stertorous,  both  cheeks  blowing  out  equally.  The  right 
arm  was  rigid;  the  left  flaccid.     There  was  no  rigidity  of  either  leg.     Ba- 


554  PHILADELPHIA  NEUROLOGICAL  SOCIETY 

binski  was  present  on  the  right  side.  The  knee  jerks  were  capricious,  occa- 
sionally present  on  both  sides  slightly,  but  absent  on  most  tests.  There  was 
no  clonus  on  either  side.  Heart  sounds  were  clear  and  there  were  moist 
rales  on  the  bases  on  both  sides.  Further  tests  could  not  be  made,  as  the 
man  was  unconscious. 

The  patient's  sister  gave  the  following  statement :  Her  brother  had  lived 
in  her  house  for  several  years,  working  regularly  as  a  stevedore.  His  only 
complaint  was  that  at  times  his  left  arm  and  leg  would  go  to  sleep  and  some- 
times at  night  he  would  ask  her  children  to  rub  his  hand  to  take  away  the 
sensation.  On  the  night  of  the  attack  he  came  home  from  work  as  usual 
and  ate  a  large  supper  of  sausage.  He  went  to  bed  early  and  she  heard  him 
singing  a  hymn  while  undressing.  About  midnight  she  was  awakened  by  his 
groans.  She  said  he  was  always  a  great  eater  of  meat,  but  was  not  an 
alcoholic.     He  died  at  6  p.m.  of  January  5. 

Pathological  diagnosis  :  Edema  of  the  lungs  with  congestion  and  small 
patches  of  bronchial  pneumonia.  The  kidneys  showed  focal  interstitial 
nephritis  and  parenclnmatous  change.  There  was  a  w^ell-marked  arterial 
sclerosis.  The  brain  was  the  seat  of  a  tumor  involving  the  dura  on  the 
right  side,  in  the  paracentral  region.  It  was  very  cellular,  the  cells  being 
elongated,  and  contained  manj-  thin-walled  blood  vessels  and  several  round 
calcareous  bodies.     Dr.  E.  O.  Case  made  a  diagnosis  of  psammo-sarcoma. 

The  tumor  is  a  spherical  mass  about  4  cm.  in  diameter.  It  is  attached 
to  the  dura  and  compresses  the  brain  in  the  right  paracentral  region,  forming 
a  depression  in  the  cortex  3^4  cm.  long,  and  in  depth  almost  2  cm.  and  about 
2}/2  cm.  in  transverse  diameter.  When  in  position  the  tumor  is  only  slightly 
elevated  above  the  surface  of  the  brain.  The  brain  tissue  is  not  invaded. 
The  brain  macroscopically  appeared  otherw'ise  to  be  normal. 

Of  tumors  of  the  dura  mater,  sarcoma  and  endothelioma  are  the  most 
common,  fibroma,  lipoma,  and  chordoma  being  of  rarer  occurrence.  Glio- 
sarcoma  of  the  brain,  and  carcinoma  of  the  scalp  may  give  secondary  growths 
in  the  dura.     The  psammo-sarcoma  is  not  uncommon. 

This  case  illustrated  the  ease  with  which  this  class  of  tumors  may  be 
removed.  In  this  case  if  the  patient  could  have  been  under  observation  long 
enough  to  have  made  a  diagnosis,  no  doubt  the  tumor  could  have  been  suc- 
cessfully removed.  The  causation  of  the  symptoms  causing  death  is  a  matter 
of  doubt  in  this  case.  The  man  was  undoubtedly  uremic  and  a  diagnosis  of 
uremic  convulsions  was  made.  The  question  arises,  did  not  the  tumor  local- 
ize the  convulsions  to  one  side? 


TIC    DOULOUREUX 
By  G.  M.  Dorrance,  M.D. 

Dr.  Dorrance  gave  a  brief  historical  sketch  of  the  history  of  the  disease 
and  gave  more  or  less  in  detail  all  of  the  early  methods  of  treatment  em- 
ployed for  its  relief. 

He  gave  in  detail  the  accepted  methods  of  treatment  at  the  present  day 
and  favored  the  surgical  and  injection  methods. 

While  selecting  five  methods  of  operating,  he  favored  that  of  Cushing 
for  gasserectomy  and  that  of  Frazicr  and  Spiller  for  cutting  the  posterior 
root. 

He  gave  in  detail  Levy  and  Baudoin's  nutliofl,  made  popular  in  this  coun- 
try by  Patrick,  and  showed  several  lantern  slides  illustrating  the  method  of 
approach  to  the  various  branches. 

Hartcl's  methrid  was  given  as  the  one  of  choice  and  here  several  slides 
and  many  anatomical  pictures  were  shown  illustrating  the  method  and  show- 
ing the  needle  in  position. 


NEW  YORK  NEUROLOGICAL  SOCIETY  555 

He  has  tried  all  the  methods  and  felt  Hartel's  is  the  most  reliable.  Dr. 
Dorrance  has  made  over  300  injections  of  the  ganglion  on  cadavers  during 
the  past  year,  using  methylene  blue,  and  made  many  interesting  observations 
on  the  position  of  the  needle  and  the  diffusion  of  the  alcohol. 

He  explained  the  number  of  failures  reported  and  showed  illustrations 
to  emphasize  the  reasons. 

He  pointed  out  a  fact  hitherto  unmentioned  of  the  presence  of  an  anoma- 
lous vein  at  the  foramen  ovale. 

In  conclusion  he  advises  the  operator  to  thorougiily  familiarize  himself 
with  the  method  and  practice  faithfully  on  cadavers  before  attempting  an 
injection  on  a  patient. 

Dr.  C.  M.  Byrnes  said  that  Dr.  Dorrance,  like  most  writers  upon  this 
subject,  attributes  the  first  ganglion  injection  to  Hartel,  but  from  Dr.  Byrnes' 
study  of  the  literature,  it  appears  that  Taptas  was  the  first  to  perform  such 
an  operation,  and  was  followed  later  by  Harris  of  London.  It  appeared  to 
him  that  the  selection  of  the  descending  root  of  the  zygoma  as  the  posterior 
landmark  for  determining  the  point  of  puncture  is  unsatisfactory,  since  this 
bony  elevation  is  often  absent  and  is  therefore  extremely  difficult  to  deter- 
mine upon  the  living  subject. 

Dr.  Dorrance's  statement  that  no  experimental  work  had  been  done  upon 
the  effect  of  alcohol  when  injected  into  the  Gasserian  ganglion  is  inaccurate, 
since  Dr.  Byrnes  presented  his  studies  upon  this  subject  before  this  Society 
more  than  a  year  ago,  and  later  published  those  studies  in  the  Johns  Hopkins 
Hospital  Bulletin,  January,  1915.  Similar  studies  have  also  been  made  by 
May  of  England.  At  the  same  time.  Dr.  Byrnes  demonstrated  his  method 
and  the  instrument  used  by  him  for  locating  the  foramen  ovale,  and  thus 
reaching  the  Gasserian  ganglion. 

Dr.  Dorrance's  lantern  demonstration  and  anatomical  illustration  of 
Hartel's  method  are  well  chosen  and  helpful,  but  Dr.  Byrnes  did  not  see  that 
any  new  technical  procedures  have  been  introduced.  It  is  well  to  remember 
that  there  is  a  small  percentage  of  skulls  in  which  the  foramen  ovale  is  so 
situated  that  the  ganglion  is  inaccessible  by  any  route,  and  his  objection  to 
Hartel's  technique  is  due  largely  to  the  fact  that  at  least  one  of  the  landmarks 
which  determines  the  direction  of  the  needle  is  itself  variable.  By  the  use 
of  the  instrument  which  he  had  adopted,  this  variability  is  overcome,  and  the 
needle  is  so  directed-  that  there  is  little  danger  of  entering  the  jugular 
foramen. 

Since  the  needle  is  sometimes  occluded  by  a  small  clot  of  blood,  it  is  well 
to  make  the  injection  with  a  syringe,  which  has  a  guard  upon  the  plunger, 
so  that  in  case  excessive  pressure  is  required  to  disengage  the  clot,  the  entire 
contents  of  the  barrel  will  not  be  injected  at  once. 


NEW  YORK  NEUROLOGICAL  SOCIETY 

February  i.  1916 

The  President,  Dr.  William  Leszynsky,  in  the  Chair 

REPORT  OF  A  CASE  OF  CEREBRAL  ABSCESS  WITH  AUTOPSY 

By  M.  Neustaedter,  M.D. 

The  patient,  a  male,  23  years  old,  had  a  negative  family  history  and  a 
negative  personal  history  for  alcoholism,  venereal  disease  or  trauma.  He 
had  had  measles  and  otitis  media  as  a  child.  Onset  of  the  present  ilhiess 
occurred  July,   191 5,  with  pain   in  the   right  side  of  the  neck,   for  which  a 


556  NEIV  YORK  XEUROLOGICAL  SOCIETY 

physician  ordered  a  tooth  extracted.  The  condition,  however,  became  worse, 
with  typical  headache,  dulness  and  difficulty  in  answering  questions.  He  was 
admitted  to  Bellevut  Hospital.  He  was  found  to  have  double  choked  discs, 
partial  auditory  aphasia,  left  oculoptosis,  unequal  pupils,  pain  on  percussion 
over  both  mastoids.  Superficial  and  deep  reflexes  were  exaggerated  and 
there  was  partial  right  hemiplegia.  Both  ear  drums  were  incised  and  pus 
obtained  which  was  stained  for  tubercle  bacilli,  but  was  negative.  Lumbar 
puncture  was  done  and  blood  examinations  made.  The  blood  count  showed : 
W.  B.  C.  20,800 ;  polys  77  per  cent. ;  lym.  23  per  cent.  A  brain  abscess  was 
suspected  and  operation  was  performed,  incising  the  left  mastoid.  Fifteen 
c.c.  of  pus  were  removed  and  the  wound  was  drained.  The  blood  Wasser- 
mann  was  positive  but  the  spinal  fluid  was  negative.  The  general  condition 
improved  with  operation,  as  well  as  papilledema  and  ptosis.  Aphasia  con- 
tinued and  hemiplegia  became  more  pronounced.  On  August  11,  while  having 
his  wound  dressed,  he  died  suddenly  from  respiratory  failure.  At  autopsy, 
the  brain  showed  marked  enlargement  on  the  left  side,  complete  flattening  of 
the  left  base  and  very  marked  dilatation  of  the  veins.  The  abscess  on  the 
left  side  was  very  extensive  and  puslied  through  the  claustrum  into  the  inter- 
nal capsule,  occluding  half  the  left  ventricle.  There  was  also  an  abscess  on 
the  right  side  in  the  tempero-sphenoidal  lobe,  burrowing  back  into  the  occipital 
lobe.     The  report  of  the  pathologist  was  a  double  tuberculous  mastoiditis. 

Dr.  Leszynsky  asked  if  this  was  looked  upon  as  a  secondary  otitic 
abscess. 

Dr.  Neustaedter  said  the  otitis  media  occurred  eight  years  before,  but 
there  was  no  history  of  a  recent  affection,  but  this  evidently  was  tlie  cause. 

A  CASE  OF  BULBAR  DISEASE  WITH  UNUSUAL  SYMPTOMS 

S.P.  Goodliart.  M.D.,  and  A.  Skversky,  M.D.   (by  invitation) 

The  patient,  Russian,  male,  22,  was  admitted  to  the  Montefiore  Hospital 
a  month  ago,  complaining  of  heaviness,  numbness  on  the  left  side,  and  paral- 
ysis of  the  left  side  of  the  face.  The  family  and  personal  history  was  nega- 
tive. The  present  trouble  dated  back  three  years  with  history  of  two  attacks. 
The  first  attack  occurred  with  pain  and  paresthesia  of  both  extremities  on 
the  left  side.  After  the  first  attack  which  kept  him  in  bed  for  two  weeks, 
he  could  not  walk  straight.  He  swayed  or  fell  to  the  right.  He  acquired 
the  use  of  the  limbs  again  but  felt  numbness  and  heaviness  in  them.  One 
year  ago  suddenly  he  felt  the  face  drawn  to  the  right  and  had  double  vision; 
his  tongue  was  thrust  to  the  side  and  he  could  not  swallow.  After  six  weeks 
there  was  slight  improvement.  The  patient  was  well  developed  and  nourished. 
Vision  was  good.  There  was  no  sexual  nor  sphincter  disturbance.  There  was 
still  complete  paralysis  of  the  left  face  and  occasional  rapid  fibrillation  of  the 
left  upi)er  abdominal  muscles.  There  was  left  adiadochokinesis,  left  upper 
asynergia,  left  astereognosis,  marked.  The  left  upper  and  lower  abdominal 
reflexes  were  absent.  Knee  jerks  present,  but  right  exaggerated.  The  X-ray 
picture  showed  that  the  whole  osseous  system  had  undergone  condensation, 
some  canals  being  obliterated.  In  conclusion,  there  was  therefore  involve- 
ment of  the  motor  cranial  nerves  of  the  left  side;  definite  sensory  disturb- 
ance, epicritic,  protopathic  and  of  deep  sensibility.  It  was  questionable 
whether  the  increased  right  knee  jerk  should  be  considered  pathological,  with- 
out further  evidence  of  pyramidal  tract  involvement.  The  case  was  one  of 
obscure  origin  when  the  onset  in  two  attacks  was  considered.  These  might 
be  apoplectiform,  but  the  course  did  not  suggest  polioencephalitis.  Each 
attack  resulted  in  a  disease  picture  which  might  be  explained  in  part.  The 
question  was  were  these  two  attacks  to  be  considered  due  to  the  same  lesion. 


NEW  YORK  NEUROLOGICAL  SOCIETY  557 

The  uniform  subjective  sensory  disturbance  of  the  initial  attack  pointed  to 
right-sided  brain  involvement,  possibly  thalamic,  but  the  second  attack  sug- 
gested bulbar  pontine  involvement.  How  was  the  isolated  astereognosis  on 
the  same  side  to  be  explained?  Was  this  a  true  cortical  astereognosis,  if  the 
the  patient  had  lost  perception  of  the  form,  size,  consistency  and  weight  of 
the  object?  The  absence  of  abdominal  reflexes  pointed  to  pyramidal  tract 
involvement,  but  there  was  nothing  else  to  bear  this  out.  The  other  isolated 
symptoms,  such  as  falling  to  the  right  and  the  present  nystagmus,  were  not 
accounted  for.  If  the  case  were  one  of  vascular  origin,  a  more  profound 
general  disturbance  might  have  been  expected.  At  no  time  had  there  been 
any  symptoms  of  intracranial  pressure,  yet  a  central  gliosis  was  a  possibility. 
One  might  account  for  the  clinical  picture  with  the  diagnosis  of  multiple 
sclerosis,  but  those  who  presented  the  case  were  not  inclined  to  regard  it  so. 
The  osseous  changes  were  those  described  in  general  luetic  disorders,  but  the 
historjr  and  serological  findings  had  not  borne  this  out.  The  possible  influ- 
ence of  the  pituitary  should  not  be  overlooked  in  view  of  the  increased  size 
of  the  sella  turcica,  with  the  general  picture  of  osteosclerosis  and  increased 
sugar  tolerance. 

Dr.  S.  P.  Goodhart  said  that  the  interest  of  the  case  seemed  the  difficulty 
of  explaining  the  symptoms  by  a  single  lesion.  A  good  deal  depended  upon 
whether  the  astereognosis  was  a  true  cortical  astereognosis.  He  would  not 
so  regard  it  on  account  of  the  inability  of  the  patient  to  interpret  objects 
held  in  the  hand.  In  cortical  astereognosis  the  form  would  be  recognized. 
A  cortical  lesion  then  might  be  ruled  out.  It  was  more  likely  to  be  thalamic 
in  character.  The  lesion  was  erratic,  affecting  the  sixth,  seventh,  avoiding 
the  eighth,  involving  the  ninth  slightly  and  the  eleventh  absolutely.  With 
the  sensory  symptoms  this  was  difficult  to  explain  with  one  lesion,  unless  a 
gliosis  were  considered  in  which  the  sensory  tract  had  crossed  the  level  of 
the  sixth  and  seventh,  but  the  lesion  was  unusual.  He  thought  the  case  was 
some  form  of  gliosis. 

Dr.  M.  Neustaedter  said  he  had  presented  a  similar  case  at  the  Section 
Meeting,  the  case  of  a  young  man,  19  years  of  age,  in  whom  the  lesion  escaped 
the  sixth  and  seventh,  but  he  had  the  other  symptoms.  In  addition  he  had 
spastic  hemiplegia  and  very  marked  astereognosis,  also  on  the  left  side.  The 
cytological  examination  was  negative.  It  was  a  question  why  there  was 
involvement  of  the  cranial  nerves  and  astereognosis  and  spasticity  on  the 
same  side.  Dr.  Neustaedter  did  not  see  why  there  should  not  be  gliosis 
producing  an  irregular  infiltration.  In  glioma  the  lesion  would  be  much 
more  circumscribed  and  produce  therefore  much  more  definite  symptoms. 
He  would  regard  the  case  as  one  of  syringobulbia. 

STUDIES  IN  THE  ESTABLISHMENT  OF  PERMANENT  DRAINAGE 
IN  CASES  OF  HYDROCEPHALUS 

By  Adrian  V.  S.  Lambert,  M.D. 

Dr.  Lambert  stated  that  procedures  had  been  evolved  for  the  relief  of  this 
condition,  but  not  one  had  been  permanently  retained.  Recently  treatment 
had  been  based,  however,  on  correct  physiology.  It  was  recognized  that  the 
fluid  was  absorbed  mainly  into  the  large  venous  sinuses  through  the  arachnoid 
villi,  and  perhaps,  slightly,  through  the  lymphatic  system.  The  absorption 
took  place  much  more  rapidly  from  the  cranial  arachnoid  space  than  from 
the  spinal.  The  so-called  "  circulation  "  of  the  cerebrospinal  fluid,  which  was 
secreted  in  the  ventricles,  was  into  the  arachnoid  space,  thence  into  the  blood. 
Observers  had  shown  that  the  rate  of  flow  could  be  increased  by  compression 


558  XEir  YORK  XEUROLOGICAL  SOCIETY 

of  the  jugulars,  and  ligation  of  the  internal  carotid  arteries  perhaps  dimin- 
ished the  rate  of  secretion  and  favorably  influenced  cases.  Hydrocephalus 
resulted  from  increases  of  ratio  of  secretion,  as  compared  with  absorption. 
One  of  three  conditions  might  occur:  (i)  an  increase  in  rate  of  secretion, 
with  normal  absorption;  (2)  a  normal  rate  of  secretion  with  diminished 
rate  of  absorption;  (3)  an  increased  rate  of  both  secretion  and  absorption, 
with  greater  secretorj-  increase.  In  all  three  cases  an  accumulation  of  fluid 
resulted,  with  increased  intracranial  pressure.  Relief  might  occur  by  increas- 
ing absorption  or  diminishing  secretion.  Cases  that  might  be  favorably 
influenced  by  treatment  were  those  whose  lesion  was  not  removable  by  opera- 
tion, or  with  increased  intraventricular  tension,  due  to  inaccessible  neoplasm. 
Two  kinds  of  cases  were  classified:  (i)  obstructive,  in  which  the  passage  of 
fluid  was  interfered  with;  (2)  co»imiinicatinij,  where,  despite  free  flow  from 
the  ventricles,  there  occurred  accumulation  of  fluid  under  increased  tension. 
Ligation  of  the  carotids  had  been  found  too  risky  a  procedure  to  use  to 
diminish  rate  of  secretion.  Methods  to  increase  the  rate  of  absorption  were 
therefore  considered.  Very  manj'  substances  had  been  employed  in  attempts 
to  drain  the  ventricles,  but  most  of  them  gave  rise  to  irritative  reactions  in 
the  tissues.  In  the  search  for  an  ideal  non-irritative  substance  for  a  perma- 
nent connection  between  the  ventricles  and  tlie  archnoid  space,  colloidin  had 
been  suggested  and  was  found  non-irritative.  It  was,  however,  impossible  to 
make  tubes  of  it  and  collodion  had  been  used  as  a  substitute.  The  tubes  of 
this  substance  could  be  sterilized,  were  not  brittle,  were  light,  non-collapsible, 
and  withstood  reasonable  manipulation.  With  the  employment  of  these  tubes 
permanent  drainage  had  been  effected  between  the  ventricles  and  the  arach- 
noid space  by  introducing  a  tube  through  the  corpus  callosum  and  leaving  it 
in  situ.  Further  opportunities  of  drainage  were  now  sought  to  increase 
absorption.  The  peritoneal  cavity  was  considered  as  it  was  well  known  that 
it  could  absorb  an  enormous  quantity'  of  fluid.  The  procedure  of  uniting  the 
ventricles  with  the  peritoneal  cavity  had  been  hitherto  considered  severe,  the 
mortality  being  high.  There  was  too  rapid  an  escape  of  fluid,  and  free  drain- 
age had  not  been  maintained.  By  the  employment  of  collodion  tubes  which 
telescoped  one  another  a  permanent  free  drainage  had  been  obtained,  the 
lower  end  of  the  tube  being  kept  open  inside  the  larger  tube.  This  procedure 
had  been  found  effective.  It  was  not  difficult  and  the  peritoneal  manipulation 
had  been  found  so  slight  as  not  to  give  rise  to  any  shock.  The  opening  of 
the  skull  was  of  such  short  duration  as  to  be  borne  by  most  patients.  Two 
incisions  were  necessary — one  lYi  inches  over  the  twelfth  rib,  deepened  down 
to  the  peritoneum,  without  opening  the  latter ;  one  in  the  neck  from  the 
external  occipital  protuberance  downward  for  2  inches.  A  long  canula  was 
passed  from  the  lower  wound  to  the  upper  and  the  larger  tube  passed  through 
it.  The  flange  of  the  tube  was  implanted  into  the  peritoneal  cavity.  An 
opening  was  then  made  in  the  occipital  bone,  the  arachnoid  space  was  opened, 
and  the  smaller  tube  was  passed  down  inside  of  the  larger  one.  The  wounds 
were  then  closed.  Collodion  had  been  found  absolutely  non-irritative  for  this 
and  other  procedures,  such  as  implantation  in  sheets  to  prevent  formation  of 
adhesions,  or  for  adherent  dura,  or  removal  of  neoplasms.  No  ill  effects  had 
been  observed. 

Dr.  B.  Sachs  said  he  had  never  attempted  to  establish  a  connection  be- 
tween the  brain  and  the  abdomen,  and  therefore  felt  very  incompetent  to 
discuss  the  question.  In  the  first  operation  referred  to  he  was  reminded  of 
a  callosal  operation  where  the  attempt  was  made  to  establish  a  connection 
between  the  ventricles  and  the  arachnoid  space.  If  one  could  be  sure  of 
establishing  a  permanent  drainage  the  case  might  be  successful,  but  the 
trouble  usually  was  that  the  drainage  was  not  permanent.  He  would  like  to 
ask  the  doctor  in  how  many  cases  this  method  had  been  tried. 


NEW  YORK  NEUROLOGICAL  SOCIETY  559 

Dr.  Lambert  answered  that  the  corpus  callosum  connection  had  been  tried 
in  a  good  many  cases,  children  as  well  as  adults,  and,  so  far  as  they  could 
tell,  permanent  drainage  had  been  established. 

Dr.  Sachs  said  the  procedures  were  very  interesting  and  the  results  in  a 
large  number  of  cases  should  be  watched  for.  He  would  like  to  ask  if  the 
other  procedure  was  an  easy  one  and  how  long  could  the  connection  be  kept 
open. 

Dr.  Lambert  said  he  did  not  know  exactly  how  long,  but  at  least  several 
months. 

Dr.  Brush  said  he  had  seen  two  such  cases,  where  permanent  drainage 
had  been  established  through  the  corpus  callosum.  A  child  had  been  kept 
alive  for  nine  months,  but  be5^ond  that  there  was  no  noticeable  improvement. 
The  death  finally  occurred  from  marasmus.  The  question  was,  was  it  really 
worth  while  keeping  a  child  alive  in  a  case  where  the  brain  was  badly  mal- 
formed from  birth  and  the  child  would  be  defective?  Simply  to  perpetuate 
malformed  beings  could  be  hardly  worth  the  trouble. 

Dr.  Leszynsky  said  he  was  not  familiar  with  the  method  of  drainage 
from  the  subarachnoid  space  or  into  the  peritoneum.  He  had  had  some  expe- 
rience with  the  corpus  callosum  method.  The  doctor  had  said  his  procedure 
was  a  simple  affair.  He  would  like  to  ask  if  it  was  difficult  to  pass  the  tube 
into  the  ventricle.  Was  it  strong  enough  to  go  through  the  callosum,  or  had 
it  to  be  passed  afterwards?  Sometimes  when  the  callosum  had  been  punc- 
tured the  opening  remained  patent  for  many  months. 

Dr.  Lambert  said  the  tubes  were  passed  on  the  stiff  canula.  They  fitted 
on  the  end  of  it.     The  canula  was  withdrawn  and  the  tubes  were  left  in  situ. 


SOME  APPLICATIONS  OF  THE  NEURO-BIOLOGICAL  METHOD 
OF  INVESTIGATION  TO  THE  STUDY  OF  CONSCIOUSNESS 

By  Stewart  Paton,   M.D.    (by  invitation) 

Dr.  Paton  gave  this  paper  to  the  Society  rather  as  a  point  of  view  than  as 
a  statement.  A  philosopher  had  said  that  only  one  thing  was  more  mislead- 
ing than  statistics  and  that  was  a  fact.  This  principle  was  apt  to  hold  where 
isolated  facts  were  concerned.  The  problem  of  consciousness  should  be 
approached  from  the  broad  biological  standpoint  and  it  would  then  be  found 
that  some  of  the  difficulties  of  this  investigation  would  vanish.  Reactions  of 
organisms  should  be  studied  as  units.  Even  the  reflex  could  not  be  under- 
stood by  itself,  but  only  in  connection  with  all  the  other  biological  reactions. 
Reactivity  depended  upon  factors  both  inside  and  outside  of  the  nervous  sj^s- 
tem.  Any  problem  of  reactivity  looked  at  only  from  the  human  standpoint 
was  unnecessarily  complicated.  Excellent  material  for  the  study  of  the 
simplest  reactions  of  the  embryo  was  found  in  the  shark,  lizard,  guinea-pig, 
rat  and  chick.  In  the  case  of  the  shark  embryo  it  was  possible  to  study  the 
primitive  functions  in  relation  to  the  structural  changes  without  disturbing 
the  natural  environment.  When  approaching  the  great  problem  of  correlation 
of  structure  and  function  from  the  comparative  point  of  view,  the  great  gulf 
which  seemed  to  exist  between  man  and  the  lower  animals  did  not  seem  to 
be  broad  or  deep  enough  to  discourage  the  investigator  in  his  efforts.  As  a 
matter  of  fact  the  functions  of  the  lower  animals  and  those  of  man  did  not 
seem  to  show  any  greater  contrast  than  existed  between  the  lower  and  higher 
functions  of  the  human  brain.  Until  quite  recently  the  number  of  investi- 
gators in  this  important  field  was  a  limited  one.  Wintrebert,  a  French  sci- 
entist, had  attempted  to  bring  the  simple  reactions  of  the  organism  into  some 
sort  of  correlation  with  the  structural  conditions.  The  first  movements  that 
took  place  in  the  embryo  were  those  of  the  heart  and  it  was  not  diflficult  to 


56o  XEir  YORK  NEUROLOGICAL  SOCIETY 

think  of  the  causes  which  gave  rise  to  the  cardiac  pulsations  as  being  quite 
similar  to  the  changes  taking  place  in  chemical  reactions.  The  first  move- 
ments of  the  body  were  not  influenced  by  incident  stimuli ;  in  other  words, 
the  organism  was  not  responsive  to  external  excitation.  At  the  moment  inci- 
dent stimuli  became  effective  the  reflex  arc,  marked  by  bundles  of  neuro- 
fibrils, but  without  anj^  signs  of  medullation,  was  completely  diflferentiated. 
A  chick  embryo  at  120  hours  of  incubation,  placed  in  Ringer's  solution,  re- 
sponded readily  to  stimulation  by  means  of  a  platinum  electrode  connected 
with  a  single  drj-  cell.  At  this  period  when  the  first  reactions  to  incident 
stimuli  began,  a  number  of  important  organs  had  been  differentiated  and  had 
received  their  nerve  supply.  Large  bundles  of  neuro-fibrils  might  be  detected 
running  from  the  vagus  to  the  thyroid ;  and  other  bundles  were  noted  in  con- 
nection with  the  adrenals.  The  sympathetic  nervous  system  had  reached  an 
advanced  stage  in  the  development.  In  connection  with  the  conduction  of 
currents  by  these  primitive  nerve  tracts  prior  to  the  appearance  of  medullary 
sheaths  it  was  interesting  to  note  that  there  was  a  possibility  of  the  nervous 
impulse  following  the  law  in  the  invertebrates  of  running  in  both  directions. 
There  were  reasons  for  asking  whether  the  specificity  of  the  posterior  and 
anterior  roots  might  not  begin  with  medullation.  The  question  was  an  inter- 
esting one  as  to  whether  medullation  determined  the  direction  of  the  nerve 
current.  The  correlation  of  structure  and  function  in  the  case  of  these  primi- 
tive responses  had  a  very  important  bearing  on  the  problem  of  consciousness. 
The  higher  forces  of  consciousness  were  undoubtedly  closely  related  to  the 
functional  activitj'  of  the  higher  brain  centers,  namely,  those  contained  in  the 
cerebral  cortex.  From  what  was  already  known  about  the  physiology  of  the 
brain  it  was  quite  clear  that  we  could  not  understand  the  functions  of  the 
higher  centers  without  considering  these  in  their  relation  to  the  mechanism 
of  the  great  basal  ganglia.  The  functions  of  the  cortex  were  long  misunder- 
stood and  only  recently  had  it  been  appreciated  that  this  structure  controlled, 
but  did  not  initiate  legislation.  In  the  primitive  reactions  of  the  embryo 
there  existed  an  excellent  opportunity  for  observing  the  development,  not 
only  of  the  basal  ganglia,  but  also  changes  taking  place  in  the  cortex 
could  be  noted,  when  it  first  began  to  be  a  dominant  factor  in  determin- 
ing the  character  of  the  mechanism.  Professor  H.  H.  Lane  had  shown 
that  the  first  reactions  to  olfactory  stimuli  took  place  at  a  time  wlien  the 
terminations  of  the  nerves  in  the  olfactor3-  bulb  were  connected  directly  with 
the  basal  ganglia,  medulla  and  cord  without  any  relations  to  the  cortex.  It 
was  an  extremely  interesting  problem  to  try  to  analj'ze  the  different  elements 
entering  into  the  reaction  when  the  higher  centers  had  assumed  control. 
Other  centers  were  capable  of  being  studied  in  a  similar  manner.  One  im- 
portant fact  in  connection  with  these  primitive  reactions  deserved  special  con- 
sideration, and  that  was  at  the  moment  when  the  embryo  first  reacted  to  inci- 
dent stimuli  in  the  shape  of  electrical  stimulation  or  needle  pricks,  although 
the  thyroid  and  adrenals  were  included  in  the  closed  circuit,  the  sex  glands 
had  neither  received  their  nerve  supply  nor  were  they  sufficiently  differ- 
entiated to  be  taken  into  account.  This  might  indicate  that  the  thyroid  and 
adrenals  became  factors  of  dominant  importance  in  neuro-biologic  reactions 
at  a  period  which  preceded  that  of  the  sex  glands.  (Dr.  Paton  then  showed 
lantern  slides,  illustrating  the  development  of  neurofibrils  in  the  embrj'O, 
showing,  the  early  development  of  the  sympathetic,  thyroid,  spina!  ganglia  as 
well  as  the  thyrriid  and  adrenals.) 

Dr.  Bernard  Sachs  said  that  Dr.  Paton  had  given  tlum  more  material  to 
digest  than  to  discuss.  He  had  great  hesitation  in  making  statements  on  the 
subject.  He  felt  that  this  presentation  was  very  much  in  line  with  the  work 
of  Edingcr  in  comparative  embryologj'.  Dr.  Sachs  believed  that  the  corre- 
lation of  structure  and   function  couli  be  l)est  attempted  on  this  line.     The 


NEW  YORK  NEUROLOGICAL  SOCIETY  561 

problem  which  engaged  Edinger  was  the  first  beghining  of  consciousness  as 
exhibited  in  the  lower  animals.  In  an  exhibition  of  some  mechanical  toys 
he  had  shown  that  what  were  usually  considered  conscious  movements,  such 
as  avoidance  of  an  obstacle,  were  really  to  be  explained  by  laws  of  physical 
forces.  The  whole  subject  was  extremely  complex,  and  Dr.  Sachs  could  not 
say  how  the  psychologist  was  coming  out  in  the  solution  of  many  of  the 
problems  offered  by  this  study.  In  most  textbooks  on  psychology  there  was 
a  long  first  chapter  devoted  to  the  anatomy  of  the  brain,  and  this  was  care- 
fully avoided  in  the  rest  of  the  book.  The  fact  pointed  out  by  Dr.  Paton  of 
the  very  early  innervation  of  the  thyroid  and  adrenals  was  of  great  interest. 
Presumably  these  organs  had  most  to  do  with  the  early. physical  development 
of  the  chief  organs  of  the  body,  and  they  needed  their  nerve  supply  very 
much  earlier  than  the  other  parts.  In  regard  to  the  point  of  localization.  Dr. 
Sachs  was  glad  to  hear  that  Dr.  Paton  was  returning  to  the  standpoint  of 
his  old  master,  Golz,  who  was  always  an  antagonist  of  the  view  of  strict 
cerebral  localization,  and  who  always  claimed  that  it  was  an  absurdity  to  say 
that  the  brain  was  divided  into  small  sections  with  special  function.  He 
claimed  that  function  was  the  result  of  cooperation  of  many  different  parts 
of  the  brain.  The  paper  to-night  gave  neurologists  a  great  deal  of  inspira- 
tion. Dr.  Sachs  hoped  that  Dr.  Paton  would  elaborate  this  early  beginning. 
They  would  be  very  glad  if  this  suggestion  led  to  a  further  study  of  the  ques- 
tion of  consciousness. 

Dr.  E.  Fisher  said  that  Dr.  Paton  had  stated  the  materialistic  side  of 
mental  action.  It  could  be  said  that  he  had  given  a  body  blow  to  psycho- 
analysis. In  regard  to  neurofibrils  and  medullated  fibers.  Dr.  Paton  was 
speaking  of  a  verj^  primitive  form  of  reaction.  In  specialized  reaction  there 
must  be  some  form  of  insulation.  In  regard  to  distinct  areas  of  localization. 
Dr.  Fisher  thought  one  must  have  these.  He  could  agree  with  the  generali- 
zation of  control,  but  in  pathology  certain  areas  were  found  destroj^ed  by 
disease,  resulting  in  impaired  function.  There  were  higher  centers,  but  one 
did  not  know  exactly  what  that  meant  in  mental  action.  At  the  same  time 
one  could  not  do  without  definite  areas  of  the  brain  that  responded  to  the 
spoken  or  written  idea.  Dr.  Fisher  thought  the  meeting  owed  a  great  deal 
to  Dr.  Paton  for  awakening  interest  in  new  ideas  of  mental  action. 

Dr.  Walter  Timme  said  there  were  two  questions  on  the  sympathetic 
development  of  the  earlj^  embryo  which  were  interesting.  The  reason  for  the 
earl}'  development  of  a  comparatively  large  mass  of  sympathetic  fibers  might 
be  answered  as  follows  :  The  sympathetic  nervous  system  did  not  alone  con- 
trol function,  but  it  did  also  control  the  actual  cell  growth.  It  regulated  both 
the  number  and  character  of  the  cells.  In  the  earty  period  of  life  cells  in- 
creased to  the  most  rapid  extent,  so  that  it  would  follow  that  the  fibers  which 
controlled  normal  development  would  have  to  be  increased  in  proportion.  In 
experiments  on  animals  results  had  been  shown,  that  if  one  cut  the  sj'mpa- 
thetic  fibers  and  excluded  them  from  performing  their  function,  the  organism 
would  change  macroscopically.  The  actual  increase  or  decrease  of  cells 
would  depend  on  the  nature  of  the  experiment.  With  diminished  vagus  con- 
trol over  the  glandular  region  of  the  stomach  and  intestine  there  was  actual 
increase  in  the  number  of  cells.  With  diminished  sympathetic  fibers  there 
was  actual  diminution  of  the  cells.  As  to  the  antidromic  passage  of  the  cur- 
rent in  non-medullated  fibrils,  that  occurred  in  the  higher  animals.  All  of  the 
post-ganglionic  fibrils  were  non-medullated,  in  distinction  to  those  which 
passed  from  the  spinal  cord  to  the  ganglion,  which  were  medullated.  In  post- 
ganglionic axon  reflexes  the  current  passed  both  ways.  Actual  stimulation  at 
the  upper  portion  of  the  gut  caused  the  current  to  pass  through  the  non- 
medullated  fibers  in  an  antidromic  direction,  and  so  cause  the  following  sec- 
tion of  gut  to  adapt  itself  to  the  oncoming  bolus.     The  meeting  owed  Dr. 


562  XEIV  YORK  XEUROLOGICAL  SOCIETY 

Paton  sincere  thanks  for  his  clarity  of  presentation  of  a  new  viewpoint  in 
the  stud}-  of  consciousness. 

Dr.  Joseph  Byrne  said  that  it  had  been  well  known  for  a  long  time  that 
the  basal  ganglia  had  functions  similar  to  those  referred  to  by  Dr.  Paton. 
It  was  a  commonplace  in  the  physiological  laboratory  to  find  that  after  re- 
moval of  the  cerebral  cortex  a  frog  could  avoid  obstacles.  Such  a  frog, 
however,  was  utterh-  incapable  of  conceptualizing,  and  would  starve  to  death 
though  food  lay  in  front  of  it.  Sherrington  had  recently  shown  that  the 
cerebral  cortex  was  not  necessarj-  for  the  elicitations  of  auditor\-  reactions. 
Again,  clinico-pathological  study  had  shown  that  in  lesions  isolating  the 
thalamus  from  the  cortex  certain  affective  elements  of  sensation  were  pre- 
served, viz.,  those  evoked  chiefly  b^'  protopatiiic  stimulation.  Dr.  Byrne  did 
not  feel  that  Dr.  Paton,  in  so  far  as  he  had  gone,  reallj-  touched  upon  the 
phenomena  of  consciousness.  The  electrical  and  olfactorj'  reactions  men- 
tioned did  not  rise  to  the  dignity  of  consciousness  as  the  term  is  understood. 

Dr.  S.  P.  Goodhart  said  that  Dr.  Paton  adroitly  avoided  going  deeply 
into  the  subject  of  higher  forms  of  consciousness,  though  stimulating  im- 
portant considerations  from  the  doctor's  most  instructive  demonstrations. 
The  theme  of  correlation  of  nerve  reaction  and  function  had  been  given  a 
clear  aspect  and  the  speaker's  experiments  and  deductions,  simple  in  them- 
selves, were  the  more  valuable  as  bearing  out  Dr.  Paton's  contention  that 
consciousness,  as  conceived  in  man,  would  finally  be  most  clearly  understood 
by  first  observing  the  simplest  processes  of  nerve  structure  in  its  relation 
to  the  development  of  function  in  the  lower  forms.  If  consciousness  in  the 
humble  species,  the  frog,  for  example,  was,  as  Dr.  Paton's  experiments  may 
be  regarded,  but  reflex,  then  in  man  too  could  not  one  regard  conscious 
activities,  even  judgment,  volition,  emotional  reaction,  as  but  highly  complex 
reactions,  automatic  or  reflex ;  such  reflex  responses  as  the  result  of  past 
experience  within  the  individual,  acquired  and  inherited  formulae,  physically 
formulated  to  expression.  Then.  too.  as  Dr.  Paton  had  set  out  to  show,  the 
basal  ganglia,  perhaps,  had  not  lost  their  original  dignity.  Thus,  the  simple 
process  of  consciousness  conceived  as  such  in  the  frog,  apparentl}^  a  simple 
reflex,  might  be  the  fundamental  physical  principle  upon  which  one  based  the 
most  complex  mechanism  of  consciousness  in  the  higher  animals. 

Dr.  L.  Casamajor  said  that  he  had  understood  Dr.  Paton  to  make  the 
point  that  the  problem  was  best  approached  by  beginning  with  simple  things 
and  working  upward  ;  thus  anatomical  structures  were  brought  into  relation 
with  function,  and  consciousness  studied  from  the  point  of  view  of  the  dif- 
ferent elements  which  go  to  form  it  rather  than  as  a  single  entity.  The  point 
Dr.  Paton  had  made  that  no  reflex  defensive  reactions  were  possible  in  the 
embryo  till  both  parts  of  the  reflex  arc  had  established  their  connection  with 
the  periphery,  was  an  important  one,  as  establishing  the  fact  that  proper 
nervous  connections  were  necessary  for  the  animal's  defensive  reactions.  Dr. 
Byrne's  remarks  concerning  the  inability  of  the  de-cerebrated  frog  to  seek 
out  food,  although  he  could  still  avoid  obstacles,  seemed  rather  far  from 
the  point.  It  did  not  prove  the  dependence  of  consciousness  upon  the  cortex. 
The  cerbrum  in  the  frog  was  merely  an  olfactory  receiving  station  and  when 
it  was  removed  the  animal  lost  his  olfactory  memories  upon  which  he  was 
obliged  to  rely  for  his  choice  of  food.  There  were  certainly  elements  of 
consciousness  in  other  nervous  tissue  besides  the  cerebral  cortex.  The  spinal 
cord  held  something  of  consciousness  in  its  reflex  active  capacity.  Likewise 
there  were  elements  of  consciousness  in  the  sensory  nuclei  of  the  medulla 
and  surely  in  the  thalamus.  The  simple  reflex  act  itself  implied  something 
of  memory  in  its  capacity  for  repetition.  This  was  the  memory  of  sensory 
impulse,  and  it  was  upon  sensory  memories  that  all  consciousness  was  based. 


NEW  YORK  NEUROLOGICAL  SOCIETY  563 

Dr.  Stewart  Paton,  in  closing  the  discussion,  said  that  he  did  not  mean 
his  remarks  to  apply  to  localization  proven  by  clinical  experience,  but  to 
some  of  the  absurd  theories  that  were  advanced  from  time  to  time.  As 
regards  consciousness,  he  had  endeavored  to  make  it  plain  that  he  had  sug- 
gested a  point  of  view,  rather  tlian  given  information.  He  wanted  to  get  as 
many  people  as  possible  to  approach  the  subject  from  the  simple  to  the  com- 
plex. If  he  had  approached  it  from  the  higher  standpoint  there  would  be 
very  little  chance  of  dealing  with  the  subject  in  one  evening.  There  was  no 
doubt  that  the  basal  ganglia  had  a  tremendous  influence  on  the  higher  centers. 
Reflexes  moved  higher  and  finally  reached  the  cortex. 

Dr.  Lesz}-nsky  said  he  knew  he  was  voicing  the  sentiment  of  the  meeting 
when  he  said  that  they  were  very  much  indebted  to  Dr.  Paton  for  this  valua- 
ble paper. 


^ranelattons 


VEGETATIVE    NEUROLOGY,    THE    ANATOMY,    PHYSI- 
OLOGY. phar:\iodyxamics  and  pathology  of 

THE  SYMPATHETIC  AND  AUTONOMIC 
SYSTEM 

Bv    HeINRICII    HlGIER 


Authorized  Translation  by  Walter  'Max  Kraus,  A.M.,  M.D. 
[New  York]. 

(Continued  from  page  470) 

17.  There  exists  a  further  physiological  fact  of  the  greatest 
importance  in  regard  to  the  vegetative  nervous  system,  that  is,  a 
definite  antagonism  between  its  various  parts.  This  antagonism 
has  been  recognized  for  some  time.  The  newer  researches  upon 
its  significance  promise  to  be  of  great  clinical  value. 

Anatomical  investigations  by  the  histological  method  and  pharma- 
cological investigations  by  the  nicotine  method  have  separated  the 
vegetative  and  sensori-motor  systems.  Further  stuflies  have  shown 
that  the  vegetative  nerv'ous  system  itself  may  be  divided  both  an- 
atomically and  physiologically  into  two  elements,  the  sympathetic 
and  the  autonomic. 

Let  us  see  how  the  physiologists,  who  of  late  years  have  devoted 
much  attention  to  this  subject,  have  established  this  division  and 
how  they  define  it  anatomically,  physiologically  and  pharma- 
cologically. The  definition  is  quite  empirical  and  therefore  some- 
what incomplete. 

"  Autonomic  fibers  are  all  efiferent  fibers  of  the  vegetative  system 
which  are  not  sympathetic  "  is  the  statement  of  Froclich,  who  draws 
his  conclusions  from  his  own  researches  and  from  results  of  the 
pharmacologists,  Meyer  and  Gottlieb.  "Those  organs  which  are 
innervated  by  the  sympathetic  include  all  involuntary  organs  whose 
innervation  is  derived  from  the  thoracico-lumbar  spinal  cord  [DT 
to  LTV].  All  other  nerve  tracts  which  supply  smooth  muNcle, 
glands  and  heart  muscle  are  autonomic."     This  is  another  of  Froe- 

564 


VEGETATIVE  NEUROLOGY  565 

lich's  definitions.  He  goes  on :  "  The  autonomic  system  proceeds 
from  varioiis  parts  of  the  cerebrospinal  axis.  The  uppermost  part 
springs  from  the  midbrain,  goes  to  the  cihary  gangHon  and  to  the 
smooth  muscle  of  the  eye.  This  is  designated  the  midbrain  auto- 
nomic. The  second  part  receives  fibers  which  travel  by  the  facial 
nerve  and  pass  into  the  chorda  tympani  to  the  mucous  membrane 
of  the  mouth  and  to  the  salivary  glands.  The  chorda  tympani  is 
a  part  of  the  bulbar  autonomic  system.  The  glossopharyngeal  and 
vagus  ner\'es  also  belong  to  this  part  of  the  autonomic.  The  latter 
nerve  supplies  the  thoracic  viscera  and  the  viscera  in  the  upper  part 
of  the  abdominal  cavity.  The  pelvic  nerve  arises  from  the  sacral 
part  of  the  spinal  cord,  particularly  from  its  first  two  segments. 
This  nerve  constitutes  the  sacral  autonomic  system.  It  supplies  the 
viscera  of  the  pelvis  and  the  genital  organs. 

Between  the  parts  of  the  spinal  cord  which  have  been  described 
there  are  areas  having  nothing  to  do  with  the  vegetative  nervous 
system.  One  may  surmise  from  this  that  the  cranial  autonomic 
had  its  origin  far  cephalad  and  then  wandered  caudad.  It  inner- 
vates the  entire  gastro-intestinal  tract  as  far  as  the  descending  colon 
as  well  as  all  organs  which  had  their  origin  in  the  digestive  tube, 
as  for  example  the  lungs.  The  sacral  part  of  the  autonomic  arose 
from  the  caudal  end  of  the  cerebrospinal  axis  and  developed  up- 
ward from  the  anal  region  until  it  met  the  cranial  part  in  the -colon 
region.  Between  lies  the  sympathetic,  which  with  few  exceptions 
reaches  and  supplies  all  involuntary  organs  of  the  body  and  with 
varying  degree." 

Eppinger  and  Hess,  the  Vienna  clinicians  of  the  school  of  v. 
Noorden,  basing  their  observations  upon  the  older  work  of  the 
English  physiologists  state :  "  The  vegetative  nervous  system  may 
be  defined  both  anatomically  and  functionally.  Those 'fibers  which 
arise  in  the  thoracic  and  newer  lumbar  segments  of  the  spinal  cord 
and  the  sympathetic  cord  comprise  an  anatomical  unit.  After  the 
fibers  have  left  the  sympathetic  cord  anatomical  dififerentiation  is 
difficult,  for  the  sympathetic  fibers  are  mixed  with  others  on  their 
way  to  the  end  organs.  The  second  anatomical  entity  is  character- 
ized by  the  fact  that  its  fibers  arise  from  the  midbrain  and  medulla 
as  well  as  from  the  sacral  cord  and  that  they  have  no  relation  to  the 
sympathetic  cord. 

On  gross .  anatomical  grounds  the  origin  is  divided  into  three 
parts,  cranial,  lumbar  and  sacral.  The  cranial  part  passes  into  the 
oculomotor  nerve,  is  interrupted  in  the  ciliary  ganglion  and  sup- 
plies  certain   parts   of   the  eye.     The   bulbar  part   passes   into   the 


566  HEINRICH  HIGIER 

facial  and  glossopharyngeal  nerves  and  supplies  fibers  to  the  salivary 
glands  and  the  vasodilator  muscles  of  the  head.  The  most  im- 
portant nerve  of  the  bulbar  part  is  the  vagus,  the  main  nerve  of  the 
viscera.  It  supplies  fibers  to  the  heart,  bronchial  tubes,  esophagus, 
stomach,  intestine  and  pancreas.  The  sacral  part,  spoken  of  an- 
atomically as  the  pelvic  nerve,  supplies  fibers  to  the  descending  colon, 
the  sigmoid,  anus,  bladder  and  genital  organs. 

For  the  sake  of  brevity  it  is  customary  to  speak  of  all  fibers 
which  pass  through  the  sympathetic  cord  as  the  sympathetic  while 
all  other  fibers  comprise  the  autonomic  or  "  extended  vagus."  It  is 
noteworthy  in  this  connection  that  it  is  comparatively  easy  to  sepa- 
rate the  two  systems  at  the  cerebrospinal  axis,  while  it  is  exceedingly 
difficult,  almost  impossible,  to  separate  them  at  the  periphery.^ 

1 8.  There  are  two  general  classes  of  fibers  in  both  the  autonomic 
and  the  sympathetic  systems,  (a)  positive,  stimulating,  vaso-viscero- 
glandulomotor  fibers,  (b)  negative,  inhibitory,  vaso-viscero-glandulo- 
inhibitory  fibers.  The  normal  state  of  irritability  of  the  ganglion 
cells  is  regulated  through  delicate  activities  of  inhibition  and  stimula- 
tion, so  that  the  apparently  superfluous  inhibitory  influences  are  in 
reality  an  invaluable  psychic  property  of  the  central  nervous  system. 

19.  Another  noteworthy  characteristic  of  vegetative  end  organs 
is  that  they  are  supplied  not  only  by  all  the  paths  going  through  the 
sympathetic  cord  (sympathetic  fibers )  but  also  by  the  fibers  of  the 
second  system  (autonomic).  Thus  practically  no  involuntarily 
acting  organ  exists  which  is  not  doubly  innervated. 

The  sweat  glands,  pilomotor  muscles  and  vascular  muscles  of 
the  viscera  form  an  exception  in  that  they  are  only  supplied  by  the 
sympathetic. - 

However,  pharmacological  j^roof,  which  many  consider  most  im- 
portant, indicates  that  these  structures,  particularly  the  sweat  glands, 
are  innervated  by  the  autonomic.  It  is  in  our  opinion  quite  improb- 
able on  a  priori  grounds  that  there  should  be  any  exception  to  the 
rule  that  all  organs  are  doubly  innervated.  We  are  rather  inclined 
to  believe  that  dififusely  located  ganglion  cells  exist  in  the  cerebro- 
spinal axis,  which  belong  neither  to  the  mesencephalic,  bulbar  nor 
sacral  groups  of  autonomic  structures  and  which  supply  the  sweat 
glands,  pilomotor  muscles  and  vascular  muscles  with  autonomic 
fibers.  .  The  apparentlv  strange  division  of  the  autonomic  would 
be  fcjund  untrue  by  this  rational  theory. 

'  .See  EppiiiKcr  and  Hess.  VaKotoiiia.  Nervous  aiul  Mental  Disease 
Monoeraph  Scries  Xo.  21. 

-  For  an  interesting  and  enlighteninp  discussion  of  this  matter  see  Gaskell, 
The  Involuntary  Nervous  System,   1916. 


VEGETATIVE  NEUROLOGY  567 

20.  Simple  investigations  with  electrical  stimulation  showed  that 
in  many  organs  stimulation  of  one  system  served  to  inhibit  the  activi- 
ties of  the  other.  Thus  both  systems,  the  sympathetic  and  the  auto- 
nomic, showed  physiological  antagonism.  Impulses  going  to  organs 
from  the  sympathetic  as  a  rule  acted  contrariwise  to  stimuli  from 
the  autonomic.  As  an  example :  The  bulbar  autonomics  have  a 
vasodilator  effect  upon  the  blood  vessels  of  the  head,  while  the 
cervical  sympathetic  acts  in  a  vasoconstrictor  fashion.  Some  doubly 
innervated  organs  do  not  have  muscles  which  act  exactly  oppositely 
to  one  another,  ?'.  e.,  like  the  sphincter  and  dilator  pupillae,  but  there 
is  but  one  group  of  muscles.  Yet  stimulation  of  one  part  of  the 
vegetative  will  cause  shortening,  of  the  other  part  lengthening  of  the 
muscle. 

The  double  innervation  is  a  very  important  characteristic,  one 
which  is  not  found  in  the  psychomotor  system.  The  cervico- 
thoracico-sympathetic  fibers  are  opposed  functionally  and  pharma- 
cologically to  the  cranial  autonomic  fibers,  and  the  thoracico-lumbar 
fibers  have  the  same  relation  to  the  sacral  autonomic,  the  pelvic 
nerve. 

(a)  The  pupil,  tear  glands,  salivary  glands,  and  cerebral  blood 
vessels  are  supplied  by  both  the  cranial  autonomic  and  the  cervical 
sympathetic. 

(b)  The  heart,  stomach  and  intestines  are  supplied  by  the 
autonomic  vagus  nerve  and  the  thoracic  sympathetic. 

(c)  The  recto-vesico-genital  apparatus  is  supplied  by  the  sacral 
autonomic  system  and  the  lumbar  sympathetic.  In  a  word  the 
autonomic  and  sympathetic  are  like  an  object  and  its  mirrored  image, 
are  like  the  positive  and  negative  of  a  photograph  (Froelich). 

Just  as  there  are  physiologically  opposed  stimuli,  so  there  are 
chemically  opposed  stimuli  both  of  exogenous  and  endogenous  origin 
(atropin  and  pilocarpin,  adrenalin  and  chohn).  If  two  oppositely 
acting  substances  are  used  at  once  the  more  powerful  gains  the  upper 
hand  just  as  in  experimental  stimulation  of  the  autonomic  and 
sympathetic  nerves  to  the  heart,  the  influence  of  the  more  powerful 
vagus  predominates,  causing  brachycardia,  and  in  the  eye  the  auto- 
nomic fibers  in  the  oculomotor  nerve  predominate  causing  miosis. 

The  normal  progress  of  activity  in  visceral  organs  is  therefore 
an  orderly  result  of  oppositely  acting  stimulation.  The  purpose  of 
this  antagonism  is  to  prevent  the  activity  of  the  various  organs  from 
going  to  one  extreme  or  the  other. 

21.  Since  the  nerves  of  both  systems  are  mixed  with  other  nerves 
on  their  wav  to  organs,  the  relations  of  the  nerves  to  each  organ 


568  HEIXRICH  HIGIER 

must  be  worked  out  anatomically,  physiologically  and  pharma- 
cologically. The  following  points  which  were  not  gone  into  in 
detail  in  the  discussion  of  the  anatomy  of  the  sympathetic  are  of 
importance  in  regard  to  the  autonomic. 

(a)  In  the  midbrain  the  autonomic  is  composed  of  those  fibers 
in  the  oculomotor  nerve  which  supply  the  sphincter  pupillje  (miosis), 
the  ciliary  muscle  [accommodation  spasm]  and  in  part  the  levator 
palpebrae  (widening  the  lid  slits). 

{b)  For  the  medulla  the  tracts  going  by  way  of  the  chorda 
tympani  to  the  salivary  glands  and  by  way  of  the  N.  lacrimalis  to 
the  .lacrimal  glands  are  worth  noting.  The  vagus,  which  supplies 
the  lungs,  heart  and  gastro-intestinal  tract  is  also  of  great  im- 
portance. This  nerve  contracts  the  smooth  muscle  of  the  bronchi. 
It  furnishes  inhibitory  fibers  to  the  heart,  which  act  in  every  way 
antagonistically  to  the  sympathetic  accelerators.  The  four  functions 
of  the  heart,  chronotropic,  inotroi)ic,  bathmotropic  and  dromotropic, 
are  all  affected.  The  vagus  also  contracts  the  musculature  of  the 
upper  part  of  the  gastro-intestinal  tract,  the  esophagus,  the  cardiac 
sphincter  and  the  sphincter  antri  pylori.  It  also  increases  the 
peristalsis  and  secretions  of  the  stomach.  In  the  small  intestine  the 
vagus  causes  emptying  movements,  more  rarely  tonic  contraction. 
Its  effect  upon  the  smooth  nniscle  of  the  gall  bladder  and  the  ex- 
cretory^ duct  of  the  pancreas  is  to  produce  intermittent  contractions. 
Stimulation  of  the  vagus  branches  to  the  pancreas  causes  an  increase 
of  its  secretion. 

(c)  For  the  spinal  cord  there  are  in  addition  to  sympathetic 
fibers  diffusely  located  autonomic  centers  for  control  of  the  blood 
vessels  of  the  skin  and  mucous  membranes,  the  pilomotor  muscles 
and  the  sweat  glands. 

(d)  The  centers  of  the  autonomic  pelvic  nerve  lie  in  the  lowest 
part  of  the  spinal  cord.  This  nerve  might  be  called  a  lumbosacral 
vagus.  It  supplies  the  descending  colon,  the  sigmoid,  the  bladder 
and  genitalia.  Stimulation  causes  erection,  spasm  of  the  sphincter 
of  the  rectum,  contraction  of  the  detrusor  of  the  bladder  and  simul- 
taneous relaxation  of  the  sphincter. 

It  is  most  probable  that  through  their  influence  upon  glands  of 
internal  secretion  (pancreas,  thyroid)  the  autonomic  has  a  consider- 
able influence  upon  metabolism. 

{To  be  continued) 


IPertscopc 

Brain 

(Vol.  36,  Nos.  Ill  and  IV) 

1.  Lymphogenous  Infection  of  the-  Central  Nervous  System.     David  Orr  and 

R.  G.  Rows. 

2.  Unusual  Type  of  Hereditary  Disease,  Aplasia  axialis,  Extra-Corticalis  Con- 

genita.    F.  E.  Batten  and  D.  Wilkinson. 

3.  Study  of  the  Posterior  Longitudinal  Bundle  in  Forced  Movements.     L.  J. 

J.    MUSKENS. 

4.  An  Experimental  Research  into  the  Anatomy  and  Physiology  of  the  Corpus 

Striatum.     S.  A.  K.  Wilson. 

5.  Aphasia  due  to  Atrophy  of  the  Cerebral  Convolutions.     G.  Mingazzini. 

6.  A  Study  of  the  Satellite  Cells  in  Fifty  Selected  Cases  of  Mental  Disease. 

S.  T.  Orton. 

I.  Lymphogenous  Infection  of  the  Central  Nervous  System.— Tht  authors 
endeavored  to  pierce  some  of  the  obscurity  which  surrounds  the  genesis  of 
almost  all  inflammatory  lesions  in  the  central  nervous  system,  and  of  those 
which  are  degenerative  except  where  a  focal  lesion  exists.  The  questions  of 
the  causation  of  the  lesion,  the  point  of  origin  of  the  morbid  change  and  its 
propagation  are  constantly  recurring  in  regard  to  cases  of  meningitis,  mye- 
litis, tabes  dorsalis,  dementia  paralytica,  and  the  non-systemic  scleroses,  and 
the  theories  advanced  have  often  been  based  on  assumptions  devoid  of  proof 
which  have  tended  rather  to  divert  the  investigator  from,  than  to  lead  him 
on  to,  the  right  path.  For  years  it  has  been  apparent  that  continued  exami- 
nation of  chronic  lesions,  affecting  the  columns  of  the  spinal  cord,  while 
increasing  our  knowledge  in  detail  yet  failed  to  widen  it  in  regard  to  etiology, 
and  though  toxic  influence  naturally  received  due  recognition,  its  source  and 
mechanism  of  action  remained  unexplained.  It  seemed  obvious,  therefore, 
that  investigation  ought  to  be  directed  towards  elucidating  the  mechanism  of 
production  of  those  lesions  and  the  first  step  naturally  involved  a  study  of 
all  possible  paths  of  infection  and  intoxication.  It  is  with  one  of  these,  infec- 
tion via  the  lymphatic  system  of  peripheral  nerves,  that  this  paper  mainly 
deals  and  in  it  the  authors  give  a  synopsis  of  their  observations  in  clinical 
cases  and  experiment.  In  all  probability  the  controversy  surrounding  the 
genesis  of  the  lesion  in  tabes  dorsalis  and  the  recognition  of  general  paresis 
as  an  inflammatory  disease  were  most  important  factors  in  directing  attention 
to  the  lymphatic  system  of  the  cerebrospinal  axis,  and  an  important  step 
forwards  was  taken  with  the  demonstration  of  a  continuity  of  the  lymph- 
stream  in  peripheral  nerves  with  that  of  the  spinal  cord.  The  injection  of 
organisms  and  colored  substances  into  nerves  showed  that  the  lymph-stream 
was  an  ascending  one  towards  the  cord  and  that  the  main  current  lay  at  the 
periphery  of  the  nerve  bundles  immediately  under  the  fibrous  sheath.  It 
must  be  borne  in  mind,  however,  that  this  statement  regarding  the  main  cur- 
rent of  lymph  in  nerves  was  based  on  experiments  in  which  organisms  have 
been  injected  into  the  nerve  substance.  Where  infection  occurs  from  without 
it  will  be  shown  that  diffusion  of  organisms  and  toxins  can  take  place  along 
the  outer  surface  of  nerves  and  give  rise  to  an  ascending  epi-  and  perineuritis. 

569 


570  PERISCOPE 

Infection  along  peripheral  nerves  had  been  deduced  for  manj-  years  in  regard 
to  tetanus  and  rabies,  and  the  recognition  of  a  wider  application  of  this  prin- 
ciple suggested  a  new  line  of  research  along  which  an  explanation  of  certain 
other  pathological  phenomena  might  be  sought.  The  researches  of  Marie 
and  Morax.  Homen,  Guillain,  Spitzer  and  others  are  briefly  cited.  In  1903 
the  authors  had  the  opportunity  of  examining  the  nerve  tissues  in  a  case  of 
left  brachial  neuritis  of  twelve  days'  duration.  The  exciting  agent  in  this 
instance  was  the  Staphylococcus  pyogenes  aureus.  The  brachial  plexus  was 
found  bathed  in  pus  which  had  burrowed  among  the  cervical  muscles  as  well 
and  surrounded  the  root  ganglia  of  the  cervical  cord.  The  microscopical 
examination  of  the  tissues  proved  of  great  interest.  The  loose  areolar  tissue 
round  the  spinal  root  ganglia  of  the  left  side  was  greatlj^  inflamed,  the  veins 
were  thrombosed  and  contained  many  cocci.  Those  not  tlirombosed  were 
greatlj'  congested ;  the  arterioles,  on  the  other  hand,  showed  no  morbid 
change.  In  the  ganglion  capsule  there  were  hemorrhages  and  cocci,  more 
evident  in  the  outer  layers,  and  amongst  the  nerve  cells  dilated  venules  and 
capillaries  containing  microorganisms.  Similar  changes  affected  the  peri- 
neurium of  the  brachial  plexus,  but  to  a  less  degree.  No  cocci  were  found 
in  the  dura  of  the  cervical  cord  or  loose  areolar  tissue  covering  it.  One  small 
group  onlj'  was  observed  in  the  pia  arachnoid  covering  the  posterior  columns. 
There  were  no  inflammatorj-  phenomena  in  either  membrane.  The  6  C.  and 
8  C.  root  ganglia  of  the  right  side  were  examined.  There  were  no  thrombi 
in  the  capsular  areolar  tissue,  but  scattered  hemorrhages  in  which  there  were 
a  few  cocci.  No  cocci  were  found  in  the  ganglion  substance.  The  extra- 
medullary  portion  of  the  anterior  and  posterior  cervical  roots  was  examined 
for  degeneration  by  Marchi's  method  and  none  was  found.  In  the  spinal 
cord,  however,  the  same  method  demonstrated  an  acute  degeneration  whose 
distribution  was  confined  to  the  cervical  region.  The  seventh,  sixth  and  fifth 
segments  showed  much  the  greatest  degree  of  degeneration.  There  was 
marked  degeneration  of  the  intramedullary  portion  of  the  left  posterior  root, 
which,  commencing  at  the  point  where  the  fibers  lose  their  neurilemma  sheath, 
affected  the  middle  area  of  the  root  entry  zone.  On  the  right  side  the  degen- 
eration affected  the  same  area,  but  was  less  marked.  There  were  degenerated 
fibers  on  each  side  of  the  posteromedian  septum.  In  the  lateral  columns  of 
the  cord  on  either  side  of  the  septa  derived  from  the  pia  arachnoid  there  was 
a  considerable  degree  of  myelin  degeneration ;  and  here  and  there  in  the 
posterior  and  lateral  regions  there  were  degenerated  myelin  droplets  at  the 
cord  margin.  A  considerable  degree  of  degeneration  was  observed  in  con- 
nection with  the  intramedullary  portion  of  the  anterior  roots  in  their  whole 
course  from  the  cord  periphery  to  the  gray  matter.  There  was  degeneration 
of  the  collaterals  running  from  the  left  root  entry  zone  to  the  anterior  cornual 
cells,  and  also  of  the  anterior  commissure.  All  the  vessels  of  the  cord  and 
meninges  were  greatly  congested.  Seven  cases  are  then  reported  in  detail. 
When  the  examination  of  clinical  material  had  shown  that  lesions  in  the  cen- 
tral nervous  system  had  a  definite  anatomical  relationship  with  the  nerve 
supply  of  peripheral  infective  areas,  and  that'  these  lesions  depended  upon 
toxic  diffusion  along  the  perineural  lymphatics,  it  seemed  that  to  submit  this 
view  to  experiment  would  be  the  most  certain  method  of  obtaining  definite 
data.  Instead  of  injecting  organisms  or  toxins  into  the  nerves  on  which  it 
was  proposed  to  operate,  a  celloidin  capsule  containing  a  broth  culture  of  a 
microorganism  was  placed  in  contact  with  the  nerve.  In  one  series  of  experi- 
ments this  was  placed  under  the  gluteal  muscles  alongside  the  sciatic  nerve ; 
in  another  scries  under  the  skin  of  the  cheek.  The  animals  experimented  upon 
were  rabbits  and  dogs,  and  the  organisms  used  were  Staphylococcus  pyoycncs 
aureus.  Bacillus  pyocyaiieus,  Gaertner's  bacillus,  B.  coli,  B.  hotuliuus,  and  a 
culture  of  a  diphtheroid  bacillus  obtained  from  a  case  of  dementia  paralytica. 
.\t  first  all  these  bacilli  were  used  in  the  experimentation,  but  later  a  strain  of 


PERISCOPE 


571 


S.  aureus  was  adopted  whose  virulence  had  been  raised.  It  was  also  found 
expedient  to  renew  the  capsule  at  intervals.  Some  of  these  capsules  remained 
intact,  others  did  not,  and  a  variable  amount  of  leakage  occurred.  From  the 
clinical  cases  and  the  results  of  experiments  the  following  conclusions  were 
arrived  at:  (i)  In  spinal  and  cranial  nerves  there  is  an  ascending  lymph- 
stream  to  the  central  nervous  system  whose  main  current  lies  in  the  spaces 
of  the  perineural  sheath.  Toxins  reach  the  spinal  cord  and  brain  by  this 
route;  and  although  they  spread  to  some  degree  in  the  lymph  spaces  of  the 
pia  arachnoid,  and  so  may  affect  structures  at  a  distance  from  the  point  of 
entrance,  they  pass  for  the  most  part  in  the  main  stream  along  the  nerve  roots 
into  the  substance  of  the  central  nervous  system. 

(2)  Outside  the  central  axis  the  nerves  are  possibly  protected  by  the  vital 
action  of  their  neurilemma  sheath;  most  probably,  however,  it  is  the  periph- 
eral situation  of  the  lymph  current  which  is  the  deciding  factor.  The  evi- 
dence given  in  the  experimental  infection  leaves  no  room  for  doubt  that  the 
lymph  stream  in  nerves  is  an  ascending  one,  and  that  toxins  and  organisms 
can  be  carried  to  the  cord  by  that  path.  The  reaction  of  the  tissues  to  the 
toxin  also  shows  that  the  lymph  not  only  ascends  in  the  spaces  of  the  nerve- 
sheaths,  but  diffuses  in  the  fibrous  septa  between  the  nerve  fasciculi  and  into 
the  adventitia  of  the  vessels.  From  the  experiments,  too,  it  is  clear  that  when 
the  toxin  gains  the  spinal  cord  it  is  carried  round  the  periphery  in  the  meshes 
of  the  pia  arachnoid  and  along  its  prolongations  into  more  central  parts.  It 
is  exceedingly  interesting  to  observe  how  the  character  of  the  inflammation 
undergoes  progressive  changes  from  the  focus  of  greatest  intensitj^  onwards, 
and  there  is  one  important  fact  to  which  attention  is  drawn,  and  that  is  how 
plasma-cell  formation  becomes  the  most  prominent  indication  of  irritation 
when  the  irritant  has  been  to  a  great  extent  neutralized  b}'  the  reaction  of  the 
tissues  close  to  the  capsule.  The  results  of  the  above  experiments  show  that 
infection  of  the  lymph  system  of  peripheral  nerves  is  followed  by  an  ascend- 
ing perineuritis  which  spreads  to  the  posterior  root  ganglia  and  along  the 
spinal  roots  to  the  cord.  The  loose  areolar  tissue  covering  the  perineurium, 
the  ganglion  capsule,  and  the  dura  mater  shows  the  greatest  degree  of 
inflammatian. 

The  clinical  cases  which  the  authors  bring  forward  confirm  the  results  of 
their  experiments,  and  not  only  is  the  same  path  of  infection  clearly  demon- 
strated, but  also  a  perfect  similarity  in  the  type  of  reaction.  This  reaction 
varies  with  the  degree  of  intensity  of  the  irritant.  Orr  and  Rows  have  also 
lately  undertaken  a  series  of  experiments  in  which  the  abdominal  cavity  was 
chosen  as  the  site  for  infection.  This  was  done  for  three  reasons:  (i)  The 
peritoneal  cavity  is  most  suitable  for  an  experiment  in  which  one  wishes  to 
avoid  an  infection  of  the  lymph  system  of  spinal  nerves ;  (2)  to  reproduce 
as  closely  as  possible  a  gastro-intestinal  intoxication,  and  observe  the  effects 
upon  the  spinal  cord;  (3)  to  ascertain  in  how  far  such  toxi-infection  affected 
the  sympathetic  ganglion  chain.  Celloidin  capsules  containing  a  broth  culture 
of  the  Staphylococcus  pyogenes  aureus  were  therefore  placed  in  various 
regions  of  the  abdomen  where  they  became  attached  to  the  mesenterj^  kidney, 
bladder,  or  lower  border  of  the  stomach.  The  number  of  capsules  introduced 
varied  from  two  to  six,  and  the  animals  were  permitted  to  live  for  from  three 
to  six  weeks.  Ten  rabbits  were  used  and  one  dog.  In  summarizing  the 
changes  above  described,  the  authors  find:  (i)  the  most  highly  developed 
structures,  the  nerve  cells,  suffer  least  of  all ;  (2)  there  is  primary  degenera- 
tion of  the  myelin  sheath  round  the  cord  margin  and  along  the  postero- 
median septum ;  (3)  the  mj^elin  degeneration  is  greatest  in  the  upper  part  of 
the  cord;  (4)  there  is  edema  of  the  cord;  (5)  there  is  active  prohferation  of 
the  perivascular  neuroglia ;  (6)  the  vessels  are  dilated,  congested,  are  hyaline, 
and  contain  thrombi  of  the  same  nature.     If  these  be  now  contrasted  with  the 


572  PERI  SCO  Ph 

cord  lesions  in  lymphogenous  infection  the  ditference  is  at  once  obvious. 
L\Tnphogenous  infection  is  characterized  by  (i)  the  reaction  of  the  cells  of 
the  fixed  connective  tissue;  (2)  the  proliferation  of  the  cells  of  the  adventi- 
tial sheath  of  the  veins  and  capillaries;  (3)  the  appearance  of  numerous 
scavenger  cells  when  the  myelin  is  disintegrated;  (4)  nerve  cell  degeneration 
and  neuronophag}'.  From  the  above  one  must  conclude  that  the  lesions  in 
hematogenous  intoxication  are  of  a  degenerative  nature  and  differ  very  widely 
from  those  found  in  lymphogenous  infection,  where  the  fixed  tissues  are 
actually  proliferating  and  all  the  morbid  phenomena  are  of  an  inflammatory 
t}-pe.  The  difference  between  the  two  might,  therefore,  he  expressed  bj^  say- 
ing that  in  lymphogenous  infection  the  inflammatory  phenomena  reach  their 
maximum ;  in  hematogenous  intoxication  they  are  reduced  to  a  minimum. 
From  the  above  clinical  and  experimental  study  it  is  clear  that  the  two  mech- 
anisms of  infection  of  the  cerebrospinal  system — the  hematogenous  and 
lymphogenous — are  characterized  by  sufficiently  distinct  morbid  phenomena, 
and  if  the  results  of  the  experiments  are  applied  to  the  human  subject,  very 
considerable  assistance  is  obtained  in  arriving  at  an  understanding  of  the 
genesis  of  certain  lesions.  The  authors  claim  to  have  brought  forward  ample 
evidence  to  show  that  acute  and  chronic  myelitic  conditions  are  readily  pro- 
duced by  infection  of  the  ascending  lymph  system  in  nerves.  The  opinion 
previously  given  by  them  is  that  general  paresis  is  a  chronic  inflammatory 
disease  of  lymphogenous  origin.  This  opinion  is  based  on  the  close  similarity 
between  the  vascular  lesions  in  this  condition  and  those  found  in  the  experi- 
ments of  these  authors  where  the  lymph  system  of  the  nerves  or  cord  is 
infected.  The  striking  predominance  of  adventitial  proliferation  and  infiltra- 
tion can  be  explained  only  by  toxi-infection  of  the  cerebrospinal  lymph. 
There  is  no  evidence  of  a  general  blood  intoxication,  for  in  general  paresis, 
as  in  these  experiments,  the  endothelium  of  the  vessels  may  be  quite  unaffected, 
while  the  adventitial  spaces  are  packed  with  the  products  of  proliferation. 
Further,  to  tabes  dorsalis  Orr  and  Rows  assign  the  same  lymphogenous 
genesis.  Tiie  vascular  phenomena,  similar  to  those  in  general  paresis,  the 
constant  primary  affection  of  the  root  entry  zones,  and  the  rigidly  systemic 
character  of  the  lesion  preclude  any  other  conclusion.  As  the  authors  have 
shown  that  certain  cases  of  acute  meningomyelitis  fall  into  the  lymphogenous 
categor}',  they  believe  that  there  is  now  a  preponderance  of  evidence  to  show 
that  acute  poliomjelitis  must  also  be  included  in  this  group.  The  whole 
picture  of  this  disease  is  one  of  a  disseminated  meningomyelitis,  and  as  the 
brain  may  be  affected  in  adults  especially,  the  more  comprehensive  term  of 
disseminated  mcningomyelo-enccphalitis  has  been  suggested  by  Wickman. 
There  are  many  facts  to  show  that  infantile  paralysis  cannot  be  a  blood 
infection,  and  indisputable  evidence  in  favor  of  the  lymphogenous  genesis. 
Tliis  latter  view  is  upheld  on  clinical  and  experimental  grounds  by  both  Wick- 
man and  Romer,  and  with  them  Orr  and  Rows  agree.  The  localization  and 
morphology  of  the  lesions  and  the  continuity  of  extension  are  characteristic 
of  lymphogenous  infections,  a  continuity  which  varies  naturally,  and  attains 
its  maximum  in  the  acute  ascending  paralysis  of  Landry.  A  consideration 
of  the  phenomena  in  the  subacute  non-systemic  lesions  of  the  cord,  such  as 
occur  with  or  without  anemia,  Addison's  disease,  cancer  cachexia,  etc.,  shows 
that  they  must  be  included  in  the  hematogenous  category.  There  is  an  entire 
absence  of  the  proliferative  change  in  the  adventitia  of  the  veins  and  capil- 
laries which  characterizes  the  lymphogenous  infections.  The  root  entry  zones 
In  the  posterior  columns  are,  except  perhaps  in  the  latest  stages  of  the  affec- 
tion, f|uitc  sound,  while  there  is  a  marked  sclerosis  around  the  posteromedian 
septum.  The  nerve  cells  in  the  gray  matter  maintain  their  integrity.  The 
morbid  picture  is  degenerative,  not  inflammatory,  in  type  and  in  the  zones 
affected  it  corresponds  with  what  is  found  in  experimental  hematogenous 
intoxication. 


PERISCOPE  573 

2.  Aplasia  Axialis,  Extra  Corticalis  Congenitalis. — The  authors  illustrate 
this  disorder,  which  is  a  famiHal  and  hereditary  one,  having  its  onset  in  the 
first  three  months  of  Hfe,  even  if  it  is  not  actually  congenital.  It  presents 
sj-mptoms  which  in  many  respects  are  similar  to  those  seen  in  cases  of  dis- 
seminated sclerosis,  cerebellar  disease,  and  in  its  later  stages  to  Friedreich's 
disease.  It  is  very  slowly,  if  at  all,  progressive,  affects  chiefiy  males,  and  is 
transmitted  by  healthy  females.  In  the  family  here  described  males  only  are 
affected.  It  corresponds  to  none  of  the  commonly  recognized  types  of 
familial  affection,  but  the  symptomatology  so  closely  resembles  that  presented 
by  the  family  recorded  by  Pelizaeus  and  Merzbacher,  that  the  disease  is  be- 
lieved to  be  of  the  same  nature,  although  no  pathological  examination  has  been 
made  in  any  member  of  the  family  here  described.  The  cases  published  by 
Nolan  also  resemble  these  cases  clinically,  but  no  pathological  examination 
has  been  made.  The  family  first  came  under  notice  when  two  boys,  aged 
four  and  two,  were  admitted  into  the  Hospital  for  Sick  Children,  Great 
Ormond  Street,  in  November,  1913. 

Family  Tree 
Wilson-Gulvin  Family,  1913 

n  -  o  -  D 
I     I 

□ 


I         I         I         I         I         I 

o       ■       o       o       o       n 


In  addition  the  authors  present  a  further  family  tree.  They  then  present 
as  a  summary:  A  familial  and  hereditary  disease,  having  symptoms  resem- 
bling disseminated  sclerosis,  is  described.  Six  males  at  least  were  affected  in 
two  generations.  .The  subjects  of  this  disease  are  almost  always  males,  and 
the  condition  is  transmitted  by  unaffected  females.  Those  affected  are  either 
congenitally  diseased  or  exhibit  symptoms  in  the  first  months  of  life,  the 
progress  of  the  disease  being  very  slow.  They  are  mentally  defective  and 
ataxic,  show  nystagmus,  speech  defect,  and  defective  development,  with  weak- 
ness and  spasticity  of  the  lower  limbs.  It  is  considered  probable  that  these 
cases  belong  to  the  type  of  familial  disease  described  by  Pelizaeus  and  Merz- 
bacher under  the  title  "  aplasia  axi^lis  extracorticalis  congenita." 

3.  Posterior  Longitudinal  Bundle. — Dr.  Muskens  presents  a  lengthy  study 
on  rolling  and  circus  movements  and  their  relationships  to  this  bundle.  In 
previous  investigations  respecting  the  circus  and  roUing  movements  occurring 
in  different  species  of  vertebrates,  he  had  observed  the  important  part  played 
by  the  posterior  longitudinal  bundle,  when  injured,  in  producing  these  phe- 
nomena; he  resolved,  therefore,  to  make  special  experiments  in  this  subject, 
and  by  means  of  the  Probst  "  concealed  needle  "  he  made  lesions  in  all  direc- 
tions, chiefly  in  cats,  in  the  area  between  the  nucleus  of  the  abducens  nerve 
and  the  posterior  commissure.  In  each  case  the  forced  movements  were 
noted,  whether  in  the  horizontal  plane  (circus  movements)  or  in  the  plane 
vertical  to  the  longitudinal  axis  of  the  animal  (rolling  movements).  Forced 
movements  were  considered  to  be  present,  first,  so  long  as  the  head  and  eyes 
remained  deviated  or  so  long  as  there  was  an  inclination  to  go  to  one  side, 
circus  movements  in  a  slight  degree;  and  secondly,  as  long  as  there  was  an 
inclination  to  lie  down  or  to  fall  to  one  side,  which  Muskens  looks  upon  as 
a  slight  manifestation  of  rolling  movement.     The  character  of  the  movements 


574  PERISCOPE 

and  the  direction  of  the  locomotion  which  is  the  consequence  of  them  are 
determined  in  accordance  with  the  normal  anatomical  position  of  the  animal, 
the  normal  posture  being  always  reduced  to  that  of  the  primary  vertebrate 
exhibiting  the  simplest  forced  movements,  for  instance,  the  fish.  In  review- 
ing the  physiological  analj'sis  of  the  vestibulary  sj'stem  and  the  posterior 
longitudinal  bundle  formation,  certain  facts,  both  physiological  and  anatom- 
ical, stand  out  clearly,  while  other  points  can  onlj-  be  considered  as  sugges- 
tions or  probabilities,  (i)  The  study  of  the  physiological  phenomena  ob- 
served after  lesions  of  different  parts  of  this  system  demonstrates  that  there 
is  a  far-reaching  differentiation  of  function  in  the  primary  end-stations  of 
the  vestibulary  nerve.  Further,  it  also  shows  that  the  different  strands  of 
fibers  which  connect  the  vestibular  nuclei  with  the  various  nuclei  in  the 
midbrain  and  with  the  region  of  the  posterior  commissure  in  a  cerebropetal 
direction  may  be  more  accurately  analyzed.  (2)  The  principal  vestibular 
nuclei  are  the  following:  (a)  The  descending  branch  of  the  vestibular  nu- 
cleus; (ft)  Deiters'  nucleus  composed  of  a  ventral  caudal  division,  named  the 
nucleus  triangularis,  and  a  dorsal  magnocellular  division  or  Deiters'  nucleus 
proper;  (r)  Bechterew's  nucleus  with  the  nucleus  tecti.  (3)  Physiological 
analysis  affords  a  practical  method  of  establishing  the  existence  of  important 
differences  in  the  ascending  and  descending  connections  of  the  above- 
mentioned  nuclei,  and  of  establishing  equally  important  differences  in  the 
functions  of  the  nuclei.  (4)  The  starting  point  of  this  analysis  is  the  fact 
that  an  ascending  degeneration  of  the  crossed  vestibulo-mesenceplialic  bundle, 
which  forms  the  bulk  of  the  mesial  part  of  the  posterior  longitudinal  bundle 
till  near  the  nucleus  of  the  posterior  commissure,  is  always  found  associated 
with  circus  movements  to  the  side  of  the  intact  posterior  longitudinal  bundle. 
This  rule  holds  good  so  long  as  the  lesions  leave  the  other  parts  of  the  vestibu- 
lar systems  intact.  It  is  immaterial  whether  the  degeneration  of  this 
vestibulo-mesencephalic  tract  is  the  result  of  a  cross  section  of  the  median 
part  of  the  posterior  longitudinal  bundle,  or  of  a  lesion  of  the  heterolateral 
Deiters'  nucleus.  Experimental  evidence  tends  to  show  that  in  the  Deiters' 
complex  the  nucleus  triangularis  is  the  principal  origin  of  this  tract  (fascicu- 
lus vestibulo-mesencephalicus  cruciatus).  (5)  The  degeneration  of  an  as- 
cending tract  lying  immediately  lateral  to  the  crossed  vestibulo-mesencephalic 
tract  in  the  posterior  longitudinal  bundle  formation  appears  to  be  equally 
associated  with  a  circus  movement  (or  rather  conjugate  deviation)  to  the 
side  of  the  normal  posterior  longitudinal  bundle.  This  tract  is  further  shown 
to  be  a  homolateral  tract  originating  exclusively  in  the  nucleus  of  Bechterew, 
at  least  in  the  oral  parts  of  the  vestibular  region,  and  terminating  in  the 
region  of  the  posterior  commissural  nucleus.  This  bundle  may  be  styled  the 
homolateral  vestibulo-mesencephalic  fasciculus.  This  tract  is  only  partially 
identical  with  that  described  anatomically  by  Probst.  Van  Gehuchten  in  1904 
suggested  that  the  whole  of  the  lateral  part  of  the  longitudinal  bundle  (fas- 
ciculus Deiters'  ascendens,  Lewandowsky,  Winkler)  consisted  of  fibers,  as- 
cending from  Bechterew's  nucleus.  This  origin,  for  this  limited  portion  at 
least  of  the  posterior  longitudinal  bundle,  may  now  be  held  as  proved,  as 
may  also  the  association  of  its  upward  degeneration  with  circus  movements 
or  conjugate  deviation  to  the  normal  side.  Both  the  circus  movements  ob- 
served after  lesion  of  the  homolateral  or  crossed  vestibulo-mesencephalic 
tract  a're  associated  with  conjugate  deviation  of  the  head  and  eyes  to  the 
side  of  the  movement,  or  with  loss  of  lateral  deviation  of  the  eyeballs  to  the 
opposite  side.  (6)  According  to  the  notions  advanced  by  Duval,  Bleuler, 
Edinger,  Bischoff,  Spitzcr,  Kohnstamm,  Bernhcimcr,  Eraser,  Wallenberg, 
Wiersma,  and  others,  the  posterior  longitudinal  bundle  represents  a  combi- 
nation of  ascending  and  descending  tracts,  which  control  the  coordinated 
movements  of  the  eyes,  head  and  trunk  and  control  or  direct  the  maintenance 


PERISCOPE  575 

of  the  equilibrium  of  motion.  Now,  from  experimental  data  furnished  by 
the  present  investigation,  it  is  seen  that  after  a  direct  lesion  in  the  region  of 
the  posterior  commissure  of  the  cat  on  one  side,  where  the  resulting  circus 
movements  were  directed  to  the  side  of  the  lesion,  a  descending  tract  degen- 
erates which  lies  at  the  innermost  part  of  the  posterior  longitudinal  bundle 
of  the  same  side.  This  tract  probably  originates  in  the  posterior  commissural 
nucleus.  As  it  stops  short  in  the  medulla  it  is  suggested  that  it  may  be 
termed  the  fasciculus  commissuro-medullaris.  (7)  Although  it  is  probable 
that  this  mesencephalo-medullarjr  tract  exists  in  all  the  higher  organized  ver- 
tebrates, such  as  selachians,  teleosteans,  amphibians,  reptiles,  birds  and  mam- 
mals, it  is  only  in  the  mammal  that  a  destructive  lesion  of  the  nucleus  and 
of  its  efferent  tracts  from  the  striate  body  is  associated  with  circus  movements 
towards  the  side  of  the  lesion.  In  the  lower  animals  a  lesion  oral  to  the 
posterior  commissure  is  not  followed  by  any  circus  movements.  The  anatom- 
ical explanation  of  this  fact  seems  to  be  that  only  in  mammals  are  the  hypo- 
thalamic and  commissural  nuclei  sufficiently  connected  with  the  prosencepha- 
lon that  section  of  the  connections  should  be  followed  by  asj'mmetrical 
locomotion,  as  evidenced  in  circus  movements  and  conjugate  deviation  towards 
the  side  of  the  lesion.  Further,  it  is  only  in  mammals  that  stimulation  of 
certain  definite  areas  of  the  cortex  is  followed  by  conjugate  deviation  of  the 
head  and  ej'es  towards  the  opposite  side.  Birds  seem  to  form  in  this  respect 
a  group  between  the  reptiles  and  mammals.  In  the  prosencephalon  of  the 
bird  is  an  area,  faradization  of  which  is  associated  with  conjugate  deviation 
towards  the  opposite  side  (Boyce  and  Warrington).  The  section  of  the  con- 
nections of  this  area  is  not,  however,  associated  with  any  alteration  in  the 
mode  of  locomotion.  As  regards  those  cases  (cats)  where,  after  lesion  of 
the  thalamus  and  cerebral  hemisphere,  circus  movements  towards  the  side 
of  the  (destructive)  lesion  were  observed  over  a  longer  period,  it  was  found 
that  there  was  a  tract  of  degenerated  fibers  in  the  lamina  medullaris  externa. 
These  fibers,  which  probably  emanate  from  the  striate  bodj^,  pass  to  the  hj^po- 
thalamic  region,  where  they  lose  their  medullary  sheaths.  The  termination 
of  these  fibers,  probably  in  the  nucleus  of  the  posterior  commissure,  can, 
therefore,  not  be  demonstrated.  The  circus  movement  in  such  cases  is  always 
accompanied  by  conjugate  deviation  towards  the  side  of  a  destructive  lesion, 
or  in  less  pronounced  cases  by  loss  of  lateral  deviation  to  the  other  side. 
(8)  Like  the  circus  movements  the  rolling  movements  may  serve  as  a  guide 
in  working  out  the  anatomo-physiological  analysis  of  the  vestibular  complex 
and  the  posterior  longitudinal  bundle  formation.  (9)  After  a  direct  lesion 
of  the  complicated  nerve  fibers,  which  help  to  form  the  vestibular  root,  a 
rolling  movement  towards  the  injured  side  is  constantly  observed,  mostly 
associated  with  a  skew  deviation  and  conjugate  rotation  of  the  eyeballs  around 
their  antero-posterior  axis.  In  only  one  case  (rabbit,  direct  lesion  in  the 
caudal  part  of  the  vestibular  root)  were  rolling  movements  toward  the  non- 
injured  side  observed.  (10)  In  three  cases  of  lesion  of  the  descending  branch 
of  the  nucleus  vestibularis  rolling  movements  towards  the  normal  side  were 
seen  lasting  over  several  days.  Although  this  experiment  was  repeated  sev- 
eral times,  Muskens  did  not  localize  a  distinct  ascending  or  descending  con- 
nection from  this  part  of  Deiters'  complex.  (11)  Lesion  of  Deiters'  nucleus 
proper  is  found  in  two  cases  associated  with  rolling  movements,  moderate  in 
character,  towards  the  side  of  the  lesion.  From  this  nucleus  the  degeneration 
spreads  upwards  along  a  tract  which  lies  in  the  outermost  part  of  the  lateral 
horn  of  the  posterior  longitudinal  bundle.  A  direct  lesion  of  this  ascending 
tract  or  connection  is  also  associated  with  a  tendency  to  roll  towards  the  side 
of  the  lesion.  This  was  demonstrated  in  five  cases.  The  fibers  of  this  tract 
appear  to  end  mostly  in  the  tegmentum,  although  some  may  be  traced  to  the 
caudal  part  of  the  posterior  commissure,  where  the  fibers  appear  to  lose  their 


576  PERISCOPE 

medullar}-  sheath :  it  is  therefore  suggested  that  it  should  be  styled  the  tractus 
vestibulo-tegmentalis  lateralis.  Its  origin  is  apparently  in  the  medium-sized 
cells  of  Deiters'  nucleus  proper,  its  termination  probably  in  the  interstitial 
nucleus.  (12)  A  comparison  of  the  cases  where  the  lesion  is  situated  in  the 
region  of  the  posterior  commissure  leads  us  to  postulate  in  that  region  a 
center,  probably  the  nucleus  interstitialis,  injury  of  which  (or  of  its  aflferent 
tracts  from  other  parts)  in  the  cat  is  constantly  followed  by  rolling  move- 
ments to  the  normal  side.  The  existence  of  a  descending  interstitio-spinal 
tract  in  the  innermost  section  of  the  posterior  longitudinal  bundle  in  these 
cases  in  which  rolling  movements,  or,  in  less  pronounced  cases,  a  tendency  to 
fall  to  the  normal  side  are  observed  seems  to  justifj-  this  supposition  to  a 
certain  extent.  (13)  The  physiological  combined  with  the  degenerative  method 
does  not  afford  such  ample  information  as  regards  the  tracts  from  Deiters' 
complex  to  the  posterior  longitudinal  bundle  formation  of  the  spinal  cord. 
This  is  partly  due  to  the  irregular  form  of  the  collection  of  reticular  cells 
which  give  rise  to  the  ponto-  or  reticulo-spinal  tracts.  It  seems  certain  that 
heterolateral  descending  fibers  of  the  posterior  longitudinal  bundle  do  not 
come  from  Bechterew's  nucleus,  although  descending  homolateral  fibers  are 
given  off  from  both  Deiters'  and  Bechterew's  nuclei.  After  experimental 
lesion  of  Deiters'  nucleus  it  was  not  in  all  cases  possible  to  decide  from  what 
cells  the  heterolateral  fibers  originate.  If  the  descending  connections  of  the 
vestibular  structures  which  control  the  circus  and  rolling  movements  and 
those  of  the  superimposed  mesencephalic  structures  be  compared,  the  conclu- 
sion seems  warranted  that  the  descending  connections  are  far  more  important 
in  the  case  of  the  rolling  movements.  Relatively  few  descending  fibers  which 
originate  in  the  structures  associated  with  circus  movements  pass  beyond  the 
sixth  nucleus. 

4.  Corpus  Striatum. — In  this  masterly  study  \\'ilson  says  that  the  exact 
nature  and  function  of  the  large  mass  of  basal  gray  matter  known  as  the 
corpus  striatum  have  hitherto  constituted  one  of  the  unsolved  problems  of 
neurolog)-.  Not  that  the  corpus  striatum  has  failed  to  attract  the  attention 
of  anatomist,  physiologist  and  clinician  ;  on  the  contrary,  since  the  days  of 
Willis,  it  has  received  its  full  share  of  investigation  along  all  the  familiar 
lines.  The  disturbing  element  in  the  matter  of  research  into  its  functions 
has  been  the  conflicting  nature  of  the  results  obtained.  Anyone  who  will 
take  the  trouble  to  read  the  curiously  philosophic  text-books  of  half  a  century 
ago  would  imagine,  it  is  true,  that  the  corpus  striatum  was  an  organ  as  high 
in  the  cerebral  hierarchy  as  the  cortex  itself,  endowed  with  motor  functions 
as  elaborate  and  as  detailed.  But  a  change  took  place  when  neurologists 
realized  that  many  of  the  functions  assigned  to  it  were  the  property  of  the 
adjacent  corticospinal  paths,  and  almost  at  once  it  seemed  to  fall  from  its 
high  estate  and  depreciate  in  ph3-siological  significance.  Under  these  circum- 
stances the  question  of  its  function  became  an  enigma,  and,  as  a  consequence, 
there  was  eventually  assigned  to  it  a  varied  assortment  of  motor,  sensory, 
vasomotor,  psychical  and  reflex  functions,  no  one  of  which  Wilson  says  has 
ever  rested  on  unequivocal  evidence.  Within  the  last  two  or  three  years,  how- 
ever, the  clinico-pathological  method  has  furnished  evidence  which  goes  far 
towards  clearing  away  this  obscurity.  In  the  last  year  or  two  a  syndrome  of 
the  corpus  striatum  has  been  enunciated  which,  however  much  it  may  come  to 
be  modified,  shows  every  sign  of  being  corroborated  by  each  accession  of 
fresh  evidence,  and  in  any  case  can  fairly  be  regarded  as  furnishing  the 
closest  approximation  to  the  exact  mode  of  working  of  that  important  struc- 
ture. In  Wilson's  review  of  the  experimental  literature  on  the  corpus 
striatum  he  has  referred  to  a  possible  association  of  these  masses  of  gray 
matter  with  the  functions  of  the  viscera,  and  some  evidence  has  accumulated 
which    goes    to    show    that    there    may   be    connections    between    the    corpus 


PERISCOPE  577 

striatum  and  the  functions  of  respiration,  circulation,  and  the  maintenance  of 
body  temperature,  as  well  as  possibly  the  function  of  the  bladder  and  ali- 
mentary tract.  As  Wilson's  own  experimental  researches  have  been  con- 
cerned with  the  motor  part  of  the  subject,  he  leaves  this  question  aside  tem- 
porarily. His  research  was  carried  out  upon  some  twenty-five  monkeys 
{Macacus  rhesus,  Macacus  sinicus) .  Both  stimulation  and  electrolytic  methods 
were  utilized.  The  instrument  employed  was  the  stereotaxic  instrument  of 
Clarke  and  Horsley.  A  study  of  the  small  and  strictly  localized  lesions  pro- 
duced shows  that  the  fiber  system  of  the  corpus  striatum  may  be  divided 
into  four  main  groups:  (i)  Fibers  arising  and  ending  within  the  corpus 
striatum  (internuncial).  (2)  Fibers  arising  in  the  corpus  striatum  and  end- 
ing elsewhere  (striofugal).  (3)  Fibers  arising  elsewhere  and  ending  in  the 
corpus  striatum  (striopetal).  (4)  Fibers  passing  through  the  corpus  stria- 
tum, but  arising  and  ending  elsewhere  (fibers  of  passage). 

Group  I.  In  the  first  group  several  subdivisions  may  be  distinguished : 
(a)  Internuncial  fibers  from  the  putamen  to  the  globus  pallidus. — These  are 
invariably  of  fine  caliber  with  a  delicate  myelinated  sheath.  They  are  massed 
into  bundles  or  pencils,  arising  by  the  approximation  of  individual  fibers,  not 
always  ver}'  close  to  their  cells  of  origin,  and  running  mesially;  the  anterior 
pencils  converge  as  they  pass  in  a  posterior  direction,  while  the  posterior 
converge  as  the}'  travel  anteriorly ;  the  most  ventral  run  in  a  dorsal  direction, 
the  dorsal  in  a  ventral  direction,  and  in  this  fashion  they  all  converge  towards 
the  lateral  zone  of  the  globus  pallidum ;  here  some  of  them  diffuse  out,  while 
others  pass  on  to  the  mesial  zone,  where  they  in  turn  diffuse  out.  (b)  From 
lateral  to  mesial  zone  of  the  globus  pallidus. — Similarly  fine  mj^elinated  fibers 
arise  in  the  lateral  zone  of  the  globus  pallidus  and  cross  mesially  in  radial 
bundles  to  the  mesial  zone,  (c)  From  caudate  to  putamen. — Many  fine  inter- 
nuncial fibers  pass  across  the  dorsal  third  of  the  internal  capsule  from  the 
nucleus  caudatus  to  the  putamen,  while  others  reach  the  lateral  zone  of  the 
globus  pallidus.  It  is  perhaps  worthy  of  note  that  distinctly  fewer  fibers  pass 
from  the  putamen  to  the  caudate  than  in  the  reverse  direction ;  and  this  is 
true  also  of  the  connections  between  the  globus  palhdus  and  the  caudate. 

2.  In  the  second  group  there  are  also  important  subdivisions,  (a)  Strio- 
thalamic  fibers. — These  constitute  the  minor  portion  of  striofugal  fibers  to 
the  optic  thalamus  and  regio  subthalamica.  They  are  derived  from  the  mesial 
groups  of  radial  bundles  of  the  globus  pallidus,  and  cross  the  internal  capsule 
obliquely  in  its  basal  third  to  reach  the  lateral  and  ventral  sections  of  the 
thalamus.  They  can  be  traced  passing  mesially  across  the  thalamus  and 
diffuse  out  in  the  neighborhood  of  the  internal  nucleus  ;  a  fair  number,  how- 
ever, do  not  extend  beyond  the  nucleus  lateralis,  (b)  Strio-subthalamic 
fibers. — The  ansa  lenticularis  is  a  somewhat  complex  fiber  system,  in  which, 
however,  certain  subdivisions  are  readily  distinguishable,  {a)  The  chief  set 
of  fibers  in  the  ansa  stands  out  unmistakably  as  composed  of  fibers  slightly 
larger  in  caliber  than  the  others,  which  are  of  the  same  size  as  the  inter- 
nuncial fibers  already  described.  This  tract  arises  in  the  lateral  and  mesial 
zones  of  the  globus  pallidus,  runs  more  or  less  at  right  angles  to  the  radially 
disposed  pencils  and  is  distinguished  in  the  descriptions  of  experiments  given 
above  as  the  transverse  group.  It  passes  directly  across  the  capsule  in  a 
slight  curve  with  the  convexity  dorsal,  and  constitutes  a  closely  set  bundle 
reaching  and  occupying  Forel's  field.  It  corresponds  to  the  lenticular  bundle 
of  Forel  (H,).  The  fibers  pass  mesially  across  Forel's  field  and  form  a  sort 
of  nucleus  (noyau  du  champ  de  Forel-Cajal)  at  a  point  where  the  general 
direction  of  the  fibers  changes  slightly  from  a  latero-mesial  to  a  more  antero- 
posterior direction.  Many  then  pass  ventrally  and  caudally  and  can  be  defi- 
nitely traced  to  end  in  the  ventro-lateral  and  ventral  capsule  of  the  nucleus 
ruber.     It  seems  possible,   from  one  or  two  of  the  experiments,  that  a  few 


578 


PERISCOPE 


fibers  continue  across  the  mesial  plane  by  the  decussation  of  Forel  to  reach 
the  contralateral  red  nucleus.  This  is  the  main  group  in  the  ansa  lenticularis, 
and  the  definiteness  of  the  anatomical  connection  between  the  globus  pallidus 
and  the  nucleus  ruber  is  of  considerable  importance.  It  is  easy  to  distinguish 
these  fibers  from  those  of  the  capsule,  indeed  from  any  other  tract  in  the 
neighborhood.  (^)  The  second  division  of  the  ansa  lenticularis  is  composed 
of  slightly  finer  myelinated  fibers  arising  from  the  radial  bundles  of  the 
globus  pallidus.  They  are  ventral  to  the  striofugal  group  to  the  nucleus 
ruber,  and  they  edge  across  the  basal  third  of  the  capsule  much  more  obliquely. 
They  can  be  traced  across  the  capsular  fasciculi  as  the  latter  extend  into 
the  crus.  The  great  majority  pass  into  the  corpus  subthalamicum  (strio- 
luysian  fibers)  and  diffuse  out  in  its  interior.  Some,  nevertheless,  cross  it 
completely  and  make  their  way  to  the  neighborhood  of  the  lateral  capsule  of 
the  red  nucleus,  approaching  it  from  in  front.  It  is  difficult  to  determine 
whether  they  effect  any  union  with  the  nucleus.  A  smaller  number  of  fine 
fibers  pass  obliquely  across  the  crus  in  a  mesial  direction,  ventral  to  the  corpus 
subthalamicum,  to  reach  the  locus  niger.  (r)  Striofugal  fibers  to  the  intcnial 
capsule  or  cerebral  peduncle. — No  unequivocal  proof  of  the  passage  of  fibers, 
fine  or  medium,  from  either  the  putamen  or  the  globus  pallidus  to  the  internal 
capsule  or  crus  has  been  obtained.  The  general  direction  of  the  two  divisions 
of  the  ansa  lenticularis  is  always  oblique  to  that  of  the  corticospinal  fibers. 
Sir  Victor  Horsley  has  examined  the  specimens  independently  and  agrees 
that  they  furnish  no  evidence  of  such  a  passage. 

3.  In  the  third  group  there  are  again  a  number  of  separate  tracts,  (a) 
Thalamostriate  fibers. — As  none  of  Wilson's  own  lesions  were  placed  in  the 
thalamus,  it  was  not  possible  for  him  to  confirm  or  deny,  on  experimental 
grounds,  the  existence  of  thalamostriate  fibers.  It  is  known,  however,  that 
such  do  occur,  the  association  between  the  thalamus  and  the  caudate  being 
close  (Edinger,  Dejerine,  Sachs).  Reference  is  made  to  these  for  the  sake 
of  completeness,  (b)  Subthalamostriate  fibers. — From  a  lesion  in  Forel's 
field  Sachs  has  found  degeneration  passing  laterally  across  the  capsule  in 
its  basal  third,  and  entering  the  globus  pallidus,  where  it  diffused  out.  No 
degenerated  fibers  entered  the  putamen.  This  degeneration  resulted  from 
the  involvement  of  fibers  passing  in  a  reverse  direction  in  the  main  part  of 
the  ansa  lenticularis.  Similarly,  Dejerine  was  able  to  follow  degeneration 
from  a  lesion  in  the  regio  subthalamica :  (i)  mesially,  according  to  the  lines 
already  fully  described,  and  (2)  laterally,  by  the  ansa  lenticularis  and  Forel's 
lenticular  bundle  to  the  globus  pallidus.  It  would  appear,  therefore,  that 
while  the  ansa  lenticularis  and  the  striosubthalamic  tracts  are  to  a  very  large 
extent  striofugal,  they  also  contain  striopetal  fibers.  Such  fibers  are,  no 
doubt,  to  be  expected,  for  it  is  a  general  rule  that  cerebral  areas  of  gray 
matter  are  united  doubly,  though  not  always  equally,  to  each  other,  by  afferent 
and  efferent  fiber  systems,  (c)  Corticostriate  fibers. — The  experiments  herein 
detailed  show  sufficiently  that  the  corpus  striatum  is  independent  of  the 
cerebral  cortex.  A  few  small  fasciculi  may  cross  the  dorsal,  ventral,  oral 
or  caudal  aspects  of  the  putamen  from  the  cortical  side,  but  they  are  fibers 
of  passage.  With  practically  complete  capsular  degeneration  no  fibers  have 
been  seen  to  leave  the  corticospinal  path  and  enter  the  lenticular  nucleus  by 
its  laminae  or  otherwise. 

4.  There  remains  the  final  question  of  any  fibers  of  passage  running  for 
part  of  their  course  through  the  corpus  striatum,  (a)  Thalamocortical. — The 
experimental  evidence  in  this  matter  has  already  been  considered.  It  nega- 
tives the  i)ossibility  of  such  fibers  passing  in  part  by  the  laminae  of  the  len- 
ticular nucleus,  and  is  thus  definitely  opposed  to  the  views  of  Probst,  Ober- 
steiner  and  others.  Tschermak  believes  that  fillet  fibers  made  a  loop-shaped 
excnr'sion   through  the  nucleus  lentiformis  on  their  way  to  the  cortex,  but 


PERISCOPE  579 

assent  to  this  view  cannot  be  accorded.  In  one  instance  only,  Wilson  says, 
has  he  found  fibers  whose  relative  caliber  proclaimed  their  extrastriate  origin 
degenerating  in  a  lateral  direction  from  a  lesion  in  the  lateral  zone  of  the 
globus  palhdus.  Thej^  were  not  laminal  fibers.  In  all  some  two  or  three 
small  fasciculi  were  seen  to  contain  somewhat  coarse  Marchi  granules,  and 
they  were  traced  lateralwards  out  of  the  putamen.  In  view  of  the  fact  that 
identical  lesions  in  other  animals  failed  to  reveal  "any  such  fibers,  those  just 
mentioned  must  be  considered  aberrant  bundles,  presumably  of  thalamo-. 
cortical  fibers.  In  number  they  were  quite  insignificant,  while  the  fact  that 
they  passed  out  of  the  putamen  a  little  more  centrally  than  the  fasciculi  pre- 
viously alluded  to,  which  "  cut  the  corners  "  of  that  structure,  is  perhaps  a 
sufficient  reason  for  making  a  reference  to  them  at  all.  {b)  Corticothalamic. 
— It  has  been  held,  similarly,  that  some  of  this  group  pass  by  the  laminae 
medullares  of  the  lenticular  nucleus,  but  there  is  no  evidence  of  such  a 
route  in  apes,  (r)  Cortioluysian. — Dejerine  says  that  "  le  corps  de  Luys 
.  .  .  regoit  de  la  corticalite  cerebrale  quelques  tres  rare  fibres  qui  passent 
par  les  lames  medullaires  du  globus  pallidus."  However  this  may  be  in  man, 
Wilson  does  not  find  them  so  in  the  apes  on  which  experiments  have  been 
made. 

The  problem  of  the  function  of  the  corpus  striatum  in  man,  difficult  as  it 
is,  is  brought  nearer  solution  by  a  consideration  of  the  anatomical  (human 
and  comparative)  and  clinico-pathological  sides  of  the  question,  each  of 
which  will  be  found  to  furnish  a  material  contribution  to  the  subject,  (i) 
It  is  essential  in  discussing  the  physiology  of  the  corpus  striatum  to  think 
anatomically.  Admitting  the  not  infrequent  error  of  supposing  that  anatom- 
ical juxtaposition  argues  physiological  relationship,  it  is,  nevertheless,  a  more 
serious  mistake  to  assign  functions  to  an  organ  which  it  is  anatomically  inca- 
pable of  carrying  out.  The  cardinal  anatomical  connections  of  the  corpus 
striatum  are  as  follows:  (i)  It  is  independent  of  the  cerebral  cortex,  (ii) 
The  putamen  and  caudate  are  closely  linked  to  each  other,  and  both  to  the 
globus  pallidus.  (iii)  The  main  striofugal  and  striopetal  fiber  groups  are 
related  to  the  globus  pallidus  only,  and  not  to  the  putamen  and  caudate  di- 
rectly, (iv)  The  striofugal  groups  preponderate,  and  link  the  globus  pallidus 
with  the  optic  thalamus  and  the  regio  subthalamica,  including  the  nucleus 
ruber,  corpus  subthalamicum,  and  substantia  nigra,  (v)  The  corpus  striatum 
is  not  connected  directly  with  the  spinal  cord,  (vi)  The  corpora  striata  are, 
directly  at  least,  independent  of  each  other.  From  a  consideration  of  these 
anatomical  data,  obtained  by  experiments  on  apes,  and  known  to  be,  in  great 
part,  if  not  entirely,  identical  in  man,  it  is  clear  that  the  corpus  striatum  is 
an  autonomous  center ;  in  other  words,  whatever  its  function,  that  function 
is  exercised  independently  of  the  cerebral  cortex.  Further,  these  anatomical 
data  indicate  that  that  function  is  motor  in  tj'pe,  i.  c,  that  it  is  exercised  in 
an  efferent  or  caudal  direction.  It  does  not,  however,  follow  that  because  the 
main  connections  are  efferent  the  motor  function  of  the  organ  is  identical 
with,  or  even  similar  to,  the  motor  function  of  the  corticospinal  system. 
Certain  other  anatomical  features  may  here  be  referred  to.  By  far  the 
greatest  number  of  the  cells  of  the  corpus  striatum  in  man  are  small  and 
of  a  more  or  less  spindle  or  spherical  and  only  slightly  polygonal  type,  with 
scanty  cytoplasm.  It  is  mainly  in  the  globus  pallidus  that  larger  cells  are  to 
be  found;  the  former  have  short  axons,  the  latter  longer  axons,  and  they 
belong  to  the  striofugal  group  of  neurons.  There  are  not,  however,  in  the 
corpus  striatum  large  polygonal  cells  unmistakably  of  the  type  of  the  Betz 
cells  of, the  motor  cortex  or  the  ventral  cornual  cells  of  the  spinal  cord. 
Again,  the  caliber  of  the  internuncial  fibers  is  very  fine,  and  that  of  the  larger 
of  the  ansa  fibers  is  less  than  that  of  the  fibers  of  the  adjacent  corticospinal 
system.     Without  laying  unjustifiable  emphasis  on  these  structural  differences, 


58o  PERISCOPE 

they  may.  the  author  thinks,  be  taken  at  least  to  suggest  that  the  function  of 
the  corpus  striatum  and  its  projection  system  is  not.  in  man,  identical  with 
the  function  of  the  motor  cortex  and  its  projection  system.  On  anatomical 
grounds  the  localization  of  "  automatic  movements  "  in  the  corpus  striatum, 
or  its  description  as  a  "  subcortical  motor  center  "  whose  motor  function  is 
in  any  way  analogous  to  that  of  the  motor  centers  of  the  cerebral  cortex, 
cannot  be  entertained.  The  independence  of  the  motor  cortex  and  the  corpus 
striatum,  and  the  peculiar  projection  system  of  the  latter,  make  these  views 
untenable.  (2)  Evidence  derived  from  the  sources  of  comparative  anatomy 
and  physiologj-  has  an  important  bearing  on  the  function  of  the  corpus 
striatum.  In  the  whole  vertebrate  series  the  corpus  striatum  is  a  prominent 
organ.  Phylogenetically,  it  is  a  very  old  structure,  consisting  of  the  basal 
part  of  the  telencephalon  or  forebrain.  In  fishes  it  consists  of  a  paleostriatum 
only,  corresponding  to  the  globus  pallidus  of  the  higher  vertebrates :  in  rep- 
tiles and  birds  there  are  additions  to  it  in  the  shape  of  (i)  the  archistriatum, 
corresponding  to  the  nucleus  amygdalae  of  the  apes  and  man,  and  (2)  the 
neostriatum,  which  represents  the  putamen  and  caudate  nucleus.  The  paleo- 
striatum or  globus  pallidus  is  the  oldest  part  of  the  corpus  striatum  not 
merely  phylogenetically,  but  also  ontogenetically.  Its  cells  develop  in  the 
fetus  in  mammals  earlier  than  those  of  the  other  divisions,  while  the  globus 
pallidus  and  the  ansa  lenticularis  myelinate  earlier  than  the  fibers  of  the  rest 
of  the  striatum.  The  fiber  connections  of  the  paleostriatum  are  important. 
In  all  vertebrates  a  well-marked  and  definite  bundle  passes  from  the  corpus 
striatum  to  the  optic  thalamus  and  be\ond.  As  Edinger  says,  a  fiber  system 
found  so  universally  and  so  obvious  must  have  a  special  significance ;  it  is, 
indeed,  primeval  (uralt).  This  basal  bundle  or  basal  forc])rain  bundle  (basal 
Vordcrhirubiiitdcl),  a  tractus  striothalamicus  and  tractus  striosubthalamicus 
in  one,  is  essentially  striofugal  or  centrifugal,  1.  <'.,  efferent  or  motor,  and  it 
links  the  paleostriatum  to  the  optic  thalamus  and  to  the  motor  centers  of  the 
mid-  and  hindbrain  and  spinal  cord.  According  to  Johnston  this  linking  of 
the  paleostriatum  to  motor  centers  situated  caudalh^  is  effected  by  means  of 
the  fasciculus  longitudinalis  medialis  (posterior  longitudinal  fasciculus),  the 
oral  end  of  which  is  continuous  with  the  caudal  extremity  of  the  tractus 
striothalamicus.  Thus  the  original  motor  pathway  from  the  paleostriatum 
is  broken  once  in  the  optic  thalamus  and  the  fibers  arising  here  prob- 
ably make  connection  with  widely  separated  motor  nuclei  in  the  brain 
and  spinal  cord.  Essentially  the  same  motor  conduction  path,  according  to 
the  same  author,  is  found  in  all  vertebrates,  although  its  functional  relations 
may  be  somewhat  modified  in  mammals  on  account  of  the  cerebral  cortex. 
Whatever  may  be  the  case  in  the  lowest  vertebrates,  the  posterior  longitudinal 
fasciculus  in  mammalia  and  in  man  cannot  have  the  same  function  as  its 
homologue  may  have  had  as  a  "  primitive  somatic  motor  fasciculus."  The 
researches  of  Eraser  (cats  and  monkeys)  show  that  only  a  few  fibers  unite 
the  fasciculus  to  the  optic  thalamus,  and  these  are  all  afferent  to  the  thalamus 
or  centripetal.  The  facts  are  important  bj'  analogy,  for  they  supply  another 
instance  of  cerebral  function  moving  away  from  its  original  localization  with 
the  development  of  the  vertebrate  species.  Like  the  ansa  lenticularis,  the 
posterior  longitudinal  fasciculus  has,  in  part  at  least,  depreciated.  The  re- 
searches of  Ariens  Kappers,  de  Vries  and  de  Lange,  in  the  lower  vertebrates, 
have  shown  that  the  paleostriatum  is  linked  to  the  optic  thalamus  and  mid- 
brain, medulla  oblongata  and  cord  by  double  connections,  both  efferent  and 
afferent.  Its  relation  to  the  trigeminal  .system  in  particular,  both  motor  and 
sensory,  seems  to  be  very  close.  This  is  well  seen  in  the  reptilia.  It  is  well 
recognized  that  the  rule  of  double  connections  between  nervous  ganglia 
obtains  almost  universally  in  the  nervous  system  of  vertebrates,  so  that  while 
the  main  connections  of  the  paleostriatum  are  striofugal,  it  cannot  be  sup- 


PERISCOPE  581 

posed  that  it  is  insulated  from  sensory  stimuli  in  any  way;  on  the  contrary, 
it  must  be  conceived  of  the  paleostriatum  as  a  correlation  center  for  various 
sensory  impulses   (olfactory,  gustatory,  etc.),  from  which  passes  caudally  an 
efferent  tractus  striothalamicus,  with  connections,  for  the  execution  of  motor 
impulses.     The  part  of  the  striatum  associated  with  olfactory  impressions  is 
more  particularly  the  archistriatum,  the  homologue  of  the  nucleus  amjgdalse 
in  man.     The  archistriatum  is  connected  with  a  tertiary  olfactory  path,  and 
Ariens  Kappers  thinks  that  even  in  mammals  a  part  of  the  corpus  striatum 
may  subserve  an  olfactory  function.     The  nucleus  amj'gdalae  can  readily  be 
distinguished  from  the  neostriatum   (putamen  and  caudate)   with  which  it  is 
continuous  onh^  in  appearance;  its  cell  maturation  is  later  than  that  of  the 
paleostriatum  and  earlier  than  that  of  the  neostriatum,  and,  as  de  Vries  says, 
there  is   doubt  whether  it  may  not  really  be  pallial  in  origin,  while  Elliot 
Smith  has  shown  that  at  the  palliostriate  junction  there  is  confusion  owing 
to  the  rapid  growth  of  (among  others)  the  olfactory  cortex  in  the  neighbor- 
hood of  the  corpus  striatum.     The  archistriatum  may  be  left  as  not  being  of 
further  interest.     Looked  at  from  the  point  of  view  of  comparative  physiol- 
ogy, it  maj^  be  regarded  as  the  original  corpus  striatum,  as  that  part  of  the 
original   cerebral   hemisphere   whereby   impressions   of   smell,   and   no   doubt 
other  sense   impressions,   may  bring  their  influence  to  bear  on  the  nervous 
mechanisms  regulating  movement.     The  paleostriatum,  then,  has  a  projection 
system  which  consists  of  the  basal  bundle,  or  tractus  striothalamicus  and  strio- 
subthalamicus,  and  which  is  continued,  according  to  Johnston,  as  the  fascicu- 
lus longitudinalis  medialis,  or  at  least  as  a  part  of  the  latter ;  this  is  designated 
by  him  the  primitive  somatic  motor   fasciculus.     It  is  therefore  to  be  con- 
sidered the  homologue  of  the  corticospinal  paths  of  man,  and  is,  for  instance, 
in  the  fishes,  the  sole  descending  tract  that  can  be  compared  to  the  cortico- 
spinal motor  system  of  higher  vertebrates.     With  the  progressive  development 
of  the  brain  the  motor  paths  become  more  complex.     When  a  pallium  develops 
above  the  original  paleostriatum  motor  center,  as  in  reptiles,  birds,  etc.,  the 
descending  paths  are  doubled.     The  earliest  appearance  of  corticospinal  fibers 
separating  the  two  parts  of  the  neostriatum  and  blending  with  the  striofugal 
projection  system  is  in  the  higher  reptilia,  according  to  de  Lange.     The  state 
of  affairs  in  the  bird's  brain  is  particularly  remarkable.     In  Ariens  Kappers's 
view,  it  is  possible  that  the  neostriatum  of  birds  acts  vicariously  for  the  neo- 
pallium  or   cortex.     In   the   tractus   striomesencephalicus   are   mingled   fibers 
both  of  striate  and  of  pallial  origin,  and  the  suggestion  is  made  that  it  is 
because  of  the  necessity  for  economy  of  space  in  the  brains  of  birds  that 
such  a  state  obtains.     It  should  not  be  forgotten,  however,  that  McKendrick, 
Ferrier,  Mills  and  others  have  shown  definitely  that  the  pallium  of  birds  is 
electrically  inexcitable;   Ferrier  obtained  no  movements  at  all;  McKendrick 
noted  simply  movements  of  the  iris  and  eyeball.     The  mammalian  brain,  in 
its  turn,  is  very  different  from  that  of  the  birds  and  reptiles.     The  reptilia 
have  an  olfactory  pallium;  birds  a  visual  and  olfactory  pallium;  the  lower 
mammalia  a  visual,  an  olfactory,  an  auditory,  and  a  tactile  pallium.     With 
further  development  of  the  pallium  afferent  systems  are  pushed  beyond  the 
level  of  the  thalamus  and  corpus  striatum  to  reach  it;  and  while  in  response 
a  definite  cortico-spinal  motor  system  is  developed  the  primitive  motor  pro- 
jection system  of  the  corpus   striatum  disappears,   or,  rather,  is  reduced  to 
the  ansa  lenticularis,  which  does  not  extend  beyond  the  nucleus  ruber.     Its 
function  is  replaced  by  that  of  the  corticospinal  or  pyramidal  tracts.     In  some 
ways  there  is  a  parallelism  between  the  development  of  the  corpus  striatum 
as  a  whole  and  that  of  the  pallium.     The  former,  consisting  originally  of  a 
paleostriatum  possessing  motor   and   correlating   functions,   develops   by   the 
addition  of  a  neostriatum  (putamen  and  caudate)  which  is  found  for  the  first 
time  in  the  lower  reptilia  and  increases  in-  relative  size  through  the  lizards, 


582  PERISCOPE 

birds  and  mammals  :  so  in  proportion  to  the  corpus  striatum  as  a  whole  the 
pallium  develops  increasingly  through  the  vertebrate  series.  But  the  analogy 
does  not  carry  us  far ;  while  the  function  of  tlie  palliospinal  system  usurps 
that  of  the  striospinal  system,  we  do  not  know  that  the  neostriatum  abrogates 
the  function  of  the  paleostriatum.  In  fact  the  exact  relation  of  these  two 
to  each  other  in  functional  activity*  is  far  from  clear,  that  is,  in  the  case  of 
animals  whose  pallium  is  still  comparatively  insignificant.  Indeed,  the  rela- 
tion of  the  neostriatum  to  the  paleostriatum  is  one  of  the  difficult  subsidiary 
questions  in  a  difficult  subject.  Ariens  Kappers,  apparenth',  is  the  only  inves- 
tigator who  has  devoted  attention  to  the  matter.  He  believes  that  just  as  in 
the  higher  mammalia  and  man  the  pallium  has  taken  the  place  of  the  corpus 
striatum  as  a  whole,  so  the  neostriatum  (putamen  and  caudate)  takes  the 
place  of  the  paleostriatum  (globus  pallidus)  in  birds.  In  his  view,  further, 
the  connections  of  the  neostriatum  with  the  thalamus  is  an  indication  that  the 
former  has  functions  in  relation  to  the  fillet  and  trigeminal  systems.  What- 
ever maj-  be  the  case  in  birds,  this  view  does  not  commend  itself  in  the  case 
of  animals  with  a  better  developed  pallium.  Wilson's  experiments  with  apes 
show  conclusively  that  the  neostriatum  has  no  projection  system  of  its  own 
beyond  the  paleostriatum ;  with  the  possible  exception  of  a  few  caudate- 
thalamic  fibers,  the  neostriatum  is  not  connected  to  the  thalamus  or  sub- 
thalamus  at  all ;  it  is  the  globus  pallidus  which  through  the  whole  vertebrate 
series  possesses  the  important  projection  system.  This  may  perhaps  suggest 
that  the  corpus  striatum  sliould  be  considered  as  a  physiological  unit,  or, 
rather  that  the  functions  of  the  neostriatum  and  paleostriatum  are  blended. 
It  will  be  understood  that  at  one  stage  in  the  development  of  the  vertebrates 
the  thalamus  and  corpus  striatum  functioned  as  a  brain  in  miniature,  the 
latter  being  a  correlating  center  concerned  with  the  translation  of  sensory 
into  motor  impulses ;  but,  even  at  the  best,  its  motor  functions  must  have 
been  simple  compared  with  the  complexities  of  the  pallium  of  the  mammalia. 
In  the  course  of  development  the  corpus  striatum  and  its  projection  system 
have  depreciated ;  the\'  have  had  to  abandon  their  position  of  hierarchy  in 
the  field  of  motor  activity.  Thus  the  facts  of  comparative  anatomy  and 
physiolog}'  support  the  evidence  derived  from  experiment.  In  view  of  the 
changing  importance  of  the  corpus  striatum  it  becomes  a  delicate  matter  to 
allocate  its  function  in  the  various  animal  groups  ;  its  function  in  man  is  not 
necessarily  identical  with  its  function  in  apes.  Altliough  the  curious  and 
unique  features  of  the  bird's  brain  demonstrate  conclusivelj'  that  evolution 
is  not  necessarily  progressive,  from  the  strictly  motor  point  of  view,  the 
corpus  striatum  seems  to  have  been  progressively  shorn  of  its  possessions ; 
its  proportionate  size  in  man  is  less  than  in  anj'^  of  the  lower  animals,  and 
it  may  be  that  the  superman  of  the  future  will  have  no  corpus  striatum  at  all. 
(3)  Wilson  states  that  whatever  function  the  corpus  striatum  once  possessed, 
there  is  no  experimental  evidence  in  apes  to  show  that  it  exercises  anj'  motor 
function  comparable  to  that  of  the  motor  cortex.  There  is  no  evidence  to 
suggest  that  it  is  a  center  for  so-called  automatic  movements.  It  is  elec- 
trically incxcitable,  and  comparatively  large  unilateral  lesions  do  not  give 
rise  to  any  unmistakable  motor  phenomena.  In  short,  the  only  proofs  that 
it  does  possess  a  function  of  a  motor  order,  in  the  widest  sense,  as  it  is  to  be 
expected  it  would  exercise  in  view  of  its  i)hylogenetic  historj'  and  the  facts 
of  anatomy,  are  to  be  obtained  by  a  consideration  of  clinico-pathological  data. 
Shcrrinj?ton's  conception  of  the  "  final  common  path  "  is  here  to  be  .empha- 
sized. .'\t  the  commencement  of  every  reflex  arc  is  a  receptive  neuron,  which 
is  reserved  exclusively  for  impulses  generated  at  one  single  receptive  source. 
The  motor  neuron  at  the  other  end,  however,  receives  impulses  from  many 
receptive  sources.  "  It  is  the  sole  path  which  all  impulses,  no  matter  whence 
they  come,  must  travel  if   they  are  to  act  on   the  muscle  fibers  to  which   it 


PERISCOPE  583 

leads.     Therefore,   while   the   receptive   neuron    forms   a  private  path  exclu- 
sivel}^  serving  impulses  of  one  source  onlj%  the  final  or  efferent  neuron  is, 
so  to  say,  a  public  path  common  to  impulses  arising  from  any  of  many  sources 
of   reception."     And,   again,   "  reflexes  originated  at  different  distant  points, 
and  passing  through  paths  widely  separate  in  the  brain,  converge  to  the  same 
motor  mechanism   (final  common  path)   and  act  harmoniously  upon  it.     Re- 
flex arcs   from  widely  different  parts  conjoin  and  pour  their  influence  har- 
moniously into   the  same  muscle.     The  motor  neurons  of   a  muscle   of  the 
knee  are  the  terminus  ad  quern  of  reflex  arcs  arising  in  receptors  not  only 
of   its   own   foot,   but   from   the   crossed   forefoot  and  pinna,   and   tail,   also 
undoubtedly  from  the  otic  labyrinth,  olfactory  organs,   and   eyes.     Thus,   if 
any  motor  nerve  to  a  muscle  be  taken  as  a  standpoint  it  consists  of  a  number 
of  motor  neurons  which  are  more  or  less  bound  into  a  motor  unit  mechanism  ; 
among  the  reflex  actions  of  the  organism  a  number  can  all  be  brought  together 
as  a  group,  because  they  all  in  their  course  converge  together  upon  this  motor 
mechanism,    this    final    common    path,    activate    it,    and    are    in    harmonious 
mutual  relation  with  regard  to  it."     This  illuminating  conception  of  a  "  final 
common  path  "  is  not  further  applied  by  Sherrington  in  a  detailed  manner, 
but  by   implication   it   may  be   applied   to   the   problem   considered.     Various 
influences   act  harmoniously  on  the  final  common  path  of  the  lower  motor 
neurons :    ( i )    The   corticospinal   motor   system   extends   from   the   Betz   cell 
"  ganglion "   to   the   arborizations   round   the   anterior   cornual   cells,   and   its 
function  is  to  innervate,  or  to  conduct  innervating  impulses,  originating  we 
know  not  how  in  the  cortex,  to  the  final  common  path.     If  this   system  is 
impaired  or  destroyed  by  a  lesion  the  result  is  paralysis.     (2)  The  cerebellar 
S3'stem  also  exerts  an  influence  on  the  final  common  path.     Its  ganglion  is  the 
cerebellum  from  which  it  extends  by  a  series  of  internuncial  neurons  to  the 
lower  motor  neuron.     The  cerebellum  exerts  a  coordinating  and  cooperating 
influence   on    the    stream    of    innervation    passing    from    the   rolandic   motor 
ganglion  via  the  final  common   path  to  the  muscles.     The  routes  by  which 
cerebellar  influence  is  exercised  are  complicated,  some  perhaps  may  pass  by 
the  tractus  cerebello-tegmentalis  to  the  opposite  nucleus  ruber  and  so  back 
to  the  spinal  cord  on  the  same  side ;  some  travel  bj^  the  superior  cerebellar 
peduncle,  contralateral  optic  thalamus  and  contralateral  cortex  and  so  back 
to  the  final  common  path  by  the  corticospinal  system  itself.     In  this  case  the 
latter  becomes  an  inter)ittncial  common  path  as  opposed  to  the  final  common 
path,  and  Sherrington  makes  it  clear  that  such  internuncial  common  paths  are 
by  no  means  infrequent.     For  the  sake  of  simplicity,  however,  Wilson  indi- 
cates cerebellar  influence  in  his  diagram  by  an  independent  path.     A  lesion 
of  the  cerebellar  path  results  in  incoordination  or  ataxia,  or  better,  dysmetria, 
while   there   is   no   paralysis.     (3)    Another    important   reflex   path   carrying 
impulses  to  act  on  the  final  common  path  is  the  vestibular.     It  extends  from 
Deiters'  nucleus    (to  which  there  is  a  private  path   from  the  labyrinth)   via 
the   vestibulospinal    tract   to    the   anterior   horn    cells.     An    additional   allied 
mechanism   is   perhaps   constituted  by  the   posterior   longitudinal    fasciculus, 
which  is  linked  to  Deiters'  nucleus  and  also  passes  to  the  anterior  horn  cells. 
Interference  with  the   function  of  the  vestibular  element  in  the  activity  of 
the 'final  common  path  results  in  what  is  called  by  the  French  school  "  tituba- 
tion."     It  is  of  course  commonly  held  that  some  at  least  of  the  cerebellar 
influx  to  the  cord  is  transmitted  by  Deiters'  nucleus  and  the  vestibulospinal 
path,  and  this  may  very  well  be  so.     But  it  is  desirable  to  attempt  to  separate 
cerebellar   from  vestibular  elements  in  coordinate  innervation,   and   for  dia- 
grammatic purposes,  at  any  rate,  one  may  properly  be  distinguished  from  the 
other.     (4)    Finally   there   is    the   striorubrospinal   path,    conveying   impulses 
from  the  corpus  striatum,  via  the  ansa  lenticularis,  nucleus  ruber,  and  rubro- 
spinal tract,   to  the  anterior  cornual  cells.     In   what  way  impulses  origniate 


584  PERISCOPE 

in  the  corpus  striatum  is  immaterial — they  may  depend  on  stimuli  from  the 
optic  thalamus  by  thalamostriate  fibers ;  in  any  case,  the  evidence  for  the 
efferent  action  of  corpus  striatum  impulses  on  the  filial  common  path,  by  the 
route  just  mentioned,  is  not  to  be  lightly  set  aside.  This  influence,  it  has  been 
said,  is  one  which  steadies  pyramidal  innervation  along  the  final  common 
path.  In  the  absence  of  this  influence  tremor  is  likely  to  occur,  and,  as  a 
rule,  with  increase  of  pj'ramidal  action  so  will  the  tremor  increase.  It  is  an 
action  tremor.  The  reader  is  referred  to  the  author's  monograph  for  a  full 
discussion  of  the  evidence  associating  tremor  as  well  as  hypertonicity  of  the 
skeletal  muscles  with  defect  of  function  of  this  internuncial  system.  One  final 
question  remains.  Admitting  that  the  corpus  striatum  has  no  longer  any 
motor  activity  comparable  to  that  of  the  motor  cortex  or  of  the  spinal  cord, 
and  that  its  motor  function  is  one  of  steadj-ing  (the  author  purposely  avoids 
using  the  difficult  word  "inhibiting")  innervation  as  it  streams  along  the 
final  common  path,  is  there  any  evidence  to  suggest  that  the  organ  under  dis- 
cussion has  developed  in  other  waj's,  and  that  it  may  be  associated  with 
innervation  of  non-striped  muscle  fiber?  Does  it  bear  anj^  relation  to  organic, 
visceral  activity-?  Has  it  to  do  with  a  central  representation  of  the  sympa- 
thetic and  autonomic  sj-stems?  Langelaan  has  put  forward  the  hypothesis 
that  the  corpus  striatum,  with  the  bodj-  of  Luys  and  the  substantia  nigra,  is 
the  highest  motor  center  for  non-striped  muscle.  A  great  deal  of  attention 
has  at  different  times  been  devoted  to  a  consideration  of  the  view  that  in  the 
corpus  striatum  is  a  heat-regulating  center ;  also  a  respiratory  center,  a  vaso- 
motor center,  a  blood  pressure  and  pulse-contfolling  center,  and  so  on. 
There  are  obvious  difficulties  in  the  way  of  accurately  determining  such 
functions  by  experiment,  and  the  evidence  hitherto  adduced  is  far  from  con- 
vincing, besides  being  in  some  wajs  contradictor^'.  The  variety  of  animals 
operated  on  is  also  a  verj'  important  complicating  factor.  In  Wilson's  own 
experiments  no  evidence  was  obtained  of  any  disturbance  of  respiration  from 
stimulation  or  destruction  of  the  putamen  or  globus  pallidus  in  apes.  And, 
further,  the  question  must  always  remain,  assuming  any  of  these  functions 
for  the  sake  of  argument,  how  are  they  carried  out? 

5.  Aphasia. — Mingazzini  describes  a  case  with  marked  aphasia  due  to 
severe  atrophy  of  the  respective  convolutions. 

6.  Study  of  Satellite  Cells. — The  author  finds  through  the  analysis  of  the 
relative  numerical  occurrence  of  satellite  cells  in  ten  cases,  each  of  five  psy- 
choses, that  satellitosis  cannot  be  considered  in  any  sense  indicative  of  the  type 
of  psjxhosis,  although  it  has  in  this  series  appeared  with  more  consistent  inten- 
sity in  the  maniacal  depressive  cases  and  has  been  of  very  much  less  promi- 
nence, in  dementia  praecox.  The  reaction  elects  the  deeper  cell  layers  both  in 
regard  to  frequence  of  occurrence  and  degree  of  reaction.  The  cortices  of 
the  dome,  precentral,  postcentral  and  frontal  seem  to  show  the  reaction  with 
greater  intensity  than  do  the  temporal  and  occipital  regions.  Age  at  the 
time  of  death  seems  to  plaj'  some  part  in  the  occurrence  of  severe  reactions, 
but  cannot  be  considered  the  only  factor.  The  duration  of  the  psychosis 
bears  no  demonstrable  relation  to  satellitosis. 

Jklmffe. 


INDEX  TO  VOLUME  43 


Figures  with  asterisk  (*)  indicate  original  articles  and  are  accompanied 
with  title.  Figures  unaccentuated,  accompanied  with  title,  indicate  abstracts  ; 
without  title,  book  reviews. 


PAGE 

A  BDUCENS   Paralysis  191 

i\.     Adductor  Responses  of  the 

Leg    121 

Abdominal  Muscles,  Tic  of   ....   510 

Adiposus-genitalis    93 

Adrenalin,    Action    of,    and    Epi- 

nine  on  the  Pupil   in   Epilepsy    93 
Aged,    Condition    Occurring    in, 
Usually  Attributed   to   Arte- 
riosclerosis       489 

Agrammatism    191 

Albumen  in   Cerebrospinal  Fluid  379 

Alcoholic  Hallucinations    471 

Alexia  and  Amnesia   256 

Alienists     and     Neurologists     of 

.  U.   S 392 

Aliens,  Examination  of  Mentally 

Defective     380 

Alloesthesia    191 

American  Journal  of  Insanity  . .   379 
American   Neurological   Associa- 
tion         47 

Amnesia  and  Alexia   256 

Amyotrophic  Lateral   Sclerosis..     94 
Anchylosis  of  the.  Proximal  Pha- 
langeal    Joints,      Hereditary 

[Symphalangism]    445 

Aphasia    94 

Aphasia    584 

Aphasia  and  Apraxia   190 

Aphasias,  Treatment  of   385 

Aplasia     573 

Appendicitis  in  Hospitals  for  the 

Insane    I95 

Apraxia    195,  285 

Archiv  fiir  Psychiatric  und  Ner- 

venkrankheiten    94,  384 

Arteriosclerosis    98 

Arteriosclerosis    and    Pseudobul- 
bar Palsy  of  Gradual  Onset     58 

Arteriosclerosis     489 

Atrophic  Myotony   284 

Atrophy  of  the  Lower  Extremity  547 

Atwood,   C.  E 94.  282 

Auer,  E.  M.,   Pathological  Find- 
ings  in    Paralysis   Agitans  .  .   532 
Axialis    573 


PAGE 

UASSOE,  P 56 

D     Blood   Examinations    285 

Babinski   Sign    547 

Blood  Tests   285 

Bomb  Wound    364 

Boston     Society     of     Psychiatry 

and  Neurology 443 

Brain    569 

Brain  Anatomy 454 

Brain  and  Liver  Weights,  Ab- 
normal       422 

Brain    Atrophy    204 

Brain  Tumor,   188,  189,  190,  362,  443 

Brain  Tumor,  Cystic 188 

Brink,  L 102 

Brown,  II,  Sanger,  Symptoms  in 
Infective  Exhaustive  Psy- 
choses      518 

Bulbar  Disease   556 

Bulbar  Palsy .  .425.  545 

Byrnes,  Condition  Occurring  in 
the  Aged,  Usually  Atributed 
to    Arteriosclerosis    489 

pADWALADER,    Williams    B.     57 

\j     Camp,  CD 54 

Canavan,  Myrtelle  M.  An  His- 
tological Study  of  the  Optic 
Nerves  in  a  Random  Series 
of  Insane  Hospital  Cases  . .  217 
Cerebellar  Artery,  Posterior  In- 
ferior         94 

Cerebellar  Diplegia   57 

Cerebellar    Function    196 

Cerebellar    Symptoms    284 

Cerebellar   Tumors   98,   198 

Cerebellum     189 

Cerebellum.  Localization  of  Func- 
tion in  the  Canine   105 

Cerebral   Abscess    555 

Cerebral    Hemorrhage    443 

Cerebro-Cerebellar   Ataxia   550 

Cerebrospinal    Fluid    in    Mental 

Conditions     192 

Cerebrospinal   Fluid   Reactions..   378 

Cerebrospinal    Syphilis    262,267 

Cerebrum,  Rabbit 96 

Chicago  Neurological  Society   . .    169 

585 


586 


INDEX  TO  VOLUME  43 


Children.    Backward    192 

Clarke,  F.  B..  Tic  of  the  Abdom- 
inal  Muscles    510 

Consciousness,    Neuro-biological 

Method    559 

Corneal  Reflex    95 

Corpus    Striatum    576 

Corticalis  Congenitalis   573 

Cortical    Spasm    95 

Cranial  Xervcs  of  Anolis  Caro- 

lonensis    287 

Crus  Cerebri.  Tumor  Involving.  505 
Cutaneous    Zone    of    the    Facial 

Nerve     156 

Cystic  Brain  Tumor   188 

DAXVERS   State  Hospital    ...  56 
Delinquenc}',  Psychiatric  Con- 
tributions to  the  Study  of  449 

Dementia 103 

Dementia   Precox 195.  .381,  383 

Dementia        Prjecox,        Pupillar 

Changes  in   386 

Dementia  Simplex   381 

Deutsche  Zeitschrift  fiir  Nerven- 

heilkunde     283 

Diller,  Theo.,  Dystonia  Muscu- 
lorum Deformans  with  Re- 
port       337 

Diplegia.    Cerebellar    ^7 

Dreams  and  their  Significance..  I91 

Dream   Problem    81 

Dreams,  Waking    191 

Dysenterj'    378 

Dystonia  Musculorum    337 

Dystrophy  .\diposo-genitaIis  in 
Hydrocephalus  and  in  Epi- 
lepsy      0^ 

Dwarfism     284 

pCHTXOCOCCUS      of      Cord 

i-j     and  Cauda  Equina   38; 

Eclampsia    97 

Electrical     Conductivity    of     the 

Human    Body    02 

Enteric  Fever    379 

Enuresis  and  Spina  Bifida   385 

Ependymitis,  Glandular   05 

Epilepsy    03.    283,  464 

Epilepsy,  the  Action  of  Adrena- 
lin and  Epinine  on  tJic  Pupil 

in 9^ 

Epilepsy,    Tacksonian     93 

Epilepsy,  Operation   in    97 

Epileptics.   Association   in    97 

Epileptic  .\ttacks    189 

Epileptic  Children  and  Anti- 
social  Acts   9'') 

Erythromclalgia    384 

Essential  Tremor  447 

Eugenics    380 


yE.^R 474 

1  Feebleminded  Family.  His- 
tory of   176 

Feeding,  Forced    192 

Fisher,  E.  D 53 

pERMAX   Brain-pathology    ...     92 

vT  (ilogau,  Otto,  Speech  Con- 
flict     37,   139 

Gordon,  Alfred,  Hydromyelia 
and  H}-droencephalia 411 

Grapholog}'  and  Feebleminded- 
ness      385 

Greenman,  J 62 

Grey,  Ernest  G..  Localization  of 
Function  in  the  Canine  Cere- 
bellum       105 

Gyrus,  Anterior  Central 284 

HALLOCK.  Frank  Mead  81 
Hamilton,  A.  S.,  Progressive 
Lenticular    Degeneration.   297 

Hammond.   G.   M 49 

Harrison.  Forrest  AL.  The  Role 
of  Hallucinations  in  the  Psy- 
choses     231 

Heart    Disease    and    Psychoneu- 

roses    96 

Hemiparesis    259 

Hereditary  Syphilis  Affecting  the 

Xervous  System  54 

Herpes  Zoster  Oticus,  with  Fa- 
cial     Palsy      and      Acoustic 

Symptoms    155 

Heterotopias     188 

Higier    jt,,   179,  272,.  2,72,  467 

Higier     564 

Hydroencc])halia  and  Hydromye- 
lia       411 

Hvdroceph-dus    03,  557 

Hydromyelia    and    Hydrocnceph- 

alia    411 

Hysteria     546 

Hysteria  Diagnosis    97 

IDIOCY,  Familv  Amaurotic    . .     93 
Insane  Hospital  Cases,  Optic 

tic  X^erves   in    217 

fnfect'on-T'vbniistinn    Psychoses.   518 
Insanity,    Inherited   Tendency   to  192 

Insanity  with    Myxedema    192 

Intracranial   Hemorrhaee    35=; 

Intraspinal  Tumor,  Epidural   . .  .   448 
Involution  Phenomenon  of  Brain 

Tumor    92 

T  ACKSOXT AX  Enilensy  ......     93 

)      Jahrbiirher     fiir    Psychiatric 

und   Xeurologie 02 

lelliflfe.  Smith  Ely   81 

Jodi's     Psychology     and     Mental 

Signs     .38^ 


INDEX  TO  VOLUME  43 


587 


PAGE 

Journal  American  Medical  Asso- 
ciation     98,   196,  198 

Journal  of  Experimental  Medi- 
cine        ig6 

Journal  of  Mental  Science. .  191,  378 

Julian-Claudian  Dynasty    385 

KORSAKOW'S     Psychosis    in 
Japan    92 

Korsakow's    Symptom    Complex, 

Peripheral  Neuritis   431 

Korsakow's  Symptom   343 

Kraus,  Walter  M yz 

Krumholtz,  S.,  A  Case  of  Atypical 
Aiultiple  Sclerosis  with  Bul- 
bar   Paralysis     425 

T   ANDRY'S   Paralysis   53 

JL     Landry's   Paralysis,   Its   Re- 
lation  to   Poliomyelitis    . .   166 
Lateral  Homonymous  Hemianop- 
sia      254 

Lateral  Ventricle   49 

Leg,  Value  and  Meaning  of  the 

Adductor  Responses  of   ....   121 
Lenticular     Degeneration,      Pro- 
gressive      297,  460 

Lenticular  Nucleus    23 

Leucocytosis   in   Mental   Disease, 

193,  379 
Liver    and    Brain    Weights,    Ab- 
normal       422 

Los  Angeles  Society  for  Neu- 
rology and  Psychiatry   488 

Lowrey,  L.  G.,  A  Study  of  Some 
Cases   Diagnosed   as   Paresis 
in   Pre-Wassermann  Days  . .   324 
Lucke,   Baldwin,   Tabes   Dorsalis  393 
Lymphogenous  Infection  of  Cen- 
tral Nervous   System    569 

MACKENZIE,  G.  M 50 
Maeder,  A.  E 81 

Makuen,  C.  H 68 

McCouch,     G.     P.,     Pathological 

Findings  in  Paralysis  Agitans  532 

McFarland,  Jos.,  In  Memoriam, 
—Isaac  Ott 201 

Memory,  Loss  of  in  Paresis  ....   286 

Meningitis,  Circumscribed  Puru- 
lent, Limited  to  Frontal  Lobe     55 

Mental    Disease,    Physical    Basis 

of     194 

Mental  Disease  or  Defect,  De- 
velopment and  Operation  of 
Laws  for  Hospital  Observa- 
tion   of    Cases    of,   in    Mass.     47 

Mental  Disorders  in  Child-bear- 
ing         195 

Mental  Disorders  in  Political 
Events    9^ 


PAGE 

Mental  Disturbances,  with  Acute 

Articular  Rheumatism    383 

Mental   Organization    195 

Mental  Symptoms,  Comparison 
of  in  Cases  of  General  Pare- 
sis with  and  without  Coarse 

Brain  Atrophy 204 

Mental  Tests   454 

Mentality,  Fundamentals  in  Test- 
ing      169 

Mercury  Poisoning   198 

Meningitis,   Sympathica   56 

Monatsschrift      fiir      Psychiatric 

und  Neurologic   188,  284 

Moore,  J.  W 191 

Moore,  J.  M.  Beacon   286 

Motor  Aphasia  286 

Motor  Apraxia   97 

Multiple  Sarcoma  of  Brain   ....     61 
Multiple  Sclerosis,  Atypical   ....  425 

Miinch.  med.  Wochenschr 197 

Muscle      Control      in      Paralytic 

Cases    357 

Myerson,  A.,  Value  and  Mean- 
ing of  the  Adductor  Re- 
sponses of  the  Leg  121 

Myoclonus,   Familial    59 

Myotonia    252,  284 

Myxedema  with  Insanity 192 

VIEURASTHENIC,    Hysterical 
IM      and   Psychotic   Symptoms..  445 
Neuritis,  Peripheral  with  Korsa- 
kow's  Symptom    343 

Neurofibromata   I53 

Neurofibromatosis,    Central    and 

Peripheral  56 

Neurological  Technique  282 

Neurones  of  Arm   285 

Neuropathology,  Teaching  of, 

443,  446 

Neuroplasty,  Splitting 150 

Neurosis,   Lightning    189 

150,  262.  355,  457,  555 
New  York  Neurological  Society  555 
New  York  Psjxhiatric  Bulletins  47^ 
Nuzum,   F 56 

/ABITUARIES 

\J    Clouston,  Sir  Thomas  Smith  487 
Gowers,  Sir  William  Richard.   485 

Ott,  Isaac,  In  Memoriam   201 

Van    Gehuchten,    Prof.    Albert  483 

Ophthalmoplegia   54^^ 

Optic  Nerves  in  Insane  Hos- 
pital Cases 217 

PACHYMENINGITIS      Hem- 

r     orrhagica     95 

Palsv,    Bulbar    545 

Palsv    58 


;SS 


IXDEX  TO  VOLUME  43 


PAGE 

Palsy  in  its  Relation  to  the  Fa- 

cioplegic    Migraine    457 

Pseudobulbar    Palsy    5S 

Paralysis,  Acute  Ascending   ....   26^ 

Paraly-is   Agitans    443,532 

Paralysis.  Aphasia  in  General  . .    192 

Paralysis.    Bulbar    425 

Paralysis.    Isolated   Sympathetic.   257 

Paralysis,   Landry's    53 

Paralysis,  Non-traumatic  Cer- 
vical Sympathetic 552 

Paralysis,    Periodic    159 

Paralysis,  Spastic   355 

Paralytic  Cases.   Muscle  Co..tiol  357 

Paresis 49 

Paresis,  a  Study  of  Some  Cases 
Diagnosed     in     Pre-Wasser- 

mann    Days    324 

General  Paresis   98.  204.  263.  380 

Paresis,  Intraspinal  Treatment  of  265 

Paresis  among  Jews   97 

Paresis,  Loss  of  Memory  in   ....   286 

Pellagra 539 

Pelvic  Diseases  and  Mental  Dis- 
orders       472 

Peripheral   Neuritis  with   Korsa- 

kow's  Symptom  Complex    . .   431 

Peripheral  >serves    360 

Peripheral  Nerves,  Regeneration 

of   62 

Pernicious   Anemia    384 

Personality,  Double  192 

Philadelphia  Neurological  Society, 

57,  251,  539 

Polyarthritis   308 

Poliomyelitis    166 

Poliomyclitic  Microorganism    .  . .    ig6 

Ponto-Cerebellar  Tumor   261 

Posterior  Longitudinal  Bundle.  573 
Price.  Geo.  E.,  An  Unusual  P.sy- 

chasthenic  Complex   58,  Z2>i 

Psychanalysis,  Criticism  of    380 

Psjchasthenic  Complex   333 

Psychical  Manifestations  of  Dis- 
ease of  the  Glands  of  Inter- 
nal Secretion   383 

Psychoses.  Exhaustive   518 

Physician  and  Psychologist,  Co- 
operation of   177 

Psychiatry   and    Education    189 

P.sychologist  and  Physician,  Co- 
operation   of    177 

Psychology,    Estimate    of    Adolf 

Meyer's    381 

Psychology  of   Stammering    ....      68 
Psychoneuroses   and    Heart   Dis- 
ease          96 

Psychopathic   Subjects    5O 

Psychopathology,  Unconscious  in  281 
Psychoses  in  the  Colored  Race  381 
Psychoses,  Heat  Treatment  in  ..     96 


P.\GE 

Psychoses,    Role    of    Hallucina- 
tions  in    231 

Psychoses,    Parturition    98 

Ps^xhosis,  Hereditj-  in   95 

Pupil  in  Epilepsy  93 

Pupil-Reflexes.  Isolated  Loss  of  286 
Pupil  and  its  Reflexes  in  Insanity  379 
Pyridine-Silver  Method   280 

KEIL'S  Rhapsodieen,  A  Criti- 
cal Historical  Review.  Wil- 
liam A.  White   I 

Religious  Delusions  386 

Review   of   Neurology   and    Psj-- 

chiatry    93,  280 

Reviews, 

Andre-Thomas,  Psychotherapie  291 

Anton,  G.,  Psychiatrische  Vor- 
triige   290 

.\ppleton's   Medical   Dictionary  481 

Auerbach.  Sig..  Die  Chirurgi- 
sclien  Indicationeii  in  der 
Nervenlieilkunde     ." . . .   290 

Benou.  R.,  Des  Troubles  Psy- 
chiciues  et  Nevrisiques  Post- 
Traumatiques     291 

Bernheim,   H.,   L'Aphasie    387 

Biesalski,  D.  K.,  Orthopiidische 
Behandlung  der  Nerven- 
krankheiten     294 

Bing.  Robert,  Textbook  on 
Nervous   Disease    290 

Bresler,  Dr.,  Die  Abderhal- 
densche  Serodiagnostik  in 
der  Psychiatric   290 

Bruns.  Prof.  L.,  Handbuch  der 
Nervenkrankheiten  im  Kin- 
desalter    294 

Budge,  E.  H.  W.,  Syrian  Anat- 
omy, Pathology  and  Thera- 
peutics        104 

Cannon,      Walter      B.,      Bodily  . 
Changes    in     Pain,     Hunger, 
Fear  gnd   Rage   478 

Chase,  R.  H.,  Mental  Medicine 
and   Nursing 102 

Chaslin,  P..  Elements  de  Scmi- 
ologie  et  Clinique  Mentales.   294 

Cams,  P.,  K'ung  Fu  Tzc,  A 
Dramatic  Poem  388 

Carus,  P.,  Goethe  39(j 

Dakin,  H.  D.,  Oxidations  and 
Reductions  in  the  Animal 
I'ody    295 

Finckh.,  Die  Nervenkrank- 
beiten.  Hire  Ursachen  und 
I hre  P.ekampfung  296 

Grignr,  .v.,  Lehrbuch  der  Psy- 
chiatrischen   Diagnostik    ....    387 

Ciorhnklc,    J.     I..     The     Eight  ' 
(  liai)ters  of   Maimonides   on 
Ethics    388 


INDEX  TO  VOLUME  43 


589 


PAGE 

Haymann,  H.,  Wie  Behand- 
eln   wir   Geisteskranke    296 

Healy,  William,  Pathological 
Lying,  Accusation  and  Swin- 
dling      292 

Hirschlaff,  Leo.,  Suggestion 
und   Erziehung    291 

Ingenieros,  Jose,  Principos  de 
Psicologia  Biologica   296 

Jacobsohn,  L.,  Jahresbericht 
ueber  die  Leistungen  und 
Fortschritte  auf  dem  Gebiete 
der  Neurologic  und  Psy- 
chiatric      294 

Jastrow,  M.,  Hebrew  and  Baby- 
lonia Traditions    289 

Jones,   E.,   Der  Alptraum    ....   391 

Kern,  B.,  Ueber  den  Ursprung 
der  Geistigen  Fahigkeiten 
des  Menschen    296 

Klemm,  P.,  Die  Akute  und 
Chronische  Infektiose  Os- 
teomyelitis des  Kindesalters.   387 

Klinke,  O.,  Die  Operative  Er- 
folge  bei  der  Behandlung 
des  Morbus  Basedowii   294 

Krause,  R.,  A  Course  in  Nor- 
mal Histology   291 

Lomer,  G.,  Ignatius  Loyola   . .   388 

Lucka,  Emil.  Eros.  The  De- 
velopment of  the  Sex  Rela- 
tions through  the  Ages   ....   479 

Margulies,  A.,  Diagnostik  der 
Nervenkrankheiten   387 

Mercier,  A  Textbook  on  In- 
sanity and  Other  Mental 
Disease  293 

Mott,  F.  W..  Nature  and  Nur- 
ture in  Mental  Development, 

389,  482 

Miinsterberg,  H.,  Psychology, 
General  and  Applied loi 

Nonne,  Max,  Syphilis  und 
Nervensystem    292 

Pelnar,  Josef,  Das  Zittern, 
Seine  Erscheinungsformen, 
Seine  Pathogenese  und 
Klinische    Bedeutung    295 

Pettey,  Geo.  E.,  The  Narcotic 
Drug  Diseases  and  Allied 
Ailments    291 

Miinsterberg,  H.,  Psychology, 
General   and   Applied    lOi 

Raeche,  J..  Grundriss  der  Psy- 
chiatrischen  Diagnostik   296 

Ruttin,  Erich,  Clinical  Study 
of  the  Serous  and  Purulent 
Diseases  of  the  Labyrinth  . .   290 

Sait.  U.  B.,  The  Ethical  Im- 
plications of  Bergson's  Phi- 
losophy         100 


PAGE 

Scholz,  L.,  Die  Gesche  Gott- 
fried       290 

Scholz,  Ludwig.  Nervos,  Zwan- 
zig  Gespriiche  Zwischen  Arzt 
und   Patient   296 

Sidis,  Boris,  The  Foundations 
of  Normal  and  Abnormal 
Psychology    200 

Stern,  W..  Die  Psychologischen 
Alethoden  der  Intelligenzprii- 
fung  und  deren  Anwendung 
an  Schulkindern   388 

Stransky,  E.,  Lehbruch  der 
Allgemeinen    und    Speziellen 

Psychiatric    387 

Syricker,  Georg,  Dengue  und 
Andere  Kiistenfieber   295 

Walling,  W.  E.,  Progressivism 

— and   after    103 

Rhein,  John  H.  W 59,     61 

Right  Temporosphenoidal  Lobe.   364 

PANDY,  W^  C 196 

vj     Scalp,     Abnormal     Develop- 
ment of   193 

Satellite   Cells 584 

Sclerosis,  Amyotrophic  Lateral..     94 
Sclerosis,     Pseudo-,     and     Other 
Conditions      Attributed      to 

Lenticular    Nucleus    23 

Scripture,     May     Kirk,     Speech 

Conflict     2,7'  I39 

Semilunar  Ganglion  in  the  Psy- 
choses       447 

Serum   and    Cerebrospinal   Fluid 

Reactions     378 

Sharp,   E.   A 92,     93 

Sharp,    Norman    49 

Sinusitis     55 

Sioli,   Emil    96 

Southard,  E.  E.,  A  Comparison 
of  the  Mental  Symptoms 
Found  in  Cases  of  General 
Paresis     with     and     without 

Coarse    Brain    Atrophy    204 

Southard.   E.   E 56,  204 

Speech   Conflict    37,  I39 

Spiller,  W.  G.,  Pseudo-sclerosis 
and  Other  Conditions  At- 
tributed to  Lenticular  Nu- 
cleus         23 

Spinal   Cord   Case    55i 

Spinal  Cord  Tumor   258,  358 

Spondylitis    368 

Stammering,  Psychology  of   68 

Stedman,  Henry  R 47 

Strangeness,  Feeling  of  188 

Strauss,  Israel  56 

Suggestibility  in  Children   I75 

Suggestion  Reactions    188 

Supernumerary  Digits    97 


59° 


JXDEX  TO  J 'O LI  ME  43 


PAGE 

Swedenborg,  E..  Psychologist  ..   194 
S.vmptoms,    Translation    of    into 

Their  Mechanisms   380 

Symmetrical  \\ounds  of  Tem- 
poral Region    367 

Synthetic  and  Genetic  Study  of 

Fear    474 

Syphilis,   Hereditary    54 

S\philis  Investigation   94 

Syringomj-elia,    Parthogenesis  of  283 

yABES    199 

1     Tabes   Dorsalis    393 

Tachycardia    197 

Taylor,  E.  W 9S 

Thorn,  D.  A.,  Abnormal  Relation 
between  Liver  and  Brain 
\\'eights  in   Forty-two  Cases 

of  Epilepsy  422 

Thyroid   Feeding    194 

Tilney.  F 50 

Tic  of  the  Abdominal  Muscles..   510 

Tic  Douloureux    554 

Time,  Discovery  of   477 

Timme,  Walter,  Tumor  Involv- 
ing Crus  Cerebri   505 

Tumor   Involving  Crus   Cerebri.   505 

Tumor  of  the  Dura  553 

Tumor    of    the    Pons,    Invading 

One  Crus  Cerebri    36-' 


PAGE 

TjXCONSCIOUS     in     Psycho- 

U      pathology.  Significance  of..   281 

Unilateral  Laminectomy 358 

Urethritis  in  General  Parahsis..    196 

Y^\CCINE   Treatment   in   Asy- 

V  lums   378 

Vagotonia,  Contribution  to  286 

Vegetative  Xeurology- 2"/^ 

Vegetative  Neurologj',  the  .Anat- 
omy, Physiology,  Pharmo- 
dynamics  and  Pathology  of 
the  Sympathetic  and  Auto- 
nomic Systems 73 

Villa  or  Colony  System  378 

^r  ASSERMANN    Standards  . .  473 

V  \       Pre-Wassermann    Days,    a 

Study    of     Cases     Diag- 
nosed  as    Paresis    324 

White,  W.  A.,  Reil's  Rhapsodieen       i 
Wilson,  Anita  Alvera,  Peripheral 
Neuritis     with      Korsakow's 

Symptom   Complex  343,  431 

Wilson's   Disease    50 

Wright.  Geo.  J.,  Dystonia  Mus- 
culorum Deformans  with 
Report    Z2>7 

VAWGER 284 


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